Joel Diamond 10/28/09

Yet More Controlled Medical Terminology

It’s been over 20 years since I read Samuel Shems’s irreverent and frighteningly realistic portrayal of medical training, House of God. It was unofficial required reading back then, and my fellow residents would quote lines as frequently as my teenage sons do from Judd Apatow movies today.

Shem referred to chronic, demented, elderly patients as GOMERS (Get Out of My Emergency Room), and Rule #1 was “GOMERS don’t die”. (Other rules were, “There is no body cavity that cannot be reached with a #14 needle and a good strong arm”, and “If the radiology resident and the Best Medical Student both see a lesion on the chest x-ray, there can be no lesion”.

I wonder how many current medical residents have read this book, and if so, does it still seem realistic? I trained near the tail-end of the days of legendary 36-hour shifts, unrestricted moonlighting, and unsupervised care at VA hospitals. The phrase “watch one, do one, teach one” was not a metaphor, it was a mandate.

Those days are gone. The tragic and famous Libby Zion case changed all that. For those who don’t remember, this young woman suffered and died as a result of a fatal medical error, allegedly due to unsupervised house staff weary from long hours. (Perhaps advanced decision support technology would have changed things … but I digress.) Her parents’ relentless publicity and appropriate legal proceedings brought much-needed reform to medical education by limiting work hours and requiring that attending physicians actually be present.

Despite this, many of us old-timers nostalgically look back to those days and sometimes wonder if current trainees lack the volume and richness of encounters that we find so invaluable in our current practices. Certainly, the gallows humor remains. So without further ado, more widely used medical terms that you won’t find in the books.

• Positive O Sign. Exhibited by an unresponsive, elderly patient. Characterized by their perpetually wide open mouth.
• Positive Q Sign. Similar to the O sign, but much more ominous, as their tongue is hanging out (thus resembling the letter “Q”).
• Throckmorton’s Sign. Experience clinicians would always point this out to naïve medical students. When looking at a male pelvic x-ray, the shadow of the man’s genitalia always points to the side of pathology (advanced research has confirmed its 50% predictive value).
• Emmerson Biggens Syndrome. Also used to to bewilder innocent students who could never find this condition in textbooks. Actually a misogynistic comment when looking at the chest x-ray of a well-endowed female patient (i.e. “‘em are some big ones”).
• Code Brown. As opposed to the better-known Code Blue, a true emergency where a patient has fecal incontinence, overpowering other disgusting odors usually present on wards.

While many of you laugh nervously at the apparent lack of compassion behind these references, remember that it often reflected an outlet for those dedicated clinicians on the front lines, toiling under unimaginable stress, which was frequently unappreciated and often futile.

Medical education has dramatically improved. More importantly, patients are rarely used anymore as mere training tools for inexperienced doctors-in-training. No doubt today’s tech-savvy residents (as well as increasingly complex patients) benefit from readily available medical information and computer-aided monitoring and support. Let’s not forget this as we design healthcare IT systems.

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 10/27/09

It’s situations like these that give insurance companies a bad reputation. CalOptima loses claims data for 68,000 members, including substantial identifying information. An HIStalk reader tipped us off on to the letter posted on the CalOptima home page. CalOptima says its scanning vendor sent an it unencrypted DVD that was never received. A PR nightmare, not to mention a huge privacy mess.

Here’s a figure I haven’t heard. On average, a breached medical record costs $211 to remediate. We’ll see whether or not CalOptima’s mess costs north of $14 million to resolve.

Virtua, a multi-hospital healthcare system in New Jersey, selects NextGen EHR for its Medical Group network. In addition to implementing NextGen across its 23 locations, Virtua will offer NextGen EHR to its community-based physicians.

Don’t know why this random thought came into my head recently, but while at MGMA this month, I sat through a few demos. I recall asking the young man (why do they all seem so young?) showing me the product if the software could do a certain function. Instead of a simple, “Yes,” or even, “Yes, would you like to see how?” he proceeded to give me a long drawn-out description of the company’s philosophy and history as it related to this particular function. At some point, I zoned out and was ready to go to the next booth. The point here is: if you are the one demonstrating software, and someone asks you what time it is, it’s rarely necessary to explain how a clock works.

Florida physician Dr. Edgar R. Blecker goes live on PWeR, the first doctor with Renaissance Health System to do so. The press release says Renaissance has over 2,000 affiliated physicians, but there’s no mention of more doctors going live on the EHR.

EndoSoft jumps into the physician EHR market with its launch of EndoVault EHR.

Rhode Island becomes the first state to use e-prescribing records to track the spread of swine flu statewide. A brilliant example of using HIT to improve patient care (although the tracking is based on prescriptions of Tamiflu and other antivirals). Maybe things are different in Rhode Island, but in many parts of the country, physicians are reluctant to prescribe antivirals, so maybe the data isn’t all that helpful (although the directional trend may be valid). Still, I like that someone is at least trying to use that data for more than tracking prescribing trends.

Zydoc Medical Transcription launches its MediSapien automated appointment reminder service. MediSapien is available in multiple languages at a flat rate of $.20 per connected call.

MedAssets Supply Chain Systems will distribute the MedAppz iSuite EHR to the non-acute, ambulatory healthcare provider customers of MedAssets. The multi-year agreement will allow MedAssets to offer the EHR as a SaaS solution.

With new players expanding into the EHR market and established hospital-system vendors trying to make a mark, one has to wonder how some of these tiny EHR vendors can survive. For example, Waiting Room Solutions just announced a couple of new sales. I went to their Web site and learned that for as little as $429 per month, you can purchase a Web-based EMR & PM packaged solution, which includes maintenance. Training is available via Webinar or with a self-guided video and demos are available via the Web. The site says nothing about a leadership team, suggesting little deadwood at the top. I suppose when you don’t have a lot of overhead from sales, training, and management you can operate on a slim margin, but will they be around in five years?

RelayHealth says its new TestTrack 5010SM for Payors tool is available.

Sequel Systems introduces an integrated patient portal application that will work with its existing PM and EHR solutions.

E-mail Inga.

Intelligent Healthcare Information Integration 10/23/09

From the Pediatric Trenches

“Dit, dit, dit, dit…dit, dit…dit, dit, dit…fresh from the front lines of the world of pediatric HIT, this is your humble grunt in the trenches reporter, Gregg Alexander, with breaking news.”

That is how I was going to start this offering. However, after traveling to Dallas to give a talk for Eclipsys’ EUN and flying directly from there to direct the “Pediatric Office of the Future” exhibit at the American Academy of Pediatrics’ National Conference and Exhibition in Washington, D.C., somewhere en route I encountered a virulent little chest-congester, sinus-stuffer, feel-like-heller of a cold germ. While very grateful it isn’t the H1N1 variety virus, it is nonetheless one powerful little booger. Thus, my writing has been delayed by both overwork and, now, by oversnot.

Here in HIStalk Practice land, I’d like to share with you what I recently experienced at the above-mentioned AAP Peds Office of the Future or “POF.” (I’d give you a bigger picture view, but the work kept my leash pretty short, thus keeping my view of anything beyond the exhibit hall quite limited). It was not the experience I expected. Let me explain…

As many of you know, with the economic downturn, many conferences are experiencing reduced attendance and diminished vendor participation. The American Academy of Family Practice (AAFP) held their annual conference up in Boston just before the AAP show and, by all the reports I received, had a decline of around 30% in attendance. (Unconfirmed.) I was worried we would experience the same. However, much to my most happy surprise, pediatricians and their entourages turned out in record numbers! From all around the globe, the pediatrically-inclined came and saw and conquered … OK, maybe the only thing they conquered was the dreary D.C. weather, but they for sure turned out.

View from the ceiling during set-up. POF is white-canopied booth in front.

Top off a record-setting attendance with an exhibit hall floor which, to my completely subjective view, was one of the most broad-swept product and informational offerings I’ve ever seen and you have a real event. Our POF exhibit also had a nice breadth of sponsors. With your indulgence, I’d like to take a moment to gratefully acknowledge them here: athenahealth, Doctations, Eclipsys, Sage, Medicomp, PediaPals, QuickMedical, and (a special thanks, Mr H.) HIStalk Practice. I also would appreciate your forbearance while I acclaim the good folks who represented each of these companies: I cannot begin to describe the wonderful efforts of every single one of the representatives from each of them. Each was more pleasant and more enjoyable with whom to work than the next.

If you didn’t make the AAP show this year, you missed out. Well done, AAP. If you did, and if you happened to come by the POF, I’d certainly appreciate your input on how we can make it better for next year in San Francisco (woo hoo!) Please send along your thoughts in an email to me or add them to the comments section after this post. We already have some great plans and sponsors, but want your ideas.

For all you vendor types who are reading along, take note: pediatricians are showing up, despite the economy, and their interest in moving forward with HIT has finally started to ascend. (We’ve been a bit behind the learning curve, but it’s looking like we’re about to play some catch-up.)

One last thanks: Mr. H sponsored a very informal meet-and-greet happy hour which I admit I didn’t really advertise to any extreme. (I think I was a little reluctant from a “who’d care about meeting me” perspective.) While I didn’t think anyone would show up, actually a nice little smattering of folks made it by, some friends, some now-friends, and I learned some good stuff and had some great chats (despite feeling like warmed-over death from the bug.) Thanks, Mr. H … and thanks to all who stopped by.

From the (pediatric) trenches …

“I believe in equality for everyone, except reporters and photographers.” – Mahatma Gandhi

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 through http://madisonpediatric.com or doc@madisonpediatric.com.

An HIT Moment with … Jonathan Phillips

An HIT Moment with ... is a quick interview with someone we find interesting. Jon Phillips is managing director of Healthcare Growth Partners, LLC of Chicago, IL.

What economic and market conditions have most affected vendors in the past year and how does the next 12 months look?

Fundamentally, vendors are indirect victims of the challenges facing their customers. Hospitals have seen access to capital disappear, operating results worsen (due to reductions in elective volumes and increases in Medicaid and self-pay/uninsured visits) and dramatic declines in investment income (which helps to fund operations).

Physicians are seeing operating pressures as well, not to mention the indirect impact of declines in value of real estate and other investments and the effect that has on their ability and willingness to spend. Insurers and suppliers remain profitable, but have become quite cautious as the healthcare reform debate works its way through Washington.

As a result of this pressure on customers, vendors are feeling significant stress related to their financial performance. The capital markets see it differently — HCIT valuations are at or near all-time highs as public investors assume that ARRA-related stimulus spending will drive billions in revenue to vendors in the space. At some point, the capital markets expectations will have to meet the reality of customer spending, or customer spending will have to dramatically accelerate to meet capital markets expectations.

The good news is that we are hearing customer purchasing trends are starting to look up, particularly on the physician side of things. However, given the fact that ARRA actually froze much of the market this year as purchasers have been waiting for clarity, our sense is that there is still a long way to go for vendors to feel that they can achieve strong sales growth.

Spending will likely improve across the board in 2010 with solutions demonstrating clear ROI leading the way. Physician sales of EMRs and related capabilities will continue to be strong as practices position for stimulus benefits. Hospital solutions, payer solutions, and supplier solutions are likely to see cautious growth next year as the implications of any healthcare reform package are weighed with regard to how the new environment will impact IT requirements.

We still see strong interest in “pay as you go” models, providing opportunities for providers to acquire systems capabilities while managing upfront capital outlays. While those types of models seem to be spurring sales, many vendors struggle when making the shift to that type of a model since, absent some type of third-party financing, the “pay as you go” model can wreak havoc on the balance sheet of a company used to selling perpetual licenses.

What will drive the M&A market this year?

The M&A market for the balance of this year and into next will be driven by two main trends. First, you will see an increase in the number of distressed transactions. We look at distressed transactions as ones in which the seller is effectively forced to consummate a transaction, generally due to liquidity (i.e. the company is running out of cash).

We expected the distressed market to pick up sooner than it has, but a number of factors have impacted that part of the M&A market. First, with the potential stimulus spending hanging out there, investors have been willing to continue to fund companies operating at a loss in hopes that revenues will pick up and profitability will be achieved in the near term. Unfortunately for many of those companies, revenue growth will recover, but too slowly for them to reach profitability in a reasonable period.

Second, many companies aggressively cut costs late last year and early this year to extend their financial runway. There is not a lot more “fat” for them to be able to take out of their businesses. The result of these two factors is that a number of companies will likely be at or near the end of their financial runway over the next six months. The closer a business gets to that point, the less leverage it will have in its sale negotiations. As a result, we expect distressed deal volume to pick up.

The second main trend relates to investor expectations versus reality. Because of all of the hype surrounding the stimulus spending on HCIT, healthcare IT stocks have rallied, in many cases to their all-time highs. However, if you look at the results being delivered to date (we’ll see if Q3 continues the trend), revenues have been soft, and earnings improvements have been driven by expense reductions. From our perspective, there is a gap between what the markets expect healthcare IT companies to deliver in revenue growth and what they can deliver organically in the short and mid term.

All of the stimulus talk has actually extended sales cycles, and even as the purchasing environment improves, it will take time for bookings to translate into revenue. Therefore, you will see public and larger private HCIT companies looking to acquisitions to augment their internal growth rates.

What companies need to be bought and which companies need to buy someone?

As we mention above, larger companies facing the reality of their sales efforts will need to buy revenue to augment their organic growth. These targets will most likely fall into two categories — share buys and technology buys. Share buys are situations where the acquirer cares little about the target’s capabilities. They are primarily interested in their customers and the opportunity to either up-sell or cross-sell those customers new solutions. Technology buys are intended to broaden an acquirer’s capabilities, using the acquirer’s distribution reach to push a strong product out to a broader customer base.

In terms of companies needing to be bought, if a business has less than six months’ cash on hand, they should be aggressively pursuing an exit, whatever products and solutions they offer. Often we see businesses waiting, hoping that they will be able to raise money or that the market will quickly improve. When those hopes fail, the outcome is generally far worse for employees, shareholders, and customers than it would have been if the business had elected to pursue an orderly exit process rather than an accelerated distressed sale.

If you were launching or buying a start-up, what niche would you go after?

We’d go after a “lowest common denominator” physician-focused EMR that qualifies for meaningful use and that is seamlessly integrated into a physician’s workflow. This type of a solution would likely be a hybrid offering, providing for electronic documentation and order entry but doing it in a way (perhaps with scanning or e-forms) that works with existing clinician workflow. The solution would be priced very aggressively on a subscription basis and would be offered as a Web-based service. We think that a simple offering like this would have the chance to revolutionize the market by being rapidly adopted by small physician groups.

What kinds of vendors will benefit most from stimulus money, both in the short and long term?

Depending on how meaningful use is defined, vendors most likely to benefit are those that help providers qualify for incentives at the lowest cost.  We also see incumbent HIT vendors in hospitals benefitting as they can help shape hospital spending to hit compliance levels.

The other group that is definitely seeing growth is the consulting side of the business- it seems that many organizations are looking to consultants to help them plan their approach to become meaningful users. Those consultants are likely to continue to benefit as organizations implement the solutions that they recommend. However, most vendors probably won’t benefit quite as much as the markets think — “up to $19B” and “incentives” doesn’t mean that the proceeds go directly to HCIT, it just means that providers are rewarded for utilizing HCIT. There’s a big difference.

It is also important to remember that the government gives and the government can take away. We are highly skeptical of business plans built on the basis of attracting stimulus money. It is important to remember that fundamentally the stimulus incentives are being paid to encourage providers to do something that nearly everyone agrees is in the best interest of the healthcare system. As unlikely and unfair as it might seem, it would not be out of the realm of possibility to imagine a scenario where incentive payments are drastically reduced to help cover some other government shortfall.

News 10/22/09

Aprima Medical Software announces its EHR and PM systems are compatible with Microsoft Windows 7. Seems like new Microsoft updates always get everyone in a tizzy as companies figure out the nuances of the new O/S to ensure it works with the latest application software. I must say I will not be purchasing and loading the Windows 7 upgrade on the day it is released (October 22nd.) I’ll stick with Vista for now, with all the flaws I’ve already uncovered.

The American Academy of Professional Coders introduces an online ICD-10-CM code conversion tool that converts ICD-9-CM codes to ICD-10-CM codes (and vice versa). The tool is free and looks pretty easy to use, even for someone who knows nothing about coding (like me). Note that the site doesn’t provide any sort of data conversion of your existing files, but advises you which ICD-10 codes will take the place of the current ICD-9 scheme.

A Canadian medical office experiences every practice’s worst EMR nightmare: the permanent loss of patient data. Fairview Medical Clinic in Alberta loses all its electronic patient records from 2004 and 2005 when it switches EMRs. Ouch.

Here’s a great, feel-good story. Gateway EDI donates $10,420 to the Denver affiliate of Susan G. Komen for the Cure. At last week’s MGMA meeting, Gateway EDI pledged to donate $5 for every attendee who allowed the company to swipe their card. Because attendance numbers were down over last year, card swipes also fell 17% from last year. So, Gateway threw in some extra money to help a great cause.

The teleradiology market is expanding slower than it was a few years ago. Off-hours teleradiology services increased from 15% to 44% from 2003 to 2007, but appears to be leveling.  The fastest growth is in small, city-based practices that don’t serve hospitals.

Perhaps the slowed growth is tied to inadequate reimbursement from private insurance, as this article suggests. Proponents of new digital and mobile technologies are encouraging new policies that “recognize the virtues” of telemedicine.

By the way, teleradiology company Virtual Radiologic upgrades its vRad Enterprise Connect product work with new mobile device and speech recognition support.

More and more doctors are saying voice recognition software is now ready for prime time. Updates to products such as Nuance’s Dragon NaturallySpeaking have made speech recognition more accurate and robust, making them an increasingly popular EMR input option.

TransforMED, a wholly-owned subsidiary of AAFP, partners with Welch Allyn to help physicians pick their EHR vendor. Even though my initial (cynical) reaction was that practices would only be directed to vendors offering connections to Welch Allyn’s devices, the offering actually looks pretty good. Welch Allyn breaks out its EHR Prep-Select Program into three tiers, based on how much help each practice thinks its need. And, the consultants have solid experience. I’d be curious to hear feedback on their services.

Epocrates announces that its drug reference will run on BlackBerrys.

University Children’s Eye Center (NJ) selects SRS’s hybrid EMR product. The Eye Center’s physicians are on faculty at RWJU and St. Peter’s University Hospital.

Nuesoft Technologies launches a new EHR offering, NueMD. It is CCHIT-certified but only for 2007 standards (why not go all the way if you are building a new product?) The EHR fully integrates with Nuesoft’s PM product to comprise NueMD Complete.

GE introduces a cool new ultrasound device it claims could become the “stethoscope of the 21st century.” The pocket-size device, which is about the size of an iPhone, includes a video screen and has an attached wand with a sensor.

E-mail Inga.