All organizations seem to have times when they are and aren’t receptive to certain communications and changes. In order to convey this concept to my staff, I found an effective metaphor, the human circadian rhythm. This rhythm is the master clock for a human being (ex: when we sleep, when we are awake). This graphic explains it all.

When I use the rhythm to explain an organization, the clock applies to an entire calendar year, rather than a 24-hour period. The "clock" for the year is impacted by the overlay of the fiscal year and the seasonality of the business. For providers, the timing of the arrival of the new residents is another example of an impact. For payers, open enrollment is an example of an impact.

Many times in the information systems department, we are separated from the rhythms of the organization. We may have the best intentions, a great idea, and the perfect message tailored for the perfect audience, but introduce them at the wrong time. My organization is nearing its "fastest reaction" and "best coordination times" (see the graphic at 14:30). So this is when I look to introduce ideas where we are making broad changes. Examples include changes to our work request and project management processes. It is also the time when I start floating trial balloons on capital investments for the following year. In the same vein, I wait for the right time to celebrate the successes (see 21:00 - a "happy bed time story").

Finding your organization’s rhythm is an important part of a communication approach, as is tuning the message for the audience. Avoiding the bad times (ex: 2:00, 8:30), can be a key to success.

The PACS Designer’s Open Source Software Review - DBDesigner 4/MySQL Workbench
By The PACS Designer

DBDesigner 4 is a popular open source database that has been in existence for many years. It is now renamed MySQL Workbench 5.0.23 with the help of Sun Microsystems and the developers of DBDesigner 4.

DBDesigner 4 is a visual database design system that integrates database design, modeling, creation and maintenance into a single, seamless environment. It combines professional features and a clear and simple user interface to offer the most efficient way to handle your databases.

DBDesigner 4/MySQL Workbench can be compared to: 

(1) Oracle’s Designer
(2) IBM’s Rational Rose
(3) Computer Associates’s ERwin
(4) theKompany’s DataArchitect

DBDesigner 4/MySQL Workbench 5.0.23 is available for Microsoft Windows and Microsoft Vista only. With the release of the upcoming MySQL Workbench 5.1, support for Linux and OS X platforms will be added to enhance its usability. Additional MySQL Workbench 5.1 enhancements will provide live database querying functionality and should grow to a fully featured SQL IDE.

DBDesigner 4/MySQL Workbench 5.0.23 has reached the 400,000 download level, so it is a popular database choice of those who want an open source solution. Now that DBDesigner 4 has the support of Sun Microsystems in its merge into MySQL Workbench, users can feel confident that they will get support from a broad base of developers.

TPD Usefulness Rating:  9.

http://www.fabforce.net/dbdesigner4/screenshots.php
http://dev.mysql.com/workbench/

EMRs: Free May Not Be Cheap Enough for Physicians
By Mr. HIStalk

Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter for a "Best Of" series for HIStalk. This editorial originally appeared in the newsletter in March 2007. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.

Now that Stark restrictions have been relaxed, hospitals are rushing headlong into the ambulatory EMR business. It makes sense. Hospitals have a lot of technology expertise and private physician offices usually have none. The government wants to increase the embarrassingly small number of EMR-capable practices, so throttling back Stark is a free solution that makes almost everyone happy.

Are EMRs the peace pipe that will suddenly bring the traditionally wary partners/competitors together in a long-awaited passionate embrace? Probably not.

Community-based physicians are often scornful of hospitals, seeing them as a hotbed of meddling management, questionable quality, and carefully hidden profits. Imagine what they’ll think when they first encounter hospital IT types, those grudging emissaries of a department built around rigid conformance to rules, perpetual understaffing, and a vision for the common good that squelches the individuality and self-determination that doctors thrive on.

Hospital CIOs like service-heavy, expensive vendors that won’t get them fired. They also like standardization and vendors that offer the theoretical possibility of integrating office-based EMRs with inpatient systems and RHIOs. For those reasons, I expect most CIOs will favor EMRs from big-iron, old-line ambulatory vendors like Misys, Epic, and Allscripts.

These are the vendors that small practices studiously avoid in many cases. They dislike them for the same reasons CIOs love them.

I spoke about this with Jonathan Bush, CEO of athenahealth, at the HIMSS conference. He has an interesting perspective, although not surprising considering that his company sells simple, easy to use systems that increase physician income through reduced claims denials.

Bush described the EMR offerings of the big, inpatient-oriented vendors as “elephant’s ass systems.” The little two-doc practice sees the hospital IT truck back up and out comes a complex application with loads of customization options, stacks of thick manuals, and no direct support except what the providing hospital has decided to offer. Free or not, there’s training to attend, configuration choices to make, and conversion from existing systems to plan. Oh, goody.

Doctors aren’t that thrilled with EMRs. Most of their benefit goes to insurance companies, studies have shown. Until pay-for-performance kicks in, there’s not much incentive. Plus, docs are always paranoid that hospitals will see how much money they make.

Benefits aside, EMRs take more of the doctor’s time to use. Something that’s free but consumes an hour or two more of the doctor’s day is hardly a welcome gift. All the doctor has to sell is time, and suddenly there’s less of it available.

Bush predicts what he calls a “hairballing up” of these feature-rich EMRs. The hospital may spend the money, staff a support center, and hand-hold the implementation, but there’s still a good chance the doc will throw up his or her hands and announce, “I’m not using this. I don’t have the time.” Then, they’ll either ditch the whole EMR idea or find an easier-to-use system that gives them a financial benefit.

Remember when insurance companies and hospitals gave away free PDAs with all kinds of supposedly doctor-friendly software on them? Docs lined up to get one. No one was smart enough to realize until afterward that asking for a free gadget was hardly a commitment to change practice patterns.

Perhaps hospitals have underestimated this hairball effect. They’re giving doctors systems that are mostly loved by hospitals: feature-rich, committee-designed for a large range of practice settings, and with extensive clinical capabilities that may or may not interest the physicians who are expected to use them enthusiastically.

It’s great that hospitals will help drive EMR adoption by private medical practices. Hopefully they’ll give the docs a voice in choosing systems that they’ll use before spending too much money on a monolithic system that may not fit all.

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

From The PACS Designer: "Re: it’s getting cloudy. Some HIStalk readers are skeptical of this whole cloud computing thing that TPD has been posting about over the past few months. In spite of this skepticism, the software giants are moving forward with their cloud solutions. Just last week, InformationWeek featured an article titled ‘Guide To Cloud Computing’ and how the major software vendors are approaching this new business opportunity by focusing on the small- and medium-sized businesses. TPD recommends that everyone read this well-detailed article about vendor intentions for this area of computing." Link. TPD also noticed that Firefox 3 sometimes has problems with my Rumor Report form, so if you’re a Firefoxer like me, you might want to painfully and growlingly fire up the obnoxious IE long enough to send me goodies (or do like I do and download Opera as a backup).

From Someone: "Re: Epic-WMC. Possibly personal - see link. Basically, someone speaking for the WMC condescendingly referred to Judy as such and the organization refused to retract the comment. There also are no women on the board of the WMC despite several women in key positions within WI. That judge election happened months ago, this personal attack was last week. They may not be completely unrelated, but I think the timing is a bit more than coincidence. Politics and business aside, I am with Judy in standing up for herself." Link. The original story and several reader comments following it are here. As I mentioned, I’m mostly in Judy’s corner, not that she needs me there.

Palomar Pomerado Health (CA) will deploy agent-based software from Novo Innovations to exchange information with its physician practices.

The New York City Health and Hospitals corporation fires six employees after security video footage showed a patient falling out of her chair onto the psych unit floor and slowly dying as nobody paid the slightest attention, including three security guards who were shown looking but not reacting. An employee summoned by a visitor finally nudged her with a foot an hour later.

Electronic Health Records, 2nd Edition, by Jerome Carter, MD, FACP of NTM Informatics (Neck, Time, & Money - funny!) is now available.

Dann tells me the HIStalk fan club he started on LinkedIn has 150 members. That’s pretty cool! It’s fun to see who reads. If you want to shamelessly pad your connections, feel free to put Inga and me down - we approve all requests in our desperate search for validation.

Catholic Healthcare West signs up for Craneware’s Chargemaster Toolkit and Pharmacy ChargeLink.

RXHub and SureScripts will merge their e-prescribing networks as an 50-50 equity partnership. Guess what the new name will be? SureScripts-RxHub. Man, that sizzles! Looks to me like the eRX pieces are falling into place quickly, especially if the DEA follows through on allowing controlled drug e-prescribing.

Cerner’s Trace Devanny says the company is "transforming ourselves from an IT company to a healthcare company," with 635 employees now involved in medical device connectivity, benefit coordination, and life sciences data mining.

Mount Sinai Medical Center (NY) gets a newspaper writeup for its smart cards. Theirs hold 33 pages, although there’s always the challenge of updating them (I think most hospitals just make new ones on request). Sounds mildly interesting, although I’ve always called smart cards "a solution in search of a problem." They don’t hold much data, but they work OK when paired up with membership-type selective marketing programs, i.e. when used as a loyalty card (which usually means they’re given only to those with good insurance or cash since financially questionable loyalty is disdainfully referred to as being a "frequent flyer").

The final candidates for dean of a proposed medical school at Oakland University (MI) have informatics ties (not the kind that go around your neck, if there is such a thing). Charles Shanley is a surgeon and chair of the Michigan Electronic Medical Record Initiative. Robert Folberg is an ophthalmic pathologist who has developed electronic teaching systems and CD-based training programs.

HIMSS will work with a Spanish group to offer education there.

Adventist Health System contracts with TKG Healthcare Technologies (both of Orlando) for a registration system add-on for its 33 hospitals.

Not everybody in India is happy about getting US offshoring business, mostly because the folks there adopt  our bad health and lifestyle habits. "Working against the law of nature is bound to hit back, MNCs lure Indian mass with money, make them work like robotic machines and burden them with only stress. What they eat is Junk, and they live like a zombie." Yep, that’s today’s version of the American dream, only getting sweeter as the dollar goes down the toilet and we all live longer, meaning our zombie employment years will extend, too. The salad days, as it were.

A member of parliament in Australia wants a telecommunications company punished after it disabled a rival’s radio link to a local hospital for two days will installing its own 3G cell tower. The company says it thought the tower wasn’t being used.

Recent flooding forced Washington County Hospital and Clinics (IA) to forget PACS and go back to film. The hospital also lost Internet access, forcing inconsolable employees to actually work instead of reading Perez Hilton, ESPN, and eBAY.

The new Ronald Reagan UCLA Medical Center, built from the ground up to meet earthquake requirements, opens: 520 private rooms, one million square feet in a 10-story building, and built from three million pounds of Italian travertine marble (a gift from a grateful patient - nice).

Despite being a public hospital that falls under the Sunshine Law, Erlanger Medical Center (TN) refuses to release salary figures for its executives, saying that information would "unnecessarily invade the privacy of our employees." Still, the hospital released a list with positions and salaries only, which the newspaper helpfully paired up with names. I expected big bucks, but compared to a lot of Taj Mahospitals, money was modest: $550K for the CEO, $200 K and down for the veeps.

NHS fires a hospital manager for leaving an unencrypted laptop containing patient information in his car while on vacation. Someone broke a window and took the laptop, which at least had a password set.

UPMC will implement a policy of centralized drug sample management, requiring doctors to request samples via the Intranet using an application from MedManage Systems. of Bothell, WA.

E-mail me.

Inga’s Update

From Glad to be a FORMER Cernerite: "Re: Computerworld Top 100. As a huge fan of yours (I also have a love for HIT AND shoes!), I just wanted to set the record straight. You wrote about Computerworld’s 100 Best Places to Work in IT and how Cerner was ranked #92. E-mails went out to cherry-picked Cerner associates in very specific roles asking them to fill out the online survey. NO consultants were sent the e-mail. It was sent within weeks of a particularly nasty reorganization in January and no one affected received it.” Well, given that we see plenty of ballot box-stuffing with the HISsies, what should make this survey much different? Except, of course, Neal fared better in this Computerworld contest.

Glen Tullman is the Midwest regional winner of Ernst & Young’s Entrepreneur of the Year award in the technology category. He’s now eligible for the national title.

Allscripts also announces Jefferson General Hospital (LA) is its latest EHR client, deploying software for 138 employed and affiliated physicians.

The Southeast Alaska Regional Health Consortium contracts for Mediware’s WORx pharmacy solution for its eight facilities. The non-profit tribal consortium is also in the process of replacing systems for nine core functions, including admissions, billing, lab, radiology, and financials.

I understand that The AC Group has released its annual EHR/PM functionality rankings. I didn’t ask Mr. H to shell out the $50 for the summary report this year, although I’d love to hear about the results from readers. Any surprises? I did hear that McKesson’s Practice Partner received “top rankings,” but find that statement slightly vague (it isn’t exactly like saying “we are #1,” is it?)

The five public hospitals in Brussels, Belgium will use dbMotion’s platform to share integrated patient information across their 11 sites.

I’ve never heard of Avisena and probably wouldn’t have noticed its announcement about 61% year-on-year growth if they hadn’t specifically mentioned athenahealth as a peer. Like athenahealth, they offer an Internet-based revenue cycle management solution. They also note the software is “free,” which I assume means they collect a portion of collected money instead. Impressive: 21 consecutive quarters of growth over seven years.

The FDA discovers that many medical equipment malfunctions are not a result of poor design or manufacturing, but rather flaws in software coding.

At the same time the JAMA article warns that RFID may interfere with medical equipment, 3M and the Fort Hood army hospital  announce the completion of the RFID Smart Shelf System to track and manage 150,000 medical files. The $3.76 million project was a pilot for future military projects. Bummer.

NextGen signs one of its biggest deals ever. Current customer Banner Health, which has 20 hospitals in western states, is providing the EMR/EPM software for its ambulatory physicians.

I am heading out for a little R&R. Actually, it may end of being one of those vacations that requires another vacation in order to recover, but perhaps I’ll refrain from overeating/drinking/site-seeing (sounds boring). In any case, I hope to send a note or two along the way. Be assured my Friday night will include time for appreciating my independence and wowing over the fireworks display.

E-mail Inga.

A reader asked for my opinion on the Epic-WMC tiff, so here you go (you may be sorry you asked). Judge elections shouldn’t be knock-down, drag-out political slugfests. The thought that a pro-business organization should donate millions to an election campaign just because the candidate is supposedly business-friendly is repulsive, especially when that candidate seeks a non-partisan seat. Epic is a private company (and claims to be politically neutral — that also gets a riiiight), so it can do business with whatever companies it wants and for whatever reasons it chooses. On the other hand, it could have just done so quietly without making a public proclamation whose apparent goal is to coerce WMC members to quit or lose Epic’s favor. I was with them 100% until that last part; now I’m at about 75%. Bottom line: it’s a local issue that should not matter one iota unless you live or work in Wisconsin, and in that case, you’ll no doubt have a stronger and more well-informed opinion than the rest of us anyway.

The co-founder of 145-location retail clinic operator Take Care has some interesting comments on technology: "[Our] electronic medical record was not designed in a vacuum by our IT organization; it was designed with the aid of our nurse practitioners. We’ve created electronic check-in systems that are very similar to an e-ticket. If there are two people in front of you, the check-in screen will automatically give you the opportunity to go five minutes down the road to another Walgreens … We have an EMR (electronic medical record) system that’s capable of sending a record to any provider once the laws allow for that to take place … We created an industry based on integrating all the information and data and making it available to the traveler. We’ve brought that same thing to healthcare. A patient’s record is available in any Take Care center in the country. The next practitioner they see, whether it’s someone employed by Take Care or not, has access as well."

Cerner spent $180,000 for government lobbying in Q1, mostly aimed at DoD and the VA. Hmm … was it an eerie coincidence that VA decided to dump its own VistA LIS in favor of Millennium right about then?

NIH/NLM money is used to create the Appalachian Health Information Exchange in Ohio, which starts with 20 members and Ed Romito, CIO of Genesis Healthcare in Zanesville, as chair.

The usual housekeeping: you can sign up for e-mail updates or my Brev+IT weekly newsletter to your right. That Google search box sifts through the 5+ years of HIStalk for anything you want (hitting the old site where the previous articles live, too.) Click that hideous green Report a Rumor graphic that I unskillfully designed to send me news and rumors goodies. Wednesdays are Readers Write days, so e-mail me your master work (500 words or less) on relevant topics. And of course, thanks very much to the sponsors who sponsor and the readers who read.

Confluence Medical Systems, the consulting company started by former Misys-ers Tom Skelton and Rich Goldberg, will advise MedcomSoft on its marketing strategy. That’s the Canadian PM/EMR vendor that recently replaced its management to prepare for an attack on the US market.

Legislators on Friday voted down a measure that would have staved off a July 1 Medicare pay cut of 10.6% for physicians.

Identity management systems vendor Initiate Systems just pulled its IPO, but it also just got $26 million in sixth round funding, bringing its total funding to $62 million. One participant was data integration vendor Informatica, which bought identity matching systems vendor Identity Systems last month. Seems like they’ve got a lot of interest in Initiate, doesn’t it?

A research article coming out next week will provide interesting insight into workarounds with bedside barcoding systems, I’m told. In addition to pointing out human factors issues, it also documents intentional system bypassing that was observed: putting patient ID barcodes on clipboards or door jambs, commingling meds from multiple patients, and scanning doses after labels were removed. My conclusion: hospital leaders assumed that they bought a barcoding system and ordered nurses to use it, so medication errors should just go away. I know folks in a couple of hospitals who freely admit that their systems provide a false sense of security to the executives, but those in the trenches know of their inconsistent use. That’s no excuse for not using them, of course, but there’s work to be done beyond declaring a go-live victory, which we seem to do a lot in IT in our urgency to move on to the next scheduled crisis.

The husband of a Cerner employee who is accused of murdering her for a $250,000 life insurance payout by poisoning her with antifreeze did laptop searches for "antifreeze human death" weeks before she died, prosecutors say. His lawyer says the laptop wasn’t password protected, so anybody could have done that or maybe his client accidentally clicked a link somewhere. For a record third time this issue: riiiight.

The reverse split worked: QuadraMed gets Nasdaq’s listing permission, moving from Amex. The new ticker symbol QDHC kicks in July 9.

I’ve noticed that hospitals are getting free and easy with the "Chief" titles. In IT, there’s Chief Technology Officer, Chief Security Officer, and Chief Applications Officer (none of which are really "chiefs" in most cases since they report to the CIO). I’ve also seen Chief Pharmacy Officer, Chief Marketing Officer, and now Chief Technology Officer of the hospital lab. My thought: if you don’t report to the CEO, you’re not a chief, no matter what inflated title you were enticed with. If you’re a "real" Chief, it’s gotta peeve you a little to see Junior Chiefs flashing your title around.

Siemens, hammered by corruption and fresh off profit warnings, is rumored to be axing 17,000 jobs.

DEA is willing to allow e-prescribing of controlled substances if doctors use two-factor authentication and allow an annual audit. It’s accepting public comments on its chatty proposal (warning: PDF) released Friday.

I don’t watch TV much, but I was flipping channels the other night and ran across the debut episode of Hopkins, which caught my attention because I’d just interviewed Stephanie Reel (although I confess I alternated between it and Kathy Griffin: My Life on the D-List, which I’d never seen and found mildly amusing). It’s a pretty good real-life medical show, a little heavy on the human interest of the photogenic subjects, and not quite up to the dramatic standards of the old Lifeline (you may remember the cowboy surgeon "Red" Duke from that one, who’s now 80, shockingly). Thursdays at 10 Eastern, apparently, on ABC, and you can watch the first episode online.

E-mail me.

From Jerry Rivers: "Re: job helper. I saw your ad that says 75% of HIStalk readers say it helps their job. I don’t believe it." The ad banner you mentioned is running on HealthcareITJobs.com and it refers to this exact question from the spring HIStalk Reader Survey: "Over the past year, HIStalk helped me perform my job better." 228 respondents answered, with 172 (75.4%) saying True and 56 (24.6%) said False. Hey, just because we make it entertaining doesn’t mean our information isn’t useful. Lots of folks are looking for competitive advantage out there and we try to give it.

From Tom Terrific: "Re: WellPoint. I’ve heard it mentioned in two separate areas that Wellpoint is rolling out EMRS to physicians. Do you know anything about this?" They did e-prescribing quite a while ago and were keeping some sort of PHR, but I hadn’t heard of new physician projects. If you know, tell me.

From Boba Fett: "Re: NextGen. Scott Decker to be named CEO of NextGen. Patrick Cline getting kick upstairs to head QSI." Unconfirmed and probably can’t be since QSII is publicly traded. But, Scott’s a reader (I interviewed him when he was with Healthvision) so you never know. Perhaps presciently, he mentioned Pat Cline then. Quality Systems CEO Lou Silverman announced Tuesday that he will resign effective August 16.

From E. Buzz Miller: "Re: Emageon. Perkins is out." An SEC document says COO and onetime heir apparent Chris Perkins has resigned, effective July 25, following all the proxy fight stuff with Oliver Press Partners.

A reader commented on my Odd Lawsuit from Tuesday that involved age discrimination, interpreting my remarks as defending the hospital where the 69-year-old employee with 42 years on the job was allegedly fired by her supervisor after a barrage of "old lady" comments. My usually full-bore sarcasm must have been masked since I’m all the way behind the lady who got canned, provided she’s telling the truth, of course. I’d much rather see the apparently obnoxious supervisor get nailed instead of the hospital, but that’s not how it works with age discrimination.

Listening: Beatnik Termites (reader recommendation). Infectiously fun summer, doo-woppyish surf-pop-punk. I was totally hooked in the first 15 seconds of Somebody Else’s Baby. Five stars. I’ve played everything on their MySpace page about a dozen times.

Royal United Hospital Bath delays its planned Millennium go-live in the UK, worried about Fujitsu’s interest in finishing the implementation now that the company is backing out of its NHS contracts.

New CIOs: Pardee Hospital (NC) names Harold Moore, formerly of Piedmont Healthcare Management Group. UPMC Magee-Women’s Hospital (PA) announces the promotion of Lou Baverso to CIO, replacing Bruce Haviland who has moved to UPMC Mercy. Antoine Agassi, chair of Tennessee’s eHealth Advisory Council, takes the CIO slot of hospitalist provider Cogent Healthcare of Nashville.

Jobs: Cerner Clinical Consultants, Epic Clarity Consultants, C++ Developer.

Sure to raise some eyebrows, including those of the FDA: an article in the new JAMA shows that RFID devices interfere significantly and sometimes hazardously with nearby ICU medical equipment. Especially prone devices: infusion pumps, with 8 of 9 models (five B. Braun and two Alaris) having problems ranging from false alarms to failure. Pacemakers were problematic, too, with erroneous pulsing, and ventilators also acted up. You will no doubt here conflicting interpretations, with RFID locating vendors claiming the study was a European lab experiment with minimal real-world applicability, while competitors whose systems use infrared and sonic waves (or maybe even barcodes) will point out that RFID was designed for warehouse pallets, not deploying to rooms full of life-sustaining medical equipment, and has the exact qualities you might expect to interfere with sensitive gear. Thanks to the reader who sent the full text article over. I’m open to comments from anyone who knows the topic and who has read the article.

CCHIT is looking for 13 new Commissioners to serve a two-year term. Senior execs are invited to apply in July for terms that begin in October. The current list is here and you can e-mail your resume to CCHIT to be considered.

Children’s Healthcare of Atlanta goes live on Epic CPOE. This may be the first time I’ve seen Epic mentioned in a significant press release, and even then only because it’s from the customer.

An Epocrates survey of medical students finds that only 20% of them believe widespread EMR adoption will happen in the next five years. Too bad they didn’t put a more reasonable timeline on there — in most cases, five years isn’t enough for a single hospital to bring up a full EMR. Still, they believe technology improves care and patient safety. When asked to rate the US healthcare system (such as it is), 40% gave it a D or F and 35% predicted healthcare reform in the next five years. It’s the Facebook generation: 6% spend more than 24 hours a month on the social networking site.

The local paper runs a story on MidState Medical Center’s (CT) implementation of Eclipsys Sunrise Knowledge-Based Charting.

West Virginia gets a nod for its EMR network covering 19 free clinics.

Politicians are knocking a healthcare IT bill around, but given how often this happens with no result, I’m not really paying attention yet.

Siemens Medical Solutions caves in to Acacia Research, which uses broad and questionable patents covering common technology to scare companies into paying licensing fees rather than court costs. This time, it was Acacia’s patent for PACS that got the company a Siemens check.

University Hospital (GA) gets a TV mention for its rollout of Horizon Enterprise Visibility, McKesson’s patient flow solution. We have good background in our February interview with McKesson’s Paul Gartman about the former Awarix product.

BIDMC CIO John Halamka tells a Red Hat Summit audience that healthcare can learn from open source initiatives. The Red Hat folks actually invited me to attend and report, which I appreciate, but the day job got in the way.

E-mail me.

Inga’s Update

A number of employers of HIStalk readers employers made Computerworld’s 100 Best Places to Work in IT, announced today. Included: Mount Carmel HS, VHA, Sutter Health, Palmetto Health, Partners, THR, NY Presbyterian, Intermountain HC, Englewood Hospital, Duke, and Cerner. (All the grief that Cerner gets and they still came in at #92 – and the only HIT-specific vendor to make the list.)

Picis is selected to provide high-acuity solutions to seven new Madrid hospitals. The applications will integrate with the hospitals’ Siemens systems.

Initiate Systems withdraws registration for a $75 million IPO, citing unfavorable market conditions.

Premiums were apparently not the only things that went up last year at several California health insurance companies. The California Medical Association reports that multiple CEOs earned $1 million+ salaries while their companies produced more than $4.3 billion in profits.

Connecting for Health announces that numerous companies and privacy groups have endorsed a set of practices to protect personal information and promote PHR adoption. The study also notes that the majority of the Americans see value in PHRs, though less than half were interested in using one. Only 2.7% of the public is using PHRs today and 57% of the non-adopters cited privacy issues as their biggest concern.

JAMA publishes a study that suggests RFID is potentially hazardous and, when implemented in the hospital environment, on-site EMI tests should be conducted. That could prove to be a boon for companies like Sonitor Technologies that use ultrasound for location and tracking devices instead.

KLAS announces an initial study of medical oncology vendors. IMPAC, IntrinsiQ, and Varian were the only three vendors with sufficient installations to provide statistically valid data. Varian got the overall highest rating, though all three were fairly close.

A record 24 million Americans, or 8% of the population, have diabetes, according a new CDC report (warning: PDF). That is a three million person increase between 2005 and 2007. Another 57 million have pre-diabetic conditions. There is no doubting that the disease and its complications continue to dramatically affect healthcare and the economy in general.

Former Misys Sales VP Scott Boyden is named senior VP of sales and marketing of Streamline Health Solutions.

Rex Healthcare (NC) announces that Novlet Mattis Bradshaw is the hospital’s new CIO. Bradshaw comes from The Seton Family of Hospitals (TX) where she was IT’s senior consultant and program director. We told you about this weeks ago, of course.

Catholic Health East will deploy Craneware’s Chargemaster Toolkit products for its headquarters and 16 acute-care facilities in eight states.

E-mail Inga.

Providers Facing Identity Crisis as NPI Vexes Claims Processing
By Martin Jensen

Hospitals, labs, clinics and physician practices large and small are used to the "flaming hoop" cycle — slicing and dicing the data each government and private health plan wants to see in order to get paid. The regulations enacted under HIPAA to establish a single National Provider Identifier were designed to correct a small but critical component of that: replacing the various payer-controlled identification systems with a single, universal numbering system that all payers would have to adopt, discarding all the state-specific Medicaid numbers, the half-dozen or more Medicare numbering systems, and various governmental and payer-specific legacy IDs.

The rule was that individual providers (i.e. human beings — doctors, nurses, physician assistants and the like) could obtain only a single number which would identify them in all contexts.  Organizational providers could obtain one or more identifiers as they saw fit, based on identifiable differences like location and care setting (acute inpatient hospital vs. rehab unit vs. outpatient surgery) and their own self-determined business requirements. Payers were specifically enjoined from telling providers how to enumerate.

But when the May 23, 2007 deadline approached, it was clear that, as usual, the industry was "unprepared" for the cutover. Providers weren’t ready to walk on their NPI legs and payers weren’t ready to drop their legacy ID crutches. Regulators at the Centers for Medicare and Medicaid Services (CMS) announced a one-year contingency period and CMS’s own Medicare division quickly adopted a phased contingency plan. First they would require billers to submit their own NPIs in combination with legacy IDs, then gradually wean them off to the mandated "NPI only" transactions. The critical issue of how to represent all of the other providers on the claims (such as the referring provider on a radiology claim, or the ordering physician on a lab claim) was left for a last-minute, untested cutover for May 23, 2008.

CMS, as usual, blamed the perennially unprepared providers for the delay. But the true culprits may lie a bit closer to home. Medicare, in what observers saw as direct violation of the regulation, issued a thinly-veiled threat (warning: PDF) to its providers to obtain NPIs according to their existing suite of Medicare numbers.

This wasn’t just a fairness issue. It was tantamount to an admission that Medicare was not gearing to deal with the post-NPI world of provider-determined identification schema. They also set an unhealthy precedent for other payers, including a number of state Medicaid plans, who subsequently communicated their own "expectations."

"If Medicare can tell them how to enumerate, why can’t we?" 

Well, how about, because if providers use one numbering system for Medicare and another numbering system for you, the claims which list both organizations as payers (many millions per day) will break down for lack of a consistent identifier? One ID per claim sort of requires that everyone use a common number, does it not?

The initial spike in claim rejections was startling, even to those familiar with the reports that some early adopters had gone unpaid for months. According to one source, Medicare rejections spiked by a factor of four, while Medicaid denials went up six-fold and Blue Cross rejections doubled.

Many of the problems have certainly settled out as providers regrouped for the new line of flaming hoops. But just as things seemed calmer, CMS imposed a new requirement: Employer Identification Numbers and Legal Business Names on NPI records needed to match an unnamed IRS data source or the NPI would be de-activated. While there was no recognition that such a change might trigger a mismatch downstream, our analysis indicates that virtually all of Medicare’s crosswalk logic relies on EIN, and nearly half of the matching goes against all or part of LBN. What’s more, secondary changes required on the Medicare side could, again, leave those claims unpaid for months, thanks to well-documented bureaucratic delays.

Catch more of our ongoing NPI coverage at the HIT Transition weblog.

It’s Time to Wake Up …
By Recruit Guy

In the realm of HIT, healthcare is unique. Healthcare is not unique. We have become so engrained that healthcare is a totally “different animal” with its own idiosyncrasies that we have totally ignored the advances and expanded maturity levels that exists in other industries. Sure, the clinical process is specialized and requires experienced trained clinicians and healthcare professionals to design and support advanced clinicals that support the care process. However, there are two broad general areas critical to any health delivery organization where we have not leveraged the advances and maturity levels that have been achieved in other industries.

The first area is often referred to as ERP that cover areas such as Supply Chain (Materials/Purchasing), HR, EDI, Accounting/Budgeting, etc. We are experiencing a severe shortage of capable practitioners that have experience in specific HIS solutions. The critical distinction here is differentiating between specialized clinical and reimbursement or revenue cycle application areas of I.T. and the other areas dealing with ERP applications. The shortages are not so much anchored around the lack of process expertise. The shortage relates to training and certification specific to the solutions (i.e. Cerner, Epic, Meditech, etc). The only way to expand or grow these qualified resources are to receive the build and design training associated with a client contract and play a principle role in the implementation project. This creates a very closed and restrictive supply of experienced professionals that very quickly join the ranks of consultants and installers that leave the provider organizations and join consulting organizations and go from project to project. These exits create an even greater shortage overall so we constantly have one organization stealing from another with many going to the highest bidder. Why exacerbate this phenomenon with the non-clinical HIS modules and applications for which there is greater expertise and functionality outside the traditional HIS solution sets?

The second area deals with technology infrastructure. Technical infrastructure is comprised of areas such as network and system architecture and processes that support the best practice components of ITIL (Service Support and Service Delivery). This expertise more abundantly exists in other industries in areas that are truly generic between healthcare and other industry environments and are substantially more advanced than healthcare.

Recruiting experienced personnel out of these mature and established industries achieves a much greater value for our organizations. Granted, a redesign of the departmental I.T. structure may be needed to align in the manner outlined. This model pushes the clinical application expertise more into the user departments that relate to clinical and revenue cycle processes. I’ve always been a proponent of this model because it fosters greater ownership and responsibility within these user departments.

Wake up healthcare. Let’s quit thinking we’re so unique in areas where we’re not and let’s join the big league. This massive amount of in-breeding has caused greater costs for less quality and we’ve created a treadmill we can’t seem to dismount.

Girls’ vs. Boys’ Clubs
By Wompa1

Ms. DeBell’s post on women moving higher into the IT ranks brought to mind a recent conversation I had with a candidate with whom I am working. For those that are unfamiliar, I recruit in the HIS field (five years). I thought some of the points of the conversation would be worth sharing. It may also help the perpetually offended to wad their panties. I promise to not refer to myself in the third person (we love you, TPD).

I called this fellow while working for one of his company’s local competitors. He returned my call months after I placed someone. For several reasons, the time had come to move on, not the least of which was the recent promotion (over him) of someone with lesser skills, but a master’s degree. His goal now is to complete either a MS/MIS or MHA.

This fellow had been in a variety of roles, including management (hospital administration, not IT), and he felt that IT need not be his only option. He asked what I thought about widening his options. I began with the usual disclaimer: “My field of specialty is Healthcare IS.” This is true; my market knowledge is limited to HIS. However, I did note to him that healthcare administration is more of a girls’ club than is IT (which is ALWAYS referred to as the boys’ club).

My response? Women earn the majority of undergraduate and graduate degrees, AND they are vastly over-represented within healthcare administration, which means more competition for the higher level roles (manager and director level for the case in point). My thought was (and I am interested in reader opinions) that he would have an easier time finding management opportunities in IT, since there are likely to be more men (fewer degrees) than women. I see him having better growth with fewer women around. The other factor is that he has spent the last 10 years in IT, not in administration.

Anyone disturbed by my analysis may send complaints to Lawrence.Summers@harvard.edu. Larry offered to field them for me. Let me also state for the record: my specialty is strongly focused on clinical IS. Women make up the majority of my placements. The rest are very likely to fall into other “protected” classes. I am curious if my perceptions match the reality (real or perceived) that you experience.

A final point that I did not share with this fellow: I’m asked all the time about “how the market looks.” Since that is the most frequent question I hear, I figured I would share. Now is not a bad time to look for something new. I’m not selling here; as far as I know, only Mr. H. and Inga know me by other than my pseudonym. Given the general perception of the economy, many people are reluctant to explore right now (being low man on the totem pole, can’t sell the house, etc). Less people exploring means less competition, especially if you work in a higher level role.

Thoughts on HCSC’s Proposed Acquisition of MEDecision
By Lazlo Hollyfeld

I’m not surprised that MEDecision got bought by HCSC, but the price they paid was pretty baffling. They were on the block since last year, when everybody in the C-suite except St. Clair was ousted/left. The way I figure it, HCSC folks wanted to have more a direct say in things, including development, and saw this as a way to compete with the other big plans who have already made these types of strategic moves (e.g, Aetna with Active Health Management). 

But why the crazy price tag? If anything, HCSC could have driven a hard bargain and picked it up on the cheap, potentially. MEDecision does it as a way to clear off a ton of debt and keep development moving forward. Otherwise who knows? That’s just conjecture, though.

While they have a solution (Alineo) that is pretty good and better than some of their competitors (e.g, CareAdvance) their client base is primarily Blues plans. It is just too expensive, really, for any mid-market plan with less than 200-250k covered lives. Say that they are focusing on TPAs and government plans but TPAs don’t have money to spend on a solution this robust (and expensive). Same for government plans. 

That means they really are just making money on customers that are migrating and upgrading to the new Alineo platform off a stable but limited install base. The only way to really upgrade their revenues there to win a whale (say at least 750k covered lives) but they’re facing a bunch of competition from existing vendors (Trizetto, McKesson Health Solutions, Landacorp) and a cost of small upstarts using newer technology (ZeOmega, others).
    
NextAlign is interesting and the Patient Clinical Summary actually does deliver some valuable data to providers (even if it’s administrative data). It makes particular sense in emergency rooms if select physicians can just get over their bias that all administrative data is garbage (yes, problematic, but is it really better than nothing or relying solely upon a patient’s recall when they have multiple chronic diseases? Problem is, it is just way too expensive for providers to seriously consider purchasing this even if subsidized by a local payer. Will providers take it for free?  Sure, and they will use it some select cases, but they balk at paying for it and they have a bit of a point.
 
This is really not an issue just for MEDecison. Every payer is facing this same challenge of how and where it makes sense to touch/interact with providers. Every large payer is conducting pilots this year with select providers, but they are mum about the results, either because they have nothing yet or regard it as too important of a differentiator from competitors.  My bet is a bit of both, but mainly the former reason. 

One thing I would love to see is some actual decent survey stuff on what/how physicians view using administrative data for clinical reasons, including diagnosis and treatment. My bet is that older physicians and those with a heavy bias against insurers are also those most likely to never use anything the payer sends regardless of its actual utility or value. 

I’m curious to see where this goes and what is actually under the hood of the latest version of  MEDeWeaver (RHIO/HIE play). Is it similar to what Ingenix is doing for State of Wisconsin with their recently announced deal? I’m also interested to see where the whole NextAlign thing goes, too.

The PACS Designer’s Open Source Software Review - Endrov
By The PACS Designer

Endrov is both a library and an imaging program. The design has made strong emphasis on separating GUI code from data types, filters and other data processing plugins. The idea is that the program can be used for most daily use or prototyping, and for bigger batch processing or integration, the code is invoked as a library.

As a program, Endrov can do what you expect from normal image processing software. It is meant to be hackable; integrating new editing tools, windows and data types is meant to be simple. The main features that set it apart from other imaging software is that it can handle additional dimensions (XYZ, time, channel) which is needed for more serious microscopy. Filters can also be used without being directly applied, and can be composed into filter sequences. Data (for example, derived from analysis) is stored together with the images.

The native image format is OST(Open Spatio-Temporal) Imageset Specification, but most other formats are also supported.

Version 2.10.0 is out, with a big overhaul of 3D rendering. It supports multiple transparent objects better and has many internal improvements to simplify writing new plugins. Other than reacting faster to user input and making use of all your CPUs/cores it comes with the following:

(1) New voxel renderer, render modes and improvements to the old one
(2) Clipping planes
(3) Scale bar
(4) Partial OST3-support
(5) Reworked Matlab bindings
(6) New nuclei rendering options

This new version supports expanded multi-modality viewing.

Endrov is for the image analysis professional who wants an open source solution that can be customized to their liking when downloading image files for interpretation. The files can contain images and data so better analysis can be obtained from a single image view. Version updates have been frequent and come from the highly regarded Karolinska Institute, a medical university in Sweden.

TPD Usefulness Rating:  8.

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