Joel Diamond 6/23/10

Random Thoughts on e-Prescribing

A few years ago, I admitted a 35-year-old man to the hospital with severe dehydration and electrolyte disturbance due uncontrolled diarrhea. The poor guy started out with fairly mild symptoms. After using his neighbor’s bathroom, he looked in the medicine cabinet and saw a drug labeled colchicine. The instructions read “Take every 1 hour– gout relief or diarrhea”.

For those of you unfamiliar with this old but effective treatment, you literally take it every hour until painful gout resolves, or stop taking it when you get the side effects of diarrhea. I will not comment on this gentleman’s intelligence or judgment, but somehow he misinterpreted the instructions as a treatment FOR diarrhea. Worse than that, as his symptoms got worse, he diligently followed the instructions and continued taking more, and more, and more… every one hour for the next 24 hours.

Sort of reminds me of the old lady who was prescribed a rectal suppository for symptoms of nausea. She called saying the medicine didn’t work. “And while I’m at it, how did you expect me to take that giant pill? And if you must know, it tasted awful!” I guess it’s not as bad as the elderly woman who didn’t enjoy the taste of the “Kentucky Jelly” on her toast in the morning. (K-Y Jelly is usually used for other purposes).

Clearly, the Sig (i.e. instructions) portion of a prescription is extremely important. Practitioners claim that the unstructured format in handwritten prescriptions offers more flexibility. For instance, writing complex dosing for a tapering course of medication can be difficult in an EMR.  This is commonly cited as an obstacle to widespread adoption of electronic prescribing. But in the end (pardon the pun), I suppose that the above suppository story could have been averted if the instructions had read “carefully place the huge waxy tablet firmly up your ass.”

Speaking of which, a colleague of mine told me of the time he once prescribed drops for a baby with an earache. The instructions were: “Put two drops in right ear every four hours” with right abbreviated as an R with a circle around it. The mother returned when the child did not get better. She showed the doctor the baby’s wet rectum as evidence of complying with the prescribed treatment. It turns out the pharmacy printed the instructions as “Put two drops in R ear every 4 hours”.

I’m a huge advocate of electronic prescribing. Elimination of handwriting errors, dose range checking, and monitoring drug-drug interactions are but a few of its virtues. My patients definitely appreciate having prescriptions waiting for them at the pharmacy.

As an aside, several years ago when I started e-prescribing, a pharmacist I knew told me that the drug store pharmacies were worried that this convenience would cause them to lose revenue. It seems that waiting around is precisely why they put the pharmacy there in the first place — to make you shop for other stuff during the 30 minutes it takes to put 30 tablets in a bottle.

Progress can oftentimes be thwarted by outdated legal issues. I still can’t figure out why I can call in prescriptions for Vicodin and Xanax over the phone (or worse, fax them), but I am not allowed to e-prescribe these controlled substances and significantly decrease illegal prescription diversion.

Speaking of old fashioned, one of my old mentors told me that he had an agreement with the local pharmacist back in the day. Whenever he had a hypochondriac in the office, he prescribed Obecalp for whatever ailed them. The pharmacist would fill the script with the biggest vitamin capsule he had in stock. (Obecalp is placebo spelled backwards). I often wish for that drug to appear in my EMR’s drop-down list. Talk about “Primum non nocere” –First do no harm (The Hippocratic Oath).

Frequently,  I just miss what might be the last bastion of the lost art of medicine … pulling a leather-bound prescription pad out of my pocket and writing Latin instructions with a fountain pen as closure to a satisfying doctor-patient encounter.

And then getting a call from the pharmacist telling me the drug isn’t on formulary!

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 6/22/10

CMS launches its official website for the Medicare/Medicaid EHR Incentive Programs. Maybe technically it is a “new website” but it looks to me that CMS simply consolidated all the Incentive Program information into one area and there’s not much, if any, new data. CMS opted to save taxpayers’ money by not incorporating any graphics. None-the-less, it’s now easier to find the specific EHR incentive data you need, regardless of whether you are a hospital, physician, or vendor.

ONC releases long-awaited details on its temporary EHR certification program. Starting July 1, organizations can pay $75,000 to apply to become an Authorized Testing and Certification Body (ATCB) for EHRs. Programs previously certified by CCHIT will not be grandfathered and will be required to go through additional certification. In addition, CCHIT, like other interested testing bodies, will be required to apply to become an ATCB. The Drummond Group, another entity planning to apply to be an ATCB, provides a succinct overview of the final rule here.

NaviNet announces plans to introduce an integrated patient information system to supplement its current healthcare communications network. NaviNet is seeking technology partners to integrate their PM and EMR systems with NaviNet’s existing claims processing and HIE solutions.

PatientPoint names Raj Toleti CEO. PatientPort provides self-service applications for healthcare providers, including a patient-facing kiosk system.

Navicure hires James McDevitt as CFO. McDevitt previously worked with Geac Computer Corporation and Bausch & Lomb.

A researcher from CSC predicts that private insurers will follow the government’s lead and impose financial penalties for contracted physicians not meeting EMR meaningful use standards. Insurers did it with electronic claims, so why not with EMRs?

Looking for some User Group meeting activities in the coming months? Here are details on a few:

• NextGen Healthcare opens registration for its 2010 user group meeting, to be held November 7-10  in Orlando.
• Allscripts Client Experience (ACE) is August 5-7 at the Mandalay Bay Resort in Las Vegas.
• eClinicalWorks  heads to Orlando’s Gaylord Palms Resort & Convention Center October 30th – November 2nd.
• e-MDs hosts their users July 22-24th in Austin, TX.
• SRS users head to Woodcliff Lake, NJ (outside of NYC) September 15-17th.
• Atlanta is the place to go August 29 – September 1 if you are a client of Greenway Medical.

Deja vu or quelque chose de nouveau? Practice management firms are buying up practices, though a few things have changed since a similar buying spree in the mid-1990’s. First, most of the buyers today are are experienced in the industry and they know how to operate practices. Purchase prices are more modest and cash is king. Finally, rather than primary care practices, today’s buyers are focused on hospital-based physicians. It almost sounds like my love/hate relationship with skinny jeans: I want them as much as I did in 1995, but with my expanded view of the world I am not willing to pay as much, and, mais bien sûr, I only pay cash.

E-mail Inga.

HIT Vendor Executives on Reactions to the Allscripts/Eclipsys Acquisition

We asked several EMR and consulting executives the following question:

Regarding the Allscripts/Eclipsys acquisition, what are some of the broader implications for the HIT industry?

J.P. Fingado, President and CEO, API Healthcare

This was a strong move by Allscripts but the key piece to watch is how well they integrate the companies and solutions.

I believe this is a clear action that demonstrates the industry will see significant consolidation over the next 2-3 years. We will be left with 2-3 major players in several key segments such as clinical, financial, workforce/human capital, and connectivity. Companies will move to create value for their clients by managing and mining vast amounts of data. The value will come from aggregating and gleaning operational and clinical insights from the data that flows between the applications inside healthcare delivery facilities as well as between disparate organizations. Once that data is managed on a common technology platform, analytics can be applied more easily and the data can be transformed into knowledge that facilitates improved care and improved operations.

Hidden within the data there are many answers to medical conditions, running hospitals and practices more efficiently and providing better quality. We have proven as an industry that interfaces between disparate data repositories, while of some value, will never generate anything more than limited results at a higher cost. Having related data, such as workforce, on a single platform substantially increases the ability to turn data points into impactful insights.

Vic Arnold, Managing Partner, AsquaredM

In general, I have watched a lot of companies try to merge themselves to greatness. Merger seems to be the most difficult business maneuver of all methods of growth.

I recall Phamis and IDX among others and somehow, these deals never quite become a full fledged single entity. The differences in organizational culture, code base, sales force and many other factors seem never to yield to a true winner.

It all reminds me of Tom Wait’s song “What’s he Building” or that nagging phrase I can’t get out of my head when I think about this deal – “King of the Zombie system sellers”, or something like that. The upside is that Mr. Tullman did get rid of his English masters and that may be the best thing to happen from all this. The truth of this deal will be to see what products in the current mash up get taken care of and are allowed to grow and prosper.

Shane Hade, CEO, EDIMS

Consolidation has been and continues to be both inevitable and necessary in the EMR industry. There are too many vendors, many with partial and inferior solutions, creating confusion and frustration for hospitals. Rationalization of the market, through mergers like Allscripts/Eclipsys can strengthen the offerings and can help to streamline decision making process for hospitals looking to acquire HIT.

Especially in critical care areas like the ED where our company, EDIMS, operates, hospitals and ultimately patients can’t afford to have inadequate solutions, yet choosing among the plethora of solutions available is time consuming and challenging, putting hospitals at a serious disadvantage. Too often we see, hospitals, afraid to make bad decisions, delay or choose to make no decision.

The industry and the quality of healthcare will be improved through strategic market consolidation.

Ron Sgro, CEO/Co-Founder, Enovate

First of all, the acquisition better positions Allscripts to gain access to $30 billion in federal funds for the adoption of electronic healthcare records! J

It would have been hard for any company to take the reins in EMR without reaching into the hospital space and it will be interesting to see what impact this merger will have on other ambulatory EHRs, such as NextGen and eClinicalWorks. Any concern I might have would  be for dbMotion as they’ve only been involved with AllScripts for a year– and Eclipsys has a partnership with Microsoft and the Amalga platform –  which is very similar to dbMotions solution.

My hope is that this is a possible attempt to unite a market where currently, hospitals and physicians choose from a wide range EMRs. Standardization is the ultimate goal here, perhaps this is one way of trying to reach it.

Peter J. Butler, President, Hayes Management Consulting

As the HIT industry seeks interoperability between disparate platforms as well as the hospital and ambulatory environments, acquisitions like this will be the true test of whether multiple platforms now being sold by a single vendor can truly be interoperable.  The industry has not been able to accomplish this yet, and there isn’t much time left for Allscripts/Eclipsys to prove this. However, if Allscripts/Eclipsys’ result is a cohesive fully interoperable product suite, it will mean a positive breakthrough for the HIT industry.

Dave Dyell, Founder & CEO, iSirona

Any time acquisitions like this take place, I get concerned about innovation in our space. Over time, you can end up with 800-pound gorillas that don’t have as much of an incentive to be on the cutting edge. A great parallel is the ERP market: when has anything new and exciting happened there?  Neither SAP, Oracle or even Microsoft is driven to come out with anything new or game-changing.

I think this specific acquisition has a lot to do with the American Recovery and Reinvestment Act (ARRA), which is laying out very specific Meaningful Use criteria. Hospitals that haven’t plugged that hole now will need to. To take advantage of that, Allscripts needed to go to the inpatient side, where they have been less than successful.  Ultimately, this step towards a connected healthcare environment—where physicians can log in from their office and see records in the hospital—will be very good for Allscripts’ end users.

This is a very exciting time in the HIT industry. Acquisitions aside, my hope is that as an industry we remain committed to exploring new technologies to advance healthcare.

James K. Lassetter, M.D., CEO, Medicity

New health reform legislation and emerging care delivery models like patient-centered medical homes and accountable care organizations mean that vendors must strategize to meet their clients’ need to drive tighter integration and coordination between hospitals and affiliated physicians.

Allscripts/Misys have traditionally focused on the ambulatory space, which worked in the ‘old world.’ Now, in the new world of ACO and bundled payments, the combined Allscripts-Eclipsys organization can help bridge the inpatient-outpatient gap and promote efforts to connect care for patients.

Earlier this year, NextGen announced its acquisition of Opus Healthcare and Sphere Health. It would have been surprising if Allscripts left that move unanswered. These transactions are the first of many roll-up strategies we can expect to see driven by – among other things – mounting pressure for healthcare to be more collaborative.

Janet Dillione, EVP and GM, Healthcare Division, Nuance

The union of Allscripts and Eclipsys marks a shift in the EMR market.

While today, the EMR market is vast, comprised of hundreds of vendors and solutions, moving forward it is likely that we’ll see more vendor collaboration in the form of acquisitions and strategic partnerships. Hospitals and physicians have too many solutions to choose from, making the move to digitize medical records that much more difficult. Combining the best resources and technologies across the healthcare IT market will reinforce the healthcare industry’s ability to evolve at a technical level.

As part of this, Nuance is uniquely positioned to support ongoing EMR innovation by adding speech recognition and speech-driven command functionality to the EMR workflow. While vendor selection is a critical part of healthcare organizations’ EMR undertaking, system usability is the make or break component as to whether these systems will having staying power.

Over the next few years the focus will remain on Meaningful Use. In order to achieve Meaningful Use, healthcare organizations must overcome the various hurdles associated with EMR adoption and the healthcare IT industry must deliver solutions that ensure non-disruptive and effective usability that will lower costs and impact improved patient care.

Craig Klein, Director, Red Hat Healthcare Vertical

The acquisition of Eclipsys by Allscripts has a number of implications for the HIT industry, both today and in the future.

First, this purchase exemplifies the move of companies in the EHR market to position themselves technologically to pursue stimulus money for HIEs. Moreover, this action highlights the desire for stronger control over the healthcare delivery system as a whole.

In addition to the acquisition’s implications for the industry today, it is also telling for the future. For example, this purchase implies further market consolidation in terms of the number of companies selling EHR applications. Acquisitions and mergers of ambulatory and inpatient application companies will continue to minimize the overall size of the HIT industry.

Bruce Cerullo, Chairman & CEO, Vitalize Consulting Solutions, Inc.

The combination of Allscripts’ industry leading ambulatory capabilities with Eclipsys’ deep hospital penetration makes perfect sense as healthcare systems accelerate their migration plans for integrated end-to-end clinical/HIT solutions.

This is a logical next step in the realignment of the healthcare IT sector in response to business opportunities stimulated by ARRA, HITECH, HIPAA 5010, and ICD-10 mandates.  Other seismic shifts have already occurred (e.g. Xerox/ACS/FCG, Dell/Perot) and others are likely to follow.

To successfully compete in the future, both HCIT product and service companies will need to be able to offer a continuum of ambulatory and hospital solutions. Bandwidth and diversity of offerings, coupled with the scale to manage complex projects, will be key differentiators.

Intelligent Healthcare Information Integration 6/18/10

EHR Push Answers “Can We All Get Along?”

I just returned from a meeting of the OHA (Ohio Hospital Association), which was centered around OHIP (Ohio Health Information Partnership,) the HITREC (Health Information Technology Regional Extension Center) as well as the HIE (Health Information Exchange) developer for the state of Ohio.

After de-acronyming my brain from these and many other much-bandied non-words, I started to debrief myself on all I had just heard over about four hours of presentation and discussion. What I came to realize was pretty doggone cool: this incredibly complex and almost overwhelming task of redesigning healthcare is bringing people together in ways I can barely believe!

Here we have competing hospitals, competing healthcare insurance carriers, competing professional organizations, and competing healthcare docs/providers all talking — and, I must emphasize, talking civilly — about how we can all work together in a very fast time frame to bring some of this much needed change to the entirety of healthcare in Ohio. (Granted, some of this realization comes from other meetings and other conference calls which weren’t focused just upon the OHA, but the truth of the cooperative nature is evident in them as well.)

Way before Rodney King rose to public consciousness, I remember always wondering why my nerd friends (you know, the science geeks who built model rockets, played with amateur radios, and thought chemistry sets were great Christmas presents) and my cool friends (who played basketball, football, kick the can, and just hung out being…well…cool) couldn’t all play together. I mean, really, I liked both groups equally. I really wanted to have both elements at my birthday parties. But, as the years wore on, it became increasingly obvious that geeks don’t mingle well with cools. Always bummed me out.

Leaving my ancient childhood behind and moving into the modern era, I am absolutely in awe of the power that this huge challenge (brought about by the acronyms, HITECH and ARRA) has become such a unifying force, at least here in Ohio, bringing together folks who have been known to work at one hundred and eighty degree odds in past confrontations..er…conversations. I’m not sure all the federal funding in the world could have done this for my nerds/cools dilemma, but, at least for healthcare, it has been almost as motivational as a 9-11 or Pearl Harbor for bringing disparate parties to a mutually agreeable consensus.

Though the healthcare crunch is putting people’s lives in jeopardy every day, I realize equating our healthcare crisis with an attack upon our nation may be stretching it. But, darned if I’ve ever seen anything else, or even heard of anything else, which comes as close to the powerful sense of community cooperation for the common good as what I’ve been witnessing here. It has my sense of snarky skepticism all balled up in almost pie-eyed optimism…and I am in awe!

“Can we all get along?” Apparently, we can…at least for a while.

From the pie-eyed trenches…

“I find nothing more depressing than optimism.” – Paul Fussell

Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

News 6/17/10

From Newt: “Re: relevance of CCHIT. Naive, but the comments are warming up.” Newt sent over this article discussing CCHIT and reasons its relevance could be increasing or fading. On the waning side, the author cites competition with other certifying bodies, the possibility that RECs won’t select a CCHIT-certified product (I find that unlikely, at least any time soon), and the chance that new vendors will place less importance on CCHIT certification. On the other hand, CCHIT is the most experienced certifying body and represents the safest bet for buyers.

GE Healthcare unveils Centricity Advance, a new SaaS solution that includes EMR/PM and portal solutions. It sounds as if it might be a “lite” version of GE’s traditional offering, designed for small practices and requiring less upfront investment, minimal training and easier implementation. The most surprising thing about this announcement is that it’s taken GE this long to jump on the SaaS/low-end bandwagon.

Mark Goines, a former SVP and GM of Intuit’s consumer division, joins Practice Fusion’s board of directors.

Virginia HIT names Allscripts, athenahealth and MDLand as preferred EHR partners. All three vendors will provide SaaS-modeled EHRs for primary care physicians working with the REC.

The HIMSS EHR Association elects new leadership and adds an executive member. Epic EVP Carl Dvorak will head the board, with NextGen VP Charlie Jarvis taking over as vice chair. Pamela Chapman, director of clinical product management for e-MDs, is the Executive Committee’s newest member.

The 21-physician Jackson Heart Clinic (PA) partners with TSI Healthcare to provide NextGen implementation services.

National Coordinator for HIT David Blumenthal says that providers are still concerned about the cost of adding EHRs, losing productivity, and overcoming the technical challenges of implementation. He also points out that if physicians don’t have EHRs, they may have difficulty recruiting new partners or selling their practices because newer generation physicians won’t “tolerate a paper world.”

eClinicalWorks purchases 100,000 square feet of office space in Westborough, MA to support its growing operations. eCW plans to add 100-200 more people over the next 12 months, supplementing its current 1,100-member workforce.

Greenway Medical Technologies launches BlogEHR, a new blog site focusing on HIT and written by Greenway executives.

AT&T issues a statement saying that the iPhone 4 pre-orders were an incredible 10 times higher those for the iPhone 3G S last year. In order to catch up inventories, AT&T is suspending pre-orders and Apple’s Web site says pre-orders won’t ship until July 14th. I think I placed a pre-order Tuesday and requested to pick up the new phone up in the Apple store June 24, but I had such problems on the Apple site that I won’t be surprised if I come home 4G-less that first day.

Here’s a new tool for the price-conscious patient. Startup Castlight Health is establishing a Web site that allows patients to search for doctors offering a particular service nearby and to also find out the costs based on insurance coverage. The company’s founder and CEO is Dr. Giovanni Colella, the founder of RelayHealth. athenahealth founder and current HHS CTO Todd Park is a co-founder.

From researchers at Henry Ford Hospital: patients are more likely to routinely take their medicines for asthma control when their physicians monitor their medication use and review detailed e-prescribing information.

Florida internist Cecil B. Wilson is inaugurated president of the AMA.

NoMoreClipboard partners with Washington DC-area providers to use PHRs with cell phones to help diabetics improve outcomes and reduce costs. The program targets high-risk Medicaid patients who may not have access to home PCs. On the other hand, administrators note that “everyone has a cell phone.”

Because truckers need maintenance too, Roadside Medical Clinic + Lab opens three new locations in Pilot Travel Centers. The new and existing clinics all have a full PM/EHR (TotusMedica.us) complete with iPads and telemedicine.

E-mail Inga.