News 9/3/10

From Bobby Orr: “Re: the new Allscripts. They rang the Nasdaq bell. Hopefully it’s not too late to have a real challenger to the mighty Epic.” Glen has rung that bell a few times, I found by Googling. Since I couldn’t find a picture from this week and their Web site seems to be down, the one above is from one of the several previous “new Allscripts”, this one from 2008. I’d like to think it’s not too late to compete with Epic either, but I think it is, at least if the goal is to match up head to head. The Eclipsys clinical apps are better in some ways, but prospects are eating up Epic’s “one record” pitch and looking that the avalanche of new Epic business compared to long, slow decline of the Eclipsys Sunrise customer base. On the other hand, those Eclipsys apps have never been in better management hands than they are today now that the acquisition is finished, so maybe Glen can turn it around. When I asked him about that, he was pretty confident that Epic is vulnerable, but then again, former Eclipsys SVP (now Allscripts president) John Gomez said the same thing right before a stunning string of Eclipsys showcase accounts announced plans to displace Sunrise with Epic.

Speaking of Allscripts, here’s an insightful comment from quadwatch on the Yahoo stock board: “We are seeing what drove this merger — Eclipsys’ inability to compete with a weak ambulatory product and Allscripts’ lack of a hospital system. Given MU requirements for hospitals (in particular, CPOE adoption) the reality is you have only three products with proven adoption rates that don’t make a new purchase a crap shoot for the CIO: Epic, Cerner, and Eclipsys. It becomes a Epic-Cerner race if the facility has employed MDs or is looking to establish a community model. This one of the most logical mergers that I have seen in this segment.”

And while I’m quoting from stock boards, here’s another excellent one from my favorite industry analyst, sonomaca, on Glen’s bell-ringing: “Not surprised he decided to go and ring the bell. This is his triumphant return to control of MDRX. He’s proven himself to be a master of the game, starting with the secondary offering back in 2000 which ultimately saved the company. You’ve got to marvel at how he took a near-bankrupt MDRX in 2002/2003 to the top of the heap in 2010. Amazing. My guess is that, in the end, ECLP will be integrated without too much trouble. In the next couple of years, US market share will be pretty well divvied up between Epic, Cerner, Allscripts, and some of the lumbering giants like McKesson. No doubt, GT is already thinking ahead. And, what’s ahead are myriad tuck-in acquisitions and, most importantly, overseas.” Above is the ten-year share price, peaking at something like $80 in 2000 and bottoming out at less than $2 just three years later, now back to $17. Glen was CEO that whole time and before. He’s got $19 million worth.

From Price Checker: “Re: UPMC. I love this creative, airline-like a la carte approach to paying for the EHR at this paperless hospital.” UPMC, like other hospitals, is charging patients a “facility fee” for being seen in a physician practice it owns, even though patients may not even know that UPMC is involved. The patient profiled in the article noted that the reception area bears a plaque thanking the donor who paid for it, making her wonder why she has to pay again. She had no choice since UPMC threatened to turn her account over to a collection agency, but she vows to steer clear of that doctor and building for her future medical needs.

From The PACS Designer: “Re: Apple TV. Apple has announced their latest Apple TV configuration containing a faster custom built processor called the ARM A4. With a hookup to an HDTV, could medical image viewing find a place in the home viewing schedule? Only time will tell if it catches on with practitioners! This iTV device also has an Ethernet port and 802.11B/G/N Wi-Fi for streaming.” I’ll say that my Roku box was a game-changer for me. I haven’t watched a minute of DirecTV or even DVRed stuff since I got it – everything else seems so primitive compared to free, on-demand Netflix streaming. I’ve discovered great TV shows and movies I would never have found otherwise. I think I saw there’s some kind of medical channel on there.

From Mya: “Re: weird medical news stories. Did you hear about this one?” Sad: a female doctor, apparently drunk, tries to break into her former boyfriend’s house while he is there. He leaves out the back door to avoid a big fight, but in the meantime, she climbs on his roof and tries to slide down his chimney. Three days later, someone checking on the man’s fish notices a smell coming from the fireplace and finds her dead a couple of feet up the chimney, where she had died of asphyxia.

From Irving R. Levine: “Re: EHR vendor. We’re converting from [vendor name omitted]. They don’t understand why an IT shop needs access to clinical data in the SQL tables, so we can’t access our clinical data on our servers on our network without using their UI. They also don’t understand why we want to do our own backups instead of using their service.” This kind of issue is going to pick up steam as people starting switching out EMRs. Small practice vendors don’t usually understand clients with real IT people on board, so they distrust their intentions in a rather parochial manner. Like Bill O’Toole said in his HITlaw, if it’s important to you, get it into the contract.

The proposed Healthcare IT site on Area 51 (geeks know what that means) needs reader commitment to move ahead, being 15% of the way there so far. If you’d like to see an place to have HIT-related questions answered by experts (or to answer questions if you’re the expert), then sign up.

Marty Larson is named executive director of the Greater Dayton (OH) HIE.

GetWellNetwork will announce that it has developed the first digital care plan for reducing admissions for pediatric asthma, including multimedia patient and family education covering triggers, medications, and equipment.

Jobs on the sponsor job page: Technology Account Executive, Epic Certified Consultants, Account Manager, Eclipsys Orders/Results Analyst. On Healthcare IT Jobs: Cerner SurgiNet and Power Orders PMs, McKesson HEO I-forms Consultants, Development Manager, Epic Report Writer/Programmer Analyst.

Listening: reader-recommended The Sensational Alex Harvey Band, 70s glam rockers from Scotland. The namesake died 28 years ago, but even though he hasn’t been reincarnated, the band has. He was quite a showman.

HIStalk stats for August: 102,047 visits, 145,694 page views, and 6,114 verified subscribers. All are new highs. Thank you for reading.

Metropolitan Health Networks and Senior Bridge start a year-long pilot project to evaluate the use of telephone-based telemedicine and specially trained staff to manage 100 Medicare Advantage patients who require frequent hospitalization. Each individual is assigned a nurse and a social worker to work with the patient’s physician to develop a care plan and to conduct in-home assessments for safety and patient evaluation.

This is ingenious: Kerry from Network Management Solutions of Garner, NC e-mailed to tell me he’s figured out a cool way to use his iPad. He downloaded the free Remote Desktop Lite app (which also works with the iPhone) and remotes into his home PC, meaning he can run all of his Windows apps on an iPad from anywhere. That sounds like it might have some possibilities for small-scale hospital or practice apps, as long as each iPad user has a dedicated PC to remote into (it’s like a poor man’s Citrix farm, although the non-poor man might run Citrix Receiver to run apps directly from a Citrix server). I bet the wheels are spinning in the heads of some readers even as we speak.

Why haven’t EHR vendors done this? A chiropractic software vendor partners with the creator of the Facebook Fan Page Generator to get its customers into social networking and promotion, or as the press release says, to create “an automatic new patient referral generating machine.”

The Community College of Allegheny County (PA) will offer free, non-credit HIT classes to qualified applicants, courtesy of $16 million of federal taxpayer money.

The presentation was from an Australian HIT executive, but the message is familiar when it comes to IT challenges in hospitals: IT gets heat to finish projects even with insufficient resources, they patch old systems together instead of buying new ones, and the IT people don’t have the clinical knowledge to run the systems used by clinicians. But it was an audience member who got big applause for describing health department IT procurement practices: “[It’s like] taking a 17-year-old and letting them buy any car they want, with any sized engine. We get clinicians to dream up what they want, then they go and buy it without even thinking about whether it will or won’t work. We have people who don’t know what should and shouldn’t be used, who have the power to make the decisions on buying".”

Odd lawsuit: a surfer hospitalized in Hawaii after a shark bite claims the hospital posted his picture of his leg wound on the Internet. He’s filed a suit alleging HIPAA violations and several more potentially lucrative charges.

More iSoft struggles: the company’s major shareholder says it will decide in April 2011 whether to unload its shares.

I haven’t quite decided whether to do a Monday Morning Update. If I don’t, or if you won’t be around to read it even if I do, have a wonderful end-of-summer holiday (just my US readers, I keep having to remind myself since that’s not all of them). I will be laboring on Labor Day in any case since I am extremely behind, so as Inga suggests below, you can always send us a Facebook or e-mail message if you are feeling lonely, unappreciated, or unfulfilled. 

E-mail me.

HERtalk by Inga

From KP Duty: “Re: Sutter’s iTriage app. Looks like a great tool for consumers, except for one thing (disclosure: I’m with Kaiser Permanente). When I clicked on the Find Emergency Department link to see the EDs closest to my house, is it a coincidence that the largest Kaiser Medical Center in Northern California is absent? I would have to drive by this large and well-established facility with its gigantic emergency department to get to the one listed. To be fair, I put in the address of one of the other Kaiser hospitals and it came up in the right order.” Is it a conspiracy or a bug? I’ll go with bug since I did a spot check on a couple addresses and KP sites definitely popped up prominently.

In what may be the first of similar announcements, ChartLogic reports it has applied for EMR certification with Drummond Group. I reached out to ChartLogic and asked them why Drummond was selected over CCHIT. Here’s the reply from Eric Sorenson, ChartLogic’s VP of marketing:

Our choice for Drummond over CCHIT came down to timing. We believe we are ready to be certified today. CCHIT has indicated that they will launch their program on September 20, and begin receiving applications then. Additionally, they’ve previously indicated that they will give certification priority to their CCHIT 2011 and their “Preliminary ARRA” certified products. We believe this would push our testing date and certification to a date much later than desired. Conversely, Drummond has indicated that they are taking applications immediately, and can begin testing within a few weeks. They have no backlog. We believe this will give us the best opportunity to be certified immediately. CCHIT has a 5 year head start on marketing their products and services, so we weighed the value of a certification with CCHIT vs. Drummond and felt we could overcome any of possible difference in marketing value by being one of the first companies certified, if not THE FIRST. Additionally, Drummond has been certifying other software for a longer time than CCHIT, so we agree with ONC and don’t believe their lack of EHR certification experience is likely to cause us problems in the certification process.

Southwestern Vermont Medical Center says it spent $1 million on its Picis periop system.

Valley View Hospital (CO) goes live on Meditech 6.0.

Actor Michael J. Fox will provide a keynote at HIMSS11, sharing his experiences as a patient and telling healthcare IT experts how IT impacts healthcare. Sadly, he’s got the dreaded Thursday a.m. slot, which means only 200 people will be in the audience. What I want to know is whether Jonathan Bush will try to schedule a meet-and-greet with his look-alike.

Memorial Hermann (TX) selects FairWarning to monitor patient privacy.

Former Streamline Health and Misys VP Scott Boyden takes over as VP of new client sales at TSI Healthcare. Kermit Copley also joins the company as CFO.

Hoag Hospital (CA) opens its new $84 million, 154-bed facility in Irvine. That’s $545,000 a bed if you are the calculating type.

HHS names its final two Beacon Communities: Greater Cincinnati HealthBridge and Southeastern Michigan Health Association. HealthBridge will focus on pediatric asthma and adult diabetic care, while Southeastern Michigan will concentrate on diabetes care and prevention.

UnitedHealth Group is loaning $10 million and donating another $1 million to help rural hospitals improve their HIT and add EHRs. Between this program and the recent Ingenix acquisitions, it sounds like UnitedHealth is trying to unload some cash.

This week on HIStalk Practice: Dr. Gregg Alexander shares the EHR-laced lyrics of some of his soon-to-be-hit tunes; Jonathan Bush tames an octopus; and an Iowa REC shares the cost of their consulting services (between $300 and $2,000 for two years’ worth.)

Stanford Hospital and Clinics commits to a seven-year agreement with Accenture to take over some  of Stanford’s IT functions. Accenture will manage applications and infrastructure and provide data centers, network, help desk, and device support. We said this was happening a couple of weeks ago, courtesy of a reader rumor from Scatman Crothers.

Memorial Hospital at Gulfport (MS) lays off 47 workers, including 10 nurses. The staff reductions are part of cost-cutting measures to offset an $11 million budget shortfall.

The Massachusetts attorney general recommends that the board of Beth Israel Deaconess Medical Center do “some soul-searching” about CEO Paul Levy’s ability to lead the hospital.This follows her office’s conclusion that his long-time personal relationship with a female employee “clearly endangered the reputation of the institution and its management.” Board chair Stephen Kay responded by saying, “We are having a great year. We have more patients than we’ve ever had before. He’s made some wonderful alliances with some quality places. He has great credibility. He’s a national leader.” I’ll bite my tongue as it relates to this toxic topic.

Sponsor News

• Enterprise Software Deployment (ESD) ranks #561 on Inc.’s list of the 5,000 fastest-growing companies. ESD, by the way, just hired former maxIT director David Tucker as its national VP of sales.
• MetroSouth Medical Center (IL) goes live with iSirona’s medical device integration solution, transmitting data from over 100 GE Unity Network devices.

If you have a three-day weekend, I hope you are not in Earl’s way and are able to enjoy the fruits of your labor.  And if you are laboring, remember you can always sneak into Facebook and drop us a note.

E-mail Inga.

HITlaw 9/1/10

Software Contracting with Meaningful Use in Mind

The final rule has been published, the incentive structure is in place, and hospitals and physician groups are investing in EHR technology. Here are some straightforward thoughts on contracting for the successful implementation of your chosen EHR.

Care must be taken by the provider customers. Some will be investing capital based solely on the prospects for reimbursement. Protection of their interests is important. This is by no means a complete list.

Certification

The best situation would be for the vendor to warrant that its EHR technology has been certified by the appropriate authority and is installed and live at more than XX (vendor to fill in the number) sites. The fallback position today would be a warranty that the product will be certified in the appropriate timeframe for full reimbursement eligibility.

Further, they must warrant that certification will be maintained throughout the reimbursement periods (note that the timelines for provider reimbursement differ for Medicare and Medicaid participants). It is technically possible for a provider to lose a year or more of reimbursement if the vendor’s EHR product was initially certified, but then misses certification during the reimbursement period. The year of ineligibility still “counts” for the provider, but they will not receive associated funding.

Be wary of “best efforts” clauses. Some vendors will take care and be uncomfortable warranting that a product will be certified, and for that they should be applauded. Others will take the “we have no choice” approach and provide the warranty. Their gamble is weighing a potential breach of warranty against lost business today when the customer selects an EHR vendor that provides the warranty. The customer has little practical choice. The warranty is essential.

Delivery and Live Status

The delivery date for certified EHR product, together with the implementation timeframe for the product, must result in the EHR in use in live environment so as to enable customer to achieve Meaningful Use. Keep in mind, though, that for long projects with work to be done on both sides, a vendor should not be expected to warrant that something will be live when considerable work must be done by the customer. That work which is completely out of the vendor’s control.

This one factor is greatly reduced as a consideration when dealing with an EHR provided in the SaaS model since time from delivery to live is in some cases negligible.

What you should look for is guaranteed timelines that, if all is accomplished on time by both vendor and customer, will allow for live use by a certain date. This is very reasonable.

Payment Terms

Assuming a certified product is delivered on time, payment should flow accordingly over the implementation timeline. That is fair.

However, some implementations will be quick and some will not. Delaying payments until reimbursement occurs would be outstanding for the small providers, if you can find a vendor that will take those terms.

Undoubtedly the primary concern for some providers is laying out capital on a project and counting on reimbursement when the possibility exists that reimbursement may not occur. If the circumstances are solely the fault of the vendor (failing to maintain certification, for example) then the customer should be protected and monies should be refunded. The requirement to make payments on a product that ultimately does not qualify the provider for reimbursement is patently unfair to the provider customer.

Some accommodation must be made for the hopefully never-to-occur failure of the project. Keep in mind that some of these contracts will be executed with the full intent and purpose of obtaining reimbursement, otherwise the investment would not be made at this time. That one major factor cannot be ignored.

Finally, Meaningful Use

The items above are tailored toward protection of the customer provider, while hopefully acknowledging the fairness factor to the vendor. Meaningful Use is another situation entirely.

In my opinion vendors cannot guarantee or warrant that any customer will achieve Meaningful Use. Vendors only provide the tools needed for that process. The customers are responsible for the work on their side, using the certified EHR tool acquired from the vendor in their operations necessary to achieve Meaningful Use.

The best I could do if writing the warranty for the vendor would be to warrant that the certified product, delivered in the appropriate timeframe, will enable the provider customer, through its efforts and implementation, to achieve Meaningful Use, but that the vendor cannot ultimately warrant that the customer shall achieve that goal. Achieving that goal is the responsibility of the customer providers that will receive the reimbursement if all goes well.

William O’Toole is the founder of O’Toole Law Group of Duxbury, MA.

HIStalk Interviews Nancy Ham and Nancy Brown, MedVentive

Nancy Ham is president and CEO of MedVentive of Waltham, MA.

Nancy Brown, formerly senior vice president of business development and government affairs for athenahealth until July 1 of this year, has been named chief growth officer of MedVentive, where she will head up the company’s sales, marketing, and business development efforts.

Tell me what MedVentive does.

Nancy Ham: MedVentive provides a physician performance management solution for whoever is clinically at risk. Traditionally in our industry, health plans have been at risk, but there’s a huge trend towards providers taking risk and becoming more directly responsible and accountable for both the quality and cost of care.

One thing that we think is interesting about our company is that we support providers and health plans, and in fact are trying to bring them together into a more collaborative environment around managing populations and managing the cost on top of those populations.

Our passion around this springs from our history. In the mid-90s, here in Boston, we started as a mega at-risk provider organization affiliated with CareGroup, which is an integrated health system with eight hospitals and 3,500 physicians. At the time, it was the leading marketplace around providers assuming risk. We were bearing full global capitated risk for about half a million patients, managing about a billion dollars.

Everything that we have today, that we believe today, was really forged in that real-world environment managing our own patients, managing our own data, engaging our own physicians, and trying to learn how to do that successfully in a provider-oriented environment. The challenge was that model was really prevalent only here in Massachusetts and in California.

What’s so exciting about today for us is that we see the whole market opening up and moving away from payer-side risk, fee-for-service risk — which hasn’t served our industry well — and into these new risk models. We’re here with 15 years of experience and a very mature product to bring to that problem.

It seems like that whole assumption of risk idea has come and gone for practices. Do you think this time they’re ready, both organizationally and technologically?

Nancy Brown: No, not generally. There have been a number of organizations who have grown up in this model. The one that Nancy Ham has just described. I grew up professionally at a staff model HMO called Harvard Community Health Plan, which is very similar to Kaiser, where we were totally at risk for a population of patients and everything about our work, our DNA, was all around thinking about populations — how to keep them well and how to deal with their illnesses in the most efficient and effective way.

The vast majority of organizations are not incented that way, are not aligned that way, and don’t have that DNA naturally. This is a major shift, meaning a shift in the industry, where more and more risk is being pushed back down to providers.

I would say the answer to your question is no, they are not generally prepared for this. Just imagine doing work the way you do it every single day being more and more oriented towards seeing the patient who’s sitting in front of you, getting paid for each encounter, and then going to a model that is really completely different. That is exactly why tools and services need to be brought out to these provider organizations to ensure that they won’t hurt themselves in the process of converting over.

Nancy Brown, let’s talk about the announcement that you are joining MedVentive. What discussion did you have with Nancy Ham about her long-term plans for the company and your contribution to them?

Nancy Brown: It’s been a really exciting couple of months, to say the least. I’ll answer that question directly, but let me start by saying that what really motivated me to go back out into the market and to leave athena was this trend towards what has really been established by all the work being done through Obamacare or the Healthcare Reform Act, which is to really think about how healthcare is delivered and to really think about how to change incentives in order to get people to think about cost and quality.

Having grown up, as I said, in a staff model HMO, it was a little bit counterintuitive to me that the management of patients was being carved out and handed to payers and third-party organizations when in fact, there’s no one better than the physicians who are in front of the patients, who really know what care should be delivered, to be the ones that think about the approach to patient care and to think about quality and cost.

I am absolutely thrilled that the country is moving away from fee-for-service and moving back towards accountable care or sharing risk and putting risk and quality back into physician hands.

I was approached by a number of people who knew my background who wanted me to either join large companies who are thinking about establishing toolsets to serve this market, or venture capitalists who were thinking about starting brand new companies that would serve this market. Honestly, the entire time I was going through that process, I thought, well, there is actually an absolutely fantastic company that has been around for over a decade that not only has come up with tools, but has lived and walked in the shoes of at-risk providers, and who has been through many, many cycles of the product. We all know, those of us in healthcare IT, that products all need to go through at least three or four life cycles before you get it right.

The conversation I had with Nancy and with Dr. Jonathan Niloff, the founder, was perfectly aligned with what I thought the market needed. I thought, here’s a company that has existed, that has had terrific tools. The market has not been huge, quite honestly. They’ve taken care of probably a lot of West Coast and East Coast clients, and now they’re perfectly positioned to fully take advantage and really educate clients as to what the needs are to take on risk.

What lessons would you say you learned from your time at athena that will be useful to you at MedVentive?

Nancy Brown: I was at athena for six years and it was a wonderful experience. I consider them to be the closest of friends. I learned about a service model. I think a lot of what we talked about in my conversations with Nancy Ham and others is that you cannot just hand a toolset to an organization — in this case, an analytics toolset — and expect them to do everything that they need to do perfectly.

What I hope to bring to MedVentive that I’ve learned — and actually, it’s really part of my DNA now, based on my time at athena — is two things. One is that we’re going to have to get even more involved with our clients to really help them through these significant transitions.

A specific example of what I mean is when you give them dashboards and toolsets, which MedVentive does now, and you point them in the direction of where they are in terms of a red zone around a particular business problem, I think we hope in the future to be able to actually be in there with them, almost as a virtual chief medical officer, to be able to get them through the ongoing change or the overall change; and then the day-to-day work that they need to get done.

Nancy Ham: Nancy’s experience — her whole career — is of incredible relevance and resonance, as you’ve been hearing. We’re very excited about the service model coming into greater use among our customers because we are very focused about real results in the real world.

We don’t build software for theoretical purposes. We’re not an IT company who’s just building something because we want to sell it for revenue. We’re a healthcare company that forged everything we do in the crucible of the real world. That meant moving the needle on cost and quality. Whether it’s pretty dashboards or beautiful analytics was really irrelevant unless we accomplished the business goals.

We have a very strong ROI story for our customers today. Along the way, for example, we were profiled by the US Department of Health and Human Services as one of the five best national practices in pharmacy cost control. Last year, we were honored to win the Microsoft Healthcare User Group Award with a lovely customer of ours, Northeast PHO, for driving breakthrough levels of quality while reducing costs.

So to Nancy’s point, we have customers today who are independently very capable-mature in their ability to take risk and to execute on risk. But as that model broadens across the country, marrying that proven experience in that ability to drive an ROI with more supportive service capabilities, I think, is going to be key.

Nancy Brown mentioned that venture capital wants to get into this and other companies want to start something up. Who would you say is the competition now and what are the barriers to entry going to be for someone who wants to be in the position you’re in?

Nancy Ham: The barrier to entry is the relevant domain expertise. Not from reading about it, not from going to conferences about it, but from living it. There is no substitute for the fact that for ten years, we were the customer. We were in the real world bearing risk for almost half a million patients and driving positive changes against our budget and our risk and our quality and our population.

There is just no substitute for that. So in one sense, unless you’ve come from that environment, it’s really hard to say you have the same relevant experience and DNA that we bring to the opportunity.

That’s what differentiates us with our customers. They come and they see and they listen to it and say, “You guys really get it. You understand what we need to do, and we take comfort in the fact, frankly, that you’ve traveled this path ahead of us and you can share with us the lessons learned — good and bad. And you can share with us how you engaged your physicians in a way that they found appropriate and relevant and caused them to change behavior in a positive direction.”

Nancy Brown: I would just add to that what I observed is this practical-tactical way of thinking about how to deliver information to physicians. But this is all about helping physicians understand what’s going on with their population and guiding them toward the right decision. That’s not easy to do. A lot of the information that comes out of these analytic tools, generally, can create a lot of noise that they tune out.

I’ve been very impressed in the exposure I’ve had from MedVentive to see what Jonathan Niloff and the team here have done to really make sure that they’re getting the most important information to the physicians and making sure that the feedback loop is staying intact. And, that it’s a practical tool that can be used versus just one of these things that the administration has bought, but that in no way, shape, or form will ever be useful at the point of service.

When you talk about the business model as a service, is there any contemplation of selling service as a percentage as athena does?

Nancy Ham: I think it’s a great question. Historically, we have been focused on wrapping services inside of our software subscription fee. Lately, we’ve been really dialing up our capabilities around clinical consulting. We just hired a new senior director to lead our practice. In there, we are starting to go at risk for the actual results that we’re able to drive.

How that evolves towards a different model or towards the athena model, I think, is something that Nancy Brown and I will be working on and thinking about over the upcoming months and quarters.

Everybody wants to talk about Accountable Care Organizations. What technologies do organizations that want to go in that direction need?

Nancy Ham: To start on the journey of taking risk, organizations need a lot of things. They need a culture of quality. They need a transformational ability. They need to think through physician alignment and reimbursement. There’s a lot they need to think through from a services and strategy perspective.

When it comes to technology, there’s really two ways that an organization can begin to assume risk. One is if they’re already financially integrated, they can jump into becoming an Accountable Care Organization. There you need a suite of tools to manage for cost and utilization and quality from a whole new perspective because it’s not about fee-for-service now, it’s around episodes of care. This was a heart attack, not a series of disconnected claims. This is a population of diabetics and I need to be able to look at them as a population — cost utilization, quality, and engagement — because I’m going to be reimbursed on it as a bundle.

If you’re going into true global capitation, you need to be able to look across the entire spectrum of care no matter where delivered, no matter whether it’s in your network or out of your network, ambulatory or inpatient, and budget it and predict it and price it and manage it very differently than what you’re doing today.

If you’re not already financially integrated, then you actually have a step before that, which is to become clinically integrated, which gives you a safe harbor, if you will, from the Federal Trade Commission. There, you really need an intelligent, patient-centered disease registry that can be distributed across the community to promulgate your quality program and to engage physicians in an interconnected network focused on driving guideline-compliant care.

We’re fortunate at MedVentive that we offer them a spectrum of solutions no matter where you are on your journey to risk. We have a technology and a capability that matches up to where you are and what you need to do next to move forward.

Who helps organizations are assess their capabilities to enter into these agreements? Are they going to become standalone at some point, or are they always going to need some sort of support — technology or otherwise — to have ongoing success in being part of an ACO?

Nancy Brown: What I’ve observed in my journey over the last few months in looking at a lot of organizations focused on this market — there’s an equal number of consulting firms that are spitting up new practices to focus on all of the human capital issues. So if you parse apart everything Nancy Ham just said, underlying it is that technology is important. MedVentive has done fabulous things, but I’m sure if Jonathan Niloff was sitting here, he would tell you that it was the people side of it. Once you get the information in front of you, it’s really getting the teams built and the mindset in place to do the right thing.

So to answer your question, I think hand-in-hand with the technology will be folks who come in — and I already see it happening — that will work a lot on everything from organizational design to organizational behavior and the creation of probably all-new incentive plans beyond the medical incentives. I think it will be ongoing, absolutely.

I also think, as I talked a lot about during my days at athena, that there will be an ongoing evolution of these reimbursement plans over time. This is yet another set of ideas that people have, from Medical Homes to P4P to accountable care. Somewhere in all of this there will be a model that begins to effect really positive change. What I mean by that is it will incent providers to actually go in and make changes to workflows and to their approach, which is what Jonathan Niloff probably observed at CareGroup and I observed at Harvard Community Health Plan.

That it is an ongoing journey of give me the data, let me observe. Then, what’s going wrong? Let me improve my processes. Give me the data, let me observe what’s wrong … it’s an ongoing effort that never ends.

The HITECH Act has stolen everybody’s attention, so everybody’s focusing on EMRs or HIEs or whatever it is. How do you expect the vendor landscape and organizational strategic priorities to change as we get past that first total focus on just EMRs?

Nancy Brown: You couldn’t have asked me a better question. I won’t get on my soapbox for too long, but I often said in Washington and other places that I felt like the HITECH Act was a little bit of a distraction. While people were busy looking at it and going out after their $44,000 and had their backs turned, they’re going to get hit by a train and the train was going to be changes in reimbursement, as well as other major changes to how people are dealing with the administrative side, such as ICD-10.

It’s very interesting because it’s very hard right now to quantify how much business is shifting from fee-for-service to these quality contracts. What I say to anyone who will listen is don’t worry so much about the percentages because right now it’s definitely a very, very high percentage still in fee-for-service.

But let’s look at the reality. You can’t bring all of these uninsured into that coverage to have insurance coverage, and then also — simultaneous to bringing this new population of patients in that will now have insurance coverage — mandate that the insurance companies cannot increase premiums and then not expect that the costs are going to go somewhere. Those are going to be really put onto the backs of the providers. The insurance companies really don’t have any other way to get the money other than to assert change reimbursement.

The accountable care concept is owned by Medicare, but I think we’re already seeing a rapid acceleration of a risk shifting by commercial payers. As that risk shifts, people are going to have to be prepared. Compared to taking on an EMR, that’s child’s play in my opinion. This is very, very serious. Meaning you have to have a lot of information, a lot of guidance, and a lot of change in behaviors to be successful.

The other thing I’ll add about the EMR side, which was a big focus at athena, is that the EMRs need to be prepared to take the information that comes out of systems like MedVentive. These are things, to be specific, like gaps in care, for instance. When they tell you that Nancy Brown has not had a particular test or is at risk for a particular disease state, that information needs to be showing up at the point of service, ideally.

Many of the systems, most I would say, the majority of them do not have the capability to take that in and haven’t even reformed themselves in a way to think about population.

I think it’s going to be a very exciting time for those EMR vendors who really step up and think about themselves as being in a continuum that starts with taking risks, managing populations, and then intervening at the point of service.

You’re right, it’s an EMR-centric world out there, and those vendors typically don’t like to acknowledge that there may be contributions from other systems or other vendors. How do you intend to work around that, from the MedVentive standpoint, to convince them that it’s in their own best interest to collaborate?

Nancy Ham: We see, in our current client base, a very interesting spectrum of organizations. We have clients today who are 95% deployed on single EMR, so they’ve already climbed that mountain. But what they have found, to Nancy Brown’s point, is that the EMR does not provide them this horizontal capability to look across their population, to manage populations in an episodic or disease-centric way. It does not allow them to look at their cost in a capitated fashion; to look in-network and out-of-network to control all the levers they need to control to be financially successful.

We have in-the-middle organizations, those who are building broad-based networks in which their physicians are on many EMRs. So there, you have a bit of a Tower of Babel approach where there’s no source of truth, no central view, no view that goes across the continuum of care and across the community.

And then we have customers who have said that $44,000, frankly, is not compelling. We’re looking for tools that we can acquire and implement rapidly to allow us to step into risk because what we hear is forward-thinking organizations know fee-for-service is dying. So whether it dies tomorrow or dies two years from now or four years from now doesn’t matter.

They know now they need to get control of their data. They need to start measuring themselves. They need to get ready so that whatever form risk takes in their market — it could be heavy pay-for-performance, it could be episodic or population, it could be true global cap — that they can’t be ready overnight to spring into that environment.

They have an urgency about that to get started now, and that’s very exciting for us as a company because as we said, we started — Nancy and her path, and MedVentive in ours — in provider risk organizations more than a decade ago. It’s exciting to us to see that model, which we know works in improving quality and reducing costs, spread across the country. We couldn’t be more excited about the possibilities in front of us to help organizations learn how to do that and to be successful.

What are the long-term plans for the company?

Nancy Ham: With Nancy coming on board as chief growth officer, our plan is clearly to execute on our growth strategy and to leverage the fact that we think we have a very unusual capability born on the provider side, but ambidextrous, if you will, because we can serve whoever’s at risk — the self-insured employer, the health plan, the provider — and bring them together on a collaboration platform, a much-overused term that rarely exists in the real world. We think it’s the right model, which is we need to be sharing and looking at the same data with a focus on changing what is a societal ill at this point.

Our collective failure to create a universal model that reduces the healthcare costs in this country is impinging our growth as a society. Really, the ability to bring that all together, we think, is unbounded in terms of size. Our focus is just on getting the word out about what we’re able to do and to do it for more people. And with Nancy Brown on board, I’m sure that that’s what we’re going to be able to do.

News 9/1/10

From Redzenskyca: “Re: Allscripts/Eclipsys merger. New company name: Allscripts. New color: green.” The announcement is coming tomorrow, reliable sources tell us (nobody official, but people who should know). Green is my favorite color, though. Here I was criticizing the sea of orange at ACE and now it’s going to be a collector’s item or something (or sold on eBay just in time for hunting season). UPDATE: the Allscripts site has been updated with the logo above and a welcome to the merged companies.

UPDATE 2: The company’s leadership team is listed as Glen Tullman as CEO (Allscripts), Lee Shapiro as president (Allscripts), Bill Davis as CFO (Allscripts), Eileen McPartland as COO (Allscripts), John Gomez as president of product strategy and development (Eclipsys), Jeff Surges as president of sales (Allscripts), Diane Adams as EVP of culture and talent (Allscripts), Laurie McGraw as chief client officer (Allscripts), Dan Michelson as EVP and chief marketing officer (Allscripts), Kent Alexander as EVP and general counsel (Allscripts), and Joe Cary as chief of staff (Allscripts).

From Curious in Texas: “Re: MD Anderson in Houston. I’ve heard they will be installing Soarian Financials. This surprises me because I thought the UT hospitals were all converting to Epic. Can you verify this rumor?” Verified. MD Anderson hasn’t signed the contract yet, but they are planning to migrate from Invision to Soarian patient accounting, ADT, and scheduling. Their primary motivation is its service-oriented architecture.

From Boomer Later: “Re: Maine Medical Center. I heard its board will meet Wednesday on a proposal to migrate from Eclipsys to Epic on a 20-month timetable. Approval is expected. It’s a blow for Eclipsys since MMC is one of their most progressive and active customers and was customer #6 on the old TDS product.” Verified. They were already using Epic on the MaineHealth ambulatory side, so this will be the next step toward their “One Patient, One Record” philosophy. Epic Enterprise will be implemented in their six member facilities in addition to Maine Med.

From Lizard King: “Re: HITECH. AAOS average member salary: $$$$. GP in private practice: $. Meaningful use is the gateway to federal $$$ to pay for HIT that providers might not otherwise be able to justify as an ordinary practice investment. Generalizing, specialists have more profitable operations and seem to have much better ROIs on HIT than GPs, so it is no surprise that MU is headed this direction. Which seems about right to this taxpayer and consultant.”

If you’ve been following the current poll and comments on Ed Marx’s Blessing of the Hands post, you may wonder why the comments suddenly turned ugly. An atheist blogger linked to it and his followers dropped by to vote and opine. Since the point was to find out what industry people think, here’s the stat that counts: the poll was running 50-50 when it was just real readers voting.

Inga interviewed Chet Speed of AMGA about Accountable Care Organizations on HIStalk Practice. It’s a hot topic, so we’ll have more soon from the hospital point of view. Hats off to her for drawing readers to HIStalk Practice, with visits up 50% or so compared to a year ago.

A Member of Parliament in England wants to know if BT was paid hundreds of millions of pounds to persuade it to stick around with NPfIT instead of bailing out like other companies did.

In the News of the Obvious, a small study finds that Facebook is a big draw for narcissists prone to encouraging shallow relationships by carefully controlling their image, bragging on themselves in their Info section, and in the case of females, posting revealing and/or doctored photos (not that there’s anything wrong with that). The conclusion is somewhat profound: “As we abandon the fake avatars and cryptic usernames of years past and begin associating our online identities with our real-world lives, our online activities begin to have more relevance to our true personality traits.”

Mike Cannavo, the one and only PACSman, cranks up a blog: The PACSman Pontificates. He was darned funny, irreverent, abrasive, and always informative when he wrote for a rag-sponsored blog, but says he got tired of being forced to change his posts every time an advertiser complained. I can only imagine what he’ll say unmuzzled. Also in the PACS and radiology world, Mike’s occasional partner in crime Doctor Dalai celebrates 200,000 blog visits. I like those guys.

Newly named EHR certifying body Drummond Group releases testing guidelines and cost (warning: PDF): $19,500 for inpatient or ambulatory remote testing, $23,500 plus travel for on-site testing.

In Australia, iSoft CEO Gary Cohen will resign after the company posts a $383 million fiscal year loss and a 20% drop in revenue. Shares are down 83% year to date to around 12 cents. I interviewed Gary in April.

WellStar Health (GA) will pay $2.7 million to settle Medicaid fraud claims, admitting no wrongdoing and blaming its claims processing software.

Ambulatory EMR vendor iSALUS names (warning: PDF) Richard Noe as president and CEO. I don’t see any mention of previous healthcare-related employment. He says he’ll double headcount there.

Retired Army General Hugh Shelton, the former chair of the Joint Chiefs of Staff and a Special Forces veteran of the Vietnam War, is named chairman of the board of Red Hat.

Detroit Medical Center says its EMR saved it $5 million last year, $4.5 million of it coming from reduced length of stay related to pressure ulcers. That’s not a great ROI for a $50 million system, but it’s a good start.

I don’t look at LinkedIn often except to verify where someone works since it’s kind of junky looking and always trying to upsell additional features. Still, I was happy to hear from Dann that the HIStalk Fan Club he started there has 1,088 members, some of them spamming my hard-won audience with their own pitches, I notice, which seems kind of tacky but common for LinkedIn. Anyway, since I seldom mention LinkedIn, feel free to add Inga or me to your network (just search for HIStalk). I even added a spiffy new photo since they removed my old one. We’re more Facebookers these days (there’s that narcissism thing), so ditto: just search for HIStalk and you’ll see individual profiles for Inga and me plus our HIStalk page. I’m feeling loserly since I have only 89 friends (although I appreciate every one) vs. Inga’s 112.

The CEO of Naples Community Hospital (FL) writes an editorial bragging on the hospital’s use of its Cerner EMR. Actually he mostly seems to be bragging on the possibility of getting taxpayer money for using it, saying the hospital will be an “early applicant” for money and hopes to get nearly $12 million continuing to do what it was already doing. He says Cerner told him Naples is the second most MU-ready Cerner site.

Markle Foundation assembles (warning: PDF) 45 organizations who advocate that HIT vendors offer the “simple, but rarely offered” ability for people to download their own health records, the so-called Blue Button.

The SVP/CFO of Danbury Health Systems (CT) is charged with defrauding his employer of more than $140,000 by directing health systems payments to a software company he ran out of his house.

IBM and Dell chase the Chinese equivalent of HITECH money. Interesting: one hospital has more than 10,000 patient visits per day.

Bizarre: an auto accident patient says he awoke in Prince George’s Hospital (MD) and asked for food, only to be told by a nurse that he was NPO for cancer surgery, which was news to him. As he was being prepped, he noticed that another patient’s wristband had been placed on him. His wife helped him pack up with intentions of getting out fast AMA, but he claims two hospital security guards beat him and advised him that “Hell, no, he don’t come up in here and be telling us what the f*** to do.” He says a hospital manager acknowledged the incorrect wristband and invited him to have “any type of drug he wanted, just to name the painkiller.” He was diagnosed with broken ribs, a sprained shoulder, a ruptured spleen, and a concussion. He’s suing for $12 million.

E-mail me.

HERtalk by Inga

From Roger Sterling: “Re: DocSite. News has it that Covisint is buying DocSite. Covisint wants to add it to the AMA portal project being rolled out in Michigan.” Unverified. I have a message out to the Covisint folks.

HealthInfoNet, the HIE for Maine, partners with Health Language to provide clinical content integration.

EDIMS licenses First DataBank’s National Drug File Plus database to integrate into its emergency department EHR.

Quincy Valley Medical Center (WA) commits $200,000 for computer hardware in advance of selecting a an EMR application. Software finalists include Meditech 6.0 and CPSI.

Sisters of Mercy Health System launches a $60 million data center in Washington, Mo. The 42,500 square-foot center will host EHR and other applications for all of Mercy’s sites. The regional business journal also points out that the medical information is secure, as it relates to “HIPPA.”

The 16-hospital system IASIS Healthcare selects QuadraMed’s coding, compliance, and reporting tools in preparation for the transition to ICD-10 code sets.

St. Mary’s Medical Center (WV) contracts with Wolters Kluwer Health for its ProVation Order Sets.

Matt Grill, Sunquest’s former manager of technical training and publications, takes over as VP of Global Client Support for MRI Software, a developer of real estate management software.

Patient education material from Thomson Reuters and its Micromedex CareNotes system is available in 15 languages, including Arabic, Chinese, Russian, and Turkish.

On HIStalk Practice: an interview with 20-year-old Greg Waldstreicher, founder of DoseSpot. Everyone who was running a viable business at age 20 while going to school full time, please raise your hand.

Sutter Health (CA) activates iTriage, giving consumers the ability to check systems and find out detailed information about doctors, hospitals, clinics, and ERs via a free mobile application.

The average American hospital barely breaks even, but some have operating margins of 25% or more, according to a Forbes survey of the country’s most profitable hospitals. HCA owns 11 of the top 25 hospitals; two of Mayo’s main facilities make the list as well. Flowers Medical Center (AL) topped the list with its 53% operating margin. Fifteen of the 25 hospitals were for-profit.

Baptist Medical Center (MS) lays off 186 workers, including 14 in management. Laid off workers are being offered a chance to apply for the 136 current openings.

Sponsor updates

• Greenway Medical Technologies says four additional HIEs, IPAs, and regional medical centers have selected its PrimeSuite EHR/PM solution.
• Cumberland Consulting Group has been named one of the 2010 Best Small Firms to Work For by Consulting magazine, having made their list every year since it was started.
• For the second year in a row, the Central Penn Business Journal names MEDecision to its 100 Best Places to Work in Pennsylvania.
• Sierra View District Hospital (CA) hires MEDSEEK to develop and deploy its Web site and clinical portal.
• Access has a new Web site at accessefm.com.
• MaxIT Healthcare makes the Inc. 5000 list, as well as being named #56 on the HCI 2010 Top 100. The company has over 430 consultants.

A baby in Italy suffers heart problems and possible brain damage after two doctors involved in his birth get into a fist fight in the operating room over the appropriateness of doing a C-section. The mother had to have her uterus removed. The region has a 60% C-section rate.

E-mail Inga.

Readers Write 8/31/10

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!

Meaningful Use:  Specialists Still Not a Priority
By Evan Steele

The HIT Policy Committee’s creation of a new Quality Measures Workgroup last week is the most recent in a string of actions confirming that meaningful use has not been defined meaningfully for specialists — and that it is not likely to be. Despite the fact that this new workgroup is charged with prioritizing Stage 2 quality measures and analyzing gaps in Stage 1 criteria, the 18 physicians selected for the 24-member group are primary care providers* — a fact that surely raises concerns among specialists.

The appointment of this workgroup comes on the heels of a growing response to the Stage 1 definition of Meaningful Use from specialists and their professional organizations, commenting on the lack of fit with the way specialists routinely practice. Every one of the six core clinical quality measures are primary care-related, and many specialists will be hard-pressed to identify three of the 38 additional clinical quality measures that are relevant to their practices.

At last month’s HIT Policy Committee meeting, committee member Gayle Harrell commented that much of the input gathered from the specialist panels convened last October seems to have been ignored, She contended that in the final rule, CMS made it more — rather than less — difficult for many specialists to comply with Meaningful Use.

This position was echoed by Thomas C. Barber MD, EMR project team leader of the American Academy of Orthopaedic Surgeons (AAOS) in discussing the Academy’s EMR position statement in the most recent issue of AAOS Now:

Orthopaedic surgeons will have great difficulty in meeting the current 25 Meaningful Use standards. Orthopaedics would derive greater benefits from standards promulgated by our medical specialty society rather than a set of generic requirements that mostly do not apply to musculoskeletal patient care.

This is not a new issue. The primary care focus of the legislation and regulations has been intentional from the outset. President Obama appointed an internist, David Blumenthal MD, to spearhead the program. There was only one private-practicing specialist among the committee members that crafted the recommendations to CMS.

It is not surprising that the Meaningful Use criteria do not reflect the practice patterns of specialists. Federal funding to assist physicians with EMR adoption has been directed towards primary care. The $357 million allocated for Regional Extension Centers, for example, was earmarked to “provide outreach and support services to at least 100,000 primary care providers and hospitals.”

The definition of Meaningful Use is not the only obstacle for specialists. The EMR products themselves are not tailored to the needs of specialists. The AAOS EMR Position Statement correctly suggests that in developing certification standards, it is essential that “the different needs and uses of EHR by disparate medical specialties should be recognized. In particular, the differences between surgical specialties and primary care specialties should be acknowledged.“

Unfortunately, because the certification criteria are linked to the Meaningful Use requirements, they are similarly primary care-driven. The EMRs most likely to be certified for Meaningful Use are predominantly those that were created and developed for primary care physicians — those of vendors that, from 2004 until recently, have devoted their development resources to meeting CCHIT’s 467 largely primary care-focused criteria. The AAOS statement continues: “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.”

Specialists are no different from other physicians in their desire to participate actively in the evolution of the country’s medical care delivery system. But until Meaningful Use is defined in a way that is applicable to the way they deliver that care, they will participate on their own terms — adopting specialist-focused EMR technology that increases their productivity and enables them to provide the highest quality care and service to their patients.

* Includes internists, family practitioners, pediatricians, preventive medicine, an internist/hematologist, and a psychiatrist.

Evan Steele is CEO of SRSsoft of Montvale, NJ.

Safeguarding EMRs Against System Failure or Downtime
By Arthur Young

Using time-saving information technology and automated patient records management ensures clinicians have faster access to the most up-to-date patient information, enabling timely diagnoses and treatment and maintaining a high quality of care. However, if the network goes down, the system fails, or a planned or unplanned system downtime occurs, clinicians are unable to access critical patient information.

Whether they are planned or unplanned, system downtimes can occur for any length of time — from a few minutes to a few days. Downtimes can also be very costly if there is no system for preserving and accessing up-to-date patient information and maintaining uninterrupted patient care. Healthcare organizations have implemented systems for recovering from disasters, but not for protecting data and continuing operations during downtime. Without such a system, downtime can become more than an annoyance — it can be a life-threatening event.

Distinct from disaster recovery — which helps get systems back up when they go down due to a power outage or property damage — business continuance keeps vital business operations running at or near normal capacities in the event of any network or system downtime. That includes the downtime that occurs while disaster recovery mechanisms are being executed.

There are various solutions available that can help healthcare organizations remain functional during downtimes. However, they have drawbacks. Redundant or fault-tolerant systems can keep computers running and available during a system failure or power outage, but if they are the only system being used for business continuance and the network also goes down, clinicians will not be able to access patient data. Printing patient reports periodically allows clinicians to have the current data on hand, however it is a time-consuming and cumbersome task that diminishes data security, not to mention a waste of paper, ink, and other resources.

To maintain access to patient information from the location its needed, healthcare organizations need to select a business continuance approach that will provide the most protection in the most circumstances. Ideally, a business continuance solution should enable healthcare organizations to do the following:

• Identify critical information and automatically distribute it to areas it will be needed in the event the HCIS is unreachable;
• Ensure the information is secured but available on local machines;
• Maintain seamless operation in the background, notifying administrators of any interruptions; and
• Eliminate the storage of data in paper form, saving paper, ink, and printers.

Intelligent report generation and distribution decentralizes data in the event of downtime by sending the latest reports from the HCIS to its system and creating secure databases in multiple locations. The information is indexed in the database so clinicians can search and find the data they need whenever they need it.

With access to critical data during periods of system failure or extended downtime, clinicians can provide uninterrupted care and healthcare organizations mitigate risks to patient safety. Patients can be assured their health records are up-to-date and secure and confident they are receiving the best possible care.

Arthur Young is the president of Interbit Data of Natick, MA.

Ode to the Dumbwaiter and Robo-Butt
By Frustrated Farmacist (Female)

I saw your blurb about the Aethon TUG delivery robots installed at El Camino Hospital. The old ECH had an awesome dumbwaiter delivery system in place.

It is rumored that the Aethon TUG delivery robot solution was something of an afterthought that came six agonizing months after the grand opening of the $470 million hospital. Apparently earlier plans to integrate a delivery system may have been (ahem) overlooked. You can see from ECH documents that the robot contract was drafted in January 2010, several months after the new hospital opened. Early reports said the robots didn’t work for all departments and some ended up using volunteers, auxiliary staff, temporary workers, and other solutions to get medications and lab materials delivered.

$470 million and NOBODY initially planned an integrated medication delivery and lab transport system for a brand new, ultimate-in-high-tech 400-bed hospital! It doesn’t take too much imagination to extrapolate how important timely medication delivery is in the patient care scheme of things and why it’s the top complaint and employee satisfaction issue for nurses.

ECH’s competitor down the road has been using a similar robot system from Pyxis for the PAST 22 YEARS. It’s on its third generation, fondly named Robo-Butt. He travels in elevators and down halls to six floors and 15 departments. He is guided by sensors in the walls and speaks aloud to nurses to alert them when he arrives and when he commandeers the elevator. He steers around obstacles. His compartments are locked and secure, requiring a numbered password to open. He’s powered by six car batteries that are recharged and swapped for backups 2-3 times daily.

He breaks down every now and then. The elevators break down more often, grounding him on the first floor. Pyxis no longer supports these robots, so parts were scrounged from the basements of other hospitals and from a hospital supply house in Hawaii. But Robo-Butt WORKS. Here’s a picture of this bad boy:

The average hospital pharmacy department dispenses at least 40% more meds than were ordered because of late deliveries or items that are misplaced. The overhead and amount of wasted labor and supplies is unacceptable and frustrating for everyone involved, including the patient, nurse, doctor, pharmacy, and departments like lab and surgery that are held up because of medication delays.

With pneumatic tubes, you place meds in padded bullets and shoot them to the receiving department. Fragile ampules and vials can be broken — think about Epogen, a blood booster whose fragile proteins are destroyed by a violent trip in the tube system. It used to cost $6,000/vial and is still in the $600-900 range. Can I tell you how many bullets have exploded inside the pneumatic tube tunnels? Can I tell you what I think about the ER department tubing patient urine and blood samples to the lab inside this system?

We still have bullets that wind up in the basement due to malfunctioning suction or drivers. It’s hilarious when it’s a $45,000 rattlesnake venom antidote. But the bad part is that sometimes meds lie in piled up bullets in the tube receiving bin. Worse, the staff goes to send an “empty” tube to lab or ER and accidentally send a bullet filled with meds. The worst part is there is no “track-ability” or accountability — we can never tell whether someone received a bullet. If they “say” it never arrived, we have to send it again.

Here’s why I think dumbwaiters may be the ultimate smart medication delivery system with the fastest turnaround times, the least amount of waste, and minimal lost meds and lost charges. The pharmacy staff places labeled / bagged medications into little sectioned trays (like your silverware drawer’s insert) and leave them in the little locked elevator. The nurse that needs meds comes to her department’s locked elevator door, calls up the tray, and REMOVES ONLY HER PATIENT’S MEDS. She leaves the other meds in their little slots.

Think about this. You don’t have one nurse removing meds for her entire department and then misplacing them, storing them improperly (oops, that expensive IVIG that cost $20,000 belonged in the refrigerator?) or just putting them in her POCKET and forgetting to put them in the med room altogether. Then the Pharmacy can call the dumbwaiter down later and retrieve unused meds, credit them back, and recycle them. 

You can imagine that the number of missing med phone calls drops in half. Anyone in the pharmacy can check the dumbwaiter and see if missing meds are there before re-making them. Can I tell you how much time I waste every day re-doing the same missing med that simply gets misplaced or misdelivered and there’s no way to track it? It’s cheaper to bag up another blood pressure pill with the patient’s name and send it again sometimes. And then we get to retrieve all the duplicates, sort them, and restock them in the pharmacy bins…

I have nightmares about this.

A reliable well-planned medication delivery system is worth $$$ millions and makes up 80% of the nursing / customer satisfaction basis. I swear this is true! Any healthcare organization that builds a state-of-the-art facility without planning a delivery system is completely ignorant.

Done with my rant. 😉

ONC-Authorized Testing and Certification Bodies Named

The Office of the National Coordinator for Health Information Technology has named two ONC-Authorized Testing and Certification Bodies (ATCBs). They are Certification Commission for Health Information Technology of Chicago, IL and Drummond Group, Inc. of Austin, TX.

Authorized by the National Coordinator, ONC-ATCBs are required to test and certify that certain types of EHR technology (Complete EHRs and EHR Modules) are compliant with the standards, implementation specifications, and certification criteria adopted by the HHS Secretary and meet the definition of “certified EHR technology.”

Monday Morning Update 8/30/10

From Packerbacker: “Re: Epic. Wins another one, selected VOC at Children’s Hospital of Wisconsin. The contract is not signed, but they have already started planning the implementation.” Unverified, but Epic doesn’t lose many deals in its home state.

From Winston Zeddemore: “Re: clinical data. I lost a lost of respect for Halamka with the whole ePatient Dave mess. As a doc, he should have known better than to inundate unsuspecting patients with a barrage of unchecked claims data in their PHR. Then, he has the audacity to state that the switch to ICD-10 would fix the problem, when ICD-10 has no code for metastasis of cancer to the skull, either. Recall, poor Dave was alarmed to see a diagnosis of mets to the brain, when he had really had mets to skull that had been successfully managed. Well, ICD-9-CM has no code for mets to the skull, so the coders used the closest thing, mets to the brain.”

From Telluride: “Re: HIStalk e-mail list. Since you started telling the numbers, it has grown each month. Do you allow unsubscribes?” Yes, and I get some of those. That’s why I look more at the ratio of new subscribers to unsubscribers. This month, for example, it has been 372:64. Some of those are e-mail address changes, of course. Like everybody else, I’d prefer readers who love me rather than hate me, but it’s indifference that I really hope to avoid.

From Eroica: “Re: Emdeon. I thought you’d like the highlighted reference below. You are now the source for Wall Street analysts!” A brokerage and investment firm’s update cites my Thursday posting about Emdeon and Blue Shield of California, although not by name (“a well read HCIT blog”). The announcement included the same confirmation I used from the reader’s rumor report (Blue Shield’s Web site) and listed the same three of 17 remaining clearinghouses that I did (which I did because those three are HIStalk sponsors and I figured it was nice to mention them, plus I hadn’t heard of most of the rest anyway). Emdeon responded to the firm’s inquiry by saying they may still negotiate a deal and their revenue from Blue Shield of California isn’t that important since “they can shift the cost per claim to providers or obtain rebates from other vendors.”

From Paul: “Re: tube system failure. Shameless plug by a robot vendor – I work for Aethon, a Pittsburgh-based company that makes TUGs, autonomous robots that deliver medications or supplies to any location. Think of it as a tubeless tube system with no fixed infrastructure that works 24/7. We also offer a Chain of Custody solution that uses biometrics and RFID to improve patient safety.” Since Paul made it clear it was a shameless plug, I’ll allow it. I’ve mentioned the company a few times, mostly when execs from other Pittsburgh-area HIT companies ended up there. Above is a video some guy made as he chased around one of the Aethon robots at El Camino Hospital. You’ll hear him say, “Puttin’ Americans out of work,” which may be true at El Camino since the hospital just announced a 140-employee layoff.

From C’mon Man: “Re: tube system at UPMC Shadyside. The workaround to avoid the >90 minute delay after CPOE deployment is marvelous!” CM sent a UPMC internal document describing a quality improvement project at Shadyside. Before Cerner was implemented, the ED stocked 95% of the meds they used in their automated dispensing cabinet and the other 5% were requested by tubing the paper order to pharmacy, resulting in a pretty good turnaround time of 28 minutes. With CPOE, the ED had no good way to alert pharmacy about those 5% of meds, so turnaround time shot up to over two hours. An ED nurse came up with a solution: tubing a yellow “Stat ED Med” card to pharmacy along with an index card listing the patient and med needed, dropping TAT back to six minutes. I was initially appalled at this solution since hand-transcribing an electronic order onto a tubed index card seems fraught with potential error, but pharmacy reviews the electronic order before sending the med and I assume nurses still verify the med electronically in the ED, hopefully with bar code checking. What puzzles me is why the original electronic order doesn’t go directly to pharmacy anyway — surely the pharmacy module should “know” that an order was entered for a non-Pyxis order and should send it to the pharmacist’s work queue for verification and delivery with no manual notification required. That’s what integrated systems are supposed to do.

All this tube system talk stirred up some old memories of a hospital I worked in years ago, where the information superhighway was a dumbwaiter system (“the dummy”, staff called it). It was actually darned useful since the hospital was built around it, so it connected the nursing units with the major departments they interacted with (lab, materials management, pharmacy, etc.) I once dared a small female co-worker to ride it up several floors, where she proceeded to scare the bejesus out of the nurse who opened its tiny door to see what had been sent. All of these “hospitals of the future” with their LCD TVs and room service should have reintroduced the dumbwaiter, an express elevator for stuff.

Listening: I’m still obsessed with the new Iron Maiden, but I took a break to listen to some catchy and refreshingly different alt rock-pop from The Last Goodnight.

Your mission, should you choose to accept it: (a) put your e-mail in the Subscribe to Updates box, just to make sure you don’t miss any news or juicy rumors; (b) speaking of news or juicy rumors, send me some by clicking the ugliest, greenest graphic on the page, to your right; (c) show HIStalk’s sponsors some appreciation by clicking on their ads to find out what’s new with them; (d) fritter away a slow afternoon at work by performing endless searches using the Search function to your right; and (e) Friend or Like Inga and me on Facebook so we can maintain our delusions of popularity. Thanks to readers for reading, sponsors for sponsing, and everyone who takes the time to leave a comment, send an e-mail, or submit something I can use on HIStalk, HIStalk Practice, or HIStalk Mobile.

Epic wouldn’t be a good choice to replace the DoD’s AHLTA EMR system, two-thirds of HIStalk readers say. New poll to your right, since Ed Marx’s “Blessing of the Hands” piece stirred up some heated responses: should hospital IT people be expected to have a higher level of compassion and spiritual beliefs than their counterparts in banking or manufacturing?

A sad medication error at Cincinnati Children’s: a seven-month-old baby dies after heart surgery when a technician apparently infuses an alcohol solution instead of saline.

Welch Allyn announces its Connex vital signs documentation system, a single device that collects automatic instrument readings (heart rate, blood pressure, temperature, pulse oximetry) and manual entries (height, weight, pain level) and modifiers (body position, O2 settings). It also allows alarm management and on-screen documentation right from the device. It’s wireless to the bedside. The company says that an average 200-bed hospital wastes 8,000 hours per year documenting vitals and makes 10,000 mistakes in doing so. St. Joseph’s Hospital Health Center in Syracuse, NY, the beta site, reports a 50% drop in documentation time and 75% fewer errors.

Yale-New Haven Hospital’s new CIO will be Daniel Barchi, who will also serve as CIO for the Yale School of Medicine. I interviewed him a few weeks ago while he was SVP/CIO of Carilion Clinic of Roanoke, VA. YNHH will be cranking up its $250 million Epic project, so I’m sure his experience in implementing Epic at Carilion will be valuable. He’s a good guy, as was his now-retired YNHH CIO predecessor Mark Andersen. Both are fans of HIStalk and have been cordially forthright in responding when I’ve pestered them to verify reader rumors.

Also on Inc.’s list of 5000 fastest growing private companies: Vitalize Consulting Solutions, among the fewer than 10% of companies on the lists that have four-peated since the magazine started the list four years ago. I’d consider Vitalize CEO Bruce Cerullo to be a great friend of HIStalk, having known him for years and interviewed him in 2007 when he was running VCS’s predecessor company Lucida, but even I didn’t know the company had grown this much: 264 employees, $48 million in annual revenue, and three-year growth of 179%.

HIStalk reader and clinical informaticist Lincoln Farnum sent over his exclusive article, Common Knowledge: Clinical Decision Support in the Era of Meaningful Use, a CDS Toolkit. I’ve posted it on Drop.io, hopefully free of the sneaky and unwelcome Facebook tie-ins that keep biting me in the rear when I post files for download. It’s a good overview of CDS, the ethics involved in deploying it, the problems with trying to measure its impact on patient outcomes, usability issues, and best practices in CDS deployment. Give it a look.

I was annoyed by a press release from Brainware that announced a new healthcare customer without naming them (is a sales announcement really news when it omits the customer’s name?), but the company’s Distiller product still sounds kind of interesting. It’s an intelligent data capture platform that “learns” the data fields from scanned documents such as invoices and orders.

New from Japan, which seems obsessed with high-tech toilets: a network-enabled health monitor version that checks blood sugar, BP, BMI, and urinalysis, all stored for a year for a family of four. Plans for the next version of the $5,000 marvel include communicating the measurements directly to physicians. Maybe it can do its own health check and page a network engineer to bring a plunger.

Interesting: McKesson’s only obvious operation in Ireland produces software documentation (check the title page of your Horizon manuals), but McKesson books (no pun intended) $10 billion a year through its Irish subsidiaries. The reason: it routes drug sales revenues from Canada, Israel, and Mexico through Ireland to avoid the higher corporate income tax of other countries, like the one its $35-million-a-year CEO lives in. Blame the politicians, not the company — wasn’t that one of the many populist windmills that President Obama was going to joust at?

Two radiology department employees of St. Luke’s Hospital (FL) are arrested for stealing hospital computers and selling them on Craigslist. Funny that nobody at the hospital missed them until a tipster told them.

A review of computer records leads to a $5.3 million settlement between doctors and Central DuPage Hospital (IL) over a case of untreated clotting problems that may have caused a patient’s death. The radiologist said he never saw the patient’s MRI results, but the computer showed otherwise.

E-mail me.

News 8/27/10

From Sweet Thang: “Re: Blue Shield of California. Pulling out of Emdeon on November 1. It’s been mentioned nowhere, including on Emdeon’s site, but it’s on the Blue Shield site.” Seventeen claims vendors remain, among them Allscripts Payerpath, Navicure, and RelayHealth.

From The PACS Designer: “Re: Office 2010 Web Apps. If you haven’t purchased Microsoft Office 2010 yet, you can download a free trial copy of Office 2010 Web Apps to get an idea of what’s new in Microsoft’s business software offering to all of us HIStalkers.” 

From e-R Nurse: “Re: Pittsburgh. Congrats to fellow Pittsburgher Rich Goldberg, a tireless worker. And last week, 90-minute waits for meds at the UPMC Shadyside Hospital ED when the vacuum tube system got plugged for hours. It is used to facilitate efficiency between ED and Pharmacy with the CPOE system.” Not uncommon. Tube systems are in many hospitals and serve as the lifeline from far-flung patient areas to pharmacy and lab, not just for paper orders, but for meds (at least the non-hazardous and non-fragile ones that can be tubed). I can say from experience in multiple hospitals that a CPOE or pharmacy system downtime is nothing compared to a tube system outage, which requires finding people to act as couriers to run stuff back and forth constantly. If anyone ever makes the Star Trek transporter a reality, hospitals will be an instant market. And like CPOE systems, sometimes you find a lot of missing items that got waylaid in transit from Point A to Point B (the tube system is the ultimate interface).

From Katrina: “Re: kudos. Keep up the great work. I owe a lot of other people’s perceptions of my brilliance to HIStalk. ;-).” That’s a nice comment — thanks! Inga and I don’t get to look brilliant ourselves since we’re anonymous (and might well look a lot less brilliant if we weren’t), so we’re happy when readers say they benefit from reading. Our favorite stat is from our annual reader survey earlier this year, in which 82% of readers said reading HIStalk helps them do their jobs better. We console ourselves with that when someone insults us.

From Lisolette: “Re: VA’s VistA. A good blog article.” It a book review of sorts, covering the well known Best Care Anywhere. It makes some good points (VistA doesn’t get used enough because it doesn’t generate profits like proprietary EMRs) and some questionable ones (VistA is being adopted in other countries because the VA model works so well, not mentioning that many of them grab it because it’s free). Minor quibbles aside, it’s a pretty good read, especially the nice, simple overview of how MUMPS and Cache’ work. It’s also true that the VA care model is one that would be perfect other than providers are paid for procedures instead of improving health: lifetime patient care, a data-driven approach, and having incentives to improve health and not just healthcare.

Changes to the Health Information Act in Alberta, Canada bring up a question for debate: should chiropractors, dentists, and optometrists be allowed to access the full electronic health records of patients?

I’m awaiting the official announcement before naming names, but the Yale-New Haven CIO job has been filled. Readers who sent me the rumor were correct. I’d ordinarily just blast out the name since it’s confirmed, but I’m bending my own muckraker rules since it’s a friend of HIStalk and the announcement is immediately forthcoming anyway. It’s a great job for the new person and a great hire for the hospital. More to come.

A Florida medical news site profiles Sushoo (bless you!), which claims to be the first independent HIE. It was started by a Florida entrepreneur and his physician wife as a small side project, but now has 40 employees.

Hilary Worthen, MD is promoted to CMIO of Cambridge Health Alliance (MA).

I didn’t scour the entire list of Inc. Magazine’s Top 5000 Fastest-Growing Companies, so here’s another HIStalk sponsors that made it: Culbert Healthcare Solutions, coming in at #988 in its first year of eligibility. Also: GetWellNetwork.

Keith Boone, “Standards Geek” for GE Healthcare, did some good sleuthing in noticing that the public health notification standards in Meaningful Use are incorrect. It uses standards intended for state reporting to the CDC, not for providers reporting to states. It’s also an obsolete version and describes only the message standards, not the content. Apparently his observation made its way to ONC, with John Halamka stating that ONC will issue a correction. Let’s hear it for the geeks (including both Keith and JH), the unsung heroes of HIT often deprecated among the Alpha Male sales jocks and cutthroat MBAs who climb their backs to reach the organizational pinnacle.

Inga and I pride ourselves on making all viewpoints available on HIStalk, not just ours. How that works: you are welcome to post article comments, send in a Readers Write piece, or suggest items we should cover or people we should interview. We’re always especially interested in hearing from provider-siders, who tend to be underrepresented simply because they don’t hire PR firms or have products to pitch.

Ingenix Consulting announces its Strategic Technology Solutions practice, which offers services related to IT strategy development, technology procurement, and implementation. 

Weird News Andy muses, “Does the C in C-section stand for ‘clean’?” A maternity ward in Sweden, short on help, tells a newly delivered mom being discharged to bag up her laundry and tidy up her room before leaving. Two midwives in the hospital confirm her story: “You can’t leave a mother while she’s giving birth. It’s true that we sometimes need to make use of the parents and that doesn’t feel good at all.”

BridgeHead Software releases a healthcare disaster recovery white paper.

Clay County, West Virginia pilots HealtheMountaineer, a PHR system modeled after the VA’s MyHealtheVet project and tying into the state’s open source systems (Medsphere’s OpenVista and the Resource and Patient Management System from the Indian Health Service). This is pretty impressive, especially if you’ve ever been to Clay County.

Sponsor jobs: Epic Certified Consultants, Account Manager. Jobs from Healthcare IT Jobs: Executive Director Epic Systems, Lab Systems Project Manager, Medical Information Officer Acute.

Businessweek sees competition between the deep pockets of UnitedHealth and McKesson to sell updated insurance company systems (enrollment, care management, and claims processing) and those moving to ICD-10. Here’s an interesting quote from a VC guy: “Every healthcare payer in the world needs an upgrade. You or I are talking about getting an iPad. They are still getting off mainframes.” Potential acquisitions mentioned are Click4Care and ZeOmega.

OakBend Medical Center (TX) chooses the Corepoint Integration Engine for its Paragon implementation.

I got a pop-up message in my Gmail account offering free calls for the rest of the year, which must mean that the very Skype-like Google Voice is live.

An two-year NHIN pilot project will test (warning: PDF) sharing of clinical information between the Indianapolis VA and the Indiana HIE.

Senator Max Baucus, a key player in writing the healthcare reform bill, admits that he hasn’t read all of it. He hasn’t said whether he knew about the unrelated tax change attached to it that will require businesses to send out 1099 forms to any supplier selling them more than $600 worth of goods or services.

Odd lawsuit: Marin General Hospital announces a lawsuit against Sutter Health, claiming Sutter siphoned off $120 million before turning control back over to the county this past June. Equally odd: a couple sues SeaWorld of Orlando for traumatizing their ten-year-old son by trying to resuscitate a trainer who was killed by a whale during a performance they attended.

E-mail me.

HERtalk by Inga

University HealthSystem Consortium (UHC) collaborates with Carefx to provide business intelligence dashboards and analytic tools for UHC’s Clinical Data Base (their spelling). UHC members include about 90% of the nation’s non-profit academic medical centers.

Passport Health Communications launches Payment Navigator to provide upfront financial triage when patients are admitted to hospitals.

The CNO of Covenant Hospital (TX), which is implementing Meditech, says it will advance Covenant’s “Design for Perfect Care” strategic initiative, with goals of “perfect care, sacred encounters, and healthiest communities.”

Epic takes top honors in yet another KLAS report. KLAS’s latest project looked at the EMR buying experience of 146 healthcare organizations and examined such elements as the true cost of ownership, scope, how well vendor kept promises, and getting one’s money’s worth. Epic was the only vendor with high ratings for money’s worth, contracting, and costs. Epic’s projects also had the largest scope of any vendor. Meditech fared OK, with clients saying they got what they expected in terms of contract, delivery, and post-live selling events. However, Meditech’s clients were disappointed in the company’s lack of proactive help in getting their money’s worth. GE earned lackluster ratings, with customers saying that GE has been on a downward trend since it bought IDX in terms of keeping commitments.

A new study finds that hospital EHR adoption in hospitals grew slightly from 2008 to 2009 (8.7% to 11.9%) and that only 2% of hospitals meet Meaningful Use criteria. In addition, small, public, and rural hospitals are less likely to have adopted EHRs compared to larger, private, and urban hospitals. Thirty-one hundred hospitals participated in the survey, which is more than half the country’s hospitals, and researchers claim their reporting methods were conservative. Even if these results significantly understate reality, it’s probably still safe to say that HIT adoption has a long way to go.

Cayuga Medical Center (NY) contracts with Summit Healthcare for its Summit Apex integrated product suite, which will facilitate patient data exchange between Cayuga’s Meditech system and physician office EMRs.

Quality IT Partners says it’s leading the Meaningful Use analysis efforts for one of the largest multi-facility health systems in the country.

New this week on HIStalk Practice: a pretty darn funny video that pokes fun of a clueless CEO trying to set up an ACO; highlights of an MGMA letter to CMS, including e-rx recommendations; and, news on a couple of New York practices that each earned $100,000 leveraging data from their NextGen systems. Make sure you are signed up for e-mail updates so you don’t miss the upcoming interview with ACO expert Chet Speed of AMGA. It’s a good read, especially if you are an ACO newbie.

Premier healthcare alliance says 150 hospitals and healthcare systems saved over $120 million in labor and supply costs participating in Premier’s LaborConnect program. It tracks labor productivity, performance, and costs.

The AHA spent $4.2 million lobbying the federal government during the second quarter, up 20% from the same period last year. Most of the activity centered around Medicare fraud and health care reform.

Allscripts, eClinicalWorks, e-MDs, GE, NextGen, and Sage all donate EHR systems to the University of Texas at Austin’s HIT program. I noticed that a few students in UT’s program had a chance to spend two weeks this summer working at the Gulf Coast REC. One project involved spending a day in a non-profit clinic that relied completely on paper records. By the end of the day, students had created a new database system for tracking the health of diabetic patients.

E-mail Inga.

CIO Unplugged 8/25/10

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

A Sacred Calling

“The Human contribution is the essential ingredient. It is only in giving of one’s self to others that we truly live.”

— Ethel Percy Andrus

Someone asked our chief medical information officer, Ferdinand Velasco, MD, why he would leave his skyrocketing career as a cardiac surgeon at New York-Presbyterian to become CMIO at TexasHealth. I will never forget his answer: “As a heart surgeon, I could help about 200 people per year. As CMIO, I am helping the 6.2 million people in our region.”

Whether we give direct care or support someone who does, we are fulfilling a sacred calling — touching human lives. Don’t discount information technology because it’s only computer stuff and nobody really knows where cyberspace is anyway. You could’ve practiced IT in any industry, yet you chose healthcare. Or perhaps healthcare chose you.

Sacred callings come in various forms. Although healthcare IT is nothing unique in itself, the element of sanctity is why I stay. If we want to live a life of significance, we must understand the depth of our calling and then perform as if our work matters. Grasp the privilege of serving humanity with your skills and talents. That is sacred.

In using our hands for work — answering service desk calls, pulling cables, creating order sets, managing projects, developing strategies, creating apps — we are helping care for the patients and clinicians. We’re telling them, “You are important to us and we value you.”

Stop for a moment. Re-read the above paragraph then hold your hands in front of you. While studying your hands, reflect on what they do each day that contributes to caring for the health needs in your community. Seriously. Have you not chosen to bless others through the work of your hands?

Wherever people are involved (life), challenges and frustrations exist. Healthcare is beset with issues. What can keep us focused during those difficult circumstances is remembering our purpose.

Let me share with you one recent technique we developed to maintain the heart-to-head connection.

Blessing of the Hands

It is not unusual for hospitals to conduct non-denominational “Blessing of the Hands” ceremonies. Here is video example from MetroHealth in Cleveland.

I had seen this done for clinicians at one of our hospitals and it got me thinking. What about IT? What we do is no less critical to the healing process. Our hands may not touch patients, but they do touch their lives in ways unseen. Arguably, IT is the only segment that touches the entire healthcare continuum.

I contacted our chaplains, and they were excited about the concept. For the first time this spring, we conducted a Blessing of the Hands ceremony exclusively for IT. The chaplains first shared with our team the sanctity of what we do in serving people and the impact we have on the lives of both patients and caregivers. They prayed over us. They prayed a blessing over a special vial of oil then used it to anoint our hands.

One at a time, we rose from our seats and approached the chaplains. While we held open our hands, they anointed them and gave us each a verbal blessing. I sat back down and simply soaked in the moment. I imagine many others encountered the same refreshing.

All I can say is that it was a holy moment for all who chose to participate, regardless of their religious orientation or belief system. We emerged inspired and empowered. We walked out of there knowing that we were making a difference in lives every day.

No matter what your area (supplier, payor, or provider), I highly encourage you, the leader, to make this voluntary ceremony available for your teams. You’ll witness a demonstrable impact and you’ll be reminded that what you do is significant. Your calling is sacred.

***

Here is a sample Blessing of the Hands prayer. A simple Bing search will bring up other samples.

· Blessed be these hands that have touched life.

· Blessed be these hands that have felt pain.

· Blessed be these hands that have embraced with compassion.

· Blessed be these hands that have been clinched with anger or withdrawn in fear.

· Blessed be these hands that have drawn blood and administered medicine.

· Blessed be these hands that have cleaned beds and disposed of wastes.

· Blessed be these hands that have anointed the sick and offered blessings.

· Blessed be these hands that grow stiff with age.

· Blessed be these hands that have comforted the dying and held the dead.

· Blessed be these hands that develop applications that improve quality of care.

· Blessed be these hands that answer the phone and empathize while solving issues.

· Blessed be these hands that reprogram the broken network.

· Blessed be these hands that enable life-saving technology.

· Blessed be these hands, we hold the future in these hands.

· Blessed be our hands for they are the work of Your hands, O Holy One.

Update 8/29/10

I appreciate all the comments. Thank you.

The point I do not want readers to miss is to know that what we do in healthcare IT is significant, impacting the health of our communities and nation.

You can broaden the definition of spiritual to include your overall sense of purpose and mission. For me it is birthed in my faith. For others it will take on a different look, but either way I maintain that healthcare IT is sacred work.

As long as your views are not forced on others or go against the values/culture of your employer, I see no reason not to allow for individual expression. I happen to work for a faith-based health system and enjoy the freedom this brings to everyone, regardless of religious or secular orientation.

 

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

News 8/25/10

From Teaberry: “Re: Verizon vs. Comcast. To provide the secure backbone for HIEs.” I keep hearing that Comcast will make some big healthcare moves soon, so we’ll see if that’s one of them.

From Eclipsys Observer: “Re: Allscripts and Eclipsys leaders. Under fire and intense scrutiny as the merger unfolds. The Newco has not identified a single product management leader, with John Gomez and Jon Zimmerman vying for power. Rumor is that Gomez is in the lead.” Unverified.

From DigiGuy: “Re: Roche/Ventana purchases BioImagene. You probably knew about it before it happened.” The Swiss drug maker will pay $100 million in cash to acquire the privately held California-based BioImagene, which sells a digital pathology system (slide scanner, biomarker analysis software, workflow, etc.) for tissue-based cancer diagnostics. The drug makers are struggling for some reason (prescription prices make that hard to believe) and are all over personalized medicine.

From WhatDoYa Know: “Re: Yale CIO job. [name omitted] is in line for it.” I left out the name while I wait to hear back from that person. Lack of response usually means confirmation. I’m waiting on that rumored Siemens surgery system vendor acquisition since John Glaser didn’t reply when I e-mailed.

From Toomer: “Re: Ingenix. I bet their next acquisition will be iSoft.” That wouldn’t surprise me, although I don’t know how interested they’d be in a company with minimal US presence.

From Wildcat Well: “Re: NJ’s HIE program. They held a conference call Friday for fielding questions from EMR vendors. The good Garden State showed themselves to be sometimes unyielding, under-informed, and at times down right combative with EMR vendor participants.” Unverified. I can’t decide if that’s necessarily a bad thing.

From Oregon Lab Guy: “Re: Portland weekly tabloid article about open source and HIT’s ‘gold rush.’ It suggests that we have ‘thousands’ of EHR experts roaming the streets of the Rose City – OHSU must have a big lecture hall!” The article says that Portland is the country’s open source capital even though the big companies took ideas and people from there and moved elsewhere. It bemoans the lack of follow-through with good ideas born there, mentioning that Portland’s techies have a reputation for wanting to head out at 5:00 each day (kudos to them). It’s a pretty good article, using the cynical mandatory EMR analogy that I thought I made up — requiring restaurants to use electronic order-taking and processing to improve their efficiency and reduce mistakes. Above is a July OSCON lecture on open source in HIT from Deborah Bryant of the OSU Open Source Lab.

Cumberland Consulting Group is named to Inc. magazine’s Top 5000 Fastest-Growing Private Companies for the second straight year, a nod to its 34% growth and its increase from 53 to 91 consultants in the past year.

Former Allscripts COO Ben Bulkley is named president and CEO of Fluidnet, an Amesbury, MA maker of what looks like a pretty sweet IV pump.

PerfectServe announces its Clinician iPhone application, which works with its system to allow doctors to make calls using the internal directory and manage their on-call schedules and notification preferences.

Ingenix completes its acquisition of Picis. That didn’t take long.

Industry longtimer Rich Goldberg, formerly of Misys and Confluence Medical Systems, joins TeleTracking as SVP of strategy and business development.

HITECH and MyEMRChoice.com are written up in the Philadelphia paper.

McKesson CEO John Hammergren is chairing the search committee of HP’s board that will choose a successor for ousted CEO Mark Hurd.

Dana-Farber Cancer Institute implements Informatica for data integration.

NIST’s approved testing procedures for temporary certification of EHRs are here.

Clairvia announces GA of mobile open shift alerts and scheduling for its physician scheduling system. The Durham, NC-based company, which sells resource management and scheduling systems, has executives from Atwork and Per-Se. It changed its name from AtStaff this past spring.

Northern Virginia RHIO will use GE Healthcare’s Global eHIE system to bring patient medication histories into Inova Alexandria Hospital’s Picis EDIS.

A PHI-containing and apparently encryption-free laptop is stolen from the University of Kentucky Medical Center.

E-mail me.

HERtalk by Inga

From KISS: “Re: (Company X). Is it me or do these guys have the worst elevator pitch ever?” I left out the vendor’s name, but I agree that it’s a pretty bad pitch when you can’t figure out what the company sells. It’s a shame that so many companies get caught up with using all these non-descriptive but trendy buzz words in an attempt to pitch their products. As Mr. H says, “they get too highfalutin’”. Note to marketing types: Keep It Simple Stupid for those of us who don’t want to read/hear your pitch more than once just to understand what you’re offering.

Community Hospital of the Monterey Peninsula (CA) selects RelayHealth’s HIE solution to connect and exchange clinical data with physician practices. RelayHealth, by the way, just achieved full EHNAC accreditation for its e-prescribing services.

Sage North America adds its healthcare division products to Sage’s Partner Advantage program, meaning its EHR/PM/EDI are now available through resellers.

McKesson names Eisenhower Medical Center (CA) and HealthFirst Care Systems (MN) the winners of its 2010 Distinguished Achievement Award competition for outstanding use of McKesson’s HIT products.

Intermountain Healthcare (UT) contracts with The Advisory Board Company for its OptiLink patient acuity solution.

BayCare Health System (FL) confirms news we reported over a month ago: Tim Thompson, most recently CIO at the Methodist Hospital System, is BaycCare’s new CIO.

Children’s National in Washington DC successfully implements the AuditACE compliance solution from Streamline Health Solutions.

CHRISTUS Health premiers a MEDSEEK-developed enterprise website that consolidates its 16 sites.

Mahaska County Hospital (IA) fires two employees for snooping in patient medical records for purely personal reasons. The violated patients included the ex-wife of a current boyfriend, an ex-husband, a husband, the mother of an adopted child, and a hospital volunteer. Ah…it is so tempting to ignore the law and common sense and just be nosy.

Epic moves into Heaven and the local papers have photos to prove it. The Madison and Verona papers provide updates on Epic System’s newest building (Heaven), which includes a curving, stainless steel slide that lets employees shoot from the first floor down to underground parking. With Campus 2 scheduled for completion next year, Epic is now contemplating a third campus. Judy — send me an invite because I really want to try out the slide.

Lenox Hill Radiology (NY) contracts with Professional Data Systems to manage Lenox Hill’s IT department.

The University of North Carolina Health Care System signs a contract to implement the Lawson Health Resource Management suite.

The North Texas REC selects WaveTwo, LLC as an official agent, tasked with helping physicians to implement EHRs and qualify for economic incentives.

I’m guessing that someone at Methodist Le Bonheur Healthcare (TN) has not signed the Oprah No Phone Zone pledge. The hospital says it will post updates on ER wait times every two minutes. The information can be accessed via Methodist’s Web site or by texting ERwait on a mobile phone. OK, I know they are not the only hospital offering this type service and I don’t mean to pick on them, but for some reason when I read their announcement, I envision a driver speeding down a highway while texting for wait times while looking in the rear view mirror to the back seat at a child holding his arm and screaming in agony. But really, I am sure it is a great service. So great that I see that MetroWest Medical Center (MA) is launching a similar program.

Canton-Potsdam Hospital (NY) names Jorge C. Grillo its new CIO. One of his priorities will be the implementation of a $2 million EHR system (Meditech, I believe.) He’s the former CIO of the Island of Bermuda’s Hospital System (sounds like a nice gig),

KLAS takes a look at RIS, awarding the top satisfaction rating to Epic Radiant in the 200+ bed hospital market. Avero interWorks and NovaRad tie for the number one spot in the community hospital market segment and FUJIFILM Synapse IS is the leader in the ambulatory market. The top four functionality items on providers’ wish lists include management reporting tools, flexible scheduling, rollout of mammography tools, and critical test results management functionality.

Modern Healthcare readers vote President Obama the most powerful person in healthcare. Lots of politicians and policy wonks fill out spots 2 through 100 on the magazine’s annual ranking of the 100 Most Powerful People in Healthcare. Rumor has it that Mr. H came in at #101.

E-mail Inga.

Healthcare IT from the Investor’s Chair 8/23/10

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First, let me offer my apologies to all, especially Mr. H. and Inga, for the heinous length of time between posts. It won’t happen again.

It’s been an interesting time with multiple industry-shifting M&A transactions (but not much in the way of public equity activity). The big question on everyone’s minds these days is not “Who is Salt?” but rather, “What is Ingenix?” (a) a drunken sailor? (b) a whale at the HCIT casino? (c) just too darned wealthy? (d) a genius assembling parts in a way that has yet to become clear? I would submit it’s actually (e), all of the above.

Let’s take each in turn. Ingenix, as all likely know by now, is the wholly-owned IT subsidiary of UnitedHealth Group, one of the largest publicly traded managed care companies. Mr. HIStalk himself recently posted a list of its recent buys.

The first thing that’s noteworthy to me is its dramatic movement from only managed care-focused companies — such as Symmetry, Claredi, or AIM — towards first the hospital business office (CareMedic, Executive Health Resources) and then towards the clinical side of the healthcare system (Picis and, most recently, Axolotl).

When Ingenix tried to buy managed care claims system vendor TriZetto a few years ago, it was going to make the questionable bet that its competitors would purchase their core systems from them. A stretch, but one with precedent. Now it’s betting that hospitals and physicians will not only pay real money to the Great Satan of Managed Care, but that they’ll entrust their clinical data to it as well.

(A provider-focused HIE vendor I know was recently licking their virtual chops over the prospect of selling against a managed care company. Even consumers will likely start to wonder if they want UnitedHealthcare to have the moment-by-moment deep clinical data inherent in some of the recent purchases).

Let’s talk valuation for a moment. As a buyer, Ingenix is, in many ways, ideal for a number of reasons. First, recall that by SEC regulation, public companies have to disclose any material information to their shareholders. The definition of material, however, is open to some debate.

When you’re owned by a company with a $35.5 billion market capitalization that expects to generate $5 billion of cash this year, materiality is a blessedly high bar (by way of comparison, Cerner’s total market cap is $5.7 billion). What this means is that outside shareholders can’t second guess the prices paid. It is, in effect, like a transaction between private companies.

Let’s imagine for a moment that Eclipsys was a private company. Because of their relative sizes, Allscripts still would have had to disclose the purchase price. It would also have been held, at some level, accountable to its shareholders for what it paid, imposing an additional layer of market discipline. Ingenix/United, in contrast, doesn’t view any of its acquisitions in the space as financially material, which no doubt helps loosen the purse strings.

An even better attribute in a buyer than ability to remain silent is ability to pay. At the time of its last earnings release (Q2), Ingenix’s parent United raised its guidance for cash from operations by $200-600 million (or almost as much as CPSI’s enterprise value). I’m sure Bill Gates’ kids would concur — when your parent generates that kind of money, you can pretty much buy what you want if they’ll let you! So when your business generates cash of almost $14 million per day, money is just not a problem.

Now I wonder is this a casino whale or a drunken sailor? One smart HCIT company president opined to me that this characterization was offensive to drunken sailors everywhere, but perhaps he’d just been outbid. Personally, I’m leaning towards whale. Unlike Misys in the 90s, United clearly understands healthcare and Ingenix clearly understands HCIT. Even some of the prices paid, if scuttlebutt is to be believed, aren’t totally irrational (though they are unquestionably aggressive).

Let’s consider Picis as an example. The company was widely rumored to have sold for about 3x 2009 revenue or about 12x 2010 EBITDA. By way of comparison, Eclipsys is selling to Allscripts for 2.1x trailing revenues and 10.5x forward EBITDA. Who’s getting the better deal? Eclipsys has a much broader product offering, but Picis’ products have great depth in the few areas of the hospital in which it plays. Both companies are coming off difficult years with fairly robust growth forecasts. Both have a great ARRA/Meaningful Use story to tell, which pushes their multiples upward.

Bottom line, to me, it appears to be a very aggressive, but not totally absurd price. Now, on the pricier side, Executive Health Resources was purchased for over $1 billion, and I’ve heard Axolotl went for as much as 9x trailing 12-month revenues, which seems a different story.

Finally, there’s the matter of motivation, which I expect is multi-fold. I have no doubt that there’s a grand strategy at play here that will be likely be revealed by the company once the pieces are assembled. But in addition to that, each year the operational dollars that are deployed towards these IT solutions are almost certainly to be counted towards patient care (as opposed to other business purposes). This will have the effect of making the optics of its medical loss ratio appear more attractive to government regulators. Further, I believe there will ultimately be some actual patient care improvements in many cases.

Ordinarily I’d say time will tell if the prices paid are fair, appropriate, or even reasonable; but in this case absent a total implosion, lack of materiality will likely make it difficult ever to learn. I’m aware of a few assets that Ingenix is on the hunt for. I’m sure, to their current shareholders, that the price paid will quite material indeed.

Ben Rooks is the founder of ST Advisors, LLC, a consultancy which works with HCIT companies and their sponsors typically on issues around strategy, financing and outcomes/exit planning . He earned an MBA in healthcare management from The Wharton School of the University of Pennsylvania, was a leading healthcare IT equity research analyst and then worked as an investment banker in over 25 successfully closed healthcare and medical technology transactions valued from $40 to $365 million.

Monday Morning Update 8/23/10

From The PACS Designer: “Re: Yale’s Epic cost. $250 million!” TPD, who tells me he works for Yale in some capacity, sent over a copy of the Certificate of Need response for Yale New Haven Hospital’s Epic implementation. No wonder it took them awhile to find the money.

From Anon: “Re: VA and DoD. I’m not sure Epic is the frontrunner, but I think you are close. InterSystems is the likely winner with their TrakCare product. Take a poke around and see the massive size of their new implementation workforce and the sizable country-based contracts. It’s worth noting the rumor that InterSystems is allowed to sell Trakcare in only two ways to avoid waking the sleeping Wisconsin cash cow: outside the US and to the US government.” Interesting … InterSystems is strong at integration and of course has endless expertise in Cache’ and MUMPS, not to mention that as a big and very profitable company can probably make believable promises to the military. I notice they’ve also been steadily increasing their annual lobbying expense, over $200K in 2009 and much of that going to VA database issues. InterSystems acquired the Australia-based TrakHealth in 2007, rolling the Web-based enterprise system into their integration and HIE offerings. You may be on to something. Even if not, I like your thought process.

From Soliloquist: “Re: Epic and the DoD. I just can’t see a scenario for this working. This would be the ultimate culture clash, as you state. I also am having trouble envisioning how the government could take the heat for forking over billions for such a system. It wouldn’t fly when the media got wind of the deal and Epic would be unwilling to cut a deal. They don’t need the business.” See new poll to follow.

From Book ‘em Danno: “Re: HIMSS and Forbes HIT magazine insert. A full-page ad costs $37,000. The lowest price option is a 1/6 page ad for $7,000.” Verified – BED forwarded pricing information.

From Traveler: “Re: Siemens. I heard they are buying [surgery software vendor’s name omitted]. Have you heard anything?” I e-mailed John Glaser now that he’s in charge at Siemens, but I haven’t heard back so far. I’ll leave out the vendor’s name for now since it annoys me that unscrupulous competitors immediately start flashing the rumor to prospects to create FUD, but I’ll update when/if I hear.

From CTCIO: “Re: two Connecticut academics lose data. Our attorney general is on it!” A UConn laptop containing information on 10,000 undergraduate applicants is stolen from an IT department cabinet. Then came another stolen laptop at Yale School of Medicine, that one with information on 1,000 patients. Encryption was not mentioned in either case.

From Irene: “Re: LTC. I am the VP of IS for a small non-profit that serves adults the ages of 20-60 with severe physical disabilities. Although the organization falls under the Long Term Care regulations and is almost solely Medicaid reimbursed, the consumers are not typical of a LTC skilled nursing facility (frail elderly). Average length of stay is 10 years. We are entering work for EHR readiness and I am looking for any/all vendors that implement solutions outside of the Acute Hospital space, that have flexibility in their design and integration between clinical and financials, and ability to data warehouse long term health data. Any information would be appreciated.” If you have advice for Irene, please leave a comment.

From BackToOurRoots: “Re: EncounterPro EMR. Going open source. Wondering what this means for their current customers …” I don’t get the strategy even after reading their reasons the product went open source, only a couple of which seem to be relevant.

From WNA Wannabe: “Re: paperless at the VA.” What a strange story … a VFW claims representative makes “a unilateral decision to go paperless” and shreds all the files he has without making electronic copies. Or at least that’s the claim – the story gave me headache as everybody involved in handling the paperwork of veterans seems to blame everyone else for missing documents that are shuffled from one group to another. I didn’t realize that VFW helps veterans with that kind of paperwork, either. Paperless, done right, would be an apparent improvement.

From HITGeek: “Re: NHIN. See Twitter #newNHINnames.” Some pundits make up witty NIHN replacement names. My acronyms are always sophomoric semi-profanities, so I’ll keep quiet even though mine are funnier.

It seems that we can never reach consensus on the CIO education issue, still divided equally among “it doesn’t matter", a BS, or an MS. New poll to your right: would Epic be a good replacement for the DoD’s AHLTA?

A reader sent over the paper evaluating hospital EMR usage in California, which concluded that EMR usage was associated with higher costs and lower nurse productivity. The methodology was as I expected and have seen in other studies conducted by people outside of healthcare (the authors are business school professors): take some conveniently available but questionably useful databases, match them up, and try to find generalizable conclusions. It just didn’t work for me. The analysis started with the HIMSS Analytics database (which I wouldn’t trust too far since it’s a self-reported sampling), assumed that EMR implementation started a year after contract signing since that date wasn’t known, and then matched that information with cost and nurse staffing databases. It covered nine years and ignored all other relevant events that occurred during that time (mandatory nurse staffing laws, changing reimbursement, individual hospital quality improvement projects, shift of patient load from inpatient to outpatient, etc.) Some of the conclusions make the data relationships questionable: EMRs were associated with reduced nurse overtime, sophisticated EMR usage was associated with higher costs and longer stays (ignoring the fact that certain kinds of hospitals are more likely to be sophisticated EMR users), and high-level EMR usage increased complications but decreased mortality. EMRs are categorized only by usage level, not how well they were implemented, what level of integration they have, and which vendor’s product was involved. And of course, the biggest problem: “associated with” is a long way from “caused by.” I just can’t get excited about the article, but if you can, feel free to send in your analysis.

The same primary author, by the way, used similar survey data noodling to conclude that EDs with sophisticated EMRs have a lower length of stay for eventually admitted patients by nearly 25%, but admitted another finding that seems to invalidate the entire premise: basic EMRs didn’t really help. I’m not buying that, either. I’d be more convinced by a short-term, one-hospital case study that measured LOS before and after an EDIS implementation. I’d also be highly wary of assuming that inpatient admission times reflect ED efficiency (instead of inpatient efficiency in having available beds, for example).

Cerner adds nearly 400 employees so far this year, bringing their total to 5,185. 

CEOs of the five largest health insurance companies made $200 million in 2009. Cigna’s outgoing CEO got $111 million in retirement benefits, while the not-retiring CEO of UnitedHealth Group received salary and options worth $108 million. Apparently those of us actually working in non-profit hospitals made the wrong career choice in choosing to deliver care rather than administer it, although wildly overpaid CEOs are hardly unique to healthcare.

Maybe the folks at Zacks Investment Research need to update their spell check dictionary.

Another stolen laptop containing patient information, this time from Cook County Health and Hospitals System. They vow to review encryption practices. Honestly, can’t someone come up with an encryption method that’s easy to implement and invisible to the end user? Organizations clearly understand the value of encryption but aren’t doing it, so that tells me it’s too much of a pain.

E-mail me.

News 8/20/10

From Scatman Crothers: “Re: Stanford Hospital and Clinics. Replacing Dell Perot, which has just a few months to transition and leave. Accenture is taking over the whole thing.” Unverified. Perot got that seven-year deal in 2004, so maybe Accenture won the next round.

From No Surprise Here: “Re: EMRs. A study of California hospitals shows minimal positive effects of EMRs.” I hesitate to comment because the article is not up in full text yet, but it concludes: “EMR implementation was associated with 6-10 percent higher cost per discharge in medical-surgical acute units. EMR stage 2 increased registered nurse hours per patient day by 15-26 percent and reduced licensed vocational nurse cost per hour by 2-4 percent. EMR stage 3 was associated with 3-4 percent lower rates of in-hospital mortality for conditions.” I’ll be interested to see whether the authors attempted to quantify before and after results from individual hospitals, and if so, how they handled the other variables that surely changed in the study’s nine-year timeframe. My experience with these database-driven analyses, usually conducted by publish-or-perish academics, is that they use public information that’s conveniently available but not terribly relevant, leaving logic holes you could drive a truck through. I’ll review the article once it’s out.

From Jennifer: “Re: CPOE and meaningful use. My hospital uses protocol orders for meds that are triggered by specific criteria. For example, a lady comes in with a troponin of 1.0, which orders a contraindication screening for the nurse to complete. If no contraindications exist, then aspirin and Toprol are automatically ordered. These orders go to the queue for the attending physician to sign and are driven by evidence-based practice, but aren’t considered written, verbal, or direct. How would these be defined under Meaningful Use?” I’ll say upfront that I have no idea and I doubt HHS does either, but it seems reasonable to count them as physician-entered (feel free to correct me if you know for sure). The physician has agreed to use of the protocol and is the first signer of the order, so that sounds like a CPOE order to me and it’s certainly not a paper order. I’ll also add that one of the seldom-discussed aspects of MU is that it resembles Most Wired in that you turn in your own numbers with minimal chance of being audited, so in the absence of definitive guidance, I’d count those orders. Not to mention that evidence-based order sets like this are exactly what the government should be encouraging.

From HIT Insider: “Re: Eclipsys. Another sales leader departs – Jay Colfer, SVP who managed the biggest revenue producing team in the company. Big loss.” Unverified, but not surprising if true. If you’re a sales stud, you can work anywhere without the uncertainty of an impending acquisition on prospects and your own career possibilities. I wouldn’t say it’s a negative development for either the company or the individual.

Listening: new Iron Maiden, slower and more complex than their frenetic 80s stuff, lapsing more into non-wimpy progressive (think Ritchie Blackmore’s Rainbow or Rush with some AC/DC admixed in). I never liked them much, but this is really good. It’s a long album, but I’m on my third listen and liking it better each time.  Based on this live video, I’d definitely go see them.

Weird News Andy warns ahead of time that this story might offend some sensibilities, so I shall word it carefully. A newly delivered mother in China claims that her midwife, unhappy with the insufficient tip given to her by the father, sutures shut a nearby but unrelated opening. Also from WNA: a quality analysis concludes that church-owned hospitals deliver better quality care than for-profit ones, with Catholic hospitals also outperforming community hospitals.

HIMSS is involved, for some reason, with a November advertising insert in Forbes called Transforming Healthcare Through IT. The pitch: “Produced in partnership with the Healthcare Information and Management Systems Society (HIMSS), Forbes’ special Health IT report offers participating advertisers the opportunity to share how your organization will contribute to healthcare transformation through IT.” Whatever happened to just doing it instead of preening in front of a business reader audience? I’d bet that the only companies that sign up are those that are publicly traded or those that yearn to be.

Thanks to AdvancedMD for supporting both HIStalk and HIStalk Practice at the Platinum level. The Draper, UT-based company offers a Web-based practice EHR, practice management, medical billing, scheduling, and e-prescribing. The company also offers its AdvancedBiller program, which connects billing service partners with practices. As often happens, our first contact with the company was when Inga interviewed CEO Eric Morgan a couple of weeks ago, apparently triggering the company’s interest in supporting what we do. It’s a good interview — Eric and Inga covered the pros and cons of being a privately held company, EHR market consolidation, how AdvancedBiller competes with companies like athenahealth, and the influence of hospitals on practice EHR adoption. Thanks to AdvancedMD for supporting HIStalk and its readers.

University of Chicago Medical Center partners with a technology company to produce an epilepsy monitoring system that uses Bluetooth and a smart phone to continuously stream EEG information to a monitoring center. Interesting: it won’t work in iPhones because Apple hasn’t opened up the APIs it needs. Also interesting: the company has patented a technology that uses text messages to trigger smart phone events, which I assume means that monitoring centers could “order” additional diagnostics remotely by cell phone.

Industry longtimer J. R. Hughes, most recently at McKesson, joins the nine-employee healthcare consulting firm The Winkenwerder Company, which has some impressive clients.

Patient Privacy Rights releases its Health Privacy Risk Calculator, which is really kind of pointless since just about every American will score in the High Risk red zone (it only takes three positive answers to questions such as do you have insurance, do you take prescription meds, and do you pay for any health-related products using checks or credit cards). Actually, I guess that was the point.

Holzer Consolidated Health System (OH) chooses help desk and performance monitoring services from CareTech Solutions.

I’ve joked that the VA and DoD should get rid of their expensive, contractor-managed systems and just buy Epic even though I’m not sure it could cleanly replace VistA or AHLTA. I recently mentioned the NextGov-generated nugget that the DoD is soliciting proposals for an AHLTA replacement. If that happens, there’s no way it will be any vendor except Epic, even though Cerner got its foot in the VA’s door by selling them Millennium lab (or nearly so — I’m not clear on whether a deal was ever signed). Epic’s the only company with experience with decentralized organizations of that size (Kaiser), not to mention that Epic’s nearly clean-sweeping the big hospital market. Benefits to DoD: it’s ready to implement instead of taking years of expensive AHLTA rewrites, it won’t choke like some of the bad software that the trough-lappers have written for the government, it will be a heck of a lot cheaper, and lots of clinicians will already know how to use it. Disadvantages: Epic’s “our way only” model won’t fly too well with the military brass, it will be missing quite a few key pieces that are unique to DoD, and there would be quite a culture clash between the Woodstock-like bunch from Wisconsin and the inside-the-beltway crew cuts.

Sponsor jobs: Web Developer, Regional VP, Project Manager/Web. On Healthcare IT Jobs: Sales Client Executive (New England), Health IT Sales, Director of Ancillary Systems, Senior Director, Applied Clinical Informatics.

I mentioned the Emendo CapPlan capacity planning software back in May. The New Zealand company wins a six-hospital deal in Canada and says it’s still planning to go after the US market.

Philips invests in a $250 million medical technology venture capital fund that will focus on home health, sleep improvement, image-guided therapies, and clinical decision support.

Rhode Island Congressman Jim Langevin visits fast-growing EHR vendor Amazing Charts, with the company’s presentation including such items as forced EHR adoption, overpriced EHRs, and the need for transparency of Regional Extension Centers (the company’s obviously got a bit of a ‘tude, which I like).

McKesson CEO John Hammergren was one of the HP board members who forced Mark Hurd out. Wonder if he’s a candidate to replace him?

Former TeleTracking sales VP Joseph Gentile joins another Pittsburgh company, healthcare robot vendor Aethon, in the same role.

MidSouth eHealth Alliance signs for the CareAlign HIE solution from Informatics Corporation of America (still my favorite company name).

Testing the North Carolina Healthcare Exchange: WakeMed and Moses Cone Health System.

Israel-based satellite services vendor Gilat Satellite, which wrote off its $4.5 million investment in Axolotl almost immediately after it made it 10 years ago, will get $24 million in cash from the proceeds of Axolotol’s sale to Ingenix, with the possibility of getting another $3 million per the contract terms.

I’m trying to strike at least a sham of work-life balance lately, so naturally I’ve fallen a bit behind as a result. I promise you’ll like me better if you indulge me by patiently awaiting any delayed e-mail replies.

E-mail me.

HERtalk by Inga

athenaHealth announces a standalone option for its athenaClinicals product. Clients had been required to use it with athenaCollector. Removing the billing and PM service requirement will likely help athenahealth get into more opportunities, especially those involving hospitals and their affiliated physicians. Pricing is expected to be a flat fee per provider per month, based on patient volume.

The Homeland Security Department plans to acquire an EHR to manage illegal aliens detained by immigration officials. DHS says the EHR could be a commercial, government-developed, or hosted service.

Over half a million Mississippi Medicaid beneficiaries can now use Shared Health’s HIE, whose contract with Mississippi Medicaid includes the implementation of an EHR and e-prescribing system for state Medicaid providers.

Now this could be fun. Jonathan Bush from athenahealth Girish Navani of eClinical Works square off to discuss their views on the future of HIT and how each is dealing with their larger rivals. It’s September 29th in Boston.

CMS names Ingenious Med an official 2010 PQRI Registry.

St. Edward Mercy Medical Center (AR) is scheduled to go live September 26th on Epic. The local paper shares some of the detail on training requirements for users: physicians 12-16 hours, nurses and LPNs 24 to 27 hours, CNAs 6 hours, and schedulers 4-28 hours. Physicians with the hospital’s cross-town rivals are also preparing for an EHR live. By the end of the month, Sparks Health System should have several practices operational on NextGen’s EHR.

From the latest HIStalk Practice: Good Neighbor Community Health Center (NE) selects Sage Intergy CHC; the AAFP’s Center for Health raises some concerns about Meaningful Use; and, compensation for doctors in hospital-owned groups now exceeds pay for those in other type practices.

St. Charles Health System (OR) selects Velocity Technology Solutions to host and manage its Lawson ERP and Kronos time and labor management applications.

Cumberland Consulting Group promotes Amanda Hage to principal.

Members of West Virginia’s Governor’s Office of Health Enhancement and Lifestyle Planning discuss the hurdles of adopting HIT and agree that EHR utilization is a problem. Stephen Sebert, MD, the council chair for the West Virginia Medical Association, provided this comment: “I have an electronic system already, but the thing is it’s not being used.”  Don’t you know his EHR vendor is cringing a bit.

Rebranding: the 20-year-old Medical Transcription Industry Association changes its name to Clinical Documentation Industry Association.

The interim administrator of Coshocton County Community Hospital (OH) says the hospital will begin a six-month installation of a new Meditech system in April. Financing for the $4 million project may be an issue: as of July, the hospital had a $3.5 million operating loss. The administrator says funds for the $246K software down payment are available from reserve funds and financing options for the rest of the project “will be researched” between now and April. The hospital hopes the system will eventually qualify them for $4.5 million worth of stimulus dollars. I wonder how many dozens (hundreds) of community hospitals around the country share similarly dismal financial pictures? Meditech, by the way, was chosen over two other vendors for “functionality, cost, and meeting government mandates.”

GetWellNetwork introduces a new interactive care solution designed for senior patients.

Orlando Health (FL) and Advocate Good Shepherd (IL) contract with PerfectServe for its clinical communications system. In addition, Hoag Hospital (CA) signs an agreement to expand its PerfectServe services to its new Irvine facility, scheduled to open later this year.

E-mail Inga.

HIStalk Interviews Peter Neupert, Corporate VP of Microsoft’s Health Solutions Group

Peter Neupert is corporate vice president, Health Solutions Group, of Microsoft of Redmond, WA.

 

I haven’t heard much about HealthVault lately. How would you characterize that product and the personal health record market in general?

You have to remember that the personal health record market is a function of how connected is it, right? People don’t want to enter data on their own. They want to be able to connect with their physicians, or connect with their service providers. What we have been focused on is providing the plumbing to get the connections. 

I think there’s been a lot of interesting or exciting activity in the last year, mostly at the policy level. When you look at Meaningful Use and Blue Button and all those things that are saying, “Hey, let’s all get together to get the plumbing going, and then we can really unleash the power of HealthVault,” which is to say that I can share the data, I can reuse the data, I can have applications take advantage of this connectedness in addition to what I want to do direct with my physician or care provider.

I think it’s been an idea that has been very, very helpful in framing the debate, in framing what the right answer is, making people understand that it was feasible and doable, and here’s what it would look like and how to make it work. So, I’m really glad that we’ve invested in it. In the last couple of years, we’ve been investing in the plumbing to make reality happen faster when people start to open the connections.

That didn’t seem obvious up front. There wasn’t disappointment that it’s taken this long?

I’m always disappointed when things take a long time because I think, in general, the health industry moves more slowly than other industries when adopting these kinds of consumer technologies or other things. But it, I think, has more to do with industry structure than anything else. We always understood that we had to do the plumbing in order to make HealthVault a consumer success.

As somebody who’s grown up through the operating systems business, you understand that you have to do an awful lot of work to bring together the physical device and the compute power and the video and the other kinds of things together, and then have an application on top of it to make it really compelling for an end user.

So, no, it wasn’t a big surprise, but that doesn’t mean that I’m not still disappointed that it’s taking many years of investment and talking to get to this stage where I actually think people have put in plans to have consumer portals that will connect HealthVault in a meaningful way.

What about the Medstory search engine? That was one of the first investments in healthcare and I haven’t really heard much about it. I think the site still says its beta, but I guess there are parts of it in Bing?

Yes, more than parts of it in Bing. You know, I’m delighted to be able to say that that acquisition got integrated into our core platform. It was one of the four channels.

You’ll remember when Bing launched, they launched with four domains that were built out. Health was one of them, all based on that technology that we acquired in Medstory. So, the fact that the Medstory site is still out there and live is more an artifact of the acquisition than what the technology has turned into inside the halls of Microsoft.

What about Global Care Solutions? It was bought to some fanfare, but now it’s going away. What was so attractive about a hospital information system with a very limited customer base in Asia to begin with? And then, what changed in two years to make it something that wasn’t that important any more?

I think the way to think about the Global Care acquisition is we have always had a vision around a plug-and-play capability and the ability to have this data aggregation platform — our Amalga UIS — and being able to have flexible solutions that sit on top of that and enable a class of workflows that are important to enterprises.

The domain knowledge and the solution focus of the Global Care acquisition were what was interesting to us. We, perhaps, mis-estimated the amount of work it would take to take some of those solutions and make them easily available on our UIS platform. From a timing point of view, it didn’t happen in the way we’d hoped.

We want to focus on UIS, focus on the value creation of workflows that fit the gaps. You know — care coordination, patient safety, things that are not in the same transactional workflow that might be in a patient administration system or an order entry system. We figure that is a better use of our investment dollars today.

What is the strategy for UIS?

I think people in the CEO chair, as they evaluate their IT strategic roadmap going forward, have to say, “What are the right characteristics of my plan that allow me the agility and flexibility to meet the changing conditions in the marketplace? Am I going to get bundled payments? Am I going to buy more hospitals? How do I get closer affiliation with physicians? What are the right IT strategies to accomplish that?” While at the same time, “I’m getting pressure to do CPOE,” however that’s defined.

My view, in conversations with CEOs and CIOs, is that a one-size-fits-all is not the best strategic roadmap and not the most flexible one. Amalga UIS is a cornerstone piece of middleware that allows you to get more value out of your existing departmental systems or EMR system — depending upon where you are in that implementation — and gives you the flexibility to acquire; to create new workflows that deliver value; to deal with new payment models that deliver value; to take some risk because of some of the capabilities; to be more predictive; and is an important component of your future strategic roadmap. That’s the role for Amalga.

Is it a big enough product to be worth Microsoft’s time?

Yes.

Do you see it extending in some other way with other technologies? That rumor’s out there about mobile device integration with some other vendors, some workflow pieces. Is this just a centerpiece or is it going to stand alone?

I didn’t mean to be flip, but our strategy isn’t a product-specific strategy. Our strategy is how do we deliver value through technology to help users? Those users are integrated delivery networks, academic delivery networks, life sciences companies, and others. There are many components along the stack for Microsoft that allow them to meet the mission critical and business critical needs that they have.

Amalga’s a great component of that. HealthVault’s a component. Those two things get connected. We connect to SharePoint, we connect to SQL. We’ll connect to, yes, mobile applications.

The question is what’s the right framework and component architecture that really allows you to do what people wanted to do for forever? Whether they talk about it as interoperability or they’re talking about SOA, or they talk about it in some other sort of interchange mechanism, we’re bringing it to life and bringing it to life in a way that people can get value out of it today.

We believe in the extension model that says, “Hey, you’re not going to get dead-ended in a particular vendor perspective.” Ours is — any data that you get in, you can get out. We’ll make it easy to get out. We’ll make it easy to reuse. We’ll make it easy for you to get the BI components that you need to still use the tools you use when you do BI and you don’t have to change everything.

I think it’s a very compelling strategy. Yes, it’s going to extend in all different kinds of ways both up the stack, if you will, in terms of specialized uses or applications, and in a breadth way, and perhaps even in a depth way when you look at how do you add new sensor class information or real-time streaming information or other types of data sources?

The great thing about health is there’s a huge amount of economics. Data really matters. Big data really matters when you think about where imaging and discovery is going. There’s going to be a huge amount of computation, and it needs to be delivered in a mobile way and in different scalable ways — for the individual, for the population of a doctor, for the population of a county, for the population of a country. We need to be able to scale along that dimension as well. We think we have the right infrastructure and architecture to be able to do that.

What about the Sentillion acquisition?

We’re really excited with bringing Sentillion on board — making the connection with their customers, maintaining their momentum and their customer satisfaction, and beginning to build the integration into our environment and our Amalga products to where we have 1+1=3. So we’re pretty excited about that.

What do you think about the proposed Allscripts acquisition of Eclipsys given that you have relationships with both companies and in New York Presbyterian, in which you share a customer?

We share lots of customers with Eclipsys. I’m less knowledgeable about which of all of our customers are also using Allscripts.

I think the vision of the Allscripts and Eclipsys guys is a good vision of how do we bring together, in a modern architecture, inpatient and outpatients and a lot of things they have hanging off the sides that not everybody knows? I think any time you merge different code bases, you have both the opportunity and a challenge to make that easy for customers and seamless. We hope to be part of helping them to accomplish that.

From a competitive framework, when you look at what’s happening in the US marketplace, it seems to be that’s what customers are looking more and more for — how do you bring these inpatient and outpatient environments together for better patient coordination and different workflows? It was hard for either of them to get to alone, and it’s really going to be about how do they go out and execute and make the promise at the marketing level, at the customer level, a reality at the technology level? Which is true of all acquisitions, right? That is always the hard part.

New York Presbyterian, I think you signed some agreements with them for both HealthVault and Amalga. Do you see that relationship changing once their two other products are under a single banner, or do you think you’ll be involved in whatever it takes to tie those products more tightly together?

I’m really excited about our relationship with New York Presbyterian. If you talk to Steve Corwin or Aurelia Boyer, I think they would say the same thing.

I don’t think the change in the vendor relationship will impact us one iota. They have a very complicated environment. They have some Epic, they have some Allscripts, they have a lot of Eclipsys, they have lots of GE, they have some Siemens scheduling. I mean they have a lot of stuff in there. Amalga is playing an integrative role, as is HealthVault playing an integrative role.

New York Presbyterian is one of our flagship thinkers in terms of how do they use these components that they’ve now invested in to meet their strategic goals as a business, both for their internal employees and providing better tools for them; and as a customer-facing, how do they leverage the connected care environment for their own competitive positioning?

We are working on their strategic roadmap. I’m very optimistic that we will continue to do more with New York Presbyterian in establishing better ways to leverage technology for them, and for their customers, using the foundational components of HealthVault and Amalga.

What do you think the lessons learned are from the problems that Connecting for Health is having in the UK?

How much time do we have? [laughs]

I’m kind of an engineering kind of guy. When you looked at the problem 4-5 years ago, the concept of a large, centrally planned, standards-driven paradigm for a large integration care delivery like NHS is always interesting on paper, but at the architectural level, I think they made some mistakes.

At the operational level, I think they made some challenging things in terms of how, really, was it going to work? It was just a little bit ahead of its time, if you will, in terms of what it was trying to accomplish, and probably off focus with the means by which they were trying to accomplish it.

The goals of a national patient repository — they’ve largely accomplished the goals for a large DICOM repository and making that part of the workflow better. But in other parts on the enterprise side for the hospital and the integration with the primary care trusts hasn’t really happened, so the technology challenges that they have remain. Not dissimilar to the technology challenges that we have in the United States when it comes to data interchange, patient record interchange, the ability to do really good registries — patient-centered registries as opposed to disease-specific registries.

As the combined payers and providers in this country, they’re motivated to focus on improved chronic care management, and the technology infrastructure they built for Connecting for Health didn’t really help them accomplish that goal. They’re now looking at, how do we do that?

I don’t know if you’ve stayed up to speed on the policy conversations that are coming out of the NHS, but I find it fascinating that they not only are trying to devolve the technology implementation plans, they’re trying to devolve the whole approach to how they think about planning for care and empower different stakeholders in that and have it be more decentralized — decentralized in a sense that it’s really important to them to empower the consumer, the patient.

They’re thinking about how can they create a marketplace for services where the patient consumer is a key component of the voting, if you will, with their dollars or with their actions? And, they’re devolving it to the general practitioner in terms of what are the right care endpoints at the right point in time in working with consumers?

They are thinking radically about re-architecting their delivery system. What the right technology is to help do that in a more decentralized approach is definitely in the future because that is more likely to lead to successful experimentation and adoption.

I’m pretty excited about what the NHS is trying to do. I think it’s a big shift and change. It will be interesting to see how they manage that big shift and change going forward.

It’s a pretty expensive lesson so far to realize they were on the wrong track. Are we prepared to not make the same mistakes here?

I think there are two things. One, it’s not clear how much money they’ve actually spent. I know they spent some. I know they got some value out of what they spent, and I know they froze some spending in other dimensions. But actual dollars spent, it’s not the reported number. At least that’s what I’m told by leaders over there.

I think the lessons that the United States is going to go through is really about will incentivizing EMR adoption through the construct of Medicare and Meaningful Use lead to better outcomes in and of itself, or is it just a component of a series of changes that are required to lead to better outcomes?

In my Senate testimony over a year ago, before they passed the HITECH Act, I argued — or tried to articulate — that technology’s not an end in itself. It’s a means to another end. What technology is appropriate is partly a function of what goals are you trying to accomplish? When people talk about EMRs, they imbue an EMR with all kinds of things that are sometimes true and sometimes not true in what today’s EMR systems do. Or, in how they are implemented in today’s institutions.

I think we need a more precise conversation about the role of technology: the role of reimbursement systems, the role of how we adopt technology given what goals we’re trying to go after to, perhaps, learn the right lessons.

I sit on the Institute of Medicine roundtable that’s talking about a learning healthcare delivery system. George Halvorson, at the time of the policy debate, the health reform debate, made a pretty clear and compelling statement that we ought to focus,as President Kennedy said, “We want to go to the moon,” that the right way to focus our health policy debate is say, “Hey, we want to improve the number of people with H1BC under control by 80%, or have 80% of them be under control.” That’s the single, best way to manage the cost curve.

Then you say, “What technologies do I need, and how much do I spend to make that happen?” Which is different than saying, “Hey, let’s everybody incentivize to have EMRs.” So, I think there’s a lot to be learned on focusing on the health outcomes and the system outcomes we want, and then to look at the technologies that are most appropriate to deliver those outcomes.

And also, to recognize that we have a lot of data in the source systems already, you know? Lab data’s digital. Medical data’s digital. Even in the small primary care systems they’re digital at some point of the process. Being able to capture, aggregate, and identify would allow you to get more value for your technology spent, perhaps. We’ve been pretty consistent about that and we still believe that. I think we’re not a lone voice in that perspective.

In terms of global health, if you went to another country with problems similar to ours — whether it’s infant mortality or chronic disease — probably the last thing you’d want to throw billions of dollars at is to make hospitals more efficient inside the four walls. You’d address health issues, not healthcare delivery issues. Are we throwing too much money at too little of the problem?

The private companies — hospitals, CEOs, IDNs — they’re looking at it and saying they understand that they need to go beyond the EMR and that they need to go beyond their four walls. That they see the future of payment reform, meaning they have to figure out how to get paid for not doing things. And so they’re already acting as if a change to payment systems really happens.

Now they’re not doing it with 100% of their investments, but they are all investing in that’s where the future’s going to be. I don’t exactly know what I need to do, but I need to be investing in.

When I look outside the US, I think the politics really matter. When you look at what China’s doing, they’re trying to move more of their care delivery out of the hospitals. They’ve got lots of motivation to do that because their hospitals are overwhelmed and overcrowded and they still have a high length of stay. They’ve put in a lot of infrastructure to move people out, but their hospitals are really very different than our hospitals. They are big clinics in addition to being big, acute care delivery stuff.

When I look at what’s going on in Germany, they’re really struggling to figure out what promise … what’s their social compact? What promise can they do, and how do they think about primary care versus secondary care? And again, you have the private delivery system actually innovating more — both from a financial and a technology point of view — than the public system.

I would say that NHS, as we already talked about a little bit, is also very much looking at their investment level. I think what you see people saying both with dollars and with decision makers trying to put more into a “prevention regime” than in a “make me more efficient” inside the “once I’m already sick” regime. That’s where you have these combined payment systems where they have more incentive to really focus on doing that.

But yes, I see lots of stuff all around the world where people … there’s just no really good business model for prevention. It’s a hard problem.

Form factor passes for innovation in healthcare, such as having cool iPad and iPhone apps. That’s where Microsoft seems to be at a considerable disadvantage to Apple and probably Google as well. How do you get involved in that, or do you want to be involved in a market where it’s less about what the application versus just having it untethered?

I would disagree with your premise to start with. Not to say that there isn’t adoption of lots of cool stuff, and so when an iPad comes out or an iPhone comes out, you see a lot of adoption in healthcare. My observation would be, however, healthcare gets less value out of those kinds of investments than other technologies and that it’s a lot of noise. It’s not really where people are spending the money, or the things that they’re making mission critical.

We look at innovation as really enabling transformation in reengineering. The “wow” stuff doesn’t enable that kind of transformation in reengineering. I’m happy to focus on less cool stuff from an end user point of view, but if I can deliver ten times the power and actually get data sharing to really work at one-tenth the cost with some of the stuff that we’re doing, I think I’ll win a lot of business and delight a lot of physicians when the speed is faster; delight a lot of nurses when I make their job easy because they don’t have to go look for information, it’s all in one spot; and win in the trenches as opposed to winning on the “in” gadget or popularity group. I think that takes a deep understanding of what problems you’re trying to solve, what jobs are really important, and how the flow and diversity and heterogeneity of data meet in order to be able to do that.

I think Microsoft is way better situated than either Apple or Google to solve the hard problems. I think if you look at our investments in HealthVault and understanding the ecosystem, and building a set of applications, and keeping pace with the changing conversation around privacy and security and app sharing and all that other kind of stuff, that we have demonstrated the level of understanding and our willingness to continue to make incremental investments to make it a reality. So, I’m happy to compete with popularity, a brand, versus reality of technology all day long. We’ll win in the long run. We may not win in the short run.

What technologies do you see that are innovative and potentially influential that have not yet really taken hold in the market?

I don’t claim to be an expert. You know, there are all kinds of really cool stuff going on. I think if I’m a CIO today or a CEO today, I think the one thing I might be asking myself as I look at a five-year time horizon is, “How do I think about cloud computing? How do I think about really changing the cost environment and the serviceability environment of my application stack at a time when budgets are getting pressured?”

And yet, I’m going to have more data. I’m going to have more applications. I’m going to have more users. I’m going to have more everything, but I’ve got to do it with less dollars. What is the strategy that will allow me, as an enterprise, to really make that a reality and still give me the flexibility to meet my changing business needs? If I want to really cuddle up with a payer or take, at risk, a large percentage of the population and I need information systems to manage that, how do I fit that into my declining footprint? Do I get some leverage out of being able to do predictive analytics in the cloud? Or, how do I think about being able to contribute to solving cancer with a large population and connecting and sharing that kind of stuff in the cloud?

Those would be the kinds of innovations that I would want to have on my horizon before I go sink a bunch more money in physical hardware or a data center or some other thing that may have a short shelf life. And, it certainly doesn’t help my P&L.

I see lots of really interesting stuff going on there. I’m not sure that its stuff that the CMO gets that excited about, but one that probably folks should be thinking about.

Any concluding thoughts?

You know, I think we’ve had a great conversation. We’re excited to be part of the health IT community. We think we, as a player that has both the consumer and enterprise offering — and perhaps a slightly different approach at trying to solve the problem — to help remind people to think beyond the EMR. We’re really excited to be part of the community and look forward to making our customers and our lives better by the smart application of technology to the hard problems in health.

News 8/18/10

From The PACS Designer: “Re: Box.net. With the Google Wave application headed to Google’s archives, another collaboration tool called Box.net may offer an alternative for developers. The path to Meaningful Use is being studied by many, and the Box.net collaboration tool can work with Google Apps to satisfy the need to work together to improve healthcare processes.”

From Jim: “Re: Ed Marx. Although I read HIStalk regularly, I haven’t paid enough attention to him. The recent mention of his strategic plan got me to go back a read many of his postings. I don’t know how I’ve missed him, but what a find. He is one of the more refreshing and inspirational voices in HIT. Very belated congratulations on spotting his talent and sharing it with us. Thanks.” I’ll accept those compliments on behalf of Ed and add my own since I agree completely. I should mention, though, that you didn’t actually miss Ed’s earlier postings here — he’s been posting only for a few months. He had been writing for one of the rags and decided to make a change, part of which involved my back-loading all of his earlier posts to HIStalk. I think he’s found a wider and apparently more appreciative audience. Inga gets some credit, too, since she was his main contact (everybody likes Inga, of course).

From Defiant: “Re: Tiger Institute for Health Innovation at the University of Missouri. Next month will be its anniversary. Would you be interested in interviewing leadership there about the progress made to date and what their vision is all about?” Sure.

Thomas Jefferson University Hospitals contracts with 3M for document management and abstracting solutions.

Sacramento Maternal-Fetal Medicine (CA) chooses the SRS hybrid EMR.

We reported a reader’s rumor awhile back that suggested the Department of Defense might be thinking about mothballing its multi-billion dollar AHLTA EMR system. That may be correct, according to some sleuthing by NextGov, which found this solicitation buried in TRICARE procurement documents. It suggests that the military is considering commercial alternatives. The scope (warning: .DOCX) includes inpatient, outpatient, intensive care, ED, expeditionary, and ambulatory surgery, with “integrated support” of lab, pharmacy, radiology, and PACS. The EHR piece must cover telehealth, referral tracking, decision support, identity management, secure messaging, NHIN integration, cost accounting, personal health records, and a patient portal.

Thanks to the readers who tipped me off early about the Ingenix acquisition of Axolotl. Actually, Ingenix itself was prompt in sending over the announcement. Much appreciated. I think many people had failed to notice the company’s impressive string of acquisitions until I listed some of them yesterday.

Pittsburgh paramedics are upset with the county’s $10 million dispatching system upgrade, which they say is incorrectly prioritizing calls.

QuadraMed will offer clinical practice guidelines from CPMRC to its QCPR customers.

HIMSS, WEDI, EHNAC, and NACHA (that’s a bunch of acronyms, but they’re spelled out in the press release) release a white paper covering HITECH and HIPAA compliance for financial institutions.

Australia’s prime minister funds $225 million for telehealth sessions, plus more money for provider hardware and a videoconferencing-based triage service.

An Australian doctor accused of defrauding Medicare in 90% of her hormone testing patients says the government is wrong in saying she maintained incomplete medical records that did not include complaints, procedures, and histories. She says she’s just one of the 90% of doctors with bad handwriting, but has since computerized and “now I write a big story and I don’t abbreviate anything.”

An odd medication error: a mother who had just delivered triplets by C-section is ordered morphine. She was holding one of the babies when the nurse pushed the morphine into the baby’s IV line instead of hers. The baby’s fine, but the mom is suing anyway. The hospital has since created a policy that prohibits giving meds to moms in the NICU.

E-mail me.

HERtalk by Inga

Former Siemens Healthcare CEO Jim Reid-Anderson  is the new president and CEO of Six Flags Entertainment. I’m sorry, but that statement is just a bad joke waiting to happen (chime in, if you are so inclined.)

Moses Cone Health Systems (NC) and WakeMed Health & Hospitals (NC) are working with their state’s hospital and medical associations, as well as Thomas Reuters and CareEvolution to develop and launch the North Carolina HIE. The HIE will initially connect seven hospitals, three EDs, and 57 physician practices.

Over 40 health systems join Premier healthcare alliance’s ACO Readiness Collaborative and work together on building the critical components of accountable care organizations. Those 40 health systems represent a lot of hospitals and doctors who are betting ACOs are going to have a big impact.

If ACOs aren’t enough to give you a bit of anxiety, perhaps consider the pending v5010 deadline. Robyn O’Connell  of Hayes Management Consulting shares information and advice for migrating to v5010 here.

The Methodist Hospitals (IN) intend to fully implement Epic’s EMR within the next 30 days.

The local business journal chronicles the leadership of API Healthcare CEO J.P. Fingado, who left Cerner two years ago to head up API. Francisco Partners bought API  shortly after his arrival. Since 2008, the 28-year old company has gone from serving 600 hospitals to 700, increased sales from $40 to $50 million, and grown its employee base from 250 to 330. Sounds like Fingado is doing something right.

Here’s a recap of some good stuff from HIStalk Practice, just in case you missed it:

• An interview with AdvancedMD Inc. CEO Eric Morgan, who shares some insights on industry consolidation, on the advantages of being a private versus a public company, and on some of his company’s recent successes.
• Dr. Joel Diamond rants a bit about statistics. Try not to grin.
• If you need some inspiration, read about the work of Kenyan pediatrician Dr. Sidney Nesbitt, who Dr. Gregg Alexander calls an “amazing pioneer.”
• I rally for the co-founder of DoseSpot, who may have been an entrepreneur longer than he’s been shaving.

MidSouth eHealth Alliance (TN) signs a multi-year contract with ICA to provide its CareAlign HIE solution.

Orlando Health partners with Isabel Healthcare to implement its diagnosis decision support checklist tool.

Patient Access Solutions intends to integrate the iMedicor portal into its offerings, plus provide users access to iMedicor’s ClearLobby platform.

Persuading influential medical centers to adopt EMRs helps speed adoption by neighboring hospitals. That’s the conclusion of a study published in Management Science, which looked at what mechanisms influence the rapid spread of technology in hospitals. Apparently hospitals seem to follow a “social contagion” model. Note the parallel with fashion: celebrities first, then the rest of us. Draw your own conclusions.

Governor Schwarzenegger and a bunch of dignitaries launch the $30 million California Telehealth Network initiative, which aims to connect over 800 healthcare facilities to a statewide medical-grade network of healthcare and emergency services.

Odd: the police are called to a Burger King, tasked with removing a woman taking blood and urine samples in the bathroom. The woman claimed to be an RN working for a mobile medical exam company and collecting samples for insurance screenings. At least she wasn’t working the drive-through.

Chinese hospitals are apparently not the safest placed to work. During the month a June, a doctor was stabbed to death by the son of a patient who died, three doctors were severely burned when a patient set fire to the hospital office, and a pediatrician was injured after he jumped out a fifth floor window to escape the angry relatives of a newborn that died under his care. Such violence is apparently standard fare for Chinese physicians. Now if I were a Chinese doctor, I might be asking Steven Slater some advice on how to resign.

E-mail Inga.

Readers Write 8/17/10

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!

How Would You Define a Secure Database?
By Robert J. Rogers, MD

While driving to work in late June, my phone rang. I saw it was my office manager calling. For those of us who own our practices, an early morning call from the office manager is rarely good news.

“Dr. Rogers, someone broke into the office last night and stole the computers!”

Thus my partners and I began our saga of learning the ins and outs of dealing with a potential breach of protected data. We are the “Texas allergy clinic” referenced by Mr. H in the Monday Morning Update of 8/9/10.

(Let me briefly mention now that our database was purely for our practice management system. We do not use an EMR yet. More on that later).

Selfishly, my first thought was, “I hope our backup is good”. A few years ago, we experienced a server crash and learned that our backup was corrupted, requiring a manual rebuild of our database. Fortunately, we learned the backup was fine when the new computers were installed. I naively thought our biggest challenge was behind us.

We decided to check with the Texas Medical Association regarding our reporting responsibilities. We were directed to the AMA’s summary of the HIPAA Data Breach Notification Rule, which was enacted in September of last year. It was at this point that we learned the very important distinction between password protection and encryption.

As I suspect is true in most offices, we were under the impression that our database was secure since we needed a username / password combination to gain access to it. We use a well-known practice management system supported by a local reseller. Password protection was the only security measure discussed.

However, we learned that the database was considered vulnerable if it was not encrypted, thus triggering our reporting responsibilities (first class letter to each affected party, and notification of local media if more than 500 individuals are affected). I will leave it to your imagination to consider the logistics of sending letters to 25,000 patients.

This was a nightmare until we learned that commercial printers and mailing services can handle everything — stuffing, addressing, stamping, and mailing (for a fee, of course). [Mr. H — I didn’t actually complain about the cost of this process. I just responded to the reporter’s question regarding the cost of the mailing.]

Being victims of this crime has triggered a number of questions that I hope some of you may be able to answer. Now that I have learned the importance of encryption, I wonder why encryption is not automatically provided by all vendors? Is it complicated and/or expensive?

In an informal survey of my physician friends, none of them understood the importance of encryption. None had asked their vendors about encryption. Many of these doctors host their own servers.

Our potential data breach was important mainly due to the potential for identity theft since we don’t use an EMR (fortunately, in this case). That’s bad enough, but I worry even more about the thousands of physicians who use EMRs and may not use data encryption, thus making sensitive medical information potentially accessible.

As a patient, should you ask your doctor about the security measures in place?

The Data Breach Rule requires notification of the local media if more than 500 patients are affected. I wonder about the wisdom of that requirement. Might the thief be unaware of importance of the stolen server until learning about it from media reports?

Because of our experience, we elected to change to an ASP model for our software, using an off-site server accessed through an encrypted virtual private network. We think this is an adequate level of security, but we thought our previous system was secure, too. Is our database now secure?

As we rush to encourage all physicians to use EMRs, how can we make sure that all involved understand these important security issues?

Robert J. Rogers, MD is a physician with Fort Worth Allergy and Asthma Associates of Fort Worth, TX.

The Business Associate “Relationship”
By Stephanie Crabb

We are working with many customers who are looking to implement Data Loss Prevention as part of their information security and compliance programs. The best-practice deployment of these solutions requires collaboration with the HIS application vendors that contribute to the ePHI data life cycle such that the DLP solutions can efficiently and effectively content fingerprint targeted data “at the source” in the applications themselves. To some, this might fall under the rubric of “integration” as we have come to define it in healthcare, a common practice.

One small client of ours, a hospital of just 20 beds with an unwavering commitment to patient privacy and data security, approached its core HIS vendor, Meditech, with a formal request to connect directly with the database (aka “dictionaries” in Meditech-speak) to accomplish the implementation of its DLP solution. The data set was minimal — six fields of basic, and I mean basic, data to start. 

This request, surprisingly to us, was met with a firm “no” from Meditech. Why? They consider this “customization.”

Respecting Meditech’s longstanding position in this area, I personally worked with our customer to develop the business case to present to Meditech as to why they needed Meditech’s re-consideration. We cited areas around breach notification, uses and disclosures, and the like to inspire cooperation from Meditech and to put into clear context that DLP was a technology being adopted specifically to demonstrate compliance with HITECH and MU.  

The Meditech account representative acknowledged that they would need to do better in the future, but until they had a “critical mass of requests” from their clients to work with another vendor (like the client’s selected DLP vendor), their answer was still no. Understanding that our client’s Meditech account rep only has so much authority, my CEO and the client CEO requested a personal meeting with Howard Messing, only to be told that Mr. Messing could not accommodate their request. 

This is about a simple permission that the vendor could absolutely grant and requires little to no effort on its part whatsoever. It is a permission that other HIS vendors have eagerly provided. Oh, the vendor did offer to sell our client a module that would make this “easier” to the tune of $40K, even though what the client needs to access is already present in their its implementation.

DLP is not the only emerging technology that holds tremendous promise for organizations looking to reduce their data loss / data breach risk, enhance the controls around their data and its uses, and protect patient privacy. Unfortunately, covered entities cannot accomplish the implementation of these technologies alone. They need the business associate to collaborate, facilitate, and, sometimes, participate. And let’s face it, the rise of technologies like DLP that offer compensatory controls for privacy and security has resulted, in part, because the HIS vendors have been slow to respond with their own system capabilities.

I really do not mean to single out Meditech here. There are certainly other vendors who subscribe to similar operational models. This is, however, precisely the client service mindset that needs to change and that HITECH is requiring, particularly when technology is not the barrier. If these implementations are technically possible and largely resource-neutral to the vendor "business associate," why delay or deny their clients the opportunity to close the privacy and security gaps that are requisite to achieving meaningful use?

While the content of the NPRM may set about a chain of events whereby business associates become even more conservative in their commitments to privacy and security collaboration with their covered entity partners, there really is no where to hide, regardless of how ambiguous HIPAA and HITECH may be written. If you are in this space and in the business of touching ePHI in any way, you have to be “all in” — technically, operationally, and in the way you serve your clients and the industry at large.

It is simply not acceptable to relegate privacy and security considerations to the back burner, or worse yet, leave leave your client holding the bag. OCR recently clarified that “willful neglect” includes failure to take action when one recognizes a risk. Business associates who fail to respond when requested by covered entities to address a perceived risk could find themselves in an uncomfortable and costly position if a breach occurs and it could have been avoided.

Stephanie Crabb is VP of client services with CynergisTek of Austin, TX.

Why Are Lab Orders from Ambulatory EHRs So Hard?
By Ken Willett

While hospitals with integrated inpatient EHR systems are claiming high adoption rates for CPOE (in some cases 100%), most providers in ambulatory settings are still creating lab orders outside their EHR. What makes it so much harder?

An integrated HIS system, which includes lab and radiology ordering, can present the provider with the correct choices for that hospital’s services. In the ambulatory world, the EHR is much more limited (being less expensive), yet the variety of external service providers is larger. There are generally multiple labs, with ordering rules governed by insurance contracts, and each has its own test catalog, data requirements for the order, HL7 dialect, and requisition formatting requirements.

The provider wants to quickly capture what tests to order and why. Their manual process is to make a few strokes on a preprinted superbill or order slip. It’s very hard for an automated system to compete with that. Ordering facilities in the EHR are often cumbersome, while at the same time too generic to capture the specifics needed by the lab or radiology provider.

The lab, on the other hand, needs an order which is complete, with billing information, the lab’s order codes, appropriate Ask at Order Entry (AOE) questions answered, and the correct requisition and specimen labels printed. To try to assure that orders coming to the lab are accurate and complete, the lab will generally provide an order entry application and workstation to the practice, for use by a phlebotomist or other staff person.

Having a lab-specific ordering application addresses the problem of making sure the order reflects the most current compendium data of that lab (test codes, AOE questions, specimen requirements, and medical necessity rules), at the expense of having a separate ordering application for each lab (and in many cases, due to Stark laws, separate workstations, printers, etc.). Re-entry of order data, together with the need to use multiple ordering applications, significantly increases the likelihood of error.

Improving lab ordering within the ambulatory EHR is difficult because ordering rules need to be configured for each lab and compendium data needs to be constantly updated. This is a significant burden for each practice to
undertake.

Given that we are now in an environment with much more seamless connectivity between applications (with web services and other technologies), I believe a better solution is to move the ambulatory ordering function out of the EHR itself and instead provide orders via a connected SaaS application. This can allow compendium data management to be done in one place for multiple practices and multiple labs while still giving the provider and phlebotomist direct access to a universal ordering interface.

Only some EHRs have the necessary integration capabilities to allow this sort of user interface extension. Still, this seems like a promising direction to improve provider adoption of electronic orders.

Ken Willett is president and CEO/CTO of Ignis Systems of Portland, OR.

Ingenix Announces Axolotl Acquisition

 
Ingenix announced after the market close today that it will acquire health information exchange technology vendor Axolotl of San Jose, CA. Terms were not disclosed.

”HIEs are bringing us closer to the point where all the health care professionals patients select to oversee their care can connect to share information and optimize outcomes," said Andy Slavitt, chief executive officer of Ingenix. "We will work with Axolotl to continue to meet the needs of multiple HIE stakeholders and to expand its technologies that serve health care communities."

We reported on July 23 that Axolotl was seeking a buyer that would be named soon, although the early rumors suggesting RelayHealth as that buyer were incorrect. We reported the Ingenix rumor earlier this afternoon.

Ingenix, a subsidiary of the Fortune 100 UnitedHealth Group, has acquired several healthcare IT companies this year: QualityMetric (outcomes measurement), Executive Health Resources (compliance), and Picis (high acuity systems). Other recent healthcare IT acquisitions by Ingenix include AIM Healthcare Services (payment solutions), Healthia Consulting, Lewin Group (consulting), CareMedic (revenue cycle), Global Works Systems (software), Integris (IT management), Claredi (e-commerce), HealthWatch (payment systems), Innovus Research (pharma software), Advana (claims management), Distance Learning Network (continuing education), and Symmetry Health Data Systems (analytics).