HIStalk Interviews Loren Leidheiser DO, Chairman & Director, Department of Emergency Medicine, Mount Carmel St. Ann’s Hospital, Westerville, OH

What made you decide to use speech recognition instead of the usual mouse and keyboard? 

I think speech recognition offers a lot of efficiency both financially and also in time savings. The accuracy is outstanding. It allows you to perform chart documentation and navigation through an electronic medical record much more effectively than without it. That is so much better than point and click with a mouse and a traditional keyboard.

What did you use before? 

I’m an emergency physician. We would document 100% of our charts with traditional dictation. That was a very, very costly process. It cost us probably close to half a million dollars a year for an emergency department that saw about 70,000 patient visits. 

The accuracy wasn’t all that good. Our traditional dictation would be farmed out to transcriptionists over in India. When it came back, it really needed to be cleaned up.

We went with the Allscripts emergency medicine product, which was a dynamite electronic medical record. The problem we had was that even the best-in-breed still left a lot to be desired with being able to capture the unique elements of the history in physical examination. And really, the point-and-click, drop-down menus were clunky at best in terms of telling the story. Even the navigation through the software was somewhat cumbersome.

Speech recognition was a natural solution to a lot of the shortcomings of electronic medical records and also with traditional dictation. Your startup costs are reasonable. The training time is very short. Even physicians, allied health professionals, nursing staff — the training time and complexity is so minimal that it’s certainly not a barrier. The cost savings once the initial costs are incurred — really, your investment just pays off over and over and over.

How hard was it to get Dragon to work with the Allscripts product and to get the accuracy up to par?

The Dragon product runs in the background and then it populates data elements right into the electronic medical record. I can tell you, from day one, we’ve had great success using Dragon with Allscripts.

We started back with Dragon 6.0, which was really a product that needed a lot of improvement. That improvement has been seen. In other words, right now, the 10.0 version is absolutely dynamite, for lack of a better way to put it.

Allscripts recognized how good Dragon was and actually started incorporating it with their software, making some special considerations with regard to being able to use speech recognition to navigate through their software, and actually started marketing the Allscripts product with Dragon as a bundled offering to hospitals’ emergency departments.

The onset of the roaming feature, which allows a group of people to save their voice files on a central server and then pull them into any application that you’re using in a given geographical area, has been huge. What a wonderful addition. That has worked well with the Allscripts product as well.

What would you say the main benefits have been and what were some of the drawbacks?

I think one of the main benefits is that you can tell the main story uniquely in terms of documenting a history and physical examination, review of systems, medical decision-making. All those functions that are key, absolutely essential to a physician and an allied health professional, and by that I mean a nurse practitioner or a physician’s assistant.

Dragon offers a way to do that that is so much more efficient and accurate than drop-down menus and with traditional typing. You just can’t achieve the level of accuracy by other means. So I think the cost savings is huge.

The drawback I see is that there have been criticisms about the accuracy, but as I said, what I’ve seen is that the accuracy just keeps getting better and the ability to meet the end user’s expectations has been a commitment that has been a work in process that has been achieved. I’ve used the product for many years, and I put on the headset — I’m a traditional headset user — and for me, it’s just part of the process of being a physician, just like putting a stethoscope on, a normal part of my evaluation of a patient.

I think some people have found that there have been occasional problems with recognition, but there have been problems with traditional dictation being transcribed when it came back with errors. You have to look at it and skim it to make sure it’s OK.

The speed is not a downside. The speed and accuracy actually improve as you talk faster. The recognition is actually improved when you do that. If you slow down, then there are problems.

So I wonder if some of the criticisms is that people don’t know how to use the product. In our institution, we’ve got about 25 physicians that use the product and probably about 15 or 18 mid-level providers. Part of what I do is say, "OK, let’s sit down together and let me show you how I use it." The macro feature where you can store a letter or a pre-set amount of text, then simply use a voice command to spit out, let’s say, a normal physical examination, is huge. That has been a wonderful feature as well. It’s all those little shortcuts that you can really use to improve things. 

These things are easy to use. To navigate through software is very easy. It’s very intuitive. Nuance just continues to make it better and more logical. 

What do you think benefits are, if any, to patients?

I think the benefit to the patients is that it more accurately reflects the medical encounter with the patient. I can be more efficient in my order entry in the medical record. I can do that much more quickly with Dragon. I can document more accurately the historical elements of what’s going on. In other words, tell the story better.

I can reflect what has actually happened in the emergency department by very efficiently using voice recognition to capture a decision or discussion of the risks, benefits, and alternatives with the patient. I can do it at a lower cost as a result of voice recognition compared to traditional dictation, or as a consequence of the increased cost that I incur spending 14 to 18 cents a line for traditional dictation.

Do you feel that, in all the meaningful use discussion, that the use of speech recognition is going to be a help or a hindrance?

I’m very biased on that and I’ve said this for years. When I first started using Dragon back long ago, I thought traditional dictation is going to go away. As much as I hate to see automation taking human jobs, I just don’t think we can surpass the accuracy and efficiency of voice recognition.

I think it’s only going to become more pervasive, in at least the healthcare industry, as we need to have short turnaround times on the documentation in a hospital setting. Now maybe an office setting is different, but the healthcare industry changes and evolving. Already, if you look at what’s going on in the government, we’re trying to cut costs and trying to take money out of the budget for healthcare, in Medicaid and Medicare. This is going to be yet another way we can be more efficient in how we operate.

It’s not going to be just healthcare, either. I think you’re already seeing that with the phone lines, where continued use and development of voice recognition just makes sense. I don’t think it’s going to go away, I can tell you that.

So why do you think so few hospital-based doctors use speech recognition?

You know, I wonder the same thing, because I’ve been using it for probably eight years. I think I’ve been patient with it, I believe in it, and I’ve seen it work. I see it in my own practice.

I don’t know if it’s an issue where doctors just don’t have the energy, or maybe they define themselves as needing to focus on having to diagnose appendicitis, but think they don’t have to focus on the things that are more business-related. I don’t know. I’m in Columbus Ohio, and I’ve talked actually to several other practices who had an initial bad experience with voice recognition, then abandoned the idea and never came back to it.

But I think it’s like most things that we see. With time, the technology improves, the accuracy improves, and all of a sudden you find that the product is now one that really works. And maybe it’s just that I’ve been patient and also persistent. But I also thought that it was going to allow us as a group to reduce our cost of doing business and be more efficient and that has been the case.

Frankly, I think in large part that voice recognition has allowed us to pay for electronic medical record in two and a half years, based on the cost savings that we’ve achieved by eliminating traditional dictation, because half a million dollars a year was eliminated as a result of two things: voice recognition and the electronic medical record. That just continues to accrue year after year after year.

But in terms of why other people haven’t seen the success? I don’t know. Maybe we have, where I practice, a very wonderful support system in the IT department, and a very open-minded, progressive hospital administration that says, "Hey, we have the same vision that you have, and we see that this is going to work and we appreciate the fact that you’re going down this road to develop this."

So we’ve had a lot of support. And when it came to me saying, "Hey, I’d like to upgrade Dragon to the next level," they said, "OK, here’s the money, we’ll make that happen."

Our sister group wanted to have $300 handheld microphones, with a built-in mouse and everything, whereas I was happy with a plug-in headset that cost $15. And I think I get better speech recognition than they get for the $300 handheld mic. But the fact is, we’ve had support from administration who says, "Yeah, go ahead, we’ll support both. You can use the $300 handheld mic and we’ll also pay for the $15 headset." 

Maybe it is that doctors don’t want to wear headsets. You look like air traffic control person. But you know what, if it gives me the desired results better, then I’m going to wear the headset, because it frees up my hands to use the keyboard and the mouse. You know it’s not easy.

I think we want instant gratification. We want a product that, boom, just works out the box. But the fact is that the effort and the time is not that great, and really, if they give it a little bit of time they find that this really is everything that it’s said to be.

QuadraMed Names Duncan James CEO

QuadraMed announced this morning that Duncan W. James will become CEO of the company when it files its 10-Q report next week. He succeeds interim president and CEO James Peebles.

James was previously with McKesson Provider Technologies, where he was group president for Health Systems Solutions from 2000-2009. Previously, he was senior VP for consulting firm Scient and VP of marketing and product management with McKesson.

Monday Morning Update 7/27/09

Top Stories

1. Enforcement of the Red Flags Rule starts this week. Providers who extend or facilitate customer credit (even doing nothing more than mailing bills after services are rendered, some attorneys have interpreted) are required to check patient ID to prevent identify theft, have a policy on handling questionable patient documents and patient complaints, and check to see that patients who claim insurance have proof.
2. Bankrupt OB systems vendor LMS Medical Systems sells its its assets to the Canadian subsidiary of PeriGen for $3.5 million. McKesson bought the IP rights to CALM OB in April, relabeling the product Horizon Perinatal Care, but LMS supposedly kept the rights to support McKesson’s customers and to sell the product outside McKesson’s customer base. Perigen, renamed from E&C Medical Intelligence in April of this year, also sells OB risk reduction software.
3. David Blumenthal of ONCHIT says he doesn’t have an opinion on whether health systems should comply with FISMA, the security guidelines for federal computer systems, to share information with federal agencies.

The Top Stories thing above is an experiment that a couple of readers asked for, putting the stories that I think are most important at the top. I like the concept, but I worry that people will infer that everything else is trivial, which it isn’t (I wouldn’t put it on HIStalk if I didn’t think it was important). What do you think, good idea or too enabling of skimmers who will miss important information? I will say that I get e-mails all the time from people who say, “Wow, I just read this and you should put it on HIStalk” even though I have already covered it in detail, so I already worry that some readers are missing good information.

From Dan: “Re: EMR powered by MS Office.” It’s CCHIT-certified gloStream, which we’ve mentioned in HIStalk Practice (in fact, I see that item is listed on the company’s News page, so that’s pretty cool). The user interface is Office-based (which I wouldn’t necessarily find advantageous if it uses Office 2007’s ribbon bar, which I spend way too much time whining about instead of just learning to love it or downloading this free utility to bring back the old menus).

From Otis Miman: “Re: Epic. Meditech hospitals in some areas are getting pressure to upgrade to Epic since physicians are using Epic in their practices. This seems like a tremendous cost burden to healthcare – to throw out a a cost-effective, integrated solution instead of a more expensive, non-complete HCIS and non-integrated solution. Having little or no competition in the marketplace is not a good thing.” Both Meditech and Epic, having sprung from related loins, have the same tendency to not want to play well with others, probably more so than any other HIT vendors. Epic is simply capitalizing on a stagnant HIT market that isn’t putting up much of a fight, although I think hospitals would be hard pressed to get ROI on the cost difference between Meditech and Epic (not many Prius owners are candidates to move to a Cadillac Escalade, not to detract from either system). Every vendor has a showcase site or two that has done great things with their system. They also have some real whiner customers who blame the vendor and vow to buy again from someone else, only to find that their failure cloud follows them. Which category a given site falls into is much more a function of their own abilities than those of their vendors. Anyone who is seriously considering buying Epic who hasn’t been on their current system for at least 6-8 years is demonstrating that they have no idea what they are doing (why didn’t they buy Epic in the first place if that’s what they wanted?) Big-name hospitals choose Epic mostly because all other big hospitals choose Epic, just like they used to buy Cerner and, before that, SMS. Theoretically, the march of the lemmings will eventually end since the market is ripe for new entrants, but so far vendors are just handing their customers over to Epic with heads hung. I don’t blame vendors for selling what customers demand – I blame customers for not demanding better, cheaper, and more open systems (and for being too easily influenced by what everybody else is doing).

From Looking for Answers: “Re: Cerner. I hear the Cerner PETA person wasn’t disgruntled, just looking to score points with his babe — though he does enjoy a good steak! ;-)” Reason enough, I say. 

From Eclipsys Watcher: “Re: Eclipsys. I’m hearing rumors of major organizational changes in the next several weeks with more layoffs, etc.” That’s usually a safe bet with most vendors these days, but especially unsurprising since a new Eclipsys CEO was brought in, presumably to make changes. And, while the excuses have changed, company performance hasn’t – shares are worth less now than 10 years ago and its limited clinical product line which, despite having CPOE and documentation that are among the best, still lags way way behind in new sales to Epic, Cerner, and maybe even McKesson. A strong CPOE and documentation system, integrated pharmacy, industry-leading EPSi, and what used to be a strong consulting practice – if none of that translates into sales and then financial results, you have to blame the corner office people. I haven’t been a big fan of most of the company’s management team once Harvey Wilson stopped being actively involved, but most of the folks I knew have been replaced, so maybe the new blood can shake the company out of its doldrums. I can’t decide whether getting into the practice EMR business is a logical extension or a distraction for them.

From The PACS Designer: “Re: Google Wave. As a software developer, TPD gets to see new and interesting applications in their early concept development stage. Google has an upcoming release of an advanced collaboration tool that combines e-mail with instant messaging and many other features in an application called Google Wave. It could be use in healthcare to improve communication amongst numerous caregivers and departments.” According to the demo, it was developed by the Google Maps people. Google has so darned many Web tools out there that I bet someone could write some cool hospital apps purely by mash-up. If I were Medsphere trying to get a foothold against legacy vendors, I’d look at that as an inexpensive way to interject some cool factor. An internal messaging app based on Gmail Chat? An Intranet based on Sites? Documentation via Forms? Social networking with Orkut or Wave? Dumping resource-intensive internal e-mail in favor of Gmail? All possible, all useful to customers, and all with a free backbone for vendors to use for their product extensions.

Listening: In This Moment, a female-led metal band now on the Warped Tour.

Jonathan Bush on Fortune, referring to Epic: “The Cleveland Clinic has software that they had to pay $200 million to get. It was written in MUMPS in 1974. There is nobody left alive who can write MUMPS any more. That’s the model … the curve of innovation, the disruptive technology engine in healthcare is broken.”

I’m a Tiger Direct junkie, but this deal is stunning even to me: Dragon Naturally Speaking 10 Preferred with a headset for $49.99 (it’s $118 on Amazon). The rebate ends 7/31. Amazon has a lot of reviews, the gist of which seem to suggest that some users will struggle to get it up and running, but those who do find it pretty amazing. It’s heartening to read the reviews of people who can’t type because of nerve disease, wrist problems, etc. for whom DNS is their lifeline. (Note: this version isn’t for use with EMRs – you would want to look at DNS Medical for that.) I keep thinking that maybe I’d enjoy dictating HIStalk, so I may get it. I know some writers who record interviews, then play them back into headphones while repeating what their subject says into Dragon so it can “transcribe”.

AT&T says the $300 subsidy it pays for each new iPhone it sells hurt its most recent quarterly numbers, but will eventually pay off in lower churn for its exclusive service. The carrier activated 2.4 million iPhones in Q2, many of them because of the new 3G S model.

Cardinal Health names Patricia Morrison as CIO after its spinoff of CareFusion and the Friday announcement that CIO Jody Davids was quitting. The new CIO has no healthcare experience, having been CIO at Motorola and Office Depot. That brings up an interesting argument: should hospitals do what Cardinal did and bring in IT leadership from another industry that’s more technologically advanced than healthcare, or is it better to get healthcare experience even though it’s a technologically backward sector? Who would you pick for CIO: a geek doctor who thinks 10-year-old, off-the-rack apps are cool or someone who knows nothing about patients, but who has vast experience with e-commerce, state-of-the-art infrastructure, and self-developed technology as a strategic differentiator? I waffle on that, I admit.

The results of my poll on CHIME’s new CHCIO credential: 9% think it’s a good way for CIOs to demonstrate competency, 13% say it’s a vanity credential, 33% say it has no relationship with competency, and 45% say it’s just another income source for CHIME (so, that’s 91% against). New poll to your right, for HIMSS members: should it devote fewer resources to Government Relations, more, or about the same?

I continue to be impressed with EHRtv. Check out its EMR Matters newcast. I don’t know how they get such dazzling video and audio quality with fast streaming, but I’ve never seen anything like it. There’s also an interview with Allscripts CEO Glen Tullman a few weeks ago that I hadn’t seen. I think it’s brilliant, much more interesting than sticking a $100 camcorder in someone’s face and asking a few trite questions.

Bill Stead of Vanderbilt and Informatics Corporation of America CEO Zegiestowsky talk about interoperability in this article. Here’s what Bill had to say about Vandy’s StarChart, now commercialized by ICA: “The simple idea was to assemble information from any source and to use computational algorithms to turn it into something that can be used. It has no boundaries and it’s analogous to what Google has done. Google answers questions by crawling over any number of sources of information — each of which are used for a single purpose but none having the original purpose of answering your question.” Bill’s the man, I say.

Housekeeping stuff: put your e-mail in the Subscribe to Updates box to your right (like 4,474 of your peers and despised competitors have done) so that you’re among the first to know when I write something new (remember Todd Cozzens of Picis at the HIStalk reception at HIMSS, asking for a show of hands of how many people run to the PC to read it as soon as the e-mail comes? Several CEOs raised theirs). It’s spam-free since I don’t use it for anything else and don’t make it available to vendors even though I get asked all the time. The Search HIStalk box lets you dig through the six-plus years of HIStalk to find whatever tickles your fancy: your name, your employer, or a vendor. Click the disturbingly green box to report a rumor to me, which I always enjoy. The links at the top of the page let you go do HIStalk Discussion, Industry Events (the HIStalk calendar), and also the Archives links to previous articles. You can e-mail me for anything else (interview ideas, guest articles, volunteering to write for HIStalk, etc.) Thanks to you for reading and to HIStalk’s sponsors for bringing it to you.

The HIMSS conference will go back to New Orleans in 2013. I’m surprised since I thought HIMSS was sticking with Orlando, Atlanta, and Las Vegas (which never seemed to pan out, actually). I figured the 2007 conference in New Orleans was strictly a one-time charitable, post-Katrina offering. I didn’t think it was all that great, so I can’t say I’m elated at the news (I miss San Diego and maybe even Dallas, which was at least cheap and had barbeque). Now that we’ve had a snowy conference in Chicago to keep attendees hanging around the exhibit hall, maybe HIMSS should have cut a deal with Detroit, Cleveland, or Pittsburgh, all of which could surely use the economic boost.

Bill Gates, speaking from India, says the American healthcare model is flawed because the government won’t adopt a national identity card, doctors aren’t allowed to share electronic medical records (?), and virtual visits are banned (?) He also predicts that cell phones will be used to test for diseases and that voice recognition will be big (maybe he got the Tiger Direct e-mail too).

The LA coroner’s office is investigating security breaches in which Michael Jackson’s death certificate was viewed “hundreds of times” by employees, some of whom were said to have printed it. They had blocked access to all but the highest-ranking employees, but later found a flaw that could have let others in. The chief coroner investigator says he thinks such violations are only internal policy violations and didn’t break laws, but my understanding that HIPAA is still in effect even when the patient is dead (although maybe coroner’s records don’t count since they become public documents when completed anyway).

HITSP’s Privacy and Security Workgroup wants EMR standards that include encryption, access controls, and audits. Deb Peel isn’t happy with their prioritization of patient consent management, which isn’t scheduled until 2015 and which she calls “foxes designing the hen coops.”

Bad news for hospitals: if CIT Group goes into bankruptcy, that could be one fewer line-of-credit vendor willing to loan money based on receivables.

Australia-based medical device vendor Applied Physiology gets $5 million in financing to launch its Navigator circulation guidance system, which turns information from cardiac monitors into graphical treatment guidance for doctors.

CPSI announces Q2 numbers: revenue up 11.2%, EPS $0.32 vs. $0.28, missing expectations for both.

The City of Los Angeles submits a plan to City Council to replace outdated e-mail technology (“the slowest, most inefficient, crash-prone e-mail system in the history of mankind”) with Google Docs. 

Odd lawsuit: an AIDS advocacy group sues the LA County Health Department, alleging that it isn’t doing enough to stop the spread of disease among porn stars.

E-mail me.

News 7/24/09

From Org Insider: “Re: HIMSS. I was told HIMSS may have exceeded the 20% lobbying limit allowed by Congress and the IRS and is trying to rearrange its financials to satisfy the requirements so its 501(c)3 status won’t be jeopardized.” Unverified, but per the Webex I mentioned below, it doesn’t sound like that’s the case. If anyone has firm information, send it over, but I would be very surprised if this is true.

Inga verified with a spokesperson that Elekta, Sweden-based parent company of IMPAC Software, laid off 100 employees as BadNoodle said earlier this week. She said it happened at the beginning of the fiscal year, which would go back to May or June, I think. They have 3,000 employees and they didn’t say where the cuts fell.

Six-hospital, 1,260-bed Kettering Health Network (OH) will spend over $50 million on its just-announced EMR project, buying from — who else? — Epic.

Electronic drug detailing vendor Physicians Interactive acquires Skyscape, which sells online medical references for portable devices.

Christopher Pike is named VP/CIO of Health Alliance Plan (MI).

The HIMSS Webex for staff about its governmental relations activities didn’t say too much. HIMSS does not employ a registered lobbyist, but estimates that it spends 4-8% of member dues on lobbying. It says it started up its government relations group in 1998 because of member concerns about HIPAA. It began offering government relations services to “sister organizations” in 2008, which seems odd (CHIME? AHIMA? They didn’t say). Mentioned: Institute for e-Health Policy, run from the HIMSS Foundation instead of the main organization.

Two of the seven out-of-cluster NHS trusts stay on with iSoft rather than switching to a local implementation of Cerner Millennium, saying it was too risky and expensive. “The implementations of CM [Cerner Millennium] in London have had a damaging effect on trusts, which has led to the creation of a new deployment model, which has yet to be tested on a deployment.”

And in Australia, Lismore Base Hospital officials claim that Cerner SurgiNet has compromised patient safety such that “negative outcomes, including death, will inevitably result from the continuing use of this system.”

If  Epic, the NHS, and bad Australian publicity weren’t problems enough, Cerner has now incurred the wrath of PETA, which is all over it for using glue traps to inhumanely kill mice on its campus. Cerner’s director of properties, PETA says, told its people that “their use of glue traps was no one else’s business but theirs.” You have to figure a disgruntled CERN employee must have turned them in.

eHealth Initiative releases the results of its HIE survey. Conclusions: more HIE initiatives are underway, those actually operational jumped way up, and doctors reported a positive impact on their practices.

From Weird News Andy: a woman gets a call from a hospital’s ED doctor saying her husband had died there from electrocution. She and her sons rush to the hospital, only to get a call from her husband, to whom she replied, “‘Doug, you’re dead. We’re going to the hospital to view your body.” The hospital had called the wrong Doug Wilcox’s family. The hospital refused to talk on camera and hasn’t contacted the woman to apologize, but e-mailed a statement blaming “a breakdown in our communications.” Understandable, but the bunker mentality won’t win it any friends.

Misys announces year-end numbers: revenue up 41%, profits up 43%, helped mightily by the performance of Allscripts.

Microsoft turns in terrible Q4 results Thursday evening: revenue down 17%, EPS $0.34 vs. $0.43. For the year, the company’s revenue fell for the first time since it went public in 1986, falling short of expectations by a mile. Windows revenue tanked a staggering 29%. Shares are down 7% in after hours trading, back to 1996 levels.

The OMB director isn’t impressed with Aetna’s claim that its software reduced the use of medical services by 6.1% back in 2001. “One cannot reject the hypothesis that the true effect … on outpatient and RX charges is zero.” Aetna’s CMO co-founded the ActiveHealth Management, which developed the software and then sold out to Aetna in 2005. OMB says it didn’t do much except for hospital inpatients. That’s its PHR above, from a pretty cool video on its site.

Credentialing software vendor Medversant files a patient infringement against Morrissey Associates, saying it is “marketing for sale a process that is consistent with our AutoVerifi process.”

A judge in a medical malpractice lawsuit in Canada gives Meditech a nice pitch from her bench, explaining a $5 million ruling against a hospital that had misfiled a patient’s paper-based meningitis diagnostic results for a full year, resulting in his incapacitation. “Despite the UBC Hospital’s acknowledgement of its heavy responsibilities and its knowledge of past failings, it relied exclusively on a manual system with no back-up system in place to manage virtually inevitable employee error. The absence of such a system is particularly unfortunate given that in September 1999, the hospital possessed that capability through the Meditech computer system, which it was using to track films for billing purposes.”

Ann Coulter is a bit of a wack job even to a conservative like me, but this is a fun quote: “The reason seeing a doctor is already more like going to the DMV, and less like going to the Apple ‘Genius Bar,’ is that the government decided health care was too important to be left to the free market .. We already have near-universal health coverage in the form of Medicare, Medicaid, veterans’ hospitals, emergency rooms and tax-deductible employer-provided health care – all government creations …  The whole idea of insurance is to insure against catastrophes: You buy insurance in case your house burns down – not so you can force other people in your plan to pay for your maid. You buy car insurance in case you’re in a major accident, not so everyone in the plan shares the cost of gas.”

HR 2630, submitted by Rep. Ron Paul, would give individuals to opt out of any federal EHR system, repeals the act requiring HHS to create a unique patient identifier, requires informed consent for any use of electronic patient information, and prohibits the federal government from requiring providers to participate in an electronic healthcare system. It’s from a few weeks back, but I just ran across it.

Christ Hospital (OH) extends its outsourcing agreement with CareTech Solutions.

I mentioned earlier that for Red Hat VP had started up Axial Exchange, which offers open source healthcare interoperability solutions. She and her startup venture get profiled in the Raleigh paper.

WebMD announces the free Medscape Mobile for the iPhone.

Zynx and eClinicalWorks sign a deal to make the former’s AmbulatoryCare order sets available to eCW customers.

Medicity spinoff Allviant, which will market consumer access tools, announces its advisory board members.

The DoD will expand its PHR pilot that ties its data into HealthVault and Google Health, but it’s also evaluating RelayHealth. DoD required Google and Microsoft to use only US-based servers and to delete all information immediately for an employee who opts out.

Odd lawsuit: a woman who gained 20 pounds during her hospitalization for Crohn’s disease is suing the hospital, saying it overhydrated her with IV fluids. She wants compensatory damages.

E-mail me.

HERtalk by Inga

The local paper reports on the status of an Epic installation at Atrium Medical Center, which  is one of three Premier Health hospitals now live on on Epic’s EHR. Ambulatory clinics are also getting on board. Officials estimate the implementation will be completed by the end of 2010.

The VA selects Anakram.TFA Two-Factor Authentication as its enterprise authentication tool for remote access to VA systems.

John Muir Health (CA) claims it saved $8.5 million using VHA’s Non-Salary Cost Reduction solution over a two-year period.

St. Joseph Medical Center (PA) selects McKesson’s Revenue Management Solutions to manage its medical billing processes. St. Joseph physicians will deploy McKesson Practice Complete for RMS services, along with Horizon Practice Management software and RelayHealth payor connectivity services.

Tufts Medical Center (MA) places an order for a Carestream Health RIS/PACS system and contracts for Carestream’s eHealth Management Services for remote disaster recovery.

Someone at the University of Michigan Health System clearly listened to his/her mother. UMHS lawyers and doctors are quick to say they’re sorry and admit mistakes up front, finding the policy creates savings in time, money, and feelings. Between 2001 and 2006, malpractice claims fell from 121 to 61 and the average time to process a claim fell from 20 months to eight months. In addition, costs per claim fell 50% and insurance reserves dropped by two-thirds. I like the words of Richard Boothman, the system’s chief risk officer: “What we are doing is common decency.”

The National Institute of Health Clinical Center picks the QuadraMed AcuityPlus platform to ensure interoperability with existing ADT and staff scheduling systems. The NIH facility will use AcuityPlus to make its nurse resource allocation process more efficient.

HIT consulting company Virtelligence is recognized by the Midwest Minority Supplier Development Council as Class II Supplier of the Year. The award is based on such factors as company growth and development and quality of products and services.

Carefx says its Fusionfx clinical workflow solution is now successfully deployed at Fletcher Allen Health Care (VT). My interview with Fletcher Allen CIO Chuck Podesta posted earlier this week. One reader wrote in saying that, based on the interview, they’d work for Mr. Podesta.  I concur.

The VC folks seem to think health care companies are worth investing in these days. In the second quarter, health care firms raised $2.2 billion in VC funds, surpassing last year’s $1.89 billion figure. HIT providers are of particular interest as result of growing demand for health care solutions.

Speaking of VC money, MedVentive, a provider of P4P software for evidence-based money, raises $7.25 million in series C funding. Excel Venture Management led the round.

Those choosing an alternative to Mr. H’s DIPSHIT certification program may want to check out Johns Hopkins new master’s degree in health informatics. The one-year program focuses on how to develop IT systems to be used in hospitals, clinics, and public health settings.

E-mail Inga.

HIStalk Interviews Chuck Podesta, SVP/CIO, Fletcher Allen Health Care

You’ve been on the job for a year now. What were some of the high and low points?

The high points actually started with the interview process. I was very impressed with the organization. I was very excited about the EHR the project with Epic. A lot of the heavy lifting had already been done around project organization, budget, and resources. I was excited from that standpoint. I was starting at a time when the project was kicking off, which is an exciting time as opposed to all that pre-planning stuff that you have to do.

Any low points?

No, I really can’t see any. Burlington, Vermont is a beautiful city. It was the first career move I’ve ever made that had a boost, not only from a job perspective, but from a quality of life as well. 

You’ve just gone live with some early parts of PRISM and Epic. What’s next?

We’re into Phase II right now. We’ve gone live with the ED, the electronic health record, which included CPOE, bedside medication, and of course all the nursing functions and charting. We’ve also got the monitors linked in to the flowsheets as well. We completed that on June 6. It’s going very well.

We have CPOE, with 92% of all orders being entered by physicians after just a few weeks of going live. That’s extremely successful for us.

Phase II is our first ambulatory site. We have a large faculty practice, so we’re rolling it out in the outpatient area. That goes live in November. In the rest of 2010, we’ll be implementing our ambulatory sites. Along with that, we are also implementing Beacon Oncology for Phase II — that’s December of 2009 — along with MyChart, the patient portal. 

December 2010 will be our last ambulatory practice and the Cadence scheduling system. That finishes up the three phases of the project.

In conjunction to that, too, we have the opportunity to offer the Epic licensing to other community hospitals in the state and in the ambulatory sites as well. Our project is called PRISM — Patient Record Information System Management — and the extension of our PRISM project is called PRISM Regional. That’s a hosted group purchase solution. We’re working closely with Epic on that.

How will you be using MyChart?

Actually we just fired that up. We’ve got a team in place and we’re working closely with marketing to put together a plan to market that to the community. Two options that we’re looking at right now since we have the inpatient up — we can roll it out from that, but we’re thinking that the biggest bang for the buck is on the ambulatory site. So there’s the decision that we have to make: do we roll it out in December for the inpatients in our first practice and then just continue on with the practices, or, do we wait until we have all the ambulatory sites up and roll it out after that?

My guess is we’ll probably implement the inpatient side of it and then we’ll add on each ambulatory practice as it comes up. So the practice will have to work with their patient population to get them signed up to use it. But we’re still in the early stages of that right now.

Have you changed the project scope or timeline due to economic conditions?

No, we really did not. We were not part of a bond or anything like that. The money was basically money in the bank, so it wasn’t an issue that we were running into bond covenants or anything like that, or we would have to stop and conserve cash or anything along those lines. We were lucky that we got all that done before the market started to tank. So the investments were there. We met all of our deadlines.

What is the expectation for return on investment?

We’ve got a benefit utilization group. We came up with some of the different benefits. We’re also convening the group now that we’re live, actually going in and start to measure those. But a lot of the standard ones that you would see: measuring medication errors, some types of quality patient safety.

But what we see as the biggest bang for the buck is utilizing the system to help us drive towards a best practice. For example, if we have an initiative to reduce nosocomial infection rates, how can we use the system to prompt the clinicians to protocols that drive that number down? That’s what we’re really focused on right now. With Epic, with the Clarity database, which we have as well, which is the clinical decision support database of the Epic system — we’re going to utilize that heavily to start looking at where we can impact the care process.

Any specific timeline for being able to show those metrics?

I think once we deal with the initiatives we have right now, like medication errors, by the end of summer we’ll have some good data on those. We did calculate the "before" picture prior to going live. We were collecting data probably for a year before we went live on certain measures. Once we get over the learning curve, we’re going to go back and see how we’ve impacted those. By the end of the summer, beginning in the fall, we should be able to do that.

How are you engaging physicians?

To me that’s been a real success here. We’ve got an orthopedic surgeon who’s about half-time on the project. He has been instrumental. He knows the system inside out and has been instrumental in working with physicians.

We also have a physician advisory committee that’s very strong, providing physician leadership. The chairs have gone along on with them, so that’s working well. Our CEO is a physician, so that definitely helps with pushing the adoption. The physician leadership actually voted in the bylaw that, to be credentialed to practice at Fletcher Allen Healthcare, you have to use the system, including CPOE. That’s part of our success in driving that percentage up as well.

That was key and also our education process. It’s one thing to have a policy, but another thing is to implement a procedure that works. We did a lot of work with pilot groups. We took a pilot group of 10 physicians and ran them through the standard eight hours of training. With their feedback, we were able to design a training program that worked for physicians which was a combination of the e-learning modules and didactic classroom training. 

We let the physicians decide which learning environment they wanted to do, e-learning or didactic training. But in all cases, when it came to the certification process, that was in the classroom. So we let them learn the way they wanted to learn, but we made sure we certified them and there was a standard way to do that. That worked out very well and was very well received because you could do the e-learning modules offsite on the weekends and such.

The other thing that was unique with Fletcher Allen is that this whole project — the PRISM project — reported up through operations, not to IS. The two executive sponsors were the senior vice president for patient care services and the president of faculty practice. As the CIO, I had operational responsibility but not executive responsibility, which showed the organization that this is not a technology project but a process redesign. It was a change to the way that we deliver healthcare. I think that was a good way to go.

I understand you’re on the board of the VITL?

Yes, Vermont Information Technology Leaders. That’s the HIE.

How will you participate in the HIE and what’s going to be your involvement technically as you move forward?

We will actually link up with the exchange based in Vermont. We have an opt-in process, so the consumer — the patient — has to opt in for the records to be shared. By the end of the summer, we should have those links in place.

We’re starting with lab results and orders, but then we’ll move rapidly to bi-directional continuity of care documents with VITL. The power of that is going to be that if we have other hospitals run Epic in our a single database, they’ll be automatically connected to the VITL exchange. That will be very powerful.

Is it tough being an Epic shop in the epicenter of GE-IDX?

Yes. I came from Massachusetts, so I don’t have the Vermont history here, but I do understand it was probably more of a tense situation back in 2003, 2004, and 2005 when the selection process was going on. I got here after that was all complete.

We do still have the revenue cycle for IDX. We also have ImageCast, the radiology system. So, we still have a relationship with GE-IDX. If we had gone with everything Epic and not had any GE here at all, it probably would have been a different issue. 

We meet with them on a regular basis. We’re actually in the process of potentially doing an upgrade of the IDX system as well, so the relationship seems to be good. GE is also the vendor that’s doing the exchange for VITL, so there’s plenty to do for everybody.

I understand Fletcher Allen gave the ACLU an advisory committee seat. Is the way you’re addressing privacy a lot different than where you worked previously?

Yes. If you look it at the HIPAA rules, opt-in is not a federal law. It does not come into any of the HIPAA guidelines. I think Minnesota is the only state that has actual legislation and made opt-in a law. But in my mind, it is the gold standard, and probably with the new ARRA privacy regs will probably be standardized in most places. So we decided at VITL to adopt that ahead of time knowing that it was coming, and then as part of PRISM and PRISM Regional we’re following those guidelines as well. We had a subgroup which I was on that is part of VITL; we did a lot of work in that area, and not only the policies themselves, but the procedures to implement.

What lessons learned can you share with other CIOs about your PRISM project?

I’ve been through a few of these with different vendors. I’ve done MEDITECH and SMS before Siemens. I’ve been doing this for about 30 years now and each one’s a little bit different; I always learned something new on each one. 

For go-live support, we had about 185 people with yellow shirts on, including the vendor, consultants, the IS team, the PRISM team, super users — it was just a sea of yellow out on the units and in ED. It really gave people comfort, even if they didn’t have a question, to look up and see four or five people in yellow shirts on. We had a lot of positive feedback on that, knowing that if they did have a question there was somebody there to answer.

We put in a best practice service center and spent a lot of time doing 24/7 with our service center. We ended up answering 9,000 calls in about an eight-day period. It was only about a four percent abandon rate. We trained those in the service center. We actually put them through the same training that the nurses went through. On the front end they had a lot of knowledge on the Epic system.

Senior leadership visibility. As senior leaders, we all had the yellow shirts on as well. We were here 24/7 doing different shifts, just being visible more as cheerleaders and support. Our management team delivered food. These seem like little things that are huge. When you’ve got a nursing unit in there struggling from the standpoint of learning a new system in patient care and all of a sudden the manager wheels a cart up in there with all kinds of food on it, it just means a whole lot to them that we were all in this together.

So those were the keys, and I think what I mentioned earlier: if you want to drive your CPOE adoption rate up, you really have to focus on that with good physician leadership. Also, potentially changing the bylaws, and the training, and support.

Also, one tip that I’ll give. If you are an academic medical center, if you have access to medical students within an urban area, use them to support the physicians. It worked out great. We paid them a small stipend. Typically they’re broke, they’re happy to get a little bit of money, and they’re young, they’re doing the Twitter stuff already so they just take to this stuff. They were tremendous. I think we ended up with about 20 medical students that supported the physicians. They were a great help as well.

But to me, what I learned on this one was really that the go-live support, the command center, the service center, and the people we had there — to me, that was the key. A lot of organizations may short-change that a little based on cost, but I think it’s key to getting past the go-live hump and then moving into a support model.

Last question: in your opinion, what are the biggest threats and opportunities across healthcare IT today?

The biggest opportunity is with the ARRA money. I think the threat is also with the ARRA money, depending on how meaningful use and certified EHRs develop and are identified. The HHS is leaving some of that open for public comment.

I think the biggest threat is that some of these vendors might not be ready. For the ones that do have the product, the line to get that product could be out the door. So from a timing perspective, it’s going to be difficult.

I think there needs to be some new models that are created for implementation across the country, because if you look at HIMSS’ eight phases of adoption, you’ll see how many are not even near meaningful use. The vendors don’t have the capacity and there are not a lot of educated resources on implementing EHRs. Those individuals that are educated are going to be snapped up by the consulting companies, then, charged back at three hundred bucks an hour.

So I think workforce development and the implementation itself is a threat, based on ARRA. That’s why I’m seeing some of these community hospitals going to their local large-hospital academic medical center and saying, "Can you help us?"

I think the model that we’re creating here with PRISM Regional — I’m starting to see with other Epic sites across the country — Geisinger, Cleveland Clinic – -some of the others where they’re actually looking at putting the system in and helping these community hospitals get to that meaningful use. So that’s where I see the opportunities are, but the threats as well.

News 7/22/09

From Ralph Hinckley: “Re: HIPAA. Looks like we have actual prosecution for HIPAA privacy violations by several individuals.” A doctor and two former employees of St. Vincent Health System (AR) plead guilty to federal charges of snooping into the medical records of murdered local TV anchor Ann Pressly out of curiosity. The misdemeanor charge carries a maximum penalty of a $50,000 fine and a year in prison. Here’s the part that always gripes me: the hospital canned the two employees, but let the doctor off with a two-week suspension.

From Wompa1: “Re: Ayn Rand Center for Individual Rights. I thought you might appreciate this.” The piece has a long quote from Atlas Shrugged about a surgeon who refuses to practice under a system of socialized medicine. Now I’m all hot to read Atlas Shrugged again, so I’ll have to go digging through the bookcases to find it.

From BadNoodle: “Re: [vendor name removed]. They have quietly laid off over 100 people worldwide, with software training and support hit fairly hard.” Inga is trying to confirm and I have suspicions about the anonymous source since the posting appears to have come from a competitor, so I’ll leave the company name out for now.

From Org Insider: “Re: HIMSS. HIMSS produced a Team Training seminar, ‘What is Government Relations’ on June 23, 2009. HIMSS discusses the differences between advocacy, lobbying, and government relations,’What does HIMSS do?’ It is produced by Carla Smith, Executive VP, and Dave Roberts, VP of Government Relations (who is also Mayor of Solana Beach, CA). It appears executive management is trying to sell the staff on the idea that HIMSS is not a lobbyist or vendor organization HIMSS will share IRS and congressional regulations with a ‘sister’ organization to keep under the radar. Is that AHIMA?” Please, sir, may I have some more? I couldn’t get to the link you sent and I didn’t follow the ‘sister organization’ part.

From The PACS Designer: “Re: What Would Google Do? Our fellow blogger Will Weider has read the new book about Google called ‘What Would Google Do" and recommends it for CIOs and other executives. Harper Collins Publishers has a browse version of the book on the Web for HIStalkers to view.” The preview looked good, although some of the Amazon reviews are scathing. I’d read it.

From Dr. Know: “Re: technology. Interesting article in US News about the use of advanced technology in hospitals.” Included: rounding robots with video, RFID, implanted identifiers (they must have missed the Verichip flop), EMRs, and cool rooms. Only in the last paragraph is it mentioned that hospitals have halted almost all of these projects because of economic uncertainty.

From Bob! in accounting: “Re: VA. Ha!” The VA stops (temporarily, it says) 45 IT projects that are over budget or behind schedule until the project managers submit new plans. They’re listed in the article. I see a lot of LIS stuff on the list, so I wonder if the VA is reconsidering its stated intention of replacing some of its own VistA applications with commercial ones from Cerner since it was to start with lab?

Apple’s Q3 numbers: revenue up 12%, EPS $1.35 vs. $1.19. Strong Mac sales and punishing iPhone demand led the estimate-beating numbers. Good timing for me since I had just finished my next guest editorial for Inside Healthcare Computing titled A Harvard Vision of One-Stop Shopping: Why Someday You Might Buy a Michael Jackson Ringtone, a “Pull My Finger” Game, and CPOE from the Same Vendor. It’s a very serious treatise on healthcare IT architecture and the disruptive technology of infrastructure instead of applications. Well, maybe not all that serious.

Here’s an iPhone example: Cannabis, an application that gives directions to medical marijuana suppliers and related services updated from iMedicalCannabis.com. Check the banner ad on the site for Marijuana Medicine Evaluation Centers, which apparently gives exams and certification cards to supposedly legal users (“Come get your medical marijuana card today!!”) There’s even a helpful ICD-9 list of conditions that can be treated with cannabis just in case one is looking for a disease to justify use of its treatment (hypertension? back pain? constipation? You’re in!)

Some folks added new events to the HIStalk Calendar (and why not since it’s free and the events show up on the main page of HIStalk?) You can add your event, too, or check the calendar to see what’s coming.

A reader provided a link to this ACLU video for its Surveillance Campaign, which frets about massive invasions of privacy using “invasive new technologies.” It ties ordering a pizza with having healthcare information immediately available at the call center.

Nasty Parts told you on May 29 that Allscripts would acquire Medfusion and Medem. He’s on track so far: Medfusion announced today that it has bought the health services operations (which I’m guessing is everything but the company name) from Medem. Then, Allscripts announced that it had signed a strategic agreement to make Medfusion’s patient portal available to its customers. Will Allscripts go ahead and buy Medfusion?

Also related: Allscripts posts Q4 numbers, but I’m not smart enough to understand how post-acquisition numbers are derived so I won’t comment. Glen seemed happy with the results, they seemed to beat expectations, and share price is down only a little since then. I think they did well.

The HIMSS Electronic Health Record Association re-elects Justin Barnes (Greenway) as chair and brings on Mark Segal (GE Healthcare) as vice chair and Carl Dvorak (Epic Systems) as executive committee member.

Listening: new from July for Kings, Cincinnati-based alt-rock.

I must be cranky today since I just saw something else that gripes me. A vendor executive lists a big-name business school in the Education section of his LinkedIn profile, right under his only other credential, a bachelor’s degree from a lower-tier state school. I checked out his big-name credential and it was nothing but an expensive, one-week executive seminar, maybe placed there with the hope that it would be confused for a graduate degree. It wasn’t by me, anyway.

Speare Memorial Hospital (NH) names Bob Dullea as director of IS, bringing him over from Dartmouth.

President Obama, making a healthcare speech from what was called Children’s Hospital (I assume it was Children’s National Medical Center in DC) mentions the CIO directly: “We just — I spoke to the chief information officer here at the hospital, and he talked about some wonderful ways in which we could potentially gather up electronic medical records and information for every child not just that comes to this hospital, but in the entire region, and how much money could be saved and how the health of these kids could be improved, but it requires an investment.”

A VA-funded study finds that all the paper records clinicians keep (sticky notes, index cards, and notebooks) can provide insight into how to design an improved human interface to clinical systems. It’s a shamefully small observation study (20 workers in one hospital), but still an interesting concept since everybody keeps paper for mostly good reasons. I’ve used this method: follow a clinician around and write down every piece of information they need, when they need it, where they were at the time, and what they did with it. That’s what an IT system will have to do if you really want to kick out paper.

Also from the VA: it’s testing a BlackBerry application that let cardiologists read EKGs remotely and order treatment to be immediately started in the ED or other location. “The ER pages a cardiologist and sends an electronic EKG to the doc’s mobile device. It also cc’s the electronic health record system, Vista. The cardiologist receives the EKG alert and opens the file by pressing on an icon and logging in. After reading and interpreting the image from a smartphone, the cardiologist clicks a ‘call’ button to contact the ER with a treatment orders. This all happens within 3 minutes.”

Yet another VA item: the Philadelphia VA’s brachytherapy (implanted radiation therapy) program, which was shut down in 2008, gave 92 of its 114 patients the wrong dose of radiation therapy over six years because the dose checking PC had been unplugged from the network.

ACS gets a five-year contract extension worth $10 million to run IT at Rehabilitation Hospital of the Pacific (HI).

A Fox News report says that the universal health plan in Massachusetts is an albatross around the neck of potential Republican presidential candidate Governor Mitt Romney. Costs are out of control, the state is being sued by Boston Medical Center for underpaying it, and legal immigrants who pay taxes are being dumped from the plan to save money. The parties blame each other, apparently, and the only idea anybody’s come up with to cover its costs is to tax smokers even more. They’d better hope those smoking cessation programs don’t work.

Who are some of the big spenders when it comes to healthcare lobbying? Other than the obvious drug companies: GE, AMA, AHA, Blue Cross Blue Shield, American College of Radiology, Siemens, and UnitedHealth Group.

Vanderbilt chooses Omnicell for supply systems.

Hopkins Medicine deploys Cernium video analytics software for security, which ads to the capability of security cameras by not requiring people to sit and watch them. It looks for erratic movements, lurkers, converging groups, and suspicious packages. A bit Big Brotherish, but cool, especially for hospitals.

E-mail me.

HERtalk by Inga

From Heard it thru the grapevine: “Re: rumor control. Hope you are doing well and up to your eyeballs in new shoes. Wouldn’t it be interesting if it were Eric Sellers was the one going to MED3OOO?” Eric Sellers is a former Misys exec, as “Little Birdy” suggested last week. His LinkedIn profile says he has been in real estate for the last five years.

Hayes Management Consulting and Aternity partner to help improve physician adoption of EHRs. The companies will combine the rapid prototype methodology of Hayes with Aternity’s Frontline Performance Intelligence Platform to organizations increase implementation efficiencies.

Hendrick Health System(TX) completes installation of Sentillion’s Tap & Go, which uses passive proximity cards for authentication. Hendricks uses the program in its trauma center to enable caregivers to instantly sign on to any workstation.

ENT and Allergy Associates (NY/NJ) announces it has expanded the use of their NextGen EMR system to 10 of its 30 practice sites. The practice includes about 90 physicians.

UC-San Diego Medical Center selects Dragon Medical for physician documentation.

Former Cisco exec Diane Adams joins to Allscripts as EVP of human resources.

E-mail Inga.

Being John Glaser 7/21/09

American Airlines. Amazon.com. Federal Express. Bank of America. These organizations and others are often cited as examples of exceptional effectiveness in applying information technology (IT) to improve organizational performance and, at times, achieving a significant competitive advantage.

These organizations are more than one-hit wonders. They have been exceptional over very long periods of time. They seem to have one IT success after another.

What is it that these organizations have done to achieve such IT excellence? What makes them different?

Several researchers have pursued answers to these questions. The have identified a series of factors that lead to organizational IT excellence.

Leadership was critical
The leadership in these organizations was smart, honest, seasoned, committed, and valued the healthy exchange of ideas. They were individually excellent and a great team. This leadership understood the strategy, communicated the vision, was able to recruit and motivate a team, and had the staying power to see the organization’s strategies through several years of hard work.

Strong, sustained and clear themes provided the basis for IT strategy decisions
Organizations often develop themes or strategic imperatives such as “we must continuously improve the care we deliver” or “we must relentlessly focus on efficiency.” If there is sustained commitment to pursuing these themes, organizations become increasingly competent at addressing them. This competency extends to IT. In effect, organizations, year in and year out, get better and better at improving care and get better and better at applying IT to improve care.

The evaluation of IT opportunities was thoughtful and rigorous
IT initiatives that involve major commitments of resources and significant organizational change must be analyzed and studied thoroughly. However, these organizations also understood that a large element of vision, management instinct, and “feel” often guided the decision to initiate investment and continue investment. These organizations were careful to ensure that IT initiatives were strongly linked to key organizational strategies and plans.

Extracting value from IT required innovation in business practices
If an organization “merely” computerizes existing processes without rectifying (or at times eliminating) process problems, it may have merely made process problems occur faster. In addition, those processes are now more expensive since there is a computer system to support. All IT initiatives must be accompanied by efforts to re-engineer the processes that the system is designed to improve.

These organizations often focused on continuous incremental innovations rather than “big bang” initiatives
Organizations will often introduce very expensive application systems and process change “all at once.” Big bang implementations are very tricky and highly risky. It is exceptionally difficult to understand the ramifications of such change during the analysis and design stages that precede implementation. As a result, organizations risk significant operational degradation and non-trivial project overruns.

On the other hand, IT implementations (and related process changes) that are more incremental and iterative reduce the risk of organizational damage and permit the organization to learn before they make the next change. Incremental change helps the organization’s members to understand that change and performance improvement are never-ending aspects of organizational life rather than something to be endured every couple of years.

The strategic impact of IT investments came from the cumulative effect of sustained near term initiatives to innovate business practices
The incremental steps in aggregate led to a competitive advantage. Organizations often took five to seven years for major initiatives to fully mature and the results to be seen. Persistent improvements by a talented team, over the course of years and across many initiatives, resulted in significant strategic gains. Exceptional effectiveness is a marathon. It is a long race that is run and won one mile at a time.

Innovation was encouraged
These organizations were comfortable and competent at innovation. This innovation was not confined to IT. They knew that innovation had to be practical and goal directed. Innovation had to focus on a real business problem, crisis, or opportunity and the project needed budgets, political protection, and deliverables.

Well-architected technology was the great enabler
Information systems that are difficult to change, unreliable, overly costly, functionally weak, and impossible to integrate can severely hinder an organization’s strategies. The organizations studied had taken the time to develop approaches and policies needed to ensure that desired levels of integration and reliability, for example, were achieved. Their CIO had, and shared with the leadership team, a strategic understanding of information technology architecture. 
 

Achieving organizational excellence in IT requires much more than great information systems and a great IT staff (although these are important). Excellence requires talented people, great working relationships, organizational thoughtfulness, and dogged, year-in and year-out pursuit of performance improvements. These factors are probably not materially different from the factors that determine organizational excellence in general.

It is more important for an organization to focus on addressing these factors than it is to work on any specific IT application.

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

Monday Morning Update 7/20/09

From Leo: “Re: HHS. HHS is expanding its health information privacy enforcement team.” They’ve opened two new positions for Health Information Privacy Specialist.

From Hal Ebola: “Re: execs. Isn’t it interesting that in the midst of the biggest news about HIS in decades, the senior execs at many of the largest companies in the space have gotten the boot? In the past 18 months — McKesson, Siemens, Eclipsys, QuadraMed, etc.” A couple of folks e-mailed to say that new involuntary executive departures have occurred at McKesson and Eclipsys, but I don’t have specifics. Obviously all that potential HITECH money has raised the performance bar, maybe rightfully so now that there’s more at stake (so HITECH’s unintended consequences may have been vendor brass turnover). I only hope they don’t bring in a bunch of non-healthcare people who see patients as widgets since I’ve worked for HIT execs like that and I wanted to maim then regularly. Some of the most frustrated employees I’ve seen were clinical people who went to work for vendors — they had always thought the problem was lack of company knowledge, not lack of company interest in doing anything beyond the minimum required to sell systems.

From The PACS Designer: “Re: America’s Best Hospitals. U.S. News & World Report has released its annual survey of America’s Best Hospitals. TPD likes to focus on who is new in the listings and who has moved up in the rankings as it shows institutions that have made progress to better themselves in the eyes of physicians.  Johns Hopkins remains #1, and rounding out the Top 5 are Mayo Clinic, Ronald Reagan UCLA Medical Center, The Cleveland Clinic, and Massachusetts General Hospital.” No surprises there except maybe UCLA. It would be interesting to see how the winners stack up in terms of cost (probably easy to do since the information is out there). You could do the same with the idiotic Most Wired awards, just out yet again, determining whether all of those highly wired hospitals have reduced cost or significantly improved outcomes in the last 3-5 years. Everybody involved with Most Wired stands to gain from the “buy it and they will come” illusion: HHN magazine, McKesson, CHIME, and resume-padding CIOs. Who knew that supporting your organization’s strategic goals through IT was a competitive sport?

From Nasty Parts: “Re: Sage. Exodus of talent from Sage continues. Dennis Mahoney, six-year vet, resigned last Friday. Dennis was most recently their top VP of sales.” Unverified.

From Looking for Answers: “Re: Banner Health. Isn’t it funny that if a vendor came in offering free software they wouldn’t be let in, but if they come in with expensive software and cut the price down, it all looks great?” Brilliant. In this change-resistant industry, maybe Medsphere should price OpenVista at $30 million and start the discounting at 50%, proceeding to 100% of the client insists. Like heavy software discounting by proprietary vendors, it would let providers think they are sharp negotiators.

From B.P. Fife: “Re: pretty darn good article.” Link. Washington Monthly’s Code Red: How software companies could screw up Obama’s health care reform. It’s yet another comparison between Midland Memorial’s OpenVista implementation vs. proprietary ones, this time the initially problematic Cerner one at Children’s Hospital of Pittsburgh, both of which I’ve reviewed amply here (in fact, I hate to say it, but I’m kind of tired about hearing about Midland Memorial since repeatability is a key concept and one implementation isn’t enough to judge Medsphere or, for that matter, Cerner). The article seems to imply that a sinister conspiracy exists among proprietary vendors, HIMSS, CCHIT, etc. to keep open source applications a big secret. They aren’t: CIOs, rightly or wrongly, are passing on a free system that they’re surely aware of, so you have to assume that (a) even though they may be overly risk averse, they aren’t stupid; (b) they aren’t universally easily manipulated; and (c) they would jump all over a free app if they had confidence in it and their hospital said OK. If Medsphere and companies like it can’t make their case and get traction, maybe vast collusion is just a convenient, far-fetched excuse for offering what the market doesn’t want, no different than a sign offering “free kittens”. 

Related to that, from my poll on open source EMRs: 45% of respondents said CIOs should consider them because they’re just as good as proprietary systems; 20% said they’re not as good but should be considered because they’re cheaper; 13% said they should be avoided because they’re not good enough to be worth the potential cost savings; and 23% said they should be avoided because they’re unproven and risky. Obviously it’s not CIOs responding unless their responses differ from their actions.

Weird News Andy checks in: (a) a Lortab Lothario male nurse suggests to an addicted patient that he will provide pills in return for her favors. He signs out the pills for another patient, leaves them tucked in the first patient’s belongings, and, well, read The Rest of the Story. (b) Paramedic fired after telling a woman in pain to have drink and she dies the next day. Also from WNA: “Here is a link to a purposely confusing Republican chart that describes the Democrats’ socialized medicine plan.” Link (warning: PDF).

CHIME announces its new CIO certification program for healthcare CIOs who “want to enhance their professional stature.” CHCIO is much like CPHIMS: pass a test and you are in, but in CHIME’s case, you have to already have been a CIO for three years or more (so maybe the point is to unmask those poser CIOs who really weren’t qualified after all?) Obviously CHIME gets the same benefits that HIMSS does: certification generates revenue, makes the organization look like the de facto authority, and locks certificants into further revenue-generating renewals and conference attendance. It seems pointless to me – if you’ve got three years of CIO experience, I doubt slapping a credential nobody’s heard of after your name is going to impress anyone further (especially potential employers or peers). Certification often appeals to those lacking academic credentials, but there is no excuse for someone holding a six-figure CIO job not to have a master’s degree, given the plethora of convenient, cost-effective offerings widely available (I did it myself for one of my degrees while working two jobs and writing HIStalk, so I don’t buy the “I don’t have time” excuse). Still, for the insecure folks looking for a vanity credential that demonstrates what you already know instead of studying something new to earn a recognized degree or graduate certificate, you’ve got a new option. I’m thinking of launching my own certification, Designated In Primary Study of Healthcare Information Technology. I think the acronym would look real nice on a business card.

So, new poll to your right – what do you think of CHIME’s new credential? Don’t let me influence your answer.

Buddy Fain is promoted to VP/CIO of the University of Tennessee Medical Center. He’s a UT alum.

A Kaiser Permanente hospital is hit with a $187,500 fine this week for failing to protect the privacy of Octomom’s babies, adding to the $250K fine levied against it in May for failing to protect the mom’s records. Kaiser says 27 employees inappropriately reviewed their records, of which 16 quit, two were fired, and nine were disciplined. There’s a good lesson there: the punishment is just as harsh when the “celebrity” is at the end of their pitiful 15 minutes’ of fame.

Sun, on its way to being acquired by Oracle, pairs with healthcare data management vendor BridgeHead Software to offer an enterprise archiving system that offers a half-day installation and storage of multiple copies of the same data when needed. Sun liked BridgeHead because it’s big in the Meditech world. Did you ever notice that our own industry gives Meditech short shrift compared to companies like Epic and Cerner and yet big non-healthcare technology players instantly recognize the massive Meditech customer base as fertile ground for add-on technology, complementary applications, and consulting services? They’re like Rodney Dangerfield: they get no respect.

Chip at PCC blogs from this week’s CCHIT meetings. He’s got a lot of interesting observations (changing CCHIT membership, some friction between Mark Leavitt and one of its work groups, dropping the “version lockdown” certification requirement, and disagreement over whether an increase in applicants means CCHIT is doing a good job). Kudos to Bill Zurhellen, MD who said this directly to them: “If our goal is to certify to get ARRA payments, we’re doing the wrong thing. We should be focusing on improving health care.” Leavitt actually agreed and suggested that perhaps CCHIT’s mission statement should be changed to emphasize outcomes improvement instead of HIT adoption (not exactly an original thought since AMDIS and other groups have pressed CCHIT on that previously). I take that to mean that (a) all the CCHIT criticism and potential competition from other certification agencies has made CCHIT more responsive, or (b) it’s at least awakened a belated need to pretend to be more responsive.

Related: the Health IT Policy Committee recommends that CCHIT not be named the sole certifying agency, that CCHIT gives the appearance of conflict of interest, and that HHS should set the criteria instead of the certifying agencies themselves. Full details and PowerPoints from the committee’s Thursday meeting are here. That’s pretty big news that everybody seems to have missed. A new meaningful use matrix is also on that page, which Inga had already found and referenced in Friday’s post.

Since some folks (jokingly) accused me of making up the positive comments posted against Gregg Alexander’s interview with me, here’s a real one send from Mike Nelson, CIO of 25-hospital Universal Health Services, that he invited me to post: “I would also like to extend my appreciation for the work that you put into the writing and the site. And while it may sound like a plug (but it’s not) I like having sponsors here so I have another avenue to identify healthcare firms when I have a need for something, especially specialized consulting services.” I’ll vouch for that: in the past, Mike has copied me directly on inquiries he made to HIStalk sponsors for services he was about to buy. I appreciate both his eagerness to give HIStalk’s sponsors a chance to earn his business and his nice comments.

Florida’s state senate launches an investigation into the state’s blood banks following an Orlando Sentinel story that exposed lucrative contracts given by  Florida’s Blood Centers, which takes in $100 million per year, to its board members. The chair of the Health Regulation Committee said he was “shocked” that FBC charges hospitals $310 per unit of blood. Most disturbing to me were e-mail comments from FBC’s $600K salary president, in which in one sentence she twice referred to the organization as “the company.”

Temple University Physicians signs up for Ingenix CareTracker Services for revenue cycle management and cost control in its radiology department, citing its 3% increase in collections and 16% reduction in payment times for the other seven departments using it.

As Inga mentioned, Nuance acquires Jott, a voice-to-text transcription application aimed at mobile users to create notes, use e-mail tools, and update application databases. While general cell phone users are its target audience, there certainly are healthcare possibilities there (nurses calling in vital signs to the EMR, maybe, or doing progress notes by cell phone).

Microsoft Health Users Group Exchange 2009 will be in Redmond on September 2-3. They have tracks for clinical informatics, IT professionals, and developers, with a presentation from Microsoft VP/CIO Tony Scott. Registration is here.

I’m making several changes that should help the HIStalk page load faster (for my nerd compadres, I had Apache upgaded, combined several WordPress widgets into one to reduce the number of MySQL calls, am having WordPress and all plugins upgraded, and am installing a caching application to render pages as static HTML instead of database-generated pages). Heavy server load is a nice problem to have, I admit.

Voalte needs field engineers, project managers, and clinical trainers, in case you are looking for a new gig. Other jobs: Epic ADT Consultants, Laboratory Requirements Analyst, Revenue Cycle Project Manager.

Cleveland Clinic chooses MediServe for referral tracking, authorizations, scheduling, documentation and the plan of care, integrating it with Epic.

UnitedHealth gets a $21.8 billion contract to manage DoD benefits, of which UnitedHealth will keep $1.5 billion for administrative services after paying providers. When it comes to “illions” in healthcare costs, “m” is so 1.0.

Bill Moyers lauds the choice of Regina Benjamin as surgeon general nominee, contrasting her hardscrabble upbringing and low-rent medical practice serving the less fortunate to the suits running the for-profit side of healthcare. Named: Cigna’s chair ($11 million in the last year), Aetna’s CEO ($17 million), and McKesson’s John Hammergren ($29.7 million). The list above was provided in a comment on the article. I wish I’d said this: “Here’s the difference. To Dr. Regina Benjamin, health care is a public service, helping people in need with grace and compassion. To Ed Hanway and his highly paid friends, it’s big business, a commodity to be sold to those who can afford it. And woe to anyone who gets between them and the profits they reap from sick people … As we reported last week, that behavior includes spending nearly a million and a half a day to make sure health care reform comes out their way. Over the years they’ve lavished millions on the politicians who are writing and voting on health care reform. Now it’s payback time.” From this hardcore fiscal conservative, amen, liberal brother Bill Moyers. If you want to make a million dollars a year without actually delivering patient care, then please choose another industry because healthcare can’t afford you, whether you’re a drug company czar or an overpaid hospital CEO (your results have kind of sucked anyway). Unfortunately, politicians gravitate to money like mosquitoes to a bug zapper, so people just as accomplished and dedicated as Regina Benjamin don’t carry much weight.

Stratus Technologies announces that PC Mall will sell its Avance high availability software.

iSoft gets a $17.4 million maintenance contract extension in Northern Ireland.

The Wall Street Journal says Internet companies are losers when it comes to investing, pointing out that they’re more like unexciting utilities. “Microsoft has spent billions on Internet strategy without a dime of profit. And even Google can’t seem to find any other business model other than the one they stumbled into when they bought Applied Semantics in 2001 that had a little piece of software called AdSense. And the new guys: Twitter and Facebook are still scrambling for profits despite blistering usage growth.”

GE announces Q2 numbers: revenue down 17%, EPS $0.26 vs. $0.54, much of that due to problems in its financial business (I hate to brag, but I said Jeff Immelt’s haughty dismissal of GE Capital’s problems as trivial early in the economic meltdown was BS and it was). GE Healthcare had drops of 12% in revenue and 21% in profit.

Private equity firm Warburg Pincus invests $300 million to form RegionalCare Hospital Partners, which will invest in non-urban hospitals. There’s a lot of talk in the announcement about meeting community needs and service to others, which sounds strange coming from a PE firm.

Another hospital computer breach: UCSD sends letters 30,000 patient letters after finding out about hackers hacking.

Informatics Corporation of America wins its second consecutive Future 50 award from the Nashville Area Chamber of Commerce in recognition of its growth.

Marietta Memorial Hospital (OH) “insources” its IT department to CareTech Solutions, keeping its employees but bringing in a CareTech director.

Red Hat will replace CIT Group on the S&P 500.

E-mail me.

News 7/17/08

From: Samuel C. “Re: Yesterday’s health care bill. After yesterday’s health care bill it is safe to say: ‘It could probably be shown by facts and figures that there is no distinctively native American criminal class except Congress.’ – Mark Twain.” The Senate health committee approves legislation that includes a plan to provide nearly every American with health insurance, regardless of income or medical condition. The program also calls for a government program to compete with the private insurance companies. Opponents include the private insurers, as well as small business owners who fear the financial burden of providing healthcare for all employees.

From: Little Birdy “Re: MED3000. I hear that in addition to Tom Skelton, another former Misys VP is coming out of retirement to join the company. Look for an announcement in the next couple of weeks.”

HERtalk by Inga

Yesterday we published an interview with Mr. H, which is a must-read for any HIStalk fan. I’m not sure he revealed too many secrets, but the piece does re-iterate how hard he works and how humble he is (am I gushing?)  I must admit I didn’t know the interview was coming and was a bit surprised by it. I’ve long asked Mr. H to do an interview, but he always turned me down. So, thank you Dr. Gregg Alexander for being a better arm-twister than me. Mr. H actually skipped town for a bit, leaving me at the helm. I am pondering if there is any correlation between the kind words he had for me and his delegation of all the HIStalk chores for a few days.

Wake Forest University Baptist Medical Center selects Patient Care Technology Systems to provide hospital asset tracking. The Amelior Tracker system will track and manage hospital assets throughout Wake Forest’s 4.1 million square foot campus.

Senator Jay Rockefeller orchestrates a donation of almost $2 million in medical equipment to Welch Community Hospital (WV). Rockefeller had asked staff members last year to prepare a wish list of the hospital’s greatest needs. GE Healthcare helped make wishes come true with donation of an anesthesia machine, EKG monitor, portable X-ray machine, and more.

Meanwhile, GE wins a $12.5 million from LSU Health System (LA). GE will provide LSU the technology to digitize its central database and radiology image repository. The GE contract is just the first phase of LSU’s $116 million, five-year plan to add EHR throughout its 10 public hospitals and 500 clinics.

Boston Medical Center is back in the news, this time for filing a law suit against the state of Massachusetts. BMC accuses officials of illegally cutting payments made to the hospital for treating thousands of poor patients. The state says it has done nothing wrong, and officials are quick to point out that BMC has received $1.5 billion in state funding over the past year.

Sunquest Information Systems introduces a new release to its lab and POC solution suite. The updated version incorporates new modules for molecular testing, along with increased functionality and workflow enhancements for existing applications.

The University of Ottawa Heart Institute cuts its hospital readmission rates 54% for patients participating in a home telehealth monitoring program. The program is also attributed with saving $20,000 for each patient not re-admitted.

Providence Health & Services (CA) names Peter Spitzer CMIO. Spitzer will oversee clinical IS systems in this newly created role.

Henry Ford Health System extends its IT outsourcing agreement with CSC for another 63 months. The value of the new contract is estimated to be $115 million.

Netsmart Technologies acquires Crown Software, a provider of pharmacy management software. Netsmart sells software and services for health and human service providers.

Ingenix subsidiary The Lewin Group launches The Lewin Group Center for Comparative Effective Research. The new entity will focus on providing fact-based, comparative effectiveness research to improve patient care and optimize resources.

United Health Group and Cisco Systems announce a national telehealth network to bring remote medical care to rural and underserved areas. The Connected Care network will use Cisco videoconferencing to simulate an in-person doctor visit.

The American Medical Informatics Association (AMIA) submits comments to the ONC and HIT Policy committee, stressing that EHR certification does not necessarily equate with effectively using the system’s available functions, nor does it assure changes in clinical practice or patient outcomes. AMIA does not believe the current certification process is sufficient and stresses that certification should focus on process and care improvements over time.

Meanwhile, the ONC’s HIT Policy Committee approves the latest revised definition of EHR “meaningful use.” Since the initial definition last month, the committee made a few tweaks to its draft, including:

• Establishing a 10% threshold of CPOE for hospitals in 2011 (rather than the original and less specific requirement for “CPOE for all orders”)
• Allowing the 2011 criteria apply not just for 2011, but for the provider’s first adoption year. In other words, rather than 2011, 2012, 2013 requirements, change to Year 1, Year 2, Year 3 requirements
• Starting clinical decision support sooner
• Making access to personal health records a requirement earlier than originally proposed.

More here.

The information storage vendor Iron Mountain sponsors a white paper recommending the federal government maintain a 10-year retention policy for paper records. The 10-year retention window would give providers plenty of time to migrate to electronic records. And, perhaps give Iron Mountain plenty of time to fully migrate its business model from its original off-site document storage roots.

The Nashville Area Chamber of Commerce names ICA to its list of Future 50 Award winners, based on its projected growth in revenues and employees over the next three years.

iMedica changes its name to Aprima Medical  Software to avoid confusion with several other similarly-titled healthcare companies. The company also rolled out a new website, aprimaehr.com.

Two former executives from Province Healthcare launch a company to acquire and operate rural hospitals. Marty Rash and John M. Rutledge have created RegionalCare Hospital Partners, leveraging $300 million in startup funds from Warbug Pincus.

HIMSS gives Dr. Regina Benjamin a thumbs up following her nomination for Surgeon General. After Hurricane Katrina, the HIMSS Foundation actually provided Dr. Benjamin’s clinic a $5,000 grant to acquire EHR hardware and services. Dr. Benjamin and her staff are featured in this short video about EHR and the HIMSS Katrina Phoenix Project.

Target considers following Wal-Mart’s lead and support mandatory health insurance coverage by large companies.

Nuance Communications purchases startup company Jott Networks, a provider of mobile voice-to-text technology.

A Florida mans sues a physician at the Age Defying Surgical Center in Florida after he was denied a hair transplant. Apparently the 28-year-old hair-challenge patient is HIV positive and Florida law forbids denying medical treatment based on HIV status. The lawsuit is for at  least $15,000. I’ve said it before, but I don’t get why men get so hung up on hair loss. Bald is sexy.

E-mail Inga.

CIO Unplugged – 7/15/09

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

Legacy Leaders
By Ed Marx

How can so many of us hold the title of leader, yet never be remembered? Why do some leaders make a difference while others do not? Fear.

Fear keeps us from making a difference. Too often leaders fade without notice or with merely a modicum of fanfare because of their longevity in a company, because they stuck with tradition, and perhaps they achieved small wins. Conversely, legacy leaders stick their necks out and occasionally go against the flow. They spin the roulette wheel while their peers play it safe. Anyone can play safe – status quo. But legacy leaders fight fear, calculate options, then jump in with both feet. Leaders who leave legacies take risks.

No risk, no legacy. Our founding fathers pursued a risky mission, and look at the legacy they left us. Martin Luther King Jr. took risks that prematurely ended his life, but his legacy endures. Pause for a moment and think of a legacy leader who advanced with nothing at stake? Thought so.

I overhear leaders say they want to make a difference, want to transform healthcare locally and nationally. Yet healthcare is stuck in neutral, if not reverse. Decision makers are overly conservative in their approach to innovation and opportunity. Paradoxically, some I know in management were risk takers early in their careers and enjoyed success. For whatever reason, they shifted gears into a risk-averse posture and ran out of gas short of their destination. We as healthcare leaders must intrepidly drive forward, or surrender the wheel to someone who will.

I want to encourage and reward the courageous, and the best way to do it is to lead by example. Push the envelope. Try new programs, systems, and services before they are mainstream. I don’t settle for giving lip service, I fund and staff risk ventures. Then I reward my risk takers publically, even in failure, because they gave it their all. Perseverance will eventually pay off.

Risk provides a competitive advantage. Do you want to create separation and differentiation in your marketplace? Risk. Tap into the creativity of those employees with a passion to innovate and transform. Yes, there will be failure. Use failure as a catalyst to increase your risk tolerance, not shy away from it. Learn and embrace failure. Edison did.

Stop analysis paralysis. Adopt Colin Powell’s leadership lesson #15, “P@40 to 70.” P stands for the probability of success; the numbers indicate the percentage of information acquired. Once the information is in the 40 to 70 range, go with your gut. Procrastination in the name of reducing risk actually increases the potential of failure or falling behind.

To those who favor remaining conservative. Do you fear losing your job? When you play safe, you’re rewarded with keeping your position, right? But if you don’t rock the boat or challenge the status quo, do you lose part of your soul?

A board vice chair told me, “Ed, if you do your job right, you won’t be here a year from now.” I took his comment as encouragement to take risks on behalf of our patients and providers. If I lose my job in the process, so be it. I do not operate under the fear of man but under the fear of not influencing my part of the world.

Risk is a lifestyle not just a work mode. When hiring like-minded staff, determine the risk quotient of potential candidates by finding out what they do outside of work. If they stick to the standard fare, move on. If they play it safe, move on. They won’t act any different in the workplace.

What about you? Are you a legacy leader making a difference? Will anyone remember your years of effort? Will healthcare be transformed because of your actions?

What are you doing today that is risky? What are you doing today to encourage risk?

Demand it. Live it.

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.”

An HIT Moment with … Mr. HIStalk

Let the record show that I didn’t want to do this since (a) it looks like a vanity piece even though I resisted and am intensely uncomfortable with the idea of featuring myself; (b) I don’t really have much to say that I don’t say every couple of days; and (c) HIStalk is about news and opinion, not about me. However, Dr. Gregg Alexander was persistent, and since he writes for HIStalk Practice, I felt bad after saying “no” the first handful of times. So, I’m disclaiming all responsibility and turning it over to Gregg. This is my first and last interview.

An HIT Moment with … is usually a quick interview with someone “we” find interesting. Today, I have been granted the unusual and tremendous honor of turning the tables upon Mr. HIStalk, HIS-self. As you know, Mr. H is founder and chief organizer of HIStalk.

You are a humble guy, but even you must admit the breadth of HIT industry folks who read HIStalk on a regular basis is pretty impressive. What’s your take on the not insignificant impact HIStalk continues to have upon this multi-billion dollar industry?

It’s hard for me to say. I just sit alone in an empty room and type onto an empty screen. I’ve never heard anyone at my job mention HIStalk. Nobody there knows I do it. I could count on one hand, probably, the number of people I’ve heard say the word HIStalk to me directly. That’s fine since it’s kind of creepy for me to hear people talking about it. It’s a private activity for me. As you know, I didn’t want to do this interview and tried to ignore your request until you asked a second time. I figured I owed you since you write some fine articles for HIStalk Practice, but otherwise, I probably wouldn’t have done it. I’ve turned down quite a few people before.

I know a fair number of people read HIStalk and I’m really happy about that, but in terms of impact I really don’t know. The only reaction I get is the occasional e-mail. I’m like the guy who throws the morning paper in your driveway. I don’t really know what you do with it, why you read it, or what affect it has had on you. I just keep doing my job and hope you find it useful enough to keep reading. If so, I’m happy to keep right on doing it.

I hope it has been fun for the people who read it. I hope it provides a virtual industry water cooler to chat around since so many of us are far-flung and maybe on the road most of the time. I hope it has educated a few industry newcomers. Most of all, I hope it has provided a dialogue, not just my monologue, on what a cross-section of industry savvy readers think about new developments and concepts that affect healthcare IT and, ultimately, patients.

Just keeping up with all you and Inga write is challenging enough, so how do you manage to work a regular day job, keep current with all the diverse news you gather, find time to write about the news you find of note (and include some insight and humor,) plus still have a family life? (I’ve heard you are actually 5 people; it would make more sense.)

It helps that I work in the industry in a non-profit hospital. Most healthcare IT writers don’t, so they don’t really know what’s important, what’s BS, and how it all fits together. They are good at crafting clever sentences, but they don’t know what they should contain. I’m pretty efficient at bringing all the information I have together and hopefully presenting it in a concise and entertaining way. There’s nothing phony or contrived about the way I write, so it’s just me, no different than what it was six years ago, so I can crank it out pretty fast. Readers help me immensely by e-mailing when they hear something new or have an opinion to share and I value that a lot. I spend hours putting together something that looks like a quick, easy read. The longer I work, the easier it looks.

I’ve gotten pretty organized at how and when I write HIStalk, but it’s still a time crunch sometimes. I’m out at least 10 hours a day at work. When I get home, we eat dinner and I head off to the computer. I’m there every evening for at least three hours, sometimes more than five. It takes a lot of time to read and reply to e-mail, to do the primitive recordkeeping I do for sponsorships and all that, and to do the actual writing. I spend a bigger chunk of time on Saturday and Sunday, sometimes more than eight hours each. Luckily, nothing invigorates me more – even after six years and many millions of words written – than sitting down fresh and starting off on another HIStalk.

Thank goodness I got Inga to help me awhile back with the writing, the research, and working with our sponsors. I was getting pretty frazzled, especially right around HIMSS time when it all comes to a head. She keeps me sane. We worked together for almost a year before we ever met in person, having decided after a five-minute phone call that we were a good match. She made it fun again.

I hope I don’t ignore my family in doing HIStalk. I worry about that. Will I look back someday and wish I’d spent more time doing something more profound? Is it really worthwhile or just a comforting distraction from reality? Or, should I be some kind of astute businessperson and make it bigger or better even though I know next to nothing about starting or running a business and I’m chronically lazy? Until I figure those things out, I’ll just keep doing what I’ve been doing.

Speaking of keeping up, there’s so much HIT hubbub these days with ARRA, HITECH, CCHIT, evidenced-based, meaningful use, etc. As you keep a pretty tight finger on the pulse of the goings on in HIT, I’d be curious to hear what your take is on the overall state of the industry.

The government wanted IT activity in healthcare and it’s getting it, albeit at a high price. Based on recent activity with the banks and auto industry, I think this administration expects to be an active partner in healthcare, not just a quiet financier of IT systems. IT will give it a way to collect information and develop policies around it. Good or bad, Uncle Sam is the biggest customer of many or most hospitals and doctors and he’s not happy about the value received, so opening the healthcare kimono via IT should be interesting.

I would be more excited about using billions of taxpayer dollars if there were at least incentives for vendors to develop new products. It’s mostly the same old systems and same old potential customers, only with federal money forcing their awkward introduction. I hope vendors use some of their new revenue to create new systems based on paradigms and technologies from this millennium instead of just patching up the old ones. I worry that all systems are starting to look and work alike since vendors keep swapping former employees with each other, ensuring cross-pollination instead of innovation. CIOs hate IT risk, though, so maybe everybody will just keep running what they always have except for some of the more exciting niche systems and technology platforms like the iPhone.

When it comes to physician practices, I’m not convinced that most of them will take the bait after comparing the potential rewards with the perceived effort required. The government hasn’t been all that reliable and supportive of a partner when it’s tried doctor programs like that before. Doctors know that everybody gets value from EMRs, but they’re the ones on the hook to actually use them. They have nothing to sell but time, so if EMRs are perceived to take more of it, I don’t think the incentives will be enough – except maybe for the small practices that have to count every penny. I would have preferred a rewards system based on sharing patient data, where you get paid extra for making your lab results, prescriptions, and notes available electronically to other providers. Then, let the providers choose whatever tools they want to support that. The final definition of "meaningful use" will most likely include that, so it will probably be fine.

All the rewards require a very short time frame for implementation and productive use, which I worry is more than either vendors or providers are ready to tackle. Resources may be an issue. We’re dealing with patient systems, so let’s hope we don’t see unintended consequences from quick and dirty implementations.

Some vendors, especially those with marketing machines that can capture the attention of prospects in the small window in which they’ll be buying products, will do very well. Those not so fortunate will have a tough time since HITECH will front-load a lot of sales that would have taken years, so those that don’t succeed in that small time window will find the pickings slim for years afterward. I think a lot of second- and third-tier vendors will scale back, close down, or sell out as a result. There’s a big wave coming, but the trough right behind it could be ugly.

We’ll get our critical mass of EMRs, at least assuming everyone gets implemented. The real job is to do something useful with them. That requires focus and change management capabilities, qualities that are hard to come by in many organizations. Without quality reporting, data interchange, and some element of practice standardization, we won’t have gained much by planting all those EMRs. They don’t provide enough efficiency benefit for that alone to be the driver. That could create a new demand for analytics, add-on tools, and formally trained informatics people who can do more than just flip the go-live switch. EMRs might eventually become a commodity as CCHIT, or whatever certifying body is named, expands their functionality checklists to become what could be a full set of specs for an EMR. Maybe you don’t need dozens or hundreds of vendors if they all meet the same basic requirements.

Overall then, I would say everybody’s going to be busy for the next five years at least. We’ll probably see mini-Gartner Hype Cycles as new customers buy systems, find them disappointing for one reason or another, but eventually gain benefits they wouldn’t have expected. Way down the road, the power will be in the connection, not the tool used to connect, so EMRs may be as unexciting as buying a PC today — just a generic tool you need do real work by connecting with everybody else on the Internet.

Your newest “offspring,” HIStalkPractice…what prompted your address of the physician practice world?

Inga came from the physician practice side of the industry, but I was a hospital guy. I knew we weren’t covering everything in HIStalk, but I wasn’t sure that audience was really interested in what was happening with practice management systems, EHRs, CCHIT, and all that kind of detailed discussion. I also knew there were a lot of potentially influential voices that weren’t being heard, such as yours, and I wanted to see if we could cultivate an audience interested in the usual HIStalk style news recap and opinion for that somewhat different market, along with more interviews and guest articles. It has been slow going, but nothing like the years it took to get a few readers of HIStalk.

Inga does pretty much all the writing for it other than what our guest authors put together, now that I’ve convinced her she has the knowledge and the ability without me looking over her shoulder. I do nitpick about how she punctuates and structures her sentences sometimes and I know she’s just neurotic enough to let that bother her, so I try to leave her alone.

On the “About HIStalk” page, you give a fairly complete background on why you started HIStalk and of your general operating standards. Pretty straightforward about your approach and principles. However, you have a sardonic wit and are often quite blunt about your opinions. Both of these traits make for a great read, but from what you do post from readers, you are often also slammed for your perspective. Do you receive more pointed or insultatory jabs for your writing that don’t make it onto the printed screen?

I run most of the e-mails I get on HIStalk if they would interest readers. I do get the occasional viciously nasty and insulting comments, usually for something silly, like years ago when I mentioned some notoriously phony schools where healthcare people were sporting MBAs and PhDs from. I got some threats over that more than once. Those were the only truly angry comments. Sometimes someone complains that I’ve been unfair to a company, have sold out to sponsors, or think I know it all. I do a little self-analysis to see if they have a point that I can learn from, then move on one way or another.

I really do try to be fair. I encourage comments that disagree with my opinions. If I rip a company one day, I try to remember to say something nice about them another day. I see my job as being a moderator who introduces a topic, maybe throws out some controversial statements to get the discussions going, and then makes sure everyone plays nice together as they debate. I like it when people get along, but I understand that some of the most valuable stuff comes from heated discussion.

I’ve heard a buzz that you and the lovely Inga might be unmasked at the HIStalk reception during HIMSS in Atlanta next year. Just wishful rumor mongering or is there any such possibility?

You never know. Inga is a lot more of a schmoozer than me. Sometimes I think she’s about to burst trying to keep the secret that she’s Inga. Unlike me, I think she would probably bask in whatever limelight there is and readers would like her even more than they do now. So, maybe we will arrange her coming out in some fashion at HIMSS. She’s probably already shopping for new shoes.

News 7/15/09

From Ex-Cerner Guy (among the many): “Re: Banner’s Cerner pricing. The pricing for the full HIS, @ $30M or so, looks pretty accurate. It likely started in the $45-50M range, then someone from KC came in and probably cut the SW pricing to get the deal. KC types will cut the pricing until the prospect says yes. From a customer perspective, there’s no value in saying yes until the SW fee is $0 and hourly rate is $125 or less. Banner probably said yes a little early.” The paper actually said each of their smallish hospitals was spending $30 million, so that’s what I questioned. Good negotiating tips, by the way.

From Bob in Accounting: “Re: sometimes you keep track of these things.” A doctor at Fletcher Allen Health Care (VT) is reprimanded by the state medical board after admitting that he improperly accessed the medical records (presumably paper ones) of eight women, one of them a previous acquaintance who found about it and turned him in. The article refers to “breeches of patient medical record confidentiality,” which either means someone makes little pants to keep records safe or the reporter trusted his spellchecker instead of his dictionary.

From Mark Moffitt: “Re: ARRA. Is anyone else viewing the ARRA as an investment opportunity v. subsidizing IT? GSMC is spending $1.3 million to net $2.7 in Year One and using the proceeds for other non-IT clinical needs.”

From The PACS Designer: “Re: SAML. The porting of applications to the web has increased the need for security enhancement solutions. To address this need, there’s a specification called Security Assertion Markup Language (SAML). SAML provides the means for multiple organizations to exchange security information to protect each other’s security requirements. Also, security software promoting federation and the use of single sign-on solution for multiple systems through the use of SAML enhances the user experience and removes the need for multiple IDs and passwords.”

From Wayne Panera: “Re: strong passwords. Pretty good paper from Microsoft called ‘Do Strong Web Passwords Accomplish Anything?’ discussing the fallacy that strong passwords produce additional security.” Link (warning: PDF). The article says that passwords are stronger than they need to be to thwart brute force attacks (as long as you don’t allow more than three incorrect login attempts) and yet do nothing to prevent phishing and keylogging. Interesting idea: it suggests making user IDs longer is easier for users to remember and equally effective in preventing brute force guessing. Their example: PayPal requires an eight-character password that isn’t in the dictionary, uses mixed case, and has at least one special character, despite the fact that even a six-digit PIN has only a 1% probability of being cracked after a 10-year brute force attack. With regard to lockouts, the article also suggests that instead of a fixed lockout, like 24 hours, that the application simply geometrically increase the lockout time between each unsuccessful login attempt and, to prevent bot attacks, consider setting the lockout by IP address.

From Lynn Devine: “Re: Healthport. They’re looking to outsource their EMR development to integrate it with their PM product. They project a year to do this – it’s only been suggested for the past five years.” Unverified. Inga is attempting contact the company.

University of Florida says it will invest $70 million in clinical and translational research over the next 5-7 years, with “a large portion of those funds” being used to roll out Epic’s EMR to the faculty practice.

Listening: Lady Ga Ga, hopelessly trendy and way outside my usual genres, but it sounds pretty good now that I’ve listened to the CD three times.

A 50-provider medical group in California drops two CCHIT-certified (“point-and-click”) EMRs, replacing them with the EMR from SRSsoft after a free pilot.

A BlackBerry executive grudgingly admits that docs love the iPhone, confirms that the Chalk Media technology BlackBerry acquired will be used for medical education, and urges healthcare customers to take advantage of their BlackBerry Enterprise Server and client licenses to push data. He also touts BlackBerry’s App World and says customers have an appetite for it “and other app stores”.  Basically, he thinks Apple is promoting innovation that BlackBerry has had in place for years. If there’s an App Store … er, App World … application to measure the sourness of grapes, it’s time to roll it out.

Thanks to the reader who sent over the BMJ article from Kaiser Permanente Hawaii on its use of HealthConnect to proactively generate risk-based nephrology referrals instead of waiting on generalists to do it. Last-minute nephrology referrals by primary care providers occurred 30-42% of the time in the pre-study population, causing missed clinical opportunities for patients. The targets and results: (a) reduce late referrals, defined as being within four months of the onset of end-stage renal disease, aka ESRD (dropped from 32% to 12%); (b) creating the “life line” arteriovenous fistula in time for it to mature (increased from 18% to 36%); and (c) start dialysis as an outpatient (increased from 35% to 56%). How they did it: HealthConnect was used to identify at-risk patients, looking at glomerular filtration rate, urinary protein, and serum creatinine lab results in a monthly download. Those patients were assigned a numerical risk rating for ESRD. HealthConnect was used to recommend the referral, capture notes about whether the PCP and patient followed through, to deliver electronic messaging between the PCPs and nephrologists, and to issue alerts for patients showing a deterioration trend from one monthly download to the next. The result was that 280 patients were referred and some of the PCPs learned how to manage the patients themselves better after electronically reviewing the work of the nephrologists. Interestingly, the original plan was to let the PCPs do all the managing themselves, but they pushed back, saying they were too busy and worried about the impending HealthConnect implementation. Good work by Kaiser, a nice example of physician collaboration, a great reminder of how medical practice can change positively once information is available electronically, and a fine service to patients who surely had better outcomes as a result.

This from Weird News Andy, who says, “They took him to get a blood test at a hospital to prove he was drunk. He proved they were right.” A DUI suspect flees Research Medical Center in a stolen ambulance before his ride is ended by “stop sticks” and a police dog’s bite. As you might expect, he was not a first-time offender, with a rap sheet that included three previous alcohol-related convictions and a revoked driver’s license.

Michael Sinno is promoted to VP/CIO of Cooper University Hospital, which is in some hitherto unknown state called South Jersey.

Thanks to IntraNexus and CEO Rick O’Pry for supporting HIStalk as a brand new Platinum Sponsor. The Virginia Beach-based company offers the Sapphire Web-based (or client-server, if you prefer that option) hospital information system (still the coolest product name ever if you ask me), a complete single-database system with patient access, document imaging, revenue cycle, scheduling, general financials, EIS, clinical care, imaging, CPOE, critical care, ED, EMR, lab, LTC (!), pharmacy, point of care, radiology, and other modules. Here’s a writeup about beta site Oswego Hospital, who said “Sapphire was the best go-live we have ever had.” They just went live at St. Luke Hospitals (KY). Thanks to IntraNexus for supporting HIStalk.

Bad news for Microsoft: a survey says that 60% of its business customers won’t buy Windows 7 because of cost and compatibility concerns (the same reasons those customers passed on Vista, in other words). Microsoft’s real problem, if you ask me (and you didn’t), is that its cash cow products aren’t strategic – everybody can live without new versions of Windows and Office. And in tough times, they apparently will.

The American Heart Association will donate $50,000 toward creation of an open source CPR learning application for the Wii.

AMDIS announces its 2009 award winners: Michael Dominguez (University San Antonio), Fallon Clinic, Cynthia Herzog (MemorialCare Orange County), Kaiser Permanente, Steve Margolis (Orlando Health), Jon Morris (Wellstar), Matt Sprunger (Dupont Hospital), and the UPMC interoperability team.

The New York Times highlights Cook Children’s Health Care System (TX), a 350-physician practice that will install a Web-based EMR from athenahealth and Microsoft’s HealthVault. It will also open an Innovation Clinic with two or three doctors that will operate under the capitation model.

Cardinal Health’s debt ratings are lowered to near junk levels because the upcoming spinoff of its clinical and technology products business means there’s not much left except low-margin drug distribution. I guess analysts weren’t distracted by the CareFusion jazz festival.

China’s health ministry puts a halt to a clinic’s rather extreme program of Internet addiction therapy in teens, saying it will no longer allow “freaky treatment” that included electroshock therapy, kneeling in front of parents, and forced confessions of wrongdoing.

While everybody’s salivating over stimulus money, here’s a sobering fact: the US budget deficit just hit $1 trillion so far this year, the first trillion-dollar deficit ever, but nothing special considering estimates are now at $2 trillion for the year (not counting the new calls for another round of stimulus money because the first one didn’t really do much, with unemployment even higher than the level threatened if the stimulus wasn’t passed).

The Terminator fires three of the six members of the California Board of Registered Nursing and its executive officer quits after a nonprofit investigative newsroom found that it took years to get dangerous RNs off the job. Newspapers run by bad businesspeople (big corporations saddled with acquisition debt) keep getting smaller, stupider, and more reliant on wire service celebrity gossip, so this example of a non-newspaper doing real investigative work in the public interest is sure to raise the debate about what journalism really is.

Odd hospital lawsuit: frightened by stories of a hospital’s hepatitis-positive surgery nurse who replaced OR needles with her own dirty ones while stealing drugs, a patient files suit against the hospital even though her own test results aren’t back yet. The patient’s attorney wants the court to oversee patient testing for hepatitis. He also says he has people who are “literally scared to death,” which even an ambulance chaser should know means they are six feet under instead of trying to jump on a class action lawsuit.

E-mail me.

HERtalk by Inga

I am back from my big vacation, a little more rested, tanned, and a new fan of rum punch. Oh, and I made time for wee bit of shoe shopping. The vacation gods made me forget the power cord to my laptop so I was forced to keep my Internet surfing to a minimum. And, low and behold, the HIT world continued without me!

Providence Associates Medical Laboratories rolls out a new billing system built on the InterSystems Cache’ database. The lab reports that month-end processing time has been slashed by 88%.

Novant Health (NC) hires CareTech Solutions to manage its web content and provide secure hosting for its 10 Web sites.

e-MDs announces the release of its 6.3.0 Solution SeriesTM, which incorporates First DataBank’s drug database solution, enhancements to its Surescripts e-rx application, support of continuity of care documents, and other features.

The National Rural Health Association’s Services Corporation selects Virtual Radiologic as its provider of choice for teleradiology services.

Image On Call, another provider of teleradiology services, promotes COO MIchael Lampron to CEO. Lampron was VP of services and GM of the Vision Series Financials Group at Amicas.

Allscripts announces it is working with the AMA to offer an AMA-branded e-prescribing tool. The tool will be available at no cost to subscribers of a new online solution being developed by the AMA, with help from Covisint.

Sales from wi-fi enabled healthcare products will total almost $5 billion by 2014, a 70% increase over today’s numbers, according to a new study.

Healthland appoints Odell Tuttle to the role of CTO. He was previously with Gearworks, focusing on  the company’s mobile healthcare product OnCare.

The financially struggling Shriners Hospitals for Children will begin accepting insurance reimbursement rather than close six of its 22 hospitals. This follows a plunge in endowments from $8 billion to $5 billion during the economic downturn. For 87 years, the Shriners have provided free care to children without billing insurance providers.

Boston Medical Center is also in financial straits, anticipating a $175 million loss in the fiscal year that starts October 1. The hospital laid off 250 people earlier this year and took other measures to cut costs by $40 million. It’s the state’s largest provider of care for the poor and also offers a food pantry for patients with special diets and legal aid. What happens when the nets collapse at safety net hospitals?

The local paper highlights EnovateIT and the niche it is building with its computer wall cabinets and moveable carts. The company, which last month announced plans to manufacture its own cart in the USA, employs 46 and has revenues of $46 million. I interviewed company president Ron Sgro last year and found him to be pretty fun (medical carts make for a pretty dry topic, but he was entertaining), plus I like their green approach to business.

Scotland becomes the first country in the UK to deliver e-prescribing services. More than 90% of all prescriptions are now submitted electronically using the national Acute Medical Service (eAMS).

Maine plans to go live on its statewide HIE later this month. HealthInfoNet will connect 15 hospitals, three health clinics, and the Maine CDC. Health information from more than 400,000 patients has already been loaded into the HealthInfoNet system, which is powered by 3M Health Information Systems.

GE announces a new partnership to integrate the Medicalis CDS-DI solution with its Centricity Imaging IT and EMR products.

The HIMSS Electronic Health Records Association (EHRA) sends a letter to the ONC recommending, among other things, that CCHIT be “the single certifying entity to avoid duplication of effort, unnecessary expense and confusion in the market.”  Uproars from the anti-CCHIT folks to follow.

E-mail Inga.

HIStalk Interviews William Bria MD, Chief Medical Information Officer, Shriners Hospitals for Children

William Bria III, MD is chief medical information officer at Shriners Hospital for Children, Tampa, FL, and  chair of the Association of Medical Directors of Information Systems (AMDIS).

What kind of response have you received from the AMDIS recommendation to not include CPOE in the first round of the HHS”meaningful use” criteria?

It’s been excellent. I’ve gotten response from our membership, but I’ve also had a number of discussions with everybody from the press to those that are in high places, shall we say, and other organizations, like the American College of Physicians. What I’ve gotten back is that both the caveat that we put in our response and the emphasis that we put the patient consideration up front was very well appreciated.

Considering the vast majority of hospitals in the country don’t yet have a fully implemented EMR, I think the concern in this economic climate of what it means to individuals personally as well as organizationally was the biggest impact, particularly when they saw how much they were going to be asked in 2011 to come up with in the draft proposal from Paul Tang and his group.

I think the patient focus of it gives us a way of balancing that concern with a very important political consideration, if I may, in that if this change in American healthcare is painted as a regulatory or a governmental imposition on the practice of medicine which some, as you well know, in the press were already doing, then it actually aligns physicians and patients against it rather than what we really believe is true, that this is one of the tools. It’s not an answer to all of the problems, but it’s a tool that can act in a very fundamental key change kind of way to empower patients and give patients the information they’ve needed forever.

My most recent experience was this afternoon at around four o’clock when my son, who has a chronic illness, a very serious one, called me and said his doctor had broken his leg in an accident. My son — he’s in his twenties — is very fastidious about seeing his doctor and careful about follow-ups, but he called the office and was told that the next appointment with his doctor was in 2010. He was trying to make an arrangement for something that was within the next two weeks before the doctor had his accident.

You know, that’s a real basic patient communication aspect that should be as difficult as saying, "Your flight was cancelled, but you can select these other flights," or "Your hotel reservation is not possible, but we can take care of you at this other hotel." The idea of some of the basic communication in the business of delivering care in America, because of the lack of automation at the level of the patient, is still far too frightening and daunting, and don’t even get into how much it’s costing to have a mostly non-automated process for delivering care in America.

Do you think ARRA encourages organizations to move too quickly in ways that may have unintended consequences when it comes to patient care? 

I think there’s no question about that. I think the first draft — and that’s all it was, it was a draft, and I think it would be wrong to make out that it’s more than that — the first draft on this saying we are going to accomplish CPOE adoption, a full EMR adoption, EHR adoption, and then successful reporting on quality and metrics out of the same system, that really speaks to me from a point of view of someone who hasn’t really done it yet. If you think it’s that mechanical that you can drop these systems in even a modest-sized healthcare setting, and moreover, settle down and actually be able to generate data, and then be able to automate a process of quality and safety reporting, it doesn’t speak to folks that actually have the experience of having to do that.

So I think that was perhaps a challenge, perhaps a way of creating controversy that levels it, because as we all know, it’s really going to be CMS that’s going to make the final decision on this, and the idea of sending the wrong message about reasonable expectations in what timeframe that should be done at some point, no question about it. Absolutely. If we didn’t put quality reporting and safety reporting as part of the expectation of the entire delivery on meaningful use, absolutely. That would be crazy. That would be a major mistake.

However, saying that it all can happen in a two-year time frame, that really puts a concern about reality testing.

Are you concerned that, since it’s an economic stimulus that requires the money to get out quickly, that they’ll just chuck out everything except the minimal criteria and say, "Look, just think of it as a slightly encumbered grant"?

Well, could that happen? Could that be a reaction formation that goes all the way or the other way? Yes. Is that what we want? Absolutely not.

From the standpoint of insisting on the introduction of tools, on the introduction of preparedness and analysis of concept redesign and genuine commitment to achieving success in introduction of the basics — departmental systems, scheduling, reporting, and data acquisition and reporting– is the key to starting the engine of information for an organization — large, medium or small — to even approach the challenge of subsequent data reporting and analysis.

So we think that dumbing it down too far is a risk, but we are anything but that. We are definitely for steadfast introduction and insistence on introduction, which I think the CMS — part of its leadership — makes it clear to most organizations, even ones that haven’t been familiar with the idea of clinical data systems as being central to their business.

Interoperability seems to have been traded off in favor of just getting systems put into offices. Do you think there will be enough emphasis on exchanging data and rewards for doing that?

I think there’s been emphasis on it, but I don’t think there’s been enough clarity about who’s responsible for doing that. If you consider the scope of the introduction of any of the existing systems, and then start to consider the scope of interconnection through interoperability of information, the systems themselves don’t need to be interoperable, the database contained must be interoperable. Who is responsible for doing that?

The idea that while you’re trying to understand and implement and accommodate the introduction of an information system into your practice — in a large, medium or small clinical setting — that you’re going to have the persons and the skill set to interconnect that data seamlessly with the rest of your community, that’s not very realistic, I don’t think, in anybody’s perception.

There has to be the identification of HIEs or other entities that are going to, in fact, have that as their main focus as communities and regions start to introduce electronic health records.

Where do you see that interoperability push coming from?

I think the notion of saying that entities — and there needs to be more clarity on what entities are going to be charged — is it going to be the small, two-doctor office that’s going to have to worry about interoperability with their region? No. That’s not reasonable or realistic, and it’s my experience that then we will have a bunch of silos, where we now have paper silos, we’ll have also electronic ones.

But the notion of making that much more explicit about in what way and in what timeframe are those considerations going to be made, will there be clear standards with regards to data exchange to the vendors? Not to the customers, but to the vendors, in order to receive approval for certification and implementation in this national scheme. That’s a whole dimension of this discussion and the response to the first draft of meaningful use. I don’t think we’ve really spent enough time with it yet as a country and in applied medical informatics as a discipline.

Since it was an economic stimulus, the bill seems to push EHR adoption as opposed to EHR benefit. Do you think those two are inseparable? Should we be trying to bring up the laggards who have no technology at all or should we be rewarding the results of the technology and let them pull themselves up accordingly?

I really believe that the idea of a critical mass of American healthcare using information technology will so tremendously change the national dialogue and the national expectation about the practice of medicine using that technology — that is the first, second and third priority.

We have to get a greater penetration. That doesn’t need to be 90% — no, it’s not going to be 90% in the next five years, but what it needs to be is greater than 17%, or 15%, or 20% even at this point. It has to be at least twice that for us to start to say that this is truly an unstoppable transformation from the standpoint of the infrastructure necessary to practice medicine and for physicians to no longer be bystanders.

I’m not talking about informatics positions, I’m talking about rank and file practitioners to no longer be bystanders in this discussion in their offices, in their hospitals, and their communities, but to be active consumers defining what is needed first, second, and third in their improvement and then moving forward.

I’ve been talking about this and speaking to physician groups on this subject since 1982 when I finished my fellowship and took my first job that included both of these paths. So the idea, I think, of really making the case that there is a critical mass and that introduction — I won’t say adoption, because that apparently is considered a bad word — of information technology in the American healthcare to a significant degree is long overdue and absolutely essential to get to the next level.

You mentioned certification. Does AMDIS support certification, and if so, do you have an opinion on whether it should be CCHIT as the certifying agency?

I think the way in which CCHIT has operated in the past has been good for that stage. I think now with the money that has been directed towards it, the idea of being anything other than an objective certification body that has at its core both the timeline and the elements of the goal of the ARRA, the HITECH portion, is essential.

What do I mean? For a number of years, since I was the chairman of the HIMSS Physician Community group, we have been asked to review the criteria that were being used at CCHIT, since HIMSS is a major partner in that. Every time, me and my colleagues, many of them from AMDIS, that were part of that re-review before CCHIT spins out its next version of criteria for certification, we said why are we delaying CDS for some future time? Why isn’t there an insistence on the existence of elements of data exchange and interoperability mandated as part of the standards of being able to have a certification of your electronic health record product?

The usual answer was that yes, they know that’s important, but they thought that that was a future development rather than an immediate necessity. That never sat well with me nor my colleagues in our review process. I would be very anxious to see that whatever new body or whatever new group was constituted that there was clearly no confusion about connection with the status quo, that it was directed towards the actual goal, the stated goals, of the ARRA itself.

You’re working on some formal informatics training programs. What do you think the industry needs in terms of the quality and quantity of people who have real informatics training, not just on-the-job training?

A lot more. (laughs) I think since the bar’s been set in this first discussion very high, I’m saying that it’s not enough to put in systems then say, "Congratulations, everybody can go home and rest," but rather data reporting and actually then make that the reason, the raison d’etre, of healthcare informatics, the quality and safety reporting and performance reporting in a national scale.

I think you’re going to need a lot more people that not only understand the information technology, which is an entry level issue, and rather get on to those who really know how to evaluate large data sources, be able to guide and manipulate information systems as necessary in order to improve performance, and a last but not least, we’ve talked for so many years about, "Are you up on CPOE yet, or did you just do results reporting? Anybody can do that results reporting stuff, but CPOE — that’s a real man’s job”.

But you know what the real man’s job? It’s to get data out of the system that is of sufficient quality, and have a dialogue with the clinicians in an organization to actually improve and change practice. There are examples of this, but boy, there’s not a lot of them. The ones that have done that as a production line, the same way we used to think about the production line of order entry and results reporting, those organizations – Cleveland Clinic, Mayo Clinic, Partners, Kaiser, etc. — those are the leadership healthcare organizations in this country. I don’t think that’s a mistake.

What are the most important projects you’re working on in Shriners and what challenges are you seeing?

We are working on clinical decision support. We are working on CIDSS, clinical information decision support services. The first one, as a practical matter, improvement in medication ordering and administration safety and quality care sets, tuning our alerts environment and refining it for the particular care line that we have — we’re a very specialized pediatric hospital system–and the CIDSS project is a data warehouse installation, evaluation, and targeting towards actual safety and quality necessities and reporting within our healthcare systems. Those are our important projects.

Do you think that outcomes analysis or process analysis in the data warehouse is going to make the underlying tool that created that data less important or more of a commodity?

Not yet, but that’s exactly what we have to get to. And again, the organizations that are leading — I don’t think people sit back and say, "Well, they did all this because of this vendor." Well, yes, it was important to have a product that had sufficient functionality and a data model and environment that could be leveraged for these reasons, but it’s really the organization and their ability to use data to make them more successful and make them appear demonstrably better than competitors. That’s the name of the game.

I truly believe that we’re going to head, in the next decade, from a time of talking about these elements of automation in the actual process of healthcare into saying, "This is the necessary tool, but that’s all it is." This is the instrument to allow leadership in organizations that are the most forward-thinking and the most attractive to the people who seek care, this has provided in the necessary grist, the fundamental data, to be able to demonstrate and succeed in innovation.

There are probably going to be a lot of organizations that are going to be pushed into buying technology only to realize that was only the little step, and the big one’s yet to come.

(laughs) Well, you know that’s how life is. Human beings need to take it a little bit at a time. If you knew how difficult it was to get married, have two kids, raise them well, help ensure that they’re going to be good people, you never would have done it. (laughs)

Anything else that we should talk about?

I just want to say that our organization, AMDIS, is for physicians and other clinicians that have now the challenge ahead of them of actually starting to deliver on all of its promise. We are so excited that the stars have come into alignment to make what we’ve been working on for many, many years now become one of the major agendas with the rejuvenation, and hopefully reinvention, of healthcare in America.

Monday Morning Update 7/13/09

From afh15: “Re: EHR data. I’d love to read your thoughts on this study and the long-term uses of EHR data in preventive care.” I don’t have access to the full text of the article, but I truly believe that once the pain of getting EMRs running as data collection appliances is over (meaning we’ve got data collection clerks known as doctors and nurses in place, which is the “pain” part), the benefit will be incredible. This article apparently deals with having nephrologists automatically consulted when the EHR finds problems. There are other benefits. You could do society-improving medical research by just slicing and dicing data from millions of patients, at least the parts of it that aren’t just clinical-sounding billing events that are useless or even misleading. You could find candidates for research trials. Patients could be followed over many years, even as they move around and use the services of a variety of providers. And for individual patients, there could be great value in putting research findings into the hands of front line doctors. Not to mention giving patients a platform whereby they can participate in their own care and add non-episodic information related to lifestyle, personal health assessment, etc. Clinical systems will not save time, as clinicians know – they exist to create data whose value mostly accrues to someone else. My advice to providers: much of your future income may be based on the data you create and the ownership in it you retain. Don’t be like the Native Americans and let greedy outsiders buy your land for trinkets.

From Anonymous: “Re: Craneware. Interesting question to ponder: How did two young Scot lads, with no US healthcare knowledge, manage to visualize and create Craneware, the country’s first automated CDM software based on complex Medicare regulations? The designer of Craneware’s core CDM products is a US healthcare consultant and not a Scot. Nora McNeil (NJ) is Keith Neilson’s American mother-in-law. She co-founded Craneware with KN and his partner Gordon Craig and taught the Scots everything they needed to know about US healthcare policy and regulations. She was  also the sole marketing and salesperson of Craneware’s CDM products for the first two years of the company’s existence. So why have the duo not publicly acknowledged Nora’s existence as a founding partner and her primary role in creating a successful company?” The company’s documents say it was founded by Keith Neilson and Gordon Craig “following on from discussions with Nora McNeil.” I would guess there’s a family squabble somewhere in the mix. And when that happens, the lawyers are usually not far behind. I don’t have a horse in the race, so I’m neutral.

From Cracker: “Re: Nuance. Nuance’s domination of health care speech recognition gets more scary when you also consider the current M*Modal customers taking a serious look at Nuance. I know second hand of two current M*Modal customers looking at Nuance and will do some research to find some more.” Cracker references a news piece describing an anti-trust investigation of Nuance’s $96 million acquisition last year of Philips Speech Recognition systems (the old SpeechMagic). My assumption, reading between the lines, is that a competitor complained and the investigation is just making sure Nuance isn’t raising prices after knocking off Philips (not likely since Philips had minimal US presence). I don’t know much about M*Modal so I don’t know how they stack up to Nuance, but they and a few other vendors are facing a large, highly successful, and aggressive competitor whose name is nearly synonymous with speech recognition.

From Captain Hook: “Re: Valco rumor. We are a current client and since the announcement have spoken with a couple of our prior contacts at Valco (and they appear to still be working for the company). It is clear that some of them have been let go. Spoke to AJ Hyland as well. No indication that Valco technology will be sunsetted, at this point but it would make sense to do so. It is clear that Hyland bought the client base and entree into Meditech clients.” Valco sold portals, electronic forms, scanning solutions, and other healthcare tools.

From Commander Cody: “Re: Medical Center Odessa. They paid $6.2 million for CPOE, but their regional neighbor Midland Memorial paid only $7 million for their entire clinical transformation project. After five years, Odessa is just now doing McKesson CPOE, two years after Midland has fully implemented OpenVista hospital-wide. Taxpayers paying for high-priced proprietary EMR systems is a bad idea.”

Should CPOE be a requirement for demonstrating meaningful use of hospital-based EMRs? Yes, according to 69% of those who answered my poll. New poll to your right, inspired by the comment above: should hospital CIOs consider open source clinical systems?

McGill University Health Centre is working with Medical.MD to develop its MedforYou PHR.

The local paper covers EMR implementations in two Arizona hospitals. Banner Health, the story says, will spend $30 million (hardware, software, and training) each at two of its hospitals: 430-bed Banner Boswell and 272-bed Del E. Webb. They’re Cerner, I believe. I hope that dollar figure is a misprint, but then again, Banner paid its CEO $2.7 million, the CFO $1.7 million,  and its CIO $600K in 2007, so maybe big numbers don’t bother them. Its 2007 profits … sorry, “surplus” …, was over $300 million. Since they’re not paying taxes, I guess the money has to go somewhere.

Say hello to TELUS Health Solutions, supporting HIStalk as a Platinum sponsor. The company, which took a big jump up the HCI Top 100 this year from #33 to #20, offers a wide range of healthcare solutions (claims management, the new TELUS Health Space personal health platform, pharmacy management systems, telehealth, patient and resource scheduling, and the renowned Oacis Unified Patient Record). The open architecture Oacis, in fact, has been supercharged into an integration platform that offers an integration gateway, EMPI, CPOE, ED tracking, clinical documentation, Web-based Enterprise EMR, and data warehouse/BI portal, making it suitable for healthcare organizations and entire regions. I remember from talking to the folks there awhile back that Oacis has two big strengths: it can handle the interoperability requirements of regional deployments and for hospitals, it can be implemented without ripping and replacing (it also excels at being customizable, as I recall). OK, I’m prattling on because I was pretty charged up with Oacis when people started telling me about it years ago, but for now, let’s leave it at this: thanks to TELUS Health Solutions for supporting HIStalk.

Cerner moves up to the Nasdaq-100 Index, replacing the Oracle-acquired Sun Microsystems.

HIMSS is thinking more and more like a vendor. How do they improve (“reposition”) the perception of its CPHIMS certification credential? Hire a marketing company to develop a “correlating creative platform and 12-month integrated communications plan.” Because of the tsunami of federal HIT dollars, “the CPHIMS new brand positioning will be more essential than ever,” at least in the eyes of the marketing people (a knowing wink to fellow grammar zealots: “more essential” makes no more sense than “more pregnant”).

The California Nurses Association union files a complaint with the state’s Department of Public Health, alleging that UC Irvine Medical Center has overdosed at least five patients with narcotics by using malfunctioning Curlin infusion pumps that let patients control the flow of pain med IVs. The hospital disagrees, saying keystroke logs indicate that in at least three of the cases, nurses entered the wrong dosage. Meanwhile, an enterprising group of ambulance-chasing lawyers has bought Google search ads trolling for victims who have “sustained damage” after a Curlin pump recall, helpfully noting that companies have to pay out even if they weren’t negligent under current strict product liability laws. Maybe the lawyer proceeds of healthcare-related lawsuits should be taxed at some reasonable rate (90%?) to help fund healthcare reform since the former lawyers in Congress keep avoiding tort reform.

Industry long-timer Bob Fetters died Tuesday at 70 in Kennett Square, PA. He worked for over 20 years at SMS and had already RSVP’ed for Vince Ciotti’s November reunion. The memorial service was Saturday morning, but messages for the family can be left here. Condolences.

I like this fresh thinking: if we’re already paying double what most countries pay for healthcare, why should healthcare reform cost anything? I also like this answer: “We owe the insurance companies, pharma, etc. a severance package, payable into the future for some undisclosed period of time. Like the Hotel California, their lobbyists are making sure we can check out anytime we like, but in fact, we can never leave.”

Former Cernerite Anne Jamieson is named CEO of Portsmouth Regional Hospital (NH).

A hospital in Canada whose computer network was infected with the CoreFlood trojan horse sends warning letters to 11,500 patients, warning that the trojan was designed to capture information and send it to hackers and therefore may have done so. The virus was not detected by the hospital’s unnamed antivirus software (considering that Symantec has been protecting against it since 2002, maybe it’s time to check the updates, change vendors, or fire employees who disabled it on their PCs). CoreFlood was written by hackers in southern Russia to capture secure information such as passwords, e-mail contents, and bank records. It’s doing its job, collecting 500G of personal financial information in just six months, including details on thousands of banking and credit card accounts.

Siemens will provide Soarian to 37 hospitals and 300 clinics in South Africa as a subcontractor. That’s a huge and much-needed deal for Soarian, which was always loaded with unrealized promise.

The VA gets $3.3 billion to spend on IT in 2010, up 30% from 2009.

West Jefferson Medical Center (LA) gets a mention from the local TV station for its implementation of GetWellNetwork, explaining that it’s not for just patient entertainment, but also patient education. The article says patients can also find a hotel, check their bill, and send an instant message to hospital departments.

I like this opinion piece on Taj Mahospitals: “If your competitors have serious woodwork, you can’t get by with woodgrain Formica. If they have armies of PR people on staff, you need them, too. If they have billboards touting the No. 1 rating conferred on their pediatric nephrology team by a local magazine, you too need billboards. If they offer their patients such amenities as wireless Internet, on-demand video, room service-style dining and concierge service, you’d better follow suit. In fact, a recent study published by the National Bureau of Economic Research found that such amenities are three times as effective in increasing demand for a hospital’s services as improved clinical results are. (What? We don’t care if we get better as long as we can have YouTube and American Idol on tap?) The irony is that it’s all necessary, even though it’s a total waste in the sense that none of it improves anybody’s health one iota.”

Scary stats out of California, not like to improve now that the state is nearly bankrupt: the state’s nursing board takes an average of three years to investigate and discipline problematic nurses, gives probation to offenders but doesn’t crack down when they mess up repeatedly, and doesn’t have records to keep fired and disciplined nurses from moving on to the next hospital. One nurse kept his license for five years after hospital complaints that he had stolen and used drugs and fell asleep while performing CPR; he admits he was high at work.

Cleveland Clinic launches its health and wellness portal.

Dossia announces an API for its PHR platform, allowing programmers of new personal health tools to exchange  information with it. Documentation for it is here.

Insurance company UnitedHealth Group announces that it will spend tens of millions of dollars to build a national telehealth network based on Cisco’s Telepresence technology. It has hired former MinuteClinic CMO Jim Woodburn to run the program. More details will be announced on July 15.

E-mail me.

News 7/10/09

From John Q. Seriously: “Re: Eclipsys. In a morning blind-side, Eclipsys has released former MediNotes CEO Don Schoen and former Bond Technologies President Travis Bond. Bond created the EHR Bond Clinician, which was acquired by MediNotes in spring of 2008. It was subsequently acquired in the the acquisition of MediNotes by Eclipsys in the fall of 2008 and renamed Eclipsys PeakPractice. Schoen was co-founder of MediNotes, known for their Charting Plus and MediNotes EMR products.” Several readers e-mailed with the same rumor, saying that business unit had been merged into an existing Eclipsys one. I’ve offered Eclipsys the chance to respond and haven’t heard back yet. It’s unusual for entrepreneurs of acquired companies to stick around after an acquisition, but they usually leave under their own power.

That rumor follows news that Chris Perkins has been named CFO of Eclipsys, rejoining his former Per-Se colleague, CEO Phil Pead. He gets an immediate 22,222 ECLP shares ($362K worth) plus options for another 133,334 shares to “align Mr. Perkins’ interests with those of Eclipsys shareholders,” who are unaligned in the sense that they had to pay for their shares with their own money. He’s also getting $400K in salary and a targeted bonus of $200K with $100K guaranteed. Also announced are severance deals with Pead and Perkins: a year’s salary, 100% of target bonus, an extra year of vesting, and 18 months of health insurance.

From Ken Kashimoto: “Re: Valco. Heard through the grapevine that as a result of Hyland Software’s acquisition of Valco Data Systems last week, all Valco employees were let go last week.” Unverified. Valco’s headcount was around 35, I’ve heard.

From The PACS Designer: “Re: Google OS. Google has announced a new web operating system called The Google Chrome Operating System. The Google Blog states, ‘Speed, simplicity and security are the key aspects of Google Chrome OS. We’re designing the OS to be fast and lightweight, to start up and get you onto the web in a few seconds. The user interface is minimal to stay out of your way, and most of the user experience takes place on the web. And as we did for the Google Chrome browser, we are going back to the basics and completely redesigning the underlying security architecture of the OS so that users don\’t have to deal with viruses, malware and security updates. It should just work.’ It appears that Microsoft and other major operating system vendors have something to worry about when it comes to competition from open source web operating systems.” Don’t underestimate the benefit of having a change-resistant customer base. Chrome is already out there and not making much of a dent in IE. Linux, on which Chrome OS will be based, is also free but has taken only a tiny percentage of PC users. People don’t like change even more than they don’t like Windows. I like all the Web emphasis, but they better not make Microsoft’s Vista mistake and tell users that dysfunctional and outdated plug-and-play drivers aren’t the fault of the operating system. Google is smart to be going after Microsoft’s cash cows of Windows and Office, though. For Netbook users and those who really don’t need anything running locally on the desktop, Chrome OS will probably be just fine, but that’s not a big bunch of users so far.

From Rhythm n’ Blues: “Re: CareFusion. I’d be interested in your response to this unique marketing tactic. Hope they’re stopping in a city near you!” Cardinal Health’s planned technology business spinoff and IPO, CareFusion, will sponsor a jazz festival series that’s going to Newport, Chicago, Montery, Sydney, Paris, and NYC. They’re using a lame excuse for it, saying that “there is a clear connection between jazz and medicine.” Dear Saint Obama, while you are looking into ways to cut massive healthcare costs by throttling the incomes of the people who deliver care, please make sure not to forget to save a little of Uncle Sam’s well-intended meddling for those companies that make a fortune from patients in the form of Pyxis and Alaris patient care devices whose high prices and market penetration have allowed them to hoard enough healthcare cash to stage an international festival series for jazz music, which nobody likes anyway except pedantic posers not quite up to classical and secretaries who aren’t allowed to play real music on the office radio. Sincerely yours, the people paying for it.

I get e-mails every few days from people aren’t getting the update blasts any more. I’m still sending them, so if you aren’t getting yours, your e-mail server is rejecting them as spam. I can’t fix that on this end, but you can contact your e-mail administrator to ask to have my e-mail address added to the “white list” of known non-spam e-mailers. If you use Gmail or one of the other free accounts, you can probably set it up yourself. I send HIStalk e-mails at least three times a week and usually 4-5, plus HIStalk Practice is good for two at minimum and sometimes 3-4. if you aren’t getting them, that’s the problem. You can also use the Subscribe to Updates box to your right to add your home e-mail address in addition to your work one since it’s usually the work one that is overly aggressive about discarding suspected spam. I don’t want you to miss anything.

Readers have added several new events to the HIStalk Calendar, which is how they got them listed and linked on the main page of HIStalk (to your right). Notice the cool way the event listings include links, direct links to a location map and weather, options to download to your e-mail calendar, etc. You can submit your HIT-related event for free. Here’s a tip for those doing so: if you click “Check If Recurring,” you can enter the event once and choose the days it covers, which is a little bit easier than making separate entries for each day.

My guest editorial for Inside Healthcare Computing this week is titled A Day in the Life of IT-Visionary Hospital VPs: Laying Out CPOE Benefits to Luddite Doctors. See if you can detect the thinly disguised sarcasm: “One was late in responding because her top-of-the- line hospital laptop had failed after her teenaged son had used it for several consecutive hours of doing Internet research for a school project in his locked room, necessitating a call to the VP-only IT support hotline so that a technician could be dispatched to her house on a Friday evening.” The publisher tells me that 88% of readers like my stuff there, with 12% chiming  in with the person who wants them to get rid of me and my “clever cynicism.” I was hoping for at least a 40% disapproval rating as validation that I’m stirring people up enough.

Origin Healthcare Solutions adds patient payment collection tools to its Origin Manager practice management system. I couldn’t follow the references to Connecticut and SSIMED, but anyone interested in that news will probably know what it means.

Jobs: Business Systems Analyst-Pharmacist, Laboratory Requirements Analyst, Regional Sales Director.

In the UK, the entire 26-member EHR team at Royal Berkshire NHS Foundation Trust has been let go as the hospital breaks away from NPfIT and implements Cerner via its vendor, UPMC (yes, a non-profit US hospital is also UK vendor, as confusing as that is). They can apply for one of 19 available one-year contracts. In the meantime, since Pittsburgh’s infrastructure is crumbling because of a billion dollars’ worth of debt, entrenched unions, a declining population (even smaller than what’s left of New Orleans, which is actually growing) and a plethora of big-income organizations that don’t pay taxes, the city is considering surcharges on its hospital admissions and college students, which would hit UPMC directly other than it will probably just pass it along in one form or another.

GetWellNetwork announces several new clients for its PatientLife System for patient engagement, including big names Florida Hospital East Orlando, Children’s National, Miami Children’s, and several Adventist facilities.

Don Miller, MD, founder of prenatal care system eNATAL, e-mailed to mention to tell me that the company has several iPhone applications for obstetrics in Apple’s App Store. The application itself is sold in an interesting ASP pricing model: OBs buy “tokens” that are good for one per pregnancy. Here’s what Don had to say about certification: “eNATAL is not CCHIT-certified, never will be, and highlights what is wrong with CCHIT certification. eNATAL is an affordable niche EMR that adds tremendous clinical value, improves patient safety, incorporates clinical decision support functionality that the ‘big boy’ EMRs only dream of, saves money for all healthcare stakeholders, and is used in a ‘meaningful’ way every day across the country. But our subscribers will not receive a nickel from Obama for its use.”

More on the government of the Philippines investigation of who spilled the beans on the rumored leaky breast implant repair of its president: the National Bureau of Investigation is interrogating employees of a hospital that it claims asked for government help to make sure its employees didn’t breach patient confidentiality.

Hospitals in New York State have readmission rates that are much worse than average. The local hospital association (trade group) blames poverty, but didn’t offer an explanation of why Harlem Hospital Center excels and IT-loaded and $3 million CEO-led Montefiore Medical Center lagged.(I noticed while snooping around Montefiore’s federal records that even its chairman of dentistry makes $1.7 million a year, which seems absurd).

Medical Center Hospital of Odessa, TX says implementing its $6.2 million McKesson CPOE system will be a “massive, difficult project,” but its seems eager to snag $5.4 million of that amount from us stimulating taxpayers. A good line from the CFO about the CIO: “I’m looking forward to the day when we have a meeting when Gary [Barnes] doesn’t speak.”

A Canadian medical malpractice jury awards more than $5 million to a man who suffered injuries from spinal tuberculosis after he ignored his radiologist’s urging to come back for more tests to investigate problems he’d spotted. The judge found the patient 30% liable as punishment for not cooperating, but made the excuse for him that he was probably to busy to follow the doctor’s advice. The hospital says it has since implemented software that will prevent misfiled records and miscommunication.

Florida-based Metropolitan Health Networks chooses eClinicalWorks for its nine internal medicine offices.

Microsoft tries to use an Obama-like pitch to get people to “join the movement” and sign up for HealthVault on its I am Enabled site. It’s loaded with the usual cliche Facebook, Twitter, and YouTube connections. Jerry Seinfeld isn’t mentioned.

Speaking of which, I think spammers are going to kill Twitter if it doesn’t die of natural causes before they can do it. It seems like most of the new followers are just the same old pests who nearly ruined e-mail.

E-mail me.

Readers Write 7/8/09

iPhone for Clinical Data – A Different Approach
By Mark Moffitt, MBA, BSEE

Many hospitals are using the iPhone as a tool for physicians to view clinical data. There are two ways to integrate the iPhone with an EMR:

• Buy a package from a vendor to display clinical data on the iPhone.
• Build a Web-based or native iPhone application.

The first option is the most common approach. Benefit: no development costs. Disadvantage: limited ability to customize the application to an organization’s specific needs.

We elected to build a Web app for the iPhone because we wanted to customize the solution to our needs and did not have funds to purchase an application from a vendor. Some of the features in our iPhone web app include:

• Sign on with four-digit PIN using large numeric virtual keypad (see image) versus entering username and password on the iPhone virtual keyboard.
• Lab data displayed as three most recent values in a simple table (see image). Lab tests grouped using common categories.
• Select and play a radiology dictation when viewing a patient’s record.
• Rounding list defined and built to physician specification. Physicians can add and delete physicians in their group using the iPhone.
• Length-of-stay information from our Case Management and Bed Tracking application, also written in-house.

It’s the subtle features that make the difference in user acceptance of software. This is especially true in healthcare for reasons too numerous to list here.

For example, physicians don’t like entering their username and password on the iPhone’s virtual keyboard, an approach many vendors use. Using the virtual keyboard takes a certain touch that is difficult for some physicians to master. We built a security feature that ties a specific iPhone to a specific physician to a specific PIN they choose. The PIN is only valid on the physician’s iPhone and is entered using a large, virtual numeric keypad that mimics an ATM. Users need only enter their four-digit PIN to log in.

The ability to ask physicians, “How would you like it to work?” versus “This is how it works” makes the difference between good software and software that physicians accept. This can best be accomplished by building the front end custom to your needs. While building software is harder and more difficult (for IT personnel) than buying vendor software, the ability to build initiative, easy-to-use software makes training, implementation, and support much easier. And the extra effort makes it much easier for the user to incorporate into their work.

It really is that simple. And why “generic” software requires much more training and process redesign than custom software. Another advantage of build versus buy is we can continue to deliver applications without being dependent on available capital dollars.

Future plans include using the iPhone with the Web app to record dictations and use of the iPhone for eMAR.

Mark Moffitt is director of information systems at Good Shepherd Medical Center of Longview, TX, proof that you don’t have to live in a big city to innovate in healthcare IT.

Meaningful Use Criteria Comments
By Arlen Dominek

I thank the members of the Health Information Technology Policy Committee and, in particular, the members of the Meaningful Use Work Group for their time and effort. I would like to provide my own comments upon the draft presentation of Meaningful Use.

I think that it will be very difficult for all ambulatory and acute care provider organizations to implement an EHR by 2011 simply because of ramp-up time and change management considerations. It takes time for an organization not only to put together an implementation team, but to ensure that the appropriate governance structure is in place. The organization must also formulate a clear focus of where it wants to go, a plan for how it’s going to get there, and how it can assess its progress in getting there.

The organization must identity the members of the implementation team. Often, the organization must recruit additional personnel or retain consultants. In addition, there is training to take into consideration. Equipment must be ordered.  Appropriate telecommunications must be in place.  Interfaces must be implemented. In addition, simultaneous implementations of ambulatory and acute applications by a delivery system can be onerous, yet a certain amount of collaboration is necessary to promote maximum utility.

Vendors will have constraints as well. Many vendors are running very lean implementation organizations today; this minimizes the number of implementations that any one vendor can support at a time. It’s no different than any other manufacturing environment;  there are capacity limitations. Moreover, any rapid implementation cycle provided by a vendor should be carefully evaluated to ensure that the needs of various provider and patient populations are being adequately met.

It’s one thing to provide content satisfying a general med/surg model, quite another to meet the needs of a pediatric BMT program. Rapid provider adoption of workflows and clinical documentation applications will be effected if provider needs are considered during the initial build of content and workflows. Workflows should be designed to meet the particular needs of the provider, e.g., a diabetes clinic or a nephrology clinic. Such consideration can minimize costly re-engineering at a later point and contribute to the success of an implementation.

Hence, Meaningful Use criteria should:

• Be sensitive to the ability of an organization to initiate its EHR implementation and in meeting Meaningful Use criteria, that is, no organization should be penalized because of implementation delays that are out of its control or the population it serves has minimal broadband connectivity;
• Be cognizant of ramp-up time;
• Reflect the maturity of any particular implementation, for instance, if evidence-based order sets comes two years after CPOE implementation, then the criterion should reflect the stage of a particular implementation and not simply a calendar year.

CDS at the point-of-care is somewhat ambiguous and restrictive. Are we referring only to those kinds of CDS that present during CPOE or are we also considering alerts which reflect changes in patient conditions and availability of new data to alert a provider and inform a decision? 

Meaningful Use calls for the capture of clinical data that can be queried and trended. I can appreciate the issue of data capture with which the Work Group has contended;  however, I feel that the objectives have minimized the value of these data and other data for data warehousing and analysis as well as for interoperability through such mechanisms as ELINCS. Hence, such data should utilize standard classification systems such as LOINC, SNOMED, and ICD-10CM to support data warehousing and analysis. Such requirements should be clearly called out so that provider organizations and vendors will incorporate this into their project plans.Such classifications are essential and often mandatory for reporting to quality, epidemiological and public health agencies and to various registries.  Meaningful Use should clearly call this out.

Moreover, there is far more information within a patient chart that could be subject to further structure and encoding. The use of standard classification systems or languages should be implemented so there is a consensual, meaningful and useful framework which governments, providers and consumers can use as a common language.Internationally endorsed classifications facilitate the storage, retrieval, analysis, and interpretation of data. They also permit the comparison of data within populations over time and between populations at the same point in time as well as the compilation of nationally consistent data. (http://www.who.int/classifications/en/) It appears to me that CCHIT and vendor organizations have avoided the issue of incorporating standard classifications or the usage of common classification languages.

Our goal should be to maximize the value we obtain by automating CPOE, clinical documentation, and result reporting.

Order sets are often viewed as provider productivity tools and are conducive to provider adoption of CPOE. Considerable effort is entailed in adopting and implementing evidenced-based order sets. The effort to implement an organization’s existing order sets only to be followed within two years by the adoption of evidenced based order sets is considerable.Perhaps such adoption should be moved up in the timetable.Reimbursements and grants should reflect the licensing cost of evidenced-based order sets. Available evidenced-based order sets tend to focus on medications;  however, standard classifications would encourage incorporation of evidenced-based data for other procedures such as radiology and laboratory.

Multi-media support capabilities are existent in many commercially available EHRs. Perhaps this objective could be moved to an earlier year.

The Meaningful Use Matrix calls for the use of bar coding in medication administration, yet it does not call for the bar coding in the administration of blood products or for positive identification of patients on whom procedures are to be performed, e.g., specimen collection. While CCHIT addresses medication administration in its category Decision Support for Medication, Immunization, and Blood Products Administration requirements, there is no mention of similar functionality for blood product administration, etc. It’s important that Meaningful Use expand beyond current CCHIT requirements and vendor offerings.

It’s admittedly difficult to elaborate workflow efficiencies, but there are some examples

• CDS for administration of immunizations and blood products and positive patient identification as mentioned previously.
• Use of commercial databases to quickly inform the provider whether a medication or procedure is covered by a patient’s payor, thereby reducing time spent in remediation or in losing revenue.  (And payments should reflect the expenses of these databases.)
• Reduction of labor costs in collecting specimens and increasing patient satisfaction by reducing needle sticks when a central line is available.
• Centralized coordination of appointments.
• Automated patient referrals.
• Improved patient satisfaction when the provider has the patient’s information at the right time and place.
• Improved transfer of information between providers.

I apologize if any of my comments have been redundant or because of my failure to notice their having been addressed elsewhere.

Arlen Dominek is practice director at Peer Consulting of Mercer Island, WA.


Subrogation
By William O’Toole, O’Toole Law Group

Regarding the SubroShare(R) press release, Mr. HIStalk was understandably a little off in his assessment; this is not about a policyholder suing the healthcare provider. It is all about personal injury claims.

Subrogation is a legal remedy that enables an insurance company to recover amounts it paid for the care of its customer (the injured patient) in situations where the patient also receives payment covering the same services from a third party (the one that caused the injury to the patient and was sued by the patient).

The key here is the third party. There must be some other party that caused the injury to the patient and from which there is the possibility of payment resulting from a lawsuit (damages) or settlement of that lawsuit.

I will go out on a limb and state that I cannot imagine any health insurance policy not having a subrogation clause. Whether or not attorneys have an obligation to inform the insurance carrier of secondary (duplicate) payments is irrelevant, because where there is a subrogation clause, there is also the obligation for the insured patient to inform the insurance company that the patient’s injuries were caused by a third party, thereby raising the flag for the insurance company.

That said, unfortunately there are those patients that do not, and processes are not always what they should be and some claims "fall through the cracks" and are not identified properly up front. Consequently insurance companies are left to hunt down reimbursement in these situations.

What I believe SubroShare(R) offers is a method to assist insurance companies in identifying situations where they may recover, through subrogation, some payments made on a patient’s behalf.  The trigger seems to be the request for the patient’s records by an attorney, which might mean third party involvement in the patient’s injury, and consequently might mean the possibility of payment to the patient directly for services already paid by the patient’s insurance company.

William O’Toole is founder of O’Toole Law Group, Duxbury, MA.

Provider Profitability
By Dichotomous Dweller

I watched with sardonic amusement as a whopping 19% of readers voted that healthcare providers are sandbagging on IT to keep the public from seeing how profitable healthcare delivery is. Really? 19% of people who read this site think that patient care plays second fiddle to profitability when it comes to EHRs?

Given the way the question was phrased, I’m supprised the number was so high, but then I think the poll question missed the point, so maybe others saw through it as well. Some better questions might have been:

• Do you believe that profitability (here defined as free market economics) enhances or threatens the quality of healthcare received by the general public?
• Do you believe that healthcare providers are have a vested interest in keeping the public from seeing how profitable healthcare delivery is?

There are lots of trick questions like these, but the answer is always both ‘yes’ and ‘no’.

The simple truth is that a dying person will usually give their last dime for a shot at one more day. Healthcare in these circumstance is every man for himself. If you are sick or dying, you’re not going to mind that the person in the bed next to you is subsidizing your stay at a rate of $100 per tablet for over the counter drugs or 33% year in income taxes. Profitability can be created by reducing costs as easily as by increasing sales, but in these circumstances, money doesn’t mean much.

Do you really think that there aren’t people profiting in healthcare from deals that they’d rather the public not know about?  (Thank god we have people like Mr H to keep us up to date on the salaries of major ‘non-profit’ executives). But why stop there? What about those doctors with lucrative research deals with pharmaceutical companies, or pharmaceutical companies who perk doctors who use their products? 

Now I have no idea if such profiteers are going to be exposed by EHRs.  Indeed, it seems EHRs can be their own unique breed of profiteering. But let’s be honest, we all know people who profit from healthcare, and no matter what happens next, single payer, socialized medicine, co-ops, EHRs, RHIOs, status quo, bankruptcy of Medicare, etc., there will always be people profiting from healthcare.

The real question is: is it fair? And it is this question, no matter how simply stated, that we can’t possibly come to agreement on. So we’ll let the market decide for us. I bid 10% of my salary. And rising.

News 7/8/09

From The PACS Designer: “Re: Palm Pre. Since the Palm Pre has employed its own Web operating system called the Palm webOS, TPD thought it would be good to give HIStalkers information on this new application. O’Reilly Media has posted the first chapter of a new book to the web on the Palm webOS covers some of the basics for this new system.”

From VSM: “Re: HITECH lawsuit. The supposed nurse (could not find evidence of license) who has filed a suit against Obama and HHS Secretary for HIPAA privacy violations due to HHS requiring EHRs has a history of legal issues. Her husband is a plaintiff’s attorney. See the court documents on their bankruptcy filing.” She’s licensed, according to the New Hampshire nursing database, and I don’t think her previous suits are relevant. It will be tough to prove her claim (warning: PDF) that HITECH is illegal because it forces disclosure of medical information from patients not on either Medicaid or Medicare. The suit’s claims wander all over the place, reading like a wacked out conspiracy theory rather than a serious challenge and making it less viable, I suspect.

From Joy: “Re: poll showing most readers don’t think providers are resisting IT to hide their profits. Isn’t this group of HIStalk readers already biased as medical and hospital informaticians?” Yes. But, we know the real reason hospitals aren’t adopting IT: they aren’t all that competent and confident about it. Still, when it comes to connecting to the outside world, I would guess that a fair number of practices and hospitals would be worried about outsiders seeing information like how much they charge and how much they make.

Listening: 10-year-old Britpop from The Charlatans.

Some calling himself or herself THR-IS Staffer left a scathing comment on Ferdinand Velasco’s interview that I deleted. It was curious for three reasons: (a) it was the only negative comment posted; (b) it was quite nasty and personal; and (c) the electronic footprints indicate that it actually came from someone inside arch-competitor Baylor Health. I like catching would-be scammers in the act, which I believe I just did.

SRSsoft bags another customer willing to drop their CCHIT-certified EMR in favor of the SRS hybrid EMR. Southeastern Orthopedic Center thought they were good to go with regard to HITECH, but says, “The CCHIT EMR we had purchased would have placed overwhelming demands on our physicians and resulted in a significant loss of productivity, even if we had overcome the initial implementation hurdles.”

A nurse poll finds that 50% would not want relatives receiving care at their workplace, 72% think staffing on their unit is inadequate, and 53% are considering leaving their jobs, most often because of staffing problems.

Emdeon, gearing up for its IPO, acquires claims processor eRX Network LLC.

Vince Ciotti is arranging a November get-together of former SMS’ers to celebrate the 40th anniversary of the company’s founding. The shindig is aimed at those who worked in King of Prussia in the 1970s, but Vince says the Malvernians who don’t mind listening to “what I did in the big war” stories are invited as well. Full details, including some cool old customer newsletter scans, phone lists, etc.

Bill O’Toole will have to explain this healthcare-related lawsuit product to me since I don’t understand it even after reading the press release and the Web site (and unless “subrogration” is in your lexicon, you won’t understand it either). It seems to be related to insurance companies being able to find out which policyholders are planning to sue providers and to get their attorney contact information. I’m sure the people who might use it would understand the description, so this is my gift to all of those folks reading.

A study of VA data finds that abnormal CT findings are often recorded in the EMR a long time afterward, if at all.

Detroit Medical Center connects to an HIE whose bizarre, contrived, and entirely forgettable name could have only come from a committee of clueless marketing people: my1HIE(R). I’m including the provided italicization to make sure you see just how weird it looks in print. Maybe it’s the same perky, brand-obsessed bunch who decided that GE-owned The Sci Fi Channel would be much more of a hot property if it “relaunched” itself as Syfy. This quote from the Syfy (gag) president should really wow its entirely geeky audience: “We really do want to own the imagination space … It made us feel much cooler, much more cutting-edge, much more hip, which was kind of bang-on what we wanted to achieve communication-wise.” They’re even mimicking GE’s “healthymagination” assault on grammar, coming up with the radical variant “Imagine Greater”, which it says is “a call to action … an aspirational, optimistic message about enhancing people’s lives.” That’s asking a lot from ancient reruns of Battlestar Galactica and Mork and Mindy.

I don’t have the records to look it up, but I wonder if Barry Chaiken is the first HIMSS board chair who works on the vendor side of the fence instead for a non-profit hospital? I’m not sure how I feel about that.

Kaiser’s Health Care Innovation Center in the San Francisco area gets a mention in the Fort Wayne paper for some reason. I think someone invited me there once, so maybe I’ll check it out one of these days.

Another use of Twitter: selling “medicinal marijuana”, including home delivery (driver tips are appreciated).

In the UK, the conservative party says they would dump NHS’s Connecting for Health and replace it with HealthVault, Google Health, or other online services. “This is an agenda we are massively keen on. We’re thinking about how in government the architecture of technology needs to change, with people ‘owning’ their own data, including their health records.”

A reporter in the Philippines says the government there is monitoring his activities after he wrote a newspaper story last week claiming that the country’s female president had breast implant repair surgery.

Merge Healthcare announces preliminary Q2 numbers: revenue up 13%, net income less than $1 million vs. $2.8 million, all complicated by its pending offer to buy etrials and the sale of its equity interest in Eklin Medical Systems.

A former Red Hat VP launches the Axial Project, which will be some kind of open source clinical information delivery system. I’m not seeing any healthcare background among the principals, so we’ll see what they come up with.

Researchers from Carnegie Mellon University (misspelled in the article) have figured out how to guess the Social Security number of people born after 1988, sending their method to the Social Security people with the suggestion that maybe they ought to start randomizing the numbers. A Social Security guy pooh-poohed the findings, saying that the code-cracking suggestion is “a dramatic exaggeration,” but simultaneously admitting that  Social Security numbers will be randomly assigned starting next year.

Sunquest names Patrice Nedelec, previously with AMICAS, as VP of Quality and Regulatory Affairs.

A Canadian woman gets a $3 million jury award for a 1999 incident in which she sat on a hospital chair that collapsed under her, causing her no physical injury except claimed fibromyalgia, an ongoing pain whose diagnosis is entirely based on what the patient says they feel.

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