News 11/3/09

From Evan Steele: “Re: feedback to the government. The government has finally decided to listen to the physicians, upon whose participation the EHR incentives’ success depends. The HIT Standards Committee’s Implementation Workgroup launched a blog / Web site seeking feedback from practices regarding their experiences with EMR adoption, both bad and good. The results will be reported to the Committee on November 19th.” Comment here.

From Greg Anderson: “Re: flu clinic. Thanks so much for the kind link to my blog (via Chip Hart) about the H1N1 flu clinic at my wife’s practice last weekend. However, I wanted to correct two factual discrepancies. I am not the doctor — my wife (Susan Kressly, MD, FAAP) is. And, 18 hours is the amount of staff time we expended in total across all of the activities listed to give those doses. My good faith estimate is that we accomplished the total job in 1/3 to 1/2 of the time that would have been expended in the ‘average’ pediatric practice. To me, the key takeaway for the average observer is ‘look how much work doctors put into what seems like such a simple act, and look how little they get paid for this effort.’” Greg sent over another link that detailed an additional flu clinic’s activities on Halloween. The practice administered 145 flu shots to 114 patients in less than three hours. Based on what insurance is reimbursing, Greg calls the shot clinic a labor of love, and not a way for a pediatrician to get rich. He also adds, “Without an EMR, it has all the makings of a financial disaster, which is why some pediatric practices have elected not to participate in distributing this vaccine.” And, my apologies to Dr. Kressly (the witch in the picture above) for getting her title wrong last post.

Drummond Group, an interoperability test lab, announces that it will apply to become an EHR certifying body once ONC releases its requirements. I think mixing things up a bit and giving CCHIT some competition isn’t a bad thing. Of course it will lead to criticisms that one certification body is superior to the other and the bigger players will feel compelled to get multiple certifications jut to cover their bases. Will other entities step forward announcing they, too, intend to be a certifying body? Could be fun to see what unfolds.

With everyone focused on EMRs and how to obtain stimulus funds, practice management systems have taken a back seat. However, here’s a reminder of some of the basics that every PM system should include. The biggest question most practices likely have is whether to stick with one vendor for EMR and PM or go a best-of-breed approach. I have a bias to the one-vendor approach, primarily because it reduces interface costs and issues that can arise each time one or the other product needs to be upgraded. This AMA article also points out that providers should budget time and money for major hardware and software upgrades every three years, which I think is a wise suggestion.

Quality Systems’ Q2 numbers: revenue up 22%, EPS $0.41 vs. $0.37, meeting expectations on earnings and exceeding on revenue. ARRA is accelerating PM/EMR sales, the company says. Market cap for the company, including its QSI and NextGen divisions, is at $1.74 billion, of which founder and chairman Sheldon Razin holds over $300 million worth.

Athenahealth reports Q3 numbers: revenue up 37% to $49 million, EPS $0.14 vs. $0.14, missing expectations of $0.16.

Speaking of athenahealth, I hope you had a chance to check out our overview of athenaClincals. Dr. Gregg Alexander, John Smaling of Vitalize Consulting, and I had a one-hour peek at the product and provided some of our impressions. Our goal was to go through the same general product overview that athenahealth would provide for a  prospect, then comment on what we saw. It was not intended to be anything more than that, and thus did not include any detail on support, company background, client testimonials, etc. Our intent for this and and future overviews is to let people know what we perceive as the product’s strengths/weaknesses based on what the vendor shows us. Since it was our first one, I would appreciate your feedback. A couple of companies have stepped forward indicating they’d like to participate in our next review, so stay tuned. A special thanks to Gregg and John for their time participating in the demo and providing their impressions. Thanks also to the athena folks, who didn’t really know what they were getting themselves into when they agreed to participate. Incidentally, athenahealth is not a HIStalk or HIStalkPractice sponsor and did not provide us any sort of remuneration.

McAllen, Texas once again makes healthcare headlines. The area’s largest hospital system agrees to pay the federal government $27.5 million to settle allegations that it paid doctors illegal kickbacks to refer patients to its facilities. The government claims that South Texas Health Systems disguised payments to doctors in a series of sham contracts that included medical directorships and lease agreements.

Half of the doctors responding to a British survey say they are too busy typing into the computer to look patients in the eye. One doctor said, “The demands of the patient’s agenda, the Government’s agenda and the requirement that everything I hear, say and do must be meticulously recorded make for an extremely crowded consultation.”

HHS issues an interim final rule that increases penalties for HIPAA violations. The maximum individual penalty for civil violations jumps from $100 to $25,000 and the penalty cap grew from $25,000 to $1.5 million. Will The National Enquirer appeal?

Ambulatory healthcare clinics have had a total of 63 mass layoffs through the end of September, which is eight less than all of 2008. A mass layoff is defined as when at least 50 workers lose their jobs.

Score one for EHRs. CMS announces that in 2010, providers will be able to submit e-prescribing usage through qualified EHR systems or registries. In the past, providers were required to report e-prescribing based on patient medical claims. Providers will also be able to use their EHRs to report PQRI data. Next year’s payments will increase from 1.5% of total estimated allowed charges to 2%.

E-mail Inga.

A Quick Peek at … athenaClinicals

Readers often ask us for our insights on various HIT products. Though we would like think we are experts in all things HIT, the truth is there are far too many applications out there for us to provide in-depth opinions on them all.

However, in our constant quest for knowledge, we decided it would be fun to take a quick peek at a few products. The folks at athenahealth were gracious enough to serve as the guinea pigs for this first review and did a demo for us. Our instructions to athenahealth were to provide an overview of their athenaClinicals product in about an hour’s time. We did not advise them in advance what specific areas we would be evaluating (which in hindsight, perhaps we should have). Because of time constraints, we did not have a chance to go as in-depth in some areas as we would have liked.

In addition to Inga, we asked a couple of industry experts to participate in the demo and provide their feedback. Our gurus included:

Dr. Gregg Alexander, who regularly writes the Intelligent Healthcare Integration columns for HIStalk Practice. Gregg is a self-described grunt-in-the-trenches pediatrician and geek.

John Smaling, an executive VP of strategic business development for Vitalize Consulting Solutions. He’s been in IT for almost 20 years, including stints at Paoli Memorial Hospital and Synexus Incorporated (which later merger with Daou Systems.) He’s also a hot commodity on the speakers’ circuit for events such as CHIME, HIMSS, and CIO Forums.

Note that the evaluation format we used was roughly based on the EMR Evaluation Tool originally designed by California’s Healthcare Foundation.

The lovely folks above are not really us, but we liked their use of scoring paddles. We actually used a 5-point scale for our ratings, with five representing the top score. Note that, in the interest of objectivity, we allowed athenahealth to look over the full review before it was posted and any points they felt were important.

If you would be interested in our reviewing your HIT product (preferably an EHR,) drop us a note.

Without further ado:

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Overall functionality of product

Gregg: 5 – I felt the system flowed smoothly and enabled “chart jumping” – moving from section to section or page to page. I absolutely loved their “Prior Visit Tab.”

John: 5

Inga: 5 – Seems pretty intuitive where to look to find different areas of the chart

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Ease of documenting the visit and clinical decision-making process

Gregg: 5 – They have made great strides on their clinical side in regards to exam note or other document handling. The use of information “buckets” was intuitive and easily understood.

Inga: 5 – The system uses a lot of drop-down tabs that appear comprehensive and easy to use. A number of things are “auto-populated” into the chart, such a Surescripts data, lab results, and vital data (if interfaced with Welch-Allen).

John: 5

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Ability to identify clinical issues by means of alerts and reminders

Gregg: 5 – As someone who has had a long penchant for office design and the interactions between design and workflow enhancement, I the ability to time each step in the care process is flat out hot. Also, athenahealth’s use of highlighting for various items and functions during the documentation process was simple, but effective. They helped provide focus being neither distractive nor overly intrusive. Their use of multicolored “flags” was also functionally useful.

Inga: 5 – Since athena is paid as a percentage of collections, they are obviously interested in incorporating tools that ensure patients return, and that the practice follows care protocols to ensure maximum reimbursement.

John: 5 – I particularly like the feature that times each step of the care process and earmarks opportunities for workflow improvement, based upon comparisons with the rest of athenahealth’s customers. This is a particularly effective capability and is a major contributor to their client’s attainment of a 1% increase in visits post-implementation.

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Clinical support functionality

Gregg: 5

Inga: 5 – Includes use of First Databank. Since athena hosts the application, they can upload updates weekly.

John: 5 – Can have links to external knowledge sources such as Wolters/Kluher.

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Prescription capabilities

Gregg: – 5 – Didn’t see (or don’t remember) if they can do weight-based dosing, something all pediatricians need with virtually every prescription.

Inga: 5

John: 5

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Orders management, including interfaces with ancillary services

Gregg: 5 – Perhaps it is my small practice perspective, but as their percentage of collections fee for services is so reasonable, I found their handling of interfaces impressively 2009-ish, something I cannot say for a lot of systems.

Inga: 4.5 – I agree with both John and Gregg here. Is there a point that it is not cost-effective for athena to provide this? However, at this point it appears they are committed to providing and maintaining interfaces.

John: 4 – Interfaces are “built in” to the system, but the number and types of interfaces are factored into the monthly % of collections fee. As a consequence, they aren’t truly free. It is also unclear as to athena’s capacity to feed ambulatory transactions to a centralized repository to establish a longitudinal record inclusive of acute care episodes. Additionally, it would be interesting to understand how they would handle interfaces in the event that a major IDN purchased the product. In this case, they may have hundreds of pharmacies, 10’s of reference labs, and other 3^rd party billing firms or other participants that would require an interface. Where is the limit and what could the cost truly reach?

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Electronic communication capabilities with colleagues/patients

Gregg: Unknown.

Inga: Not covered

John: Unknown…this capability was not covered in the demo.

Athenahealth comments: athenaCommunicator provides not only patient portal functionality but a back office service that is fully integrated with athenaCollector and athenaClinicals to provide outbound calls to patients as well as electronic interactions. The portal provides for secure messaging between patients and providers and provides consumer friendly health information. It also connects with mainstream PHRs such as HealthVault.

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Coding capabilities

Gregg: Not covered in the demo but with athenahealth’s tremendous reputation for the practice management side of things, I’d be inclined to think they have a targeting lock-on engaged for these issues,

Inga: Not specifically addressed, but athena doesn’t get paid unless the practice does; I would assume they have this covered pretty well. They do/will monitor whether or not physicians are doing all steps required to qualify for meaningful use.

John: Unknown…this capability was not covered in the demo.

Athenahealth comments: athenaClinicals is natively integrated with athenaCollector. Charge integration capabilities allow for translation of documented orders and procedures into CPT codes. Details of the visit translate into an appropriate E&M code for billing purposes via an integrated E&M calculator.

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Compliance with rules and regulations on privacy, consent, etc.

Gregg: If I’m remembering clearly, we touched on HIPAA, but didn’t do the detail

Inga: Not covered.

John: Unknown. This was not covered in the demo.

Athenahealth comments: athenaNet, athenahealth’s centrally hosted national platform which houses all products is 100% HIPAA compliant and has been since 2003. We also have additional SAS70 Type 2 certification of our network. athenahealth is a covered HIPAA entity.

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Aggregate individual data into longitudinal records for easy viewing and graphing

Gregg: 5 – Well done here

Inga: 5 – Graphs, etc. can be created on the fly. Pretty extensive capabilities.

John: 5 – Solid capabilities here inclusive of the ability to annotate in conjunction with the graphs

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Ability to manage the individual patient’s chronic diseases and conditions

Gregg: 5 – I really appreciated some of the “look-back” abilities of the system.

Inga: 5 – Again, an area that athena is likely focused on as they help doctors with P4P programs, achieve meaningful use objectives, etc.

John: 5

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Standardize disease management goals for subgroups of chronic disease sufferers within the practice

Gregg: Not covered, but I have suspicions they may have skills here cultured from their strong PM management tools.

Inga: Not discussed

John: Unknown. This capability was not covered in the demo

Athenahealth comments: We are set to launch by the end of 2009 a global P4P rules engine and service offering whereby the physician will be notified in real time of disease management information and data capture requirements. Athena specialists will enroll providers and will help monitor and submit data on behalf of physicians as part of this service. Unlike guidelines in traditional software systems, athena’s service team can monitor and inject rules into the workflow as part of this new service and which are available to all clients on the network at no additional charge.

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Ability to query the system’s database to produce both individual and group reports on clinical issues — care, quality, outcomes, and associated costs

Gregg: Unknown.

Inga: Not covered

John: Unknown. This capability was not covered in the demo.

Athenahealth comments: Related to the P4P service offering, athenaClinicals includes population management reporting in addition to its existing suite of reports and reporting tools enabled by athenaCollector.

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Ability to conduct research, registry, and clinical trial-related efforts

Gregg: Unknown.

Inga: Not covered

John: Unknown. This capability was not covered in the demo.

Athenahealth comments: Athena is in the process of becoming a PQRI registry for submission of data to CMS.

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Incorporate information originating with the patient and, as a separate matter, with medical or patient devices

Gregg: I have a different take than John does, but I don’t know if it derives from this demo or another discussion I had shortly after this with another athenahealth rep during an unrelated interview. Their patient portal features are quite solid.

Inga: What is clear is that they have tools to input information not specifically generated from the chart note. Faxes are directed straight to athena and practices forward other data to athena for input.

John: Based upon the information covered in the demo, they are proficient at handling faxes and scannable content, they adhere to an HL7 standard, so feeding an industry leading portal/data aggregation product appears to be feasible. However, their inherent email capability wasn’t covered and I’m unclear as to the capability.

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Usability and ease of inputting data using a variety of methods, e.g. keyboard/mouse, touchscreen, dictation, voice recognition, handwriting recognition

Gregg: 4 – I’m going to say 4 of these methods for sure, but I’m thinking they might hit all 5. They mentioned voice recognition, but I’m not sure about handwriting recognition.

Inga: 5 – They mentioned all these areas

John: Keyboard and mouse, but also I only recall them mentioning an ability to support light pen in addition to keyboard and mouse

Athenahealth comments: Yes we offer handwriting recognition, voice recognition, paper documentation, and transcription support for the provider.

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Ability to customize capabilities to suit personal workflow preferences

Gregg: 5 – Demonstrator seemed comfortable with ability to customize, though taking the word of any EHR sales/demo guy can be a risky naiveté!

Inga: 5 – The indication was that pretty much every screen/template/process can be customized by user

John: 5 – Time did not allow for a deep dive into the customization capabilities of the product, but the demonstrator appeared very comfortable with the level of forms customization, screen flow, and other tailoring features of the app

Athenahealth comments: While athenaClinicals allows for customization we also leverage the knowledge and experience of our entire network to provide out of the box best practice configurations to optimize clinical workflow, speed of implementation and reduced cost of implementation and overall longterm ROI. We recently launched a five-stage patient encounter UX that integrates the patient visit workflow across Collector and Clinicals. This was launched to 100% of our Clinicals users overnight.

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Screens are easy to interpret  (menu categories, graphics, icons, and symbols)

Gregg: 5 – Though I initially thought the EMR appeared rather bland, their excellent use of white space, minimization of lines, rows, and columns, and their deft use of color for highlighting and focus won me over after a while. Flags, warnings, buckets, highlights, and chart-jumping were clear and easy to follow. Pop-ups signaling patient movement were nice. If we had a “4” ranking, I’d go with that as I still think some more color or perhaps some user customizable skins for individualization would be optimal.

Inga: 5– Personally I liked the fact the product isn’t overly “flashy.” Too much color and pop-ups can be confusing. The graphics and icons were intuitive.

John: 5

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Integration with practice management systems and claims processing services

Gregg: Clearly 5

Inga: 5 single database for PM/EMR

John: 5

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Access the EMR system remotely; ability to use a mobile devices

Gregg: Uncertain

Inga: Clearly can access the EMR remotely but we didn’t touch on its use via a mobile device

John: Unknown. This capability was not covered in the demo.

Athenahealth comments: athenaNet is the only centrally hosted web native platform, meaning that it was specifically designed to be accessed anywhere at any time over the internet. All of our services, including athenaClinicals, are delivered via this web based platform.

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Process, exchange, and store graphics and images

Gregg: – 3 – I’m going to grant a 3 here as our discussions on fax/chart/paper document scanning leads me to feel comfortable that imaging issues are probably well-considered, but I cannot verify PACS/RIS nor DICOM from our demo.

Inga: – 3 ditto Gregg’s impressions

John: Unknown. This capability was not covered in the demo.

Athenahealth comments: athenaClinicals will easily interface to a RIS/PACS system so that images can be launched in those systems in the context of the clinical visit or image review process.

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Overall Impressions on functionally, intuitiveness, graphics, overall flow

Gregg: 5 – From the grunt in the field level, athenahealth should be near the top of the EHR consideration list. The abilities facilitated from the practice management side are significant. The work transferable to athenahealth from the practice management side should allow office staff a much greater focus upon patient care issues. Having more folks in the office more directed upon real care issues and not business operations should be attractive to anyone who still wants to provide healthcare, not just run a business. athenaclinicals are developed enough and intuitive enough to rate a 5. (Well, technically, it’d be a rounded-up 5, but a legitimate top-ranked EHR on my scale.)

Inga: 5 – I had looked at the product a year or more ago and found there to be a number of gaps at that time (e.g., templates were not as complete.) However, the system has matured. athena’s approach may not be for everyone, but it’s fantastic for a group that does not want to have to worry about the IT “stuff,” like loading regular updates. Also, it would be great for the practice that wants to minimize in-house staff for mundane tasks like document imaging. Also for physicians who don’t want to worry about learning about all the meaningful use rules, but prefer to have someone tell him/her what is required and leave it at that.

John: 4 – Not to be difficult, but the demo was too brief to provide a thorough rating. My sense is that athena has made great strides with their product, but it may be more attractive to smaller practices or even larger groups who have no desire to invest in an internal IT capability. IDN’s may find the SaaS thrust of the product to provide a degree of constriction that they would find unattractive. Again, these are extremely high level observations and I wouldn’t stake my professional reputation on them; not that I have one to begin with!

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I would use this in my practice and/or recommend to others

Gregg: 5 – I would definitely rank athenahealth near the top of my “Overall Smokin’ EHRs” list.

Inga: 5 – John makes a good point that this model may not be for everyone. But from feature/function/ease of use standpoint, it appears very solid.

John: 4 – I would qualify this by saying that it may be a good fit for many standalone practices, but IDN owned or strongly affiliated practices may find this model a bit wanting.

E-mail Inga.

Intelligent Healthcare Information Integration 10/31/09

Meaningful Ewes

What’s all this fuss I hear about the government trying to define “meaningful ewes”? What in the world could they be thinking? Now, I’m not exactly a farm boy, but I am small town born and raised and have been on enough of my friends’ farms to know a thing or two about ewes. I think this whole conversation about trying to define the meaningfulness of ewes is just downright silly.

I mean, aren’t all ewes – be they Massese Ehrs or Elliottdale Emrs or Padova Pdf/hs – meaningful? Why would anyone buy one of these creatures to be anything other than meaningful? Goodness knows adopting even one of them creates an entirely new set of tasks and major changes in workflow around any farm. I find it hard to believe that any farmer in their right mind would spend the time and effort it takes to own one of these, no less suffer the upfront expense, if they weren’t planning on putting them to good use. Really, why would anyone buy one of them just to have them around? It’s not like they jazz up the joint just by standing around baaing and bleating.

If I had a farm and I was thinking about getting ewes on it, I can guarantee you that I would make sure they were meaningful. I would spend some time up front to make certain that whichever breed I bought had some real viability for my farm. I’d study up on how to care for my particular variety and maybe even have a professional ewe-ser teach me how best to shear so that I got the greatest yield possible from my efforts and investment.

I just can’t imagine anyone going into ewes without making sure they were doing it meaningfully. What would be the point? Just to have a ewe is a waste of money that no farmer can afford. It is, by definition, the meaningfulness of the ewes that provides the value. Otherwise, the drain on the farm’s resources and operations would make owning one counterproductive, or at the very least, improvident.

While it may take time for any farmer unfamiliar with them to learn all the best ways to keep and care for them, I firmly believe we don’t really need some governmental committee of big city boys (or girls) trying to tell end-ewe-sers how to make our ewes meaningful. Honestly, guys, don’t you think we have enough brains in our little country heads to figure that out?

Instead of offering us money if we follow your definition (if you ever figure that out) of “meaningful ewes,” why not help us up front to fill our pens with stock and have a little trust that we’ll ensure that every ewe is meaningful. What would be so wrong with…

…What?…What’s that you say?…Ooooohhh, meaningful use. Well, well, that’s a lamb of an entirely different color. Never mind.

From the trenches (with a tip o’ the sheepskin hat to Gilda Radner and Emily Litella)…

“It is useless for the sheep to pass resolutions in favor of vegetarianism while the wolf remains of a different opinion.” – W. R. Inge

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.

News 10/30/09

From Sherman’s Auntie “Re: data breach. I read your bit about CalOptima and found this article. Read carefully this line: ‘The data is used in performing internal matching analyses to compare BCBS provider networks to the networks of other health plans for employer groups’. Boy, if the docs did that, the FTC would be on them in a heartbeat! Talk about possible price fixing 10 different ways.” AMA President J. James Rohack, MD posts a note to on the AMA website, assuring members they are doing all they can to help CalOpima rectify its recent “lost claims” issue. Did he really mean to suggest BCBS is doing some price fixing?

Chip Hart sent over a link to the Office Practicum blog. Take special note of the October 23rd and 24th posts, which detail how Dr. Greg Anderson and one assistant dispensed 112 H1N1 flu vaccines AND fully documented the patients’ charts in a mere four hours. He estimates that without EHR, the same process would have taken about 18 staff hours to complete.

Whether you are or are not a regular reader, make sure you are signed up to receive automatic e-mail notifications for our new posts (see top right corner of the page). We publish HIStalk Practice 3-4 times a week.

Mednax pays an unnamed cash amount for a two-physician neonatology practice in Louisiana. The purchase marks Mednax’s ninth medical practice acquisition this year.

St. Paul Eye Clinic (MN) selects SRS EMR for its 15-provider group.

GE Healthcare’s Medical Quality Improvement Consortium (MQIC) is submitting anonymous clinical data to the CDC to provide H1N1 tracking information. MQIC is a repository of de-identified clinical data captured from GE’s Centricity EMR users. MQIC sends updated data collected from 14 million record patient records to the CDC every 24 hours. Great use of EMR data, though I wonder if the patients are aware their de-identified clinical data is being used for this purpose. Or, if they need to know.

Healthcare ratings company Health Grades reports a 33% rise in quarterly revenue compared to last year to $13.3 million. Net income grew from $1.3 million to $1.8 million.

John Tooker, executive VP and CEO of the American College of Physicians, announces his resignation. He will stay on the job until a replacement is named, likely within the next six to 12 months.

If you are looking to purchase an EMR, sell an EMR, or simply want to know more about the subject, here is a must-read guide. The Texas Medical Association, in cooperation with the Physicians’ Foundation, releases Electronic Medical Record Implementation Guide: The Link to a Better Future, 2nd Edition. The comprehensive report includes EMR readiness assessments, details on ARRA, factors to consider in the selection process, sample pricing, recommended contract wording, implementation suggestions, and more. Don’t miss this if are searching for an EMR. And if you are a selling EMR (especially if you are a newbie), this should be a must-read.

Finding a one-size-fits-all Meaningful Use definition seems to be quite a challenge for the Health IT Policy Committee. Members realize that many of the clinical and quality measures that are appropriate for primary care physicians are not applicable for specialists. So, the wait for final recommendations continues. Meanwhile, there are plenty of providers content to maintain their wait and see stance.

Coming up with recommendations for iPhone applications is definitely less complicated. Here’s nice list, complete with product summaries and pricing.

Our friends at Hayes Management just posted their fall newsletter, full of solid HIT recommendations for practices and hospitals. I checked out the article entitled  “Scanning Solutions for EMR Implementations,” which provides an extensive scanning strategy checklist, as well as guidance on different ways to organize the scanning process. If you need a chuckle, peruse the article on HIT System Selection, which includes one of Mr. H’s typically irreverent quotes.

E-mail Inga.

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.