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‘home grown’ is used as a derogatory statement that refers to software that was developed by a single person using outdated technology with limited testing and no documentation.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.

House Stimulus Bill Draft Calls for $2 Billion for ONCHIT, $18 Billion for CMS P4P Incentives

The discussion draft (warning: PDF) of The American Recovery and Investment Act of 2009 in the House of Representatives contains only $2 billion in new funds specific earmarked for healthcare IT, with that entire amount to be managed by the Office of the National Coordinator. The remainder of the $20 billion figure that was quoted for healthcare IT would  be distributed by CMS as pay-for-performance incentives that have not yet been defined.

ONCHIT’s short-term $2 billion spending would be targeted for nationwide information exchange, healthcare professional training (possibly in informatics, not specifically stated), and grants for hospitals and doctors to acquire CCHIT-certified products.

A report from Piper Jaffray analyst Sean Wieland says that most of the CMS incentive funds will go to hospitals, with the intention of covering 1/3 of the cost of electronic medical records systems, but not prior to purchase.

Meanwhile on the other side of Congress, testimony from yesterday morning’s Senate hearing on Investing in Health IT: A Stimulus for a Healthier America is available online in video and PDF formats. Witness testimony is included from Jack Conchran of The Permanente Foundation, Janet Corrigan of the National Quality Forum, Valerie Melvin of the GAO, Peter Neupert of Microsoft, and Mary Grealy of Health Leadership Council.

News 1/16/09

From Seattle: "Re: HIMSS. At the HIMSS Washington dinner last night, Dave Garets of HIMSS Analytics disclosed that he and others from HIMSS had been working with the Congressional Budget Office on the HIT proposal.They were asked what would it take to get all hospitals to Stage 4. Apparently the proposal includes both inpatient and ambulatory and will be a combination of grants, loans, and Medicare rewards, including up to $1 million in ‘reimbursements’ for systems already implemented. When the speakers panel discussed this, two of the four suggested that this was a lousy idea and seriously questioned why we should be reimbursing anyone. They suggested instead delaying ICD-10 or using the simpler Canadian version or simplifying claims and payments, also focusing on reducing provider time by eight hours a schedule using technology instead of just buying more technology." HIMSS Analytics shows that 95.7% of hospitals haven’t yet made it to Stage 4, which requires all ancillaries to be installed, CDR, controlled medical vocabulary, CDSS for both error checking and clinical protocols, clinical documentation, PACS in all areas, and CPOE (even though you only need one live floor to claim victory). Maybe someone should get the cost and outcomes stats from those who have since I doubt there’s a corresponding improvement. Using that logic, Detroit should be rewarded for buying new robotic welders as a way to create safer and better cars. Why not just pay them for making safer and better cars? Makes sense unless you sell robotic welders.

From Terry Jacks: "Re: Ministry. Is anyone going to point out that this Cattails system that has been recognized recently in the press is not a vendor, has no clients, no implementation staff, no service staff, and no customers other than their own docs? I thought we went away from home grown systems in the 1980s?" I think you may have given Pete inspiration for a future posting. From its data warehouse design above, it’s not exactly a stripped down, spur-of-the-moment system and it’s also CCHIT certified, so I’ll be interested to hear more about what they’ve built.

From Snake Pliskin: "Re: Sutter. The period of time that it has taken Sutter to implement Epic is NOT a reflection of Epic. Sutter is pushing the envelope. When you look at Epic, it’s pretty amazing to realize just what they have accomplished over the course of the past eight or nine years since they entered the inpatient arena. Sutter is a confederation that covers a huge geographical expanse. It’s been about establishing common governance, common processes, achieving consensus, responding to changes in technologies and patient care needs, the desire to improve work flows. I’m going to give Epic and Sutter kudos. Really. It’s a monumental task."

From Seattle: "Re: ICD-10. Compliance deadline extended to October 1, 2013." Link. AHIMA is "applauding" with its imaginary hands, but only for HHS’s approval of ICD-10. It’s not happy about the deadline extension. On the other hand, AHIMA doesn’t sell or use information systems, so that’s easy for them to say (good for coders, too, probably).

From Rommon: "Re: Palmetto Health Baptist Easley. The 50-year-old upstate SC hospital to be spun-off from the largest healthcare system in the state, Palmetto Health, and co-owned by PH and GHS. ‘Not related to the economy.’" Link. 

From RIS Guy: "Re: Agfa. Agfa is, for the second time in four weeks, today going through a US reduction in force of about 60 people. This time, it’s front line sales and service."

From Billy Lyall: "Re: site visits. I have worked for vendors for much of my life and I’m always sensitive to site visits. They’re no easy thing to manage from the vendor perspective. They can be risky — even the best site visit could go downhill quickly. They consume a lot of time for the host. Of course the host is going to get something, maybe some discount on support hours or licensing of new products, but maybe even just special attention from the vendor. But, my impression of the people from the hosting site has always been that they are candid about support issues, implementation hurdles, staffing, and ability to meet end user needs. There’s always the opportunity for sidebar conversations." I enjoyed Ricky Roma’s piece and have asked for more if he’s willing. Inga and I found him by accident and were enthralled by his writing.

From Webbed_Feet: "Re: OHSU. Reorg and layoff alert; Oregon Health & Science University (OHSU) completely re-orgs IT. The final numbers are not published yet, but dozens have been told they will be laid off and will get formal notice on Wednesday. As part of the re-org, the CIO and CHIO formally announce the Clinical Informatics department that encompasses workflow analysis, clinical reporting, HIM nad RN and MD champions for the Epic project." OHSU has been struggling, so it’s probably not too surprising that something had to give.

From Medarling: "Re: Ivo Nelson. I heard interesting comments that Ivo Nelson, former CEO of Healthlink before selling to IBM, may be doing a comeback? Anyone else hearing this?" His LinkedIn profile indicates that he has started a new consulting business in Houston called Ivo Inc., which may or may not be just him puttering around a little. I finally found a personal e-mail address for him and sent an inquiry, but I haven’t heard back.

The House Appropriations Committee released a summary of its stimulus plan Thursday, which includes $20 billion for HIT. It will be interesting to see where the money would go once the details come out. Since Obama wants a quick jolt, the only reasonable way to disburse it would be through organizations that have been efficient and trustworthy in the past. How else, other than parachuting in pallets of cash a la Iraq, could that much money get into play quickly? Who would you trust to dispense it thoughtfully?

David Brailer writes his thoughts on the national health IT agenda, which unfortunately came out about six hours after I sent him a list of interview question and hoped for a response. He says he hoped to let the market drive EMR adoption when he was running ONCHIT, but it didn’t happen, so government incentives are needed. However, he nearly echoes my previous writings, I’m proud to say: "We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care." He advocates pay for use. He also points out the obvious need for bunch of clinical informatics people to get all this stuff up and running, which of course is a hundred times harder because every vendor’s system is different and it takes years to really learn each one. He also suggest updating HIPAA and privacy rules, arguing that trusted providers are constrained while companies like Microsoft aren’t because they aren’t providers. Here’s his big pitch: "President-elect Obama should consider one single change that would do more to reshape medicine into an information industry than anything else: have Medicare treat electronic visits as equivalent to in-person visits." Brother Dave, this choirboy hears you loud and clear and says amen, although I might change that last big pitch to: "President-elect Obama should consider one single change that would do more to reshape medicine into an information industry than anything else: put a stop to all the ridiculous documentation requirements for getting providers paid, many of them imposed by Uncle Sam himself through his big payors like Medicare." Imagine how good EMRs would be if all the crap involving billing and malpractice defense could be eliminated and systems redesigned from scratch for the patient’s benefit, not that of the government and the insurance companies. It’s no surprise that the best clinical improvement came from the VA’s VistA – the hardhats didn’t have to program in that 80% of the average hospital system that has nothing to do with patients. Hospitals bought their first computers because of Medicare complexity and that hasn’t changed.

The chair of the House VA committee says he will investigate reported software problems that caused patients to get wrong drug doses and miss treatments. The problems: IVs ran longer than intended and information showed up on the wrong patient. If he finds the perfect information system anywhere in the world in all that investigating, I’d like to hear about it.

Frustrating: I bought those squiggly, energy-efficient Sylvania bulbs from Sam’s that say on the box they’ll last seven years. So far in one bathroom, four of six have burned out in just a handful of months. Ripoff?

John at Chilmark Research weighs in on the Medicity-Novo Innovations merger.

Simon Samaha MD, who we old timers remember as CIO of Cooper University Hospital, is named president and CEO of Summit Medical Group, a 140-physician medical practice in New Jersey.

McKinsey Quarterly noodles on Why Americans Pay more for Health Care. The big reason: outpatient care, which is theoretically cheaper than inpatient care, but only if it replaces it. One culprit CT and MRI scans, which makes it very profitable. Also: "Well-insured patients who bear little, if any, of the cost of their treatment have no incentive to be value-conscious health care consumers. Moreover, even if they wanted to be value conscious, they don’t know enough." Let’s repeat: providers will do whatever they can get paid to do, just like every other profession. It’s not illegal, immoral, or even harmful – it’s just expensive for whomever is picking up the tab (not the patient, in most cases). If you want them to stop, then don’t pay them for doing it.

As Inga mentions below, LinkedIn yanked my photo, a shot of the Unknown Comic. How do they know it wasn’t me wearing a bag? Here’s my thought: I’ll chose an HIStalk reader’s picture and put it on my profile. Then, I’ll see who recognizes them at HIMSS and ask them to report back whether they received any accolades, assaults, or indecent proposals. In fact, I could swap reader pictures once a month so that I am, in fact, an HIT Everyman or Everywoman.

MedAvant, rescued from bankruptcy in September by selling out to Marlin Equity, acquires the Medicare Crossover business of HDM.

The Motion Picture & Television Fund will close its hospital and nursing home in Woodland Hills, CA due to $10 million a year in operating losses, laying off 290 employees.

GE Healthcare announces the merging of its two Milwaukee area divisions, diagnostic systems in Waukesha and clinical systems in Wauwatosa (did they intentionally choose towns with odd yet similar names?) The company boldly claimed it was about growth, no doubt the same reason they’ve been laying employees off and closing plants. It’s also shutting down the GE Healthcare Lunar office in Madison, moving manufacturing to Milwaukee. Despite the oddball name, it makes equipment to measure bone mineral density.

In that vein and locale, Wheaton Franciscan also announces its latest growth strategy: the forced evacuation of another 100 or so employees on top of the 250 positions already eliminated. If you live in Waukesha County, watch out for traffic near the unemployment office.

<shameless self-aggrandizement>A New Zealand integrator working on an RFI there asked me a few weeks back if I would mention their interest in hearing from US software vendors who might participate in a big patient records project. I did and the company says they got more than a dozen inquiries. Also, from a company who ran a text ad like those you see to your right, "We have seen more clicks from your site than any other of our ad locations (Google, Yahoo, etc.). You have a great site and I love reading it every day." </shameless self-aggrandizement>

That’s an HTML joke above, in case you didn’t get it.

Planned business closings and layoffs, courtesy of CoStar Group: Irvine Regional Hospital and Medical Center (CA) was to close Thursday, laying off 510 employees (above). Health Research Association (CA), the clinical trial support organization of USC, will lay off 79 employees on January 30.

Odd lawsuit: the family of a man who died after elective spinal fusion surgery at specialty hospital West Texas Hospital is suing the now-closed facility, claiming its medical staff didn’t recognize his blocked airway complications. His wife repeatedly asked staff for help, the hospital PA covering the ED (!) was paged, nobody thought about establishing an airway, and the wife gave him CPR. The hospital’s action: they called 911.

Jonathan Bush is on CNBC again. He quotes the IOM report and rails against the government gravy train. Worth watching, even if the gaggle of amped up hosts constantly interrupts him at a nearly intolerable volume. "Pay for data, pay for results, and you can’t believe how fast doctors will get out there and get online."

Hospital layoffs: Gaylord Hospital (CT), 11; Wyoming Valley Health Care System (PA), 20; Banner Health (AZ), 334; Mt. Carmel Health System (OH), 300; Rogue Valley Medical Center (OR), 20.

The CEO of Carolinas HealthCare System is doing OK, though, having been paid $3.5 million in 2008. They claim he earned it, which at least is slightly different than the standard excuse of having to pay competitively to attract such notable talent to a non-profit endeavor.

E-mail me.

HERtalk by Inga

From LinkedIn Customer Service: “Re: your profile picture has been removed. The picture is in violation of the LinkedIn Photo Policy because it is not an accurate representation of you.” What? My avatar is absolutely an accurate representation of me (in an optimized, sexier, Barbie-ish sort of way.) Apparently only “photographs” are acceptable. Mr. H is also miffed because his profile picture (a photograph) was also removed. His was the one with the bag over his head, which apparently is one of Mrs. H’s favorites since he likes to wear the bag around the house all the time (I didn’t ask). I just posted a new photo of myself. We’ll see how long before that one is also removed.

I have to say the quality of the writing and commentary from our readers is amazing. In the last week we’ve had some excellent stuff out there, both on HIStalk and HIStalkPractice. Thanks to everyone taking the time to support our sites by providing thought-provoking, smart, and entertaining material. We are always looking for great content, so drop us a note if you have any HIT reflections to share.

Retired Gen. Eric Shinseki, Obama’s pick to head the VA, vows to develop an EHR for active duty personnel and veterans and make business practices as paper-less as possible. Shinseki tells senators during his confirmation hearing that the barriers have not been technical, but rooted in the VA and Defense department’s leadership.

Also on Capitol Hill, NQF CEO and President Janet Corrigan tells a Senate committee that effective use of HIT is essential to improve quality, safety, and affordability.

GE Healthcare confirms its former IDX Systems headquarters in Vermont is cutting staff and other costs. A GE spokesperson would not discuss the number of employees affected.

Hill-Rom Co. also confirms job cuts and operational consolidations. The company plans to cut about 450 positions in the US. Hill-Rom laid off 150 employees at the end of 2008.

If you’ve been affected by all the recent layoffs, perhaps it will make you feel mildly better to know that healthcare workers in other countries are also suffering. Swedish medical officials announces plans to cut 900 jobs (6% of the workforce) in order to reduce costs.

Toronto General Hospital pilots its first surgery checklist, aimed at reducing adverse events.

Here is a new must-have item for fashion-conscious, cold-fingered iPhone users. The thumb and index-fingers on these $40 gloves by North Face are covered with special fabric that includes silver.

Mr. H mentioned an odd lawsuit last week that involved a deaf patient who sued her doctor for failing to provide a sign language interpreter. She ended up winning $400,000. A company called LifeLinks saw the lawsuit as an opportunity to promote its remote translation services, which allow providers to connect with interpreters and sign language specialists via the Web. Providers only pay for the interpreters’ time, which undoubtedly costs far less than $400K.

Medicare beneficiaries in Arizona and Utah test new PHR software that includes two years worth of Medicare claims data. Patients can manually enter additional data. Some additional information can be uploaded electronically. Personally I think I would be more inclined to use an EHR that was pre-populated with at least some data, so this sounds like an interesting pilot.

University Hospitals (OH) launches a new physicians’ portal that combines electronic prescription writing with medication reconciliation.

Blue Shield of California Foundation announces its intent to stop issuing HIT grants, citing more pressing healthcare needs. Last year the foundation issued almost $11 million in HIT grants.

Two Illinois hospitals settle lawsuits alleging they overcharged uninsured patients tens of thousands of dollars. Resurrection Health Care and Advocate Health Care have agreed to recalculate bills and give refunds to needy patients eligible for free or discounted care. In addition, Resurrection will extend a 25% discount to all uninsured patients, regardless of income level.

Anne Arundel Medical Center (MD) implements VISion:Asset Management from Versus Technology to provide real-time tracking services for hospital assets.

Nuance Communications and IBM announce a licensing and technical services agreement to enhance and expand speech solutions, including incorporating IBM technology into Nuance’s speech products. Nuance will also purchase speech-related products from IBM. Nuance also reveals that Warburg Pincus has agreed to purchase $175 million of Nuance common stock. Nuance plans to spend some of the money on merger and acquisition activity. The purchase represents almost 17.4 million shares.

CSC wins a $265 million, 7.5-year contract to replace North Carolina’s Medicaid Management information system.

Polaris Venture Partners acquires a substantial interest in National Electronic Attachment, a provider of secure electronic data for claims attachments.

Telephone equipment maker Nortel Networks files for Chapter 11 bankruptcy protection

CareTech Solutions and EnovateIT team up to create a custom wall station for Crittenton Hospital Medical Center (MI). The e645 Computing Wall Station will be mounted into individual patient rooms for point of care documentation.

The University of Pennsylvania School of Nursing and Eclipsys form an academic partnership that will incorporate Eclipsys technology into the curriculum.

Tawam Hospital in Dubai goes live on Royal Philips’ iSite PACS, the first public hospital in the Middle East to do so. Tawam Hospital is affiliated with Johns Hopkins Medicine International.

E-mail Inga.

Pete Sanderson’s Responses to Comments from Yesterday’s Post

Comment #1
A partner and I are ramping up to start a consulting practice sharing best practices for HIT projects. We are consistently amazed at what a little project management rigor can do to keep the ship on course. Thanks, always interested to hear success stories and lessons learned on HIT projects.

Feel free to share a few of your success stories

Comment #2
I can understand that you don’t want people padding their budget estimates to ensure 100% success, but I also understand why someone might bristle at having their project labeled a failure for completing work too far ahead of schedule or producing something at a lower cost than expected. Much is learned during the course of a project, and it seems like you might inadvertently be disincentiving people from taking advantage of optimization opportunities.

Good point. Every project includes identifying named human resources to accomplish tasks and achieve deliverables. You identify named resources to make sure they are not over allocated.  You seek to avoid asking someone to do 100 hours worth of tasks during a 40-hour work week. As you learn during the course of the project, you produce change requests that either free up resources or seek additional resources for your project. The Project Management Office balances all the change requests from a portfolio of projects trying to balance organizational priorities and resource availability. It can be tricky, but allows the organization to track projects and provide adequate resources where and when needed. An added benefit is the ability to forecast needs and being proactive to meet needs months down the road.

Comment #4
‘Good process and leadership trumps bad software.’ There are some many things wrong with this statement I don’t know where to start. Suffice it to say I completely disagree. Nothing trumps bad software.

With truly bad software, you are correct. The statement should really read, "Good process and leadership trumps marginal software or software that is mislabeled as bad software." How many times have you replaced a product thought of as bad software only to find the problem has not been fixed? We often find our trouble with software is due more to how we have chosen to implement it rather than with the software itself. The point is, business leaders should optimize processes and use of the software before deciding the software is truly bad. Good process and leadership can often improve the use of software mislabeled as bad saving the time and cost of implementing a new product.

E-mail Pete.

CIO Unplugged – 1/15/09

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

Employee Annual Reviews
By Ed Marx

I admit it. I don’t like doing annual reviews. Few people enjoy them. Even fewer are good at them. I wish I were the anomaly, the freak. Sure, I’ve read all the theories and attended requisite training classes on how to make a review a non-event and make it productive. But this is supposed to be CIO Unplugged, right? Not CIO Fantasyland.

Most believe they are a star and, whatever your rating scheme, they should qualify as the poster child for the “top box.” Many of us desire to be number one in all our endeavors. Though I do appreciate the self-esteem and confidence this attitude exhibits, can everyone be “top box”? Should they?

No.

It’s easy to cave into temptation and give overly optimistic reviews to avoid discomfort. I’ve done it; I’m tempted every year. Then I kick myself for giving in because ultimately I’ve benefited no one. In fact, I end up undermining my employee and my organization. Worse yet, if I’m not modeling appropriate and accountable reviews, my subordinates will follow my poor example. (Ouch, I feel the pain as I write.)

Therefore, this post is as much encouragement to me as it is to you. Since it’s that time of year again, we the leaders are going to invest the time and energy to make the review honest and meaningful. You with me?

Here are 3 tips:

1) Spandex—man’s brutally, honest friend. If you want to know where you stand with weight management, pull on a pair. I can try to fool others in terms of fitness, but the single best test I have is spandex. Someone can tell me I’m fit, but when I see the rolls of fat hanging over the spandex… This sort of accountability keeps me on the right path. We need spandex attitudes in our careers to ensure our performance is in check. Give honest feedback even when it’s uncomfortable. You’re employee deserves to know the truth no matter how brutal. Nobody likes flab.

2) Satiate the hunger. While I did say we tend to believe we are top dog, deep down most of us long to improve. If I can give my subordinates one tangible thing to improve, most will clutch it like a pit bull clenching a bone. Imagine if your boss gave you one strength to focus on every year to help you move to the next level, and you really did something with it. You might become CEO! That annual performance review might start to look pretty admirable.

3) Break it down. Two years ago, I switched to doing performance reviews quarterly. This helped make the annual review less dreadful. When you’re tracking progress, evaluating, and encouraging throughout the year, there are no surprises to contend with. In fact, I leverage this same format with my manager monthly! I desire constant feedback. My recent annual review ended up uneventful, and I got a nice big bone to chew on.

My final reminder to myself and a word of encouragement to you. Not only is it our responsibility to our organizations to give accurate and meaningful reviews, but aren’t our people worth the effort, despite potential discomfort?

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.”

MD Leader 1/15/09

Successful Projects

With the use of project management methodology, Ministry Health Care has consistently improved the success rates of IT projects. Any effort installing new software or requiring more than 100 hours of IT time is considered a project. Even using project management, 25% of our closing reports reflect a failed project; one that was not managed to the agreed upon timeline, scope or budget.

Before you start thinking your projects have a better success rate than ours, here is what we define as failures:

• Actual expenses varied by more or less than 10% of budget
• Total project hours varied by more than 10% of planned hours
• Completion date varied by more than 15% of the original completion date
• Two or more material scope changes
• Less than 80% of project objectives attained
• The project’s impact on the organization was not anticipated or was not effectively communicated

Business leaders often bristle at being told their project was a failure because they brought a project in under budget or with fewer project hours than budgeted (the cause of the majority of failed projects). However, we are managing a portfolio of projects limited by resource constraints. If all our projects come in 20% under budget, that means the organization accomplished 20% less than it could have with the same resources.

We also do an additional evaluation at least six months after the closing report evaluating if the project achieved its long-term objectives. Many failed projects are subsequently vindicated. 

I recently completed a Physician Executive MBA ( PEMBA) at the University of Tennessee. My classmates were physician leaders from across the county and numerous foreign countries. Their experience with IT projects was uniformly negative. In general, they thought IT was done to them rather than with them. These leaders reaction to IT should give us all a pause to evaluate our implementation strategy.

Will Weider, our CIO, recently listed Ministry’s "lessons learned" based on 2008 projects:

• Test thoroughly
• Good process and leadership trumps bad software
• Roles should be clearly defined and consistent with our Lean and Six Sigma engagement and acceptance strategy
• Business leaders should fully understand current practice and issues before new software or process change is considered
• Hours are consistently under budget due mostly to the assignment of unnecessary contingency in the project plans.
• Formalize Lean and Six Sigma activities in EHR project plans

We did have one perfect project last year (on time, one budget, satisfying all objectives): a medication reconciliation project at one of our internal medicine offices. This project was not initially supported by our CIO because it was a duplication of effort. We are in the process of implementing CattailsMD electronic health record, but this site will not go live for some time. The CIO correctly pointed out the existing software that was utilized will be replaced by CattailsMD.

The Project Team, comprised of nursing and clinician staff, rightly argued the software was the easy part; the tough part was establishing a standardized process for medication reconciliation. A standard process can be adapted to the future software solution. The team was lead by a Black Belt utilizing lean methodology to map out a future process flow and then used standard change management tools to achieve stakeholder engagement and acceptance. IT and project management played a supportive role. The project was done with the clinicians rather than directed at them.

Our deployment of the EHR will be accomplished with the same techniques used in our medication reconciliation project. Ministry Medical Group will own the implementation assisted by IT and Project Management. While the organization will establish certain high level standards, each practice site will use lean methodology to define its own standardized work flow. A system-wide rollout the EHR software will be accomplished through multiple small work site-centered projects allowing clinicians and staff to improve and own their work flow.

With the new year starting, sit back and evaluate the success of your projects. Share with us your lessons learned, the common characteristics of your successes and how you were able to achieve the acceptance and engagement of your stakeholders. I look forward to hearing from you.

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.

Readers Write 1/15/09

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

Comments on the National Research Council’s Report
By Peter Basch, MD, Medical Director of Ambulatory Clinical Systems
MedStar Health 

Kudos to the National Research Council for their comprehensive and sober analysis of the state of health information technology as it exists today, and for their thoughtful recommendations. These recommendations reflect not just their research and editorial advice, but the current conventional wisdom and implementation approach of nearly all clinical informatics leaders. These recommendations call for continued federal financial support for:

• Improved care enabled by HIT (and not for HIT adoption per se);
• Innovation on workflow and process improvement;
• Development of enhanced and highly functional clinical decision support for providers and patients;
• Health care institutions and communities that appropriately aggregate data for quality improvement;
• Continued education and training; and
• Interdisciplinary research.

However, in spite of this clear support for funding and continued development of HIT, some media headlines have painted this report as harshly critical of the potential of HIT in general and EHRs in particular. This media misinterpretation resulted primarily from two faults inherent to the report : (1) the NRC’s mislabeling of their recommendations as a change from what health IT leaders are advocating for; and (2) the NRC’s inappropriate assignment of blame to EHRs as being the cause of dysfunction rather than their understanding that EHR functionality and implementation deficits are a result of a dysfunctional reimbursement system, which is based on volume of episodic care and verbosity of documentation.

While it is true many early adopter systems believed (at the time) that merely switching off paper medical records to EHRs would lead to improved and safer care, nobody has believed that, or has advocated that position in years. The current conventional wisdom is that HIT is quality and safety agnostic, and that its role is to serve as enabling infrastructure (toward whatever ends it is pushed to support). And as long as providers are incented primarily for procedures and volume, it is a surprise to no one (including the health systems studied), that their implementations have resulted thus far in only modest care improvements.

That said, there is a much clearer understanding in 2009 of where potential value lies in HIT implementations, and most health systems implement very differently now than even a few years ago — focusing on custom clinical content and targeted decision support — which can lead to further care improvements even within a dysfunctional health care system.

The NRC faults current EHR build as not supporting the cognitive support necessary to optimize care. This deficiency is obvious and abundantly clear to veteran EHR and HIT users – many of whom work on their own or with vendors on new and better functioning clinical decision support. However, let’s be fair as to the root cause of this deficiency. It is neither lack of vendor vision nor limitation of IT technology; it is lack of a market. 

EHR vendors must build applications that will sell, and the advanced clinical decision support that the NRC appropriately calls for does not and will not have a market — until health care is less fragmented, efficiency goals are aligned, and payment policy moves away from procedures and volume to information and quality outcomes. In our current fragmented and dysfunctional system, EHR purchasers are looking for a toolset that helps their practice to function more efficiently (and pay off the HIT investment) — which equals coding and documentation support. This is not the fault of EHRs, but squarely the fault of our healthcare system.

The NRC also makes the point that EHR technology needs to change because many providers find that they spend more of their time on using the EHR to document care rather than spending sufficient time on providing care. While it is certainly true that EHRs could make documentation easier, let’s not forget that providers using paper records voice the same complaints. Documentation changed from a medical art to a burdensome chore, not with the advent of the EHR, but with the Evaluation and Management (E/M) payment system changes of the mid 1990s.

This payment schema effectively eliminated the possibility of concise and relevant documentation, replacing it with a “pay-for-verbosity” system. These payment requirements (along with the very real threat of fines and prosecution for billing fraud) have unfortunately also served as the basis for many EHR sales to physician practices, as there was and still is a clear market for documentation and coding support. Again, the fix is not technologic; it is health system and payment reform.

In spite of these criticisms, the NRC offers good advice on improving HIT and EHRs and sound recommendations for federal support. However, the key to getting it right is combining support for HIT with health system process and payment reform. Without alignment of efficiencies and defragmenting healthcare and healthcare delivery processes, even better HIT will not be consistently and optimally used. And without a concomitant commitment to a sustainable business case for health information management and quality, even universal adoption of optimized HIT will be a disappointment. The time for change coupled with wise investments is now.

Just Watching FnC and Not FnC
By Duuude

Can we have a cat fight? Just what we need to spice up my Wednesdays – watching Fish and Chips and Not Fish and Chips!

In looking at Not FnC’s comments, the first thought I had was the lyrics from These Things by She Wants Revenge:

There is nothing to see here people keep moving on
Slowly their necks turn and then they’re gone
No one cares when the show is done

OK, back to the serious stuff. Fish and Chips is off on how long the Sutter implementation has gone on. Not two years –I believe it’s been going on for five or six years. If a Sutter resource can confirm that timeline, feel free to confirm or correct. 

In defending Sutter, even though there were questions concerning the selection process of their Electronic Health Record (was there a bona fide selection process?), whether Sutter realized what it actually would take to implement across the enterprise as well as the whole standardization processes, to achieve said Electronic Health Record, they figured out their strategy in rolling out to their acute care affiliates. Note, they already have Epic ambulatory up and running at several ambulatory sites. Most notably, PAMF. Just ask Stanford (wasn’t that their primary business reason to ditch Carecast?)

FnC, do you realize how many disparate hospital information systems Sutter had across their enterprise? It literally spans across the vendor community! While they have a physician portal, that’s not the same. Also, supporting these disparate systems in Sac-town is a huge challenge! They needed to change and consolidate systems, standardize workflow, etc.

Now, can you raise a question about their selection process? Absolutely! In fact Mr. H can probably dig up previous discussions. Project planning methodology, cost realization, ROI, whether the Citrix farm will work across Sutter? Heck yeah! But remember, if you stack up Epic, Cerner, McKesson, Siemens, etc. and you’re looking for a good, integrated HIS, who do you think people will pick? The market is saying Epic, and from what I’ve seen, it’s a solid choice.

Now having said that, here’s my beef with what I’ve seen over the past few years. There are a lot of health systems that implemented one costly solution and decided a couple of years later to throw more money around at another solution when really the two different systems are hardly different. In a homogenous environment, if I have Cerner Millennium and I’ve been running it for four years, why would I then go and say, “Well, let me ask the Board to toss out a few hundred million more and get Epic because my competitor has it.”

Is Epic better than Cerner? Yes it is! Is tens or hundreds of millions dollars better? Not by a long shot. It looks like for the past year or so, the bandwagon-hopping system selection methodology has slowed quite a bit, but there are hospitals still looking for solutions and if they’re big or an academic setting, more likely than not, they’re implementing Epic.

Being Ricky Roma, … Or, Tales From the Dark Side – Episode IV 

As a long-time reader who has enjoyed the high quality of the Mr HIStalk and HERtalk musings, I would like to share some personal thoughts, observations, and recommendations in the area of healthcare IT sales; aka, "the Dark Side". I have lived in both the hospital IT management world and the vendor world and have learned that most of you who work in hospitals ‘don’t know the power of the Dark Side’.

Sales is often called the "Dark Side" of our industry because of the perception of having to forfeit one’s ethics, morals, ruth (as in the opposite of ruthless), and all other goodness remaining in one’s soul in order to be successful. Plus you generally have to wear a suit and fancy shoes all of the time.

In many cases, an attempt to characterize any large group defaults to the actions of a few tainting the image of the many. However, in sales, this is usually not the case. Most sales people in nice suits in fact should be treated like Sith and duly avoided.

Even in this current economic climate, you may have an occasional desire to purchase new, or possibly even better, technology; and sometimes must engage with those who are specifically compensated to separate you from as much as your hard-budgeted money as possible. In this mini-ecosystem, all sales people and sales organizations plot to favorably position their wares. Some, will occasionally misrepresent their goods and/or services. To help you fight the Good fight, here are a few simple tips from the Dark Side

NEVER believe the demo
ANYTHING can be made to work in a PowerPoint/Web/canned environment. Please say this out loud, right now, in your best Senator Stuart Smalley affirmation voice. Anything, even an enterprise EMR that connects seamlessly with any and all other applications, can be shown to work on a laptop. There are plenty of companies that put more resources into building demos than the product itself. The vendor product demonstration is a fair way to baseline what the product or service is supposed to do, but should always be viewed with suspended belief. Don’t believe the demo.

A good plan to ensure reality meets expectations is to write out the functionality you are looking for (some people use categories such as "Must Have" and Like to Have" for this) and then ask at least two vendors to see this functionality working in several actual installed customer sites (Web conference is a good way to do this logistically). Do this at the very start of your process. If the vendor balks at this, you should either run away as fast as possible or be fully cognizant that you will be signing a development deal.

Remember, the demo is an illusion. A lunch demo, doubly so.

Think carefully about the site visit
If it isn’t obvious to you, the site visit is the most one-sided event since the war in the Falklands. In my vendor career, I have only ever lost one deal out of many, many, many where we did a site visit. And that was my own fault for mismanaging cultural personality differences. We on the Dark Side love the site visit since we get to stack the deck and script 99.44% of the event. In my hospital career (pre-Dark Side), I usually felt like I was the mark in a shell game on these visits. How about you?

In the same amount of time that it takes to travel to TX, NY, CA, FL, WI, PA, KS, TN or anywhere else from that Johnny Cash song, you could do at least ten reference calls or Web meetings, while at the same time saving some of that hard-budgeted money. The bottom line is that ALL vendors have their one or two showcase sites in their proverbial back pocket. Getting beyond these "set-ups" and talking to regular customers will mean the difference between purchasing a solution that will bring value to you and your hospital and explaining the failure at next year’s capital budgeting committee meetings or at a job interview.

If you do decide upon doing a site visit, be sure to ask if the organization you are visiting receives any compensation (such as maintenance credits, discounts on past or future purchases, paid-for trips, etc) from the vendor for their hospitality.

Negotiations
The variety of individual and organizational negotiating styles never ceases to amaze me. Zillions of books, ranging from achieving win-wins to subconsciously hypnotizing your opponent, have been written on negotiating, so I won’t belabor this point except to provide two snippets of inside information from the other side of the table.

The first is to not agree to terms until you have had at least one "walk-away" from the deal. Even if you are the most soft-ball negotiator in America, you can get more of what you want (lower price, better terms, better support, etc) in this fashion. A week or two of delay in your buying process generally won’t harm a well-planned project, but it is just murder on a sales person who thinks he/she is close to signing a deal with you, especially when their sales manager/VP is breathing down their back to close it before the end of the month/quarter/fiscal year or pink slip.

The second point is to ALWAYS maintain a line of discussion with your back-up vendor, and tell your chosen vendor that you are still also in discussions with their closest competitor. I have often seen some hospitals take this a little too far literally undertake dual contract negotiations. My personal belief is that this is a waste of time. Lawyers, (who mostly live in an even Darker World ) may recommend this, but just keeping a back-up solution in the wings is generally sufficient.

The Good, the Bad, and the Ugly
My final recommendation from the Dark Side is to proactively do your best to work with good sales people. This may sound like the ultimate in oxymoronism to you. But, in my experience in interviewing more than a few sales candidates over the years is that Pareto Principle rules. Almost all sales organizations are made up of roughly 20% standouts (Good); 60% who are OK and can do the job (Bad); and 20% who should cause you to demand a replacement (Fugly). So, before you condemn all sales people back to the used car lot, there are several upsides to working with that top 20% sales person that you should know about:

• They are a good litmus test for the quality of the company. They won’t stay at bad companies because they cannot earn the type of money they know they can command. Like the Canary in a Coal Mine, they will not be around if the company’s oxygen is depleting.
• They carry a lot of clout in their organization, much like your hospital’s surgeons. If you need to ask a favor, they can almost always get something done for you.
• They are almost always well connected in the industry and can make connections for you, for things like back door references on other projects, quality IT personnel you may want to poach from other healthcare organizations, pulled pork recipes, etc.
• They can actually add value in helping you with your process and end goals. This may sound like heresy to those who think all sales people are predatory scum, but the Good’s history of success generally means that they have observed many best practices which can ultimately help make you more successful.
• Show your sales person the door if they over-rely upon their number of years in healthcare to try to win credibility; or if they "name drop" more than four or five people in your meeting. If industry longevity is their only way of winning your trust, then you are not dealing with someone who can help you.
• To test the credibility of your sales person, try asking a ridiculous question. Ask if their product will do something that is technically impossible or that you know cannot be done. Ask if the service can be customized to do something outside the bounds of reality. This may sound a little silly, but some sales people will say just about anything to try to win your business, especially if they are struggling or had their nest egg  invested in Fannie Mae. I guarantee you will be surprised and amused by the variety of responses you get to these character tests.
• Finally, if do you get stuck with a Fugly, someone who is in that bottom 20% or even in the bottom 80% for that matter, but you think you might like the product or service they are selling; you should e-mail the company’s CEO to let her/him know that you were a underwhelmed by the quality of the sales effort. Tell them that you would like to either work directly with said CEO or be reassigned to the company’s top sales person. Either way, you are going to be guaranteed a high level of service going forward. Also, you are more likely to get a really good deal. If you didn’t already know this, a selling CEO is the bane of any VP Sales’ existence. We all know that the CEO will give away the farm to close the deal. As the top dog, he/she simply cannot allow himself or herself to fail at closing the deal.

I hope this brief peek into the power of the Dark Side was helpful for you. Also, for the sake of my Good peers, I ask that you use any of this information for good, not evil purposes.

END

News 1/14/09

From Fish n’ Chips: "Re: Sutter. oneHITwonder hit the nail on the head. Epic is not going well with Sutter. More delays. 2+ years behind schedule. And money … well, can Sutter print money like the Fed does? They are going to need it."

From SQLImplosion: "Re: Sunquest. As the days go by, more and more Sunquest personnel are being escorted out the door. Not just your every day Joes, but the heart of the former Sunquest team. Tuesday, January 6 saw many employees let go, followed by the former service executive team on Friday the 9th. Now today, Tuesday the 13th, 49 more senior members of staff are gone for about a 20% headcount reduction. The number of years of experience of this staff, well over 600." I’ve contacted the company about the several reports I’ve received in the past few days. They promise a statement here Wednesday. I’m realistic: companies both good and bad are making tough decisions for reasons beyond their control. The first obligation of a business is to survive since it’s not doing the remaining employees any favors to let the entire ship go down together. We’ll hear Sunquest’s side soon, but unlike in giddy times when layoffs were just a convenient way to trim deadwood, I don’t think employers are happy about job cuts this go round. Condolences to those affected in any case.
 
From The PACS Designer: "Re: Cloud 20. Nicholas Carr of the RoughType Blog has a new book out called ‘The Big Switch’. He lists his 20 early cloud computing adopters as the Cloud 20: Adobe, Akamai, Amazon.com, Cisco Systems, Citrix Systems (including XenSource), EMC (including VMware and Mozy), Facebook, Gh.o.st, Google, IBM, Intuit, Metaweb Technologies, Microsoft, Mint, Salesforce.com, Sun Microsystems, 37signals, 3tera, Workday, Zoho." Link.

From Atlas Shrugged: "Re: Akron General. Cutting senior administrators." Link. Out: COO, SVO of marketing, president of the physicians’ group, and the VP of managed care. Layoffs are possible, the hospital says.

From Walnutz: "Re: NJ. Meridian Health buys Bayshore Community Health System and Southern Ocean County Hospital. Also, Bayshore cutting hours in lieu of layoffs. All hearsay from my vantage point, but plausible." Meridian and South Ocean announced exploration of a merger late last week and Meridian had already announced that it was talking merger with Bayshore. Given the desperate hospital situation in NJ, I would be surprised if it doesn’t happen.

From John: "Re: Web 2.0. Web 2.0 and social networking are already playing a role in healthcare. People are helping each other out, providing information and support. It’s happening right now, go and see for oneself. For example, a few quick searches in Facebook finds the group ‘Support the fight against cancer with just a click’ has 1,400,000 members, Autism Awareness has 60,000 members, and ‘Find a Cure For Juvenile Diabetes’ has 27,000 members. Now if by ‘healthcare’ one means ‘the sustainable business model one can come up with to monetize healthcare communities of interests,’ that poses a different question. However, the answer might stem from the large number of folks currently participating in the former notion of ‘healthcare.’" Brilliant and well said. Maybe healthcare as a business has made all of us too cynical about any manifestations of it that don’t come with a big-name CEO or a liquidity event.

Update: I forgot to mention that Medicity and Novo Innovations have formally announced their merger. I’ve thought Novo was one of the coolest companies out there when I interviewed mad scientist Robert Connely in 2006 (one of the most fun ones I’ve done – I need to get him to sit still for a second round). What makes the merger interesting is that Medicity has made great leaps with its technologies and understanding of the RHIO/HIE market and Novo brings its "intelligent agent" technology that provides a more direct connection to physician office EMRs. As my poll and the new report I mention a few paragraphs down indicate, people are beginning to realize that unconnected EMRs are first generation and a some companies (Medicity and RelayHealth come to mind, but there are others) are approaching the EMR benefit model from the other side.

I’m really excited about some upcoming goodies in HIStalk and HIStalkPractice. I always get discouraged through the holidays because the energy (and readership) drops, but it’s going great guns again. We’ve got some super, hand-picked guest authors coming on both sites (and isn’t it cool to see what John Glaser is thinking?) I’m pretty sure Inga and I have never worked harder to get information out there. The bad news is that I’m behind again, so be patient if you’ve e-mailed me. I’m cranky if I don’t sleep and something had to slide a little.

Shares in practice financial management company MedAssets rise 8% after the company reaffirms its 2008 outlook and raises 2009 earnings guidance.

Cerner’s second managed on-site medical clinic opens at Cisco. The article says it was a money-saver at Cerner, which is not surprising if the employee reports I received are accurate (high prices, low coverage). I’d like to think employee satisfaction with the service is important, but in a buyer’s market, it probably isn’t.

Housekeeping: drop your information in the Subscribe to Updates box to your right to get an e-mail blast when I write something new (and do the same on HIStalkPractice if you’re interested since they are separate lists). Right below that is an oh-so-convenient Email This to a Friend button that lets you easily tell people about HIStalk. There’s a search box over there too, which will obediently dig through 5.5 years of HIStalk to find whatever you’re interested in. And, a hideous green Rumor Report button by which you can send confidential stuff my way, even including scandalous attachments.

Listening: The Trash Can Sinatras, lush jangle pop that’s how REM would sound if they were raised in Scotland instead of Georgia.

A report from Booz Allen Hamilton and the Federation of American Hospitals concludes that healthcare IT emphasis needs to be on improving electronic communication among patients and providers rather than getting EMRs installed, with a shift needed way from EMRs as the "big bang" or "magic bullet". Some of its key points:

• Focus on e-prescribing, electronic results, and medical imaging.
• Tie payment to desired outcomes.
• Implement a national health information exchange. The UK already has 90% EMR penetration and a single national broadband network, but they’re still pursuing interoperability as its own separate project.
• Give patients access to their records and a way to communicate with their physicians about them.
• Create a voluntary personal identifier.
• Provide more funding to ONC to go beyond demonstration projects.
• EMRs adoption is poor, but could be improved by generating a "pull" for available electronic data.

I’ve said that here before, of course: PC vendors didn’t have to beg for adoption once the Internet came along. Create valuable content and people will find a way to obtain and use the devices required to access it. This is the second thoughtful report in a handful of days, of course, that questions whether just buying a lot of EMRs will improve healthcare. My theory, for what it’s worth: there will be limited success (defined as improved outcomes) in bringing technology to healthcare IT until everybody realizes that doctors won’t work as typists for free (my previous analogy that everyone wants to consume information, but few want to create it). Drop the guilt-inducing term "EMR/EHR" immediately and focus on deconstructing it into the individual functions that provide value to a given practice. Current technologies can support the market’s demand for functions that are modular, Internet-based, paid for as a service, and in full communication with the outside world, so vendors who don’t want to fight to overpower a generally resistant market will find success in going around that obstacle instead of trying to climb it.

But maybe you already knew that about connectivity is important: the leading vote-getter in the "Spend Obama’s Money" poll to your right is creating a national infrastructure for sharing data (43%), double the percentage who think subsidizing today’s EMRs is the best way to goose HIT.

Interesting: David Bowen, CIO for the Federal Aviation Adminstration and safety whistleblower, came from BCBS of California, Catholic Healthcare West, and Baptist Birmingham.

Caswell Family Medical Center (NC) gets a $99,000 grant to install an EMR.

Hospital layoffs: Westchester Medical Center (NY), 400; Memorial Hospital (PA), 32; Saint Alphonsus Regional Medical Center (ID), 66; Brockton Hospital (MA), 6; Mercy Health Partners (MI), 31; St. John’s Hospital (MO), 19; St. Joseph’s Hospital (WV), 20.

Estonia’s patient portal is delayed. I might be the only one who cares, probably because I’ve been there.

i-Rox, an Israel-based software development company whose employees are all ultra-Orthodox women (thus the name, a play on Internet and Orthodox), is developing a clinical information system for Palestinian Authority hospitals.

An Alaska hospital stops providing birth notices to the local newspaper, even if the parents sign a consent form, fearing abductions.

ED departments and after-hours clinics in Wales will have online access to patient information if the vendor’s final business case is approved.

Health Level 7 releases (warning: PDF) a child health functional profile for EMRs.

Jobs: Cerner Practice Director, McKesson HPP V13, Cloverleaf Integration Consultant.

David Brailer’s Health Evolution Partners announces a partnership called 21CM (21st Century Medicine) that "will identify innovations which change how medicine is practiced." Sounds like he’s found well-known hospital CEOs who are going to give him free investment ideas. Whether they get anything in return isn’t stated.

Intelligent transcription software vendor MD-IT closes $11 million in Series B private equity funding.

CMS tells WellPoint that it won’t allow the insurer to enroll new Medicare drug plan customers because it hasn’t fixed its ongoing computer problems. 

Toronto General Hospital performs a study to find the cause of pseudomonas infection in its ICU that killed 12 people. The answer, published in a journal this month: the sinks. The result: one patient who claims his complications were caused by contracting pseudomonas is suing the hospital for $40 million.

E-mail me.

HERtalk by Inga

From Famous Publisher: “Re: HIStalk. Flattered to hear from the famous Inga! Your site kicks butt. I’ve seldom seen IT folks swarm that way.” Famous Publisher sent me this note after I signed up to follow her on Twitter. Thanks for the nice words. By the way, thanks to all 35 of you following me on Twitter. Since I am the one who encouraged Mr. H to start twittering, it hardly seems fair that he already has 53 followers. Oh well.

Speaking of Twitter, I am following our possible next Surgeon General, who posted the above message Tuesday afternoon. Just think what a fit nation we’d be if Dr. Gupta was at the helm! Kind of inspires me to do some sit-ups tonight.

President-elect Obama taps William Corr as HHS deputy secretary. Corr is a longtime anti-smoking advocate and is currently the executive director at the Campaign for Tobacco-Free Kids.

The healthcare sector gains 30,000 jobs in December, while the nation as a whole loses more than 2 million. About 14,000 of the jobs are in ambulatory care, 12,000 in hospitals, and the rest in long-term and home health care.

Michelle Obama officially resigns as VP for Community and External Affairs at the University of Chicago Medical Center.

I was on the HIMSS site today and noticed there are only 81 days left until the annual conference. There are over 200 educational sessions, which is pretty overwhelming to consider. I would expect Mark Leavitt’s CCHIT Town Hall session to be a big draw. Personally, I might pop into the session called “Change EMR Vendors Midstream? What Were You Thinking?” Harry Lukens of LVHHN is the presenter and he is pretty entertaining. Of course, I’ll probably try to get a peek at Dennis Quaid. I wonder if he’d like an invite to the HIStalk event?

Opus Healthcare announces that its OpusMobility system now runs on the Google G1 phone.

ICA appoints John Tempesco VP of Client Services. Tempesco has been with ICA since February 2008 and previously worked at HealthPort and Companion Technologies.

Former Intel executive Greg Symon joins Red Hat as VP and GM of North American sales. We noticed that former Red Hat VP Dave Nesvisky (who Mr. H interviewed last May) is now EVP at Voxiva.

Memorial Hospital (NJ) signs a six-year agreement with PHNS to provide all the hospital’s IT services.

UHIN (Utah) selects Axolotl’s Elysium Exchange to power its HIE.

Oleen Pinnacle Healthcare Consulting acquires New York IT consulting firm Partners in Health Systems.

The Stratus Avance product wins a InfoWorld Product of the Year award in the category of Best High-Availability Solution for SMBs.

E-mail Inga.

Being John Glaser 1/13/09

The National eHealth Collaborative

In 2004, the Federal Department of Health and Human Services (HHS) established a series of organizations and initiatives in an effort to further the adoption of interoperable electronic health records (EHRs).

The Healthcare Information Technology Standards Panel (HITSP), the Certification Commission for Healthcare Information Technology (CCHIT), and the Office of the National Coordinator for Healthcare Information Technology (ONC) were established. Demonstrations of aspects of a National Health Information Network (NHIN) were conducted, analyses of privacy regulations were undertaken, and assessments of EHR adoption were performed.

Overseeing all of these activities and organizations was a Federal Advisory Committee, the American Health Information Community (AHIC). You can learn more about all of the above at www.hhs.gov/healthit. AHIC was chaired by the Secretary of Health and Human Services and the committee’s membership was composed of individuals from diverse sectors of healthcare and various HHS agencies and Federal departments.

AHIC was set up to transition, at the end of 2008, to a successor organization. During 2008, the Brookings Institution managed an extensive series of meetings and analyses which involved hundreds of individuals from across healthcare, which designed the successor. This successor was to be a public-private organization and continue the work of the AHIC.

The resulting successor organization is the National eHealth Collaborative (NeHC). You can learn more about NeHC at www.nationalehealth.org.

NeHC is focused on advancing the adoption and effective use of interoperable EHRs. To do that, the NeHC will:

• Use Value Cases to define opportunities to establish interoperability standards. The Value Case approach modifies the AHIC Use Case by performing more upfront analyses to ensure that the standards have a compelling value proposition and are likely to be adopted quickly by the market. In addition, the Value Case approach requires greater participation by healthcare organizations and seeks external funding of the work. It is highly likely that the Value Cases will be broader than transaction standards; Value Cases could also be policy and architecture frameworks and best practices. HITSP and CCHIT would continue their respective roles of interoperability specification development and product certification.
• Develop preliminary strategies and approaches for governing the emerging National Health Information Network.
• Identify barriers to the adoption of interoperable EHRs and commission work designed to overcome those barriers. This work might center on financial incentives, privacy approaches and procedures, data use agreements, and implementation practices.

NeHC will focus on “the ground.” In other words, while NeHC will work with government and industry on policy, its core orientation will be practical – how do we help those of us who are trying implement these systems overcome barriers and have a greater likelihood of improving care?

NeHC is a membership organization. Its members are organizations that have an interest in interoperable EHRs. In the next couple of months, information will be made available that outlines the membership application process and dues structure.

You all should check out the NeHC web site for new developments and announcements. You can also contact me (jglaser@partners.org) or Laura Miller, NeHC Interim Executive Director of NeHC (lmiller@ahicsuccessor.org) with questions and comments.

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

Bill Stead on the National Research Council’s Report

Full text of the report is available here.

The report calls for a change in approach to health care IT.

This conclusion does not reflect negatively on the sites visited. To the contrary, their pioneering work and suggestions let the committee see the way forward. It does not contradict calls for increased investment in health care IT. Better management and use of information are essential to improving the health care system.

The report suggests that a larger dose of today’s health care IT will result in both improvement and harm. It will cost more and take longer than people expect. Collectively, the result will fall far short of what is needed.

For example, today’s clinical applications tend to be monolithic and complex. Rather than enabling small improvements in practice, the many information system interdependencies actually slow down improvement! Instead, clinical applications should reduce barriers to clinicians and patients doing what is best for care – even if doing what is best requires rapid cycle, iterative change in clinical behaviors and work flows.

A different outcome is possible. We do not need to wait for better IT before we move aggressively forward. However, near-term success will require a fresh approach to managing the investment by health care organizations, our health care IT vendors, and the government.

The report lays out five principles for use of IT to support evolutionary change in health care that are actionable in the near term. With a longer view, it identifies four principles to support revolutionary change and several research challenge problems.

It includes six recommendations directed at the senior management of health care organizations and, through them, to their vendors. Let me highlight a couple.

Organize incentives, roles, workflow process and supporting infrastructure to encourage, support and respond to opportunities for clinical performance gains.

In other words, the IT infrastructure should evolve with the improvement process, not lead it.

For example, if your goal is to reduce medication administration errors, start with incentives and infrastructure for blame-free reporting. Next, identify the situations with a high rate of "wrong patient, wrong dose" errors. Then, target deployment of technology support like bar code medication administration to those situations. Finally, continue to monitor performance, refining the combination of process and technology if needed, or extending to the next highest problem area.

In this way, you guarantee improvement. Use the technology only where needed and correct unintended consequences early.

Balance the institution’s IT portfolio among the four domains of automation, connectivity, decision support, and data mining capabilities.

The majority of today’s health care IT is designed to support automation, with some investment in supporting connectivity and little support of decision making or data mining. Yet the IOM’s vision for 21st century health care expects support for cognitive activities (helping providers and patients think about complex choices as they make decisions) and a learning health care system (mining related bodies of data to recognize and respond to patterns).

These activities are much more about connectivity, decision support, and data mining than about automation. The required shift in focus is large. Technology exists to support movement in these directions, but it is outside the comfort zone of many health care organizations and the established health care IT vendors.

Finally, read the report! It is short. It reflects careful study and review. With complex issues, one sentence may balance another. Hearing one sound bite without the others can mislead.

Health care organizations and health care IT vendors should read section 3 (rebalancing the portfolio), section 4 (principles for success), and section 6.3 (recommendations for health care organizations. They add up to only 12 pages.

In addition, I would point vendors to Appendix C, which summarizes the committee’s observations, the consequences, and opportunities for action, with the latter tagged as short term or research. Check your current offering and product direction against the ones tagged as short term.

William W. Stead, MD is associate vice chancellor for strategy/transformation, director of the Informatics Center (which includes the Department of Biomedical Informatics of the School of Medicine, the Eskind Biomedical Library, and the Center for Better Health), and CIO at Vanderbilt University Medical Center; and chief information architect for Vanderbilt University. He is chair of the Committee on Engaging the Computer Science Research Community in Health Care Informatics, which produced Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions under the auspices of the National Research Council.

Monday Morning Update 1/12/09

From You Missed This: "Re: another e-mail blunder from an HIT CEO." Eclipsys CEO Andy Eckert accidentally copies an equities analyst from Thomas Weisel Partners on what was supposed to be a private e-mail to CFO Bob Colletti and EVP Jay Deady, in which he remarked that a Weisel research note questioning the company’s growth rates, "certainly zeroed in on our organic growth rate." Andy told the analyst that what he was saying is that organic growth is a focus, not admitting that Weisel had uncovered a weakness. Still, the analyst’s generally positive opinion didn’t change.

From oneHITwonder: "Re: Sutter. My father was recently a patient at Sutter General Hospital in Sacramento (he’s home and doing well now). While visiting, I watched a nurse enter his room and pull down a wall-type desk, which revealed a keyboard and monitor. I was very impressed, but the nurse did not use the computer — she just pushed the keyboard out of the way and used the desk for a writing surface. I later asked another nurse if she uses the computer in the room and she said only if all the workstations at the nurses’ station are being used. Another nurse joined in, saying they were put in the room for ‘e-charting’ that never materialized, assuming ‘it must not be going well at other Sutter hospitals’ (I believe the reference here was to Epic). They occasionally look up lab orders, but that is about it. Sutter General uses Eclipsys for CPOE."

From The PACS Designer: "Re: Palm phone. Palm has released its challenge to the iPhone and it created quite a stir at the Consumer Electronics Show. Perhaps there’s a place in healthcare for the new Palm Pre to support user requests to add it to existing systems." Link.

This sounds interesting: Infirmary West (AL) launches an Internet system that lets patients self-register (for a $25 fee) for non-life threatening ED appointments, then come in at the appointed time instead of sitting around watching Judge Judy amidst the mayhem. They take it seriously: if the patient isn’t seen within 15 minutes of their appointed time, their visit is free. The nurse who runs the ED came up with the idea. An employee checks each registration as it comes in to make sure the patient’s condition doesn’t require immediate evaluation. Notice that the registration screen also provides an estimate of when you’ll be seen even before you sign up. The system provider is InQuickER, which runs the same service for several hospitals, but I can’t find out anything about the company.

A reader sent over a local article about December layoffs at North Memorial and Park Nicollet in Minnesota that were to affect over 600 positions.

Medfusion, the Raleigh, NC vendor of consumer-facing technologies for physician practices (like patient messaging, online registration, online payments, etc.) buys the former A4 and Allscripts office building in nearby Cary for $7.25 million, citing strong sales and the need to add up to 50 employees to join the current 70 in 2009.

Tennessee RHIO Shared Health hires Adnane Khalil, formerly of MedAvant, as VP of technology.

I’m doing some tentative experimentation with Twitter, so if you want to follow me, I’ve put an icon over in the right column. You won’t get much except updates when I publish something new, at least until I make it part of my routine. I might use it from HIMSS.

The CFO of Misys PLC resigns "by mutual consent."

Last chance for HISsies nominations. When the voting starts, you’ll say, "Why didn’t that idiot include these obvious nominees?" and I will smugly respond, "Because you and your passive ilk couldn’t be bothered to click a simple link to nominate them." To avoid all that unpleasantness between us, you might as well cast your nominations.

Nobody likes it when welfare recipients complain about the free money they get from the rest of us, so maybe HIMSS should be careful about how it characterizes its EMR Welfare Program. In Modern Healthcare, its director of congressional affairs is quoted as saying, "Our minimum is $25 billion."

I’ve never heard of Leap of Faith Technologies of Crystal Lake, IL, but the eHealth technology vendor is looking for testers for its "virtual pillbox" for smart phones. The eMedmobile application extracts information "smart labels" on pharmacy containers to issue medication reminders and to notify someone if the patient misses doses. Grants to help cover its development cost came from NIH, the National Cancer Institute, and the National Institute on Aging. Check out the demo – it’s cooler than it sounds. 

Interesting: medical students at University of Washington practice surgical technique in a mocked-up OR that includes a computerized patient. What’s different is that they’re also using simulations like these for nurses, dentists, and pharmacists and will combine the programs to teach the professionals communicate better, not just to practice their technique. A good line from the executive director of UW’s Institute for Simulation and Interprofessional Studies on the traditional surgeon’s training of learning on live patients: "I’d rather be able to tell some surgical resident, after 25 unsuccessful tries on a simulated patient, that maybe he ought to consider going into pathology.” UW is is also trying to get Microsoft to adapt the Xbox to allow training students at remote locations, but apparently hasn’t had much luck.

Reports suggest that troubled Satyam Computer Services is looking for a buyer. The CEO was arrested and the board dissolved this week after admitting that revenue was overstated and $1 billion of cash assets did not exist. Law firms are lining up to get a shot at the lawsuit coming against auditors PricewaterhouseCoopers, about which one big equity firm’s head said, "If you’re an auditing company and your client says they have $1 billion in cash, you do check with the bank." The company’s interim CEO was formerly president of its commercial and healthcare businesses.

Cardinal Health cuts its fiscal year outlook, citing hospital cutbacks in capital spending.

I’m guessing Bush and Obama don’t agree on much (thank goodness), but here’s one goal both think is important: having electronic health records for all Americans by 2014 (and that you can deficit-spend your way out of a depression, apparently). In a speech Thursday, Obama said the government will make "immediate investments" on IT, which will not only save money, but "reduce the deadly but preventable medical errors that pervade our health-care system." With that in mind, Gerson Lehrman Group predicts a 14.1% annual growth in the EMR market, although they oddly list Google and Microsoft as big potential winners (and also GE and Siemens, whose products I sure wouldn’t want my taxpayer dollars to fund if it’s innovation that’s needed). It’s funny that the Republican pushed free open source solutions like VistA, while the Democrat seems to be in favor of just buying commercial products with federal money. You’d think it would be the other way around, although not when the goal is just to spend a bunch of government money.

With that in mind, new poll to your right: where should the billions be spent?

Hospital layoffs: Good Samaritan (NE), 32; St. Francis (NE), 22; Blue Hill Memorial Hospital (ME), no number given; University of Chicago Medical Center (IL), up to 1,000; St. John’s Regional Medical Center (CA), 33; Los Robles Hospital & Medical Center (CA), 8; Ventura County Medical Center (CA), 30; Central Kansas Medical Center (KS), 50; Carson Tahoe Regional Healthcare (NV), 30; Erlanger Medical Center (TN), 80. Tenet Healthcare announces cuts in vacation time, sick time, and 401k contributions for its 50,000 employees. CGH Medical Center (IL) shuts down its free nurse hotline that gets over 550 calls a week.

West Penn Hospital says it fixed a patient-reported problem in which its online bill payment application that allowed users to see information about other patients. The hospital blamed a billing partner, but didn’t explain why the patient e-mailed the hospital twice and didn’t get a response until she called the local TV station.

More on the National Research Council’s Report on Healthcare IT

I worked late Friday night to get a summary of the report out because I think it’s important. I’m already getting some thoughts back from folks in the industry, so I think we’ll have a good dialog about what it means.

Much of what I’ve written in the past aligns with what the report says. In 2005, I cited an excellent report from The Advisory Board Company as the basis for an editorial on the shortcomings of clinical systems like CPOE, which the report said fails to improve practitioner performance 87% of the time. I said, "Several years after the IOM report that supposedly opened our eyes, clinical systems really haven’t delivered on the expectations. They haven’t made us much better … Everyone is buying and implementing and improving, but the patient doesn’t seem to get much benefit from all this clinical system churning. We’re still plagued with poor integration, sloppily designed bolt-ons to old products, and outdated architecture. We’re also not good at changing business processes on the provider side, so let’s take a few lumps along with our vendors. We’re equally guilty."

The logical question people might ask themselves: I agree with the report to some extent, so what happens next? Will the conclusions cause years of sustained activity and industry self-reflection like IOM’s "To Err is Human"? Some thoughts:

• Who’s going to pay for all this clinical and IT improvement?
• Is the IOM’s vision of patient care a reality or a pipe dream? Will hospitals commit to it? If not, there’s no reason to build automation that won’t be used – we already have that problem.
• Show the numbers that justify the cost. Did UPMC’s cost or outcomes improve after they spent tons on IT? Are they better than less-automated facilities? So far, the link between IT investment and excellence (of any kind) seems iffy, especially when held to the standard that IT caused the improvement, not just co-existed with it.
• The report suggests that a complete shift in systems development, implementation, and use is needed. So how do you put that into play, especially in a competitive IT market where vendors can’t just scrap what they have and start over? And in a competitive provider market that’s struggling with low margins and entrenched inefficiency?
• Were conservative CIOs part of the problem, happy to ditch best-of-breed systems in order to gain integrated mediocrity that’s easier to support? And is that still necessary with more modern integration technologies? All of those systems were designed even before the Internet caught on.
• Maybe the next step would be to create specific standards from those goals that could be used to assess specific systems and their use. I’ve often said that a big problem with clinical systems is "having them" vs. "using them to improve care."
• The challenge will be the lack of standards in hospitals, even the lack of repeatable processes within a given hospital. Hospitals are notoriously unwilling or unable to get employees and physicians to follow even obviously important rules (like "wash your hands"). Systems are hard to support and enhance because hospitals resist change, forcing vendors to build in an infinite number of configuration options.
• The committee intends to follow this report with others, although in the case of "To Err is Human," most of the reaction came from the shock and public shame of the first one (Googling "98,000 medical errors" gives 83,000 hits).
• It will be interesting to see how HIMSS reacts. My first thought was that it would rush out a vindictive, clearly vendor-serving defense like it did with Ross Koppel’s articles, where he studied the unintended consequences of a clinical system implementation that actually increased patient harm, and HIMSS took offense. I think they’re smarter now, though, and will simply suggest more research while staying the course, i.e. still insist that the government should subsidize the purchase of today’s EMR systems, which is diametrically opposite to what the report concludes. HIMSS sees itself as the voice of healthcare IT, so it will surely recommend actions in which it (and organizations it influences) will be a prominent player.
• With that in mind, the last organization that I would want at the table when discussing healthcare IT changes is HIMSS. No offense to them, but their world is high-paying vendor members and flashy exhibit halls, not upsetting the gravy train. The approaches IOM says are wrong are the ones HIMSS pushed us into: RHIOs, CPOE, and "clinical transformation" that rarely had any impact.
• Nothing in the report should be interpreted as blaming vendors for anything. It merely says, "We’re here and we need to change direction to go to there." The job of vendors is to sell what customers will buy, so I take the conclusions as more of a criticism of providers who not only don’t demand systems that might work differently, they don’t even use the ones they have optimally. Providers should be setting the vision, not vendors, but have shown a remarkable inability to do so. Still, current products were based on old paradigms and old technologies, so it’s a good time for vendors to take stock.
• Despite the long list of problems in the report, it should be noticed that some hospitals have had success (quiet or otherwise) using off-the-shelf systems. I see it like this: today’s systems have taken us about as far as they can, hopefully providing value and benefit along with way. Now we’re ready to envision the second generation of systems (I’m arguing that we’re still in the first generation, but you may disagree), assuming that providers are simultaneously ready to embrace the changes that these new systems will support.
• Software vendors and hospitals dedicate a huge chunk of resources to billing and malpractice avoidance. If you want to reform healthcare and healthcare IT, simplify payment and free up all those people working on billing and  other administrivia to do something that actually benefits patients.
• If you want to know what a given person or organization will excel at, look at what they’re paid to do. If you want someone to change their behaviors, make sure you’re rewarding the behaviors you want. If you’re paying someone to paint your house, don’t base their pay on what they spend for paint.
• The bottom line: the goal is measurable quality improvement and reduced cost, not conspicuous consumption of IT. If you pay people to deliver better and cheaper outcomes, they’ll figure out what tools they need.

E-mail me.

A Summary of the National Research Council Report on Healthcare IT

The full text of the report is available free here.

I’ve gone through the report and will summarize it loosely below (the most interesting parts, anyway). A couple of industry experts have volunteered to provide their interpretation. Bill Stead, chair of the group, told me he will write up a short statement on the implications for hospitals and vendors for HIStalk. I’d like your thoughts, too.

Make no mistake, this report is important. The IOM has clout and is generally not seen as biased or influenced by industry. Anyone working on the front lines of patient care will identify with nearly every one of the observations and recommendations, although there’s no easy fix for most of them. The most important thought as you read, I think, is this: what traditional wisdom does the report challenge and who will be upset by that?

• HIMSS won’t like it because they didn’t think of it and it is somewhat critical of today’s systems (I expect a quick rebuttal). It’s quite a contrast to the exhibit hall.
• Not all vendors will like it because it may not align with their architecture or products and it questions today’s concept of integrated systems (note the line about monolithic, integrated systems that can’t support changing ideas – you know a couple of vendors and probably even some CIOs are shooting out of their chairs).
• HIMSS, rah-rah press, and anything Most Wired will hate it because it concludes that, despite big investments and painful implementations, today’s IT is not really helping patient care as much as it could and maybe we’re going further in the wrong direction.
• Users will like the observation that vendors don’t often take human factors design into account, resulting in systems that are hard to learn and use.
• Hospitals will take some offense because it holds them accountable for not using what they’ve bought and using automation mostly for purposes that have minimal patient care value.
• Not everybody in the government will like it because it emphasizes that healthcare needs drastic changes, not just more of the same systems, especially when it come to complicated government payment for services that aren’t necessarily in the patient’s best interest.
• Even the big hospitals that served as the site visits may not like it because, despite the mind-boggling sums all of them have spent on IT, the report doesn’t suggest impressive results. It mentioned one unnamed site (almost certainly UPMC) that has spend $500 million on IT in the past 10 years, but still isn’t where it should be.

For me, the most impactful statement echoed one I’ve made here several times recently: the government should not be in the business of funding IT systems, whether they’re archaic or state of the art. It should reward quality and let providers use whatever tools, IT or otherwise, that will help meet them.

In fact, nearly every conclusion in the report has been covered in HIStalk at one time or another (I’m not bragging on that, just pointing out that for a bunch of academics, their conclusions resonate way down here where Mr. HIStalk plies his IT trade by day and sees what they saw, which I think means they hit the target squarely).

Here’s the summary:

This report was produced by the National Academies, of which the Institute of Medicine is one division (along with the National Academy of Sciences, National Academy of Engineering, and National Research Council). Members of these groups work without compensation to advise the government and the public on science and technology issues.

Members of the Committee on Engaging the Computer Science Research Community in Health Care Informatics are:

William W. Stead, Vanderbilt University, Chair (CIO and information architect)
G. Octo Barnett, Massachusetts General Hospital (Harvard professor and research informatics)
Susan B. Davidson, University of Pennsylvania (computer science chair)
Eric Dishman, Intel (general manager of Intel’s Health Research and Innovation Group)
Deborah L. Estrin, UCLA (computer science professor)
Alon Halevy, Google (research scientist)
Donald Norman, Northwestern University (design professor)
Ida Sim, UCSF School of Medicine (associate professor of medicine and informatics director)
Alfred Spector, Google (VP of research)
Peter Szolovits, MIT (computer science professor)
Andries Van Dam, Brown University (technology and education professor)
Dio Wiederhold, Stanford University (professor emeritus of computer science)

This is an interesting group: mostly computer experts who could bring an objective viewpoint to the table (no vendors, no advocacy people, no caregivers). Some bias was obviously introduced upfront when choosing the committee members, the site visits, and the guests providing briefings (the "smart table" and Azyxxi-like analytical tools obviously were inspired by Microsoft, which did one briefing).

The committee disclaimed upfront that it did not look at all care sites and roles, particularly the 1-2 physician practice where much of the medical care is delivered in the US. It is hospital-centric.

The committee’s charter was to determine how well providers (hospitals, for the most part) are using technology support to strive towards the IOM’s vision. The tenets of that vision and visionary examples of how computers might support them are (from my interpretation and their examples):

• Comprehensive patient data. Computers could identify and count home meds, then using RFID-encoded prescription information to assess patient compliance.
• Patient-specific clinical decision support. Instead of looking at paper EKG strips, the doctor sees them overlaid with an animated electronic model of the patient’s heart. Historical information is presented in a consistent format for easy comparison.
• Application of evidence-based practice guidelines and research into practice. Doctors can subscribe to medical literature alerts, download new clinical guidelines into their systems, and use them to construct a series of patient flowcharts to choose from, when will then update disease management dashboards, order sets, and pre-programmed reminders.
• Tools that can highlight patient and population problems. A doctor can review a dashboard of all their diabetic patients, with all measures of disease color-coded so that all patients can be quickly assessed visually and interventions planned. During the patient’s visit, the system chooses drugs based on their therapeutic class and insurance coverage.
• Rapid integration of devices and historical patient information as a "learning" system. Patients run applications on their smart phones that measure activity and post it to their Facebook page widget. Inhalers are Bluetooth-enabled to monitor compliance and provide alerts tied to activity and environmental factors.
• Integration of information from alternate care sites, such as the home. Diabetics wear continuous blood glucose sensors that suggest action and dial an emergency number on their cell phone if readings advance to dangerous levels.
• Empowerment of patients and families with personal health records, education, and provider communication. EHRs allow patient access via the Internet and have an interpretation function that gives a lay explanation comparable to what a physician would provide.

What’s wrong with today’s use of IT

• There’s a big disconnect between systems and clinical practice.
• Systems place too much emphasis on clinician data entry without giving them value in return.
• Implementation cycles are too long, often measured in decades.
• Clinicians spend too much time digging through raw data that systems dump in their laps, leaving them to figure out how to use it in thinking about the patient.
• Today’s systems are build on a transaction-heavy foundation, with minimal context or grading the importance of information.
• Decision support should provide cost analysis, grade the quality of information, and allow clinicians to simulate interventions before doing them for real.
• Systems should be designed as thinking systems with transactions built in, not as transaction systems with decision support bolted on.
• Caregivers should not have to manually enter data that is being collected by electronic sensors – systems should be self-documenting.
• Users should be able to pose questions and have retrievals query multiple databases without requiring data in them to be standardized.
• Physician-patient interactions should be captured by real-time transcription and camera/microphone recording with suitable privacy consideration.
• The government’s role should be to embrace quality improvement, not to promote specific technologies that lock users into inefficient workflows. Incentives should be aimed at infrastructure, hardware, and data mining.
• IT should not be promoted en masse to clinicians until it helps them do their jobs better.
• A wide variety of payers with their own rules wastes a lot of clinician time trying to get paid.
• Clinical systems require extensive training, unlike PC applications that follow standard UI design and require no training.
• When clinicians round, applications add little value to the discussion and its results aren’t recorded anywhere for later use.
• Provider IT investments should be evaluated within four IT domains: automation, connectivity, decision support, and data mining.
• Organizations should at least scan their paper documents to make them available electronically.

Observations from the committee’s site visits

• Hospitals have a mix of paper and computer records, so users have to learn where to look.
• Work lists are usually managed on paper.
• Clinical systems were simply built to look like the paper they were supposed to replace, such as flowsheets.
• Documentation is after the fact.
• Clinical roles and responsibilities are not explicit.
• Clinical users value speed over everything else, but they don’t understand the systems that are supposed to support them.
• Legacy systems predominate, each with their own setup parameters and content, implemented with the goal of getting up and running rather than doing anything useful.
• Change management in hospitals means nobody moves ahead until the slowest party is ready.
• Biomedical devices were universally poorly integrated.
• Semantic interoperability is almost non-existent. Systems weren’t designed to guide users through the process of completing common fields with standard terminologies.

Recommendations

Evolution

• Focus on improving care, not on the technology.
• Seek incremental gain for incremental effort, rather than huge IT projects that take forever.
• Capture all the data you can.
• Design systems around human factors principles.
• Support the cognitive function of caregivers.

Revolution

• Design systems with disruptive change in mind, i.e. genomics, which are more easily supported with connected systems rather than monolithic, integrated, all-encompassing systems.
• Archive data in ways that future interpretation and analysis can yield new knowledge.
• Design technologies to eliminate ineffective work processes.
• Design systems that can put data into context.

IOM Report: Today’s IT Systems and Implementation Efforts Aren’t Good Enough to Support IOM’s Quality Standards

A new report published today by the IOM’s research council concludes that today’s hospital systems "fall far short … of what is needed to support the IOM’s vision of quality health care."

In its summary, the report says, "IT related activities of health professionals observed by the committee in these institutions were rarely integrated into clinical practice. Health care IT was rarely used to provide clinicians with evidence-based decision support and feedback; to support data-driven process improvement; or to link clinical care and research. Health care IT rarely provided an integrative view of patient data. Care providers spent a great deal of time electronically documenting what they did for patients, but these providers often said they were entering the information to comply with regulations or to defend against lawsuits, rather than because they expected someone to use it to improve clinical care. Health care IT implementation time lines were often measured in decades, and most systems were poorly or incompletely integrated into practice. Although the use of health care IT is an integral element of health care in the 21st century, the current focus of the health care IT efforts that the committee observer is not sufficient to drive the kind of change in health care that is truly needed. The nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade."

Free access to the full text of the report is available here.

Bill Stead of Vanderbilt chaired the group, which conducted site visits at UPMC; the VA Medical Center in Washington, DC; HCA TriStar; Vanderbilt University Medical Center; Partners HealthCare; Intermountain Healthcare; UCSF; and Palo Alto Medical Foundation.

Given that the facilities observed have what is considered comparatively advanced IT systems and massive budgets compared to the average hospital, the report is sure to have far-ranging implications to the industry, especially as debate continues over whether the best use of federal stimulus money is to fund purchase current systems instead of revisiting whether they are adequate to deliver the changes needed in healthcare. 

News 1/9/09

From Peter Marshall: "Re: layoffs. Here’s another one: Cabell Huntington Hospital (WV)." Link. The hospital laid off 40 people on Tuesday. Like everybody else jettisoning employees, the CEO says the goal is to flatten the organization, making you wonder why he let it get un-flat in the first place (and whether the managers who hired them should be left unscathed). Also in WV, Weirton Medical Center forcibly parts ways with 36 FTEs. Other layoffs: Crozer-Keystone Health (PA), up to 400 employees; Uniontown Hospital (PA), 50 FTEs; Wilkes Regional Medical Center (NC), 45 employees; Noble Hospital (MA), nine employees; Mercy Health Systems (KS), 44 employees; Baptist St. Anthony’s Hospital (TX), 47 employees; Meridian Health (NJ), 65 positions. Erlanger Medical Center (TN) announces plans for a hiring freeze, layoffs, and renegotiation with suppliers. In case it’s not obvious, hospitals were waiting until after the holidays to cut staff, but the plans were in place long before Christmas.

From djk: "Re: Swedish Covenant Hospital, Chicago, is named a HIMSS Analytics Stage 6 EMR hospital." Their congratulatory letter from Mike Davis says 25 hospitals have now hit the Stage 6 mark.

From Boutros Boutros-Ghali: "Re: Web 2.0 and social networking. I’m interested in what role it will play in healthcare." I’d like to hear some opinions on this. I have to say I’m skeptical because some of the ideas seem obviously lame and the folks behind them are often light on track record, with a singular fixation on selling out their fledgling enterprises to the first willing party, so I’ll say that lots of the "companies" (more like "Web sites") will sink without a whimper without accomplishing much of anything. I’m always suspicious, too, that they tout fresh thinking only because that’s all they’ve got. Still, some will likely survive. The question is whether patients really have enough clout to matter in the grand scheme of things. Patients paying out of their own pockets could band together via social networking, but healthcare is mostly divided as those with insurance or those unable to pay — there’s not much middle ground because of absurd hospital policies on pricing and non-discounting.

Allscripts-Misys just announced Q2 numbers: revenue up 33%, EPS -$0.05 vs. $.07, slightly missing expectations on revenue but beating earnings estimates. The stock is up nicely after hours (3.5%), probably because the recent Leerink downgrades already took the wind out of its sails (not a bad thing, maybe, since reaction to the news will appear more optimistic and maybe rightfully so). And, surely the combining of the two companies made the numbers sketchy until that settles out. No matter how you look at it, the jury’s still out.

I should mention that I’m way behind on e-mail, so if you’ve sent me something, I’ll try to catch up over the weekend. Between the day job and HIStalk, I’m tied up from before daylight until bedtime.

The AHIC Successor organization is finally announced as the National eHealth Collaborative, hoping to get face time with Obama’s underlings in the next day or two. Our esteemed contributor John Glaser is on it, so I’m trying to twist his arm to explain the organization’s role and its plans going forward.

Clinical trials imaging services vendor Bio-Imaging Technologies sells its CapMed personal health records division to Metavante Technologies, a $1.5 billion annual sales banking and payment technology vendor whose healthcare offerings include benefit payment cards, eligibility and claims processing, ID cards, and (here’s the tie-in, I’m guessing) health savings accounts. CapMed and its icePHR was an early HealthVault partner, won TEPR’s "Best PHR" in 2008, and was supposed to be the medication PHR provider for IBM’s NHIN prototype, although I don’t know how that turned out.

I played around with Twitter once (for about 30 seconds) and lost interest, but I see several folks have signed up to follow me. Coincidentally, Bruce Friedman tells me he finds it useful for short thoughts and reminders about news items (he’s a lot smarter than I am). Question: what would I do with it? I can see that it might be fun to Twitter from HIMSS (since I could use the Bold instead of waiting to get the laptop online). Otherwise, am I missing something that would be valuable to readers?

HIMSS says it will work collaboratively COCIR, a European medical equipment trade association (its words, not retracted like HIMSS did) for "public policy activities" and conference production. Being psychic, I’ll predict that HIMSS will just buy it outright before long. One of its main activities, according to its site, is helping push the products of its vendor members (sound familiar?): "COCIR sees a negative trend in the age of the EU equipment base and is extremely concerned about this lack of investment. Continual investment in state of the art electromedical equipment is essential for the comfort of patients and medical staff." Not to mention profits.

California bars ED doctors from billing patients directly when their HMOs won’t pay the full bill. The California Medical Association complains that the ruling lets HMOs pay ED doctors whatever they want.

CHIME’s advocacy people mail (warning: PDF) Tom Daschle to let him know how much it supports EMR adoption (notice the letter manages to slightly botch the full name of HIMSS, leaving out the "and"). At least CHIME wasn’t as blatant as HIMSS in snaking a long tongue in the general direction of the federal feed trough, mentioning only incentives ("necessary funds") for EMR adoption. Still, they’ve got advocacy people.

Rick Peters, like me, is critical of the HIMSS EMR Welfare Program. He’s unhappy that HIMSS doesn’t talk more about its HITSP and CCHIT affiliations (I don’t see that as a problem and they haven’t tried to hide that fact, but maybe it’s less obvious than it seems). There’s a lot of dense and less interesting stuff in the middle, but the conclusions are interesting: that HIPAA was subverted by EDI claims clearinghouses who convinced Congress that they already had the best solution available, which killed all the positive possibilities of bringing in new approaches. The EMR tie-in: "Federal funding should go to fund research and innovation in health care IT along the lines of the NIH, NSF, and DARPA, not the status quo. Direct purchase of products and their subsidy should be avoided. There is a market (finally) for EHRs after all these years and the market should figure itself out without artificial influence. If vendors or institutions seek funding from the Federal government they should have to compete openly with academic institutions, independent contractors, start-ups, and all their competitors, without unfair and anti-competitive artificial constraints." That’s not to say that the current vendors may not be the best electronic medical records solution, only that nobody’s opened up the competition to see if the money might be better spent elsewhere or in having those same vendors take a different direction.

Jobs: Senior Network Analysts – Cisco Wireless, Cloverleaf Integration Consultant, Soarian Consultants, Revenue Cycle Consultant.

I’ll be winding down the HISsies nominations shortly, so if you haven’t voted yet, now’s a great time. Some of them gave me a chuckle, I’ll say that, and some of the serious ones (best CIO, CEO, and hospital) have some good nominees to choose from. That will lead up to the HIMSS conference, of course, so if you have suggestions on what Inga and I can do there to make it more fun for everybody, then let’s hear them. I thought about doing a live Internet radio broadcast from Chicago, or maybe a nightly recap with call-ins, but that sounds like a lot more work than my typically lame brainstorms involving Fake Ingas and free drinks.

American Sentinel University adds new members to its healthcare advisory board, including Roy Simpson of Cerner. It’s not regionally accredited, instead holding the less-accepted DETC accreditation that online-only schools often earn (meaning you can’t always transfer credits to a regionally accredited school). That’s at least better than the highly iffy Kennedy-Western University that’s popular with healthcare people, which just changed its name and fled from California when the state cracked down on diploma mills. I used to link to the bios of vendor and hospital executives whose degrees came from phony schools, but I got tired of the nasty e-mails demanding that I not mention that their "schools" were complete shams. Let’s just say there are a lot of those folks, some even double-appending "Dr." before and "PhD" after their names (usually a sign of stupidity or vanity) with only a mail order credential.

Dumb press release headline: "Solos Endoscopy, Inc. Receives Purchase Order from Cleveland Clinic." I can’t wait for the follow-up ones announcing shipment, receipt, and payment.

How does this happen? Police reports say Christ Hospital (NJ) threw out a newborn baby’s body in the trash, leading to search of garbage dumps in two states. The mother and the hospital can’t agree on whether the baby was born alive, a key point in the inevitable lawsuit to come.

The chairman of Indian outsourcing company Satyam Computer Services, in a story being called India’s Enron or India’s Madoff, admits that the company falsified its earnings and assets for years, saying specifically that over $1 billion of cash on its most recent financial report doesn’t exist and revenue was 20% less than reported. Shares were down an astounding 91% before trading was halted Wednesday, dropping from $9.35 to $0.88. You’re doing a heckuva job there, PricewaterhouseCoopers, auditors for the company. Enron took down Arthur Anderson, so PwC has got a heap of trouble on its hands. Anybody want to buy PwC Healthcare cheap? You may get the chance. The lawsuits will still be flying by the time you would graduate from law school in case you’re considering a career change.

Ohio passes a law requiring that pharmacy technicians register with the state board of pharmacy and pass a competency exam even though the state (like all others) already required held pharmacists accountable for checking their work. It came after a two-year-old died from an incorrectly compounded IV. That’s great for the techs, of course, since the now-limited supply will raise wages.

The Jerry Seinfeld commercials couldn’t save Vista (although they won lots of "stupidest waste of money" awards), so Microsoft moves right to the Windows 7 beta and hopes everybody forgets the debacle of dysfunctional drivers and wildly underestimated system requirements intended to keep its PC partners happy while burning its own customers.

Loma Linda University opens a new hospital with all the latest sexy stuff: robotic surgery, private rooms with balconies, room service, and flat screen TVs. The cost: $4 million per bed. The impact on local health: we’ll see.

The local business paper writes up Polymap Wireless, a Tucson company that makes Bluetooth-enabling technologies for scales, blood pressure cuffs, and glucometers so they can transmit results over the Internet to providers.

Iatric Systems creates an endowment to provide one hospital in need with its Security Audit Manager and related services.

Someone steals $60,000 worth of nurse call center hardware from Bear River Valley Hospital (UT), which was storing it in an unsecured storage until a new hospital opens up next month.

Creighton University (NE) is losing $10 million a year on its faculty practice organization, blaming a lack of patients and computer problems that delayed billing. The plan: hire 50 or more new doctors to bring in more patients. The impact on local health: we’ll see (I know I said that before, but I’m now fixated in Don Berwick’s statement that all this increased supply of medical horsepower just raises costs). I suppose it’s unthinkable to simply scale back the services to match the income. That’s like asking the government to live within its means.

The family of a toddler killed in an Illinois medical helicopter crash sues the company that operated the helicopter, its parent company, and the estate of the pilot killed in the crash. The former chair of the National Transportation praised the family for bringing the case forward "to push the industry for tighter rules," but he’s hardly unbiased: he’s one of the lawyers hired by the family.

E-mail me.

HERtalk by Inga

From Frank Sinatra: “Re: MyWay product. I hear that the Allscripts-Misys MyWay sales are strong. Results are well above goal. MyWay is the repackaged iMedica product that is now being sold strictly through resellers to 1-3 doctor practices.” Good news for Allscripts, though I still can’t figure out why they would choose to sell this seemingly popular product through resellers only. Aren’t the majority of the country’s physicians in 1-3 doctor practices?

Summa Health Network utilizes new technology from MDdatacor to use data from physician systems to determine compliance with evidence-based guidelines.

Tufts Medical Center warns thousands of BCBS HMO patients that providers will not accept its insurance as of February 1. Tufts is not happy that BCBS is paying them 20-40% less than other Boston-area teaching hospitals. BCBS admits an imbalance in rates “that can be because of market clout.” Tufts does not want to sign up for a new payment system that includes per-patient payments, plus additional payments for meeting quality targets.

Merge Healthcare cancels plans to sell its China-based operations. Inqgen Technology intended to purchase Merge’s Cedara Software Shanghai, but Merge’s new management wants to focus on growing its business internationally.

Just two weeks after raising $6 million for expansion, Motion Computing CEO Scott Eckert resigns. The company also laid off 25% of its workforce, or about 30 people, following its previous layoffs of 55 employees in April and July.

This could be a fun lawsuit to track. A San Francisco chiropractor sues a former patient for libel and invasion of privacy after the patient posts a negative review on Yelp. The patient disliked the doctor’s billing practice and felt he was being dishonest with insurance companies.

Parkview Medical Center (CO) takes top honors in a national patient safety contest sponsored by Patient Safety & Quality Healthcare magazine and Precision Dynamics Corp. Parkview implemented a new barcode technology system that reduced medication administration errors from 20% to 8%.

The executive director of Maine’s HIE initiative HealthInfoNet expresses concern the project will run out of money before it’s operational. It has relied on grants, but the director hopes to receive additional dollars from a possible federal HIT economic stimulus package. After all, federal bailouts are all the rage.

This sounds like one nice guy. A New York surgeon demands that his estranged wife either give him back the kidney he donated to her in 2001 or pay him $1.5 million. He’s a little miffed that she had an extramarital affair.

Back in 2003, People Magazine named Sanjay Gupta one of the “Sexiest Men Alive.” You would think that once you get that title, there isn’t too much more a guy could aspire to. Yet, now he is being considered for the Surgeon General post despite skimpy public health experience and a cozy relationship with the drug companies that sponsor his TV career. Kind of makes you wonder what might be in store for Brad Pitt.

Vendor Deals and Announcements

• Diversified Radiology of Colorado streamlines its billing operations with its new AMICAS partnership. Diversified will utilized the AMICAS financials, dashboards, and claims processing solutions.
• CareTech Solutions signs a five-year agreement to provide IT outsourcing to Central Maine Medical Family (ME).
• The 49-bed Cogdell Memorial Hospital (TX) implements an integrated clinical and financial system from Healthcare Management Systems.
• Newton Memorial Hospital (NJ) signs a six-year agreement outsourcing IT to PHNS.
• Axolotl integrates M*Modal’s Speech Understanding engine into its Elysium medical transcription workflow solution.
• Cancer care provider OnCare (HI) selects IntelliDose for chemotherapy treatment management to integrate with its Allscripts EHR/PM system.
• Novo Innovations announces a record year in 2008 that included 17 new customers, more than double the previous year.
• Press Ganey Associates acquires PatientFlow Technology, hoping to increase its clinical and operational presence while broadening its consulting services.

E-mail Inga.

Being John Glaser 1/8/09

A byproduct of the implementation of an electronic health record is the creation of a relatively large clinical database. The core value of this data is supporting the provision of care. There are other uses — secondary uses — which are important.

Perhaps the most important secondary use is assessing the quality, efficiency, and safety of care. Care patterns can be contrasted with national guidelines; a physician’s practice can be compared to that of other physicians; and the health of a population of people with a chronic disease can be assessed.

However, several organizations have begun to look at additional secondary uses of this data. Two areas show great promise.

One area is post-market surveillance of medications. The graph above (Brownstein, PLoS ONE, 2007) was developed using data from Partners HealthCare. It shows a dramatic increase in admissions due to heart attack. The arrows indicate when our physicians began to prescribe Vioxx and when they stopped prescribing Vioxx. This example raises some interesting possibilities — could we begin to monitor a medication soon after it is introduced and do a much better job of detecting problems earlier?

Another area is leveraging EHR data for clinical research. An area Partners is working on centers on genome association studies (www.i2b2.org), e.g., are there genes associated with depression treatment success? The graph above (Kohane, Internal Partners Analysis, 2008) is a bit complicated, but it shows that studies that leverage EHR data (the lowest set of lines) can cost five times less than studies that rely on manual chart extraction (the top set of lines). In addition, it appears that EHR-based studies can be done in one-tenth the time. These gains in efficiency and speed could dramatically alter clinical research.z

There is still much work that remains, e.g., developing sound methods for dealing with the often poor quality of EHR data. However, both of these examples show very compelling potential secondary uses of clinical data.

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

News 1/7/09

From Inside Outsider: "Re: Sunquest. Hearing from Sunquest insiders that the New Year layoff axe has begun and folks with close to 20 years of time served have been shown the door." Unverified, but I’ll invite the company to respond.

From Health Care Consumer: "Re: video. This video made me laugh — you should watch it." Loved it — Red Sickle Red Armor Insurance. The tag line: "This is what health insurance corporate videos would look like if they told the truth. And, if they hired crappy animators." They make fun of "non-profit" RSRA (wonder what insurance company that could be?) "As a non-profit, we don’t have stockholders. No, we don’t have to answer to Wall Street when we’re meeting your healthcare needs. And we don’t have to share the money we make with anybody else. We’re free to stockpile it and use it to build the infrastructure that keeps our company running properly. For example, did you know that we have 4,000 corporate vice presidents?" 

From Andy: "Re: errors in the UK." Link. NHS records show that 3,645 people died in one year due to "patient safety incidents" that included surgical errors, incorrect diagnosis, staff or employee abuse, falls, medication errors, and equipment errors. Those are the errors that were reported and proven to cause death, of course, so the real number is almost certainly a lot higher (only 54 died from medication errors, the reports say, which is only a little higher than the number of fatal equipment errors, so that’s probably a too-low number for meds). Still, deaths (or, more accurately, reported deaths) were up 60% in two years.

From The PACS Designer: "Re: Cloudo. If you want to have an online PC to collaborate and share files with with others, there is a new application called Cloudo, or a PC in the cloud. It does just about anything a physical PC does with the added benefit of easier sharing of documents, photos, etc. and also includes the ability to do cell phone file sharing and retrieval." Link. Looks pretty cool, "a computer that lived on the Internet, instantly accessible from any computer or mobile phone."

From Ted Peters: "Re: ThedaCare’s lean program. They use lean events to streamline work flows. Epic is flexible enough to accommodate the new work flows and Epic’s done quite a bit of development to enable the stuff Theda wants to do, making life easier for other customers as well. ROI doesn’t come to those who wait, it comes to those who are going out and using a good EMR as a tool to get there." Link.

Listening: Interpol, post-punk indie rock out of NYC. And watching (rare since I almost never watch TV): Psych.

I’m not exactly sure why HIMSS needed to acquire a privately published magazine, but it’s the new owner of Government Health IT. I don’t like that for several reasons: (a) it was the only magazine I actually read and sometimes referenced here other than Computerworld, so I have this feeling that it’s about to become a lot less interesting and objective; (b) HIMSS will surely use it to beat readers over the head with its pro-vendor advocacy agenda even more than it already does through other channels; (c) only one employee is coming over in the deal; (d) it was one of very few HIT publications out there whose original, independent reporting didn’t sound like some fresh-faced 2.5 GPA state school journalism grad trying hard not to sound clueless about both the subject matter and the audience; and (e) it was already free anyway, so it’s not much of a HIMSS member benefit. I got the internal memo sent out by the selling media company to its employees, which said "we were made a very attractive, unsolicited offer," so the HIMSS salivation over possible HIT lollipops from Obama must have set off a fierce desire to get even closer to the feds.

Allen Tien MD, president of Medical Decision Logic (mdlogix), e-mailed to let me know that Washington University School of Medicine and BJC (MO) have signed a 10-year license for the mdlogix Clinical Research Management System.

Someone just sent me a LinkedIn connection request, which reminds me: Inga and I will approve any we get because we’re enablers in your quest to dominate other LinkedIners with your impressive connection list. The HIStalk Fan Club is up to a startling 461 members, outdoing some of the magazines that started their own groups since readers didn’t do it spontaneously.

Army doctors at Landstuhl Regional Medical Center in Germany report excellent experience using Nuance’s Dragon Medical with the AHLTA clinical system. The Surgeon General says the 10,000 copies bought for world-wide use will pay for themselves in less than a year with transcription savings.

Medicity reports 81% revenue growth in 2008, its tenth anniversary, with strong sales and the hiring of 51 new employees focused on R&D and customer support.

A non-profit organization created to raise money for the University of Hawaii medical school is deep in the red, owing the school $7 million. The organization was supposed to generate revenue, manage grants, and provide billing services. The dean sounds like he’s running GM: "We have collectively inherited an entity undercapitalized at the beginning that has limped along and has required a re-infusion of capital to upgrade its operations."

Inteoperability vendor dbMotion brings on new executives: Marty McKenna (Allscripts) as VP of commercial operations and marketing; John Jordan (Insite One) as east VP of sales; and Steve House (Cardinal Health) as west VP of sales.

Children’s National Medical Center (DC) chooses eClinicalWorks PM, EHR, and community health record for its employed, clinic-based physicians.

A New York Times article covers personalized medicine, tailoring drug selection and doses based on individual patient genetic makeup with the strong possibility of choosing more effective treatments, reducing cost, reducing side effects, and speeding up response. EMRs are going to be a key, of course, which is why smart vendors like Cerner, Epic, and others are building genetic data capabilities into their products. Not that you care, but here’s how I’ve explained it to people: it’s like the vastly increased accuracy in weather forecasting that happened once meteorologists discovered air mass behavior and the effects of barometric pressure instead of looking at old weather charts and basing today’s forecast on last year’s weather.

Don’t forget to make your nominations for the HISsies awards. The actual voting will start in a few days, but the only choices you’ll have are those that have been nominated (you’ll feel guilty if Neal isn’t on the ballot for The Pie, won’t you?) The winners will be announced at the HIStalk event at HIMSS, assuming there is one, of course (stay tuned).

Eclipsys completes its acquisition of Premise.

Ray Beerman, former CIO of Jackson Memorial Medical Center (FL) and healthcare IT pioneer, died last week at 73.

Hospitals in Yemen’s capital city go on strike after a doctor is killed by a man who said his father died from the doctor’s medical error.

Odd lawsuit: a rheumatologist’s patient claims she asked him repeatedly to provide a sign language interpreter during her office visits. He declined, saying as a a solo practitioner that he couldn’t afford the $150-200 per visit cost when Medicare was paying him only $49. The woman’s visits were routine and she had no complications, but she sued the doctor, claiming he violated federal and state anti-discrimination laws by depriving her of the opportunity to fully participate in her care. The jury awarded the woman $200,000 and another $200,000 in punitive damages, all of which comes from the doctor’s pocket since it wasn’t a medical liability issue (and in fact, he wasn’t allowed to bring up her satisfactory medical outcome as part of his defense).

Hospital layoffs: Lee Memorial Hospital (NY), Merrimack Valley Hospital (MA).

Here’s why healthcare costs keep going up: Grand Rapids, MI, reluctant to allow growth and tax revenues to slow, bets the farm on a Medical Mile of new hospitals and healthcare vendors to create high-paying jobs. As Don Berwick says, will that really improve health, or will it just increase cost?

The owner of several defunct medical software companies in Tennessee is charged with fraud in an alleged $17 million scheme to obtain loans based on bogus software sales.

Memorial Hermann claims its "quick look" ED program, where nurses give patients a quick check within five minutes of ED arrival to get the really sick ones to a doctor faster, says the wait time to see a doctor has dropped from 93 minutes to 20. It’s amazing that we still haven’t figured out an acceptable way to keep routine patients from clogging up the ED.

E-mail me.

HERtalk by Inga

From Jon Bon Jovi: “Re: CD sales. Yes, CD sales continue to plummet, but downloads continue to grow (whether or not anyone is paying for those downloads is another issue!) Quite a few of my musician friends are now moving to the idea of not even pressing indie CDs anymore, and just offering new recordings online. Amazing.” The article I referenced last time indicated that one reason vinyl sales were up is that they were cheaper than CDs or downloads.

From Clement Clarke Moore: “Re: poem. Loved the Night Before Christmas poem.” Thanks to everyone who said they enjoyed the HIStalk version, which I presented to Mr. H as a Christmas present. IMHO, I thought it was kind of clever.

I’ve been a little behind on my news and my e-mails with the holidays, but I think I’m almost caught up. My apologies to "Lindsey,” who I e-mailed back at 2:00 a.m. New Year’s Eve morning (note to self: try that new Mail Goggles feature).

Wells Fargo Insurance Services donates $25,000 to Cabell Huntington Hospital (WV) to help purchase a GE Healthcare OmniBed.

A Leerink Swann analyst predicts that Obama’s plans for funding healthcare technology will not help the sector for at least 12-18 months. Bret Jones downgraded several HIT stocks, sending HIT stocks down in Tuesday’s trading.

Virtual Radiologic names Mike Kolar VP, general counselor, and secretary.

Gwen Darling with Healthcare IT Jobs has been telling me I need a Twitter account, so I finally set one up this weekend. I am not sure that I need something else to keep up, but I’ll try it for awhile. If you care to tweet (twit?) me, look up IngaHIStalk.

INTEGRIS Health extends its deployment of Allscripts Care Management from two hospitals to all 13 of its Oklahoma facilities.

A VA study of 35,000 patients finds that telehealth programs help patients to better manage their health. Hospitalization days dropped 25% for patients using home telehealth and hospital stays fell 19%. The services cost an average of $1,600 a year.

IBM CEO Sam Palmisano predicts that more than 900,000 jobs will be created if the government invests $30 billion in HIT.

I’m predicting we’ll see stories similar to this one in coming months. MRI operator Metiscan Technologies negotiates $1.97 million in debt forgiveness with its largest creditor.

And more stories like this: Baptist Health of Pensacola fails to obtain financing for the $245 million purchase of West Florida Healthcare, a unit of HCA. Baptist has always received recognition for its quality and patient services programs, but it never seems to make money despite that (apparently there’s no profit in either one, which is a pretty sad commentary in itself).

Like Mr. H, British physiotherapists (aka physical therapists in Yank-talk) enjoy the Wii Fit and even incorporating it into rehab routines.

Faithful readers will recall that my background is more in the ambulatory world, unlike Mr. H, who lives and breathes hospital stuff. I finally convinced him it would be cool to have a HIStalk site that focused on the physician world and he finally gave in. Please check out HIStalkPractice if you are interested in technology for the doctor’s office. If you like it, sign up and tell all your friends (we have 208 subscribers so far on our second day – thanks! and also a couple of sponsors to announce shortly). I feel like I used to when I sold a brand new version of software … kind of like, now that I have made the sale, will it really work?

Alaska launches a new Web-based database designed to track immunization history.

Partners HealthCare, Pfizer, the Clinical Research Information eXchange, and the Clinical Data Interchange Standards Consortium form a coalition to test ways to improve electronic reporting of adverse drug events. The group will study how standards, technology, and a new business model can improve drug safety by helping physicians better recognize and report adverse events.

The Wall Street Journal reports that in 2007, healthcare spending grew at its lowest rate in almost a decade, although the 6.1% increase is still a faster rate than the overall economy. Interesting statistic: we spend $7,421 a person for healthcare ($2.2 trillion overall).

Iowa institutes a new computer system designed to track purchases of most prescription drugs. The database is expected to help doctors and pharmacists track drug seekers.

E-mail Inga.

Being John Glaser 1/6/09

I travel. Not all of the time, but enough of the time. Like many of you, I attend conferences, sit on various external committees/association boards, and visit vendor headquarters.

Air travel has become a sport. A sport that has millions of participants and seems to be growing.

Any sport that has a broad participation and is experiencing growth eventually sets its sights on becoming an Olympic sport. Admission to the Olympics requires that the sport has events, in particular, events that require displays of cunning, physical prowess, and human drama.

A small group of experienced healthcare industry travelers from across the globe has developed the following set of initial events.

Security Sprints

The sprints involve heats, semi-finals, and finals. The fastest traveler-sprinter wins.

Event 1
Sprint through security with only a briefcase.

Event 2
Sprint through security with a two large bags, toiletries, laptop, overcoat, and shoes with laces that are all tangled.

Event 3
Same as Events 1 and 2 with the following obstacles:

• Family of six with four misbehaving children
• Young person who can’t understand why they have to surrender their bottle of water
• Older man who seems to not understand that you have to remove the metal from your pockets
• TSA screener who wants to make sure, double sure that he misses nothing on the x-ray

Baggage Stowing

Winners have the fastest times. Contestants can be disqualified per the constraints below.

Event 1
Fitting a bag that is two inches too long into the overhead without breaking the overhead door or using duct tape to secure the door.

Event 2
Placing a 4x4x3 foot duffle bag under the seat in front of you without breaking the crystal goblets in the bag.

Event 3
Placing a 150-pound bag in the overhead without dropping it on the head of the passenger in the aisle seat.

Seat Defense

These events are scored on “technical skill” in which points are gained or loss based on execution of the maneuver.

Event 1
Silencing a chatty seat mate (Using “Talk to me again and I’ll kill you” costs the contestant 5 technical skill points. Using “I’m on the verge of developing the formula to cure cancer — could I have a moment or two to concentrate?” earns the contestant 5 points.)

Event 2
Preventing the person in front of you from reclining their seat (Spilling soda on their head is minus 5 points. Pointing the air vent so that it blows on their head is plus 5 points.)

Event 3
Stopping the person next to you from reading over your shoulder. (Saying “Read my stuff again and I’ll kill you” is minus 5 points. Turning the book/newspaper upside down and continue reading earns the contestant 5 points.)

These events are preliminary. And there is work that remains in refining the events, e.g., some European nations are not in complete agreement with the US/Japan proposed Seat Defense point schema. However, the International Olympic Committee has given initial approval of several Air Travel events making their debut in the 2012 Olympics. It is not too early to begin training.

I expect to see many of you training on upcoming flights.

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

Monday Morning Update 1/5/09

From SQL Goddess: "Re: American CareSource. I thought this was interesting, having never heard of the ancillary care networking business." Link. The Dallas-based American CareSource (warning: the horrid white-on-puke-green color scheme will give you an instant migraine) had the best performing stock of North Texas companies in 2008 with 120% appreciation and a $105 million market cap. It contracts with labs, dialysis centers, and imaging centers to offer their packaged services to small insurance companies and employers. The CEO says it deals with the best and cheapest ancillary providers. "Do you really need 15 imaging centers in North Dallas? How about five that offer the best quality and best prices?" Somebody’s buying it (literally): the company handled 500 claims annually three years ago and is doing 550,000 now, with good prospects in a cost-cutting healthcare environment.

From Topexecit: "Re: Microsoft getting ready to lay off 17% of staff." Link. Rumors are flying that Microsoft will have massive layoffs on January 15, with up to 15,000 employees getting the axe. I don’t doubt that layoffs could be imminent with Q2 reports due on January 22, but despite a plethora of gaffes, MSFT is still doing OK in some markets. And, a number that high would surely have triggered firmer and more numerous leaks of what’s about to happen, not just one guy posting on an obscure tech site that starts ping-ponging around. On the other hand, as I’ve always said, terrible market conditions are a great time to get rid of deadwood, announce all the previously hidden bad news, and make all the tough but unpopular decisions.

From Garrnut: "Re: Partners. Getting skewered by the Boston Globe. This is the third article in a series." Link. The opening sentence about the Partners-Blue Cross insurance cost agreement gives the conclusion away: "It was the gentleman’s agreement that accelerated a health cost crisis." The article claims that Partners got a 75% increase in insurance rates since 2000, forcing other insurers to give it similar increases and encouraging competing hospitals to to seek the same rate, creating inequity, delivering only a tiny percentage of expected cost savings, and leaving duplicative services intact between the two formerly competing hospitals. Deeper into the article, however, is a key fact: Partners has never had a margin greater than 2% and makes a good bit from investments, so its prices aren’t out of line. Here’s some cold water on that, though, from none other than IHI’s Don Berwick, who worries about the inarguable fact that medical oversupply creates its own demand: "When Partners decides to expand . . . the prediction would be it will not add to the well-being of the population. It will add to cost." My opinion: we’re back to the "exactly how well do we want our hospitals to do financially" argument, where everybody’s proud of the the local hospital, its highly compensated executives, and its fancy buildings as long as they’re not the ones directly paying for them. All of that was probably inevitable when the industry turned to the "business model" instead of the "charity model" of yesteryear, encouraging hospitals to run like businesses instead of charitable and religious missions.

From Lupe Velez: "Re: Blueware. A quick check of LinkedIn reveals the CEO is Rose Harr, formerly with IBM. Businessweek.com confirms that and lists David G Holland, formerly with Genesys Health Systems, is COO. I can’t figure out what they offer either." Someone sent over another announcement from them, but I’ve lost interest.

Several people have told us we should write more for the physician office audience, so we’ve started an HIStalk-like site for them called HIStalk Practice. Coverage here won’t change a bit, so for the majority of HIStalk readers who find its ambulatory EMR and related coverage deep enough, then don’t worry about reading it. Otherwise, check it out, sign up for the e-mail updates on that page, and watch for some new contributors who will be helping us write about medical practice IT topics (and let me know if you’d like to contribute).

Most folks are back to work, so I’m ready for your submissions for Wednesday’s Readers Write and suggestions for "An HIT Moment with …" subjects. HIMSS is coming up before you know it, which means (thankfully) that lots of folks will be asking about HIStalk sponsorship, HIStech Reports, text ads, etc., so time is running short for prospective sponsors who want to get on board (that’s not a sales pitch, just a statement of reality that, if it’s like past years, we won’t be able to accommodate the laggards).

I put in some significant Wii time over the holidays, with this conclusion: if all-but-canonized Saint Barack Obama really wants to spend $25 billion of taxpayer money to buy EMRs for doctors who don’t really want them, he should nationalize the Wii Fit programming team to write a free EMR (it’s nearly a PHR already). I didn’t get the Wii thing until I tried it. No wonder they can hardly give away the Playstation and Xbox. As to the first part of my conclusion, my upcoming Inside Healthcare Computing guest editorial is called Buying Doctors Systems They Don’t Want: Why Even Detroit’s Bailout is More Progressive than the HIMSS EMR Welfare Program.

Speaking of sponsors, the last couple of weeks have seen two of them involved in what should be great acquisitions: Novo Innovations was picked up by Medicity and Premise will become part of Eclipsys. It’s really surprising how many HIStalk sponsors have been involved in rewarding acquisitions over the years (that’s not always good for me, of course, since one sponsor acquiring another means I lose one). Inga brought up the fact that a disproportionate number of our sponsors are top ranked in KLAS as well. I don’t understand it, but it’s interesting.

It’s HISsies time! (for either the fifth or sixth year — I can’t remember). Since the voting covers all of 2008, it makes sense to open up the nominations now while that generally awful year is still fresh in your mind. Please fill out the 20-category nomination form. Everybody has fun with the final voting, which will follow in a couple of weeks, but it’s the nominations that make it interesting. As always, I’ve thrown out a few of the less-interesting categories and replaced them with some fun new ones. Which vendor will be acquired in 2009? Who’s the best healthcare CIO? Who will get The Pie? You tell me.

Listening: Elf Power, Athens-based psychedelic indie rock. For all you Misys-Allscripts folks in Raleigh, they’re kicking off their US tour in Chapel Hill on January 21.

It appears that predictions were correct: Obama names healthcare IT as one of the key elements of his economic recovery plan.

The York VA Medical Center (TN) found that it had performed colonoscopies using possibly contaminated equipment, so it used its EMR to identify affected patients to offer them follow-up care (hopefully not a free repeat colonoscopy).

Jackson-Madison County General Hospital (TN) avoids layoffs by cutting back on discretionary spending, including "software packages."

I’ve chided "free EMR" vendor PracticeFusion for what sounded like wildly inflated marketing claims, but I have to admit that its 2.0 screen shots look pretty good. Lots of docs have signed up, although I haven’t seen proof that they’re actually using it fully.

Newspapers love "first baby of the New Year" stories, which I’ve previously observed always seem to involve young, unmarried, and unemployed parents (often just one) who get a bunch of promotional samples from local businesses hoping for free PR. My local paper didn’t let me down this year and neither did most of the newspapers I checked – how about yours?

I mentioned a fascinating profile a few months ago about Kaiser informatics pioneer Morris Collen, MD, who’s 95 and still working. Here’s an even better article from the LA Times. He works on clinical decision support and is writing a book to be called The History of Medical Informatics: The Clinical Support Systems.

Hospital layoffs: Albemarle Hospital (NC); Cambridge Health Alliance (MA); Also: University of Maryland Medical Center asks employees to take unpaid time off to avert a budget crisis.

Healthcare Association of New York State, which pays its CEO $500K according to tax records, launches a "Help Your Hospital" Web site to enlist public support for "vital funding" as the governor tries to cut costs (emphasizing lost jobs more than anything else). It also offers a HIMSS-like closed loop in which vendors are encouraged to buy corporate sponsorships or host the ever-present golf tournament in return for access to its members: "What value does your organization place on networking with more than 550 not-for-profit health care providers? How can you establish a powerful presence and make critical connections with these key decision-makers?" One of its surveys claims that New Yorkers would overwhelmingly rather see their taxes increased than to cut healthcare costs of any kinds, which would be a lot more believable if it were on a ballot and not on a special interest group’s survey.

Odd hospital lawsuit: a Pennsylvania woman is suing a local hospital for allegedly using her image in commercials without her approval, claiming invasion of privacy and being "deprived the value of the exclusive use of her likeness."

And another: a prostate surgery patient sues Shawnee Mission Medical Center, claiming the operating table malfunctioned during the procedure and permanently injured him when it dumped him to the floor. The hospital was previously sued by a patient who claims he was paralyzed and his neck broken when an X-ray table dropped him on the floor while he was sedated.

Ed McMahon files papers against Cedars-Sinai, demanding a protective order for the privacy of his medical records as part of his lawsuit for what he claims is medical malpractice.

Memorial Hermann yanks the name of its $3 million donor Roger Clemens off its sports medicine institute, citing reasons other than the obvious one that he’s been irreparably linked to his denied steroid use (or the claims by a woman that the married Clemens had a longstanding affair with her starting when she was 15).

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HERtalk by Inga

Parents magazine names The Children’s Hospital of Philadelphia the nation’s best pediatric hospital.

A Juarez hospital opens a sales office in El Paso to recruit patients and help them navigate medical tourism issues.

John C. Lincoln Health Network and Mayo Clinic (AZ) end their family-practice training programs due to funding issues. Lincoln Health estimates 2007 losses from the program were $650,000.

Hershey Medical Center monitors infection outbreaks via a computerized system. The software provides staff with quick charts and graphs illustrating how many patients within a particular unit are infected and which lab specimen contained the germs.

Good news from Allscripts-Misys. The company revises its Q1 non-GAAP net income to $15.4 million from $13.4 million.

The Detroit News cites CareTech Solutions as one of the bright spots for Michigan’s tech industry. Though the state has lost 6,100 positions over the last year, CareTech has added almost 150.

Music purist Mr. H claims he has done nothing to contribute to this trend, but I’m not so sure. Vinyl record sales double from 2007 to 2008, while CD sales fell. I actually still have a record player, though it’s been 10 years since I touched it (obviously I am not an audiophile). Now I’m wondering if I still have that REO Speedwagon album somewhere.

In Tennessee, e-prescribing increases 127% over the previous year.

E-mail Inga.