Intelligent Healthcare Information Integration 11/16/09

Sex, Drugs, and EHRs

Flashback, 1975.

Within hours of arriving home from a short tour of the southern states with the wonderful Randy Newman, my roommates and I were called back to our Baltimore-based shop to immediately repack the truck and drive non-stop to Florida. Our sister sound company from Washington state was touring with the Eagles, Linda Ronstadt, and the Charlie Daniels Band and needed some extra equipment for an outdoor show at the old Tampa Stadium.

Thus, the three of us headed right back to load the truck and begin the 24-hour drive: Jack, my towering, hair-to-his-butt sound engineer friend and housemate. Marcy, Jack’s long-time friend and roomie (and now mine) who comes along as moral support and driver keeper-upper. And me, an 18-year-old rock-n-roll roadie and audio engineer from the sticks of southern Ohio living large the rock-n-roll life of the 1970s.

Arriving late to the stadium courtesy of a tow truck for the final fifty miles thanks to a busted front axle on our rig, we find we have but two hours to get showered and settled before we begin set-up. The early morning start is assisted by one of the road crew’s “Drawer of Wonders,” a 10” by 12” by 2” deep drawer in one of the stage cases that, literally, is filled to the brim with every color, shape, and size of pill you could possibly imagine. “Help yourself,” were the only instructions.

The very long day that followed led to a great evening concert under a beautiful Tampa moon. However, many days on the road driving and humping large pieces of sound gear around along with minimal sleep on the nights between had led to a very big fade on my part. I didn’t think I’d be worth anything by tear-down time. Until, that is, I saw Cheryle.

Cheryle (I even found the superfluous “e” sexy) was a 29-year-old Baton Rouge beauty who had come to Tampa to see an old friend. She had long auburn hair that was silky and straight, a seductive southern drawl, and was about the most sensual and sultry creature I’d ever laid my young eyes upon. How she’d gotten backstage I don’t remember, but it was desire at first sight. After some heavy conversational intercourse (and some even heavier necking in a stand of bushes nearby,) it was clear we each had found a soul mate, at least for tonight.

Remember that “big fade” I mentioned? Ha! The sapped-energy sad sack was replaced by a stage-stripping madman. I was heaving giant speaker boxes around as if I’d received transfusions from both Barry Bonds and Mark McGwire. My roommates were in disbelief when I told them I hadn’t hit “The Wonder Drawer,” but was energized by romance. Four legendary days later (thanks to a layover as the axle was repaired,) when Cheryle and I finally left each other’s company, my friends had become believers. They saw how I almost floated to the truck as we headed out.

Flash forward, 2009.

The ex-roadie, sound man, rock-n-roller is now a small-town pediatrician. The only drug drawers I now encounter hold dwindling samples from pharmaceutical companies for my patients or the triptan du jour for my chronic cluster headaches. I have married the woman of my dreams and adore my sons, though I admit to avoiding full disclosure conversations about my past with any of them. Perhaps most amazingly, I have been blessed enough to recognize a prolonged passion that, while not as meteoric as the hormonally-driven adventures of my youth, is nonetheless just as pronounced and just as exciting.

This moment in healthcare time is historic. If you are in healthcare and have even a smidgeon of geek in your soul, I hope you, too, are just as aroused. Struggling through the birth pangs of HIT can be admittedly frustrating and exasperating, but the promise of the “baby” we are attempting to deliver is almost incalculable. The benefits we’ll bring to our patients — to each other! — and the additional insights and knowledge we’ll add to the global healthcare database will exponentially rise once we unravel the HIT Gordian knot. Such an amazing opportunity to help so many people the world over with the combined efforts of each little one of us has never before existed.

Personally, I find that being a part of this early time in the “Age of EHRs” to be as exhilarating and as awe-inspiring as any moment from my youth. It gets me out of bed with rare need of an alarm and helps me overlook the frustrations of our still paper-based medical world. OK, maybe it won’t generate any majorly romantic tales to tell my grandkids, but at least full disclosure will rarely be an issue. Guaranteed, the outcome will be far more world-shaking than any rock-n-roll weekend … except maybe that one on Yasgur’s Farm.

From the trenches…

“I wouldn’t recommend sex, drugs, or insanity for everyone, but they’ve always worked for me.” – Hunter S. Thompson

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached throughhttp://madisonpediatric.com or doc@madisonpediatric.com.

Readers Write 11/14/09

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

Athenahealth Summit
By A Practice Administrator

I just returned from the athenahealth Summit. It was billed as an opportunity for administrators and physicians to learn more about recent healthcare developments in light of HITECH, P4P, and payment reform.

This is was athenahealth’s first meeting of this type. In previous years the user meetings have included both training opportunities and industry updates. This year athena split the meetings, offering a training-based University as well as the Summit. They wanted to create smaller groups of participants and give everyone more opportunity to network with people who worked in similar roles. The meeting was a day and a half, with about 125 users there.

I’m relatively new to athenahealth, though not to healthcare. Over the years I have had the chance to attend the user meetings of a handful of vendors.

Almost all the presentations were offered in one general session. Topics included overviews of stimulus money, reform, and changes in payer reform that may affect practice revenues. Presenters also discussed encounter workflow, including an overview of athenaClinicals, and some newer tools that athena is working on, like a portal. Lunch included athena-facilitated discussions on healthcare’s biggest challenges. There were also a couple of short break-out sessions that focused on topics like reporting, implementing clinicals, and month-end close.

An interesting presentation covered a field study that athena conducted on the attributes of a high-performance physician’s office. Using Lean Six Sigma principles, athena looked at whether or not and how EMRs may slow patient flow and to find best practices for documentation (the key is having the doctor delegate as much as possible.) What really fascinated me was the amount of time/effort/resources that athenahealth expended to figure out how to make providers more productive.

Athenahealth’s revenue model is based on physician reimbursement, even with its clinical product. Since athena makes more if the doctor gets paid more, it of course makes sense that they want doctors to see more patients and document thoroughly. I have not heard about other EMR companies paying such close attention to how physicians actually use their software.

Unlike many software companies, I didn’t get the impression that the company is as much sales driven as it is process driven. That is not to say they don’t want to make sales. Rather, I didn’t feel that making sales is the focal point of every activity. Because of their revenue model, utilization and process are important to them and management is focused on making both the revenue and EMR software as efficient for users as possible. This is not a company whose modus operandi is to make a sale and move on to the next deal.

The management team in general is very bright and educated, though my impression is that clinical experience does not run deep. Jonathan Bush appears to be well respected by his staff and does not seem to be an autocratic leader. He seems to have done a good job of surrounding himself with smart people and giving them ample rope to transform his visions into reality.

Despite all these positives, athenahealth is not without its issues. For example, it’s not obvious that athena has leaders with strong enough clinical backgrounds focused on the athenaClinicals development. And in my discussions with other users, there is a general concern about athenahealth’s ability to execute on the more immediate needs of customers. Small bug issues can take too long to resolve, as can the development of interfaces and new templates. The company seems to lack an adequate internal process for acknowledging the status of enhancement issues. The software lacks an interface with iPhones and other mobile devices. These perhaps small issues lead to the bigger question of whether athenahealth will prove nimble enough to address its growing infrastructure requirements.

Athenahealth has acquired a couple of companies in the last year and gave a peek at their offerings. I was encouraged to see that athenahealth is willing and able to incorporate non-organic products and expertise. My guess is the company will need to continue finding niche companies that complement its offering, while management and the worker bees focus on athena’s self-proclaimed mission: helping clients make more cash.

Did I learn new things? Yep. Did I have ample opportunity to network? Definitely, plus wined and dined at the same time. Did I learn more about athenahealth and its culture? Check.

HIStalk Practice Interviews Glen Tullman

Glen Tullman is CEO of Allscripts.

 

What kind of companies are winning and losing as everybody waits for HITECH to settle itself out?

I think that HITECH has generally been directed and the bulk of the funding has been directed at the ambulatory area, focused on electronic health records. So what we see as the winners, there’s two factors going on.

One has been the economy, generally, and that has put a crimp on anyone who’s out there doing bond issues, raising money, or the like. Then the second one, in a positive vein, has been the stimulus, which is known as ARRA. That injection — of what was $38 billion, now revised up to $48 billion — has been a positive. 

The winners in the space are the ambulatory companies like Allscripts, who are seeing strong interest in electronic health records because physicians know that they can get $44,000 each.

The “losers” — and I want to put quotes around that because I’m not sure there’s going to be any losers in healthcare information technology — but let’s say the folks who are seeing a little slowing of their sales have been the traditional hospital companies. Primarily because the big hospital projects that require bond issues and the like have generally been put on hold and people are more focused on electronic health records.

Then you have a third group of folks who are not typically involved, who are trying to get involved in electronic health records. There are some groups that are trying to say, “Hey, we’re electronic health records too,” even though the reality is they don’t have a lot of presence in the electronic health records space.

Hospitals have gotten more involved in some of the practice EMR decisions more than a lot of people expected. What is it that they’re looking to accomplish?

It’s been very interesting because a few years ago, there were a lot of folks who were writing hospitals off. I think that hospitals — many hospitals — have been very strategic, have used the relaxation of Stark paired with these incentives as a way to say to physicians, “We will get connected to you and we will help supply the know-how, the technology, the hosting in some cases, and we’ll make it easy for you to adopt electronic health records. In many cases, we’ll provide additional funding to provide those electronic health records.”

So hospitals are playing an important strategic role, especially with smaller practices, as one way that electronic health records are going to get adopted.

Do you think Regional Extension Centers will have that same kind of impact in moving doctors along the EMR continuum?

I think no one’s exactly sure the impact of the Regional Extension Centers. We all hope that they accelerate adoption. We all hope they play a role in connecting physicians with solutions that work in providing support and training to those physician practices.

I think there’s some concern that putting a third party in between some of the users of the systems — the physicians and other caregivers — and the providers of the system, organizations like Allscripts and our competitors, may in fact, slow the process. I think there’s a lot of eyes focused on the Regional Extension Centers — exactly how they will operate and the role they will play.

We are very interested in being of assistance to them. We’re working with some of them right now. We’ve been fortunate to have been selected in some of the areas so far. So all of that is very good, relative to how those are operating. But I think it remains to be seen, the exact impact that they’re going to have, but we’re hopeful.

Would you say your biggest competitive pressure is aggressive competitors or lack of physician adoption?

It’s a good question because not too long ago, I spoke at an investment conference. One of our major competitors went right before me and they talked about a pause. The physicians were waiting to adopt to see how meaningful use came out and the like. 

I came out afterwards and I said, “All we’re seeing is interest in acceleration.” And in fact, last quarter, we publically reported that our bookings — our sales number — was a 47% increase year-over-year. I think that indicates what we’re seeing, which is very, very strong interest and strong buying signals and strong buying.

We’re already seeing that. We don’t see that as a hurdle. Frankly, we see the same competitors that we always see, At the high end, typically Epic. In the mid-market, we see Quality Systems. In the smaller independent physician groups,less than ten, we see eClinicalWorks. Those are the three. Those are the kind of primary competitors in each of the three measurable market segments, if you will.

We’re seeing strong demand, strong interest, and we’re seeing that right now. We also see, as you’ve already mentioned, a lot of the larger hospital systems getting very actively involved in physician adoption and the acceleration of these systems. We think that’s very good and very healthy because that’s what’s going to help connect all of these systems together, which is very important.

Some of the U.K. financial analysts are opining that Misys should be getting out of the healthcare IT business to focus on their financial business. What would the impact be on Allscripts and its customers if, for some reason, they decided to do that?

Misys is a large shareholder, as you know. We stay focused on what’s happening in healthcare in the U.S. and we’ll let the U.K. folks speculate and analysts speculate.

The reality is we have the largest base of physicians in U.S. healthcare, almost one in three physicians in the United States, or over 160,000. We’re the largest player in practice management systems. We have the largest group of physician offices in the “less than 10” space. We’re the largest provider of electronic health records.

When you look at all of that, the reality is, we’re the market leader. We’re here and we’re going to keep executing. Who exactly owns which shares at what time has very little impact on how we’re running the day-to-day business.

I think that U.K. analysts speculating about the fact that the shares that Misys PLC as a publicly London-traded corporation owns in Allscripts had become very valuable. There’s some speculation that if they split up the company that you could get better shareholder return. That’s really analysts speculating.

No different than last week. I heard two rumors. One, that NextGen was being sold. Another one that Cerner was being sold. That’s speculation as well and I treat that all in the same way. We’ve got a business that’s growing very rapidly. We’ve got clients that we’ve got to satisfy. We’ve got the largest R&D investment in the industry. That’s what I spend my time on.

The Misys merger didn’t seem all that attractive when it was announced, but it looks smart now. Are there other acquisitions that would help round out your offerings?

We’ve said all along that we don’t need to acquire anything else to execute on our strategy and to be successful in the market. That said, we’ve also said that it’s clear that the industry is going to consolidate, that there are going to be opportunities, and fortunately we have a very strong balance sheet. We have very strong cash flow and revenues and we’ve got an increasingly strong management team. We’re going to be opportunistic.

But right now, again, our main focus — what we call ‘true north’ — is all about taking advantage of the stimulus. We’re at a very unique time here. We think this is the fastest transformation of a large sector of the U.S. economy in the history of the U.S. What we’re watching is this major sector that’s going to transform faster than any other sector in history, and Allscripts is positioned as the leader in the sector in leading that transformation. So that has to remain, and is, our focus.

That said; we’re going to continue as we have in the past to be opportunistic. When we did the merger,  as you point out, people didn’t quite understand it. They think our competitors understood it because they kept saying, “Hey, this is going to fail.” But much to their dismay, we executed very strongly. We stayed focused. We executed against it and we have a much stronger company today, and the beneficiaries are our customers because they’re getting more products, more R&D, better execution, than ever before.

I think one good example is — I don’t have to tell you — in the past there were a lot of questions about our investment in our Version 11 Enterprise software, and we had some challenges. Anytime we do something really innovative, there’s some risk, and we had some challenges. The great news is just at the right time, we’ve moved past those challenges. Now we’re installing it faster than ever — 40% faster.

It’s interesting. There’s the competitors and other folks who like to focus on the past, but when you look at the numbers, it’s pretty astounding. In October, there were more than 24,000 physicians using Version 11 Enterprise software. That’s the equivalent of about 3½ million patients being touched. There were millions of prescriptions written and over 13 million orders. When you look at those kind of numbers and people say, “Oh, they’re having problems,” and this and that; that’s about the past. We’re very focused on the future.

Do you think, as a company, that was a valuable learning experience — the struggles with Version 11?

It’s always a valuable learning experience, but I think that the sign of a great company is to take risks, to provide innovative products, and if you have challenges, you work your way through them.

The great news is if you talk to some of our customers that experienced those issues, what they’ll tell you is — did they have problems? Yes, they did. Did they work through them? Yes, they did. Did you ever doubt that they would figure it out? And they say, “Nope, never doubted it.” Did they ever stop taking their calls? Did Glen ever stop picking up the phone when you called? The answer was no. We went head-on. We worked closely with our clients and we resolved them and we’re better for it.

If you name me a great company, a world-class company, I’ll tell you one or two areas where they went out, they tried something, and they may have had some challenges, but they worked through it and they’re stronger for it. You always learn from your mistakes if you’re good and you get stronger for it.

The issue is that no one ever doubted our resolve. No one ever doubted that we were going to get there, because unlike some of our competitors, this is our only business. This is what we live for. This is why you and I and others are here on Friday night, right? Because this isn’t just about a business, this is a passion. We want to transform healthcare and we want to lead that transformation.

At the end of the day, software changes. The software we’re selling today, two years from now is going to be different. But when you look at innovation, when you look at just the innovation that we’ve introduced in the last year — software available on the iPhone. It’s available on BlackBerry, it’s available on Windows Mobile.

We have a leading kiosk. I was just at George Washington University Medical Faculty Associates. I was in their lobby with the CEO and some folks from the White House, and you put your hand in and it reads the veins in your hand. It takes your picture, scans your credit card, facilitates payment, patients are checking themselves in.

What was fascinating was that the CEO stood there with me and he said, “I want to show you something.” I said, “Well I’ve seen our kiosk there. That’s really cool.” He said, “No, no, no. Do you notice that there’s people waiting in line to use the kiosks and we have people — the normal check-in procedures — and they’re waiting and there’s empty desks?” And he says, “We need more kiosks.” But people are more comfortable and they like using the kiosk, and they feel more secure and we get more information from the kiosks then we get from the paper-based check-in process.

When you’re introducing this kind of innovation, along the way, are you going to have some hiccups? Of course you are. By the way, I always say to people who are implementing electronic health records, I tell them, “I can almost guarantee that you’re going to have some challenges if you do it right.” If you implement the system, not just to do what you were always doing, but to challenge some basic assumptions, to put some new processes in.

But I also tell them that no one in the industry is going to stick with you and be there to help you figure it out and optimize the use of this technology like Allscripts. So lesson learned for sure, but does that make us gun shy in the future? No, because there’s no one else in the industry that can do real-time clinical trials. There’s no one else in the industry that can provide the kind of connectivity and services that we’ll be able to provide. That’s in part because we are willing to go out there and take software that people like and upgrade it and go to the next level. There’s always some risk in that.

When you talk about the stimulus bill, what aspects of it do you think have changed since the original thoughts about how the money should be spent versus now?

The best thing about this is prior to passage, there was at least some school of thought that said we’re going to give every physician $15,000 if they don’t have an electronic health record. Fortunately, that was changed and the idea was that, look, just giving physicians money to buy one doesn’t get the taxpayer — who is the ultimate patient — doesn’t get them the benefit. 

That’s where meaningful use came in. This was a very good bill because it said, not only do you have to buy it, but you’ve got to use it. You’ve got to see the benefit of it, and that’s really what’s going to help transform our healthcare system. So fundamentally, this is a very good idea.

Relative to meaningful use, we have been pushing very hard to say these standards ought to be tougher than they were in the past; and in some areas like interoperability, I’m not sure that we’ve been as aggressive as we should be. We are pushing to have some dates out there by which every system will have to talk to each other. The idea that in 18 months or 24 months, every system needs to pass messages, not only being able to send it, but receive it with the patient information.

Those kind of things ought to be required with a definitive date by which, if you don’t do it by that date, there’s no funding. We want to make sure this bill gets the taxpayer a return on investment because they are making a very big investment. If that means pushing the vendors a little harder, so be it.

That said, I think directionally this is very good. What we’re saying is we need privacy. We need security. But then we’re going on to say we need some clinical return on investment. We need the uploading to registries. We need the ability to write electronic prescriptions; and clinically, we need interoperability. Because what we can’t do is replace our paper silos of today with computer silos of tomorrow.

We need an interoperable system no different than the ATM networks that we use, no different than cellular networks. We have many different competitors, but they’re all using — they’re all connected to a network exchanging information; and of course, no different than the Internet. That’s the model that everyone ought to be forced to play in. We have some holdouts who are really not supporting this idea of full interoperability. So if I could change one thing, I would say we’ve got to much more aggressively push on interoperability.

Once the stimulus bill has encouraged the purchase of systems that are available today, how do we get to the next generation of systems and what are they going to look like?

Keep in mind — and this is not readily understood — what the bill actually says is each year, you’re going to have to affectively re-qualify. Each year, the standards are going to get tougher. That’s good news, and what that really says is that we have an opportunity to continue to push the vendors and the industry forward.

That said, I believe the biggest changes that we’re going to see are not necessarily in functionality. They will come in interoperability and connectivity. They will come in the ability to deliver real-time information to physicians, and they will come in ease of use. 

In the future, I see a system that we ship, perhaps, through an ASP cloud-type system to a physician. He or she downloads that. There’s no training involved, it’s completely intuitive. Then when he or she sees the patient, there’s information provided to them that says, “Here’s best practices. Here’s the way this patient’s plan would like you to treat them. Here’s the medications. Here’s what they’re allergic to.” They get a whole information briefing just like a financial analyst or a stock trader would get on a stock before he or she would purchase it.

That requires a few things: very smart systems; very good connectivity; and a focus and an understanding that the healthcare system of the future is an information-based system. Healthcare, at the end of the day, is an information business. We have the best physicians in the world. We have the best medications in the world. We have the best medical technology in the world. What we need to do now is equip our physicians with the best information in the world to allow them to take advantage of all those tools. That’s what we haven’t done to date. That’s what I think this new world of healthcare will allow us to do. What we have to do is make sure we don’t squander that opportunity by setting our standards and setting our objectives too low.

That’s where we are today. We’re fortunate to have great products. We’ve moved past some of the challenges that we had in the past. I think everyone has concluded that the Misys merger, which is over a year old now and in one respect is old news, and in another way it’s old news because nobody’s really focused on it any more. But the good news is that gave us the tools and the footprint to compete in this new world of healthcare.

While we had some challenges with our Enterprise software, the good news is that the clients who are being installed today are very pleased with it. In fact, we just this past week had one of the largest go-lives that we’ve had with a client, with Sharp HealthCare out in California. They went live on the order entry phase of their project with hundreds of physician in a big bang, and it went unbelievably smoothly — so 350 physicians simultaneously live on order entry. The physician informaticist there noted that this go-live was flawless and the physicians loved the workflow, in part because they helped design it. The reality is a year and a half ago, I couldn’t have said that to you, so that’s what you’re seeing today.

That’s what we’re seeing with some of the great new expansions. We have North Shore-Long Island Jewish, a great example of a commitment to not only electronic health records and practice management — not only for their employee physicians, but for the entire community — and then a vision to connect all those electronic health records to 13 hospitals and to their entire home healthcare network. Now that’s pretty expansive vision. So kudos to the leadership shown by Mike Dowling and the whole North Shore-Long Island management team. We’re going to see a lot more of that.

Then we saw similar kinds of efforts going on in Hartford. Harford is built without any federal funding. They’ve essentially created an HIE that’s connecting a good part of the state now. It’s 20 hospitals the state’s top physician groups, Hartford Healthcare, St. Francis Medical Center, ProHealth Physicians, and I could go on and on. But these folks came together and said, “The time is now. Let’s get going.” They weren’t held back by, “Oh, there’s a problem with the software,” or anything like that. They’re making it happen real-time, so we’re pretty proud to be associated with folks like that.

Any final thoughts?

This is not an issue of technology any longer. This is an issue of leadership. The great healthcare organizations, whether they’re academic medical centers or integrated delivery networks, or whether they’re three-doc practices in Wilmette, Illinois or Tampa Bay, Florida; the fact that people are moving ahead and making this happen is really critically important.

The great news is that, especially as you move down into that smaller base to our Professional software, we have some pretty amazing customer data that 100% of our Professional EHR clients said their implementation — these were ones that were newly implemented in the last six months — said their implementation was within budget and cost. That’s a pretty amazing statistic, and those are the smaller offices. Those aren’t some of the largest ones. Then you fast-forward to some of the largest organizations and you look at the success we’re having at a place like UMass where again, great success. They’re rolling out, not only for their employee physicians, but also for their community.

One last point and this is this interoperability point. I can’t stress that enough. We have to get this system connected because what we want, ultimately, is a connected system of health. Not healthcare, but of health. To do that, again, we’ve got to get everyone working together. The great news is that places like Lahey Clinic in Massachusetts — leading organizations that are visionary. Or Columbia — we are connecting with competitors there. We’re connecting with Eclipsys. Out at Sharp, we’re connecting with Cerner. At many smaller practices, we’re working with our direct competitors there. So it can be done.

What customers have to do is suggest that it be done because we won’t have one system of healthcare. Healthcare networks in different areas look different. The independent physician is not going away. We just have to figure out within that, how we allow people to compete, to innovate, but to be connected. That’s really critical.

News 11/12/09

From Jesse Spencer: “Re: EMR reviews. Guess I’m in the minority, but I enjoyed the athenaclinicals review and hope you will do more. I wonder if you mainly heard from vendors who were worried about their own products? As a physician in the trenches who has not selected an EMR yet, I like all the information I can get!” Readers don’t often reveal their true identities and backgrounds, so it’s hard to tell who sent what comments. Vendors are a good guess, as well as consultants who rely on us to remain unbiased (or who resent even vastly experienced amateurs rendering a public opinion based on a quick impression). Who knows, maybe we will sneak in a review from time to time.

Primary care doctors are spending more time with patients, though overall care has probably not improved, according to a new Archives of Internal Medicine paper. The average patient visit was almost three minutes longer in 2005 than 1997. During the same period, physician net incomes fell 10%. The abstract does not mention this theory, but I wonder if any of the extra time can be attributed to providers documenting EMRs at the point of care?

The American College of Surgeons names David B. Hoyt, MD, FACS its new executive director. Hoyt is chairman of the department of surgery and executive vice-dean at the UC Irvine Medical Center.

Walgreens reports big increases in e-prescribing, with about 22% of all eligible prescriptions arriving electronically. The pharmacies filled 4 million e-prescriptions in October, which is 185% more than October 2008.

In its first quarter as a public company, Emdeon announces that revenues grew 10.6% over last year. However, quarterly net loss jumped from last year’s $1.2 million to $7.2 million.

Allscripts contracts with DecisionOne to provide hardware infrastructure support to its clients. Allscripts internal hardware service personnel will integrate with DecisionOne’s field service organization. Sounds like a good move as it allows Allscripts to focus on the software side of the business. Having an internal field service team is less critical in today’s server/PC world than it was in the old days of proprietary hardware.

NIS-Systems (FL) signs on as the latest EHR/PM reseller for Aprima Medical Software.

The healthcare sector added 28,500 new jobs in October, including 4,800 in physician offices.

NextGen Healthcare just completed its user group meeting in Washington DC, reporting attendance of over 2,700 and featuring keynote speakers Newt Gingrich and Howard Dean. The hot topics: ARRA, healthcare reform, interoperability, and patient-centered medical homes.

Initiatives by the American Heart Association and the American College of Cardiology will likely persuade more cardiologists to move to electronic medical records. They can now participate in a national registry that compiles outpatient clinical data.  Officials believe that data collection efforts will be easier for providers using an EMR. Proponents also support the theory that the patient-specific prompts found in EMRs help physicians provide better care.

Google launches a new online map service to help consumers find the nearest locations to receive seasonal and H1N1 vaccines. I did a quick spot check and if you live in Baltimore, Jacksonville, or Los Angeles, you’ll likely find a source. You will see a lot of “temporarily out of stock” messages if you live in Denver, Wichita, Dallas, or San Francisco. Google developed the tool in collaboration with HHS and can be found here.

In a lawsuit involving non-compete provisions and trade secrets, the Georgia Supreme Court rules that a software engineer cannot use trade secrets of his former employer. In this case, the former employer was a medical practice that hired the engineer to customize its medical billing program. The engineer resigned in a dispute and then removed the software’s encryption keys and source and access codes. There’s more to the story, but it sort of makes you want to think twice about who you’re hiring to tweak your software.

Elsevier releases MD Consult Mobile, which provides an entire library of medical content on a mobile device.

I can’t decide if this is goofy or brilliant, but researchers say their cough-analyzing software can diagnose disease by measuring coughs. The application, based on research funded by the Gates Foundation, will run on cell phones or MP3 players.

E-mail Inga.

HIStalk Practice Interviews Bill Henderson

Bill Henderson, FACMPE, is administrator of Upstate Neurology Consultants, LLP.

Give me a little bit of background on the practice.

We’re a neurology practice. We’re obviously a private practice. I’ve got an eight-provider practice that is seven MDs and a PA and we’re in Albany, New York.

What software are you using?

We use Sage Practice Management. We use Sage EHR. We’re running that on a Stratus server. We also run, within the practice, Xen servers for virtual machines. We run terminal services on a Windows 2008 server for remote access.

I run a bunch of other applications, Websense as well as standard kind of things that you would expect in this small network.

We also use Microsoft DPM for the purposes of data backup. Microsoft bought that product three or four years ago and it is a backup product. It kind of reminds you of the Symantec backup product that had continuous protection, only it’s significantly better in that it can do its “data backup pictures” much more often. It writes on the hard drive primarily and it’s far more robust and reliable. At least that’s my experience. I also have it on one of the servers running the practice analytics product that interfaces with the Intergy product — both the practice management side and the EHR side.

How long have you been using the Sage products and why did you pick them?

The practice management side we started in March of 2004. The EHR side we started and we went live on that toward the end of December of 2005.

I had done research for a couple years before we purchased the product. In the end, what finally convinced us to do this was a one-stop-shop, which it was an integrated solution that provided an EHR, a practice management product, and also a scanning interface. It also had the ability to do a lot of the connectivity things we wanted to see developed, such as electronic interfaces to labs and e-prescribing.

From the perspective of a small practice, it’s a lot easier to manage an integrated solution than it would be to manage two solutions — one for practice management, one for EHR. Maybe even another one for imaging, depending upon what’s out there. The product also benefited from the fact the interface could adjust to the work responsibilities of individuals, so that the clinical people using the EHR interface saw the things that are clinically focused; the office people saw the ‘base product,’ or the things that were relevant to the day-to-day billing operations and/or scheduling and/or tasks or communications with patients. So that was positive.

Plus the product also ran on PDAs and it ran on mobile phones. That capability would reduce the number of devices my doctors carried at one time from the three they carried at one down to one, which is obviously a very significant thing.

Tell me a little bit more about the analytical reports that you’re running and the software you’re using. What are the different reports for?

The product is Practice Analytics. It has two distinct features in version 5.5. One is the ability to run reports in what would be considered the standard financial analyses of a practice; such things as charges and collections and the analysis of procedures by provider. But the ability to be able to customize that is very important.

Examples of the kinds of reports we would run under that segment of the product are things related to pay-for-performance. We’re doing CMS stuff right now and e-prescribing for 2009. I’m able to run reports that look at specific procedure codes by a specific insurance carriers, by specific G codes by provider to be able to run tests throughout the year. I’ve been able to do that so far to see that we’re meeting the minimum requirements for reporting for each of those G codes.

So there’s just one example of what I consider to be fairly sophisticated reporting, even on the financial side. The product allows me not only to run reports, but to convert them to graphical charts if I want to do that; or also, to export the data to Excel. That’s fairly standard in a lot of the products that are out there. I’ve used Business Intelligence now for, oh my gosh, about 10 or 15 years. I’ve used Cognos and the like in the past. What I particularly like about this product is it actually allows me to get at each of my data buckets, if you will, so I’m not restricted about what I can necessarily pull out of the data that’s been collected. That’s just looking on the financial side of the product.

Looking at the clinical side, Intergy itself is built on a standardized database called MEDCIN. We had designed a unified template that all of our physicians use. It’s a multi-tabbed template because we obviously see general neurology and we cover a broad number of diagnostic categories. So we’re collecting clinical data on all the individuals that we see, which in turn means that I can run reports on a number of clinical factors, if you will.

I could give you examples of the kinds of things we do. Not too long ago we had a FDA recall on a particular drug and we needed to know who was on the drug; why they were on the drug; whether they would qualify for any humanitarian use, because the company would be allowed to continue it for that. I heard about the recall when the drug rep walked in. In fifteen minutes I had identified everybody in the practice who had that. We were able to contact them and do that because we had that clinical data recorded. In the old days, what that meant with paper charts was you’d have to remember who you had, you’d have to run a report of your diagnosis codes. Then you’d have to pull the charts and actually look. Now you don’t have to do any of that stuff because it’s all built into the data that you’re collecting. So that’s good.

For clinical research work, we can actually really drill down to find such things as the number of patients, by sex, who have a particular diagnosis who have never been on this particular drug and may have these other secondary conditions to see if they may be eligible or someone that should be spoken to at some point regarding the clinical trial. You actually have the ability to data mine clinically in a way that would benefit your patients.

Do you find your doctors are asking you for more and more reports now that they’ve seen the power of them?

Where the power of this product comes in is in the ‘dashboards’ that they’ve introduced in this new version. I use that actually with my doctors and bring into our meetings a laptop and LCD projector. We look at the data and let them see it graphically. You can click on one little button and it changes the look from a graph to a line chart and compare to the previous years. What makes it so exciting is that when you have a report doctors will spend some time analyzing it and then ask questions of the data. Before, if they need you to answer their questions, you would have to turn around and run another report, answer that question, print out more paper.

But now we actually can sit in the meeting look at a particular category of services that we provide; how is our E&M coding compared to last year; how are our neurological procedures compared to last year? We can change what are we seeing, how our population is changing by way of insurer, or where are we seeing people from different zip codes.

Before, you could run those reports — that’s not an unusual thing for an analytical product. The difference here is you can do it on the fly. You just make a couple little quick little changes. Click on what your options are while you’re there looking at the product and you could see how it changes. I could see if my referring doctor patterns changed in the last three months, and if so, how have they changed? Is this hospital providing enough work for us is another question; and, should we continue to work there or is it costing us too much money to see patients there? What you do again by just clicking on the place of service in the hospital and see how that hospital compares. Then you can look at that back over a couple years because now we have data that trails back now for us financially, back to ’04 and clinically to ’06.

Across the board, has the passage of the ARRA changed your focus at all in terms of technology adoption?

That’s an interesting question. I have been a long-spoken advocate within the American Academy of Neurology where I serve on a couple committees, to basically say that we need to have heavy investment in health IT. I felt that way for a long time. People come into my practice just to observe or to see it would say how much time it saves, how beneficial it is. And so for me and for our practice, we have invested heavily in IT all along the way. The new stimulus is nothing more — since we’ve already paid off all of our stuff and we’ve earned the money to do it — it’s nothing more than money coming into the practice. I would say however, that for practices that have not invested at this point, they need to play some serious catch-up to do and I think this bill really incentivizes them to be able to do that.

Why do you think EMR adoption, in particular, remains to be low?

I think pretty traditionally people tend to say the adoption rate for EMR is somewhere in the low 20%. The first thing you have to ask is what’s the average group size in the United States? Some numbers that have floated out there say 50%, at least, are three providers and less. When you’re in a group that’s that small, the costs for providing what I would consider significant IT and health IT is pretty great in comparison to what the revenue would be to a practice. You have to make a decision as to whether you’re going to make that investment or not and there hasn’t been a tipping point.

But the other side of the equation is, up until I had this level of data, the group that had more data than I had was the insurance company. So if I wanted to negotiate contracts, discuss reimbursement rates, I was dependent on the data they could show me about the work that I was doing. Now I’m in a position where I actually have more data than they have about their own patients because not only do I have the billing data, which we both all have — the insurer has it and we have it — but I also have the supporting clinical data and that’s something that they yet do not have.

I’m answering your question in a slightly different way, but having that level of data allows doctors to play on a more level field, if you will, with insurers in terms of the information that they have. And that’s just one example of why it’s hard for me to imagine why physicians have not adopted this. My guess is that the bottom line they look at is the cost. They don’t think their return on investment will be significant enough for them and they make the choice not to do it. I suspect that’s what most groups are doing, but that has not been our experience. So it’s a little bit harder for me to identify with that, although I have empathy with that.

What is your general impression of some of the major changes that may happen in the healthcare technology industry in the next couple of years?

I think one of the first things that’s going to occur is that meaningful use, whose definition has not been finalized yet, is clearly going to extend beyond CCHIT products. It’s going to probably look at what we would call less expensive ones. I think that will make a change because I think physicians will argue that if they can find a less expensive solution, that’s more beneficial to them. I think, however, in the long term, it’ll prove not to be beneficial because I’m not sure how many of these vendors will be in place so to speak, a decade from now.

I think one of the other big changes that will occur is that in exchange for providing money, the government is going to look for access to the clinical data. I don’t think we have actually, as a country, yet resolved the debate as to who owns that data. I think that is yet to occur. I see that as something that is coming down the road and may change.

I think that in the end of the day, a lot of these smaller private groups will merge into larger groups just for the sake of purchasing health IT or doctors may join hospitals or multiple specialty groups for the purposes of getting the benefits without the costs involved in it. Those are a couple things.