Maybe Hospital IT Should Embrace a Non-Punitive Culture

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.

Hospitals realized several years ago that medication errors are rarely the simple screw-up of a single nurse, pharmacist, or physician. They occur because an organizational system of assumptions, processes, and communication fails, the so-called “Swiss cheese effect” whereby a number of usually self-correcting practices sometime line up unfavorably like the holes in Swiss cheese. That alignment of individually unusual circumstances causes errors.

Knowing that’s the case, it doesn’t make sense to fire someone involved in a medication error. The underlying system is still broken. Disciplinary action also discourages others from reporting their own mistakes and near-misses, thereby depriving the organization and industry of the opportunity to learn from them.

Maybe we should think that way in hospital IT. We’re still stuck in the old “fire everyone involved” mindset when projects fail, which is disturbingly often. Software implementation is simply business change with a technology component. Therefore, when a project deviates from expectations, it doesn’t make sense to have a knee-jerk firing of the IT project manager, the CIO, or even the vendor. Supporting cast changes won’t improve the flawed underlying system that allowed them to fail.

A non-punitive IT culture would acknowledge that all executives, not just those in IT, bear responsibility for the success of business changes involving technology. It’s their job to support process change, contribute resources, and participate in project decisions. The kickoff meeting doesn’t happen until they’re on board and they don’t get to go incognito when the project blows up and the CIO lynch party is being formed.

Some of the worst CIO and vendor behavior involves rationalization and ass-covering once projects have failed spectacularly, much like the nurse who kills a patient through a mistake not entirely under his or her control. We’ve built incentives for people to keep quiet, to dodge blame, to avoid risk, and to criticize others. Eventually everyone gets tired of the finger-pointing, so the only remaining task is to ban mention of the project in polite conversation, at least until the same mistakes doom the next one.

When it comes to IT projects, hospitals are more like surgeons than internists. Cutting is the cure: the vendor, employee, or consultant must be removed and publicly blamed to provide closure. Everyone must believe that lessons have been learned and the chances for future success increased. To admit otherwise would require a lot more self-analysis and work, and after all, Men of Action believe in their keen ability to simplify complex problems and fix them with quick, skilled incisions.

We make a lot of mistakes, many of them eminently preventable if we could just learn collectively. Most of them are quietly buried away, often taking a few careers or contracts with them.

Hospitals are mostly non-profit and non-competitive. Maybe we could improve our odds of IT success by sharing our misses and near-misses just like we do for medication errors.

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News 2/13/08

From The PACS Designer: “Re: PACS Pioneer. TPD was saddened to hear that PACS pioneer Samuel Dwyer, PhD passed away recently. Sam’s early experimenting in creating a PACS and earning the title ‘Father of PACS’ eventually led to the creation of our DICOM standard as we know it today. He also influenced TPD’s early 1990s experimenting with how to come up with a better method of connecting radiology image systems to PACS and also improve teleradiology. TPD sends sincere condolences to the Dwyer family.”

Interested in my HIMSS party? I can’t divulge all the surprises, but we may have a very special guest speaker (a big name). You will also be impressed with two lovely ladies (Inga and Miss HIStalk) who will be chatting up my guests and posing for pictures with those interested. Food, drinks, announcement of the HISsies winners, a prize drawing, and an impressive list of attendees to chat with – it’s up to you, but I’d sign up now (I need to sign up myself, in fact, before Healthia tells me we’re maxed out on attendees). Also, the Red Hat people tell me that they’ll have their own Inga in their booth offering shoe shines (see Inga’s shoe fetish below), so I’m checking that out. Information on goodies and HIStalk-recommended booth stops here (warning: PDF) so you can take it along to the show floor.

A Wisconsin investment guy likes Epic as a company, but since it’s not publicly traded, he’s touting Cerner.

Sad story: a man undergoing bypass surgery has a monitor placed into his heart for monitoring. A known programming error in the monitor causes its catheter tip to heat up to 500 degrees, cooking his heart from the inside and requiring a transplant. The company that makes the monitor knew about the problem, but didn’t recall them. They admit the error. He’s suing. Nobody wins.

Steve Liebel MD, a Stanford oncologist and Varian Medical Systems board member, died last week in Hawaii of a heart attack.

An upcoming medical journal article looks at diabetes self-management software from Colorado software company PHCC.

An Iowa newspaper’s story on the local hospital’s Visicu implementation has a pretty cool picture of the system.

WebMD’s stock is struggling and its acquisition by major owner HLTH Corp. is in jeopardy.

Want to see what was going on with electronic medical records a few decades ago? See below.

E-mail me.

Sponsor Updates and Housekeeping

Welcome aboard to new HIStalk Gold sponsor Innovative Consulting Group of Evansville, IN. The company’s been around since 2002 and has an impressive client roster. Led by CEO Wayne Kinney, the company offers consulting for products from Siemens, McKesson, and Cerner; deployment and project management; integration; and management. Thanks to Innovative Consulting Group for support HIStalk and its readers – we appreciate it.

EnovateIT announces its SmartCart, the intelligent medication cart: compact, supporting multiple computer form factors, smart power management, and individually lockable patient med drawers. They sent over a picture and its very cool: blue and white, rounded edges, big wheels, and a stylish design. I’m definitely giving it a test drive at HIMSS since their stuff is satisfying to the touch.

Ensemble from InterSystems is named the #1 interface engine in the year-end KLAS report.

Inga’s Update

Red Hat announces that Beth Israel Deaconess Medical Center continues to move from HP-UX to Red Hat open source solutions, including Enterprise Linux, Global File System, Cluster Suite, and Network. Beth Israel is the home base for “he seems like a nice guy” John Halamka, who was just appointed to the board of analytical software provider SafeMed.

Healthcare Management Systems apparently beat out some of the bigger players and is selected by 50-bed Homer Memorial Hospital (LA) to provide its clinical and financial software.

Willis-Knight Health System claims it has saved $500K as a result of eliminating dictation and utilizing MEDHOST’s EDIS system across their four hospitals.

eClinicalWorks is selected to provide EMR/PM to more than 160 affiliated providers across 10 locations in San Mateo county in California. This initiative is grant funded, with support coming from sources that include Kaiser, Avon Foundation, Blue Shield, Safety Net Institute, San Mateo Medical Center Foundation, and the Sequoia Healthcare District Foundation.

When at HIMSS, please make time to visit my new BFF Suzanne with Active Data Services (booth 3787). She provided me with some super tips on Successful Show Shoe Management. For example: “A black bag is crucial to success. Contained in the black bag are two replacement pair of shoes. Lower heeled shoes to walk into the building, especially if you’re walking in with men. It’s hard to stay in front (you never want to follow) if you’re worried about a heel getting stuck in a pavement crack. Duck into the ladies room and upgrade to medium heels for walking around. When you are ready to party, putting the 5” heels on is a treat and instantly transforms you from “working girl” to “party girl”! There’s no sexy in comfortable shoes.” Suzanne says she will be handing out “I’m not Inga” pins (for both men and women!) You working girls may also want to ask her for the complete Successful Shoe Management Guide if you, too, are faced with the Great Shoe Dilemma.

Without healthcare, it’s likely that fax machines would have been put completely to pasture years ago. So here’s a product that should help save a few trees. Sfax by SecureCare Technologies is being marketed as a “truly paperless electronic fax management system for health care providers.” The product includes digital signature. While many/most EMRs offer similar functions, this looks like a good alternative for the 70%+ physicians that have yet to go paperless.

ProHEALTH Care of Associates of NY is investing $4.4 million for a bunch of GE Healthcare products, including EMR, EDI, RIS, Billing IT, and PET/CT imaging modality. ProHEALTH has nine sites and 88 physicians.

The AAFP publishes the results of a user satisfaction survey from 422 family physicians. Similar to a study they did two years ago, the physicians were self-selected and the authors note that “it is probably most useful to consider this report as the kind of information you might get if you could ask a few hundred colleagues how they like their EHR systems.” That being said, the colleagues seemed to like e-MDs, Practice Partners, Amazing Charts, and Praxis best. The FPs were least high on Allscripts Touchworks, Misys, and Cerner PowerChart.

E-mail Inga.

HIStalk Interviews Peter Pronovost MD PhD, Johns Hopkins University

I was hopping mad when I read that an obscure HHS group had put an end to Peter Pronovost’s US projects involving using simple checklists like “Wash your hands, wear a mask” to remind physicians to help prevent hospital infections, especially since those projects continued in other countries and absolutely saved lives when used. The project’s data collection, even though it did not involve identifiable patient information, was claimed by the Office of Human Research Protections to violate patient consent requirements (notwithstanding the fact that the project was funded by AHRQ, the government’s reseach and quality agency). A fabulous article in The New Yorker is worth a careful read before proceeding here. Peter is the medical director of the Center for Innovation in Quality Patient Care and a professor in the Department of Anesthesiology/Critical Care Medicine at Johns Hopkins University’s School of Medicine. Thanks to Peter for explaining the project to HIStalk’s readers. This is some of the most exciting work I’ve heard of in the elusive task of getting proven research into practice quickly and inexpensively.

Let’s start out some background about you and your work.

I’m an intensive care physician and anesthesiologist. I did a PhD in clinical research and, because I had free tuition, I did a joint degree in health policy and management, really focusing on quality of care. My emphasis has been on bringing more robust clinical research tools to quality improvement. In other words, the belief in that if you’re going to make inferences that care is better, they have to be accurate and truthful and do that in a very practical way.

I’m trying to find the sweet spot between what’s being scientifically rigorous and what’s practical. That’s sometimes no easy feat. We’ve been looking at very practical ways or applied research ways to improve quality of care. The way we do this is that Hopkins is our learning lab. We package programs that we think can improve quality of care. We implement and measure them at Hopkins. If they work, we make them in a scalable way and share them with the broader healthcare community, in this case, with the State of Michigan.

We packaged a program to reduce catheter-related bloodstream infections. The results were just phenomenal. We nearly eliminated these infections — saved the state over $200 million a year, a tremendous number of lives. So I think the model of doing rigorous quality is key.

One of the things that we’re struck with is that biomedical research in this country needs to be broadened. It’s a bit too myopic in that we view science as understand disease biology or finding effective therapies, but then whether we use those therapies or how to delivery those therapies safely and effectively is “the art of medicine”. We’re not really looking at that. What we’ve been doing is to say, “Let’s apply the same rigor of science to the delivery of care so, at the end of the day, we can say whether care is better or not.”

Obviously, a lot of folks will want to talk about your “list method.” What was your reaction when you heard that HSS Office of Research Protection decided that it was unethical and said that the program had to stop?

Shocked. I had submitted it to our IRB, who reviewed it and said, “This is quality improvement, not human studies research,” because we’re not collecting any patient-identifiable information. When they came back to say, “No, you should have had this”, it was quite chilling. I don’t know if you saw their latest statement where they seemed to say, ‘You can go ahead and do Michigan now, but if you do any of the quality improvement work and you collect data, that’s research”. The implications of that for any kind of management effort are just profound.

Every hospital does some sort of ongoing quality studies, chart reviews, audits …

If you read their statement, it would seem that all of those qualify as research.

Nobody’s ever heard of that office. Is their ruling final or can HHS come in and say, “You’ve overstepped your limits”?

This hasn’t been played out yet, so I think they’re still sorting out what’s going to happen.

Wasn’t it true that your original work was funded by AHRQ?

Correct.

So you’ve got one government agency paying you to do the work and the other one that says it’s got to be stopped.

Exactly right. Go figure. And you have the Secretary of Health and Human Services, who publicly said that he is for value-based healthcare purchasing, efforts to improve quality and reduce cost – exactly what this program did. This program is like the poster child for what he’s advocating for.

It makes you wonder whether the government’s role is really protecting people. If you asked one of those patients, I’m pretty sure they would say, “Yes, please use the list.”

Exactly. It’s Mom and apple pie. So, who knows. I think the field erupted with concern with OHRP. There’s so many e-mails to Secretary Leavitt or Congressman saying, “This is absurd. What are we going to do about this?”

Let’s hope that reason will win. Tell me how you came upon this seemingly simple idea of consolidating information into a list.

I’m a practicing doc and, most evidence summaries in medical care, like these long 100-200 page guidelines that are exquisitely detailed and summarize the evidence, but they present them in what’s called a series of conditional probabilities or if-then statements, like, “If a fever, yes, if white count, OK.”

The problem is nobody uses them. I read a book by Gary Klein called Sources of Power, where he looked at how people in ICUs and firefighters and fighter pilots think under pressure. What he says is that no one thinks in conditional probabilities. They stick their head in the data stream and they see patterns. I reflected on that and I said, no wonder we never use these things. It’s not how our brains work. Our brains can only have one conditional probability at a time.

I was studying the aviation world and safety and how they made their progress with with checklists and said, that’s it, we need a checklist. OK, let’s take this 200-page guideline and summarize it. Given the data from our telephone numbers, the most numbers of things we can remember are five, plus or minus two. That why our telephone numbers are seven digits.

I said, OK, let’s take these guidelines and pull out the five, plus or minus two, strongest interventions for reducing infections that have the lowest barrier to use, and word them as behaviors. Behaviors are easier to fix than wording things in vague statements. We pilot tested at Johns Hopkins. The results were quite dramatic and we packaged it in the program and the result is history. The results are so dramatic.

I’m sure there’s more to it than, “Here’s a piece of paper with some stuff on it”. How do you operationalize the list and can you replicate that into other types of interventions?

Absolutely. Summarizing a list is one thing. Getting people to use it is a whole other. That requires a behavior change. We worked on giving people strategies to say, “OK, now that you have this evidence, how could you make sure every patient gets this evidence in your hospital?”

We gave them strategies, like standardize what you do. Create independent checks for things that are important, and when things go wrong, learn. So we said, “There are about eight different pieces of equipment that you need to comply with these CDC guidelines — caps, gowns, masks , gloves. Go store all the equipment in one place. Eight steps down to one.” And people really loved that.

We then said, as an independent check, docs, when you’re putting in these catheters, nurses are going to check to make sure you do it. So, nurses, we want you to assist docs and make sure that they do all these things. When we first said it, the nurses said, “Hey, my job isn’t to police the doctors, and if I do, I’m gonna get my head bit off.” And docs said, “You can’t have nurses second-guessing me in public. It looks like I don’t know something.” To which I said, “Welcome to the human race. You don’t know things.”

I pulled all the teams together and said, “Is it acceptable that we can harm patients here in this country?” And everyone said, “No.” So I said, “How can you see someone not washing their hands and keep quiet? We can’t afford to do that. In the meantime, you can’t get your head bit off, so docs, be very clear. The nurses are going to second-guess you. If you don’t listen to what they say, nurses page me any time day or night, they’re going to be supported. There’s really no way around this. We have to make sure patients get the evidence.”

When it was presented that way, the conflicts melted away, because issues became not ones of power and politics, who’s right and I’m a doc and you’re a nurse, but one of the patients.

Is it hard to assemble an inarguable body of concise items to create the list initially?

Let me tell you what our vision is. It does take some effort. It takes probably about a year and roughly $300,000 to produce a program. What that means is to go from a concept: “I want to eliminate MRSA”. To summarize the evidence; to develop practical ways to measure that in the real world that are valid and sound; develop the performance measures; to get a data base in place; to do what I call the technical work.

We view it very much like a form of pipeline. We have a process to say, “Let’s go from idea to program. We pilot test it at Hopkins, and then we launch it to the broader community.” It’s a very scripted process now. We’ve become more efficient at doing it, and we absolutely need to be, but we have a very clear program of how to translate evidence into practice. The concerning thing is that there’s no darned funding for this. NIH doesn’t fund this kind of work. AHRQ’s budget is so anemic that it can’t really do anything. So we end up with all these therapies that we know will work, but patients get them about half the time in this country.

So does the work that has to be done only have to be done once and then you can just basically pick it up and drop it in everywhere?

Generally, it’s so inefficient and so ineffective for every hospital to do their own programs; to do what I call the technical work. Now these programs require both technical work and what we call adaptive work, or culture change. The culture change is all local. So we summarize the evidence of the checklist and then we go into a hospital and say, “OK, given your own culture and resources, how do you make sure every patient gets this?” And they modify it a little bit, but the technical pieces, the evidence supporting the checklist, the way to measure if it works or not, so the data collection – are all standardized, as they should be. So those are the science pieces that are true that the central group develops. But once you develop them, there’s virtually, minimal, marginal costs to put it in a thousand or ten thousand hospitals.

Other than grant funding, wouldn’t there be other sources of funding, either private or that one hospital will get so much benefit that they’ll pay for it and share it?

Certainly there’s some philanthropy that people now have become interested this with the New Yorker article, but unfortunately there hasn’t been much federal funding in it. I believe insurers ought to be funding this because they get a windfall from this. There’s no doubt they reap substantial benefits.

This is a non-profit effort that you’re leading right?

I’m an academic doc at Johns Hopkins. Exactly right.

Nobody making money off this? Basically, you’re looking for somebody to cover the costs enough so you can roll this out, in essence, for free?

Exactly right. I’m an academic doc, so any grant I get’s just off my salary. No one’s making money off of this.

Surely you’ve gotten a ton of publicity?

There’s certainly been a lot of people that say, “Hey I’m interested in this.” We’re certainly working on a number of angles. There needs to be more than a vision. There needs to be a strategy for this that’s saying, OK, lets take pediatrics, let’s take emergency medicine, let’s take OB, let’s take surgery. Let’s make sure we develop a model that translates evidence into practice. We just have to find some financial support to make it happen.

I guess the cynic in me always says that healthcare’s pretty distinctly profit-seeking in most areas. If there’s no money to be made in better treatment …

I’ve had people who want to make money off of this hounding me. I’m getting called by everyone who’s saying, “You’re onto a goldmine here. You saved the state $200 million. It costs $500,000. That’s a great ROI. Let’s go make money on it.” I personally think that some of these things … This is a not-for-profit tool. The initial thing’s funded with public dollars, it ought to be public good that we put in broadly.

Most of my readers are information technology people. I know you’ve done other work other than just “‘the list”.

We did this kind of naively. I think there’s huge information technology potential. One is automating the checklist into the work process. We had a very hard time monitoring compliance with it because it was paper-based; people lose the forms. There’s enormous opportunity. I’m not an IT guru. That partnership, I think, we need to make stronger. We need to partner with IT people because this could be an automated checklist in a handheld or a variety of formats that is used at the point of care.

The other thing that’s information technology that’s striking is, when we go into these large hospitals and ask what their rates of infections are, virtually none of them have the data stored in a queryable database. Its pathetic. One of the things that we did in this Michigan project was we built a Web-based data entry. They put in each month the number of infections and the number of catheter days so we can calculate the rates. We made it scalable so you could click and see what the rate was in ICU 1, what the rate was in all of in all of your ICUs, what the rate was in your hospital, or your health system, or the whole state.

So we created some architecture to underly this. It was really simple. And hospitals loved it because, for the first time, they had the data in a real-time time, scalable database. It just shows how rudimentary our clinical information systems for data quality are in hospitals. Even a hospital like mine, University of Michigan, they’re not stored. We haven’t invested in a database infrastructure to do these things in a scalable way.

I’m just speculating, but lets say a big systems vendor came to you and said,’ We’ll underwrite five of your programs in return for the ability to distribute them either exclusively or not”. Do you ever see that happening, where a vendor would maybe fund some of your work?

I have. A couple of the big health IT vendors have come. I think that’s a great support. You can see that these things are easily built in to an information system. It’s crazy not to. Instead of having all these pieces of paper around, you click onto “Central Line” and here’s the central line checklist. I’m doing palliative care, here’s the palliative care checklist. So, absolutely, I think there’s great potential for that,

The data management, it sounds simple, but there’s very few hospitals, or any, frankly … I can tell you large systems that have won awards for reducing infections. When I say,”So what’s your infection rates?” they say, “I don’t know.” or “It’s stored on this piece of paper or Excel file.” We haven’t invested in data management for quality reporting and we desperately need to.

There are two key success factors for this project. One is that it was evidence-based so the interventions are for sound evidence. But two, that we had valid measures, that docs believed that data. This wasn’t marketing like so many quality improvement projects are, where it’s “Come look how great I am,” but the emperor has no clothes, or the data has no credibility because there’s no quality control. It’s seemingly poor quality and the inferences are probably incorrect, the inferences about whether care got better. Docs believe this because they say, “Yes, it’s standard definition. Here’s the data. You can look at how much missing data you have. Here’s the data quality.”

In many senses, we created a monster in Michigan because now there’s a hunger in these hospitals for a pipeline, but we don’t have the infrastructure to deliver the pipeline. The docs are saying they love this approach, “Peter, you’ve transformed the state”. The hospital CEOs love it. You have their docs, nurses engaged in quality. The results are good. They’re all excited. So what’s next? Could we do the same model for VRE or MRSA and for palliative care and sepsis and for emergency medicine and for pediatrics? We certainly could, but we don’t have financial support. We have the model to create this pipeline. We’re working on it. We just launched, funded by MHA, a safe surgery project that has the same model. We’re going be looking at safety in surgery with some checklists and things like that.

How many of these do you think there could be? Are there enough solid facts?

Hundreds. Think about it. Stroke care, headache care, acute MI care, arrythmia care, asthma care. Our brain can’t remember all these things, so the key is the medical community responded to that by making these 200-page eviddence summaries, but nobody thinks that way so they’re not used in practice. The simple checklist approach conforms with how we think. I don’t want to trivialize it because the reality is, to summarize 200 pages of evidence into five checklists that are worded into behaviors that are practical but yet scientifically sound, takes some trial and error.

That sweet spot is a big part of what our key to success is. It’s what our shop does well, is that all of our people are clinicians, but trained in research methods. We know both the biases and the evidence and the clinical realities and we try to hone in on that sweet spot. Inevitably we get it wrong and that’s why we pilot test it and revise. So what you serve up is ultimately very practical, very scientifically sound, and usable in a variety of types of hospitals.

The biggest problem in medicine is probably getting stuff out of journals to the bedside. Even if this was short term, it seems there’s a lot of opportunity to use this a vehicle to push out recent findings.

Exactly right. We could translate evidence into practice quickly. The investment, from what you see, is trivial. You can use it throughout the whole world. We have formed a partnership with the World Health Organization to help put these things out more broadly.

The implication is that if the list works, the doctors were doing it wrong up until they had that tool. So basically, are they acknowledging that they’re just overwhelmed and can’t do as good a job unless they have some reminders?

I think what we say is, sure, they were part of this. What we’ve done with this is created a system. So yes, they’re human. Their brain doesn’t remember everything like mine or yours doesn’t. So what you’re alluding to and what I saw was that our pre-condition for using a checklist is the humbleness to say, “I’m not perfect.”

Healthcare wasn’t there five years ago and perhaps some physicians still aren’t there now. What we’ve shown is, when you accept that, like in anything in your life, when you acknowledge a shortcoming, it’s very liberating. You say, “I could use this aid.” And we changed the system to make it easier.

That chlorhexidine that I told you about reduces infection risk by half. But most of the central line kits didn’t have that soap. The doctors and nurses didn’t know how to change the purchasing to get it. So I sent a memo to the CEOs at the hospitals in Michigan at said, “There is a soap called chlorhexidine that that cuts infections by half. It costs pennies. Please make sure its in all of your central line kits. I’m going to e-mail you back in a month to make sure you did it.”

I have no authority over them, but what I found was that, when we did focus groups with them, they all knew safety was a problem. They were all committed to doing things to improve it, but they didn’t know what to do and most of them were to scared to say so, because you don’t get to be a CEO without having answers, right? I said, “OK, I’ll make it easy for you. I’ll send you a task every month. A really concrete task to have you go do it.” One of the tasks was putting the soap in. Lo and behold, a month later, the whole state has this soap in.

You’re an anesthesiologist as a specialty. I still would argue today that the most dramatic quality of improvement that’s ever been done, in any area of medicine, was when anesthesiologist got together and said, “Look. This risk of general anesthesia in surgery in absurd, We’ve got to make it better”. How did that come about and are the same sorts of roadblocks that the anesthesiologists figured out how to get around going to have to be overcome again with the rest of medicine?

What allowed that discussion was that humbleness to say, “We make mistakes. We’re not perfect.” A big part of our work was getting docs to reclassify harm. Most people put harm in what I call “the inevitable bucket.” Things happen because you’re sick or you’re old or you’ve had a big operation or you’re really young. That “bad things happen” kind of colloquialism. What we did is to say, “No, I think a lot of that is in the preventable bucket. Let’s reclassify it.”

When we did these infections, docs said, “We’re at the national average and these are the people infected and there’s nothing we can do about it.” I said, “I don’t know if we can do something about it, but what I do know is that we’re not using these five central evidence-based things in all patients. Let’s out a system in place where every patient gets it and lets see how well these rates go. I may be wrong and they may stay exactly the same, but my hunch is most are preventable. So can we agree that this evidence is strong and we’re going to create a system where patients always get this evidence because we owe it to them.” Of course, docs agreed on that and the results were breathtaking. It really opened them to say, “Wow. Maybe most of these are preventable.”

You also mentioned the airline industry, where early pilots were free spirits who eventually saw the benefit of having conformance to accepted rules. Does the same psychological way that it took to get pilots to give up what they perceived to be their independence need be applied to equally headstrong physicians?

Exactly right. That’s the tension that we have. How much evidence do I need to give up my autonomy? We’re still uncertain about that. As an industry, healthcare is grossly understandarized, compared to that pilots have to use checklists or they won’t be flying. Healthcare is still very much like the Wild West or like Chuck Yeager in The Right Stuff, where we have this cowboy mentality and we’re just beginning to accept that standardization is a key principal to making care safe. We need to do that. I think we have, especially among the younger generation of physicians, broad acceptance that they need to standardize. What the field of quality has to mature is, “How much evidence do I need before I take away your autonomy or, at least, put some restraints on your autonomy?”

I think you did an article, study, or consultant work involving computerized physician order entry. And there were some sky-rocketing error rates that occurred after implementation. What was your conclusion from that, since I’ve got a lot of technology readers?

What we saw is after the implementation of POE, errors went up dramatically. Though I think that publication surprised healthcare workers, they really shouldn’t. We learned this from aviation and other industries, that any time you change a system, you may defend against some errors, but you will inevitably introduce new ones. This always happens. You’re going to create new risks.

I think healthcare approached POE perhaps naively in that they simply sought to replicate the paper world in doing work electronically. Even the forms are alike. We want to make it look the same way. What that does is, it introduces new errors that weren’t there. So you’re substituted handwriting errors for, what I call, choosing one for many. Most physician order entries have drop-down lists because we have ten different doses of morphine. We haven’t standardized those yet. It’s a huge issue. We need to.

So predictably, some people are going to click the wrong box when they do that. It’s guaranteed. It’s part of human nature. It’s cognitively predictable that they will click the wrong box. Or we’ll have other types of errors, so that you’re substituting new types of errors. We probably hadn’t reflected on how to defend against those enough. We’re focused so much on learning the technology, replicating what the paper workflow looks like, that we didn’t simulate or say, “I’m going to introduce these whole bunch of hazards and how am I going defend against that?”

And, much of the decision support tools that really would’ve benefited from these technologies weren’t part of the initial systems. They’re developed in later. That’s not to say I don’t believe in technology. I think POE is a great tool, and it needs to be done, but we have to do it wisely with eyes wide open. Like, anytime I put something in, I’m going to introduce new errors. Let’s try to proactively identify these so we can defend against them.

The second, the significant mistake, is that we under invest in training and support for these systems. Learning a system takes a lot of ongoing training and support and risk reduction. So, as in real-time I introduce and I see a new hazard, how am I going to fix this and defend against it?

One of the absurdities that I see with POE now is the amazing amount of waste and ineffectiveness of having every hospital home-grown their own decision support tools for these systems. So Hopkins, the main hospital spending thousands upon thousand of person-hours designing their own order sets and decision support tools. Those things take a tremendous amount of time and person-hours. If you add those up across the six thousand hospitals in the US that are doing this, the collective cost is outrageous. It would almost be like each air traffic control developing their own technology and system and not working together.

So somehow, I think, the industry needs to begin to say, we have to work smarter. It’s inefficient and ineffective for everyone to be doing their own thing for these tools because good decision support takes a lot of work. It’s just like the curriculum or good safety programs. We’re going to break the bank if every hospital has to invest hundreds of teams of people developing their own. But perhaps our inability to do that is emblematic of the cowboy mentality, that we can’t get the docs in one institution to agree, let alone talk among hospitals. It says how understandardized we are. You don’t want have every airline or every pilot developing their own checklist to say, “No, my checklist is ABCD. Your is this.” There’s an industry standard.

My audience is mostly executives and informatics people. Is there any message you’d like to leave them with as far as informatics and technology in healthcare and error prevention?

Sure. I think that the most important message is that no one group can do this alone. There needs to be greater partnership between clinicians, information technology, and methodologist or safety experts or measurement people, so that we can put programs together that could help clinicians use evidence in interventions and evaluate the extent to which they actually improved care. That’s going require the collaboration of all three of those groups.

Monday Morning Update 2/11/08

From Bill Kilgore: “Re: Cerner. Cerner opens an office in Dublin is kind of ironic since the Irish don’t have the money or the emerging market as the Middle East. Maybe they should consider Doha since there is fresher growth market in new hospital construction.”

From Gob Bluth: “Re: QuadraMed. QuadraMed’s recent layoff and offshore decision is for the entire Quantim HIM Suite. Management told the remaining Quantim employees that ‘some of you will get the opportunity to go to India to train the new team members.’ Sounds a lot like POWs being forced to dig their own graves before being summarily executed.”

From HITPundit: “You are starting to cross the line where you exalt your sponsors every chance you get. You have no practical or actual knowledge of the sponsors other than what they tell you. Are you a bought blogger?” Well, I noticed your IP address is of a vendor and not a charity, so you’re not working for free either, right? I believe that close reading will prove that “exalting” just means mentioning them along with anything factual that I happen to know -that they’re nice people or that they’ve announced something. Nothing more. I don’t think you’ll find a case where I recommended them or their products specifically unless I actually do have first-hand experience with them as a customer, which I do in some cases. The rules I’ve followed for years are here. Sponsors get only one thing that non-sponsors don’t: I’ll sometimes mention their announcements. The agreement they sign even says so, that they’re fair game otherwise. I’ll compromise with you since I’ve been thinking about doing this anyway: I’ll put sponsor stuff in its own subsection of HIStalk. Worth a read, but you can skip it if you like (you could do that now, of course, but I’ll even mark it clearly for you). Fair enough?

From Dr. Lisa Cutty: “Re. Wikipedia. Hi, since the English Wikipedia page about HIS is sadly nonexistent, I would like to suggest to create a competition about who writes the best definition. The winner text will be published in Wikipedia. Come on folks, let’s define us…” Say, you’re treading on government contractor work there, young sportsman. OK, I suppose we can accept volunteers. Anyone?

From Jerry Riggs: “Re: Halamka. His reputation was made before the BIDMC fiasco (give Cisco some blame for that, too) and his response just burnished it. Since then, HITSP, NEHEN, Harvard Med. He does a lot. It helps that he doesn’t need to sleep like the rest of us mortals. I’ve known John for a long time. Sure, he’s got a firm grip on marketing and spin, but what top-notch senior executive doesn’t? The difference with John is that he backs it up with dedication to his work, an impressively deep fund of knowledge, plain well-spoken openness, and as you noted, exemplary graciousness. I’ve seen him post-talks, where he politely takes time to speak to just about everyone who comes up to him. Add another category, above ‘seems like a good guy.’ John is one.” I dare you to test him at HIMSS. Walk up at the IHE booth or wherever you see him and strike up an excruciatingly dull conversation and do most of the talking yourself, spouting the most asinine nonsense you can think of. I bet he’ll listen attentively and make you feel like his equal and compliment you on your perspective. That’s my experience, anyway, from watching him in action. I’m jealous of him too, but willing to give credit where it’s due. Maybe I’ll do the black turtleneck under black jacket thing at HIMSS as my homage.

From Festus Peashooter: “Re: QuadraMed. That’s right, they were the first to see the value of care based revenue cycle … but alas, all we hear about is that they are cutting back on Misys /CPR staff. But this always happens in an acquisition like this. The staff that remain need to ask themselves: would they be better off with a ‘dead’ product that would be limping along under Misys, left eventually to die on the vine, or are they in a better place now that someone has taken a real interest in keeping it going, even investing money trying to improve it? If you are a QuadraMed CPR employee today … which do you want?”

From Soul Survivor: “Re: QuadraMed. Why the surprise about layoffs from QuadraMed? Keith Hagen is from the Tom Skelton/Misys school of leadership: focus on management weaknesses and blame the staff. ABC – anyone but the CEO.”

From Murphy Blue: “Re: care-based revenue. I don’t know whether this will go anywhere, but it’s the first time I’ve seen prominent press about an insurer’s proposal to help with health care costs (while believing they can also help themselves…novel idea.)” Link.

SIS, which has been pretty quiet lately, brings on Chris Giglio as SVP of customer operations and Eric Nilsson as CTO, coming from McKesson and Infor, respectively.

McKesson will move 500 people from its Louisville and Broomfield (CO) offices to Westminster.

Jim Burton, formerly of FCG, takes a VP job with Emerging Health Information Technology.

Richard Granger of NHS is officially finished there, to be replaced with two positions: a CIO and a project executive for Connecting for Health.

Revolution Health claims its sites have passed WebMD as the #1 health property on the Web, but it doesn’t sound all that convincing that it means much.

E-mail me.

Inga’s Update

Thank you Imelda M. for reminding me that in addition to finding the perfect party outfit, there is the shoe dilemma as well. Do you wear the sensible shoes for walking around the convention hall all day or do you become a fashion slave and get the 5” spikes? You guys just don’t understand how hard it is ensure we are objects of your fantasies.

A dress makes no sense unless it inspires men to want to take it off you. ~Françoise Sagan

I clearly opened up a can of worms about the LA hospital issues. From Dr. Webber: “When MLK-Harbor was forced to close, 75% of their ED patients starting coming to Harbor-UCLA (where I work). We are in the same “system” but we don’t get their medical records, so often we have no idea what their primary care looks like. We have asked for additional resources from corporate to handle the influx of patients, but have received few useful additional resources. In fact, our CEO had to take a 10% budget cut on top of more patients from King. That’s insult upon injury. CMS was explicit in their exit interview. They stated (!) they knew the problem was not a fault of the hospital, as we can’t stop people from coming in to the ED, and we have only so many staffed beds and ICU/PCU beds to hold them. We have minutes from our Governing Body meetings where we are quite literally yelling for help, but have been ignored. MLK-Harbor. Olive View. Now Harbor-UCLA. CMS is sending a message to the LA County Board of Supervisors to get out of the healthcare business. Did you know that the last time JCAHO did an unannounced there were 10 surveyors? How many hospitals get that type of scrutiny?”

And from Dr. Shepherd: “The next time you’re in LA, I doubt if you become ill you’ll end up at a county hospital. They are the symptom, not the disease. The disease is massive overcrowding and it isn’t just in county hospitals. Coupled with a 20% nursing shortage in the state and mandated nursing ratios, no money, no staff and no interest from a board of supervisors that only respond to crises, the safety net for LA is a warning for the rest of the nation. Hey, board, you’ve got a crisis to deal with now! It is a mess. As a practicing ED MD for over 30 years, LA is NOT unique. As a patient, I’m scared. As a doctor, I’m fatalistically depressed. As a consumer, I’m mad as hell and I don’t want to take it anymore. I think everyone is looking for a solution, but not willing to be so drastic as to throw out the entire system and start over. Think about 20% of our healthcare dollars going to big insurance management and what could be done with it. We must also re-introduce personal responsibility and buy-in. ‘Americans are willing to consume all the healthcare someone else is willing to pay for.”’

The NHS says there is no cause for alarm over the misplacement of 6,000 smartcards for accessing patient records. Why do I feel good over the news that the US is not the only country with ridiculous security lapses?

St. Mary’s Medical Center in Huntington, WV renews its agreement with MED3000 to provide revenue cycle management, PM services, consulting, and coding services for their physicians.

Encentuate is selected by the 80-provider group Northwestern Memorial Physicians Group in Chicago to provide single sign-on and authentication services.

E-mail Inga.

Sponsor Updates and Housekeeping

Jobs: Network Analyst, Systems Support Applications Analyst, Director of IS.

Reminder: sign up to your right for instant updates when I write something new here or to receive the Brev+IT weekly newsletter in your inbox.

New postings at HIStech Report: EnovateIT mobile devices, Design Clinicals medication reconciliation, McKesson’s Horizon Expert Visibility, Sage Software, and Healthia Consulting. A good read before HIMSS.

Jerome H. Carter, MD, FACP Replies to Bignurse

I really enjoy your blog. I saw the post by BigNurse and thought I would respond since implementation problems are of particular interest to me.

The meaning of “implementation” is very important and is rarely formally defined for EHR projects. Heeks and Mundy published a white paper in the UK that I think addresses this matter quite well. They define types of implementation failures and by extension, successes. They define the following types of failures:

• The total failure of a system never implemented or in which a new system is implemented but immediately abandoned. A much-reported example is that of the London Ambulance Service’s new computerised despatching system. This suffered a catastrophic failure within hours of implementation, leaving paramedics unable to attend health care emergency victims in a timely manner (Health Committee, 1995).
• The partial failure of an initiative in which major goals are unattained or in which there are significant undesirable outcomes. Anderson (1997:87), for instance, cites the case of “An information system installed at the University of Virginia MedicalCenter [which] was implemented three years behind schedule at a cost that was three times the original estimate.”
• The sustainability failure of an initiative that succeeds initially but then fails after a year or so. Some of the case mix systems installed under the UK National Health Service’s Resource Management Initiative fall into this category. They were made fully operational and achieved some partial use but with limited enthusiasm from staff for using them. Ultimately, they were just switched off (HSMU, 1996).
• The replication failure of an initiative that succeeds in its pilot location but cannot be repeated elsewhere. Although presenters may not realise it at the time, every health informatics conference is jam-packed with replication failures about to happen; with wonderful innovations that are tested once and then disappear without trace. As an audience, we hear all about the pilot, but we tend not to hear about the replication failure.

In my experience partial failures are quite common with EHRs. Very common examples are:

• Key features are never utilized or under utilized (quality and preventive care features)
• Not all providers in the practice use the EHR for all patient documentation
• Features are never implemented or do not work (lab interfaces being the best example).

Partial implementations are costly in a number of ways because paper/electronic hybrids are more difficult to secure, search, analyze and maintain. Also, ROI is not maximized until the implementation is complete. From this perspective “go-live” is simply the start of an implementation.

Unfortunately, I have seen my share of “declared” implementations as well. These are situations in which an organization flails at an implementation until everyone is tired of it (or someone has been fired). They then “declare” that whatever state of implementation they have achieved is what was intended. Alternatively they look for the most palatable excuse for their lack of success (the doctors were uncooperative, the software did not work as expected, the CIO was not the “right person” for the task, our organization is unique.)

Practically, I believe that organizations would do well to use at least a two-tiered approach to defining a successful implementation. Level One success would occur when all patient data that originate at the practice site are entered directly into the system. Level Two would occur when key features/functions (e.g. quality/safety) are used by ALL providers as part of routine care.

A Level Three might then be defined as all patient data, whether external or internally generated, are in the system. However, this requires interoperability capability that is beyond organizational control. I would guesstimate that maybe only 10-15% of organizations make it to Level Two. IMHO.

Jerome Carter is a principal with Neck, Time, and Money Informatics, Inc., an EHR consulting firm based in Atlanta.

News 2/8/08

From Art Vandelay: “Re: Wal-Mart. Wal-Mart has now announced it will expand its partnerships with local non-profit care providers for some retail clinics. This is a potential boon for those who can win the business in the Wal-Mart, which provides a direct entry point for directing referrals to their diagnostic centers. As Wal-Mart launches the pilot to its Dossia Personal Health Record (PHR) based on Indivo, it will be interesting to see if this becomes an option for tracking of personal health information generated or reviewed at the retail clinic. I fully expect Microsoft to make a run at Wal-Mart with HealthVault if Dossia falters for technical reasons.”

From Kelli Bywater: “Re: Medseek. I was one of the 22% laid off in December. I hear it’s not going well there. The company supposedly is sub-leasing half its new space in Birmingham and in Solvang, CA. Some of us who were laid off are getting calls at home from AMEX regarding overdue balances on the company’s credit card. It is really too bad, as all four portals are good, just bad executive management and a VP of finance who can’t seem to get the numbers straight.” I figured it was only fair to give Medseek President Peter Kuhn a chance to respond since there are always two sides to a story, so I e-mailed him. He’s an avid HIStalk reader, he says, and says the company is investing in existing and new technologies, product management, client support, and the usual business needs. He’s still expecting double-digit revenue growth and hiring to support it, with cash flow and profits supporting all funding requirements. He says, “We believe in controlling our own destiny by operating the business with sound fundamentals and good solutions, and our December decisions were made to do just that. For what it’s worth we ended 2007 with an employee headcount commensurate with our 2007 revenues. We believe this is good business practice and the right way to operate a business to best support our clients and employees.” He didn’t exactly answer your specific questions, but presidents are big-picture people, after all. So, there are your two sides, for which I appreciate the contributions of both. 

From Bee Bop: “Re: Parkland. Is Parkland really dumping Perot for another outsourcing firm after the Epic failure last year?” Beats me, but I know some folks from there read here, so perhap an update will ensue.

From Bobby Orr: “Re: Cerner layoffs. Your 401K match was mandated to be in Cerner stock. You were not given options on that front, so you were forced to tie up your 401K with your company (at least it didn’t collapse like Enron). Pretty lame that Neal missed an earnings call.”

From Man in BlackBerry: “Re: Halamka. Nice guy. You talk about marketing and spin – Hillary or McCain should hire him. The guy that built his entire reputation off a major, debilitating crash that left Beth Israel and Harvard’s whole IT infrastructure down for two weeks. His mea culpa turned into a major InfoWorld cover story and he was the hero. Did he go to the Judy Faulkner school of reverse marketing?” I will say that his contributions otherwise have been exemplary (he was fairly new on the job when BIDMC went down hard). He’s accessible to the press, to be sure, but he also spends time and energy working with HITSP and other groups. I used to rip him for the downtime, his Verichip, etc. but his boss lauds his work highly and publicly (not all that common for a CIO) and I’ve seen him be quite gracious in talking to everyone interested in bending his ear about IHE or standards. I’m elevating him to the “seems like a good guy” camp, which is about as high as the cynical Mr. HIStalk’s rating system goes except for those who’ve made sainthood.

From Billy Bob Bob Carter: “Re: QuadraMed. I find it very funny that someone believes that it is all the employees’ fault when a company such as Misys or QuadraMed does not make money. Management is in control of the product, not analysts, programmers, QA, or tech pubs. QuadraMed RIFfed its people to make money by outsourcing its departments to India. No, people, CPR has gone down that route before and failed. The knowledge and skill set is with the people within the company itself, not people that work for $98 a month and cannot understand the industry, product or English. QuadraMed has taken any chance of being successful by kicking their employees and walking away. May the customers revolt and kick back.” Here’s the press release on the layoffs, or if you prefer, “In an effort to provide high quality, feature rich products to our clients in the least amount of time QuadraMed has re-allocated financial and personnel resources to expand our product development capacity.” QuadraMed axed 68 employees from QA, tech pub, and development, sending their work offshore to Tata. The stock is down a little.

The initial response to HIStalk’s reception at HIMSS on Monday, 2/25 is strong. I peeked at the signup list and I’m impressed: informatics people, clinicians, CIOs, VPs, media people, investment folks, and 10 CEOs (!) have RSVP’ed in just the first few days. I’m immensely flattered and I’m honored that you’ve chosen to spend a little time with the HIStalk crowd and the sure to be dolled up Inga (incognito, but lookin’ fine, I predict). If you’re reading this, you are invited – please RSVP here so we can haul in enough liquor and fancy food to keep you happy. Thanks to Healthia Consulting for sponsoring it. One day, I’ll sit back and marvel at the fact that a fine company in which I know no one volunteered to underwrite a lavish shindig for an anonymous, abrasive blogger and his readers, which is just about the coolest thing I’ve ever heard of. If you’ve never been to the Peabody Orlando, it’s really nice and is an easy stroll from the convention center (right on the property, pretty much).

A few more HIMSS housekeeping items. The HISsies awards will be announced at the reception, so bring your pies. I’ll have a couple of giveaway items at the reception that won’t be available elsewhere unless there are leftovers, but the others are listed on this page that I just made. It includes HIStalk’s sponsors and those vendors I’ve featured (or will be featuring shortly) in HIStech Report. Helping host the event along with the good folks from Healthia is Gwen Darling, also representing HealthcareITJobs.com. Gwen had a good door prize idea: we’ll give a lucky winner a full-scale interview in HIStalk (including your picture) plus a free big ad on HealthcareITJobs for your employer for any month in 2008. I’ts not a Hummer like those big-money guys hand out, but it’s still pretty cool.

Scott Shreeve is cautiously optimistic about the involvement of Misys in open source initiatives. I’m openly caustic about it, but it’s definitely his area of expertise and not mine. And speaking of fun bloggers, Marty Jensen of Healthcare IT Transition Group claims that Medicare’s National Provider Identifier runs afoul of HIPAA. I don’t always understand the nuances of billing, but I always enjoy reading his stuff.

Picis sent over a schedule of customer presentations at HIMSS. That’s interesting because Osler CIO Judy Middleton is on it, in the running as you know for the HISsies Best Provider CIO. Also on their agenda Lynn Vogel from MD Anderson, who I’ve swapped e-mails with a few times.

A survey by investment guys Leerink Swann suggests that big clinical vendors like Cerner, Eclipsys, and McKesson will benefit from the desire of hospitals to form a care-based revenue cycle management strategy, choosing integrated clinical and financial systems. I don’t understand how that helps Eclipsys, but I am surprised that QuadraMed wasn’t mentioned since they figured that out early and were the first to use the term “care-based revenue cycle,” at least as far as I know.

Scott Anderson of NextGen reseller KIG Healthcare Solutions sent over a press release describing a demonstration project his company is doing with two Illinois Critical Access Hospital Network (ICAHN) hospitals, partially funded by HHS. Planned: PACS, EMR, and NextGen’s Community Health Solution. ICAHN paid for the portal, while the hospitals will buy EMR licenses and training for their docs. He seemed nice enough, so I figured I’d give him a little plug.

IBM and Cerner will collaborate on putting BMJ Group’s order sets into Millennium. And speaking of Cerner, ComputerWeekly suggests that NHS is whitewashing problems with Millennium in England. From the Audit Commission, “Significant problems with the implementation of the Cerner system have resulted in poor data quality and a lack of robust information …” From NHS Cancer Services, “Current opinion regarding Cerner is that it will not support cancer data collection and reporting requirements for at least 5 years, possibly nearer 10 years.” From an NHS region, “Deployment problems at those sites that have implemented the [Cerner] system has created concern amongst those organisations in the deployment pipeline.” To be fair, big implementations are never pothole-free, so you never know if this is just the usual bellyaching about change or a hint of real problems.

Investment guy Jim Cramer isn’t a fan of CERN: “I am proud that I never went back, because it just keeps going down. I do not like the medical records business anymore.” The stock is actually up a little today, but still not far above its 52-week low.

VMware runs a press release about some of its big hospital customers that use its virtual desktop solutions.

Allscripts will distribute medical software from TeamPraxis, a Honolulu vendor that will take in up to $18 million from the deal.

E-mail me.

Inga’s Update

Design Clinicals announces Mary VanHoomissen as their new VP of Implementation. I actually had a chance to chat with Mary for an upcoming HIStechReport interview. I was impressed by her credentials (MBA, BSN, and RN) but she earned my respect for her obvious passionate commitment to the patient and safety in particular. Design Clinicals will its their own booth at HIMSS for the first time, by the way, so stop by and say hello to Mary.

Speaking of the HIMSS soiree, I am feeling the need to shop for that perfect outfit. Even if no one knows I’m Inga, a girl still needs to feel alluring (you ladies know what I’m talking about). So here’s my subtle hint that Mr. H might need to slip an extra Ben Franklin into my paycheck (the less material, the more expensive the outfit).

Tidewater Physicians Multispecialty Group in Virginia purchases NextGen PM and EMR for their 66 physicians across 23 locations.

Next time I am in LA, I’m just not going to get sick. In August, the county closed MLK-Harbor Hospital after it lost federal funding over lapses in care. Now Harbor-UCLA Medical Center faces a citation for an overcrowding crisis that is putting patients in jeopardy. And, the feds may also pull funding from Olive View-UCLA Medical Center because of deficiencies in care. Is there anyone in charge of fixing things?

Cerner opens an office in Dublin to serve its growing Irish presence.

Robert Wood Johnson University Hospital in NJ will implement Eclipsys Sunrise Clinical Manager at its 584-bed facility. Also, the Robert Wood Johnson Foundation has joined with the W.W. Kellogg foundation to donate almost $1MM for EMR and billing for school-based health centers in Greater New Orleans.

Healthport is now certified to connect to the SureScripts Pharmacy Health Information Exchange.

I found this press release a bit odd. Practice Fusion announces it has signed up over 100 practitioners across 70 practices since the end of October. All good. But then the CEO Ryan Howard supplies this comment: “Physicians are realizing they no longer have to be gouged by existing enterprise vendors, such as Misys.” Why pick on just Misys, and not Allscripts, NextGen, GE, etc.? I could understand if it were said in some off-the-cuff remark, but in a formal press release? Makes you wonder if he has some sort of axe to grind.

Numerous companies are announcing various 2007 performance results. Here are a few highlights:

• PatientKeeper announces a dramatic increase in its client base, including agreements with five major health systems. Additionally, they added six new applications and now serve 14,000 physicians.
• For the three-month period ending December 31st, the Sage Group says its performance was in line with expectations. The exception was their North American healthcare market, though they expect improved revenue growth in the medium term. Also, they’re still searching for a permanent North American CEO.
• Sentillion announces strong year-end results, including ten new customers in Q4. Other milestones: their ranking as the #1 SSO vendor by KLAS and the launch of a new channel reseller program.
• Greenway Medical Technologies announces a 52% year-on-year growth in quarterly bookings for its Q2 period ending December 31st. They also earned a #1 KLAS ranking for the 6-25 physician ambulatory EMR segment.
• NextGen’s parent company QSI posts numbers for their third quarter ending December 31st. The NextGen segment earned $44M in revenue, up 29% over the same period last year. Operating income was almost $18M, up 33% year-on-year.

E-mail Inga.

Charlie McCall 1, Pre-HBOC McKesson Shareholders 0

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 November 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I didn’t even know Charlie McCall was on trial. The former HBOC chairman was acquitted of one securities fraud charge last week and got a mistrial on six more as a lone juror’s holdout deadlocked the jury. I feel deprived that I missed a blow-by-blow report of his being grilled and then left to await his fate.

Federal prosecutors had worked their way up through the HBOC food chain over the years, leading everyone to speculate: wonder when they’ll get Charlie?

In case you’re a newbie, HBO and Company was the pre-Enron corporate malfeasance poster child, a prodromal symptom of dot-coms in waiting that used its optimistically valued stock to buy everything in its path. The frenzied transacting caught the attention of drug wholesaler McKesson like the mating dance of a spider, which paid a mind-boggling $14 billion for the company in January 1999.

Industry long-timers chuckling knowingly, having watched similar companies take it in the shorts for the same expensive, ill-advised healthcare IT dabbling. Investors scratched their heads after running their calculators and finding no possible way that HBOC was worth that kind of money. The general consensus of all interested parties: what the hell was McKesson thinking? Three months later, McKesson’s stock tanked on charges of book-cooking by Charlie’s crowd. Shareholders lost $9 billion of value in a single day, thereby forcefully proving the true value of HBOC.

McKesson’s executives were perhaps the only people on the planet who weren’t suspicious about the Atlanta high-flyers. Everyone was swapping insider stories. I sent two anecdotes to a healthcare IT publication in 1998 (who missed out on the scoop of the century by ignoring them.) First: I’d heard from an HBOC employee that he was ordered to mail out empty tape boxes to customers for not-ready enhancements so revenue could be recognized anyway. Second: programmers were griping about the HBOC revenue quotas each was assigned (!) since all the Y2K remediation revenue had already been booked by late 1998, leaving the programmers to scramble for new bookings while doing the already-committed work. Recognizing revenue on the basis of a shipping receipt? Oh, my.

You know how it ended. HBOC’s brass were indicted, McKesson’s were fired. Charlie went off sailing (so the story goes.) The reeling McKesson lost many employees, came up with strange ideas like co-CEOs, jumped on the dot-com era right as it imploded (taking with it hastily conceived names like i-this and e-that), and retired the stench-ridden Pathways name. Throw in the nearly $1 billion they eventually paid to settle shareholder lawsuits and the grand total for those few weeks of consensual coupling is $10 billion. What they got for their trouble was a mongrel pack of products that Charlie had hastily snapped up without having any real plan except to keep the printing presses running off stock certificates.

Among those involved were certainly some crooks and some fools, but let’s not forget those who suffered most, those McKesson lifers who had stashed away years’ worth of shares of their unexciting company’s stock instead of risking it on flaky enterprises like Microsoft and Dell. When lonely old conservative widower Dad McKesson brought home a sexy young step-mom named HBOC, she stole the kids’ piggybank. The stock went from the mid-80s to the mid-teens. People I knew glumly tried to estimate how many more years they’d have to work until retirement, with 80% of their investments gone. Even today, after eight years and with good company management, McKesson’s stock has recovered only by about half.

Only the jury can decide whether Charlie McCall and his associates are guilty or innocent, but I can say one thing: if they are found guilty, then I hope the pain they receive is commensurate with the pain they caused.

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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 2/6/08

From The PACS Designer: “Re: Sun xVM. t looks now like virtualization may be the hot topic of 2008. In addition to Oracle that was mentioned in TPD’s last post, Sun Microsystems also is promoting Sun xVM as its virtualization solution for the enterprise. Jonathan Schwartz, Sun’s CEO and president, states, ‘xVM is our free, open source virtualization platform, which we unveiled at Oracle Open World, alongside our management platform, xVM Ops Center. xVM will virtualize Windows, Linux or Solaris, on either Dell, HP, IBM or Sun hardware.'” Link 1, Link 2.

From Sleepless: “Re: Cerner stock. Don’t forget that ‘realigned’ former associates also take it in the shorts x4 — lose your job, lose your 401K match, lose value in your 401K (it’s Cerner stock), and get to watch your stock purchase plan lose value since you’re handcuffed from selling your stock for a year.” Big mistake putting the bulk of your investment in one company’s stock, at least if you have a choice. Speaking of Cerner, here’s the transcript of last week’s earnings call. On Medicare cuts: “So we think given that there’s always been haves and have nots in healthcare. We tend to be fortunate enough to sell to the haves, and if this would become enacted, it clearly will hurt the have nots, which, fortunately for us, are not really our target market.” Now that’s a stirring and beautiful statement, to a beancounter anyway.

From Mel Cucamonga: “Re: QuadraMed. Huge axe is swinging right now at the San Bernardino (CPR) location of QuadraMed. So very sad. It is characterized as ‘almost everybody but Programming’ … and programming was already terribly, terribly thin.” Other sources report that QA, internal office support, data warehouse, and all the technical writers were hit, including some 20+ year employees.

From Jyoti Diot: “Re: QuadraMed. The RIF makes sense. New year, budget approved last week, and execution of that plan begins this week.The development talent in-house has not been all that impressive over the last few years. Why not partner with some development team that does it better than they can? The other side of it is if you’re proven not to be a marketing/sales organization, and now you’re saying your not a software development company … what exactly are you?”

From Salad Days: “Re: John Halamka. I was in an elevator that runs news and trivia on a screen (because God knows I need to be entertained and targeted for the 30 seconds I’m in there). BlackBerry has been running ads there that feature an exec with the tag line, ‘Just ask someone why they love their BlackBerry.’ Imagine my surprise when the Man in Black (Halamka, not Cash) turned up in one, listed as the CIO of Harvard Medical School. What next? Will he be on an LCD screen installed above a urinal?”

Sonomaca weighs in on Neal Patterson’s absence from the Cerner earnings call last week: “Always embarrassing when your leader refuses to show up for a bad call. That’s sort of like the CO hiding in the rear as the bloody battle commences. Oh, and the ‘traveling abroad’ thing: it’s pretty lame that a tech company can’t figure out how to dial-in its CEO from the UK or Dubai or wherever. I feel for the guys taking bullets on the call.”

I believe I’m safe in saying that the economy (and those running it) will continue to cause layoffs, both vendor and provider. It’s happening all over. It’s tough to take, but I know of few people who didn’t end up better off after being let go (not necessarily true of their former employers). Hang in there. It’s only fair that companies can quit you just like you can quit them (no Brokeback Mountain reference intended) so walk away strong and prove them wrong.

Care to join your fellow HIStalk readers at HIMSS? The HIStalk reception is at The Peabody Orlando, right next to the convention center, on Monday 2/25 from 6 to 8 in the evening. Gracious sponsor Healthia Consulting has posted the sign-up page, which I’d ask you to fill out to guarantee a spot. All the A-listers will be there, of course, hopefully some CEOs, CIOs, informatics people, doctors, celebrities, nurse, Inga, and anyone cool enough to read here. Note that you can put your “HIStalk Pseudonym” on the form and the Healthia folks will use that on your badge, just in case you want to keep it on the down-low like me (I’m such a slang-slinging hipster). Should be fun. I may get a couple of beers in me and start yelling to the world that I’m Mr. HIStalk in some sort of long-repressed purge.

Speaking of Healthia, I just posted an interview with CEO Glenn Galloway over on HIStech Report. If you’re a consultant or have yearnings to be, I would definitely check them out.

Here’s a nod to new HIStalk Gold Sponsor Sonitor Technologies, whose ad is to your left. They make ultrasound indoor positioning systems that can track people and equipment down to the room level. Their site has a creepy but effective “bat” analogy (I bring that up because I was watching one of my favorite movies, The Great Outdoors, last night and the key scene, such as it is, involves bat-chasing, or “radar-guided vermin” as Dan Aykroyd’s character Roman Craig says while cowering). So, back to Sonitor: my well-placed spies (not in Sonitor) tell me that the company’s locating technologies are the key component of the very cool UPMC Smart Bed project. Caregivers wear a tiny Sonitor ultrasound device and when they enter the patient’s room, their name displays on the wall-mounted monitor and clinical data pops up for them based on their role, all hands-free. The deal with ultrasound vs. RFID is that sound waves can fix locations more accurately because ultrasound has no reflectivity and doesn’t penetrate walls, which means the system knows what room the tag is in, not just what general area. OK, I’ll shut up now and welcome and thank Sonitor Technologies as an HIStalk sponsor. I appreciate every one of the companies that support my work. Thank you.

Face recognition in healthcare? Interesting.

I read an article today suggesting that Windows Vista is so bad that Microsoft is already leaking information about its replacement, Windows 7, finally realizing that Vista’s only customers are choiceless Best Buy laptop buyers, not corporate IT shops. I begrudingly bought a laptop with it and was ready to chuck it right in the trash – it wouldn’t recognize any USB devices, constantly prompting for a driver (uh, isn’t that the whole point of plug-and-play?) Finally, the same error gave me a hotfix alert this week and it’s now working. Still, if I could easily go back to XP, I would. Here’s the article’s parting shot: “For now, whether Microsoft likes it or not, XP, and not Vista, is the Windows those businesses will continue to use. And the companies that want to move on to a truly better operating system? They’ll be moving to Linux or Mac OS.”

A former US attorney from California is back in the same job after many years. In between, he defended HBOC’s Al Bergonzi, who sang like a castrato to avoid hard time. If you like to be a member of a very exclusive group, announce that you think Charlie McCall and his henchmen were innocent.

MEDSEEK claims massive demand drove its most successful year. Guess it wasn’t the reportedly equally massive pre-Chrismas layoffs. I suspect you’ll be hearing more about them when the HISsies winners are announced. but you never know.

Children’s Boston picks Perceptive Software’s ImageNow for document imaging.

Odd: bedside barcoding vendor IntelliDOT didn’t get enough responses to be included in KLAS’s barcoding report. The company laments that fact in a press release, but cites all the numbers that are statistically insignificant anyway. Surely KLAS can’t be happy with this quote: “Indeed, had IntelliDOT remained in the rankings in this year’s report, the company would have again earned the highest overall user satisfaction scores of all vendors listed, although the data would still reflect fewer than 15 unique organizations required by KLAS for full listing.” Isn’t the whole point of labeling results as statistically insignificant to get people to ignore them since they don’t mean anything? I’m pretty sure it isn’t intended to encourage press releases.

Speaking of press releases, MedeFile issues one that contains no news whatsoever except that it “today formally applauded U.S. Presidential hopefuls.” The company was excited, as you might expect, at the prospect that all the candidates pay occasional token lip service about EMRs (MedeFile’s in the PHR biz). How, exactly, does one “formally” applaud? Had we been witness to today’s applauding at the appointed hour, what would we have seen, exactly — tuxedo-wearing clappers, maybe screaming “Free Bird” at Hillary’s picture?

New FCG parent CSC reports preliminary Q3 results: revenue up 14.3%, EPS $1.05 vs. $0.85.

Physician systems vendor Unified Medical Informatics of Wilkes-Barre, PA shuts down after laying everyone off and saying it will not be able to repay a county loan.

TriZetto Group’s Q4 numbers: revenue up 32%, EPS $0.16 vs. $0.16. Shares were up nearly 5% today.

Maricopa Integrated Health System (AZ), stung by a bad Joint Commission visit that led to a preliminary denial of accreditation, refuses to release the report to the press, claiming it’s not a public record because it is in draft form and is protected under peer review laws. A hospital spokesperson already got caught lying to a newspaper in claiming that they had received no report.

Case management software vendor CH Mack gets a $4.2 million investment to take its Q Continuum software national.

President Bush flashes a tablet PC on which his massive $3.1 trillion spending plan lives, to be distributed to Congress over the Internet. So much for the huge surplus that was on track until he took office, now setting record deficits while cutting social services like Medicare. Here’s a good line: “Democrats joked that Bush cut back on the printed copies because he ran out of red ink.”

E-mail me.

Inga’s Update

The Brooklyn HIE will use Initiate’s Patient software for their master person indexing application. I also noticed that Initiate just hired a new CFO. Dan Kossmann has a strong background in public offerings and mergers and acquisitions, so it makes you wonder what Initiate is planning.

I am not a runner and fortunately don’t qualify for this offer but I thought it was cool. Medical device company Medtronics is offering up to 25 all expense paid trips for two to participate in the Twin Cities Marathon. Runners can come from anywhere around the world, but you personally have to have be benefitting from some sort of medical technology (insulin pump, heart value, etc.) to qualify.

Allscripts teams up with TeamPraxis to provide its new Clinical Quality Solution (CQS) for automating quality reporting requirements. The CQS also includes a physician dashboard feature.

David Corbett is named SAP’s new VP for US healthcare. Corbett previously spent time with Lawson Software and SMS/Siemens before that.

I will be glued to the TV tonight watching the Super Tuesday results. A must-read for the winners will be the newly released HIMSS Technology Briefing Book (warning: PDF) to understand the top HIT policy recommendations. The recommendations are listed on a single page, but the overachieving candidate can read through the other 130 pages for some HIT 101 and learn more about other HIMSS initiatives.

Compuware’s Covinist subsidiary claims it is now the world’s largest on-demand collaboration platform for lab and Rx sharing, following its acquisition of Hilgraeve that was announced today.

Mediware’s stock plunges 23% after reporting a second-quarter loss compared with earnings over the same period last year and lower revenue compared with last year. Q2 loss was $337K ($0.04 per share) compared to $905K gain ($0.11 per share) last year. Revenue for the quarter was down 23% ($8.7 million vs. $11.3.) Ouch. Mediware cites pipeline gaps and contracting delays.

A $6 million EMR install is going into Leon Medical, a large Medicare provider in south Florida. The costs include about $3 million for NextGen’s EMR and services and another $3 million for equipment. And I hear that NextGen is about to announce another big win.

E-mail Inga.

Monday Morning Update 2/4/08

Your gas dollars at work: check out Sidra Medical and Research Center, being built in Doha, Qatar as part of Education City and in affiliation with Cornell. Operational funding is $9 billion, an insider tells me, which doesn’t even include the construction cost of $2 billion for the 380-bed facility (but check out amazing virtual tour of how it will look on the site). It’s being overseen personally by Her Highness Sheikha Mozah bint Nasser Al Missned, Chair of Qatar Foundation and Consort to the Emir. Core sciences listed: functional and anatomic imaging; stem cell; genetic, genomic, and proteomic; bioinformatics; and tissue management systems. Opening 2011. All digital. They’re hiring if you don’t mind the heat (over 105 degrees in the summer).

Jobs: Director of IS in Arizona, Senior Software Engineer in WA, Business Analyst in CO.

Listening: Marmalade, psychedelic pop, circa 1967. You would know “Reflections of My Life” if you heard it.

New healthcare CIO blog: Dale Sanders of Northwestern Medical Faculty Foundation.

Health First (FL) chooses Eclipse Project Portfolio Management for starting up its project management office.

Cerner shares drop 10.3% Friday and hit a 52-week low after the company fails to meet Wall Street’s revenue expectations and forecasts weaker Q1 sales, even though earnings beat estimates by the usual penny. Good lesson: publicly traded companies waste time and energy managing the share price instead of the business.

McKesson shares also drop on Q3 numbers announced Thursday: revenue up 15%, EPS $0.68 vs. $0.80, with $0.11 due to one-time charges for “restructuring, severance, and pending legal settlements.” So, those of you they canned have extracted at least a little revenge, that is unless you’re also a stockholder, in which case your involuntary march-out has now doubly screwed you. At least it hurts John Hammergren more than you, unless you hold more than his $14 million worth.

I’m running a comment left by Deborah Peel below, so here’s a related reminder: she’ll speak at HIMSS on Tuesday, 2/26 at 2:15 on “The Privacy Imperative in Healthcare IT”. I’ve already marked that session as a must-see on by HIMSS dance card. I’ll admit once again that I assumed she was a paranoid flake until we swapped a couple of e-mails in which she was thoughtful, rational, and entirely logical. She’s not against healthcare IT, just the lack of attention to privacy it involves. I’m pretty sure if privacy were improved, she would happily disappear from the limelight.

Speaking of patient privacy: how many days will it take before somebody sells the current inpatient medical records of Britney Spears to trash magazines for the gratification of their undermotivated readers? It’s already been announced that she’s under psychiatric care, is on Adderall, and was taking up to 10 laxatives a day. How much more detailed can it get?

Wyse Technology announces its TCX Virtualizer, which allows virtualized desktop users to connect to USB devices.

University of Michigan is on a $1.75 billion construction spree, including a new $51 million data center for the health system.

Sparrow Health System (MI) rolls out the T SystemEV EDIS running on the Motion Computing C5 tablet PC.

I noticed that Misys is an anchor exhibitor at HIMSS. Since they sold off all their inpatient products, that’s a lot of space to show physician office stuff. If you need a place to take a break, I bet they’ll fill lots of the excess space with comfy chairs.

CPSI’s Q4 numbers: revenue down 6.9%, EPS $0.36 vs. $0.39. The company also declares a dividend, which always sends the message that investors are better off with cash for investing elsewhere instead of having the company do something useful with it, like improve its performance.

Medical Associates of Erie (PA) chooses MedAppz for community-based EHRs. I checked out the website to see who runs the company, but apparently it’s a guarded secret, with the “Who We Are” section failing to answer that question, containing only marketing-speak, trite slogans, and stock photos without listing who’s in charge, making it feel distant and impersonal. There’s no charge for that marketing consultation.

The Scottish Centre for Telehealth will pilot Cisco’s HealthPresence, a telemedicine platform built around Cisco’s acclaimed but expensive TelePresence videoconferencing system. For healthcare, it will interface to diagnostic and monitoring equipment. Cisco’s Danny Sands, MD discussed TelePresence in my September interview.

Microsoft wants to buy Yahoo for $45 billion to compete with Google, which is like a guy who’s jealous of his buddy’s gorgeous girlfriend hooking up with two unattractive ones in response.

Omnicell’s Q4: revenue up 35%, EPS $0.40 vs. $0.14. Shares tanked to a yearly low anyway, down nearly 23% on Friday, since investors don’t like declining order backlogs for hardware vendors. Analysts said Omnicell was talking up some big deals during the ASHP Midyear Clinical Meeting in December but failed to close the business in Q4.

Strange: a 31-year-old medical resident accused by her physician husband of bisexual affairs and drug abuse disappeared on September 10, 2001 after shopping at a department store. Investigators initially suspected she took advantage of the World Trade Center situation to skip town, but an appeals court declared her a September 11 victim last week despite no proof that she was in or near the area at the time. They want her name on the memorial. The family speculates she rushed in from her nearby home to help victims.

Leon Medical Center (FL) has started a $6 million NextGen implementation in its five Medicare clinics.

INVISION earns CCHIT’s inpatient EMR certification. The press release headline brags that it met 100% of the criteria, which of course is redundant since you can’t pass with anything less.

The Army’s MC4 combat medical records system hangs in there despite the widespread Internet outage in Asia and the Middle East last week. Combat hospitals had offline-ready systems to fall back on.

The quoted reply of athenahealth’s Jonathan Bush when asked at an IPO forum “how is the President related to you?”: “The President is my cousin, and he lobbied hard for the role and succeeded in the end. We took him. Sometimes we think about putting him back.”

Physician software user groups create a website to advocate allowing England’s physicians to choose their own clinical systems instead of being forced by patient care trusts to standardize.

Sonoma Valley Hospital (CA) blames its financial problems on a billing system outage that lasted several days.

West Virginia University Hospitals will go live on its $90 million Epic system on March 1.

Kaiser Permanente will be Oracle’s landlord in Pleasanton, CA, buying three Oracle buildings totalling 186,000 square feet and renting them back to the company.

E-mail me.

Deborah Peel, MD on Rogue’s Example of EMR Privacy Concerns

As far as I know, there are no existing EMRs that ensure consumers control all access to personal health information. This is a HUGE market opportunity. So, all of Rogue’s highly sensitive old medical records can and will be used, shared, and sold without his consent to discriminate against him and his children (depression has a genetic basis) because electronic health records systems were NEVER designed to ensure Americans longstanding legal and ethical rights to control access to PHI.

Electronic health information systems were not designed to replace paper medical records systems (whose function was SOLELY to help doctors care for patients). They were designed to deliver information to corporate end-users. It will be very difficult and expensive to successfully rebuild existing EHR systems to conform to existing strong state laws, common law, Constitutional law, tort and contract law, the physician-patient privilege, and medical ethics that all require informed consent.

Vendors, insurers, hospitals, drug companies, and data miners do not want new HIT systems that restore our rights to privacy because that will put an end to the billions in profits from the sale of stolen prescription, health, and claims data (IMS Health and the BCBS Blue Health Initiative come to mind).

The original HIPAA Privacy Rule required consent. But the consent requirement was gutted in 2002, legalizing the data mining and data theft that HIT systems were originally designed for. HIPAA is now the data miners’ DREAM regulation — because it puts “covered entities” in control of when PHI can be used for TPO, not consumers.

Learn what Congress and federal agencies are up to and what you can do to stop them from destroying your health privacy by signing up for our e-alerts.

In 2006 and 2007, Patient Privacy Rights and over 50 bipartisan national organizations in the Coalition for Patient Privacy urged Congress to restore Americans’ longstanding basic rights to privacy: i.e., our rights to control access to personal health information. The Coalition was the key force that stopped the HIT bills which had no rights to health privacy. We need your help in 2008.

Rogue, maybe you can sue the hospital (your employer) for disclosing your PHI under strong state laws that require informed consent before the disclosure of mental health records. But first, you will have to have audit trails to prove where your data went and also be able to prove how you were damaged. Good luck.

Or you can be an advocate and work with Patient Privacy Rights to restore and strengthen your privacy rights.

Inga’s Update

Bariatric surgeons take note: a proposed bill in the Mississippi legislature would prohibit food establishments from serving “obese” people. Shares for Gold’s Gym are up; McDonald’s shares down.

CoxHealth in Springfield, MO adds Krptiq ePrescribing solutions.

Less than a month after announcing a secondary public offering, athenahealth withdraws its registration. Seems as if the current market conditions created a risk that athena wouldn’t be able to sell the deal to investors at a price that made sense. Is this an isolated incident or a sign of the times?

Privacy rights “warrior” Dr. Deborah Peel is again in the news. Her Patient Privacy Rights organizations plans to evaluate EHRs and award seals of approvals for those that meet the organizations standards for protecting the privacy of personal health information.

Perot Systems announces it won over 90 revenue cycle solution contracts last year that resulted in the collection of over $2.4 billion in cash and the resolution of $4.6 billion in A/R for its clients.

E-mail Inga.

CIO Unplugged – 2/1/08

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

Why Offshoring Works
By Ed Marx

I feel fortunate to have relocated to a community with a thriving HIMSS chapter. Recently, I was honored to participate in a DFW-HIMSS luncheon meeting as a member of the CIO outsourcing perspectives panel. On the panel with me were two giants in the business, which enriched my experience. Rather than rehash what was said, none of which was particularly new, I want to give you a unique perspective on outsourcing. In particular, offshoring.

To lay a foundation for my perspective, I will acquaint you with my past experience. I had worked for years in a system where operations were entirely outsourced, and 25% of my staff was offshore. In other environments, I employed selective offshore sourcing for routine and project based work. I have collaborated with top global sourcing firms. More recently, I visited India and toured the universities and factories of select firms. Perhaps the greatest insights gained however came from hosting dinner parties in my home for the rank and file offshore staff as they completed mandatory onsite rotations. Breaking bread at the dinner table created the single most effective time for listening. Why? When you minimize formalities and distractions, people tend to be more transparent.

As a general observation, offshore staff has provided a higher quality of service. Couple this with the price, and the value equation speaks for itself. Not only have I found this true with traditional offshore services, such as application support and interface development, but with our service desk as well. More important than reducing costs, our key service desk indicators improved, including overall customer satisfaction. What was the key to this offshore success? Hunger.

From the analysts to the executives, my offshore staff had one thing in common. Hunger. Many of their American counterparts simply did not display the same intensity and desire. Yes, the offshore men and women were highly educated, but they also possessed an insatiable desire to further themselves through service and develop themselves professionally. The emphasis on quality and the execution of it proved far superior. While visiting some of the facilities, I sat back in amazement, asking myself, “What if we had this pervasive focus in America?” I had the offshore staff teach us continuous quality improvement and share their processes and best practices so we could adopt them locally.

In some cases, Americans have become complacent. We’ve taken for granted our prosperity and competitive position, and many have adopted an entitlement mentality. Rather than confronting the realities of the global economy and the increased competitiveness, we’ve rallied for protectionism and bantered “Buy American!” It wasn’t always like this, of course. I believe the Greatest Generation had this hunger, which enabled us to reap the benefits. In order to sustain our prosperity and position, we must rediscover our hunger.

How do we develop that appetite? I am at my hungriest after a vigorous workout, after maximizing muscle hypertrophy and sweating off pounds. It is almost self-perpetuating: work hard, build hunger, nourish, and repeat. As leaders, we must develop and perpetuate this ethic within our organizations. We must ensure that support systems, like exercise equipment, are in place to cultivate hunger. Remove barriers and allow staff to perform at their best. Instead of relying on crude formulas based on education and length of employment, we must hire people with talent and attitude.

As we do this, the disparity between offshore and onshore will decrease, and we will find ourselves competitive again. Hunger will replace lethargy.

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 2/1/08

From Bignurse: “Re: EMR/EHR. Assuming that a completed implementation is characterized by some level of utilization, what would that level be? How would you experts define ‘implemented’? Should it be based on percentage of functionality used, attainment of predefined success metrics, etc.? And if so, what would you suggest?” Good question. Is “implemented” a word to use any time you’re live, or only if you’re getting usage and/or value you expected? Answers welcome, although if anyone from HHS is reading, please don’t engage one of those trough-lapping consulting firms to define it and then invoice me $500,000 like I was Uncle Sam or something.

From Phil R: “Re: RemedyMD. Not sure how much Kool-Aid that former staffer has been drinking, but the number of ex-Remedy employees sending resumes our way would suggest that they’re leaving en masse these days.”

From The PACS Designer: “Re: hospital labs. Hospital & Health Networks online magazine has an interesting article about hospital labs and how they can be outsourced to bring in much needed capital to alleviate the cash crunch hospitals are facing because of DRA cuts. Also another benefit would be to speed the transition to populating PHRs with lab results since most lab services have digital repositories of patient tests. Another revenue increasing option is for hospitals to offer their lab services to local physicians similar to what is being done by many hospitals in Michigan.” Link.

Confirmed: CEO Bob Cullen has left Thomson Healthcare “to pursue other opportunities,” according to a marketing contact Inga reached there. Mike Boswood is the new president and CEO, coming over from the company’s legal business side. A reader noticed the tip we ran from Curious George this week and asked to have it confirmed. We are responsive, yes?

Listening: Airbourne, Aussies that sound like AC/DC circa 1976 with some Spinal Tap cliches mixed in.

Interesting seminar: The Unsummit, three days on bedside barcoding with some really good-looking sessions (including a discussion with Julie Thao, the nurse whose admitted medication error led to her legal prosecution). April 30-May 2 in Austin, TX. I know some of the folks speaking and it should be good, plus I like barbeque and I’m sure there will be some.

January will set the record for most monthly visits to HIStalk, around 54,000 or so. Man, that’s a lot of readers, every one of whom I appreciate (along with the great sponsors who get what Inga and I are doing and want to support us). I don’t get all swell-headed about it since, from this chair, it’s more like a videogame than something real, just pecking on keyboards in a quiet room and never talking about it to anyone. Sometimes I’m tired after a long day at work, but this never gets old.

Jobs: MPI Project Manager, Account Executive Sales, VP Research Services, Online/Internet Marketing Manager.

Misys put its name on iMedica’s EMR, so it’s only natural that they won’t host it, either. If there’s innovation in there somewhere, it must be in marketing.

Southeastern Regional Medical Center (NC) signs up for the RadarFind RFID-based asset tracking system.

AMICAS signed more than 60 radiology and imaging contracts last year.

HHS Secretary Mike Leavitt’s editorial on healthcare information technology runs in the Memphis newspaper. Nothing new, but aimed at the lay public: EMRs, P4P, and the FCC’s rural broadband telemedicine grant program.

UPMC South Side’s department of medicine chair is sentenced to three years in prison after pleading guilty to possession of child pornography. UPMC says he won’t be coming back, naturally. And in Louisiana, a 72-year-old retired anesthesiolgist gets 16 1/2 years for trying to get what he thought was a 14-year-old girl online to send him dirty pictures. It’s just my perception, but after many years of working with doctors, there sure seem to be a disproportionate number of horndogs among them.

Speaking of doctors in trouble, a physician peer reviewer for NEJM is caught tipping off Avandia maker Glaxo that an article he was reviewing was about to blow the lid off the drug’s heart attack risk. He was a paid shill for Glaxo, racking up the usual doctor consulting and speaking fees to push their products on his peers. His excuse: “Why I sent it is a mystery. I don’t really understand it. I wasn’t feeling well. It was a bad judgment.” Is that a multiple choice excuse?

Four hospitals that previously employed nurse Charles Cullen, who admits to having killed at least 29 patients by injecting medication into random IV bags, argue that the victims’ families shouldn’t be allowed to sue them, even though they didn’t report his previous errors and investigation for tampering.

A University of Minnesota doctor is in trouble for losing a flash drive that contained his fertility patient data backup. It was supposed to be encrypted, but wasn’t.

University of Alberta researchers have developed a $1,000, shoebox-sized microchip system (i.e., “lab on a chip”) for performing lab and genetic tests.

Sumter Regional, the feel-good recipient of a lot of good press after its tornado damage and its grace under pressure afterward, has not-so-good news this time: 31 of its employees will be laid off Friday.

UnitedHealth Group’s PacifiCare insurance subsidiary faces fines of up to $1.33 billion for not paying claims, which caused some providers to stop accepting their patients. UnitedHealth, which bought the company for $9.2 billion two years ago, said they’re sorry. California’s insurance commissioner is obviously not in a forgiving mood: “After years of broken promises to California regulators, it became crystal clear that PacifiCare simply could not or would not fix the meltdown in its claims-paying process. We’re going to put an end to that. If PacifiCare can’t understand the ABCs of basic claims payment, maybe it will understand the dollars and cents of regulatory action.”

CAP puts the lab at Yakima Valley Memorial Hospital (WA) on probation after an unannounced inspector found a patient who was transfused with another patient’s blood because a lab tech misread a computer screen listing single-spaced lines of tests. Some of the changes involved software.

Great idea: a hospital installs wall-mounted “Yacker Trackers” that look like stop lights, turning yellow and then red when noise levels get too high in patient care areas.

Physician EMR vendor MedcomSoft closes a $500,000 private placement. Its shares trade on the Toronto Stock Exchange.

E-mail me.

Inga’s Update

Re: Rogue and his PHR/EMR concerns. I have had the opportunity to hear privacy advocate Dr. Deborah Peel speak on this very topic. Dr. Peel can be a bit extreme at times, but her overall position is that patient medical records belong to the patient and not the doctor and not the facility. Her belief is the government is capable of creating a national health record bank with “Fort Knox” type security and the patient regulates who gets to see what information.

I guess it was destiny that for Hopes and Deams to come together. HopeHealth, a SC FQHC and member of the Community Integrated Management Solutions IPA will be implementing DREAM EHR and CARE Disease Management solution from Visionary Medical Systems.

Cerner announces 2007 bookings were up 14% over 2006 and revenue up 10%. Fourth quarter bookings were up 5% over 2006 and revenue up 4%.

Healthgrades says (warning: PDF) that if you go to one of the top 5% of hospitals, you are nearly 1/3rd less likely to die. Their study claims 171,424 lives could have been saved and 9,671 major complications avoided between 2004 and 2006 if the quality of care at all hospitals matched the level of those in the top five percent. Will people consider this before their next hospitalization?

Trizetto wins a $100 million contract with Blue Shield of California for a system-wide technology upgrade.

The LA County DHS contracts with Sunqest to expand and transfer its existing Sunquest LIS to a new facility and implement and integrate new enterprise applications.

E-mail Inga.

Conglomerate Vendors 101: Healthcare IT Customers Carry Little Weight with Corporate Toe-Dippers

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 October 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I doubt most Misys Healthcare customers are following the company’s corporate drama as it plays out in England. They want to go private. Wait – no, they just want to sell it to someone! The CEO will lead a takeover group. Hold on, he just resigned! Their board chair is optimistic about their prospects. Shhh … did I just hear him say the company’s software was old and non-competitive?

Healthcare makes up about a third of the Misys portfolio. Within that, the lineup is a salad bar of old, mixed-heritage applications from Per-Se, Medic, Amicore, Payerpath, and Sunquest. Sometimes the blended family gets along, but often they don’t (and I’m speaking both technically and culturally.) If you know of any healthcare IT conglomerates where any of the above isn’t true, that makes one of us.

Why did a British financial software company get into the US healthcare IT market in the first place? Well, let’s just say it wasn’t a noble desire to better humankind. From their website, “The main objectives were to reduce the Group’s exposure to a single market (insurance) and to increase its size in an already consolidating software sector.” That’s about as passionless as an accountant’s nimble calculator fingers determining the net present value of three dinners with Myra the secretary vs. the potential payout.

With just two software sectors, Misys is focused, at least compared to bigger conglomerates that dip 1% of their corporate body (a toe) into the healthcare waters. Since Misys is the only company actively considering deconstructing healthcare IT out of the soup, what can we learn?

• The best way to make money as a conglomerate is to break it up into parts that are usually worth more than the whole and are more affordable to prospective bidders.
• Conglomerates often reduce corporate value unless they can harness some elusive benefit in supply chain management, reproducible management excellence, or marketing.
• Conglomerates are fine until you want to sell to someone else who doesn’t share your love for some of the corporate children.
• Product investment matters more than that impressive brand name. You may be getting free milk every day, but at some point, you better start saving up for a new cow.
• In most cases, button-down corporate management saps out the innovation that made formerly independent companies interesting and successful in the first place.
• Healthcare IT divisions of big companies live and die by the quarterly (or twice-yearly) numbers. Ambitious division executives will sell their souls to avoid being called out as company laggards among their peers.
• Healthcare IT customers carry little weight with toe-dippers. Are GE brass more worried about the flat-lining former CareCast or sagging toaster sales at Wal-Mart? Does patient safety come up in Siemens corporate meetings as often as power generators?

Just about every outcome suggests that Misys Healthcare will be carved off and sold. If you’re a foot soldier, hang in there at least long enough to see if the change benefits you. If you’re a suit, well, Misys publicly labeled its healthcare unit as underperforming, which isn’t a highly valued resume bullet for the new owners. If you’re a customer, anything or nothing could happen, but you’re stuck either way. If you’re a prospect, there’s a lot of uncertainty ahead, so act accordingly. And if you’re a vendor focused only on healthcare IT, especially if you’ve resisted the urge to cash out by going public, I say thank you.

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News 1/30/08

From Curious George: “Re: Thomson. I’m surprised no one has mentioned that the CEO and VP of sales at Thomson Healthcare were both fired a couple of weeks ago.”

From The Alchemist: “Re: Middle East. On an engagement for a few months in the Middle East — you know, where all the money is. Let me propose a scenario to all you HIStalkers out there. If you had the funding, approximately 100 times the average U.S. hospital construction, what would want in your hospital? All fantasies will be accepted, but try to keep them earth-bound.”

From Scott Shreeve: “Re: athenahealth. My normally calm demeanor got a little rankled after reading Cady Heron’s comment that athena is just a billing operation.” Scott’s riposte is here.

From Tex Arcana: “Re: Christine Stanfield and QuadraMed. Yes, Christine was terminated on Thursday after receiving an unsolicited contact by another company about potential opportunities. In her research, she asked her line manager what her future role was with QM. Based on a brief discussion, QM considers these inquires as acts of resignation and promptly terminated her! The sad part is there are less than a handful of people left who know the CPR product. It’s apparent QM doesn’t get it after all.”

From Dave DiVida: “I can confirm the ‘departure’ of Christine Stanfield. I was just informed by current QuadraMed employees that QuadraMed showed her to the door. These people now report that since this development, morale there in San Bernardino is now lower than it has ever been … which is a real accomplishment, considering how low Misys could keep it. I’m dumbfounded. This is one of THE most knowledgeable CPR employee on the planet in my humble opinion. Potential employers should watch for the name to come across your desk if she’s seeking, or even proactively find a way to get in touch with her. If you have the opportunity, SNATCH HER UP.”

From Slim Whitman: “Re: Sumter. I remember reading in the rules (they’re now gone from the website) something along the lines that the MRI had to be installed in a permanent location and wondered how Sumter would qualify given that it would have to be located initially in a temporary structure. That may be the ‘gotcha’ here as on December 28th, Sumter was way ahead of Lockport in votes. Regardless, I am thrilled that Siemens chose to donate one to them as well. That’s TWO patient populations that will benefit!” I bet you’re right. Sumter did say that it would work out much better for them to take delivery later, when a permanent location will be ready. I rarely say anything nice about Siemens, but they did the right thing here and deserve kudos.

From Steve Lamo: “Re: Revolution Health. Revolution Health may have a PHR, but as a company which seems to have a strategy de jour approach, it is not very compelling and is not getting any traction in the market. The B2C model for PHRs which Revolution Health is pursuing  is not working. Also, with the impending release of Google Health, my bet is CEO Schmidt will introduce during HIMSS keynote, Revolution Health’s PHR prospects will be increasingly bleak.”

From Rogue: “Re: musings on data sharing. Hypothetical case: When I was 19 and in college, I was treated for an STD at the hospital connected to the university. Three years later in grad school, at a community hospital down the road, I saw a psychiatrist for a bout of depression associated with flunking two courses and changing my major. On meds for two months. Fast forward 10 years. Married now. One kid. All those electronic records are, of course, just archived on terabytes of EMC storage media. Why bother to electronically shred old EMRs? With storage so cheap, it’s easier to just file them. The new RHIO links those two hospitals with everyone else in the area/state. My new medical record, in Employee Health at hospital #3 where I now work, contains all this juicy info, right?  It’s just a Social Security number link away. And of course, since the patient doesn’t own their records, the facilities do, I have no control over who sees what. My hospital (employer) EHR now contains links to all this old stuff, right? Is this possible? What am I missing? I’m in the business and I can’t figure out how to reassure my neighbor that a certain degree of privacy IS possible with EMRs. Is some measure of privacy and personal control only possible if RHIOs fail?”

From For the Record: “Re: Cerner. For the record, John Goodrow used to work at Cerner as a lab sales person. Not sure how forthcoming he will be.” That’s in reference to the downtime rumor. I’ve heard from several readers that Cerner puts contract language in that prohibits hospital people from saying anything bad about them, but I don’t recall seeing that in there. If you have, send it over, please. That would be fascinating to know.

Several vendors e-mailed offering to hand out HIStalk goodies at their HIMSS booths. I’ve sent out the pitiful supply I have to the vendors who asked first, but if anybody wants to create their own HIStalk trinkets or arrange some sort of in-booth entertainment that would benefit HIStalk readers, I’ll promote it (I’m thinking a buxom Miss HIStalk in evening gown and sash — along with a male equivalent — to hold court at booths at an appointed time, but I’m open to ideas).

The VA’s had quite a few data leaks, but it’s the water variety that got them in Tennessee. A broken water pipe damages the VA’s servers, so clinics all over the state were shut down yesterday and today.

Leslie White, PR VP for McKesson, e-mailed to say that it’s not the end of the line for the Dubuque crowd. The company will move operations and 340 positions to a new facility in the spring of 2009 to provide space for growth.

I hoped you enjoyed the interview with Denis Baker. Denis noted that he’s getting calls galore from people he’s known but not heard from over the years because of my wide readership, many of them trying to sell him something. Surely salesfolk aren’t so desperate that just mentioning his name here would open the floodgates? (other than GE, which he called out specifically as ignoring him).

Marshfield Clinic CIO Jeremy Miller is nominated for a case study award on the use of Fujitsu tablet PCs at Healthcare IT Summit.

American Hospital Dubai announces what it says will be the most advanced integrated healthcare information system in the UAE, using technology from Meditech, Lawson, Siemens, Cisco, and HP.

The Military Health System will enhance AHLTA’s imaging capabilities for scanned documents and photographs using a Web-based front end for its Documentum content management system.

Sweeny Community Hospital (TX) is written up by the local paper as the CCHIT certification site of Prognosis Health Information System‘s inpatient EMR.

I’m really buried, so don’t give up that I may eventually reply to your e-mails. I barely have time to sleep between work and after-work. I’m sure it will build my character if I survive.

E-mail me.

Inga’s Update

I am still trying to figure out how I was on the mailing list for a particular mailing received over the weekend. I was notified of a new physician house call service that specializes in providing at-home Botox injections. (I was embarrassed to ask my more youthful neighbors if they got the same mailing). But, it does beg the question whether or not the cutie Dr. Parkinson provides this service. Anyway, I have spent too much time in the last couple of days looking in the mirror and wondering if someone in my life is suggesting it’s time for Botox.

Federal health inspectors fault Kaiser’s Fresno hospital for not acting on complaints and keeping a closer watch on its medical staff following an investigation into one its perinatologists. It’s a sad story with no winners and includes the death of at least two babies and the resignation of hospital administrator Susan Ryan.

Eclipsys announces the availability of Sunrise Clinical Essentials, a seemingly “lite” version of their original Sunrise Clinical Manager solution. It offers more pre-configured software and pre-defined implementation methodology for quicker setup and easier support. Coming soon to a small community hospital near you!

HIMSS Analytics announces they’ve doubled the number of free benchmarking reports available to healthcare providers. The only catch is that providers first have to complete HIMSS Analytics’ Annual Survey to populate the HIMSS Analytics database.

Re: RemedyMD. A reader considering a job with them recently asked for any insights from any current or former employees. A former staffer told me the CEO was great and they have some great products, although for a sales position, it’s always good to verify how ready they are for market.

Cerner Millennium will be implemented in the three hospitals that are part of Health Quest healthcare system in NY’s Hudson Valley.

EpicTide is now FairWarning. The supplier of privacy auditing solutions for EHRs also announces a 200% growth in software bookings for 2007 and expectations for a positive cash flow by the end of this quarter.

Newton Memorial Hospital is appropriated $146K from the federal budget, courtesy of the efforts of their Congressmen. The money will be applied towards their $7 million Cerner computer infrastructure. This announcement comes a couple of weeks after the hospital laid off eight people, blaming the cuts on $3 million in state Medicare spending cuts and squeezes from physician-owned ambulatory surgery centers. (The same article also indicated their marketing department had to be streamlined as well, but I would say they still did a pretty good job blaming others with nary a mention of the $7 million elephant in the room).

More CCHIT 2007 certifications: Allscripts Healthmatics EHR Version 2007.1 and MediNotes e Version 5.2. Both have pre-market approvals.

Here’s a new networking site for all the HIT geeks out there. The description: the Healthcare Technology Alliance is a group of technology specialists working in the health care industry. Clearly they are in need of a marketing specialist to help spice up that language.

If you haven’t already, check out the cool interviews at www.histechreport.com. Don’t miss Mr. H’s “Bottom Lines” which include a bunch of those well-loved “Mr. H-isms.” (Ok, that isn’t a word, but it should be.) The latest ones are on The White Stone Group and Stratus (both who are going to be exhibiting at HIMSS.)

E-mail Inga.

HIStalk Interviews Denis Baker, VP/CIO, Sarasota Memorial Hospital

One of Denis Baker’s employees e-mailed and said I had to interview him, including a long list of reasons she enjoys working for him. I knew of Denis mostly because of Sarasota’s work with Eclipsys and CPOE and was happy to visit with him by telephone.

Tell me a little bit about yourself and about your job.

I started in healthcare during Vietnam as a Navy corpsman, thinking that I would end up on a ship or a Navy base someplace. Then, out of total ignorance, I realized that I was probably going to end up in the Marine Corps, which I did for short while, but fortunately stayed out of Vietnam.

I got into laboratory medicine and then became a med tech. I worked in a hospital in Portland, Oregon for ten years, in a chemistry department. They were implementing their self-developed lab system. So I got involved interfacing all of the instrumentation to the computer system. This would have been early eighties. Then they thought the computer system was going to support itself, so they were going send me back to the bench. So I jumped to another organization and supported an HBOC Star lab system for a couple of years there.

I ended up being the manager of the clinical systems. Then a new CIO came into the organization and created a new position of Office Automation and End-User Computing Manager, which is the worst title in the world that I can think of. Was it meant, basically, was supporting PCs. It was a four-hospital system back then. They had no centralized support. So I pulled together a good support group for training around PCs.

I left the organization in 1991 and then ended up working for an outsourcing company that has since disappeared, moved to Cincinnati, and worked as a director of IT at one of the suburban hospitals there. Then, ultimately became the CIO for the four suburban hospitals who were part of the system. The whole consulting company crashed. At about that time, the CIO that I worked with in Portland, Jim Turnbull, had since moved down here to Florida and there was a Director of IT position. So I moved down here in 1995. I was the Director of IS for five years. Jim left in 2000 to go to Denver Children’s. I was promoted to CIO.

Your background is as a clinical department end user. Do you think that’s a good background for a CIO to have?

I think it so, because I looked around early on at who the early CIOs were. It seemed to be most of them were promoted directly out of IT and really didn’t have any exposure to the clinical world. I think that has really helped me as the whole shift in the industry is gone to clinical information systems. I can talk the lingo with not only lab folks, but also nurses and other clinical folks. Physicians as well. I think that’s been a leg up.

I think the future for healthcare CIOs in particular is to have a clinical background, whether that’s nursing or one of the ancillaries. I think you really need to understand what happens in a hospital, not just producing bills.

Should the ultimate goal be to have a physician running IT or does it really require that?

I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do.

What do you like most and least about being a CIO?

Most is seeing technology applied to operational improvement in the organization and moving healthcare out of the dark ages. We’ve been on paper for a hundred years and many people have said there are industries that are far beyond us in adoption of IT. With good systems and good implementations, it’s remarkable what you can change within healthcare with IT.

Do you think clinical systems are realizing their potential, or are those systems still a generation away?

My chief medical officer asked a similar question a couple of days ago. He compared it to the automobile industry, where the tires might last for five miles and then you’d have to replace them. He thought that maybe we’d moved now into maybe the thirties or forties as far as automobile technology in comparison.

But I think we’re really in the fifties. I think the systems work, but they don’t have all of the bells and whistles that the current car today would have. It’s going to be an evolving process. We’ve been at this, with the clinical information system, for twelve years and it seems like the work is never done. There’s always something changing and something new. New functionality or, typically, some new regulation or reporting that has to be generated out of your clinical system, so the work never stops.

You never stop implementing a clinical system once you start. That, I guess, one of the downsides. You asked me the pluses and the minuses. I think the downside is, it’d be nice to wrap up a project and move onto another one, but it just never goes away.

Nobody can afford to replace those systems every few years. How important is it for the CIO to establish a relationship with a vendor and stick with them?

Let me start from day one, with negotiations with the vendor. Obviously the vendor’s interested in sales, market value, and stock price, but I think you need to reach a common ground on what you’re trying to achieve. I’m not a big one for really tough, upfront negotiations. I don’t try to nickel and dime them, but I do want performance guarantees. I do want access to senior management. I do want them listening to us as a customer base as to where their systems need to go, and hopefully they’re listening to us. Because you’re right, this system we’ve had for twelve years — I would not want to be here to be the one to replace it. I would not want to go through that agony again.

A lot of places just trade Vendor A for Vendor B while the hospital down the street is trading Vendor B for Vendor A.

Once again, I think it comes down to personalities, and if you can develop a relationship with your vendor at a personal level and not slam your fist on the table every time there’s a hiccup, but thank them for when they help you solve problems … I think that’s the key to the partnership. I think some people get caught up in egos. They’ve negotiated some super-duper contract and the vendor, for whatever reason, is unable to deliver, and potentially the CIO or whoever negotiated is being held accountable for making it happen. So the knee-jerk reaction is, “Let’s go find Vendor B. That’ll work out much better than Vendor A did.”

How much are hospital executives involved in IT decisions?

Well, here, they’re pretty involved. The Chief Operating Officer, my new CEO that’s been here for about two and a half years – both of them have been involved in some pretty major IT implementations where they came from. I think they have a good understanding of technology and what the limits of technology are. Their caution to me and the organization is, “Just because you’ve got a problem doesn’t mean IT necessarily needs to solve it. We need to focus on our workflow and the operational improvement.” And then if there’s an opportunity for IT to get involved and ease that along, that’s probably the best course to take. I think all of my peers within the VP ranks have that same understanding.

How often is IT part of the strategic solution?

It’s hard for me to gauge at this point. We’ve had a new CEO for two and half years. Our Chief Operating Officer, he’s relatively new as well. I think the last thing they look for is an IT solution, but we’re still going through our version of Six Sigma or Lean Management or Process Control Management, whatever you want to call it. And then you take a look at, “OK,is there an opportunity for IT to get involved and help solve that problem?” So as we have a fairly new executive team, I think we’re still working our way through that.

Every CIO wants to run a world class IT operation, but hospitals don’t usually have large IT budgets. How do you choose your battles and stretch your dollars?

Number one, I’ve got a great staff. I have about a hundred people on staff. Being in Sarasota, Florida, it’s fairly easy to recruit good talent to this part of the world. We pay well. So I think that’s the first key, I guess, to making it a success.

I can only think of one project in twelve years that we’ve backed out of. Some of the projects may have taken us a little bit longer or cost us a little bit more than what we thought, but we’ve only had one complete failure in ten or twelve years, out of I don’t know how many projects we’ve been involved in. I think we’ve developed a reputation, as a division, for getting things done on time and relatively on budget. That lends some credibility, not only among my peers at the executive level, but also with staff; and also, even more importantly, with the physicians. If you get them involved in something and it turns out to be a success, you get less and less resistance as you move into other things to implement.,

If you look back two or three years, what projects gave you a lot of bang for the buck or made you glad you did them?

Probably the first one would have been what’s now the Eclipsys Sunrise Clinical Manger. It was created by a company called HealthVision, then called CareVision, the product. We were the first customer. We started to roll it out in 1998 to deal with nursing documentation and physician order entry.

At some point, the voluntary CPOE hovered at about 25%  and finally, nursing got tired of having to deal with the paper and electronic world. Our elected board then told our physicians, “OK, a year from now, it’s mandatory that you put your orders in.” Almost immediately, we saw the percentage starting to rise. We run probably about 80% entered by physicians, 10% verbal, and another 10% written or faxed in.

I think the whole CPOE and at least the beginning of the medication order process of transcription illegibility and so on – that went completely away. It created other problems, but at least it solved the illegibility and who actually ordered something.

Another project that took us a few years, but I think was ultimately a good decision … we needed an ERP system. We looked at Lawson and PeopleSoft and ultimately decided on PeopleSoft. That product has been rock-solid ever since we implemented it, even after the Oracle acquisition. In fact, we’re going through an upgrade to the HR side of this system right now. We had to engage some fairly expensive consultants to help us get it implemented and augment our staff. But I don’t lie awake at night worrying about PeopleSoft at all. It really helped with supply chain management, on the one side, and then we also had some issues with HR and payroll on the other. I think Peoplesoft solved both of those.

Anything on the infrastructure side that turned out to be a good investment of time and money?

Early on, as we implemented the electronic medical record, we were looking for a fairly robust network infrastructure. At the time, about the only thing was available was a technology called ATM. Implementation was good. It provided campus-wide network backbone capability up to gigabit speed. That served us well for a few years, until Cisco and the rest of the world got Ethernet up to speed.

Since then, we’ve gone with Cisco and that’s been rock-solid for us. Built in an awful lot of redundancy to make sure that the network never goes down and, knock on wood, it never goes down. Early on, the intent with the electronic medical record was to maintain all of the records on everybody forever. So we made an early investment with EMC and their technology. This would have been back in 1996 or 1997. We’ve been with EMC ever since. So from a storage perspective, expandability, once again, that’s worked out very well for us.

You made CPOE mandatory in 2003. What advice would you have for hospitals considering doing the same thing?

I‘ve looked at some of the organizations that have tried the voluntary route, but I think you can only do that for a certain period of time before you have to make it mandatory. Like I said, we coasted along for a few years with a 25% compliance and that was driving our nurses nuts. Having to check not only the paper chart, but the electronic chart for recent orders and so on. That’s going to cause quality and safety issues. So at some point, if you’re not making it with the voluntary, I think you better go mandatory.

You’re not going win them over with technology. They’re always going to complain about the time it takes to log on and how much longer it takes to place an order. But after a period of time, in our case ten years, they can look at patient information back to 1998. There’s nothing archived. Everything’s available and I really think they see that as a value in exchange for the whole CPOE piece, but it takes a while for you to build up that database for them to appreciate that.

Are you seeing any impact of the Stark relaxation and are you doing anything with physician office computing?

In a very minor way. We’ve had Siemens’ PACS system since 1996. I think three to four years ago, we implemented Siemens Magic Web, which is the online retrieval of images. They were able to do that within the organization. Obviously, they came to us and said , “OK, we want to see those images in our offices, and by the way, we don’t want to buy any equipment.”

So we were able to seed a few workstations out into some of our specialty physician offices; orthopedic surgeons and so on. That’s all they can do with them, look at our images. They can’t load it up with games and other stuff.

Physicians have the expectation that the hospital should provide them with an office EMR. We’re trying to figure out if our direction should be in that area. Obviously we’d have to charge some nominal fee. On the other hand, as my CEO reminds me, there’s a whole host of other companies out there like eClinicalWorks and so on that are offering ASP models that have relatively reasonable prices. They offer not only EMR, but also practice management.

So why, as an organization, should we get involved in that? The only challenge I have to that is that it would be nice to be able to have longitudinal medical history on our patients, whether they’re seen in an office or in the hospitals. I’m not sure how well some of those ASP offerings could be integrated into what we’ve got. So we’re kind of exploring that right now.

Are you seeing any impact of interoperability?

We’re the only not-for-profit hospital in four counties, surrounded by HCA, Universal, and HMA organizations,and they really have no desire to exchange data. I don’t think it makes sense, from a corporate perspective, for them to get into that. So we’ve really not been too successful in creating a RHIO environment here locally.

I tried to get some money out of the State of Florida. Jed Bush budgeted $10 million to get RHIOs off the ground. I made an application and one of the requirements was that it had to be with a competitor. I tried to make the argument that, in some cases, our physicians are competitors, but the state wasn’t going for that, so I didn’t get any of that money.

How would you say Sunrise is working compared to a year or two ago?

We did the 4.0 upgrade probably close to two years ago. That was probably some of the worst software I’ve ever seen. It took us probably eight months and I don’t know how many hundred patches and service packs to get all of that fixed. But finally, everything settled down and the performance came back.

Two months ago, we did the 4.5 upgrade. That’s was probably the easiest upgrade that we’ve ever experienced. That was real quality software. I think you could see the impact of John Gomez and his development team on the quality of the software they’ve produced.

With Andy Eckhert involved, do you think the direction of the company or its likelihood to success has changed?

Yes. Andy made a few visits here since we were one of the early adopters and I’ve liked the changes he’s made in the company. I’m not sure how successful offshore development is. I’ve never dealt with a vendor who has really relied on that quite a bit. I know they’re expanding their office in India to four or five hundred developers. So hopefully we’ll see, once again, a continued emphasis on quality software when that’s released.

Some of the other changes he’s made is decreasing sales staff and so on, and focusing more on support and development folks. The consultants that we’ve had involved in the 4.5 upgrade … the quality of the individuals, I think, has risen dramatically as well. As I understand it, they have to go through a three-month boot camp to learn the system before they’re ever turned loose on the customer base. I can remember years ago when a new hire would get hired on Friday and be assigned to us to fly in on Monday, knowing little to nothing about the system. They were just here as a body filler. But, like I said, the quality of individuals we’re dealing with now is much better.

Their future success in a having a broad clinical offering like the market wants is based on making Sunrise Pharmacy work. What are your thoughts on that?

I always thought that pharmacy really needed to be, not an interfaced system, but integral to the whole order entry process. Because they didn’t have that product five years ago, when we needed a pharmacy system, we went with McKesson’s Horizon Meds Manager. We had some transition issues with McKesson. So we implemented their system; we interfaced it with a bi-directional interface. That has its own uniqueness and causes its own problems. Now that Eclipsys has a pharmacy component, we’re going through an evaluation of, “OK, where’s McKesson right now? How would their new Meds Manager and Admin-RX compare to an integrated pharmacy module with Eclipsys?” So we’re going through that process this week, comparing and contrasting that.

One of the things I remembered about the hospital is you were one of the first, if not the first, to offer a turnaround time guaranteed time in the ED. Were there technology implications to that strategy?

Actually, no. That was all workflow. A new CEO came in two and a half years ago from Detroit. At least a couple of hospitals had implemented the thirty-minute guarantee. She walked in the door and said, “OK, we’re going to do that here” and turned to the ED folks and said, “Make it happen. Figure it out.” And it really had nothing to do with technology. It was all workflow and handoffs.

Now, somewhat after the thirty-minute guarantee was in place, we purchased the Eclipsys ED module, displaced boards and all that other stuff in there, and I think that helped. Now we’re on ED doing nursing documentation. And then finally, ten years later, asking the ED physicians to do order entry. Back in 1998, they screamed bloody murder, so we started someplace else. So it’s taken us ten years to get back to them. I’m anxious to get that piece wrapped up. But no, the thirty-minute guarantee had nothing to do with technology.

Tell me more about your department.

There’s actually three departments that report to me. I had more at one point, but right now I’ve got Information Systems, which is the pure technology stuff: the servers, the network, PCs, and all of that. There’s about sixty people there. The original project team that implemented SCM has been maintained as a separate department. They used to be all clinicians, with nurses, pharmacists, radiology techs, whatever. Perhaps less so today, but I wanted to maintain a real emphasis that there was a support department called clinical systems. It was responsible for, not only SCM, but now they’ve taken on the rest of the world: radiology, pharmacy, laboratory, all the ancillary systems as well. Their focus is more on the application side, with the IT department really worrying about the infrastructure piece.

We’re about 3.1 or 3.2% of the operating budget. Our routine capital is about $30 million a year and typically we get $5 to $7 million of that, This year, we’ve got $7 million, which is about a quarter of it. In fact, that was one of the attractions when I came down here. I came from an organization whose IT capital budget for four hospitals might be $1 million. When I came down here, my predecessor Jim Turnbull had gone through a planning process and gotten a commitment from the board to spend $50 to $60 million over seven or eight years. So that was a big attraction — being able to do things without scrimping on the basics. And I’ve been able to maintain that capital commitment board and administration. This is my third CEO. I’ve been able to continue the capital investment in IT for the last seven years since I’ve been CIO. So I feel pretty good about that.

With a large amount of money being invested, how do you decide where to spend it and how to justify the ROI that results?

I think I’ve been fortunate. We’ve really never been an ROI organization, which I appreciated as well when I first walked in here. It’s been focused more on what are the problems that the organization needs to solve. What’s the solution to it? How much does it cost? And then it goes into the budget.

I don’t have an IT steering committee. My IT steering committee is my CEO and she can be very direct at times. We had a JCAHO survey a couple of years ago. We ran into a couple of situations that IT could solve and she said, “Go make it happen.” And the real focus over the last eighteen months, if not more, has been on quality and safety. Now that we’re doing CPOE and eliminated the upfront transcription errors, how do we solve the problem of wrong meds, doses, and all that on the back end. That’s why we’re really focused on the barcode administration piece right now.

Are you worried that vendors seem to be moving toward hiring inexperienced employees right out of college?

I can’t say that I’ve seen that within Eclipsys. Most of the people that I’ve interacted with, all the way from implementation consultants to project managers, these people have got a number of years of experience behind them. I’ve seen the comments about Epic and the implementations and so on, but I cannot say I’ve ever seen that with Eclipsys. There always seems to be a requirement that either they have a clinical background and know something about how the department operates. And then they get educated in IT. And as I reflect on our original project team for SCM, that’s the approach we took. We attracted the best and brightest clinicians in the organizations and then took them through the IT training piece. That worked out very well for us. I think it would be very difficult to take some computer science graduate that just got out of school and teach them how a hospital works without a whole lot of supervision and good mentorship and/or project management.

Then we get into my concern about a company that is publicly traded is having to pay attention to what’s going on in Wall Street, and try to come up with, may be not the best model, but the most economical model, and hope that it actually works. I wish there were more healthcare IT companies that were privately owned. I see Wall Street as a huge distraction. A good example — I don’t know if you remember Transition Systems Inc.?

Yes. Eclipsys bought their decision support.

They missed the mark on one quarter. Their stock price dropped and then they got scooped up by Eclipsys. At the core, I think TSI was a good company. I think they had a Cadillac of decision support systems at that time. Through acquisition, good talent left.

That’s what I get tired of — the mergers and acquisitions. When we were looking for radiology systems, Siemens had a partnership with IDX at the time. They didn’t have their own good solution. So we went with IDX for radiology. Then that faded after about two to three years. IDX went to GE, and I can’t say I’ve seen a GE rep in the last two years since the acquisition. So this whole vendor churn and having vendors figure out how the new products that they’ve just acquired are going to integrate with what they’ve got seems like a huge distraction, not only on the front end of the acquisition, but on the back end on how are you going to make this stuff work.

What technologies do you see on the horizon?

I’m not sure I’ve got any original thoughts. I know there’s a lot of negative bias against it, but it occurred to me after Katrina, the paper records in New Orleans were gone and the only organization that seemingly did well at recovery was the VA. They took their backup tapes from their data center in New Orleans to Houston and, within a week, everybody in the nation had access to those records. I was trying to think, since I’m in the potential path of a hurricane as well, what would we do?

The whole idea with smart cards appealed to me. Downloading the CCR from our inpatient systems; providing read-write devices to our physician offices so they can populate it as well. The card isn’t so much the issue. The opportunity is having a redundant data center in Dallas or someplace where all the data is stored. But from a smart card perspective, not only has the core clinical data on that card to be read any place, its also available on some website somewhere. It provides a marketing opportunity for us with our logo all over the face of it. And then from an efficiency point of view, them walking in with their card, we swipe them, they’re registered, and they are done. Then they can go on to their appointment.

One of the issues that I’m not sure is unique to us is the length of time to identify the right patient, get them registered, and double check the insurance information. I believe that smart cards would solve that. Some of the discussions I’ve heard is, “Well, we should be downloading that to people’s cell phones.” Somebody’s always looking for the next technology and we’re really focused on trying to do smart cards this year, but we’ll see how well I do. It’s kind of a data concept, but I think it’s potentially could solve three problems for us.

One of your employees e-mailed me to suggest that I interview you and said, “As long as Denis is the big guy, I will work at SMH.” How do you command that kind of loyalty?

I’m honest with them, sometimes to the point of probably saying things that maybe I shouldn’t. Like most larger organizations, there’s rumor mills all over the place and I want to make sure that my folks hear from me what I think is going on and what the organization is actually doing. So I think, honesty and also being upfront and fair. We’ve had certain situations with employees that have not been popular decisions. So when I go back to explain, to the degree that I can, what the situation was and why that individual no longer works here, they appreciate the fact that I made the right decision. They understand it.

I give them quite a bit of latitude into the decision-making, particularly to my management group. An idea will be thrown out on the table, we’ll talk about it, and sometimes I’ve overridden the consensus decision from the management group, and I’ve tried to explain why I made that decision. I’ve had very little disgruntlement because of that.

Who do you admire in the industry?

I would say John Glaser at Partners. He was way ahead of his time when they started writing their own MUMPS software in, I think, 1988. They’ve always been ahead of the curve as far as development of their clinical systems and the fact that they self-develop them. They’ve got a staff of six hundred or something like that, but to take something massive like that on and be that successful at that large an organization is remarkable.

The same employee that e-mailed me that said that you’re a faithful HIStalk reader. Why is that?

I appreciate the insight. You’re one of my twice-weekly reads and the Brev-It e-mails as well. It gives me an insight into stuff that typically wouldn’t be available to me regarding acquisitions of vendors. Sometimes the rumors are interesting as well. I appreciate the fact that you wait for secondary validation that its true. It’s well written. I think you cover the industry pretty well. Obviously I think you have the trust of your readership. It’s a good read. I guess the other piece that I appreciate is that but you’ve always got the link. The article allows me to go out and find out more about it, so I don’t have to go someplace else.

Is there anything that you wanted to talk about?

I just received the invitation for the Most Wired survey again. I wish somebody would kill that. I’ve seen your comments. I share your sentiments about it.

I’ve talked to some of my peers that have been on the Most Wired list and asked them if they’re really doing some of that, and they said, “Of course not.” So I think somebody needs to audit some of this and put this to rest. Fortunately my CEO doesn’t have a whole lot of belief in it either, so she’s not holding me accountable to what some of the other organizations are doing. Not that there aren’t some good, innovative things going on out there, but having an unaudited survey of what you’re doing … the polling results are in from New Hampshire. Everybody thought they had the pulse on what they thought was going happen and then it changed overnight. So in that case, the pollsters were throwing out the numbers, but the voters really showed up and indicated what reality was. So I wish somebody would do that with the whole Most Wired survey as well.

Monday Morning Update 1/28/08

From Mitt Romney: “Re: Lowell. Lowell General Hospital is the only full Cerner site in Massachusetts and a fairly new install. They had a multi-day,system-wide downtime last month that has been kept very quiet. It would be good to hear from CIO John Goodrow what the outage was and its impact on clinicians.” Inga will make inquiries.

From Big Fan: “Re: Cerner. Lazlo has the Cerner health plan mostly correct, but we associates have always been told that the TPA processors are not Cerner employees. Cerner has received numerous Top 100 awards for Best Places to Work, citing the health club, onsite daycare, etc. but to me, it is not as good as it sounds. The health club/associate center is more costly than the local gym, the onsite daycare is convenient and nice but more expensive than nearby places, and the health care plans are expensive compared to most area employers. Three days paternity leave – hey, at least it is something. They offer an FMLA-like option for people employed less than one year, which isn’t a bad thing. If that makes one a Best Place to Work, then I guess just having those sorts of things exceeds what most other companies do for their employees.”

From Dan Tanna: “Re: progress notes. We are moving our inpatient progress notes online. An issue that has come up has been during a code or RRT situation, people have to leave the bedside to find a computer and look at the ‘chart’. I recommended using one of the nurse’s medication carts since they are wireless, portable, and hooked up to the EMR, but was wondering if there are any better ideas. We don’t want to print out notes.”

From Walt Ducati: “Re: Cerner in the Middle East. Cerner was chosen by the American Hospital in Dubai, but later lost because ‘management couldn’t deal with the arrogant Cerner salespeople, so we took our next choice – Meditech.’ The hospital did not look at Epic because ‘they didn’t have plans to sell internationally.'”

From NY Customer: “Re: QuadraMed. Could someone please confirm the departure of Christine Stanfield from QuadraMed? She was one of the few who really knew the CPR system.” I’ll defer to anyone who knows one way or the other.

Intercepted e-mail: Drexel DeFord has resigned as VP/CIO of Scripps Health, according to an internal memo dated January 22. His last day will be February 22, after which he’ll head off to be SVP/CIO of Seattle Children’s after two years at Scripps. You may know him from his Air Force hospital CIO days or his HIMSS involvement. The anonymous source sent the e-mail over by confidential Rumor Report.

Jobs: MUMPS Software Engineer, Centricity Consultant, SCM Project Manager (Contract), Allscripts Consultant.

McKesson joins the “vendors laying off” club, wiping out 79 IT jobs in Dubuque, IA and announcing plans to sell the old department store it occupies. Sounds like the end of the line for CyCare, the practice management and EDI vendor that HBOC bought for $287 million in 1996.

The Raleigh paper declares that Misys Healthcare is “on the mend,” although its numbers don’t seem quite that rosy and betting its future on a relabeled competitor’s physician system seems both risky and uninspired. Maybe it’s just me, but they’ve got a lot of train wreck baggage to unload before I’d project their success.

HHS recognizes three of HITSP’s interoperability specifications.

Calgary Health Region reveals that a problem with fax software held up delivery of radiology reports to doctors’ offices last year. I’m still amazed that anybody faxes anything. If someone e-mails me some document to be signed, I print it, sign it, scan it, and e-mail it back. Primitive, but way better than faxing.

This seems preordained: in Michigan, St. Mary Mercy Hospital will join St. Joseph Mercy Health System.

Investigators say that an electronic medical records system is partly to blame for the low productivity of its contracted prison doctors, calling the documentation function “achingly slow”. Their recommendation: get rid of it.

I’m puzzled: Sumter Regional didn’t win the MRI from Siemens, according to announcements that proclaimed Lockport Memorial Hospital (NY) to be the winner despite what looked like about a 2 to 1 Sumter victory based on the online vote counts. I’ve seen no mention of how or why the auditors overturned the tally, although the phrase “qualified votes” has been thrown around. Still, Siemens is giving them a free MRI anyway, saving themselves a PR headache in having to explain how, in the absence of an electoral college, the popular vote winner lost. I’m trying to hold back on the Siemens bribery jokes.

Physician billing company MTBC is named a Microsoft Gold Partner, which I don’t care much about, but I did look at the company’s site since I’ve never heard of them. Looks pretty good and the management team has great credentials. Says they take care of all physician office billing for 4%. You can download their free EMR in case it’s a slow weekend.

Big problems at $3.8 billion insurance company WellCare Health Plans, which probably thought they’d bottomed after state and federal investigations and a stock price freefall. Well, maybe: the CEO, CFO, and general counsel all quit Friday. At least the CEO has an impressive resume to take job-hunting; he was also CEO of a subsidiary of Oxford Health Plans, which had a similar meltdown.

Nice reporting by an Idaho reporter: researching the governor’s claim that the RHIO he wants to start will be self-supporting after the grants run out, she dug up several sources from our industry citing how hard it is to wean off RHIO grant money. Both the writing and the research behind it are better than what most of the industry rags put out.

John Dvorak says Sun’s aquisition of open source database vendor MySQL is such a bad idea that surely Sun is trying to kill MySQL off to benefit Oracle. Evidence: Sun’s terrible acquisition track record and its willingness to pay $1 billion for a company whose annual revenue is only $60 million. I’ve also heard that the price was really too low and that the stalwart Swedes who run MySQL should have shopped it around before simply handing over the keys to Sun. Since its database runs most of the Internet (mostly because it’s free), it’s surely got a footprint.

Bizarre hospital lawsuit: an Illinois hospital will pay a $100,000 EPA fine but still faces a civil suit from a man who says he saw a hospital employee toss a cardboard box of body parts into the open grave of his father and stomp on it, explaining that the hospital contracted with the cemetery for such disposal.

E-mail me.

News 1/25/08

From Kevin Gnapoor: “Re: HIMSS Analytics mention of HIStalk. It came off better than you reported. Of surveyed healthcare IT execs, 65% reported reading a technology blog in the last year. When asked to mention specific blogs read, 13% identified HIStalk, whereas no other blog was mentioned more than once.” Glad to hear that, although I’d like think I can compete well with mainstream publications and not just blogs. It makes Inga happy to be anonymously famous.

From Cady Heron: “Re: Misys. Misys will have a big roll-out of an SaaS solution. athenahealth may start feeling some heat if Misys can overcome its current dismal perception in the market. As my contact stated, athenahealth is nothing more than a service operation for handling billing with a software front-end.”

From Broadway Joe: “Re: Keane. We run their RCM product and some clinical apps and we were happy to see there recent press releases with some new deals. I know they are actively installing new business in the NY/NJ area.  I think the CHS move was a provider acquisition that is causing the move away from Keane.”

From Gretchen Wieners: “Re: Leapfrog. I agree Leapfrog has become irrelevant, but they started with the realization that employers held the purse strings in many cases and had motive for lower cost and better quality of care and better negotiating power given their role. So they analytically looked at what would have the biggest impact on medication errors and chose them. That included CPOE, which can play a key role if the system is designed for clinical decision support. The others were also no-brainers, e.g. the intensivists. But, they never used their clout and their demands were unfunded. Once the MDs balked, they caved.” 

From The PACS Designer: “Re: Oracle VM. Virtualization has been mentioned in past posts by TPD. Oracle has a new software offering called Oracle VM, which makes it easier to implement virtualization within the institution at a relative low cost for both Oracle and non-Oracle applications. Edward Screven, Oracle’s chief corporate architect, states ‘Oracle is the only software vendor that combines the benefits of server clustering and server virtualization technologies to deliver integrated clustering, virtualization, storage, and management for grid computing’.” Link.

From Cliff Pantone: “Re: AMIA. This job posting on the American Medical Informatics Association website nearlymade me spurt my morning coffee over the screen: ‘Applicants should have experienced first-hand the creation and rollout of a commercial software product, or else should possess a good sense of humor.’ Too true, too true…”

From Jerry Aldini: “Re: Cerner in the Middle East. I wonder if Cerner will sue IBA since the hospital IBA supposedly took from them was never in the Cerner-Health Authority contract? Also, I have heard that the delayed go-live is mainly due to data center delays. In the Middle East, there is NO experience on the client side when it comes to projects of this magnitude. If a data center is not ready, PCs are not ordered, or end users are not trained, it’s the vendor’s default.”

From Lazlo Hollyfield: “Re: Cerner. It’s funny how an organization supposedly trying to improve healthcare treats its own employees poorly in health benefits and policies. Cerner offers only high-deductible health plans. It created its own TPA (whose medical director was a Cerner associate) to handle employee healthcare claims and Cerner employees manage precertifications, claims, and medical records, meaning the company is looking at the medical records of its own employees. HealtheExchange uses a second-tier provider network that leaves major metro areas uncovered, so if an associate falls seriously ill while working at a client site where the plan has no in-network providers, the associate gets stuck with the bill for any charges over the usual and customary amount, typically 60-75% of the provider’s claim.” I’ll just jump in to disclaim that I don’t know this officially, so you’ll have to take Lazlo’s word for it unless somebody wants to second his emotion.

From Charles Bronson: “Re: RevolutionHealth. They already have a PHR, soon to be CCD-structured.”

From Dr. Lisa Cutty: “Re: Cerner. We get rumors from Asia about Oracle buying Cerner. I know they are interested in the company since 2004 and Cerner is using Oracle’s platform, but are there any new developments?” None I’ve heard. The floor is yours if you have.

MedStar Health, the Baltimore/Washington system in which Azyxxi was created, chooses Cerner Millennium for all seven of its hospitals, although not all apps. A couple of people e-mailed me wondering if that means anything beyond the obvious. I’m guessing no. From Art Vandelay: “I wonder if they used the funds from the sale of Azyxxi to pay for Cerner? Ironic … at least there was no mention of replacing the ED module. Do you really still need your own CDR/Viewer if you are going away from a best-of-breed strategy?”

This must have been embarrassing. HealthTrio is working with CMS in a PHR pilot, which requires going through a security audit. Auditors connected their equipment to power in a server rack and blew a power circuit. That was fixed, but somehow the connector on the server’s RAID controller card was broken. They failed over and were up again within a couple of hours, but this morning went down again due to DNS problems. It’s running, although not very well, and another outage this evening is needed to catch up the primary server.

I’m guessing that Sumter Regional Hospital won the MRI since the Sumter folks sent me an invitation to attend a joint Siemens-SRH announcement tomorrow morning. Good for them. Unusually smart marketing by Siemens, too.

Inga and I finished the first of several new HIStech Report interviews, this one with Stratus Technologies. Pretty interesting stuff. We’re proud of how cool our reprint format (warning: PDF) looks considering we’re moonlighting amateurs.

Jobs in cities: Nashville, Chicago, Denver, Los Angeles. I see we now have 230 jobs listed.

Meditech’s Magic 5.6 is now CCHIT certified.

Premise had a 260% increase in revenue in 2007 (2,265% over five years). I interviewed CEO Eric Rosow in November about hospital throughput.

Ann Carey of St. Vincent’s HealthCare (FL) is promoted to VP/CIO.

Suffolk RHIO in New York chooses HealthUnity.

Last chance for HISsies voting.

Former State of California CIO J. Clark Kelso replaces the receiver of the state’s prison system. I had to look up what that meant: California’s prisons provided such bad medical care that the federal government seized the system in 2005, calling conditions deplorable despite annual medical costs of over $1 billion. The guy in charge is the receiver.

Cleveland Clinic is a big sponsor of Arab Health Congress and CIO Martin Harris will speak. Mr. HIStalk was not invited to attend as a guest of the countries he so richly supports through his regular gasoline purchases, so he sends his regrets. Dubai seems pretty cool.

MedAvant’s shareholders approve the sale of its preferred provider network for $23.5 million.

Wal-Mart starts an employee pilot of its Dossia PHR system, a quick rollout considering it wasn’t long ago (September 2007) that Omnimedix was replaced with Children’s Boston as the technology supplier.

Busted: a Massachusetts doctor is reprimanded for reviewing the electronic medical records of a nurse he was dating. The hospital caught him in an audit and gave him a written warning, but the medical board fined him. Another employee found that the doctor had checked out her OB/GYN records, so she’s suing the him and hospital for $250,000.

The Massachusetts Attorney General is investigating the $16.4 million parting gift that “nonprofit” (despite a $157 million “surplus” in one year) BCBS of Massachusetts gave its retiring CEO this month.

Varian Medical Systems announces Q1 numbers: revenue up 18%, EPS $0.43 vs. $0.37.

The government is anguishing over those five acronyms that are holding the industry at bay due to imprecise definitions, but there’s another mammoth problem that’s keeping Uncle Sam awake at night: the job descriptions of HIT employees. HHS secretary Mike Leavitt asks AHIC to come up with job descriptions and their required credentials in the next year. It is mentioned that the shortage of trained HIT experts is getting critical and not just in the US.

E-mail me.

Inga’s Update

Misys PLC announces its interim results from the first six months of their fiscal year. While overall revenue for the company (including banking and financial services) was up about 3%, healthcare saw only a slight revenue rise and order intake was up only 1% over the same period last year. One of the most painful numbers has to be the 34% decrease in initial license fees. No doubt they are hoping MyWay will turn things around for the rest of the year.

Medcomsoft signs a $750K agreement to put EMR in Puerto Rico’s largest owned drug store chain. The deal includes licenses for 100 physicians.

Just the other day I was wondering if I should consider a health savings account and if anyone really used them. Well, according to HSA Bank (warning: PDF), quite a few folks are using them, given the bank’s status as the first HSA administrator to surpass $500K in HSA deposits.

Revenue cycle management provider Accuro Healthcare Solutions files a registration for an IPO to raise up to $144M.

McKesson adds Intel executive Andy Bryant to their board. Bryant is an Intel executive vice president and chief administrative officer.

HIMSS announces that registration for this year’s conference is up 17% over this time last year and more top-level execs than ever are attending. Mr. H swears it’s because I’ll be at the Healthia/HIStalk soiree, but I think he’s just saying that to get me to wear some fancy ball gown.

Read about Meriter Hospital and details on its $30 million all-digital hospital in Madison, WI. Epic is called the “centerpiece” of their showcase for the latest in healthcare technology for patients with cardiovascular disease.

E-mail Inga.

Leapfrog’s Big Leap Into Irrelevance

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 October 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

I remember sitting in a hotel ballroom back in 2001 or 2002 hearing about The Leapfrog Group for the first time. I was both energized and worried. I liked their idea of pushing a short list of evidence-based quality measures for hospitals to follow. However, I was worried that my own hospital employer might not be able to meet their expectations, thereby raising the ire of the big-employer healthcare dollars behind Leapfrog.

Leapfrog didn’t sound like someone to mess with. The post-dot com era would be bleak, with too many hospital beds competing for the business of the newly savvy baby boomer consumers, capable of making shrewd healthcare decisions because they’d ordered books from Amazon.com.

If the IOM’s “To Err is Human” was embarrassing, Leapfrog was threatening. Their changes were downright prescriptive, encouraging no debate or deviation, and backed by the folks who pay the bills. Experts in their individual Leaps howled to see the evidence behind their choices, but it was not forthcoming.

Somewhere along the line, Leapfrog fizzled. Nowadays, they’re a quaint anachronism. Their role seems mainly to trumpet the accomplishments of other groups on their website.

In fact, I just compared their Members webpage with an archived version from 2004. Today’s count: 44 members. 2004’s count: 152 members. Among the missing: Allscripts, Cerner, Eclipsys, McKesson, Misys, Siemens. I hope no one got hurt in the mass exodus.

A new Leapfrog press release illustrates how little influence they have. They did a study that found over 90% of hospitals have ignored their CPOE mandate. Over 90% don’t meet their standards for two surgical procedures. 70% don’t use intensivists in the ICU as Leapfrog demands. Are they suffering from the financial retaliation of Leapfrog’s few remaining members? Not that I can tell.

Also unfortunate was their inclusion of Indianapolis’s Methodist Hospital as one of their Top Hospitals of 2006, fresh off headlines detailing the deaths of three newborns there due to a medication error. That could have happened anywhere, but the timing was terrible for Leapfrog. To cynics like me, that was yet another indicator of their irrelevance.

I’ll leave other experts to comment on some of the widely ignored Leapfrog standards, but I’m not about to pass up the chance to point out how ridiculous their CPOE requirement is.

CPOE prevents few patient errors. It prevents mistakes, but mostly those that would have been caught anyway by skilled professionals, such as transcription errors and clinically questionable orders. Just about every study done by AHRQ and others have said exactly that: there’s nothing wrong with CPOE, but just don’t expect it to make much of a difference in patient outcomes, particularly considering its immense cost and failure rate.

Leapfrog should have been smart enough to steer clear of the CPOE bandwagon. Maybe they didn’t look around at the available products, small in number and large in functional deficiencies. Maybe their healthcare IT members twisted their arms to sell a few CPOE systems by mandate. At any rate, Leapfrog’s urgings probably sold a lot of CPOE systems, but their own survey shows they aren’t being used. Millions spent with little to show for it, apparently.

It isn’t that healthcare won’t change, it was just that Leapfrog didn’t do it. For those making it happen, check out Don Berwick’s Institute for Healthcare Improvement. If you want to see research in action, look at AHRQ. If you want to see cutting-edge informatics, consider Kaiser or Intermountain Healthcare. For mass market mandates, even JCAHO’s core measures are getting the word out. And if you want to see a group living in its own formerly large shadow, check out Leapfrog.

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 1/23/08

From Neal’s Pizza Guy: “Re: Cerner. 21 June 2005: Cerner wins a seven-hospital Abu Dhabi contract and no doubt promises the world. Arab pizza futures soar on the news. 14 June 2007: Cerner opens a new office in Dubai to supplement efforts in Abu Dhabi. The smile on Doug Krebs face says the parking lot is full and the pizza is yummy. The other Cernerbots smile pretty for Neal. 22 January 2008: Doh! What do you mean we had to deliver?!? IBA Health boots Cerner from Abu Dhabi hospital after ‘lengthy delays.’ Abu Dhabi pizza futures are down …way down. No word on whether Krebs is still smiling. Also: Computer Weekly reports that Fujitsu is ready to pull the plug on NPfIT program. UK pizza futures are rocketing on the news.” Link.

From Rich Davis: “Re: Cerner layoffs. Go back and check your lists of healthcare IT employers in KC. There are several pharmacy tech vendors of size and lots of other niche players. Other IT only places are Garmin, Yellow Freight, etc. Don’t cry too hard for these folks. If they have any skills at all they will easily find work.”

From Kenny Crawdad: “Re: Keane. What is up with Keane? I hear they are imploding because of the new acquisition and the loss of CHS business. No real new sales in over six months, and the only thing going is some offshoot deals with MedSphere. Sounds pretty scary.” Unverified, assumed inaccurate unless someone wants to confirm.

A sponsor tells me (via Inga) that HIStalk was mentioned in a recent HIMSS Analytics webinar, with 13% of surveyed healthcare CIOs saying they read here regularly. I’m a glass-half-empty kind of guy, so I’m thinking that having 87% who don’t is a terrible disappointment, but I guess that’s pretty good.

My editorial this week: Cerner Layoffs in Review: Why Marching People Out Makes Sense, but Sickouts Don’t. A short teaser: “Personally, I’m blaming Meditech.” Want to guess the connection?

Houskeeping issues: the search box to your right plows through millions (literally) of words of HIStalk going back to 2003, so Google yourself or a company for fun. That Rumor Report button to your right lets you send me anonymous, secure messages (including attachments if you’re so inclined), so give me some good dirt and I can write about. Sign up for e-mail updates when I write something new here or for the Brev+IT weekly e-mail. Try HIStalk Discussion or the stock page. Our friends at Healthcare IT Transition Group have a text ad to your right for their 2008 Health IT Grant Resource Directory (you can check out sample pages and full details). And please take a moment to do a little click-visiting to the sponsors whose ads grace the left margin and thereby keep my keyboard clacking until all hours of the night like Design Clinicals (HIStech Report coming soon), SCI Solutions (ditto), high availability architecture gurus Stratus Technologies (ditto again), and patient flow experts Premise.

Speaking of Google search, I was scouring HIStalk for something yesterday and ran across this post from May 2006, when Electronic Slide laid on some heavily sarcastic criticism of my skepticism about the rumor that Allina was bailing out on Epic, saying I play Epic favorites and have no journalistic standards. Since then, Allina’s live on Epic and, in fact, won the Davies Award. So there.

Jobs: Account Executive Sales (note: it’s in KC!), Physician Liaison, Information Architect, Sales Executive. Signup is quick for a weekly jobs update.

Stocks started out in meltdown mode this morning, then rebounded, with the Dow down 1% and Nasdaq down 2%. Most HIT stocks did a little but worse than that, but Eclipsys and Perot Systems were up.

Jim Wilson is promoted to president of Craneware’s US subsidiary, which sells charge master software.

Philips had a big Q4, doubling profits to $2 billion on a 3.8% revenue increase, but US sales were down 10%. Healthcare is right up there with shaving and grooming for US investment, the company president says.

King’s Daughters Medical Center (KY) names Cathy Cooper-Weidner as VP/CIO. I think she used to be CIO at Memorial at IU South Bend.

West Georgia Health System is bringing up a $12 million Meditech system. It wasn’t clear what it is from the newspaper article, but C/S 6.0 is mentioned.

If you have to make a medication error, make sure no celebrities are involved. Dennis Quaid criticizes Cedars-Sinai in a Sundance Film Festival interview, something the average patient isn’t often asked to do.

Looking for a laptop deal? Best Buy has a Gateway with Pentium Dual Core 1.6 GHz, 2 gig memory, 160 gig SATA, DVD/CDRW, 15.4″ display, and Vista Home Premium for $549. I got one and it’s sweet, even to the laptop-indifferent like me.

GE Healthcare will exhibit at Arab Health 2008 in Dubai next week. So will just about everybody else in HIT, according to the conference page. Which reminds me: if you’re an HIStalk sponsor, Inga will be contacting you about some cool HIMSS benefits: a free sign for your booth (autographed by her, no less!) and a mention in the upcoming “Mr. HIStalk Goes to HIMSS” guide. Thanks to the companies who volunteered to help out with our little giveaways there. We’ll name them soon.

Siemens will announce the MRI winner in a live webcast Friday morning at 8:00 Eastern. Sumter says they haven’t heard anything.

The Ann Arbor Area Health Information Exchange gets a Detroit mention. Its annual budget is only $140K, which is darned good. NextGen is mentioned because all the partners use it.

An embarrassing NHS glitch: a server crashes at midnight, the primary on-call tech forgot to turn his cell phone on, and the backup support tech didn’t have a data center key. The ED and results inquiry function were offline for 12 hours. Maybe not as embarrassing as this NHS gaffe: a patient’s newly transplanted kidney has to be removed when caregivers notice that the patient’s blood type was recorded wrong in the computer.

E-mail me.

Inga’s Update

The country’s oldest visiting nurse association, VNA of Western NY is partnering with Cardiocom Multi-Disease Management to provide home telemonitoring technology.

Cerner Millennium PowerChart 2007 and MEDITECH MAGIC 5.6 just gained 2007 CCHIT EHR certification. INVISION Clinicals Version 27.0 with Siemens Pharmacy and MAK Version 24.0 is conditionally certified, pending a “verifiable customer reference.”

Awarepoint and Skytron announce a new integrated active RFID asset management and information resource solution.

McKesson pats itself on the back a bit for having 18 solutions ranked in the top three in the recent KLAS rankings. Not shabby at all.

Greenway Medical Technologies was another strong KLAS performer, named Best in KLAS for ambulatory EMR in the 6-25 physician practice. Greenway’s also making headway into the RHIO/IDN/IPA segment since the Stark laws were modified and has signed on 10 community healthcare organizations since July.

Fujitsu announces a more secure and powerful mobile device targeted for healthcare (and some other industries.) The newest design of the P1620 includes such features as a biometric fingerprint sensor, secure asset tracking software, and a weight of just 2.2 lbs.

Is it tougher than ever to be in healthcare sales? Out of 180,000 surveyed docs, 19% said they refuse to see drug and device sales reps at any time and 23% make the reps to set an appointment. However, 73% of the physicians said they’ll take details from reps at any time of the day or week. A couple of curious observations here: first, the numbers add up to greater than 100 (what is up with that?) and second, this study by SK&A Healthcare Information Solutions (who sell physician databases) claims they reached all 180,000 doctors by phone. Why would a doctor take a phone call from a marketing company but not see a sales rep in their office? Are there perhaps no restrictions on paying physicians for their time to answer surveys?

E-mail Inga.

Art Vandelay on Social Networking in Healthcare

The spigot is opening. Another Web 2.0 company, IMedix, is stepping onto the scene to take social networking and apply it to healthcare. This company offers a virtual gathering place for patients to share their experience and search for useful health info.

This is one of those trends I follow from outside of our industry and try to figure out when it will make inroads into our strategy. I have seen small communities arise around support groups on Yahoo Groups, FaceBook, and MySpace. These venues aren’t tailored to health information. CarePages offers a somewhat similar concept but is usually offered through a specific health care institution. WebMD offer this service but it can be a challenge to navigate. Revolution Health (RH) seems to be the player with the most momentum. They offer the communities and health info, but also aim to link in information about physicians (typical find-a-doc search), insurance companies, and health risk appraisals. Like RH, IMedix makes money by selling targeted ads.

What does all this mean for us? Other than “never a dull moment”, I see four blips on the radar. First, these sites are yet another logical platform for personal health records (PHRs). Second, they are a platform for physician and insurer report cards. Third, we will be monitoring content sources to provide a list of approved sources for patients. Lastly, our media awareness requirements will evolve.

For PHRs, start brushing up on your HL7 Continuity of Care Document (CCD) specification and quizzing your vendors. Then, start tracing the data sources that feed the CCD. The CCD content in a PHR will be just like a patient receiving a bill and questioning the details (“Did I see Dr. ‘A’? I don’t remember her coming in.). In the PHR scenario, it will be patients questioning diagnoses, procedural descriptions, and results they see. Decoding the trail of consumer terminology versus medical and billing terminology and norms will be the challenge.

For report cards and content sources, the responses of our organizations are pretty clear. We will be asked to either try and compile the same report card info or develop systems to align with or challenge the scores. For content sources, we will be asked to provide a place where our clinical content managers or librarians can add or remove approved sites while also educating our physicians about the sites where we usually direct patients.

Media awareness, outside of health care, is a niche service. There are services that scour the public sources of information (ex: Internet, publications, radio, TV) for mentions of a company and sell the transcripts to the company. We may soon be in this challenging situation – finding all the mentions of our organizations and attempting to validate that what was said was correct.