HIStalk Interviews Mark Zielazinski, CIO of Children’s Hospital of Central California

You may remember Mark Zielazinski from his days as CIO at El Camino Hospital. He responded in 2006 to a reader comment about that hospital’s problems with its Eclipsys Sunrise implementation, which caused great organizational upheaval and nearly got the hospital shut down, according to newspaper accounts. We agreed to do an interview at some point. It’s taken awhile, but we finally had a chance to talk. Mark’s now CIO at Children’s Hospital of Central California. He was trying to get out of the office for a long Friday commute home when we connected, but was gracious enough to spend time with me.

Tell me a little bit about yourself and your job.

I am CIO at Children’s Hospital of Central California, which is the only rural children’s hospital in the United States. It’s actually a pretty big facility. We’re located just outside of Fresno, California, the central valley of California. I think we’re going to be 320-something beds next month. We’re opening up 28 more beds.

Describe your IT shop and how it’s structured.

We’re primarily a Meditech shop. We’ve been a Meditech hospital for 20+ years, so we were an early adapter of the Meditech system back in the mid-eighties, I think.

Beyond Meditech, we have the typical gaggle of supporting systems. We’ve got Picis in the OR. We have Kronos for time and attendance. We’ve got a couple of ancillary systems and KaufmanHall  products for budget and capital. This year we’re going to be replacing our Meditech ERP modules with the Lawson system for ERP. We’ll start implementation this summer and then go live sometime in ‘09. And then for the Meditech products, we’re just starting to do nursing documentation. We’re on the old Magic platform.

We’re doing some things with physicians in ambulatory order management and pharmacy in prescription writing. We’ll upgrade to Client Server in the fall. We’ll start the process this fall. I think that will be done just about the time we go live with the ERP system.

Most readers will remember you from El Camino Hospital. You had problems there with the Sunrise go live and pharmacy department problems on top of that. What lessons did you learn personally from that and what should other vendors and the industry learn?

We did a lot of things right there. I think we were on track with being very successful. I think they’re going to very successful right now. I know Eric Pifer’s there. I think that’s going to go well for him. He’s got a good environment to go from.

We went live in the first part of March 2006. I don’t remember the exact dates, but it was sometime in early 2006. We had missed our initial go-live, which would have been the middle of November 2005. The primary reason for missing was the fact that we couldn’t get our doctors educated. I think the training we had set up for them was about four hours total, in two-hour segments. We actually did it, but we could have done it a little better. We started paying the physicians to attend those classes. We paid them a fixed fee for the two classes. To get the payment, they had to go through and demonstrate proficiency. The lesson is that you have to pay them.

You get so much momentum. We had gone almost three years. We were in the process of building, creating, and moving when we missed our November date. So it was three and half years by the time we went live. I think one of things that’s got to happen is it can’t take that long. You’ve got to find a way to get that stuff to work in such a way that it doesn’t take three years to build a product and get it ready.

This was a place where we had the experience. El Camino had been doing physician-based order entry. They’d been doing nursing charting and documentation. We were doing all that stuff and it still took us a hell of a long time. The products vendors have, and I don’t believe Eclipsys has a monopoly on this problem, are really a tool set. They don’t have a very good set of schematics and plans and starting places for you, as an organization, to be able to drive with that tool set quickly to using it.

You hit the third thing on the head when you said we had department issues in pharmacy.  We really needed to have dealt with that prior to that change. That was a major league change for pharmacy. Even though we were using the pharmacy product, the old E7000 product, it was a pretty manual process without any kind of real automation to it. Even though it was SCM 4.0 and I know everyone talks about the fact that it was an interfaced product versus an integrated product, people have been using interfaced pharmacy products for years and years.

That wasn’t what the issue was there. We had a very serious problem and the pharmacy didn’t do a very good job of managing that. I take some of the hit for that, but I think the organization takes some of the hit for that as well. We ended up actually outsourcing the whole pharmacy management. Once that was done and in place, the vast majority of the issues that were affecting us at the time of go-live and about five months later when we actually did the outsourcing, it kind of disappeared. Not to say that there’s not still learning that’s going on.

Somewhere, I have documents from the original Lockheed-Martin system that ultimately became TDS. It went live in 1971 at El Camino. There was study done in ’75 and another in ’77. They’re really good studies talking about adoption. In six years post go-live of that system, they only had about a 40% participation by physicians. So it’s not something that happened fast back then.

Looking back now, with the benefit of 20:20 hindsight, should the plug have been pulled at El Camino because it wasn’t ready?

I think if we would’ve had the issues in pharmacy fixed, I’m not sure that would have had such a negative impact that it had. I don’t know that the system wasn’t ready at that point. I don’t know if we had made some of the pharmacy outsourcing decisions prior to go live; would we have said at go live, “We aren’t ready”, and would we have experienced the same problems. I don’t think we would have, so I think that was where that all ended.

But I think you’re right. We had a committee, a very large group that included the chief nursing officer, myself, and the chief financial officer, looking at that, making the decision and recommending to the board of directors whether we went live. The three of us made that decision. Primarily myself and the chief nursing officer made the decision to pull the plug on the November go live because we didn’t think we were ready. We had physician input on that committee. The committee was basically a group of 28 people that met as we were getting ready to go live on a very regular basis. Not just weekly, but multiple times per week. We made the decision and took it to the board of directors.

When you left El Camino, you went to Sensitron as the COO there. What did you like and dislike about working in that environment as opposed to a hospital?

I’ve been in the private sector and consulting or working for small companies before. I was employee sixteen with Superior. I was very early on with DAOU systems. I actually went through taking DAOU systems public. So I looked at the opportunity with Sensitron as, here was a start-up company. I’m at that time in my life — I’m fifty today — where I thought, “I could try that one more time”.

They were pretty good folks. They were a service provider for us at El Camino. I knew their technology. The CEO had left the hospital. The guys from Sensitron had come to me and offered me an opportunity to participate in that small company start-up thing. To me, it was one more opportunity for me to do that. I’m not sure how many time you can jump in, try to take something and see where it goes. So it looked like a great opportunity.

We never really got our funding set up appropriately. So for them to continue to carry me would have really put an undue burden on their ability to the R&D kind of work. While I was there, we were able to put out a new product. Sensitron does the wireless automation and collection of vital signs from the devices that you move around from room to room in the hospital. While I was there, we also came up with an ICU product that took information off of the stationary monitors in the ICU. So I was able to get a new product out and help them develop a new version of their existing product, and do some alignments with companies

We struck up a partnership relationship with a portable monitoring company. Then our money dried up. We didn’t have any more money coming in, in terms of investment money. And our sales weren’t keeping up with the payroll. I said, “Look, what we really need to do is continue to build our engineering group and our customer services group. Carrying my salary doesn’t make any sense, guys.” So I told them I was going to go off and do some other things, which is what I did. I went off and did my own consulting and then landed a job here at Children’s.

How would you compare your Meditech shop versus being at El Camino?

It is a little bit different. It’s a little tighter system. Looking at the Client Server version of the product we’re looking to go to and looking at the documentation features, there’s a lot of stuff that … quite frankly, I was surprised at how similar it was to some of the capacities in the SCM that I’d put out there. They’ve come a long way.

The last time I had ever worked on anything at all with Meditech was when I was back with Superior in the late eighties. So I’d been away from it for a pretty long time, but they are still pretty rigid in their product. Quite frankly, they’re pretty rigid in their relationship with their clients. When I got here, we didn’t have a plan to go to Client Server, but we had a strong desire to get to doing a lot more electronic documentation, and ultimately of getting CPOE. As I did my research for the first couple of months I was here, it was pretty clear to me that, in order to do that in a very reasoned fashion on a Meditech platform, you really have to be on a Client Server environment, not on a Magic environment. All of the big groups like St Joe’s and Christus and the guys who just went live in Colorado — they’re all on the Client Server platform.

It’s part of the vendor dilemma, where they’ve got an old legacy product on the Magic side that they’re saying ain’t gonna go away for a while. The reality is that it’s really hard for a vendor to maintain multiple products like that. They’ve got to really get on board with something. I think ultimately they will get to that Client Server platform. I don’t know what’s going on in that market yet to see why they feel they’re going to keep managing both Magic and Client Server, but it’s a pretty bulletproof product set for us.

I think, on the ERP side, it’s pretty darned weak. In this organization, before I’d even got here, they had made the decision they wanted to get off of the Meditech ERP products. On the clinical side and the billing and accounts receivable side, I think it’s a really good product. The market share that they have speaks a little bit to that.

Tell me about your department’s operating statistics.

Historically, the budget runs at about 2.6 or 2.7%. Our fiscal year starts October 1. I came on board just in time to finish up the budget process. We are budgeted to be at about 3.2% this year. As I took the position, one of the things we talked about with the executive team coming on board was that I thought that an organization this size should be nearer 4% of the operating budget in terms of the group. At El Camino I was at 4.7% of the operating budget. So that seems right to me.

I have a director of applications, a director of technology, and the director of HIM reporting to me. I’ve also just hired a director for project management and a director … well, I haven’t hired it, but it’ll be an executive director role, physician liaison. I’ll probably to that either late this fiscal year or the beginning of next fiscal year.

In total FTEs in the applications and technology area right now, we’re about 44. By the end of this year, we’ll be at around 48. Into next fiscal year, we’ll probably be into the mid fifties. I don’t see us being larger than 60 people at the top end.

We’re pretty straightforward in terms of the capital budget. We haven’t done a very good job managing the replenishment of the physical infrastructure. So this year, we were about half of the equipment budget for the hospital on a capital basis, and the lion’s share of that is going into replenishing the physical infrastructure. We’re putting in new networking, new wireless, and getting us onto a program that says we’ll replenish the desktops and all that stuff.

We’ll start to roll out some mobile devices. We really haven’t had much mobile device work here, but we’ve got to get that in place if we’re going to electronic documentation. So we’re going add the C5s and some mechanism for putting up some other type of cards. I think that stuff is all happening.

The other part of the capital budget this year is for the Lawson project. I suspect we’ll be somewhere between 20 and 40% of the capital budget for equipment for the next two or three years. And then we’ll get to a point were we’re between 15 and 20% on an annualized basis. We’ll have a real serious replenishment program in place so that we don’t get stuck in this kind of environment again. The board is aware of and has bought into that process.

We’ve had our first IT steering committee earlier this week. They haven’t had an IT steering committee in about nine years here. The last IT plan was done in 1996. But there’s just some bread and butter kind of things that we have to get done and we’re working on.

You were a mobile device advocate at El Camino. How would you say overall the industry is doing in that whole mobile workforce area?

From what I can see overall, we’re typical healthcare — we’re behind the curve. Lots of other industries have taken over mobility a lot faster than we have in healthcare. I think the idea of a specific medical mobile device, like the C5 … I got to participate in that in a very big way, from the conceptual design phase. We were involved in that at El Camino. So I understand it, I believe in it firmly, but I also believe that there’s not silver bullet solution.

Some people are going to want to use mobile tablets. Some people are going to want to use mobile carts. That’s just a fact of life that we’re going to have to deal with here. I believe its true for about every hospital. But, I think, if you were to look out five or ten years from now, I think mobile computing will be the rule for the way access happens in a hospital. Whereas today, even at El Camino, where we deployed it very, very extensively, we still hadn’t gotten to 50% of the devices being mobile devices. El Camino will be one of the places that gets there the fastest, but it will probably be three or four years more where half or more of the devices are mobile devices. But I believe that is going to happen.

You mentioned voice over IP. We did the Vocera stuff. Here, we use VoIP phones. We don’t have a VoIP infrastructure fully deployed. We’re going to do that. I think that concept of personal communications is going to expand in hospitals. I’m a firm believer that and I think it’s got to happen in hospitals relatively soon, and that is, that we have to issue all of our employees some kind of communications access device.

I use the example of this. My youngest child just went to college. He was at California Polytechnic. In order for him to register for class at Cal Poly, he had to prove to them that he had a computing device that he was going to use. He couldn’t register for class until he’d gone through this process of proving to them that he had this computing device. We hire employees here at the hospital, we don’t have that same approach.

I think, at some point, that’s going to happen at hospitals. We are information providers. That’s what we do as an organization. When you really get down to it, we’re really information dependent workers. At some point, just like when we give you your badge, we’re going to give you some kind of computing device. You’ll be responsible for it and use it for all the interactions you have while you’re at work. I don’t know how far off that is, but I think its something that’s coming.

You were at a great location at El Camino for watching technologies develop. When you look across the technologies that might be promising for healthcare, what things do you like?

I like some of the devices that are bringing everything together. My phone, whether it’s a cell phone or a VoIP phone … that same device is going to be my computer. I think that’s happening. I think, in that device, its going to have this concept of personal recognition. So it’s a personal device. Rather than dialing a telephone number, you’ll just type in my name and it’ll get me via voice or via message. However you want to get me.

We’re going get more and more into monitoring people’s conditions. Do you remember Goldsmith’s book Digital Medicine? If you remember that first chapter, where he writes about a scenario, I guess it was the year 2015. The thing that was the most vivid to me out of that whole chapter that he wrote was the fact the guy who was the patient received his treatment diagnosis and everything without ever being either in a physician office or in a hospital. Pretty impressive. I think there are technologies that are coalescing to allow us to do that. They’re going to happen pretty soon. We’re at that tipping point for that stuff to happen. Its a combination of being able to monitor inputs and get information out of folks, without it being necessarily an invasive process, in terms of diagnosing things. Then having a mobile workforce that gets out to deliver care to the patients or the people, wherever they are.

Do you see that as a growing role for a CIO?

I think so. It’s really got to be more upstream and visionary. I haven’t done day-to-day operations for a long, long time. In fact, I’m not sure I’d be qualified to do day-to-day operations. It’s more of a vision, planning and really working with the executive team and the board to get a sense of what’s out there.

A lot of folks say we’re supposed to manage our vendors. One of the main roles of the CIO is to work and manage vendors and vendor relationships. I don’t think that’s a part of my job, but a bigger part of my job, I think, is kind of like what I did when I was with El Camino and Intel … building a partnership where we do interesting things together and bring that to the organization.

That process is what we went through to conceptually design the C5 and see it come out. I was pretty non-involved with the process and outcomes. I worked with the nurses and doctors, but I got them to work with designers and engineers and watch the output. I kind of guided it. I wouldn’t say I was completely out of it, but I wasn’t into the integral processes of that.

Nurses and doctors were just jazzed. There’s no other way to describe it. They were really jazzed that there was someone listening to them and trying to figure out things that they could do. I think that’s the role the CIO needs to play to facilitate those types of activities. Because once those people are jazzed like that about the technology and what’s happening, they start to think about how to change processes to make that stuff allow them to give better care, deliver quality and those type of things. Otherwise, if they’re not involved and jazzed by that process that way, they look at it as just another set of changes coming down on top of them.

When you think about how busy and how difficult it is for the clinicians with increasing activity and increasing volumes, they’re just getting creamed. The last thing they want is another set of changes. So somehow, you’ve got get them jazzed about that in order for them to say, “OK. I can see how this fits in. I can see how I can modify my normal work process to do it this way which will be better. It’ll be better for the patient. It’ll be better for me. Everyone will benefit.” You’ve got to figure out how to get them into that. That’s the role the CIO’s got to play.

What are the biggest problems and opportunities that CIOs face?

Trying to compete for what I believe is going to be a shrinking capital dollar. That’s going to be a huge challenge for them. Secondly, it’s going to be the political challenge of trying to change from simple vendor relationships to partnerships that allow real change to occur. The technology changes are not going be done from within the hospital. You’re going to have to bring technologies from outside the hospital, more likely from outside of healthcare, and apply them in a hospital setting and in a healthcare setting in such a way that brings success to the organization. These are huge challenges for a CIO.

Let’s get to know you better. I’ll give you an item and you tell me what you favorite of that item is. TV show: I watch football. I don’t watch TV other than sports. Sports team: Chicago Bears. Food: Veal chops. City: Verona, Italy. Music: Chuck Mangione. I’m a jazz guy, but I like his horn. Vacation destination: The Orient. I married a Chinese woman. My wife is Taiwanese. I love the Orient. HIMSS conference event: The keynote. Hobby: Bicycling.

Who do you admire in the industry?

Dave Garets. I’ve known him for a long time. Bill Childs and Bill Bria. Those are guys I really admire.

Is there anything that you wanted to talk about that I didn’t ask you?

I know there are a lot of folks I’ve talked with recently. The folks from McKesson are like, ‘What’s going on with Eclipsys?” I did a lot of work before Eclipsys was formed, I did a lot of work when I was at Superior with TDS. So I had a long experience with that company. When I was at Superior, each of the executives had a vendor they were responsible for. I’ve also had a lot of stuff that I’ve done with Cardinal. I guess the one thing that I would tell you about me that people probably don’t know; when I was at El Camino, IT was a big part of my job, but we were completely outsourced there. I was the only non-outsourced employee at El Camino in IT. IT, while it was a big thing, it probably only took about 35-45% of my time.

The remainder of my time there, I was responsible for materials management, all of our purchasing, central distribution, central sterilization. I did a lot of other stuff, which was very intriguing to me. I learned more about hospital management in 5-6 years I was at El Camino by having direct responsibility for that stuff. That was a lot of fun. I did some neat stuff and I learned about logistics distribution. I actually did some work with MIT. We had two graduate students with their teams come out to do work on our logistics stuff. I think we did a lot of neat things in information technology at El Camino. On the supply side, I think we did some even crazier and neater things. As far as I know, we were the first hospital in the United States to go from a six- or seven-day supply delivery schedule to a three-day supply delivery schedule. We did some neat stuff around that. I learned a lot of that stuff that I didn’t know that I’d ever get a chance to do. I really enjoyed that.

Monday Morning Update 1/21/08

Francisco Partners acquires practice management software vendor AdvancedMD, a pretty good billing and scheduling performer in KLAS.

Charges against a suspect in the 2003 murder of a Cerner sales associate are dropped for police misconduct but will be re-filed, the prosecutor says. The 25-year-old Connecticut-based rep was in Kansas City for a Cerner sales conference, went to a bar and strip club, left to buy cocaine and methamphetamine, and was later shot dead in a prostitute’s bed in a crack house during a robbery attempt, according to testimony.

ZDnet says Misys is one of the “biggest open source health care outfits.” For making one tiny, zero-demand niche connectivity product available, sort of? Either ZDnet drank some purple Kool-Aid or it only takes one product to reach the Big Outfit list in healthcare.

Richard Temple, CIO of Saint Clare’s Health System (NJ) is profiled in Information Week.

GE Healthcare’s Q4 numbers: revenue up 6% to $5 billion, earnings $1.04 billion, down from $1.08 billion. Immelt blames Medicare for lower profits. I’m sure Medicare blames GE for higher costs to taxpayers.

Memorial Health of Savannah will lay off 130 employees in its elimination of 180 positions. They’re combining RT and PT, which seems odd. The president says the level of care won’t change, they’ll just become more efficient. If that’s the case, I’d lay off the management team who waited until now to make it so.

SMDC Health System (MN) bans drug company gifts and hauls off 20 shopping carts of mugs, pens, and notepads. The drug company trade organization, naturally, is horrified at the terrible misunderstanding in which they were cast as anything less than noble. “It’s a bit draconian. But the onus is on us now to do a better job of explaining the job and the importance of marketing representatives. Unfortunately there are a lot of cynics in America who want to think the worst.” Unfortunately, a lot of those cynics are right.

A new CHCF report reviews federal HIT initiatives. Summary: the President’s agenda hasn’t improved HIT/EHR adoption, NHIN is wasted money because it won’t work, EHR certification efforts turned out to be the easiest project, state and federal privacy laws need to be merged into something usable, the government isn’t exerting its purchasing influence to encourage HIT adoption, and ONCHIT isn’t doing enough to get federal support.

MedPlus is chosen as the preferred LIS for the Canadian healthcare system.

Green Bay (WI) hospitals get a mention in the local newspaper for their physician portal project, for which Medicity is the vendor.

NAHIT’s still working on defining those five acronyms (HIE, RHIO, EHR, EMR, PHR) so they’re holding two-hour work group sessions at HIMSS. The press release quotes the chief marketing officer (!) of NAHIT (which they insist on calling The Alliance, which sounds sinister and mysterious) who says the definitions “will remove a major barrier to HIT adoption.” Say, what does HIT mean since she used that acronym? Healthcare or hospital? Is healthcare one word or two? I smell more BearingPoint contracts! And maybe a follow-up study on how the HIT floodgates will open once these five pesky acronyms that confuse no one are put in their grammatical place by big government contractors more than happy to undertake fool’s work as long as it pays well.

E-mail me.

Inga’s Update

Add a couple more products to the 2007 CCHIT certification list. Intergy by Sage and Noteworthy EHR 6.0 by Noteworthy Medical Systems gain approval this week.

The current issue of The Annals of Family Medicine has a report on the state of EHR adoption for FPs in academic facilities. A survey showed that 72% have implemented an EHR and another 18% plan to do so in the next 12 months.

E-mail Inga.

Art Vandelay on Patient Command Centers

I share Jim Stalder‘s vision of a patient command center. I never considered using SNMP and Zenoss as a core engine for communication of information from the devices. Merging Jim’s concept with what I have been thinking for some time, the patient command center is similar to the air traffic control center at a busy airport. The air traffic control center knows who is arriving, when and where they are leaving, and they share status with all the others on the ground and in planes.

My vision is that the patient command center will be a physical or virtual department where traditional admissions, financial folio, bed, transport and discharge management are handled. It will manage service desks for IT, facilities, clinical engineering, and equipment, as well as clinical alerts and data from medical devices and the computerized patient record for singular issues and trended problems. It will monitor throughput bottlenecks, such as ED, OR, and patients ready for discharge.

I had envisioned using real-time location tracking systems (RTLS) integrated with a real-time data store of ADT, orders, billing, enterprise scheduling and results data. Large screens with various real-time reports would be available. Think of this like the status boards for the Emergency Department on steroids. With a complex event processing (CEP) engine monitoring the information, the proper resources could be alerted to the status of the facility, patients, and staff at any point in time via visual queues on the big board, a user-specific screen, or various reports. Alerts could also be sent to the device of choice, i.e., PC, handheld, Crackberry, local mobile phone. Sorry nurses, it looks like there is another job for you to consider – Command Center Czar.

SNMP isn’t that complex. What are the chances of getting the medical device vendors to add this to their devices? It already runs on the private networks and servers they use. In my opinion, the companies to watch in this space are Cerner, with their medical device push, and Philips, with their recent acquisitions. All-in-one vendors like Epic and Meditech are also well positioned with the data their systems have – in theory.

News 1/18/08

From Latka Gravas: “Re: Cerner layoffs. Interesting that this subject was broached prior to Thanksgiving, when the internal job site was taken down for ‘construction,’ not allowing anyone to review possible openings and make a move prior to being escorted out the door. None of this has been handled with dignity and grace by Cerner, as ‘associates,’ rather ’employees,’ were escorted out the door by HR and security. This is from someone who is still employed by Cerner, but observing the action from my office.”

Speaking of Cerner’s layoffs, the Kansas City paper’s website has several pages of interesting comments from readers on that story, including one ripping the company by an Indian associate (you know you’ve stirred people up when the offshore employees are livid). Those severed are planning to connect at Ameristar Casino Friday night at 5:00 for a “We’re Finally Free – No Pity Party” to which all former and current associates are invited. They’re even planning a dramatic reading of Neal’s infamous “tick tock” e-mail (YouTube it and send me the link) which I’m sure all this will give him a few more Pie votes. With the big price drop yesterday, he’s down to $294 million worth of CERN.

From Shiftcycle: “Re: RemedyMD. Anyone every worked for them? Thinking about a job with them, but wanted to hear anyone’s experiences.”

From The PACS Designer: “Re: Web x.0 hysteria. What brings up the Web x.0 headline is TPD recently noticed a website touting Web 3.0. There has been a lot of Web 2.0 stuff, some valid and some not, but we are years away from even beginning to consider Web 3.0 solutions. Since we are only in the first inning of this new Web 2.0 era, be skeptical about anything purporting to be Web 3.0 ready. Instead, HIStalk readers may want to peruse the Oracle website and their Oracle WebCenter offering for Web 2.0.” Oracle WebCenter. PC Magazine’s Web 3.0 overview.

From Curious: “Re: RPP. Anatomical Pathology standards question – does anyone know how commonly RPP is used these days? Is it still in test phase? Will it be commonly used in the visible future?”

From Hillary Flammond: “Re: HISsies. I’m a little surprised that you only placed Picis on positively stated questions within your HISies poll. I’d bet that, had they been a candidate on some of the more negatively phrased questions, you’d have received some more votes for them. I do remain hopeful, however, that their performance and our experience with them will improve over time.” A couple of folks commented that certain vendors showed up only in positive categories. It’s important to note that I didn’t choose the nominees – you did. They’re exactly as nominated by HIStalk readers, with no intervention by me. Good to remember next year, especially for the folks who didn’t nominate but now are unhappy with the nominees of those who did. I re-checked the nominations and Picis got one vote in the “stupidest move” category and one in “worst vendor.” That’s certainly no groundswell among those doing the nominating, considering that companies nobody’s heard of got more than that and still didn’t make the ballot.

Jobs: Manager Corporate Systems, Sales Executive, Data Center Technologies Analyst.

Your opinion: for the HIMSS get-together, would you like to see any particular agenda item? I may have the HISsies announced there. I could maybe get a CEO or two to say a few words, although there’s no guarantee since anonymous bloggers are low on the food chain. Or, we could just eat, drink, gossip, and admire how smart and attractive we all are. I’m picturing Inga like in one of those old movies, wearing a fabulous gown and smiling suggestively as 10 tuxedoed guys eagerly thrust out lighters, jostling to be the one who gets to light her cigarette in its gaudy holder while she throws back her head in self-indulgent laughter at the silly boys who adore her.

For those who care (not me), the Most Wired Survey is open, with a new appendage “& Benchmarking” tacked on, most likely to appease survey co-sponsor and outsourcer Accenture. If you can buy the shaky premise of such a survey, the questions are vastly better than those from years ago, although subject to the same overly generous respondent interpretation. There’s a PDF link at the bottom of the page if you want a look.

Elsevier acquires Florida predictive analysis company MED-ai, finally putting an end to its years of struggling.

Alex Rodriguez, CIO of Ohio’s Health Alliance, leaves to become VP/CIO of St. Elizabeth Medical Center (KY) in a ten-year, $252 million deal. Maybe I’m confusing him with someone else.

Scott McMullen, formerly Misys, joins Medsphere as VP of engineering. From one open source evangelist company to the next, eh?

Sonitor Technologies says it gained more than a dozen new real-time location system hospital customers recently, with 20% of its sales replacing dysfunctional RFID tracking systems. That’s what RTLS stands for, I keep reminding myself, since that’s an acronym on the rise.

Eight Ohio hospitals will use Premier’s SafetySurveillor infection control system. Premier bought Cereplex and that product along with it in 2006, if I recall.

ClinicComp gets an Essentris electronic medical records contract for Landstuhl Army Medical Center in Germany. One interim step is to generate PDFs for inpatient records to share with the VA.

Defense and aerospace contractor Harris Corporation announces the formation of Harris Healthcare Solutions. Bart Harmon, formerly of DoD, was announced as CMO.

Forgot to mention: thanks to AT&T Healthcare and eScription, both of which just upgraded their HIStalk sponsorships to Platinum. Thanks to both companies for supporting HIStalk and, by doing so, supporting its readers. Sponsors provide the money I need to hire fabulous colleagues like Inga, pay server and software bills, give stuff away at HIMSS, and support a worthy cause every now and then. Give the ads a look and click over to those with interesting stuff. It really helps. I was far less jolly when it was coming out of my day job paycheck with mumbled excuses to Mrs. HIStalk about the odd expenditures.

Information Week looks at the cost of health IT projects touted by presidential candidates. Clinton wants $3 billion, Obama says $50 billion. See Harris Corporation item above.

UPMC pilots an internally developed “smart room” program in which patient rooms are equipped with monitors that display medical information.

Arizona surgeons are developing simulated surgery trainers for the Nintendo Wii. Surgical residents who warmed up with a Wii training tool scored better on tool control and performance.

Sun Microsystems will acquire open source database vendor MySQL for $1 billion.

A SureScripts analysis finds that 50 times the number of prescriptions were transmitted electronically in 2007 as in 2004. Allscripts was the most used e-prescribing system.

Bizarre hospital lawsuit: an injured construction worker is told by ED docs that he needs a rectal exam to rule out spinal cord injury. He refuses and hits a doctor who orders him held down so he can do the exam. The patient is arrested afterward on assault charges that are later dropped, but he’s suing the hospital because “he has absolutely no trust in the system at all”, “has post-traumatic stress syndrome”, and is unable to work.

E-mail me.

Inga’s Update

Opus Health Care Solutions names Brad Karagin VP of sales. He previously worked as a sales executive for T-System and, before that, Cerner.

Medicity gets some press in Green Bay, WI, home of Packers’ cutie Brett Favre as well as St. Vincent’s and St. Mary’s Hospitals. The hospitals, along with 11 others in the Hospital Sisters Health System, are implementing Medicity’s centralized medical record repository and physician portal.

Hayes Management Consulting announces their new Technology Solutions business division, along with the appointment of two new VPs. Former IBM associate partner Peter Zazzara is Hayes’ new VP of client services, while Andrew Treanor is the new technology solutions VP. Treanor comes from GE/IDX, where he served as VP of client support and operations.

I went to Sears a couple of weeks ago to buy a dryer (one of those “incidentals” that is never part of the budget.) Who knew that Sears also sells a loaded Linux desktop PC for under $200? Definitely less than my dryer.

Allscripts partners with billing company CHMB Solutions to provide an outsourced EHR and PM solution to CHMB’s 500 clients. CHMB will provide the hosting, support, and implementation services.

The state of Maine is jumping into the IHE arena. More than $4 million has been raised to begin the nonprofit HealthInfoNet. 3M Health Information Systems and Orion Health have been retained to build and operate the program.

Survey update: glad to see most readers are like me and prefer free stuff (you can never have too many pens or bags) and invites to an event (I still have some open spots on my dance card) over attractive reps. Also tied for the lead is cool demo technology.

E-mail Inga.

Clinical vs. Clerical Systems – Why FDA Software Regulation is Inevitable

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

Most hospital information systems are old. Faded pictures of the original system architects feature bushy-haired guys wearing plaid pants, wide ties, and CPO jackets. Given their unfortunate fashion sense, it’s not surprising that their precognition of today’s healthcare environment didn’t include having physicians and other clinicians use their creations directly. The goals of information technology were simple: capture charges, batch-bill the heck out of Medicare and Medicaid, and maybe provide a simple order entry function.

Today’s so-called “clinical” systems mostly sit on that antique and unsuitable foundation, outdated not because of old programming languages and hardware platforms, but because their original design mindset is now hopelessly obsolete. Clinical applications are really just green-screen type data entry forms that happen to accept clinical information. It’s the mainframe mentality at its worst – the all-knowing system that requires regular data feedings from subservient users who, despite their occupational disposition, are relegated to data entry clerks.

Eventually, some company will actually design a new system from the ground up. We can fervently hope that when they do, they’ll start with a blank slate and not simply port outdated, monolithic thinking to a newer technology platform. With that innovation, though, will come the crossing of a huge chasm: the no-man’s land between “information systems” and FDA-approved systems.

Clinicians gripe that clinical systems are user unfriendly, do little to help them perform their jobs, and add little value to personal productivity or patient outcomes. They’re just accounting systems dealing with clinical widgets. One reason: HIT vendors are terrified of FDA regulation. It’s easier to make sure systems are too dumb to require it than risk exposing sometimes bad software practices to government oversight. No wonder our clinical systems are substandard.

Clinicians are overwhelmed by too much raw data whose presentation can’t be individualized, i.e. don’t insult bone marrow docs with low platelet warnings. That picture that’s worth 1,000 words can’t be included because 1980s-era programmers didn’t see cheap multimedia and storage coming. Systems deliver data like an obedient mailroom clerk, with equally unimpressive value added.

It’s like Lucy working on that candy assembly line – reams of often irrelevant information is unceremoniously dumped in the laps of physicians and nurses, who are expected to manually figure out what’s relevant and then “process” it, often by entering even more on-screen information. Eventually, the administrivia buries someone who ought to be making patient care decisions instead of romancing a keyboard.

IT vendors have good reason to fear the FDA, who won’t be happy to hear about buggy code, poor testing practices, slow updates for known defects that have clinical implications, and head-scratching user interfaces that merited no more than an afterthought. Maybe that level of scrutiny would slow development and increase costs, but accepting possibly dangerous software as long as it’s fast and cheap (both debatable) doesn’t seem like much of a bargain.

A smart clinical systems vendor would build FDA approval into their long-term plans and build killer applications around it, thereby scooping their competition by years. Redesign the first-generation systems, step boldly into the FDA-regulated space before the device vendors instead step over into the IT space, and build systems that improve patient care, not just caregiver data processing skills.

Today’s software was designed around old constraints and its design shows it. Clinicians should get together with no programmers in the room and design the systems of tomorrow. Clinical systems need to interrupt the care process less and enhance it more. Doing that right will require FDA approval.

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 1/16/08

From Stanley Twanger: “Re: career move. If anyone has advice on moving from academic medicine to the corporate world, I’d be happy to hear it.”

From Neal’s Dog: “Re: Cerner. Cerner is letting VPs and directors go in an effort to trim the executive level roles and put more associates on the front line.” It’s hard to be against that action unless you’re one of those axed. Unlike some companies, Cerner at least waited until after the holidays (they surely planned this well before). The stock’s down 8% on a day when the market dropped 2.5%. Earnings are out in a couple of weeks. The Kansas City Star reports 97 jobs cut, with a total of 152 positions eliminated. In my experience, you can’t fault a company for a one-time layoff, as long as they handle it professionally, with dignity and sensitivity toward those let go, and after exhausting other options. In other words, it needs to be as distasteful to management as it is to employees, to the point that no one wants to do it again. Condolences to those affected, for whom it’s a cold, frightening winter’s night.

Julie Wilson, Cerner’s Chief People Officer, sent this to me through a high-ranking Cerner friend of HIStalk: “As HIStalk readers will see from my comments in the attached coverage, ‘Cerner continues to anticipate growth at our locations worldwide’ and is ‘actively recruiting and hiring at this time.’ We currently have dozens of roles posted on cerner.com. We have 45 new hires in orientation classes this week alone. Ultimately, these new associates will share the same goal as our more than 7,500 current associates: value creation for our clients. And as we deliver, it will have positive implications for ongoing growth and future job creation here at Cerner.”

From Danny Noonan: “Re: HHC. I can verify that they’re looking for a QuadraMed CPR replacement. They’ve hired a guy to evaluate vendors. There’s a big disconnect between management and users. They’ve built some cool stuff that’s better than the mess that they paid Misys to develop. The customizability is a plus and the back end is stable. Instead of paying $10 million to bring in some programmers, they’ll spend $500 million (at least) to buy a new product. Almost every CMIO and CIO in the corporation wants to stay the course, but the central office seems to be set on the new vendor route. They’ll lose the local control that has led to many impressive applications.”

From GE Insider: “Re: interview. Wow! Not sure how I missed this interview initially, but what a crock! I used to work on the IHC project. When it ‘goes live’ in a few months (and I hear it’s not even code-complete with a go-live date of March 08), it will be attached to the IHC back end (the HELP system). So, for all of their investment, all IHC will have to show for it is a new UI. Just now are they starting to plan for the new infrastructure and in the future, you’ll completely have to throw away your IDX solution and drink the new Kool-Aid. Already IHC is getting tired as they have instructed employees to discontinue some of their content work until they can reevaluate. Eventually GE will get tired of all of this, and when they’re not getting new sales, and they’ll bow out, leaving IHC holding the bag.” Just to be clear, this isn’t verified (but it’s interesting).

New text ad to your right: Medziva, which has an SaaS-based clinical lab collaboration platform, is seeking companies interested in making a cash or equity offer.

I see a company or two is encouraging employees to stuff the HISsies ballot box. That’s OK – that happens ever year. Since I can’t stop it, I have fun with it. There could be some surprising results (who’ll be wearing The Pie in a few weeks?) Statistically valid or not, it’s fun. I’m still considering making the official announcements at the HIMSS get-together, putting them online nearly simultaneously. Please vote just once because I have to pay by the response if it goes over 1,000.

Listening: L7, foul-mouthed, all-female punk metal, now disbanded. The second video down shreds it. My new favorite drummer.

David Starr joins Queen’s Health System (HI) as CIO, coming from BearingPoint.

The Fort Myers, FL paper has a good article on Lee Memorial’s implementation of Epic for its physician group.

Dennis Quaid goes public with his complaints about Cedars-Sinai, saying family members didn’t hear anything until a gossip website broke the story on their heparin overdose, which he believes a hospital employee leaked. The hospital’s now going after presumed HIPAA violators.

Jobs: Director of Outpatient Clinical Systems, Manager of Clinical Support Systems, Director of Sales, HL7 Integration Expert.

This seems like a really bad idea: a Pennsylvania start-up records the examining room conversations between physicians and consenting patients, transcribes and de-identifies them, then sells the recordings and transcripts over the Web to drug companies. The docs get paid and the patients are told the recordings support “medical research.”

For the other side of the coin, see No Free Lunch: Just Say No to Drug Reps, a non-profit started by a New York doctor. ” … the doctor-patient relationship … is a fiduciary relationship … Patients rightly expect their physician to act in their (the patient’s) best interest. Patients do not enter the examining room caveat emptor. Patients should be confident that the drug being is prescribed is the best, the most cost-effective, not the best promoted.”

The Houston Fire Department is implementing software that will direct ambulances to the least busy hospitals.

E-mail me. It makes my day, even though I’m just buried and may not e-mail you back anything other than gibberish. It’s interview season, so look for new ones soon.

Inga’s Update

I think Mr. H has found an even better give-away option than rejected vendor trinkets for the Healthia-sponsored HIStalk party. In light of Hollywood writer’s strike and canceled Golden Globes bash, he worked his connections to get all those extra swag bags donated for our faithful readers. I personally can’t wait to get my eyelash-strengthening serum, pearl necklace and Croton watch.

Special note to Pokenoke who suggested I might not (!) be female. Be assured, this cougar is all woman!

CSC is told to pay the NHS £5m in penalties for late delivery of patient administration software.

Quest Diagnostics HIT subsidiary MedPlus wins a contract to implement a clinical portal and information exchange for the Brooklyn Health Information Exchange.

I think I may be in love. Peter sent me this lovely note: “Booth babes are like when they give away free key chains. Initially they are attractive, but you find out later that they aren’t really useful and they get in the way. Spoken like a true fan of the mature woman …”

CSC’s acquisition of First Consulting is now complete. All $365 million of the purchase was in cash.

Beth Israel Deaconess selects Concordant to assist them with building and managing their EHR infrastructure for up to 300 practices.

Aetna donates $500K to UC Davis Children’s Hospital to expand its PICU and telemedicine functions.

Dublin Methodist Hospital opened its doors last week with an all-digital setup with McKesson’s Horizon Clinicals throughout.

Emerging healthcare market trend: cellulite treatment. Since 85% of women have cellulite, it’s no wonder that medical device companies are scrambling to enter into this estimated $3 billion (!) “cosmeceutical” market. (I personally blame it on booth babes! OK, I admit I’m obsessed with them, but not in the same way you guys are!)

Fallon Community Health Plan in Massachusetts selects Trizetto’s QNXT enterprise admin system and application hosting services.

SureScripts announces that Allscripts eRX NOW and TouchWorks have achieved GoldRX advanced product certification for 2007, meaning they really work. More specifically they have “gone beyond SureScripts baseline product certification to establish a proven track record in pharmacy interoperability.”

Health Affairs announces the results of new study of ED wait times and documents increases of more than 4% a year from 1997 to 2004. It’s really bad news if you had an acute MI because your waits increased over 11%. Blacks, Hispanics, women, and patients seen in urban EDs waited longer than other patients did.

Docusys signs a letter of intent to buy surgical planning software vendor Prompte. Docusys has had an exclusive marketing agreement with Prompte for the last two years.

A reader sent me a note saying he’d heard that athenahealth might have performance issues with a high number of users. I checked with the folks there, who gave this response. “We have the same stacking architecture as eBay and Amazon and have thousands of providers billing, ordering labs, and prescribing on the system daily with approx 35k daily users on athenaNet. There is only one instance of the application and we put out new versions 6-8 times a year automatically. The athena network is supported by hundreds of people that are athena’s virtual back office. Our infrastructure can currently exceed 4x its current volume and will increase when we open our new operations center in Maine.”

E-mail Inga.

CIO Unplugged – 1/15/08

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

Faces: The Toughest Aspect of Being CIO
By Ed Marx

In answering an often asked question—what is the most challenging part of being CIO?—several dated situations came to mind. Losing a data center when the electric grid went down in the northeast. Personnel matters. Providing champagne service and applications on a beer budget. The weight of my responsibilities while knowing patient lives are at risk. Facing down angry physicians. A multi-million dollar project gone bad. These situations ranked as tough, but not toughest.

I think back to Zarema, a woman on the staff interview panel when I came through as a candidate. While her peers tossed softball questions at me, she played fast pitch. I loved it! I respected her glasnost approach and assertiveness. A recent immigrant from Russia, Zarema spoke with a thick accent and held to cultural mannerisms that sometimes clashed with our health system’s progressive environment. Nevertheless, as a tireless and productive employee, she evolved into the go-to person of our division.

Before I left that division and eventually became CIO, Zarema confided in me that she was ill. I stayed abreast of her condition. She was very private, but over time, she received my prayers and support. Then, one day, I got the call. Disease had stolen her life. I lost an exemplar employee. Despite being sick, she had demonstrated how to strive for excellence, for she never settled for less than 100% on her yearly review.

“I still see your face, Zarema.”

A couple of years later, our IS Division underwent an incredible transformation, and much of the progress was attributable to our Field Engineering Team. We suffered “ticket tennis” issues, meaning service requests were lobbed between internal teams while the customer’s needs remained unmet. By combining the silos of Desktop Support, LAN Admin, and Network, we adopted a Field Engineering concept that encouraged and rewarded collaboration, which resulted in higher velocity and customer satisfaction. Dale was one of our young field engineers and a solid performer. Outside of work, he engaged in another passion: his motorcycle. One morning, tragedy came at him fast, and he was killed while riding his cycle to work. That week, the funeral was packed, and the majority of our field engineers joined me in attendance. Listening to them share words of support to the grieving family I gathered morsels of this man’s passion and added them to my treasury on life.

“I still see your face, Dale.”

I recall “Bill,” the husband of one of my direct reports, taking ill. After a few days in the hospital, his wife told me that he had tired of cafeteria food. (Imagine that!) My son and I snuck tastier cuisine past the nurse station then hung out for a little bit and prayed with him. His death devastated me, as he left behind an infant daughter and a young wife. He was brave; he fought hard. And he reminded me how life was too short to not live it abundantly.

“I still see your face, Bill.”

Most recently, another member of my division passed away suddenly. I regret, given my short tenure, that I did not have the time to get to know “Maggie.” Co-workers shared that she was a dedicated employee and a wonderful person, someone I would have appreciated. During a moment of silence at an all-staff meeting, I studied this woman in a picture on power point. I imagined visiting her at her desk, and I wondered what wealth of character I might have gained from knowing her.

“I still see your face, Maggie.”

So what is the most challenging experience as CIO? Identifying with tragedies that befall my department: lives taken prematurely; the impact of death and disease on families and communities. A good leader will morn with those who morn and rejoice with those who rejoice. I have attended many wakes and funerals to console grieving staff who lost children, parents, grandparents, spouses, and other loved ones. I have kept some in my contacts and scheduled their birthdates to chime annually on those bitter yet beautiful days.

I still see their faces.

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

Monday Morning Update 1/14/08

From Kim Chi: “Re: QuadraMed. They are losing people by attrition, layoffs, and cutting CPR development. Word has it Health and Hospitals in NYC decided to look for another solution.” Unconfirmed and assumed incorrect unless someone wants to go on record (anonymously is OK). I’m always cautious about specific rumors involving publicly traded companies, although this one comes from a good and historically reliable source.

From Abigail Papshmir: “Re: Is this El Camino story highway robbery or what? They screw it up with a flawed and now-defunct system, then offer to evaluate the mess for millions.” Link. Eclipsys, which sold El Camino Hospital an interfaced Sunrise to Meta Pharmacy solution since abandoned in favor of Sunrise Pharmacy, says they’ll evaluate the hospital’s medication ordering situation for $3.4 million, requiring 16,000 consulting hours to do so. The end result will be “recommendations and training.” The original implementation, along with some underlying process issues, nearly caused the state to shut the hospital down when its medication error rate tripled. The hospital had outsourced the entire IT department to Eclipsys, I believe, with only the CIO as a hospital employee. The hospital says it needs another $6.6 million for pharmacy system upgrades this year. That’s $10 million, plus the original $8 million that Sunrise cost, plus a previous $2 million in upgrades planned in 2006, plus the cost of outsourcing the pharmacy to Cardinal that was required to keep CMS from padlocking the doors. That’s one expensive medication management system for a 400-bed hospital, especially considering that it still seems dysfunctional judging from this latest decision.

From Wilma Nordberg: “Re: One Laptop Per Child initiative. Intel has pulled its financial support.” Link. Intel joins Microsoft in boycotting the project, which hopes to give the world’s poorest children inexpensive laptop PCs. An Intel salesperson tried to talk Peruvian officials out of buying the nonprofit’s cheaper PCs, which come with AMD chips and open source software, in favor of the company’s own proprietary product. Maybe Craig Barrett can get involved since he thinks he’s already got healthcare figured out.

From Inside Outsider: “Re: Dennis Quaid. All I can say is – NO WAY! He has every right to be outraged and he should be outraged. The simple fact that hospital errors kill people all the time is not a good enough reason to say that the damage done to his kids should not be considered a bad thing. Yes, death is worse than maiming or brain damage or temporary damage, but the day that we look at it as acceptable is the day that we should get into another business. Just my two cents.”

From The PACS Designer: “Re: WiserWiki. TPD has discovered a new free wiki called WiserWiki by Elsevier. Only board-certified physicians can post. TPD browsed cardiovascular disease,diabetes, and COPD and found significant detail. It would be a nice complement to a PHR that would give it precise health information from prominent physicians.” Link.

HISsies voting is open. Thanks for your nominations. Time to vote … now git. I was serious when I said that Inga led the nominations for industry figure of the year, so you can congratulate her even though I didn’t include her on the ballot.

Listening: Big Elf. Black Sabbath meets the Beatles.

eScription earns 2007 Best in KLAS for its #1 ranking in Transcription and Back-End Speech Recognition for the fourth consecutive year.

Jobs: IT Manager, Product Manager, Web Developer. We’re getting lots of hits at HealthcareITJobs.com, so sign up for weekly e-mail updates of new listings.

Speaking of job listings, HIStalk sponsor Intellect Resources has quite a few their site. They’re also listing on HealthcareITJobs.

Delano Regional Medical Center (CA) and Sentillion get mentioned for the hospital’s single sign-on implementation, which it says boosted business because doctors are now willing to use its Meditech, Dictaphone, Cerner, and GE systems instead of sending patients elsewhere because of complexity and the myriad of passwords formerly required.

A former St. Cloud Hospital (MN) programmer pleads guilty to putting a logic bomb in a training program he wrote for the hospital. The code activated after he quit in June 2006 and trashed his program. He probably thought he was pretty darned clever until the FBI’s cybercrime unit came knocking on his door, for which he’s now facing 10 years in federal prison and a $250,000 fine. Doh!

Stratus Technologies is offering (warning: PDF) a free “Fault Tolerance for Dummies” book.

CraneWare announces software that links pharmacy purchasing to CDM pricing.

Missouri’s governor wants $15 million for a Web-based electronic health records system for MO HealthNet, which I think is a cute marketing name for Missouri’s welfare program.

Odd lawsuit: a Canadian drug addict wins a negligence lawsuit against her former drug dealer for getting her hooked on crystal meth and causing her hospitalization for an overdose. “”I sued him for negligence … for selling me (illegal) drugs and getting me hooked when I was vulnerable”. The dealer’s defense said the woman “voluntarily consumed illegal drugs, thus contributing to her own condition. She assumed the risks.”

Sutter Medical Center lays off 49 employees and cuts back on housekeeping services after its divisional profit drops to $111 million. It blamed that financial crisis on salaries and technology investments. Why didn’t they invest in technology that pays for itself instead of laying off janitors? You may recall that its Epic implementation will price out at $500 million or more. They even hired a “transformation vice president.” (Note to providers: any time anyone mentions the word “transformation”, do that little “make a cross with your fingers to repel vampires” thing and run for the hills. All that will be transformed is your money into someone else’s.)

An HHS/OIG report blasts the capability of physician-owned specialty hospitals to handle medical emergencies. The investigation came after two patients died following elective surgery complications when no physicians were in the building. Both hospitals called 911. Findings: less than one-third of specialty hospitals have a physician on site at all times, some had neither physicians or nurses present on some days, and two-thirds include calling 911 as part of their emergency procedures.

San Antonio Community Hospital (CA) gets local coverage for its use of scribes to follow physicians and do their paperwork. It’s the anti-CPOE solution, variants of which I’ve advocated here on occasion.

E-mail me. I’m a busy boy, but I read every e-mail even though I can’t always respond. Thank you for reading.

Inga’s Update

Special thanks to the (female) reader who sent me a note with her opinion on booth babes. “While I’m not a fan of putting a younger, thinner, cuter version of myself in my booth to draw traffic, I’m not proud.” It was such a spot-on comment! While the guys might love the eye candy, it serves as too much of a reminder for us “former” 22-year-old babes that perhaps we’re past our prime! (This is when all you mature guys can send me notes telling me how you much prefer your women to be worldly and a bit more mature).

Meanwhile I have been glued to the latest survey to see what attracts you to HIMSS booths. I’ve been happy to see “free stuff” and “cool technology” pull ahead of “attractive representatives,” proving that not all our readers are as shallow as Mr. H predicted.

As Mr. H noted earlier this week, we have some great new interviews on tap for HIStech Report, just in time to pique your interest about some of the more innovative companies exhibiting at HIMSS. Coming soon: chats with McKesson, Sage, and QuadraMed, to name a few.

E-mail Inga.

News 1/11/08

From Rogue: “Re: HIStalk get-together. Thanks, Healthia. I propose the price of admission be a wrapped/bagged trinket from your vendor company or organization —  a go-live t-shirt, hat, pen, stress ball, Post-It pad, or whatever logo item you have lots of. (And Mr. HIStalk can get rid of the bag of last year’s leftover buttons, too). Drop yours in as you arrive, take one home as you leave. Something fun to talk about later. Maybe a couple vendors will seed the grab bag with a neat MP3 player or two. BTW, the Communities open house is Monday night until 6.30 pm, so I’ll be late. And isn’t the Chapters Open House night on Monday traditionally since Tuesday is the awards dinner and Wednesday is the Universal Studios event? Stagger from one open house to another. Maybe I’ll be lucky and they’re all in the Peabody. Do we use our real names when we RSVP to keep our blog pseudonyms secret?” I like the swag idea, a modified Christmas party idea where you bring a wrapped toy. Would anyone do that? I know there will be conflicts with the time since every HIMSS event is either Monday or Tuesday night, so we figured making it 6:00 to 8:00 would allow hitting the big blowouts afterward (we know our place in the universe). I think you’ll want to use your real name on the RSVP, but we can try to guess each other’s secret HIStalk identity. Inga and I will be undercover most likely, so we can all play.

From Animal Mother: “Re: temper your envy. There is certainly a happy McK rep – or reps, actually – but no one is retiring. McK has a 27-page comp plan: one page on how to earn the money and 26 on how to actually get it. There’s a cap of around $300K on the commission will be paid out in total for any one contract, even if there are three, four, or five reps on the deal. Then you start the clocks on what will be paid when, based on the deal. The result is that the McK retention plan holds around $50-100K from the performing rep. The comp plan is the #1 reason reps leave and leave the money behind. It’s a monthly slap in the face to see that the largest number on the commission statement is the money you don’t get.”

From Willem Seminole: “Re: your free research. I got an e-mail update from [magazine] and it’s obvious they’re just writing up the news you’ve found. Some of your links from Tuesday were obscure and, what do you know, they covered those stories like they found them themselves.” I know. Adds to my legend.

From Leonard Pratt: “Re: ECG. I heard a rumor that ECG, the company that owns CHIMES, shut its doors yesterday. This is third-hand info, but I thought I would see if you heard anything about it.” I assume this is the contract worker firm. If so, yep, they’re toast. Ensemble Chimes Global was a subsidiary of Hollywood payroll services Axium International, which filed bankruptcy and tied up lots of payroll deposits this week when it defaulted on a $140 million loan.

From Lumpy Rutherford: “Re: Allscripts. This was posted on the MDRX message board: ‘Allscripts announced to customers yesterday that they’re halting all further upgrades and installations of version 11.0 and waiting until 11.1 can be released. This is in response to massive technical problems in v11.’ Any truth to this rumor?” According to my internal source, it’s not true. Lots of folks are already live on v11 (some upgraders, some net news) and v11.1 will GA in a few weeks.

From Eightball: “Re: athenahealth. Word is athena’s big win at Harbin was an IDX install and Allscripts lost out.” Here’s an announcement of their 2002 TouchWorks intentions, anyway, so it seems likely.

I’m not naming names, but a reader was looking for some help and someone from HIMSS stepped forward. Enough said, other than thanks.

Listening: Maeder. Also: Zebrahead.

Last chance for HISsies nominations. We have a couple of frontrunner disqualifications already, namely me in the “HIS industry figure with whom you’d most like to have a few beers” category and Inga in “HIStalk HIT Industry Figure of the Year.” We appreciate the support, but we’ll keep it honest. And to think I had my beer alone today while watching a Gilmore Girls rerun and waiting for Mrs. HIStalk to get home. We’ll have no remarks about Inga’s figure, please.

Jobs: Web Developer, PathNet Architect, Senior Account Executive, Epic Consultants.

McKesson claims to be the first vendor to GA software for the Intel C5 tablet PC. Says it will support Admin-RX barcoding, which could use some improvement.

Verispan announces availability of a database of retail clinics.

Jay Miller, president and CEO of Vital Images, resigns (with someone else’s hand firmly forcing his signature on the resignation letter, no doubt.) The guy he hired as COO will take his job.

I haven’t mentioned them in awhile, so here’s a plug for The Revere Group, a big hitter in providing Microsoft services to healthcare providers. Thanks for sponsoring. Ditto for MedMatica Consulting Associates, a fine source for experienced healthcare consultants.

Midwest Regional Regional Medical Center (OK) goes live with SafeScan medication barcoding.

And speaking of a potential SafeScan client, Dennis Quaid is really peeved at Cedars-Sinai now. He found that his twins got two heparin overdoses each, not just the one the hospital told him about. Not to belittle DQ since I’m a fan of his Right Stuff work, but Dennis … hospital mistakes kill patients all the time, unfortunately. Your kids got protamine and are fine, with no lasting consequences. I know actors are self-centered and all, but leave the outrage for someone looking at a headstone instead of healthy, happy babies. Go ahead and sue since that’s the American way, but remember how it could have turned out. Start a foundation or something for those not so lucky.

Speaking of positive ID technologies, Mercy Medical Center (AR) will implement a state-of-the-art RFID scanning system. In its gift shop, along with Camille Beckman lotions.

FCG’s shareholder merger vote on its CSC acquisition forges ahead. The court told a couple of legal firms that always file shareholder class action suits to stick it. Surely no one with any shred of sanity thinks FCG could do better.

Washington Hospital Center, fresh off selling Azyxxi to Microsoft, apparently will turn its ED into a mini-HIMSS, with its technology vendors running around with reporters for the launch party … errr,  “unveiling,” as the press release says. Somebody keep those unsavory patients out of the camera shots, please.

In the UK, a passer-by finds a bicycle courier bag in the street that contains sensitive lab results. He turns them over to the local newspaper, of course, since people who find medical records always seek a media outlet instead of just giving them back.

The remains of shuttered practice managment vendor AcerMed are bought for $500,000 by a newly formed subsidiary of an ophthalmic sofware vendor. Former AcerMed CEO Michael Bina is brought on as CEO of the new Abraxas Medical Solutions, Inc., along with seven other former employees. Could be good news for practices who figured they were stuck with an albatross.

Elekta AB is negotiating to buy CMS, Inc., a St. Louis radiation treatment planning software vendor, from its private equity owner.

Former Summit Medical Systems execs form clinical trials software vendor MedNet Solutions.

Mayo Clinic and IBM announce formation of The Medical Imaging Informatics Innovation Center, whose bulky and voluntarily chosen name is helpfully pushed as MI3C, which they might have picked upfront if it tickled them so darned much that they immediately started using it instead of the real name.

Cleveland is a healthcare investing hotbed, although the local paper doesn’t mention Cleveland Clinic’s doctors who have been caught running up patient tabs for medical devices and treatments produced by companies in which they have a financial interest.

Sounds interesting: a new documentary investigates the massive doping of American children with ADHD drugs. “Ethics, or as Miller reveals, the lack of such, is a central theme of the film. As he investigated the culture of medicine, the producer was shocked to learn that a vast majority of psychiatric drugs being prescribed to millions of children worldwide have never been proven safe and/or effective for the very conditions they are purported to treat. In fact, he uncovered a pattern of collusion between drug manufacturers and their regulatory watchdogs at the FDA, who literally hid evidence of suicidal thoughts and violent acts long before these drugs were approved for the marketplace.” Maybe he should offer CME and a free lunch.

The new drug benefit increased Medicare’s costs by 18.7% in 2006, now up to over $400 billion. Demanding boomers should be able to bankrupt the entire country in a few years at that rate of increase.

If you read this snip out of context, would you guess the article is about EMR software developed by a doctor in Viet Nam? “Medisoft makes things too explicit. Even one dong cannot be concealed. Perhaps that bothers some people.” Maybe it’s just me.

E-mail me.

Happy New Year – Now Get Back to Work

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 January 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Happy New Year! Considering the alternative, be glad that you were alive and well enough to eat and drink too much over the past couple of weeks. Now get back to work!

You’ll notice your local newspaper, having slyly given many of the real news staff time off for the holidays, is padding out their already-slim editions with time-insensitive material written in advance or copied off the wire services: witless phony New Year’s resolutions for local politicians, tired rosters of the biggest local stories and celebrity deaths of 2006, and pleas for donations to community causes.

I can see why. Healthcare IT news is sparse this time of year. No one wants to bring out new products, start implementations, hire or fire people, or make changes in the strategic plan when no one is paying attention (hmm: that would actually be good time to announce bad news, wouldn’t it?)

If our industry was a sport, the season would actually begin at the HIMSS conference in late February. It sets the tone for the year to follow, as everyone saves up positive announcements to coincide with the annual bacchanal. Vendors who make a bad impression at HIMSS will find it difficult to recover throughout the year, with attendees critically evaluating their demonstrations, booth size, staff attire, and cheery spirit or lack thereof. Even those companies in imminent danger of collapse spend the equivalent of a small country’s gross domestic product on one glorious, go-for-broke HIMSS splash, hoping against odds to get their money’s worth in new business.

Hospitals, too, get busy after months of letting IT projects lie fallow. No wonder ROI is hard to come by when projects come to a screeching halt because of non-IT staff refusal to get involved during (a) the November to January holiday block; (b) summer vacations; (c) school spring breaks; (d) impending JCAHO or state inspection visits; and (e) local, state, or national conferences involving anyone remotely involved. No wonder implementations take forever – they’re on hiatus half the year.

CIOs have plenty of work to do. All those clinical systems projects still need to be finished. Celebrate the completion of major phases with some downtime and reflection, don’t forget to keep pushing at needed process changes and system improvements, and then jump into the next round of work. Clinical systems projects are like painting the Golden Gate Bridge: they’re never finished.

Speaking of clinical systems, if you haven’t yet made a commitment to bedside barcode verification of medications, then now’s the time. Same, too, with tightening up your Pyxis access with biometric security, override vigilance, and double-checked stocking procedures.

Microsoft has a new operating system and Office version – yay! Users will be upgrading at home, scornfully wondering why your IT department is holding them back in the Stone Age with systems they shamefully underuse anyway. You needed that non-strategic headache, right? At least PC hardware keeps getting cheaper, right about the time Vista will eat up more of it.

RHIOs will want your attention in 2007. Your data, too. Maybe now’s the time to catalog all the electronic data elements you have available and to develop a plan to move important paper-based ones to electronic formats.

If you haven’t already, let one of your computer geeks play around (officially) with Linux, both server and desktop. If you aren’t running it at all now, you will be soon.

Stark relaxation means you may need to support a new class of impatient, computer-illiterate users: doctors in private practice and the inconsistent employees they hire. Keep stats to get budget dollars since those support hours have to come from somewhere.

Lastly, if you’re in management, please make sure to recognize and reward those who work for you. When you get too full of yourself, make a list of which essential personnel would be needed in case of system failure, natural disaster, or clinical emergency. You’re probably not on it.

I hope our industry and all of us working in it have an excellent 2007. If in doubt about a particular course of action, remember WWIWAAP (which you may pronounce WEE-WEE-WAP, since I just made it up): what would I want as a patient?

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 1/9/08

From James Ballard: “Re: checklists. HHS’s ruling on the checklist issue is a perfect example of the loss of common sense caused by excessive regulation. If we call the documentation of the checklist a ‘Nursing Intervention’ and we then call the study a ‘Chart Review’, the Joint Commission would be singing our praises for an effective quality improvement initiative. I can’t help but wonder if I was breaking the law during most of the chart reviews I was asked to take part in.”

From Mac MacGuff: “Re: checklists. Check the credentials of the person the Bush Administration put in charge of the Office for HUMAN research protection (Acting Director). You’ll find he is a veterinarian. Apparently human protection has gone to the dogs. It appears there’s a new acting director now, but I don’t know his background.” Bet he’s driving improvement guru Peter Provonost through the woof. Sorry.

From Sam: “Re: Greenway. I was contact by Greenway Medical about a position. Do you know anyone who worked there or anything about the company?” I’ll need some reader help here since I know next to nothing.

I heard from Mike Quinto and others with clarifications about a reader’s comment involving Mike’s new CIO job at Applachian Regional Healthcare System. Mike says he’s not the only one who sold Affinity deals during his time there, although he was the big gun (he didn’t say it like that, but I spiced up the wording since I always picture sales guys as swaggering former jocks who talk that way). He also mentions that this particular ARH is not the one I was thinking of in KY and  WV — it’s a three-hospital group in Boone, NC (I gave him a barbeque joint tip since that’s one of my core competencies, but he’d just been there the night before).

From The Shelton Shadow: “Re: PACS in NPfIT. Word has come that the PACS installation in the UK has reached conclusion. The positive responses from users are starting to roll in, with many reporting faster processing of patients and quicker access to image files, thus saving money. Another key decision was made by Philips Medical to exit the installing of any further PACS for radiology in the UK, leaving the potential future business for Sectra and others to pursue.”

Mark your HIMSS calendar for Monday evening, February 25, from 6:00 to 8:00 at the Peabody Orlando, right at the convention center. It’s the first ever HIStalk get-together, unbelievably sponsored by the cool folks at Healthia Consulting. This will be first class in every respect — food, drinks, and who knows what else. I just about fell out of my chair when Shawna from Healthia sent me the menus, which just happened to include costs (I’m parsimonious), but they graciously volunteered to make the arrangements and spend the bucks to support HIStalk’s readers. Details to follow (including an online RSVP page so we can reserve those $7 Peabody shrimp, which is about what I pay for one of those barbeque dinners I mentioned). If you’re an outgoing sort, I may need some “ambassadors” to mingle on HIStalk’s behalf (I’m considering hiring cheery booth babes and boys, which even Inga thinks would be fun, although I’d be too embarrassed to have Healthia pay for them).

Speaking of booth candy: I put up a new poll to your right, playing off Inga’s earlier question. What would draw you into a vendor’s booth if you otherwise had no particular interest? I se that “attractive representatives” is doing well, so it’s not just me.

Houskeeping stuff: check the Healthcare IT Stocks page, which displays current (well, delayed 15 minutes, anyway) stock prices of some bit HIT vendors. Also, the Best Practices question is still open, with good feedback from readers about their choice of project tracking and communications tools. There are new text ads to your right — thanks to Dragon Medical, CodeMap, and Patient Placement Systems for supporting HIStalk. And, time is slipping away to get your HISsies nominations submitted, joining 137 of your colleagues so far in deciding who will be on the ballot shortly. I was thinking of unveiling the HISies winners at our Orlando soiree, although that may take more organizational skills than I can muster. Wouldn’t it be cool to have The Pie winner show up to accept? Unlikely.

Nearly 200 jobs are listed on HealthcareITJobs.com, including listings from QuadraMed, Partners Healthcare System, Intellect Resources, and DocuSys. Employers can post jobs at no charge for a few more days.

Listening: Chevelle.

My editorial in tomorrow’s Inside Healthcare Computing electronic update: “RHIOs 2.0 Dying Uglier Deaths than 1.0,  but Hardy Survivors Guarantee Another Round.” I might surprise you with my tiny, guarded RHIO optimism, including this comment about my previous posture: “I was a real buzz-kill, raining rational thinking onto the frenetic, obedient parade of RHIO trough-lappers.” I notice today that Marc Overhage has an editorial in the Indianapolis paper, although he isn’t unbiased like I am since he runs a RHIO.

American Radiology Services Inc. will be sold by its buyout owners for $151 million to CML HealthCare Income Fund. Johns Hopkins owns a big chunk.

Cerner, Microsoft, and Spectrum Health (MI) will partner to develop the Cerner Care Console, one of those combination clinical/entertainment systems that companies keep trying to sell. Cerner’s version will include an Xbox 360, patient-physician communication, patient schedules, surveys, and hospital propaganda.

McKesson signs a big deal with Community Health Systems (TN) that includes its physician portal, EMR, and clinical systems in over 40 hospitals. There’s one happy salesperson out there somewhere who will eventually pocket a fat commission check (How much, since I’m an incentive-free provider sider? A million?)

Provena Health signs up for Misys EMR, Tiger, and Homecare.

Lonnie Johnson joins Zotec Partners as COO.

Goldman Sachs puts money into portable clinical information vendor Epocrates.

The DoD wastes so much money that another $4 million and over 100 employees for a “Military Interoperable Digital Hospital Testbed” doesn’t register, even when it’s in that high-tech haven of Johnstown, PA and paid out to Northrop Grumman. Still, you have to guess this announcement is a lot more about federal pork than technology.

Former Amicore president Richard Noffsinger is named CEO of SafeMed. I couldn’t figure out what they sell from the lofty-sounding press release, but it’s something to do with health analysis and it brims with buzzwords: actionable, empower, architect, etc. According to my trustworthy Bullfighter software, “Diagnosis: You like to hear yourself write. Despairing of the thought of bringing a sentence to a close with something as demeaningly ordinary as a simple period, you shower readers with gratuitous, interminable and often weighty if not impossibly labyrinthine prose. Meaning lingers, albeit awash in a thick tide of metaphor and exposition that threatens to drown the writer’s message. Seek help.” I didn’t think it was that bad, but I don’t question BF.

Sage Software announces go-lives of its Intergy Practice Portal for patient-physician communication.

CalRHIO announces that Cisco will join Medicity, Perot, and HP in developing its information exchange.

InterSystems announces that partner Oleen will provide its Cache’-powered SurgiDat system to the VA.

E-mail me. Inga’s working on some HIStech Report stuff tonight, trying to catch up for HIMSS, so it’s just me.

Monday Morning Update 1/7/08

From Christine Slater: “Re: HIMSS legislative success. HIMSS sponsored 92 healthcare IT bills. Zero passed. Anything wrong? Nah.” And in more bad news for EMRs, fading presidential candidate Hillary Clinton says she’s all for them.

From Is CCHIT Irrelevant?: “Re: CCHIT. The CCHIT home page lists Epic as the only vendor with a certified ambulatory EHR and inpatient EHR system. Is the baseline functionality that CCHIT requires really missing from other enterprise vendors, or have vendors just stopped caring about CCHIT certification and the advantages that it is supposed to bring their customers?”

From Patrick Ayephbee: “Re: new vendors. I’m seeing more get rich schemes and dirty tactics from the usual greedy vendors plus companies new to HIT. Greed, inexperience, and arrogance – great combo. Most of the IT world seems to think that poor industry performance can be explained because we’re in the pioneering stages. No, THEY are in the pioneering stages. The industry is 40 years old and they have not stopped to learn one damn thing. In fact, they don’t even ask. If you heard some of what the [vendor name removed] folks are saying, it would bring a tear to your eye.”

From Gail Pileggi: “Re: real time location systems. The area of RTLS is suddenly the ‘next new thing’. We fail with overhyped CPOE, so turn to nursing documentation and BCMA. Oops, that’s not easy either, so let’s focus on supplies since they can’t gripe. Not a bad thing, just another detour and hype cycle to deal with.”

From The PACS Designer: “Re: 2008 outlook. The outlook for 2008 is rosy for some new software applications. We will be hearing about successes and failures of PHR efforts and implementations of thin client applications Another innovation that will begin to find a home is the ASTM International Continuity of Care Record (CCR). Since TPD was a participant in its creation, it would be gratifying for me to hear that it’s in use and working to improve the information flow of healthcare!”

From Stratto Cumulus: “Re: cloud computing. Reminds me of the late, unlamented ASP model, where clients wanted to outsource everything, lay off staff, and make huge profits. In real life, the vendors were running cloud servers with vanilla COTS applications that they would not modify, which killed the business since enterprise apps always need customization and interfacing. Questions to ask: who’s handling authentication and security? Will the cloud vendor tell you if someone snoops in George Clooney’s records, or if you suspect someone is, how fast will they look into it? How will COTS licensing be handled, or will only open source stuff be in the clouds? Will the cloud be a data repository with local data marts or will local systems collect the data and batch it up to the cloud? Will it be transaction driven and Web-based, and if so, how many critical clinical apps are really Web-enabled? How will APIs and web services be handled? Are you sure you have the bandwidth? Clouds could be great for research repositories, provided authentication and architecture is adequate to handle the multiple query services. It would be great if we could integrate research findings across multiple studies to increase statistical power or see relationships across organizations, genes, etc.”

My editorial in last week’s Inside Healthcare Computing: “How the Layoff Grinch Stole Christmas: Clueless Management 101.” I gave myself some love (is that immoral?) for this line about how suits pick layoff targets: “Extra points are assigned if the victim doesn’t seem like the sort to argue, sue for discrimination, or return with armament (the worst part of being laid off is realizing that management put you in the same league as those losers who got axed with you.)” I’m not claiming it’s Tolstoy, but it sounds like me.

Heard: Lucida Healthcare IT has been acquired by Vitalize Consulting Solutions. Lucida’s execs have taken key roles (CEO, CFO, and CIO) in the new entity, which has the financial backing of some big players that include Bank of America and SV Life Sciences. Vitalize’s Mary Pat Fralick will stay on as COO.

Jobs: Manager of Clinical Informatics, LIS Director, HRIS experts, Sunquest lab consultant. Employers can list jobs free for a couple of more weeks.

Make your HISsies nominations now. Surely you have thoughts on the best and worst HIT vendors, the smartest and stupidest vendor strategic move of 2007, and the HIStalk Industry Figure of the Year. There’s about 100 nomination votes so far and the top nominees will go on the ballot. Maybe the obvious choices haven’t been named, so why take the chance?

I’ve got a few giveaway items for the HIMSS conference and need vendors to make them available to attendees. If you want a little extra booth traffic, drop me a line. These are small items, so they won’t be hard to handle in the convention center. Unlike those damned “I Am Mr. HIStalk” buttons from two years ago, which I can’t believe I found a forgotten sackful of while cleaning out my computer closet this weekend. Maybe they’re reproducing like Tribbles. Unless someone saved theirs, I could wear one myself and have an exclusive (plus they say “I Am Mr. HIStalk”, so I’d be telling the truth).

Former QuadraMed sales guy and HIStalk reader Mike Quinto has joined Appalachian Regional Health System in Boone County, NC as CIO. Fun fact somebody told me: he sold the only Affinity deal made in the last three years and his customer was … Appalachian Regional Health System. He must be persuasive.

Kelly Barland, formerly of GE Healthcare, has joined InfoLogix as senior director of professional services.

Somebody sent me a Medicity Christmas letter of sorts (I always appreciate forwarding!) Revenue doubled again for the third year in a row (notable considering the obvious floundering of their interoperability competitors). They also signed a big deal with HSHS. I always harp on idiotic RHIO business models and Medicity’s customers seem to be a lot smarter about theirs (including CalRHIO, which is hush-hush about their arrangement but promises to spill it someday).

Remember that glowing article about Peter Provonost’s reminder checklists that were saving tons of lives and money, just like a pilot’s pre-flight checklist? They were cheap, easy, and set to roll out in the US and in other countries. Well, make that just “other countries” now because the geniuses at HHS’s Office for Human Research Protections, apparently in need of a moment of bureaucratic limelight, have declared the use of such lists unethical and have shut the program down. They decided that using a safety checklist and tracking the results violates IRB requirements, claiming that using a list is no different than injecting a patient with an experimental drug (huh?) Knowing that patients will die otherwise, that seems like a puzzling decision (who wouldn’t want their caregivers to use a list that could save their lives?) I’m not one to advocate storming the castle with pitchforks, but you could e-mail acting director Ivor Pritchard (ivor.pritchard@hhs.gov) your courteous, well-informed opinion if you agree with me that this seems ludicrous. Peter Provonost (of Johns Hopkins) agreed earlier to be interviewed here once we work out details, so I’m sure he’ll have plenty to say.

Former Navy hospital CIO David Yovanno has been named COO of Internet advertising firm ValueClick.

UK researches think Google’s PageRank technology can be used to identify MRSA hotspots in hospitals.

California’s data breach law, which previously covered only financial information, now requires patients to be notified if their medical information has been exposed.

ONCHIT’s 2008 budget will be the same as 2007’s, about half of what President Bush wanted. Rob Kolodner says they’re on track to meet Bush’s goal of EHRs for every American in the next six years. If Vegas gives odds, go the other way.

KLAS has announced its year-end Best in KLAS report. Since vendors aren’t shy in telling you when they’re #1, I like to focus on those products that are dead last in their respective categories: GE Centricity CDR, Siemens Invision ADT, Cerner FirstNet ED, Cerner Scheduling Management, GE Centricity LIS, Siemens SIENET PACS, Cerner PharmNet Pharmacy, Sunquest RIS, and GE Centricity Perioperative.

Bizarre medical lawsuit: a strip club owner whose penis is tattooed with the words “Hot Rod” is suing Mayo Clinic’s chief surgery resident, who admits taking a photo of it while catheterizing the man and showing it to other doctors.

E-mail me.

Inga’s Update

An Arkansas neurosurgeon pleads guilty to soliciting and accepting kickbacks from a surgical device company. The doctor has agreed to pay $1.5 million, of which $1.1 million will go to the state and to the whistleblower (who happened to work for a competitor.)

Overheard: two Misys operational superstars with over 30 years of combined tenure say goodbye to Misys to work for former Misys VP’s Marc Winchester and Scott Sanner at Digital Healthcare, a retinal risk assessment company. Their resignations come on the heels of at least a couple of senior sales superstars over the last month or so. Guess they’re all choosing the highway over Misys MyWay.

Mr. H and I have had a few conversations about what attracts people to booths at big shows like HIMSS. Let’s say you are only mildly interested in the company’s offering, or perhaps have no clue what the company does. Does a free latte or margarita get you to step into the booth? (my favorite). A beautiful young female with a bit of exposed skin? (Mr. H’s favorite). Pictures of Mr. H and me? (that was what our friends at The White Stone Group want to give away). Or, various trinkets and chances to win some exciting prize? Let me know.

Apparently the bean counters at PricewaterhouseCoopers will begin performing a new type of audit: PwC has been hired by CMS to perform 10 to 20 HIPAA “compliance reviews” of organizations facing complaints.

After an “independent strategic reviews,” MedcomSoft announces an overhaul to its board of directors. They are also looking for a new US-based CEO, if anyone is interested.

Barnes-Jewish Hospital in St. Louis is partnering with iMDsoft to implement MetaVision anesthesia information management system.

Reminder: our new “Best Practices” section of the Forum is up and running with this week’s question: what software or forms do you use to track an active project … tasks, percent complete, assignments, due dates, etc.? Add to your list of New Year’s resolutions to post a message or two to share your wisdom.

At the top of my personal resolutions is regular exercise, especially since I don’t seem to be too good at skipping cocktails or carbs. Happy New Year, by the way!

E-mail Inga.

News 1/3/08

From Lazlo Hollyfield: “Re: AHRQ. It amuses me how some of the health news outlets are highlighting the AHRQ focus groups on how consumers perceive health IT. Besides an area that several market research companies already cover, this is a complete non-story at best and lazy journalism at its worst. NIH budgets have dwindled/been flat and so has AHRQ’s budget. Most of the bureaucracy is leaving before the end of this presidential term and decisions to award money have gone astray. This is probably a case officer at AHRQ who basically had some extra money to throw around. Nothing more. I would be shocked if something truly interesting gets published from it. Probably just verifies existing customer data out there from the various market research firms.”

From The PACS Designer: “Re: Cloudy 2008. TPD took a well-deserved vacation and a break from HIStalk, but is now back in the groove as we approach 2008. Speaking of ‘Cloudy 2008’, it’s not weather or financial predictions, but refers to the emergence of more ‘Cloud’ offerings in the healthcare space, with Clouds being bundled software services which include  automatic upgrades from time to time which will remove the burden and worry from institutions. Since hospital budgets are tight due to reduced Medicare expenditures, you can expect more C-level execs to consider outsourcing many of the more laborious tasks to vendors who offer their services as ‘Clouds,’ which will expand the size and number of clouds employed to get the jobs done in 2008 and beyond. Short term, it will mean lower software revenues for vendors, but longer term will provide stable monthly/yearly business revenue volumes for companies offering this option. Happy 2008 from TPD to all HIStalk readers!”

From Nasty Parts: “Re: rumor. I can confirm your rumor of a British EMR company’s SVP of sales leaving. He came from outside of healthcare, a decision I never understood. Morale is high with his departure.”

From Marge N. Alperformer: “Re: HIMSS. Do you know of any inexpensive way to to attend?” Registration’s going to set you back $740 if you get it in by the 28th and there’s not much way to avoid that unless you: (a) “share” a badge with someone else and split your time; (b) find a vendor to comp you, which isn’t likely; (c) do something for HIMSS that will get you a free reg, but it’s probably too late for that; (d) skip the educational sessions (or assume credentials won’t be checked closely) and buy just an exhibit hall badge for $175. You can save on flight and lodging by using Priceline (I’ve done that), especially since rental cars are cheap in Orlando so you can stay further out and off the shuttle line. Anybody else have ideas?

From Kiera Whitlock: “Re: MGMA. They are very visible in the Medical Group Practice world; their founding fathers practically invented the large multi-specialty group practice. Most of the big groups are members, but MGMA is catering more and more to the smaller practices. Their sectional and national conferences are big, though not as big as HIMSS; but also don’t have HIMSS’ price tag, for vendors or for members. If you don’t know much about medical groups (or even if you do),their training and publications are a good value. If you want to hang around exclusively with the bigger (50+ MDs) groups, you’ll probably want to check out AMGA; their conference is smaller, but the biggest groups and the best vendors are there. AMGA does not (as far as I know) have individual memberships; so if you’re looking for a personal (as opposed to organizational) membership, MGMA is the place to go.”

From Techman: “Re: HL7. I work for a software vendor and I am interested in the way HL7 is used in practice by healthcare providers, like which parts of the HL7 messages are used. Anyone have suggestions for information sources?”

From Grizzled Veteran: “Re: Alteer. The California-based EMR/PM company is being acquired by VisionaryMED, a Florida EMR/PM company.” I saw nothing in the news or on either company’s site, but I’m not doubting you.

From Porchean Cantrall: “Re: HISsies. athena’s insane IPO and ongoing industry buzz around their disruptive SaaS model have got to make it for biggest industry event. Loved Beers with Bush last year in any event – thought that was pretty cool.” Beers with Bush was fun, especially since athenahealth brought out the good stuff right on the exhibit hall floor for HIStalk readers who dropped by. We need another fundraiser for a worthy cause, if anyone has ideas.

And speaking of HISsies, it’s that time again: your nominations for “The Brutally Honest Healthcare Information Systems Awards” in 18 categories are now welcome. Among them: who’s the worst vendor, what’s the biggest HIT news story of the year, who is the HIS industry figure in whose face you’d most like to throw a pie, and who gets the biggest award: the “HIStalk HIT Industry Figure of the Year.” Nominations will run until the end of next week, then voting begins. Don’t discount the importance of voting now: only the top handful of nomination vote-getters appear on the final ballot. If you’re new, don’t think this is a joke just because the categories are cheeky: it draws 1,000 or more voters each time, some vendor always tries to rig the voting by urging employees to vote for them as Best Vendor, and the number of people who read the results announcement is off the scale.

Cardinal Health recalls another 200,000 of its Alaris Medley smart IV pumps. Springs inside the pump were assembled incorrectly, leading to the potential for overinfusion.

Pennsylvania get its usual abundance of federal pork barrel money, including $86,000 each for clinical IT projects at Mercy Hospital Scranton, Moses Taylor Hospital, and Mid Valley Hospital.

Inga mentions her Christmas presents below. Mine: the rest of the Gilmore Girls DVDs (so femme, I know, but I’m addicted); Call of Duty 4; a couple of books, including How Doctors Think; and some Boy Scout popcorn from Mrs. HIStalk’s batty but adorable 90-something aunt.

Let’s get this Best Practices thing going! What software or forms do you use to track an active project … tasks, percent complete, assignments, due dates, etc.? An HIStalk reader has asked, so share your thoughts in this new HIStalk Forum topic. Register to post if you haven’t already.

If you found the Rose Bowl coverage annoying (nearly assured since Brent Musburger was involved), you’ll find this funny.

CPSI signs a deal with NeoTool to use its NeoIntegrate interface engine.

Listening: Blonde Redhead.

Merge Healthcare did some restating and reporting, but I just can’t get interested in their ongoing troubles any more.

Sumter Regional Hospital wins the Siemens MRI with over 260,000 votes, 101,000 more than the second-place finisher. The official announcement will come in a couple of weeks. Congratulations to them and thanks to the HIStalk readers who voted for them.

A Malaysian hospital has developed its own information system using free Oracle software. It includes ADT, ED, surgery, HIM, case mix, and patient accounting, with CPOE and HL7/DICOM integration planned for 2009. Says it costs millions of ringgits to implement (a ringgit is around 30 cents US) and that distributors are interested in selling it.

A former GE Healthcare bigwig, soon to be CEO of a small medical data analysis company, says he wants to sell clinical-genetic information systems to vendors like Cerner and GE.

Jobs: Pharmacy Application Specialist, Epic Trainers, Director of Global Training & Education.

A doctor creates a video e-mail for each patient to explain their lab results.

Allscripts acquires discharge referral system vendor Extended Care Information Network for $90 million in cash.

E-mail me. It’s time to get back in the swing of things.

Inga’s Update

I am back from a week in the land of no Internet access. I loved my time with the extended family, but truly, how does one survive in a world with no Wall Street Journal, one FM radio station, and 20 miles from the nearest manicurist? The highlight was driving into “town” one day and seeing a plethora of beefy country boys in their nice-fitting jeans. They all looked like they spent a lot of time hauling things around all day, though I bet none knew anything about healthcare IT. Next year I am voting for a Four Seasons somewhere (I love their towel boys.)

My best Christmas present is my 320GB external disk drive that I haven’t hooked up yet. Probably next was the 1000-page “World Without End” by Ken Follett. No healthcare IT references at all, though it is Oprah-approved.

I was pretty amused by the number of posts related to Meditech and their technology. To be fair, I should note that I am the one who introduced the MUMPS technology issue when asking if Meditech had difficulty finding employees with expertise in MUMPS (to which he pointed out that the current technology was not MUMPS.) I was a bit surprised by the passion my Meditech friend still had for his company. Whether or not you agree with his opinions on Meditech and its technology, my impression was he honestly believed in the company and their products. On one hand that is commendable, and certainly understandable. How could you stand by your company and its products and people for so long if you didn’t believe in them? On the other hand, it’s easy to get blinders on after a period of time. I know little about Meditech’s management but I hope they take time listening to the market (and not just their clients) since it appears the world views things differently than the Meditech folks.

CIO Unplugged – 1/1/08

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

CIO reDefined: Chief Ironman Officer
By Ed Marx

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

The photo that serves as my avatar melds two of my passions: delivering technology innovations to improve the patient experience, and triathlon. In the foreground is my laptop. In the background is my tri-bike with associated gear. My dress is a mix of business and triathlon attire. Needless to say, the typical business picture idea bored me.

The avatar picture’s conception is rooted in my Army Basic Training at Ft. Dix, N.J., 1982. Despite my varsity high school accomplishments and the recruiter’s assurance, I failed the Army Physical Fitness Test. I lacked the strength to perform the requisite push-ups, sit-ups, and run. Humiliated, I promised myself that I would pass the final test. I decided right then to never let anything I had complete control over compromise my ability to influence.

In the end, I passed. From that point forward, I consistently ranked with the top 1 percent of American soldiers in fitness for the rest of my military career.

Because of my avid enjoyment of sports, not to mention my early Army failure, I pushed my son too hard to “be like dad.” As a result, he not only rebelled but maneuvered down the fast track to obesity. As an overweight middle schooler, he found team sports unpalatable — too much mocking and ostracizing. Thus, we toyed with multi-sports. Triathlons, biathlons and duathlons. A short time later he would become a routine podium finisher and eventually he ranked No. 4 in the country in duathlons. Our entire family had gotten involved, winning numerous races. My son and I in particular were hooked and have completed over 50 multiple sport events since then, including 2 half-Ironman events in 2007.

A full Ironman had not initially made it on my list of objectives. When a friend of mine was suddenly diagnosed with cancer early last year, I elected to battle the cause with her in my own way. All current training is carried out in honor and support of her fight. My time logged in preparation is sprinkled liberally with prayer for her and for the clinicians and researchers, that a cure might be found. In grooming for the Ironman (April 2008), I completed my first marathon in December (3 hours and 43 minutes). That’s a lot of prayer sprinkles.

While I am not advocating that all CIO’s should become an Ironman, I want to illuminate the profound lessons that apply to our profession:

• Training. Many CIO’s believe no further training is necessary once they have reached the top. To the contrary, the requirements only increase with elevation. Continually equip yourself or you’ll end up being removed from the race for taking up precious space. Like riding a bike, you can coast for a little bit but if you stop peddling, you will fall over.
• Shape. To the extent it is medically possible, stay in shape. The people you lead take their cues from you. Leaders bear the burden of visibility. Would you go to a pulmonologist who smokes? Or an orthodontist with crooked teeth? Studies have proven a correlation between physical and mental fitness. CIOs work long hours, which requires great stamina. You don’t have to be an Ironman, but I encourage you to, at a minimum, follow the fitness recommendations of the American Heart Association.
• Embrace change. During triathlons, a racer faces many unforeseen circumstances. A strong wind. High tide. Or worse, a flat tire. No one is exempt from these trials. Do you accept the change and make the most of it, or do you spend energy fighting the elements you cannot control? Adapt to the curveballs thrown your way, and then thrive.
• Guts. It’s not merely the most fit who wins Ironman. It’s those who are fit and who want it. Crave it. I have surpassed colleagues in my career who were much brighter than I, but they had neither the fortitude nor the focus to push through all the challenges. Painful things happen that will tempt you to quit. Develop and harness the power of passion, for passion will create guts and drive your success.
• Boundaries expanded. Early on, a 10K seemed like the ultimate race, an Olympic challenge. I never imagined attempting a marathon. Today, a 10K is a walk in the park. Ironman is busting the boundaries I originally believed invincible. As a CIO, you must continuously bust boundaries lest your organization becomes complacent and your vision dimmed and potentially lost.
• Planning. No one simply wakes up and decides to do Ironman that morning. It takes advanced planning and years of transformational steps to see grand visions achieved. You must plan similarly for your career and your organization, analyzing both from short-term and long-term points of view. No greater sensation will seize you than when you see a plan fully executed and realized. It will fuel you to carry the journey into the future.
• Rest and refueling. There is a science to Ironman which includes rest and refueling. Continuous activity leads to burnout. If you do not take the time for nourishment you will run out of energy, perhaps even collapse. Constant action is not synonymous with effective action any more than eating junk food is nourishing. Build in time for rest and refueling.

Some may scoff at how, and why, I have portrayed the Chief Ironman Officer. Others will complain about the limitations, physical or otherwise, and to why this post is irrelevant. Yet thinking back, I recall events in which the blind, the aged, the amputee, even the quadriplegic passed me along a course and encouraged me to keep going. I never thought I would say it, but I am thankful for my experiences as a 17 year-old basic trainee and for Drill Sergeant Moultrie screaming at me to eek out yet another push-up and run another lap. It is not so much about the physical act that inspired me but the leadership insights I internalized. Little did he realize the impact he would have on my life and career.

Or did he? Thank you, Sergeant Moultrie. Now, get out there and race!

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.”

HIStalk Interviews Shaun O’Hanlon MD, UK Physician

Hi, this is Inga. Shaun O’Hanlon, MD works for EMIS, the largest supplier of EHR products to primary care docs in the UK. Mr. H and I were intrigued by his note: “I really enjoy reading your website. There are stunning similarities and differences between the EHR functionality in the US and that in the UK. There is undoubtedly room to learn as, underneath it all, we are all caring for patients.”

Thanks, Shaun, for providing some great insights. “Whilst” I had a bit of a struggle understanding the accent and the British-isms, it was a fun conversation that got me thinking about what we could learn from the UK model and what aspects we independent-minded Yanks would never embrace.

Give me some background information about you. 

I am a physician by background. I qualified from Cambridge in 1986 and I pursued a career in hospital medicine in cardiology. Then I decided to be a General Practitioner (GP), which is the UK equivalent of family practice. I spent 13 years being a GP in Guildford, just south of London, which I loved. My interest in healthcare informatics products started after working on a smart card project in 2000. Since then, I have been working for EMIS in healthcare informatics.

The company I work with today provides the GP EMR for 60% of patients in the UK, so it is a fairly prevalent system. Largely, it will do everything for EMR, management recall, appointment scheduling, and orders, all done through a single application. Billing is included, but in the UK it’s not that important. The economy is such that the government pays for healthcare through the National Health Service (NHS) and there is very little pay for services aside from some hospital ones. 99% of it is free. Well, not free – it’s paid for by taxes. [laughs] There is a secondary insurance market, used mostly for second opinions.

There is little competition for patients in General Practice because there is a match between doctors available and the number of patients. The government is generally reluctant to set up new practices. Since 1947, GPs have set up partnerships of five to 10 clinicians. That practice has a contract with the government to provide all General Practice services to their patients.

Can you give me UK Healthcare 101?

The practices are largely where they have been for many, many years. GPs have a geographic catchment area for patients. Although there may be several practices in one area, the competition is not widespread, as the government tries to match the number of doctors available to the number of patients. To set up a new practice, you have to have a pretty strong case and show local need. It is therefore fairly uncommon. The number of GP physicians is fairly stagnant.

We are now seeing some attempts to try to bring in private providers to improve patient access to healthcare. The number of doctors is relatively low and you have some big companies trying to provide an alternative model of providing care. Some of the bigger healthcare providers are trying to set up private clinics, as there is a perception that the GPs are stuck in their ways and innovation is needed.

Most GPs offer office hours from 8 to 6. Outside those normal office hours, service is provided predominantly by “out of hours” or emergency facilities. This is a problem for patients who are in employment, especially those who commute, and need to see their doctor early or late in the day. This has triggered a desire to find more innovative ways to provide care.

Patients are registered at a particular practice, which usually contains five to 10 physicians, equating to 6,000 to 12,000 patients per practice. Everyone who lives in the UK has one GP. The practice will provide all their primary care, including managing all their prescriptions, tests, and referrals. If you are on holiday, you can see someone temporarily, but your records will remain with your GP where you live.

So if I live in the country and commute to the city and need to see a doctor, I can’t see one in the city?

Right. Not very easily. A bit rubbish, isn’t it? They are considering creating a concept of dual registration to enable commuters to have a city doctor. The model now is one of a monolithic cradle-to-grave record. That has many advantages for continuity of care, cost containment, and quality care delivery. You begin to worry if you fragment a patient’s record, then you fragment care and may have dual care, redundant tests, and increased cost. In order to offer dual registration, you have to be able to share records around as well.

What is overall state of technology?

If you are a GP, every practice will have an electronic record on one of three or four available systems. That information will be held in a largely codified, structured manner. It will include a full medical history and all consults. It will include problems or diagnoses, all results, tests, prescriptions, and letters, resulting in a full, rich record that is fairly advanced in its structure.

The information is now transferable electronically between GPs in a structured format. If you move to a different location, then your record will follow you. What happens at the moment is that the record is held in a server in a practice or an enterprise with central service. When you move, your record transfers. There is a national standard that allows you to transfer the record around. We have a national messaging service that relays the messages from the practice database service to the receiving service. You request the records and you receive them the next day. A copy is extracted to the new practice. The patient’s complete medical record is sent and then imported in a coded format.

You indicated that there are stunning similarities and differences between EMR functionality in the US and UK.

A lot of my experience from that side of the pond comes from Canada. I find it quite difficult to talk about specifics because I haven’t been on the hospital side in US. But there are a lot of similarities around the need to share information. There is this conception that the GP performs one role and the hospital performs another role. The result is that information silos exist with pieces of paper — referral letters, outpatient letters, etc. — connecting them.

The other similarity, very macro, is that we are seeing increased focus on what patients want to know about themselves. Up until recently, this has been resticted due to technical issues. There also exists a kind of a high-handed attitude that patients can’t have their records by some clinicians.

We have brought the patient into the loop and now offer them access to their records, appointments, and electronic ordering of prescriptions. We have hundreds of thousands of patients using EMIS Access for just this every month. Projects like Healthvault will further enable this citizen involvement across the globe.

Suppliers are realizing that the real benefit of their data is sharing with other providers. People are sharing data between different systems. You need your applications to work together. Now that there is increased requirement to look at the lab system and radiology, interoperability has been become the core business that companies are beginning to focus on. We work hardest at determining how to share data and what data should look like. By sharing information everything works better. Everyone’s data is much richer when it is shared. Interoperability is the key to future EMRs.

To interoperate, you have to have standards. Unless you come up with agreed standards, you can’t have interoperability. Standards for coding data, messaging data, and viewing data.

EMIS has adopted SNOMED-CT as it does appear to be becoming the universal standard for record coding. We are working quite hard to understand SNOMED-CT because, whilst it is very advanced and offers granularity and breadth not found elsewhere, it is not a straightforward taxonomy, either for data entry or for reporting. So, new and innovative ways of entering data will need to be designed.

Message standards are now generally focused around HL-7. In the UK, we have adopted V3 XML, but our Canadian teams are now using V2 as well

Data display standards are equally important. Microsoft has been working with NHS and some suppliers like EMIS in defining a Common User Interface for healthcare applications. Their approach is to help establish a set of evidence-based standards for display and entry of healthcare data which is platform and location independent. The program is in its early days, but they are beginning to look at some of the challenges that SNOMED-CT and citizen records have on the healthcare user interface

Is the UK ahead of the US in terms of technology?

In certain areas, we appear to be in a luxurious position of having a national approach of how medical record and information should be used in the National Health Service and in Connecting for Health. We are mandating the use of HL-7 and are required to adopt these technologies and standard so we can share information between systems. It is putting us in good stead in some respects, but central control can be slow and laborious and does not always follow business drivers. If you don’t have an economy with that central control, the supplier sets standards based on business drivers, which can be more adaptive to the changing market.

Anyone would be well to learn from the issues that the UK has in providing a national EMR solution. There are a lot of lessons learned about standards and where they do and don’t work and how to go about implementing them

What is the state of adoption for EMRs in the UK?

Hospitals primarily use PAS, patient administration systems, PACS, and order systems. All have back-end billing systems to make sure they get paid by NHS. A lot of them rely on paper records for the medical record piece, although some use components of EMRs.

It’s a very mixed bag in terms of hospital adoption of EMR. Cerner is a big player and being employed, though it is going slower than they would have hoped due to implementation issues. Localizing the product has taken time and effort, as the requirements in a UK hospital are different than an American hospital. They are also going into sites with mixed technology and systems. That isn’t my area of specialty, so I can’t really comment further. iSoft also has a product called Lorenzo which is a single system for GP and hospital, but the full release has been delayed for several years.

How are EMRs funded?

It is all paid for by the government. In General Practice, they are provided through an NHS agency. The clinicians have a choice of systems, which was assured after a lot of pressure from the clinicians as the government didn’t want initially to offer that. The current situation is that the GP can pick the EMR solution they wish, so long as it fulfills a set of basic and interoperability requirements.

There is a also a big move to central hosting and enhanced data sharing across regions, if you like, so you can share between hospitals and physicians. What you call RHIOs — it is exactly like that, driven by the government. Some physicians think it’s a good idea, whilst some are concerned with losing control of their data. Others might argue it’s the patient’s data and that it is up to them who sees what information. The legal status is somewhere in between, that the doctors are the guardian of patient data.

Personally, I think the citizens have different expectations about their records. Most patients would be startled if they knew the hospitals couldn’t see the information that GP has, that historically it couldn’t be shared for technical and non-technical reasons. The non-technical reasons revolve around clinicians and administrators not wanting to mobilize data, sometimes for legitimate security reasons, whilst at other times, they are scared of someone seeing “their” data.

Some concerns are rational and some not rational. There is a need for putting solutions in place to encourage the sharing of data on terms they feel acceptable with. A patient can say, “I don’t want this one piece of information shared” and control who can see what. At the end of the day, the patient has to be able to see that. If you put in technology controls, then the clinician is the guardian and the patient controls who has the access. That has to be the way going forward. We need more control with the citizen and less with the clinicians whilst respecting that the clinician needs some controls because he is a stakeholder in the information, too.

Are physicians receptive to technology?

How you get clinicians to adopt EMR is a really interesting question. Before I went on the industry, side I tried to evangelize GPs about importance of coding data. I suspect 25 to 30% understood that and took it as a trigger for change. It has to be easy to do and have a business case behind it for it to be a success.

Prescriptions and repeat medications – the computer is very good for that. Appointment scheduling – no doubt that the computer helps. But what the government did over here was put part of the remuneration for the doctors based on how they are providing for the patients. Twenty percent of GP income is now around achieving targets for quality of care. For example, patients with heart disease have a certain level of cholesterol and blood pressure that the clinician should achieve to trigger the quality care payments.

The key is that if you see 10,000 patients, then there is no way you can collect the information required by the government on an ongoing basis without an effective EMR. All GPs now know it will pay to use an EMR package and, at the end of the day, it helps with quality of care. Once they realize how easy it is to enter data for disease management, they use it more.

The emphasis on chronic disease management was the big driver for adoption. Now that we are beginning to share the records, that will become the next business driver, I am sure. Some doctors complain it is check box medicine, but most recognize the improvements in care and data quality that have resulted. One very positive effect has been that there is now much more quality data on EMRs, something we gave been able to take advantage of and have used this data for some very high quality research. That has been an incredible falling out from all this.

Are citizens interested in having access to their medical history?

Very much so. I was recently looking at some stats. We have had 250,000 hits on our patient-facing service that is based on the EMR. Sending messages to doctors and ordering prescriptions online is now very popular. There are some issues that we have overcome around that, including privacy, but it is beginning to take off here in the UK. Our health portal is restricted to one part of the UK. You can log in and see your records provided you and your doctor are happy for that to happen.

How did you come across HIStalk?

[Laugh]s I got an e-mail from a person in our Canadian install. I read and found it an interesting mix of suppliers and users essentially talking to each other. In the UK, there isn’t a forum like HIStalk where you have senior suppliers and physicians sharing their knowledge. I think I learn a lot reading the e-mail that comes through. I don’t feel I can contribute much because I come from a different space.

Do you have anything else to share?

Our problems are complex and some need addressing on a national or international level. We have to have something to shoot for. The approach we’ve had involves citizen and doctor groups, as we have found there are a lot of concerns. Frequently they are unfounded, but we don’t realize they are unfounded until we analyze them in detail. If you told me 10 years ago I could log into my bank account online, I would have been horrified, but now I do it all the time. Suppliers and clinicians need a citizen view as well as a self-interest view.

News 12/28/07

From Bruce Teeler: “Re: MGMA. Does anyone have any feedback on this organisation? They claim 21k members, which doesn’t seem like a lot to me.” MGMA is the defacto member organization for physician practice management. 21,000 members sounds like a lot to me (I don’t recall how many HIMSS has, but I bet MGMA is nearly as large.) If anyone has first-hand experience with MGMA or its conference, feel free to provide an opinion and I’ll run it here.

From Neal’s Pizza Guy: “Re: Cerner. Rumours abound that Fujitsu is pulling out of the NHS contract, leaving Cerner in a prime contractor role for the Southern Cluster of England. Townsend has been spending a lot of time in the UK to negotiate, along with Neal, who presented how they would take on a cluster direct. Get the pizza ready!!!!” Speaking of pies and Neal, I’ll be opening up the HISsies nominations very shortly. If you’re new here, you can check out the writeups for 2005, 2006, and 2007. Neal’s a three-peater for The Pie, of course, the most recognized subset (and least desirable) of the HISsies awards. So if you’ve been anxious for this year’s round, I’ll say just this: tick-tock. Billy “Biff” Jutjaw is getting fitted for a new tux for the ceremony since he’s put on a few pounds since the last one, so I hear.

From EX-Xtenity: “Re: layoffs. It seems that one of the only certain things in this industry is that there will be layoffs. My heartfelt condolences to those who were recently laid off during this time of year. You might want to consider pulling together as a group for the purpose of networking. Best of luck to you all from someone who has been there a few times.” Agreed. It’s not much consolation while the wound is still fresh, but I’ve known a bunch of people who were laid off and nearly all of them ended up better off because of it. The companies doing the deed don’t usually fare so well (how talented are executives who can’t plan far enough ahead to dump payroll expense sometime other than November or after December knowing how bad that makes them look?) It’s a good reminder that, despite feel-good HR talk about being a “valued associate,” we’re all expendable horseflesh. I’m not against that concept at all since it’s a two-way street in our capitalist society, but sometimes companies say one thing and behave entirely differently and I’ve got a problem with that. I’ve laid off a bunch of people in my time and didn’t like it one bit (like a death camp guard, the clueless commandants didn’t exactly give me a choice). One thing I’ve learned: a company that’s laid people off more than once is entirely likely to do it again, meaning think twice before taking a job there no matter how superior you believe your skills are. Those laid off aren’t necessarily the least-capable employees, just the easiest targets because of their assignments or lack of political connections. There but for the grace of God go you.

From Matchless: “Re: St. Joe’s. I don’t think you published this, but St. Joe’s in Atlanta has to pay the government $26m for overbilling Medicare. Case workers of the world unite!” Link. The most interesting part of the story: a nurse whistleblower gets $5 million for documenting that the hospital billed outpatient and observation services as inpatients. Sweet.

From TheCoolerKing: “Re: [British EMR vendor]. Fired their SVP of Sales last week. It took over two years to find him and he is gone in less than a year. 50% of plan will do that to you.” I expunged the company’s name because that would single out a guy who’s out of work (if the rumor is true, anyway). Those who care will easily figure it out. Hint: it’s not Misys.

From Malvern: “Re: selling patient data. The desire to keep patient data confidential is understandable, but we tend to forget what is known about each of us who uses a credit card, takes out a loan, or swipes the grocery store tag to get the store discounts. When you ask the credit report companies what they know about most of us, there is not a whole lot that escapes the electronic eye.” True, although they need to know lots of stuff to gauge your credit risk and there’s no morally acceptable equivalent in the healthcare insurance business. Maybe that in itself is illogical: other insurances are priced by risk (living in a flood zone, driving like a maniac, skydiving, etc.) but health insurance is supposed to be blind to higher-risk purchasers with no cost adjustment for risk factors. If we were designing the concept from scratch, I don’t think we’d come up with today’s system of voluntary participation and employer-based signup.

From Billie Jean Queen: “Re: mining EMR data. Issues include: disparate standards across specialties and vendors; HIPAA and patient consent information, which requires metadata; control of the repository and how it will be secured, since search engine technology is so good that re-identification of patients is frighteningly easy; and getting enough data to make it useful for research (how BP was collected, for example: sitting, standing, etc. and most EHRs don’t capture that). The most useful thing that could be done would be to get device vendors to output all the information about how a signal was collected, such as device name, parameters for the study, methods used, software version, patient ID, etc. and automatically put that in the EHR in a standard form.”

A Washington Post article describes the software-driven ED turnaround at Inova Fair Oaks, with sophisticated applications forming the cornerstone of Inova’s plan to integrate its six Washington-area hospital EDs and several more freestanding emergency centers. GWU Hospital is also mentioned. The software isn’t mentioned by name, but a little Googling turns up that it’s Picis ED PulseCheck at both places.

Housekeeping reminders: you can sign up to your right for electronic updates when I write something new or for the Brev+IT weekly newsletter. New interviews are coming soon to HIStech Report, whose interviews delve deeper into vendors and their products (it will swell right before HIMSS). HIStalk Forum gives you a place to start discussions or participate in them — we’re planning to open up a Best Practices section there with an assigned focus area every couple of weeks for tip-sharing (grateful kudos for Noteworthy Medical Systems for sponsoring HIStalk Forum). There’s a site-specific Google Search box to your right, the first place I look when someone asks a question about a company or person since it covers 4 1/2 years of HIStalk. Lastly, please take minute to read and click those sponsor ads to your left and text ads to your right since they make HIStalk possible (and free).

A group of Paris hospitals withdraws its $110 million contract for patient systems development, awarded to GE and other companies, because the companies struggled to define their proposal. The tender has been reopened and a local paper says Capgemini and McKesson will probably jump back into the bidding.

Jobs: Medical Knowledge Engineer, Clinical Content Production Manager, Corporate Manager of Clinical Applications, Project Manager.

Barring last-minute voter fraud or eBay-type sniping, it looks like Sumter Regional Hospital will win an MRI machine from Siemens. The hospital has accumulated 244,000 votes, far ahead of #2 Grant Regional Health Center with 151,000.

Odd story: the Fiju hospital trust is running its own IT system after its vendor failed to meet its needs. The vendor’s owner is a businessman wanted for questioning over an alleged assassination plot.

Varian Medical Systems completes its acquisition of a radiology equipment distributor in China. Maybe I should study the Chinese HIT market since everybody seems to be looking there for growth unattainable elsewhere.

Idiotic hospital lawsuit: Wisconsin’s governor takes $200 million from the state’s medical malpractice fund to balance the budget. A patient is suing St. Luke’s Hospital for a medication error that occurred before state pain and suffering caps were enacted, with a potentially huge payoff on the line. The state’s medical society has filed a counter claim against the hospital to make them pay their own damages, claiming the hospital’s employee training is inadequate. The state’s hospital association, as you might expect, begs to differ, saying St. Luke’s should be covered by the malpractice fund because that’s why it was created in the first place. Now the medical society is suing the governor. An epidemic of lawyer paper cuts and 30-hour billing days is next.

Healthcare spending in California’s prison system has doubled in two years. Prisoner count is up 8% since 2003, but the budget increased 79% to $8.5 billion and expected to exceed $10 billion next year. The state faces a $14 billion budget shortfall, which surprises no one in the 49 other states who find it hard to suppress a guffaw. Surely The Terminator will blow away the deficit and save El Lay.

Interesting: an electronic stethoscope under development will use onboard Linux despite perceptions that it will make FDA approval difficult.

athenahealth’s IPO was the ninth best of 2007, one of 10 that doubled their IPO price. Implantable RFID chip maker VeriChip was the worst IPO of the year, down nearly 62% from $6.50 to $2.49.

I hope you’re enjoying the holiday. Shockingly, it’s just nine weeks or so until HIMSS. Save the early evening of Monday, February 25th if you’re headed to Orlando. That’s all I’m saying for now.

E-mail me.

Can EMRs Moonlighting as Research Databases Sweeten Their ROI?

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

I’d never heard of the Clinical Data Interchange Standards Consortium (CDISC) until last week. That’s when that group announced the kickoff of a new interoperability project, this one involving linking EMR systems to the information systems of clinical investigators who are performing drug or disease research. The audience might be researchers, the Centers for Disease Control and Prevention, or registries for patients or disease. The IHE is involved in the testing and will demonstrate the results at the HIMSS conference.

I’m not usually interested in this sort of project. I’ve seen first-hand what an insurmountable effort it can be just to get hospital systems to swap clinical data across the hall, much less with national third parties. Still, this is an exciting indicator of how quickly the now-common idea of interoperability has taken hold. If nothing else, RHIOs have made hospitals think about the value of their patient information and how to exchange it in a standard electronic format.

Getting and keeping drugs and devices on the market is expensive and information-intensive. Several small, highly profitable companies have sprung up to help enlist patients in studies, to do the rigorous paperwork required, and to design research methodologies. Their key commodity is information.

Hospitals have patient information that’s available nowhere else, the kind that arouses researchers and manufacturers with far deeper pockets. Repurposing that existing information by making it available to those willing third-party customers, even when motivated purely by mission-supporting cash, is at least more beneficial to society than running a McDonald’s or building medical office buildings.

Let’s say your hospital implements a well-integrated, information-rich EMR system that can easily tie together everything about patients from medical history to demographics to procedure history. Suppose you add genomic data to the mix, storing information about family history, lifestyle, and a longitudinal history of disease, treatment, and outcomes. All of that could be used to the advantage of your own patients and institutions, but it has an equally high value to those third parties trying to assemble or execute big research projects.

Drug companies and device manufacturers need the data that lives in your clinical systems. How else will they be available to target research to a very narrow range of patient types, maybe even those with a specific genomic profile? It could help them identify appropriate research subjects, design post-marketing surveillance, study population-based outcomes, and catalog adverse events. The information you provide could either be de-identified or made available only if individual patients opt in. The benefit to patients is access to a wider variety of treatments and protocols, most likely free to them if tied to a research project.

You wouldn’t just give that information away, of course. Hospital information is far deeper and more detailed than what’s available from any other source, with a wide scale to match. All you need is sophisticated EMR functionality and a relentless push to get every scrap of clinical information codified, categorized, and cross-referenced.

In the movie Wall Street, Gordon Gekko says, “The most valuable commodity I know of is information.” That is true of clinical data, especially when those who value it can afford to pay. Just don’t sign away too cheaply the rights to your treasure trove of data, even if the interested customer is a RHIO or third party data vendor.

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Monday Morning Update 12/24/07

From Orthopod666: “Re: selling patient data. This is from an interview with the CEO of the AMGA regarding the AMGA/Anceta National Collaborative Data Warehouse, which provides groups with access to comparative healthcare data. ‘The revenue for the company (Anceta) will come from making the totally identified, HIPAA-compliant data available to third parties.’ If this is true, how can they possibly be HIPAA compliant?” Link. Other references to Anceta indicate that the data in the Collaborative Data Warehouse is de-identified, so I assume the reporter misquoted her source (her freelance articles elsewhere cover everything from beauty academies to LCD projectors to real estate, so she may have been in over her head, but surely the editor should have caught that goof).

From Former Medseek Employee: “Re: Medseek layoffs. Yes, it’s true. I was one of the chosen few who got the boot a week before Christmas. I believe there were 30+ employees shown the door. Cash flow was stated as the problem. Mike Drake is out too. The rumor mill has it that egineering folks are not happy in Jackson with losing their leader. Many are are ready to leave, which will only put Medseek in more dire straits.” Maybe you’ll get separation counseling from Chief Strategy Office Gale Wilson-Steele in the form of a free pass to her upcoming lecture called “Promote the Best, Improve the Rest: The Power of Positive Reinforcement.” Feeling better now?

From MedSlease: “Re: Medseek. Mr. HIStalk, you are a good judge of character and hit the nail on the head. Do you remember? Mr. Grehalva has been shaking the clients’ hands and working his free hand to pass out pink slips yesterday, five days before Christmas. There have been some very talented, seasoned people let go, including an older employee on medical leave whose wife is in intensive care with a brain hemorrhage. Merry Christmas, Medseek, and a Happy Lay Off. May 2008 bring you all that you deserve.” The reader is referring to this mention. Layoffs are part of corporate culture, unfortunately, and not entirely unsavory provided that: (1) companies don’t overhire and then correct their own excesses by downsizing; (2) the decision of who gets let go is made fairly; (3) executives share the pain by reducing their own compensation or benefits; (4) volunteers are first solicited to leave before axing those who don’t want to go; (5) separated employees are treated fairly and professionally without the usual security guard escort BS; (6) executives realize that layoffs are their failing, not those of the employees involved, and take appropriate actions to either improve their own skills or find better managers to replace them; (7) layoff decisions are a rare exception and not a routine management tool; (8) management is open about why the actions were taken and what they plan to do to avoid it in the future; (9) management doesn’t expect the shell-shocked survivors to cheerfully work extra hard to make up for the loss of downsized employees; and (10) employees aren’t singled out just because the company has at some point in the past decided to pay them higher salaries.

From Dr. Elias Kuando: “Re: Medseek. First Healthvision, now Medseek. It would seem that a lot of these size HIT vendors keep getting it wrong. Healthvision was expected. They lacked focus. But Medseek? This one surprised me. In my contacts with them as both a partner and a customer using their product, I always had the impression they had it right. That the CEO has left either by design or request speaks volumes about the company’s stability or instability. We have had discussions with Geonetric, but felt they were too small to be considered a serious player. The impression we got from their demo and functionality was that they aspired to be Medseek someday. Given this recent news, I would rethink that position.”

The SEC creates a Web-based tool that allows comparing executive compensation at 500 big companies, although the only healthcare IT one I could find was GE.

I decided not to send a Brev+IT today since not much is going on. Next week.

Listening: Catatonia, witty Welsh (and disbanded) chick singin’ alternative rock. Also: new Nightwish, icy, cinematic, and operatic Finn prog metal.

James Pennington, former CIO at Blue Ridge Healthcare (NC), joins JPS Health Network (TX) in the same role.

University of Miami’s heart clinic will use Active Ink‘s electronic forms software for patient check-in on tablet PCs.

Your federal tax dollars at work: bankrupt Bayonne Medical Center (NJ), soon to be sold off to a for-profit company, gets $487,000 for an EMR upgrade.

Philips hasn’t run out of acquisition money yet. The company announced Friday that it will buy sleep therapy products manufacturer Respironics for $5.1 billion in cash.

Merry Christmas (or its equivalent for whatever holiday you may be celebrating).

E-mail me.


Art Vandelay on Vendor Project Management

Many days, I feel like a boxing trainer looking at all kinds of boxers but not finding any with a solid one-two punch – a solid product with strong professional services. More and more, I have been focusing on the strength of the second punch – the vendor’s ability to provide technical assistance and manage a project. You have a real contender when you find one who can help with integration into our diverse environments.

The vendor’s ability to provide technical assistance includes application config., getting their product to work in our hardware environments and delivery of standard interfaces. As virtualization and monitoring ( e.g., response time, SNMP) become more prevalent, the vendors need to develop these skills. The challenges in the hardware environment are the lack of standards and number of varied products we all own. We now include information about these topics in our RFPs to set expectations with vendors.

Managing a project includes a flexible project plan and managing scope, issues and risks. Vendors need to leave appropriate “stubs” in the project plan where we can insert our tasks so that we have an integrated plan. This is always expected from our vendors answering RFPs.

Integration into our diverse environments involves more than just technology.  It is about people, processes and other vendors’ technology as well in order to drive real workflow changes. As the number of broad independent consulting firms dwindle, the opportunity for vendors to step into this space will grow. I have yet to see the “heavyweight” vendors really grab this concept and run with it, directly, or through channel partnerships with others. Right now, we operate as our own integrator as the vendors really aren’t looking outside the domain of their products.

Inga Talks to a Former Meditech Director

I had the opportunity to talk to a former Meditech director recently. He had some interesting commentary about the company, its culture, technology, and people. Here are a few interesting tidbits.

Product development

I would say that a very wise move made six or seven years ago was to consolidate all development efforts throughout the company into one organization. Prior to that development had sprouted up and was going on in all different parts of the company. But when the product efforts were consolidated under Bob Gale, the process of developing products matured to the extent that now there are some really good processes in place that have much less in the way of redundancy and reinventing the wheel many times over and also for more rapidly deploying resources to customers.

Orienting new employees to Meditech

The new employee orientation process is either two or three days and consolidates together a large group of people who all start at the same time. Everyone starts at the same time, and there is a certain bond that people have with that group that they started with. They get to know each other and I think that that method of bringing people on board is a good one in terms of not having to individually deal with so many people on common issues such as enrolling in health plans and understanding benefits and just general corporate culture pieces such as how you page people in buildings and so forth. And without that sort of centralized dissemination of the information you’d have all sorts of crazy things going on that would seem small but would make kind of a funny footprint over the whole organization.

Neil Pappalardo and whether he has a hands on or a delegating leadership style

Both – there are certain things he doesn’t get involved with day to day. He is very closely involved with the broad vision of where the company is going and the broad vision of the company’s financial direction but he is not one who would want to see every single detail of what is going on. He just wants to see if the broad vision is heading the way he has asked it to go. He has a very small number of people that report directly to him who would sort of fill him in whether or not we are moving in the direction he has asked for. He doesn’t have an office and sits out in the open in a workstation with other people. He goes right down in the cafeteria with everybody and just grabs his lunch. If you didn’t know who he was you wouldn’t know who he was (laughs) if you know what I mean. If someone didn’t point out that guy over there at that workstation is Neil, you would be likely to think that guy has been here awhile and looks a little older than everybody else. He has always made time for me.

Technology

The products are now developed in a much newer technology than MUMPS. The latest version of their products 6.0 client/server is written in a brand new technology developed by Meditech. Meditch develops the technology that is used to develop the applications and that has always been the case. MUMPS has not been used – I am not sure it was ever used to develop any Meditech products. A close cousin of that is named MIIS was the first language that any product developed by Meditch was written in. Over the years, that evolved into Magic, and Magic evolved into a Magic-based C/S. This newest technology is a brand new development environment that runs in Windows NT and but it also has ability to run in other environments as well because it relies minimally on the server side. They have applications that are used internally for administrative purposes that are running on Linux instead of NT just to give it a test and see how platform independent the technology can be. That is a newer product that is more of a staff scheduling kind of model that’s issued internally.

Why Meditech has been able to achieve such long-term success

Simply the fact the products do work. That is the key thing. It sounds almost like – why wouldn’t they work. You buy a car and expect to drive off the lot, not that they will have to tow it to your house and hopefully in a couple of months you can drive. I think because the products have been written to work together has been is a key to the success of their stability. They have never acquired other companies’ products and tried to put a portal or some kind of other face on top of that product and interface it behind the scenes. It’s true integration. The products were developed with the same technology under the same leadership and that really gives them true integration and not just the appearance of integration.

Meditech’s biggest challenges and opportunities going forward

I think continuing to retain good talent is going to be a critical piece for them. That is really what the company is built on. It’s human capital. You can be financially solid in many ways, but you have to be able to have the people who can carry out that vision and that plan. Another thing that will be a big challenge is getting customers moving forward on new technology. Magic is very solid and I know for a fact there is no plan to scale back or sunset Magic at all. Magic has been moving forward because there are so many clients on it. It would be very difficult from a logistical standpoint envision trying to get more than 1500 customers over to a brand new platform in a short amount of time. It would take a decade or more.

Whether Meditech will lose clients in the migration to newer technologies

I think the cost factor will be far too compelling to leave. And that people would benefit with staying with Meditech because it is only going to be a fraction of the cost to implement a newer technology then it would be to go out and license brand new software from a brand new vendor and do all the conversion. And who knows how much of the data would go with you and now more than ever be able to keep and maintain that data. Staying with Meditech would allow you to keep your historical data. They have migration plans in place that would allow customers a way to do that with minimal effort and maximum retention of historical data. That is an important thing I think to customers.

The biggest misconception about Meditech

That Meditech systems aren’t open. That is a long time fallacy that people have somewhere grasped onto. I think it is because it is not written in a language that they know, the assumption is it’s a closed system. The newer version, the 6.0 version of c/s, is even more open, even with data repository as one of the standard products that Meditech sells, which is a relational copy of their entire data set. That is about as open as you can get by today’s standards. And, even if you think about it, if the technology is different to write or to develop the product, it can be done in such a way that it will allow you to get at data you want to get at if you know the way to do it, and at the same time it can help protect your data from hackers and viruses and other malware that you want to keep away from the software. If you are running an application that is written in a technology that millions of people are familiar with, then millions of people would potentially know how to write something that would do harm, whereas with a Meditech environment you are not going to find that.