CIO Unplugged 11/30/10

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

Go to Grow

In 2007, I dropped off my oldest child at Biola University in LA. We arrived a few days early so Brandon and I could attend the student-parent orientations. In the name of father/son tradition, we also squeezed in some workouts and ate bad but tasty food.

After we got his belongings organized in his dorm, we huddled for a final prayer and blessing. We embraced, shed a man-tear or two, and then I left. Sitting in my car in the parking lot, I watched him walk to the final student orientation.

Leading up to this point, I had planted seeds: encouragement to grow, encouragement to test his personal boundaries, and warnings against complacency. Brandon was officially beginning his journey into the future and to independence. The results of my optimistic seed planting were soon to blossom.

What happened next surprised me. As I drove down the Pacific Coast Highway, I began to wail. From the depths of my soul, I cried so hard my stomach convulsed. Wheezing in breaths, I mourned my treasured son’s rite of passage. Then mourning turned to dancing, and I rejoiced for Brandon and his future. I can only imagine what the drivers in the cars next to me must have been thinking of my spectacle. I pretended to be singing.

Three years later, Brandon graduated. We’ve seen amazing growth in our son — growth that could not have occurred had he stayed home. Despite an enriching and loving environment, his potential would not have been fully realized without a dramatic change and challenge. Part of us would have loved to have him stay, but we knew and accepted the truth that he needed to go to grow.

My career has been much the same. I can’t think of a single employer that I have ever wanted to leave. Yet with each one, I knew at some point I’d need to go to grow. Indisputably, my former employers offered ample career growth and challenges. But to gain exponential growth, I had to enroll myself on a journey of sorts. I had to break out of my comfort zones and push the envelope of security.

Each successive move has pushed me out of man’s natural bent toward complacency. They’ve shaped and sharpened my abilities. The breadth and depth of divergent experiences have broadened my skill set in an extraordinary fashion. My talents have gained a sharper focus and my leadership quotient has multiplied. I have become a better servant. I attribute my personal and professional growth to pushing my boundaries and circumventing the traditional career path.

Naturally, we need to create internal opportunities and have career ladders — something for every kind of employee. Yet at some point, the best thing for some will be a new environment, a place that challenges them to accelerate to the next level. I believe it is a leader’s imperative to fight complacency in the workplace and encourage others to go to grow. If it benefits our children and ourselves, then we must be willing to encourage subordinates and peers to do the same.

Sound inconceivable? Untraditional? Scary? An exceptional leader is not afraid or insecure to give away their best.

I have helped some of my best go. I have brought them opportunities for external advancements and served as their reference. At each departure, I felt the loss of their daily presence, skills, and talents. I cried in secret, yet I never regretted a single endorsement. I’ve stayed in touch, and what a thrill it is to see how they’ve grown in ways far more enriching than the opportunities I or my employer could have given them. They had to go to grow, to reach their fullest potential.

I recall a sunny afternoon run along the San Diego harbor with one of my colleagues, the president of a well-known hospital. We spoke about “go to grow” and the fruit we have seen in careers as a result. He resigned a short time later, citing this conversation as the catalyst for him to leave a secure position and take on a new growth opportunity leading a health system on an opposite coast. Catching up recently, he shared that it was the best career decision he had made. His growth has proved exponential.

Are there people in your life and work who need to go to grow? Does complacency have a hold on your organization? Are you selfishly clinging, or do you have a heart to see the best opportunities made available? (Picture the able-bodied forty year old still living at home).

If one of your staff has significant potential but circumstances are such that you can’t fully exploit that, do you give that person the freedom to advance elsewhere? Are there other staff members who need you to encourage them to leave for these same reasons but who won’t on their own out of fear?

We only have one year left with our teenage daughter. We will cherish every minute. But we’ll also do our best to prepare her mind to take on challenges and enriching opportunities. In love, we will push her to learn from the past and fail forward, to maximize the present in preparation for the future. Ultimately, the time will come when she will go to grow, just like her brother.

Now it’s your turn. Go to grow!

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

Monday Morning Update 11/29/10

From Bit Byter: “Re: Samsung Galaxy Tab. I’m interested in it.” The new $600 iPad tablet competitor (discounted by carriers selling data plans) runs on Android, has a 7-inch touchscreen (the iPad is 9.7”), two cameras, integrated GPS, Flash support, the cool Swype typing system, Wireless-N, Bluetooth, and seven-hour batteries. It’s too early to say (or buy, probably), but it looks like a reasonable alternative to the iPad for anyone who wants one (just like there are many smart phones better than the iPhone in some ways, but that most people don’t want because they aren’t iPhones).

From Train Wreck in Progress: “Re: CONNECT. ONC can shuffle paper, but they are screwing up real software and progress in treating the CONNECT team like unloved stepchildren despite multiple awards and demonstrated progress in connecting VA, DoD, and Kaiser. It’s a sad day when initiatives like CONNECT are not celebrated, embraced, and supported. Doug Fridsma’s framework was attacked at the HIT standards meetings as not practical, yet he marches on.” The top two CONNECT consultant managers quit as the program stalls while GAO investigates a complaint from Harris, the incumbent contractor, over a new contract awarded to CGI. The open source CONNECT platform, which won WSJ’s technology innovation award for HIT this year, was developed by a group of more than 20 federal agencies to support secure healthcare information exchange among providers, insurers, government, and consumers. ONC standards director Doug Fridsma says ONC wants to make it easier for providers to exchange information directly through NHIN Direct.

From Capiche: “Re: ONC clarification. Any thoughts on hospitals and practices being required to implement all Core and Menu items?” It’s a ONC FAQ that seems to mix vendor and provider requirements in a confusing way, but I’m interpreting it as being applicable only to providers with self-certified, homegrown EHRs. To do that requires implementing all of the Menu set items even though as providers, they could qualify for MU by using a vendor-certified EHR to meet only five of the 10 menu set items. But another interpretation is that all providers must meet all 10 Menu items even though CMS requires reporting only five. Click the above image to enlarge and let me know what you think it means. Or maybe someone from ONC can clarify their clarification since it’s a pretty big deal if that latter interpretation is correct.

Hospitals may lock down their internal e-mail systems with malware protection and tools to prevent PHI transmission, but docs can just go to their Web-based e-mail on those same PCs and do whatever they want, so say 80% of respondents to my poll. New poll to your right, rekindling an old argument — who should be calling themselves “informaticists”? As usual, click the Comments link in the poll to support your position.

Listening: reader-recommended Ry Cooder’s I, Flathead. I haven’t warmed up to all the music yet, but I like that he’s a non-conformist roots music songwriter who doesn’t really care what the masses think. This one’s a third of a three-part concept album series dealing with the Southern California culture in the first half of the 20th century. The alternative to auto-tuned, air-headed, ad-packaged Barbies and Kens singing about lust. And Watching – one more thing I hadn’t thought of that you can do on an iPod Touch: stream your Netflix movies over WiFi, which I did this morning in watching MST3K while brushing my teeth in the bathroom, just because I could.

A five-year study using trigger tools (instead of unreliable self-reported errors) finds that hospitals have made no progress in reducing incidents that cause patient harm. Nearly one in five hospitalized patients were harmed by the care they were given; nearly two-thirds of their injuries should have been prevented; and those injuries contributed to their deaths in 2.4% of the cases. The article concludes that preventing mistakes isn’t rocket science since every hospital knows that they should be doing. The problem is that they aren’t doing those things consistently: handwashing, medication reconciliation, decubitus prevention, etc.

A good article with the great title of The Doctor-Patient-Laptop Relationship looks at how doctors typing into computers changes the doctor-patient dynamic. A past president of the Connecticut State Medical Society says medical schools in her day taught doctors not to see patients from behind a desk since it served as a barrier, but they aren’t teaching today’s medical students ways to keep computers from becoming an equally disruptive barrier. It makes an excellent point: writing makes no sound and people can do it while they’re talking, while keyboarding makes noise and requires most people to look at the keyboard and monitor. I was thinking about that and I agree: when someone’s typing, I usually stop talking because they won’t hear what I say anyway.

Politicians get involved in the plans by two Canadian hospitals outsource IT to Cerner. They don’t like losing local jobs and they also don’t like the fact that Cerner sells de-identified patient data from this side of the border. Meanwhile, the IT department’s “whistleblower” who heard rumors of the discussions and quit in protest says the hospitals are making a mistake in turning over system knowledge to contractors who will have the hospital over a barrel. Anything related to HIT is a touchy subject in Ontario after audits last year found that eHealth Ontario was wildly overpaying no-bid consultants who were filing padded expense accounts, kicking off a political scandal in which heads rolled. The papers are making a big deal about the fact that IT staffers weren’t consulted in advance of the outsourcing discussions, which is ludicrous – in what world does management seek the input of those who would be negatively impacted by one of the two potential courses of action?

Inga interviewed David Delaney MD, CMO of MedAptus, about revenue cycle management tools.

NEJM runs the case study of the Mass General surgeon who performed the wrong surgical procedure on a patient and went public afterward to help prevent errors elsewhere. The Swiss Cheese Effect was in full force, with several potentially minor problems adding up to one big one in which the surgeon performed a carpal tunnel release instead of a trigger-finger release. Contributing factors: (a) the patient did not speak English and the hospital had no interpreter available; (b) the surgeon did several hand cases the same day; (c) the nurse had not marked the planned incision site; (d) the OR suite was changed because other cases were behind; (e) the change in room also involved a changed in staff, including the nurse who did the pre-op assessment; (f) the change in rooms delayed the surgery, so the surgeon saw another patient while waiting; (g) the circulating nurse fell behind in her documentation to go find a missing supply item; (h) the patient’s site marking was washed off when the area was cleaned; (i) the surgeon spoke to the patient in her native Spanish, so the circulating nurse assumed that was the mandatory time-out and didn’t call for one; (j) the nursing team changed mid-procedure; (k) computer monitor placement in the OR forced the nurses to look away from the patient. The best takeaway came from another physician in the case review:

Surgeons need to take ownership of these policies. When the airline industry evaluates a crash, the pilot is not considered responsible except in two circumstances: the pilot was under the influence of drugs or alcohol, or the pilot did not follow protocol. All hospitals need to have a culture in which surgeons feel responsible for making sure the protocol is followed.

Another HIMMS sighting, as even trade show supply companies can’t spell it right.

Funny: Steve Wozniak, the goofball half of the founding team of Apple Steves, mistakenly says in an interview that Apple has acquired speech recognition vendor Nuance, sending that company’s stock on a tear. The Woz says he must have read something wrong.

A court rules that the Iranian government owes McKesson $44 million for illegally seizing its dairy there in the 1979 revolution. The company was Foremost-McKesson back then.

Here’s why you probably don’t want to buy penny stocks of companies more competent at selling shares than product. Shares in would-be HIT vendor Healthmed Services, which I mentioned last week along with pictures of its “headquarters”, go down just as quickly as they’d gone up when pumped earlier in the week. Share price was less than four cents on Monday, up to over 12 cents on Tuesday, now back to under four cents and dropping. Considering the company has zero revenue and prospects for earning any, even the current $7 million valuation is ridiculous. Penny stocks aren’t usually worth even a penny.

IT application coordinators and analysts working for Kaiser Foundation Hospitals get a $2.91 million settlement from Kaiser for being misclassified as salaried instead of hourly. The employees were part of the HealthConnect go-live team, which required uncompensated travel, overtime, and on-call support responsibilities.

In the UK, a hacker gets 18 months in prison for send spam-infected e-mails that allowed him to take control of the PCs of anyone who clicked a link. He bragged on being able to turn on the webcams of infected PCs and to browse their files without the knowledge of their owners. One of his targets was a hospital. About one in 250 of the spam recipients clicked the link. The man is a father of five, runs a computer security firm and did his hacking from his mother’s living room.

The founder of India-based Apollo Hospital Group judges healthcare ideas for a reality TV show about entrepreneurship, choosing Medsynaptic. The Pune company offers imaging solutions, including PACS, low-bandwidth teleradiology, and image workstations.

The South Asia president and CEO of GE Healthcare says the company’s “de-featured” (up to 40% less expensive) medical devices will improve healthcare efficiency, adding that “India will teach the world healthcare innovation.” GE’s healthcare business there is growing 25% a year and they’re planning to hit annual revenue of a billion dollars within five years.

Strange: a UK nurse who accidentally killed a premature baby by giving 50 ml of sodium chloride injection instead of the ordered 5 ml gets in more trouble when the dead baby’s parents find that she posted a Facebook picture of herself asleep beside the baby’s bed a week before the mistake. Afterward, she posted messages asking for friends to “wish her luck” in the inquiry, and when allowed to return to work after her suspension, posted a message saying, “Has had a fantastic day! Is goin 2 treat herself 2 bottle wine!” The hospitals says they knew about the posts.

The Australian government issues $55 million in grants for interoperability projects, or at least that’s what I assume the article is referring to with the term “personal e-health records.” The government is looking for vendor bidders, just in case you’re interested.

A patient sues Halifax Health (FL), claiming his ex-wife, a former hospital employee, provided information from his electronic records to a hearing officer in their divorce and child custody trial. The hospital had already fired her for accessing the records of another plaintiff, which one might assume is hubby’s new love interest.

Nuance will collaborate with Montage Healthcare Solutions to offer radiology users the ability to search their Powerscribe 360 reporting database using voice commands or keystrokes. They’re demoing at RSNA if you want to drop by for a peek.

Surely we can agree this is excessive: the CEO of 128-bed Sturdy Memorial Hospital (MA) is paid $1.18 million per year. You know the excuses: they have to dig deep to prevent her from leaving, the not-for-profit hit its performance targets that enabled it to bank a big surplus, etc.

E-mail me.

The Obligatory but Heartfelt “What I’m Thankful For” Thanksgiving Post

This will be one of those really rare times where I get all reflective and maudlin, it being a holiday and all. I was moved by Inga’s Thanksgiving post. I might have sniffled a little, but I did cook Indian food for dinner, so it could be that the oils from the chili peppers I was chopping for the aloo matar found their way from my fingers to my nose. That’s my story, anyway.

What I’m most thankful for is that I don’t have to think hard to come up with a “what I’m thankful for” list every day of the year. That’s the great thing about having low expectations and a cynical outlook. Any day above ground is a good day.

I love my day job and the hospital that pays me OK for doing it. It’s the best place I’ve ever worked. I’m just as happy when the alarm goes off Monday morning as when it doesn’t on Saturday.

I am thankful for my family and that I found a woman early who not only tolerates my eccentricities and insecurities, but appreciates them. We ought to be sick of each other after all these years, but the first thing Mrs. HIStalk said when she came home tonight, instead of complaining about the paint-peeling stench of my simmering chana masala that she detests, was that I looked sexy. That’s doubtful (especially since I had just sneezed violently from accidentally inhaling sinus-searing masala vapors) but characteristically commendable of her to say. She’s as cute to me as the day we met in college.

I’m happy that I’m healthy, protected by those in military service, and still moved by good music. I’m glad I don’t care much about money, power, and fame since I’d be worrying all the time about losing them even if I managed to get them in the first place.

I’m glad I started writing HIStalk way, way back in the dark ages of 2003. Nobody was reading and I didn’t care, but somehow it has improbably allowed me to meet some pretty amazing people who are trying to make a difference. Sure, and a few douchebags too, but that’s a small minority. We have our differences and our debates in healthcare, but we always end up on good terms.

I’m thankful for everybody who spends their valuable time reading what I write (even the music recommendations, especially the weird ones). I’m grateful that companies support HIStalk just because they appreciate my work and knowing that I’m still going to rag on them when they deserve it.

I appreciate everyone who takes the time to e-mail me, write guest articles, submit thoughtful comments, be interviewed, and tip me off to news and rumors. You make me look smart and your efforts benefit many.

I’m really thankful for whatever cosmic forces sent Inga my way. She keeps me sane and amused, balancing my negativity with cheery optimism and funny e-mails. The insecurity oozed from her early writing as she struggled to keep inside her tiny industry comfort zone. Now she’s confident, insightful, and eagerly read by her many fans (and just as insecure). You’d like her even more if you knew her in person.

I’m thankful that Mrs. HIStalk knows her culinary limits without me having to remind her, so I’ll be doing the cooking Thursday (after popping Zantac all night because the chutney for the samosas was a little too hot). She does make a mean pumpkin pie, though. I’ll just need to crank up the iPod while she’s watching those idiotic televised parades she likes so much.

Have a fabulous Thanksgiving, Black Friday, and the long weekend. And, in my final “what I’m grateful for” item, thanks for reading.

News 11/24/10

ONC invites the public to weigh in on personal health records as long as they do it by December 10.

A just-in report from Canada says that two hospitals there are talking to Cerner about outsourcing IT.

Central DuPage Hospital (IL), a long-time Lawson customer, says it has implemented Lawson Contract Management in less than four months.

Listening: new from My Chemical Romance, high-energy, defiant punk/pop with some nice hooks that provide a needed break from auto-tune singers and phony country warblers. Driving music.

St. Joseph Medical Center (TX) develops a 10-physician hospitalist program with Intercede Health, which includes the use of the company’s Order Optimizer software. It provides SaaS-based diagnosis-specific order sets and order set management tools, medication alerts, physician favorites, and a nine-week implementation time. That product is also available separately from a subsidiary.

In Ontario, Sunnybrook Health Sciences Centre partners with Telus Health Solutions to roll out a consumer health portal / PHR that will allow Telus employees to upload and enter medical information that providers can review. Its underlying technology is Microsoft HealthVault.

Happy birthday to Ed Marx, whose special day was Tuesday. You can post belated best wishes on Facebook.

Jobs on the HIStalk sponsor-only job page: Implementation Consultants and Project Managers, Director of Technical Readiness, Implementation Consultant. On Healthcare IT Jobs: Health Information Technology Support Manager, IS Senior Project Manager, Ambulatory EMR Implementation Specialist.

I received a nice response from AMIA President and CEO Ted Shortliffe about a reader’s question as to whether the organization will decline financial support from vendors who won’t go on record as not using “hold harmless” clauses in their customer contracts. He says AMIA’s vendor contracting task force received redacted contract copies and have no knowledge of how specific vendors are writing contracts. He mentioned that Senator Chuck Grassley had sent letters to vendors asking that very question, but he has not made whatever responses he received public. Ted says AMIA’s role is as an educator, not an enforcer, so it made strong recommendations. I can see that point of view: other than Epic, most vendors aren’t going to walk away from business if the prospect insists on removing clause like that one. Nobody makes customers sign on the line which is dotted.

Speaking of that, I’m amazed that hospitals allow vendors to provide the first draft of a contract, loading it with vendor-friendly boilerplate and making sure to look astonished and hurt at any suggestion from their “partner” that it be changed before they hand over their large check. Job #1 is to create your own contract draft and give it to the vendor as the starting point for negotiation. I’m thinking of starting a telenegotiating service where I whisper electronically in the ear of hospital and practice IT people, telling them what to say and how to use classic negotiating techniques to their advantage. Customers are always complaining about the bad deals they got without accepting blame for taking what was offered without a whimper. In negotiation, 80% of the money on the table is going to be split equally between the two parties. When you’re negotiating, you’re fighting for a bigger share of the remaining 20%.

Investment bank TripleTree will host a Webcast about cloud computing in healthcare on December 1. The panel includes top executives from Castlight Health, SCI Solutions, MedVentive, and Connextions. Two of those four are HIStalk sponsors (SCI and MedVentive), so tune in and support them if you’re so inclined.

Nuance announces Q4 numbers: revenue up 17.7% to $310 million, EPS $0.01 vs. $0.02 after some accounting adjustments. 

British company Cambridge Consultants announces the Minder smart device, which transmits medical data in real time to EMRs. It can also receive checklist information from providers to instruct patients. Technologies used: Bluetooth, Wearable Mobile device hardware, accelerometer, the Continua-compliant Vena platform, and input devices that include a blood pressure cuff and scale.

iSoft’s former auditors face misconduct charges over – what else – allowing questionable recognition practices.

Odd: Healthmed Services, which has staked its fortune on some kind of iPad-to-desktop communication tool for healthcare use, floats a bunch of press releases touting its vaguely described agreements with Facebook and Google. Its also-vague Web site features a video of President Obama and a lot of generic information about the vast healthcare IT market it plans to conquer. The company today announced a development agreement with Veritas Software Systems, which might sound like the big backup system vendor unless you recall that Veritas was acquired by Symantec in 2005 (and its name was actually Veritas Software Corp. – this particular company has no Web presence that I could find). It also announced this week a new Web-based practice management system called HealthTrac, with no details whatsoever. What’s really newsworthy about the company: (a) it just filed an 8-K disclosure that it paid a company $600K to develop its flagship product, armed only with an oral agreement, but that company is holding them up for more money; (b) the company’s stock was being pumped and dumped by cocaine-smuggling New York longshoremen (note this “monster pick” that ran up the price 93% on Monday, with 42 million shares changing hands); and (c) its SEC filings from August indicates that the company had zero revenue, had no expectations of any revenue, and was down to its last $52 in the bank. I Googled its listed address and came up with the Las Vegas building above from Google Maps, which I assume is a mail drop. The address it uses for its SEC filings is a one-person virtual office in California that’s currently for rent for a minimum period of one night (that photo is above, too). The CEO quit in August and the CFO was replaced. Shares are at $0.08, with a market cap of $14 million. Maybe I’ve finally found that HIT vendor who’ll have me on their board, enjoying the corporate headquarters any time I can come up with the daily rent.

Odd: Spirit Airlines refuses to give a surgeon’s pregnant wife water while their overheated plane is sitting on the tarmac, offering instead drinks for sale. He makes a scene and makes vague references to terrorism, his son kicks a flight attendant in the groin, the flight crew kicks the family off, the surgeon is suing for $11 million.

Attachmate acquires Novell for $2.2 billion, if there’s anyone left who cares. A Microsoft subsidiary chips in $450 million to get a bunch of Novell patents, leading to speculation that their interest is either in suing other companies or perhaps porting .NET to Linux.

I think we probably won’t have enough news to be worth posting new issues of HIStalk, HIStalk Practice, and HIStalk Mobile through the holiday, but I’ll have the usual Monday Morning Update. Inga has written a sweet Thanksgiving piece that I’ll run on HIStalk Practice and I may write one myself for HIStalk since we are both sentimental, dreamy-eyed romantics anxious to give our BFF readers a clingy holiday hug, just like the watch-those-hands Uncle Bill on the porch after a little too much spiked eggnog and cheap Thanksgiving wine. We’ve been ultra-busy with new sponsors, interviews, and party planning, so we will enjoy the short break. if you’re headed off to RSNA this weekend, travel safely and make sure to crack up your fellow airline passengers in the security line by loudly delivering a few carefully rehearsed jokes about TSA’s full-body scanners. Have a wonderful Thanksgiving.

E-mail me.

HERtalk by Inga

Fun fact: at Cerner’s on-site cafeteria in  Kansas City, color-coded serving tools prompt employees to notice good food choices. Green handles indicate a great choice (think broccoli), yellow handles suggest you might want to limit your portion (pimento-stuffed olives), and red handles (burgers and fries) mean you might want to make time for a workout after work (that is, if you can sneak out of the parking lot without Neal noticing).

Austin Regional Clinic (TX) implements Webmedx’s Enterprise5 platform for its outsourced transcription and speech recognition services.

CMS will give providers online tracking capabilities to check the status of their Meaningful Use incentive payments. The payment information will be available online once a provider is notified that they have met Meaningful Use requirements.

In an article profiling Epic, the story’s author notes that the company rarely advertises and doesn’t encourage media articles. Apparently the reporter had difficulty getting answers to some basic questions. After several phone and e-mail attempts, she was basically told no one was available to assist. Finally an Epic spokesperson told her that the company’s “managers and leaders were too busy to speak with newspaper reporters, even if the reporter in question was writing a major feature story about them.” I bet lots of companies wish they were that busy.

Meanwhile, another local publication points out that Epic makes financial contributions to over 100 nonprofits. The company also donates older computers to local school districts, supports the local public library, and hosts area high school graduations in its auditorium.

The US Bid Committee announces  that Cerner is now an official partner in efforts to bring the FIFA World Cup to the US in the 2022. The committee chair says that Cerner has “clearly demonstrated” its commitment to the sport “in their innovative web-based health surveillance system for professional soccer players in the United States.” I was aware of the Cerner / Kansas City Wizards connection but didn’t realize Cerner also has an “athlete-focused” solution that was launched earlier this year and is now used by all 16 Major League Soccer teams.

Microsoft’s Peter Neupert says the company is abandoning efforts to make HealthVault profitable because of the complexity of the country’s health system. Neuport told  the Financial Times that HealthValult’s benefit to Microsoft was simply to increase the brand relationship” by raising Microsoft’s image with customers as “important, critical and trusted.” Compare those thoughts to what Neupert had to say at HealthVault’s unveiling three years ago:

The way we make money is by encouraging online activity, and through our search application.We know that search is a big business, it’s an important tool, it’s where consumers are today. And by growing the overall search market and delivering more value to consumers, and delivering a better end-to-end search experience, that’s where we can make our money to support this effort.

Florida doctor Arturo Carvajal sues a restaurant after injuring himself while consuming an artichoke. The doctor claims the restaurant failed to “explain the proper method of consuming an artichoke.” Carvajal, a brain surgeon, ending up eating the entire outside of the vegetable, which caused him "severe abdominal pain and discomfort," ultimately resulting in "disability, disfigurement, mental anguish," and "loss of capacity for the enjoyment of life".  OK, Carvajal really isn’t a brain surgeon, but I thought that sounded funnier than family practice, which is his real specialty. Regardless, I hope he has better luck eating his turkey and that someone advises him not to eat the wishbone.

Sponsor updates:

• NextGen Healthcare partners with Scimage to release a jointly develop the NextGen Medical Image Integration Module. The new module will give NextGen EHR ambulatory users the ability to view images produced by any imaging modality or PACS from within the NextGen EHR.
• Eight MEDSEEK healthcare clients win a total of 14 awards at the Strategic Communications eHealthcare Leadership competition. The program recognizes outstanding health web sites.
• Consulting firm North Highland hires Rebecca Whitehead Munn and Brent Holman as account managers. Munn was formerly the SVP of sales and marketing for Consensus Point. Holman comes from a large for-profit healthcare system (which I assume is HCA since both Munn and Holman are based in Nashville).
• North Sunflower Medical Center (MS) will deploy a suite of McKesson products, including Paragon HIS, Practice Partner EHR, and RelayHealth claims and eligibility  processing solutions.
• Surgical Information Systems says its SIS Version 5 is the first perioperative system to be certified as a modular EHR.

E-mail Inga.

HIStalk Interviews Edward Fotsch MD, CEO, PDR Network (EHR Event)

Edward Fotsch, MD is CEO of PDR Network.

Tell me what PDR Network does.

PDR Network distributes drug safety information, typically FDA-approved drug safety information. The full FDA-approved labels, drug alerts, the new REMS programs, and now increasingly collects drug and device safety information. Our focus is really on the collection and distribution of drug and device safety information, including the appropriate use of drugs and devices.

We publish the PDR, we have PDR.net, PDR Mobile, and a growing suite of services integrated into electronic health records.

Why was EHR Event formed, by whom, and via what process?

We work with a not-for-profit board called the iHealth Alliance. They Alliance is made up of medical society executives, professional liability carriers, and liaison representatives from the FDA. They govern some of the networks that we run, and in exchange for that, help us recruit physicians. Professional liability carriers, for example, promote our services that send drug alerts to doctors because that’s good and protective from a liability standpoint.

In the course of our conversations with them roughly a year ago, when we were talking about adding some drug safety information into electronic health records, we came across the fact that there were concerns from the liability carriers that there was no central place for reporting adverse EHR events or near misses or potential problems or issues with electronic health records. They were interested in creating a single place where they could promote to their insured physicians that they could report adverse EHR events. Then it turned out that medical societies had similar concerns.

Rather than have each of them create a system, the Alliance took on a role of orchestrating all of the interests, including some interest from the FDA and ONC in creating an electronic health record problem reporting system. That’s how it came into play.

Our role in it, in addition to having a seat on the iHealth Alliance board, was really in network operations — in running the servers, if you will, which didn’t seem like a very complicated task. Since business partners we rely on for our core business were interested in it, it was easy to say yes. It frankly turned out to be somewhat more complicated than we originally thought, but now it’s up and available.

What is the relationship with FDA, AHRQ, ONC, and some of the existing tools, such as the MAUDE database?

AHRQ has a thing they call the Common Format, which is a common set of questions for reporting patient safety-related events. They try to promote the use of their common format so that there can be some standardization of patient safety across multiple different reporters or reporting systems. We incorporated the AHRQ common format.

The role of the FDA is pretty much what is expressed in the press release, which is that they’re very supportive. They’re interested in seeing information about EHRs and issues associated with EHRs.

The exact relationship with the FDA and electronic health records, at least from my reading of the press, isn’t clear. Our goal is not necessarily to clarify that or be a spokesperson for the FDA, but we appreciate their support and their promoting the idea of reporting of electronic health record vendors participating in EHR Event.

They currently have some voluntary reporting associated with EHRs, but it is far from ubiquitous. At least based on my understanding of it, it’s more focused on inpatient systems, where EHR Event pretty much looks at inpatient or outpatient systems. One of those areas of perceived growth is in in the outpatient — the typical doc practice.

I’ve now exhausted my knowledge of what’s going on inside the FDA, but we certainly appreciate their support.

I think that Dr. Blumenthal and ONC did a great job of explaining their position. I think any network or new system that’s being rolled out appropriately has some kind of feedback loop, so they were quite supportive. I don’t know if you know if any kind of adverse reporting is going to be a part of Meaningful Use requirements, but if it is, it would certainly make sense. EHRs have great potential. It’s not just because they turn paper into electronic format, but they represent a communications platform to US providers.

To the extent that the federal agencies that either have systems in place or algorithms in place like AHRQ are generally supportive of the effort. This is sort of a “more the merrier” kind of thing.

Assuming ONC doesn’t mandate the use of reporting and FDA hasn’t had much luck in getting people to report into its database, how will it be different with EHR Event?

To my knowledge, the FDA hasn’t had any outreach at all to providers — docs like me. If they made the call, I missed the message. I don’t know how they’ve gone about other reporting initiatives. I certainly know what they’ve done with device and drugs and MedWatch and that kind of thing. From my standpoint, it’s comparing something that doesn’t exist.

I think the reason we got reports rolling in the door within 24 hours, frankly, is because of the relationship that exists between the liability carriers or medical societies and their insured or their members. Actually someone had called and said, “Why isn’t the FDA doing this?” I assume what they were saying is,  “Why hasn’t the FDA created an EHR adverse event reporting system.”

There’s probably a lot of political reasons. I don’t work for the FDA and I wouldn’t speak for them, but I have had a medical license in the US for the better part of three decades and I would say that for any federal agency to take any action is not always a quick process. I don’t know all the steps, but I imagine there would be public notice and this and that, perhaps some politics involved. I’m not an expert. I don’t work for the federal government and I suspect I never will.

There’s also the reality that most physicians, I think, if you ask them, would indicate that they would be more comfortable with a system that is operated largely by their professional liability carriers and their medical societies with whom they have great trust and a longstanding relationship.

Do you think those insurers and medical societies will mandate, to some extent, reporting of errors to back their members?

I don’t think that a medical society has any authority to mandate anything of members. Again, I don’t work for them and wouldn’t speak for them, but how would they do that? Docs practice medicine based on state licensure. I supposed you could talk to the state medical boards, but I think that’s a long slog.

The other problem, of course, is that even if someone mandated that you reported EHR events, how would you actually enforce that? How would you know that they did it?

I don’t look at this so much as a mandate. I look at this as liability carriers are in the business and regularly reach out to their insured doctors saying, “These are the kinds of activities that we suggest you do and these are the kinds of activities that we suggest you avoid.” Having written checks for hundreds of thousands of dollars to professional liability carriers in my years of practice, I can tell you that you know that the only goal they have is to improve patient safety and protect your liability.

I think mandate is probably not the right word. I think educate and encourage and promote are the kinds of things that medical societies and liability carriers are doing and will continue to do.

FDA is supportive and interested, but not to the point they did it themselves, which would seem to be something they would have done if they were all that interested. Is there a plan to share the information that’s collected in EHR Event with FDA?

I guess the premise of your question I’m not in agreement with, which is that if the FDA were interested, they’d do it. I’m sure the FDA has a lot of things they’re interested in. Whether they do it or not probably has to do with budgets and politics and the reality of what it would take to actually get something going.

Again, I’m not an expert in government process, but I’ve been around long enough to know that the federal government doesn’t turn on a dime. The FDA has to follow the rules of the federal government, which has a fair amount of process around it, at least as far as I understand.

But to your question about the FDA learning and getting smarter from the EHR Event reporting system, as a federally designated PSO, there’s some contractual requirements for any third party — whether they be federal, private, not-for-profit — to get reports from the PSO. I assume that the FDA, based on our discussions with them, will enter into an agreement that’s dictated by AHRQ for access to the kinds of reports that will come out of EHR Event, as will liability carriers, as will medical societies, as will regional extension centers.

The big parties that you didn’t name are the vendors of the systems that are having errors reported about them. What involvement have they had or will they have?

They have the option of participating, which means they sign an agreement with the PSO and reports that are pursuant to their system are routed directly to them. But they certainly don’t have to do that. Everyone who participates in this is doing it on a voluntary basis.

So far, the response has been very favorable. I saw the quote in the press release from the e-MDs folks. But I think all of them understand that the systems aren’t perfect.

Probably what we’re seeing more often than not, the real challenge with EHRs like any technology, turns out to be some form of user error. “I didn’t know it would do that,” or “I didn’t know that it pre-populated that,” or “I didn’t know I shouldn’t cut and paste,” or “I wasn’t paying attention to this,” or maybe the user interface was a little confusing. Actual software errors appear to be the exception rather than the rule as it relates to EHR events. That’s at least as I understand it. I don’t get to see the reports because I don’t have that right within the PSO structure.

Anecdotally, from hearing the kinds of issues that liability carriers had talked about that they had seen, and hearing it from the high level of reports that have been coming in, they’re actually more frequent that you have a learning curve type issue, which is I think anticipated and the point of the exercise, which is most liability carriers promote electronic health record adoption, but although they promote it, they also know that these are new systems and new workflows and there’s a learning curve. The interest is in getting as much information as quickly as possible.

Is this is a business? Is there a revenue stream? Does PDR Network make money from this service?

I wish I could say yes, but the truth of the matter is that it’s more or less pro bono work that we’re doing on behalf of partners whose relationship is important to us. There’s other types of adverse event reporting that we’ll be rolling out over the next year that you can actually make money from. We certainly aren’t smart enough to figure out how to make any money off EHR event reporting.

Fortunately, because we are in the business of collecting and disseminating information and run networks and servers and integrate with EHRs and do all that stuff anyway, it’s not a heavy burden for us. But it is not a revenue center. I’m reasonably good at figuring out how to make money, but I haven’t cracked the code on this one.

If I’m a provider, what’s the benefit to me to submitting a problem report?

I guess the same as if it was an adverse drug reaction. Sometimes I have to say that just knowing docs, sometimes it’s sort of being a doc, right? You raise your hand when you see a problem. You certainly don’t make any money for doing it and not everyone will report every problem, but it’s amazing how frequently docs do the right thing even though they’re not getting paid to do it.

I think in this case, there’s probably a general feeling, at least among the target audience, that if nobody says anything about a problem, the problem never gets fixed. The analogy that I would make is that there are 500,000 adverse drug events reported into MedWatch every year, and to my knowledge, nobody makes a cent from reporting them, but they report them anyway. My view is this what docs do. They often do the right thing even though they’re not necessarily getting paid or otherwise not getting some benefit for it.

If I’m a doc and submit my incident, what happens next? How does that help fix the problem?

It goes in the PSO. Those who have the right to do that, which are only a handful of people, will create reports. Other physicians will know that inpatient hospital systems are having these kinds of problems or those kinds of problems, or maybe there’s a software problem, although again more often than not, it seems to be user error type things. The reports will go to groups like professional liability carriers.

I don’t know what the FDA would do. I assume they’re going to access PSO reports because they’ve indicated that they plan to, but the liability carriers and the medical societies and regional extension centers will turn the reports into education programs. There’s an effort to create CME programs that the liability carriers will promote to docs, the specific CME program for docs who want to adopt electronic health records. Oftentimes those programs from liability carriers are tied to patient safety credits that actually reduce liability carrier premiums. But most of the focus is educational.

As for the reporting physician, they’ll get a response back, “Thank you for the report.” If they wish, they can enroll in a monthly update newsletter sort of a thing that will be an extract of the PSO reports — here’s how many patient safety-related reports we got this month, here’s some high-level stuff — although PDR Network, at this point, isn’t planning on creating any CME programs from this. But we know that some of our partners are and we’ll probably help distribute links to the CME programs.

With the FDA’s drug reporting system, there would be capability to immediately trigger some sort of a black box warning or recall. If I’m a provider submitting to this database, do I have any assurance that other providers using the same system, if it’s a system problem, will find out what I reported or that I’ll find out what they reported?

There’s a number of pieces to that. First of all, if you’re familiar with the MedWatch system, it’s quite a bit more complicated than what you described. There’s not really lightning-fast turnaround from MedWatch reports. Black box warnings have to go through an entire process before they come out. Some of them may be triggered by MedWatch, oftentimes not. Often it’s based on post-market studies or some other piece.

Secondly, 95% of of MedWatch reports don’t come from providers directly. They come from the manufacturers. Out of 500,000 that the FDA gets, only 5%, one in 20, are directly reported to the FDA. Most of them go to the manufacturers, who bear the responsibility for chasing down the information and getting all the facts and details. The FDA is certainly not staffed to do all that legwork and the manufacturers have a regulatory requirement to do that.

That kind of infrastructure is not in place for EHRs, or least that I’m aware of. Perhaps it will be someday. I don’t really know what the regulatory environment is going to be for EHRs.

If I have a problem with an EHR and I report it, there’s two pieces to it. One is that my vendor has a responsibility, if it’s a problem with their system, to correct or improve the systems and notify other people of the problem. If they didn’t have a regulatory reason to do that, they’d certainly have a liability reason to do that. We will route those reports dutifully, but we’re not a regulatory agency and we’re not attorneys.

What we can do is get the reports and get them into the hands of groups like liability carriers, medical societies, and regional extension centers and then let them reach out their physicians and educate them. If it turns out that it’s a specific software problem, most of the burden for that will fall on the vendor.

I’m sure that will come up more frequently as an education issue, so how do you educate docs? Part of that is the vendor’s responsibility, part of it’s the liability carrier’s responsibility, part is the regional extension center. That’s why they get, whatever it is, a third of a billion dollars to educate docs about electronic health records.

From the standpoint of who bears the responsibility of acting on a software problem, that will largely be the EHR vendor. They have that responsibility now. Hopefully we can add to the flow and speed of information to them.

Anything else?

Most of folks who’ve called, whether they be press or … we’ve heard a little bit of, “This is overdue.” [laughs] I’m sort of like, “OK, now here it is. Sorry we were too slow.”

I’ve heard a fair number of people say, “The federal government should be doing this” without much knowledge of what it would take for the FDA or some other agency to create a system. There was a real concern, frankly, among the liability carriers that any involvement by the federal government might actually reduce the amount of reporting that occurred. I certainly heard it. It resonated with me as a doc. It’s one thing to report something to my liability carrier or medical society, but as soon as you get the federal government involved, someone’s going to say, “I’m less likely to report that because I just don’t want to deal with it.” 

I think there are challenges associated with it. I think this is a point along the way on education related to EHRs. It’s not a regulatory effort. The federal government is going to do or not do whatever they’re going to do. This is some federal government support and cheerleading and participation, but this is not a mandate from the federal government. Whether that will ever occur or not I really don’t know.

Monday Morning Update 11/22/10

From SpaghettiCode: “Re: GE. The recent reorganization confirms that they made a huge mistake with the $1 billion IDX acquisition. After many attempts to defibrillate the CareCast business, they finally orged the legacy business under the EMR side and key execs were moved out.” Here are snips of what I had to say about the acquisition in September 2005. I mentioned collaboration with Intermountain Healthcare as a positive (that’s gone nowhere that I’ve seen), although I was focused mostly on the inpatient apps:

If you’re an optimist, you might assume that a mega-conglomerate like GE will pump R&D into the old warhorse IDX products, make them wonderful in a way that a small player like IDX never could … Pessimists would ask for even one example where that has ever happened, including with prior GE acquisitions … Much of CareCast was written 20 years ago by that little band of Phamis employees in Seattle. Does it contain enough intellectual property or technical excellence such that a quick spit-and-polish treatment will make it a world-beater? I don’t think so, but maybe GE does … Conglomerates have a way of screwing up products (McKesson, Siemens, and maybe even Misys.)… IDX needed a white knight. It was devaluing itself day by day, with an embarrassing UK performance and no CareCast sales. The acquisition announcement mentioned that IDX needed a partner with global reach, but it had already created its own opportunity in the UK and blew it. Cerner and Epic were threatening to run the table on them … Somehow HIT companies seem to lose their passion when swallowed up by multinational firms selling everything from light bulbs to Jay Leno. That’s kind of sad, don’t you think?

From Boston Patient Advocate: “Backlash is building by patient advocates against self-appointed ePatients who make a living selling a modified version of their story. They often fail to mention that they misunderstood information they found online, weren’t really as sick as they thought, or that it was their doctors that found the correct treatment or gave them an RX for online communities. Then again, we love myths of the little guy in America.” I ignore news stories in which reporters try to mask their opinionated reporting with phrases such as "debate rages”, “some are questioning”, or “pressure is building”. In other words, I don’t doubt your sincerity, but I’d like to know specifics behind your “backlash is building” assertion. As we say in the medical world, “In God we trust … others bring your data.”

From The PACS Designer: “Re: Continuity of Care. TPD is happy to see that HHS has embraced the concept of Continuity of Care as it is laid out in the ASTM Continuity of Care Record (CCR) and requires providers to include it in their EHR certification submission request. Healthcare organizations will have to include the ASTM CCR in their discharge process to get their EHR certified, and at the same time, we’ll have a chance to transfer information between providers to help eliminate duplication of procedures and reduce medical errors.”

Eastern Maine Medical Center (ME), preparing for a three-day lockout of striking RNs by bringing in replacements, will shut down all of its clinical systems except the eMAR and go back to paper. Here’s a hint for those living near Bangor: go somewhere else if you’re sick this weekend. Or, if you’re one of those “EMRs are evil” naysayers, this is your rare chance to do some Maine-based medical tourism to receive critical, elective medical care at a paper-based hospital.

The usual list of stuff you can and should do here: (a) subscribe to the updates so you aren’t embarrassed by the idiot three offices down who learns breaking news before you and rubs your nose in it; (b) use the search function to amplify your HIT intelligence in real time; (c) Friend or Like us on Facebook or connect with us on LinkedIn so that we may both pretend to be more popular than we probably are in real life; (d) click some of the sponsor ads to your left to see what they’re up to; (e) visit HIStalk Practice and HIStalk Mobile to get mostly different news particular to physician practices and mobile health, respectively (and sign up for those updates, too, if you want to stay on top of stuff).

Listening: the remastered 1978 debut solo album of former Pink Floyd leader David Gilmour, recommended by a reader. I appreciate that: I really like his music and respect him for his charity work, but I never think to recommend his solo stuff, which at that early stage of his career was kind of Pink Floyd Lite (not necessarily a bad thing). He’s supposed to be reuniting with former bandmate Roger Waters at one live performance of The Wall, which is on tour now.

Forbes runs maybe the weirdest, worst HIT article I’ve seen, apparently intended to be a cheerleading piece for Allscripts. It claims that open source is about to make its healthcare debut, courtesy of Allscripts (meaning Allscripts Helios, previously Eclipsys ObjectsPlus, which has been around since the 1990s). It claims that many tech vendors have gone out of business because they “chose to cling to closed, proprietary software or hardware” (care to share names and proof of the cause of their demise?) It mumbles something about the need to interface a “computerized drug order system” to an EHR (huh?) It says Judy Faulkner’s statement that you can’t mix and match vendors is an Allscripts advantage, failing to notice that Judy’s company (whose industry-leading product is closed and proprietary) had pretty much killed Allscripts (nee Eclipsys) Sunrise single-handedly since to install Sunrise, unlike Epic, required mixing and matching vendors to cover the many hospital areas it doesn’t address. To top it off, the article uses the old Allscripts logo pulled from Wikipedia instead of actually checking their site directly to get the current one. All of this was a lame attempt to create an interesting, insightful article around an October press release in which Allscripts announced that it would create an apps store for the former Eclipsys Sunrise, which has nothing to do with open source in the first place since nobody’s seeing and contributing to anybody else’s source code (extensibility isn’t the same as open source). It’s just amazing to me how many people write authoritatively but wildly inaccurately about healthcare IT (usually spinning entire articles around press releases and a couple of Google searches) who have never worked a day in either healthcare or IT except as a cheap-seats spectator. Caveat lector.

A little more than half of respondents to my poll say they’ve seen “hold harmless” contract clauses, although I liked the excellent comment by NotQuite, who pointed out that a “hold harmless” clause is not the same as a “limit of liability” clause. I’m no lawyer, but that sounds legally insightful. Gotham City CIO requested the new poll to your right, for hospital people: does your organization block access to outside e-mail services by physicians using hospital PCs? They block access to Gmail, Hotmail, etc. at his place to prevent the possible transmission of PHI via untrackable e-mail services, which is apparently common in other industries. The new CEO is getting heat from the docs even though they can still use a dedicated PC in the doctors’ lounge or their own PDAs to get to those services. Feel free to add any comments to the poll that would help our CIO colleague.

Thanks to new HIStalk Platinum Sponsor Orion Health. The international company, based in Auckland, NZ and with US offices in Santa Monica and Boston, offers solutions that include an HIE platform, the Concerto Physician Portal with single sign-on to provide a single patient view across multiple clinical systems, the Rhapsody Integration Engine for inter-system messaging and integration, the Rhapsody Connect solution for connecting to public health agencies, and the Symphonia developers’ messaging system for rapid system integration. The company just reported an 80% increase in revenue for the first half of the year and has 22 HIE sites in 12 countries. In the US, Orion’s HIE solution was recently chosen by the Wayne State University Physician Group and Maine’s state HIE. Rhapsody 4 just came out with new support for SOA integration and Web services, with Philips choosing it as its integration tool. The company offers a much broader product line than I knew about (EHRs, registries, whiteboards, bed management, chart deficiency, etc.) so feel free to cruise over to their site to learn more. Thanks to Orion Health for supporting HIStalk.

McKesson’s Horizon Clinicals earns ONC-ATCB certification through Drummond Group.

Marty Mercer is putting together a HIT sales training class for newbies and is looking for input from industry long-timers. You can help out by completing his short survey like I did. He’ll send me the results afterward since I think they might be fun to review here.

Inga emulates Weird News Andy with this link: doctors warn of the psychological dangers of social networking after an 18-year-old boy’s asthma attacks are found to be triggered by looking at the Facebook profile of his former girlfriend. His mom measured his peak expiratory flow before and after.

The Rural Nebraska Healthcare Network starts construction of its Nebraska panhandle fiber optic network that will connect nine rural hospitals and their clinics.

Vendors beware: patent troll Acacia Research buys 11 patents for wireless physiologic monitoring. Let the nuisance lawsuits begin.

A company that has developed an electronic parking space finder wins at the IBM SmartCamp World Finals in Dublin, but a couple of HIT-related companies were in the hunt: CareCloud (Web-based practice management and revenue cycle tools for practices) and Sproxil (checks the authenticity of drug products via SMS messaging, primarily in developing countries).

Speaking of “cloud”, everybody’s hopping on that bandwagon with as much self-serving enthusiasm as they did previous sloppily defined fad terms (ASP, EHR, clinical transformation). Since HIStalk runs from a Web host, I think I should start referring to myself as a “the leading cloud-based business intelligence and collaboration platform for the healthcare technology and life sciences sectors.” I’m thinking investors will line up at my door dripping saliva at the chance to throw money at me. 

St. Paul Heart Clinic (MN) closes its doors, with its 36 cardiologists going to work for either Allina or HealthEast. A key reason, as explained to patients, was the ability to share a common EMR.

Orlando Health (FL) offers local medical practices a discount on GE Centricity.

Weird News Andy likes this story: the call center for TennCare is a women’s prison, as discovered and reported by the overly dramatic and pot-stirring local TV station anxious to use that “breaking exclusive” graphic typically rolled out when someone’s flat tire backs up traffic almost a quarter mile. WNA likes the eloquently expressed consternation of one Leon Rippy, apparently goaded randomly by the TV station to weigh in on the issue of the potential but entirely theoretical impact on patient privacy: “That ain’t good.”

Coliseum Hospital (GA) investigates a former employee who dropped by to attend a nurse’s birthday party, then logged into the hospital’s computer system with her still-active password and looked at patient information. She’s caught by hospital security, which was apparently more effective than IT security considering the terminated employee’s credentials had not been inactivated. Assuming HR let them IT, of course (and trusting the competency of any hospital’s HR department is indeed foolhardy).

A blog entry in The Economist says HITECH could be as big a bust as NPfIT in the UK, suggesting that France provides a better model:

Maybe the Americans (and the British) should swallow what the French would term their “Anglo-Saxon” arrogance, and look at France. A French citizen presents his credit-card sized Carte Vitale to the doctor or the pharmacist or the hospital and everything—for example, the date and dosage of a prescription—is recorded by a national computer system (which also usually deals with payments). Visit another pharmacy or doctor in another town, and the patient’s details are automatically available. Perhaps this helps to explain why the World Health Organisation in 2000 (the last time it did the exercise) put France at the top of its rankings for health care. By contrast, Britain came 18th and America 37th. Mind you, it may also explain why the French pop more pills than anyone other than the Japanese.

E-mail me.

Being John Glaser 11/10/10

Meaningfully Using Industry Buzzwords at Home

With the HITECH and ACA legislation and rules. many new phrases and words have been introduced and old ones have gained additional prominence. I have found that these phrases and words also have use in several situations at home. See some examples below.

Death Panel. Your sixteen-year-old son returns home drunk at 2 a.m. after a long Saturday night. He parks the car sideways on the lawn. You and your wife are sitting on the couch in the living room waiting for him. As far as he is concerned, you and your wife are a death panel.

Stimulus funds. Your spouse shows you the new clothes that she bought. You like the clothes, but are mystified by the apparent need for new clothes when the old clothes aren’t that old and you liked those too. Moreover, the clip-on tie you had in third grade is still good and forty years later you still wear it from time to time. You don’t realize that the household income is really a stimulus fund to keep retailers employed.

Data exchange and interoperability. Your daughter (a senior in high school) wants to spend the weekend with her new boyfriend, who is a freshman at a local college. You, recalling quite well what’s always on the minds of young males, say “No.” Your daughter protests, “But Dad, it’s not what you think. I will be staying at his cousin’s (who is a girl) dorm room. Nothing will happen!” You think – I don’t believe that for a second – and again say “No.” You and your daughter are engaged in data exchange, but there is no interoperability going on.

Certification process. The first time you met him, you instantly liked your daughter’s new boyfriend. The second time you met him, you engaged him a lengthier conversation and discovered that he is a moron. The third time you met him, he had been invited for dinner and was clearly stumped by the role of the napkin. You decide that you and your daughter need a new boyfriend certification process.

Meaningful Use. You notice a dead tree in the yard. You find your chain saw and install a new chain. You assure your wife that you know how to fell this tree so that it won’t hit the house even though the tree is close to the house. You miscalculate and tree branches take out the kitchen window. Your spouse is less than impressed. You are clearly not a Meaningful User of advanced technology.

Bundled Payment. You are arm-wrestling with a new car salesman over the price of a car. He mentions all of the features that come with the base price – seats, steering wheel, front window, headlights, and an engine. He informs you of all of the extras – roof, glove compartment, and radio. You want the extras for free. Plus you want a sun roof, Jacuzzi, and toaster. You and he are negotiating a bundled payment.

The great thing about words and phrases is that they have so many uses and meanings.

John Glaser, PhD, FCHIME is CEO, Health Services of Siemens Healthcare. He describes himself as an "irregular regular contributor" to HIStalk.

News 11/19/10

From Karen: “Re: Meaningful Use: Doctors Have No Choice. Written by my husband, but still true!” Jim O’Connor, MD of MDcohort makes the argument that Meaningful Use isn’t as voluntary as it sounds, offering as evidence: (a) CMS will start imposing penalties on EMR non-users in 2015; (b) private insurers will tie MU to their P4P programs; (c) MU will apparently be made a requirement for renewal of board certification; (d) states can impose their own penalties, possibly even requiring MU for medical license renewal.

Ed Marx has a lot of fans here, so if you want to read more from him, he has posted a special article about his relationship with his daughter on Texas Health Moms, a site managed by his employer, Texas Health Resources.

Listening: new from Guster, which I’ve mentioned before. Solid, harmony-driven alt-pop (kind of R.E.M.-y to me), but they’re also funny: they enlist fans to sell CDs and sometimes open their own shows in disguise. If you’ve heard any of their stuff, it was probably Satellite.

Timing is everything: just after Aurora Health Care (WI) announces plans to eliminate 175 jobs in a cost-cutting effort, the press gets wind of the $8.2 million its former COO was paid upon his retirement last year. They make the standard excuses (accrued benefits, they have to compete with for-profits anxious to hire away executives who have spent their entire lives in healthcare, etc.) but I note that they paid the CIO $739K and the CEO got over $2 million according to their most recent tax filings. They have 30,000 employees, so maybe that seems reasonable by inflated non-profit salary standards these days. We may suck at population health in this country, but we lead the world in the executive-to-grunt compensation ratio.

The Aurora guy, who wasn’t even the CEO, made even more than Cerner CEO Neal Patterson, who took home $3.3 million in 2009, a little less than he made in both 2007 and 2008. And speaking of Neal, I’m clearly not at his level of business acumen because this just seems weird: he and Cliff have renamed their soccer team from the Kansas City Wizards to Sporting Kansas City. They’re doing some kind of membership thing, apparently, but that name sure make a weird fan cheer.

Think this will reduce healthcare costs? Mayo Clinic is building proton-beam cancer treatment centers at its Minnesota and Arizona locations. The price tag: $370 million.

On the sponsor-only HIStalk Jobs Page: Director Technical Readiness, Implementation Consultants and Project Managers, Healthcare Consulting Leader, Account Executive. On Healthcare IT Jobs: Program Manager IT Implementation, HED AdminRX HArx Remote, Implementation Engineer – Integration, Epic Inpatient Opportunities.

A New York Times article describes the problems San Francisco Department of Public Health is having with its $11.2 million Avatar EMR from Netsmart. Conversion problems caused delays in Medi-Cal payments to individual therapists and some therapists and social workers are complaining that using the software is eating into time for patient care. A post-implementation audit showed that mental health services volume dropped by 55% and substance abuse by 32%, with the deputy financial officer concluding that, “It’s pretty clear none are getting Avatar.” A social worker agreed: “This is not the job we accepted when we chose to do clinical work for the city.”

Strange: a Walmart pharmacist is disciplined by the Maine regulatory board for dispensing zolpidem instead of Zoloft to a patient. Before his own drugstore went bankrupt, he was also found to have overbilled the state by $1.6 million. The odd part: he’s a state representative in line to become the next speaker of the House.

The VA will develop two prototypes of Aviva, a virtual implementation of its VistA system and its apparent replacement, according to its just-released Fiscal Year 2010 Performance and Accountability Report. I thought they already had demonstrated the prototype earlier this year, but maybe this is something new.

Verizon will offer free credentials to providers in starting in January that will allow access to its Verizon Medical Data Exchange. It offers a provider portal, a secure inbox, and connections to the Verizon Health Information Exchange.

E-mail me.

HERtalk by Inga

From MrSoul: “Re: Kindle It. Encourage your readers to tell the publisher of Connected for Health to publish in Kindle so we can read it on our iDevices! There is a link on Amazon to do just that and then they can have this great resource always on hand.” I would think a book like this would already be in digital format!

West Penn Allegheny Health System selects athenahealth’s RCM service for its 600-doctor physician organization. They are apparently replacing GE’s RCM product. On the EHR side, they use Allscripts.

Venture capital firm OpenView Partners makes a minority investment in Prognosis Health Information Systems. Prognosis CEO Ramsey Evans says that OpenView’s investment will allow the company to “move forward and take our business to the next level.”

North York General Hospital in Toronto goes live with 300 order sets, using tools from Zynx Health’s ZynxOrder and integrating them into Cerner EHR.

CMS says the error rate for Medicare fee-for-service claims in 2010 dropped to 10.5%, or $34.3 billion in estimated improper claims payment. That’s down from 2009’s $35.4 billion in payment errors. I guess we should all be thrilled that CMS is getting better, but I am stuck thinking about all the better ways that $34.3 billion could have been spent.

The Stone Center of New Jersey IPA signs a 15-month contract with iMedicor to connect its 120 urologists into iMedicor’s National Health Communications Network.

Central Maine Healthcare eliminates 20 jobs as a result of outsourcing its medical transcription to Precyse Solutions. Precsyse offered positions to all 20 employees, though only 10 accepted. The move to outsourced transcription is part of a $11 million cost-cutting initiative.

Health management company Continuum Health Alliance contracts with Ignis Systems to provide integrated lab orders management for its EMR application services.

The Indian Health Service (IHS) commits to a $3.3 million contract with Orchestrate Healthcare and Vangent to plan, implement, and support the national deployment of the IHS HIE, enterprise MPI, and NHIN capability. Vangent’s HIEOS open source software will be used to establish connectivity between IHS facilities and the NHIN.

Miami-Dade County Commissions tell Jackson Health System to cut ties with the company handling its international marketing after a recent report details excess spending for such things as flowers and birthday cakes ($7,000), local meals ($37,000), and limo rides ($12,000).  An additional $6,000 was spent on a Royal Caribbean cruise for five of the marketing firm’s senior executives and their families. Foundation Health Services was the organization handling the health system’s international marketing efforts. It’s a not-for-profit, so I guess the execs had to get their perks from somewhere.

Teleradiology service provider Century Digitec Services goes live on eRAD’s hosted teleradiology software platform.

A study of 15 IDNs leads the Government Accountability Office to declare that EHRs can improve the quality of healthcare, making patient information more readily available and improving communication and coordination between providers. Providers still face challenges in terms of maximizing their use of EHRs, including limitations on sharing patient records outside their health system.

New on HIStalk Practice this week: 15 HIT vendor execs share what their company is doing to help physicians qualify for Meaningful Use. Evan Steele of SRSsoft provides commentary on the Meaningful Use challenges for specialists. Fun details on the eClinicalWorks national user conference, including a party pic with a uniquely attired CEO Garish Navani. And, the EHRevent patient safety reporting system. There’s a bunch of other good stuff as well, none of which you will find on HIStalk. Make sure you remain smarter than your co-workers and take a read.

"But Inga,” you say. “I’m too busy, just give me the highlights.” For grins and because I believe it’s important stuff, here’s a short summary of what the HIT vendor execs had to say about helping providers reach Meaningful Use:

• Several are incorporating dashboard tools or similar reports to help providers assess EHR usage based on Meaningful Use requirements.
• Most are offering webinars; many are setting up regional meetings to educate users on what needs to be done; most have online tools available; and, most mention the option for personal assistance, either on-site or remotely.
• Only a couple mentioned working with regional extension centers to share expertise and help beef up local infrastructures.
• Allscripts and athenahealth remind users that they offer Meaningful Use guarantees.
• Not surprisingly, some of the vendors have nicely packaged answers, which to me suggests (a) the vendor has established a clear-cut plan,  or, (b) the vendor has a great marketing department, or (c) both.
• A couple are short on specifics and don’t say much more than vendors needs to help physicians in the process.
• Jonathan Bush of athenahealth wins the prize for the most entertaining answer.
• Evan Steele of SRSsoft  has the most unusual reply, saying the company has spent considerable time reviewing the requirements and are helping its clients make an informed decision as to whether participation is right for the individual practice.

Sponsor Updates

• Encore Health Resources had a contest to see who could do something creative with 100 Legos in celebrating the hiring of the company’s 100th employee. Above is one of the submissions by employee Paul Murphy, who went with a multimedia strategy with an Ivo bobble head approach. I was thinking that I could have cheated and added extra Legos and come up with something spectacular.
• Nuance Communications introduces Nuance Transcription Services, which combines the eScription speech recognition platform with medical transcription and editing services from two of Nuance’s newly acquired companies, Outsource Solutions and Encompass Medical Transcription.
• MEDecision earns NCQA HEDIS software certification for its Alineo Clinical Intelligence Rules 2.4.0 and 2.5.0 programs.
• CareTech Solutions launches CareWorks 4.0, which includes enhancements in audit reporting, directory utilities, and several mobile modules.
• Fast-growing EnovateIT will move its headquarters from Ferndale, MI to Canton. The company’s mobile and wall-mounted computer workstations are used a third of the hospitals in he US, with last years $19 million in sales expected to reach $35 million this year.
• dbMotion appoints Prematics president and CEO Keving Hutchinson to its board of directors.
• 3M Health Information Systems and IQMax partner to offer 3M’s coding and documentation tools using IQMax’s mobile healthcare platform.
• Hayes Management Consulting will provide its Legacy Application IT Help Desk services to Moses Cone Health System as they transition from GE Centricity Enterprise to Epic.
• South Australia’s Public Health System names Allscripts its vendor of choice to provide EHR to its 80 hospitals. The agreement to purchase Sunrise Enterprise 5.5 is subject to contract negotiations, with final approval expected during the first half of 2011.
• Sage is named a group purchasing EHR vendor by PA REACH, which will offer Sage Intergy Meaningful Use edition to providers at a discount.
• A new KLAS report on ED solutions names Epic and Wellsoft as tying for the top spot.

E-mail Inga.

HIStalk Interviews Jonathan Phillips

Jon Phillips is founder and managing director of Healthcare Growth Partners.

Explain what you do. I don’t really understand it except I figure it’s lucrative.

We are an investment bank focused on healthcare technology and services. What we do is analogous to being a real estate agent for companies where we help companies sell themselves, or we help companies buy other companies.

So a good bellwether of how busy that market is would be how often your phone rings. Are you finding that it’s a lot busier now than it was?

What’s interesting is that it is a lot busier now, although the best bellwether is still the number of deals that actually get done. One thing that’s just a fact of life in the mergers and acquisitions business is that when you start a process, you don’t always finish it.

What you see are a lot of situations where companies decide to sell themselves and they don’t get a buyer for reason A, B, or C. It could be that the price that the market thinks that they’re worth isn’t what they think they’re worth and so they decide to wait. Or, it could be that they just don’t get interest at all. Or, it could be that they decide they’d rather do something different — that maybe they’d rather raise money instead of selling themselves, go buy something.

The key challenge in terms of this business is getting things to the finish line. What you’re seeing in the market as a whole is a significant uptick in terms of the number of transactions getting done as compared to a year ago or two years ago, both in terms of the number of deals and the value of those deals.

Where we sit right now is that there are more deals trying to get done than deals that have gotten done, and so you have a lot of folks who haven’t been able to get things done and there’s some interesting dynamics that go along with that.

Do you think it’s because companies that are trying to sell are seeing a top in the market and figure, “Hey, now’s my chance, although I’ll keep going if it doesn’t work out” or do you think they’re desperate, like, “I’ve got to do it now or it’s never going to happen?”

Early in the year, a lot of those were driven by the fact that healthcare mergers and acquisitions activity emerged faster than other sectors. What you saw was a lot of individual shareholders or private equity firms or venture firms looking to sell companies because healthcare was a hot area. Healthcare IT in particular was especially hot, and so you saw a lot of books come out early in the year. Early in the year was driven by, “Hey, the market is hot, and it’s getting hotter. Let’s go out and get a good value for our business.”

Later on in the year, what you started seeing is a little bit of a different trend, where you have some folks who are pulling the trigger on an exit because of tax-related concerns. There are absolutely companies out there that have decided to sell because their sense is that capital gains tax rates are going to go up next year.

Even if capital gains tax rates don’t go up next year — if there’s some type of an extension of the tax breaks — capital gains rates will go up at some point down the road. That does have some impact on decision-making, because even just a five percentage point increase in the tax rate, if you’re doing a $100 million deal, that’s potentially $5 million of more money that you’re paying to the government on January 1 as compared to December 31. That’s been another driver.

The other thing that you’re starting to see — and I still think it’s an early phase of this — but you’re starting to see this phenomenon that I thought we would see a while ago. Companies that are somewhat weaker, that aren’t growing as quickly or aren’t growing at all, or don’t have as strong of a product set and product capability — some of those companies are finally saying. “You know what? Either this market is moving, it’s not moving fast enough, or we’re not moving fast enough in terms of our internal growth to really dig our way out of our current predicament, so we’re going to sell because it’s probably not going to get any better.”

That’s something I think we’re going to see more of, because the way that I characterize the M&A market right now is it’s really kind of a world of haves and have-nots, if you will. Normally what you see in terms of valuation multiples — the multiple of revenue or the multiple of earnings for which a company sells — normally you’ll have a normal distribution of that. If the median multiple is 10 times EBITDA, then you’ll have a bunch of deals happening close to 10 times EBITDA, you’ll have a few deals happening at 15 times EBITDA, and a few deals happening at five times EBITDA.

Where the market is right now is much more in kind of a bimodal distribution. You have a some deals happening at very high multiples, and you have a bunch of deals happening at much lower multiples. You don’t have a lot going on in the middle. I think as this M&A market continues to mature and as the cycle continues, I think you’ll see more activity in the middle. You’ll see more kind of eight to 10 times EBITDA deals happening, but right now, it’s really at the extremes.

I would assume that the number of deals on the high end probably has always been the same. Does that mean more people are unloading for less than they expected or less than historically has been the case?

There are certainly a few more deals on the high end than over the last couple of years at least, but it does mean that more people are unloading at the low end.

Some of that comes back to putting yourself in an investor’s shoes, where you’re an investor in a company that is $3 million in revenue, and you put money in it maybe five years ago, maybe seven years ago. Just to use hospitals as an example, although it would apply to the physician software, it would apply to payer software in 2008, when the hospital spending really froze because of the capital markets early in the year in terms of the auction rate securities and the lack of liquidity for hospitals, later in the year as the market downturn occurred when hospital spending slowed, then the growth source for a lot of these companies slowed down.

But coming into 2009, you had this grand stimulus package that was going to drive all this growth in healthcare IT. Well now it’s a year and a half later, and a lot of those companies that were doing $3 million in 2008 did $3 million or maybe $3.1 or $3.2 million in 2009, and did maybe a little bit more than that or are going to do a little bit more than that in 2010. But from an investor perspective, they’re saying, “How long am I going to have to wait for this market?”

While there are certain subsets that are seeing tremendous growth, my opinion just from talking to a lot of different companies out there, a lot of companies are having a tough time just getting decent growth because resources are geared toward making sure that you can get your Meaningful Use dollars. Resources that aren’t geared toward Meaningful Use dollars are severely restrained, and they’re going to be focused on those things that are going to drive the highest ROI for the hospital.

It’s very competitive for those capital dollars. As a result, demand is soft, and investors say, “Well, do I want to count on demand improving in 2011? I’m going to have to invest more. I’m going to have to wait a few more years.” Or maybe it’s not throwing up the white flag, but it’s certainly, effectively surrendering and saying, “All right, I didn’t do well on this one. I’m going to move on to the next one.”

If you look at the effect of federal money on the potential for company profitability, when do you see that peaking?

I think you’re going to see it peaking in 2012 or 2013.

Really? So you don’t think it’s here yet, so there’s still a lot of opportunity for companies to improve their bottom lines in the next couple of years?

I think there are a lot of opportunities to do that, but the problem is you have to be really disciplined leading up to that point.

Part of the challenge that you see with folks who are selling at less than optimal values is that they’ve found themselves between a rock and a hard place. They see the potential a couple years down the road, that whether they would be direct beneficiaries of the stimulus dollars or not. As those dollars flow into the system, it will create a much more favorable capital spending environment for hospitals. Maybe not much more, but at least a more favorable capital spending environment for hospitals, but you’ve got to get there.

Candidly, I’m still of the view that if you really dig into the performance of the large majority of companies out there — whether they’re selling to hospitals or physicians — I think that the reality of sales momentum is far short of the story that’s been told. Not story as in a negative thing, but kind of the potential that’s out there. I just think this market, it moves slowly. You’ve been around the market long enough.

It’s like nothing happens fast here, and while the HITECH dollars would drive all the spending, effectively what they did is they froze things for a very long time. Consultants got a ton of business over that timeframe as people tried to figure out what to do.

But now as the middle-of-the-market folks are actually implementing their plans, it still is just going to take time. In that time, you have to be really disciplined. You’ve got to figure out a way that you’re not going to be reliant on outside money to come in to fund you. You have to make sure that you can figure out a way to cash flow yourself rather than being dependent on an investor to do it because investors very likely will get impatient with your performance if you can’t show that very immediate path to profitability.

Given how slow this market, is you’ve got to be able to hunker down and make it through. Down the road, there’s a ton of money to be made here, but it’s going to take time.

Companies will need to ride the wave up now and then down again when the surge of money runs out. Do you think that’s a concern, where companies look good now but will be terrible later?

I think there’s definitely some of that. That’s one of the things that as folks are looking at investment opportunities or are looking at companies you want to line up with. You do have to be careful about that.

It comes back to if you look at what happened to the professional services space in healthcare IT leading up to Y2K and then what happened after that. You look at it and you go, “Wow. All these companies were growing like crazy, and then business fell off really quickly.”

It wasn’t all just Y2K-driven, but what it came back to was you had the combination of the outside threat went away, you had a recession that came along, and then hospitals cut back on the professional services spending. You had this very quick retrenchment that a lot of those organizations had to do. For some of the bigger ones, it was really hard to dig out of that at all because it’s one thing to grow, it’s hard to cut. I think that’s the risk that you see.

And once again, not until 2015 or beyond, but the risk that you will see is that there will be all this money flowing through the system and folks will invest on the assumption that that will be there forever. It won’t. You’ll certainly see some businesses that will really struggle at that point.

Who are the potential buyers out there, and what is it they’re looking for?

In terms of the buyers, my fundamental belief is that this is still more of a buyer’s market than a seller’s market, if you want to have kind of a general view of the market. Now in certain subsectors of the market, it’s definitely a seller’s market. You can’t just say it’s a buyer’s market across the board, but in more places than not, it’s a buyer’s market.

Before getting to who the specific buyers are, generally what buyers are going to be looking for are businesses that can grow and that are growing, and businesses that either are or can show that they can be immediately profitable. Folks really aren’t interested in spending much money on businesses that are declining in revenue or going sideways on revenue and are either just making a tiny bit of money or losing money. Those are tough things to get to the finish line, and the value that you’re likely to see in situations like that will tend to be that you’re not going to get great valuation multiples.

Where you’re going to see the really big valuation multiples are going to be in situations where the business is growing, they’re making money, there’s significant growth left for them to go after, and then you’ll see some of these well-capitalized strategic buyers stepping in and making a play. The case examples on that really come back to you look at the deals that Ingenix has done over the last few months, and obviously varying multiples in terms of what they paid for things. But they’ve certainly been willing to pay more aggressively for businesses that they feel they can use their existing infrastructure — their existing customer reach — to generate substantial incremental value. Ingenix absolutely is going to continue to be a significant buyer. Emdeon is going to be a significant buyer.

You look at the McKesson / US Oncology deal. Very interesting in terms of how that changes the axis of that company a little bit beyond where they’ve ever sat before. In organizations like that, you’re going to see substantial increased acquisition activity because they can afford to look at a lot of different things and they’ll be able to pick and choose those deals that make the most sense for them.

I think, realistically, all of the large — whether it’s a diversified healthcare entity like a McKesson, or a specific healthcare IT company like an Allscripts — I think you’re just going to see a lot of acquisition activity on an ongoing basis because there are a lot of companies that want to sell and I’m not going to say there’s a very short list of buyers, but it’s not a huge list of buyers. The pure healthcare IT- and healthcare-focused companies are going to be able to pick and choose and pick those things that are going to drive the most value for them.

I think you’re going to see more folks coming into healthcare from outside of the space. Traditional software players are absolutely going to continue to increase their presence in healthcare. You’ll see traditional services players increasing their presence in healthcare.

Then, alongside all those groups, you’re going to see the private equity universe, whether bio guys or growth equity investors. You’re going to see them looking at healthcare technology and services as well because at the end of the day, it’s a market that healthcare as a whole is going to be growing in  2-3-times GDP over the foreseeable future. Healthcare technology and services will be growing faster than that. So if you get a business that is just growing at the market rate, it’s a nice business. If you get a business that can grow faster than that market rate, it could be a great business.

I think there’s a pretty broad universe of buyers right now. The problem is that buyers are picky because they’re getting to see a lot of different things, so they can afford to be picky.

In the past, the big money came from outsiders who didn’t know the market very well and got taken to the cleaners by buying something that industry folks would have thought was puzzling. Would you agree that if there’s big money to be made, it’s probably going to be somebody who just wants to buy a foothold in healthcare and doesn’t really understand the positioning of a specific company?

I think that’s one of the ways. The “stupid money” coming in is something that has been around healthcare forever. I don’t think that goes away. I actually think the folks who can stand to make the most money and make the best returns, in my opinion, are ones where you can make a very simple case. Some of this comes back to the case that can be made for somebody coming into healthcare from outside of healthcare.

But if you think about healthcare IT at its most basic level; you have, just round numbers, 6,000 hospitals. You have anywhere between 600,000 and 800,000 physicians and thousands of other care providers in this space. Just think about the provider universe and think about how fragmented that provider universe is and how hard it is to have a footprint that touches more than a fraction of that provider universe.

In my opinion, where folks will get the best exit multiple — where they’ll get paid the highest multiple for their business — and where the acquirers will make the most money on that are situations where you have an acquirer who has really broad reach and you have a seller — a target — who has a great product that is getting traction on its own, but will get a lot more traction if it can just access that acquirer’s distribution network.

Those are the situations where, honestly, if you look at the financial models, acquirers can afford to pay a lot. They can afford to pay what may seem to be irrational prices because the return that they get is incredible.

You go back to my favorite case study on that is the McKesson acquisition of ALI way back when. They hit the market just right. They bought a great company with a great product. They paid a huge number for it, but it really worked out for them and they made a mint on it because they could increase the price. They rolled it out to their customer base and it’s been a great outcome for them.

I think you look at some of the other deals that have happened over the last 10-15 years in the space and those are generally the deals that are the best outcome for everybody — that you have something where it’s a great product, a great capability, a great solution that gets acquired by someone who has a customer base that’s already interested in that solution. You put the two together and they get to take the market by storm. The sellers made a lot of money when they sold, and the buyers make a lot of money on being able to sell that product to their customers.

Sounds like it’s time for Oracle to buy Cerner. What do you think?

I don’t know about that.

You know Oracle wants in. They’ve got to buy something. They have so much cash that surely they want to be in healthcare.

They definitely want to be in healthcare, and I think you certainly can make a case that they’d buy Cerner. I actually think if they were trying to really mix it up, the angle that somebody would take — and once again, I know Epic’s not for sale and Meditech’s not for sale and eClinicalWorks isn’t for sale — but the concept of a big outsider coming in and picking up one of those folks would be the really big game-changer. They’d have to pay a huge number and maybe there’s not a number that’s big enough, but that could be a huge game changer.

But you’re right. From Oracle’s perspective, they did pick up Phase Forward, which makes them not the 800-pound gorilla, but the 2,000-pound gorilla in the clinical trial software space. But they certainly can’t sit here and look at the hospital market and the physician market and say, “Well, we’re not going to touch that.” I mean, there’s too much potential spend there for them to overlook it. The question is whether Oracle and folks like them, whether they decide to take a big jump or a little jump.

Interestingly, if you look at what historically works the best for folks entering the space, generally the big jumps have been tough. You think about McKesson/HBO. You think about Siemens/SMS, GE/IDX. You run down the really big deals and they haven’t worked out that well as compared to some of the ones where there have been much, much smaller plays. They’ve generally worked out a lot better.

If you had Larry Ellison’s wallet, how much would you be willing to spend on Epic?

That’s a great question. I would be willing to spend if I had his wallet — and I don’t have his balance sheet in front of me — but if I had his wallet, I’d be willing to pay a huge number for Epic because I think that in doing that, you’re effectively locking up a lot of the market for a long time to come. You go in and you say, “Well, what are the biggest hospitals in the United States worth from an IT spending perspective over the next 10 years?” You’re not talking about a two-year horizon or a five-year horizon. You’re talking about a really long-term horizon just given the decision cycles on these systems, and it’s a really big number.

You didn’t give me a number, so let me give you mine and you tell me if it’s too high or too low. I was thinking between $5 and $10 billion.

I actually would have said, without knowing exactly where Epic’s numbers are, $5 to $7 billion.

Of course that means you’ve got to have a seller.

Now honestly, I think that Judy and her team would still probably say no. I’d be surprised if somebody hasn’t come to Epic and offered them an absolutely tremendous number. But from Epic’s perspective — and I think this is part of the issue you’d see with a lot of folks out there — that’s not why they’re doing it. It’s not to just throw a bunch of cash in the bank.

I think if they felt that doing something like that would allow them to do a significantly better job of serving their customers, I think they’d do it and I think maybe they’d even do it for a much more reasonable price. I think that’s the take with Epic. That’s not the reason that they’re in the game.

Give me a handful of companies that most people haven’t heard of that you like.

As I look at the market, I think that there are a couple things that are going to be really, really important. The most interesting area for me really, circles around cost containment and quality management. What it gets back to is the fundamental challenge that we have as a healthcare system is that we have no control over cost and we’ve got, effectively, a fee-for-service model. We have a piecework model.

As we roll forward in healthcare broadly, we’re going to run into situations where those new approaches to care delivery and to care management and case management. Those companies are going to have a chance to build a tremendous amount of value.

There are a number of companies that are focused on — some people call it physician analytics, and some people call it the quality infrastructure. Some of these guys are thinking about it as local HIEs, but technology platforms that allow for capturing information from disparate sources and analyzing that information and deriving useful, actionable outputs from that information. That for me is a huge opportunity. The challenge that you see is that a lot of companies that play in that space are coming at it from very different angles.

I haven’t come across a company that I’d say wow, they’ve really got it. Some folks are coming at it from the HIE angle, some people are coming at it from the payer angle, some folks are coming at it from a clinical trials angle, but you haven’t had somebody who comes out and says well, here’s an infrastructure that it’s truly going to support  — whether it’s called an ACO or whatever the buzzword of the day is that’s used to describe that — but here’s an infrastructure that’s going to allow for integrating disparate data sets. In flagging issues with patients getting the right intervention and then monitoring the results, those types of things are going to be huge.

One of the other areas that I get really excited about is the home monitoring space. Home monitoring has been just a backwater in healthcare for such a long time because the reimbursement models haven’t been there to support it. Now what you’re seeing is the beginning of a trend toward coming up with new ways to go about monitoring patients when they’re in a home environment.

Honestly, once again it’s reimbursement-driven because people are fast-forwarding to when they’re not going to get paid for the 30-day readmits and saying, “All right, how are we going to keep these people out of the hospital?” Well, there are these tools that are out there that have been well proven that if you’re doing the right types of monitoring at home, you can keep people out of the hospital. Well, that’s getting pretty exciting.

Area one, it’s not interoperability, it’s really interoperable analytics. Area two is home monitoring.

I still get intrigued by the fact that I think there are a lot of opportunities in just niche-y areas that the big guys don’t necessarily focus on. Even in areas where the big guys do focus, you have the opportunity to build real expertise and just own a sub-segment.

You look at folks like Curaspan out there, in terms of the discharge management, and you look at TeleTracking in terms of the patient flow solutions. Folks like that that just pick what they’re going to do and they do it really well and just stick to their knitting and build up. Those are pretty exciting. I think most folks have probably heard of those guys, but that’s really exciting.

I know a lot of people disagree with me on this one, but I still come back to I think there’s still opportunity for — whether you call them best-of-breed or departmental solutions — I still think there are opportunities within hospitals for non-enterprise vendors. Now, do I think there’s an opportunity in a hospital for a non-enterprise vendor that has one function that’s a very narrow function? Probably not. If you just have a software product that handles valet parking at the hospital, yeah, you’re probably at risk for somebody taking you out.

But if you have a suite around access management that you could go in and you’re better than the access management capabilities of the hospital’s enterprise vendor and you have enough functionality that you’re not just a one-trick pony, there’s real opportunity for that.

I think you will see a consolidation in terms of the number of vendors because you don’t want to have 200 vendors out there. You want to have a manageable amount. The key is if you want to play in the hospital market and you’re not an enterprise guy, you’ve just got to figure out how to get big enough and add enough capability that you’re one of the surviving vendors. That’s pretty exciting to me. I think it’s an area where there haven’t been a lot of folks focusing on it, and I think some companies can really take some interesting steps there.

Last question. You get one-sentence answers.Give me three predictions on anything related to healthcare IT.

Prediction #1 is that the M&A market in healthcare IT will be very strong in late 2010 and through 2011, and then will fall off significantly in 2012.

Prediction #2 is that by the end of 2011, there will be multiple deals north of a billion dollars in the space, which would be a big disconnect from history that generally, there’s one of those deals every couple years. But before the end of 2011, there will be multiple large deals.

The third prediction would be that the actual payout for stimulus funds will be a fraction of the total potential amount.

CompuGROUP To Buy HealthPort’s Systems Business

Germany-based medical software vendor CompuGROUP Medical AG announced today that it will buy HealthPort LLC of Columbia, SC, the solutions business of HealthPort, for $24.3 million in cash.

The Alpharetta, GA HealthPort will apparently keep its other business lines, including Release of Information and auditing services, as they were not mentioned in the CompuGROUP announcement. The company was named as the top-selected RAC vendor in a recent KLAS report.

Rumor reporter Iggy told HIStalk readers in August that HealthPort was preparing to sell its non-ROI business, possibly in preparation for an Initial Public Offering like the $100 million one it cancelled last November, citing poor market conditions. Another rumor reporter Staff Infection specifically mentioned on August 11 that CompuGROUP was in talks with HealthPort.

CompuGROUP also announced its Q3 earnings today, reporting revenues of $102 million and operating profit of $24 million. The company has 3,000 employees and a market cap of $720 million.

CompuGROUP acquired Cleveland-based ambulatory systems vendor Noteworthy Medical Systems in February 2009. In September, CompuGROUP acquired the US-based Visionary Healthcare Group for up to $65 million, noting that gaining the PM/EMR vendor’s 10,000-physician customer base was a commitment to CompuGROUP’s plans to make the US a key market. CompuGROUP also announced this week that it had completed the acquisition of Swedish hospital EMR vendor Profdoc Care.

News 11/17/10

From HIPAA Police: “Re: spelling. You would think a group sending a mass e-mail pitching its market research services would spell HIPAA correctly.” You would indeed.

From Limber Lob: “Re: getting physicians to standardize processes. Princeton economist Uwe Reinhardt says that trying to get physicians to work together is like trying to get eagles to fly in formation.” I like that analogy a lot.

From Capone’s Vault: “Re: Motion Computing Mobile Clinical Assistant C5V. This is slick. The pressure will be on the iPad to match the healthcare-friendly features of this.” It’s a full tablet with a docking station, optional barcode scanner, camera, Gorilla glass breakage resistance, and hot-swap batteries. It weighs three pounds, can be disinfected, and can withstand drops (big thumbs down to the iPad in that regard). Sounds great, just a little bit expensive at the mid-$2,000 range, but IT-friendly. Motion was bad about not getting enough nurse input on their previous models, so I’ll withhold judgment until I heard from nurses who have used a C5V at the bedside.

From Randy: “Re: Connected for Health review. I am enrolled in a Health Systems Management class at Morehead State University. This book is required reading.” I’m glad to hear that – I bet its great for that. Another reader is using it in an informatics course for public health students they’re teaching. For those who don’t know, Morehead State is in eastern Kentucky. I went to a seminar at St. Claire Regional Medical Center once, which is how I knew. Thanks for the report.

From Duke Nukem: “Re: NEJM article saying doctors should beat hospitals to the punch in forming their own ACOs to protect their own interests. Harrumph – you mean the same way they protect themselves by walling off nurse practitioners and claiming medical expertise is required to deliver acupuncture? A hundred years ago, they were barely better trained than barbers and butchers.”

Microsoft says its genomic sequencing project with Seattle Children’s Hospital consumed $18,000 worth of cloud-based supercomputing resources compared to the $3 million it would have cost using traditional local hardware. It used the Windows Azure cloud computing platform.
 
Wake Forest University Baptist Medical Center is going Epic, I’m told.

Nuesoft’s IT and product groups throw down a pretty good Lady Gaga video spoof. It sounds a lot like her and many other singers today, i.e. heavy on the Auto-Tune, which I really dislike — think Cher’s Believe from 1998, which sounds kind of Peter Framptony like somebody’s singing into a keyboard (meaning you don’t really have to be able to carry a tune to be a “singer” with computer-perfect pitch – it just came a few years too late for Milli Vanilli, but in plenty of time for the cast of Glee). But I digress – it’s a pretty good video. 

A former Fallon Clinic (MA) doctor brags on the clinic’s EMR, but complains that his access to it was terminated when he left to join another clinic. His point: he can’t treat patients as effectively who have chosen to move with him since “their” information is being held captive by Fallon Clinic, who says they’ll mail him a CD in a few weeks. I think it’s a bit presumptuous to assume that his former employer will continue to let him use their systems and I assume the CD they’re sending will have the information about his patients in some standard format he can review. Beyond that, that’s why there are HIEs (other than to get federal money).

The OncoEMR oncology EMR by Altos Solutions becomes the first oncology-specific EMR to receive ONC-ATCB certification as a complete EHR, the company says.

Patient Privacy Rights releases an informed consent white paper and the results of a new patient privacy poll. The rags are picking up the poll result as big news since it finds that 90% of Americans want to be able to decide who can see and use their health information, but I should add a cautionary counterpoint that the questions were loaded with what the ever-witty Inga always calls bias of the “Do you like babies and puppies?” variety. For example: it asked lay people whether providers should be able to “share or sell your sensitive health information without your consent” and “Who should make the decision on whether corporations and researchers can see and use the information in your health records without your permission?” I don’t know how far that skewed the percentages that ended up in the 90s, but I’d say quite a bit. Still, I don’t doubt the conclusions, just the methodology. I’d also guess that quite a lot of Americans would divulge just about anything for cash (like those Brits and their passwords a couple of years ago), so maybe that’s the backup plan for those profiting from their data – just buy it from them and mark it up.

Stanford Hospital runs a pilot project in which cath and angiography patients are given iPads preloaded with movies, books, games, and Internet access to entertain themselves before and after their procedures. The hospital likes the idea because TV installation was going to be a pain.

Inga did her usual bang-up job with the latest installment in her ongoing Vendor Executive Series on HIStalk Practice. She asked 14 top executives to comment on a recent survey that found that about half of physicians in private practice expect their EMR vendor to help them qualify for Meaningful Use money. It’s always fun to compare and contrast their answers.

McKesson CEO John Hammergren comes in at #10 in the list of the highest-paid CEOs of publicly traded companies, bringing home $24.5 million in total compensation for the year ending September 30. The company declined to comment.

Vocera acquires two Tennessee hospital communications companies: Clinical Health Communications and Integrated Voice Solutions. Guille Cruze, founder of White Stone Group that spun off Clinical Health Communications, will run both organizations as a Vocera VP in charge of handoff communications products like the ones offered by those two vendors. I interviewed him back in January 2008. The companies have 30 employees and 150 hospital customers between them.

Bill Gates says robots will be the next big technology. Maybe he’s right: check out the Actroid-F from Japan, which the developing company will market to provide social services such as those delivered by hospitals. I creeped myself out when I realized that I was thinking that she’s pretty cute. I bet I’m not the first.

Healthcare is the #3 enterprise user of iPads, trailing only financial services and the tech sector.

Maybe the iPad will rank higher in healthcare in Australia, where Victorian Premier John Brumby promises that every state hospital doctor will be given an iPad if his party is re-elected. He says $12 million will cover it, but he seems vague about exactly what’s going to be running on those devices that will give doctors “easy access to time-critical clinical information,” not to mention who’s going to support them. 

In the UK, Portsmouth Hospitals NHS Trust wins a patient safety award for co-developing a PDA vital signs capture application.

Odd lawsuit: a prisoner serving 10 years for running over and killing a teenager on a bicycle while going 83 in a 45 mph zone is suing the dead teen’s parents, who he claims were negligent in allowing the dead teen to ride his bike without a helmet. He wants compensation for his “great mental and emotional pain and suffering.”

E-mail me.

HERtalk by Inga

UPMC says it will add 815 new full-time jobs, including up to 80 in IT. This announcement came following the release of UPMC’s first quarter financials, in which operating revenues grew by $77 million to $2.1 billion and profit increased $28 million to $93 million from July through October. The health system is on track to spend about $500 million on capital improvements this year, including about $100 million on its EMR implementation.

Former Sentillion and Microsoft executive Rick Dean moves to Humedica as VP of provider sales.

KLAS introduces an RSNA Resource Center that features several radiology-focused KLAS reports, including the Medical Imaging Buyers Guide. It’s free for providers and thousands of dollars for the rest of us.

Florida Hospital DeLand, which is part of Adventist Health System, goes live on Cerner CPOE.

Memorial Hospital (IL) selects Summit Healthcare as its integration partner as it migrates to Meditech 6.0.

Saint Luke’s Health System (MO) will implement the SeeMyRadiology.com platform to share medical images across the enterprise.

I’m guessing that Mr. H is the new BFF of Louise L. Liang. MD. In case you missed it, Mr. H wrote a terrific review of her book, Connected for Health, recommending that that basically anyone with an even remote interest in IT and healthcare read the book. The masses took the message to heart and from about 8:00 this morning until 3:15 this afternoon, the book has climbed from #2,223 on Amazon’s bestseller list to #218. It also moved from #90 to #8 on the Medicine bestseller list and from #4 to #1 in the Public Health category. Heck, Dr. Liang should buy Mr. H a Christmas ham. Speaking of Christmas, I’m putting the book on my list.

Preliminary data from HIMSS Analytics suggests that 22% of hospitals are capable of achieving 10 or more of the required core measurements for Stage 1 Meaningful Use; 40% have the capability to meet five or more of the menu items. HIMSS Analytics says it will provide quarterly updates on hospitals’ progress beginning January 2011.

Apple’s AppsStore rankings for the Top 10 EMR and Operational apps can be found here. Bedside by IMS MAXIMS tops the EMR and Operational apps list and ranks 150th in the overall medical category.

A spokesperson for Advocate Health Care says patients experienced little or no interruption in care despite an 11-hour computer crash that affected 10 Chicago-area hospitals. The health system’s Cerner system went down about 5:00 a.m. Saturday, requiring employees to take patient orders on papers and access records using backup computer systems.

Sponsor Updates

• Chandler Regional Medical Center (AZ) will implement the GetWellNetwork interactive patient care solution and integrate it with its Meditech 6.0 system.
• API Healthcare names Lisa LaBau COO. She was previously with Cerner and Dynamic Healthcare Technology.
• Precyse Solutions appoints William F. Bria II, MD, CMIO for Shriners Hospital for Children in Tampa, to its advisory council.
• Allscripts wins the 2010 Excellence Award as the fastest growing company by the North Carolina Technology Association.
• Baptist Health Care (FL/AL) executes an agreement with NextGen to deploy its EHR and PM solutions  for its employed physicians. Baptist will also offer system access for community physicians who choose to purchase the solution.
• CareTech Solutions added three new healthcare clients to its Web products and services division last month, including San Juan Regional Medical Center (NM), Southern New Hampshire Medical Center (NH), and  Wheaton Franciscan Healthcare (WI). The company also announces Version 4.0 of its CareWorks content management system for hospitals.
• CapSite will present at the 22nd Annual Piper Jaffray Health Care Conference, to be held November 30 – December 30 in New York.
• ICA earns a spot of The Nashville Post’s Fast 50 Award for being one of Middle Tennessee’s fastest growing companies.
• At its annual user conference last week, Nuance recognized 25 healthcare organizations for saving one million dollars or more on medical transcription costs as a result of implementing Nuance’s eScription platform. Eight other organizations were also recognized for their gains in medical transcriptionist productivity.
• McKesson partners with the Emergency Nurses Association to offer the ED Benchmarks Collaborative, a Web-based subscription service that helps EDs identify trends and compare their performance with that of other facilities.
• Ingenix CTO Art Glasgow will speak Thursday at a congressional luncheon on the state of HIE initiatives at the Institute for eHealth Policy in Washington, DC. It will be broadcast online for those who can’t make it to DC.

E-mail Inga.

Book Review: Connected for Health

I’m rarely a fan of healthcare IT books. My criticisms generally fall along these lines:

• The author isn’t original, authoritative, or knowledgeable.
• The book tells me nothing that wasn’t obvious or that I don’t already know
• Its content isn’t really “meaty” enough to get excited about.
• It uses too much material already available elsewhere, with lots of citations and excerpts that make it look like an imitative journal article.
• Whatever knowledge the author possesses isn’t generalizable to everybody else.
• The book is a chore to read because it’s written pedantically or without skill.
• It doesn’t deliver an end result that makes me happy to have spent the time and money to earn it.

Connected for Health: Using Electronic Health Records to Transform Care Delivery raises none of these criticisms. I found it to be fascinating and informative. It is easily the best work I’ve read on healthcare IT’s role in changing how healthcare is delivered.

I’ll try to keep my review short, but there’s literally something on every page that’s highly useful even to someone like me who’s been in the industry forever and thought they’d figured it all out by now. I’m pretty sure I’ll read it at least five times over the next few weeks since there’s a lot to absorb.

(By the way, if you teach any kind of healthcare or healthcare IT class, this would be a great course resource).

In the interest of disclosure, here’s all I have to share. A book PR company asked if they could send me a free copy in case I wanted to review it. I said OK, but didn’t commit to anything since I don’t like reviewing books (I almost always have lots of criticisms, but then I feel guilty for laying them out even though someone asked me to review their book honestly). I don’t have any connection to Kaiser, I don’t know any of the authors, and I didn’t even try to sneak one of those commission-paying Amazon links above just in case you click on over to buy a copy.

Now I’m not about to sell out my integrity for the price of a book, so rest assured that it’s the same old cynical, dismissive Mr. H talking. Keep that in mind because I’m about to turn into an uncharacteristic cheerleader for Connected for Health. I’m hoping this doesn’t taint my curmudgeonly image (or encourage other authors to send me books to review that I’ll probably not like).

Every hospital that’s using or planning to use clinical information systems should buy copies for every board member and executive. It’s that good. It sets the vision and perspective needed to embark on big-budget projects involving CPOE, nursing documentation, ancillary systems, and data warehousing. It doesn’t tell you what you should do, but it tells you what KP did. And a lot of what KP did and is doing is what everybody else should aspire to.

I think you’d have a tough time arguing why KP’s methods wouldn’t work in some form for other hospitals. Instead of having one of those dopey CPOE kickoff meetings where the winner of the “name our clinical system” contest is announced and everybody pretends they are committed to something they don’t even understand, pass out copies of Connected for Health (even better, do it well before any important decisions are made, like choosing a vendor or developing the project plan).

The book covers in perfect detail Kaiser Permanente’s HealthConnect project, the largest non-governmental HIT project in the world. You might think, “What does that huge organization and its $4 billion project budget have to do with my hospital?” Plenty, as it turns out. Most everything in the book is relevant to the EMR-type projects of even modest-sized organizations. Only the scale differs. The issues are pretty much the same everywhere.

Maybe the most important takeaway is that you’re wasting your money on software if you can’t back it up with the pieces that go with it. Hospitals where I’ve worked shot their wads buying an arguably overpriced clinical system, then ensured mediocrity by trying to run it as an on-the-cheap IT project. We didn’t have enough dedicated resources, we weren’t willing to pay community-based doctors for their time to help out, and we went cheap on end user devices and support resources. Maybe Kaiser did a lot more than a typical hospital could afford, but their results have been proportionately more impressive. They spent a ton of money, effort, and planning to go live, but then as the book says, “Welcome to the starting line.”

If you ask me, the foreword by Don Berwick (then of the Institute of Healthcare Improvement, now of the Center for Medicare and Medicaid Services) is worth more than the cost of the book. Don’s a quality and outcomes guy, not some IT geek doctor with four smart phones on his belt. He focuses on patients, not vendors and deals and Gantt charts. I could have worn out a highlighter marking the parts that had my head nodding.

Here’s a snip that struck home as I thought of all the failed, expensive implementations that are wasting the budgets and energies of hospitals looking for an electronic magic bullet to will absolve them of the responsibility to change themselves and instead just convince themselves that swapping out their data plumbing is the Holy Grail:

Without clear incorporation into the actual processes of care, and without the re-engineering of those processes, and without the changes in norms, capabilities, and culture to allow those new systems to take root, KP HealthConnect would become what far too many other health care organizations had already discovered in their own modernization journeys: the computerization of a defective status quo. Kaiser Permanente was not after a modern information system; they were after a modern health care system. Halvorson called building KP HealthConnect “laying tracks”, but he and I both knew that, in the end, it would be the trains, not the tracks, that mattered more.

Kaiser’s former SVP of quality, Louise Liang, MD, ran the HealthConnect project and edited the book (quite nicely, I should add, since I’m highly critical of editing in general). Its chapters were written by local Kaiser experts on everything to system selection to redesigning primary care. Every one of them is a gem, coming from slightly different perspectives, but with a lot of useful information from an organization that has actually done what all hospitals wish they could do.

Now a cynic (like me) might assume that some of the accomplishments might have been glorified a bit by the home team authors, and maybe they were (certainly anyone who has attended a “look what we did” presentation at HIMSS knows that reality and PowerPoints sometimes don’t intersect). KP probably struggled more than was detailed here, and most likely made some stupid implementation mistakes not listed and let politics and let executive egos drive expensively bad decisions that are regretted to this day but not brought up in polite company (like everybody else does, in other words).

I didn’t find that possibility at all concerning since the material has high value even if that’s true. If you’re a skeptic, just consider the book a picture of a desirable future state that Kaiser may or may not have achieved.

Besides, there are some KP warts in there. They had a terrible time getting regions to standardize (I loved this saying: No one is either so high in Kaiser Permanente that they can make a decision, or so low that they cannot veto a decision.) They wasted a lot of money on failed EMR projects. They had to fight human nature. They overspent. They first decided to expand the use of a homegrown system that one of its regions had developed, but then reconsidered when it fell short on its ability to turn KP into an enterprise-wide electronic backbone going beyond just automating clinic offices. They had to sell the vision to the board with the frank admission that KP was “betting the farm” that KP’s form of medicine was where the country was going and their existing systems couldn’t support the transition.

I found this tidbit interesting. They could find only two commercial vendors able to handle everything from medical offices to hospitals. Epic was named, but KP thought they were shaky because their hospital experience was limited back in 2003. The other vendor wasn’t named, but I assume it had to be Cerner, and whoever it was got axed because of inadequate ambulatory experience. Everybody always wants to know why the Epic wins big hospital deals – the book makes it clear from the customer’s perspective that it’s partly because of the company’s vision and leadership, but maybe mostly because their competitors aren’t very good, especially when it comes to connecting the multiple venues of care offered by larger health systems.

KP did a lot of upfront thinking about HealthConnect, which hospitals unfortunately rarely do beyond choosing their vendor. They brought in a wide variety of people to set the vision, not just for the Epic system, but for how care should be delivered. The items that group came up with in 2003 are pretty much dead on with what’s happening today. Their themes were: (a) Home as the Hub; (b) Integration and Leveraging; (c) Secure and Seamless Transition; and (d) Customization.

The book has a wealth of information about project structure, implementation, budgeting, and leadership. Maybe you don’t buy the vision thing (which probably means you shouldn’t be in charge of anything involving patient-centered IT) but these project details will make your time spent reading worthwhile.

The idea of a Collaborative Build was key, where HealthConnect would be built at a national level, but with some customizability allowed by each Kaiser region. The key point was: first standardize, then diverge. They knew that it would be much easier to force standardization and then relax it later as needed, rather than trying to tighten up after the fact (that’s a Management 101 principal that I’ve always embraced – start out as a tough guy, then loosen up later, because the opposite never works).

There is much detail on how KP identified and involved physicians of different capabilities (operational leaders, opinion leaders, and technically adept). They helped choose the system, develop the clinical content, and sell the idea to their peers (clinicians won’t necessarily be faster, but they should be better, they said).

I’m happy to see that a whole chapter was devoted to nursing leadership and impact. It talks about standardizing terminology, involving nurses in system decisions, and looking at specific goals for barcode medication administration and medication administration.

There’s a really nice chapter called Making It Matter that looks at value and quality.The best part was the description of how the goals of HealthConnect were aligned with KP’s commitment to members, something I have pretty much never seen by hospitals anxious to whip out their checkbook and get their CPOE implementation underway before everybody loses interest. KP knew exactly what it wanted to do in a big picture way: make clinical information available around the clock, deliver superior outcomes, become national leaders in patient safety, use patient preferences to make decisions, and several other very specific organizational goals. HealthConnect was the technology enabler, not the project itself.

An idea I really liked was called SmartBooks for Value Realization and Optimization, which was an extremely well developed list of 250 opportunities that each Kaiser organization (region, department, etc.) could use to improve performance by using HealthConnect. The book also has a lot of information about quality data, outcomes measures, and a full chapter on population health (nearly always ignored by four-walls-centric hospitals and health systems). When you see the scope of HealthConnect, suddenly it’s clear where the $4 billion went — most of it not into Epic’s pocket.

Kaiser took a creative approach to designing primary care services. They decided to design processes to meet the needs of their populations even if capacity seemed insufficient, expecting that they could increase capacity virtually by offering more services by telephone, group visits, and e-visits. They had to have a lot of confidence to go that route.

Everybody’s heard of Epic’s MyChart, which Kaiser calls My Health Manager. The book makes an interesting argument about personal health records: surveys that show low PHR use by consumers are asking the wrong question. Consumers will use them if their services are useful and of high quality, and KP’s patients are big users of patient-to-doctor e-mails, checking online lab results, ordering prescription refills, reviewing office visit summaries, and self-scheduling their appointments.

The book has a very nice summary called Refocusing on Systems Versus Individuals that lays out a hierarch of controls for reducing risk. It says that the most effective changes are, in order: simplifying and standardizing, removing opportunities for error, making it hard to do the wrong thing, making it easy to do the right thing, providing intrusive alarms and warnings, and using reminders and non-intrusive decision support. What doesn’t work as well: policies, procedures, and training. Surprised?

Just about every group involved with clinical systems that I can think of would get an immense amount of highly useful information from the book: clinical leaders, physicians, informatics people, and executives. Every group, that is, except one: the average CIO. Kaiser intentionally ran HealthConnect without much direct IT strategic involvement, correctly identifying it as a huge change project, not an IT project. IT’s job was to handle the infrastructure and technology components, not to convince the doctors to use order sets or demand that nurses scan meds before administration. That’s nearly always true of successful big-hospital clinical IT projects. People on the IT dark side don’t usually have a lot of credibility with clinicians, no different than a Mac-using surgeon who thinks he can educate the CIO on how to run a networking team.

If you’re a CIO who thinks you need to be in charge of anything that plugs into a network jack, you will probably be licking your wounds that it’s not Kaiser’s CIO or IT people bragging about their key involvement in the book. Those willing to look at the big picture and share project responsibility without feeling threatened will find it refreshing and enlightening. It isn’t that the CIO’s role was marginalized, it’s that KP let the operational and clinical leadership lead the changes, with IT providing the technical support to enable them. The CEO set the vision, paved the way with resources, and set up the means to collaborate across several regions. CIOs will still look darned smart among their executive, medical, and technical peers for having read this book.

I would consider Connected for Health essential reading for leaders of any hospital that has an interest in quality, data, clinical transformation, and yes, technology (and I would hope that every hospital falls into that category, or at least any that I’d want to be admitted to). The $40 cost of the paperback (the hardcover isn’t out yet) is just ridiculous. At five times that price, you would be getting a steal considering the ideas it has for projects costing dozens or hundreds of millions of dollars. If they packaged up a tenth of what the book covers into a two-day seminar, you would happily pay 50 times the price of a copy. If you are an enterprising consultant, you could probably make a handsome living for many years by just traveling around the country like a honeybee spreading pollen to grateful plants, sharing your purloined wisdom about strategic vision and IT’s role in quality and cost that’s all right there for the taking.

Like I said, I don’t generally like HIT books. I hit the HIMSS bookstore with enthusiasm, but I’ve been burned too many times. I recommend Connected for Health without reservation. It did for me what no book, presentation, or article has done recently: it got me excited all over again at the potential of IT to change healthcare in a way that actually benefits patients.

CIO Unplugged 11/15/10

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

How Opaque is your Transparency?

All humans desire relationship. Solitary confinement is the greatest torture. A psychologist would tell you that no person can mentally survive being alone for long periods.

Even the entertainment industry knows this. One reason for the long-term success of the television hit Cheers is that the producers and writers tapped into our human need. Their theme dwells in the show’s chorus.

Be glad there’s one place in the world,
Where everybody knows your name,
And they’re always glad you came.
You wanna go where people know,
People are all the same,
You wanna go where everybody knows your name.

Leaders talk of transparency and its many forms — from quality outcomes to business performance to personal. Many opinions on the level of transparency arise, especially when it comes down to personal revelations. How open should you be with your manager, peers, and staff? Does familiarity really breed contempt? How much is too much information? Should there be a wall between professional and personal?

As I began my career, I wondered what it was like to be a manager or director, vice president, CEO, etc. I wondered how they prioritized, how they managed their time, and how they dealt with challenges. This was always a great mystery, and I wanted to know more. I longed to observe, learn, and understand the essentials and what it took to get there. Therefore, as my career journey unfolded, I elected to be as transparent as I hoped my management would be.

I recall the advice Captain Davies gave to us impressionable 2nd Lieutenants on this topic at our army engineer school. “I am all for hanging out with troops after hours. But once the conversation gets into work matters, I take leave.” I believe personal transparency carries more benefits that costs. I acknowledge the risks and am careful not to violate necessary confidences. And, like Captain Davies, I avoid discussing work matters.

One benefit of personal transparency is a friendlier work environment. When people see that you’re a genuine person and that you want to get to know them, you’re breaking down the walls between management and staff. Once people see your heart and understand your motives, they’ll be more compelled to follow.

Your authenticity will expand your level of influence. Over time, your proactive interest in others will increase their level of engagement. The fact that your manager knows you and cares about you can speak louder than an annual raise. People also enjoy the recognition that comes with the investment and gift of your time.

Another benefit is the opportunity to model appropriate behavior. Many emerging leaders have not seen management up close and may not know the protocol for social and business contexts. This can help remove the fear of interfacing with executives and understanding etiquette. 

I employ the following to ensure a level of personal transparency:

• Host annual wine, cheese, and chocolate parties for emerging leaders and significant others (my wife also helps spouses see the genuine human side of an executive).
• Host annual Christmas parties at my home with leaders and their significant others.
• Host in-home parties for teams to celebrate accomplishments.
• Attend almost every event I’m invited to, including parties, weddings, and my favorite — RockBand jam sessions.
• Attend funerals of an employee or his/her spouse.
• Yammer (micro-blog) daily on my agenda and other items of interest, and sometimes offer an impromptu lunch.
• Accept Facebook invites and Twitter followers from co-workers.
• Participate in all work events, such as fundraisers, contests, and celebrations (dancing, sumo wrestling, etc).
• Organize and participate in sport events.
• Volunteer my home and time for work-related fundraisers.
• Send handwritten notes saying “thank you” or “good job”.

This open approach has greatly accelerated the development of relationships with my leaders and staff. Something magical happens when you put aside the pretenses and trappings of the formal work environment, let your guard down, and be who you truly are. Create a place where everyone knows your name and you also know theirs.

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

Monday Morning Update 11/15/10

From Simon Stiles: “Re: Georgia HIT Leadership Summit. It was a huge success in that it united the leaders and vendors to begin talking ‘collaboration’ to benefit the growth of both large and small companies that are part of the health IT cluster that has developed in Georgia. The organizers are focused on attracting and creating more HIT vendors in Atlanta and Georgia that will provide high-quality, high-paying HIT jobs, not to sell products. Success was measured by the number of participating companies (110), the number of speakers and panelists who agreed to future collaboration (100%), and the number of companies that are interested in ongoing events that bring Georgia’s HIT companies together (100%).”

From Jenny from Venice: “Re: you and Inga. Let’s hook up at HIMSS. I love everything you both do, I really do. Lurve you!” Thanks, but I ran your proposal up the Mrs. HIStalk flagpole and she didn’t salute. I can’t speak for Inga. I had to look up “lurve” since I wasn’t exactly sure what it means, so that’s probably a good indication that we wouldn’t have hit it off anyway.

From MarketWatcher: “Re: Merge and Fletcher Flora. That was a very quiet acquisition and and odd one at that. Insight?” Coming soon, quite possibly – I’ll be interviewing a top exec there shortly, provided I can figure out a time after work to connect (darned day job).

From Tony: “Re: HIMSS reception. Has the signup page gone up yet?” Not yet. Look for it in January.

Inga mentioned that Henry Ford Health System is working on rolling out a new version of its CarePlus Next Generation EHR. A reader tells me that the Web-based SOA system was developed by RelWare, which offers its commercial version of it under the EXR nameplate.

AMIA says it doesn’t like “hold harmless” clauses in vendor software contracts. At a reader’s suggestion, I e-mailed CEO Ed Shortliffe to ask if AMIA will put some teeth behind its proclamation by turning down the sponsorship of vendors who won’t go on record as saying they don’t use those. He hasn’t responded, but I’ll let you know if he does.

It’s close to an even split whether recent election results will reduce or delay HITECH payments. New poll to your right: have you personally seen a “hold harmless” clause in a HIT vendor’s software contract? They’re supposed to be everywhere, but nobody every provides an example. I know I’ve seen them in some old copies of contracts that I discarded a few years ago.

San Juan Regional Medical Center (NM) sends four tons of old computer hardware to a Canada-based company that takes electronic waste for free, pays a third party to process it, and donates the profit to Feed the Children.

A Tampa publication mentions the cost of implementing clinical systems at a couple of local hospitals: BayCare ($200 million) and Tampa General ($120 million).

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Four small, closely-located Texas hospitals (the largest has 45 beds) join to create a RHIO around the Prognosis ChartAccess EMR.

Cloud-based population data analytics vendor Explorys, co-founded last year by Cleveland Clinic, hires Anil Jain, MD of the Cleveland Clinic IT department as its part-time chief medical officer.  

The health authority of Norway signs a $120 million deal with IBM to provide a variety of services and to implement a custom logistics solution built around SAP.

Healthrageous, which offers consumer health solutions based on technologies developed by the Center for Connected Health at Partners HealthCare, is chosen as one of the 50 most promising tech startups. It collects health data from patient biometric devices, analyzes it, then sends out recommendations to the patient. I like the name.

Laboratory middleware vendor Data Innovations is sold to Battery Ventures. Old news from last month, but I missed it first time around.

The government of Hong Kong invites proposals to develop a territory-wide platform for sharing electronic health records. More information on the project is available from the eHealth Record Office.

Newborn twins die of a IV-related medication error at a scandal-ridden UK hospital that is already under public inquiry for the unnecessary deaths of 400 to 1,200 patients.

The CEO of National Health Insurance Board of Turks and Caicos Islands has a financial interest in the vendor chosen to process medical claims there, critics claim. The CEO disclosed his “minority interest” in Mitan, but the company’s Web site lists him as founder, director, president, and CEO since 1999.

Odd lawsuit: the transplant center of Georgetown University Hospital calls a cirrhosis patient who’s on the liver transplant list to tell her that a matching donor liver is available for immediate transplantation. They didn’t call any of the emergency numbers she had given, instead leaving a message on her home answering machine. The woman, as it turned out, had a good excuse for not being home – she was an inpatient at the same hospital at that time. When her family found the message and returned the call, they were told that the liver had been given to the next patient in line. The woman died, her family is suing.

Sponsor Updates

• MedPlus announces collaborations with several regional extension centers that involve the company and its Web-based Care360 EHR .

E-mail me.

mHealth Reaction
By Deja Vu All Over Again

For anyone who attended Web or Internet conferences in the mid-90s, your description of the market is a flashback. mHealth as a separate model does not make a lot of sense, which is why they are having a hard time trying to figure it out.

Like in the late 90s for eHealth, all those new mHealth corporate groups will be integrated back into the main lines of business. Mobility is just a different (and exciting) way to deliver much more interactive and innovative value for core health care processes. The dot-com bubble experience will keep the fervor in check this time around.

Having said that, mHealth will have profound changes in US health care over the next five years for the following reasons:

1. Our 5-10 year industry technology lag sets up a great deal of potential disruption for mobile components as the current brittle systems start to move towards loosely coupled modular application platforms like in other industries. Many large HIT vendors are about to enter the SAP enterprise model death spiral.
2. Historically institutions and "back channel" processes have been the focus, not mobile savvy consumer / patients who are rapidly becoming financially forced to be more engaged in their health.
3. Care delivery transformation from payment reform and skill shortages will require fluid care approaches that require mobility, and
4. Most care is now done in the home, but will move from routine to chronic disease management due to aging and the obesity explosion.

Note to bright-eyed entrepreneurs who have not been in the health care industry a long time: the existing HIT vendor mafia has always been much more effective in squashing innovation from disruptive outsiders to maintain the status quo than competitively innovating against each other. If you fashion yourself as David vs. Goliath, make darn sure that God is on your side before you start hurling rocks.

Therefore, there will be a great deal of opportunity for those niche companies that focus on meeting the needs above by complimenting the old guard entrenched HIT vendor systems, but with an eye towards explosive disruption when they are embedded, delivering value, and the market timing is right.

Readers Write 11/12/10

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

On the Largest Medicare Fraud Case in History – $100 Million
By Deborah Peel, MD

Key points:

• This case is “the largest single Medicare fraud case” in history.
• “There were no real medical clinics behind the fraudulent billings, just stolen doctors’ identities," says Janice Fedarcyk, FBI assistant director-in-charge. "There were no colluding patients signing in at clinics for unneeded treatments, just stolen patient identities."
• The organization stole the identities of doctors and filed applications to bill Medicare in their names, often providing a clinic address on the application that was, in fact, the location of a mailbox, according to the indictment. The organization then obtained the stolen identities of thousands of Medicare beneficiaries, including the identities of about 2,900 patients treated at the Orange Regional Medical Center in Orange County, NY.
• Members of the organized crime ring also are charged with operating a multi-million dollar scheme to defraud health insurance companies in the New York area by submitting claims for medically unnecessary treatments.
• In some cases, defendants allegedly staged auto accidents to generate fake patients who would then undergo unnecessary and expensive treatments that would be billed and reimbursed.

What I still do not get is the inability of very smart people in government, healthcare, and HIT to miss the REALLY big picture.

Privacy isn’t about preventing tomorrow’s profits or blocking meaningful use of data. It’s about the fact that if Americans lose ALL control over personal information in healthcare, we will lose all our privacy rights in the Digital Age. Period. All of them. For every kind of information / data about us. Our strongest rights to control personal information are our rights to control health information.

If we lose the war over control of personal information in health, the US will become a total surveillance state and we will have lost the most precious right individuals have in Democracies: the right to be let alone. Do you think that we can remain a Democracy if everyone — government and private corporations — knows everything about us? There is a reason for the saying “information is power.” 

By the way, I am not in the Tea Party or a radical. Standing up for medical ethics, the law, and the right to privacy is a very conservative position!

The big take-away is that as long as patients’ sensitive electronic health information and demographics are so poorly protected, millions of employees of hospitals, clinics, insurers, pharmacies, and health IT vendors will have open access to steal it. We will continue to see an explosion of multi-million dollar healthcare fraud, identity theft, and medical identity theft, unless we radically redesign our health IT systems, protect health data wherever it flows, and restore the right of consent.

The high-profile of this case is supposed to discourage criminals and potential criminals, but when millions of employees in healthcare, government, and health technology corporations have open access to all patient health data, the likelihood of getting away with data theft is high. The innumerable outside hackers and criminals whose business is stealing valuable health data will never stop.

The only solution is to require comprehensive and meaningful privacy and security for all health data, wherever it flows:

1) Restoring patients’ rights to control electronic health information would end open to the nation’s health data by millions of employees of the healthcare system, insurance, government agencies, and technology industry. Requiring informed consent before ANYONE can see our records is simple, cheap, and easy if we require robust electronic patient consent for all data use or exchange.

2) Requiring and enforcing ironclad, state-of-the-art security for all health IT systems and health data wherever it is held online is essential.

If we don’t require and build trusted systems now, before ‘wiring’ all health data systems together, before systems are ‘interoperable’ and before every American is required to have an electronic health record, we will destroy privacy for generations. Once our sensitive data is ‘out’, like Paris Hilton’s sex video, it can never be made private again. And when healthcare systems cannot be trusted, people refuse to get needed treatment, fearing their jobs and futures will be endangered. Creating a healthcare system that people are afraid to use is a national disaster. Trust takes a long time and is very expensive to rebuild.

The implications for Democracy if we lose the right to privacy in healthcare are dire.

Deborah C. Peel, MD is the founder of Patient Privacy Rights.

Before Extending Software Support Contracts, Consider Alternatives
By Tony Paparella

It’s common for a healthcare organization to become unnecessarily tied to an extended support contract when it retires an HIS in favor of a new system. The old system is not an ideal data storage solution. Although patient accounting and clinical data sets still require some functionality and real-time user access, the legacy application is expensive overkill for what is needed.

Support contracts typically run a year or more in length, meaning they’re oftentimes paid for longer than necessary. Furthermore, it may be difficult to negotiate favorable rates and terms with a vendor facing long-term loss of revenue.

Other times, purchasing a contract isn’t an option; the system may be so outdated that the company that owns the software no longer offers support. This places the organization in a precarious position, facing potential loss of vital data. Furthermore, IT staff may become burdened with legacy system upkeep, deflecting efforts away from the new HIS.

“Doing nothing” or opting for an inadequate option invites serious compliance and financial risks. Millions of dollars (and the jobs of CIOs and department directors!) can be lost to: interruption to account billing/cash flow; inability to respond to a payer audit (such as RAC and commercial insurance audits); noncompliance with Federal and State data retention requirements; loss of access to the legal medical record and; increased hardware/software expenditures.

Additionally, fines for non-compliance with Federal employment record, HIPAA and other retention requirements can be significant. Depending on the statute, data retention requirements range from three to 28 years – meaning a short term, one-dimensional solution won’t do.

Fortunately, signing an extended support contract isn’t the only option for organizations that must access and manage legacy data.

Internal warehousing may be considered as an alternative – metaphorically, a home for data, albeit largely unfurnished. Though data access and management is inherently restrictive, this option is typically the most time- and cost-efficient to implement.

In a full detail conversion, all legacy account data is converted into the new system. If precisely executed, compliance and cash flow are maintained. Often, however, the vendor will decline to bring old data into the new HIS. Hence, the risk of cash flow interruption. A high degree of planning and analysis is required before implementation.

Legacy data can also be migrated to a healthcare active archive specifically designed to allow end users to access and update accounts, run reports and, in some cases, post payments and bill accounts. Advance preparation is essential. In some instances, an organization may need to specifically task an IT team member with helping coordinate the migration of data.

Proper planning and preparation will help your organization sidestep a burdensome legacy system support contract. Understand the risks and investigate your options many months in advance.

Tony Paparella is president of MediQuant Inc.

What one hospital charges for a particular procedure varies widely based on a host of factors. Understandably, many providers who are otherwise all for transparency when it comes to patient outcomes are reticent to disclose cost data. There are real reasons for concerns on the globalization of medicine. However, health care is largely a local phenomenon.

What are the compelling reasons for being as transparent with prices as with anything else? For one, increasingly, consumers are armed with price information today that exceeds anything they could have assembled even just a few years back. Also, in the mind of many consumers, price equals quality. Logical or not, this notion has become ingrained as a result of their consumer experience in other industries.

Wine under one label is deemed more expensive than wine under another label, even in the case where the wine has proved to be exactly the same, from the same source, processed and delivered in exactly the same manner.

Reputation Enhances Price

At the supermarket, branded merchandise still sells at a premium compared to store or generic brands that offer the same ingredients, molecule by molecule. Your hospital’s reputation could prove to be the deciding factor in whether or not a patient will plunk down more money to be treated by you over others who, based on all comparison measures, offer exactly the same care and service.

Suppose a consumer does his homework and finds that you and a competitor have entirely equal success rates for particular procedure, and you charge 15% more. Is this a reason to fear price transparency? No, because with all the data available for a consumer to peruse to his heart’s content, the decision to choose one provider over another is multifaceted. Price is one factor, albeit an important one, among several.

Many consumers will go with the lowest price. Many will choose the best value – a blend of price and quality. Short term, there is not much you can do about the prices for some of the procedures you charge. In the long run, everything is up for grabs.

More Business, Lower Prices

The more often a hospital performs a particular procedure, and the more experience its doctors accrue, the better it is able to offer that procedure at a lower price. Even in health care, greater business volumes contribute to economies of scale. In the short run, you can’t do that much about the volume you handle for any particular procedure. In the long run, you could seek dominance in your local or regional area by publicizing your experience in a given procedure. Thus economies of scale could result and price transparency would work to your favor.

At Alegent Health, based in Omaha NE, the prevailing attitude is that consumers have a right and ought to be able to easily know how much a provider charges. Three years ago, Alegent launched My Cost, found at www.alegent.com, a consumer-friendly feature that offers cost estimates for a variety of tests, procedures, appointments, and services.

So, You Want Cost Data

Visitors can simply enter the name of their insurance providers and any co-payment or deductible information. The system then presents a cost estimate that is useful in personal health care decisions.http://www.alegent.com, The visitor is also treated to financial assistance information via links provided, and a phone number in case their anticipated procedure is not listed on the site. Now up and running for nearly three years, more than 50,000 cost estimates have been generated at My Cost.

Alegent’s experience in promoting price transparency has been that consumers appreciate the honesty and openness of the organization. Instead of price transparency scaring away potential business, in this case it has led to stronger provider-patient relationships. Alegent’s CEO says transparency “isn’t necessarily easy, and it does take courage, but in the end it is the right thing to do for consumers and the community.”

Make the Commitment

Commitment to transparency takes guts. Yet, what other choice is there? Fortunately, as we’ll see, there is room for creativity and initiative.

Providing information on the results that your hospital achieves for patients, at the medical condition level, is vital. Your data needs to include patient outcomes with an adjustment for risk based on prior conditions, the overall cost of care, and measurements for both extending through the care cycle.

Transparency also encompasses offering the experience your hospital has in treating specific medical conditions, by volume of patients, coupled with delineation of such treatments based on methods of care offered. Your processes, in the long run, can be improved only by understanding how results are achieved, which methods are most effective, how they might be refined to make critical differences, and what the actual outcome of such refinements have been.

Details Count

Outcomes for a specific medical condition can and should be expressed many ways. For, say, shoulder surgery several validated measures exist such as range of movement, reduction of pain, and ability to function. Still other outcome measures for shoulder surgery include the interval between the initiation of care and return to normal activity such returning to work or playing tennis again.

Data related to the particulars of patients, known as patient attributes, such as gender, age, genetic factors, and prevailing conditions, are vital elements of transparency and are essential for assessing risk. Accurate diagnoses are vital for both the patient and the provider. A transparent provider will publish measures of diagnostic accuracy including cost, timeliness, and completeness.

Outcome measures that only address episodic interventions fall short because they fail to yield results meaningful to the patient. Such short-sighted reporting and consequence scoring can be counterproductive and lead to the publication of misleading data.

Failure is not pretty and human beings instinctively want to avoid reporting their own shortcomings, much like organizations. Still, ineffective treatments – errors in procedure, medication, or treatment – and complications following a procedure need to be identified and scored. As unpleasant as this task may be, it is a step on the path to improved levels of treatment and overall service. You cannot fix a problem that you refuse to acknowledge.

Expand Your Measures

A traditional core measure, “the 30-day readmission rate,” tracked by the government, is of course a potential indicator of poor quality. Who wants too many patients are readmitted within 30 days for the same problem.

You may be able to devise your own kind of data measures by tinkering with traditional data measures. For example, you could align your total quality management efforts, such as your Six Sigma Performance Improvement initiatives, around improving the 30-day readmission rate and devote resources to that. In turn, for each of the core measures which need to be fully transparent, you may wish to devise two, three, four or more strategies to ensure that your scores improve over time. Rest assured, other providers will be doing the same.

Costs Mysteries No More

Unlike most businesses, many hospitals, to this day, don’t know what their actual charges ought to be. They charge for this procedure or that based on tradition, competition, payer contracts, or whatever cost data they can scrape together. A comprehensive understanding of true cost is often lacking. If and when the government mandates that hospitals publish price and quality information, they will need the technical ability to do so.

In almost all cases, some web restructuring proves to be vital. There needs to be a huge consumer section that is highly inviting. Take the bull by the horns and invite the consumer to go patrolling through your data. Just as industrial companies publish annual reports with a profit and loss statement, balance sheet, and cash flow analyses, you might choose to offer a five-year projection as to the life cycle cost of a procedure and its follow up.

Implications for Your Hospital

• Is transparency part of your agenda for your weekly and monthly meetings?
• Has your hospital developed policies and procedures in relation to transparency?
• Within your own office or division, are top officers involved in the transparency discussion?
• Have you attended any conferences and symposiums on transparency?
• Are you monitoring other providers who have already made the conversion to transparency?
• Are you devising plans to capitalize on the inherent opportunities in offering transparent data?

Colin Konschak is the managing partner of DIVURGENT, a management consulting firm. His book on this topic was just released.

News 11/12/10

From The PACS Designer: “Re: CCHIT’s EACH program. TPD is happy to see that the CCHIT organization has realized that many hospitals have custom EHRs, and now through their new EACH program, they will be able to get current hospital EHR configurations certified more quickly than going to an all new EHR product.”

From Mrs. Marine: “Re: Veterans Day. Many thanks for your gracious acknowledgment of our servicemen and women. My husband is a 20-year Marine and I still get a chill when someone goes out of their way to thank him (or me) for his service. I would also like to acknowledge the many companies in healthcare IT that provide opportunities to military spouses like me to achieve in our own careers in spite of the many challenges that a military life presents. I can tell you from my own experience that I am a better employee, wife, and mother because I have had the support of my company in every way. To Mac, Mike, Tom, and Clair — I will be forever grateful. To the industry, thank you for taking care of us…all of us.”

One more military note: congratulations to HIStalk pal Admiral Cindy Dullea, who retired from the Navy after 30 years of service last month. She is a board-certified informatics nurse and was Deputy Commander, Navy Medicine National Capital Area and Deputy Director, Navy Nurse Corps, Reserve Component. She continues as SVP of marketing at SCI Solutions, which has been a sponsor of HIStalk for most of the 7.5 years that I’ve been writing it.

Accelarad announces its Turbo Gateway DICOM image transmission technology, which it says will speed up image delivery to and from cloud-based repositories via the Internet by up to 300% (4.5 CT images and 9 MR images per second).

Wilson Memorial Hospital (OH) names Larry Meyers as CIO. He was previously IT manager with Children’s Medical Center of Dayton.

A study of 250 hospitals by CapSite finds that 25% plan to invest in new Vendor Neutral Archive solutions.

Jobs from the HIStalk Sponsor Job Page: Healthcare Consulting Leader, Channel Account Manager – Cerner, Product Manager – Mobile Point-of-Care Solutions, Senior Manager Segment Marketing. On Healthcare IT Jobs: Implementation Engineer – Eastern Region, Systems Analyst Programmer V, Cerner FirstNet Analyst, Interface Engineer.

PolyRemedy brings on two new executives: Jeffrey Tingle (previously with the Risk Management Foundation of Harvard Medical Institutions) as software development VP and Heath Umbach (from WebMD) as director of product management. The company offers a Personalized Woundcare System that allows clinicians to assess and document using Web-based tools.

Aetna’s incoming CEO says the company will enter the US HIT market to take advantage of healthcare reform. Earlier talk I’d heard pointed to mostly consumer-focused Web tools, but you never know who they might buy.

The Norwegian government will support the Maternal mHealth Initiative with a $1 million donation.

The Institute for Clinical Systems Improvement licenses Nuance’s RadPort radiology ordering solution to support a Minnesota initiative to ensure medically appropriate use of MRI, CT, PET, and nuclear cardiology tests. The state expects to save $28 million per year based on the success of a 4,000 physician, year-long pilot. Docs get the benefit of not having to get pre-approval for the tests as long as they complete the online information needed to generate a clinical appropriateness score using rules derived from the American College of Radiology’s Appropriateness Criteria.

Coro Health receives $2 million in funding from a former Walmart CEO to deliver music “prescriptions” to long-term care patients that can help with cognitive stimulation and socialization, claimed to improve memory, reduce medication needs, and improve mood.

One of the companies showcased to President Obama during his recent visit to India was Teleradiology Solutions, India’s largest teleradiology vendor. The company says its radiologists cover the night shifts of 100 US hospitals from Bangalore. They’ll be at RSNA.

Speaking of RSNA, if you’re going and want to provide updates for HIStalk readers, we’ll take ‘em.

I’ve been really behind after attending the mHealth Summit, trying to catch up at the hospital and at HIStalk Intergalactic Headquarters (an upstairs bedroom that I just painted because Mrs. HIStalk was tired of the crappy builder’s whitewash that we had never changed). I have new sponsors to announce, reception details to hint at coyly, and HISsies to get started shortly. I’m hoping to dig out this weekend in case I’m tardy with something you’re expecting from me. To those folks, thanks for your patience, and to everyone else, thank you for reading and thereby giving me an excuse to do something that at least passes for productive on occasion.

A Harris Interactive study finds that smart phone users don’t care whose brand name is on their apps as long as they are highly recommended and offer a good user experience.

This flies against everything I’ve been taught about medical errors: the systems and procedures at Seattle Children’s were not at fault in three serious medical errors, a state investigation concludes. Everything was in place to protect patient safety, it said, which is then puzzling as to how the errors could have occurred. It also doesn’t explain why the hospital revised its medication policies after killing an 8-month-old with a tenfold overdose of calcium chloride. The investigation now focuses on the individual caregivers, which often means they get all the punishment as rogue operators (which they sometimes are, but not usually).

A Massachusetts county sheriff faults a police dispatcher for the death of a woman who choked to death on a marshmallow. Her husband called 911, but the dispatcher didn’t give him instructions on performing the Heimlich maneuver or CPR during the 12-minute call.

An Associated Press article covers informed consent applications that allow patients to review the risks of their procedures using multimedia, even from their own homes. Mentioned specifically: Chicago-based Emmi Solutions, which sells such a system used by 100 hospitals. Also mentioned: Dialog Medical, which is used by all of the VA’s hospitals.

It’s shocking that Weird News Andy missed this story: a South Carolina man high on hallucinogens is arrested after attacking officers investigating a home burglary, resisting to the point deputies have to use pepper spray, nightsticks, and a Taser on him. He’s taken to the ED, where the doctor notices a computer mouse cable dangling from his nether regions. An X-ray confirms that the rest of the mouse was where you might expect. He doesn’t remember how it got there, which is quite a testament to the power of hallucinogens.

E-mail me.

HERtalk by Inga

From Saxifraga: “Re: Facebook fan. Do I win a prize for being the 1,000th person to like you on Facebook?” I’d send you some fabulous virtual gift if I had one of those goofy Facebook apps set up. Thank you, Saxifraga, and our other 999 fans for your support. Mr. H and I are feeling very connected these days and we’re always happy to friend you on Facebook and connect with you on LinkedIn. You can also join the HIStalk Fan Club on LinkedIn, be a fan of the HIStalk page on Facebook, or follow us on Twitter. Basically, we are trying to be very hip when it comes to social media. It’s satisfying in a pathetic sort of way.

A reader tells us that Saint Alphonsus Regional Medical Center (ID) went live on Cerner October 15th and has reached almost 90% CPOE adoption, also deploying SurgiNet and FirstNet across all its patient and ambulatory areas.

Henry Ford Health System (MI)  announces plans for a $5 million expansion of its Rochester Hills data center, which will create 20 to 30 jobs a year for the next several years. Its technical employees are focused on the rollout of CarePlus Next Generation, the newest version of the health system’s homegrown EMR.

Healthcare providers rely on vendors with which they have an established relationship when selecting a Recovery Audit Contractor (RAC), according to KLAS. The most-considered vendor is Healthport (23% of the time), followed by MediRegs (16%) and 3M (14%.) Of the 98 provider organizations participating, 92% said they already selected a RAC solution; more than half only considered one RAC offering.

VHA selects TeleTracking’s RadarFind and its RTLS network as an option for its 1,400 member hospitals.

Yuma Regional Medical Center (AZ) will use InterSystems Ensemble for the development of interfaces with its Epic EHR application.

The VA contracts with DSS, Inc. for its Mental Health Suite EHR, which it will implement in all 153 of its hospitals.

Accenture wins a 10-year, “indefinite delivery / indefinite quantity" contract with the CDC for information management and IT infrastructure services. The total contract has a ceiling of $4 billion over the life of the contract.

The president of GE Healthcare’s business unit predicts that his division will see 10% profit annual growth, mostly due to an increase in world demand on big medical equipment. John Dineen expects particularly strong growth from China, which could grow 20% a year through 2015.

Halfpenny Technologies names Gai Elhanan, MD, MA as the company’s CMIO. He was most recently chief of healthcare informatics at 3M Health Information Systems.

The American Medical Informatics Association declares that “hold harmless" clauses in contracts between HIT vendors and providers are unethical and that vendors should not be automatically absolved for errors or defects in their software. Instead, vendors and customers should share the responsibility for patient safety and error management. AMIA also states that safe and successful HIT systems require ethics education on the part of vendors and clients. Great recommendations, but I don’t see vendors rushing to ask attorneys rewrite their standard contracts.

CCHIT announces that it will offer a new EHR certification program for hospitals beginning December 15th. The EHR Alternative Certification of Hospitals (EACH) program is an ONC ATCB certification program that is designed for hospitals that have uncertified legacy software, customized commercial products, or self-developed EHRs.

MonteFiore Medical Center (NY) activates DaVincian Technologies’ GUARDIAN to streamline patient registration and scheduling and improve data accuracy.

Sponsor Updates

• The Methodist Hospital System (TX) engages MEDSEEK to create an integrated patient portal based on data from its Eclipsys inpatient system, NextGen outpatient program, and Medicity HIE.
• Informatics Corporation of America (ICA) promotes John Tempesco from VP of client services to chief marketing officer and hires Brian Higdon, formerly of Affinion Group, as vice president of client services. Former TeraMedica Healthcare Technology VP Sandra H. Lillie also joins ICA as VP of sales and business development. In addition, ICA adds three Vanderbilt University Medical Center officials to its board of directors.
• Bridgehead Software partners with Perceptive Software to offer a combined solution that includes Perceptive’s ImageNow enterprise content management application and Bridgehead’s virtualization storage solution.
• Picis hosts an audio conference November 16th featuring several HIE leaders discussing the financial, operational, and clinical considerations of establishing health information exchanges.
• MED3OOO is recognized by Everything Channel’s CRN Magazine as a Top Healthcare VAR.
• Gillette Children’s Specialty Healthcare (MN) chooses Carefx and Indigo Identityware for single sign-on, context management, and clinical workflow.

E-mail Inga.

News 11/11/10

From Icarus: “Re: HIMSS Middle East conference in Dubai. Over 400 attendees are here. Lots of interest from providers in Qatar, Saudi Arabia, Pakistan, and UAE. Vendors include Allscripts, Cerner, First DataBank, Zynx, InterSystems, GE, and Hospira.” Thanks for the photo.

From Matt Yourity: “Re: business models and mHealth. What will work is ‘mHealth Plus,’ apps that are integrated with a person-centric longitudinal health record (with clinical information, claims, patient-entered information, and data from devices). Apps can integrate with each other and with processes in a robust middle layer. The business model is that we’re all paying for the cost of bad behavior, so there’s the incentive. Cute apps built in a silo are not the future.” It struck me at the conference that mHealth is where HIT was 20 years ago – everybody building their own single-purpose app because it’s cool (and because they can) rather than thinking big picture with regard to integration and user convenience. That’s a function of maturity, I think, so hopefully the “cute app” state will go away when investors realize there’s no profit potential and they probably won’t get much patient or clinician uptake anyway. If your solution requires going to a specific product’s Web site, there’s a good chance it won’t fly. The mHealth people need to be put in room with the PHR people since both need some help. The mHealth projects seem to mostly involve people with no enterprise IT experience. They’re doing what spare bedroom programmers always do – building cool stuff that may not be optimal if it ever needs to scale or broaden.

From Hollis Figg: “Re: Dell. Roger Davis, SVP of physician services outsourcing from the former Perot, has left abruptly.” Unverified. His LinkedIn profile is unchanged.

From Scratching my Head: “Re: EHR certification process. Any consultants you’d recommend that can help vendors make sense of it?” I’m sure there are several. The one I know that’s offering that service is Frank Poggio from The Kelzon Group. You’ll notice his text ad running in the right column (which is how I knew he was working with vendors on certification). Others can comment on this post and I’ll waive my usual “no commercial pitches” rule.

From Jesco White: “Re: mHealth. Your report concludes that there is no money to be made, but the opposite appears to have been reckoned by Verizon. They are supporting a big Health IT event in Atlanta.” I should have qualified my assessment by saying that the cellular carriers and phone makers are fully intending to monetize mHealth in some way, perhaps my making it a value added service that either costs extra or results in higher service fees. They were the dominant vendors at the mHealth Summit. It’s the people writing apps that haven’t figured out a business model.

From Digital Bean Counter: “Re: TAG healthcare IT summit in Atlanta. Aside from a decent turkey sandwich, it was a letdown. McKesson took the cake for the most part. I was surprised that the Verizon and Intel reps knew little to nothing about HIT, let along whatever it was they were trying to sell. The summit was mostly around the hype of hiring new people. I was amazed at how many attendees were out of work, between jobs, or in school. Funny thing is, when the floor opened up for questions, panelist balked at the ‘why can’t I get a job when I have experience’ question. At least the eye candy was decent – the industry is still doing a great job at hiring pretty ladies to rep their respective companies.” Maybe that’s what the panelists didn’t want to say – you can’t get a job unless you’re cute.

From Lucky Tech: “Re: weird news candidate. What’s next – pregnancy testing via SMS messaging?” UK researchers are working on a smart phone app that will analyze urine to instantly diagnose sexually transmitted diseases.

From CIODude: “Re: IBM. I’ve had numerous meetings this week with with ex-IBMers. It struck me that the lead healthcare people at most of the major technology companies  are all people who left IBM. Neil de Crescenzo left and is now Oracle’s lead executive. Jamie Coffin leads Dell’s healthcare group and Doug Cusick who led IBM’s global healthcare team is now leading HP. The IBM/Healthlink execs are all at Encore. Who’s left? For the first time in my career, I can’t name a single IBM healthcare executive and I’ve been very active in this industry for many, many years. What’s going on at IBM where they can’t keep people?”

From Happy Valdez: “Re: LSS. At the Meditech CIO conference, rumors were swirling about LSS Data Systems being shut out and Meditech opening a partnership with eClinicalWorks.” Unverified.

I don’t usually post news on Wednesday night, but I’m way behind from being at the mHealth Summit this week, even though Inga skillfully kept things under control. I figure I might as well clean up my inbox now instead of waiting until Thursday evening. It will be back to normal Thursday night.

Listening: We the Kings, Florida-based power pop. They’re young, clean (no explicit lyrics), and cheery. Nice sound.

Google changed its appearance this week in honor of the 115th anniversary of the X-ray, Weird News Andy noted. He also brought up the fact that Google was caught (accidentally) sniffing personal information from WiFi connections, adding, “Just how do people trust their PHR on Google Health? I don’t.”

Thursday is Veterans Day, observed on November 11 as the signing of the armistice ending World War I, which took place on the 11th hour of the 11th day of the 11th month. This is a day set aside to honor all military veterans, living or dead (Memorial Day is for those who died in their service to the country, which I say because people often don’t know the difference). But the main thing you should do tomorrow is to thank those who have served, regardless of whether their orders involved something that you agree with (they don’t get to choose). Which I would like to do right now: thank you.

I’m pleased to welcome Thomson Reuters as a new Platinum Sponsor of both HIStalk and HIStalk Mobile. The company offers the Clinical Xpert solution suite, which delivers real-time data to clinicians via the Web and a variety of smart phones (Windows Mobile, Palm, BlackBerry, and the just-added iPhone/iPad/iPod Touch). Clinical Xpert has been the KLAS Category Leader for Mobile Data Systems for eight years in a row. It gives providers tools to improve quality and reduce cost without changing the underlying IT systems, including the pharmacist dashboard I’ve written about lately, a surveillance tool to prompt clinicians to intervene, the patient information app, a billing system (powered by Ingenious Med), and a handoff tool. Thanks to Thomson Reuters for supporting HIStalk and HIStalk Mobile.

Beryl adds two new regional VPs for its Patient Experience Group: Rick Jacob (formerly of CareTech Solutions) and Nicole Nicoloff (from Community Health Network in Indiana).

Weird News Andy notes that some Romans have put a halt to construction of a planned NHS Lothian primary care clinic in Scotland. They’re not walking a picket line, they’re dead – construction is delayed for at least six months after workers uncovered Roman artifacts from 140 AD, including skeletons and weapons.

Nova Scotia’s health minister denies the request of two large hospitals to change privacy laws to opt-out instead of opt-in, which would have allowed them to market to patients and families using information on file unless those individuals expressly declined. The hospitals said they would make sure not to send promotional materials to parents of deceased children, for example, but the health minister said they should stick to taking care of patients. The hospitals implied their marketing campaigns could have raised $40 million over the next five years.

Virginia Commonwealth University Health System chooses 4medica’s lab and anatomic pathology result viewing and exchange solutions.

Someone who should know tells me that the Kansas City paper had the story wrong in saying that Cerner and Pulse didn’t make the original HITREC cut there, but were added afterward because they are local. Here’s the real story, they say: the Missouri and Kansas RECs had different lists and came together in a complex way to arrive at a single list, but that list was only for negotiating purposes. Missouri’s list was the one in which docs and office staff scored vendor demos and both Cerner and Pulse made that list, which wasn’t intended to be a final preferred vendor list. The whole thing was a little too complex to hold my interest, but basically the paper was correct in saying that there were two lists, but incorrect in assuming that Cerner and Pulse were added to List A to create List B.

Another point of view from someone who knows the HITREC situation there says the news isn’t whether Cerner is or isn’t on the list, but rather that their Tiger Institute investment made it questionable at all considering the whole KC-MO joint process was killed off because of that. This person says Cerner has never said how much it’s spending on the Tiger Institute program since it would then be obvious what benefits they expect to achieve from it, so they just call it “cost neutral” and nobody asks further questions. There’s speculation that since the newly elected governor’s campaign organizer is a Cerner VP that Cerner will somehow take over the state HIE effort, especially since their big campus investment on the Kansas side gives them additional clout.

Someone forwarded an e-mail update from Shareable Ink to Inga that noted two events it mentioned as making “a big splash in the industry news over the past couple of weeks.” One was $4.5 million in new financing. The other was my interview with T-System CEO Sunny Sunyal, who talked quite a bit about the DigitalShare joint project between the companies. That was pretty cool to see.

Interesting: the DoD keeps finding reasons not to use the VA’s VistA system (arrogance seems to be the main one), but the Army is looking for someone to install WorldVistA in a military hospital run by Iraq’s government in Baghdad.

Sponsor Updates

• Blanchard Valley Health System (OH) renews its outsourcing contract with CareTech Solutions.
• An article by Maryland McCarty, IS director at Atlanta Medical Center, in the Atlanta hospital newspaper talks about its implementation of SCI Schedule Maximizer and Order Facilitator. The hospital says they’ll be at the forefront of patient scheduling, which will increase the use of their registration kiosks to reduce wait time. It also mentions that physicians can view availability in real time to make sure their patients get scheduled as promptly as they would like.

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