An Argument Against Giving CIOs Control Over Clinical Systems Projects

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in June 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

It’s hardly news that clinical system implementations in hospitals fail with astonishing regularity. Sometimes they explode in a huge fireball of organizational upheaval. Other times, they simply fail to deliver the benefits everyone expected. By failing, I’m referring to not just the IT part of the project, but the overall change management required to be successful.

It seems we as an industry don’t learn well from our past mistakes. We keep making the same ones over and over again. Many of those I’ve seen involve the role of the hospital CIO in the project.

CIOs rarely have a clinical background, most often having risen through the ranks of programming, managing, or consulting. I’m therefore postulating that they should not be given control over major clinical system implementations.

CIOs don’t always have the respect of physicians, nurses, and those other key clinical personnel actually carrying out the organization’s mission. They may be recognized as holding authority over needed hardware and software tools, but to most clinicians, the CIO is the besuited mid-level functionary whose job it is to say “no” to IT requesters who did not pay adequate homage when defining for themselves which technology tools would improve patient care. Since IT controls the budget, innovation is allowed only if committee-approved.

Some CIOs I’ve known made it their personal mission to set clinicians straight, convinced that without their wise paternal oversight, the wacky clinicians can’t be trusted with money or system selection power. Clinicians armed with reams of objective and factual system data are overridden with logic such as “It just doesn’t feel right” or “I know that company from another job or my peers,” which seems reasonable other than it fails to prevent the train wreck most of the time.

CIOs like to make executive decisions even when they’re ill equipped to do so. Since IT executives have little influence when they’re not making big decisions, they tend to relish the chance to buck convention or override carefully designed committees. Their veto power is absolute.

IT executives fear for their jobs, much more than they fear for the well-being of patients. They’ll override nurse informatics people nearly all of the time and MDs 50% of the time when it comes to delaying an implementation when faced with dangerous shortcomings. The most common reasons: (1) we’ve spent the money, so we have to go live; (2) it’s bad and not likely to get better, so we might as well go live, or (3) I promised my peers this system would work and I won’t tell them differently.

Should CIOs be involved in clinical systems projects? I honestly don’t know. Programmer-trained logic doesn’t add much value. Neither does having been involved with a similar project somewhere else or sporting an MBA. Golfing and free lunch vendor relationships seem to hurt more than they help.

Some of our big-name CIOs were directly involved in some of our big-name clinical systems failures, although the ensuing spin often hid that fact from everyone except the hospital employees and medical staff. Whether they made wise decisions or worried mostly about the Dilbert-esque world of timesheets and timelines I can’t say. But they’ve failed enough times that it’s worth trying something new.

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CIO Unplugged – 4/1/08

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

Who Are Your People?
By Ed Marx

As I sat down to blog, I had every intention of going back to a non-Ironman-related post. My attempts to post on matters more closely associated with health care IT failed to excite me. If I can’t be passionate about one of my own posts, my readers will pick up on that, and I will have failed to connect in a meaningful way. Not to mention that many of you have e-mailed me asking about the Ironman Arizona. So indulge me one final time and glean from the lessons that can apply to both leadership and life.

APRIL 10, THURSDAY– I pulled in a few days early to acclimate to Tempe and to finalize preparations. Though it was a long haul from Dallas, I chose to travel via car so I could bring everything I wanted, plus keep control of my bike. You can better guarantee success by having the right tools and by making sure they stay in optimal working condition.

FRIDAY/SATURDAY– No grand feat, whether it’s a major race or going live with CPOE, is performed well if attempted alone. Surround yourself with people who lift you up. One of my employees, Don, stopped in my office a few weeks prior to inform me that he had started running for the sole purpose of praying for me. He timed his April 13 run to coincide with the start of Ironman. Another employee, Aaron, flew out after the race to help me drive back to Dallas. I welcomed both their embraces.

My son, also an experienced triathlete, flew in from college on Friday to assist me with the final prep and provide counsel. As a film major, he shot all aspects of the race — a potentially interesting YouTube feature this summer. We attended the Iron Prayer event to connect with other like-minded athletes. My wife and daughter, whose support I consider invaluable, arrived the day before the race.

RACE DAY– Athlete #1345. I awoke at 3:00 a.m. to begin the nutrition phase. I consumed a few hundred calories then slept again. Waking at 4:30 a.m., I mixed my drinks and headed down to the transition area. My son was filming and helping carry the specialized bags of equipment. By 5:30 a.m., my body was marked and my bike tires were pumped one last time. I found a spot under a tree and lay down to rest for the next 45 minutes. Appropriate preparation and planning can allow time to rejuvenate while others around you are scrambling to meet the deadline.

T-MINUS 30 MINUTES– Under the scrutiny of the camera, I changed into my wetsuit. After final interview, I jumped into the lake with the other 2,299 Ironman wannabes. I remained unusually calm, partially because I did not shortchange my preparation. When the cannon fired, I was physically, mentally and emotionally ready to race. Proper preparation preludes proficient performance. (Say that 10 times…)

SAM– Climbing out of the water, I picked up my bike bag and ran into the transition tent. My first transition was dedicated to Sam, the young son of one of my employees who got hit with cancer last autumn. I pulled out the handwritten card with his name on it and placed it on the ground before me. I prayed for him as I put on my bike gear. His fight to the finish line would far surpass mine.

112 MILES in 6+ HOURS– The strong head winds and the 95 degree weather were killing my expected biking pace like a defunct router on network uptime stats. Complaining wasn’t going to change it. I had to make the best of it. Persevere. Keep focused on the bigger picture. I loaded up on fluids and consumed 400 calories per hour, a total intake of 3,000 calories, partly to prepare for the marathon ahead. Combating an urge to keep rolling, I made myself stop and reapply lotions to keep from chaffing. It would pay off later. At mile 80 — my last time up the wicked hill — one leg started to cramp, and I realized I had yet to urinate. I forced down more drinks and salt tabs and the cramps subsided. At last, the final 15 miles were downhill and flat. Relief engulfed me.

* During the last lap, the cameraman passed me backwards on his motorcycle, which meant the Ironman leader was right behind me. I sped up a little so when the scene unfolded on TV, it would look like I was in second place! That lasted about 3 frames as the leader made me look like I was standing still.

PAM– The transition from bike to run was dedicated to Pam, who had breast cancer, the wife of one of my employees. I placed her name card in front of me and voiced prayers as I changed. Only a marathon to go, and I would be an Ironman. But how many marathons of treatments did Pam have left? My suffering paled in comparison. Thanks for your strength, Pam and Sam.

DEDICATED PLAYERS– Ironman staff had trained an abundance of volunteers to assist at every stage. At the first transition, volunteers stripped me out of my wetsuit while others applied sun lotion before the bike. As I ran down the middle of the bike compound, someone was at the end waiting with my bike. When I returned to the transition area, one volunteer took my bike while another handed me my run bag. I was again rubbed down with sunscreen before the run. Planted along the run route were hundreds of signs created by race families in support of their athlete. My family had made 3 to help focus me on my purpose in doing the Ironman. Surround yourself with people dedicated to your success, positive people who will encourage you despite the circumstance. They will get you through the loneliness and pain of challenging times.

STRENGTH vs WEAKNESS– In training, I deliberately chose to concentrate on my strengths: bike and run. I had invested a combined total of 353 hours on these two events. Had I invested extra time on the swim, I might have gained 5 percent in overall time. By concentrating on my strengths, I gained an estimated 20 percent. Twenty years ago, I almost made the mistake of returning to school for a technical degree. Realizing my strength was in leadership, I opted to develop those skills instead, and it paid off. What I might have learned in technology would have already been lost — and outdated. Don’t misallocate precious resources by strengthening weaknesses.

FIRST, BREAK…THE RULE– I violated a cardinal race rule, which warns to never ingest something during a race that you have not used in practice; it could make you sick. Following a fellow Ironman’s suggestion — that he declared had saved him on the run — I indulged in a flat Coke. The sugar-caffeine high juiced my battery. Picking up the tempo, I cruised along with renewed vigor. Sometimes you’ve got to shake things up a bit and not do the same things over and over, especially if they are not working.

THE END– I remember spotting the 26-mile mark on the marathon, but the last few hundred yards were a blur. Roaring crowds lined the grandstands. Officials held out the Ironman finish ribbon, and I raised my hands in triumph and received my medal. It was over. I had held nothing back. There is no rush like that of a mission fully completed.

Yet my eyes were searching for my family. My wife and I cried as we hugged. While my son continued filming, I embraced my daughter. This had been a long journey of very early mornings and regular sacrifices. A journey that took over our bathroom and kitchen with a plethora of Ironman gear and foods.

WHAT’S YOUR BIGGER PICTURE?– At the end of the greeting pen was Ellen, the person for whom I had run this race. I had given her all my medals from the events leading up to Ironman with high hopes that in some small way they would be an encouragement to her and to her family. Throughout training, I had focused prayers against the cruel disease that had invaded her body. I desired that, through the providence of God, those prayers would improve Ellen’s quality of life. I presented her with the Ironman finisher’s medal, and we both put up brave fronts for the camera though tears were streaming down our faces. Ellen does an Ironman daily, especially on chemo days.

As a leader, do you have a significant purpose? Or is it solely about the money and the new house? Put people first. Seek to serve. In health care, the Sams, Pams and Ellens are the ultimate endurance athletes running a race that nobody should ever have to run. We are there for them.

FYI- the last 20 weeks training log:
• Swim 111 hours (lost count)
• Bike 235 hours 4230 miles
• Run 118 hours 944 miles
• Lift/Stretch 76 hours n/a

I did get the Ironman tattoo which was nearly as painful as the Ironman itself.

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

News 4/2/08

From Jackie Chiles: "Re: McKesson. It’s probably not really a rumor anymore, but McKesson is acquiring Rosebud Solutions, a maker of tracking software for tissue, instruments, scopes, etc.  Press release will likely hit today. The Rosebud booth at AORN conference has the McK logo hanging above it.Another more juicy nugget that I have heard from several independent sources is that McKesson is making some major changes in its salesforce, with some significant restructuring likely. One well-placed source told me McKesson’s cost of sales is about double its competitors due to current sales force structure." Here’s a link to the press release on Rosebud.

From Sophie Winslett: "Re: RHIOs in Europe. They’re not that monolithic in the UK and Canada. Primary care providers are in their own clinics in the UK.  Even though it is a single payer system, they all buy their own IT systems. The UK is trying to get them to standardize on a few systems to provide competition and flexibility while limiting the number of interfaces, but each doc decides on their own. In Canada, hospitals the hospitals I’m familiar with are the equivalent of non-profit groups (such as you would see in a metropolitan Catholic consortium in the US). They are not directly owned by the government and they all made their own informatics decisions."

From EasyRHIO: "Re: RHIOs in Europe. There is already a country with a nationwide RHIO for all eight million citizens. All clinics in the country are connected and most hospitals are connected with the remainder rapidly deploying. Welcome to Kaiser country, my friend."

From Amanda Rada-Range: "Re: Brev+IT. I quite enjoy this – thanks for publishing it. You might have heard that AWP stands for ain’t what’s paid." Amanda was commenting on the latest issue’s lead story.

From Lester Bangs: "Re: Axolotl. Axolotl has won the Queens NYC HIE contract, which adds to their dominance in NY state — they also have Buffalo and Rochester, which are also live. Check the details of the press release for what they are doing — EMRLite, e-Rx. It’s not just results reporting."

From Chang Kai Shek: "Re: Epic campus. Looked pretty basic, but cool drive-through. Do you have other vendors’ campuses?" Well I mapped Cerner’s campus and found a drive-through just for you. Here’s a shot (if that design feature stays that way for more than four hours, I’d suggest going to the company infirmary). Thanks to the power of the Internet, I also found Judy Faulkner’s house with drive-by pictures and its appraised value (surprisingly modest), but that’s nobody’s business, of course, including mine. I’m thinking I’ll do a series featuring hospital pictures – what do you think? You could try to guess the hospital from its exterior.

Greenway Medical announces expanded support for PQRI/P4P programs.

If you want a copy of the 101 Healthcare IT Marketing Ideas booklet I mentioned, e-mail Steve Bennett (he said it was OK to give his e-mail, although he may regret that once he starts licking a mountain of envelopes and stamps).

Heard: Hayes Management Consulting is working with a Fortune 100 company to develop an employee health clinic — consumer-centric, paperless, and with an EMR linked directly to medical devices.

CIOs or other hospital IT execs: help me out by completing a questionnaire on medical devices and IT. We’ve got a crackerjack group working on a white paper and we need some input. Thanks.

Jobs: Clinical Applications Analyst Lab (WA), Business Analyst (CO), Centricity Senior Healthcare Consultant (CA), Client Manager (TN).

I thought Dennis Quaid was just being a self-centered movie star in his ripping of the medical system after his twins were overdosed with heparin at Cedars-Sinai. He’s changing my mind: he implies he won’t sue the hospital if it does the right thing — implement bedside barcoding of medications (from his foundation page). He also seems to have a handle on the "system problems, non-punitive culture" concept: "Individually, the doctor, nurse, pharmacist, or other staff members, who commit these unintended medical errors, are not bad people. Indeed choosing a career devoted to curing the sick and easing the suffering of others is one of life’s highest callings. But these health care professionals are working in, and are sometimes victims themselves, of a broken health care system that has become more and more obsessed with the threat of exposure to liability and protecting it’s bottom line rather than being vigilant about correcting the flaws in that system that are the root cause of that very exposure." Damn well said, although this quote surely means he hasn’t seen the barcoding products currently available: "They have a bar code system in every checkout stand of every supermarket in the country. How could it be so complicated, and so expensive?"

A UK health minister admits that work on Cerner Millennium in the South has stopped because of contract disputes with Fujitsu and Cerner.

Problems in Australia, where devices set their clocks back for fall (seasons are backwards from us down there, remember) even though daylight savings time had been extended by a week in New South Wales.

It was hard to tell with all their goofy April Fool’s announcements, but Google is apparently serious that its Google Docs word processor can now be used offline, courtesy of the Google Gears project.

Here’s a pretty interesting look at telehealth in India. Interesting comment: "Technology has never been, and never will be, a stumbling block to progress in telemedicine." Another: "We should, however, remember that a fool with a tool is still a fool, and ultimately therefore it is the individual, not the technology, that can make or break the system." Sounds like they’ve got some great ideas over there. How long before someone starts offering telemedicine consultations from there at low rates?

Fun: a Wales hospital has had its own radio station for entertaining patients for 40 years.

A VA patient who nearly had unnecessary surgery because a nurse mistakenly read an old lab result proposes a software solution that the VA is considering: modify VistA to show only current lab results unless users explicitly request older ones.

E-mail me.

Inga’s Update

McKesson announces its acquisition of Rosebud Solutions, which provides software to track and manage surgical instruments and implant materials.

StatCom hires former Siemens and Lawson sales executive Michael Holland to head up sales and marketing.

David Brailer’s Health Evolution Partners launches a $200 million investment fund aimed at early stage and venture companies. The fund’s advisors include a former US Surgeon General, a past Kaiser CEO/President, a Leapfrog Group founder, and a founder/CEO of The Health Technology Center. Former Partech International/First Consulting/Accenture executive Roy Ziegler will lead the group. I guess when you have been a healthcare IT czar, you’re able to get all sorts of folks to come to your party.

Elmhurst and Queens Hospital Centers plan to make a go of a RHIO using Axolotl’s Elysium technology. The project is expected to take three years.

I am not sure how significant this news is, but I smiled a bit at the press release. gMed announces the launch of a new EMR product called gCardio, which the company claims is a solution that “thinks like a cardiologist.” Hmmm.

Cardiac Science announces that its HeartCentrix ECG software is certified with NextGen and the two have already deployed their first installation. Meanwhile, Cardiac Science also just signed a letter of intent to start working on a similar connectivity model with the Misys MyWay product.

Nuance announces the release of Dictaphone healthcare division’s Veriphy-Ready HL7 Integration Server to automate the closed-loop communication process.

Picis announces version 8.1 of its total perioperative automation and critical care applications.

Soarian clients have a new users’ forum available at www.soarian.com. Formed with the help of Stoltenberg Consulting, the group will initially focus on question posting/answering and discussion.

Health Management Associates and Novant Health announce a partnership in which Novant will purchase a 27% stake in HMA. The two organizations will co-manage 16 hospitals.

Sachi Rath asked if there were other CIOs besides Halamka writing blogs. Check out Ed Marx’s CIO Unplugged. I like Ed because he’s a regular HIStalk reader.

A Dell issue or sign of the times? Dell announces actions to restore its competitive advantage and drive $3 billion in cost savings. Included in the plans is the closing of its Austin desktop manufacturing facility, eliminating 900 jobs.

E-mail Inga.

Monday Morning Update 3/31/08

From Up to You: "Re: Scott Wallace. From a magazine: Wallace said he will continue to work in the area of healthcare IT at, ‘something really exciting, but I’m not quite ready to announce it yet. I’ve got another six weeks of really intensive work before I can announce it.’" NAHIT seems to want to reinvent itself following (and may related to) his departure. So, where’s he going?

From Tree Adams: "Re: RHIOs in Europe. Points worth mentioning: (1) Taxpayer money and government are the only available sources of funding and administration in a cradle-to-grave welfare state; (2) Might it be easier to introduce a single, electronic solution within an existing nationalized bureaucracy when compared to our disparate, private organizations?; (3) Is it theoretically easier to finance and implement technology when the populations in question are so small (less than 10 million)? But go ahead and keep comparing them to our model."

From The PACS Designer: "Re: Philips acquisitions. TPD is impressed by the recent acquisitions of Emergin, Visicu, Respironics, and Tomcat  With the addition of these four, it appears a move by Philips toward the center of the IT process in the enterprise. The mini-EMR mentioned in my HIStalk interview may have to be revised to a main player in the EMR competition!"

Listening: new B52s, the first album with all four members in 16 years. If you liked Cosmic Thing, this is for you – the always-cute, beehived Kate and Cindy still sound young when they soar on the harmonies. Bet they’d play a mean HIStalk party next HIMSS.

A reader pointed out that the Rumor Report button wasn’t working all of a sudden, so I made a new one and moved the form to a new page. It now loads instantly and takes you back to the "new" HIStalk page. So, send me a rumor.

Why Epic is so expensive: take a virtual drive through its new campus Google Street View (the car-mounted 3D camera thing). Nice buildings surrounded by endless muddy fields, but it probably looks better now (or will by summer).

Cool booklet: Steve Bennett, VP of Snelling Executive Search and Chuck Christian, CIO of Good Samaritan Hospital have published 101 Healthcare IT Marketing Ideas and sent me a copy (I had mentioned their quest for reader ideas, although I don’t know if they received any). Item #38: "Station the Help Desk in the cafeteria for a day." Fun. Some of my smarter IT management ideas have involved internal marketing, so I can vouch for these 101 as useful for ensuring IT department visibility and CIO job security. I don’t know how you can get your copy, but I expect the Snelling folks can hook you up. 

Execs may like the Allscripts-Misys merger idea, but the sales natives are apparently restless. Resumes from both companies are hitting the street in great numbers, a recruiter tells me.

Your federal tax dollars at waste: a for-profit hospital in New Jersey gets $500K for PACS upgrades. The hospital won’t peg a completion date until it can take another lap around the trough for more federal money. A real estate development company bought the bankrupt hospital in October. Maybe New Jersey has hospitals that aren’t bankrupt, under investigation, or both, but those aren’t making the papers.

A bunch of New York RHIOs gets $105 million in grants.

I mentioned that AT&T’s booth at HIMSS was busy, with a lot of potential partners sidling up as well. If you wonder what the company’s healthcare strategy is, check out my HIStech Report interview (just posted).

A demonstration project says its "best practices" processes reduced medication administration errors by 56%, but of course leaves off the most important stat: how many of those would have caused patient harm? Most people miss the point that a "medication error" is usually something as benign as not being given your daily 8 a.m. laxative until 8:30. Fixing that doesn’t do … well, you know.

More jobs: Account Executive (NC), Revenue Cycle and Operations (MA), Healthcare IT Project Manager (FL), RVP Sales (Western US), Information Security Manager (CA), MUMPS/Cache’ Software engineer (VA), Epic/Bridges Senior Integration Analyst (MA).

Deborah Moore, a former RN and CEO of Accustat EMR of of Myrtle Beach, SC, is named as state Small Business Person of the Year (I assume it’s the business that’s small and not her).

LSU wants a $250 per semester tuition increase on top of $43 million extra it’s getting from the state. They plan to spend $20 million for a new hospital EMR system.

I was looking for a lesser-known EMR vendor and found them on the list of 321 covered by EHR Scope. I didn’t realize there were so many.

Strange hospital lawsuit: Dongwoo Chang, a UC Davis neurosurgeon, accuses his supervisor Jan Paul Muizelaar of incompetence and practicing illegally. UCD suspends Chang citing his high complication rate and being a general pain in the ass. Chang is suing UCD’s top physician officers, saying he was fired in retaliation and that his own death rate and number of malpractice suits is zero, compared to Muizelaar’s high numbers of each. Makes you feel real good about needing trauma work done there.

HHS launches a hospital comparison site that includes process of care measures and patient survey results (when available). I doubt most patients would understand the clinical measures (although they can review bathroom cleanliness and noise), but providers might find competitive bragging rights therein. Unmotivated newspaper reporters are already crafting stories around how the local hospitals did, I’ve noticed.

Sad: a man whose mother died at Doctors Hospital (GA) in 2004 after what he believed was substandard care returns to the ICU armed to the teeth, killing a nurse, a secretary, and a bystander. I’m scared to say it out loud, but I’m surprised that it doesn’t happen more often with all the wackos that pass through hospital doors.

The charitable foundation started by IDX co-founder Bob Hoehl donates $1 million to a Vermont literacy organization.

Vermont Information Technology Leaders changes its mind – it now backs a surcharge on medical claims to pay for physician EMRs. Getting doctors to use them wasn’t mentioned.

Oracle’s Larry Ellison is bonkers, but smart: he successfully challenges the tax valuation of his $200 million Japanese-themed estate, arguing that Larryland is so bizarre that it’s worth a lot less than he paid. Result: he’ll pay taxes on only $65 million, earning him a $3 million refund.

ZDNet says Janet Dillione, CEO of Siemens Medical Solutions,was the smartest person at HIMSS, apparently because the reporter thought she looked a little like Hillary Clinton and because of her daringly insightful predictions such as "PHRs will be popular" and "Healthcare IT needs to change." ZDNet fawns over Soarian, apparently unaware that nobody’s buying it.

E-mail me.

Thoughts from the HIStalk 2008 Reader Survey

Thanks to those to responded. Inga and I pored over your survey submissions endlessly, so your time was well spent.

Not surprising: about 4% of readers are CEOs and 4% are CIOs, not much different than last year. As to the degree that HIStalk influences your perception of products and companies, 8.7% said none, 68.6% said some, 22.7% said a lot. The most popular HIStalk elements (in order) are news, rumors, and humor.

Surprising: to the true/false question of whether reading about a company in HIStalk raises interest or appreciation for those companies, 80.3% said yes (that’s a lot). Best of all, to the question of whether reading HIStalk helped you do your job better in the past year, 75.4% said yes (a 10% jump from last year). I don’t know of any organizations or publications that can claim that strong of an endorsement, so that’s pretty darned cool.

The comments were nearly universally complimentary (thanks for that). Some specific themes I teased out: you would like to see more interviews with non-CEO/CIO types, such as clinicians and non-hospital IT leaders (we’ll work on that). You’d like to see more activity in HIStalk Discussion (so would I.) You suggested a raffle or other incentive for readers who recommend new HIStalk readers (good idea). You suggested changing the sponsor ads (smaller, simpler, different layout) which we will review with the sponsors since they’re the ones keeping the virtual presses running. You asked me to highlight small, innovative vendors who might not make your radar otherwise, another good idea (if you know one or are one, check in).

You also gave us a couple of great ideas for major, separate offerings that we may do if I can figure out how create extra hours in the day. Since I work full time, I’m close to maxing out at maybe 90 hours a week, so maybe it’s time to hire more helpers or something. The ideas were good and have been suggested before, so I’m confident they would be successful.

Inga’s Update

Cerner is participating in a community outreach program that will bring in 45 Kansas City area high school students for half their school day. The curriculum will focus on teaching students the skills necessary to succeed in the workforce, particularly team work and problem solving. Good stuff.

The chairman, CEO, and CFO of Misys show enough confidence in the company’s direction to pull out their checkbooks and make substantial purchases of additional shares.

The chief of neurosurgery at Brigham and Women’s Hospital is accused of sexual discrimination in a lawsuit filed by a female surgeon who believes she was denied promotions in favor of male colleagues with less experience. Whether true or not, the chief definitely has odd taste in office decor and at a minimum has been accused of having a pretty annoying sense of humor. (I will leave my “men are pigs” comments to myself.)

MD Anderson is implementing MedAptus’s Facility Charge Capture and Infusion Services modules. Eight infusion centers will initially use the programs for reconciling the charge review, approval, and transmission processes.

E-mail Inga.

News 3/28/08

From Cherry Rojas: “Re: PHR fiasco. The State of Washington issued a $2 million dollar RFP for a demonstration project to link the EMS system in four counties to PHRs last fall. An out of state vendor won it December 12 using smart cards to verify patient ID and to hold their critical patient information, readable by portable reader. Two in-state consultants who wanted to sell the state proprietary software and (and who sat on the Health Information Infrastructure Advisory Board) got their legislators to cancel the RFP before the contract could be signed in February. SMART Association, the apparently successful vendor, had no idea it was an inside game. All references to the RFP have been pulled down from the DIS web site (but we have copies). How will we ever change healthcare if it’s just another inside game? Some DIS staffers were so upset that they were ready to quit.”

From Bruce: “Ars Technica, a popular tech news web site, has posted an interesting article on EHRs and PHR. Very high level, but it’s interesting to see this hit the mainstream tech community.” Link.

From Up to You: “Re: Scott Wallace stepping down as NAHIT CEO. This was WAY overdue.”

From Dutch Treat: “Re: PHR/EHR. EMC and InterSystems are testing the PHR/EHR waters in Northern Europe. IBM runs Denmark. Who’s next? Case in point: unlike RHIOs in in the USA, governance and funds make a difference in Euroland.” Link 1, Link 2.

From Art Vandelay: “Re: dumb EMRs. Many specialists using Epic find the EMR dumb until more configuration is done. This is always a tough position for hospitals or medical groups rolling out Epic. In the typical Epic EMR implementation, the first step is to focus on primary care in the ambulatory setting and hospitalists in the hospital setting. To make it more usable by the specialty physicians, a second round of tailoring then occurs. It is much easier for the implementation team to initially go with SmartText macros for notes and a few order sets for specialists. The team comes back again later with more focused templates for specialists. This causes many headaches in organizations without strong leadership, a large team, and good content management capabilities. By now, a couple of years have gone by and it is time for an upgrade, so progress may stall while the upgrade is tested. Still later comes the health maintenance reminders with the specialists saying, ‘WOW, you mean I get to use some of the discrete data I entered?’ Next, comes the focus on making sense of the order set and template proliferation. Few places take content management seriously and later have clean-up to do. It may or may not be time for another upgrade or the roll out of more specialty models. At last, many places then get to publishing queries in Clarity (data warehouse) for more advanced users to use in delivering care where some reminders may not exist. As with larger clinical systems, it is a toolkit. If the organization doesn’t have the right size team to match the hospital or clinic’s desire to implement and strong sponsorship to focus attention on the goals of the implementation, it is a rough uphill climb. It takes time, money, super-users, technology resources and a strong infrastructure to deliver the product. A place implementing an EMR can learn from Allina and Kaiser. Allina seems to have had great super user involvement. Kaiser has a content management discipline and content teams to quickly go area-by-area.”

I got an e-mail from Bryan Walser, MD, JD, CEO of Perlegen Sciences, Inc. about the company’s activities with the unnamed EMR vendor. Actually, it was the same “letter to the editor” sent to other publications, so I don’t see much point in running it here. I asked him for an interview and he declined. I’m mostly interested in the EMR vendor, of course, and I’m still trying to find out who it is.Design Clinicals has a new web site, I noticed.

Philips will buy Irish cardiology software vendor TOMCAT Systems. Lots of informatics activity in Ireland, it seems (field trip!)

Information Week digs around the Gnutella file-sharing network using LimeWire peer-to-peer software to see if business documents might actually be found there. Downloaded:  banking passwords, credit card numbers, credit reports, tax returns, cell phone numbers of senators, meeting notes, and medical documents listing patient names with HIV status. The default setup of those P2P clients is often confusing about which PC folders you’ll be sharing with the world, so it’s likely that employees were so anxious to start downloading that they were sloppy in its setup.

Jobs: EMR Developer, Clinical Improvement Analyst, Meditech Clinical Consultants, Physician Liaison. There’s a ton of new jobs listed, I see, so take a look and sign up to get Gwen’s weekly job listing.

A few folks missed the HISsies cartoon, so I’m listing the winners below.

HIStalk readership will break another record this month. It’s nearly there already with four days left in March. Sitemeter projects 66,796 visits and 101,700 page views. Thanks to those who read, sponsor, e-mail me stuff, and spread the word among colleagues. It means a lot. I’ll have an update on the broad themes from the reader survey in a couple of days. One of them: everybody loves Inga (and rightly so).

New text ad to your right: InteGREAT Healthcare, which offers consulting services in the areas of application integration and interoperability.

California will delay for two years its plan to track prescription drugs to prevent counterfeiting, moving it back to January 1, 2011. Everybody in the drug supply chain said they wouldn’t be ready and would have to stop selling drugs in California (riiiiight). How about that nimble pharma industry, of which Pfizer says it will need 5-7 years just to put serial numbers on its products, even though it’s already doing that for some of its high-profit drugs like Viagra?

Allscripts files a new 8-K that describes the mechanics of its proposed merger with Misys Healthcare. It says the per-share value to MDRX shareholders is $14.30 to $16.20, an 85% premium to the share price the day before the announcement. Shares closed today at $9.06 if you want in.

Cerner shares hit a 52-week low today. Share in athenahealth are dropping, too, and PSS sold some of its pre-IPO stake Wednesday. Nothing’s going to do consistently well in this market, of course.

Former Harvard Vanguard CIO Tom Congoran will fill in as CFO of Massachusetts practice group Atrius Health, which has cleaned house on its executive team after parting ways with former CEO Debra Geihsler.

Harvey Picker, founder of the Picker Institute that promotes measurement of the way patients experience healthcare, has died at 92.

Cambridge Consultants says its Vena single-chip platform can allow medical devices to transmit data wirelessly for less than $10.

RemedyMD will integrate the disease models and biospecimen management system of GulfStream Bioinformatics Corp. into its Investigate research software.

The all-lower-case api software (annoying, yes?) acquires EPEPCS, a tool that estimates required nursing hours and skill mix.

E-mail me.

Inga’s Update

Dr. Deborah Peel’s Patient Privacy Rights organization has posted a summary outlining each remaining presidential candidate’s stand on patient privacy. It’s worth a read if the topic concerns you.

Mediware announces that its blood management software systems are ready to accommodate ISBT 128 labeling.

Oshsner Health System is implementing new DocuSys technology for pre and post surgical care. The solutions will be used across Oschner’s 28 operating room and 15 other anesthetizing locations.

Some not-so-good news for McKesson. A US District court certifies a $7 billion nationwide class-action lawsuit against McKesson on behalf of consumers and third-party payers. It has the potential to be the third largest class action suit in the US. It charges McKesson engaged in a scheme to fraudulently inflate the price of more than 400 prescription drugs.

While it’s unlikely to cover the extra $7 billion, McKesson is partnering with Clorox to develop and promote disinfection protocols for mobile equipment and handheld devices.

Nebraska’s Great Plains Regional Medical Center selects Eclipsys Sunrise Clinical Essential for EMR and medication management. They’ll add additional Sunrise products after Essentials is deployed.

Thank you Wheaties Gal for sending me this link for an inspiring new bingo game. “This does not have to do with big mergers or company layoffs- has to do more with passing time in those boring IT meetings where they think nothing of rattling off acronyms and trying to put together sentences around the latest business buzzwords. Here is a site that you can print out ‘B-S Bingo’ cards. I think you would have to be careful not to yell out (like the girl in the TV commercial). Some meetings I have been in lately, I could get a cover-all in 30 minutes- or less.” I am on the same page as you on this, Wheaties Gal. Going forward, for all mission critical enterprises Mr. H and I will simply set our goals, leverage our resources, and just get it done.

Speaking of getting it done, I was making up some pretty charts for Mr. H showing the growth in readers over the last 18 months. The number of monthly visits has doubled during that time period, which is pretty darned impressive. So keep telling your friends because it sure seems to make Mr. H happy!

E-mail Inga.

HISsies 2008 Winners

Smartest vendor strategic move
athenahealth, for its initial public offering (IPO)

Stupidest vendor strategic move
Medseek, for laying off employees right before Christmas

Most impressive vendor sales deal
Epic, Cedars-Sinai

Best healthcare IT vendor
athenahealth

Worst healthcare IT vendor
Cerner

Best provider healthcare IT organization
MD Anderson

Vendor most likely to be acquired in 2008
Allscripts

HIS-related company in which you’d love to be given $100,000 in stock options that can’t be cashed in for 10 years
athenahealth

Most promising technology development
Software as a Service/Service Oriented Architecture

Most overrated technology
RHIOs

Biggest HIS-related news story of the year
athenahealth’s IPO

Best speaker you heard at a conference in 2007
Jonathan Bush

Most impressive vendor at the HIMSS Annual Conference in 2007
athenahealth

Most overused buzzword
Interoperability

Most effective CIO in a healthcare provider organization
Judy Middleton, William Osler Health Centre

HIS industry figure with whom you’d most like to have a few beers
Jonathan Bush, athenahealth

HIS industry figure in whose face you’d most like to throw a pie
Neal Patterson, Cerner

HIStalk Healthcare IT Industry Figure of the Year
Jonathan Bush, athenahealth

You and Vendors Stop Groping Each Other — Pass on Swag, Keep Your Integrity

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in September 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Stanford Hospital last week joined the growing number of academic medical centers that prohibit their physicians from accepting gifts from drug company salespeople. The reps aren’t even allowed on campus, except by appointment to conduct product inservices.

Bravo to Stanford. Physicians think they’re too savvy to be influenced by free lunches, rounds of golf, or drug samples, but drug companies know better – subtle bribery works. If it didn’t, they’d stop. A $100 staff lunch influences even a $500K a year doctor whose prescriptions for one medical condition might generate thousands of dollars a week of business for the drug company.

I’ve taken my share of IT vendor goodies: junkets, executive dinners, trips on private jets, and one memorable evening spent in an internationally known billionaire’s back yard. Having thereby flouted the rules of propriety myself, I’m qualified to issue my first-ever standards of conduct for CIOs and other provider-side executives.

The most important fact is this: it doesn’t matter whether your acceptance of vendor swag is improper; it matters only that it might appear improper to an outsider, like the attorney of a bid-losing vendor who’s suing you for tortuous interference or the 60 Minutes camera crew accosting you on your way to drop the kids off at school.

It’s obvious, but if your organization is sending out RFIs or RFPs or is otherwise involved in system selection, accepting anything is unwise. Even speaking to vendor reps is not smart. Don’t let vendors provide free lunches or giveaways for employees attending demos. Vendors shouldn’t pay for your site visits – if you can afford their product, you can spend your organization’s own money on flights and hotels. Besides, spurned vendors aren’t nearly as chummy afterwards, I’ve found.

Otherwise, lunches are always OK, whether one-on-one or group. Stuff for the IT department is OK, like shirts, food brought in, or sports tickets. This is the IT version of the unrestricted grants that drug companies offer, where you accept small items without reciprocating and the chance of undue influence is minimal. Corporate ethics people are usually OK with this, as long as the gifts aren’t for the specific benefit of an individual.

On the other hand, it’s never OK to solicit stuff from a vendor: free software from the Microsoft rep, donations for a pet cause, money for a department party, or entry fees for a fundraiser. Vendor strong-arming is tacky.

I also don’t like the idea that vendors buy access by sponsoring conferences and giveaways for HIMSS and CHIME, but that’s apparently a hopeless cause. It looks like Halloween, except the trick-or-treaters are wearing suits or conscientiously casual golf apparel.

Spouse trips are out. So are ridiculously transparent junkets, phony advisory board conferences, honoraria, or a visit to the German countryside to see your future PACS system being assembled. It’s tempting when all your cross-town colleagues are lining up at the feed trough, but it’s still wrong, don’t you think?

Having decision-making authority means vendor reps will try to soften you up like gangsters wooing supermodels: with flattery, rapt listening, and a shower of baubles. You know what they really want. Surely your integrity is worth enough that you won’t sell it that cheaply, especially knowing that they won’t respect you in the morning.

This editorial is copyright-protected by Algonquin Professional Publishing, LLC., publishers of Inside Healthcare Computing. Please do not copy, forward, or reproduce this material without prior permission.  To obtain permission or for more information about Inside Healthcare Computing’s reprint policy, please contact the Customer Service Department at 877-690-1871 or go to http://insidehealth.com/ihcwebsite/reprints.html.

Mr. HIStalk’s editorials appear each Thursday morning in the subscribers-only version of Inside Healthcare Computing’s E-News Update.  To subscribe, please go to:  https://insidehealth.com/ihcwebsite/subscribe.html or call 877-690-1871.

News 3/26/08

From Mitch Router: “Re: PatientsLikeMe. This really isn’t my bailiwick, but I thought your readers might be interested. It’s easy to see why doctors and researchers (in particular) would not like PatientsLikeMe.com. As a social network, great. But without scientific scrutiny collated anecdotal data may well be “interesting-in –> mathematical model + statistics –> garbage-out.” Link. An interesting New York Times article on PatientsLikeMe, where patients with a handful of specific conditions are posting detailed information about their treatments, right down to drug dosages correlated to their symptoms. It’s advertising-free, but hoping to sell information to drug companies (of course). The article has some interesting thoughts on the privacy implications of such a service and physician questions about having patients take actions based on what other patients report.

From The PACS Designer: “Re: creating your PHR. TPD has been a member of the ASTM International Healthcare Informatics E31 Committee for some time and worked with others to create the Continuity of Care Record or CCR.  Now, anyone can create their own PHR using the CCR format by using the Consumer Empowerment National Demonstration website called CEND PHR, sponsored by the American Academy of Family Physicians Center for Health Information Technology. After you creating an ID and password, you will find the following categories available for inputting your health information: Personal, Emergency contact, Insurance, Primary physician, Problems, Medications, Allergies, Family history, and Social history. After completing entries into the PHR, you can save the file and then access your PHR Portable Document File (PDF) for local printing and also save an XML file to a storage location.” Link.

From Mrs. Brown’s Lovely Daughter: “Re: McKesson Paragon. It’s cleaning Meditech’s clock in a number of regions. Key replacement announcement pending”

From Bearly Stern: “Re: Allscripts-Misys. The amazing thing about the Allscripts-Misys merger is that it could have happened years ago. John McConnell repeatedly pitched the idea to Goldberg and Skelton, but they were so focused on becoming a mini-Cerner or Epic that they squandered $500M and a huge lead in the ambulatory space. Was there any real growth or value added to Misys from year 2000 onward? Leadership’s main ideas were cutting cost as a growth strategy and making it prohibitive for existing practice management clients to buy a non-Misys (read: workable) EMR. This while touting ‘interoperability’ in a failed strategy to connect the products of three business units.”

From Esther: “Re: data mining. I CANNOT confirm the vendor, but I can tell you, as an ex-[company] employee, that [company] is very interested in data mining of patient information. Prior to the opening of the [company] employee clinic, we were told at a town hall meeting that any lab work done in our clinic could and would be used for a DNA project [company] was working on. Trust me – you could hear a pin drop during that announcement. There was a lot of uneasiness expressed after the meeting, but as far as I know, no one ever took them to task on it. Those of us who were truly concerned made sure that we didn’t get any blood work done on the premises!” I expunged the company name since it’s a bit of a hot topic right now and I don’t want to cast any unearned aspersions, but you can probably figure out who she’s talking about. Unconfirmed and still waiting on the smoking gun. Possible clue: four million patients? That’s a big footprint. Maybe it’s a clearinghouse owned by an EMR vendor – the Perlegen press release didn’t say it was EMR data, only an EMR vendor, and it refers to an “information warehouse” that would imply either hosted systems or a transaction database. Hmm.

From Dutch Treat: “Re: data mining. What about this company helping the pharma sector?” Link. IntrinsiQQ LLC, the company behind web-based chemotherapy dosing system IntelliDose, didn’t rack up enough paid monthly subscribers, so it started selling de-identified information about drug usage to drug companies. At least the drug companies don’t have plans to re-identify data or contact patients. Still, patients not only have to trust a company with which they have no legal relationship, they probably don’t even know their data is being bought and sold. Somebody could start a nice little company testing and certifying de-identification processes.

From Larry Lonesome: “Re: development. I would be interested in the perspective of users/purchasers of clinical applications, as well as developers of these applications, regarding AJAX application development versus smart client versus any other relevant methodology. Do hospitals have a preferred technology platform? Is AJAX development robust enough to handle the heavy lifting of clinical applications? Does a .NET smart client really solve deployment issues as neatly as a web application?”

Recommended: if you’re a Firefox user like me, upgrade now to the Beta 4 version. I don’t generally use beta releases, but this one’s a screamer (many times faster in Google Docs and other AJAX-type apps). Most plug-ins aren’t available yet for the Beta version, but all I really use is the Google toolbar and it already has a Google search box. Zero problems here.

Girish Kumar of eClinicalWorks passed along a short comment on the Mass BCBS conclusion that EMRs aren’t worth their cost to doctors. He says that eCW has a 95% adoption rate and that most of the physicians using their system would say they’re better off with it than before.

Reminder: if you’re not getting e-mail updates, put your e-mail address in the “Subscribe to Updates” box to your right, even if you’ve already subscribed from the old site (which is no longer being updated, thus not sending out e-mails). If you’re not sure, sign up anyway – it will tell you if your address is already on the list and you won’t get double e-mails.

Intercepted e-mail: Kaiser’s medical group will start a pilot this summer of a thumb drive-based Personal Electronic Medical Record for emergency use. Files are encrypted and read-only, printable to PDF. Contains a concise record of hospitalizations, allergies, doctors, visits, labs, problems, and demographics. Sounds pretty cool.

Tennessee Medicaid will pilot e-prescribing using Cerner software.

Donna Krause is named CIO at Truman Memorial Veterans’ Hospital, having worked her way up from pharmacy aide over a 25-year career there. Congratulations – darned impressive.

Financial Times says investors are skeptical of the proposed Allscripts-Misys merger, with investors passing on the new shares issued to fund it, leaving ValuAct Capital to eat them themselves. From the piece: “… suggesting US shareholders either don’t believe Misys Healthcare is worth this much, don’t believe the deal will go through, don’t understand it, or don’t trust a management that has presided over 64 per cent share price decline over the course of the year.” They missed one: that continued Misys involvement might actually be negative to the business Allscripts was already doing.

The CEO of MedAssets is team director of the US Olympic wrestling squad. Something else to wrestle with: its Q4 numbers, Revenue up 45.7%, EPS -$0.20 vs. -$0.16. Shares are down a third since the December IPO, with a market cap of $706 million.

Stolen, unencrypted, PHI-containing laptop #650 or so: NIH.

An Australian hospital is accused of hiring a nurse to manipulate the “time seen” ED triage data to make the hospital look better.

Robert Wiebe, formerly of the VA, is named SVP/CMO of Catholic Healthcare West.

E-mail me.

Inga’s Update

Lynn County Hospital District (TX) selects Opus Healthcare Solution’s OpusClinicalSuite for its patient information system. The three rural hospitals within the district will use OpusClinicalSuite ASP.

Design Clinicals adds a new client in Iowa. Myrtue Medical Center (IA) is implementing its MedsTracker medication management program.

Medinotes partners with Hawaii’s Akamai Practice Management to provide EMR to small, independent practices. Akamai is a practice management and reimbursement service provider.

digiChart’s OB-GYN Version 7.0 is the latest EMR ambulatory package to receive CCHIT certification.

I suppose because it is such an important use of our tax dollars, HHS just opened a second public comment period to define the following terms: EMR, EHR, PRH, HIE, and RHIO. Actually HIE has already been defined as “the process of electronic health information exchange, not a governing function or entity” so HHS now needs names for a sixth term that will describe “the function or entity that governs health information exchange beyond the confines of a specific regionally based community.” Personally I think Mr. H and I should have opened the blog up and gotten readers to define the terms and then pocketed the millions HHS is spending on this project.

Transcription system provider Healthcare Technologies is partnering with GSA vendor Network Federal. The agreement will facilitate the delivery of HTI’s medical transcription programs to federal, state and local government healthcare customers.

EMR Dude sent me a link to his blog “The Crabby Daddy,” where he provides some commentary on the Allscripts-Misys deal, noting his ties to both companies (he worked at Medic and A4 and now Allscripts.) His take is that the market was in need of consolidation and sends a reminder to the new management that “people enjoy working for a company where quality of life and a fun factor are present.” Probably a good reminder if Misys is involved. Remember this post from a few months back? “From Dan Panama: Re: Misys. Vern said at the business update yesterday that an overwhelming number employees in the employee survey said they are not having fun anymore. Vern’s response: ‘You have to earn the right to have fun.'”

And while I was on Crabby Daddy’s site, I noticed a post about the Common Ground Clinic going live on EMR. This is one of the New Orleans clinics that received funding from HIMSS (and Allscripts in this case) to fund EMRs in the Katrina aftermath. It’s led me to wonder how many other clinics have successfully gone live as part of the HIMSS Katrina Phoenix project and what applications they are using.

I sat in during part of HIMSS’s first virtual conference last year and found it interesting enough, especially for a person who lacks the discipline to listen to a webcast without checking e-mail and taking the occasional phone call in between things. I am almost positive that the first time around that you had to pay a fee if you wanted to participate in the education sessions for CME credits. However, for this third one coming up April 23-24, I notice the whole event is free. Plus there seems to be a strong list of speakers, including Jonathan Bush, Matthew Holt, and John Halamka. I have to assume the exhibitor packages (which start at $5,000) are selling like hotcakes or else HIMSS wouldn’t be offering the conference at no charge.

I am sad to report that I a clear loser in the basketball pool. I knew my selection of Duke was risky, but who would have guessed they wouldn’t make it past the second round. My sole consolation at this point is that I am ahead of Mr. H, but given North Carolina is his top choice he still has a good chance for a strong finish. I’m cheering for Davidson here on out.

E-mail Inga.

HIStalk Interviews Frank Clark PhD, VP/CIO, Medical University of South Carolina

  

A reader heard that MUSC was implementing the Oacis clinical data repository/EMR along with McKesson’s Horizon clinical systems and asked me to find out more. CIO Frank Clark was quick to offer to let HIStalk’s readers know what’s going on in his organization. Some interesting projects, as it turns out, of which the Oacis implementation is certainly one. Thanks to Frank for letting me call him at home to chat.

Tell me a little bit about your organization and what kind of projects are happening at MUSC.

We are a freestanding academic medical center. Our mission is education, research, and patient care. We have about 800 physicians and another 300 residents and fellows. We operate three hospitals – two adult facilities, a children’s hospital, and a psychiatric hospital, for a total of about 850 beds.

Of course, we have the big outpatient clinics where the College of Medicine faculty hone their clinical skills and stay current. It’s probably a $1.6 billion operation enterprise-wide.

Tell me about your IT department.

IT has 250 FTEs. Most of those are centralized within the Office of the CIO. The combined clinical and academic operating budget is probably $35 million. The capital budget ebbs and flows, depending on the projects. We’re in the throes of a big clinical implementation of advanced point-of-care clinical systems within the hospitals, about two years into that and another year to go.

That’s all McKesson, right?

Pretty much. We’ve been a best-of-breed organization. When I came in about five years ago, we had a lot of stuff in place. We couldn’t rip it out and start things over from ground zero. We’ve got systems like Cerner lab, IDX radiology, and Agfa PACS. 

We made a decision for McKesson as a preferred vendor. In fact, on Wednesday, we signed a large revenue cycle contract with McKesson . They have a new product, a new ADT, registration, and patient accounting product. We’re implementing their document imaging technology in the business office and also in medical records.

You have a PhD in mathematics. That’s got to be a difficult academic accomplishment. Do you find that’s a good fit for what you’re doing today?

I think I do. I’ve always been involved in computing, very early on as a user and more recently as a provider of services. I’ve always used computing in my academic career and in teaching. My PhD was in applied mathematics, so it had a nice fit for computational analysis.

I started out in an academic career and sort of drifted over into providing IT services. Then the CIO role become an established C-level position, so I moved into that.

How do you run things with regard to IT governance?

Governance is essential to good IT service and a good IT environment. It was one of the first things I set about to establish when I came in here. With any organization, the first thing I’d put in place is a well-defined IT governance structure.

We have various committees that represent different factions of the organization — the clinical, the education, the research, the infrastructure — and we structure that and have it well-documented and then get buy-in from the leadership. I think the key to that is constituting those committees and councils with the right people, people who have an interest and a passion and have the time and who are going to participate in the settings. That really forces stakeholders to take ownership and responsibility. It doesn’t put all the responsibility on IT.

Often issues will come up and people will automatically say, “That’s an IT issue”. Because it has some computing faction to it, people just want to default to IT. The governance really forces users to look at workflow and process and management issues. More often than not, it’s not a technology issue. It comes down to poor workflow, poor process, poor management. So it really pushes back. It doesn’t let people dump on IT. It really forces people to take ownership. It brings people’s common interest and needs together, and looks at technologies.

I think it avoids duplication and re-duplication of functionality because it forces people to look at the inventory of stuff that you already have. Often, people just automatically say, “We need to go out and get a system for this.” More often than not, that functionality exists, so if it meets 85 or 90% of our needs, then we’re not going to go out and buy another system.

What would you say your most important or most pressing projects are right now?

These clinicals that I mentioned, which are nursing documentation, barcode administration, meds administration, and CPOE. We have a lot of research systems that are going on. We’re trying to really streamline and organize the research process. We do about $200 million in funded research and we want to try to scale that to $300 million over the next four or five years. So we’re working with those provosts of research, reorganizing that whole research support sector. Once they’ve identified their strategic imperatives, goals, and objectives, we will look at how we can use technology to assist them.

Going back to the governance issue, it forces people to not just look for technology solutions, but to identify what their strategic imperatives are and their goals and objectives. Then, from an IT perspective, we try to align our initiatives in support of those goals and objectives so we don’t get the cart before the horse. Often this happens — people tend to throw technology at it. It’s been my experience that if you’ve got a bad process and you automate it, you just it do it bad faster. I think that governance helps people to realize that technology is not the panacea or the magic elixir.

So if you’re with McKesson that means you’ve got Meds Manager, HEO, AdminRX, and HED, probably. Tell me where you are with those and what you’ve learned along the way.

Meds Manager is fully deployed. Expert Documentation, we’ve got half of those beds that I mentioned a moment ago. CPOE, we started the initial roll-out in April. AdminRX is probably, like Expert Documentation, about half rolled out.

I guess the vendor is not always right. They still have problems. You would think that as many implementations that they’ve had with these products that most of the issues have been worked out, but I guess that’s not always the case. The people on the ground, the McKesson people who are here on site, are often not the most knowledgeable or the most skilled.

What I’ve learned is that you try to identify within the organization, say McKesson — and it’s huge — it’s a difficult challenge to find the right person to get the right answer, rather than trying to work through the people who are here. I know McKesson doesn’t like that. They like for you to work through the team and the protocol, but we don’t do that.

We just had a team go to McKesson’s clinical brain trust outside Boulder. We send a team out there twice a year. They talk with the right people. So you establish names and contacts. These are the people that we go to when we have issues. That’s been my experience and it’s proven to be successful. That’s just the way I work. McKesson can like it or lump it.

If they’re not performing, we just don’t pay them. Of course, we’re a big McKesson client, so it doesn’t take long for the AR to build up. When it gets to be a million or two million dollars, they pick up the telephone and they call you. I say, “Well, look, when you start performing, I’ll start paying.” I think that’s one of the advantages of the single vendor. You’re doing so much business with them that you really show up on their radar screen. If you stop that revenue stream, it doesn’t take long to get their attention.

You’re hitting some big change management projects that involve a lot of clinical users. What kind of structure are you putting in place, on the informatics side, to get this done?

Going back to the governance model, big projects like this call for an overall steering committee. They’re at a high level, the 50,000 foot steering committee that makes the very big, broad decisions. For each of those products that you mentioned, there’s an implementation oversight committee or council that has people at the operational level. They look at workflow and change management. How is Expert Documentation going to change the way nurses deliver care?

We spent a lot of time before the implementation in thinking through that and talking with other organizations like Vanderbilt and Duke, organizations in our state — Spartanburg Regional and Anderson. These are community-based McKesson clients. Talking with counterparts — “How has that changed the way you deliver care and the workflow?” We’ve really paid a lot of attention on the front end to those kinds of issues.

What are you looking at in terms of success metrics?

Being an academic medical center, we have access to people who are very helpful, skillful, knowledgeable, and experienced in this area. A lady who is in the College of Health Professionals — we bought part of her time. She has worked with the nurses to identify metrics. She did a baseline on these metrics. Like how long does it take to do assessments and how long does it take to get vital signs into the chart?’ Now she’s gone back, once we got a sample size large enough, and done the post-measures.

We’ll do the same thing on trying to measure the reduction of adverse drug incidents. On CPOE, we’ll look at the reduction in lab orders like Chem7’s and portable x-rays. So, we have some well-established metrics that we are measuring. We will report those out. The same thing is true in the perioperatives, OR and anesthesiology. Measuring throughput. We’ve been able to move more people through the OR. Also, the anesthesia coding and charting. We’ve got a project to measure that as well.

How are you going to implement the Oacis repository?

Oacis has been in here since 1994 or 95 and its predecessor before that. Don Simborg started that company many, many years ago. So they’d been in here a very long time. We have a number of very knowledgeable Oacis users as well as IT people. We know Oacis probably as well as anybody, collecting data and the ODR, the clinical data repository, since ’95. That’s thirteen years of clinical data.

It’s rather elegant. The commitment I made when we signed the McKesson contract was that if the McKesson Physician Portal, which is their physician viewer, was not superior to the existing product, we wouldn’t change it out. So about a year ago, we began to look at installing the portal and we got our physicians to look at it. They said, “No, this won’t work.” It won’t work in an academic setting because most of the work is done by the house staff. A resident might have to cover 80 patients, so its not like a community-based physician who comes into the hospital and has one or two patients. The portal is great for them. I had installed the portal in a community-based setting and it worked well.

I thought it had matured and evolved over time, but when we looked at it a year ago, in my judgment, it hadn’t evolved much. So we came to the conclusion that it would not work. It just so happened that Emergis Oacis had a new release, a Java-based release of the viewer and the repository, so we stuck with it. We’ve rolled it out and it will be our enterprise-wide clinical viewer. We import Expert Documentation information into it. Physicians can launch CPOE out of it. So, it’s kind of a single sign-on type environment.

So you are responsible for doing the back-end integration with the Horizon database back into Oacis?

Yes. We’ve worked with Vanderbilt. Vanderbilt did it. It’s not a strategy that’s strikingly different from what is being done at Vanderbilt and Duke, which are both McKesson clients. In fact, Vanderbilt developed the McKesson CPOE. It was called WizOrders and McKesson licensed it. Vanderbilt has installed most of these products that you alluded to a moment ago — Meds Manager, Expert Documentation, barcode administration. They have a homegrown product that’s similar to Oacis called StarCharts/Star Panel. It’s something they developed there. It’s very similar. So they had cracked that nut as far as importing Horizon stuff into it, so we worked closely with them and emulated what they’ve done.

Do you think this will get people’s attention to look at Oacis as an alternative?

Yes, I think it will. In fact, my counterpart in Greenville, Doran Dunaway of Greenville Hospital System, which is one of the largest hospital systems in the upper state — he’s very keen on it. I don’t know whether he’s signed the contract. He looked at the Vanderbilt StarChart/StarPanel, which is being marketed. He looked at a number of different products. He came to the conclusion that it was as good as anything around.

Who’s commercializing the Vanderbilt product?

It’s called ICA, Informatics Corporation of America.

That’s right, I know those fellows.

They’ve got an install in Bassett Health in Cooperstown and it’s being used over in Memphis and it’s a nice product. We looked at it long and hard, but when our caregivers looked at it they said, “This is good, but what we have is equally good, so why would we change it out? If it was vastly superior then we could do it, but what we have is good.”

You’re right, I think the Oacis product is one of those jewels in the rough. It’s widely used in Canada and Australia. Texas Southwestern Medical Center uses it. A lot of people jettisoned it in the nineties –- Atlantic Health, University of Chicago pushed it out. I guess we were on the threshold of doing it until we looked at the McKesson portal and it wasn’t a good fit for academic medicine in our judgment.

As a matter of fact, we signed the contact with Emergis to put in their data warehouse. That’s a Sybase product. We’re in the process of bringing it up. It will be a true research warehouse. In the past, we’d gone against our transaction systems to extract data, but we’ll pull stuff out of our production systems and put it into this warehouse. The schema is optimized for research.

You’ll be able to take your data that’s historic, since you’ve got all that longitudinal data, and move that over to the warehouse?

Absolutely. We’ll pull out all thirteen years, extract it out, put it into Star schema, and optimize it for research.

That’s interesting. What kind of projects do you think will come out of that?

Any of the principal investigators of clinical trials, research … as I said, we do about $200 million now and we hope that the warehouse is going enable us to grow that in scale. Most of it is NIH-funded research, but we do a lot of clinical trials. I think it will make it easier for the researchers to get access to patient data and financial data. We’ll use it for outcomes, accreditation reporting, and CMS.

It will be the gold standard, the system of record. We hope that we can terminate the existence of a lot of these pop-up databases. We’ve got a myriad of them and hopefully we can consolidate it all into the warehouse so we’ll know that any information that leaves this organization came out of that repository, that warehouse, and hopefully it’s accurate and consistent.

Other than Oacis, are there any other applications or vendors that you’ve run across that you think, “Wow, the average hospital has probably never heard of this product or this company, but it’s really cool and it’s doing a lot of good for us.”

There’s a product called Novo out of Georgia.

Novo Innovations.

Yes, Robert Connely. I think Robert is a smart guy. He used to be with McKesson. I think that product seems to be on a very strong trajectory. They seem to be really winning business.

Any kind of tools or anything you’ve found made a big difference or fixed a major problem?

No. I think it’s difficult for these niche players to break in because of the really big players like McKesson, Cerner, Eclipsys, Epic, and GE-IDX. I  think more and more organizations are going to move towards preferred vendors because most of these big players now have a fairly robust suite of products, both clinical and financial.

It’s going be difficult for these small players to continue to exist in the major product areas. In the small niche areas, they’ll continue, but for basic HIS kind of stuff, I think its going to be difficult and for standalone labs systems or standalone PACS. We see the integration of radiology and PACS. All these big players have that product now, so I think it’s going to be difficult for some of the small players to continue.

The HIMSS leadership survey seemed to indicate pessimism about funding, capital, and IT resources. Are you seeing any effects?

The housing market is in a rut, but people will continue to get sick and continue to need care. All the predictions show that by 2017 we’re going be spending $4.3 trillion. I don’t see that dissipating.

We seem to be doing OK. Our margins are very respectable. As I said, we just opened the new adult hospital. So I don’t see that healthcare sector being impacted by this so-called bad economy or recession. I think the demand for healthcare will continue to grow. People will continue to get sick and need the service. I don’t see the pessimism, unless it’s a spill-over from the general mood of the country.

Do any vendors stand out as either very well positioned or struggling?

I think Epic is in a good position because of their work with Kaiser. As you know, with the relaxation of Stark, hospital systems are going to do more with community-based physicians. Those organizations that have a suite of products which allow them to do that, I think, are going to be in an attractive position.

All the big players are scrambling to integrate the outpatient and the inpatient. I think that world is going to change. In the community-based setting, it’s always been bifurcated, but the model is going to be more like us. More like the academic medical centers, where you have a closed staff model; and more like what we’re trying to do with Oacis and the viewer is to have an enterprise-wide clinical environment, where a caregiver can access a patient’s information and it’s transparent to them as to where this information was gleaned, whether it was captured in the clinic or whether it was captured in an acute care facility.

With the relaxation of those laws, I think hospitals are going to be able to woo physicians and say, “OK, if you will bond with us, if you will only admit to us through this ASP model, we’ll provide an electronic medical record. We’ll house your data. It will be your data." I think that’s an issue that will have to be resolved — who owns this data. Hospitals will be able to say, “We’ll host this and you won’t have to outlay any cost”. So it think those vendors that are positioned to do that, and I think Epic is because if all that work with Kaiser, I think they’re going to be in an enviable position. I know McKesson is scrambling to try to close that gap. That’s true of Cerner, GE IDX, and others.

Anything else important going on in your world that we can talk about?

We are just trying to finish out this clinical implementation and start the revenue cycle because that’s where the money is. We’re trying to capture more of the money and collect more of the money. It all goes to the bottom line and provide the margins to fund other kinds of things.

One of the big buzzwords was PHR. A lot of the big players are moving into that, players like Microsoft and Google. McKesson has RelayHealth and, I’m sure Cerner and others. Medem, I don’t know if you’re familiar with them …

Yes. Ed Fotsch.

They look very attractive and I think they’re well positioned to do that. My understanding they have partnerships with Google and Microsoft. I think they are going to begin to gain a lot of this market share. That will be a big initiative to us — driven by marketing — trying to have more of what people want and that is online services: read the bill, pay the bill, do some pre-admission/pre-registration scheduling, online consultation with physicians.

We don’t have a lot of referring physicians, but we do have some physicians who have a special case, a transplant or whatever, and they need to move their patient into the center here. How do we push information or pull information back to those referring physicians? Also, as consumers take more control of their healthcare, they will want these health records stored somewhere. So I think that’s going to be a big push over the next few years.

Monday Morning Update 3/24/08

From Fresh Prince: “Re: P4P. There are several patient satisfaction measures in P4P that makes it a horse of a very different color. Medicare will hold back 5% of total Medicare payments, then you have to ‘earn’ it back through quality measures, like patient satisfaction surveys. I think it’s inevitable that it will turn hospitals upside down more so than DRGs in 1983. Think about this: you can give the patient the best medical care on the planet, but if he/she has to wait four weeks for an appointment, gets bumped due to ER cases, or has to sit outside X-ray for an hour, do you think they’ll say they are satisfied? Oh yeah, and what about that hospital food? There isn’t an HIS system out there ready to deal with it.”

From Artie Lange: “Re: eClinicalWorks. eCW may have implemented their systems in MA, but looks like they aren’t working. I wish you would have asked their CEO a question on this.” Link. Reported here earlier – Mass BCBS says EMRs aren’t worth the cost to doctors. But, that has nothing to do with eCW or any other EMR not working. In fact, it says the opposite – that EMRs provide value to everybody except the physician who’s expected to foot the bill. I agree that I should have asked Girish about this – it’s a conundrum that isn’t going away soon and I bet he has an interesting take on it. Maybe he’ll respond.

From LaToya Jackson: “Re: Walnut Creek. I’ve heard that there is a big Epic implementation going on in Walnut Creek, CA. I think this would have to be Kaiser or John Muir. Kaiser is a known Epic site but, I thought that JM was a McKesson shop. Anyone know who is doing the project?”  

Intercepted e-mail snips about Misys/Allscripts: “Misys has a huge client base running the old +Medic/Tiger product. In the new environment this old COBOL based system cannot survive for long. Just think of the product mix/mess these guys are in. +Medic/Tiger, Misys Vision PM, Misys EMR, Healthmatics PM, Healthmatics EMR, Touchworks EMR (and all the jumbled pieces that make up Touchworks), Imedica. What the heck will they be selling, and what will they sunset? [A Misys rep who lost a deal] had offered a 60% discount!!! … The two ugliest people in town just got married, and it’s scary to think of what the kids are going to look like.” A bit exuberant, perhaps, but I tend to agree in general. Few will buy until the dust settles, which will take at least a year. Neither company was exactly tearing it up on sales, so now competitors have another weapon to create FUD in the minds of those hospital CIOs and big practice administrators who tend to buy stuff like theirs. Does having Misys involved make Allscripts more attractive to prospects or vice versa? It wouldn’t to me.

To put the Allscripts dilemma into perspective, here’s how the shares of some publicly traded HIT companies did over the past year, sorted from best to worst.

Eclipsys – up 2%
Dow Jones Industrial Average – no change
McKesson – down 3%
Nasdaq Composite – down 8%
Quality Systems (NextGen) – down 18%
Cerner – down 31%
QuadraMed – down 36%
Misys – down 41%
Allscripts – down 66%

The two worst-performing companies will hold a shotgun wedding, with the one that’s burned through 2/3 of its shareholder value in the past few weeks providing all the management talent under the board oversight of former competitor that’s down 41%. I’m not seeing the magic, especially looking at the science fair of products soon to be under one roof. People keep talking about “footprint” and “combined sales”, but what would make you like the two companies combined that you didn’t like about them separately? Or, what synergies will help them boost sales against the same formidable competitors like eClinicalWorks, e-MDs, athenahealth, and NextGen? Sure, the Misys customer base has low EMR penetration, but so does the entire industry – that doesn’t mean they’re going to buy an EMR from Allscripts or anybody else, especially at high prices. Allscripts keeps trying to sell vision instead of results, while Misys just wants to protect its big but steadily eroding maintenance revenue from old sales. And the kicker is that fickle investors who were quick to bail out on Allscripts will now have even higher expectations for the MDRX/newco shares after all the flowery talk about synergies.

So, here are my predictions. Odds that the Misys/Allscripts merger will get shareholder approval (especially with John McConnell as a major MDRX shareholder): 60%. Odds that the proposed management team will survive a year intact: 40%. Odds that the market cap of MDRX will increase in one year after the deal closes: 20%. But, I’ve been wrong before.

Jobs: Business Intelligence Analyst Developer, Senior Network Analyst, Senior PR Account Executive, Sales Executive – Healthcare IT. Sign up for weekly job alerts.

I messed up a couple of Inga’s links in the last issue, so those are fixed now. It wasn’t a devious ploy to get more readers for Scott Shreeve’s blog since that’s where the links mistakenly pointed.

Great idea: the Michael J. Fox Foundation offers up to $1 million in grants for the development of web-based clinical assessment tools for patients with Parkinson’s disease, which will allow clinical research to be performed without the burden of patient travel. Proposals are due May 14 and funding will be available in October. Thanks for that tip from the guys at Healthcare IT Transition Group, who also report that their cartoon announcing the HISsies winners has been viewed more than 2,000 times (the connection being, of course, that they portrayed Jonathan Bush as Marty McFly from Back to the Future in the cartoon because he kind of looks like MJF).

UCLA’s psych hospital, fresh off the Britney Spears debacle and a new incident where patient photos were published on a social networking site, bans cell phones and laptops.

Guess HIMSS gave up on the idea of blogging live from the conference. Its HIMSS Live! site now brings up a “page not found” error, although HIMSS still owns the domain. And speaking of fun domain name facts to know and tell, who knew that Cerner has pre-emptively registered CERNERSUCKS.COM?

Speaking of HIMSS, I checked the hotel site for HIMSS09. The cheapest Chicago hotel is $225 a night. I may Priceline it since that’s worked before.

A couple of folks expressed interest in producing something about medical device connectivity. I’m thinking we could put together an informal white paper for CIOs from multiple viewpoints. If you’re interested in helping, e-mail me. I’m curious to see if we can harness the collective knowledge of HIStalk’s readers to create something useful for the industry.

Inga wants me to brag on how well she and I are doing (for now) in the unnamed vendor’s NCAA basketball pool. We may have peaked Friday night, when a lucky Siena pick over Vandy (time for McKesson to buy the team?) propelled me to #1, with Inga right on my heels at #3. She was quick to conclude, “You and I are clearly geniuses.” Some bad luck since sent us to #2 and #8, respectively, and I’ve got some early losers going deep that will hurt me. I’m thinking of handicapping the pool by choosing schools that aren’t on the Most Wired Hospitals list.

Speaking of Inga, she’s in touch with HIStalk’s sponsors regularly and reminded me of something important. Some sponsors are interested only in page views and ad clicks like with any other advertisement (which is fine), but many/most of them support HIStalk because they believe in what we do. I can’t explain how gratifying that is. Magazines and other online sources would kill to have our loyal sponsors and readers. Just in case I haven’t said it lately, I sure do appreciate it. Thank you.

Deborah Peel renders an opinion on the data mining agreement signed by genetic medicine vendor Perlegen and an unnamed EMR vendor, calling it The New Tuskegee.  I want to know who that EMR vendor is. Everybody seems to be beaming about their data deal, so let’s name names. If you know (and especially if you have documentation to prove it), use the confidential Rumor Report to your right to tell me about it. It’s ironic that the EMR vendor is demanding privacy about its deal to sell patient information.

British researchers are working on an enhancement to the Da Vinci robotic surgeon that will allow it to be controlled by the surgeon’s eye movements.

Rural hospitals in Tanzania are using the Internet, scanners, and digital cameras to connect with a referral hospital for telemedicine services, important in a country where transportation to the hospital can cost several months’ of the average wage.

It took a TV station’s intervention, but a Sentara Norfolk ED patient finally gets his medical record corrected to show that he had not, in fact, delivered twins there.

SafeMed, a San Diego decision support engine vendor, will provide Google Health’s drug interaction and treatment recommendation capabilities. Former Amicore CEO and Microsoft manager Richard Noffsinger is CEO. For those who say nobody ever sells anything at the HIMSS conference, Google execs happened to pass SafeMed’s HIMSS06 booth in San Diego and asked for a demo, which was followed by a deal.

Harris Corporation gets an HHS contract to plug federal healthcare agencies into the Nationwide Health Information Network.

I’m sure it will offend someone, but I’m still wishing you a Happy Easter in a non-denominational, rabbits-and-eggs sort of way.

E-mail me.

News 3/21/08

From Gail Kafka: "Re: P4P. Do you or your readers have any data on the Patient Reported Outcomes market and the IT providers in it? I rarely see articles on this topic unless they are from academia or IHI/IOM. If P4P comes to be, which seems inevitable with consumer cost and awareness increasing, then why isn’t there more chatter about measuring performance from the patient’s perspective?"

From Larry Lezure: "Re: Misys/Allscripts. It’s a reshuffle of the deck with two players holding bad cards. All they have in common is overpriced products and getting their asses kicked by eCW, which will benefit even more as they try to retire products. The most interest part of the story is currency arbitrage — a UK company getting a big discount because of the low value of the dollar against the pound." New poll to your right: is the merger a good idea? So far, 76% say no.

From Stan Zloty: "Re: Medcomsoft. I know eCW doesnt like athena’s EMR, but looks like Medcomsoft sure does." Link. The Canadian EMR vendor gives up on direct sales and seeks partners to create an athenahealth-like business model.

From Nicholas Birdcage: "Re: medical devices. With today’s mention of device connectivity as well as Isarona, any thoughts at doing a piece on the players in these market?" I like the idea, but would need some help since I haven’t followed it all that closely.

Intellect Resources will host a webinar on becoming an independent consultant on March 25 at 8:00 Eastern. They’re also starting e-mail newsletters for job seekers and employers, with sample issues coming soon.

I hope everybody made the transition off the old Blog City HIStalk site. Put your e-mail in the "Subscribe to Updates" box to your right if you aren’t getting an e-mail blast when I write something new. You can sign up for the Brev+IT newsletter over to your right, too. And in looking over there, I just realized that HIStalk’s fifth birthday is coming in June.

My editorial this week in Inside Healthcare Computing: "In a Capitalist Society, Somebody Will Always Sell a Fat Man a Speedo or an Unprepared Hospital a Clinical System." A CIO e-mailed me to say he liked it, so I’m relieved (I bet the free mags don’t work a Speedo reference into many headlines, at least unless it’s one of those lame puns they love).

The New England chapter of HIMSS will host a killer HIT forum (warning: PDF) in Norwood, MA on April 9. Speakers: Senator Richard Moore, Blackford Middleton, Karen Bell, Francois de Brantes, Girish Kumar, and Jonathan Bush (there are other big names, including CEOs). Frankly, I like the lineup better than HIMSS, plus it’s one big day for $80. I should have had an HIStalk bash there.

Maine Medical’s CEO, Vince Conti, quits for unnamed reasons.

More on Misys/Allscripts. Most of the UK analysts think Misys is paying too much, while most US analysts think Allscripts sold out too cheap. Since the deal has to be approved by shareholders, that could come up in the voting. And, it’s subject to Allscripts getting a better offer, which has happened with similar companies (iSoft, for instance). I doubt John McConnell would make a run of his own on MDRX, but I wouldn’t rule it out. I just have this vague feeling that it isn’t over yet, especially since the response from all camps has been underwhelming.

Stock and HIT expert Sonomaca had some good thoughts on the Allscripts stock message board. He says it will help Allscripts because the company can focus on long-term strategy and not quarterly results. Also, since the market seems unimpressed from the current share price, ValueAct Capital could buy up more of the company. From his calculations, Allscripts shareholders get a Misys Healthcare for four cents per share, based on the one-time dividend (or, looking at the other side of the coin, the market is valuing the combined company at just $4.40 per share, or 10x earnings). Maybe that’s why the Brits were howling.

And in more Allscripts news, former star customer Tennessee Oncology is suing them.

Orion’s Rhapsody integration engine will be used to integrate systems in Saudi Arabia.

A Minnesota hospital admits that a chart error caused surgeons to remove the wrong kidney from a cancer patient, leaving the patient with only its still-cancerous twin.

E-mail me.

Art Vandelay on Cerner

As Mr. HIStalk noted, Cerner is diversifying its revenue streams in a coming bear market. Cerner’s medical device and drug-development are long lead-time investments with major barriers to entry. The barriers include human capital, systems, and process & procedure knowledge to navigate regulations. They also have to handle new competitors. I see this strategy being copied by all the major clinical systems vendors.

The approach we will likely see from vendors will evolve to full venture capital investments. There is power in using some of the de-identified data that should be captured with the vendors’ systems to find potential investments. The vendors can then use the data to prove the value of further investment independent of the necessary FDA regulations (ex: 21 CFR 11). This could keep investors interested. To make this real for everyone, only organizations with "Stage 6" EMR deployment can reliably make this happen.

For Medical Devices, expect copycats to mimic Cerner’s CareAware or Cisco’s Cisco Compatible Extensions (CCX) strategies. Vendors will likely certify and partner as opposed to developing medical devices.

Is this a distraction from their core business? You bet it is. The vendors will view it as a necessary strategy to preserve their publicly traded prospects in a bear market.

What does this mean? Three things. First, R&D will be negatively impacted. The enhancements you expect from your vendors will be slower in coming. Expect the vendors to ask you to share the burden of investment for new functionality saying it is beyond standard maintenance arrangements. In other words, "great idea, you want the function, help us develop it (with your human AND financial resources)." Second, the privately-held companies will be even better positioned to weather the storm. Third, companies that are already diversified (ex: McKesson, Cardinal) have a chance to catch-up or pass their competitors if they focus their investments.

Inga’s Update

For the parsimonious (like Mr. H) here is a great list of free or cheap software products, with substitutes for such programs as Word and Adobe Photoshop plus anti-virus tools.

Time Magazine also published a recent article, Is shrink-wrapped software dead? which included a handy side-by-side comparison of the free solution versus the commercial option. The article’s title reminds me of the bright yellow tee shirt Jonathan Bush was seen wearing at HIMSS which said "Software Is Dead" – to the 4th power. Apparently Jonathan tried to convince his PR handlers to let him to wear the shirt for his CNBC interview conducted during the conference, but eventually was persuaded to wear a more Street-pleasing coat and tie.

I guess I didn’t sound pathetic enough when asking for advice on the NCAA basketball brackets. I had to fly solo on my selections and ended up picking Duke to take it all. I actually hope I am wrong because I have a favorite team I’d rather see crowned, but I wasn’t willing to risk my $10 bet on them.

From Nasty Parts: “I was one of the early guys calling the Misys/Allscripts merger. I’ve been talking to guys from both sides of that divide. Here’s the scary part: both of them think they are in charge. Could be a slow motion train wreck. Wait until the long knives come out and folks start fighting for their areas of authority -  it won’t be pretty. Plus, we are not even yet talking about product go-forward strategies.” If Nasty is right, maybe John McConnell was the smart one to get out of the way now.

From Poo Flinging Monkeys: “Most Allscripts folks feel like they are getting the short end of the stick, as the big M is generally seen as a dead carp around someone’s neck. There are a LOT of folks who migrated from Misys to Allscripts who groaned out loud at the announcement. The Misys folks are a bit relieved as the last few months and years really have been obviously leading up to SOMETHING, but nobody knew what. All knew Vern was coming in, stripping it down, and selling it off. Most think that Misys EMR should have died a while back. The Allscripts product will be the flagship EMR and there will be an obvious push to get the Tiger folks introduced to it. Big open market there. The Allscripts PM is okay, but generally not as shiny and end user intuitive as Tiger, so there will probably be a push to interface those 2 products while sun-downing the Misys EMR product.” Heard that Misys had a town hall meeting for employees today. I doubt that Vern has answers to all the questions, particularly the one that employees are asking most: how does this affect me?

And if you haven’t heard enough on the topic, check out Scott Shreve’s posting at Crossover Health entitled The Lawrie Dowry: Misys Acquires Allscripts in Rushed Marriage. Lots of interesting points out the new “Allscripts-Misys-I-am-NOT-giving-up-my-name Health Care Systems” company.

Minnesota law will require all healthcare providers to use an EMR by 2015. It provides six-year, no-interest loans to help providers get there. The first two loan recipients are Swift County-Benson Hospital and Mille Lacs Health System, which are borrowing a combined $2.3 million.

I haven’t heard if Dr. Peel is gnashing her teeth on this one or not, but genetic research company Perlegen Sciences announces a collaboration with an unnamed EMR vendor for access to the clinical treatment and outcomes data on about four million patients. The information will be supplied from the EMR vendor’s information warehouse. Perlegen will use highly specific inclusion and exclusion criteria to identify and develop genetic markets for predicting patients’ likely response to specific medication treatments. What I find curious is that the EMR vendor remains anonymous. If this particular EMR company believes providing the data is ethical and not in violation of any customer agreements, why not allow themselves to be named?

Duke University will implement Premise’s PatientFlow Platform to facilitate patient flow across its three hospitals.

Big controversy brewing in Texas over who owns the ankle. Seems like podiatrists and medical doctors are both claiming it’s theirs to treat and are going to court to let a judge decide. Lawyers for the podiatrists claim “you don’t have an ankle” because is really part of the foot…no foot, no ankle. Of course the orthopedic surgeons say that if ankles don’t exist then why do podiatrists want to operate on them. Quite the conundrum obviously. I have been told I have nice ankles and I don’t think my feet are nearly as attractive, so I’m thinking I will go with the MDs on this. If the podiatrists win then I’ll have one less appealing asset.

E-mail Inga.

Let Patients Control Their Healthcare Data: Give Them an Al Gore Lockbox

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in February 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I’ll confess that I’m paying minimal attention to the RHIO craze. Everybody’s starting one, conferences are showcasing speakers who’ve done nothing more than announce theirs, and tiny grants are getting the whole industry atwitter. It’s like living the dot-com frenzy all over again, irrational exuberance and all.

I’m not against RHIOs, but they’re as annoying as CPOE was awhile back, taking resources away from projects that could provide more benefits to patients without the minefields.

I recently interviewed Denni McColm, an award-winning CIO of a 74-bed rural hospital no different than 80% of those out there. Oh, except that they’re 100% paperless and 100% CPOE, something virtually none of the celebrity CIOs and Taj Mahospitals have been able to accomplish. I’ll listen to her, thanks.

First, Denni believes that organizations should be banned from using the word “interoperability” until they can bring their own electronic information to the table. If your IT house isn’t in order, RHIOs don’t need you. Anything short of everyone’s contributing information equally will cause the whole concept to collapse like an imploded 1960s Las Vegas hotel, so paper jockeys need not apply. Work instead on projects that will help your patients more than the begrudging swapping of routine lab reports with your cross-town competitor. Or, integrate all those systems you already have. Your admission ticket should be a checklist of what data elements you can supply electronically right now.

Second, Denni advocates a patient-centric RHIO model instead of the common payor-centric one. Do you like insurance companies enough to let them control patient information?

By patient-centered, I don’t mean personal health records. People are too irresponsible to reliably collect and store data with life and death importance. On the other hand, they could be given control over the trusted information generated by hospitals, physician practices, and other providers.

Suppose everything resided in an Al Gore-type lockbox that contains everything from discrete electronic data to scanned documents fed over the Internet. Either the patient controls the key (similar to a password) or only they can initiate data delivery to a provider. If they don’t want you to see it, you won’t.

This model makes most privacy concerns go away. It avoids the largely unsolved problem of how you assign some sort of universally mandated patient identifier (aka “political suicide”) to sort out the throngs of people sharing the same name. The patient simply says, “send my data to Dr. Jones” and it’s done. They keep control and there’s no arbitrary “regional” service area beyond which lies a medical no-man’s land.

Maybe some RHIOs work this way. Like I said, I don’t follow them. And, if I can’t see a quick and obvious patient payoff, I probably won’t start following them any time soon. I’ve got plenty of challenges working on clinical system projects that will hopefully save lives right now.

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News 3/19/08

From Joe Bob: “Re: consultants working on percentage of savings. I find it not only deplorable, but outright thievery and total ignorance. Children’s Hospital National Medical Center is an example. They were a top pediatrics hospital, then a new CEO hired consultants based on percentage of savings. The hospital is out of top 20. P.S. Hasn’t everyone had enough of HIMSS and their organization, or is it just me?”

From The PACS Designer: “Re: One Portal. TPD mentioned the concept of looking at personal health information in the same light as a personal online banking account. Now it comes to light that Denmark has had an online health portal for recording your health history called One Portal since 2003. It could be used as a model for other countries to emulate and get the PHR/EMR process started as an online solution.” Link.

From Niven David: “Re: economic concerns. I would have to imagine many vendors and hospitals are seeing an impact from current economic concerns, with sales slowing and hospitals tightening the purse strings. Any comments or perspectives?”

From Reggie: “Re: Allscripts. There is a rumor that McConnell quit the Allscripts board in disgust at what he felt was a low-ball offer.” It must sting. Allscripts, Glen Tullman, and John McConnell were on top of the world and McConnell’s former company Misys was on the ropes. Suddenly, one bad earnings report sends MDRX stock reeling from the high 20s to below $10, allowing Misys to gain control on the cheap. What could be lower on the HIT totem pole than having Misys as your new daddy? I bet Glen Tullman won’t like reporting to the board-controlling Brits very much. Can two struggling companies combine to make one good one while maintaining their traditionally high prices, complex technologies, and indifferent customer bases, not to mention keeping their antsy shareholders happy as the inevitable product and people consolidations occur? In this market, with nimble competitors nipping at their heels, and with the current economy, let’s just say they’ve got plenty of work to do. I expected a much better outcome for Allscripts. Mothers, don’t let your children grow up to be publicly traded.

Update: John McConnell did resign in protest from the Allscripts board Monday night. See the comment I posted at the end of this article.

From Reggie: “Re: Allscripts. There is a meeting in New York tomorrow where both Misys and Allscripts management teams will answer analyst questions. I am not clear on whether this was an emergency meeting designed to convince obviously skeptical Allscripts shareholders that this is a good deal. On paper, this is a $13 deal, which is why Tullman described it as a ‘big premium.’  Since the stock closed at $9.75, the market has priced in $3.25 worth of doubt about the combined entity’s prospects. Clearly what Allscripts needed was the help of a big operator like GE, Perot, CERN, or EDS. Were any of these companies interested?” Surely others peeked up their skirt and passed before Misys got a turn, although the overused prospect of synergy has led to many a troubled marriage.

From the conference call announcing Allscripts-Misys Healthcare Solutions, Inc. (boy, talk about an uninspiring first decision – that name reeks, at least when it’s not screaming “YOU give up your name – we’re not budging on ours.”) Sounds like some products will not be developed further (the first step to sunsetting, of course). Synergies are predicted. They like the idea of selling into the minimally EMR’ed Misys customer base (which Inga suspects means that Misys EMR and A4’s EMR are goners – they can’t walk in the prospect’s door waving competing systems). They talked about merging a year ago, but Allscripts was too expensive (the stock market took care of that little problem). I heard the two companies huddled hard for days right before HIMSS, which I assume means they desperately wanted to make the announcement there.

Someone sent me the communication sent from Misys to customers. Other than the sudden love between two formerly bitter competitors, the most interesting point was the standard boilerplate, “connect all stakeholders through the continuum of care.” Wasn’t the utterly failed Connect strategy of Misys supposed to do that? And do stakeholders, in the form of customers anyway, really care about connecting to the rest of the continuum of care? Only if you’re trying to sell to hospitals and their affiliated practices, which the new, badly named company will try to do.

Lost in the shuffle: Misys PayerPath and Home Care. They probably should deal off the latter to Sunquest or somebody, but PayerPath has promise with a bigger sales footprint (unless they sell it off for cash to QuadraMed or McKesson, which wouldn’t surprise me since it isn’t even being mentioned in all the pleasantries).

HIStalk ran plenty of speculation from readers that the Misys-Allscripts deal would happen. I admit that I was skeptical, but I said all along that bringing in ValueAct Capital was a sign that Misys wanted to shed its healthcare lines. All of you who called the shot early – nice going. Nobody else was even talking about it until it ran here. Even the high-powered analysts at the HIStalk HIMSS event were buzzing a little because I’d mentioned it the night before, plus HIStalk readers had just voted Allscripts “most likely to be acquired.” Smart readers. I didn’t mention it, but the Allscripts PR person tried to get me to kill the HISsies because Allscripts didn’t want to be named as an acquisition target. For good reason, as it turns out.

Connectologist (you know him) posted a very nice writeup in HIStalk Discussion about medical device connectivity. This stood out: “A perfect day for an IT person is to fix every problem that comes up from their desk, monitoring systems, rebooting servers, documenting support, etc. A perfect day for a biomed is to go to the point of care and work one on one with clinicians solving problems with training, problem diagnosis, and repairs. This is part of the ‘great divide’ between biomeds and IT.” Worth a read.  

Thanks to the 134 of you who responded to my consultant survey. Great information. I’ve e-mailed out the results to those who participated and supplied an e-mail address. A reader already contacted me and said the results were helpful in making a career decision, so he or she appreciates it. Also, thanks if you completed my reader survey, which I’ve now closed. I saw some very nice comments there, so I’ll have more about that once I’ve digested your thoughts.

Fair Warning did a webcast last week on EMR privacy and compliance challenges, including HIPAA enforcement. John Wade was one of the presenters and over 400 folks tuned in. It’s archived for playback.

Jobs: Manager of Lab and Pharmacy IT, Clinical Information Systems Analyst, Manager of Clinical Support Systems. That first listing had an ingenious leadoff: “If you attended the HISTALK party at HIMSS, you know that the ‘most significant IT sale of 2007’ was the Epic contract with Cedars Sinai. I guess that would make these the ‘most significant HCIT job opportunities of 2008’. Read on.”

Medical device data integrator iSirona gets a $1 million private placement. Joining its board are industry long-timers Carl Witonsky and Jim Hall.

Ohio State and Wake Forest Baptist choose the ClairVia staffing system from AtStaff.

Little doubt about it: the iPhone will be big in healthcare.

Thailand medical tourism hospital Bumrungrad International, birthplace of what’s now called Microsoft Amalga, installs the first robotic drug management system in Asia, going with Swisslog. The hospital’s CEO, Mack Banner, appears to be an American from his educational background, which I didn’t realize.

The Australian Medical Council will move its Visual Basic systems to the web-based Ruby on Rails platform.

Merge Healthcare delays yet another SEC filing, this time its annual report. I swear its accountant must be a moonlighting shoe salesman from the local H&R Block.

Holy Cross Hospital (FL) chooses the E/Point ED charging application from LYNX Medical Systems (aka Picis).

Two doctors who were sued for $67 million by John Ritter’s family are acquitted. The family already received $14 million in settlements from other clinicians and a hospital. I don’t mean to speak ill of the dead, but I never found his mugging, camera-aware style anything more than annoying, but to each his own. It’s still a shame, of course. Maybe he really would have made another $67 million in future earnings like the suit claimed. Your Honor, I call Adam Sandler to the stand.

What else could they mess up? Haywood Regional Medical Center (NC) fires a nurse and former Army lieutenant colonel for giving state inspectors information about hospital medical errors committed there, saying the Army taught her to discuss and fix problems, not hide them. She’s suing. So is another former hospital employee turned whistleblower who was canned for giving CMS information about medication errors (CMS agreed and stopped reimbursement to the hospital). The loss of 68% of the hospital’s revenue led to the resignation of the hospital’s CEO, board chair, HR director, and nursing VP. Now the hospital is fighting the press to keep the former CEO’s compensation private despite its being public record. The board is thinking about selling the facility. Good idea.

E-mail me.

Inga’s Update

DR Systems announces nine new contracts for Unity RIS/PACS worth more than $3.8 million.

Thomson Healthcare releases its 15th annual 100 Top Hospitals. To come up with the winners, Thomson analyzes data from Medicare Provider Analysis and Review data for 2005 and 2006 and Medicare cost reports for 2006 and evaluates hospitals on eight measures of clinical quality, operating efficiency and financial performance.

Does anyone care to explain this MedCom Soft press release for me? Is there: 1) no real message at all; 2) an announcement they want to increase US marketing efforts; or 3) a well-hidden announcement about “right-sizing” the organization?

Walgreens announces its new Health and Wellness division that will manage its health centers and pharmacies located at large-company work sites. They are also buying a couple of companies providing work site health centers, raising their total number of work site and retail health clinics to 500. Walgreens estimates the potential for onsite work site clinics will grow to 7,600 corporate campuses with at least 1,000 employees each.

One of our fun sponsors asked Mr. H and me to participate in a NCAA basketball pool (I am not naming them in case the IRS reads this blog, even though they claim winnings go to charity). I was hum-ho on the whole thing until I read this section of the memo sent to all employees: “This year, we have added a Group Message Board option, which is a convenient outlet for those of you who may want to elaborate on their respective bracket picking strategies, defend seemingly half-witted picks, talk smack, or just have daily alternative to your Mr. HISTalk addiction.” I may have to participate to ensure folks don’t inappropriately make basketball more important than HIT gossip. Since I like winning and don’t really consider asking for advice equates to cheating, feel free to send me your best picks.

From Insider Outsider: “In regards to your note about Bill Gates appearing before the US House Committee on Science and Technology, and his predictions, my only response is …yawn. Bill G. has never been one to have very good or accurate predictions. He is usually very general – ‘technology will get smaller and faster’ (duh) or he is very wrong ‘within 5 years, all computers will use voice commands and the mouse will disappear’. Billy G. predicted that spam would be solved in 2 years (still waiting), that OS/2 would be the most important operating system of all time, that no one would ever need more than 640k of memory, etc. Yeah, he’s gotten some right, but even a broken clock is right twice a day. He made his fortune by buying someone else’s technology and reselling it. He’s the used car dealer of technology. As for the future, his best picture of the future is to look at what Steve Jobs is doing and to copy that.” Yeah, but he’s rich. Doesn’t that count for something?

My favorite part of the interview with eClinicalWorks Girish Kumar Navani was is brief commentary on various vendors. You have to be pretty confident to swagger the way he did.

Thanks for all the Linked-in invitations. (Do people like Linked-in and other network sites because it makes them believe they are popular – or at least have friends?) Regardless, it helps me with my swagger.

E-mail Inga.

Allscripts, Misys Healthcare to Merge

Misys announced this morning in London that it will spin off its US-based Misys Healthcare Systems and merge it with Allscripts, paying $330 million in cash for a 54.5% stake in the combined entity through a complex financing arrangement that also involves hedge fund ValueAct Capital, which will underwrite a new share placement to finance the transaction.

Glen Tullman of Allscripts will remain CEO, while Misys CEO Mike Lawrie will become chairman of the board. Misys will appoint six board members, with four from Allscripts. Allscripts shares will continue to trade under the MDRX ticker and the new company’s headquarters will be in Chicago.

The announced name of the new company is Allscripts-Misys Healthcare Solutions Inc.

Misys shares are up 20% on the London Stock Exchange.

HIStalk Interviews Girish Kumar Navani, President of eClinicalWorks

  

I interviewed Girish Kumar Navani of eClinicalWorks nearly two years ago and wanted to find out what’s changed since (you might want to read that interview first for perspective). You’ll notice from his industry assessment and predictions that he’s an extremely sharp businessman and modest leader. What the company is doing would be big news in any industry, but shaking up healthcare IT like eClinicalWorks has done is unheard of (well, maybe other than Epic and Meditech, which he happily acknowledges).

His major point is that smart businesspeople can run a highly profitable company while keeping customers happy and focusing on the long term instead of next quarter’s profits. When he says the company will be doing $500 million a year in ten years, I don’t even question it.

Don’t skip reading just because you aren’t involved in PM/EMR systems. I’m not either, but there’s plenty to learn no matter where in healthcare IT you work.

Thanks for talking to me again after our interview two years ago.

It’s great to read your blog. I promised you at that time that I was going to start reading your blog and I did. You’ve grown in popularity faster than anything that I know of. People are reading your blog everywhere. I had a large customer talk to me last night and he says, “So, you’re talking to HIStalk tomorrow,” and I said, “How do you know that?”

I think you should take tremendous pride. I can’t name the customer yet, but this is a group that has got hundreds of hospitals in the country and they read your blog regularly. They think it keeps them up to date on health IT and they find value in it. I do too. It’s great.

What did you think of HIMSS?

I have general opinions about conferences. I think we attend them because if you don’t, people spread rumors otherwise. I personally don’t care too much about conferences. Conferences used to be great to go and get customers that you wanted talk to. Now conferences are becoming more for networking. But with the advent of the Internet, you really don’t have to be in a location to network.

I think HIMSS was busy. I think a lot of hospital guys liked it because they felt it was worthwhile for them to be there and meet either with their existing customers or potential customers. I had dinner with Wal-Mart one evening and a few others, so I found the conference useful. It’s changing for sure and not just HIMSS. Almost every conference is changing with more and more people gathering information online versus waiting for a show.

I agree, but the attendance numbers keep going up. Did it seem bigger to you than last year?

It was a great location. Orlando always attracts people. Location has a direct correlation to how people get attracted to conferences. I think Orlando helps tremendously because you have families coming there and it’s a great time of the year. I don’t know if I noticed it was bigger, but Orlando is such a big convention center that sometimes you get lost. I like the location a lot.

eClinicalWorks has really taken off since we talked two years ago. Tell me what’s changed.

We have about 625 employees now and Westborough, Massachusetts continues to be a strong place. At our headquarters, we have over 425 people. We opened an office last year in New York City for the New York project. That’s going well and we have about 30 people there. We have an office in Atlanta and we have support and sales people that work out of their homes.

Revenues last year — we did $60 million and actually pushed a contract out into this year because I didn’t want to sign that $3 million contract in December. That’s the difference between being a private company vs. a public company. Imagine my customer saying, “I’ll sign by December 31 if you can give me something” and their surprise when I said, “I really don’t mind, actually, if we sign it on the 6th of January.” $60 million was our target and we did that, so I was content.

Our profitability continues to be good, with net profit margins around 30 to 32%. We have zero debt, zero liabilities, zero investors. All our payables our current and we pay them off in 15 days. In a way, the business has grown very big, but I still run it like a cash business. That makes it really easy to run the company. We don’t play the games of writing off R&D to depreciate just to make the books look good. We write it off and pay it off as we can.

The financial strength of the company, or at least the balance sheet and income statement, has become a bigger asset now over three years ago. Three years ago, we were about an $18 million company. Then we went to $25 or $26 million, then $40 million. Those were good years where we could show growth, but you always have to answer to customers and your $18 million is still a bit smaller than maybe you’d like for a large customer base. At $60 million, and $75 million minimum this year, we feel we’re able to handle and convince even larger customers about the strength of our company and our balance sheet.

Customer growth has been phenomenal. We have not slowed down in that regard and I don’t want to, either. [laughs] We are managing the growth, but as I have said to you before, we’re managing it by not slowing down. Very, very good numbers on training and implementation and support, which still makes up a very high part of our company. Over 68% of our expenses are from those departments and rightfully so. Rather than spending on sales, I spend in the areas that matter the most, which is to take care of our customers. That strategy has worked out well for us in both the short and the long term.

They key now is that Starbucks experience, as they say. It doesn’t matter how many stores they open, it’s the cup of coffee for every small customer that walks in. To grow very large, we’ll need to do all the little things right. To grow big, we need to grow small or stay small. That holds true not just in customer size, but in how we take care of every customer who puts their trust in us.

Did you ever think it would get this big?

[Laughs] I think it’s a journey. We don’t want to look back because if we did, most of us would be surprised that we’ve come this far. We were surprised in a positive way, but at the same time, none of us underestimates that we could have done this.

It’s both the feeling of being very confident that it could be done, but at the same time, gratitude and satisfaction and all the things that go with achieving success in the old fashioned way – organic growth, no acquisition growth, building the product that you sell, taking care of your own customers and not trying to grow them from another customer base. There’s a lot of pride you get from doing those things. From that perspective, there’s a lot of pride within the company and all the individuals that have been here and that continue to do work every day. That’s very, very obvious. I think we’ll say the same thing ten years down the road when we’re a $500 million company.

You’ve said that your supply chain background has made a difference.

I would say so. If you look at supply chain in retail, the success of that business may be because of how well it runs from a sale to replenishment and distribution. I think in the world of the Internet, the same thing applies, because pricing pressure is there and will always be there with the increased availability of price.

We know we’ve caused that. eClinicalWorks has been a great instrument for making price differentiation in ambulatory. You can actually dictate that if eClinicalWorks is at that price point, I can’t pay five times that amount, nor three times. Price will continue to be a pressure in terms of ambulatory solutions and a company that is going to do well and still have high profitability, which means you can take that and invest it in your future growth years, you need a company that is very well run, both in terms of process and also an organization in teams.

I believe that the background of looking at in that way, as an ongoing continuous improvement cycle, is one big reason why eCW continues to do as well as we do. We take a small one-doctor, two-doctor, or five-doctor group and make them go through a process. Then, we take a big project like New York or Massachusetts, where we are 185, and we break that down into a supply chain. Or if I go take a 120-doctor group, I break them down into a process and we implement them as well. So, there is definitely the learning that we’ve had in following a protocol of handoffs that are seamless, to go from sales to project management to training to support to getting feedback and replenishing your entire core process, is a big differentiation, no question.

We aren’t hierarchical at all. We are more laid out to be like an assembly line in how we work. We work in teams, we have team leaders. At any one time, I see that as a solar system. I see the team leader being the nucleus of that solar system, around which the team members revolve,  but nowhere would you ever find a team leader trying to say “I’m better than the people underneath me.” He or she coordinates a lot of what happens, but at the end of the day, we see ourselves as very different and that’s one of the reasons we’re so successful.

What’s the scope of the New York project?

For the first eight years of eCW, we always focused on speed. Make it faster. Take away clicks here, make it more intuitive, make the learning cycle shorter for your end users. We did that very well with our product.

It’s not that we don’t focus on that aspect of our company or that we don’t need to still improve, but what New York taught eCW, by working with the Department of Health, the focus was not about just speed and adoption, it was around quality improvement.

I recall an incident sitting with the assistant commissioner of New York City at a dinner table, with five eCW folks and him and his team, literally right after the contract was signed and we were going to plan out the deployment. The commissioner asked us a question: "Tell me what you would consider to be the success and failure of this project?" I said, "I think if physicians don’t adopt the EMR and use it every day, I’d classify that as a failure." We went around the table and everyone said the same thing in different words.

He said, "I disagree. If at the end of this project we cannot demonstrate that we improved the quality of care, i.e. we did not improve hypertension or control blood pressure and get diabetes under control and look a those 10 different values that the city measures themselves on, we will have a failure."

That statement was an eye-opener to me and to many in that room. The vision of that project was not just get it implemented. It was, "After the implementation, prove to me it’s going to improve quality." They worked with us for a year because it was part of our contract with the city. We’ve been doing joint development with them. Whatever we develop we will make part of our commercial release and every customer will get it.

Their leadership in understanding quality measures, decision support, and how that whole thing works and making that part of our product cycle will be part of our version 8.0, which will be launched in the next four weeks. It’s going to be revolutionary in its concept and adoption. In a year, I’ll want to see what the measures of improvement were.

We’re looking at it differently and maybe that’s the right way to look at it. New York is not just about implementing an EHR, it’s about demonstrating that you can improve quality of care. Then, it’s all about expanding that to connect into the local RHIOs. There’s another level and degree of integration that’s big in the city – connecting with their school health program, with their immunization registries. You’re now talking about a truly digital healthcare system.

The Piper Jaffray stock analyst said he’d heard about implementation backlogs and support problems.

Investment analysts have agendas that sometimes go beyond the obvious. I spoke to him at the show and disagreed with him because he’d never bothered to speak to any eCW employee or customer, so it’s very coincidental that something is written without due diligence.

The facts are the facts. We took Massachusetts and finished in 13 months when we were asked to finish it in 18 months. We started New York and are finishing that at least on schedule. In January of 2007, we took 14 to 16 weeks to implement. We ideally wanted it to be 12 weeks because that’s the template we like. Today we are at 12 weeks and we can actually do it in eight weeks if the customer really wants to do it and they have some sense of urgency to get their hardware in place.

In reality, we are in real-time mode. You sign a contract with us today, we start your implementation 24 hours from today. We follow a template and we implement it. We expanded our support system to 24 hours the middle of last year and it was so well received that everyone in our user group commented about it. We introduced real-time chat at the beginning of Q4, which was very well received.

I think there was a clarification posted by the analyst afterward, where he clarified that after speaking to me and some of the sources, that he felt that the information that he had reported was not complete. I think we’ll leave it that — there’s no validity to that statement.

Last time, you were amused that customers always wanted a server under their desk instead of an ASP. Has that changed?

It’s changing, but it’s not changing overnight. What I’m finding that centralized hosting is becoming more common. Maybe we’ll host it, maybe a data center, maybe a hospital. So the hosting is becoming more acceptable.

Software as a service, which we’ve been doing since 2003, continues to grow for eCW and is growing rather well. I still think, though, at the end of the day, physicians still believe that the data they have, as long as it’s the same system, they will be more comfortable with it. We have other solutions that we offer, like remote disaster recovery, so we’ll actually back up their data in their data centers in case they every need to use that service. Both the client-server model and the SaaS model are growing well. On the other hand, things like patient portals seem to be mostly hosted by eCW. Rarely will a customer ask to host a portal themselves.

What’s the overall status of EMR adoption after Stark relaxation?

We are still seeing growth in a big way. I’ll give you some numbers. We did $60 million last year. We did $11 million in the month of January. February was not slow either. We’re seeing real growth in terms of numbers, in terms of physicians, and implementations are good.

I think you’re seeing a slightly different curve. Youv’e got the early adopters and are moving into the mass adoption market, with more questions and more due diligence. That’s good for the market. It won’t get adopted overnight. Nobody expected it. It’s moving along at a steady clip.

Some vendors are getting more business than the others. There seems to be the delineation between the ones that can implement and have very satisfied customers and the gap continues to widen. We at eCW think that Q1 is going to be significantly higher than Q1 of 2007. The same held true for us in Q1 2007 over Q1 2006.

When Stark laws were relaxed, there was definitely the apprehension that it might help the inpatient vendors more than the outpatient vendors. As we see our traction, it’s becoming increasingly obvious that CIOs of health systems and hospitals do delineate legacy inpatient vendors and modern, web-based systems for Stark relaxation for outpatient. You have seen a continuous momentum about leading hospitals following that trend. You will see us make some significant announcements in the next quarter in the same regard.

How much of your business is replacement business?

We continue to see a very high replacement for practice management for our unified product. One product, one client, one web-based system, one application server. We’re seeing a very significant demand for private physician groups wanting to go with unified products. There seems to be a tremendous replacement of legacy PM systems in that market, so that trend is almost universal. It would be very rare for a private physician group to buy just one and not both pieces.

On the other hand, when you’re going to the hospital-employed group, interfacing to existing systems like IDX or Meditech or Siemens and Cerner like we do, replacement is not common in terms of practice management. They tend to keep the PM system or the system that they’ve used in the past for patient registration and patient accounting.

On the outpatient side, there is a significant demand for the unified product. For EMR, we saw when Amicore went away, PenChart, we got some customers out of it. We actually have a full-blown program that can migrate Amicore into eClinicalWorks. We’ve had some traction in doing conversions of Amicore customers or PenChart into eCW, but in terms of EMR to EMR, it’s not very common still. I think we’ll hear about it here and there and see some opportunities, but it’s not as rampant. There’s still momentum in the market for new implementations.

Will ad-supported free systems have an impact?

It doesn’t sit by my business model to try and do that type of solution for building an advertisement-based EMR. It doesn’t sit by my principles of how we run a business. At the end of the day, you need to be able to have predictable growth revenue so you can staff up accordingly. It can’t be seasonal. You need to be able to predict your SMS and your ASP revenues and continue to grow the company.

It’s tough to grow it the way the advertisement model might dictate. Somebody might question me since Google does it. I think it would be tough, especially considering that you have a product of the caliber of eCW available at the price point it is. You’re not making a significant investment, especially if you’re using an ASP. The pain you’re avoiding is software costs, and at eCW, an EMR for 250 bucks a month or EMR plus PM for 400 bucks a month really doesn’t make too much of a difference whether you do advertisement revenues or you don’t. I don’t believe in the model.

You mentioned Google. What did you think of the Google and Microsoft PHR announcements at HIMSS?

There is definitely a big buzz in the industry that something needs to be done regarding personal health records and employer health records. We definitely have a perspective. As it’s been written, although we haven’t written a press release, Wal-Mart has selected eClinicalWorks. We will be integrating with employer-based records there as well. In the coming months and years, PHRs will have a purpose. What mode they take or which company operates them is anybody’s guess right now.

You’ve got EMR companies that are doing patient portals and there’s a value proposition there for the EMR companies and the physician to do it and their patients can have access to their personal health records. Then, the portal can deposit that health record in any PHR system of their liking to share it with the proper entity. I think there will be intermediaries that will help – it could be Google it could be Microsoft,  it could be Dossia, it could be any of the ones that will eventually interoperate around a personal health records system.

But I also think that the big traction within that market, the patient portals, will continue to accelerate. Physicians want to have a way to communicate with their patients and that value proposition is strong. We’re seeing that with our patient portal product. I see the patient portal of eClinicalWorks plugging into not just one PHR, but multiple PHRs.

When we talked two years ago, you said the end of the line was near for the old-school EMRs. Were you right?

I think definitely so. You’re seeing that. The legacy ones have hardly any market traction. Some of them have tried to morph themselves into other companies. Many of them are essentially figureheads with no real market traction.

I predict that, over the next year, you will find desperation among public companies in ambulatory EHRs whose stock value is not doing well, in terms of pricing, giving way anything and everything. That’s going to be fascinating, because as I’ve always mentioned to you, we’re here for the long term. I see eCW and its current management being around for at least 10-15 years before we hand it over to the next generation.

I see this market being tremendously appealing. You’ll see even successful companies desperate over the next four quarters. Will it weaken their companies in the long run? I think so. We’ll keep investing what we need to in R&D this year because we have the cash, we have the profitability, and we don’t have Wall Street expectations to meet. We’ll keep plowing money back into where we need to, which is to develop newer products. 

Those we compete with will struggle in terms of being able to make that commitment because earnings per share is now at a premium. You’re trying to focus on just one single fact, which is shareholders instead of customers. We’ll see that and I think we’ll both keep watching that trend over the next 12 months.

Last time, I named some companies and asked you to give me some adjectives. Can we do that again?

[Laughs] I don’t mind doing it, but it was tough last time.

Let’s start with Allscripts.

Desperate. Company that has grown via acquisitions struggling to develop new products.

Misys.

Non-factor.

Even with iMedica?

No. Misys, non-factor.

Sage.

The only business they’ll have is where their practice management is existing. Open market traction, open market competition, usually won’t compete. Non-competitive. We don’t see Sage as much at all. Very, very small places.

GE.

Diminishing. Less of a factor in 2008 than they were in 2006.

PracticePartner.

With the acquisition by McKesson, they’ll show up in the McKesson accounts. How well they’ll do is still open. You’ll never see them in the non-McKesson accounts.

athenahealth.

Billing service. No competing EMR.

Nextgen.

Complicated, same as last time.

Epic. You admired them last time.

Respect twice. As I said to you before, if over the next 15 years we can do what they did, we’ll be thrilled.

Epic may be the only company that’s been a game-changer in an established market. eClinicalWorks would be right up there in that category. What do you think the lessons are for ambulatory or inpatient vendors?

I’ll give you two parts to the answer. It is increasingly known that to be a big player in healthcare, you have to be a long-term player. There are two companies that have proven that – Meditech and Epic. Both successful and with a large customer base. They proved that you need to be around for 20 to 30 years and be able to make decisions that are in the long-term interests of the customer vs. the short-term interests of Wall Street.

In the capitalist market on the Street, it’s ruthless for software companies. You’re running every 12 weeks trying to close the quarter. I’ve lived on that side. I used to be at Fidelity Investments and I started a subsidiary of a publicly traded software company. I learned my lessons as to what we should and what we shouldn’t do. It’s increasingly obvious that you need long-term relationships in healthcare. You also need to be able to plan a strategy of development which is years out.

I’ll give you an example about the patient portal. When people thought it was not going to be a big part of any our product roadmap, we kept investing in it, we kept developing, we kept putting money into it. While people were trying to find a partner or a third party to bolt on to sell just so they could be competitive, we kept innovating and building our own product line. Today, the tight integration that exists between the portal and the eCW EMR has become one of our big strengths. It took us two years, maybe even three plus years, to get there.

I don’t know if you would have made that decision in a publicly traded company. You would try to partner just to get some deals done. Way down the road, you might never realize that decision was made with such short-term goals and focus that you essentially sacrificed your long-term sustenance because of it.

I think the same thing holds true for some other products we will announce in this year alone. Last year for eCW, we built a foundation for our services side, where we have 24-hour support, more trainers, more project managers, more people on the interface teams so we could do everything we needed to in terms of services. 2008, for me, is the year for product innovation.

We’ll start off with Version 8 right off the bat in the next four to six weeks. We’ll come out with the next version of the portal and you’ll see eCW on smartphones and voice integration before the year is out. I don’t see too much revenue coming out of those products this year, but we still continue to invest in them because we think that’s the right strategy for us as a company because I’m looking 15 years out.

Ask the CEO of a public company if he or she is thinking 15 years out today. The answer is no. You’ve got that dilemma and I think it’s increasingly true in healthcare that the product is used for such a long period of time that product innovation is fundamental to success. So is growing a thriving company, investor-free, debt-free so you don’t have to make decisions with external entities involved.

I might go so far as to say that as a company, I have the luxury of never having to go to an external board meeting. I never get questions from people outside on why eCW made this decision vs. making that decision. The board is the five principals in the business and that’s it. We discuss and challenge each other on what we need to do. It’s a whole different paradigm to running a business when you have that much flexibility and agility.

It is increasingly difficult for publicly traded companies to meet expectations and still continue to invest in their future in terms of product innovation. It will be one of the reasons you’ll find that in our industry, Epic and Meditech and eCW will do better over the next five to 10 years than others.

And then there’s a perspective as a company CEO. I’ll use a sports analogy. I love sports. If I told you that a 21-year-old golfer showed up at Augusta National in 1997 and was asked what his odds were for winning that Master’s and he said, "I’ll do my best and we’ll see at the end of four days." And he goes on to winning it by 12 strokes and scores 18 under par. I don’t think you and I would still remember him for one bit unless the guy actually proved that he could win 13 other majors after that and 65 other tournaments. You remember Tiger Woods today for who he is. He’s been consistently able to do what he did in 1997.

That’s the spirit of a privately traded company. You focus on how you’re going to leave a legacy behind, both of a positive reputation and change, and execute for the next 10 or 15 years, year in and year out. You just make very different decisions when you think of the corporate world that way vs. what am I going to do at the end of June and the end of October and the end of December in terms of my earnings.

I see the world increasingly different for the two sides and that’s the reason you’re seeing poorly performing publicly traded companies being bought by private equity firms. That trend is not actually common in healthcare yet, but it is very common in other places. The only challenge we face in software is private equity firms like to buy companies with guaranteed revenue streams and they like to turn it around. In healthcare, companies tried to take the position of all the license fees upfront, without much focus on ongoing, recurring revenues. That hurts that model of private equity.

eCW has always focused on recurring revenues being a driver for its bottom line. The situation today is that my recurring revenue stream from existing customers balances my fixed operating expenses. You just keep moving on and innovating and coming up with newer products. I just think we’ll make it very difficult this year to compete, both in terms of functionality, product spread, pricing, and reputation with all the large customers that pot their trust, but more importantly, all the small customers that put their trust in eCW.

You’ve reached a point where you could do anything you wanted financially. Is there anything else you plan to do?

eCW is my hobby. Other than my family, that gets a lot of my time. the only other thing I do is spend my time thinking and working at the company.

My goal is in 15 years to leave a legacy behind of a very successful software company that did it in different ways than were discussed. I don’t think I’ll do anything else, at least in the short term. I’m 41 years old, so I’ve got a long way ahead. 15 years from now, I might have other hobbies and interests, but right now it’s eCW and I think it will stay that way for a long time.

Anything else?

Watch for some news to come out over the next three months. It’s going to be spectacular, both in terms of product and customer traction ongoing. You’ll definitely say,"Here’s the changing of the guard."

We’re looking forward and 2008 started us very well. We had a company event that we do once a year for all employees. The message I left them with was that we’ve talked about growth since 1999 – can you manage the growth, how much can you grow. What I told them was that the G word is out. It’s A and F, but not for Abercrombie & Fitch, but for accountability and focus. Have the responsibility for your own actions, that’s accountability, and have the focus to execute what you do every day. If you do it, the company will continue to grow. The market is very large and the product is very well received. We’ll just keep doing what we’ve done for the last nine-plus years.

CIO Unplugged – 3/15/08

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

CIO reDefined: Chief Interpretation Officer
By Ed Marx

The roles of a CIO are as varied as the companies and sectors they serve. Even within these roles are multiple combinations and permutations that are expressed according to circumstance. The moniker “CIO” itself is not limited to “Chief Information Officer.” No, to be effective in our calling we must stretch the traditional definition beyond this commonly accepted interpretation. This post continues a series on how the “CIO 2.0” will push the boundaries of conventional thinking surrounding the role. We continue with the “Chief Interpretation Officer.”

3:15. Shanghais. After taking the ferry from Kowloon to Hong Kong, we take the bus across the border into China. It is our honeymoon, but we separate as we head into customs. If one of us is caught we don’t want to put the other in jeopardy. Plus, because we were just recently married, my wife’s passport has her maiden name and we don’t want to bring any more attention upon ourselves than is wise. We are both carrying contraband.

We both are stopped and our bags inspected. They don’t find our contraband but we can’t find each other on the China side of the massive and busy custom center. As I sit on a bench praying and contemplating the next move, a smiling customs officer walks quickly towards me and with gestures informs me that there is another young person from America traveling alone and than he introduces us. Little did he know the beautiful young woman was my wife. We play along, lose the helpful official and head to a taxi stand. Our Chinese is straight out of Berlitz and the drivers English is wanting but we are able to traverse the right directions. Our 4 hour journey begins to Shanghais where we will transfer our 120 bibles to the underground church.

All we have is an address to a hotel where we will stay for several days and honeymoon. We expect a call on our first night with more information for the drop. The call comes in. Per the instructions, we go to the downtown bus station and walk around, toting our bags full of treasure. After a few minutes of walking the length of the station, two old Chinese ladies walk along side of us, put their hands over ours, we release our grip, move to the side and they walk off into the night. Our hearts were racing but we were overcome with a sense of relief. Despite language and cultural barriers, we completed our mission.

Sometimes in healthcare, it can feel as if we are speaking different languages surrounded by a multiplicity of cultures all trying to complete a common mission. And it is true. Healthcare is a melting plot of clinical, business, academia and technical languages all coming together in service of patient care. You mix these languages together in a pot with an equal number of varying cultures and its no wonder that the father of modern business, the late Peter Drucker, called healthcare, academic specifically, the most complex organization in the world.

We have seen a dramatic shift taking place with the emergence of CIO 2.0. No longer a technophile, the new CIO can speak and understand multiple languages interpreting and synthesizing the messages amongst related complex cultures. This CIO often has a varied background with a healthy mix of clinical, business and technology skills along with the requisite leadership talents. When with clinicians the CIO speaks clinically, when with business persons they speak business speak and when with technologists can communicate equally well. In each case, the CIO must interpret what they hear in the language of the speaker and translate that amongst all the stakeholders. Conversely, if the CIO cannot communicate technical innovations or challenges to the clinician or business person, outcomes will be substandard.

CIO’s can learn and sharpen these skills. There are multiple ways to do this and I have found the following personally helpful.

Mentors. My formal mentors have purposefully included administrators and clinicians. I have mentored with CEO’s, COO’s, CFO’s and CMO’s. I asked questions, listened and transformed myself.
Rounding. I have rounded routinely with physicians and nurses. Despite my time as an Army combat medic and in the OR, I still have so much more to learn. Every time I round I deepen my customer understanding.
Reading. I read journals for administrators and clinicians while staying current in technology. I learn their languages and culture and apply them when possible.
Hire it. I try and surround myself and embed my department with individuals who have business and clinical backgrounds. By introducing their languages and cultures, I hope to create an environment where there is no longer a need for interpretation but we have a common language everyone understands.
Listen. When I am with administrators and clinicians I do a tremendous amount of deep listening. As I gain greater insights into their challenges and opportunities, I am able to respond with technology enabled solutions but in a language they can understand.
Conferences. At conferences, I always try to attend sessions outside of the technical domain. I want to know the top issues facing administrators and clinicians alike and see if there are answers that leverage technology.

Sometimes it can seem like we are all from different cultures and languages and everyone is speaking but no one is understanding. It is imperative for the CIO to be multi-cultural and proficient at multiple languages. Even if you only begin with modest understanding, these are skills that can be learned and mastered. You may not find yourself on the other side of the globe interpreting languages and signals to complete your mission, but you may feel like it at times as you gain mastery. This is no longer optional, but required to be a successful Chief Interpretation Officer.

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

Monday Morning Update 3/17/08

From Irwin M. Fletcher: "Re: Interactive Care. Do you or your readers have any knowledge and/or opinion of Interactive Care? They are a newer entrant to the telemedicine arena." I don’t think I’ve heard of them. Website here.  

From Terry Tate: "Re: consultants. I can’t believe I am saying this, since I have never been a fan of them. However, over the years I have learned that few hospitals have the people and skills needed to make the process improvements needed to optimize their HIS systems, and MUST turn to consultants. Since most will work on a percentage of the savings, this can be a win for everyone." I didn’t realize that most would work for a percentage. If so, I can still see some hospital folks still balking because they aren’t comfortable placing a value on even those improvements that involve critical success measures (maybe because they’ll be unable to actually capitalize on them or because reimbursement quirks mean they really can’t). Example: a hospital says its #1 priority is to reduce medical errors. I’m selling systems and services that I claim can help you do that to the tune of a 50% reduction and I want $500,000 or $1 million or whatever. What’s it worth to you? How many hospitals would happily write the check even when benefits exceed that amount? It’s as shortsighted as a vendor that thinks paying sales commissions is bad.

From Scot Silverstein: "Re: CMIO war stories book. I am one of those CMIOs. Expect stories a bit more PC than at my website on health IT difficulties, but with more analytics. I kept detailed analytics out of my web site, because 1) the lessons are obvious to all but the most obtuse; and 2) the best techniques for avoiding project failures cannot be learned from a book or website. You have to live it. But first, you have to accept that clinical computing projects are complex sociotechnical endeavors in unforgiving medical environments that happen to involve computers, not IT projects that happen to involve doctors. The book will be a good step in giving ‘gut understanding’ to those words to a wider audience."

From The Shelton Shadow: "Re: NPfIT. The NPfIT has started to prove that the effort to computerize healthcare in the UK is providing savings that will be significant in the years to come and attract attention from all over the world." Link.

Robert Miller, a director of QuadraMed, is named to the new board of Grady Memorial Hospital (GA), along with the CEO of Waffle House (if you’ve ever eaten in one, and I’m certainly not suggesting you do, you might be surprised to find that a corporate structure exists behind the equally tattooed short order cook and waitress who run the entire place.)

Physician, health thyself: a Westborough, MA psychiatrist loses her medical license for good after assaulting hospital police officers and hospital staff. She was taking psych call for UMass and refused to leave a party when paged. The medical director relieved her but she came in later and refused to leave when security guards told her. She was arrested screaming and kicking the officers involved. She was committed but released after two days.

E-mail me.

Blogger Boy on Exhibiting at HIMSS

Blogger Boy, a vendor person who thinks I know his identity even though I don’t, took a three-year hiatus since last describing his HIMSS conference experience. Here’s his account from Orlando.

Another HIMSS has come and gone. Here are some musings from a small vendor on the main aisle.

Thanks to all of you who came into our booth. Although most of you were there searching for items to take home to your kids (or to prove where you were) instead of a new Hospital Information System, we still appreciate it. All of you who registered at our booth either for the drawing you failed to attend on Thursday morning or because you felt bad just taking our giveaways (yes, all both of you), we still appreciate it. We love meeting new people who may one day remember when the need arises that we have a marvelous, function-rich system written entirely in the newer languages (even IF Mr. HIStalk is not impressed by that!). Silly me, I always thought mumps was a virus.

Traffic was light for us this year. We are always trying to find that combination it takes to get you into the booth for something other than a free pen. Again, we love having the opportunity to show our products even if you are not in a buying mode. This is such a small market that one day we figure you’ll give us a shot after the big guys make you mad with their ridiculous license fees, drawn out and overpriced implementations, and poor customer service.

On another subject, any one who thinks contracts are signed at HIMSS is misinformed. Oh, I am certain that decisions are set based on expensive gifts, dinners, and more exposure than most potential clients will see at any time in the future of their relationship with that vendor. But no one, and I mean NO ONE, comes to HIMSS to select a system. It continues to be our belief that most of you come to spend a few days away from home (and/or the family) at the hospital’s expense having a good time. Yes I know YOU actually come for the sessions and to see all the new stuff at the exhibit hall. I am talking about everyone else.

That is why there is not a single vendor who will complain about the show being in Chicago next April. Hell, we’d like them to have it there in February! Then instead of chasing Mickey or Shamu, maybe you guys would come into the exhibit hall and buy something from us. Oh wait, that’s right — you don’t do that either! But seriously, we do figure the number of people we’ll lose to golf during exhibit hall hours will decrease next year. While you can play in the snow, it takes an awful lot of mercurochrome to coat the balls so you can find them for 18 holes (related from drunken experience). Our biggest fear is that we will get snowed in and not be able to get home for Good Friday, the real reason HIMSS was moved to a Sunday start date for Chicago.

For just a second, place yourself into our shoes. Even the smallest of vendors is spending several hundred thousand dollars to exhibit at this show. So we come there and spend a pile of money, all the while hoping against hope that we’ll get some good leads. Then we spend the time and money over the next 18 months cultivating those leads, doing demos, meeting with the 15 different selection committees at each location, only to find that a salesman from one of the big vendors came in, planted some scary thoughts with key decision makers (AKA lies) and they wind up going with the big overpriced vendor because it is "safe". I guess it depends on how you define safe!

I see more and more often, high-profile CIOs are losing their jobs because of implementations that either never happened or never seemed to have an end in sight. Maybe next year we’ll get that one lead that we close before the end of the year! If I sound cynical, I apologize, but you guys are tough!

We did enjoy searching out all of the HIStalk ribbons. Many in our booth had at least four. I was only able to get three for my badge. It generated a lot of conversation. I hope HIStalk will do something similar for the next show. Sorry we missed your shindig. Let me know if it needs a sponsor next year. Do you give HIMSS points?

And to wrap up, trust me, we vendors know how you feel about being bugged. I swore I would move out of the country if one more offshore development person came by our booth to speak with me. I am now fielding no less than 10 calls a day from other vendors to whom I was simply cordial at the show. It is funny to hear them describe to me how enamored I was with their products. I simply don’t remember it that way in most cases! So when you get the letter from me thanking you for visiting our booth, just indulge me a little. Read it, then toss it. Who knows? One day you may want a vendor who has a great product, gives terrific service and does this because they love what they do.

Inga’s Update

You knew it was only a matter of time. UCLA Medical Center will fire 13 employees and suspend another six others for checking out Britney Spears’ medical records. Six physicians also apparently took a peek and face discipline as well. I can’t decide if I would have done the same thing in their shoes since I’m the nosy type. I might have just waited to read all about it in the juicy rags at the grocery checkout stand.

Mike Leavitt was in Pittsburgh this week stumping for the expansion of EHR systems in physician offices. An interesting number I hadn’t heard before was that the Medicare P4P project he promotes could provide physicians up to $58K over five years if they meet certain benchmarks of quality care. It’s not a ton of money, but for a primary care provider making $150K a year, that equates to a bonus of about 7.5%.

Bill Gates appears before the US House Committee on Science and Technology and makes some interesting technology predictions. The future includes tablet devices in place of textbooks in schools, natural user interfaces with sophisticated voice recognition software, and computers with the ability to recognize objects and people. Additionally, data centers will need less human intervention and software development will require less code.

HHS and AHRQ hand out $5 million of your money to Brigham and Women’s Hospital and Yale University School of Medicine to help develop and implement best practices using clinical decision support.

Mdical transcription and workflow software provider MedQuist supposedly had a nationwide system failure this week. For about a day, system issues prevented received transcription to be properly routed internally. Will vendors promoting in-house systems use this anecdote as a reason to avoid ASP software providers?

Investor’s Business Daily interviews Allscript’s Glen Tullman, who claims Allscripts’ stock price drop (almost 50% since the first of the year) is a result of not properly managing the Street’s expectations. He also indicates analysts are still predicting more than 40% earnings growth.

By adding MedBasics Family Health Centers to its network, CIGNA gives a thumbs up to retail health clinics. Other carriers will likely follow CIGNA’s lead, despite opposition from some medical organizations that believe the retail clinics should have more restrictions.

Coincidentally, Las Vegas-based Medical Marts just closed a dozen clinics last month after losing VC backing. Unlike most of the other retail clinic models, Medical Marts were staffed with physicians rather than nurse practitioners.

The 300-physician Carle Clinic Association selects D2 Sales’ new My Patient Passport ExpressT kiosk system for patient check-in and payment.

Not to have Mr. H outdo me at everything, I wanted to point out that I also have a profile on Linked In. Not surprisingly, his profile is far more witty and well-thought out than mine, but connect with me anyway. It makes me believe you care.

E-mail Inga.

News 3/14/08

From Gesundheit: "Re: CHW. Ben Williams, CIO at CHW, is changing the IT outsourcing model. They will insource part of the operations from Perot and eventually bring 40-50% of the functions in-house. With 800-900 Perot people on the account, major changes are coming."

From No Name in PA: "Re: UB. Any truth to the rumor that University of Buffalo has just signed with Epic as an EMR?" If it’s Epic and a rumored sale involving a hospital of over 400 beds, it’s usually true, but maybe someone will confirm. In fact, a second reader asked the same question, so there’s your smoke. Fire, anyone?

From Former High Level Exec: "Re: Eclipsys. I just heard that ECLP is going to outsource to India their Sales and Marketing responses to RFIs and RFPs. Can this even be possible for a sane executive to consider?"

From Mikey Likes It: "Re: consultant survey. Poorly worded question: does your company typically lay off or bench people when there is a gap in business? It should be multiple choice, not yes/no. Some companies will lay off immediately, some after a month, etc. Some will keep consultants on the bench for quite a while, maybe send them to training during that time. Whether and how long you’ll be on the bench is a BIG indicator of the company’s loyalty to their employees and their overall corporate culture. Good question when evaluating firms: ‘What’s the longest any consultant has been on the bench in the past 12 months?’ The longer the time compared to other firms, the better the attitudes, mutual loyalty, and likely the happier and more productive the consultants. Would you fire a bunch of nurses if the inpatient census dropped for a couple weeks?"

From The Real Deal: "Re: consultant survey. What every consultant should want to know is what percentage of the hourly rate goes to the company. It appears to be between 30 and 50%, which seems like a lot for job placement. Consultants eventually make their way to independent consulting to get a larger slice of the pie. You start out at more than you made at a facility or vendor, but over time, after you’ve developed knowledge, spent years on planes, and disconnected with family and friends, you start to question how much your time should be worth. The company values you at a high price when selling you to the hospital, but doesn’t place that same value on you as their employee."

Listening: The Concretes, Swedish pop. Mazzy Star meets The Supremes.

Unrelated: one of the funniest phony news stories I’ve read.

Great Red Hat Summit speaker lineup: BIDMC CIO John Halamka and a writer for The Simpsons.

McFarland Clinic (IA) picks Epic. Does anybody else ever win a deal any more? Of course, it’s kind of like taking candy from a baby when most of your competitors voluntarily carry the smothering baggage of being publicly traded.

Sounds interesting: NVivo qualitative research analysis software, which now handles media files. Free trial download. Costs a few hundred dollars. There are lots of cool, cheap data discovery tools coming out that can read just about any data source.

Big numbers for QuadraMed, but with an asterisk: revenue up 31%, EPS $0.68 vs. $0.05. Without a one-time tax treatment, earnings were flat. The company projects a revenue increase of 6-10% for 2008. The stock is down 4% after hours, a little above its 52-week low.

CDC issues $38 million in NHIN trial grants: Indiana University School of Medicine, SAIC, and Health Research, Inc.

Allscripts signs a deal to distribute its product to 1,000 physicians in Hawaii. Shares are still down 4% on the day.

Odd lawsuit: a fired hospital employee is suing her former employer, claiming she was fired because she was shipping out to Iraq with the National Guard. Her job: chaplain. Go ahead and make out the check.

E-mail me.

Art Vandelay on IT and Process Change

Mr. HIStalk has a great editorial in the latest Inside Healthcare Computing electronic update. The tagline is, "Everybody Hates Their IT Department: Where Alignment, Control, and Honesty Collide." The two-line summary is that IT is in the position to execute leadership’s vision, within a set timeframe and budget and usually with imperfect technologies. IT’s typical approach lacks the finesse to deliver in the middleman role between the users and leadership.

In the current Information Week, there is a short article about Jeanne Ross’ current thinking on IT. She is part of the IT Governance study team. If you haven’t read that book, I highly recommend it. She comments that systems will never deliver full-value without process change. CIOs are uniquely positioned be strategic execution officers responsible for delivering the change. The article stops short of providing advice about how to get the job done.

Two thoughts. To Mr. HISTalk’s point, IT organizations with expertise in process change that can effectively influence the users can get the job done. Those who don’t or can’t always have an uphill battle. The only means of getting through this challenge is highly involved and influential senior leadership; drafting cross-silo thinking users into the project; supporting them with process analysis staff who back recommended changes with hard data (i.e., turn-around time is "x" hours); and lastly, with incentives.

Second, the problem is intensified in this time of enterprise clinical systems, where change is required across business silos. The most difficult changes involve cross-silo handoffs, communication, and accountability. Implementing a department-based system is always easier.

How will organizations who are in the middle of implementing enterprise systems handle the current economic challenges? Will they back-pedal and focus on departmental systems? Will they try and eat the elephant faster to just get ‘er done? Will they try to eat the elephant slower, focusing on high-value processes? That still requires bigger bites when the system changes business processes.

Another option: focus on revenue cycle through the small systems that improve their aging systems. Somehow they have to cover the recurring costs of the enterprise clinical system they bought.

Inga’s Update

The University of Michigan selects McKesson’s Horizon Medical Imaging PACS for its three-hospital, nine-clinic health system. Expected go-live is early summer 2008.

Mark D. Barner is named Ascension Health’s new CIO after serving almost a year as interim CIO. He has had several leadership roles within Ascension and spent 19 years with EDS.

The Ohio State Medical Society releases the terms for its Standards of Excellence Program, plus the list of participating vendors. Allscripts, e-MDs, Greenway, iMedica, Misys, and Sage have all agreed to include OSMS’s "physician-friendly" terms and provide OSMS members with preferred pricing. Some of the special terms: the inclusion of upgrades in service agreements, a cap on maintenance fee equal to the CPI index plus 3%, stepped payment plans, and compliance with OSMS’s e-Rx requirements.

The U.S. Chamber of Commerce hosts an HIT forum bringing together stakeholders from government and private industry. The focus was on how businesses could improve healthcare quality and value for their employees with investment in healthcare IT.

I have been skiing for the last few days (with a very cute boy, I might add) and thus have been blissfully out of touch with much of the news of the world, much less the HIT world. Fortunately I had no need for direct contact with any healthcare facilities, though I do have plenty of aches and pains. Back to reality next week…

E-mail Inga.