News 8/6/10

From Astonished: “Re: University Medical Center of Southern Nevada in Las Vegas. They have selected McKesson over Epic as VOC.” Oh, my. They should print up a lot of signs now that say, “Remember, this one was cheaper.”

From Patty: “Re: your logo’s head. I spy your cartoon likeness at the MBA HealthGroup booth at ACE. Your head is smaller than I imagined it would be.” I checked it out during the opening reception and you are right — they apparently lifted my logo’s image, which cost me a pretty penny to have custom drawn. They need to do something clever to placate me, so I’ll go by their booth again Friday to see if they’re creative enough to have come up with something. Stop by and ask them. I take enough heat from literalists who don’t get the intended irony of the pipe-smoking doc.

From RumorReporter: “Re: Eclipsys and Allscripts. Word on the street is that once the merger is completed, all finance functions will be relocated to India. So who is coming out on top here?” Unverified. It’s probably not a big deal (if it’s true) as long as it’s the grunt stuff that makes up a lot of what finance does.

From You’ll Know Who: “Re: Sunny Sanyal. The former McKesson Provider Technologies president now the CEO of T-System.” Unverified.

From PrettyKitty: “Re: Epic Beaker LIS. After a four-year project rolling out Epic to 10 of their hospitals and replacing existing systems in an effort to standardize, Sisters of Mercy Health System is developing Epic’s Beaker lab application for their next two hospitals to be implemented in the second quarter of 2011. They had been retaining and integrating the previous lab systems — Cerner and Meditech — but have been told that Beaker is ready. They are in the selection process for a Blood Bank system since Epic will not offer that.”

From Dino: “Re: Kaiser. They say they have 99.96% availability. At least now we know that $5 billion doesn’t even get you five nines of uptime. They have come a long way from aiming for 99.7%, though! Remember that Oakland forced Pleasanton to come up with a ‘revised systems availability formula’ a few years ago — a formula that would have made Arthur Andersen blush. It basically only counts the power being off in the data center as downtime. Still, if you’ve got $5 billion and some change, you can get a nice, fully (and somewhat frequently) functioning EMR than can help improve and save lives. We just need to get the cost down and the reliability up, and then we’re good to go.”

From Allscripts Client Experience 2010

I’m in Las Vegas, checking out ACE 2010 as an attendee. Full disclosure: Allscripts invited me and comped the registration and hotel, but I’m paying otherwise. I’m still anonymous to them and I told them I was going to report what I saw and heard objectively. I don’t usually go to user meetings, but I knew the timing would be perfect to hear what people think about Meaningful Use and PM/EMR systems.

Note: the questions I asked were opened ended, such as, “What products do you have and how do you like them?”, so I was not asking leading questions that were positive or negative. Still, I can’t say for sure that the comments I got were representative of the Allscripts customer base. And keep in mind that I have no hands-on experience with any Allscripts product, so I’m just a wide-eyed noob at this conference.

They say 3,500 people are attending, which I believe since at least 3,000 of them were in the Starbucks line at 7 a.m. due to logistical challenges that I don’t need to explain since we attendees heard the gracious Allscripts apologies all day, from Glen Tullman on down. But no kidding, that was the longest line of people I’ve ever seen, at least 2-3 hours’ worth snaking back hundreds of yards (you people are seriously hooked on caffeine), and the buffet lines weren’t much shorter. It didn’t bother me since they had fruit and drinks in the meeting area anyway, so I was just as happy with a protein bar and a Diet Pepsi.

Some observational bits:

• Half the attendees were first-timers, the registration person told me.
• The lunch buffet was the best I’ve ever had at a conference. In fact, the overall meeting logistics were outstanding, from the handouts to the music to the friendly Allscripts people always willing to guide folks to their meeting room or connect them with an Allscripts contact.
• On the other hand, I don’t want to see another orange shirt for a year or two.
• A couple of users told me their Patient Portal (which I was told is the former Medfusion, but I don’t know that for sure) attempted implementations were disappointingly unsuccessful. They liked the promise of the portal, but said it was not ready for prime time. That’s a problem since it’s basically required to meet MU requirements. It’s obviously a key part of the Allscripts strategy (and an expensive recent acquisition for Intuit), so getting those problems fixed is key. There were demoing some pretty cool online payment functions.
• Related to that, several users said their main gripe with Allscripts was releasing and pitching products that aren’t ready (not uncommon for vendors in general).
• One user said the QA of Allscripts is much better than before.
• I saw a couple of iPads in use.
• Glen is an excellent speaker. Most of those I heard were good, except one who inserted the dreaded conversational crutch “sort of” every 2-3 sentences. Nuance was in the Hub and I wanted to ask them to use their speech recognition capabilities to set off a siren each time she did that, which should provide operant conditioning to help her stop. This is a near-epidemic – when I edit my interview transcriptions, I have to exterminate dozens of “sort ofs” in probably half of them.
• The biggest news to me was the announcement of the Allscripts Referral Network, a service that lets users of Allscripts products communicate with each other. People seemed to be pretty happy about that announcement, including a practice manager and a consultant I talked to. Glen said they’ll open it up to users of other vendors’ EMR products by the end of the year.
• Odd products that had surprisingly fanatically supportive users that I talked to: Homecare and Tiger.
• I wanted to look at Payerpath, but I forgot to stop by. Maybe tomorrow.
• A couple of people said they felt the meeting felt more like a heavily orchestrated cheerleading session and sales opportunity than something geared for their benefit. Hopefully they’ll get more out of it in the remaining sessions. I saw some very meaty sessions on the agenda, especially in the more specific technical and product tracks, so I’m pretty sure there are nuggets to be mined through careful session choices.
• I went to the Professional roadmap meeting. A show of hands made it clear that even though MU awareness is nearly universal, very few attendees are really ready for Meaningful Use. Based on the graph shown of client release levels, a great percentage of Professsional’s 2,000 sites will need some serious upgrading. Most are on Version 8.3 and down.
• I saw one person wearing a badge that said “No Hybrid EMR”.
• I got no indication that MyWay is on the outs. They showed its MU deliverables and I spoke to several users who love that product, including some surprisingly large ones (one Enterprise EHR customer said semi-seriously that they were considering replacing it with MyWay). I think it’s a keeper for the company.
• I asked one somewhat unhappy Enterprise user what they would be using otherwise. They hated Epic and said the product to beat was Greenway. Another liked Sage Intergy, saying it was truly integrated between PM/EHR instead of the “two screens” method of visual integration.
• I talked to a handful of Enterprise users. That group seems to be the least happy with Allscripts, with gripes that include unresponsive support, lack of proactive contact from reps, the cost of buying the Stimulus Pack vs. Analytics (Allscripts was a bit evasive on pricing, turfing users off to their reps, but promised to make it right for customers who have purchased previous products), database bloat caused by the technical method of updating physician notes, and some obvious residual bad feelings from the premature TouchWorks Version 11 upgrades that caused significant practice disruptions. It’s always hard to keep the bigger customers happy, I guess, but Allscripts needs to do some work to delight that constituency again from what I heard.
• I got the sense that all of the Allscripts growth has strained communication capabilities (reps not calling back, no direct access to support people, etc.), which may explain some of the new customer tools that Glen introduced.
• One person bragged on how great their remotely performed upgrades are, with everything done overnight or over a weekend by Allscripts.
• Glen showed an “upgrade wizard” thingie called the Upgrade Enablement Center that was explained further in the Enterprise MU session. It was created for migrating Misys users to Professional, with parts of it used by the customer and parts by Allscripts, but they said there’s work remaining for it to be finished. They said they had cut migration downtime from 4-6 days to 4-6 hours with the tool. One user said they had experience with it and thought it was great.
• One Enterprise customer said they have no worries about meeting MU requirements since their doctors happily enter their own orders.
• Glen also announced a new Web service that allows customers to one-stop-shop a lot of Allscripts services and communicate with each other.
• Allscripts announced a new Web-based project management tool, where a client chooses their desired date for a the Stimulus Set upgrade and the application backs them into a schedule that Allscripts can work from.
• Eclipsys was barely mentioned, probably since it’s not a completed transaction yet.

As someone with no skin in the game but a lot of conference experience, ACE is fun and well run. The company has obviously grown hugely and has a pretty big vision, although with a few inevitable rough spots in execution that are probably inconsequential in the big picture. I’d like to hear from my fellow attendees who are real customers, though, so please leave a comment if you’re at ACE. You know how conferences are – you can ask a bunch of people and all will report different conclusions.

News 8/4/10

From HIStalk Junkie: “Re: Alert Medical. The company has hired and fired several chronically underfunded US ‘consultants’ / salespeople, preferring to pay straight commission. Some have said they won’t pay for even basic tools for understanding the US market. I have run into them in several countries. They hired a very smart fellow who was at HIMSS looking for a US partner to ‘invest’ in the chance to represent ALERT. Sounds to me like they want to sell their US marketing rights. They have no revenue cycle product, but a very pretty clinical product” Unverified, although I do remember that someone told me that before.

From J.G. Giant: “Re: odd but true. In keeping with the season, I thought you would appreciate this. Keep up the excellent work!!!” I wonder if these providers use EMRs?

From Hitchens: “Re: Meditech. I work for a Meditech partner and I hear they are looking at offering Allscripts for certain interfaces. Also, this may be Step 1 in a buyout of Meditech by Allscripts, as Meditech’s founders have been looking for a few years to exit and the $$ now is so high.” Unverified. Seems unlikely, but it’s a crazy industry right now.

From LISales: “Re: Epic Beaker LIS. Word on the street is that they have one SMALL site using the system within the Wisconsin area, but nothing major yet. I’ve also heard that they are beefing up the development team while including the licensing right to the module within ALL of their enterprise licensing agreements. Also heard is that the functionality is being somewhat oversold compared to actual capability with no desire to develop certain aspects of a full-scale laboratory’s needs, Blood Bank to name but one.” Unverified.

From UKnowMe: “Re: business associates. What training are consulting firms using to ensure their employees take appropriate measures with regard to PHI?”

From Kermit: “Re: NHS. Britain is proposing a shake-up. Here’s one article.” The new government changes its mind about its pre-election promise to leave healthcare alone, planning a reorganization of NHS. The goals are to move central control back to doctors, cut out administrative layers, and give patients more say-so. Here’s an interesting (condescending) quote from a research group about giving doctors control of the equivalent of a $3.4 million annual budget each to pay other providers:

It’s like getting your waiter to manage a restaurant. The government is saying that GPs know what the patient wants, just the way a waiter knows what you want to eat. But a waiter isn’t necessarily any good at ordering stock, managing the premises, talking to the chef — why would they be? They’re waiters.

From The PACS Designer: “Re: OneNote on WP7. As we learn more about Windows Phone 7 (WP7), it appears Microsoft will be pushing the use of MS Office OneNote for mobile users with its scheduling, meeting notes, and To Do List features, among others in the application.”

From Cassie: “Re: Mercer does it again! Apparently Mercer lost another piece of IT equipment in the great state of Idaho, this time for St. Al’s hospital ,therefore losing numerous employee data. Supposedly it’s been missing for months (and is still missing) and Mercer is just now telling St. Al’s staff.” Verified. Mercer lost a backup tape in March containing information on 1,000 employees of St. Alphonsus.

Watching (instead of Listening this time): Better Off Ted, a just-cancelled, brainy comedy from my streaming Netflix recommendations (rightly so — I love it). What’s not to like about a soulless, thoroughly evil and Dilbert-esque conglomerate (its motto: Money before People, and check out the amazing phony commercials) and the ever-luscious Portia de Rossi? It rounds out my personal TV triumvirate that includes Arrested Development (there’s Portia again) and 30 Rock. All are on Netflix, so I can watch whenever I have time (which is rarely).

Surescripts will announce tomorrow that Microsoft HealthVault users will be able to download their pharmacy prescription history into their PHR.

mHealth Summit books Bill Gates as a keynote speaker. I’m thinking about attending since I need to get out from behind a desk more often.

RIM announces the BlackBerry Torch 9800 and BlackBerry 6 OS, offering a slide-out keyboard, a touch screen, and a 5-megapixel camera. I think it’s safe to say that iPhone and Droid users won’t be interested, but it might keep some non-corporate BlackBerry users in the fold for awhile longer and placate the business user suffering from iPhone envy. The Torch will cost $200 with a two-year AT&T contract.

Weird News Andy packages this story with a pun: “He asked the nurse if he could use her needle and thread and thought she said ‘suture self’.” A man with a leg cut waits an hour to be seen in an ED in Sweden. He becomes impatient, notices the “needle and thread” in the room, and sews the cut up himself. Unappreciative hospital employees reported him for using hospital equipment without authorization.

Thanks to Neil Versel at FierceHealthIT for saying nice things about Inga and me in mentioning our little link exchange project. I like that he envies “the Cult of Mr. HIStalk,” which I’m pretty sure is apocryphal, but it still makes a good fantasy for my next dull hospital meeting. He does seem to harbor some doubt that I work in a hospital, but I assuredly do, full-time and mostly happily. My self-selected theme song is Rush’s Working Man.

A hospital in Australia says its upgraded Philips Intellivue Clinical Information Portfolio has reduced ICU costs by 20-25%. If provides clinical decision support, a patient summary, clinical guidelines called “care bundles”, order management, ICU scores, digital picture documentation, analysis and reporting, and wireless access.

Keane Optimum 3.1 earns CCHIT Preliminary IFR Stage 1 certification as an inpatient EHR.

July’s HIStalk stats for those scoring at home (you know who you are): 97,368 visits, 138,957 page views, 5,941 e-mail subscribers. As always, thanks to my readers and sponsors. Back in the old days, I wrote HIStalk without either and would do it again, but it’s a blast knowing someone’s actually reading.

VMware will co-market Imprivata’s authentication and single sign-on products with its VMware View virtual desktop.

Boston-based SV Life Sciences, which has invested in six HIT companies, plans to fund more healthcare IT startups, with a primary interest data mining solutions. Its investments include Vitalize Consulting Solutions, Phase Forward, and eMed Technologies.

GE and Intel form a 50-50 joint venture to start a technology company that will target telehealth and independent living, extending their alliance from last year. That squares them off solidly with Philips, it would seem.

Orion Health announces GA of Rhapsody 4, a new version of its integration engine. Features: secure Web services, support for lookup tables, a monitoring API, Web-based monitoring tools, and a drag-and-drop user interface for analysts.

The Singapore Ministry of Health awards Accenture a contract to implement its national electronic health record system, scheduled for initial release next year. 

A New York Times investigation finds that at least 400 patients in eight hospitals have been overdosed on radiation during CT brain perfusion scans. The FDA was unaware of the problem and doctors and hospitals missed symptoms such as hair loss in the irradiated areas. GE’s equipment wasn’t the problem, but two hospitals said technicians confused a feature that raised radiation levels and thought it lowered them, saying the feature was “counterintuitive.” Interesting: Cedars-Sinai, one of the hospitals named, overdosed a member of its board of governors, who left the board when she found out. The best comment came from a plaintiff’s lawyer: “What is amazing and seems painfully obvious is if someone walks in with a band of hair missing around the entire circumference of their head, you would ask the question: Have you had a CT scan? Not ‘What did you eat for breakfast yesterday that would cause your hair to fall out today?’”

E-mail me.

HERtalk by Inga

A bi-partisan group of legislators introduces the EHR Incentives for Multi-Campus Hospitals Act, designed to ensure that multi-campus hospitals receive their fair share of economic recovery dollars. The way the law is written, multi-campus hospitals receive the same dollars as a single hospital despite higher implementation costs.

Advocate Health Care (IL) is deploying Fusionfx physician portal from Carefx Corporation at its recently acquired Condell Medical Center facility. Condell is also in the process of migrating from McKesson Horizon to Cerner.

The 100-physician Manhattan’s Physician Group selects ITalagen to host, support, and manage its EHR.

Corner Children’s Hospital (IL) plans to integrate its EpicCare inpatient clinicals with GetWell Town, a pediatric interactive patient care solution. The connection will support the bi-directional flow of patient information so that nurses can order educational material specific to a child’s diagnosis, then document progress in the patient’s record.

The local paper highlights the transition of Doctors Hospital (TX) to Cerner EHR and its desire to automate 300 community physicians.

Fremont Area Medical Center (NE) advances its HIE plans, signing a contract to implement Lawson Enterprise Exchange.

I don’t love Las Vegas, though I usually find a one-or two-day visit  is pretty fun. I had hoped to trek to Sin City this week to attend ACE with Mr. H, but alas, “real” life is getting in the way. In exchange for keeping the home fires burning, I’m thinking Mr. H should waste at least $20 in quarters playing the slots on my behalf. If you are one the 3,000 attending, feel free to send me some pics.

OA Centers for Orthopaedics (ME) chooses the SRS hybrid EMR for its 41-specialist practice.

Greater Baltimore Medical Center (MD) picks eClinicalWorks to provide EMR and PM to its 100 employed physicians.

Scott Bagwell takes over as SVP of sales and marketing for Passport Health Communications. Bagwell held a similar position with McKesson Pharmacy Systems and RelayHealth Pharmacy Solutions.

Q2 results for Henry Schein: earnings up 14%, though North American medical sales fell 0.4%. Total revenues of $1.85 billion exceeded analyst expectations.

Marion General Hospital (OH) implements GE Centricity Enterprise via a remote hosted delivery option.

A new eHealth Initiative survey on HIEs finds that the number of exchanges is growing, with at least 73 of 234 total HIEs now operational and transmitting stakeholder data. This is up from 57 last year. Sustainability continues to be a challenge, although 107 report they aren’t dependent on federal funds. Another challenge: addressing government policy. Participants also say the HIEs are helping reduce staff time and redundant testing.

Speaking of HIEs, the Electronic Healthcare Network Accreditation Commission (EHNAC) names the Utah HIE the first entity accredited through the HIE Accreditation Program.

From another local paper: the soon-to-open Mills Peninsula Medical Center (CA) will have no paper records. The new Sutter Health facility is replacing Peninsula Medical Center, which runs Epic.

Finally, Nielsen Co. says Americans spend 23% of their online time checking out Facebook, Twitter, and other social media sites. Which reminds me: Mr. H and I would love to suck more time out of your day, so feel free to friend us on Facebook and become a HIStalk fan.

E-mail Inga.

HIStalk Interviews Peter Stetson, CMIO, ColumbiaDoctors

Peter Stetson, MD, MA is chief medical informatics officer at ColumbiaDoctors, The Physicians and Surgeons of Columbia University of New York, NY; assistant professor of medicine and biomedical informatics at Columbia University; and associate director, quality informatics at New York-Presbyterian Hospital.

 

Tell me about yourself and your job.

I’m the chief medical informatics officer for ColumbiaDoctors. We’re a multi-specialty physician group of about 1,000 physicians here in New York. We have about 150 practice sites in the Tri-State area of New Jersey, Connecticut, and New York, with our primary base at Columbia University Medical Center. We’re affiliated with New York Presbyterian Hospital, which you may know is the recently re-ranked sixth in the US, so we’re proud to be partners with them. Our physicians admit to the Columbia campus, New York Presbyterian Hospital when their patients go in the hospital.

My other position is assistant professor of clinical medicine and clinical biomedical informatics, trained here at Columbia in informatics. I’m a hospitalist — I work in the hospital part-time while I’m not doing the CMIO thing. I also do research and patient safety and quality using healthcare IT.

Quite a busy guy.

Yep, it’s a busy time.

You’ve got skin in the game, to some degree, with both Allscripts and Eclipsys. What was your reaction when you first heard about the merger and what do you think of it?

We look upon the merger favorably. We actually work pretty closely with both vendors, and have for a couple years, to do integration work.

We felt that this was a natural outgrowth of some of the things that we had explored with the two vendors. We think that it’s going to have a positive impact on patient care and quality of life for the physicians in the long run. We’ve spoken with the presidents of both companies here at Columbia and participated in some conversations with them and other client sites that share Allscripts outpatient and Eclipsys inpatient. I think, as a group, we look favorably on the news.

Would you have stuck with Eclipsys and/or Allscripts had the merger not been announced?

The hospital is deeply committed to Eclipsys’ inpatient Sunrise Acute Care. They’ve had it installed since 2005 , starting with order entry at the Columbia campus, and had Eclipsys Sunrise Clinical Care in place on the inpatient setting at Cornell. As you may know, New York-Presbyterian is both the Columbia University and Cornell’s common hospital. They’ve put a lot of years of investment into Eclipsys products. There was no plan for changes there as far as I know.

We selected Allscripts for the faculty practice after a bake-off of a number of vendors run by an independent evaluation group, a physician-led independent evaluation group within our practice. We selected Allscripts as the product that we wanted to roll with. That was back in 2007, before there was any discussion of merger, obviously. Knowing that we had two different systems, we began our rollout in 2008.

Just give a word or two, if you don’t mind, about where we are in our implementation with Allscripts for the faculty practice, which is ColumbiaDoctors. We are 85% rolled out across those 1,000 physicians and have about 3,000 users. We’re coming to the close of our initial rollout. We’ve gone live on all modules, including electronic documentation — all the features that would be defined as a fully functional EHR, according to Blumenthal’s New England Journal survey.

Even before we started with the first group, we began working on ways of connecting Allscripts and Eclipsys. We’re the first group in the country to connect them using HL7 messages that contain the text of a Continuity of Care Document that we send from Allscripts to the hospital, automatically triggered by admission events in our ADT system for the hospital. We’ve been working with other clients that share Allscripts and Eclipsys to let them know how we accomplished that, and participated in a number of technical calls on that. That went into effect around May 2009 and we’ve been running that live since then.

Is that the route that Allscripts is going to go, sending the CCD over?

Well, I’m not sure. This is the subject of quite a bit of discussion, obviously. Are we going to have two different systems or one? Are we going to have two different databases or one? We’re in a period of pre-SEC approval, so they’re not at liberty to divulge a ton of detail about what they think the future vision’s going to be. The discussions have been pretty focused on patient care and physician quality of life to date. There’s going to be a number of discussions ongoing about what that future looks like as they’re permitted to discuss it.

One of the things that this has meant for the two business partners, ColumbiaDoctors and New York Presbyterian Hospital, is we’ve been asking ourselves internally, what would we like the future to look like; and is there an opportunity for us to influence how that would look with the two vendors? We’ve been having conversations with them about it and how to set that up.

You’ve got probably more experience than anybody trying to make these products work together. I’m sure they’re going to look to you for advice. From your experience, how hard will it be to integrate the two product lines and how long will it take?

I have been very impressed with both vendors, actually, in their ability to do integration work. Let me say a word or two about that, technically. Both applications have, as you may know, open hooks. Objects Plus, which is now Helios, for Eclipsys and Stanley Crane’s Universal Application Integrator toolset for Allscripts. We’ve been leveraging those and building solutions. We’re in the final stages of development integrating note writing and professional physician charging. We’re using those two open toolsets to do this work.

The ability to do that work using those tools is pretty easy to do if you have the experience with those toolsets. That gives me quite a bit of confidence that they will be able to do integration work. Whether that happens at a deeper level, or using this toolset in each case, or additional tools that they have like dbMotion for Allscripts or some other solution that might come from Eclipsys … you know, I’m not sure how that’s all going to play out and they’re not at liberty to say at this point. But, I can tell you from experience that we can hook things together using these open hooks that each of the applications have, and that’s what we’ve been pushing forward on here at ColumbiaDoctors.

From a high level, not necessarily even specific to those two products, what does integration look like to you between the practice side and the hospital side? What are the checkpoints of things you’d like to see it do?

We have what I like to call ‘meaningful interoperability’ that goes deeper than just the normal summary document exchange at transitions of care. That’s health information exchange, I guess, but I like to talk with my crew about meaningful interoperability which happens at a workflow level. One of the key things is discharge integration. You know, you’re in an inpatient space, but doing professional charging is typically something that’s managed by a practice organization. That’s one example.

As it is today, doctors have to manage a bunch of different lists of patients that they take care of, and the different applications, to make sure that they don’t forget to see patients and they generate handoffs. We’ve created a custom handoff application in Eclipsys as well, and so we’d love to see list management happen across both applications so you only have to do it once.

We’d like to see exchange of what I call ‘discrete document types’. Take, for example, patients who are coming into the ambulatory surgery area who then need to be admitted to the hospital. It would be nice at that point to ensure that the documentation from the ambulatory setting and any of the preoperative evaluations that took place for those patients are immediately available in the inpatient nursing station. Those are the points of contact that we’ve focused on developing, and they go beyond the normal ‘give me a snapshot’ — which is what we do today — of meds, problems, and allergies.

Then beyond that, the kinds of integration I think need to happen are around medications, problems, allergies, and immunizations. Those are the things that we target here. Medication interoperability is a challenging one. As you know, these two products use different drug formularies. Allscripts uses Medi-Span and Eclipsys uses Multum. Translating meds from different drug dictionaries at the transition of care is quite a challenge. We may see some changes in the way the combined entity addresses that issue.

Those are the things that I’d like to see emerge as solutions for the merged entity to tackle.

It seemed like the industry was fixated on the concept of physician portals, but doctors never really wanted portals because that meant that they had to go look up stuff. Do you think the industry has moved into the workflow piece that you’ve mentioned, so that doctors can do things automatically without being so aware of the venue of care?

I do. Particularly with the concept of the patient portal, we’ve stressed with the vendors that we speak with is that the docs, the quote I’ve heard from some of my emergency room colleagues here at NYP is that they “cannot have too many rocks to look under” — that’s the quote. If a doctor can manage to interact with their patients through a portal that’s integrated in the tethered model with their EHR, it’s easier for them because they don’t have to leave the application workspace that they use to manage their other patient care duties. I do believe that there is an increasing sensitivity to workflow solutions for docs so they don’t have to look in five different apps.

Are you seeing a lot of demand for or doing work with mobile devices? Are they changing the strategy?

There’s a lot of demand. I don’t think we chose Allscripts for this originally, but we’re really happy that they have an iPhone and now an iPad application that works. We are in very early pilot mode with the use of those devices and feeling out what our appetite level is with the doctors. But from everything that I hear when I’m on the road, in our institution, there’s a big appetite for mobility.

I think that mobility is a solution for managing some of the accountability mechanisms that EHRs have. Let’s take, for example, results verification of tests that are ordered. Sometimes you don’t have the time to respond to all of the messages you might get for critical, abnormal results while you’re in the office. But then when you’re out doing rounds or in meetings and conferences, there’s not a lot of time to get to a desktop PC to respond to those tasks or renew prescriptions and whatnot. The ability to have like a subset of the functions that you could do out of the office in a mobile platform is going to enable better quality, in my opinion.

I think that’s probably what’s driving the interest from the doctors’ perspective because they are accountable for following up on these things, but they can’t do it if they’re tethered to a desktop when they’re on the move.

You’ve done research on the quality of electronic physician documentation, and there’ve been stories lately where information was filed electronically, the doctor never saw it, and patient harm resulted. Are we overloading doctors with automatically generated and template documentation that really doesn’t have much clinical value?

For that reason, we’ve taken an approach with our physicians called ‘structured narrative’; where we embrace the concept that some of the stuff they want to say is going to be narrative, especially the history of the present illness section and discussion and assessment sections. We encourage them to use whatever means necessary to get narrative into the record, whether that’s typing, dictation, Dragon. We want them to do that. Then, where there are things that they’re interested in collecting for secondary use purposes like research or quality reporting at the organizational level and Meaningful Use requirements as they’re emerging recently with the final rule, we try to go after structure.

I’ll give you a good case point — transplant. We’re bringing our whole transplant group up on our ambulatory record with Allscripts Enterprise. There are some standard things that need to be collected for UNOS reporting and we’ve leveraged that as structure. But for the clinical care components that are really narrative, we encourage the use of narrative. That’s what we mean when we say a structured narrative approach.

I think that there is a link to the quality of documentation in two important regards. One is a sense of professionalism between the doctors who take care of common patients. The quality of output of notes that go back to referring providers. We’re a multi-specialty group. We take a ton of referrals into our organization. It is the professional handshake that goes back to the referring doc — the letter. We’ve spent a lot of time working on the quality of the note for professionalism, but more important is the ability of a doctor who’s picking up a case or cross-covering, or even the physician themselves who see the patients at intervals, to be able to tell what’s going on with the clinical care.

We’ve used the research principles that we’ve developed in my lab, and in the informatics department here, to implement documentation in a way that supports those two efforts, to the extent that the EHR can deliver it.

You mentioned Meaningful Use. What was your reaction to the final requirements?

We’re happy with some of the relaxation in the rules. I like the combination of core-minimum sets of rules, and then the additional five that you can select. In point of fact, I think as an organization, we’re going to need to be able to deliver all 10 of the menu set.

Depending on which practice we’re looking at, they may not be able to meet all of the individual items, so organizationally, we still have the full set to address. But within them, the relaxation of some of the rules is going to make it possible for us to meet … we’re optimistic we will be able to meet all of it.

Eclipsys is very strong in CPOE, so I assume you’re OK on the inpatient side.

I’m co-chair of the Alerts Committee for the inpatient for New York Presbyterian. We call it the Clinical Decision Support Committee, actually, and I co-chair it with Rob Green, who is an ED physician. We’re five years into CPOE at the West campus, and I think they are more like 10 years into CPOE at the East Campus we call it, which is Cornell.

We have probably thousands of order sets. We consider that an organizational asset. We have a lot of alerts in the system, and that’s an organizational asset. We consider quality a three-legged stool, with documentation, alerts, and order sets being the three legs of that stool. We actively curate all three. We think we’re in good shape on the CPOE stuff at NYP.

Are you using Sunrise for nurse documentation?

Yes. Nurses document and physicians have come along a little bit later, but my department and my service, actually the hospital service, has just moved on full bore to Eclipsys documentation.

One of the things that we learned in Objects Plus development here at NYP was that we could make calls into the application to get data to externalize it. We were able to create — not me personally, but a colleague I work with in the informatics department at Columbia named David Vawdrey — was able to externalize that data and re-represent it and get it into documentation using a function he calls ‘smart paste’.

To the point that I was making before about enabling structured narrative, that has made the notes faster to write, easier to read, and include data that is meaningful to the users. Nurses now actually can access that function as well, and they’re very progressive and started documenting in Eclipsys very early at our hospital. The doctors have come along a little bit later, but most of the major departments are now using not only CPOE for Eclipsys, but Eclipsys documentation on the inpatient setting as well.

What should the next generation of EHRs do that the current generation doesn’t?

I think that the challenges that we face are specifically in coordination of care. If you imagine trying to infuse an EHR with the principles of Patient-Centered Medical Home and the Accountable Care Organization, it’s going to require workflow solutions that enable communication and coordination.

I see elements that have Web 2.0 and 3.0 technologies being major factors in that design. We imagine enabling a heads-up displays that allows doctors to write their notes, but also write orders immediately and message each other, either within or without the outside of the EHR, to coordination of care — easier ways to mash up data for data visualization so that you can more easily see a temporal trend than a multi-provider-centered view. I see the infusion of Web 2.0 technologies into EHRs being critical to the success of EHRs to meet the coordination of care componentry that’s needed.

You may have read David Bates’ couple of editorials that he’s had recently where he’s talked about trying to improve diagnostic accuracy, improve coordination of care, and try to get the EHRs to move in that direction. I wholeheartedly support that. I think that’s where a lot of the vendors are already looking.

The second thing that I think is going to become more infused into EHRs, and is something that we’re working on here at Columbia, is to enable the representation, the manipulation and physician understanding of personalized medicine concepts — genomic and pharmacogenetic data. I’m not aware of many EHRs that support that as structured data or actionable data that physicians can use to make decisions right in the EHR. A lot of the stuff ends up being scanned for the time being, so as HL7 special interest groups and clinical genomics start to have their standards permeate the health IT space, I think we’re going to start to see ways of collecting and manipulating genetic and pharmacogenetic data in EHRs in ways that we haven’t seen today.

What are your priorities for the next five years?

From the perspective of what we’re doing at ColumbiaDoctors, we’re like everybody else who is two years into their implementation — focusing on finishing our remaining departments. When we’re done, we’ll have probably 4,000 users on the system.

Phase II for us has already started, which is leveraging our order sets, decision support rules that we already have in place, and creating custom ones to start to tackle issues associated with chronic disease management in a multi-specialty practice group.

Then we’ll focus on priority disease states, you know, the common ones; but we’re going to ramp up on our quality mission and start to focus on those things that demonstrably impact patient care and go, not just with Meaningful Use, but those things that also extend to those things we do from a specialty practice perspective.

What I see happening on a more global scale is the two issues we talked about, in terms of what do I see happening next in EHRs — better workflow support, better coordination of care support, and the embedding of genetic and pharmacogenetic data in EHRs.

Any concluding thoughts?

I would say we’re pretty excited about the merger. We actually are looking forward to working with both vendors to create solutions that work really well at NYP and other sites who have it, or might consider having the two applications.

Monday Morning Update 8/2/10

From Capillary: “Re: Allscripts. The CEO announced last week on the earnings call that the company was chosen by the Indiana REC, but the selections have been announced and Allscripts was left off. Anyone know what happened?” Allscripts confirms that you are correct. They have apologized to the REC for the unintentional miscommunication. The vendors chosen by the Indiana HITEC as appropriate for small and rural providers are athenahealth, iSALUS, and MDLand.

From UK Watcher: “Re: Aspira. Aspira is/was the UK feeder to IntelleHealth/iCapital, the consulting entity working some of the Cerner projects in the Middle East. Many of the recruits that they had secured in the UK were from Cerner UK and had been moved to the ME anyway. Will be interesting to see what happens to their tax-free and prior negotiated packages with the ‘new’ boss.”

From Privacy NOT: “Re: security breach. The Achilles right heel of HIT is failed privacy. The Achilles left heel of HIT is failed safety and efficacy. The rotator cuff tear of HIT is failed usability.” I don’t know about all of that, but it was in response to news of a stolen laptop from Thomas Jefferson University Hospital in June. The laptop was password-protected, but was not encrypted (I swear the hospital laptop encryption rate must be even lower than CPOE adoption, but in this case, it the employee’s personal laptop and storing PHI on it violated hospital policy). Laptops apparently aren’t encrypted at Texas Children’s Hospital either, as the hospital admits after the theft of a doctor’s laptop containing patient information.

From Smart Room Needed Here: “Re: UPMC. Hospitals should get their employees to watch the monitors.” A patient’s family sues UPMC Mercy Hospital, claiming he suffered permanent brain damage after choking on a clogged tracheotomy tube for 40 minutes before ICU nurses answered the cardiac monitor alarm. And in other UPMC news, it creates a VP of community relations position for a state senator who’s quitting. The closed UPMC Braddock Hospital is in his district, leading an official with Save Our Community Hospitals to state, “… Sen. Logan worked to ensure UPMC’s objective of closing and demolishing the hospital. Now we know why. Mr. Logan has received his ’30 pieces of silver’ as payoff for his work on UPMC’s behalf.”

A reader asked me to put together a list of some of the music I’ve recommended over the years, so I compiled and posted a list here. And in digging back through those archives, I dug up an old favorite to revisit: Nine Black Alps, hard rocking Brits.  

As hospitals issue press releases congratulating themselves on being Most Wired, most HIStalk readers think awards of that type mean nothing, while the majority of the remainder think they’re just self-promotion for magazines and CIOs. New poll to your right: will state HIEs be viable once their stimulus money has been spent?

Speaking of Most Wired, AHA says the criteria have been toughened up, requiring hospitals to at least claim (on the self-reporting survey) that they are actually using technology. So, if you are among the Most Wired skeptics who think it means nothing, imagine what it was like before (those old and now-suspect awards still pepper CIO resumes, I’m certain). If this were an art contest, it has gone from (a) who owns the most paintbrushes, to (b) who uses the most paintbrushes, but is still far short of actually evaluating (c) whose painting is the best and whether having the most paintbrushes made any difference. I was in charge of completing the survey for a Most Wired hospital for several years (I have a Most Wired Winner shirt somewhere) and even my hospital made fun of it given our hopelessly outdated and seldom-used clinical systems back then. I suspect that we and our fellow award-seekers were as optimistic as a vendor’s RFP department in our responses.

Are patients better off in a Most Wired hospital and can it be proved that the technology is responsible? No on both counts.  As I always say, if you are a good hospital, judiciously deployed IT can make you a little bit better. If you’re a bad hospital, all the technology in the world probably won’t help you improve (and may well increase your level of suckitude). If you are marginal, you might see improvement, but I wouldn’t count on it.

The folks at FierceHealthIT and I are swapping links for a few weeks, so you’ll see their headlines to your right and mine on their site. It’s a trial to see if we send each other readers. If not, we call the experiment quits.

Scott Storrer is ousted as CEO of MEDecision, replaced after just eight months by un-retiring founder David St. Clair (above) until a permanent replacement is named in six months or so. David’s blog entry on the subject is here.

Q1 numbers from NextGen parent Quality Systems: revenue up 24%, EPS $0.42 vs. $0.36, missing on consensus earnings.

A reader sent over workshop documents from a July 27-28 invitation-only meeting involving the Institute of Medicine and ONC, addressing the role of technology in continuous healthcare improvement. Some of the issues discussed: what can IT do to improve health and healthcare by 2020, what are the rate-limiting issues, how can data be used, how can innovation be fostered, how can healthcare cost be reduced by technology, how can disease management be improved by technology, how can consumers be engaged, and how can a global public network be created? Some familiar names were on the participant list: Molly Coye, Bill Bria, Mark Frisse, John Halamka, Rob Kolodner, Marc Probst, Stephanie Reel, and Paul Tang (familiar names not on the list were yours and mine).

UMass Memorial Health Care will announce Monday that it has chosen the Symedical terminology management and interoperability tool from Clinical Architecture to create a central data repository with a single terminology set.

HIStalk sponsor jobs: Interface Analyst, Epic Clarity Analyst, RVP Sales – Southeast, New England/NY, and Mid-Atlantic Territories.

McKesson’s Q1 numbers: revenue up 3%, EPS $1.10 vs. $1.06. My interpretation of nuggets from the call transcript: (a) Health Solutions and RelayHealth did fine; (b) Provider Technologies (the hospital technology part) underperformed, with revenue growth slowing to just 2% and profit down 7%; (c) they’re spending a lot of money on Horizon Clinicals and Horizon Enterprise Revenue Management, taking an $8 million accounting hit on HERM amortization during the most recent quarter alone; (d) John Hammergren says the company is interested in global acquisitions, but is often named just to increase the price that someone else eventually pays; (e) MCK isn’t seeing an increase in technology purchases by physician practices, but Hammergren says it’s because those practices aren’t yet paying attention to HITECH; (f) the company is confident that its products can get providers to Meaningful Use. My cheap seats analysis: Horizon Clinicals and HERM are struggling, which is hardly news other than it’s McKesson saying so (indirectly).

HHS withdraws HITECH’s breach notification final rule after reviewing the public comments. Organizations involved in a privacy breach would have been allowed to decide on their own whether to notify patients or just keep them secret. That’s significant given that the rule had already gone to OMB. A replacement rule will be issued “in the coming months.”

DrLyle weighs in on Meaningful Use on HIStalk Practice. A snip: “To correctly measure many of these details (e.g. give clinical summary to 50% of those who ask) we would need to figure out a way to keep track of who ‘asks’. That seems like a strange request for structured data and certainly should not be what a doctor is spending his time doing.”

Dossia Consortium names Jim Hansen, former CEO of the Kansas City-based CareEntrust HIE, as VP and executive director.

TriHealth and University of Cincinnati will spend up to $100 million each on clinical systems, with Epic being a candidate in both (I’d say shoo-in given that TriHealth already uses Epic in its physician practices). Also named as local hospitals bringing up Epic and spending more than $50 million each to do so: Mercy Health Partners, Cincinnati Children’s, Christ Hospital, and St. Elizabeth.

A senior at University of Maryland who created the DoseSpot electronic prescribing system is named a finalist for an entrepreneur award.

Doctors and nurses in Thailand wear black lab coats to protest a draft law that would allow patients to be immediately compensated for medical malpractice from a special fund. A medical union representative says, “It means our staff would have to be extra careful during work, which would decrease efficiency.”

An Alaska clinic becomes the first US site to use ALERT Clinic software, which I assume is from the Portugal-based ALERT that made a mini-splash a couple of years ago at HIMSS (I think I recall cute booth staff in red-striped white jumpsuits, but I could be wrong), then seemed to disappear without a trace. Everybody (me included) was impressed by what we saw, so I don’t know what happened. I pegged them as a hot new entrant.

A hospital employee is fired for posting a Facebook comment about the suspected killer of a police officer that she treated, saying she hoped he rotted in hell. The hospital said she violated HIPAA even though she didn’t mention the name of the suspect or her hospital.

A Stanford Medical School professor and novel writer worries about letting technology interfere with patient-physician relationships:

Rituals are about transformation. You know, we marry with great ceremony to signal a transformation. We are baptized in a ritual to signal a transformation. The ritual of one individual coming to another and confessing to them things they wouldn’t tell their spouse, their preacher, their rabbi, and then even more incredibly, disrobing and allowing touch, which in any other context would be assault, you know, tell me that that’s not a ritual of great significance. And if we short-change the ritual by not being attentive, or you are inputting into the computer while the patient’s talking to you, you basically are destroying the opportunity for the transformation. And what is a transformation? It’s the sealing of the patient-physician bond.

Hospitals in Victoria, Australia will arm 500 doctors and nurses with iPads in a pilot program.

Boy Scouts at this year’s Jamboree at Fort A.P. Hill, Virginia have access to AT&T WiFi and a wireless EMR system used by its 20 medical centers and team of EMTs. Next thing you know they’ll be using a GPS to track snipe.

Standard Register’s healthcare revenue fell short of expectations in Q2, mostly because of cheaper document management solutions.

The former CEO of Baltimore-based insurance company CareFirst BCBS, recipient of a contested $18 million severance package, joins Healthcare Interactive as an advisor. The company offers healthcare performance management systems of several types.

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News 7/30/10

From SnagMonkey: “Re: confirmation of Providence Oregon’s transition to Epic.” He (or she) sent over the July 19 internal announcement. GE Flowcast, GE Centricity, McKesson Horizon Clinicals, McKesson Star, and pretty much all the unnamed ancillary systems will be shown the door. Implementation starts in January, the first go-live will be in 2012, and the project will be finished 30 months after it starts. Thanks for the scoop.

From Girls Just Wanna Have Fun: “Re: acquisitions. Hold on to your hat the next six weeks. Lots about to start shaking loose. Can’t say more, but August and early September will be the most active HIT M&A announcement months in a very long time.”

From TooLate: “Re: iSoft. Massive cuts continue and positions will be eliminated. Major shifts, consolidation of leadership, off-site London meetings are more frequent, and more stock will be issued. Sound like everything is being done right except fixing the actual problems — product and leadership. Can’t wait to see this annual report.” Shares are at less than 14 cents US.

From ThinGreenLine: “Re: management changes at Meditech. It was previously announced that Steve Koretz would assume all installation and support responsibility for 6.0 product line. Now Joanne Wood will assume same for all Magic and Client/Server products. Joanne being promoted to Senior VP. Two new VPs promoted under her, Leah Farina and Helen Waters. Leah has her roots in the HCA group, while Helen came from sales. This is the change Howard Messing hinted at in his interview with you.” Verified by Howard. That’s Joanne above.

From MaxPayneUK: “Re: Apira. Closes operations and gives all employees to IntelleHealth, which insists that new employment contracts be signed. Not sure how that happened without violating labour laws, but there you go.”

From Jenny Penny: “Re: Jay Deady. Cheers Across Atlanta may be thrilled that he’s leaving Eclipsys, but as much as an ass as he can be, I challenge anyone who has ever worked for him to debate that he challenged them to do their best. He is super duper intense about work – certainly no dumb slacker like many HIT sales guys.” Ouch!

From Buck S. Pearl: “Re: West Virginia Health Information Network. Five vendors still in the running to run the state’s HIE: Thomson Reuters, CSC, Deloitte, Medicity, and HealthBridge. The selection deadline was June 30, but they are re-evaluating functionality (which probably means they don’t have enough money to buy what they want). They are also negotiating with NaviMed and Quadax for a separate claims and eligibility portal, with one or both offering it to the state at no cost to open up the chance to sell other services to providers (clever buggers).” Board meeting minutes are here (warning: PDF). I knew Thomson Reuters jumped into the HIE game in December, but it still seems odd to see their name among those others.

From Laboratorian: “Re: Epic’s Beaker laboratory information system. Anyone know much about it? Are its big new clients implementing it?” Beats me. Anyone know?

From Jimmy DeLorean: “Re: posting the Monday Morning Update on Sunday. It’s always great feeling like I’m getting Monday’s news a day or two early.  ;)  But, you certainly have earned more than a few Saturdays off, and I’m sure Mrs. H appreciated having your undivided attention for the weekend. How you’ve managed to hold down two full-time+ jobs all this time and still have a personal life (and sleep) is a remarkable feat, though. Someday you’ll have to write a book on time management and life balance, even if pseudonymously.” Thanks – that made my day. I like having a few readers who get antsy when I don’t post until Sunday afternoon since it makes me feel needed. Mrs. HIStalk did indeed appreciate my attentions (and vice versa).

From Loyal Reader Kathy: “Re: Meaningful Use. Since you put together such a great spreadsheet over New Year’s, I thought someone ought to do it for you for the final and give you a little time for Mrs. HIStalk.” Kathy did a great job putting together the final rule information, including both the requirements and the quality measures (download it as Excel since it won’t look right otherwise — it has two tabs). Very cool, thanks! UPDATE: Scribd has some Facebook auto-login crap that isn’t obvious, so if you’re not on Facebook, download from here or here instead.

Listening: new from Asia, back with the original members (Palmer, Howe, Downes, and Wetton). I’ve got tickets to see them live soon.

Q1 numbers from The Advisory Board Company, the new home for much of the former HIMSS Analytics management team: revenue up 18%, EPS $0.29 vs $0.27. Market cap is $682 million.

pMDsoft announces its native iPad charge capture application.

Weird News Andy goes non-weird in finding this: Americans are consuming fewer healthcare services, according to financial results of publicly traded healthcare-related companies. Evidence: fewer elective procedures performed, increased numbers of high-deductible insurance plans, fewer new prescriptions for maintenance drugs, and (of course) increased insurance company profits. Athenahealth was quoted for its observation that the number of claims per physician and the average value per visit dropped over last year. The WSJ article seems optimistic that consumers are getting smarter, but I’d bet they’re just holding off until they get those shiny new insurance cards courtesy of healthcare reform.

St. Vincent’s HealthCare (FL) signs a deal with CVS Caremark’s MinuteClinic to provide medical staffing and to work together on disease management. The organizations are integrating their respective EMRs to share histories and visit summaries.

Cerner’s Q2 numbers: revenue up 13%, EPS $0.65 vs. $0.52, guidance raised. Shares jumped a little (one-year CERN against the Nasdaq above, with Cerner in blue). I’ll repeat what I said earlier this week: it’s one thing for Epic to take some business away from Cerner, but Neal’s always going to book great numbers, keep shareholders happy, and let everyone who wants to ride the Ferris wheel with him do so by purchasing shares. Millennium may have fierce competitors, but the company is doing just fine.

Speaking of Cerner, the earnings call transcript is here. It’s mostly the usual hack phrases used by executives and analysts (traction, footprints, give some color around), but there were a few interesting points. They’ll open a Vision Center in Europe. They don’t sound like they’re doing too well (my read, anyway) in the small hospital and physician practice markets. They expect 75% of their clients to earn full HITECH payouts. They’re going after revenue cycle services with RevWorks. One analyst asked directly about Cerner repeatedly losing against Epic in academic medical center sales, which COO Mike Valentine deflected by bragging on CERN’s success with for-profit hospital chains because of Cerner’s predictability and ability to scale (he also referenced HIStalk indirectly, saying “So we added 15 new footprints this quarter. In more than half of those we competed against the firm that you mentioned that gets mentioned a lot on the HIT blogs, and that’s good. We’re like the strong silent type. We’re going to continue to compete with them.” I snorted Diet Pepsi with Lime out my nose when I read the part about the “strong silent type” given Cerner’s notorious (over) marketing machine (i.e, the Vision Center), but that probably resonated with the stock guys as being humble. Neal dropped by for his usual one quick comment at the end, obliquely mentioning the acquisition of Picis by Ingenix (United HealthCare) and implying that they see opportunity in the platform that digitization enables.

CPSI’s Q2 numbers: revenue up 22%, EPS $0.39 vs. $0.32, beating consensus estimates of $0.36 and providing in-line guidance. In the 8-K, they mention that fired former CFO Darrell West not only charged $55,000 to a company credit card to pay his taxes, he cashed in almost 5 million membership reward points for personal benefit.

IBM will sell and implement the “smart room” developed by UPMC, which involves staff-worn ultrasound tags that trigger the display of role-based clinical information on the monitor when they enter the patient’s room.

Paris-based Cegedim acquires Pulse Systems, vendor of the CCHIT 2011-certified Pulse Patient Relationship Management ambulatory EHR, along with solutions for e-prescribing, practice management, revenue cycle management, and patient self-service. Cegedim sells life sciences technology and is a pretty big deal with 8,600 employees and annual revenue of $1.2 billion (a little smaller than Cerner). They make it clear in the announcement that their interest is ARRA money. It also says that Pulse is profitable on annual revenue of $16 million, that Cegedim will pump another $13.5 million into the company, and that the value of the acquisition won’t exceed $58 million.

The former chair of the British Medical Association’s IT group urges doctors not to upload patient records to the Summary Care Record, saying it’s unsafe and should require patients to opt in instead of opt out. He’s setting up his EMR to prevent uploading unless patient consent has been checked off and is telling his peers to contact their EMR vendors to make the same arrangements.

This interesting article describes the advanced status of EMRs in Finland (91.1% penetration and a national health network), but calls out the pitfalls: it’s still hard for individual systems to communicate with each other, each local jurisdiction has different privacy rules, and the only way to transfer information when a patient moves to an area that uses a different EMR is to print everything out. I may need a site visit to Helsinki since I’ve not been for a few years and I like it there.

EyeHealth Northwest chooses NextGen’s PM/EMR for its 30 providers.

Free EMR vendor PracticeFusion launches its Research Division, which will publish lists of top-prescribed meds by specialty (which was in the announcement) and sell de-identified patient data (not announced, but that’s been the company’s stated plan, along with advertising to doctors, from the beginning — how else can they give away an EMR?) Some of their arguments on the Research Division page for providing patient data are a bit lame: (a) it’s a public health service; (b) it’s a research service; (c) Kaiser and the VA do it, so why shouldn’t we? (d) and lamest of all, under the category of Social Responsibility, “To keep this information from medical researchers would be a disservice to the safety and advancement of medicine in this country.” If you’re going to sell patient data, just say so — don’t try to make it sound noble.

Guess who’s an HIT demo dolly? Todd Park gets the thrill of having the leader of the free world pitch the site he built. Pretty cool. The President isn’t a Mac man, apparently.

United Health Group is rumored to be buying Executive Health Resources for $1.5 billion, making it part of Ingenix. The Newton Square, PA company staffs hospitals with Physician Advisors to maximize reimbursement, improve efficiency, and improve quality of care.

Mediware renews its agreement with William Blair, which includes exploring “a variety of strategic alternatives to enhance shareholder value.”

Odd lawsuit: a former nurse manager sues Halifax Health (FL) for discrimination after a failed romance with a radiology manager. She provided evidence that included a receipt for a romantic couples massage, but she dumped her beau after discovering she wasn’t the only co-worker with whom he was consensualizing. She says she was harassed after the breakup, including being asked by HR to dress as a go-go dancer during the employee banquet and having one of her patients delayed in radiology for no reason.

E-mail me.

Readers Write 7/28/10

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 to Use Meaningful Use Measures to Improve Internal Processes
By Shubho Chatterjee, PhD, PE

The final ruling on Meaningful Use was released by the Centers for Medicare and Medicaid Services in July of this year after a year of comment period and revisions. According to the final ruling, to be eligible for incentive payments, Eligible Professionals (EPs) are required to submit to the CMS, starting October 2011, 20 objective measures for 15 core objectives and an additional five from a menu of 10. For hospitals and Critical Access Hospitals (CAHs) the corresponding measures are from 14 core objectives and five from a menu of 10.

There are various efforts, dialogues, and debates underway regarding the ability of EPs, hospitals, and CAHs to meet the reporting requirements, whether the cost justifies the incentives, and the sheer human and technical capacity needed. I will not further add to the discussions but will rather focus on how the MU criteria can be used to further improve care delivery process, make it more efficient, and positively impact the operating margin. After all, a measure is related to the output of a process, and while a measure can be met, it can also be used to hone into the process and sub-processes for improvement.

Let us consider some of these Stage 1 measures and how the underlying processes supporting the reporting of the measure can be identified and improved to further improve the measure, the care delivery, and the operating margin.

Stage 1 Measure
More than 30% of unique patients with at least one medication in their list seen by the EP or admitted to eligible hospital’s or CAH’s ED have at least one medication order entered using CPOE.

Implication
Let’s assume that the provider meets the 30% threshold for the reporting period. A logical follow-through is to examine why the remainder are not CPOE and what were some barriers overcome to reach this threshold. Is it because for the remainder unique patient population, data entry is manual because other providing locations are not CPOE enabled, CPOE is available but under-utilized, or are there manual data entry requirements into and between various systems and consolidate the data to one final measure?

Each of these barriers point to a different challenge. The first is system unavailability (a business decision). The second is a change management (a people challenge). The third is a technical and process automation challenge requiring an interface or other electronic inputs, such as document management and integration.

Stage 2 and Stage 3 measures will increase the threshold. Thus the underlying process or system gaps should be identified not only to meet later Stage measures, but to improve process efficiencies as well.

Stage 1 Measure
More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

Implication
Assuming the 40% threshold is met, what is necessary to increase the measure? Is it because of volume of data entry from single or multiple locations, or system not fully utilized, or could it be because the receiving pharmacy or is unable to manage additional increases to their receiving capacity from their customers? Again, the barriers are similar to the above and need to be analyzed and overcome.

Stage 1 Measure
More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to health information subject to EP’s discretion to withhold certain information.

Implication
This requirement has procedural, technical, and operational implications. The procedural requirements are in providing HIPAA compliant health information, while the technical requirements are in the mode of providing the information. For example, will a secure patient portal be created, will the information be provided in memory sticks or other portable devices, and if so, what is the encryption or data protection policy?

Note that, depending on the technical solution selected, there are supply chain and purchasing requirements as well, to maintain and increase the measure threshold.

Summary
While the MU provides financial incentives for healthcare organizations, it ends in 2015. It is important for healthcare organizations to use this opportunity, not only to prepare, apply for, and receive the incentives, but to examine their organizations deeply from People, Process, and Systems perspective to utilize and enhance the measures.

Only when these three supports are robust and reliable will the Meaningful Use be truly meaningful to the healthcare system, where the improvement of quality of care is the most important objective and operational improvements and business growth will likely follow.

Shubho Chatterjee is chief information officer of Miami Jewish Health Systems of Miami, FL.

Bringing Medical Terminology Management into the 21st Century — Just in Time for ICD-10
By George Schwend

ICD-10 promises to improve patient safety, the granularity of diagnosis codes, and diagnostic and treatment workflows as well as billing processes. Sounds like a dream, right? But close to three years from the mandated switch on October 1, 2013, most hospitals and health systems are still thinking of it as a nightmare, dreading the massive amount of time, effort, and money the transition will require.

What many fail to grasp is that ICD-10 is just one step on an endless road. There are already dozens of code sets that will probably eventually need to be integrated with each other — from SNOMED-CT and LOINC to RxNorm to local terminologies and proprietary knowledge bases — and all of them are constantly evolving. Look down the road and you can see ICD-11, already in alpha phase in Europe.

Instead of tackling each new iteration as if they were setting off on a major road trip through uncharted territory, providers, payers, and IT vendors need to ditch the proverbial roadmaps and get themselves a GPS unit. That way, they can simply enter each new destination as it comes along and travel there automatically.

And automation is what true semantic interoperability requires. Our metaphorical GPS could either be embedded in proprietary HIT software or plugged into a hospital’s or payer’s information system and triggered by specific events such as an update or the need to create new maps. It would allow users to automatically:

• update, map, search, browse, localize, and extend content
• incorporate and map local content to standards
• update standard terminologies and local content
• generate easy-to-use content sets to meet the needs of patients, physicians, and customer support professionals
• reference the latest terminology in all IT applications
• codify free text
• set the stage for converting data into actionable intelligence

Happily, software that fits the bill is already available, in use today at more than 4,000 sites on five continents. It provides mapping and terminology for leading HIT vendors, for health ministries like the UK National Health Service, and for standards organizations such as the IHTSDO, owner of SNOMED-CT., allowing them to not only implement new codes but synchronize codes throughout an enterprise, be it a physician practice or a country.

If you are still having nightmares about ICD-10, this your wake-up call. The ability to merge and manage diverse content from multiple sources — including free text from physician dictation — is what will turn ICD-10 from a frantic, one-off billing upgrade to one in a series of opportunities seized: to move clinical diagnosis to a new level, for example, to optimize EMRs, to meet meaningful use requirements, to satisfy quality initiatives such as the Physician Quality Reporting Initiative and to support robust analytics and reporting.

Can a roadmap do all that? Hardly.

George Schwend is president and CEO of Health Language, Inc. of Denver, CO.

HIE Market, A Shot in the Arm
By Tim Remke

The HIE market finally got a shot in the arm with the passage of the federal stimulus. This and other tailwinds sent hundreds of millions of dollars over the next few years toward the HIE market. From this point on, the HIE market gets muddled. Questions such as who is marketing their solutions to which markets, what deployed-use cases are functional or even operate at a high level, and what differences exist between multi-stakeholder, state, and private HIEs are mixed among many other multi-faceted questions.

The definition of a health information exchange has diluted the significance of surveys and results, particularly when they seek to understand what types of data are exchanged, the number of HIEs in the market and their respective operational capacity, and technological and governance structures. Simply, too many results are ‘self-reported’ and produce statistically insignificant, inaccurate, or misleading data points.

Of particular concern, several market surveys and reports related to the HIE market have commingled data by combining statistics from provider organizations that use solutions developed for basic hospital portals — a far cry from a broader HIE platform. Finally, HIEs may be private, multi-stakeholder, or statewide entities. In addition, payer system and public health play a role of delineation. The idea of ‘community HIE’ is limiting, and does not tier appropriately the HIE market.

With this perspective and understanding, we assess a few basic aspects of the current state of the HIE market.

Target Markets
A tremendous amount of friction exists over what specific HIE markets are accelerating at a pace greater than others, and which companies target each market. For example, a few vendors are persistent in their belief that the private HIE market is really the first ‘go-to-market strategy’ place. They look for localized geographies or a few hospitals to install an HIE platform as an overlay solution to act as a ‘buffer’ to a larger regional or statewide exchange.

Within the same HIE market, but more counter to this strategy, are the vendors who seek larger contracts from statewide or vast regional, multi-stakeholder exchanges. Two different approaches that produce some small and other more significant variation in solution focus and offerings. However, the data indicates a consistency that is expected. A

ll vendors will market to almost any market. However, slicing through the data, we see vendors that are targeted. All focus on hospital to hospital environments. Approximately 85 percent focus on providing an acute to ambulatory framework, also; and less than 40 percent offer a platform that readily integrates physician groups.

In addition, and somewhat paradoxically, many solutions are simply not designed to operate as platforms for vast geographic or state exchanges. Therefore, for the multi-stakeholder market, HIE solutions are discriminating. Contrast arises between target markets and the ability of the solution to match the specific market. Unlike other segments, HIEs seem as equally conflicting in details as they are syncopated — characteristics of a nascent market (relative to the past few years).

Critical Minimal Requirements
In recent months, we have seen a number of RFPs that contain a significant number of demands. However, they mask a serious issue in the HIE market. The reality is most HIEs are ill-equipped to take on sophisticated and complex solutions, use-cases, and technical architectures they greatly desire. Furthermore, over 65 percent stated the minimal exchange of data from information systems were posing “mission critical problems” with their respective exchange, and will succumb to “serious delays”. The table below looks at minimum versus preferred requirements for an exchange structure.

Conclusion
Finally, the HIE market is dynamic and has hit full stride. Companies that have weathered the storm seek potential exits (i.e. merger and acquisitions) while others are ramping their solution for the future. The market will likely extend an abnormal growth rate for the next one to two years.

However, many unanswered questions will remain. Business models, measured quality improvements, and funding, among other items persist into the future as open question marks. For example, initial stimulus funds will jump start statewide HIEs. However, after these funds have been depleted, real concerns about long-term viability and funding sources will endure.

Tim Remke is vice president of business development for HealthcareCIO, which produced the Health Information Exchange (HIE) Comprehensive Analysis & Insight report from which aspects of the above article were taken.

News 7/28/10

From Gregarious: “Re: HCA. They are doing competitive pilots of Meditech 6.0 vs. Cerner, possibly as a move toward displacing the long-term HCA / Meditech relationship.” Verified. HCA will run a Cerner pilot in at least one hospital sometime next year. Meditech 6.0 is a big step from HCA’s Magic (pretty much starting over), so it makes sense to test the waters. The wild card could be how the hosting models compare. Several HCA hospitals have reached EMRAM Stage 6 on Magic, which ironically makes it harder for HCA to switch since you’d need heavy clinical usage from Day One to avoid moving backward. Any change (even to 6.0) will be painful.

From BeCarefulWhatYouWishFor: “Re: Epic. They are about to pick up another large academic facility in Nebraska. You can only imagine who is going to have the LastWord now.” Unverified, but thanks for the excellent punmanship in any case. As a couple of readers pointed out, it will be interesting to see if Epic can scale its model up to cover all these big implementations going on at once. A CIO reader who knows both systems says Cerner requires clients to take ownership of the design and use outside consultants, while Epic offers a more turnkey implementation at a higher price. It’s also interesting that Epic doesn’t offer hosting and Cerner is runnin hard with that offering, so that’s a key differentiator to some prospects.

From SnagMonkey: “Re: Epic. Not officially announced, but all Providence hospitals and hospitals in Oregon will convert to Epic.” Unverified.

From You’ll Know Who: “Re: Epic. Not only is Epic replacing Eclipsys and Cerner at sites, they are likely removing 30+ year old financial systems from McKesson, such as HealthQuest or the old Ibax product. That again highlights the lack of success with the ‘new’ Horizon ERM. It would be interesting to hear which products the CIOs looked at.” My ears are open if anyone wants to share.

From Ragnar Danneskjold: “Re: your comments about Cerner and corporate bureaucracy. Man, can you turn a phrase! I’m going to have that framed and put on my office wall (and then wonder why my career is not going anywhere :-)). Been loving your work for many years now. I don’t know how you do it, but keep on doing it.” Thanks.

From Cheers Across Atlanta: “Re: Eclipsys. Jay Deady announced today at the Eclipsys sales meeting that he will be leaving concurrent with the Allscripts acquisition.” Unverified.

From Reddy Kilowatt: “Re: PM/EMR in Asia. I’m looking for information (Web sites, articles, databases, etc.) on penetration in the smaller private practice market.” I have readers there, so if you know some sources, let me know.

From Anonymous: “Re: Merge Healthcare’s ortho imaging products. I’m surprised you didn’t catch wind of this.” I did, earlier this month when a reader tipped me off that Stryker was selling its imaging division (i.e., ortho products) to Merge.

From Lori S: “Re: AirStrip Technologies. They will announce that their cardio and critical care apps have received FDA approval, setting the bar high for other vendors.” Verified. The news just came across the wire Tuesday evening. AirStrip users can monitor patients in real time from their iPhone, iPad, and other mobile devices. That sound you heard was change jingling in the deep pockets of GE, Philips, etc. as they suddenly think AirStrip Technologies looks like something they’d like to get their hands on. I interviewed co-founder Cameron Powell, MD in February.

SRS will offer customers its hybrid EMR bundled with practice management and scheduling systems from Ingenix, calling it SRS CareTracker PM powered by Ingenix. SRS will also offer its EMR customers a migration path to the Ingenix CareTracker EHR. That’s interesting — Ingenix has been promoting CareTracker much more heavily recently, plus rumors suggest that the company won’t stop its HIT-related acquisitions with Picis.

I’m a sucker for hospital music videos, so here’s one from Lake Pointe Medical Center in Rowlett, TX, a top-rated Tenet facility celebrating its 5-Star Patient Satisfaction Rating for the full year of 2009.

Marshfield Clinical lists its CIO job. An advanced degree is not required.

CIO Unplugged 7/26/10

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

The Authentic Leader (Death to the Cliché)

Summer of ‘86. The gas chamber awaited me.

This time, I made sure my protective mask was on correctly. Four years prior, at basic training as a seventeen-year-old, I had panicked and failed the test. Today, during the final days of training before being commissioned as an officer, I entered the tear gas chamber and approached the awaiting officer. Removing the mask, I stood at attention, mostly. Dry heaves bent my body in half.

The commander yelled, “Cadet Marx, do you have what it takes to lead your troops in difficult situations?”

“Yes, sir,” I gasped. Do. Not. Panic.

“Do you really have what it takes? They need courageous leaders, willing to lead by example.”

“Yes, sir!” The stinging gas closed my eyes to slits. Mucous cascaded over my lips and chin.

As if he knew my struggle, he kept me longer. “Cadet, I want you to sing the national anthem.”

Crap. I gave it my best shot. I’m certain I missed a couple of lines. But as I ran out the exit and filled my greedy lungs with fresh air, I emerged a leader. I now had an authentic story.

I’ve tried to never ask a subordinate to do something I would not do, or haven’t done. I’ve scrubbed toilets and worked factories with the best. Those leaders who pontificate on theories they don’t practice get zero respect from me.

If you say, “Go to where the puck is going,” do you know the precise nuance of that statement? Have you played hockey or just watched it?

“Pace yourself. It’s a marathon, not a sprint.” How many can relate to the effort it takes to sprint or run 26.2 miles? Probably few.

Although I hate clichés, I’m guilty of using them. I do my best to speak from direct experience. The difference between telling your own story and using a cliché comes down to credibility of message and messenger.

Where I work, our strategic plan is centered on climbing a mountain, to include base camps and a summit. At first, I thought I understood the immensity of what it meant to conquer a mountain, though I struggled to articulate the concept. I’d never done it. Sure, I walked a trail to the top of Pikes Peak in my youth. But climb a serious mountain?

I asked my fellow leaders if any of them had executed a technical climb. None had. So a few of us got together and planned a climb.

During our nine months of preparation, we lost 60% of our team. We invested, we studied, we sacrificed, we trained. Boy, did we train.

On July 17, 2010, five tired but exhilarated officers summited Long’s Peak. There, we unfurled our organization’s flag, a moment we’ll cherish for years.  
 

“Climb a mountain” took on an entire new meaning. We realized the sweat it takes to reach base camp. We faced the risks involved and the saw value of the teamwork required. When we speak with our respective employees, we can genuinely convey the energy it takes to reach a summit — genuineness based on experience.

By definition, leaders are in front guiding by example. Leaders explore. Just like in mountain climbing, leadership is risky, which is why so many stop actively showing the way. Sadly, some become active antagonists. I’ll save that for a future post.

Practicing visionaries. I believe a CIO cannot rely on how he or she operated 20 years ago or even one year ago. Don’t just talk about social media, live it. If you personally don’t tweet, yam, yelp, blog, etc, then don’t bother preaching about social media. You’re only lowering your credibility.

Patient care is shifting to the home setting, which means the virtual patient has arrived. Are you virtual, or are you still tethered to a landline in an office?

Do you discuss Mobile Health, HIE, Connected Health or Cloud, yet not actually deliver? I’ve encountered CIOs who talk HIE at length and could exchange information tomorrow, but they refuse to take action.

Your presidents face P&L pressures. Have you run a P&L center to make yourself aware of their challenges?

The healthcare industry has adopted electronic health records and has transitioned to a paperless environment. Are you still reliant on paper?

I wonder how many leaders grasp the double standard they communicate to their people. We talk about patient accountability, but is our physical fitness and lifestyle up to par with our vocation?

Finally, list the modifications you’ve made to your leadership style in the last two years. How have you adjusted to the emergence of multiple generations in the workplace? When you pass people in the hall, do they whisper, “He’s old school”?

Leading via clichés might make communication easier, but our people deserve more. The next time you hear grandpa’s hackneyed truism come out of your mouth, take it captive. It’s time to develop your own experienced-based story that will increase your credibility. Allow a cliché to catapult you to try new things and live your own genuine story.

Ever thought about climbing a mountain? Pick the peak you need to summit, and elevate your authenticity.

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

Monday Morning Update 7/26/10

From Gamara: “Re: Epic. Random stuff found in Googling Epic.” Good sleuthing, although some have turned up previously The following organizations appear to be going Epic: Stormont-Vail HealthCare (KS – above), University of Colorado Hospital (CO), The Mount Sinai Medical Center (NY), Maricopa Integrated Health System (AZ – old), University of Miami Health System, South Broward Hospital District.

From LookingForAnswers: “Re: Epic. They’re winning deals like Cerner did 15 years ago when they were small. Cerner seems to be a revenue-churning machine that the public can participate in by buying stock. The only people who benefit from Epic are the owners and/or Judy. Which company has made more millionaires? Which company will change the face of HIT for the long run?” Here’s the real question: why can’t Cerner, with all its billions in market capitalization and name recognition, compete with Epic for new sales? As has been asked of other Goliaths (Microsoft, GM, Dell, GE, etc.) how could Cerner, given its ample lead time and resources, let the once-tiny David called Epic beat them year after year? My theory is threefold: (a) even entrepreneurial big companies naturally evolve into highly ineffective corporate bureaucracies that are motivated by fear and executive entitlement, the antithesis of innovation; (b) publicly traded companies let their numbers drive their business instead of vice versa, and (c) corporate Darwinism would have Cerner just buying Epic outright, but Judy throws a wrench into that evolution by refusing to sell the company.

But all is not lost: we don’t know Epic’s profitability, so Cerner may be beating them where it counts. And we know that Cerner has built a business that could weather Neal’s transition or sale to another organization, but we don’t know that with Epic. What I care about most is why Epic beats Cerner for every important deal, which would seem to indicate that Millennium isn’t up to the task. In other words, a $6 billion market cap company with a single, fairly low-rated product line that’s getting hammered by a smaller and much higher-rated competitor should think about developing a better product. Here’s another way to look at the value of ongoing R&D: the only company that beats Cerner consistently in new sales is also the only one with a newer product.

From JA: “Re: Epic. More details on the Yale and Epic adventure.” Yale Medical Group describes their plans for Epic, also mentioning that a CMIO will be hired who will share time with the School of Medicine and Yale-New Haven Hospital. The specific Epic features that seemed to seal the deal were the obvious ones: ambulatory-inpatient integration and MyChart, areas in which Millennium is clearly inferior.

From Dave U. Random: “Re: Epic. Google RGHS+Epic.” Rochester General Health System has chosen Epic.

From SEC Fan: “Re: University of Michigan. CareWeb does many things well (less than they claim), but they have installed Eclipsys Sunrise over the last five years for inpatient. Interesting that after 3+ fails at EMR, they get one right and now replace it.” Thanks for reminding me. That’s another big Eclipsys loss to Epic, six years after the contract was signed and less than two years after Sunrise went live at UM.

From The PACS Designer: “Re: Windows Phone 7. The mobile phone marketplace will have more competition soon, as Microsoft has announced the beta for Windows Phone 7.” It had better be good if it’s going to displace the iPhone, Android, and BlackBerry this late in the game. I don’t see Microsoft as being good at come-from-behind victories; it’s better at running a prevent defense to protect the leads it generated a couple of decades ago. On the other hand, Windows 7 was a hit, so maybe they’re finally getting it.

From Vendor CEO: “Re: HIStalk. I have really enjoyed watching your progression. It’s kind of like watching the New York Times and Murdoch sites (HIT rags) try to get customers to pay for their sites while hordes of readers are rushing to all the free specialty news sites (HIStalk). Fascinating!” Thanks. Maybe I’m the open source alternative, a marginally skilled but enthusiastic spare bedroom pseudo-journalist trudging home to a PC after a long day at the hospital.

Listening: new from Grand Mal, which sounds like the Rolling Stones playing a smoky New York club in 1973.

Tom Ogg is named CIO of Akron Children’s Hospital, coming from Oakwood Healthcare Systems (MI).

Stuff you can do here: (a) put your e-mail in the Subscribe to Updates box to your right and be the first to know; (b) use the Search All HIStalk Sites box to dig through all HIStalk-related sites, including the 7+ years since HIStalk has been around; (c) send me your secret information and rumors via an anonymous Rumor Report, the lifeblood of HIStalk; (d) Friend or Like us on Facebook; (e) support my sponsors by giving their ads an occasional look and click; and (f) send in a pitch-free Readers Write article.

Not many readers think the final Meaningful Use requirements are too hard for providers to meet, but beyond that, it’s pretty much even as to whether they’re too easy or about right. New poll to your right: who benefits most from Most Wired-type awards?

A reader mentioned a JAMIA article last week, eliciting only a general reply from me since I didn’t have access to the full text version. Thanks to the folks at AMIA, who read my comment and hooked me up with anonymous access to their site so I can give a better answer next time around.

This from Weird News Inga: a medical practice sues its landlord over rights to a meteorite that crashed through the roof and into their examination room. The landlord claim it belongs to them, but the doctors say the landlord plans to renege on their promise to sell it to the Smithsonian for $5,000. The doctors say they’ll honor that deal and send the money to Doctors Without Borders for Haitian relief.

These rumors come up all the time, but once again Oracle comes up as a potential acquirer of Cerner. An Oracle VP supposedly claimed the company will spend $70 billion on acquisitions over the next five years, which always leads to talk about vertical markets such as healthcare, which means Cerner.

Duke University researchers develop software to predict MRSA drug resistance, offering it free to researchers.

Interesting: All Children’s Hospital (FL) will become part of Johns Hopkins Medicine (MD). In related news, the governor of Maryland wants to position the state as a health IT leader, citing a statewide HIE, EHR implementations, and recruitment of HIT professionals.

E-mail me.

News 7/23/10

From Erin: “Re: Medicity and Axolotl. I heard a rumor that both were on the sale block with active participants. That sure would give a new stimulus to the HIE market.” Unverified. The rumors I’ve heard say that Raymond James is shopping Axolotl, with a possibility that RelayHealth will be announced as the buyer soon. Medicity is getting feelers, supposedly, but it’s going to take some serious cash to get their keys and I’d expect the company to do some acquisitions of its own to raise the stakes. It’s a pretty great time to be in the HIE business since everybody wants government money, connectivity, and control of massive amounts of data. The proposed Ingenix acquisition of Picis may be the first signal that insurance companies (like Ingenix parent UnitedHealth Group, market cap $35 billion) are putting their smartest guys in the room on the problem of how to position themselves for healthcare reform.

From Dan Mann: “Re: Epic. Signed LSU’s 10 hospitals.” Unverified, but this is getting ridiculous. Does any vendor other than Epic ever sell a full system to a 400-plus bed hospital these days?

From Flynn: “Re: Most Wired. Why haven’t you mentioned the winners?” Because I don’t care. Hospital IT is not a competitive sport, other than for magazines hoping to sell ads, their vendor advertisers hoping to sell systems, and their participating CIOs seeking a career-enhancing resume credential. Filling out a survey of what you’re doing with computers doesn’t impress me nearly as much as proving your technology-driven superior patient outcomes and lower costs. Unfortunately, the winners can’t usually do that (and in fact, the relationship often seems to be inverse).

From Kelly: “Re: Mike Cottle. The IT director at the former Sumter Regional Hospital has taken an IT director job at Newton Medical Center (KS).” I interviewed Mike after a tornado destroyed his hospital in 2007.

From Laura V: “Re: Picis. What’s up with your sponsors getting bought?” Inga and I were just talking about that. I’m not claiming a relationship, but companies that sponsor HIStalk seem to have a great track record in being acquired under favorable terms. We like to take a small amount of credit for their success even though we usually lose a paying sponsor, so our celebration is short lived. I did get some nice e-mails this week from some investment banker types who appreciate what I do, so thanks to them.

From Ted Nugent: “Re: Ingenix. The Picis acquisition implies they’ll be doing other acute care deals soon. Healthland or SIS, perhaps? Both have a book out.” Unverified. It’s funny how you’ve never heard a phrase, then suddenly you hear it from a bunch of different people. “Have a book out” means a company is seeking a buyer, as I now smugly know.

From Briana: “Re: CPHIT, CPEHR, and CPHIE certifications. Are they worth pursuing? Do hiring managers care? I have 25 years in healthcare IT.” You’ll get different opinions, mostly depending on whether the person you ask holds certifications, but I consider these (and any other certifications, whether it be CPHIMS, certified healthcare CIO, etc.) mostly a waste of time and money unless you have no other credential and are desperate to hide a lack of experience or formal education. I’m not trying to be harsh, just realistic: non-technical certifications don’t mean anything except as an income source to those who offer them, some of which are purely for-profit companies exploiting career insecurity (lack of a degree, lack of work history, lack of US experience, etc.) If in doubt, read a bunch of healthcare IT job listings and count those that require or favor certification (the military is a possible exception since they do in some cases). Nobody’s going to hire you just because you wave some credential they’ve never heard of. We’ll know the industry has lost its mind if it requires a 25-year HIT veteran to prove they didn’t snooze through it by passing a multiple choice test. But certification can’t hurt, so if you don’t mind spending the time or money, do it with appropriately modest ROI expectations.

From Safety Not: “Re: JAMIA article on unintended consequences of e-prescribing. It is not known whether there are advantages over paper in the real world of medical care.” I didn’t see a full text link, but the abstract says the problem is allowing prescribers to enter free text instructions, basically turning e-prescribing into a clipboard with the same inherent risks. I wouldn’t take that as being indicative of a problem with those systems, but rather how they are deployed.

Listening: Scarlet Storm, “female-fronted symphonic gothic metal.” Found them accidentally, like them.

Inga did her usual bang-up job in collecting the thoughts of over 20 vendor executives on the final Meaningful Use rules (and in doing so, earned herself the night off from HIStalk). Some of them are really insightful, offering a fresh take that providers should notice. You can’t ask executives a question without expecting a little sales pitch and she got some of those, but I think every person she interviewed gave some good perspective or advice. Definitely worth a read. You’ll make Inga happy if you add your e-mail address to the Get Instant Updates box while you’re over there since she’s passionate about tracking her stats (she’s insecure in the cutest possible way).

Q2 numbers from athenahealth: revenue up 28%, EPS $0.04 vs. $0.06, beating expectations. Shares are up 7% in after hours trading as I write this.

Microsoft’s Q4 results: revenue up 22%, EPS $0.51 vs. $0.34, beating expectations. Good numbers, helped by Windows 7 and Office 2010.

Weird News Andy goes all culinary in his observational humor, asking of Terra Haute Regional Hospital, “Does their cafeteria serve Haute cuisine?”

Doctors in Australia complain about the new EMR installed in two hospitals, saying that it’s “unfriendly and wastes a lot of time” and “is an awkward electronic and written hybrid.” I can’t swear to it, but I think it’s Cerner, although the doctors say it’s an old version of whatever it is. “It is a US developed system, but in the US they are using version 11 while we are using version three.”

Confirmed: University of Michigan signs with Epic, ditching its homegrown CareWeb. The price was quoted at $20 million, but I would be shocked if that’s all it will cost (although that’s probably software only). The article also said that UM will be eligible for only $2 million in HITECH money, which also sounds way too low for a 930-bed hospital system.

Jobs: QA Engineer, Clinical Product Analyst, Project Manager – Physician Liaison, Web Application Developer.

Tim Thompson’s former CIO job at Methodist Houston is posted. Like many or most CIO jobs, this one requires only a bachelor’s degree and experience.

North Shore-LIJ chooses Skire Unifier for managing its capital projects. I’ll be honest: I hadn’t heard of it, but several big hospitals apparently have.

Harvard Medical School toughens up its conflict of interest rule for faculty, prohibiting them from shilling drugs and accepting free meals and trips. Their consulting and board income is also limited and payments of $5,000 or more must be reported on the school’s Web site. My hero, Senator Chuck Grassley, is largely responsible since he investigated some Harvard docs for taking Pfizer’s money (an excerpt to his letter to Pfizer’s CEO above).

GE Healthcare and Boeing are fighting over a section of the communications spectrum. Boeing uses it to test planes; GE wants it for patient monitoring.

WNA competitor Guy ran across this story. A woman who had just delivered a baby is visited by a group of women who enter her hospital room, shut the door, and start beating her up over comments she made on Facebook. People who’ve never worked in a hospital would be amazed at how often human drama unfolds right in the rooms. I’ve taken guns away from patients, watched a newly delivered 12-year-old mother hitting on a hospital security guard, and declined the offer of patients to share their recreational drugs. There’s a reason they put metal detectors and police officers at the ED door — hospitals are one place other than the driver’s license office where community demographics are proportionately represented.

E-mail me.

Ingenix To Acquire Picis

Ingenix announced this morning that it will acquire Picis, the Wakefield, MA-based vendor of high-acuity systems for surgery, anesthesia, intensive care, and the emergency department. Terms were not disclosed.

The announcement describes the strategy behind the acquisition:

Ingenix is best known as a leader in health intelligence and analytics throughout the health care system. The combination with Picis significantly strengthens Ingenix’s position in the delivery system, where Ingenix serves nearly 6,000 hospitals in the U.S. with consulting, technology and outsourcing solutions. Picis will extend Ingenix’s capabilities into the high-acuity information systems market.

Ingenix CEO Andy Slavitt was quoted as follows:

This marriage of ‘health intelligence’ and clinical workflow will provide substantial value to patients, physicians and hospitals. Tremendous opportunities exist to use information and technology to modernize the high-acuity area, delivering better care and greater efficiency to these high-volume areas of the hospital, where resource consumption is often at its greatest. Working with Picis’ world-class senior leadership team and talented employees, we believe we can make meaningful change in this critical segment of health care.

I spoke Wednesday morning with Todd Cozzens, Picis CEO and vice-chairman, who explained the rationale behind the acquisition.

”I’m happy with it –  this is a great home for Picis,” he said of Ingenix. “These guys are at the epicenter of what’s happening with healthcare. They know all aspects of reform – data mining and data analytics. Winning the game in reform is about having the best health intelligence. Ingenix has bought into the strategy of hospitals becoming high-acuity centers that need data to drive decisions and to understand the supply chain.”

Cozzens will serve as chief executive of the Ingenix high-acuity business. Most of the Picis management team will transition as well. Operations will remain in Wakefield.

Cozzens says the acquisition was driven by capital requirements. “The minimum market cap to be a serious publicly traded company is now at $1 billion,” he says. “It would have taken 3-4 years for us to get there.”

News 7/21/10

From News This Week: “Re: sale. One of your quoted CEOs will announce the sale of his company on Wednesday and hold an all-employee meeting on Thursday. A solid acquisition that will give the company extensibility internationally, although you will scratch your head for 3-4 months on what the purchaser is doing until the strategy emerges over the fall of 2010.” That’s Picis, I assume, although I don’t have solid information on the acquirer if it’s them (one reader says Ingenix, another says it’s a less obvious but unnamed player).

From Htx: “Re: Tim Thompson, CIO at The Methodist Hospital of Houston. He’s leaving to return to Florida.” Unverified. UPDATE: verified – he will be announced as the new CIO of BayCare (FL), Lindsey Jarrell’s old job.

From Cabrini Green: “Re: HIMSS Analytics Europe. HIMSS Analytics staff visited Germany to meet their new colleagues. The picture is funny — it looks like Steve Lieber and Jeremy Bonfini are holding hands.” It does, even though they aren’t.

From Elsie EHR: “Re: IBM. Who remembers ten years ago when IBM (along with Pfizer and Microsoft) sunk a chunk of change into an EMR called Amicore? Amicore was acquired by Misys in 2006, and of course Misys was acquired by Allscripts last year, which will merge with Eclipsys this year. Golly, I can hardly keep my dance card straight!”

Also from Elsie EHR: “Re: Aprima, formerly iMedica. I wonder if they will go after the Allscripts MyWay customers since MyWay and Aprima are the exact same product?” Careful … I don’t have confirmation on the rumor that Allscripts will sunset MyWay in 2012, so I assume it’s not true. Also, just to clarify, MyWay was the same product as Aprima only when that deal was originally signed in August 2007 (see my interview with Michael Nissenbaum, president and CEO, for more background). Since then, Aprima has continued to develop and sell the product separately from Allscripts, so they are no longer the same product even though much of their DNA is identical.

From UK Horlicks: “Re: British Medical Association. It has recognized Horlicks, the drink for HIT, with the slogan, ‘A drink other than Kool-Aid for HIT.” BMA demands that the government suspend access to Summary Care Records, saying it is unreliable since doctors aren’t keeping the uploaded patient records current.

From Anesthete: “Re: University of Michigan Hospitals. Recently signed with Epic to provide enterprise clinicals and financials in a plan to achieve MU.” Unverified. I mentioned that Hurley, which is affiliated with UM, had signed on, but that’s all I know. UM used to have a homegrown system that someone was trying to sell as I recall, but I never heard much about it.

From Zooey Rice: “Re: Amalga. A user of the Microsoft Amalga HIS says the company will exit the HIS market to concentrate on other things, like HealthVault or UIS. Love reading you every morning — smells like … victory.” Verified. Microsoft will announce Friday that its Health Solutions Group will discontinue sales and development of Amalga HIS to focus on Amalga Unified Intelligence System (the former Azyxxi). I didn’t really understand why they bought it in the first place considering it was a Thailand-based product with one notable customer, medical tourism hospital Bumrungrad International in Bangkok. Hanging the Amalga name on it was just plain confusing since in the US, Amalga was just the former Azyxxi product. My comment in 2007: “I don’t know why Microsoft wants to be in this business either, although maybe Azyxxi needs a little brother.” More from the company:

Amalga HIS, based on technology acquired from Global Care Solutions in 2007, is a traditional hospital information system designed to address all of a hospital’s transactional and reporting needs. Working with customers over the past three years, we’ve learned that an all-encompassing solution is not optimal for meeting the varied and dynamic needs of health organizations around the world. As a result, this approach is not well aligned to Microsoft’s broader health IT strategy moving forward. We will continue to develop and sell a RIS/PACS solution based on Amalga HIS and will look at other opportunities to leverage Amalga HIS functionality on the Amalga UIS platform.

HSG will continue to support our customers’ use of Amalga HIS through sustained engineering and support services for at least five years. We are working with each Amalga HIS customer to address their short and longer-term needs – moving them forward to HIS version 6.0 or identifying partner solutions that, together with Amalga UIS, could meet their requirements. Amalga UIS, based on the Azyxxi technology, is a highly flexible solution that enables healthcare organizations to reengineer workflows and get information to professionals when and where they need it.

From Cassie: “Re: St. Luke’s Health System in Boise. They’ve had a data breach in which a significant number of employee records, including SSNs, have gone missing. They are trying to squash the news report, especially given the other recent news from them.” Verified, but it wasn’t the health system’s fault. Mercer, the HR consulting people, loses a St. Luke’s backup tape when moving to a new office. St. Luke’s was in the news last week when its data center lost power, forcing clinicians back to paper.

Listening: Built to Spill, Boise-based, mature, Northwest-style indie rock.

Allscripts’ Q4 numbers: revenue up 14%, EPS $0.10 vs. $0.09, guiding up. The company beat expectations on both revenue and earnings for the quarter, but fell just short on consensus yearly revenue. CORRECTION: Allscripts actually slightly beat yearly revenue expectations – it was the company’s 2011 guidance that came in slightly low in the range of expectations, an announced $780 to $790 million vs. estimates of $787 million. All of these numbers exclude the impact of the Eclipsys acquisition. The conference call transcript is here.

Apple’s Q3 numbers: revenue up 61%, EPS $3.51 vs. $2.01, handily beating estimates. The company sold 3.3 million iPads, 9.4 million iPods, 8.4 million iPhones, and 3.5 million Macs in the quarter. Market cap is $229 billion, $6 billion more than Microsoft, and shares are naturally up on after-hours trading.

Iowa’s HITREC names e-MDs as a preferred EHR vendor.

ONCHIT is looking for a policy analyst to focus on consumer e-health.

Weird News Andy is reduced to puns in describing medical technology put to a seedy use — MRIs of food. Obviously fixated, he adds, “The one I found most interesting was the watermelon. The way the seed groups spiral puts to rest my sleepless nights wondering about their seemingly random distribution.”

HCA Midwest names Sarah Bloom as CIO.

Kingman Regional Medical Center (AZ) chooses SIS for periop.

Another backup tape mishap: South Shore Hospital (MA) determines that backups with 800,000 patient records were lost by the shipper on their way to destruction.

Epocrates files for a $75 million IPO, the same amount it planned to raise in its aborted 2008 attempt. Sales are at $100 million, but the company lost money in the most recent quarter. It plans to bring out some kind of EMR application for small practices this year.

Confirmed, thanks to a reader’s forwarded company e-mail: Kate Kervin joins NextGen as  SVP of marketing and product management, leaving Siemens. Brad Block of IBM (and former Doylestown Hospital CIO) is hired as VP of NextGen Consulting.

Minneapolis-based HealthPartners will use a mobile healthcare communications platform from Toronto-based Diversinet, starting with a two-way secure messaging system for discharged patients with chronic illness and women with high-risk pregnancies.

New Hanover Regional Medical Center (NC) chooses Perceptive Software’s ImageNow for scanning and approval of invoices, integrated with Lawson.

SAP partners with a consulting firm to develop financial and logistics applications for under-400-bed hospitals.

Jersey City Medical Center (NJ) rolls out the Isabel diagnostic checklist system.

Iron Mountain announces its EMR Enablement Solution to help hospitals organize and digitize paper records. It sounds like a marketing repackaging of existing offerings.

Small practice EMR vendor Patagonia Health gets a startup grant from a technology accelerator in its home state of North Carolina. Its product went GA on March 31. Former Misys software director Ashok Mathur is a co-founder.

This fun article profiles some doctors who write medical smart phone apps.

MedPATH Networks announces a marketing agreement with a digital rights vendor to commercialize security technologies that are used for military EMRs, including a secure information exchange based on NHIN standards. I haven’t heard of any of this, but it sounds interesting.

E-mail me.

HERtalk by Inga

HIMSS names three additional finalists for the Davies Awards, including Open Door Family Medical Center (NY) in the Community Health Organization category and Sentara Healthcare (VA) and Nemours (DE) in the Organizational category.

Beaufort Memorial Hospital (SC) says the installation of MEDHOST in its ED increased gross revenues by $1.3 million increase and saved $240,000 annually by replacing dictation with electronic charting. And, Tenet Healthcare has contracted with MEDHOST to add the Care Clock application, which enables hospitals to automatically post current ED wait times to their Web sites.

New from KLAS: a report on homecare finds that three of the top four rated homecare systems are sold by best-of-breed vendors. The top-rated vendors were Homecare Homebase, Delta, and CareAnyware. Meanwhile, Meditech clients find that PTcT is outdated and difficult to use, with 40% saying they’re considering a switch.

HHS wants to use ARRA money to develop a national inventory of research on the most effective treatments and medical interventions. The information would be available as a searchable online tool for physicians and the public.

Huntington Memorial Hospital (CA) selects the Allscripts Community Solution to power its HIE. The Community Record solution is powered by dbMotion. Centra (VA) also plans to implement the Community Exchange platform as well as provide Allscripts EHR for 70 staff and affiliated providers and Allscripts Homecare for its home health nurses.

Globally, wi-fi technology in healthcare grew 60% last year. The US healthcare market will add more than 500,000 additional networks this year, representing a 50% jump over last year.

Giant Mr. Whale has apparently found a new home at Epic’s headquarters, according to the artist. He (Mr. Whale) looks like a happy guy. The artist has a link on his Web site to more attractions on the Epic campus. I think my favorite is the subway.

ITalagen and Medificiency form a partnership to promote a physician practice solution that includes Allscripts EHR and ITegen’s medical billing services and IT support.

No surprise here: an survey finds that EHR implementations are the top priority among the HIT crowd, with 85% saying they are in the  midst of an EHR project or plan to start one within 18 months. More surprising: of the 110 professionals surveyed, 13% reported using Epic, 11%  Cerner, and 8% Siemens. How “random” are these results if Meditech or McKesson weren’t named?

I must ask Matt Holt if this qualifies as Health 2.0. A 64-year-old Pennsylvania woman avoids dialysis after finding a donor kidney via Facebook, getting 197 responses to her plea.

Philips Healthcare’s second-quarter sales were up 4% over last year and second quarter earnings were $280 million, compared to $198 million. CFO Pierre-Jean Sivignon said the US healthcare market was “bouncing back” after a period of financial crisis and regulatory uncertainty.

E-mail Inga.

HIStalk Interviews Barry Chaiken

Barry Chaiken, MD, MPH, FHIMSS is chief medical officer of Imprivata.

 

According to your LinkedIn profile, you’re CMO for Imprivata, CMIO for Symphony Corporation, and CMO of DocsNetwork. You’re on a couple of advisory boards, you own a vineyard, and you just finished your term as chair of the HIMSS board. I’m not sure exactly what you do all day.

I’d like to say that what I do is try to tend to my grapes, but they’re too far away, so I don’t do that.

DocsNetwork is my personal consulting company. It’s just me. I will contract with companies like Imprivata, who basically are at a size where they really don’t have enough work for a full-time CMO. I make sure that none of the people I contract with cross industries and such.

I essentially work for Imprivata. I’m really their healthcare lead and advise them and help them with their healthcare advisory board and basically function as a CMO as much as they need a CMO at this stage. I imagine if they grow, they’ll need more of my time.

Symphony Corporation is a company out of Madison, Wisconsin. I essentially function as an advisor to them. They currently do have their own CMO who works considerably more time than I do. I just help them with some informatics issues.

My vineyard is Chaiken Vineyards down in Uco Valley in Argentina.

I’m most intrigued by the vineyard thing. How does that work?

It’s really a great deal. Woody Allen once said 90% of life is just showing up. I love to travel down to Argentina. I visited Mendoza and I’ve had a long-standing interest in wine. I collect some, drink some, give away as gifts some.

I just stumbled on this wine project that two Americans and the Argentines started several years ago. I got to know friends and family with them and it’s been a great project. I was one of the original 13 of 14 private vineyard estate owners and investors. Now they have almost 80 and they’re going to go to 100.

They just announced they’re going to build a resort on the property. It’s about 60 miles south of Mendoza. They have a great team, great winemakers, and it’s something that you can do in Argentina which you really can’t do in the US or France unless you have a lot of money, which is not one of the things that I have a lot of.

Let’s get back to business now, although that’s a business for you, too. As a physician who works for an organization whose forte is user access and security, you must be the guy who has to make the argument for convenience versus application security. How do you think most hospitals fall in that continuum of convenience versus IT’s lockdown?

First off, you have to address the issues of security and privacy. I think that’s incredibly important. If we digitize everything, you’re going to need to do more of that.

I’m not sure security and privacy and convenience and ease of use are mutual exclusives. I think you can do both of them together. I think the technology exists that you can do them together. Maybe 10 years ago it didn’t, or maybe five years ago, or even maybe two years ago that didn’t exist, but I think it really does exist now.

We have smart cards. We have other ways of authentication, whether it’s fingerprints and things like that, that can make it easy for people to login and log off, just like we’re spending the time learning about workflow. For clinician workflow, how to present the clinical information for the physicians in a way that is useful for both them and efficient and useful for the patient. I think that we’re also learning about the importance of the workflow, securing a desktop, and we can do that today with a variety of technologies we have.

Imprivata has a lot of those technologies. What made me very interested in Imprivata and wanting to work with them is that I understood there’s clinical workflow that’s within, say, an electronic medical record or a clinical decision support tool. But the reality is you’re bringing together multiple applications either from a single vendor, more than likely from multiple vendors, so that has to be created into a clinical workflow which is what hospitals and consultants work on.

There’s this other piece, which is how do you glue all these pieces together? Single sign-on can clearly happen. There’s an intelligence about how you secure a desktop. How long is a timeout? What devices to use to log on and log off? What makes sense with those devices that you use to log on and log off or back on?

For example, one of the products Imprivata has is Secure Walk-Away. It’s very simple. Basically, when you logon to a desktop and a workstation, it uses a camera — which we know today are very inexpensive — and it doesn’t go to a database to look up your photo or your image. What it does is it takes multiple images of you when you log on. It takes images with you turning your head, it takes images with and without your glasses on — whatever you may focus on that camera, it takes that image. The minute you’re out of the view of the camera, the screen goes blank. It goes black. You walk back in within a specific time period and the screen will come up again as if you were there and automatically you’re logged on.

What’s nice about that is it allows the workflow, right? The doctor might be talking to a patient and then walk back into the view of the camera and wants to be able to enter some information. Walk away, walk back, walk away, walk back — it instantly brings up the screen, but when they’re out of view, it blanks the screen and that secures that desktop, yet still facilitates the workflow.

What’s really nice is that you don’t have to have this database of images of you in different styles of glasses or haircuts or whatever. It’s just for that moment when you log on at that desktop, so it works to facilitate that workflow while securing the desktop.

Even though IT shops spend a lot of time worrying about applications, it seems like a lot of the physician frustration is one of two simple things that are infrastructure-based; either they have to wait in line to get to a device or log in multiple times once they get one. If you were a hospital, how would you choose a single technology? Or, what would you do to assess that situation and resolve it?

Let me give you an analogy. I’m sure you’ve flown. I’m sure almost all of us have gotten to the airport and you had to go fly. We’re waiting on line to go through TSA and security and we don’t get really happy when we don’t have enough people who screen people in screening lines, do we?

The first thing you have to do is do an assessment of how many workstations you need. Not by counting numbers, by looking at the workflow that’s within your existing environment in your hospital. Make sure that they are available, because in reality, those devices are relatively cheap compared to the time of the clinicians — the physician, nurses, and others — who may need to access that. You want to make sure you have enough devices available.

Then, you have to design the clinical workflow within the application to make sure that fits two needs. One, it is streamlined — it makes sense. Also, it produces good outcomes.

The last thing is you should look at the existing technologies to facilitate the workflow between applications — single sign-on, secure authorization, things like that — to make sure you’re able to keep the medical information private and secure, but facilitate the workflow. That technology exists. Every day it’s less expensive to do, but I think the IT department has to focus on workflow. Workflow backs up to enough devices, backs up to a secure way to access those devices. That facilitates, encourages, and makes seamless that workflow. That way, the hospital can focus on the clinical care of the patient and the physicians can focus on the best clinical workflow to deliver the best care to those patients.

How do you think mobile devices are changing the whole security picture?

Big problem. They’re really a big problem. I have to tell you, for years I’ve been speaking to people who’ve talked about that problem of securing those devices. Now we have an iPad and I imagine revision two or revision three of the iPad’s going to have a camera in it too, besides a smart phone.

Now you have these unsecured networks sending personal health information over them. That’s a big problem. I think that problem needs to be addressed. As best as I know, there’s no technology to specifically address it right now. I mean, I guess you can shut off everybody’s smart phone, but still, they can take pictures and when they leave the hospital they can obviously send them.

I think the first thing you have to do is to educate the clinical people about the security issues and privacy issues about using their smart phones or their iPads or whatever else device they may have — or their cameras, even — and understand what the rules are and why those rules need to be followed. Then, over time, I think we’ll develop technology to lock down. I should really use the word ‘secure’ — to secure, whether it’s a smart phone, the iPad, the tablet, the whatever — to make sure that the PHI is protected.

Do you think part of the reason doctors and other clinicians like portable devices is that they bypass a lot of the IT restrictions on devices that aren’t theirs full-time; can’t be personalized, and aren’t really under their control?

You know what? That’s possible, but you know what I think it really is? Let’s think about what a physician does. The physician is the only professional that I know of, the only one I know of, who every single day of their career is never like the day before. I’m not talking about what they see or the work they have to do. I’m talking about where they are, where they physically are. No physician walks into their office and sees patients, room 1, 2, 3, 1, 2, 3 — they don’t do that. They move whatever is happening for the day. They may spend more time in one room or the other, and the same thing in a hospital, they roam all over the place and it’s never the same.

But if you think about an attorney, an accountant, those types of professionals — they walk into their office, they sit at the desk. Their pencil is in the same place, their computer screen is in the same place. Everything is the same for them and they get to do their work.

What happens is doctors have to have their desktop roam with them. The only way today that we do that all over the place is through these smart phones. They have their own personal device they put in their pocket, they have it in their arm, and they can use it for multiple things. You could use it for Hospital A, Hospital B, Hospital C. They can use it for their practice, depending on how they set it up. It’s a very convenient device for them. Applications that allow that desktop to move around with the physician are the ones that will usurp those smart phones and the other things that they carry around with them.

Imprivata has a product that allows them to do that with the roaming. It moves the desktop around the hospital. But for now, it works within the hospital, in the application. At some point we’ll have a device that allows that desktop, in whatever form factor we have it in, it will allow that physician to move around everywhere with that secure desktop and do their clinical work. Then they won’t care about having IT locking it down and wanting to go outside IT. Except the way the applications are implemented and the workflows don’t fit in to how the physician wants to work.

I understand the concerns of the IT departments around security and I commend them for the work they’re trying to preserve — the security and privacy of the PHI. What we need to do is let’s think a little bit outside the box here. Let’s put a couple of things together. Let’s think about the clinical workflow and let’s think of the IT issues in securing the desktop. Let’s get a bunch of people together, those multidisciplinary people together, to figure out what’s the best clinical workflows that we can satisfy both for those stakeholders.

As you look back at your term as chair of the HIMSS board, what would you say the organization is doing right and what would you like to see it do differently?

First off, I really enjoyed being part of HIMSS. I think that HIMSS has been a great experience for me, and probably for a lot of my colleagues. The thing that’s really wonderful about HIMSS is that, really, all the volunteers really decide what happens at HIMSS and things bubble up from committees. A lot of times people on the outside really don’t see that.

When I was on the board, anything that would be presented to the board that we would vote on and endorse, so to speak, or any position that came through, always came from all of these committees of volunteers that were just spread all over the place. As HIMSS chair, I got to review some of those resumes of those people on the committees and then appoint them at recommendations by staff and others. The diversity was enormous. I think the thing that’s wonderful about HIMSS is the fact that it has this diverse group of folks.

In this past year, one of the things I specifically emphasized in my HIMSS keynote was the idea of clinical transformation, which was, let’s see if we can make access to care better. Let’s see if we can make it safer. Let’s see if we can make it higher quality. Let’s see if we can reduce the cost of providing the care. My belief is that IT is able to do that.

I think that I’d love to see HIMSS continue with that and emphasize that clinical transformation and emphasize helping other stakeholders in other disciplines be able to improve healthcare and make it affordable for us. We’re on this cost curve that’s really unsustainable and we need to fix. Our quality isn’t there, our safety isn’t there, and our accessibility isn’t there. I just believe IT can help and I think HIMSS can be a leader for that.

I noticed in your keynote that you were talking about population health and arguing that automation is needed. But what HIMSS does is primarily just work within the four walls of the provider’s office, helping make episodic healthcare delivery more efficient and caring nothing about health in general. Other than the fact that healthcare services delivery is profitable and population health isn’t, why do those areas have to be so different?

Well, let’s look about healthcare policy. It’s, you know, reimbursement.

I just recently had a conversation with a colleague of mine. We were talking about accountable healthcare organizations, talking about medical home, things like that. Currently, providers across the spectrum are incented to provide volume care. They’re not incented to deliver value. I don’t blame any of those providers. We know from studies of human behavior that even if the conscience says, “I want to do X;” if there’s an incentive that’s subconscious, they end up not doing exactly X.

We need to change our reimbursement system that reimburses all of us for quality, accessible, safe care. That’s what we need to do. HIMSS has to and will, with other stakeholders, medical organizations, other hospital associations, medical societies, nursing societies and others, get together and decide what they need to do as stakeholders and push towards changing that reimbursement so it compensates providers for their quality and value that they deliver, as opposed to the number of times they’re able to do a particular test or procedure or have an admission or whatever.

We see, in organizations that have different types of reimbursement models, that we see different utilization patterns. I know the society is very concerned, our public is very concerned, about limiting care, but the one thing you have to understand is more care is not better care. More care is just more care. What we need to do is forget about more or less care. Let’s just get better care.

You also said that the industry needs to create solutions that are so compelling that people want to use them and that it shouldn’t be because an executive order, that demand should be created by the quality of the products. Is anybody doing that? I’m not seeing anything where people are getting excited about somebody’s product to use it voluntarily.

Well, I think we’re still at a tipping point. I think I wrote about that in a piece called “The Glue” recently. People are working and making the applications work better, you know? Let’s be fair to these folks.

You’ve probably used Mac, an Apple product like an iPad or an iTouch, or an iPhone I imagine, right? If you compare that to your experience using some other, whether it’s a Microsoft product or somebody else’s product, clearly there’s something about that user interface that makes it incredibly compelling to people. Look, they sold over two million iPads in the last six weeks. Man, that’s a lot of iPads in six weeks.

We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better. Let’s hold them accountable if they don’t. Absolutely, hold them accountable if they don’t; and the marketplace, I hope, will be able to make those choices and hold them accountable when they don’t. But, we’re still learning.

But HITECH has pushed the marketplace into buying today. Everybody’s picking their dance partner now for a lot of years, so everybody’s buying the same stuff that was already being sold. Where’s the market incentive to put out a better product when everybody’s bought what they’re going to be stuck with for years?

Well, there’s still the clinical workflow. You still have to worry about putting together the clinical workflow. It’s not just the app.

OK, but if you’re the vendor, what’s your incentive? If you’ve sold all of the systems you’re going to sell because everybody’s blown their HITECH money and now there’s no market out there, what’s the incentive? How do you get existing customers to convince vendors to improve their product when they’ve already signed on the line which is dotted?

I think you’re going to have to ask the vendor that. I’m not a vendor of an EMR system, so you’re going to have to ask the Epics and McKessons and Cerners and Eclipsys, and Meditechs and GEs of the world what they are doing, I think. I still emphasize the fact that it’s about the clinical workflow, and they need to go — and the hospital has to be a partner in that — to improve that clinical workflow and make it better. You know, the reimbursement systems are a little bit crazy.

I did work for a vendor. It’s really weird. On the one hand, when you have an EMR, for example, it’s really dealing with two masters. One master is I want to be able to record the clinical data on a patient so I can treat them as best as I possibly can. I’m a clinician, I know that. I want to record the data so I can do a better job. I’ve seen plenty of paper records that you don’t know what the heck is going on if you want to do that.

On the other hand, I have to record the data in a way that I optimize my coding so I get paid what I deserve. If you’re an EMR vendor and you have to write code to be able to address those two issues, that’s a real challenge. Then, for the end user, it’s a real challenge. But, I think we can get around that. I mean, there are things that new technologies are coming out all the time.

I think, relevant to the workflow, again, we have to redo that workflow. I think what Imprivata has to offer allows, at least — that single sign-on and the authentication and privacy protection — that allows us to bring these apps in a way that hospitals and the clinicians in those hospitals can work to develop their own effective workflow.

Last question. If you look out five to ten years, what would you predict will happen with healthcare IT versus what you would like to happen?

OK, let me say what I’d like to happen. I think the whole way that we deliver healthcare in the US has to be completely redone. Of course, our incentives — we talked a lot about that, but what I think is we have to really leverage information technology in such a way that doctors no longer do what they do today, nurses no longer do what they do today, other clinicians no longer do what they do today.

In other words, if I have a runny nose, I don’t necessarily need to see a physician to be able to be diagnosed on that runny nose. I can go ahead and see somebody who’s trained at a lesser level who will see hundreds and hundreds and hundreds of thousands of runny noses. Then, if my runny nose is different than the normal runny nose, they know to escalate, to triage me up to the clinician who’d be better suited to treat me.

What we need to do, is if we know best practices, if we know clinical knowledge, we know the things that really make people better that deliver better outcomes at lower cost. Forget about the cost for a moment. Just deliver a better outcome, less morbidity, less mortality, OK? We need to have that, to have everybody access that best care. Right now, we don’t access that best care.

If you want to predict what a physician’s going to do in their practice, all you need to do is look at where they got their medical degree and look at where they did their residency. That will predict the practice patterns that they will follow. We need to change that. We need to choose best practices.

I think IT is the way to deliver, at the desktop, at the point-of-care with the patient, best practices. There isn’t a single best practice most of the time. There may be a couple of different best practices, and for a variety of reasons, you may choose one over the other. The thing that a human being does better than a computer, and will do for some time, is their ability to use disparate pieces of information.

Let’s assume a patient has coronary artery disease, so they have high lipid levels and they have diabetes. Maybe today they also have a cut on their arm and it looks like it’s getting an infection. You can look at best practices for treating that patient. Computers can’t pull those three diseases together today, but a human being can do that. They can look at those best practices and put together a treatment plan for that patient that really will work well for that patient. Oh, and on top of that, the physician or the nurse or the other clinician can motivate that patient to take their medications, to follow their treatment plan to get them better — again, something that a computer can’t do.

What I want to see, what my vision is 10 years from now, is you’re going to see more and more clinicians who are going to be rewarded, who are going to be respected for their ability to synthesize multiple sources of information and then deliver it in a good care plan for a patient and treating their patient, instead of being looked up to because of their ability to remember a long list of facts. Computers are great at remembering facts. We don’t need to do that as human beings anymore. Human beings are great at pattern recognition. We should be able to move in the clinical space where physicians and nurses and others are doing their skill set around pattern recognition and treating the patients. IT is the source of that.

You asked me what I didn’t think was going to happen? Well, what I don’t think will happen, I don’t think it’s going to move as fast as I want it to, you know? I think we should do this now. I think we should be teaching this kind of stuff in medical schools and in residency programs and switching to that type of environment. That’s the way we’re really going to leverage healthcare IT.

Monday Morning Update 7/19/10

From Friend of Tim: “Re: Yale New Haven. They’ve signed with Epic and the CIO is out.” Verified. Health system SVP/CIO Mark Andersen confirms that YNHH signed a contract with Epic this week (no surprise there – I said months ago that they were going Epic if they could find the money and Mark confirmed). They just brought up Eclipsys Sunrise CPOE and pharmacy a couple of years ago and were also running nurse and physician documentation, so Eclipsys loses a high-profile customer. With the Epic deal done, Mark will be leaving in a couple of weeks after 13 years there. He’s always been gracious and quick in responding to my questions. I wish him the best.

From CP Uh-Oh: “Re: Chicago CPOE error detailed in a Friday happy hour e-mail blast.” The purported e-mail from a Chicago hospital radiologist:

We have discovered a systems issue that may convert CPOE orders for CT examinations without IV contrast into CT examinations with IV contrast in Radiant. I have asked all Radiology Faculty and trainees to be particularly cautious in protocoling CT contrast examinations, and would like to enlist your assistance in carefully checking contrast CT orders. In addition, until the problem is solved, it would be prudent to call CT to verify that contrast will not be administered to at risk patients. Your support is appreciated.

From CPAhole: “Re: Allscripts MyWay. I heard they’ve said they won’t support ICD-10 in MyWay since it will be sunsetted in 2012.” Unverified. I’ll be incognito at the Allscripts user meeting August 5-7, so if I don’t hear anything before then, I’m sure I will there in Las Vegas. Inga and I speculated when the merger was announced that MyWay was the square peg in a round hole, but we were just guessing then, too.

From A Once-Burned Skeptic: “Re: IBM’s $100 million healthcare investment. This strikes me as funny. Didn’t IBM invest roughly the same amount a few years ago by buying Healthlink, which had doctors and nurses focusing on healthcare transformation? If IBM would have simply retained the talent they had from that acquisition, they would be well positioned to do exactly this right now. Call me a skeptic on IBM’s interest in healthcare.” Everyone should be skeptical since companies like IBM and Oracle are always immersing themselves in healthcare for a couple of years, then losing interest after spending a ton of money with little to show for it. IBM couldn’t keep Kaiser as a customer for its expensive custom software development once Epic got traction, blowing through $400 million of Kaiser’s endless fortunes before they were replaced with Epic for $2-4 billion. I’m not sure how its $400 million deal with UPMC turned out. Healthcare IT is one of those things that seems to work backward from nearly every other product: the bigger and more diversified the company selling it, the less impressive the result.

HIStalk readers would have voted Don Berwick into his CMS administrator job given the chance, but only barely. New poll to your right: are the final Meaningful Use requirements for providers too easy, too hard, or about right?

Ed Marx has added his responses to your comments on his Strategic Plans – Getting to 2.0 post from last week. Want him to write about something specific? He would be pleased to hear from you.

CapSite will announce Monday that Saint Like’s Health System (MO) has subscribed to its service, which offers line-item pricing breakdowns from healthcare IT contracts and proposals in 60 categories.

Everybody, me included, is sick of hearing about Meaningful Use now that the regs are final. I think a few more practices in the 1-5 doc range might be interested with the bar lowered a bit, but I’d still bet most of them will run the numbers and pass, at least for now. The final MU requirements, as flexible and less demanding as they may be, still aren’t worth meeting in strictly financial terms, so that means hospitals, large practices, and tech-savvy small practices will get most of the checks. The great majority of practices and hospitals are small (1-5 docs and <100 beds, respectively) and I expect they’ll look at the ambitious timeline, the cost, and the stress on already-stressed doctors and simply say no to Uncle’s strings-attached cash (I’ve always called that my “Free Kittens” theory). We’ll see how accurate all those surveys have been that claimed the only thing holding docs up was upfront EMR cost.

Another new Epic site: Hurley Medical Center (MI).

Apple’s response to its embarrassing Antennagate iPhone 4 problems have been quite un-Apple like. I can imagine an HIT vendor faced with angry customer backlash over a CPOE bug reacting the same way in sequence: (a) it’s your fault for using our product incorrectly; (b) it’s actually not a problem, but a minor bug that makes it look like one and we’ll fix that eventually; (c) we’re not really sure if it’s a problem, but the best option is for you to spend your own time and money adding on a third-party solution; (d) OK, it might really be a problem, but it hasn’t been reported much, so it’s not a big deal; and (e) OK, it’s definitely a problem, but it’s the entire industry and not just us and everybody needs to do a better job.

GE’s Q2 numbers: revenue down 4%, EPS $0.30 vs. $0.27. Jeff Immelt says healthcare orders, along with oil and gas, were “particular bright spots.” GE Healthcare’s revenue and profit were up, at $4.1 billion and $661 million, respectively.

Verizon announces the Verizon Health Information Exchange, offering a clinical dashboard, patient index, and secure messaging. The MedVirginia RHIO has signed on, presumably meaning that its original (struggling) vendor Wellogic is out. Verizon’s offering runs on the Oracle Healthcare Transaction Base, which I thought had fizzled out years ago after the usual big splash followed by corporate indifference. Just in case it isn’t obvious, Verizon’s healthcare interest surged recently when taxpayer wealth was redistributed to make it more lucrative. Since HITECH, the company has announced services for security, telehealth, and physician data sharing.

A fun story: the guy responsible for killing a proposed Anthem Blue Cross 39% medical insurance rate increase in California is a work-from-home actuary who did part of his analysis from a hospital bed. California law requires the state to accept insurance rate hikes as long as the company proves it’s spending 70% of the premiums to pay medical claims (obviously that idea contains endless misaligned incentives that help keep healthcare costs rising). Hired by the state to double-check the insurance company’s numbers, the actuary found obscure mistakes in some of its inflation projections. Anthem and its corporate parent WellPoint claim appreciation for his diligence and express their relief in being able to hit the state up for less money (anybody buying that?) They resubmitted an increase request for half the original amount and then tried to hire him. A consumer group said, “He slew the giant. It was David versus Goliath, except David was armed with a calculator rather than a slingshot.” His tiny company also offers hospital services, including provider contracting and medical management reviews.

More only-in-California goofiness: 1,000 nursing union members picket the $3 million house of billionaire Meg Whitman, former eBay CEO and current candidate for governor. They’re upset at her promises to cut the state’s budget (including their pensions) even though it’s running a $20 billion deficit. She’s even in the polls with Jerry Brown even though she’s never held office and doesn’t even vote all the time. She’s spending up to $120 million of her own money to gain the seat.

St. Luke’s Health System (ID) loses power for 24 hours, forcing it to go to paper when its backup power systems also fail. My experience with backup generators is about the same as with data backups: they work about 80% of the time, which means IT is going to look really stupid in 20% of the unexpected disasters.

E-mail me.

HIStalk Interviews Rick Stockell

Rick Stockell is president of Stockell Healthcare Systems of Chesterfield, MO.

Tell me what Stockell Healthcare Systems does.

We write software for patient access and revenue cycle management. By patient access, that’s the registration and scheduling components. The revenue cycle is all of the regular registration, ADT, charge capture, medical records interfaces such as a 3M encoder, a collections module, and the 837 and 835 back. Eligibility checking, medical necessity checking, and those types of things.

Our roots are all the way back to McDonnell Douglas Healthcare that was here in St. Louis. We’ve been in the healthcare market for quite a while. We were a contract programming group from McDonnell Douglas. We did a lot of development for McDonnell Douglas and their mainframe and minicomputer lines.

We go back to the original UB-82. We were writing that, so we’ve been in the patient accounting and billing space for years and really understand how it’s changed and how it’s evolved. We’ve got a tremendous amount of experience in the patient accounting area and we’re going to use that to our advantage as we pull this product together. We’ve been in the business a long time, so we’re not an upstart.

Maybe everybody’s more familiar with the company than I am, but I mostly remember back in the days where 3M used your order entry system for Care Innovation, if I recall.

That’s correct.

Who would be most familiar with the company today?

We typically partner with electronic medical record companies. We’ve partnered with, like you say in the past, 3M. Until GE bought IDX, they used us for the same thing — order communication and order management. We also partner with Medsphere, with OpenVista. DSS is another one. They tend to be in the government space more than others.

They don’t have revenue cycle solutions. When they compete against the other healthcare vendors in the marketplace and to have complete solutions, they need an answer for patient access and revenue cycle. We’ve partnered with them. We’ve done that multiple times with them.

Also, some new ones that are international. Alert is one out of Portugal. We are also partnering with Eclipsys internationally. We closed a deal in Kuala Lampur, Malaysia — Pantai Health System.

I saw that. How did that come to be? You don’t think of revenue cycle when you think international, yet you’ve got this string of hospitals in Malaysia.

It has to do more with the footprint of the product. It’s all on a Microsoft technology, so it doesn’t require mainframes or any of that type of thing.

A lot of the older patient accounting and billing systems — ones that have been in the market for years, really, 25, 30, maybe even 40 years in the case of the Invision product line — most of them came from batch-oriented systems. They require a lot of hardware, a lot of software, layered products, and bolt-ons for them to be useful. It’s just not conducive to the international market because there’s such a large amount of the architecture dedicated to third-party reimbursement here in the States and the regulatory environment here, so it’s a lot different there.

It’s a real-time system as opposed to batch. The footprint’s smaller and it’s easier to use. It’s very user-friendly. It makes sense really quick. It’s got a complete relational database designed underneath it. To configure it for different needs is relatively easy to do. We’re in a lot of different market settings — behavioral health, long-term psychiatric, government, all kinds of different reimbursement models.

At Indian Health, we have three sites. We’ve gone independent from the Indian Health Services and we’re opening our own facilities and they’re like a commercial private/public consortium. We’re very, very flexible in our abilities to implement different revenue cycle designs, Because of that flexibility, it lends itself to the international market.

You mentioned the Alert product and a couple of variations of the VistA product. How easy is it to coexist with those applications?

It’s actually very easy. I think we’ve integrated now with interfaces to about eight different clinical information systems; including Cerner and Eclipsys. We did it with GE as well, their original Centricity line. I think they re-labeled all that. Now it’s really the IDX product, but we haven’t integrated with the IDX system. But the precursor, the original versions of Centricity, we’ve integrated with. So, yes, we’ve done quite a few. In the behavioral health area, Sigmund, MindLink, and Sequest. 

We’re really, really good with HL7. You recalled we did order communication for 3M — their Care Innovation suite. We also built the order communication component for the original Centricity product for GE. Since we’ve had so much experience with HL7 integration with these electronic medical records and departmental systems, it’s really pretty straightforward for us to do integration to a clinical suite.

It sounds like you could either be the revenue cycle component for a vendor that has only the clinical and departmentals; or you could be the clinical component for someone who has the revenue cycle.

No, normally we’re really the revenue cycle. We’ll do some order communication if they don’t like order management. If they’re not really good HL7, bi-directional — you know, orders in and out and ADT and all that — if they’re really not good with HL7 or have limited capabilities with HL7, we can stand in as the order management system for them until such time as they can get that on board. Principally, we’re patient access and revenue cycle.

It seems like a lot of companies are either offering revenue cycle services or software, or both. What trends are you seeing out there since you’re the independent among that group?

The traditional revenue cycle sector is a lot of bolt-on technologies. They’ll work well or co-exist with Epic, Siemens, or McKesson and do a lot with the output of the bills. UBs and 1500s are produced off the primary patient accounting system. They do contract management, for example, a standalone; and then the 837 and 835, some of the electronic claims, and that type of thing. Maybe eligibility checking on the front end, that they just offer services that are really kind of bolt-on. They’re really integration-oriented, just in different pieces of an existing patient accounting system like the older ones.

Our approach is that we’ve built everything into the products, so contract management is part of the product. The eligibility checking and medical necessity checking is part of the product. We don’t need a bolt-on to do that. The 837 processing, 835 processing is embedded in the product so there’s less of a dependence on bolt-on technologies.

We find some of the bolt-on players are trying to get into where they can start to integrate more directly with the electronic medical record to increase their value. We can already do that, and have done that for about a decade now, plus, the order communication piece.

What would be the attraction for customers to look at your solution?

If they are in the market for a new electronic medical record system and they don’t have a good solution or it doesn’t integrate well. Their traditional system, their registration and patient accounting and billing systems — if they don’t integrate that well with the new EMR or if the vendor doesn’t have a good solution for that, then what we are is a replacement opportunity to replace that older patient accounting system with something that works more seamlessly with the electronic medical record. That’s so we can capture charges at the point of care if the electronic medical vendor that they choose doesn’t do charging very well. It handles the clinical components for orders and those end results, but it doesn’t do charging very well.

We can interface at the order level and convert those to charges — charge on order, charge on result — and map those orderable items to the appropriate charges. Then, of course we have a charge master and we can have the HCPCS codes and modifiers imbedded in the charges and make that a little bit more seamless, which reduces the batch charge entry requirement and less manual entry of charges.

I can see, with one of the VistA products or with Alert, they would probably bring you in as an option, but it must be tough if you’re trying to get replacement business. You’re competing against the vendor who’s already in-house. Is that difficult?

It can be because they’ve been in place for long periods of time, maybe 10 years or longer, that they’ve been working on the patient accounting system. But some of the problems with that is that they can’t get the reports they need. It’s difficult to get the information out of the system. They don’t have as good a control over the revenue cycle. Either their AR days are longer or there’s more leakage of cash or reimbursement because of all the integrations they have to do to the bolt-on products.

We can build a pretty good business case that it’s more seamless, it works better with the clinical information system, reduces the amount of staff that’s required versus a lot more automation in our solution. Where a lot of the other systems require a lot of manual touching — they’re more like inspection-based instead of exception-based — so there’s an opportunity for operational efficiency with using our system over some of the older mainframe or batch-oriented systems that have been in the market for years.

How do you think the Meaningful Use and the whole healthcare reform change is going to effect the revenue cycle side of everybody’s business?

It seems that regulatory compliance is one of the big change agents that are always in healthcare. With Meaningful Use and ICD-10 and some of those things, I think it’s going to have an impact on the back-end systems as well. I’m not sure that the clinical information systems just on the front end are going to be adequate to address all that successfully.

I know that in the case of ICD-10, specifically, you’re talking about a larger field length because it’s a larger coding method than the ICD-9; like six or seven digits versus like four or five. So then that’s a change of storage location. That’s got a lot of different places to go and fix that because they’re on traditional file systems where the applications were originally written. We’re already ready for ICD-10 because ICD-10 is what’s being used right now in Malaysia, so we have an advantage there.

I think that all these regulations, as they come along, are going to put a lot of pressure on the older systems. It may be the cost of making changes to those systems may be more than the vendors that own those products are willing to put into them.

I think with all the excitement about clinical systems, maybe people have forgotten about things like ICD-10. What are your thoughts on how that change is going to affect everybody?

There’s the coding. I think, in the medical records area particularly, where they’re coding; that there’s so many codes that coding method’s going to cause a lot of change for all of the medical records departments. With the Correct Coding Initiative, that’s a lot to learn. Everybody’s been on ICD-9 for quite a while and ICD-10 is a lot different.

Then, all those codes will have to filter through for the claims and the edits that come along with those. New codes are going to be a little bit more complex. I’m not sure what impact they would have, specifically, on the bills themselves, but that would open it up for a lot more rules. There may be a lot of gaps in the older systems that might take quite a while to fill when they move to ICD-10 and I think we’re ready for that.

What do you think about ERP systems?

That’s a very mature market. In the US, it’s Lawson, which seems to be the one that has most of the market share.

We are integrating with Oracle in Malaysia. That is an opportunity. Oracle had a couple of tries at trying to get into the healthcare vertical and hasn’t really had much success with that, especially in the US. I think that an opportunity to get into the healthcare market, probably internationally, is what we’re going to see more with Oracle.

We don’t run into PeopleSoft or SAP very often. Those seem to really high-end and geared more towards the manufacturing environment than healthcare, but I think they’re going to continue to do all right.

I think that most people have made decisions for the ERP system, but again, traditionally, accounts receivable would be part of that solution. But when you’re having to do everything down at the encounter level and case mix and all those types of things in healthcare, it really strains the architecture of those ERP systems, which seem to be much better suited for direct customer-vendor relationships as opposed to this third-party and multiple payers and coordination of benefits.

One of the other things that everybody’s paying some attention to, at least, is data warehouse, data retrieval, and business intelligence. What are you seeing in the marketplace for that?

That’s another bolt-on opportunity, it seems, in healthcare. That’s another thing that’s embedded in our products.

Since we’re on a Microsoft environment, you have the whole Analysis Services that’s part of SQL Server 2005. And now, 2008 is even stronger — we’ve got scorecards and analytics. The warehousing is built right into the product, so the detail source that’s coming from our applications feeds the warehouse directly. We’ve got some pretty good score-carding and reports right out of the application set that makes BI a lot easier.

For us, it’s not a bolt-on. The product automatically can see it’s a warehouse that has a lot of those key performance indicators and scorecards and analytics built right into them. For example, we have one for denial management because we get the 835 detail back. We post the details from the 835 so you can drill all the way down to the level of detail of a line item that would be on a bill. If that detail was passed from the 835 from the payer, we can capture all those details and report on that.

Elimination of denials is something that’s much easier for us to do. It’s integrated right into our collections module. If you get a denial, if it’s something that’s workable, we will map that denial right into the accounts receivable system. The user knows that there has to be some action item to clean that up or address that denial. We’re using the business intelligence and warehouse for operational efficiency and management insight.

Does that complement or compete with Amalga?

I don’t know if it competes with Amalga. I guess it could complement Amalga, but Amalga seems to be really more of a framework around the whole care delivery delivery model. Ours is operational efficiency — all of the revenue cycles like AR, days calculation ratio, collector productivity. Those types of things are what we’re using for the warehouse, as opposed to trying to capture various points of care. I think Amalga’s got a much broader approach to healthcare than we do. We’re more specific to our area.

You’ve been in the industry for a long time. Looking outside of your company and your products, what’s going to be happening over the next 5-7 years?

I think that moving from paper to electronic, there’s going to be a lot of workflow issues from that. I think the traditional batch system that we’ve had for quite some time –  they’re going to have to have replacements for that. I know that all of them — Siemens, McKesson, Eclipsys, etc. — have large revenue cycle systems that they’re trying to bring to market to replace those older systems. They’re usually larger. I think they’re really aimed up-market more than they are mid-market or even down-market.

I think there’s an opportunity at the community hospital level, for certain, because they do have money and they’re the ones that haven’t been able to automate like the larger institutions. They have more wherewithal to spend on electronic medical records. A lot of them already made decisions on what they’re doing. Then they’ve got those vendor relationships that probably are going to go with their revenue cycle solutions.

But you get into the community hospital space — the pressure to have an electronic medical record in place for Meaningful Use and all these other things — I don’t know that the revenue cycle systems are going to be able to keep up with the older revenue cycle systems that some of the smaller vendors have. They’ve got to be able to keep up with all that.

One that comes to mind is QuadraMed. QuadraMed’s had a difficult time trying to handle both the clinical R&D and the revenue cycle side, which is a tremendous amount of R&D. They’re kind of caught. They can’t go up-market very well; that’s pretty much saturated by the larger vendors. I think the community hospital space is underserved and I think it’s a great opportunity for us. In that real small footprint, we’re more affordable, easier to use, and have less moving parts when you start looking at all the bolt-ons that have been traditionally required. I think that’s an advantage for us.

Any concluding thoughts?

I think that we’re going to continue to see what we can do in the international space, continue to partner with clinical information system vendors that don’t have a revenue cycle component. There are people looking to get into the electronic medical record, but outside vendors that are taking a look at the US market and say, specifically for the community hospitals that the vendors served — and there’s a lot of competition out there and there’s a lot of clinical information systems that are already written and up and operational around the world — they’re looking at the US market, maybe, for an ability to expand for them. They won’t have a revenue cycle solution with the US regulatory and third-party. A company like ours that’s independent would be a good partnership opportunity for them.

We could help bring some competition into the US market, maybe, from overseas that hasn’t been here before.

News 7/16/10

From Lumpy Rutherford: “Re: Kate Kervin. Moved from Siemens to NextGen as SVP of marketing and project management, started this past Monday.” Unverified. Neither her LinkedIn profile or the NextGen executive page says so, but that doesn’t mean much.

Listening: Margot and the Nuclear So and So’s, polished, sweeping indie rock (or Indy rock, since that’s where they’re from). They are amazingly good.

IBM will spend $100 million over the next three years on healthcare transformation projects: creating evidence-based protocols, simplifying healthcare delivery, and studying the shift to an outcomes-based reimbursement model. The company says it will hire new people, among them doctors and nurses working on the front lines.

Fujifilm will commercialize the iPhone-based stroke diagnosis application developed by a hospital in Japan. Physicians are using it to review CT scans remotely.

I was talking to the new crop of residents at my hospital, most of whom were unimpressed (justifiably) with our clinical systems. I asked three of them which systems they had used that were better. Two said Epic and one said Eclipsys. I didn’t disagree.

OB-GYN EMR vendor digiChart brings on former McKesson sales VP Bob Allen (sales) and former Healthgate CTO Stephen Faris (R&D).

The number of Americans who support President Obama’s healthcare reform package: 36%.

Camden-Clark Memorial Hospital (WV) signs up with Eclipsys for what sounds like all Sunrise modules plus EPSi. Camden-Clark is also connecting its 70 owned or affiliated physician practices, which run the Allscripts Professional EHR, using Eclipsys HealthXchange (which is Medicity).

Scottish charge master software vendor Craneware says its sales reached a record $54 million in the year ended June 30.

Healthcare Growth Partners releases its Q2 report covering HIT-related capital markets, mergers and acquisitions, and capital funding.

Weird News Andy delivers this story about a woman pregnant with two babies that aren’t twins. She has two uteruses (uteri?). Or as WNA says, quoting Homer Simpson, “It’s uterus, not uterme.”

Dan O’Neil let me know that he’s taking a job with consulting firm Arcadia Solutions, leaving his CIO slot open at Quincy Medical Center in Boston just in case you’re interested.

Eclipsys shareholders will vote on the company’s planned acquisition by Allscripts on August 13.

Jobs: Senior DBA and Storage Engineer, Web Application Developer, Lab Systems Project Manager, Project Manager – Meditech Conversion.

Australia’s Lingo Systems will give away $1 million worth of software licenses as a promotion for its SMS message-based hospital staff scheduling system. Nurses indicate their availability on a Web page and are texted when the hospital needs one of those shifts covered. The first nurse to text back “yes” gets the shift.

Disciplined nurses are using multi-state licensing agreements to keep delivering care after misconduct. Recordkeeping isn’t up to date, so nurses disciplined in one state sometimes have clean multi-state licenses. One Wisconsin nurse who was fired and later convicted of stealing Dilaudid said, “When I went to go for the job in North Carolina, looked at the status of my license, and it was still active. That kind of surprised me, so I figured I would take it."

HHS launches a Meaningful Use Web site that includes the final EHR incentive details and final EHR standards and certification criteria.

Hospitals in Greece were overcharged for medical equipment by Siemens, prosecutors say, with some hospitals paying more in annual maintenance than the equipment was worth.

The iSoft tailspin continues: two of its Australian executives quit and the company downgrades its expected revenue based on NPfIT delays. Market cap has shrunk from $1.5 billion to $170 million and an Australian publication says iSoft has cut 600 jobs and will eliminate another 500 by the end of the year. Private equity firms are poking and prodding, of course (who wouldn’t at that price?)

Announced this week and darned cool: Google’s App Inventor for Android lets non-programmers build apps for Android phones using predefined controls. Some of the available tools can access a GPS sensor, automatic texting, and interact with Web sites. Brilliant. Somebody build something cool for healthcare and write up your experience – I’ll run it here.

E-mail me.

HERtalk by Inga

From Ed Marx: “Re: final Meaningful Use regulations. I am pleased with the compromise reached by CMS/ONC. The program remains as designed, an incentive, not a give-me. It strikes a strong balance between a stretch goal while being realistic with industry current state.” I had asked Ed to share his initial, high-level impression of the final rules. It’s interesting to note that several months ago, Ed expressed concern over the preliminary measurement requirements, believing they represented a “high hurdle” for many organizations. 

From Really?: “Re: final regs. They lowered the bar so much that my four-year-old could achieve Meaningful Use! The government might as well hand out money to everyone.”

From Chicago Skyline: “Re: The fine print. In talking to a few folks, vendors seem to worried that they will need to include in their software the reporting tools for the meaningful use metrics. In other words, the software must have a report that shows what percentage of all meds were electronically prescribed. What do you understand?” Just when I thought I was nearly an MU expert, I have to punt. I didn’t have time to look through the fine print today, but maybe someone who has can chime in.

From CheerLeader: “Bravo! Hurrah! Well done, Inga! Great work on your synopsis — I actually have something to pass along to by C-levels that they will understand.” You would think that after 3-1/2 years of doing this I would no longer be surprised that people really do read what I write. If you are more interested in how the final regs affect Eligible Providers, check out the summaries posted yesterday on HIStalk Practice.

Wellsoft wins a couple of EDIS deals in Canada. Kingston General Hospital and Hotel Dieu Hospital, which share hospital information systems and IT support, will jointly implement Wellsoft.

Westbury Hospital (TX) is implementing ChartAccess EMR from Prognosis for is new 137-bed facility.

Healthcare providers are generally still confused about certification requirements for ambulatory EHRs, according to a recent CapSite survey. Two-thirds of providers consider certification to be a very important element in their EMR evaluation process and more than half think that CCHIT certification is a requirement to receive stimulus funds. Sixty-nine percent weren’t aware the feds would be accrediting other organizations beside CCHIT. If I handled marketing for CCHIT, I’d figure out some sneaky way to leverage this last data point with vendors. Nothing like a little fear to scare a physician away from an otherwise good purchase decision.

Sharp Healthcare (CA) selects Allscripts Community Record, which is provided in partnership with dbMotion. Sharp uses Allscripts EHR for its employed physicians and has deployed Allscripts’ Care Management and Referral Management applications. The Community Record will connect the Allscripts systems with third-party clinical applications to create a single community patient record.

CAP STS signs a collaboration agreement with the Barcelona-based healthcare consulting firm Gesaworld. The two organizations will provide consulting, training, and implementation services for HIT standards.

Trace Devanny won’t be unemployed more than a weekend. The former Cerner president is taking over as CEO for The Trizetto Group, effective July 19th. Trizetto founder and current CEO Jeff Margolis will remain chairman of the board. Devanny will be based in Greenwood Village, CO, which will also become Trizetto’s new headquarters.

Home health and hospice software provider HealthWyse partners with ZirMed. HealthWyse will combine ZirMed’s claims management tools into its clinical and financial information system.

IOD Incorporated, a provider of release of information services, is infused with $35 million of growth equity from LLR Partners, a PE firm.

A reader sent over a note suggesting he had some “scoop” from the AMDIS Physician-Computer Connection Symposium, which is going on right now in Ojai, CA. Unfortunately he was in a hurry (something about a blackberry martini reception) and so far all I’ve gotten was this picture. I’m not sure who the speaker is, but the crowd looks totally engaged. I await rumors and/or martinis.

E-mail Inga.

Readers Write 7/15/10

Achieving EMR Usability in Today’s Complex Technology Market
By Odell Tuttle

As HIMSS began recognizing the importance of human/computer interaction, its EHR Usability Task Force developed the 11 principles of usability — a framework which provides methods of usability evaluation to measure efficiency and effectiveness, including patient safety. This framework is invaluable as many of today’s clinical systems do not provide adequate support due to poor interface design.

From multiple data interchange and reporting standards, to formatting and encoding standards, to clinical processes and procedures — not to mention the government organizations and legislation — the EMR domain is vast and complex. For hospitals looking to implement an EMR, it is important they choose a technology partner experienced with proven, tested, and used systems. For rural community hospitals, it becomes critical, because their needs are so unique.

The HIMSS 11 principles of usability is a valuable tool in the EMR selection process. A summary of the HIMSS usability principles include:

Simplicity
Everything from lack of visual clutter and concise information display to inclusion of only functionality that is needed to effectively accomplish tasks.

Naturalness
This refers to how automatically “familiar” and easy to use the application feels to the user.

Consistency
External consistency primarily has to do with how much an application’s structure, interactions, and behaviors match a user’s experience with other software applications. An internally consistent application uses concepts, behavior, appearance, and layout consistently throughout.

Minimizing Cognitive Load
Clinicians in particular are almost always performing under significant time pressure and in environments bursting with multiple demands for their attention. Presenting all the information needed for the task at hand reduces cognitive load.

Efficient Interactions
One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users.

Forgiveness and Feedback
Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Good feedback to the user supports this goal by informing them about the effects of the actions they are about to take.

Effective Use of Language
All language used in an EMR should be concise and unambiguous.

Effective Information Presentation – Appropriate Density
While density of information on a screen is not commonly measured (though it can be), it is a very important concept to be cognizant of when designing EMR screens.

Meaningful Use of Color
Color is one of several attributes of visual communication. First and foremost, color should be used to convey meaning to the user.

Readability
Screen readability also is a key factor in objectives of efficiency and safety. Clinical users must be able to scan information quickly with high comprehension.

Preservation of Context
This is a very important aspect of designing a “transparent” application. In practical terms, this means keeping screen changes and visual interruptions to a minimum during completion of a particular task.

Reliable usability rating schemes offer product purchasers a tool for comparing products before purchase or implementation.

Making complex things appear simple is a very difficult job.  However, by utilizing the HIMSS 11 usability principles, healthcare providers are armed with a powerful tool in the EMR selection process.

Odell Tuttle is chief technology officer at Healthland.

Tech Talk and Market Strategy – Smart Phones
Mark Moffitt and Chris Reed

Tech Talk – Dictating Reports within an iPhone App

Good Shepherd Medical Center developed an iPhone app that has achieved a very high rate of adoption by physicians (95%) by providing a high degree of customization. The second most popular feature of the app is accessing and playing radiology dictation when a report has not been transcribed and is not available for viewing. Viewing lab data is first.

One reason this feature is popular is that it eliminates the need for a physician to call a dictation system and enter an ID, medical record number, etc., on a telephone keypad. Using the iPhone app. they simply press a virtual button to play a dictation on the iPhone. One less gadget a physician has to futz with.

It seemed logical that physicians would appreciate being able to record a dictation and view clinical results on the iPhone simultaneously without calling a dictation system and entering information on a telephone keypad.

Initially, we planned to integrate our iPhone app with a native dictation app. Unfortunately, this configuration requires multitasking to dictate while viewing clinical information on the iPhone. About one-half of the physicians using the app have the 3G phone. iPhone OS4 (operating system) supports multitasking but runs slow on 3G phones.

iPhone OS3.1.3, the latest OS designed for the 3G and 3GS, supports viewing Web pages while talking on the phone. We used this configuration to provide for the ability to dictate reports and view clinical results from an iPhone. Our iPhone web app uses the URL scheme “tel” to send commands to the iPhone phone app.

tel: <1>, <2>, <3>, <4>, <5> # note: “,” instructs phone to pause

Where:

1. Telephone number for the dictation system.

2. Physician id.    

3. Site id (hospital).  

4. Job type (H&P, discharge summary, progress note, etc.).

5. Medical record number.

The shortcoming of this approach is that the iPhone dials slowly the entries after the initial phone number. However, it is a big improvement over having a physician call the dictation system and enter information manually.

This is not our final solution. Sometime late this year or early next year when most physicians are using a 3GS or iPhone 4, we will switch to using a native app to dictate a report. If we had more resources, we would provide a version for iPhone OS3.1.3 and one for OS4.

Market Strategy – Smart Phones and EMRs

If the battlefield for winning the hearts and minds of physicians using electronic medical record (EMR) systems is shifting to smart phones and iPad-like devices, and I think it is, this trend may open the door for vendors like Meditech, Cerner, etc. to derail the Epic juggernaut.

Newer systems like Epic hold an advantage over older systems in terms of usability and user interface design. Software written for smart phones that operate over an underlying system can hide these flaws. It is possible, I contend, to neutralize Epic’s usability advantage over older systems among physicians using an “agile” smart phone software model. An agile model is one that puts in the hands of the customer the ability to rapidly modify and deploy smart phone software to fit the specific needs of an organization. This approach does not change the functionality of the underlying system.

Customers using agile smart phone software can:

1. Configure the app in different ways to greatly improve flow for different kinds of users, e.g. hospitalists, specialists, and surgeons; and for different types of smart phones.

2. Add data to the user interface to guide users toward a specific objective. For example, display house census, length of stay, observation patients and hours since admission, pending discharge, one touch icon for pending discharge alert, etc.

3. Add features that make the physicians work easier. Examples include one touch icon to call patient’s unit or nurse, play recording or dictate on the smart phone while viewing clinical results; access medication list directly from a PPM EMR without a patient master index between systems; receive clinical alerts; etc.

To compete, smart phone software must be core to your business. Give credit to Epic for recognizing the strategic value of their smart phone software. However, Epic’s smart phone software is “rigid” and that leaves them vulnerable to smart phone software that is agile.

Mark Moffitt is CIO and Chris Reed is Manager at Good Shepherd Medical Center in Longview, Texas.