CIO Unplugged – 2/1/09

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

No Pain, No Gain
By Ed Marx

Sounds trite, I know. Some will accuse me of simplemindedness. Others will say this high school football-coach philosophy is dangerous. I agree, but still embrace.

In my thirties, I got back into playing tennis and started thrashing on the courts with some friends from work. As we verged on competitive levels, I realized we needed to pick up the intensity. A consistent first serve was the performance key. Reliance on the second serve would allow your opponent to take the offensive. Although a high, first serve percentage alone would not make you a Wimbledon champion, you’d at least guarantee yourself a quarter final match. We practiced at 6 am thrice weekly, but I showed up at 5 am to serve buckets and buckets of balls. I’d chase them down and start over again. No pain, no gain.

Now in my forties, I’m taking on the challenge of perfecting the Argentine Tango with my wife. In addition to a weekly two-hour lesson and a monthly milonga, we practice. Even if for only twenty minutes, we practice every evening. We have to, because the Argentine Tango happens to be the most artistic, intellectual, and difficult dance ever created by man. If I catch my partner’s foot too late, we miss our sweep. If we’re too far apart, one of us loses balance. I figure if we aim for expert, we might reach proficient by the time I’m eighty.

Like our dancing, my relationship with my bride of twenty-four years has been full of ups and downs. The overall trend slopes upwards to the right, but it’s interrupted with numerous peaks and valleys. Some downturns take years to correct, yet we keep at it. Annual strategic planning vacations, numerous marriage conferences, lots of books, prayer, and counsel. We’ve fought hard to reach the point we’re at today, and there is more pain to endure, I’m sure. Had we chosen not to push through the pain during any of the valleys, who knows where our marriage would be? Certainly not growing, not gaining.

And what about a career? Can you ascend the leadership ranks by good luck or good looks? Not in my case. It took pain—blood, sweat, and tears. Which meant not taking shortcuts. Not submitting C-level work. Not shaving time here and there to start the weekend early. But it’s so tempting!

I hear you. But do you want to reach the fulfillment of your calling? Then sacrifice. Love the pain.

A few years back, I had to spend a significant amount of time on the road. The librarian at Parkview Episcopal Medical Center (CO) supplied me with endless materials, from business books on tape to vocabulary building materials. While driving, I’d listen to these resources over and over until they became part of my intellectual fabric. Would have I preferred to listen to U2 or another favorite band? Of course. But to grow, I needed to take advantage of every morsel of time. I also volunteered for everything in my path; some related to IT, others benefited the hospital or another department. Would I have preferred to go home early or have a smaller to-do list? Certainly. But to maximize my potential and opportunity, I needed to self-sacrifice—so far as it didn’t harm my family. Plus, it was only for a season. Every season brings different opportunities, which require fitting sacrifices.

Today, I’ve made sure we have a library of materials available for our staff to checkout. Hundreds of books and cds on tape. We have subscriptions for “book of the month,” a concept I leveraged from the Parkview librarian. Just as serving thousands of balls to ghosts at the break of dawn paved the way to winning several tournaments; or investing the time and money to improving my tango to keep me on the dance floor, pain brings gain.

Don’t expect to just show up on the dance floor and look like a pro. If you want someone to ask you to dance, practice.

No pain, no gain.

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.”

What Usability Is and How to Recognize It

By Jim Bradford, Ph.D.
The Bradford Report

From time to time when I use a new application, I seem to develop a kind of Tourette’s Syndrome characterized by teeth grinding, fist clenching, and dark mutterings. As I struggle through yet another badly designed, user-unfriendly system, I find myself wishing fervently that Bill Gates had finished college.

Technically, the user friendliness of a system is known as “usability.” There is an entire academic discipline (variously called “Human Factors” or “Ergonomics”) that is devoted to the study of usability. But if you don’t happen to have a Ph.D. in Ergonomics, how do you recognize a well designed, highly usable system?

Mental Models and the Psychology of Geeks

The human brain constantly monitors the environment and creates models about it. This allows us to think about our environment and make predictions about what will happen next. We carry over this natural tendency to model things into our interaction with computers.

Not all models are created equal, however. I have a friend who believes that if you set a thermostat as high as it will go, it will warm up the house faster. It is not an unreasonable model — it just doesn’t happen to be right.

The best system designers work hard to give you many clues about how a system works. This allows your brain to make a good model that produces accurate predictions about system behavior. When you encounter such a system, you begin to feel that the system is natural, intuitive, and easy to use.

Unfortunately, geek psychology doesn’t often lead to this kind of design process. In 1971, Gerald Weinberg published his (now classic) book, The Psychology of Computer Programming. To boil a long tome down to its essence, the kind of person attracted to computer programming is frequently the type of person the media would characterize as a “troubled loner.” Unfortunately, the design of usable systems requires a well-developed ability to understand how people think, feel, and react when confronted with a complex system. As a rule, troubled loners are not good at this.

As a consequence, human factors experts are often drawn from the “touchy feely” disciplines (i.e., anything other than engineering or computer science). They are often brought in to fix computer systems that are so horribly hard to use that almost no one can make them work. This strategy is akin to bringing in a doctor only after the patient has died. The usability specialist does what he or she can, but the result is usually a system that has evolved from being impossible to use to the point where it is merely frustrating to use.

The traditional approach to developing computer software (design-code-fix) is pretty well entrenched. Thirty years of preaching from academia has not noticeably improved the usability of computer systems. The key to usability, I believe, is an informed and demanding consumer. This is rooted in a fundamental property of a free market economy — if people stop buying poorly designed products, companies will eventually stop making them.

The Informed Consumer—How to Recognize Usability

Affordance

This design principle dictates that the appearance of things should provide a strong hint about how they are used. A hammer looks like it would be good for driving nails. A screwdriver suggests how screws should be managed. An espresso machine … well, not so much. Hammers and screwdrivers have good affordance and espresso machines have poor affordance. When you look at the user interface of a new piece of software, do the commands, buttons, menus, and other gizmos give you a good idea of how to use the system? If they don’t, it’s Strike One against the designer.

Prescriptive Feedback

When using complex systems, people will make mistakes. This provides the acid test for usability. Have you ever encountered an error message that says something like, “Illegal command or filename”? Good grief! Which is it, the command I just used or the file I just named? What law did I break? What makes a command illegal? Why can’t I call a file anything I want?

Can you imagine if other products were designed like software? Can you imagine a dashboard trouble indicator saying, “Illegal battery voltage or engine temperature”? If software doesn’t help you fix mistakes, then it is Strike Two against the designer.

Task Fit

Software is a tool. Some software is a tool for creating documents, other software helps manage your finances and still other software exists purely to entertain you. Well designed software should focus on doing a small number of distinct tasks (a half dozen at most) and it should be obvious how the controls of the user interface help you do each task.

Unfortunately many software companies prefer a “one size fits all” approach to development and end up creating a “one size fits nobody” product. If it’s not obvious how a software application’s capabilities relate to the task you have in mind, then it is Strike Three against the designer.

The Bottom Line

In recent years, the nature of our daily lives has changed to such an extent that many of us spend the majority of our working and private lives sitting at a keyboard. Usability has become an important determiner of the quality of life for citizens of the twenty-first century. If the software you use is not intuitive, if it is not helpful, and if it doesn’t fit the tasks you want to do, then walk away … just walk away.

Jim Bradford is a scientist, professor, and consultant dedicated to the art of making technology easier to use. He wrote this article specifically for the readers of HIStalk after we exchanged e-mails about the problem of usability in healthcare applications.

Monday Morning Update 2/2/09

From Sam Axe: "Re: Scott & White. I am reasonably certain that GE/IDX is supporting the physician revenue cycle – not the hospital, which remains Siemens Invision. The GE article referenced in the response agrees with that and I believe they are probably accurate in their claims around the physician revenue cycle in academic medical centers." Thanks. I wish the press release had been more clear since both the customer and vendor in this case have separate offerings for inpatients and outpatients.

From Blago: "Re: Big shake-up at GE HCIT. Vishal Wanchoo out as CEO." Not according to Jennifer, a GE spokesperson and Inga’s new BFF, who said, "absolutely not." Inga was tickled, though, that Jennifer knew who she was when she called, even though she had thought Inga was someone I just made up. Now I’m inspired to invent up a huge staff of imaginary people, a seeming force to be reckoned with instead of some guy hunched over a PC for immoderate hours each day. Jade and Mariposa, massage my shoulders as I type, yes?

From Spanky: "Re: stimulus. How are pediatric providers going to get reimbursed for EHR use when they don’t bill Medicare?"

 

January’s HIStalk traffic set a new record, up about 40% from a year ago. Thanks for reading.

Listening: The Connells, jangle pop from Raleigh, NC since 1984.

Two Utah hospitals buck the trend and open up new expansions.

I heard from a CIO reader whose hospital, a big place, is 100% CPOE. I said I’d never heard of one doing all oncology and neonatal orders on a general CPOE system, but there’s at least that one. I agreed not to provide specifics, but I’ve asked for more information since I know many of us would like to know how they did it.

Who knew? The owner of ambulatory EMR vendor Purkinje, according to their site, is the famous VC billionaire John Doerr, backer of Compaq, Netscape, Sun, Amazon, Google, and others. His brother is the CMO and chairman of the executive board. John Doerr put $10 million into the company in 2007. The logo on the site now says GenesysMD even though the Purkinje name is used otherwise, so the company name appears to be changing (just confirmed with Margalit, the company’s product management director, who’s like me and working on the computer at 11:30 at night). Their deal: $399 per provider per month for software, unlimited support, hosting, interfaces, all clinical content (CPT, ICD9, First DataBank, etc.) and free training and implementation for users who sign up in February.

Over on HIStech Report, Inga interviewed John Shagoury of Nuance Communications.

DrM made a year-by-year table of payments and penalties for the House’s stimulus bill that just passed. I inserted it as a graphic above, so click to enlarge.

Hospital and employee information in Japan is exposed on the Internet when an employee copies data from a damaged flash drive to his PC, forgets the file is still there, then fires up his file sharing software at home. That’s happened before in Japan, I seem to vaguely remember. They love that Winny P2P client over there.

Speaking of which, a Computerworld article mentions on the danger of data exposure from peer-to-peer file sharing, citing a study in which a researcher found a document with full data on 9,000 lab patients, 350 mb of data from an anesthesia group, and an 82-field worksheet on 20,000 hospital patients. The last sentence is a little shot: "The range of health care information floating on P2P networks and the variety of sources from which it is being leaked highlight the disorganized and decentralized manner in which health care data is being collected, stored, used and shared, he said."

Here I go and run an interview with Peter Waegemann and he fails to tell me that they’re renaming TEPR to M-Health Conference. HITgeek has an idea: "If TEPR is changing its name, perhaps you could hold a contest or survey for what it should be."

A University of Chicago study finds that 90% of hospitalized patients couldn’t correctly name even one of the doctors taking care of them. Three quarters had no idea and 60% of the rest were wrong. Academic medical centers have a gaggle of people rounding in teams, of course, popping in for a few minutes once or twice a day, so maybe that’s not surprising.

Here’s an example of how insurance has corrupted the whole idea of patient responsibility: an LA Times article marvels that practices using real-time adjudication "can, and sometimes do, ask patients to pay those costs at the time of service." Shocking! Why can’t medical practices be like restaurants, gas stations, and mall stores in just letting people take what they want, walk out, and be billed sometime later to pay whatever amount is convenient? That should be the #1 step in healthcare reform — get patients to understand that healthcare isn’t free just because you have (or once had) an insurance card. The insurance companies escape consumer wrath because it’s the doctor’s office who has to come collecting what they didn’t pay.

The IT department was at fault in the recent PC virus infection in England, incorrectly configuring antivirus software on some PCs and failing to get AV updates to some of them, an outside IT auditor finds.

If you want to know how the HIT industry is doing, forget all those publicly traded companies with a mishmash of products and businesses and look at the software-only company that has the most hospital customers: MEDITECH, which 2,200 hospitals are running today. For FY08: revenue was up just under 6%, but net income dropped 60%, mostly on investments (I hear that). Interesting: CEO Neil Pappalardo and CFO Barbara Manzolillo asked that the Board give them only the same bonuses other employees get and not the special Director bonuses since the company didn’t do very well, reducing their paychecks by 64% and 52%, respectively, over their 2007 comp. Neil’s shares are worth over $500 million even at the internally set share price that the militant shareholders always complain is artificially low.

A WV doctor and former town mayor is ordered to repay an insurance company $180,000 for blood tests and injections that patients never received. The doctor blames his billing staff and software, says he has nothing to do with billing, and that judges discriminated against him. He was nailed in 2007 for underreporting income from 2000-2002, when he also worked as a day trader.

GE Healthcare is following its Burlington layoffs with mandatory unpaid employee furloughs.

Hospital layoffs: Clearfield Hospital (PA), 33; Saint Joseph Medical Center (PA), 40.

Sure to fuel the healthcare debate: is it a good use of healthcare resources to provide expensive fertility treatments and preemie care to an unmarried, apparently unemployed, and bankrupt woman in her 30s and her new octuplets that bring her up to 14 children, all of them conceived through in vitro fertilization? She’s trying to be self-sufficient, though: she wants $2 million and a career as a TV child expert from either Oprah or Good Morning America in return for her story.

I don’t get how magazines think. An article mentions that Philips sold CPACS to a hospital in Saudi Arabia, but the headline in SmartBrief says "Philips strikes a partnership with Saudi Arabian hospital." If that’s the case, I struck a partnership with the local sports bar at lunch today when I bought a very good burger there. Just because salespeople murmur the P word to make prospects comfortable doesn’t mean there’s a legal agreement to share expenses and profits. Anything else is called "a sale." Funny thing is, the article it referenced called it that — SmartBrief added the "partnership" line.

CPSI announces Q4 numbers: revenue up 14%, EPS $0.45 vs. $0.36, falling short of earnings expectations but raising guidance and declaring a dividend.

MEDSEEK announces a 47% increase in contracts and a 33% increase in licenses for 2008, referencing its KLAS 2008 Category Leader status in clinical portals.

California is out of money, so it plans to stop paying bills Sunday. The controller whines that withholding money from Californians will delay economic recovery, blaming everybody except the state itself. CA is $25 billion short for 2009, unemployment is 9.3%, and median home prices are down 50% in less than two years. Like Florida, they weren’t complaining during the boom that benefited them, but can’t accept the idea that the good times have already rolled.

Amanda Adkins, a 34-year-old Cerner executive, is named chairwoman of the Kansas Republican Party. It probably wasn’t a total shock since she was the only candidate.

E-mail me.

News 1/30/09

From Dr. Strangelove: "Re: medical education. Medical care & physicians take a lickin’ on this study of revamping their education. The issue was never getting enough physicians trained – it was getting them to work anywhere except the big cities where they could make enough money to stay entrenched in the social class created for them in the last half of the 20th century (and pay off medical school). Their attitude… well… that’s another thing entirely. It has to do with ‘the chief god in charge’ formula taught to them in medical school and in part to the kind of personality profiles it takes to survive medical school, an internship, and residency." A sentence from the report (warning: PDF) that advocates the reform of medical education: "The overarching theme that coursed through the discussions was the urgent desire to bring medical education into better alignment with societal needs and expectations."

From MM: "Re: vendor calls. The vendor calls and e-mails have gotten completely out of hand. A confluence of a new year and a very slow economy has everyone with anything to sell trying to make contact. My assistant, who is good at spotting the legitimate calls from random sales calls, has been tricked a few times this month. I can’t take it any more! Anyone else feeling a high level of sales activity?"

From Chef Tony: "Re: sponsor ads. We’re a sponsor and I’m a reader. I really dislike the animated ads, too. Nobody is hanging around to read each screens change. I deal with huge NYC agencies whose designer kids are often clueless about what gets information out to the target market. Unless it’s Super Bowl Sunday, educate or inform with ads, not entertain."

From Doug Dinsdale: "Re: Allscripts. A stock board posting claims that Allscripts Healthmatics and Allscripts Professional were scheduled to lose CCHIT certification last week. Is that true?" I don’t think so, but I’m sure Allscripts will clarify. According to the CCHIT Certified Ambulatory EHR 2007 list, both products were certified a year ago. I’m working from memory here, but I think certification is good for two years, i.e. even though CCHIT issues new criteria every year, vendors don’t have to recertify (with one exception: Stark and anti-kickback donations require products to have been certified within the past 12 months, but not necessarily on the current criteria, and extensions are available). You just have to pay CCHIT’s annual maintenance fee (huh? CCHIT requires payment of a maintenance fee even when a vendor doesn’t use any certification services, which was the justification for the fee in the first place?) For stimulus purposes, I think both products are good for another year in any case. I’m sure someone with a more expert opinion than mine can help.

From Friend of Tim: "Re: it’s a good thing you’re a nice guy." Link. Michael Arrington, the "surly and macho" founder of the Silicon Valley blog TechCrunch that carries quite a bit of investor influence, takes a leave of absence after receiving death threats and having someone walk up to him at a conference and spit in his face. I am a nice guy – thanks for noticing (cynical and juvenile, sure, but we all have our crosses to bear).

From Dinger: "Re: Baylor/Perot. Any word on how it’s going? I’m hearing rumblings."

From Paul Molitor: "Re: HITECH. I have to respectfully disagree with John Glaser’s interpretation of HITECH. You get the same compensation per clinician regardless of when that clinician starts to use an EHR. The declining payment schedule per ‘eligible professional’ begins with the ‘payment year’ in which that professional becomes a ‘meaningful EHR user’. The start of the declining schedule is not anchored in a specific calendar year and the schedule applies to each individual. A relevant excerpt from Sec. 4311: ‘(ii) AMOUNT- Subject to clause (iii), the applicable amount specified in this subparagraph for an eligible professional is as follows: (I) For the first payment year for such professional, $15,000. (II) For the second payment year for such professional, $12,000.’ See here for the full text."

From Moose Haas: "Re: MRI/TEPR. Completely washed up. Went to their event last year. It had to be one of the worst events I’ve ever attended. Rumor is MRI is being shopped, but no takers." I appreciate Peter Waegemann’s taking the time to share some thoughts (several  of which I agree with). 

From Sam Butcher: "Re: physician practices delaying EMR purchases. Many groups will delay. Those interested in EMRs for business or clinical reasons have already bought. The remaining ones are resisting change claiming EMRs cost too much or aren’t better than paper. These are the same groups that resisted electronic claims years ago. It’s no surprise that many of these practices are poorly managed. The same paralysis happened with practice management stimulus during the debate over Hillarycare." That’s an interesting observation. As much as I don’t believe the Most Wired hype, it would be interesting to compare the quality and profitability of non-technology using practices to the others. There are certainly plenty of badly managed practices out there (one way to identify them is to check the name tag of the least competent person in the reception area: if that person’s last name is the same as the doctor’s, expect the worst).

From Carpluv: "Re: physician practices delaying EMR purchases. Obamanations, grand idea for financial help for EHRs, has stopped the buyers in their tracks. They’re all waiting for the handout. Great momentum change!"

From Elsie EHR: "Re: physician practices delaying EMR purchases. Same song, different year. On July 21, 2005, the NY Times ran an article about the VA’s VistA system titled ‘U.S. Will Offer Doctors Free Electronic Records System.’ The article, which was widely quoted and reprinted, painted a rosy picture of the ‘free’ system. It was eagerly read by practitioners who were actively looking for an EHR as well as those who were on the fence. All that press prompted thousands of physicians to put their EHR plans on hold so that they could ‘wait and see’ what free goodies the government would provide. Some are still waiting." Link. That’s the most over-hyped and under-delivered part of Brailer’s original plan — giving away VistA (hospital and office) to legions of clamoring providers. Flop (see: Free Kittens).

From E. Buzz Miller: "Re: event. Will there be an HIStalk reception at HIMSS this year?" Wow, lots of people have been e-mailing that question, so thanks for the anticipation! I believe that’s affirmative, so keep Monday evening free. I’m hoping to line up a couple of notable speakers, maybe (and/or holding a spot for a HISsies winner or two if they’re game). For those who went last year, I’m open to suggestions on how to maximize the networking opportunities or anything else that would make it more meaningful and memorable. I never really asked attendees what they liked best or how to make it better, so now I am. Some people would just put out food and drinks, but I’m too neurotic to just let it unfold.

From Trimaxion: "Re: Stanford. Stanford Hospital has again delayed its Epic CPOE Oncology (Beacon) go-live of their Comprehensive Cancer Center. They have serious patient safety concerns, need new development, and can’t scale the complexity of the site." Unverified, but I know some Stanford folks read and may reply. I can’t say I know of any oncology app that isn’t a work in progress, though. The protocols and pre-dose monitoring and calculations are a bear. Even the so-called "100% CPOE" hospitals usually punt on oncology (and some or all of peds, like NICU).

From Bobby Peru: "Re: layoffs. Keep up reporting them." An interesting counterpoint from Think Positive: "I would propose to you that it is no longer news worthy or interesting news if another company has a layoff. I agree in better economic times this type of insight into a company’s fortunes or failures is helpful guidance to your readers." Think Positive is right, I believe, because it is indeed neither newsworthy or all that insightful that a vendor lays off staff these days, unlike the pre-recession when such activity might foretell future problems or shifts in strategy. Maybe this is a happy medium: I’ll keep reporting layoffs (provider and vendor) only if they have been reported elsewhere. Is that good, or should I follow Bobby’s suggestion and keep running whatever I hear? Let me know.

In the meantime, in the absence of a ruling, Omnicell supposedly dismissed somewhere between several dozen and a hundred field support employees on Wednesday, but an official number of 101 was given with its Q4 report: revenue up 7.1%, EPS $0.10 vs $0.09. Those are darned good numbers if you ask me, but cutting payroll is the most common hunkering down for weathering the economic storm overhead. Cold, but smart.

It’s your last chance to cast your HISsies ballot.

Listening: brand new alternative hard rock from Hoobastank, who kind of disappeared after one hit several years ago. I like it a lot – it’s harder than their older stuff. I still hate the name, though.

Intellect Resources has a new newsletter, which I always enjoy. The "traveling Flat Healthcare IT Man" piece is fun – wish I’d thought of it for HIStalk (it’s from a children’s book called Flat Stanley). They also have a new website with both HIT positions and candidates.

A huge win for GE: Scott & White chooses Centricity Business (the old IDX billing system, I assume) for patient access, revenue cycle management, and BI.

Jobs: Cerner Clinical Systems Analyst, Pre-Sales Engineer, EHR Clinical Trainer and Implementations, IT Director. There are some nice positions and employers posted.

Here’s an interesting example of commitment to healthcare: El Camino Hospital is purchasing the physical plant of Community Hospital of Los Gatos, putting current ECH CMIO Eric Pifer in charge there. ECH is taking over June 1 when Tenet’s lease runs out, but Tenet said, screw it, we’re closing the hospital on April 10 because it’s losing money anyway and we’d rather just cut and run. Employees thought they were finally going to be safe under ECH, but now they’re all getting the axe. ECH says they can’t get it ready to re-open until the fall. As a for-profit company, it’s the right business decision for Tenet, I suppose.

Humana will contribute provider incentives to encourage participation in the Wisconsin HIE (would one sound that out as WHEE or WHY?)

While I’m thinking about it, I’d like to thank the companies that sponsor HIStalk and HIStalk Practice. It takes guts to put your ad (flashy or not) beside some of the stuff I write. For most of them, it’s not a sterile transaction handled by detached PR people — it’s company executives who want to support what we do and who pull the strings to get the bean counters to write a check to a vaguely untrustworthy-looking enterprise working out of a PO box. Make your own decision on what to buy or from whom, but if you get the chance, thank them for their support.

Investor’s Business Daily covers athenahealth in an article purportedly about subscription EMRs, but mostly about ATHN stock.

If you’ve e-mailed me lately, hang in there and I’ll get back to you. It’s nearly impossible for me to do much more than skim the inbox until the weekends since HIStalk, HIStalk Practice, and HIStech Report are kind of in full swing at the moment (there will be record readership in HIStalk this month, which is surprising since the first several days were a long holiday weekend for most folks).

Speaking of CHLG, I heard this from Vendor Val: "El Camino Hospital plans to bring CHLG up on their Eclipsys Sunrise computer system and introduce physician order entry. Great news – for their competitors. CPOE had some success at El Camino because the city subsidizes the hospital and the hospital subsidizes the close-knit Independent Physicians of El Camino with free eClinicalWorks. Of course these MDs are very tech-savvy and have link-ups with the hospital’s Eclipsys Sunrise systems and can view lab data, medical histories, and procedures from the comfort of their own offices (they attract a lot of Stanford Hospital doctors who cut their teeth on computer glitches, spotty interfaces, and lots of downtime). But Los Gatos is a diverse collection of paper-happy independent physician practices who have no incentive to invest in technology and many are aging retirees with no interest in learning new programs."

Nextgov reports that Rob Kolodner will be staying on as ONCHIT.

California’s ED doctors sue the state, claiming that the ED system will collapse without additional funding. The state is ranked last in ED access and 43rd in ED payment. The docs claim EDs are getting the state’s burden of caring for the poor and elderly dumped on them. The state’s Department of Health Care Services had a cheery response: more budget cuts are likely, with proposals on the table to cut Medi-Cal’s budget by $1.1 billion and cutting physician reimbursement on March 1. I’m no expert, but this sounds like a seriously explosive situation there since I remember how ugly the King-Drew situation got.

Rich Elmore reminds me that his blog post mentioned the possibility of delayed provider EMR decisions because of Uncle Sam’s potential golden handshake.

St. Luke’s Regional Medical Center (ID) restructures its 28 IT positions into 18, forcing incumbents to play musical chairs to decide which 10 get the boot. It seems that hospitals are falling into one of two camps: (a) those who have big-ticket IT projects underway and aren’t about to jeopardize them to save a few IT salaries, and (b) those who never really believed that technology was all that valuable and are robbing the IT operational and capital budgets for more critical needs.

A UK survey calculates that dry cleaners there found an estimated 9,000 USB sticks, some no doubt full of sensitive information, that were left in the pockets of clothing dropped off.

E-mail me.

HERtalk by Inga

From Comforter: “Re: layoffs. Cabell Huntington laid off between 30 and 40 middle managers a couple of weeks ago, saving between $3 and $4 million per year. Many were-long time employees, with more than 20 years of service. One questioned how the hospital could have committed $40 million to Cerner a couple of years ago, but now finds itself in dire straits. Security escorted the employees out of the building immediately, standard policy for sure, but compounding the duress of getting fired.” The local paper reports that 40 jobs were eliminated earlier this month.

From Jason: “Re: Faxton-St. Luke’s Healthcare. You may have already heard, but Faxton St. Luke’s is an Eclipsys client.” Thanks for the correction. I erroneously said they had Cerner.

From Inside Outsider: “Re: Rob Kill. Is the new CEO of Virtual Radiologic Corporation really named Rob Kill? First time I’ve ever heard of a person named for breaking two commandments." Funny, although I bet Rob’s heard it too many times to do anything except grimace and give a polite, dry two-beat chuckle (HAH ha).

From Ziggy: "Re: Hospital marketing. With all the troubling economic news, budget cuts, and all, I am wondering the effect on hospital marketing? What are other hospitals finding to be most effective for the money?” Medicare fraud?

Sometimes it’s the little things about a company that can turn you off. Last September, I semi-seriously made fun of this Med Com USA press release because the first sentence went on forever. Lo and behold, here’s a new one just about like it: “MedCom USA, Inc. (OTCBulletinBoard: EMED) a leading provider of HIPAA compliant healthcare and financial transaction solutions for the healthcare industry, which recently signed letters of intent to acquire PayMed USA, LLC and Absolute Medical Software Systems, a leading provider of HIPAA compliant medical, dental, healthcare and financial transaction solutions for the healthcare and dental industry is pleased to announce that it has appointed an additional board member resulting in three independent board members and one inside member.” But what annoyed me the most was that in order to open their Web site with my Chrome browser, I was required to upgrade to a newer version of Flash (which I blew off, because I decided I didn’t need to see their site that badly.) If you read the press release, you’ll notice they had some high-level turnover, so I’ll give them the benefit of the doubt and assume they haven’t had a chance to focus much on marketing.

With the meltdown of Satyam Computer Services, other outsources like EDS, Perot, and ACS hope to pick up a few new clients. One consultant estimates Satyam will lose $2 billion worth of business to competitors over the next two to four months.

Tennessee expands its medical video network to allow physicians to treat pregnant women in rural counties. BCBS of Tennessee Health Foundation has provided $1.8 million in funding to allow perinatologists to view live ultrasounds remotely.

HIMSS announces its support for HIT provisions under consideration by Congress, citing three reaons: 1) the economy will benefit as jobs are created; 2) patients will benefit because of increased safety, and, 3) doctors will benefit because it reduces the current cost barriers. They don’t mention this, but of course it would be helpful to their 350 corporate members (and thus they themselves) as well.

A survey finds that hospitals and health systems are cutting back on both capital spending and unprofitable healthcare services. Hospitals are worried about declining investment values, shrinking margins, and stagnant philanthropy. This report reminds me of our own little survey to your right. If you are a vendor or a hospital, let us know what effect the economy is having on your world.

I wonder if this is just a co-incidence? Mr. H and I start using Twitter to keep abreast with all things HIT. Three weeks later Twitter seeks to raise at least $20 million in Series D funding. That’s a bunch of tweets.

The U.S. Bureau of Labor Statistics reports that retail prices for hospitals increased 5.9% in 2008, compared to 8.3% the year before. Wholesale prices for hospital services increased 1.5%, compared to 3.9% in 2007.

A CDC report finds that the total number of outpatient surgeries increased from 1996 to 2006, from 20.8 million to 34.7 million visits. Outpatient surgery visits accounted for about one half of all surgery visits in 1996, but nearly two thirds of all surgery visits in 2006.

Eastern Maine Medical Center announces 76 job cuts, reductions in overtime, and holds on several projects. The hospital was a 2008 Davies Award winner. The local paper also noted that the hospital’s CEO received almost $700K in compensation and benefits last year.

Wetzel County Hospital (WV) receives government approval to seek up to $6 million in bonds, which includes $175,000 to upgrade its CPSI EMR and Payroll applications.

Trustees with Regional Medical Center (SC) approve a $78,000 contract with HIMformatics to oversee its Cerner IT project.

Tenet Healthcare says it expects a Q4 net income of $5 million and $63 million in earnings for 2008.

Would the average person pay $20 to e-mail a medical specialist for advice?  A physician group is betting on it, having launched a Web site designed to give anyone with a medical question the chance to receive medical advice, medical recommendations, and medical information from specialized medical doctors. 

Revenue cycle management company MTBC outfits its own airplane to be a flying promotional platform. Well, why not? Guess it beats the yellow pages, especially if you’re marketing to pilots.

Norton Healthcare (KY) selects Unibased Systems Architecture to provide resource management software and services.

ICA announces the deployment of its data and technology aggregation solution at Lourdes Hospital (KY).

E-mail Inga.

An HIT Moment with … C. Peter Waegemann

An HIT Moment with ... is a quick interview with someone we find interesting. C. Peter Waegemann is CEO of the Medical Records Institute.

People often compare HIMSS and the Medical Records Institute, often on the basis of their respective conference (the HIMSS annual conference and TEPR). How would you characterize the difference and do you see HIMSS as a competitor?

HIMSS and Medical Records Institute (MRI) have very different goals and points of view. Both started about 25 years ago. HIMSS developed into a very successful “mainstream” trade show with an attached membership organization. MRI’s conferences have emphasized the education component and helping providers to understand the consequences of EMRs and HIT.

For MRI, the main goal was to promote EMRs and to stimulate and provide leadership in standards development. I was instrumental in the initiation of standards organizations such as ISO TC 215, but when MRI felt that there was a lack of meaningful results, it supported ASTM International’s, relinquishing its leadership to HIMSS, which took over technically. While HIMSS has been a strong supporter of ONC, HITSP, and CCHIT, MRI has pointed out the negative influence these efforts have had on HIT developments. 

In summary, MRI has been the counterpoint to HIMSS in terms of strategy.

Why is Medical Records Institute set up as a for-profit organization rather than a non-profit like HIMSS? Is there much of a difference and are other healthcare membership or conference organizations set up similarly?

HIMSS, having gotten the not-for-profit status early on, has been a huge, profitable organization that is well funded, with reserves in the millions. MRI is the small, independent organization that has always been more interested in making a difference than making money. MRI felt that it could be more effective in its mission unfettered by a Board and the complications of a not-for-profit organization.

What is MRI’s point of view on the state of EMRs and best use of any healthcare IT money that’s made part of an economic stimulus package, particularly in light of the National Research Council’s report about the unmet technology needs for improving patient care?

MRI has repeatedly stated that the progress in the field of EMRs is shameful and argued that this cannot be blamed on such myths as lack of physicians’ interest (see this article). 

Unlike other organizations, MRI is not driven by the prospect of big money for the industry. MRI welcomes the prospect of funds to improve the quality of care with technology solutions, but it is one of the rare voices that warns that the expected savings may not occur quickly, that the infrastructure is not ready, and that (as in the past) wrong avenues appear all too likely to be pursued. 

In its letter to President Obama, MRI  asked for orchestrated efforts to determine the necessary healthcare infrastructure changes in order to achieve electronically enabled healthcare. In other words,  rather than rushing into a big spending spree, a national effort needs to be funded that openly addresses all the hypes, explores various and perhaps unpopular strategies, and develops effective ways to spend this money safely and efficiently.

Why did MRI develop an interest in cell phones in healthcare?

MRI has a long history regarding cell phones and mobile technologies. Almost 10 years ago, MRI joined the Mobile Healthcare Alliance (MoHCA) to coordinate cell phone activities in healthcare and I served as chair of MoHCA. Several years ago, MoHCA’s Executive Director joined MRI as Vice President. It has been natural that we followed that industry and recognized its potential value to healthcare.  

There has been a re-emerging wave of mobile phone applications for healthcare. With over hundred companies, this is big and will be disruptive to providers and other stakeholders. MRI calls it the “mHealth revolution”. For this reason, the Center for Cell Phone Applications in Healthcare (C-PAHC) was formed in 2008. 

Mobile devices and applications will be instrumental in the success of many health IT goals, such as documentation at the point of care, success of personal health records, integration of personal health records into EMR systems, disease management, and many more. Most of all, mobile technologies represent the breakthrough opportunity for EMR interoperability and implementation among many other applications. MRI supports the formation of the new, independent, not-for-profit mHealth Initiative Inc. and will encourage its efforts toward accelerating mHealth and its benefits nationally and internationally.

What predictions do you have for the healthcare IT industry over the next 1-3 years?

MRI sees four major drivers for the next three years. The first is, of course, the new Administration and whatever comes out of its efforts.

The second is the “mHealth revolution”, addressed above. Expect, for example, that in 2012 more than 50 million people will have their PHR on a mobile phone and will send information in advance of any visit to a provider. 

The third driver will be the interoperability standards through ecosystems (Microsoft, Google, mobile phone, etc.) that will enable true continuity of care. Expect most of these developments to come from industry innovation, not from traditional standards bodies.  

The fourth driver will be the Internet/consumer movement.

Overall, there should be more progress than in the last 10 years toward a safer, more efficient and cost-controlled healthcare system. 

Being John Glaser 1/29/09

The current version of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is part of the larger economic stimulus legislation, will alter the HIT industry and the IT plans of our organizations.

For outpatient electronic health records, the Act puts some non-trivial money on the table. A provider who uses a certified EHR can get a maximum (through Medicare) of:

This totals $41,000. This will clearly increase interest in adoption and could represent a lot of revenue for a provider organization.

To get this money, a provider must demonstrate that they are meaningfully using health information technology. What does "meaningfully" mean?

• Using e-prescribing
• Connecting through HIEs to improve the quality and coordination of care
• Submitting information on clinical quality measures.

While we might be more or less clear about what e-prescribing means, clarification is clearly needed about what we mean by the second and third criteria.

It is anticipated that HHS will spend 2009 providing specifics and clarity about what providers have to do to demonstrate meaningful use. This means that most providers will have one year – 2010 – to finish EHR implementation and put in place the infrastructure, applications, training, etc. needed to get the as much of the incentive money as possible.

This is a tall order. And it means that providers should start moving now (if they aren’t already) even though the dust has yet to settle on the specifics.

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

VA Will Pay $20 Million to Settle Stolen Laptop Lawsuits

The Department of Veterans Affairs will pay $20 million to settle a class action lawsuit involving a privacy breach caused by a laptop stolen from a VA employee in 2006, according to a proposed settlement.

The laptop and its external drive contained names, dates of birth, and Social Security number of over 26 million military members and veterans. The equipment, stolen in a routine burglary of a data analyst’s home in Maryland who had taken it home without permission, was recovered by authorities, who concluded that its information had not been accessed.

The settlement will be paid to veterans who can show they were harmed or incurred credit monitoring expenses.

News 1/28/09

From The PACS Designer: "Re: best hospital workplaces. Fortune Magazine has just published its 2009 list of top 100 places to work, which includes 13 hospitals. The highest ranked is Methodist Hospital System (Houston) at #8; followed by #19 – Ohio Health; #45 – King’s Daughters Medical Center (KY); #62 – Griffin Hospital (CT); #63 – Mayo Clinic; #67 – Children’s Healthcare (Atlanta); #68 – Southern Ohio Medical Center; #75 – Atlantic Health (NJ); #76 – Lehigh Valley Hospital and Health Network (PA); #77 – Northwest Community  Hospital (IL); #79 – Baptist Health South Florida; #85 – Arkansas Children’s Hospital; #98 – Vanderbilt University. TPD congratulates those selected as being top notch in their treatment of employees." Link.

From FIT003: "Re: McKesson. They have started laying off staff. Long-term employees are the first to have been laid off. Initial numbers, placed at 50-75 people within the Alpharetta operations." Unverified.

From Songbird: "Re: Perot’s MEDITECH solutions group, formerly JJWILD. Planning a third round layoff this Friday, January 30." Unverified.

From KFC: "Re: Keane Healthcare. About 10% or 30-35 employees from the Keane Healthcare division over the last two weeks. With the sunsetting of the old First Coast Systems patient billing application and the merging of the Unix product, I wonder how this will impact the always-delayed timeline?" Unverified. For all these unverified layoff rumors, by the way, I will run a brief company response if one is provided, whether confirming or denying. That’s fair.

From Ken Kercheval: "Re: physician practice EMRs. It is going to be an interesting year. Lots of companies will go away. Like they say, ‘When the tide goes down, you find out who isn’t wearing a swimsuit’. Indeed."

From Jackie Martling: "Re: sponsor ads. Just a suggestion. The animation is annoying to the point I copy and paste your great content to avoid the distraction. Seems unfair to the non-annoying ads." Noted and dutifully passed along to the sponsors for their future consideration.

HISsies voting will be winding down shortly, so cast your vote now.

Listening: The Gaslight Anthem, a reader suggestion. Good Jersey Shore bowling alley ballads with a soupcon of punk. Should be on an indie film’s soundrack. They’re on Letterman Friday night and touring everywhere.

The Raymond James folks sent over a couple of briefs about the healthcare IT stimulus proposals on the table. They predict that HIT adoption incentives will be around $32 billion over ten years, with the biggest adoption jump happening in 2011-2014 and with the biggest potential beneficiaries being physician practices and hospitals in the 300-499 bed size. They question, as I did yesterday in HIStalk Practice, whether prospects may actually hold off on purchasing clinical systems until the federal involvement shakes out. With that in mind, I’ve put two new polls to your right — one for vendors, one for providers — asking about any purchase delays your employer has been involved with. Your comments are welcome, too, so feel free to e-mail me. The stimulus could actually be detrimental in the short term if potential customers become indecisive.

A Fort Bragg military team is the first to use the AHLTA-Theater battlefield EMR to document patient encounters stateside.

A former Kaiser Permanente employee in Los Angeles kills himself, his wife, and five children ages 8 and under (including two sets of twins), apparently after being fired in a dispute with an administrator. His suicide note claims that the administrator told him on coming to work one day that "you should have blown your brains out." His wife had also previously worked for Kaiser. Update: according to CNN, both parents had been fired from Kaiser for cause.

A reader says Ivo Nelson, formerly of Healthlink/IBM, will launch his new business next week. It’s called Encore Health Resources. The domain is registered to a PR firm’s contact and address.

IBA’s iSoft gets a deal to install its software at 38 Healthscope hospitals in Australia.

New on HIStech Report: an interview with Steve Ura, CTO of MED3OOO, including questions about its InteGreat acquisition.

Capsule (they seem to have dropped the "Technologie" part of their name except when referring to their Paris headquarters) announces the addition of 80 more medical device drivers to its library of 400.

Consumer Watchdog demands that Google "cease a rumored lobbying effort" related to stimulus bill discussions that would allow the company to sell patient information to Google Health advertisers.

Members of Parliament want individual trusts to be able to buy their own systems if NPfIT can’t get its Cerner and iSoft software problems fixed within six months. Also reported: one trust that’s merging with another may be planning to drop Cerner and go with the other hospital’s 20-year-old Atos Origin legacy system. All of this, of course, is a warning to anyone who thinks huge healthcare IT projects can work fine if given the proper money and oversight, neither of which is in short supply in the UK as NPfIT disintegrates.

This may sound off topic, but I’ve been involved with similar solutions that made IT a hero: an Indiana Web 2.0 startup announces that its WiFi digital sign technology has been installed at several hospitals. It’s a terrible press release (as any would be that references rotten teeth) but maybe interesting.

Hospital layoff: Hennepin County Medical Center (MN), 100.

The Wisconsin paper investigates a touchy topic: do hospitals provide enough free care to be worth all the tax breaks they get, especially when governments are strapped?

A rumor site reports that Apple CEO Steve Jobs will undergo surgery at Stanford Hospital, citing as a source "a secondhand account passed along from an employee at Stanford." I’m sure the HIPAA-violating source will provide updates throughout the day if the story is true (he was rumored to have been thinking about a liver transplant).

A phony doctor is arrested at his fake doctor, nurse, and dentist school in India. Graduates of the "Medical Diploma Training Agency" are actively practicing, it’s believed. The doctor was printing his own diplomas, but later outsourced it to a computer company. He was turned in by a night guard who paid for his dentist’s diploma, was told he had to ante up more money, and then was allegedly beaten by the fake doctor for complaining.

Siemens says its healthcare business isn’t so great, but it still sucks less than GE’s.

An Australian hospital is in such dire financial straits that employees, feeling sorry for patients, are spending their own money to buy groceries, bandages, light bulbs, and computer paper.

Venture investing declined in 2008 for the first time since 2003. Green tech companies are hot; software vendors and Web start-ups are ice cold.

Archives of Internal Medicine Article
Clinical Information Technologies and Inpatient Outcomes

"Health info technology saves lives, costs" screams the Yahoo News article. Modern Healthcare fires out an e-mail news blast, claiming that "when computers replace paper, patient mortality rates drop 15% during hospitalization."

The headlines are misleading (as they often are to lure in readers). You need to interpret the article yourself.  It’s available online.

Here’s the conclusion, verbatim from the article: "Hospitals with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs."

Sounds promising. Even more so when the article talks about the researcher’s use of a survey tool that actually measures how much technology is being, not just how much has been bought (although that CITAT survey instrument itself isn’t available in this or the predecessor articles that I could find, which is odd since that’s a key part of interpreting the findings).

However, the study had compromises:

• It covered only patients >50 years old and only four medical conditions.
• It randomly surveyed physicians using an AMA file, asking them to respond and to include the hospital in which they provided most of their inpatient care, but it wasn’t clear whether they provided all that much inpatient care at all or whether they were the most prolific doctors at the hospitals being reviewed.
• Since the doctors who responded drove the choice of hospitals, those hospitals studied were not typical: they were much larger and more of them were academic medical centers.
• Outcomes were determined from claims data.
• Some results were predictably erratic, such as the lack of correlation to length of stay and the conclusion that use of electronic notes and records increases the odds of heart failure complication.

Compared to studies that preceded it, this one’s pretty good, but it suffers from Most Wired-like conclusion-leaping (not in the article, but by those who try to turn it into a sound bite). Nothing suggests that technology use caused the improvement, only that it seemed to coincide with it. So, we know what we already knew or presumed: good hospitals are more likely to do many things (including deploy IT) better than bad ones.

Nothing in the article suggests that a given hospital will see its quality improve just because its starts using technology (in fact, that might have been an even more interesting study: take those same hospitals studied, identify those that recently implemented clinical systems, and compare their before-and-after numbers to see if anything changed).

The bottom line: it’s a pretty good study that has encouraging conclusions, even if they are iffy. IT won’t make bad hospitals good, but it can help make good ones a little better if it’s used right and along with other improvement measures. The article does not, however, suggest that IT is the can’t-miss answer to quality and cost problems.

E-mail me.

HERtalk by Inga

Consultants warn that as the economy worsens, more hospitals will lay off employed doctors or slash their pay. The US Department of Labor reports that 107 hospitals had mass layoffs (50+ employees) for the first 11 months of 2008.

Despite all the bad news of layoffs, many believe that healthcare still offers more stability than other sectors. In fact, the US Bureau of Labor Statistic predicts 3 million new wage and salary jobs between 2006 and 2016, more than any other industry. In nursing, older students, men, and second career newcomers are joining the ranks.

In a paper entitled “Hospitals as Hotels,” researchers conclude that amenities such as good food, attentive staff, and pleasant surroundings may play an important role in hospital demand. “From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4 percent on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality.” Sounds like the message is to buy nice furniture instead of improving care if you want to keep the beds full.

Turmoil at Tri-City Medical Center (CA) has employees wondering about the facility’s long-term stability. Last month, a new board majority placed the hospital’s top eight administrators on paid leave and brought in a temporary management team that opponents claim have no hospital experience.

An Ohio man sues a nightclub for $25,000 after a stripper’s shoe flies off during a tricky dance move, chipping a bone in his nose that will require surgery to fix. No word on whether her shoe was damaged, but I say shame on that stripper for risking her shoes.

HealthGrades releases (warning: PDF) its seventh annual Hospital Quality and Clinical Excellence study. Medicare patients treated at top-rated hospitals are 27% less likely to die there, on average, than at other hospitals.

The Association of Academic Health Centers calls for a revision of the HIPAA privacy rule following a study in which HIPAA was found to impede study recruitment and study diversity.

McKesson reports mixed financial results for its fiscal third quarter, losing $20 million because of the $493 million paid to settle AWP price fixing charges. Without that, EPS would have been $1.05 vs. $0.68 last year on slightly higher revenues. Technology Solutions grew but missed expectations due to contract signing delays in hospitals and physician practices. Cost cutting was the key to a pretty good quarter. The company raised its earnings outlook, running the stock up 12% on Tuesday.

MedAvant Healthcare Solutions appoints Troy Burns as CTO. He previously worked at Misys and Payerpath. MedAvant’s president Andrew Lawson is also a former Misys guy.

Philips Healthcare reports 9% sales growth in Q4, driven by sales in imaging systems, healthcare informatics, and customer services. Royal Philips as a whole ended the year with a $1.9 billion loss and will lay off 6,000 employees.

Scott Perra, the new president and CEO of Faxton-St. Luke’s Healthcare and Mohawk Valley Network (NY) claims the implementation of an EMR is his first priority. The health system is about 18 months into installing its $15 million clinical system (I believe Cerner).

In what the company calls a planned transition, Virtual Radiologic Corporation promotes President Rob Kill to CEO. Company co-founder Dr. Sean Casey will remain chairman of the board. The announcement coincides with the release of the company’s Q4 and full-year financials, which include a 24% jump in revenue for the year. Adjusted net income grew from $7.0 million to $9.7 million. The company also just signed its third internal client, this one in Saudi Arabia.

Griffin Hospital (CT) implements the Logical Ink electronic charting system in its new Center for Cancer Care.

Madonna Rehabilitation Hospital (NE) plans to adopt (hopefully they’ve signed a contract) Eclipsys clinical solutions.

The Outpatient Rehabilitation Center of Margaret Mary Community Hospital (IN) implements Chart Links therapy documentation and scheduling system for its 19 physical, occupational, and speech therapists.

PHR vendor MediKeeper announces the appointment of David Ashworth as CEO.

The Queen’s Health System (HI) renews its IT outsourcing contract with ACS. The new contract is valued at $26 million over three years and includes Queen’s Medical Center and its affiliates. ACS has been providing IT services to Queen’s since 2001.

BJC HealthCare (MO) signs a five-year agreement with CareTech Solutions. CareTech will provide BJC and its 11 affiliated hospitals a suite of Web products and services including CareWorks content management system and BoardNet communications portal.

I was amazed to learn there are now over 10,000 applications available for the iPhone. A cool new HIT tool just announced: Safe OR, which includes a 19-item surgical safety checklist A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.

Picis CEO and Vice Chairman Todd Cozzens will chair the Business Office Improvement educational track at TEPR+ next week. I’m envious of anyone who gets to spend a few days in Palm Springs right now. If you’re attending, send us updates and impressions.

Medsphere announces the successful implementation of BCMA at all eight of West Virginia’s state network of acute, psychiatric, and long-term care hospitals.

athenahealth and the Illinois State Medical Society announce an agreement to offer special pricing on athenahealth’s PM solution to its 12,000 members. I also saw that athenahealth hit a 52-week high Monday, following Jonathan Bush’s appearance on CNBC’s “Mad Money” with Jim Kramer.

E-mail Inga.

MD Leader 1/27/09

Ministry Health Care Will Implement CattailsMD

Ministry Health Care has chosen to implement CattailsMD electronic health record. For over 20, Marshfield Clinic has developed a comprehensive electronic health record, now available as a CCHIT-certified ambulatory EHR product known as CattailsMD. The EHR is also available with a data warehouse to actively drive decision support and population management.

Conventional Wisdom

Conventional wisdom speaks against the use of an internally developed product. While conventional wisdom is often used as a rule of thumb, tunnel thinking can limit your options. Every software decision is the result of a complex analysis of objectives, risks, benefits, values, and mitigation strategy. The purpose of this post is not an exhaustive explanation of our decision, but rather a review of several factors influencing our thoughts.

EHRs Are Becoming a Utility

Within a few years, EHRs will be more of a utility than a unique product. Increasing CCHIT certification and government incentives are driving standardization of function. Many organizations are turning to SureScripts to satisfy the CMS E-prescribing incentive. SureScripts standards will be just one of many leading to an ever-increasing identical functioning of EHRs. Simply having an EHR will not lead to process improvement nor increase clinical quality.

EHRs Do Not Improve Quality

Most EHRs have not improved quality of care. Simply automating our traditional process should not be expected to fundamentally improve quality. Improvement occurs when we redesign our care systems and standardize our processes (often enabled by use of an EHR). It is not the EHR that magically improves care; it is the people and processes utilizing the EHR that improves care. If you are both vendor and end user, then you can first vision how care should be provided and then deliver the necessary software to support it.

Marshfield Clinic has effectively demonstrated the value of this approach by achieving improved quality of care resulting in decreased health care costs in an ongoing CMS Demonstration Project.

The Status Quo Will Not Meet Future Needs

Our health care system is broken, we simply are not meeting the prevention, wellness, and primary care needs of our patients. We do not have enough primary clinicians to meet our current needs and we are not producing enough primary clinicians to meet our future needs. In Wisconsin (warning: PDF), the demand for primary care clinicians in the next 10 years is projected to increase by as much as 33% with only a 5% increase in clinicians. We will need to redesign our health care delivery system if we hope to meet future needs.

Our use of CattailsMD maximizes our opportunity to influence the design of an EHR to meet the needs of our patients. Although our vendor is interested in the commercial success of the product, as a provider of health care, their prime objective is the same as ours: caring for patients.

It Is All About the Data

Ministry Health Care and the Marshfield Clinic have a large number of common patients and will share the same EHR. While a shared EHR with a single source of truth for medication lists, allergies, labs, and documents is appealing, the real value is an extensive data warehouse ten years in the making. The data warehouse currently contributes to a number of activities including population management, disease management, maintenance of numerous registries, formal research, and increasingly, decision support.

As our business intelligence tools become more robust, I expect increasing emphasis will be placed on activities such as searching the database for trends of best care, identifying potential drug interactions, post-marketing surveillance of medications, and identifying care opportunities that will improve the health of the communities we serve.

A Decision Without Risk?

Is our decision to use CattailsMD without risk? Nope. But then again, no decision is. During the 20 years I have been interested in health care IT, I have seen numerous vendors (both large and small) come and go. I have also been through the agony of “upgrades” in hardware, operating systems and entire new versions of software forced on us by our vendors.

What has not changed is our need for information to improve health care. We are on the threshold of having EHRs and data warehouses that do not just present information, but actively support the practice of medicine.

A Future Post

Ministry Health Care and the Marshfield Clinic have been actively working to build the infrastructure necessary to support a joint EHR. In a future post, Dr. Carlson (Marshfield’s CIO) and I will discuss some of the issues we have dealt with that will have national significance if government seeks to foster greater sharing of patient data.

While you are waiting for a joint post, please take some time to read Will Weider’s (Ministry’s CIO) advice for President Obama.

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.

An HIT Moment with … Michael O’Neil, Jr.

An HIT Moment with ... is a quick interview with someone we find interesting. Michael O’Neil is founder and CEO of GetWellNetwork, Inc.

People may think of GetWellNetwork as an TV entertainment service for hospital patients. How do you describe your company?

GetWellNetwork was founded on the principal that patient engagement is a core strategy for performance improvement and a critical puzzle piece in the elusive search for service, quality and safety improvement in healthcare. GetWellNetwork provides technology, as well as process and skills training, to effectively actively engage patients in the care process. 

Today, we are leading this emerging HIS segment called Interactive Patient Care (IPC). Every day, we are humbled to work alongside leaders at the Adventist Health System, Catholic Health West, Children’s National Medical Center, Christiana Care, Henry Ford, Thomas Jefferson University, and Poudre Valley Health System, the 2008 Malcolm Baldrige National Quality Award Winner. Their commitment to patient-centered care energizes and inspires our work. It matters, and it works.

We developed a patent-pending workflow engine called Patient Pathways. Patient Pathways leverage existing clinical workflow and HL7 interfaces as triggers to directly engage patients in the care process via their in-room television.

For example, a physician entering a Coumadin order via CPOE triggers a Medication Teaching & Pain Assessment Pathway via GetWellNetwork. Consequently, the system prompts a patient while watching the Oprah Winfrey Show, provides critical education on this high-alert medication through an interactive video, and then tests the patient on comprehension through a series of on-screen questions. The Pathway concludes by documenting the education results back into the EMR and alerts clinicians in real-time if the patient fails to complete the education. In another example, a Discharge Pathway guides patients through a series of activities, including a patient checklist and the ability to order discharge medications from their bed.

In summary, GetWellNetwork is a patient care tool, automating and hard-wiring critical service and quality tasks for nurses and providing an exceptional, personalized care experience for patients and families.

And yes, GetWetNetwork patients can also watch movies, send instant messages, surf the Internet, and play video games until they break every record imaginable. So we do entertain patients as well. Entertainment can be quite a powerful healing tool for patients and families.

Hospitals are struggling with reduced utilization and lower payments. How can you help them?

Alongside our hospital partners, we are measuring the application’s impact on HCAPHS scores, Core Measures, and preventing "Never Events" such as falls and hospital-acquired infections via patient engagement. As the transparency of service and quality data increasing rapidly, pay-for-performance systems and value-based benefit design are gaining significant traction. Top performing hospitals will continue to attract the best physicians, best nurses, best staff, and best patients. 

Over the past 18 months in particular, our hospitals are seeing exciting movement in their HCAPHS and Core Measures where we have implemented a focused Patient Pathway. In addition, we are also seeing encouraging indications regarding patient engagement on reducing cost per case. In 2009, we are investing quite significantly in research regarding the efficacy of patient engagement on outcomes, with heavy participation from our client community. It’s an exciting time.

Early in-room applications had facilities challenges, such as replacement of TVs, concerns about suitability of keyboards or other peripherals, and the need to rewire patient rooms. What’s required to install your products?

As one of the first companies in the Interactive Patient Care market (since 1999), we were among those applications the facing  the facilities challenges you mention. Through significant blood, sweat, tears (READ: lots of mistakes, frustrated early clients, and significant R&D expense), our engineers and supplier partners have created proprietary and cost-effective ways to implement Interactive Patient Care. Today, we are relatively infrastructure (wiring) agnostic and can run the system in old buildings on coaxial cable alone and, of course, on Ethernet where available. In both cases, digital video streaming and full Internet browsing has been integrated into the application. 

As for peripherals, today we offer a pillow speaker device that interfaces with all major nurse call systems and a fully-sealed keyboard for under $40/unit. This year, we will be launching a next generation keyboard that will finally make Internet through a patient room television as elegant as being on your laptop or desktop at home or work.

You’re working with Florida Hospital on their "Hospital of the Future." What elements of that do you think are important?

Late in 2008, we were chosen by the Adventist Health System as the exclusive provider of Interactive Patient Care throughout their organization. Since then, several facilities have contracted for GetWellNetwork, with one of them being Florida Hospital, where projects including their new Ginsburg tower as well as the Disney Hospital for Children @ Florida Hospital. 

The top three elements of success with Interactive Patient Care are 1) executive sponsorship to provide strategic outcomes priorities; 2) integration with EMR (they use Cerner, which we successfully interfaced with at Christiana in ’08) to provide triggers for our Patient Pathways and a place to document patient activity for compliance automation; and 3) nursing engagement. 

When nursing leadership embraces Interactive Patient Care as a tool vs. a task, the impact is powerful on their service, quality and safety initiatives on the floors. Florida Hospital is highly engaged and committed to setting a new standard in patient-centered care. We of course are thrilled to contribute to their vision for patient care.

Are hospitals getting better at involving patients and family members in their care?

Yes, they are. But, it’s hard work, takes a genuine commitment and accountability, and does not happen without strong leadership. On November 17, 2008, the National Quality Forum published their National Health Priorities and the first one listed was patient and family engagement: ‘PRIORITY STATEMENT: ENGAGE PATIENTS AND THEIR FAMILIES IN MANAGING THEIR HEALTH AND MAKING DECISIONS ABOUT THEIR CARE.’ So, hospital leaders are listening and they are acting. 

Of course, this does not happen overnight, and the technology, applications and interfaces are perhaps the easy part of the equation. Interactive Patient Care is a commitment, and when hospital leaders make the commitment, their patients and families are winning. Hospitals are experiencing fairly spectacular improvements in satisfaction, quality, and operations measures that have been difficult to move the needle on in the past.

Lastly, keep up the great work on HIStalk … it’s simply terrific! Thanks for having me.

Monday Morning Update 1/26/09

From RSNA Body: "Re: RSNA. Don’t believe this RSNA whitewash about attendance. These were pre-attendance numbers — wait for the audited RFID traffic numbers. I was there and, for the first time, there were hardly any lines for anything. I spoke to cabbies, bus drivers, restaurateurs, vendors, etc. who all reported thin crowds. One cabbie asked me on Wednesday if the radiology show was over because he said the traffic was so light. Several vendors told me that a number of hospital customer contingents had cancelled their RSNA trip or only sent a few rather than the scheduled dozen or so staff. With IT vendor layoffs since November and a worsening economy, I predict a huge decrease in HIMSS attendance." You’re probably right. Conferences, like sports venues, have been known to report big attendance despite obviously empty seats.

From Eclipsys on the Ropes?: "Re: Eclipsys. I understand that McKesson just took another revenue cycle customer away from Eclipsys: ‘Baptist Healthcare System Selects McKesson to Optimize Physician Revenue.’ Can you verify this for your readers?  If so, it seems like Eclipsys is in a certain death spiral. Also, the client that represents 10% of the ECLP revenue is probably North Shore Long Island Jewish since they have both outsourcing and software." I’ll have to call in a lifeline on that because I have no idea. It’s the Baptist group in Kentucky that contracted with McKesson for physician revenue cycle management. I don’t recall hearing anything about Eclipsys there, but it may well be. Update: the group is not an Eclipsys customer, so the reader’s understanding is incorrect (to the other reader who said my facts are incorrect, they aren’t my facts: the blue text is a reader’s question; my answer in black text was "don’t know, never heard of ECLP being there.")

From I’m Just Saying: "Re: Eclipsys. The 10% of revenues client may be Baylor. Also, expect more layoffs this week in Services. One VP resigned in December (J. Bell) and two others were termed last week (B. Pille & D. Tom). J&J could be a good answer."

HIMSS is not too many weeks away. I haven’t come up with any HIStalk-related activities yet since I’ve been swamped, but we’ll have some HIStech Report interviews coming very soon. The conference was awash last year in Fake Ingas, HIStalk shoeshines, badge ribbons, the big bash, and probably stuff I’ve forgotten (like that $1,000 worth of tote bags I bought – is anyone still using theirs or did I waste my money?) I’m open to ideas from vendors on anything that would be cool for readers.

A Georgia family puts everything they own except their house up for auction on eBay to pay the medical bills of their children, a 7-year-old with an autoimmune disease and another with autism.

HHS announces acceptance of HITSP interoperability standards (warning: PDF) that took effect January 16. Complete list here.

Jobs: Sales Account Executive, Northeast, Director of Channel Sales, Epic Clinical Reports Writer, MEDITECH Consultant – Advanced Clinicals. Sign up here for a weekly jobs blast.

Speaking of jobs, several folks at Eclipsys lost theirs this week, which I reported as a rumor on Wednesday. At least 100 have been shown the door, a couple of folks say, and the purge may not be over yet.

And speaking of layoffs, Children’s Hospital of the King’s Daughters (VA) laid off 28 employees on Friday and also cut 90 unfilled positions. It’s also shutting down its child care center. Mike e-mailed about Alegent Health (NE – Immanuel Medical Center pictured above), which laid off seven VPs this week and will eliminate 285 more positions by March. It also forced 20 senior managers to take a 10% pay cut.

And more layoffs: GE Healthcare dumps an unnamed number of employees in Burlington, somewhere between 8 and 39 given their sketchy announced percentage range. The staggering giant has never been forthright about its cutbacks in the old IDX office, probably due more to smothering bureaucracy rather than intentional obfuscation. Kind of like when Jeff Immelt put on his happy face about GE Capital while the rest of the world (me, anyway) proclaimed loudly that the company could not possibly avoid fallout from the financial sector meltdown. Let the record show that Jeff was way wrong: GE’s Q4 numbers announced Friday after the market close showed revenue down 5%, EPS $0.35 vs. $0.66. GE Healthcare’s profits were down 9%. The stock dropped nearly 11% during Friday trading and is down another 11% after hours.

And even more layoffs: NorthShore Skokie Hospital (IL), 150; Frankford Health System (PA), 100; Hamilton Health Sciences (Canada), 250; Irvine Regional Hospital and Medical Center (CA), 510.

Intel’s chairman Craig Barrett will retire in May. He’s been loud about healthcare and technology (I quoted him in July 2007), so maybe we’ve not seen the last of him.

Two PricewaterhouseCoopers executives in India are arrested and charged with conspiracy for the company’s role in signing off as auditor on the books of Satyam Computer Services, whose chairman admitted that $1 billion of claimed cash didn’t exist. I mostly associate PWC with dumb names: its own and the one it announced for its consulting organization in 2002, "Monday," which thankfully never happened because the company sold the whole organization to IBM just five months later.

The State of Massachusetts signed a big mandatory EMR law in August with $25 million a year in funding to get doctors online by 2015. The state cut the budget to $15 million two months later, which everybody agrees is far short of what’s needed to get the job done. Also agreed, judging from the comments, is that not much benefit has been derived so far.

Another victim of Bernie Madoff’s Ponzi scheme: Charleston Area Medical Center (WV), whose foundation lost $800K and the hospital $200K.

McKesson CEO John Hammergren gets his name and picture in The Wall Street Journal, although it’s hardly a flattering mention. The article addresses the methods companies use to calculate executive pension value into a single lump sum payment, with some using an obsolete federal formula that boosts the number as "a sneaky way to give executives larger pay." McKesson tweaked the formula for Hammergren last March, jumping his parting gift’s value to $85 million (everybody’s outraged about healthcare costs, so you might think that would raise an eyebrow or two).

Former QuadraMed CEO Larry English gets a new job as CEO of CIFG Holding, Ltd., a Bermuda-based holding company running a French bond insurer recently bailed out after getting burned on derivatives.

Think we’ve got healthcare challenges? Malawi has 14 million people, of which 1 million are HIV positive, and only 280 doctors. Their answer: treatment protocols managed by non-physicians using touch screen clinical workstations (developed in Ruby on Rails) at the point of care. Scroll down for several YouTube demos. It would never work here, of course, because vendors couldn’t load it down with proprietary bells and whistles to boost the price. Still, you have to like this quote extolling the virtues of designing systems to take the use through a consistent, guided function (which I always argue in saying that charting a med should be as easy as the import wizard in Excel): "If the system is useful, then other people want to use the system. This is a nice problem that gets solved with…training! But soon, the developer notices that users keep using the system in a way that was totally unexpected. Time for another training session… But there is another approach that doesn’t rely on training. They are called constraints … The amount of training required is usually inversely proportional to the number of constraints in the system.."

Two sides of a Connecticut hospital’s proposed health information exchange. Pro: the hospital is raising money for the $8 million project and hopes the federal government will pay for it while it’s slinging money around. Con: the president of the state medical society says the government shouldn’t pay because mandated physician usage would just make the state’s doctor shortage worse because they’d steer clear of Connecticut.

Debbie Turpin, clinical systems manager at Alton Memorial Hospital (IL), is named chief nurse executive.

Odd lawsuit: a mentally disturbed female prisoner is taken by corrections officers to a hospital for psychiatric treatment, where she "went berserk" and bit the nurse’s hand. The officers watched and did nothing, later saying they believed it was outside their jurisdiction. The nurse is suing the city.

E-mail me.

News 1/23/09

From Dr. Yes: “Re: athenahealth. Because of the big deal Athena did today, Jonathan Bush was just on CNBC. He was almost as funny as he was at your HIMSS party. The guy is truly charismatic. I’ll bet the stock goes wild.” The company bagged a big win today, signing University Hospitals of Cleveland (450 doctors) for revenue cycle services. The stock was actually down around 1% today even with the early morning announcement, but the market was down overall.

From Clarence Trauma: “Re: Orlando Health’s Web site. Are women are not adults, or possibly in this politically correct world, are men are no longer referred to as such, but rather addressed merely as Adults? Or, based on the cozy couple next to the Adults button, maybe they’re tapping into the XXX market.” I’m not a fan of the pinkish-red design, I’ll say that. The marketers have been allowed to run amok, obviously, given the biggest headline on the page: Learn About Our New Brand. Your Brand is like your high IQ or dynamite sexual prowess — don’t yap about it constantly; let the few people who care arrive at that conclusion themselves.

From Shawn Spencer: “Re: Tom Skelton. Going to work at MED3OOO, supposedly, maybe to run sales and work up from there. There’s a Pittsburgh connection and some former Misys people at MED3OOO.”

From Songbird: “Re: Hayes Management Consulting. They reportedly laid off consulting staff this week.” We have a contact there since they’re a sponsor (Pete Butler, president), so Inga asked him. “It is always interesting to see how rumors can get blown out of proportion. On January 13th Hayes did make a 7% reduction in force. Some segments of our business are exhibiting significant growth while other segments have slowed due to vendor slowdowns and market conditions. We continue, however, to hire selectively in areas that we have identified as growth areas for Hayes. As the unprecedented economic uncertainty continues to challenge the healthcare industry everyone is being compelled to make adjustments. We consider ourselves fortunate that our adjustments are small relative to those of the industry. We credit this to Hayes’ history of being a well run company that has grown prudently over the years. In 2008 we experienced 15% revenue growth over 2007. We expect our revenues to continue to grow in 2009 including in areas of federal initiatives in Health IT. We remain committed to building long term trusted relationships and we look forward to continuing to serve our clients for many years to come. Honestly Inga, this was a difficult action for us to take and one Hayes has never taken before. We consider all of our employees close members of the Hayes family yet we need to remain good stewards of this company in these challenging economic times. We have a confident outlook for 2009 and continue to experience growth as we kick off this New Year.” Hayes runs a good shop and is #1 in KLAS in overall services, so you can bet it’s not just them. And if you know which areas they pruned back, you’d also know which systems vendors are struggling since it’s a direct relationship.

From Mr. G: “Re: Eclipsys. According to MorningStar analysts, 40% of Eclipsys’ revenues are attributable to the 20 largest clients. One client represents 10% of revenue. Does anyone know who this client is?”  

From Carol Dedmon: “Re: Jeff’s comment. Jeff is a sourpuss – the whole freaking world is celebrating a new beginning and our industry is hopeful of renewed energy and investment. He slaps you down with a ‘mind your knitting’ remark. Jeff left a curt comment on Tuesday’s post saying he was tired of the Obamafest (his word) and that only political pundits should discuss such sensitive topics like the inauguration. I compared Obama’s speech to Jimmy Carter’s, so I figure Jeff was sniping at a brief Inga mention since she’s gushier than me. Well, no hard feelings. At least I found someone even more cynical than me.

From ORISpilot: “Re: Alert. The president of Alert Life Sciences publicly berates the executive sales team from North America for low Q4 sales in front of a large crowd at its annual retreat in Portugal. Staff are being let go.” Unverified. They made a big splash at HIMSS in 2007, but I haven’t heard a word since and had completely forgotten about them. I don’t see anything about US customers on their site, which claims $34 million in 2007 sales but no 2008 number yet. I remember it as being exceedingly cool, but the US is a tough market to crack from Portugal. Or here.

From Spencer Haywood: “Re: HealthVault. I signed up for Microsoft’s HealthVault and starting playing with it. You can enter e-mail addresses to give others access to your records. You can choose spouse, domestic partner, … and pet. Good thing my cat signed up for Gmail last week. Not on the list: provider or physician. Guess my cat needs access to my record more than my doctor.”  

Listening: Fiction Family, brand new duo pop, not my usual cup of tea, but some nice hooks. One guy’s from Switchfoot, the other from Nickel Creek (for bluegrass fans like me). 

Not available in Hallmark stores: e-cards that allow people to anonymously notify sex partners that the sender has a sexually transmitted disease. Noting that gay men often exchange bodily fluids but not e-mail addresses, health departments are also setting up profiles on gay Web sites as an outreach. I don’t know how well it works, but it’s certainly worth trying.

HISsies voting. Be there. Thanks.

You may have noticed that industry news is picking up quite a bit, as is HIStalk readership (keeping me extremely busy). If you don’t get the e-mail updates, you might want to sign up over there to your right. That list is up to over 3,500 confirmed, active subscribers, so everybody will be walking around knowing stuff you don’t if you don’t sign up. It would be cool if we hit the 2 millionth visit by HIMSS, but I’ve counted on my fingers and I don’t think it will quite make it. Still, I’m staggered to have that many folks reading, so thanks much for that. I’m really honored by the number of people who e-mail nice comments and tell me how important HIStalk is to them (Mrs. HIStalk isn’t one of them since she feels she’s been denied my consort, but I’ve tried to explain the whole HIT thing and she just glazes over).

Eclipsys shares hit a five-year low after the company announced low Q4 preliminary earnings yesterday. Shares closed at $8.01, down over 29%, giving ECLP a market cap of just $438 million. I don’t get the primary excuse, that customers planning to go with a traditional license purchase decided to take a subscription license instead and therefore delayed revenue. First, ECLP must be offering bad subscription terms if customers were even considering buying a license instead of stretching out the payments by subscription. Second, the company has always said that the subscription model would provide a nice recurring income stream, which still isn’t clear after all these years. The good news for them is that Cerner doesn’t seem to be making any new sales, but the bad news is … well, Epic’s everywhere you turn, especially when your product line is limited. ECLP has made some nice acquisitions in MediNotes and EPSi, current management is better than the old regime, and the yearly numbers still look good, so here’s my impression: the company needs to fix some problems, but this may just be the first wave of bad news when it comes to the big iron boys whose only customers are cash-strapped hospitals.

Maybe J&J will  buy them. Drug maker Johnson & Johnson is not expecting a great 2009, but is still looking to pick up some acquisitions that have had the wind knocked out of their sales (pun intended) by the recession. The CEO says he’s especially interested in healthcare information technology and wellness and disease companies.

More layoffs at GE’s Burlington office. Songbird had tipped me off that it would happen yesterday and he or she was right.

I heard (indirectly) from a consultant who just lost his ambulatory EHR consulting job after the main vendor his company supports (I won’t name them, but they’re big) had major product issues, causing users to put upgrades on hold, which dropped the demand for consultants. His employer was small, so they didn’t have the resources to cross-train people on products with a higher consultant demand. The person who passed his message along is considering dropping that same vendor’s product and moving to another vendor, possibly eClinicalWorks.

Some Houston fans of open source software in healthcare are holding a July 31 weekend conference, promising good speakers and some cutting edge companies. Only $60 if you sign up stat.

Microsoft was to have laid off 1,400 people Thursday, the first wave of an eventual 5,000 jobs cut in the company’s first-ever layoff. Q2 profits were down by 11% and the company declined to forecast earnings for the rest of 2009. Also announced: travel budgets have been cut, salaries are frozen, and physical expansion of the Redmond campus has been scaled back. Shares were down almost 12% today, dragging the entire market down with them.

Microsoft’s arch-competitor Google did a little better, maybe. The company just announced Q4 numbers: revenue up 18%, but earnings were down 68%, the first time in the company’s history that earnings dropped. It, too, laid off employees, but just 100, and also wrote down most of its $1.5 billion investment in AOL and Clearwire. Cost control was obviously excellent. Shares are up.

A fire broke out at Mount Sinai Medical Center (NY) Thursday, forcing the horizontal evacuation (my HEICS training shines) of 600 patients. Flames were visible from Madison Avenue, but the fire was contained to a mechanical room and was put out with no injuries reported.

Internet inauguration watchers overloaded the network pipes at University of Kansas Hospital (KS), causing patient records to be unavailable for around 30 minutes. An e-mail was sent telling employees to get off, which apparently worked.

TriZetto’s CEO says that government and payers are going down the wrong road with EHRs. “For example, the new Obama administration is promising to spend a good portion of a $50 billion investment with physicians to adopt EHRs and the infrastructure to share them. But, those plans indicate that many in Washington are overlooking a faster, far less costly path to ubiquitous PHRs. Health plan information systems are the single richest repository of comprehensive diagnostic and treatment data and benefits information in the entire U.S. healthcare system. Both government and payers are missing a key opportunity.”

St. Clare’s Health Services (NJ) fires five VPs so the CEO, who’s been there since last May, can bring in his own people. He told employees that operational changes are being considered, but a source tells me that hundreds of employees will be laid off in the next few weeks.

Thanks to Barbara Benson, a reporter for Crain’s Health Pulse and Crain’s New York Business, who e-mailed me to let me know that she had written about NYU’s $186.4 million Epic project. Having run across it while researching the state’s certificate of need records, she checked HIStalk to get some background (it was reported here back in July by Motown HITman and Mad Man). They told her that Eclipsys Sunrise won’t go away, which seems highly unlikely. Here’s what Mad Man said then: “I have heard, from multiple sources, that NYU is moving off of Eclipsys to Epic because Epic provides a comprehensive (i.e., inpatient, ambulatory, physician EMR) solution where Eclipsys XA does not. I find this very interesting since NYU just went live with XA to much hoopla in the trade papers. The system move has caused a lot of chaos in the NYC Eclipsys office.”

John Glaser gets a Wall Street Journal mention in a political story about the economic stimulus. He warns that trying to spend a bunch of federal healthcare IT money too fast may be wasteful and counterproductive, especially if systems are slammed in without regard to the needs and work flow of users. I agree, but Uncle is looking for some fast spending, so here’s a question: if you were doing the disbursing, which projects would you choose that would require hiring lots of people, have good oversight already in place, and are ready to provide near-immediate return on investment?

I think Marshfield Clinic CIO Bob Carlson agrees. In Part II of an excellent interview, he says, “Implementing an EMR can be a very dangerous thing. There are studies that show that given the complexity of healthcare, it’s easy to miss steps in processes and delay important information; in essence, instead of a positive impact on healthcare, if done wrong it may actually be a step backward. That being said, EMR is the first step toward moving healthcare where it needs to go. Once you’re in the electronic format, now you have the ability to take all the tools, the technology, the intelligent assistants, the data mining and trend analysis, and the outcomes and start bringing them to bear where the rubber meet the road – at the point healthcare is being delivered.”

An audit of California’s prison medical system finds that $27 million in technology contracts were issued without legally required competitive bidding. One IT manager was fired in June for being involved, although there was no evidence that the prices were out of line or that employees benefited.

RSNA 2008 did OK considering the economy, with attendance, exhibitors, and exhibit square footage down only in the single digits. Will HIMSS be so lucky, especially since they’re in Chicago for the first time, in April instead of February, and starting on Saturday?

Hospital layoffs: King’s Daughters Medical Center (MS), 21; Memorial Medical Center (PA), 47; Providence Saint Joseph Medical Center (CA), 94; Blue Hill Memorial Hospital (ME), 15; Excela Health (PA), 70; Butler Hospital (PA), 18; Southcoast Hospitals (MA), 12; Grenada Lake Medical Center (MS), 14.

Saint Luke’s Health System (MO) adds ePharmacy to its eICU center, scanning physician paper orders to a remote pharmacist for computer entry, which releases the correct meds from the dispensing cabinets for nurse administration.

Duke University School of Medicine gets a $1.25 million federal grant to develop an infectious diseases ontology for Staph aureus.

Cardinal Health fires an employee for refusing to work Sundays, saying they told him he could take off, but only if he arranged his own coverage. The employee, a minister, is appealing to a higher power – Charlottesville Federal Court, where he’s suing Cardinal for religious discrimination.

E-mail me.

HERtalk by Inga

From Mikey Likes It: “Re: LinkedIn photo. Nice shoes.” So far I have made it a week with my contraband LinkedIn photo. I have the same kind of feeling I did when a bouncer would let me into a bar, even though I was underage. (Geez, I hope my mother isn’t reading this.) I see the HIStalk Fan Club has swelled to 511 members, so we’ve all got to get together sometime.

In case you missed Mr. H’s recent commentary for Inside Healthcare Computing (The Obama-HIStalk Digital Stimulus Grants: Why Letting Me Hand Out the Freshly Printed HIT Cash Makes Sense), he is angling for the chance to hand out $20 billion of economic stimulus money at HIMSS. Personally I think his approach makes as much sense as anything else we have seen recommended so far. Plus it might help boost conference attendance (and thus stimulate the Chicago economy, no doubt), I’m thinking if he gets that gig, I will follow behind him and film the whole thing to post on YouTube.

Just in time to train people to on ways to spend all that economic stimulus money, American Sentinel University (CO) adds a Bachelor of Science degree program in Health Systems Management.

AHRQ releases a series of new reports highlighting the lessons and best practices from the recipients of AHRQ grants. The reports focus on the implementation and use of such technologies as CPOE, EHR, and BCMA.

Minnesota’s attorney general sues Allina Health System for charging illegally high interest rates. The lawsuit contends that Allina charged as much as 18% on unpaid medical bills, which is substantially higher that the 8% cap allowed under the state’s usury laws.

The recession and rising unemployment rates creates unprecedented increases in Medicaid rolls. Many states are seeing 5-10% more Medicaid recipients than a year ago. Growth rates have at least doubled from the previous 12 months.

Earlier this week Mr. H mentioned that Haywood Regional Medical Center (NC) named former EDI and McKesson leader Sheldon Tyndall as interim director of IT. Haywood is bringing on a new CFO, Gene Winters, who has served as CFO HCA, Acadia Healthcare, and Transitional Hospital Corp. Haywood made headlines last year following a temporary loss of Medicare and state certification after inspectors found potentially dangerous problems with medication administration. The story included whistleblowers, lawsuits, and a replaced CEO. Tyndall’s most pressing challenge is to complete the hospital’s EMR implementation.

I must confess that when I heard the names of this new Web site, I immediately envisioned some sort of virtual haircut, or at least someone like Vidal Sassoon administering the latest hairstyling advice. Elsevier announces eClips Consult to help physicians identify and assimilate information from professional medical journals.

Highmark Inc. and Independence Blue Cross announce they are withdrawing their merger applications with the Pennsylvania state insurance department. The companies believed the transaction would not be approved because the state insurance department believed it would adversely impact competition.

Precyse Solutions and Ingalls Memorial Hospital (IL) sign a five-year outsourcing agreement. The $4 million deal includes technologies and services to support Ingalls’ medical transcription functions.

Yalobusha General Hospital (MS) chooses a financial system from Healthcare Management Systems for its 26-bed hospital and two rural health clinics.

Partners HealthCare (MA) selects MDsoft’s MetaVision for acute care and preoperative technology. The system will be used at both Mass General and Brigham and Women’s Hospital.

Oasis Medical Solutions, a UK HIT provider, appoints Chris Spence, formerly with GE Healthcare IDX, as CEO.

Anne Arundel Medical Center (MD) implements VISion: Asset Management by Versus Technology, an RTLS solution the hospital is using for asset tracking.

Edward Hospital (IL) successfully deploys InfoLogix for wireless asset tracking.

Clara Maass Medical Center (NJ) selects Axolotl to support its HIE initiative.

Baptist Healthcare System (KY) signs with McKesson to manage the revenue cycles of its affiliated physicians. The deal includes McKesson’s Revenue Management Solutions group overseeing all facets of the physician billing and collection process. McKesson, by the way, was just named the #1 place to work for Six Sigma professionals.

Nuance Communications appoints a new head of marketing for its India operations.

MEDSEEK announces a new Webinar entitled Hope is Not a Strategy: Neither is Web 2.0 for a Hospital.

E-mail Inga.

Are Portals Becoming Obsolete?
By Robert Connely, Medicity

I wanted to add a comment to the question you raised – are portals becoming obsolete? 

From my perspective, it’s a bit like asking the question “Have mainframe computers become obsolete?” The answer is, of course, that they have not. They have gotten smaller and faster, but they’re still in place, doing their work day-in and day-out. By the same token, portals are not obsolete, they’re just not sufficient by themselves to address all of the information needs of an organization like a hospital in today’s world.

I believe that hospitals need to think more broadly in terms of what I refer to as an “information outreach” strategy. Let me explain.

Today’s CIO is faced with a plethora of requirements that they’re charged with addressing, including:

• Providing remote access to physicians that need data that’s often found in multiple systems
• Exchanging information with an affiliate physician’s EMR
• Participating in the sharing of information in initiatives like HIEs or RHIOs

In these three common examples, there is often a desire to use a single technology to address all of them. This is, of course, nothing new. 

When portals emerged in the late 90s, CIOs would say, “I already have a remote access solution – why use a portal”? The answer was that portals made it simpler for physicians to access a broad range of data from a single, personalized view. As advanced features like electronic signature emerged and physicians could perform useful work remotely, the use of portals expanded.

When new technologies like agent grids evolved to push data to EMRs in the early 00s, CIO’s would say, “I already have a portal – why do I need an exchange solution”? The reality is that if you have an EMR, accessing data from the portal is no longer acceptable. Instead, you want the data pushed to the EMR, where it can be viewed alongside other data on the patient collected by the physician.

In the mid 00s when RHIOs and HIEs emerged, CIOs would either say, “I have an exchange solution, so I don’t need the HIE”, or, “I’m planning to join the HIE, so I don’t need an exchange solution.” As we learn more and more about this emerging world, it is clear that the needs of sharing information in an HIE is quite different that those required to exchange data with an EMR. Considerations like identifier reconciliation, local queuing of information if participating in a federated HIE, and others must be addressed by the chosen technology.

Now add the fact that hospitals serve a large number of physicians who are themselves at various levels of technology use and it becomes clear that there will always be physicians who need to interact with the organization in a variety of ways.

Thinking in terms of an information outreach strategy accepts this condition as a fact that must be dealt with to enable the organization to conduct business. It will likely require an array of technologies to address these varied needs. Because, just as you would never play a round of golf with just a putter, why try to use a single technology to address a wide range of information needs that are substantially different? It will only do one thing well, and everything else poorly. I suggest that instead, we think more like a golfer and have at our disposal a broad array of technology “clubs” to ensure that we have the right one for the shot we need to make.

Using this logic suggests that:

• Portals will continue to be useful in addressing the needs of physicians who either don’t have an EMR or want to access inpatient data that they don’t want in the EMR (physicians often elect to not receive inpatient lab tests in their EMR), or to perform workflow functions like signing off reports that are generated within the hospital.
• EMR exchange solutions must be put in place or risk losing business to another hospital or lab that accepts orders and delivers results electronically to and from the EMR. While it’s true that only 17% or so of physicians use an EMR, these tend to be larger, high revenue-generating practices that few hospitals can afford to lose to the competition.
• As HIEs evolve, the CIO may one day be told that the organization must participate in the initiative, which requires new consideration to what it means to “publish” information to the entity or entities (multi-system organizations often are required to participate with many local HIEs). In this case, portals or EMR exchange strategies are by themselves insufficient, and newer technologies that cache data outside of the internal systems must be put in place, with mechanisms to interact with the HIE core that may or may not include Record Locator Services, Master Patient Indices, and the like.

There may come a time when portals finally do become obsolete (for example, I don’t imagine many hospitals still using analog dial modem banks for remote access), but I can clearly see them continue to play a significant, albeit not an exclusive role, in the hospital’s “bag” for many years to come.

Eclipsys Misses Numbers, CFO Resigns, NYU Chooses Epic

Eclipsys shares are down over 17% in after-hours trading following a disappointing Q4 preliminary earnings report. For the quarter ending December 31, 2008, the company expects flat revenue and GAAP EPS of $0.07 to $0.11 compared to $0.45 a year ago. Revenue for the full year is expected to be up around 8%, with full-year GAAP earnings of $1.82 to $1.86 compared to $0.76 for FY07.

President and CEO R. Andrew Eckert called the quarterly results "disappointing," blaming delayed customer closes, a shift to back-loaded subscription deals, reduced customer utilization of professional services, an increased allowance for doubtful accounts for specific customers, and lower margins on third-party software due to market pricing pressures. "Economic factors are affecting our business, and the business of our clients," said Eckert. "In response to this uncertain environment, we are taking actions to adjust our cost structure and business practices." 

Eckert announced that Robert Colletti, senior vice president, CFO, and treasurer, resigned his position on January 14. David Morgan, VP of finance and assistant treasurer who joined the company in August 2008, will assume those roles in an interim capacity.

Meanwhile, an article published Wednesday reports that NYU Langone Medical Center will purchase a fully integrated clinical and patient financial system from Epic Systems Corp. with a total project cost of $186.4 million. The hospital installed an inpatient system from Eclipsys in 2007, but says it will be enhanced rather than replaced.

Unverified rumors reported to HIStalk today suggest that Eclipsys may reduce professional services headcount and announce the discontinuation of bonuses and merit increases for employees later this week. 

An HIT Moment with … Michael Christopher

An HIT Moment with ... is a quick interview with someone we find interesting. Michael Christopher is CTO and senior development analyst with Healthcare IT Transition Group.

Healthcare Transition Group has an interesting mix of reference, educational, and consulting products. Give me a short summary of your offerings.

When we put together this new version of our company three and a half years ago (we had been set up as a straight consulting operation for about ten years before that), we had all this on-the-ground expertise in healthcare IT, software development, and capital development, but we wanted to start creating scalable products. Billable hours are about the least scalable business model on the planet, next to maybe cattle ranching.

The kinds of research and analysis we had been doing for clients seemed to fit nicely into packaged business intelligence products, comprised of documents, tools, and video of us splainin’. Consulting had always been mostly about learning and teaching, and now the videos teach what we’ve learned from all those gigs. And instead of paying us $20k over several months, our customers can order a package for a few hundred bucks and have it now. It’s way more scalable and frees us to go out and find fresh heroics to get up to. So far we’ve done "BI Packs" on real-time adjudication, getting ROI from HIT, funding, and various topics related to maximizing reimbursement, including one on the new Denial Engines.

To support that, we began to grow a media side. We had been doing the HIPAA Transition Blog since the birth of the HIPAA era, so we renamed it HIT Transition Weblog and developed some related channels. We started doing lots of Webinars and developed a complete media studio.

Then it was time to leverage our NPI and NPPES (National Plan and Provider Enumeration System) chops and all that new computing power to expand into data products. We had done NPI remediations, working with the official enumerator Fox Systems and others, so we knew some ropes that maybe hadn’t dawned on everybody yet. Like greasing your 837s to glide through adjudication and maximize reimbursements by updating your NPPES record with every legacy identifier you’ve ever used (taxonomy codes, UPINs, Medicare PINs, OSCARs, license numbers …) 

You’ve written extensively on funding for RHIOs and other IT projects. What are some creative ideas that most people haven’t figured out?

Taken together, our backgrounds are split between in-the-trenches HIT implementation, software development, and capital development. I owned a software company in the early ‘Naughties that built finance and constituent management applications for the human services sector, so then I got to do it all at once, develop the software, implement it, and the raise the money for the company (and for our customers, too). A large part of my finance side has been with nonprofit organizations, as executive director, director of development, or marketing VP, and as a consultant in fundraising. So RHIO made immediate sense to me and I started following it very early on. Marty Jensen, our COO, suggested the initial study. We did the first deep analysis on RHIO business models and funding sources based on the RHIOs’ own data, and updated it a little over a year later. We’re considering whether and when to revisit that research in light of changes in mission at the federal level.

What we found and reported was actually shocking. Nearly all RHIOs are constituted as nonprofit organizations under the IRS "charitable" rubric. Logical, since they are in the business of doing public good. But only two of the fifty RHIOs we studied had developed private foundation grants. All but one in our sample said they plan to be self-sustaining through earned revenues, but more than 80% said they expected to rely on grants into the foreseeable future.

Doh! Where do they expect the money to come from? One word: Government. No, three more words: And Big Hospitals. Private philanthropy is responsible for the vast majority of the money for public projects in this county, a 180 flip from Europe and elsewhere, where government has that task. So it made no sense to us: here was this nascent public good looking only to government and its members for its survival while leaving vast quantities of philanthropy untapped. RHIO leadership still seems frightened of the word "fundraising." That’s what drove us to create the Health IT Grant Resource Directory. As far as we know, it’s the one resource that will take you directly to the prospects for private involvement in health IT funding.

I recently sat on a panel with Jack Anthony of Beacon Partners and Cheryl Austein-Casnoff of HRSA to hopefully give the industry some guidance on health IT funding in light of the new Administration. They asked me to talk about strategies, so I picked two: the "Study/Meet/Case" method of capital development (don’t Google it, I made up the name) and vendor Grant Assistance Programs. The latter is where a vendor develops the fundraising/grant writing resources on behalf of its customers so they can buy their systems.

You are doing some interesting work to make actionable data available to providers for billing and for targeting service opportunities. What products have resulted and what ideas do you have for the future?

Two product lines here: NPIdentify Desktop Provider Directories and CarePrecise Data Services. NPIdentify is available as a free download and it looks like it’s starting to go viral. The idea was to put state-by-state NPPES data in a fast, cool application that would fit on your own computer and that your average non-technical office manager would find user-friendly. But since just anybody can download it, NPIdentify is being used across the industry in practice management, health plans, marketing, and even scientific research. You would not believe the customer list. We figured out that we can sell ads (hint, hint) for mad money.

The newest line, CarePrecise, is just now starting to roll out in tests. It will leverage our provider experience, software and data management, and research assets to offer not only provider data sliced and diced for various systems and applications, but also to pull business intelligence out of it. Let’s say you’re planning a clinic expansion. What specialties will thrive there, and which will shrivel? Where should you site a new group practice based on a given stable of specialties? Or if you want to reach a particular underserved population, we can map where they live. We’ll be rolling these out as standard products over the coming months. One product, CarePrecise Access is already available. It’s the complete, huge NPPES database in a form you can easily manipulate on a laptop in Microsoft Access. Way cool for people who want to develop their own products.

Give me some predictions on the healthcare IT industry for the next 1-3 years.

When the numbers start flooding in on IT-driven patient safety and more effective care that go hand-in-hand with cost reductions and revenue increases, we’ll see a rapid expansion in our industry like little else that’s gone before. I would be the first to agree that there’s plenty of evidence here already, but it has yet to begin steering the provider zeitgeist like it will in a year or two.

We need to make better arguments for health IT. Actually, we need to learn how to argue all over again. Health IT has never enjoyed the same focus as that new MRI, and now that could be changed. Sitting in the hospital basement all morose about how we’re being treated like the light bulbs never got us anywhere. We need to organize, bone up on regional strategic initiatives in healthcare, get to know all the players and make them know us, and hit the ground. I want to see a poster that says "HIT Workers Unite: Take It To The Suites!"

I think if I say the "I Word" one more time, I should have to wash my mouth out with soap. But the babble of interfaces and other short-sighted proprietary interests are still the huge barrier to adoption of HIT. Systems that can talk to one another fluently should be the simple, no-excuses objective. Cooperation, or coopetition, needs to be the deep green valley for all our roadmaps in this space. Everything we build needs to plug into what everybody else is building. Whether you are an open source fiend or not, I think that open sourcery, and especially FOSS, is drawing the maps right now, and you really have to look at them.

The NHIN seems to be stirring awake with the recently announced SSA application. RHIOs won’t look the same in a few years, but there will definitely be a network of essentially egalitarian, provider-agnostic information exchange that starts winning goals (i.e., reducing medical errors, containing costs resulting in expanded access to care, and boosting profits across the board) on a game-changing scale within three years. And there will also be rapid growth in proprietary exchanges — possibly faster than the community-based RHIOs — as we watch the technology fragmentation get sorted out. We might see those perceptions of maturity shift enough within a year to start looking for a few hockey sticks on a two- or three-year horizon. I’d like to promise more, but our most recent RHIO data suggest that the dollar size of the RHIO vendor space is still in pancakes.

What’s it like working for a small, agile company and what do you do for fun?

I never want to work anywhere else! … unless the money’s right. Seriously, at HITTG we can be basically autonomous, sprouting new stuff that we see as a need in the industry whenever we like. And when we get opinionated about something, we can just say it out loud; I don’t need to scream at anybody (although that can be fun!), I just make an animated cartoon when I need to vent about HealthVault and the patient privacy folks. Or I draw a comic. Now that we’re shifting to these really scalable products, I can also see a heavier consulting load, and maybe we, too, like our friends in the financial industry, can become as obscenely wealthy as we were truly meant to be.

Never been to the Googleplex, but we’ve decided that our corporate culture must be a lot like Google’s, only a little bit more compact for now.

News 1/21/09

From The PACS Designer: "Re: Microsoft Photosynth. TPD has been experimenting with Microsoft’s Photosynth and its 3D capabilities for photo collections. It appears to be a nice way to enhance the photo experience after using your digital camera. It could enhance your photo skill level and at the same change your perspective on creating better photos. Once you download Photosynth, you’ll have to reboot your system to activate the software and also obtain a Windows LiveID before you accessing the application." Link. It takes a bunch of digital pictures and turns them into something like Google Maps Street View, from what I can tell, allowing you to navigate around by clicking arrows (but obviously without a BIG bunch of pictures, you’re just jumping around jarringly). Maybe the technology could be used to create 3D images from plain old X-rays.

From Dillinger: "Re: medical weblog awards. How could Medgadget not even have HIStalk listed as a nominee in the informatics category?" Beats me, but I’ve long ago figured out that blogs giving other blogs awards is nearly always a ploy to get traffic to their OWN blog, hoping nominees will send their readers there to vote. HIStalk has been around since June 2003 with quite a few readers, so I’ll satisfy myself with that accomplishment more than having some other blog declare me a winner.

From Elsie EHR: "Re: TV knee-slappers about Jonathan Bush being the President’s cousin. According to a Chicago Sun-Times article, he and Barack Obama are 11th cousins." Link. The only good thing is that since their last names aren’t the same, it will sail right over the talking heads. That makes two reasons to be grateful that his first cousin has joined the ranks of the unemployed.

From Webbed_feet: "Re: OHSU. Article on the layoffs and IT restructuring." Link. Oregon Health & Science University will eliminate 60 of 400 IT jobs and reclassify another 80, giving employees the pure joy of interviewing against their peers to see who gets to stay on the payroll. The union representing IT (who knew?) claims the university just wants to change the employees from hourly to salary to avoid paying them overtime and differential.

From Microsoft Guy: "Re: dabbling in healthcare. You were puzzled about the value the Senate and NRC place on Microsoft’s input on healthcare IT when we’re ‘dabblers at best’ but then highlight the work we’re doing at MD Anderson a mere half-page later." I don’t know that selling a hospital copies of Visual Studio and Windows 2000 (!) qualifies the company to pontificate to Congress on lifelong wellness, healthcare reimbursement, and appropriate IT investments. All those millions of physicians, informaticists, nurses, management engineers, and healthcare executives out there go unheard so someone who’s never worked in healthcare can advise Congress on healthcare reform? That’s somewhere between arrogant and preposterous. Dabblers like Oracle and Microsoft pop in every now and then as the healthcare market opportunity looks more or less lucrative (see: Healthcare Transaction Base and Amicore, respectively). The rest of us have been here all along.

Obama mentions healthcare IT in his inaugural speech: "We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost." He gave a stirring, impressive speech (pretty similar to that of Jimmy Carter, in fact, so caveat emptor). The campaign and the fanboy fawning are over, so now he gets judged on actions just like his predecessors. I’m cautiously optimistic so far.

HISsies voting is now open. Thanks to those who nominated the slate you’ll see (some no doubt motivated by the not-so-subtle urging of their employer). Anyway, use your inaugural enthusiasm to get your participative democracy on. The future of The Pie is in your hands.

Jobs: Senior Application Analyst (Sibley Memorial Hospital), Clinical Pharmacist (MedVentive), Chief Applications Officer (Snelling Executive Search), Chief Technology Officer (Snelling Executive Search).

We’re finding a comfortable voice for HIStalk Practice, including regular interviews with private practice physicians and industry experts. We’re up to 300 or so subscribers and a few thousand visits, which isn’t bad for our first couple of weeks. Sign up there for e-mail updates if you follow the EMR market. We’ve already filled our two Founding Sponsor slots there and also added some Platinum ones, so we will announce those shortly. Thanks to everyone supporting us there by reading, commenting, and writing – like the early days of HIStalk, it takes awhile to build up a readership.

Have physician portals become obsolete just as hospitals finally get them up and running? Robert Connely of Novo Innovations (now Medicity) said so when I interviewed him in 2006: "If you’re a doctor with an EMR, you don’t need a portal. In fact, you hate the concept. You want to see the data in your own system … Your physicians are bringing on EMRs and you need another way to get data to them." Stephanie Massengill says pretty much the same thing in a new article: "It seems the time for portals has waned. The marketing value of them is dubious, as the physicians have found that always seeking information is time consuming and, therefore, have stayed away in droves." Not that you need a third opinion, but here’s mine: portals are exactly what you would expect hospitals to have come up with given that they see themselves as center of the data universe, in charge of the conversation with physicians, and pleased to offer a solution that could be checked off as mission accomplished while missing the mark completely when it comes to physician workflow ("if you want to use the data in our systems to help our shared patients, even though it doesn’t benefit you or your practice personally, dial in and look it up yourself, make a copy or manually enter it into your own system, then repeat for each competing hospital in which you practice.") Portals were a good 1.0 stopgap and surely will continue to provide patient value, but for the ever-increasing number of practices with an EMR, better integration tools are available than that busy guy or gal wearing a stethoscope.

Just in: HIMSS announces the winners of its industry service awards. Pat Skarulis of Sloan-Kettering is CIO of the Year, Rosemary Kennedy of Siemens wins the nursing informatics leadership award, and Brian Jacobs of Children’s National is named for physician IT leadership.

Consumers are interested in personal health records … or do actions speak louder than words? A new report (which I’m not about to pay for, so I’m citing only the press release) says that only about a tenth of those people who claim they’re interested are actually using personal health records. Not surprising: if you believe self-reported consumer surveys, Masterpiece Theater is the most popular show on TV instead of innumerable morgue yarns and junk reality TV.

Sheldon Tyndall is named interim IT director at Haywood Medical Center (NC). He used to be at West Georgia and McKesson.

Danbury Hospital announces HealthLink, some kind of RHIO/HIE. Seems like the lawyers should be all over that choice of name since it’s been used about a zillion times.

An interesting article in The New Yorker (thanks to SQL_Goddess for the link) postulates that healthcare reform successfully happened in other countries not because it was rigorously planned, but because it evolved from experience to address current conditions. "Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it … In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s)."

So where does this guy fit in when talking healthcare reform? Yelling, bearded, ubiquitous cheeseball infomercial pitchman Billy Mays ("IT’S NEW OXICLEAN DETERGENT — GET ON THE BALL") is hawking health insurance. I’ve seen the commercial dozens of times already, even though I don’t watch much TV. Of course, he doesn’t scream out how much risk you take on when you sign up for "affordable" insurance (its mini-medical plan pays just $100 per day for a hospital stay). You know hospitals and doctors are going to eat the balance when the "insurance" covers next to nothing and the "insured" can’t pay, which is sad because they at least tried to do the right thing instead of just dropping all coverage. As highly recommended as the ultra-annoying Vince the Slap Chop guy ("YOU’RE GONNA LOVE MY NUTS").

Hospital layoffs: Waterbury Hospital (CT), 160; Integris Health (OK), no number given; Inter-Lakes Health (NY), 15.

South Australia’s Department of Health plans to deploy an ERP system covering all of its hospitals.

E-mail me.

HERtalk by Inga

I’ve been glued to the TV all day and have gotten teary a few times. It’s been an extraordinary day. I keep hearing Lee Greenwood singing in my head. It’s great to see so much pride and optimism. Oh, and I loved Aretha’s hat!

The Pennsylvania Medical Society has followed Mr. H’s lead and is now twittering (OK, maybe they didn’t start just because we did, but Mr. H likes to think of himself as a trailblazer), I know there of a number of hospital CIO’s twittering – I wonder if there are any hospital systems?

Canadian EMR vendor MedcomSoft fails to reach an agreement with creditors and files for bankruptcy. The company is now in trusteeship. The press release warns that it contains "forward-looking statements." Hardly.

A hospital-owned clinic in rural Colorado prepares to close its doors, falling victim to difficult financial times.

Nuance Communications continues to bid for Zi Corporation. The current offer was scheduled to expire January 16th, but Nuance as extended it until January 30th. So far, Zi’s stockholders have indicated they aren’t interest in the $.40/share offer. Zi’s stock closed at $.39 on Tuesday.

In Washington, House leaders suggest a December 31, 2009 deadline to complete an initial set of HIT standards. Also under consideration: $65,000 per physician in provider incentives; payments for hospitals that become fully wired; and penalties for not adopting HIT beginning in 2016. Privacy advocates are paying close attention to make sure their concerns are not overlooked.

The majority of Americans don’t consider HIT spending a priority, which may not be a surprise given the turbulent economic times. A recent study by Kaiser Family Foundation and the Harvard School of Public Health finds that 79% of the 1,628 participants want spending for HIT to decrease or stay the same, dead last by far of all the healthcare spending possibilities.

Revenue cycle solutions are all the rage in Michigan, as hospitals attempt to maintain revenues. With rises in unemployment and uncompensated care, hospitals are seeking new tools to update their billing and collection procedures.

Anesthesiologists have a cool new iPhone application available to them. iAnesthesia provides case log tracking, drug calculations, and administration guidelines.

Tomball Regional Medical Center (TX) equips its physicians with real-time patient updates on their mobile devices. The hospital is sending critical patient information to physicians using Clinical Xpert Navigator solution from Thomas Reuters (the former MercuryMD MData solution).

Pathology Service Associates launches a pathology CPT coding services Web site, PathLab Coding Solutions, that will provide responses to coding inquiring and access to automated and online coding resources.

Parkland Health & Hospital System (TX) licenses Lawson Software to automate administrative processes, simplify reporting, and improve data access.

Andrew Bolles joins Zotec Partners as director of business development. Bolles most recently worked as a VP and national sales manager for Dominion Medical Management.

United Regional Health Care System (TX) activates multiple Eclipsys clinical solutions across 35 inpatient units and two locations.

Marion General Hospital (IN) selects MEDSEEK to develop and implement an enterprise-wide healthcare portal.

South Jersey Healthcare (NJ) chooses Sage’s Intergy EHR for its affiliated physicians. The health system will subsidize the cost of the EHR and interfaces to the hospital’s IS/HIE.

Hayes Management Consulting announces that MedicalEdge Healthcare Group is providing MDaudit software for its physician clients.

E-mail Inga.

Ricky Roma Responds

… to comments from his recent guest posting.

A few people asked about the Site Visit problem, especially with respect to compensation. These questions actually highlight the root of the problem. Yes, site visits are lengthy and expensive. Risky? Not so much. 

I completely agree there are plenty of opportunities for sidebars and candid discussion, but these are the customers that the vendor has hand-selected to show off. These are the customers that get things like the best PMs; customized software; direct lines to the vendor’s senior leadership; discounts all over the place; pizzas sent Fridays; paid trips and dinners out with their Inga wannabes at trade shows; and anything else they so desire. These site visit hosts do not generally intend to mislead their wide-eyed visitors — they are just the beneficiaries of a relationship that is rarely repeatable at scale (“at scale” being vendor-speak for “you”).

Are the hosts compensated? Abso-fugly-lutely. Do they get better service than the average bear? Of course they do! That is the very reason why you are being directed there, so you can be guided into thinking ALL of said vendor’s customers live in this state of perpetual bliss. If this utopian state is something that can, in fact, be delivered “at scale,” there is only one way to find out — do your evaluation at scale (“at scale” here being my speak for, well, “at scale”).

The remedy here is to stack up the references. Stay away from the airport and choose quantity over false quality. Use the phone and your Web meeting tool-of-choice. Also, do back channel references — ask one or more of your Good sales people from a different product category if he or she knows any hospitals using Product X and would they facilitate an introduction. The time invested in 5,10, 15 or more calls will pay much greater dividends than getting a fancy trip somewhere.

I would augment this recommendation by having key members of your evaluation team each make calls to their respective counterparts. Find hospitals that are much like yours as possible and avoid the eight-person conference call. Make them one-on-one instead. A direct conversation is much more likely to generate an honest answer than from a crowded conference room. Plus, think of all the new LinkedIn contacts that can be made!    

Make sure your team agrees on a basic set of questions (actual, real, usable functionality; implementation reality; support reality; hidden costs; etc.) so that you can compare notes on the same topics. Also, be sure to ask the classic, "Knowing what you know now, what would you do differently if you came to work for us on this project?” The Dark Side HATES all this and will work hard to discourage this type of enlightened behavior. We want you to follow our script in showing off our wares, not yours!

If you follow this process and have five or more of your team calling at least 5-10 references (more for bigger projects, fewer for smaller), you will have developed a powerful matrix of 25-50-100 or more interviews. This information will serve as a great big spotlight to illuminate the future path you will be headed down with that potential decision. THEN, if you really want to go see this s#@& running somewhere, hop on that airplane and go.

While you are there feeling like a big shot, insist upon dinner with your Good sales person and the company’s CEO (aka, Mr. Discount) and let the negotiations begin …

Being John Glaser 1/20/09

In about a month, it is highly likely that our industry (healthcare information technology) will be very different. In my almost thirty years in this industry, there has never been an industry change of the depth and breadth that we are about to experience.

Last week saw the introduction of the first of the Congressional bills that will cause this change. These bills are part of a broader set of government efforts designed to stimulate the economy out of its distress. The healthcare IT portion of these bills intends to rapidly accelerate the adoption and effective use of information technology in healthcare. The House Ways and Means bill (PDF – go to page 138 and read from there) describes some proposed changes:

• Provision of $40,000 in incentives (beginning in 2011) for physicians to use an EHR
• Creation of HIT Extension Programs that would facilitate regional adoption efforts
• Provision of funds to states to coordinate and promote interoperable EHRs
• Development of education programs to train clinicians in EHR use and increase the number of healthcare IT professionals
• Creation of HIT grant and loan programs
• Acceleration of the construction of the National Health Information Network (NHIN)

All of these changes (and more) are accompanied by the infusion of $20B into the healthcare sector. To put this in perspective, in 2007 the HIT industry in the US was $26B (Gartner).

The “final” form of these changes is not clear. The Ways and Means bill and the Energy and Commerce bill and the Senate bills need to be reconciled. As I write (a snowy Sunday morning in Boston waiting for the NFL playoffs to start) I am sure that a wide range of industry professional associations, lobbying firms, and interested individuals and organizations are plowing through the language to identify improvements, concerns, and sections that need further clarity. Their voices will need to be heard.

And while the legislative process and discussion that arrives at a final bill will be (as it often is) complicated, confusing, and full of ups and downs, we should fully expect that sweeping changes will pass within 30 days.

What should you do about this?

First, to the degree that you have time, you should weigh in on the legislation. Your comments can be sent to your employer (if they are planning to provide feedback to Congress), your elected officials, and/or to industry professional societies (CHIME, HIMSS, AHIMA, AMIA, AHA, etc.) that will be providing feedback.

Second, get ready for an interesting 2009.

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

Monday Morning Update 1/19/09

From MM: "Re: home grown systems. Foul! When I read people call software built by healthcare providers as ‘home grown,’ I can feel the hair on the back of my neck rise and my blood pressure go up. In the 1980s, that may have been an accurate statement, i.e. that providers built ‘home grown’ systems, where ‘home grown’ is used as a derogatory statement that refers to software that was developed by a single person using outdated technology with limited testing and no documentation. Today, there are some leading healthcare organizations designing, building, and deploying commercial grade software. With the move towards ‘Agile’ development, one can no longer equate the number of developers with the quality of software. Another point is that the software developed by a healthcare organization is ‘lighter’ and simpler than vendor software because the requirements are lighter." See below for an example of this from MD Anderson, which hardly fits the ‘home grown’ label.

From Salesgal: "Re: EEOC. [EMR vendor] is under investigation by the EEOC for unfair layoff procedures during the June 2008 layoff. All of the complaints are lodged in [sales manager’s] district. Seems he let go pregnant, ill, and staff who were not his groupies and kept his favorites who were not selling. He was ultimately let go, but several reps with solid experience and sales numbers were lost." I’ve omitted the names since I have no official documents to back up the statement. Sounds juicy, though. 

From Rowdy Piper: "Re: layoffs. Orlando Health (formerly Orlando Regional Healthcare System) has ‘reorganized’ positions across the institution by eliminating positions and placing many of those affected employees into other (many times lower paying) jobs. Additionally, they have instituted a system-wide hiring freeze and have started to cut hours for many and even forced time off over the holidays."

From Corndog: "Re: UHIN. Very impressive that Axolotl beat out Medicity right in its own backyard. Intermountain Healthcare has been shrewd in using technology to advance the quality agenda and must have liked what it saw." Maybe, although its big GE partnership doesn’t seem to show infallibility. Still, Axolotl has strung together some pretty good wins recently.

The President-elect is still talking up healthcare IT, this time in a TV interview: ".. in the economic recovery package that we put together, we have a lot of investment in making the health care system more efficient. Those are things that had to be paid for anyway. Just a simple thing like converting from a paper system to electronic medical records for every single person can drastically reduce costs, drastically reduce medical error, make not only health care more affordable, but also improve its quality."

HIMSS Analytics brags (confusingly) that "85 percent of hospitals in the contracting phase of an IT acquisition have signed with a CCHIT Certified vendor since November 2007." There’s no such thing as a certified vendor, only certified products, and even that certification only covers EMRs, not most of the software applications a hospital uses. Does that mean that 85% of hospitals that have bought any IT system in the past year also bought a certified product, or that those who bought a product covered by CCHIT (inpatient or ambulatory EMRs) certification chose the certified one? If they only bought a server (which is an IT acquisition) and no software, how were they counted? Mumbo jumbo aside, it doesn’t really matter — everybody shamed the vendors to lay out the cash to get certified, so it’s not like hospitals have much of a choice other than in office-based EMRs, where they might pick a lesser-known vendor despite dozens of certified ones. It’s not like having certified products available opened the floodgates – they’re buying the same old products that just happen to be certified now. Results, not surprisingly, haven’t changed – just the cost. Products are interoperable, but users aren’t.

And speaking of CCHIT certification, Allscripts Professional earns Ambulatory 08.

UC Irvine Medical Center is proud that its anesthesiologists have stopped falsifying surgical records by filling out forms before the surgery starts as CMS found earlier, now thwarted by its new SIS software the prevents them from doing so.

Former Healthlink VP Ed Kopetsky is named CIO of Lucile Packard Children’s Hospital.

Jonathan Bush and David Brailer were on CNBC. There’s not much new since the TV guys require everything to be simplified so they can understand it, but I bet JB can’t wait until Tuesday when the talking heads will have to drop their "president’s cousin" knee-slappers unless he’s also related to Obama.

Conditions are so bad that Columbia St. Mary’s (WI) intentionally slows down its $417 million new hospital project that’s already almost four years old.

Big layoffs for Wellpoint: the struggling insurer will drop 600 employees and another 900 unfilled positions.

GE Healthcare will lay off in "the low to mid-single digits" as a percentage worldwide.

Hospital layoffs: Tulare District Hospital (CA), no number given; Excela Health (PA), 70; Wellmont Health System and Mountain States Health Alliance, 195; Fox Chase Cancer Center (PA), 80; Montgomery Hospital Medical Center (PA), 17. Brazosport Regional Health System cuts the hours of hourly employees and issues a mandatory 10% pay cut for salaried ones. There are more, too many in fact for me to keep writing about, so suffice it to say that nearly every hospital is freezing discretionary spending, cutting capital budgets, and laying off staff.

West Virginia University Hospitals and its physician group were to have gone live with Wave 2 of their $90 million Epic implementation over the weekend. That’s $18,000 per user or $180K per doctor, just in case you were wondering.

Sen. Chuck Grassley’s investigation turns over another hidden fact: the orthopedics chair at University of Wisconsin-Madison pocketed over $19 million in five years from device maker Medtronic. He claims the money was royalties for patents he holds. So how the heck was he able to keep all that money without the university knowing (that is, unless he was intentionally cutting them out of the deal even though he’s a full-time employee)? He claims he fully disclosed his relationships and never implanted any of the devices in his own patients (so does that mean their care was better or worse?) In fairness to him, the university’s disclosure forms have a top category of "over $20,000," so that’s their fault for not being more specific.

I’m puzzled: why did the National Research Council and then the Senate ask Microsoft (and Intel, for that matter, in NRC’s case) for its opinions on healthcare and technology? Peter Neupert gave the company’s view (warning: PDF) of what the future of healthcare should look like, but everywhere I’ve worked, they just sold expensive, trouble-prone IT plumbing and gave CIOs free trips to Redmond. Of course Microsoft envisions a radically different and technologically future – that’s their only hope for elbowing aside companies like Meditech that have been automating healthcare while Bill Gates and Jerry Seinfeld were still in high school. I’m not saying they shouldn’t have an opinion, only that I don’t get why anyone would give it much value when they’re dabblers at best. At least its rumored layoffs apparently didn’t happen.

Two 19-year-old students develop Refill300, a free e-prescribing and refill site.

AT&T is developing software that will use both WiFi and a low-power technology called Zigbee to send home monitoring information to providers.

Amazon Web Services makes some of its huge public data sets, including genomic and census data, available at no charge for developing cloud applications.

Three UK hospitals are rolling out e-prescribing in what’s called the UK’s biggest eRX project. JAC Computer Services, a subsidiary of Mediware, is providing the application.

E-mail me.

M.D. Anderson’s EMR Project
By Lynn H. Vogel, Ph.D., FHIMSS, FCHIME
Vice President and Chief Information Officer
Associate Professor, Bioinformatics and Computational Biology
The University of Texas M. D. Anderson Cancer Center

I asked Lynn Vogel about the project they’ve been working on at M.D. Anderson. Here is his response.

The January issue of Advance will have some comments on what we are doing with regard to ClinicStation and its SOA architecture, with some observations regarding comparisons with commercial products.

The fundamental problem is that every commercial clinical systems product on the market today relies on a single, physical data repository, generally with HL7 interfaces, and is based on relational data base architectural models that are now close to 20 years old. Outside of healthcare, the IT world has embraced Services Architectural models and is now moving into semantic data models as well. But the cost of a major architecture change is simply prohibitive for commercial healthcare IT vendors. For all the talk about interoperability challenges, not being able to incorporate new data models into our clinical systems environments down the road may be a much larger constraint on improving our nation’s health.

The advent of genomic (or personalized) medicine presents very different types of data from what we have been accustomed to historically. For the most part, clinical data has been viewed as a series of discrete data models — you have a particular laboratory value, or a radiology report, or a graphic from an echocardiogram that you send to a repository via an HL7 message — so incorporating new data of this type into the repository via HL7 has not been a problem. But genomic data models tend to be based more on pattern-matching than discrete data, and products that rely on a single physical data model have real problems integrating these new data types. In addition, the vast volume of genomic data that is now being collected and increasingly available for matching can become unmanageable within a single data model and repository structure.

M. D. Anderson is now working on a parallel product, ResearchStation, also built on the SOA framework, that for the first time promises true integration of research data (e.g., biomarker data) with data from clinical practice. We hope to exploit UDDI capabilities as the actual linkage process between data and services from ClinicStation and ResearchStation. All of this, of course, says nothing about the vocabulary and terminology challenges we face in healthcare, for which is there is simply no comparison in any other industry. This is where semantic models promise to make a significant impact — and major technology vendors such as Oracle are already incorporating such capabilities into their product suites — but these are not even on the radar of the major healthcare IT vendors.

A couple of references with more specifics on what we are doing:

Case study from Microsoft (Word document)
Case study from Avanade, our strategic partner in software architecture and development

Wes Rishel from Gartner included our work as a case study in his presentation a couple of weeks ago at the Gartner Healthcare IT Symposium, so I think the word is getting out about the usefulness of SOA and how it can help us to deal with a number of the data challenges in healthcare.