News 9/16/09

From Herb Alpert: “Re: Eclipsys. They are designating three business partners that will replace their own professional services people. Eclipsys is emphasizing speed-to-value, pushing cookie cutter implementations. They listed the partners last week on their Partners page, but appear to have removed that page from their site.” I know that Orchestrate Healthcare picked up some of their people and used them on their SCM/eLink project at UC Irvine (someone from there told me).

From Roger Dodger: “Re: videos. These hit the big vendor mentality on the head.” The animated videos are pretty funny (Video 1, Video 2). Guess along with me which vendor the animated CIO is talking about. “Our front-end processes blow and your 1970s-build application is the problem. The competition is killing us with ease of access and the payors are denying every claim we send them. When is your effing next generation system going to be ready?”

From William Faulkner: “Re: Epic. I can tell you without much discomfort that expectations are high and few places give 20-somethings this much autonomy. I have truly enjoyed working for one of the two hottest companies in one of the hottest industries despite little healthcare experience. The employment structure is incredibly flat, so high turnover and burnout have put five-year vets in fairly senior positions, which keeps new hires motivated. KLAS is king – I must have seen our KLAS ratings 15 times in training. Everyone does get an office, in my case fully equipped with an office mate.”

From Been There, Done That: “Re: Caymans. It’s been a while since I heard of Cayman Island Healthcare! At one point, the old CIO from U of Miami was ‘consulting’ there and bringing in his old friends from Cerner.” Brand new CIO Dale Sanders posted a comment to Monday’s post, so I e-mailed to ask him for an update. Nothing heard so far, but I’m sure he’s busy.

The Health IT Standards Committee submits its recommended EHR privacy and security standards. The initial set is basic, but by 2013, EHRs would be required to use HL7 BRAC role-based access control, security assertion markup language, and WS-Trust for secure exchange of Simple Object Access Protocol messages.

Several new events were added to the HIStalk Calendar (and you can add yours for free, of course). Among them is a September 22 free Webinar entitled Understanding State and National HIT Policy, sponsored by eHealth Initiative and featuring John Glaser.

Weird News Andy likes this story detailing Medicare’s stance on buying assistive technology for patients with speech problems. They will buy an $8,000 desktop PC whose only function is generating speech from text, but not a $150 iPhone app that does something similar. Personally, I’m riding the fence here because I keep remembering those “free scooter” commercials that beg any Medicare recipient with any kind of walking problem to get their sporty ride, courtesy of taxpayers. And if it’s that great of a device, maybe patients should spend their own money on it instead of relying on Medicare to cover every little thing.

Retired hospital CEO and current hospital consultant Ronald Gade, MD joins the board of Doctations.

Hybrid EMR vendor SRSsoft is named to the Inc. 5000 list of fastest growing private companies in America.

Newt Gingrich does a video pitch for StatCom, remarkably coincident with StatCom’s ponying up big bucks to join Newt’s civic-sounding yet entirely for-profit Center for Health Transformation.

IASIS Healthcare implements Sentillion single sign-on in seven of its 15 facilities, yielding a 60% reduction in password reset calls to the help desk. They say they’ll have all 15 running by the end of the year.

Inga and I thought it would be interesting to get a look at eClinicalWorks from the customer perspective, so she attended their user group meeting in Las Vegas this week. Her updates are on HIStalk Practice: #1, #2, #3, where she also covers some eCW announcements, including opening some new offices.

Speaking of eCW, Children’s Boston announces that its Indivo/MyChildren’s PHR will bring in data from both the hospital’s Cerner system and the eCW system used by its physician group. It will use eClinicalWorks Electronic Health Exchange.

Athenahealth announces its guarantee that physician users will be able to quality for HITECH incentives, offering them six months of service free if not. The announcement covers in some detail the complex corporate accounting that’s required to offer something like that, which is interesting in itself. Jonathan Bush quotes Malcolm Gladwell in saying it takes 3% to reach a tipping point, so he’s hoping the program takes the company over the top.

Swedish Medical Center (WA) takes an equity position in 72-doctor multi-specialty group Minor & James Medical, citing their belief that healthcare reform will require cooperation beyond having hospitals simply buy practices. The local newspaper article speculates that the group will move to Swedish’s Epic system, which sounded possible if not likely when I interviewed Swedish CIO Janice Newell a couple of weeks ago.

I visited my doctor recently and have to say I was impressed with the practice’s EMR use. He conducted the whole session with both of us looking at the monitor, walking me through labs and meds (sounds simple, but it was amazingly effective and the display was great even on his puny 15” or so monitor). He mentioned that he would never put a keyboard or monitor between him and a patient, which was cool. I had a sleep study done awhile back and he pulled up the on-screen transcription from the polysomnography people and walked me through their findings. I needed a prescription refilled and he shot that off electronically, saying he was a big fan of e-prescribing, especially for drug interaction checking. The practice is just starting to use speech recognition, which he seemed to like, and also templates, which he seemed to hate (he said he refuses to use them because they create reams of worthless junk data in the EMR). He likes his EMR, I’m in fine health, and we’re both happy. He also said he would definitely get the H1N1 flu shot when it comes out, just in case you’re waffling like me.

A Buffalo group gets a $1 million grant to develop a data sharing pilot project.

Spacelabs announces its Sentinel cardiology information system.

The West Virginia Health information Network delays its RFP for creating a statewide HIE as it figures out how stimulus money and meaningful use definition could change its plans. The new date is November.

Odd lawsuit: a hospital stages a fake pharmacy stickup as a drill without telling employees. A pharmacy technician is suing the hospital and its parent company for false imprisonment, claiming the drill’s aftermath required her to have ongoing therapy for depression, anxiety, panic disorders, post-traumatic stress syndrome, and emotional distress.

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CIO Unplugged – 9/15/09

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

The Politicalization of Health Information Technology
By Ed Marx

Admit it. Health information technology (HIT) deployment is headed nowhere fast. Despite the evidence and supply side rhetoric, demand wanes. Depending on whose study you believe and their definition of HIT, industry adoption of CPOE is languishing in the low teens at best. We can do better for our patients.

Before we dive in, I want to acknowledge the Office of National Coordinator for Healthcare Information Technology (ONC). The National Coordinator plays a central role in how information technology transforms our care delivery system. The leadership is strong, and the Office is blessed by a greater level of funding and authority than in the past. ONC is the principal Federal entity charged with coordinating nationwide efforts to implement the use of the most advanced health information technology, including the electronic exchange of health information. The position of National Coordinator was created in 2004 through an Executive Order and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act [HITECH Act] of 2009.

Next to the ONC, the Centers for Medicaid and Medicare Services (CMS) is another powerful division of the Department of Health and Human Services (HHS). The CMS mission is “To achieve a transformed and modernized health care system.” A key tool for success in their workbench is leveraging information technology. CMS, a professional bureaucracy, was clearly the driver for federal HIT direction and investment until recent legislative changes codified ONC. The ONC and CMS will need to work in concert, finding unity of command and vision, in order to achieve their unsynchronized goals.

Complicating the situation is the legislative branch attempt to control healthcare reform and policy via HIT. On one hand, you have ONC laying out a firm HIT direction; they have the necessary framework, but it’s juxtaposed to the quagmire of healthcare reform. Congress and the white house are materially on different sides of what to do, when to do it, and how. The only certainty is that HIT will be a key component. Unfortunately, due to the lack unity of vision and clarity of goals, HIT is quickly becoming a political lever. And that scares me. HIT is the means, not the end.

Morphing into a government program, HIT could rank with cash for clunkers. We’re incentivized to turn in the old and adopt the new. Although I’m a serious advocate of care transformation via IT, I fear that the motivation is becoming more political than substantive. Where the cash for clunker strategy is a onetime event, we should be investing long term (10 plus years) in HIT and looking for sustainable advocacy with demonstrable support. Incentives are misaligned.

We need to push for challenging meaningful use criteria. What started out provocative and game changing has since been watered down to a welfare-like program. The bar is set too low. Everyone qualifies!—which means we’re not demonstratively leveraging HIT. Instead of reaching high, expectations are lowered, thus removing the incentive to progress materially.

Advocacy groups. Although active dialogue is essential and everyone deserves a seat at the table, too much politicking will derail HIT. Potential is lost in the quagmire of uber engagement, and special interest groups tend to lower expectations and standards. Each group claims to represent a large number of constituents, but at the end of the day, hospital leaders are the ones who will need to make the tough decisions, and execute.

While I appreciate the private/public approach to forming advisory committees, we must intentionally set aside our personal biases to favor the common good. If you look closely at the outcomes derived thus far, you can trace the DNA back to some of the participating organizations. I face the same challenge at the State and City level. It takes a degree of maturity to set aside personal thoughts, prejudices, and organizational goals to pursue the common good. Keeping the patient benefit foremost in our minds will yield the best outcome.

What can we do to help ensure ideal outcomes and prevent the politicalization of healthcare information technology?

• Actively support the ONC leadership.
• Contact senior staff of the House Committee on Ways and Means.
• Contact senior CMS leadership.
• Advocate for more meaningful meaningful use.
• Provide feedback to advisory committee members and pushback on tailor made recommendations that may be of a minority interest.
• Lead by example by ensuring your organization is ahead of the curve.
• Actively participate in your region and state HIT efforts.
• Keep pressure on for healthcare reform

Do it while we still have the freedom to make these choices and influence government decisions.

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.”

Healthcare IT from the Investor’s Chair 9/15/09

Thanks to all who commented on my earlier posting, I appreciated all the feedback and look forward to an ongoing dialogue here courtesy of Mr. HIStalk and the lovely Inga. I’ll compile all questions asked and answer one or two with each posting in addition to my current topic.

With the recent stock market recovery, companies are once again going public (or, as they say on the Street, “the IPO window is open”). Emdeon returned to the public market with a successful IPO in mid-August and Healthport recently filed its prospectus with the SEC. I’ll sound off on both of those shortly, but I’m sure some might appreciate a plain English translation of what I just said along with how it happens.

Following my last post, Healthfreak asked, When does an investment banker tell a company to go in for an IPO or plain loan from a bank?

First, traditionally there were two types of banks — commercial banks (loans) and investment banks (IPOs). Both did much more, of course, but the Glass-Steagall act signed in 1933 drew strict firewalls between the two. While Glass-Steagall was repealed by the Gramm-Leach-Bliley Act of 1999 (and we can see what fun that led to in the financial world of late), let’s assume it’s still in place as different bankers within the a larger bank that offers both services still do different things.

Why would a company go public? It’s expensive, intrusive, and, as the leadership of such companies as Epic, Meditech, or eClinicalworks would likely attest, requires a dramatically increased focus on short-term results over potential long-term benefits. Not to mention it means anyone with a Web browser can learn what senior management is paid.

Companies typically go public for two reasons: they need the money for corporate purposes (such as developing a product, expanding a sales force, or making an acquisition) or they want to provide liquidity to investors or shareholders. Microsoft, for example, never needed additional capital, so its IPO was to allow its employees and founders to ultimately sell stock. Even if existing shareholders aren’t selling stock in the IPO, part of the goal is to create liquidity and a marketplace so they ultimately can, be they founders, employees, or investors.

A loan makes more sense if the company needs growth capital and has, importantly, a business that will generate sufficient cash flow to ensure the loan’s repayment, and if the owners don’t want to give up any control by selling stock. In the case of, say, a biotech or early-stage software company, the business is perceived as too risky to loan to, but is often financeable, as equity investors will take on significantly more risk (in exchange, of course, for significantly higher return potential). Incidentally, the economics of running IPOs are inherently more attractive than loaning money, hence the spate of commercial banks buying investment banks — Citi, Bank of America, and Chase, to name a few.

What’s the process? It typically begins with the company and its board of directors selecting the underwriting team (aka, “syndicate”) by conducting what is fondly known as a “bake-off”. This is a grueling ordeal for both sides, where the company invites a large number of investment banks to come pitch for the business. The banks are often pre-screened based on the firm’s reputation, the quality of the research analysts they have covering the space, and how successful the bankers have been at showing love to management and the private investors.

Bake-offs consist of 60-90 minute sessions during which a team of bankers from each firm parades through the company’s boardroom and explains, through dramatic interpretation of huge PowerPoint decks, why their firm should be part of the underwriting team and, ideally, lead the process.

In an act that has become almost ritual, each bank comes in and presents their firm’s credentials and skills in taking companies public as well as which buy-side accounts they would expect to participate in the wonderful stock offering. Each firm has, in effect, the same map of the country with the same mutual and hedge funds highlighted and talks about their special relationship with the buyers. “But we’re not here to talk about ourselves, we’re here to talk about HIStalkCo” the senior team member says (typically the more the merrier in these meetings, as it shows the prospective firm’s view that this is a client worth dragging senior people across the country for).

The bankers then drop to their knees to talk about what a wonderful company HIStalkCo is (“transformational” and “game-changing” are always good words) and how they would position the story to prospective investors. Prior to Elliot Spitzer’s intervention, this part was done by the research analyst, but subsequently, the bankers have had to play that role, with varying degrees of success.

Next comes the part the investors really care about: stating just how much the bankers think the company is worth.

Here’s where people lean forward. As I shared in an earlier post, stocks trade on their earnings potential and so the company has already shared its projections with the bankers to help them prepare their valuation analysis. I’ll note that at this point one assumes that management’s projections are gospel and (at this point) never challenges them.

(Incidentally, everyone seems to ignore the fact that management’s projections rarely see the light of day — prudent analysts always “haircut” management’s forecasts to help ensure the company can actually achieve them, and valuation is ultimately driven off those projections.)

To predict value, the bankers define a “comp group”, a peer group of similar companies with similar characteristics. The assumption is that similar companies will trade at similar multiples of earnings / revenues / EBITDA, and it’s not an unreasonable assumption. Of course HIStalkCo will trade at the high end of its peer group, so one assumes a similar forward price-earnings multiple and then applies a 15% “IPO Discount” to reach your best guess of the likely value of the stock once it’s publicly traded. The reason for the IPO discount is that portfolio managers need to be compensated for taking the risk inherent in an untried stock. For some reason, it’s always 15% — I’ve often wondered why (perhaps it’s like 186,000 miles per second or other laws of nature).

The fun part in valuation, however, is choosing the comps themselves in such a way as to maximize the predicted value. Everyone wants to hear their company is worth a huge amount, so this is where it gets laid on the thickest. Every software-as-a-service (SaaS) company is comped to salesforce.com. Every HCIT company is comped to athenahealth or whoever the high flyer-du-jour happens to be. Desperate to win the battle of the value, some bankers were comparing Emdeon to Mastercard to goose the expected value — after all, they both process transactions!

It astounds me that companies seem to give so much credence to this part of the presentation, because picking an underwriter based on their take on value is like picking a realtor based on what they tell you your house is worth. As I’ve said in more than one pitch (stating the obvious), it’s the buyers that will set value here, not the bankers.

After all this bragging, positioning, discussing the marketing plan, and valuation, the board room has become a bored room and it’s time to thank the bankers for their thoughtful work and invite the next group in. Then, most likely, hear a presentation that has 90% overlap with all the rest. Finally it’s time to chose the lucky team and move to the next phase.

Time to start writing the prospectus? Sorry, there’s still the happy task of informing the winners, consoling (and justifying decisions) to the losers, and then dividing the hoped-for spoils of victory. Companies, in effect, typically pay the underwriters 7% of the offering proceeds. For a $200 million IPO, that means there’s $14 million to go around. How it’s divided is, as you’d expect, is topic near and dear to everyone’s hearts.

IPOs have a lead manager who typically does most of the work — running drafting sessions, coordinating diligence, scheduling investor meetings (the “road show”), taking orders from accounts, and ultimately setting the price. Not unreasonably, they want a good chunk of the fees for those services — sometimes as much as 70% (way too much, IMO).

There’s also some prestige associated with it. Lead-managed deals are tracked and give bragging rights, so the phenomenon of “co-lead managers” emerged. After negotiating with the lead (aka, bookrunning manager) on how much they get, the company needs to divide what’s left with the co-managers. Each co-manager will insist that they need more — for fairness’s sake, to “motivate the organization to pay attention to the deal”, or due to precedence.

Start writing? Not yet. Besides how much they make on the deal, the banks also care about what order they appear on the cover as that’s another source of prestige and bragging rights. While names on the prospectus cover are first set by order of how big a share of the underwriting the banks receive, after that, it’s due to “precedence”, and it really matters to the banks.

(Please don’t laugh — in my banking career, I’m sure I spent literally hours pleading for a better placement on various prospectus covers even though there was no extra money involved. I even had junior bankers research the vaunted precedence to prove that William Blair was listed under B, not W, and my counterparts no doubt did the same to prove the opposite! Why do the banks care? Candidly, I always wondered.)

Now that the underwriting team has been chosen, we’ll take a short break and my next topic will take us from the organizational meeting through pricing the deal and beyond.

In the mean time, RustBelt Fan asks, What are the signs and symptoms that my vendor is being shopped for buyers?

Ideally, there should be none. Part of a banker’s job is trying to minimize the potential of a leak. As you can expect, that’s a challenge, as information exchange is the lifeblood of the Street. However, while investors and companies might find out, it’s much harder for customers and employees to learn it.

I first encountered HIStalk a number of years ago when a client of mine whose business we were selling called us on the carpet for allegedly leaking information to Mr. HIStalk. The blog had almost perfect information about the process. I confessed with embarrassment that I’d actually never read it (nor had any of my colleagues). But, needless to say, I started reading it then.

Bottom line, RBF — in a skillful process, you rarely can tell. But remember, where there are outside investors, there’s an ultimate need for them to get liquidity in their investment, either through a sale or IPO. Whether you’re talking to a potential vendor or employer, I don’t think asking about investor plans, or, in fact, the state of the company’s balance sheet, should be taboo. As a customer, you’re making a commitment to a vendor, and while a sale of the company might not impact it, hearing what the vendor says can never hurt. Just keep the grain of salt in mind, as they’re often not able to predict what investors will want them to do.

Ben Rooks is the founder of ST Advisors, a strategic consultancy offering long-term and project-relationships to companies and financial sponsors. He earned an MBA in healthcare management from The Wharton School of the University of Pennsylvania, has done healthcare IT equity research, and has worked as an investment banker in over 25 successfully closed healthcare and medical technology transactions valued from $40 to $365 million.

Monday Morning Update 9/14/09

From Ex-Cerner Guy: “Re: Cerner. Not only does Cerner re-sell the data they collect, but it’s part of their Lighthouse agreement and the client gets to pay for the privilege of giving their data away. Look closely at the wording of the agreement — it’s in there. It’s good to read their contracts closely. It’s more fun to sit in on the negotiations and watch the squirming.”

From The PACS Designer: “Re: Govt 2.0 Summit. Tim O’Reilly, of Web 2.0 fame and founder of O’Reilly Media, had some interesting comments at the Gov 2.0 Summit about turning government into a platform to foster true innovation in the years to come.” Tim’s got some shopworn analogies about the iPhone and Twitter in case you haven’t had enough of those, making the point that third-party products should plug into the “government platform” to build citizen services, no different than the Interstate system and the Internet (oops, more analogies). All I could think of was the cool movie Startup.com that documented the quick ride up and equally quick ride down of Govworks.com, which was going to make the founders zillionaires by allowing people to pay parking tickets online. Where were you during the dot-com wars?

From Needs_Gas: “Re: Eclipsys. A recruiter says they have a new model and will be partnering with third-party firms to provide services.” Unverified.

From Luke O’Scyte: “Re: anonymization. There is no such thing as real anonymization any more due to the science of re-identification. You can uniquely identify 87% of Americans with only zip code, date of birth, and gender. Release of such information by companies like Cerner should not be allowed.” I’ve covered that topic before, but it’s worth another mention: all you need is a second database that state or federal governments sell cheap and you can re-identify most of the records in a “de-identified” set. Luke sent a link to a fun article describing a well-intentioned 1990s mandate from Massachusetts state government to release anonymized data covering state employee hospitalizations, which sounded great until a grad student mailed the medical history of the governor to his office. She had easily obtained his full record of his diagnoses and prescriptions by matching the anonymized employee data to a voter database she bought for $20. Only six people in Cambridge shared his birth date, only three were men, and only one (the governor) lived in his ZIP code. That grad student was Latanya Sweeney, now a noted Carnegie Mellon professor and privacy technology expert.

The Conficter worm shuts down takes down all hospital information systems in the Cayman Islands. What’s most interesting about the story, though, is that the article quotes new CIO Dale Sanders, who has been on the job less than a week and who, until recently, was CIO at Northwestern Medical Faculty Foundation. I’m interested in how he ended up there since that sounds like a fun move. I’ve been to the Caymans several times and my impressions are (a) it’s beautiful with stunning green-blue water great snorkeling; (b) it’s also horrendously expensive and has a bad exchange rate on the US-to-Cayman dollar, and (c) it’s an international haven for tax-dodging corporations and shady banks (was that redundant?) whose physical presence is a post office box. Oh, and it has a turtle farm and rum cakes.

Opinions about working at Epic are mixed on Job Vent, which is always entertaining as well as hardly reliable. General observations of those posting: (a) they hire only easily controlled new grads of any major; (b) job evaluations and promotions are based only on hours worked; (c) if you quit to work for a customer after the mandatory one-year waiting period specified in the contracts of customers, you are an untouchable who isn’t allowed to interact with current employees; (d) the money, benefits, and the non-cubicle environment is nice for new grads. Some of the posters claim a 1984-type environment where employee conversations and Web activity are monitored, warning of the “thought police.” One pro-Epic cheerleader claims, “We hire scary-smart people, so if they can’t cut it at Epic, they will still be a rock star somewhere else” which maybe means in a different industry since 22-year-old philosophy grads with zero work experience of any kind aren’t exactly in high demand in HIT. As a capitalist, though, I like the model: pay a little more than you have do, bring people to a location where they have few career alternatives, demand more than you should expect, proclaim cheap meals and snacks a benefit instead of a way to get extra hours out of employees who might actually leave for lunch otherwise, keep enough quirk on hand to fool wide-eyed noobs into thinking that wintry Wisconsin farmland is a hip Silicon Valley Midwest, and keep a big file of backup resumes to feed the churn. It’s working for Epic and, greenhorns or not, they innovate more than their competitors.

Cerner will hire 12,000 new employees by 2020, Neal Patterson says to the government of KCMO to soothe the civic feathers he ruffled by choosing the Kansas side of the border for his soccer and HIT complex.

Thanks to Kronos for becoming an HIStalk Platinum Sponsor. The Chelmsford, MA company offers a wide range of workforce management systems that optimize the cost of delivering quality care, minimize risk due to noncompliance with requirements, and maximize productivity. Some of its applications include timekeeping, human resources management, payroll, workforce analytics, employee scheduling, and absence management. They have several research and case study papers on their site. My thanks to Kronos for supporting HIStalk and its readers.

Results from my poll about vendors notifying customers when their software has patient-endangering problem: 37% said their vendors were bad about that, 39% said mediocre, 25% said good. New poll to your right: how much impact will Dell have on the healthcare IT market now that it will offer EMR hardware, software, and services?

I like this idea: an online debate on whether to implement CPOE vs. barcoded medication administration first. It features two highly regarded pharmacists with informatics expertise. 

I think I may have joked before that RHIOs might as well try for ARRA grants as regional extension centers since they often don’t have a business model otherwise. Apparently it’s no joke: the Harrisburg Health Information Exchange (PA) submits its grant request. 

Another reason to ignore stock analysts who cover industries they clearly know nothing about: this article covering Dell’s announcement about reselling EMRs is full of eye-rolling inaccuracies: (a) the headline says Dell will “make” electronic records; (b) it calls EMRs “the device”; and (c) it opines that Dell’s big competitors will be Google and Microsoft, apparently confusing PHRs with EMRs.

An odd lineup on yesterday’s CBS News Sunday Morning: “Dennis Quaid discusses electronic medical records; the end of ‘Guiding Light’; poetry; upcoming fall films.” Dennis’s G.I. Joe did great until word got around, disappearing without a trace after three weeks. He’s up next in the sci-fi (or is it Syfy?) thriller Pandorum, which opens September 25. The trailer looks lame to me, but my taste varies considerably from the apparent mainstream.

Merge Health extends its agreement with Russian medical equipment vendor Rossyln Medical, which will integrate Merge’s PACS technologies into its custom solutions.

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HIStalk Interviews Avery Cloud

Avery Cloud is CIO at New Hanover Regional Medical Center in Wilmington, NC.

Tell me how your Project S is structured, what it’s designed to accomplish, and your thoughts on portfolio and service management.

Project S is exactly that. It’s a service management initiative in disguise. I’ve tried to move away from this idea of talking in a language that means nothing to my customers. We basically took service management concepts and repackaged it into something that was explicable and digestible by our audience.

What created the need to do this in the first place was an analysis of where we stood and our ability to meet service levels or to create customer satisfaction, also to build an infrastructure that would support the coming strategic initiatives that we saw down the pike.

For example, we’re moving rapidly into full-function EMR. We knew that we have to have a structure that supports remote ambulatory care environments. We have to have different service levels for that.

Analysis showed that we just weren’t set to work quite ready for that. We had a maturity study done and we had about a 1.2 level maturity against a maximum of 5. It also revealed that we need to move somewhere around a 3.2, 3.3 maturity level in order to provide the kind of services that would be required to make our organization successful. That gap represented the tools, skills, policies, standards, procedures that are necessary to deliver high levels of service.

Our goal was to create stability: stability in our systems, stability in our service, stability in our satisfaction levels. That’s four Ss and that’s how we coined the term Project S.

Is the maturity level you mentioned CMM or is there something other that you measured that with?

IBM has a customized version of ITIL. They have a service level maturity or service maturity index.

How rigorous and involved was it to get that number back to tell you where you stood?

It was pretty rigorous. It was about a two-month-long analysis.

You got some help from Compuware in putting this together. What did you find you were lacking in terms of knowledge and abilities? Were there any new things that they insisted you bring to the table that you didn’t already have in your shop?

That’s a great question. One thing we lacked was a repeatable process. That’s where adopting ITIL came to bear.

Another we lacked was skills in the right areas. We had plenty of skills, but not necessarily the presence of the right skills for the right job.

We were also lacking tools. Tools essentially mean that we weren’t in a position to automate ourselves so that we could provide higher levels of service. As you well know, you can’t do everything in a manual fashion and be efficient and effective.

Those will be the areas that pretty quickly emerged, and that’s what led us to an analysis of what our toolkit should be.

We believe in the idea of integration. Integration is something that is quite absent in many IT organizations. We tend to be the worse, we’re much worse than our customers when it comes to buying one-off tools for every problem. What we try to do is buy an integrated toolkit that helps us run the business of IT.

That, in fact, was our mantra. We wanted to manage IT like a business, and therefore put in the business systems required. A good example is that we wanted to mimic our financial department, financial and HR. We have one product that manages finance and HR, and that’s Lawson. It has materials management, and then it has payroll, it has financial reporting, accounting, general ledger — you get the drift. It’s a well-integrated product which redoubles its ability to produce efficiency than if you had individual products for each of those foci.

We wanted to help this integrate into one product set, our monitoring initiatives or monitoring processes, our early detection and warning processes, but also our project management, change management, problem reporting, our time management, our budgeting process, our IT governance reporting process, our automated workflows.

That was really important to us. The system lets us embed the knowledge of experts and the systems, therefore driving a repeatable process. I said a mouthful there, covered a lot of territory, but I hope you get some sense out of that.

I don’t want to ask you what it cost, but how much of an effort and investment was it to move from where you were to where you are?

It’s probably the biggest thing this IT organization has approached since its inception.

How did you get the support to undertake such a project in these times?

It was simply outlining the gaps between customer expectations and our ability to deliver and matching a solution to those gaps. The organization wanted those gaps filled enough that the sale was much easier.

It’s kind of interesting. I had to highlight my failures, [laughs] which really is a risky and uncomfortable approach, but in fact, it is the right thing to do. I had to highlight the fact that I had a 30% drop call rate at the help desk. I had to highlight the fact that nine out of 10 problems that we encounter are called in to us by our customers rather than us notifying the customers of the existence of the problem. In other words, they find it before we do.

So you begin outlining all these things, and then you start talking about what’s coming in the future, and you’re going to have doctors who are going to need the services of that help desk with that low performance. You’re going to have doctors who don’t want to have their systems to fail when they’re in the middle of a surgery. You’re going to have nurses that can’t administer medications to patients in pain if the barcoded med system is down.

We were able to use kind of Walt Disney’s “imagineering” approach, just tell a story about how things are and how much better things could be.

ROI was not as necessary when you looked at it that way, because when you really looked at it, the case we were making was a case of staying in business. [laughs]

Overall, is the end result that you have restructured the department and changed the staffing mix and staffing levels?

Yes. We’ve done two substantial re-orgs through this process, continued to evaluate our staffing plans, and brought on a chief technology officer. We made some major staffing changes, major training changes. Our organizational processes don’t even resemble what they used to be.

If you’re talking to your CIO peers, what would you tell them is the key to know that you need to have this done and the thoughts to entertain before they start?

I think, you know, customer’s king. The key is to evaluate the customer’s level of satisfaction with services being provided. You can’t do that without getting very involved and face to face with the customers. So that’s number one.

Also, the study of where your organization is going is vital. You’ve got to forecast what are the strategic demands coming into your organization, and what are your current abilities to support the future.

One of the things I’ve said quite often in team meetings is we have to future-proof IT. We’re not future-proofing it against outside attack; we’re future-proofing it against internal demand. The whole idea is to create an IT organization that is not a constraint to business decisions.

Did the evaluation find that the IT department was underfunded?

Oh, yeah. There were some adjustments made there also. Probably another way to look at it is funding is not in the right places. It was not just underfunded, but the distribution of money and funds — are we spending our money on the most important services and problems?

How much larger did your operational percentage of total budget need to be to meet these standards that were laid out in the evaluation?

Let’s see … what was that percentage increase? I don’t want to guess at it. Suffice it to say that it went up modestly. [laughs]

And you had that commitment going in, knowing that there were things to be accomplished that might cost money, that the folks writing the check would say, “Yes, we’ll buy those recommendations and fund them?”

Right. You have to prepare an organization to accept that. Obviously, marketing the project as goals and describing what it takes to meet those goals helps prepare an organization for an additional cost.

I believe we really did an excellent job on not making those costs burdensome. If you really look at our budget, we have stayed at just about the same expense percent revenue. It has gone up slightly, but not enough to sound alarms. [laughs]

What are you doing to establish relationships with your physicians?

One of the things we’d done is strengthen our governance process. We have a group of physicians that are integral to our governance and decision making to represent physician needs. We’re also looking for better support models for docs. We know service levels required for docs are far different than anybody else in the organization. They don’t have five minutes to hang on on the phone.

We’re looking for easier ways for them to communicate to us that there is an issue. They might want to simply let us know one of the keys is sticking on a keyboard. You’ll never hear about that from them because they’re far too busy to stop and tell you if you don’t make it easy for them to do that. They’re not going to pick up a phone because they don’t like being put on hold.

All those things we’re doing from a clinical perspective. We continue to enhance their portal. We make that their one windowpane to clinical information, or one pane of glass to clinical information is what I’m trying to say. We continue to enhance the speed, we set service level agreements for response time on the full transactions that represent 80% of their work. We are spending a lot of time right now prepping up for computerized physician order entry. That’s going to be a big one for them. Those are the big things.

In summary, the two most important things if you were to ask a doc is that the systems fail a whole lot less, and they run a whole lot faster.

Are you doing anything specific to stimulus funding?

Yeah. CPOE is going to be part of the “meaningful use” definition. We’re working with our physicians not only in the hospital, but with community docs that are affiliated with our hospital, and even extending our reach to all the counties that we serve, and collaborating with other hospitals and their physicians to start talking about health information exchange and how we can better share information, and how we can help them achieve the maximum stimulus dollars available.

What kind of things are you doing with the physician practice EMRs and practice management systems? How are you tooling up to get them prepared and to get your integration strategy with the doctors going?

Boy, I tell you, it’s essential to have a meeting before we talk about that. [laughs] It’s probably one of the more interesting things I get to spend my time on.

Anyway, here’s our strategy in a nutshell: we are going to standardize on one system, one physician EMR that we will recommend, and we will pre-build any necessary interfaces back to our hospital systems. Therefore, if a doc agrees to select that system, and of course we can’t make them do it, but if they agree to select that system they know that they automatically are going to be joined in the information sharing with the hospital.

This is also where HIE comes. We are looking for our own kind of mini-HIE for docs that might not agree to purchase that particular system, and at least provide some way for them to participate in information sharing with the hospitals that they have admitting privileges to.

We’re differentiating very clearly between docs that we employ and docs that we have affiliations with, and trying to provide those two levels of service. We’re really trying to work out the kinks on what is going to be our support model. Are we going to be the ASP, or is there going to be a vendor ASP involved? Might there be a hybrid model? There’s still a lot of unanswered questions, but we are right in the middle of trying to sort all of that out right now.

What would your credibility have been before you did Project S as opposed to now?

They would have run me out of town for real. Don’t you write that. [laughs] They would not have even considered it because our service levels were so abysmal that there was no confidence. There was a crisis of confidence in our physician staff with IT. Rightfully so.

What had happened was the needs of the organization had grown faster than the IT of the organization’s abilities to support those needs. That’s not unusual. That is the reason you have these clearly defined and measurable maturity levels for IT organizations, because you have to match up your IT organization’s capabilities with your internal customer’s demands.

Last question. If you look back at the last couple of years, what are the smartest things you’ve done as CIO?

What a great question. Smartest thing I’ve done as CIO … probably dealing with IS as an internal business. Allowing that perception to govern how I make decisions helps me make the right decisions. That would be one.

Another one would be taking no prisoners when it comes to hiring the best. I’ve got to have a team of people who better and more ideas than I do. I want to be the idea vetter, not the idea creator. Surrounding myself with good people — it takes a while to finally get that figured out, but if you do that right, the rest of the job gets easier.

In terms of information systems, specific or technical things that I’m proud of — I kind of don’t know how to say this, because I don’t know how to say this and make it print right, but I’ve spent time with a particular vendor and greatly influenced their product direction. We use a product here, a bed management system that a particular vendor and I drew on the back of a napkin, and he turned it into a product. So I’m pretty proud of that. I didn’t get a doggone thing out of it, but I’ve got a doggone good system.

Maybe another way to put it is I’ve always worked very hard to match a technology to a problem, and not just push technology.

I’ve got to share this one, too: putting in strong governance. If you want to succeed, have strong IT governance.

I always liked somebody who’s got a really firm vision on what needs to change without getting so wrapped up in the minutiae like hospital folks so often do, so it’s refreshing to have somebody with a plan who actually made it work, especially when you get into stuff like infrastructure and staffing and IT governance, which is usually kind the Vietnam of CIOs. [laughs] You get wrapped up in all the stuff you really can’t get closure on.

That’s so true. I tell you, my boss and I had a long conversation. He said, “Avery, what you’re very good at is the visioning part of being a CIO,” and he said, “I really like that about you, and what you’ve got to do is make sure that you have a structure around you and manage the details.” Because what happens to a lot of CIOs is they get pulled down into details and never get up the 30,000 feet to see what’s going on.

Is that inherent in their background, though, when you’ve got a lot of folks who worked to move their way up through IT, which is the argument of “are you better off with someone who’s risen through the IT ranks”, or better off to get a visionary who just lets other people worry about the nuts and the bolts?

That’s an interesting debate. I’ll just tell you about me: I came up through the technical ranks. I hold an MBA, but more importantly, I have an affinity to business. When people ask me about me and my job, I tell them I’m a business person who just happens to know IT.

I’d like to think that I could run any of the departments in this hospital. A good example is that nobody is surprised when the CFO runs the pharmacy department, or the CFO runs materials management. It should be no big surprise either that the CIO can do the same, or does the same. A very good friend of mine in another hospital — he’s the CIO there — runs the pharmacy down there. Another friend of mine who’s a CIO runs the home care division.

So a chief information officer is not a propeller-head. A good one is a business person. You think like a business person, and you recognize the importance of your specific trained professional discipline, which is IT, but you don’t let it rule you.

I think there are advantages to having a technical background because it does help you understand when your people are talking to you. I’ve seen the other side of the thing where the person did not come up through the technical ranks. It must be horrifying to be a person who has a strong grasp of the business but has no clue about technology, because the language we IT professionals talk on can be scary.

That’s why, frankly, a lot of CEOs are uncomfortable with IT reporting directly to them. If you’re not the kind of CIO who’s a business person, your CEO is not going to take to you. CEOs don’t want to hear about the bits and bytes and stuff.

I’m going to share this with you real quick. One of my crusades is to make my organization think about what we do from the customer perspective. Don’t tell me that the systems are up 99% of the time. Tell me how many hours you were down, because that’s how the customer looks at it. Don’t tell me that the server 214 is down. Tell me how many patients are getting backed up in the ED. Tell me how many fewer registrations I’m going to do per day because of this. Tell me what my impact’s going to be to the bottom line.

Part of our monitoring effort here is to cause our monitor to tell us what’s happening in the business based on what’s happening in IS. You’re not seeing a whole lot of IT leaders thinking that way, and that’s a problem.

I really want to pick up my phone and say, “You can probably expect a two or three percent decrease in collections today because we have some stress on one of the segments on the network that prevented as many bills going out.” That’s a different phone call than if I called my CFO and said to him, “Just wanted to let you know that your people are going to be a little frustrated because systems are running slow today.”

So I think that is really what IT leaders have got to strive for, the user viewpoint, the user view of the services that IT provides.

News 9/11/09

From Chi Lover: “Re: Eclipsys. Eclipsys is having another round of layoffs today (9/10/09). How can they sustain their implementations with so few staff?” Unverified. Another rumor making the rounds is that Allscripts is thinking about buying Eclipsys, but I mention that purely for entertainment rather than business value since lots of signs point to the likely inaccuracy of that speculation.

From Bobby Orr: “Re: Cerner. I’m disappointed in your thoughts that Neal would do anything that is not motivated by money. Cerner would compile a massive database of patients that could de-identified and sold to the pharma companies for research, trending, etc. Go with the cynical version because it is great business idea that big pharma would be willing to pay big dollars for. The stock is not blowing everyone out of the water because Neal has bad business ideas.” You’re probably right, especially with all the non-proprietary ways the government could get surveillance data (I let my cynicism down for one moment and got busted!) One reader commented on the article, asking how Cerner would deduce H1N1 given that there’s no ICD-9 code for it; another replied that they would simply be looking at ED admissions in which the patient has a temperature that’s a certain amount above normal. If that’s all it does, then it’s worthless.

From Who Pays For EHRs? Patients: “Re: Cerner. People might have forgotten that Cerner already is selling patient data to pharma and there really isn’t any such thing as anonymized data. I guess no one is buying Cerner, so they need to do something.”

From Sr Health Integration Tech: “Re: Cerner’s H1N1 surveillance tool. I believe the CDC already has the capability, known as BioSense. It takes HL7 messages, which are made anonymous prior to transmission, and the aggregated data is analyzed for the region to determine if a ‘biological incident’ exists.” That brings back a memory that UPMC had developed a biosurveillance tool for the CDC or NIH years ago (I remember downloading it). I don’t know if it’s the same one.

From Cal Worthington: “Re: HIEs exchanging data. From what I’ve seen at many of the state-wide HIE conferences being put together to respond to the HITECH act, only the PhD/MDs are salivating over the HIE to HIE exchange because of the research they are doing. Most are professing my patient imperative, ‘the closer to the patient the faster the information is needed’ — which I believe cannot be done in a cost-effective way as you get farther and farther away from the patient’s home turf. However, I do believe that certain CMS, CDC, SSA, and research data could be exchanged in that manner, making reporting a behind-the-scenes activity to healthcare delivery. Once that happens, we’ll get better data without the administrative overhead. HIEs are effective collaboration tools in a community of healthcare providers with significant overlapping patient populations.”

From Mike Mills: “Re: iPhone emergency apps. I bike a lot, so I bought the Road ID, a wrist bracelet with my wife’s name and number and an 800 number and PIN. The system ‘talks’ to the EMT and tells them my name, blood type, any medical conditions, meds I am on, allergies, etc. That is much better and easier than a phone app, easier to find, and they make one version of the wrist band that is nice looking so you can wear it all the time.” Pretty cool for $9.99 a year. EMTs call the phone number or go to the Web page on the bracelet and a text-to-speech app reads off the information.

From Colorado Kid: “Re: Steve Hess. He left Christiana Care and joined the University of Colorado Hospital as CIO.” Thanks to the several readers who passed that info along. I feel like John Walsh for tracking him down publicly.

From The PACS Designer: “Re: wait times. As we digitize more health information, we start to see more innovations migrate to the Web. Middlesex Hospital (CT) is one institution that is going digital in their Emergency Department when it comes to posting wait times on the web for treatments which exclude real emergency situations.”

dbMotion, Allscripts, and Initiate Systems will host a Healthcare IT Executive Summit later this month in San Francisco. The topic is, of course, ARRA, which has dislodged every other topic from every HIT event (maybe HIMSS will be nothing but people talking about Meaningful Use and getting government money). It’s invitation-only, so if you didn’t get one, join the club.

Readers have added quite a few events to the HIStalk Calendar in the last few days, so check them out or add your own events for free (I keep saying “for free” since I don’t think everyone has caught on).

Listening: brand new from Phish, who shows they’re more than spaced-out live jammers. Lots of little 70s prog bits in there. Meanwhile, the music industry’s only possible savior is a group whose last album was recorded in primitive tape equipment nearly 40 years ago, the 50%-still-alive Beatles. Quality really does last, apparently.

Midwest Orthopaedics chooses SRS after taking its free EMR free trial.

Dell gets into the PM/EMR business, offering a sponsored solution to hospital-affiliated doctor groups that can include hosting, HIE services, a monthly lease payment, onsite services such as practice and workflow assessments, and 24×7 hardware and software support. Tufts and Memorial Hermann were early adopters. Partners include eClinicalWorks and Perot. That’s bigger news than the Sam’s Club announcement, I think, since Dell is offering everything for one monthly payment and practices need a lot of support. We’ll have our interview with Bill Shickolovich, CIO at Tufts-New England Medical Center, posted shortly.

The Dell story made The New York Times, which dug deeper to see what other vendors are doing. GE will roll out a hosted version of its systems in a few months, eClinicalWorks has 10 data centers for hosting, athenahealth will announce a marketing drive and technical assistance program within the next three weeks, IBM is creating a cloud-based service for EMRs, and Verizon started a 500-employee healthcare unit that will offer hosting and data sharing.

Construction will start soon in Wyandotte County, KS on an 18,500-seat soccer stadium and a 4,000-employee Cerner office park with 600,00 square feet of office space. The $414 million project, funded by bond money, covers the two organizations that Neal Patterson and Cliff Illig own most of — Cerner and the pro soccer team there. Not shown: the pizza delivery man observation platform atop the giant ticking clock.

The CRIMSON Initiative, a physician profiling system sold oddly enough by The Advisory Board Company who bought the company last year, announces that it’s being used by over 200 hospitals. One hospital CEO is quoted strangely: “If I had the ear of President Obama, I would tell him that we need two things, a national fishing holiday and the CRIMSON application.” He also calls it “a diamond in the rough,” implying there’s something “rough” about it.

The Physicians’ Drug Reference (PDR) is merging with the Health Care Notification Network to form PDR Network, offering the online drug reference and FDA provider alerts. A reader reported in May that something was up with Medfusion and Medem, Medfusion bought Medem’s health services business in July, and former Medem CEO Ed Fotsch is now listed as CEO of the new PDR Network.

The cost to McKesson to provide security to John Hammergren: $402K per year, the fifth-highest cost in the Fortune 100, way more than the cost of protecting the CEOs of ExxonMobil and the car companies.

Rockingham Memorial Hospital (VA) chooses NextGen’s PM, EMR, imaging, and community health solutions.

I missed this: Medicity CEO Kipp Lassetter, MD spoke Wednesday at the Robert W. Baird Health Care Conference.

Who believes this? Delnor Hospital (IL) says it hasn’t had a medication error in 15 months. I guarantee I could snoop around for an hour and find several, although maybe they really meant medication-related sentinel events.

Halo Monitoring announces that its home monitoring and personal alert system can send data to Microsoft’s HealthVault.

Informatics Corporation of America brings on three new regional sales directors for its ICA CareAlign data sharing and portal solution.

The State of Kentucky opens registration for its e-Health Summit, which is Wednesday at the Hyatt in Louisville. John Glaser is on the agenda (warning: PDF) representing ONCHIT.

GE Healthcare announces its plan to develop wireless monitoring systems it calls Body Sensor Networks, replacing hard-wired medical monitors with wireless versions that could be used anywhere in a hospital or at home. The company has also petitioned the FCC to create a dedicated frequency band for low-power, short-range monitoring systems. That sounds like a great alternative to moving patients around in the hospital just to get them to a monitor-covered location.

Insurance company WellPoint apparently has cleaned up its much-publicized software glitches that nearly drove the company out of business, receiving notice from CMS this week that it can resume selling its Medicare insurance plans.

Mediware announces Q4 numbers: revenue up 4.3%, EPS $0.07 vs. $0.04.

E-mail me.

HERtalk by Inga

Fall River Health Services (SD) alerts patients they are converting to Meditech Client Server EMR this week, a change that will allow them to connect with Rapid City Regional Hospital.

The DoD signs a contract with CliniComp to deploy its Essentris inpatient clinical documentation package at 36 additional military treatment facilities.

West Park Healthcare Centre (Toronto), Northeast Georgia Health Systems, and Hunterdon Medical Center (NJ) are awarded 2009 QuadraMed User Excellence in Software Technology awards. The award recognizes success in maximizing operational efficiencies and delivering high quality through QuadraMed technologies.

Weeks after MetroSouth Medical Center hosts a first year anniversary barbecue, the Blue Island, IL hospital lays off 120 employees. Just a month ago the Chicago Tribune reported things were looking up at the former St. Francis Hospital & Health Center. Now administrators are blaming the decline in patients for creating additional financial pressures.

E-mail Inga.

Readers Write 9/9/09

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Healthcare Clearinghouses
By Skip Tumalu

You’re asking the right questions about X12 and clearinghouses. The answers, as is sometimes the case with EDI issues, may lie beneath the surface. And bravo for insisting on transparency. But do take the time to investigate, measure and test. Do not let the inability of your business partners to approach transparency trap you into a corner with no exit. Let’s take a quick snapshot of the surface issues and “what lies beneath.”

Eligibility on the surface
Provider transmits data elements per payer requirements. Payer responds with Eligible or Not.

Eligibility underside
The more non-required data elements the provider transmits, the more likely the payer will falsely respond Not Eligible. Why? There was a keystroke or other error in one of the data elements. The data set did not match. Not Eligible. Or, the payer eligibility system is old, cranky, or attempting to comply with governmental program rules and “just says no.” Don’t worry — false negatives on eligibility are usually less than 15%. Remember this when we discuss how much you might invest to get YOUR own revenue cycle to Six Sigma, as measured internally.

Claims on the surface
Provider transmits complete claim and “scrubs” the data elements or pays for “scrubbing.” Payer accepts and pays some claims, but a double-digit percentage are rejected or pended. Providers don’t like to reveal their percentage of claims that are sent in a second time. Want to see real discomfort? Just ask about the percentage that must be sent in a third time. It is not always a single-digit number!

Claims underside
Payers have massive legacy rules tables for claim editing/adjudication. A payer might say they have XX thousand rules they apply to filter and route claims in their processing silo. If you run enough claims and keep track of results, it is not hard to show that the payer is wrong. It is not XX thousand rules, but perhaps 150% of XX thousand rules.

How can this be? Payers edit their adjudication tables. They do it frequently. The process may be less than Six Sigma, folks! Over time, they have a table full of best efforts — not a Six Sigma system. And no, you won’t get any payer to agree that this is remotely possible. This also means that if you measure diligently, your payers won’t be very responsive to this issue. Why? Can you imagine the consequences if they stepped up to solving this one?

I met with a provider who admitted to having most claims submitted more than once and many claims submitted a third time before payment. I said, “Gadzooks – your Days Revenue Outstanding must be really large.” They said, “No, it is less than two days.” I asked how that could be. The response was, “We deposit payer reimbursement checks the same or next day — we have about 1.5 Days Revenue Outstanding.” I said that we need to count from the day the claim dropped and had my head handed to me — I was yet another false expert with no understanding of how the revenue cycle really works. This type of “unintended conspiracy” of weak partner systems and small misunderstandings can indeed cause some major pain!

It is interesting to note that with big ERP installations down, the large systems integrators are selling a lot of engagements for “total Six Sigma healthcare revenue cycle reengineering.” I’ve chatted with some nice folks about the view above regarding eligibility and claims, the surface view, and the underside view. They’ve said, “So what, our re-engineering is underway and we are not Six Sigma yet.” I’ve asked the about the cost and payback for total re-engineering and heard of many projects investing more than $10 million with paybacks greater than one year.

Cheeky bloke that I am, I’ve asked what the “process quality” of eligibility and claims might be, based on local estimates of the “surface” and “underside” issues mentioned above. Folks will readily agree that process quality on eligibility may be 80% on a good day and claims process quality may be 60% on a good day. I then ask what happens when the middle of the 80% and 60% goes to Six Sigma. The response is, “Please don’t mention this to anyone — it was an important investment that we were counseled we had to make urgently.”

If you’re still doubtful, there is a test you can perform to understand “aggregate process performance” — not of your provider systems, but your total environment. Got Self-Pay? Got Unpaid Self-Pay? Sending any Unpaid Self-Pay to Early Collections? Screen your output file heading to Early Collections a day in advance — ONLY if you’re prepared to see 5% or more of the accounts with valid current eligibility that will pay the claim! If you get 7.5%, 10%, or more, be prepared to call it “an anomaly” and do re-testing over an extended timeframe. 

You can do your own math on the implications this has for what payer eligibility responses and payer claims adjudication are doing to YOUR revenue cycle, regardless of your standalone process quality. Besides, don’t you think there might be a compliance issue you’d rather avoid in heading towards collections with folks covered by Medicare, Medicaid, or a commercial payer where you’re in-network? If you don’t have resources to do this screening, then it might be worth paying to get it done. And remember, this is hardly your fault. Even if your “process pipes” are Six Sigma, if you’ve got “gray water” in the eligibility data incoming and “gray water” in the claims back from payers, you are simply using a pristine Six Sigma solution to “pump gray water.” At least don’t promise that the new Six Sigma system will reach process levels that your business partners don’t support and have no capability of reaching. Prepare to measure and report the “grayness” of your business partners’ water.

OUCH!

What are the implications of these possibilities? (I don’t expect them to be real for you until you check it out in your environment with your own payer mix, systems and data results)

1. Ignore processing charges at first. Instead, focus on process performance. If you’ve gotta pay to get process quality end-to-end, pay for performance before you get trapped chasing “false economy.”
2. Expect weak results on eligibility and focus on making it as easy as possible for staff to check eligibility when and where it makes sense. Unless it is absolutely EASY, your results will only be worse than the typical “gray water result.”
3. Expect >> 90% of claims to be accepted and paid as submitted, first time in. Impossible? Ask around. Quality solutions are not free and they are out there. Don’t settle for “we send the claims on as quickly as we can” or “we check each data bucket, for sure.” Use process metrics and announce that your headed for excellence. You’ll be surprised to see the world change around you. And yes, you may need to pay some small fees. Those are small compared to the cost of carrying one or two months of needless Days Revenue Outstanding at a time when banks and revenue bonds are “not behaving normally.” Your Treasurer can provide updates on that issue. Only ask if you have time to listen to a true tale of woe.

The Value of Clearinghouses
By Jim Denny

Scott Bayou’s Sept. 2 commentary on healthcare clearinghouses raised some good questions — and ultimately was dead-on.

In theory, there should be no necessity for transaction or interface fees. The intent of HIPAA was to provide, and ultimately enforce, an interoperability standard. In reality, however, that hasn’t happened. This means that practices and hospitals must force the issue by refusing to do business with vendors that charge these fees. They must instead insist upon free and unlimited access to X12 transactions.

Within this imperfect environment, it’s also wise to recognize the value that clearinghouses bring to the current marketplace — hospitals and medical practices alike — through standardization, efficiency, and leverage.

First of all, if electronic transactions were truly standardized as noted above, today’s typical clearinghouse might indeed be redundant. But the truth of the matter is that different payers transfer files in divergent formats with varying content, supported by a wide range of service levels. Providers are saddled, in other words, with a myriad of technical challenges when it comes to claims and revenue cycle management. Advanced clearinghouses serve as an “EDI translator” that can streamline submissions, provide meaningful visibility into claims status and adjudication, and reduce days in A/R.

Secondly, clearinghouses give providers efficiency (and economies of scale) they otherwise would not have. Let’s say that all providers across the country unerringly run into problems submitting one type of claim with one specific payer. To make adjustments, each provider would have to modify its own system. A clearinghouse, however, could update its edits engine or change processes for all its clients, relieving them of monitoring and “fixing” payer-specific anomalies. This is particularly true for SaaS-based clearinghouses.

Lastly, clearinghouses provide operational leverage. Consider data warehousing and the business or clinical intelligence it can supply to providers. If information is locked in a payer-biased clearinghouse, providers will be unable to extract, aggregate and analyze data in ways that are meaningful — much less beneficial — to them. Payer-sponsored data clearinghouses perhaps provide a more cost-efficient option. But we must remember that their objective is to serve payer interests, not provider interests.

Provider-centric clearinghouses, on the other hand, are able to offer provider-focused information that delivers valuable insight about performance, utilization, and outcomes that allows them to track key measures and gain leverage during contract negotiations.

Jim Denny is president, CEO, and director of Navicure of Duluth, GA.

Follow the Yellow Brick Road
By Craig James

Call me the EHR heretic or the guy whose sister the house crushed in the Wizard of Oz. My comments have nothing to do with how hard everyone is working, their professionalism, or their skills. So much for my disclaimer.

You can’t read a blog or Twitter post without tripping over hopeful accolades anticipating some miraculous intervention by one of the standards committees, the RHIOs, the HIEs, or the Meaningful Use  or Certification Committees. Example:

State CIOs Get ‘To-Do’ List, HDM Breaking News, August 25, 2009 — The National Association of State Chief Information Officers has published a report giving guidance to CIOs as their states implement health information technology provisions of the HITECH Act within American Recovery and Reinvestment Act.

The act requires state leadership in two primary areas: oversight for the planning and deployment of health information exchanges and management of the Medicaid incentive payments for meaningful use of electronic health records, the report notes.

“The HITECH Act placed a significant amount of new responsibilities on states in regards to state oversight for HIE and the planning and implementation grants for preparing for HIE,” the report states. “During this initial planning period, state CIOs must secure a seat at the table to establish themselves as key stakeholders and also to recognize strengths and identify weaker points that require resolution within their own offices relating to statewide HIT/HIE planning. They must ask themselves what they, with their unique enterprise view, can do to support and contribute to each of these areas.”

Let us remember the mission — accurately and timely delivery of your records from A to B. You are 1,200 miles from home, unconscious, and are rushed to the ER in a clinic in Smallville. EMRs from your oncologist and cardiologist, your CT-Scan, and your nuclear stress test, along with a list of your meds, are in the hands of the nurse practitioner as she awaits the doctor’s arrival.

Now let the grownups apply logic. Hundreds of vendors, an equal number of standards — by definition, an oxymoronic statement — home-made EHRs, outpatient EHRs, EHRs serving as RHIOs, IPA EHRs, IPA RHIOs, real RHIOs, and HIEs. Certification and Meaningful Use — another oxymoron.

Here’s a simple question. Who among us can make a reasoned argument that the current plan will enable everyone to get from A to B in 3-5 years? Right now, we call it interoperability. It’s the fly in the ointment and its degree of difficulty and costs are grossly underestimated. If you believe you can, I would love to see it articulated. I do not think the RHIO / HIE / Certification / Meaningful Use plan will work, not do I think anyone who isn’t making revenues from the current plan can make a reasoned argument. Couple that design with the fact that the vast majority of IT projects that cost more than $10 million will fail.

So what? In six to eight years we will have an open, national, browser-based EHR. Maybe we should spend time figuring out how that will work.

TPD’s Review of Semantic Web Concepts
By The PACS Designer

The Semantic Web is a term that some might find confusing when they hear about it from others. The Semantic Web consists of websites that can converse with each other to provide a more robust web experience. Sir Tim Berners-Lee, an English engineer, computer scientist, and MIT professor is the director of the World Wide Web Consortium (W3C), which oversees the Web’s continued development. He is the inventor of the World Wide Web, which was launched on December 25,1990.

Berners-Lee in 1999 had a vision of what the Semantic Web should be. “I have a dream for the Web in which computers become capable of analyzing all the data on the Web — the content, links, and transactions between people and computers. A Semantic Web, which should make this possible, has yet to emerge, but when it does, the day-to-day mechanisms of trade, bureaucracy and our daily lives will be handled by machines talking to machines. The ‘intelligent agents’ people have touted for ages will finally materialize.”

In order to improve the World Wide Web (WWW) with more semantic capabilities, we need to review the current framework of the web. The World Wide Web is constructed using a Uniform Resource Locator (URL), the generic term for all types of names and addresses that refer to objects on the World Wide Web. A URL is one kind of Uniform Resource Identifier (URI).

Another Web term is Resource Description Framework (RDF), which is intended to provide a simple way to make statements about Web resources such as Web pages and other online resources.

Now, at the end of our first decade of the 2000s, we are set to embark on a move to a more interactive Web experience.

One way to improve the Web experience is to improve the linking capabilities to the various web resource storage locations.

The Universal Data Element Framework (UDEF) provides the foundation for building an enterprise-wide controlled vocabulary. It is a standard way of indexing enterprise information that can produce big cost savings through the linking of Web resources.

One of the early linked solutions available that employs semantic Web attributes is called “Twine.” Twine is a new way for you to collect online content — videos, photos, articles, Web pages, products — and bring it all together by topic, so you can have it in one place and share it with anyone you want. Twine can be called a “mashup for the Web 3.0 era” as we move toward a Web 3.0 world. All we need now is for Tim O’Reilly to say it is officially here!

So for healthcare collaboration, if we combine linked resources in a secure private cloud, we can create a place where decisions can be made to treat patients using a broader  base of information sources.

Also, healthcare can really benefit from the move to employ more semantic Web concepts in the years ahead and begin to obtain more knowledge in the war against diseases!

http://semanticommunity.wik.is/
http://en.wikipedia.org/wiki/Tim_Berners-Lee
http://www.viswiki.com/en/Universal_Data_Element_Framework
http://www.twine.com/

News 9/9/09

From Cynical CIO: “Re: Cerner. Interesting initiative. What’s in it for them?” Click the graphic above to see the letter from HHS Secretary Kathleen Sebelius to Cerner CEO Neal Patterson, taking him up on his offer to create an H1N1 surveillance network made up of Cerner clients. Attached to the letter was Cerner’s pitch to its customers, asking them to sign an agreement allowing Cerner to distribute HIPAA-compliant aggregated data from their facilities. It sounds kind of cool. Benefit to Cerner? Well, Cerner got face time with Sebelius, did her sort of a favor, and may get unspecified IT vendor benefit someday. Add that to having a former Cerner director as President Carter’s … err, President Obama’s healthcare reform czar and you’ve got friends in high places who are spraying great gouts of taxpayer dollars directly at healthcare IT. Still, I’d say Cerner’s intentions were more noble and focused primarily toward their clients and their patients, so I tend to believe their claims of sincerity.

From Michael: “Re: Texas Toast. A certain high profile technology / billing service company issued walking orders to 30 practice management billing employees at 2:00 PM Thursday. Word on the street is that physicians are ‘heated in Houston’. Silicon Valley VC types have learned that hand-to-hand combat the physician office billing trenches is a different kind of war. The VC types ‘donated’ $13.8 million to a lost cause in March of ‘08. I’m wondering about the physicians, their cash flows, and how many physician-initiated lawsuits are on the dockets.”

From Bells are Ringing: “Re: UPMC. From their site: ‘Alcatel-Lucent, a telecommunications industry powerhouse, has played an important role in delivering innovative communications platforms, including multimedia and data infrastructures, wireless and wireline broadband access, and full network optimization.’ Fact: so-called high tech telecom has been disruptive to care processes at the new Children’s Hospital since inhabitation in May. Shhhhh.” UPMC and Alcatel-Lucent are joint venture partners, so there’s no chance of discouraging words being heard.

From Fred: “Re: Meditech. Their latest technology first was known as Focus (internally), then C/S 6.0, and the latest is Advanced Technology. You wonder how long they spent thinking about this one.” That name makes me think of the IBM PC AT, which wasn’t advanced for very long. Interesting: did 6.0 sound too much like an easy upgrade when it wasn’t, or maybe was it a good marketing opportunity to rebadge a big technology change to impress the market? I have to say I like the strategy even though the name is kind of white bread. I’d have gone with Meditech Optimized FOcus , or MOFO for short. Quick, no peeking — which name do you remember, theirs or mine?

From Mike Mills: “Re: HIEs exchanging data. Maybe the people living in those regions could get stimulus funds for travelling to the other regions, where they could get sick, so that the providers could actually have a reason to view clinical data for someone who lives four hours away!” I tend to agree that the “unconscious in the ED while on vacation” is a stretch, but somehow people always assume that happens a lot. I figure it’s 0.005% of the healthcare that raises the interoperability cost by maybe 25,000 times over just connecting everybody in a single region, but everybody likes irrelevant analogies like those involving cell phone service or ATMs.

From Mick: “Re: Steve Hess at Christiana Care. What happened to him?” Nothing that I’ve heard. His name is still on some recent press releases and his LinkedIn profile says he’s still there.

Listening: relatively new music from David Byrne and Brian Eno, reader-suggested. I’m not a huge fan of either (maybe more of their former bands, Talking Heads and Roxy Music, respectively), but it sounds pretty good.

HealthHiway, an India-based HIE platform vendor that offers connectivity to doctors in India for as little as $200 per year, gets $4 million in funding from Greylock Partners.

I’ve been getting hammered lately by vendors and organizations wanting me to provide free advertising. For Webinars and conferences, you can add them to my events calendar yourself at no charge. I won’t link to your survey, run your press release if it doesn’t interest me, or give you space for your promotional article, sorry. Everybody would stop reading if I cluttered it up with all that stuff like lots of industry sites do.

Craneware announces FY09 results, with sales up 68%, revenue up 23%, and profit up 29%. I just now remembered that I was on the hospital IT steering committee that approved what must have been one of their first US sales going back at least eight years ago. They had a pretty good story even then.

Inga is turning into Weird News Inga, having sent me this: a 65-year-old man gives the finger at a healthcare rally — literally. Healthcare reform advocates and protesters in California get into the stereotypical heated discussion (likely armed with lots of emotion and minimal facts) when a pro-reformer allegedly confronts an anti-reformer. The anti-reformer, saying he “felt threatened”, punches the pro-reformer in the nose. They get into a full-on fight and the pro-reformer bites off the anti-reformer’s pinky. It’s nice to know that such an important issue is being debated with civility by well-informed citizenry. I’m beginning to think that 90% of Americans don’t have the intelligence or knowledge to debate laws, vote, or serve on a jury, being intellectually suited only to vote contestants off reality shows.

The US Patent Office grants TeraMedica a patent for its Evercore solution and its concept of Clinical Information Lifecycle Management. 

Regenstrief EMR pioneer, HL7 co-founder, LOINC developer, and IOM member Clem McDonald receives the President’s Medal for Excellence from Indiana University. He’s now director of The Lister Hill National Center for Biomedical Communications, a research organization that’s part of the National Library of Medicine.

A great PR gimmick: the MyMedicalRecords PHR people offer to reimburse subscribers up to $5,000 if they get H1N1. The relationship between the offer and the product is tenuous at best, but it’s kind of fresh.

Up to 11% of doctors aren’t offering immunizations because insurance pays less than the cost of the vaccine itself. Studies show doctors send patients to public health clinics instead, but parents don’t often follow up and kids aren’t being immunized. CDC is very interested, having observed that half of kids with measles were seeing doctors, but didn’t get the shot.

Which of these doesn’t belong with the others: Eclipsys, athenahealth, HIStalk Practice, and Sage. The answer: none — all of those organizations (and others) are sponsoring the AAP Pediatric Office of the Future exhibit at the American Academy of Pediatrics conference in Washington, DC October 17-20. This isn’t one of those lame “media sponsor” deals where all you do is run free ads. HIStalk Practice is a real, “I’m writing a check” sponsor in support of our regular contributor, Dr. Gregg Alexander. Now I doubt you’ll start making travel plans just because HIStalk Practice is involved, but if you’re going to the conference anyway, check it out and maybe find Gregg to say hi. There’s no booth or anything, just a PC running a presentation that I haven’t figured out yet.

Norwalk Hospital (CT) CIO Jamie Mooney is named as a mentor for Columbia’s technology management program.

Former Eclipsys SVP Keith Figlioli is named SVP of the healthcare informatics division of Premier. He has no informatics background that I can discern.

From Weird News Andy: in Australia, Queensland Health has the answer to patient harm caused by overworked medical residents whose on-call shifts run up to 80 hours: drink six cups of coffee a day and eat more sugar. Maybe they should have added regular trips outside for a smoke or maybe a snort of cocaine.

Doctors from St. Vincent’s Hospital in Manhattan develop an AIDS exposure treatment widget that will be available throughout New York State. They treat exposure “as a gunshot wound in terms of urgency”, saying that infection risk is reduced by 80% if treatment is started immediately.

The Social Security Administration gives a former IBM futurist his first job as CIO, putting him charge of a $1.3 billion IT budget. He’s a good blogger, so maybe that sealed the deal.

Just as I suspected: using Facebook is a good mental workout that keeps your mind sharp, while texting, reading Tweets, and watching YouTube make you stupid. Evidence abounds.

The Army’s MC4 battlefield EMR wins two government technology awards. 

Fidel Castro editorializes on healthcare in Cuba, railing against Philips for offering discounts on medical equipment for Cuba and Venezuela, but backing off when the British government started investigating the patented software and parts it was sending there. They’re buying instead from Siemens, which is hardly shocking.

Former 3M executive Alan Wittmer joins Mediware as SVP of corporate development.

Ambulance chasers increased their TV advertising by 1,400% in the past four years.

E-mail me.

HERtalk by Inga

The nation’s unemployment rate increases to 9.7% in August. Also up: the number of jobs in healthcare, with the industry adding 28,000 more last month. Since the recession began in December 2007, the sector has added 544,000 new jobs. The biggest growth areas are in ambulatory care, nursing, and residential care.

Given the current employment situation, it’s not too surprising that more college students are showing interest in healthcare informatics and information management. Colleges offer 270 accredited programs (53 at the bachelor’s level) and another 30 are expected to be certified by the end of the year.

Healthcare data analytics company Verisk Health acquires TierMed Systems. The acquisition will allow Verisk to offer TierMed’s HEDIS reporting solution.

 
Here is a new iPhone app that sounds kinda cool, but I wonder if it will take off? For $2.99, you can buy ICEbeacon, which allows you to add family/physician contacts, allergies, medical conditions, and current meds. You also get a sticker to put on your phone, which alerts emergency personnel how to access the information. Personally, I don’t want to put a sticker on my phone. And do EMTs spend much time looking for patients’ phones?

The Department of Defense Military Health System extends its 16-year relationship with EDS, signing an $8.1 million, 12-month add-on contract. EDS will make technical enhancement to to DHIMS systems.

Christ Hospital (OH) implements EpicCare Ambulatory EMR at its 35-physician medical group and regional therapy centers. The hospital is also giving community physicians the opportunity to purchase the EMR and connect to the hospital’s system. When I went to the hospital’s Web site, I noticed they have end-user training roadmaps that can accessed (not sure if that is by design or mistake). The level of detail is pretty impressive.

The local newspaper discusses the recent Epic live at Carilion Franklin Memorial Hospital (VA) and its sounds as if all went smoothly. The hospital’s IT director is quoted as saying, “No one has cried, and that’s a good thing.” Yup.

I see the AMA has set up a Facebook page to communicate updates to physicians and patients. I guess I am not social media-savvy enough to appreciate using Facebook to get news from groups like AMA or HIMSS. I’d rather use Facebook to learn what my friends are up to (stuff like, “I washed the dog today,” and “My daughter had her first soccer game”). I also got yet another request in my Inga inbox to set up an account. I guess I could and then post things like, “Boy, was that CIO I interviewed today boring!” or take some inane quizzes like, “Which shoe are you?” Or not.

E-mail Inga.

HIStalk Interviews Janice Newell

 

Janice Newell is CIO at Swedish Medical Center, Seattle, WA.

Do you think the government’s strategy of subsidizing EMR purchases is the best way to improve patient outcomes with technology?

I certainly share their belief. I think the only thing that’s going to push adoption is money. Whether or not their approach is the best way to do that, I haven’t given a lot of thought to. But I don’t think anything’s going to move these docs but money.

Will subsidizing the purchase of EMRs themselves incent usage or will there need to be more steps that follow?

This is the easiest question?

[laughs] The second part got harder.

Well, yes. Certainly, incenting them to adopt it is a necessary first step. Then at the other end of it, there’s this little, minuscule penalty they’ll take if they don’t adopt it. That’s certainly more significant as time goes on, the penalty.

But I think the other thing that’s going to be key is really getting some significant measures of outcomes in performance, and how is this really changing the outcomes and cost, because if it’s not doing all that, why bother? 

Is your strategy any different at the health system based on what the government does or doesn’t do, or are you pretty much down the path that you plan to stay with?

We’re pretty much down the path. We had really made a huge commitment. We’re a relatively small health system, about $1.3 billion. We had already made the commitment that we were going all in with the Epic system, and so committed about, let’s say, $120 million to it over the past four years. We were going there anyway.

When you look back at that investment, would you say it has paid off as you expected four years ago?

I certainly wouldn’t say that it paid off yet, because in fact, we still have pieces that we’re implementing. But yeah, are we starting to achieve the things that we had outlines we were going to achieve? Absolutely.

What kinds of things were you looking for as measurable benefits?

Certainly we were looking for providers in general to have the information that they need as they’re actually caring for patients wherever they are. We’ve certainly achieved that, in that we have it available everywhere.

Also, in terms of improving our quality metrics, I’ll give you just one small example. Pain reassessment is always an area of interest as both a customer satisfier as well as a JCAHO requirement. Our pain reassessment measures were not that good. We made some changes to Epic in terms of what kind of notices the nurses get about pain reassessments being due. It has moved the pain reassessment measures from the low 60s to the mid-90 percent. The nurses are doing the pain reassessment in the timeframes that are required just by changing how the system was supporting them.

So certainly on the quality metrics, we’re starting to get some traction. Also, in the financial arena, we’re getting some traction. It’s a pretty broad swath there. Certainly it has improved the revenue cycle in terms of how long it takes us to get the bill out the door. It’s improved the level of billing we do, more accurate with better documentation.

Also, still in the financial arena, it’s also helping us standardize processes across the organization. One area that’s a biggie for us is the operating room. Before Epic, we had so much variation that it was incredible. The surgeons have taken it upon themselves with Epic to really start the standardization process of what supplies they use, what supplies come into the room, what ones shouldn’t be there at all. So all kinds of good fiscal outcomes.

But a lot of that must have been other than just technology. You must have had a lot of change initiatives to go along with it. How did you package up your implementation and your change management to make this all work?

It terms of actually sitting down and changing wholesale processes in our operations, we actually started out doing that. We quickly abandoned that approach because what we found out is, sure, we can sit down and talk workflow with our folks in operations. They would describe to us what they thought happened and how they thought things worked. But in fact, we found out that it was pretty consistently not happening that way.

We ended up adopting the approach of, let’s use a good model system, get it in, and make the improvements after that. So in fact, many of the process changes are coming afterwards.

It seems that anybody your size and bigger, along with some smaller, are buying Epic. What’s their secret sauce?

A couple of things. One is that they are an integrated system. I don’t even know how many modules they have any more, but they have one system that supports care in the clinics, care in the hospital, in the operating rooms, all of the billing and revenue cycle, pharmacy, lab, home care, you name it. They have modules to support all of the different functions.

Instead of us going on in a best-of-breed world, where we add two dozen different systems, each individual system, we now just have Epic. It is much more effective from both a user experience and an IT experience to have the same data, the same application be available wherever you are. If you think about healthcare as just a continuum of care, it just happens in different places, either the clinic or the hospital or the ED, it really supports that kind of a model if the organization itself thinks it’s a system. So that’s one reason.

The other big reason is that the Epic implementations are successful. They’ve done this enough. I think they provide very good support for organizations to actually have a successful implementation. I’m not sure I can say of all their competitors that their implementations go relatively smoothly.

How does that work when basically they are young people trained usually from scratch with no industry experience? What are other vendors doing wrong that they can’t do what Epic does?

Certainly the young people without the industry experience has some downside to it. Frequently they’re great technicians without the industry expertise. And if something goes wrong, that could cause some problems. But in terms of the process for actually going about with kind of a project, they have been doing it long enough in documenting what the process is.

Just insisting that their customers go through this process, sure, we all have some variation in how we do it. But Epic is pretty clear in the way they want you to do things. And so we all do things in a somewhat similar manner in implementing Epic.

They are there the whole time. No matter what, you’re going to have an Epic team with you through the implementation.

Meditech and Epic seem to have a similar approach that, right or wrong, they genuinely believe they know better than the customer and protect them from doing things that don’t make sense. Do you think other vendors are too catering to their customers instead of saying, we know the product, just do it our way and it will work?

I think so. Yeah. And the other ones are run by a bunch of marketing people. Meditech and Epic are the only ones that are run by software people. The other ones have a huge marketing influence, sales and marketing.

You have to deal with the idiosyncrasies of Epic, but at the end of the day, if it works, it’s OK.

You’ve said that federal stimulus money must be carefully managed or it will go down a rat hole. Did you have something specific in mind or was that just a general comment?

[laughs] Yes, actually, I did have something very specific in mind. What I had in mind is that there is so much variety in the systems that people have now, and these are just the organizations who could afford to be moderately early adopters.

I mean, if you think about the hundreds of systems that are already in the marketplace, and then you think about multiplying that by some factor as every Tom, Dick, and Harry sees an opportunity in the marketplace and comes up with the $99 EMR, I think it’s scary.

And then you have these little offices who really don’t know that much about technology or how to really use it in their practice, or what can go wrong with that technology in your practice — you know, 99 bucks and I’m going to be able to get $44,000 from the government, how could I go wrong?

So while we already have the data exchange issue in healthcare, some of it because not many of us have much electronic data in front of it because there’s so much variety, but if you multiply that by whatever factor is appropriate with people going out and doing every Tom, Dick, and Harry system, it just seems that there’s a lot of opportunity for that to turn bad.

I think what the government is trying to achieve wouldn’t be achieved if we just end up with, instead of three million islands of information, now we have 23 million islands of information.

Do you think that the certification process as well as the “meaningful use” criteria are going to make that less likely to occur?

No. Say we double the number of EMRs in the marketplace so that people have on their plate trying to exchange data. They’ll not all pass certification, but it’s still going to be a data exchange challenge.

I read your local newspaper’s article that said, hey, what an irony, we’ve got three of the best hospitals in Washington that are basically almost in the same neighborhood, and they can’t exchange information. How do we address this issue of everybody’s being their own silo?

At the end, at making it Epic-specific — with our Epic system, we are actually in the middle of a project to bring our largest affiliated group, about 150 docs, on to our Epic system. So they will be using Epic in their clinics, their own service area. All they have to do is share clinical data with Swedish, and they’re using our Epic system.

Instead of just having a system that supports follow-up functions within Swedish, we now have a system that supports all of the patients in our largest affiliated group, too, that we cross over thousands of patients every year. Our intent is to do that with a lot more of our affiliated groups where they can create their own little space within Epic. They can have their own service area.

It’ll be like they have their own system, except that it will be our Epic system and we will all share clinical data. We won’t share financial data, but we’ll share clinical data.

Another piece, once again at the risk of being Epic-specific, Epic actually has a capability where there are a number of us now around Puget Sound that have Epic. We have it, MultiCare has it — that’s another billion-plus organization — Everett Clinic up north. Epic actually has a feature where in fairly short order, we can have the Epic systems exchange data with each other.

Was that something that led you to choose Epic initially?

At the time, no. It was more the integrated feature that let us choose Epic initially.

How about MyChart? Is that an important part of your strategy to get closer to patients?

Absolutely. It has the ability for them to get at their information without us being the guards at the gate. Sure.

If you look at where you are and where you need to be, what do you say are your most important priorities and your biggest challenges right now?

We still have a few big pieces that we haven’t implemented yet. Two of them happen to be billing. So we need to do those other two big pieces for the professional billing and hospital billing. We’ve actually started that.

The tail end of the spectrum that we haven’t done yet is home care. So we still need to do that. Also included in that is getting it out to our affiliates. So that’s one bundle of work, which is implementing it in more places, more functions.

The other priority is a combination of improving the systems that’s been installed and actually continuing to work out how we’re going to get value out of it. So using the system to be a facilitator for our standardization efforts or workflow improvement efforts. Those are big items for us.

Improving the system itself, making the system simpler, I should say, and using it to improve our work processes.

News 9/04/09

Children’s Boston releases free iPhone infectious disease outbreak application
Rosemary Kennedy leaves Siemens Healthcare for National Quality Forum
Three HIEs are sharing data

From HomeCareMD: “Re: PDF Healthcare. Our small house call practice has been using PDF charts and CCRs for five years and love the convenience and universal applicability of Adobe files. However, it is still hard to direct-admit a patient to a hospital from a house call by sending the PDFs of images and chart elements in advance so the receiving hospitalist / institution has proof of the clinical state signed by the referring physician. All our regional hospitals use silo EMRs which block out any e-mails or attachments unless you pay to play on their medical staff and/or pay to create middleware. My understanding is that ONCHIT is about to break up this cartel-like behavior by requiring realistic ‘interoperability’ standards in such settings. Let’s hope they do. Even HIPAA has reduced requirements in urgent care situations.”

From RockStar: “Re: meaningful use. To Winchester: not sure about your angst. We find MU to be straightforward and have assured our CEO that we will be compliant with all 2015 objectives and measures. Can you be more specific about your concerns?” Personally, I think too many organizations are waiting for what is likely to be an unsurprising set of criteria only to find that they’re too late to get up and running in time.

From The PACS Designer: “Re: Web 2.0 popularity. While we haven’t seen  many Web 2.0 solutions in the healthcare space, there is much more being done elsewhere that has been bringing value back to the institutions that employed Web 2.0 concepts. McKinsey & Company recently polled almost 1,700 executives and found that most are benefiting from the Web 2.0 experience. Healthcare will be joining these early adopters in the coming years since collaboration can only bring more high quality digital solutions to healthcare practices!”

Listening: Nick Cave and the Bad Seeds, bleak but insightful theatrical dirges, one of my all-time favorites. 

I love the online photo celebration of Meditech’s 40th anniversary (check out the “dial up table” shot). I’m still hoping for that Neil Pappalardo interview one of these days. Also announced (albeit belatedly) is that some of the company’s execs met with David Blumenthal sometime before Vice President Biden’s grant announcements back in August at Mount Sinai Hospital in Chicago (a Meditech customer).

Speaking of interviews, I thought I had an inside connection that would get me one with Patrick Soon-Shiong, the billionaire who’s donating $1 billion for “the Bell Labs of healthcare,” but he shot me down.

Healthland partners with the Performance Management Institute to offer an executive information system for its small hospital customers, touting its ability to provide evidence of meaningful use.

Froedtert & The Medical College of Wisconsin credits its applications from Surgical Information Systems with reducing surgical late charges from 43% to 1.1%.

It’s a busy month for HIT meetings and Webinars according to my online calendar. You can add your event for free, you know, which will put it on every page of HIStalk.

Newcastle Hospitals NHS Foundation Trust is delaying its big-bang Cerner go-live via its vendor, UPMC. I just realized that it’s an odd, two-way street: UPMC is implementing HIT systems overseas, while Cerner, through its employee clinic, is delivering patient care.

August was a good month for HIStalk readership, especially since summers are always slow. It was the third-busiest month ever, in fact (barely missing the #2 spot), increased somewhere between 40 and 50% over August 2008. You never know with other sites copying what they see here. Luckily for me it’s harder than it looks, especially for someone who doesn’t have industry background or experience, so they aren’t putting a dent in readership. Thanks for reading. I don’t advertise, so if you want to help, e-mail your colleagues a link, possibly lying and telling them I ran an expose’ about them. That should get me one page view, anyway.

Ohio Pain Clinic creates a virtual clinic with free online patient tools such as videos, activity tracking, and a full electronic medical records system designed specifically for pain medicine. The $1 million EMR system was paid for by outside investors, which is probably an interesting story on its own.

Weird News Andy notices that another hospital decided to Tweet a live surgery. The fact that the Tweeter was a hospital media relations specialist is a good indication that the motivation was right out of some hip marketing newsletter, but the patient’s family said it was nice for them, at least. Of course, if a marketing person sat through all surgeries, they could convene a private family conference call or something instead of using Twitter for the whole world to see, but that just wouldn’t be as cool to report back to the New Media people. Wonder what the plan was if the patient died on the table? And how do you top that — a Tweeted Code Blue?

Children’s Boston develops a free iPhone application to show infectious disease outbreaks in real time, complete with alerts when the bugs are approaching. They call it “participatory epidemiology”. I guess you head for the uninfected hills when you get the beep.

The Pfizer whistleblower will be paid $52 million. Correction: he and his lawyers will be paid $52 million, which probably means he’ll end up owing money.

Richard Tayrien, DO is named chief health information officer of HCA, a newly created position overseeing EMR development and implementation that reports to CMO Jonathan Perlin. He’ll come over from Catholic Healthcare West, where he’s been VP of clinical information systems. Some of the sloppy fact-checking rags apparently don’t understand osteopathic medicine, taking the “Dr.” bait and titling him an MD (although the press release could have been more helpful and said so since “Dr.” covers a huge swath of non-specific ground, but it did say he graduated from a school of osteopathic medicine rather than an allopathic school).

An interesting snip from an interview with the CEO of the best-known medical tourism hospital in the world, Thailand’s Bumrungrad International Hospital (he also shot me down, or more precisely, ignored me completely when I e-mailed to suggest an interview a year or two ago). Anyway, “In 2007, Microsoft was looking to enter the health care arena … and it purchased the H2000 software from a company called Global Care Solutions and they renamed it Amalga HIS. As part of that transaction, we became a partner with Microsoft to develop some of the next generation of the software, which will be a totally digital version…. We’ve identified 37 modules that are the core of the offering and we’ve got various teams working on all of those and some of them have already migrated [to the new modules]. We have different releases coming out, about two a year, over the next to year so that we will be a totally digital hospital … But it requires doctors to type in these things and it’s not easy to get doctors to do that. It could also take something away from the doctor-patient interaction if the doctor has his head buried in a computer rather than looking at the patient and having a dialogue with the patient…. Hospitals, not just our hospital but I think hospitals everywhere, are facing this challenge.”

A laptop containing information on 40,000 patients from the Naval Hospital in Pensacola, FL is missing from the pharmacy department. It was beat up, so they’re thinking (praying) that maybe somebody had it destroyed but didn’t do the paperwork.

HERtalk by Inga

The American Dental Association and HL7 agree to develop joint HIT standards, which should be of great interest to EMR vendors. The goal would be to create consistent IT standards and enhance the coordination of care between medical and dental practices. Does this mean, perhaps, that ambulatory practice management systems might one day be suitable for dental offices?

The public healthcare IT programs for Boston and Denver are named winners of the 2009 Davies Award of Excellence in Public Health. Boston was recognized for its syndromic surveillance system that enables officials to track diseases seen in emergency rooms across the city. Denver was honored for its integrated health information system that includes a patient-accessible web portal for lab results.

Norton Healthcare (KY) hires MEDSEEK to rebuild its consumer website. The official press release says that Norton “partnered with MEDSEEK to accelerate its eHealth ecoSystem strategy”, which meant nothing to me. You kind of have to read a paragraph or two down to understand that Norton is really just building a better website. When did it get so hip to come up with confusing names?

Rosemary Kennedy RN leaves her Siemens Healthcare job as chief nursing informatics officer to be named senior director of nursing and healthcare informatics for the National Quality Forum.

Here’s a shocker: the 30% of doctors who earn $250K or more and significantly more satisfied with their careers than those making less money. Overall, pediatricians represent the most satisfied specialty. Hopefully you (or your doctor) are not one of the 15% “very dissatisfied” with his/her career.

Three HIEs are now able to share data, which I think is pretty exciting stuff. HealthBridge from Cincinnati, Indiana HIE from Indianapolis, and HealthLINC from Bloomington are now able to send to one another data on their combined 12 million patients.

Spartanburg Regional System (SC) plans to deploy Concerro’s shift management system, a component of Premier health alliance’s LaborConnect program. 

Teleradiology company Franklin & Seidelmann Subspecialty Radiology raises $12.5 million to expand into new markets and add services.

Allscripts sends out a tweet that 83 people attended its EHR Stimulus tour stop in Las Vegas today. There seems like there should be some clever gambling joke in there somewhere, but it’s not coming to me.

This settles it. I am learning Spanish so I can spend a few of my early retirement years in Mexico. Thousands of Americans have already headed down there, lured by the flat $250 a year fee for a health care plan with no limits, courtesy of the Mexican Social Security Institute. The plan has no deductibles, free meds, free tests, eyeglasses, and dental work. The biggest question left to figure out is mountains or beach.

E-mail Inga.

Readers Write 9/2/09

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Implementing the Continuity of Care Record in PDF Healthcare Format
By Stasia Kahn, MD

 

As an Internal Medicine physician working in a small digital office, I am frequently called upon to share data with other healthcare providers and patients. In 2005, a colleague introduced me to the Continuity of Care Record (CCR) standard. 

I was impressed with the interoperability of the CCR standard that would allow me to exchange healthcare data electronically with my peers, some of whom are working with an electronic medical record and others whose records remain paper-based.

Since the fall of 2006, I have been exchanging healthcare data primarily for referrals of complex patients. Data exchange based on the CCR is richer than the traditional paper medical record that most primary care physicians fax to their consulting providers.

For example, one of the beauties of the CCR is that complex medical terms are presented in a codified manner, such as ICD-9 codes for problems, NDC codes for medications, and LOINC codes for laboratory tests.  In addition, the CCR generator I use to pull the data from my database allows me to be selective and choose the relevant information that is needed to solve a particular medical problem; thereby improving the efficiency of the receiving providers.

The PDF Healthcare Best Practices Guide and Implementation Guide, which were released in 2007, supplied me with the tools to attach diagnostic images and text documents to the summary document. Most tests and procedures are in either image or text format, and by including these in the information exchange, I am able to help reduce healthcare costs.

In addition, the positive feedback I received from my peers who received PDF Healthcare files in place of traditional medical records gave me the confidence to recently begin exporting PDF Healthcare files to my patients for the purpose of populating an untethered personal health record (PHR). I believe that a patient-directed PHR that has been pre-populated with authoritative data from a primary care physicians’ electronic medical record is the quintessential, longitudinal health record that our national leaders believe to be the Holy Grail that can solve the ills of a broken healthcare delivery system.

In closing, my implementation of the CCR in the PDF Healthcare format has helped me to improve the quality of care I deliver to my patients and at the same time reduce the cost of caring for them. The CCR standard used with the PDF Healthcare Best Practices and Implementation Guides allows for the interoperable, electronic sharing of relevant, codified healthcare information at the point of care for specialty referral and into a robust longitudinal health record of interested patients.

Stasia Kahn, MD is an internist with Fox Prairie Medical group of St. Charles, IL.

Healthcare Clearinghouses
By Scott Bayou

Perhaps I am missing a piece of the puzzle, but I really don’t understand clearing-houses like Emdeon and others.

We have X12 transactions that are supposed to level the paying field, yet most hospitals that I speak with are still sending their payment data through a clearinghouse and receiving the remittances back from the clearinghouse.

On the way back is where the real confusion comes into play for me. I know from companies like HDX that there is a per-transaction fee associated with the creation of the transaction. This per-transaction fee is variable (based on your ability to negotiate?) and varies from 15-40 cents per transaction.

Why? What benefit is being purchased? Each hospital has the right to obtain their 835 remittance, and there are various products on the market that allow for conversion to fixed text formats. Buy once and create postings to your HIS while avoiding per-transaction fees.

What am I missing?

Reporting? Most people I speak with get a limited set of reports from their vendor, and have to pay more if they want to customize reports or add new.

Archival? These transactions are not that big and can be held in most hospital’s Imaging or Document Management applications.

Relationship with vendor? Perhaps, many Siemens customers are given options to purchase HDX – or are they a partner?  Not sure of the real relationship, but someone is making a ton of money out of something that should be transparent.

Management of variances? Perhaps, this is a problem that shouldn’t be, but always seems to exist in the X12 transaction processing world.

Managing the minute differences that are expected by various payers? This might be it! Lack of governance in the payer market begs the need for clearinghouses?

Maybe, but I would love to hear what others think about this.

CIO Unplugged – 9/1/09

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

Healthcare Passion Refueled
By Ed Marx

My passion for healthcare sprouted in high school while working in environmental services at an outpatient facility; they called us janitors back in the 80’s. From that point forward, different encounters have renewed that passion. The most dramatic experience was personal.

A Journey Home. Three years ago this month, my mom traded her earthly rags for a robe of righteousness. After a courageous four-year fight against the ravages of ovarian cancer, Ida Wilhelmine Marx bid us farewell. The entire experience had a profound impact on me not only as a son but also in my profession.

My mom and I were tight. As I blindly plodded my way through adolescence, she represented mercy and grace. When I shoplifted, got arrested for joy riding (14 yrs old), set the house on fire, partied excessively, and flunked junior high, she was there. I’m convinced that if it weren’t for my father’s discipline balanced by my mother’s care, I would not enjoy the successes of today in my education, career, and family.

Radiance. Mom suffered much from illness her entire life. She took the cancer in stride: eight rounds of chemo; two rounds of radiation; and a couple of surgeries. Her sole desire before transitioning from this life to the next was to celebrate her 50th wedding anniversary. When we transferred her to hospice, it became apparent that she would be a few weeks shy of reaching her goal. With my parents’ permission, my brothers and sisters planned an early 50th anniversary party and vow renewal—the final celebration of Mom’s life. Knowing our world would change the following day, that night we put on a heck of a celebration.

Hollywood could not have written a better script. Hospice physicians agreed to give my mom life-sustaining nutrients and fluids through the big day (normally not allowed). They arranged for a “Sentimental Journey” pass: a limousine (ambulance) service for my mom and dad to the picturesque Cheyenne Mountain Resort in Colorado. Two paramedics waited in the background just in case their services were needed (they weren’t). They quipped how special my mom was because the only other person who ever received two paramedics as an escort was Dick Cheney when he came to town.

All 7 of us children attended plus all 15 grandchildren. My parents invited their closest friends. With the backdrop of the Rockies and all the majesty of a traditional wedding ceremony, I had the privilege of walking my father to the front. My oldest brother, Mike, had the honor of escorting my mom in her wheelchair to join my dad at the altar. She looked ravishing; my sisters had dressed her to the “nines.” Her dream was unfolding in real time.

Each of her children had a part in the ceremony as did each grandchild. Assigned to deliver the sermon, I decided not to use notes but instead prayed that God would intervene and deliver a message that would bless my parents and set vision for successive generations. The primary message: my parents had created a legacy of marriage that would impact not only the first generation (me and my siblings), but the grandchildren, and their grandchildren, and so forth. The fact that my parents stuck it out and endured a lifetime full of sickness and health is a testimony to the world: “Yes, it can be done.”

The ceremony ended with the exchanging of vows. A co-worker of mine had arranged for a Papal blessing of the 50th milestone as well, which touched my parents deeply. We printed the blessing in the renewal program. Unity candles, songs, prayers, and standing ovations lent to the evening’s incredibleness. But this was only the beginning.

One Heck of a Show. We then entered the adjoining room for a superb five-course meal. Taking advantage of the live music and dance floor, Dad rolled Mom out in her wheelchair to dance. My parents are fantastic dancers, and seeing my dad wheel my mom around was moving. Throughout dinner and beyond, we danced to our hearts’ desires. All four sons danced with my mom, who was clearly delighted. Even my son, Brandon, danced with her, to which she commented: “You’re not dancing. You’re just shaking your ass!” Next came toasts and the garter ceremony, and all the similar accruements of a fine celebration. At that point, Mom addressed the room with loving words. Dad tried but fell apart. As a finale, guests and family formed a tunnel by joining hands. Dad wheeled Mom through as we hugged, kissed, cried, and spoke blessings. Returning to her limousine, she was still beaming. My dad shared that as he laid Mom in her bed that evening, she said, “We sure gave them one hell of a show tonight, didn’t we?”

Timing. During her illness, I flew out often to visit her. I wanted to be at her side when she transitioned, just as she had been at my side so many times. I missed by 8 hours. But that was okay. Over the years, I’d left no doubt in my mother’s heart of my care, admiration, appreciation, and love for her. Arriving shortly after her passing, I supported my brokenhearted father and assisted with the funeral arrangements.

Kiss. My mom had taken her last breath shortly after midnight. Two of my siblings and my father were at her bedside and described that, while painless, her body struggled for every last breath. As a result, her mouth was stuck wide open. The hospice nurse explained that, given the timing, the mortician would be the only one able to close Mom’s mouth. My sister in-law, an ICU nurse manager, validated this.

Meanwhile, my dad knelt at Mom’s bedside and held her frail body, the first time in months where he could hold her without causing her pain. He kissed her lips. Wept over her. Sometime in the next two hours, while they awaited the mortician’s arrival, Mom’s mouth closed…and she smiled. Comfort permeated the room and reinforced our belief that she had indeed transitioned to a happier place.

Passion Fueled. My mom’s battle allowed me to spend considerable time in various care settings. I observed the processes, evaluated technology, and pondered how things could be improved to benefit caregiver, family, and patient. The clinicians treating my mom lacked the communications and clinical decision support needed to deliver the highest quality of care. I was shocked by the lack of access to critical and timely clinical data. The wasteful amount of paper utilized and manual processing disappointed me. I swore it would never be this way in my work environment. As I took mental notes from the perspective of patient and family, my passion to leverage technology and transform the clinician and patient experience was renewed.

It’s this passion that drives me in my daily work. This is why I’m tenacious in advocating technology, why I continually innovate and collaborate with clinicians, and why I blog. This is why I advocate for more meaningful, meaningful use. It’s the heartbeat behind why I spend more time with my people on leadership, customer service, process, and passion than I do on bits and bytes. Until my people have a heart for patients and are in a position to empathize with their plight, the bits and bytes will be limited. The full potential of technology in the delivery of high quality healthcare comes with a transformed heart.

Thanks, Mom, for refueling my passion as a leader of healthcare technology.

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

News 9/2/09

Medsphere gets $12 million in funding
AHIMA Foundatation gets $1.2 million HHS grant
Nurse develops iPod nursing reference

From Winchester: “Re: Meaningful Use. I’m surprised we’re not seeing more debate on Meaningful Use given the stakes involved. Readers, I hope you’ll chime in: (a) are you delaying given the vagueness of MU? (b) what do you most wish was clarified? (c) do you anticipate major changes by December? (d) are your vendors giving you all the right assurances? (e) is there a scary scenario where you’ll have to tell your CEO you’re not going to achieve MU after all?”

From CDiff: “Re: NHS. Gives another meaning to rationing.” UK researchers find that prisoners are fed better than hospital patients, even though hospitals spend more on food. A quote: “If you are using food as a treatment, it’s not working.”

From Nicole: “Re: EHRs. You did a series of short interviews with several EHR vendors. Can you tell me where to find that?” The interviews with 12 vendor executives ran on HIStalk Practice as a five-part series called EMR Vendor Executives on HITECH. They’re here: 1, 2, 3, 4, 5. 

From Back Pocket: “Re: Navin Haffty newsletter. The newsletter questions KLAS results. Aren’t KLAS results from clients? So, John Haffty is questioning Meditech client comments.” The Meditech consulting company principal complains that a particular magazine’s story about Meditech’s Version 6.0 is “more dramatic and pessimistic” than the KLAS report it cites, which he characterizes as contributing “to unnecessary and misleading negativity and one can only wonder whose purposes are being served.” I’m just happy than an HIT magazine didn’t cheerlead for the entire article, frankly. We know which self-serving interests are at stake: the magazine’s (to get and keep readers) and the consulting company’s (to get and keep Meditech customers). Meditech is at a crossroads with 6.0, which is a really difficult upgrade, readers have told me. It’s a natural time for customers to re-evaluate their options. I’m pretty sure they will not use a free magazine’s article as a key decision-making tool (nor a vendor’s free newsletter either, I would hope). I score the magazine criticism as Messenger 1, Would-Be Shooter 0.

From Hank Kingsley: “Re: HIStalk logo. I don’t think the doctor should be smoking a pipe!” Man, healthcare IT people are so literal. It’s supposed to be ironic, OK? As I’ve explained before, I told the graphics person to give me something very 50s, with the reflector thingie, the square jaw, the old-school white coat, and the pipe with wispy smoke. Ward Cleaver, MD, you know?

From Beulah Balbricker: “Re: comments. Reader comments start off with ‘Re: some topic’. Are they initiating these remarks on their own or responding to specific news items?” Could be either. It’s like a letter to the editor that starts with their subject (which is whatever the Re: says) and a short comment, with all of that in quotation marks and in blue. Whatever follows is my reply. People usually e-mail about something I wrote in a recent HIStalk posting, but sometimes they just send something they want to say.

From Gary Numan: “Re: non-disclosures. A peer of mine was just asked to sign a non-disclosure to get trained in GA-released (not Beta) EMR software from Siemens, so it does exist.”

From Gregg Alexander: “Re: Healthcare Crisis News with Rosalie Michaels. Debuts September 1. A Colbert-esque take on the ‘crisis’, though Rosalie is far more attractive than Mr. Colbert.” I think it proves that everything is fascinating and amusing when a former Mrs. Arizona reads it while smiling and wearing a deep-cleavage clingy black shirt. It’s sponsored by the No Insurance Club, which is really a prepaid doctor visit plan that costs $480 for 12 visits per year, but only has a handful of doctors across the country (I’d be suspicious of doctors willing to work that cheap) and does not cover emergency room, hospital, or specialist visits (so it’s really more of a selective uninsurance program that covers doctors but goes bare on hospitals).

From The PACS Designer: “Re: As the Software as a service (SaaS) marketplace evolves, we are going to see low cost solutions appear for consideration as a service. One that has appeared recently is a security service called the Egress Switch. The UK firm offering this service uses e-mail addresses to validate each member of a secure network, and then encrypts the messages to meet the needed security level for the application being used by the validated members of the group.”

Atlanta Women’s Specialists puts out a press release about its EMR capabilities and its ability to exchange information with other medical practices via the Medicity Novo Grid. It can post and flag abnormal test results within 24 hours and to send prenatal records directly to the hospital. The practice will deploy to smart phones as well.

TeraMedica will offer its Evercore medical imaging system to the healthcare customers of technology solutions vendor Logicalis.

Epic finally works out a deal to get the Epic.com domain from the company that owned it (epicsystems.com still works too). 

A MEDSEEK Webinar next Wednesday features an eHealth Director talking about whether your hospital needs one of those.

Atlantic General Hospital (MD) signs a deal for Keane Optimum Patcom and other apps. Another Keane client, 25-bed Montgomery County Memorial Hospital (IA), is mentioned in an article about IT investments in small hospitals.

Baylor Medical Center at Frisco (TX) chooses Orchestrate Healthcare and Vitalize Consulting Solutions to roll out a new clinical and technical architecture.

The Columbus paper covers the diagnostic image sharing capability of some Columbus-area providers. A doc from the radiologist group complains that Ohio State isn’t one of them.

Jobs: McKesson Paragon Consultants, Clinical Business Analyst, Associate RIS Administrator.

Orion Health and Cisco announce a public health reporting and notification solution.

California can’t manage its fiscal crisis, but has time to legislate the speed with which managed care plans see patients. New regs require that routine PCP visits be scheduled within 10 business days, specialists 15 days, and urgent care appointments within two days. After-hours emergency calls must be returned within 10 minutes. Sounds good except physician payments keep going down and so does their number, both problems that can’t just be lawyered out of existence.

Another example of lawyers fixing everything: the attorney general of Kansas files suit against a non-profit hospital, its board, and its corporate parent. The charge: it’s going broke and will close. The AG is mad that the hospital hasn’t transferred its critical access designation to some other entity that otherwise couldn’t survive financially in Pawnee County.

A nursing professor and her husband develop Nursetabs, a pocket reference for the iPod Touch. They’re in Michigan, I found out after only 10 minutes of digging through the rube newspaper’s site to finally find something that mentioned which of the 50 states Livingston is in.

E-mail me.

HERtalk by Inga

Saint Barnabas Health Care System (NJ) selects MedAssets to provide revenue cycle process re-engineering services.

Medsphere secures $12 million in a secondary round of VC funding, to be used for ongoing development and expansion efforts.

Greenway and RelayHeath introduce a new partnership that will leverage Relayhealth’s Virtual Information Exchange to provide Greenway clients access to lab results, radiology reports, and transcribed documents from their community health systems.

Speaking of Greenway, the company announces its 11th consecutive fiscal year of positive growth, ending its 2009 fiscal year with a 38% increase in sales over 2008 and 88% over 2007. Ever since I can remember, Greenway competitors have loved to discuss how the privately help Greenway wouldn’t be able to make it long term, that they would run out of money and never turn a profit. While higher sales do not necessarily equate to increased profits (or any profits, for that matter), you have to hand it to Greenway for its tenacity and continued growth. There are a lot of sunset companies out there that would have loved eleven years of positive growth.

eClinicalWork partners with Correctional Medical Services (CMS) to provide EMR solutions to correctional facilities affiliated with CMS. eCW already provides its EHR to Rikers Island in New York.

Jeffrey L. Sunshine is named VP and CMIO of University Hospitals (OH) after serving in these roles on an interim basis since November 2008.

athenahealth’s Maine Operation Center is named one of the 2009 Best Places to Work in Maine.

Sheila M. Sanders takes over as VP for information services and CIO for Wake Forest University Baptist Medical Center (NC.) Sanders most recently served in a similar capacity at the University of Alabama at Birmingham.

If you are feeling the need to get up to speed on the upcoming ICD-10 coding system, you can review the new fact sheet being offered by CMS. I assumed it was going to be dry and technical, but actually found it to be easy to understand, nicely laid out, and informative.

QuadraMed names Bonnie Cassidy VP of Health Information Management Consulting Services, to direct the expansion of QuadraMed’s HIM services business and lead the company’s consulting team. Cassidy is the president-elect of AHIMA and formerly worked for CCHIT in certification development and program delivery.

HHS awards the AHIMA Foundation a $1.2 million grant to continue its state-wide HIE consensus project project.

A study finds that the quality of care provided by retail clinics is on par with physicians’ offices and urgent care centers, yet treatment costs were significantly less, although the study covered only sore throats, ear infections, and UTIs. The cost of care was 30-40% less than in a doctor’s office and 80% lower than in an ER.

Oklahoma State University Medical Center selects Lawson S3 Enterprise Financial Management and Supply Chain Management suites. The Medical Center, by the way, was recently purchased from Ardent Health Services by a City of Tulsa trust.

If you are reading HIStalk, you are likely already involved with HIT. Fortunately, the Bureau of Labor Statistics says it’s a good field to find a job in right now, with employment for medical records and HIT technicians expected to grow faster than average for all occupations with an 18% increase through 2016. Within the field, there are different 125 job titles in more than 40 settings, but expect the most opportunities to be in integration, programming, project management, and training.

Stephens Memorial Hospital (TX) plans to add a new EMR in time to qualify for stimulus incentives. The 44-bed hospital will pay CPSI $443,286 for the new technology.

Look for state and local governments to increase their spending on HIT over the next few years. INPUT forecasts that state and local government investment in HIT will grow at a compound annual growth rate of 4.6% between 2009 and 2014, from today’s 7.6 billion to $9.6 billion. Spending on EMRs will grow from $850 million in 2009 to $1.85 billion in 2014.

As of this week, Medina General Hospital (OH)  is officially affiliated with Cleveland Clinic hospital. Now known as Medina Hospital, the community hospital is receiving $40 million in capital investments from Cleveland Clinic and will implement MyChart within the next year to 18 months.

I am fascinated by this new “intelligent” pill organizer that beeps or calls / e-mails patients (or family members) to alert them to comply with treatment regimens. In addition to reminding patients when to take what medications, the MedMinder also produces weekly or monthly reports of missed medication. It’s being offered to consumers for $77 plus $30/month for support and wireless connection. Sort of pricey if you are on a fixed income, but kids of aging baby boomers might find it a worthy investment for their folks. However, I am sure that plenty of patients will find it annoying and will resent the intrusion.

E-mail Inga.

CIO Unplugged – 8/31/09

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

The Secret to Successful CPOE Adoption—Revealed
By Ed Marx

Before revealing the secret, let me establish credibility. I first implemented electronic health records in 1995. A few years later, while CIO at University Hospitals, we achieved a 95% CPOE rate at our academic medical center. Presently, with 12 of our 14 hospitals implemented at Texas Health, we are averaging over 80% CPOE. Remarkably, half of these are entered via standardized order sets. What makes the Texas situation particularly unusual is the lack of executive mandate. The all-voluntary medical staff made it happen. Although I had little to do with the above successes, I did learn the secret.

Organizations will spend millions on consultants, hoping to tap into some sort of magic sauce that they can liberally apply to ensure significant adoption. The majority of these consultants will have had no direct professional experience implementing or supporting the technology. The secret to successful CPOE adoption rides not on one silver bullet, but many. You can do better than a consultant can, and here is how.

These 21 factors, when in synch, will bring your institution success with CPOE. You must be excellent at 18 or more of these to forge the secret.

· Senior Leadership Engagement- CEO must actively promote and reinforce, and receive regular reports. Base enterprise incentives on CPOE adoption levels.

· Hospital Leadership Engagement- Presidents need to be very visible and articulate. Same with directs.

· CMIO- This rare individual can bridge the gap between IT and medical staff. If IDN, recommend multiple CMIO approach. (Not an expensive tactic in the big scheme of things)

· Project Leadership- They must walk on water and be clinicians. They are the face and brains of the operation. Surround them with grace and all the resources they ask for.

· Project Team- Majority should be clinicians. 90% of your team must be actively engaged. The road is long with many winding curves. Build up staying power.

· Clinical Staff- Can’t be successful without engaged physicians and nurses. Sometimes you must facilitate their engagement if initially resistant.

· Culture- Culture eats strategy everyday. Set up literal shared incentives for success. If IDN, culture must acknowledge but transcend individual hospitals.

· Relationships- Relationships cover a multitude of sins. Develop relationships with everyone from clinicians to support staff to leadership.

· Visibility- Key leaders must be visible during Go Live and after. Most of our leaders participate in Go Live support, even if just to answer phones.

· Agility & Velocity- Have a pool of highly trained staff who can respond to crisis at a moment’s notice. Team should report to CMIO.

· Build- Lay a solid foundation from the onset to withstand the continual storms. Design must include clinical staff for usability and acceptance.

· Standardized Order Sets- Present CPOE as the ultimate tool to drive transformation, clinical quality, and drive out costs.

· Governance- Set up an effective decision-making body on two levels: a senior executive team for strategy; a larger team for tactics and operations. Assign clinicians to key roles.

· Change Control Process- Control application evolution at a rate that introduces new features while maintaining an acceptable learning adaptation curve.

· Implementation- Keenly organized, with additional staffing at the physician’s elbow.

· Marketing & Communication- Need a multi-dimensional, targeted strategy including actual customers. Don’t limit yourself to traditional media; be innovative and leverage social networks.

· Training- Use multiple venues: traditional methods blended with modern, such as our video vignettes. Make access to applications dependent upon completion of training.

· Support- Post implementation support must be impeccable and ubiquitous.

· Vendor Connections- Best relationships start at the top, with C-Level execs exchanging strategy and vision. Establish escalation paths to solve issues quickly.

· Infrastructure- Monitor and tune to ensure optimal uptime and response speed.

· Software- Select a seasoned application. Test and retest enhancements and patches prior to releasing to clinicians.

If you can’t deliver on the majority of the above factors, stop your project. Take the hit early where impact is limited rather than when you are too far down the tracks where a collision will occur. I.e. we took a three-month hiatus because our standardized order sets were suboptimal. We retooled. Today, we have 80% CPOE adoption with 50% of all orders coming from the standardized order sets.

A final point to remember. None of these factors is a onetime event. Each requires continual care and feeding. Indefinitely.

Want more? Follow our CMIO and Medical Director on Twitter; ftvelasco; Isaldanamd

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.”

Being John Glaser 8/31/09

If you had to answer the question below in one sentence, what would you say?

What is the fundamental contribution of information technology?

My answer — information technology enables complexity.

Our personal financial assets are much more complex that those of our grandparents; savings accounts have been replaced by retirement plans and mutual funds that can automatically shift assets based on a person’s risk tolerance. Handwritten flight manifests have been replaced by the ability of an individual to book air travel involving multiple stops and carriers. Weather forecasting based on seasonal expectations and reports from adjacent states has been replaced by sophisticated models. Complex activities such as sending a satellite to Jupiter, non-invasively observing metabolism in the brain, and simulating the interactions between proteins would not be possible without information technology.

These problems of healthcare cost, safety and quality are based in and exacerbated by the complexity of healthcare. The knowledge domain of medicine is vast and evolves rapidly. Patients with complex acute problems and multiple chronic diseases will be seen by many providers within a short period of time and undergo several parallel treatments. The delivery system is highly fragmented and dominated by small physician groups and hospitals. Standardized care processes have multiple varieties. Managed care contract provisions can fill volumes.

Information technology can be applied to enable the complexity in healthcare. Clinical decision support and clinical documentation applications can assist the provider in keeping up with medical evidence. Results management systems can highlight the patient data that deserves the most attention. Interoperable electronic health records can support the coordination of multiple providers taking care of an elderly patient. Telemedicine can assist patients and providers in joint management of chronic disease.

Maybe that’s the fundamental contribution of information technology in healthcare. It might enable the current complexity to actually work.

John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

Monday Morning Update 8/31/09

VA plans emerging technology research center
iSoft lays off in England
Children’s Pittsburgh leads peds hospitals in HIT

From Scott: “Re: Joint Commission and nondisclosure. Yesterday’s Sentinel Event Alert provides further support for providers’ rejection of vendor nondisclosure clauses that could limit the sharing of information on software problems that have patient safety implications. The Joint Commission’s previous Sentinel Alert, Safely implementing health information and converging technologies, is also worthwhile reading for providers who might rush to deploy EHR systems in response to federal incentives.” Joint Commission should be all over healthcare IT in the context of patient care. It would give customers a way to collectively pressure their vendors (with regard to design and disclosure, for example). For vendors, it’s still better than having the FDA in your shop. For patients, Joint Commission is the one group that looks out for their best interests as a package, not just how technology is deployed and managed in a vacuum. And unlike HIMSS and its spawn, they have no vested vendor interest.

From Billy Roentgen: “Re: Stanford. Stanford is going live on Epic September 1, replacing Siemens Invision. Palo Alto Medical Group is going live on Epic at about the same time, replacing IDX. Epic is EVERYWHERE, starting in the physician’s office and carrying through to the hospital.” It’s easy to see with 20-20-hindsight why Epic owns the markets they choose to play in: (a) they built new products that reflected that inpatient-outpatient continuum while their competitors kept bolting on marginally useful features and acquisitions onto old platforms that were clearly unsuited for them; (b) they created MyChart before anyone cared about sharing data and PHRs; (c) they didn’t get bogged down in a Viet Nam of unsuitable customers by selling indiscriminately to just anyone; and (d) they ran their implementations firmly and protected customers from their own success-sapping indecision. Nobody else is even close, handing over the entire upper-end market to Epic without much resistance. Cerner had a shot but doesn’t seem to be selling much new business, while the reps from GE, Siemens, and McKesson might as well carry a white flag when they visit hospitals of more than 400 beds. Eclipsys is strong in the traditional inpatient core of CPOE, pharmacy, and nursing, but won’t get a foothold with customers who want a broad application line that covers outpatient in a single database. Epic owes its success to weak competition as much as anything else. In a perfect world, someone would step up to offer an Cadillac alternative, but for now, Epic is running its own Cash for Clunkers program (they get the cash).

From Joce: “Re: Logi-D. Heard a rumor that Stanley InnerSpace might have entered into an agreement to acquire Logi-D. Any truth to this?” I’m probably the wrong guy to ask since I don’t follow either company. Stanley makes carts and cabinets, Logi-D is a Canadian logistics consulting company specializing in the OR.

From The Nuge: “Re: claims. The reader’s comment hit the nail on the head, but that’s only a small part. Look at what happened with Emdeon and Aetna a few years back when they went exclusive (how can that even be legal?) Misys couldn’t send electronic claims to them for months! And what when PCN bought Versyss, declared bankrupty (iirc), was picked up by Medical Manager for pennies, and sold zillions of ambulatory claim events to WebMD? Very well orchestrated.”

From Kwame Mojito: “Re: GE. The nurse call group (formerly Dukane) has been sold internally from GE Security to GE Healthcare under the clinical systems division. It will be interesting to see if they can tie this into their Centricity product in a useful manner. To my knowledge, this will make GE the only EMR vendor who also owns a nurse call system.” And a theme park.

From Curious George: “Re: OSHA. I hear that hospitals are definitely on their toes in case an OSHA inspector drops in for a chat. Do you have any information on how many physician clinics are being targeted by OSHA? Have you heard of anyone who has and what their top five non-compliant issues were?” I’ll take a lifeline. Anyone?

From Ditka: “Re: sales. Greenway, according to a sales rep, is having the best year of their lives. Office Practicum is a small peds EMR with rabid fans and their pendulum is swinging mightily up. I keep seeing eCW everywhere. I’ve run into a bunch of e-MDs sales.” I had not heard of Office Practicum – looks cool (although I’d get those old TEPR awards off the front page). None of the others you listed are surprises.

From Norberg: “Re: sales. What can I say? It’s slow. The problem is that most organizations are almost singularly focused on ARRA. And because of the ambiguity around meaningful use, they’re doing nothing. I would hazard a guess that imaging and all other ancillary (read: non-EMR) solutions are not being given any attention / considerations by providers these days. If it’s not related to ARRA, it’s not getting done. If you’re the incumbent vendor at a facility, it’s probably high cotton for you there. But you can’t even get a meeting at a facility where you’re not the incumbent HIS/CIS vendor. I have some friends in the indy EMR space and they say they’re doing pretty well. I guess there are enough independent practices who are buying that the top 3-5 vendors are making out OK. But the large , monolithic vendors are struggling.”

A funny phony magazine cover from The Onion. Some good headlines: Researchers Quietly Chuckling At Placebo Group, Congress Deadlocked Over How To Not Provide Health Care, U.S. Government Stages Fake Coup To Wipe Out National Debt.

Children’s Hospital of Pittsburgh, says KLAS, is the pediatric hospital IT leader, coming in at #1 of the top five. Of course, it’s only the pre-season poll.

HealthPartners (IN) saved $430K in one year with its implementation of Epic and Merge Healthcare, which the local business paper concludes “is providing some proof for health reform advocates who say that electronic medical records can save providers money.” With a payback period that spans generations, I’d say that particular proof isn’t compelling.

A reader tells me his hospital’s Epic contract has no nondisclosure terms. That’s hard to believe given Epic’s legal lock on everything from employment to implementations, but that led me to a sobering thought: what if Cerner is the only company demanding that language in its contracts? Could this medico-legal brouhaha be over just one overzealous vendor’s contracting practices? A Fan was right in the last issue, though — being legally allowed to talk about known patient-endangering software defects is not worth much if (a) the vendor doesn’t tell you about them until you find them, and (b) the customers who are aware of the problem have no incentive or platform to get the word out to other customers (assuming the vendor isn’t doing it). In fact, some of the IT departments I’ve worked in kept the lid on known errors in a manner little different than the vendor themselves and for the same reasons – vanity, lack of resources to address the issue, and condescension toward end users who shouldn’t bother their pretty little heads with computer topics (which is actually sort of true – if you e-mail any of the big clinical departments about a computer problem, they drive you nuts with repeated uninformed questions and a flood of wildly unrelated problem reports that they suddenly observe and decide are related to the one you mentioned).  

Intellect Resources is doing a three-question HIT hiring survey of recruiters and hiring managers if you are one of those and want to chime in .

Institute for Safe Medication Practices weighs in with ample expertise on the Ohio pharmacist’s error that killed a child. If you’ve done FMEA or other root cause analysis, it won’t surprise you that the Swiss cheese holes aligned once again. Contributing issues: (a) the pharmacy computer system was down, causing the pharmacist to be swamped; (b) pharmacy staffing was short that day; (c) they were too busy to take breaks or even eat; (d) the technician who made the IV was distracted; and (e) a nurse called to get the IV early even though she didn’t really need it, causing everyone to rush it out without following the usual cautious procedure. ISMP likens sending the pharmacist to jail to Whack-a-Mole: “Marx notes that this child’s game is a telling depiction of how we set unrealistic expectations of perfection for each other and then unjustly respond to our fellow human beings who inevitably make mistakes. We play the game at work by writing disciplinary policies that literally outlaw human error.” The bottom line: nobody’s child is any safer now than that two-year-old was then.

The board of Phelps County Regional Hospital (MO) approves a measure that mandates physician CPOE usage.

An excellent Wired Magazine article makes a point that companies that can turn out “cheap but good enough” alternatives to expensive products can thrive, giving fresh-thinking startups a big advantage over their Goliath competitors who “believe the myth of quality” and fail to see "the rubric of accessibility”.  One example is a Kaiser experiment to put high-tech offices in strip malls. “In 2007, Flanagin and her colleagues wondered what would happen if, instead of building a hospital in a new area, Kaiser just leased space in a strip mall, set up a high tech office, and hired two doctors to staff it. Thanks to the digitization of records, patients could go to this ‘microclinic’ for most of their needs and seamlessly transition to a hospital farther away when necessary. So Flanagin and her team began a series of trials to see what such an office could do. They cut everything they could out of the clinics: no pharmacy, no radiology. They even explored cutting the receptionist in favor of an ATM-like kiosk where patients would check in with their Kaiser card. What they found is that the system performed very well. Two doctors working out of a microclinic could meet 80 percent of a typical patient’s needs. With a hi-def video conferencing add-on, members could even link to a nearby hospital for a quick consult with a specialist.” Makes perfect sense to me. Wouldn’t electronic triage be a lot more efficient and convenient to all involved?

University of Central Florida launches its 20-month master’s in healthcare informatics degree.

This can’t be entirely good news: iSoft will lay off up to 100 technical employees in England, but brags it will offset that by hiring up to 50 salespeople.

Odd: PACS vendor UltraRAD gets an FDA warning for “failure to validate computer software for its intended use.” The software that drew the warning: Microsoft’s SharePoint portal and the HEAT help desk system.

The VP of human resources at St. Joseph’s Medical Center (CA) is indicted for paying no income taxes in the past 12 years, also charged with altering the hospital’s computer records to reduce her withholding.

My last poll found that the employer of 18% of respondents is using Skype for some business purpose. Pretty interesting, although now the obvious question is “for what?” New poll to your right for providers: how good are your vendors of clinical systems at notifying you of patient-endangering problems and getting them fixed fast?

The VA is soliciting proposals to build a San Diego-based Emerging Health Technologies Advancement Center. Projects to be conducted there involve identity verification, interoperability, and developing an interface for patient consent directives.

Raj Dharampuriya, one of the founders of eClinicalWorks, is interviewed by India Knowledge @ Wharton. He mentions that the company has opened a Mumbai support center to handle US customers that run 24 hours a day, such as a prison. The company will hire 500 people in the next two years, most of them in implementation and support, and will open an office next month in San Francisco. He credits the Indian culture of the founders in helping them focus on their goal of building a business and changing the delivery of healthcare. He still practices medicine part time and says he’s in the top 10% of performers according to BCBS.

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News 8/28/09

CEO donates $1 billion to create “Bell Labs of healthcare”
Investors seek HIT companies that improve provider cash flow
Organizations partner to create next-generation LIS

From Roger Murdock: “Can you figure out a way to shake the truth out of HIT vendors and consultants? It seems to me that sales and acquisitions of anything HIT have really stalled since the beginning of the year. What do you think? I know vendors are reluctant to say anything other than ‘Sales are through the roof!’, but I don’t think so.” I don’t think so either, in most cases. Some companies, especially those with big market share and some diversification, are doing OK. Most, I’m guessing, are limping along as meaningful use uncertainty and capital constraints keep customers on the sidelines, at least for now. I think you’ll see the rich and the best get richer, while those with mediocre leadership, uninspiring products, and a shrinking war chest will find it hard to keep the vampires away until daylight finally comes. Vendors, please leave a comment (anonymous is OK) about your experience – is it boom times, so-so, or bust?

From Vilma Banky: “Re: MUSC. Funny, but I can remember community hospitals and vendor executives saying that they didn’t need anything that one of those big tertiary care or academic hospitals might need. MUSC provides care across a wide spectrum of patients in the Charleston area. I just can’t imagine them not needing everything for clinical documentation or medication administration. There are relatively standard charting requirement or needs (as well as medication administration needs).” I think Frank was saying that he doesn’t necessarily want it all from a single vendor. I’ve interviewed him twice and I really like him, by the way. I can never tell how someone comes across in the written interview transcript, but I can tell you that he impresses me as honest, sincere, and respectful.

From The PACS Designer: “Re: another WebOS. WebOS platforms are gaining more popularity, and this month SourceForge has named eyeOS as project of the month. The eyeOS  application was created in Spain and is an open source Web desktop that would be good for testing potential cloud applications.”

From Seeking Truth: “Re: Cigna’s decision to stop receiving electronic claims via the Emdeon clearinghouse. The battle is presumably over the fees Emdeon charges payers to receive electronic claims. Cigna doesn’t want to pay and Emdeon doesn’t want to offer a lower price. Emdeon and Cigna may resolve this price battle, or alternatively, Emdeon may ‘reclassify’ the payer as ‘non-participating’ payer (similar to Medicare and Medicaid, which are prevented from paying clearinghouse fees). This reclassification may allow Emdeon to charge providers a higher per claim charge per their contract terms with the provider. The Cigna e-mail indicates other options available to providers, but those options require a vendor change, which may involve other costs to the provider community. Obviously, the healthcare industry is being hammered to ‘reduce costs’ and this may be a payer response to that pressure. As a publically traded company, Emdeon will try to preserve their revenue, though clearinghouse charges may be difficult to justify. Since the advent of HIPAA Title II – Transactions and Code Sets (TCS), clearinghouses have had growing difficulty justifying transaction charges incurred by both providers and payers (consider how many ownership changes for Emdeon, NDC Health, Per Se’ and other clearinghouse vendors since 2002). The upcoming ANSI 5010 conversion may also influence how payers and providers exchange transactions. Dare I say, ‘never a dull moment in healthcare EDI.’” 

From Ex-Cerner Guy: “Re: Waterbury to Meditech. Waterbury hosts site visits and reference calls for Cerner and WH Clinicians are happy. Could be for Patient Financials / Rev Cycle, but even then, I doubt it.” Me too. A reader’s got a line on a source there who may give us the real scoop, which I’m betting is no scoop since I doubt they’re switching.

From A Fan: “Re: vendor disclosure. We’re coming at it from the wrong angle. The real issue here is not what your vendor is preventing you from disclosing, but rather what your vendor discloses to you (whether or not it came from another client). The other thing I wonder is, of the issues that are reported to someone like Dr. Koppel, how many make it to the vendor? There’s no question vendors gear development towards sales, but as we all know, health care has arguably as much bureaucracy as government and the feedback loop from real users to vendors is not great.” I know my vendor doesn’t seem to care much about issues we report, even those with patient safety implications. Their excuse always is: (a) it’s working like we designed it, as suckily as that might well be; (b) nobody else has reported it, so it can’t be much of a problem; (c) you’re doing weird stuff, so stop it; (d) we begrudgingly acknowledge that it’s a problem, but we plan to give you an unrealistic workaround and mark it as a future development project until you simply wear down; and (e) it will take at least a year to get a quick fix into your hands, so that automatically makes it unimportant since you’re stuck with it until then. I’ll also say that none of my vendors have ever been very good at proactively letting customers know about issues reported by others, meaning you go through a ton of testing and documentation to place the neatly tied package into their laps only to be told they already knew about the problem. If your vendor is better than mine, tell me.

All Children’s Hospital (FL)will open its new building in December (a very cool set of daily construction pictures is here – check out the Time Lapse option) and will use the Pediatric Edition of the Patient Life System by GetWellNetwork.

SNOMED Terminology Solutions is offering a free course by teleconference, SNOMED Clinical Terms Basics. New courses offered: Introduction to Terminology and Classifications and Introduction to Mapping.

I’m guesting (is that a word?) at Inside Healthcare Computing with an editorial called Lessons from Shark Tank — Beware of Vendors Borrowing Money or Going Public, where I drew my inspiration from (what else?) a TV show. Here’s a snip: “It also makes me wonder how many dull, average companies got that way because they took someone’s cash, put the founders out to pasture, and set all the fun, smart ideas aside and turned themselves into a bad mutual fund run by second-tier MBA school graduates.” I also worked in a fun reference to, as I call him, Dead Billy Mays.

I guess a wheezing economy has led us to this TV news headline, which refers to temporary jobs at a McKesson H1N1 vaccine center: Swine Flu Brings Jobs to West Sacramento.

Sunquest, Mass General, and Partners will jointly develop a new generation of LIS that focuses on anatomic and clinical pathology. I’ve said for years that if you want to see inarguable success in getting benefits from IT, find yourself some lab people. It’s no accident that the first really useful and clinically-focused hospital systems were LISs, back in the day when “nursing systems” meant online requisitions (aka, “order communication”). The most advanced automation of its kind is in the big reference labs, where you see a lot of computers and not so many people handling pipettes and swabbing agar plates. Instead of complaining about automation, laboratorians embraced it, designed it, extended it (rules capability, standard interfaces, repositories, barcoding, digital imaging, FDA-regulated instrument interfaces, portable data collection, RFID), and are now on the cutting edge of genomics, clinical alerting, and data warehousing. Among all providers and ancillary departments in hospitals, labs are about the only ones that we don’t have to be embarrassed by when talking to people from other sectors that are decades ahead of healthcare. The MGH pathology informatics doc said that tomorrow’s labs will “utilize advanced diagnostic and information management technologies, such as digital pathology, molecular studies, business intelligence and service-oriented architectures to simplify and strengthen the informatics infrastructure.” That ball you saw going over the Green Monster was Sunquest smacking one out of the park in a blockbuster boost to the company.

You know when a press release says somebody “applauds” some government action, they’re smelling cash. The HIMSS Electronic Health Record Association “responded with enthusiasm” (salivation) to Uncle Sam’s decision to donate $1.2 billion in freshly printed and rapidly devaluing currency to pay for the software its members sell. According to the “About” section, membership is open only to HIMSS Corporate Members. Should a non-profit, advocacy-heavy member organization like HIMSS really be running a vendor trade group while claiming to be impartial and patient-centered? As a provider, should I be paying dues to an organization that sells my information to vendors (mailing lists, HIMSS Analytics survey results, conference information), organizes those vendors to influence government policy, and runs Webinars and sales pitches on their behalf that are aimed at getting us poor provider members to buy stuff from its far more lucrative vendor members? It’s Ladies’ Night – I’m getting cheap drinks, but only if I can stand being constantly groped by those paying full price for that privilege.

Peace Health expects to get $30 million from HITECH.

This is one of those times where I say that I’m a bit behind despite working absurd hours, so if you’ve e-mailed me about something lately, be patient – I read every e-mail and respond appropriately, but it might be a bit slow in coming (working two full-time jobs is sometimes challenging).

Another vendor heard from who does not put non-disclosure language in its contracts: Eclipsys. They join Meditech and Medsphere. So. what say you, Cerner, Epic, and McKesson? 

Inga connected with one of our old pals at Noteworthy Medical Systems (they used to be a sponsor pre-CompuGroup) since a reader asked about the Cleveland office. She says it’s alive and well and nobody has moved to Phoenix, although all locations have had some restructuring.

If you don’t read HIStalk Practice, you missed this excellent piece, DrLyle’s Meaningful Discussion about Meaningful Use. Put your e-mail address on that page if you want updates when we write something new on HIStalk Practice – it has its own e-mail list separate from the HIStalk one. We have some fine sponsors, guest writers, and interviews there – like HIStalk, but more oriented toward physician practices.

Sparrow Hospital (MI) kicks off its EMR project.

A sweet deal for Misys PLC CEO Mike Lawrie: his contract requires him to be paid in dollars, so the significant drop in pound against the dollar didn’t cost him loss of several hundred thousand dollars of buying power. With a projected US 10-year deficit now up to $9 trillion, I don’t think he’ll have that problem for long.

In India, Apollo Group of Hospitals has started on its IBM-led “Health Superhighway” connectivity project. It’s also working on a unique ID number project. I’m pretty sure I’ve mentioned both before, but it’s still pretty cool.

A WSJ blog on venture capital says investors are looking for opportunity at the intersection of healthcare and IT (that’s us). It credits athenahealth and its $1.3 billion market cap for increasing investor interest, also juiced by HITECH headlines. As we’ve said here before, though, investors want companies that can improve the cash flow of providers, not those trying to sell a nice-to-have product.

Dayton Children’s (OH) goes live with its $27 million Epic project.

So why isn’t this making headlines? A drug company billionaire CEO/MD is donating $1 billion of the $3 billion he made from the sale of his company “to create the Bell Labs of healthcare”. Some quotes from him: “The idea is to create a health grid that empowers the patient and the provider. This should be a public utility, basically what I call a U.S. public health grid … The idea is to actually go across the country and bring scientists, mathematicians, computer scientists, engineers, biologists, clinicians, surgeons, oncologists, pathologists, all together. And really integrate, truly integrate, information from the basic science to the bench to the clinic … So I’ve started funding and bringing together computer scientist to implement the grid, in an open architecture for the country … We have now the opportunity to jump-start health care, straight into molecular world. Or having the integrated, open-source software system that allows access to the 200-300 Legacy systems of software. So my great concern is, if we go ahead and implement a plan that just says, ‘OK, everybody just has an electronic medical record, with 200 proprietary systems, that don’t talk to each other by its nature.’” This is truly amazing, fascinating, and inspiring all at once. If anyone has a connection, I’d like to interview this guy (maybe sucking up a little in a quest to become Official Blogger of the Bell Labs of Healthcare at a significant salary).

Everyone thinks Cache’ is a healthcare-only MUMPS thing, but here’s proof that they’re wrong: a private bank for rich people selects it to run its Web-based banking system.

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HERtalk by Inga

Christiana Care Health System (DE) selects Patient Care Technology Systems’ Amelior Tracker system to automate the management and tracking of its hospital assets.

Five hundred doctors with Jefferson University Physicians  (PA) will soon be live on Allscripts EHR.

The newly public Emdeon signs a 15-lease for a new data center in Nashville. Emdeon, whose IPO raised $367 million, will rent  34,200 square feet for $39,500 a month, making the lease value more than $8 million.

Thanks to Mike and those crazy guys at Compuware for sending over their latest Youtube creation. This Rockstar CIO interview is definitely worth a 41-second diversion. And since I was amused enough to watch it over and over, I’ll give the company a little pitch for a survey of hospital clinical system users they’re doing that should take about 60 seconds or less of your time.

Covenant Medical Center (IA) agrees to pay $4.5 million to settle alleged violations to the Stark Law and submitting false Medicare claims. The federal lawsuit claimed the hospital paid the five specialists “above fair market value” for their services at rates that were “commercially unreasonable.”  The government claims the physicians, who referred patients to the hospital,  were among the highest paid hospital-employed physicians in the entire country. Records show the doctors were each paid between $633,000 and $2.1 million.

A couple of traditional ambulatory vendors announce they are now offering HIE functionality. Greenway Medical introduces PrimeEnterprise, which enables a community of Greenway customers to share select clinical and financial data. Also, Rabbit Healthcare Systems implements the first phase of its HIE solution, going live with data exchange between McKesson’s Lynx Mobile Inventory Management System, GenPath Reference Lab, and Docuda’s ERCard patient product (it doesn’t sound like an HIE, but that’s what they say).

The Stevens Institute of Technology (NJ) plans to use a $2.8 million grant from HHS to create an electronic system to boost the care of women of color with HIV/AIDS.

The Northwest Pennsylvania AIDS Alliance was also a recipient of grant money to support their IT projects. The HRSA awarded the alliance $45,188, which will allow it to create a new computer network and permit real time access to the Lab Tracker database.

More consolidation in the medical transcription world: Transcend Services will pay $16.2 million in cash and stock to acquire Medical Dictation Services.

The National Quality Forum endorses 18 standards for measuring quality and safety metrics for over-the-counter and prescription medications.

A friend was diagnosed with the H1N1 swine flu, which got me surfing a bit, just to assess the likelihood that I, too, might end up being bedridden. Fortunately my friend is now fine and I seemingly dodged the bullet. Anyway, I found this cool flu-tracker map that allows you to see the the number of suspected and confirmed cases in your community. Or, perhaps to figure out what vacation spots to avoid.

Another ex-hospital worker is arrested for allegedly stealing personal information from patients. The former Our Lady of the Lake Regional Medical Center (LA) employee opened 46 debit cards and filed fraudulent income tax returns. He also received $20,000 from fraudulent claims.

Researchers now believe that women with stronger thighs might be better protected from knee pain. Surely my thigh abundance is related to strength. Thus, I’m no longer going to obsess about the size of my thighs; rather, I’ll now be thankful that they are helping to preserve my articulatio genu.

E-mail Inga.