DOCtalk by Dr. Gregg 1/27/12

Have Fun, Make Money, Change the World

Last year at about this same time, I was introduced to Health Care DataWorks (HCD). Located in Columbus, OH, they were a start-up with about 11 employees working in an almost archetypically Spartan start-up office space with programmers all sitting around one large conference table, pounding away on laptops, coding and debugging and trying to build a future.

They invited me back last week to see their new digs – and probably to show off just a bit as they had been having a pretty good go of it since last we met. I had truly enjoyed our first meeting so, as they are geographically near, it wasn’t that hard to decide to drive over.

Economic downturn be damned. HCD apparently hadn’t gotten the news of the economy’s slowdown. They had expanded to some 40 employees. They had moved into a gorgeous new space with real offices, real furniture, lots of lovely lake view windows, plus a company ping pong table. They were even getting ready to knock down some walls to expand yet again.

Of course, that’s all bows and ribbons and wrapping paper. The package inside is what I was interested in.

I’m very happy to say that the folks there had not let the transition from start-up to emerging growth company and their successes against some giants like IBM and Oracle go to their heads. They remained focused, clear, and personable.

Providing “business intelligence solutions that enable healthcare organizations to improve quality and reduce costs”, HCD delivers enterprise data warehouse and research solutions along with hospital and health system analytic dashboards to help improve quality and control costs. Sort of the “Intel inside” for hospitals. Their tools are pretty slick and very comprehensive. As they were recently featured on HIStalk’s Innovator Showcase, you can read more about “the what” there.

Here, I’d like to give just a little more of “the who,” because, if you’re like me, you also want to know about the people behind the scenes of cool tool creation and which way their personal bents bend.

Herb Smaltz is in his first role as a CEO, having lived his prior life in CIO shoes. He is well trained to see the problems he’s trying to help solve. He’s also enjoyable and enthusiastic with an almost child-like awe and joie de vivre. One very enjoyable trait: while he fills his role as the company’s head cheerleader well, he is not so mired in his own world as to miss the view of what might expand it from beyond.

COO Jason Buskirk is their business intelligence (BI) engineer. He’s just as pleasant as Herb, but quiet. He listens intently and seems to gobble up information, speaking rarely. But when he does, it’s with keen and concise insight.

Co-chair and CFO Jeff Wilkins provides a sense of comfortable confidence to the team. His self-assured nature completely avoids any sense of pomposity despite his long track record of corporate success. (Among other things, he founded CompuServe back in the ‘60s and helped open the World Wide Web to us all.) He easily mixes great stories about wild swans and “Henry and Dick” Block with insights into corporate culture and strategies.

They seem to swim in a pool of “I get it.” Not only can they expound upon the values and challenges and solutions within their current laser focus market of BI for large to mid-size hospital systems, but they easily perceive potentials that may be tangential to their foci. I have found this rare. To me, C-suiters seem to more often have an air of “we know best” rather than having a willingness to listen or examine other perspectives (especially when speaking with any lowly non-C-suiters.)

Maybe they’ll gain some proper C-suite arrogance once they move beyond emergence into maturity. But for now, they are the type of people you want to see behind any technology, product, or service you’re considering. (Shhhh… Yes, that’s right. Don’t say anything, and nothing’s firm, but they did hint at some potential tools that would more directly serve the trench grunt world.) Maybe when HCD grows up, they’ll abandon their Pollyanna-esque corporate approach, but I hope not. Personally, it’s one of my favorites, summed up by their Jobs-ian company credo, “Have fun, make money, change the world.”

Makes a geeky American capitalist smile.

From the trenches…

“I would trade all of my technology for an afternoon with Socrates.” – Steve Jobs

Dr. Gregg Alexander, a grunt in the trenches pediatrician at Madison Pediatrics, is Chief Medical Officer for Health Nuts Media, directs the Pediatric Office of the Future exhibit for the American Academy of Pediatrics, and sits on the board of directors of the Ohio Health Information Partnership (OHIP).

News 1/26/12

eClinicalWorks releases a letter from CEO Girish Navani, who recaps 2011 accomplishments and outlines plans for 2011. Some highlights:

• The company now serves 60,000 physicians across 22,000 ambulatory practices, including 33% of the country’s community health centers.
• Revenues grew by 35% in 2011 to more than $200 million. The company remains private and profitable.
• Employee count grew to 2,000, including 600 new hires in 2011.
• 2012 initiatives include the introduction of an iPad solution, 500 new enhancements, an ACO portal, and a commercial version of its Hub Population Health System platform.
• Live chat capabilities will be introduced in the customer service area and at least 250 more support engineers will be added.

If you are on of the 355 Eligible Providers who unsuccessfully attested to MU last year, CMS now offers an appeals process for both the Medicare and Medicaid programs. Beginning in February, appeal decisions will be posted on CMS’s Website under the Office of Clinical Standards and Quality.

Mississippi Coast Physicians negotiates special member pricing for MediStreams’ remittance automation services.

An Internet-based survey  of 1,000 practices finds that 45% of doctors in small to medium-sized offices report their practices are doing better this year compared to last. The top negative pressures facing practices were insurance, reimbursement, and patient compliance issues.

SOAPware partners with Ambir Technology to offer Ambir’s document scanning technology to SOAPware’s EMR clients.

The executive director of the American Academy of Private Physicians (AAPP) says the surge in government-backed to physicians offices indicates the financial struggles of today’s independent physicians. SBA loans to doctors have grown from $60 million in 2000 to $675 million in 2010 as physicians in solo and small offices struggle to make payroll and pay monthly expenses. Decreasing reimbursements, rising costs, and technology investments are contributing to the financial woes of doctors.

Physician referral rates doubled between 1999 and 2009, likely a result of increased specialization in medical care and the increased responsibilities of primary care providers who lack the time required to treat patients with certain chronic conditions. Researchers suggest a correlation between the increase in referrals and rising healthcare costs.

E-mail Inga.

More news: HIStalk, HIStalk Mobile.

Joel Diamond 1/24/12

ICD-10:  A Brief History

Those who follow my not so regular posts will know that I make an incredible effort to avoid offensive and controversial material. Today, I will keep to the high road and offer an academic discussion of ICD-10. 

But first… a few words about the term douchebag. Not only is it regularly used on TV nowadays, it is a word frequently bandied about in hospitals—often as the quintessential description of certain patients, but more often aptly used to describe particular physicians.

The term d*bag was defined in the Oxford English Dictionary in 1968 as popular epithet for "an unattractive coed." It was later defined as "a general term of disparagement, esp. for an unattractive or boring person." Clearly there exists a need to stratify this description, not only for general insults, but also for standardized documentation and even commerce and billing. 

Many believe that ICD-10, or the 10th revision of the International Classification of D*bags, will resolve this issue. Its deep dictionary of 68,000 terms (compared to 13,000 in the 9th revision i.e. ICD-9) will go well beyond the general term for disparagement, while its 3-7 alphanumeric character codes will allow for greater specificity and detail. For instance, I do not need to delve into the benefits of ICD-10’s detailed description of body parts compared to ICD-9’s generic terms.

I believe that these benefits alone will justify the estimated implementation cost for conversion—thought to run from $5.5 billion to $13.5 billion, with additional productivity losses of $752 million to nearly $1.4 billion.

I thought it would be interesting to gain some historical perspective on this subject. (please note: the names are correct, but the facts are altered to protect the humorless).

Early History

Francois Bossier de Lacroix (1706-1777) is often credited for the first rigorous attempt to classify d*bags in his now famous Nosolgia methodica. He formalized the many ambiguous terms used in his day, such as “Beetle-headed, flap-ear’d knave,” “canker-blossom,” “bolting hutch of beastliness,” and the ever-popular “lump of foul deformity” and organized them according a rough hierarchy.

In 1837, the first medical statistician for the General Register Office in England, William Farr, noted that “the nomenclature of various miscreants in our midst is of much importance in this department of inquiry… and should be settled without delay,” which led to the 1st International Statistical Institute and it’s now famous Classification of Douchacity.

It wasn’t until the Fifth International Conference for the Revision of International Classification of D*bags held in Paris in 1938 that the more familiar insults that are still used today began to be assembled in an organized nomenclature. For instance, under the pejorative “dumb,” one could also classify “imbecile,” “idiot,” and “moron.” Furthermore, for the first time a combination term emerged, which allowed the specification of “a stupid- idiot.” Nonetheless, historians will recall that representatives from Austria and Luxembourg walked out on the sessions, as they felt that these terms did not fully express the gestalt of the true d*bag.  

The Ninth Revision

Meeting in Geneva in 1975, the now common three-digit codes were agreed upon and the currently used International Classification of D*bags-9 (ICD-9) was formalized. Most practitioners agree that ICD-9, while useful for general insults and humor, severely limits the accurate description of people we dislike. Take for instance the term “D*bag Not Elsewhere Classified.” It has serious and negative implications in epidemiological studies and retrospective analysis. Similarly, the combination term “D*bag with or without a stupid grin that one might want to punch” is frustratingly ambiguous. Finally, so much has already been written about the plethora of “worthless” E-codes pertaining to injuries (i.e. motor vehicle accident secondary to d*bag talking on cellphone,) yet the classification misses common conditions such as “d*bag at the gym who constantly looks at himself in the mirror.”

ICD-10

Now seriously, I hope the above parody sheds some light on the absurdity of our ridiculous emphasis on billing at the expense of true descriptive medicine, clinical communication, and interoperability. 

In fact, the closest real-life ICD-9 code that describes a d*bag is 301.81 – Narcissistic Personality Disorder.   

At least ICD-10 allows the more clinically rich picture to emerge:  F602- Dissocial personality disorder, with Z437-Attention to artificial vagina, Y607-During administration of enema. 

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

News 1/24/12

From States Wrongs: “Re: Medicaid MU. In looking at the latest CMS figures, it looks like several state Medicaid programs had no payments as of the end of December. That’s crazy.”  Yes, that’s a bit troubling. According to the CMS website, Idaho, Hawaii, Minnesota, Nebraska, New Hampshire, Nevada, Virginia, and the District of Columbia still have not launched their Medicaid EHR incentive programs, though most expect to be ready this year.

Kareo introduces an automated telephone appointment reminder service for its Kareo Max plan customers. The PM and billing service provider also redesigned its Help Center to include a more simplified layout and new search capabilities.

The eight-provider Raleigh Eye Center (NC) selects NextGen’s PM/EHR system from TSI Healthcare.

The 91-provider Commonwealth Orthopaedics (VA) contracts for SRS EHR.

By the end of 2011, over 10,000 New York State healthcare providers had enrolled in either the NYC Health Department’s NYC REACH program or the NY eHealth Collaborative. Both RECs achieved their enrollment goals.

RCM and EHR provider Office Ally reports adding 1,400 new practices in 2011. Last year  the company moved its headquarters from Vancouver, WA to San Antonio to accommodate its growing operations.

Clinical documentation vendor MD-IT names Bard Betz as CEO, replacing former President and CEO Tom Carson. Kevin Shaughnessy is promoted to president.

GE Healthcare reports a revenue increase of 1% to $5.16 billion, but operating income dropped by 5% to $953 million.

Care360 enhances its Care360 HD EHR app for the iPad, adding new features for medication management and documenting patient encounters.

E-mail Inga.

Practice Wise 1/20/12

New Year’s Resolutions I Hope to Fulfill

I gave up making personal resolutions years ago, when I realized I never stuck to them past January 10. But I do try to set a few resolutions or personal business goals at the start of every year. These aren’t business plan type financial goals. Instead, they are usually relationship growth goals.

As the owner of a small consulting firm serving mostly small to medium practices (with a few bigger systems thrown in the mix,) I have the opportunity to have very personal, almost intimate relationships with our clients. We are part of their practice family. We know a lot about their personal lives, and they about ours. I’m constantly striving to improve those relationships. They are the lifeblood of my business; the reason we exist.

Resolution #1: help my clients to understand the importance of their vendor relationships and how to foster them into practice family relationships. In particular, as practices adopt EMR software, they need to incorporate their EMR vendor and their IT support vendors into their team. I want to help my clients understand the value of their technology, and more importantly, the value of their technology partners in their practice success. With standardization of the elements of certified EMR products and generally standardized hardware, the value of technology is not solely the technology itself, but the partners who make technology successful in the practice.

I had a third-party business associate comment to me the other day that in all his years in business, he’s never seen customers treat their vendors the way that some medical practices treat their IT support vendors. He didn’t mean that in a positive way. He observed interactions between practices and their technology support vendors and was shocked that the clients were making demands and laying down ultimatums. In his mind, the demands seemed unreasonable.

It got me thinking about out why perfectly intelligent and reasonable people can seem so unreasonable and difficult to please when it comes to their computer environment. Of course, there are many factors at play here. It’s no secret that the medical field is anywhere from 10-15 years behind corporate America in the adoption of business computer systems. Smaller practices are at the tail end of that curve. They are approaching all of these major business technology changes to their practice with the adoption of EMR from a bit of a disadvantage.

Many small to medium practices don’t even use corporate e-mail before they move into a complex EMR. They often don’t understand the difference between buying a computer with Windows 7 operating system and Office 2007. They have no frame of reference of how these things should work. Nobody has set expectations for them. Vendors recommend solutions, install them, tell them how they work, and expect that they will be effective users and grateful support customers at the end of an implementation. The customers think if it’s a complex technology, it should just work. They are frustrated and fearful. We’ve upended the way they practice medicine. They don’t know what to expect. We have failed them by not setting realistic expectations.

Resolution #2: set realistic and appropriate expectations. OK, I could use this one is all areas of my life, but that’s another story. In relation to my business, my goal is to help define appropriate support expectations with my clients. Not only for my firm, but with all the vendors that help my clients keep their practices running.

We know that end users become effective with ongoing support. Part of that support should be educational about the processes, not just the products. For instance, I had a provider complain that we do too many software updates to his EMR; he only wants one a year. He thinks updates are about new features and functionality only. I showed him the Microsoft Automatic Updates history on his computer. It was setup to download and install automatically at 3:00 am.

He wasn’t aware that this was happening weekly. It answered his question as to why on Wednesday mornings when he comes in, his computer is rebooted and all his applications from Tuesday are closed. He thought he had a computer problem and nobody believed him that some days his computer rebooted itself. Understanding what software upgrades entail and why they are necessary was not something he ever thought about, until he started using an EMR.

We can’t expect them to set expectations of how their products or vendors will perform if they’ve never experienced these in the past. I certainly would have appropriate expectations about a cardiothoracic surgical procedure outcome having had no experience with one.

This is not a new discussion. There was an excellent post on this site last year about having empathy and compassion for the customer, and likewise, the customer for the support team. It dealt primarily with internal hospital teams. Those of us who provide support services to private medical practices have the extra challenge that these are our paying customers. We don’t have control over their environment or unsolicited sway in their culture. If they don’t feel like their needs are being met, they’ll take their business elsewhere.

And let’s be clear: not all vendors are created equally. There are plenty of vendors who do not meet even the minimum expectations, set or not.

Someone will read this and state that it is elementary and pedantic. Nevertheless, I see hundreds of providers in small practices, and by and large, they are in the same boat. I have a handful that are really computer savvy and understand what to expect. I value my clients and the work I get to do with them. I want to make sure they are given the opportunity to play on an even playing field, knowing all the rules of the game, so that they can be successful in this part of their business.

We can all help them set appropriate expectations. Then, hold them and us — the vendor community — to those standards. We can only expect them to have reasonable expectations if we agree to them, and then meet them.

At least I won’t be fretting over another year of wasted gym membership fees after another failed resolution to start exercising and lose 15 pounds.

Julie McGovern is CEO of Practice Wise, LLC.