From The PACS Designer: “Re: Microsoft’s updated BAA. Microsoft has released an update for its Business Associate Agreement to encompass more secure communications tools for HIPAA compliance. The changes provide for healthcare organizations to leverage cloud solutions to improve clinician productivity, care team communication, and care transition coordination while maintaining compliance with the recently updated Omnibus HIPAA Final Rules.”

From Laboratorian: “Re: University of Michigan. Goes live June 1 with a massive IT rollout. This includes a new Epic (Denali) implementation and a completely new LIS, an experimental version of SCC-Soft being used at U-M for the first time. The LIS rollout, in particular, is particularly audacious in scope, being the culmination of a seven-year implementation cycle. Barcode-based tracking of both tubes and surgical pathology specimens will be on par with the level of automation seen at BML labs in Japan. The spatial location of every asset in lab space will be tracked in real time. The project benefitted from co-development of code with support from U-M’s own software engineering teams. Nearly 2.5 million lines of new code above base SCC product will drive this new version.” SCC is often forgotten as maybe the leading LIS vendor for big health systems, and writing 2.5 million lines of new code is just crazy. Obviously Beaker wasn’t going to do the job for UM, although it’s improving to the point that some larger Epic customers are cautiously committing to it.

More than two-thirds of respondents think that Meaningful Use Stage 2 should be extended for a year before starting Stage 3. New poll to your right: CMS released hospital Medicare pricing information for the top 100 DRGs. How valuable is that information to the public?

Jamie Stockton of Wells Fargo Advisors sent over his monthly summary of hospital EHR attestations by vendor. Customers of the big multi-national corporations whose business is mostly not healthcare IT (McKesson, Siemens, and GE) are the clear laggards.

Just in case you are wondering what it would be like to have HIMSS darling and cardiologist Eric Topol, MD as your doctor, ponder this quote from an NBC fluff piece from January that I just ran across: “These days I’m actually prescribing a lot more apps than I am medications.” He claims that up to 80 percent of the 20 million echocardiograms performed each year could be replaced by in-office smart phone tests, saving the healthcare system $13 billion per year. In a stunning piece of investigative journalism, the on-camera talking head (also a doctor) who has clearly performed her research convinces him to eat tortilla chips and goads him into saying positive things about his own books and devices.

EHR vendor Mitochon Systems notifies its customers that it will shut down its free cloud-based EHR service in mid-June. The company isn’t sure how doctors will retrieve the data they’ve entered on patients before the system is turned off, but says it will come up with something.

Data visualization software vendor Tableau Software, whose product is popular in healthcare, raised $254 million in its Friday IPO as shares soared 64 percent. I’ve played around with it a couple of times and it’s pretty cool – there’s a free trial download on the site.

Sheila Sanders, VP/CIO of Wake Forest Baptist Medical Center (NC), will step down effective May 31. The hospital says she’s leaving the $465K job for personal reasons that are unrelated to its struggles with Epic.

 

CareWire names advisors Ken Saitow and Phil Hotchkiss as president/CEO and EVP/chief product officer, respectively.

Encore Health Resources CEO Dana Sellers was recognized Friday, May 17 as a Distinguished Engineering Alumna by the Cockrell School of Engineering at The University of Texas at Austin. She was also named Friday as a finalist for the Ernst & Young Entrepreneur of the Year for the second consecutive year.

James Holtzman is promoted from CFO to CEO of Prognosis Health Information Systems.

Terry Boch (JET Health Solutions) joins Wellcentive as SVP of sales and marketing.

Susan K. Newbold PhD, RN-BC, director of Nursing Informatics Boot Camp, is selected as one of the 2013 “Women to Watch” by the Nashville Medical News.

MD Anderson, which just announced Epic as vendor of choice, will freeze wages, cut back on hiring, and postpone construction projects, hoping to offset an anticipated 2014 financial shortfall that it blames on the federal government (the Affordable Care Act, the budget sequester, and federal deficits) even though its rapidly increasing operating expenses seem to be its primary problem.

A controversial decision by Britain’s NHS allows life sciences and insurance companies to buy access NHS’s patient-identifiable data (“bespoke patient-level abstracts), even providing companies with an Excel worksheet to calculate their cost.

Partners HealthCare System (MA) made a $133 million profit in the latest quarter even after it took a $110 million accounting charge to write off computer systems slated for replacement. Most of that came from investment income, as operating income dropped from $41 million last year to $5 million.

Vince covers Part 1 of the HIS-tory of Allscripts this week (more specifically, TDS, which passed through many hands before landing in the Allscripts lap via its acquisition of Eclipsys.) Vince also scored a major coup for upcoming episodes – he e-mailed Judy Faulkner at Epic and asked if could talk with her about the company and she invited him to meet with her in Verona, which he did last week and is still gushing about. Those are going to be some great HIS-tory installments.

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Sponsor Updates

• Carl Fleming of Impact Advisors raised $6,000 for St. Baldrick’s Foundation by having his head shaved at Impact Palooza 2013.
• Sunquest Laboratory v 7.0.1003 is certified as an EHR module by CCHIT.

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Contacts

Mr. H, Inga, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.

More news: HIStalk Practice, HIStalk Connect.

Here are a few I have come across last week. Note: Each link is followed by a title and few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment. ----- http://www.fiercehealthit.com/story/global-healthcare-it-market-estimated-reach-567b-2017/2013-05-10 Global healthcare IT market estimated to reach $56.7B by 2017 May 10, 2013 | By Ashley Gold The global healthcare IT market is estimated to reach $56.7 billion by 2017--up from $40.4 billion in 2012--due to the demand for clinical information technology, administrative solutions and services, according to a new analysis by MarketsandMarkets. ----- http://www.fierceemr.com/story/most-us-docs-use-ehrs/2013-05-10 Most U.S. docs use EHRs May 10, 2013 | By Susan D. Hall Doctors in the U.S. are embracing electronic health records, even if reluctantly, with 93 percent reporting they actively use an EHR system,...

This is the initial part of the post - read more by clicking on the title of the article. David.

256 Shades of Grey(scale): The Dirty Little Secrets of Radiology and PACS
By Brad Levin

There is widespread agreement that radiology has been the epitome of success spreading PACS far and wide over the last two decades. Thousands of organizations transformed from the dark ages of film to digital operations. Early activity started in the mid-1990s and peaked in the mid-2000s. Once the 2000s were in full swing, many groups moved to PACS for the first time, but it was relatively common for PACS early adopters to have implemented their second or in rare cases, their third PACS by then.

Along came the late 2000s, when industry analysts KLAS and Frost & Sullivan called for the next wave of PACS replacements. Many systems had aged well beyond the average 5-7 year lifespan of PACS, and it seemed like a solid market forecast. However, in reality the replacements never came in earnest. 

Fast forward to present day and the institutional use of PACS has stagnated. PACS continue to be used past their useful life, problems persist, and upgrades are delayed. The other contributing factor is a majority of institutions today are using PACS born in the late 1990s or early 2000s. Their vendors purchased PACS largely through acquisition, and while these systems have been upgraded periodically, most of the core architectures remain largely unchanged.

This would be fine if time stood still, but of course it hasn’t. Over the last two decades, modalities have advanced at breakneck speed, producing computed/digital radiography, multislice CT, PET/CT, digital mammography, and the newest modality, digital breast tomosynthesis (or 3D mammography).

Modern technology has also dramatically changed consumer and physician expectations. Everyone expects instant gratification. Pay phones are extinct and we all use smartphones. The world is app-driven and tablet accessible. LPs/CDs have been replaced with MP3s. Medicine is mobile, and we’ve ditched our VCRs/DVDs for streaming media.

Today’s challenging healthcare environment, supported by yesterday’s PACS technology, has led to widespread chronic problems and missed opportunities. When I was told recently that some of the most senior leaders in imaging informatics had convened and were discussing how "Radiology Has Solved The Problems of Going Digital", I was stunned. Based on what I see at community hospitals, academic medical centers, IDNs, imaging centers, radiology groups, and teleradiology vendors, I know that statement couldn’t be farther from the truth.  

The vast majority of practices are digital, but are their problems solved? In my view, absolutely not. Just this week I spoke with a PACS administrator from a 400-bed hospital in the Southwest. I was told that when their network access peaks, performance gets crushed on PACS, taking up to a minute to launch even a small CR study. Radiologists launch the study on PACS, grab a coffee, and hope that when they come back they can start reading the study. While this may or may not be just a PACS issue, it is a persistent, unacceptable problem nonetheless.

If you are unaware of the state of your imaging operations, I encourage you to speak to your radiologists, referring physicians, PACS administrators, and your IT staff. You may also consider meeting with your affiliates, and plan on attending the upcoming SIIM 2013. If you tackle today’s Imaging problems with the same vigor you used to transform from film to digital, your problems will quickly go into the rearview mirror.

Brad Levin is general manager, North America for Visage Imaging.

Trade Shows: How to Make Sure You’re Heard When Everyone’s Screaming
By Cindy Thomas Wright

More than 1,000 companies exhibited at this year’s HIMSS. Did you go? If you did, can you name 10 companies and describe their trade show exhibits?

If you’re like most attendees, you can’t. Because with 30,000-plus people there and row after row of exhibits, you were probably on trade show overload.

Now let’s put you on the other side of the exhibit table. Your business is there, in a giant room filled with the hottest prospects in the world. How are you going to get their attention when you’re one in a thousand?

Well, you can’t just hit play on a PowerPoint and toss some business cards on a table. You need to engage, quickly and with impact. Here are a few points that will help you do so and can apply to HIMSS or any other trade show, such as HFMA coming up in June and AHIMA following in October.

 

Point 1

You have a brand. Bring it to the trade show. What is your brand positioning? What is your brand personality? Have you done the hard work to define who you are? Without a clear positioning, marketing is futile. You can’t tell a story that you haven’t written yet.

But if you do have your brand strategy locked down, that’s what your exhibit needs to tell the world. Throughout your trade show exhibit’s development, keep asking yourself, “Does this align with our brand?”

 

Point 2

Make sure the best people are manning your exhibit – and be sure they know their goals. Most people that you meet on the floor aren’t professional trade show folks. At HIMSS, for example, you might see people at the exhibits who are CIOs, program managers, or system developers by day, and they come to this one trade show a year. They are then tasked with “booth duty”, shall we say. 

What you see when you walk the floor is often folks looking down at their phones or a laptop, sitting in chairs meant for would be prospects, or perhaps taking a break to eat their lunch. Let’s face it, are you really going to approach anyone whose obviously eating lunch? Or who has their hands in their pockets or are busy texting? These are all issues that need to be addressed prior to the show. Be sure your representatives are outgoing, have their messaging perfected, know how to “triage” exhibit visitors and how to get them to the right person, and most importantly, be sure they know how to make everyone feel welcome and engaged.

 

Point 3

Don’t forget that you’re all about technology. We’re in the tech business. So don’t fire up your seven- year-old MacBook at the exhibit. And don’t click through a PowerPoint that looks like it was designed in 1989.

Look at the people manning the booth – do they look “modern”? Are they wearing shoes and eyeglasses from this millennium? Remember, everything you put out there has to be clean, polished, high-tech, new and smart. Because that’s what your company is, right?

 

Point 4

This isn’t just about you. It’s about them. So many trade show exhibitors see this as their chance to tell everybody all about them. But remember, people are looking for solutions to their own situation. Find out what people need, and show them how you can fill that gap. Trumpet your solutions in a way that’s interesting, but tangible.

Cindy Thomas Wright is the owner of Thomas Wright Partners.

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in November 2008.

If EMR Vendors Designed Cars, the Steering Wheel Could Be Anywhere: Why a Universal Physician Interface Makes Sense (and will never happen)
By Mr. HIStalk

I used to work in a two-IDN town. In fact, I had worked in the IT department of both of them (not at the same time, unfortunately, since that would have been a sweet paycheck).

Both IDNs bought big-ticket inpatient clinical systems within a few months of each other. Those who have worked in a two-hospital town or remember the Cold War understand this instinctively.

As inevitable as it was that rumors of one of us buying a system sent the other scurrying to draft an RFI, it was preordained that we would not consider the same vendor. Whichever IDN bought last would look like an unimaginative lemming, so there was no doubt that two vendors would be shuttling people into town for years.

I was shocked that the local newspaper not only cared about our respective deals, they took both IDNs to task in a rather scathing editorial for going our separate ways. In their minds, we had blown a golden opportunity to finally agree on something other than the fact that one of us was a plainly second-tier system (which one was another thing we didn’t agree on).

From a community perspective, they were probably right. Both places served mostly community-based physicians who practiced in hospitals of both IDNs. Our ruggedly individualistic decisions meant that most of the doctors in town would not only have to learn to use an EMR to keep in our smothering good graces (since ROI was dependent on massive, yet unlikely voluntary physician usage). They would have to learn TWO systems with nothing much in common except they both had a screen and a keyboard.

(That allowed us both to argue that we had chosen a better system than our cross-town loser competitors. In addition, there were only three real vendors that would have been acceptable and one of those was a little shaky at the time, so we went out of our way to avoid consensus).

Vendors would never object to this, of course. Software that looks and works alike has a name: “commodity.” In that respect, vendors had as much interest as we IDNs did in bucking the trend set by our competitor or vice versa.

Here’s an interesting idea, though. Why couldn’t CPOE and EMR systems have the same common user interface? They provide and accept the same basic information. Are screens really so highly proprietary and ingenious that they can’t be the same on all systems? Couldn’t they put their high-margin secret sauce somewhere else, like in clinical decision support, scalability, cost, or maintenance quality?

(You could almost make this happen in the old character-based days by using screen-scraping applications to redesign the front end, like Attachmate or programmable fake Windows front ends).

Everybody always says, “You can use a browser without reading a manual first.” As annoying as that statement is, everybody is right. Browsers, cars, TVs, and credit cards all look and work pretty much alike to the user. That increases adoption, yet still allows plenty of criteria on which vendors can compete and differentiate.

Physician systems operate under the most bizarre paradigm of any software application. The organization that buys them isn’t the one using them, for the most part, since doctors are self-employed (unlike pharmacists, rad techs, nurses, etc. who practice in just one place using just one system). Usage is voluntary and therefore sporadic. Those voluntary users (who are really our customers) are supposed to deal with it, show up for training, and read ongoing messages about bugs, upgrades, and downtime (times two or three, depending on the town).

If I were HIT King for a Day, my second decree (after putting a spending cap on HIMSS exhibits) would be this: every system intended for physician use will employ a common user interface whose visible appearance, terminology, and user interaction is fixed. Vendors who fail to comply will have their kneecaps broken by CCHIT.

What vendors do behind the scenes is their own business, but when you’re selling cars, no matter how clever your designers are, the steering wheels and pedals need to be in the same place if you want to move iron.

Have you considered what an EMR would look and feel like if it integrated telemedicine? Rashid Bashshur, director of telemedicine at the University of Michigan Health System, has given the idea a lot of thought.

In an interview with InformationWeek Healthcare, Bashshur tells IW’s Ken Terry that it’s critical to integrate HIEs, ACOs, Meaningful Use and electronic health records.

Makes sense in theory. How would it work?

To begin with, Bashshur said, healthcare providers who have virtual encounters with patients via a telehealth set-up should create an electronic health record for that patient.  The record could then be ported over to the patient’s PHR.  The physician can also share the health record via an HIE with other providers.

When providers attempt mobile and home monitoring, it steps the complexity up a notch, as such activities generate a large flow of data. The key, in this situation, is to use the EMR to sensitively filter incoming data.

Unfortunately, few EMRs today can easily pinpoint the information providers need to process, so most organizations have nurse care managers sift through incoming monitoring data. That’s the case at University of Michigan Health System, where care managers sift data manually to determine whether patients seem to be seeing changes in their conditions.

Unfortunately, even attentive care managers can’t catch everything a properly-designed system can, Bashshur notes.  To integrate EMRs and telemedicine/remote monitoring, it will be important for EMRs to have sophisticated filters in place which can pinpoint trouble spots in a patient’s condition, using a standard protocol which is applied uniformly.

According to InformationWeek, vendor eClinicalWorks has promised a new feature which can pick out relevant data from a large data stream. But until eCW or another EMR vendor produces such a feature, it seems that remote monitoring will be labor-intensive and expensive.

Judith Faulkner, founder and CEO of Epic, is warming up to the media according to an interview in Forbes by Zina Moukheiber (see: An Interview With The Most Powerful Woman In Health Care). Here's the reason that she offers in the interview:

I’m recognizing that when we were small, we could stay under the radar, but now it’s harder. I get so many requests for interviews. If I talk to everyone, we can’t do our job with our customers and work on our software. It would be hard to stay focused.

Here's one of the many reactions to the piece by David Shaywitz, also of Forbes (see: Two Quick Reactions To Epic Faulkner Interview: SV Should Show Judy More Love; We Should Shouldn't Let Hospitals Off Hook)

Interoperability issues associated with Epic may reflect tacit preferences of hospital systems.  Tory Wolff and I have discussed the interoperability challenges associated with Epic, and it’s potentially negative impact on the innovation ecosystem (see here and here).  Faukner’s comments don’t particular assuage my concerns, but certainly highlight Epic’s laser-focus on delivering what customers want – and make no mistake, the customer isn’t the patient but the hospital.  This is critical to appreciate.  Thus, while it’s easy (and appropriate) to critique Epic for impeding data sharing, it’s probably also important to remember that if hospitals were all that keen to share data better, I suspect Epic would rapidly find a way to accomplish this. It’s almost as if Epic provides hospitals with plausible deniability.  While it may be convenient to blame EMRs in general, and Epic in particular, for data access challenges, I suspect we also need to dig deeper, and hold hospital systems themselves far more – what’s the word? – accountable.

I couldn't agree with Shaywitz more. In fact, here's a quote from my note of September 14, 2011 (see: Judith Faulkner, EMR Interoperability, and Washington IT Politics)

Now comes a little secret that is not discussed much. Hospital CEOs and CIOs have little interest or enthusiasm for multivendor interoperability, either within their hospitals or hospital systems or across the outside hospital systems that they compete with. Customized interfaces between heterogeneous systems are a pain in the rear-end for the CIOs. They would thus rather have shrink-wrapped integration delivered by a vendor like Epic, the so-called "enterprise solution." Moreover, CEOs don't want to encourage broad patient and clinical data portability because it gives the payers (insurance companies and the federal government) a strategic advantage during negotiations about reimbursement.

So, when the feds raise the topic of interoperable EMR software, most hospital CEOs and CIOs will stand up and cheer. However, when they go out to purchase EMR software, they largely select Epic, particularly the larger ones that can afford it. Faulkner provides the non-interoperable product that they really want. She can also runs political interference for them. She donates generously to the Democratic party, she is tight with the Wisconsin congressional delegation, and takes no prisoners in her political feuds (see: Epic Flexes Its Political Muscle in Wisconsin with Boycott). And she can now try to block any inconvenient initiatives in the arise in the Health Information Technology Policy Committee.

Epic will provide some measure of interoperability to her hospital clients but slowly and most efficiently among Epic client hospitals. This is what her hospital clients want and this is what she will give to them. Here are the (slightly garbled) Epic "rules of the road" in terms of working with other HIT vendors, quoted from the Forbes interview:

We don’t let anyone write on top of our platform, come read our code and study our software. I worry about intellectual property at that point. With our customers, we make sure we have signed agreements. They know they have to respect our software. Customers can do it in a controlled environment, but not the whole world. You’ll see us do more and more of that.

There was another press release from another part of the Government that was relevant this week. Joint media release Mark Butler MP Minister for Mental Health and Ageing Senator the Hon Stephen Conroy Minister for Broadband, Communications and the Digital Economy Leader of the Government in the Senate Minister Assisting the Prime Minister on Digital Productivity NBN to pilot new models of health care for 2500 patients The Gillard Government is providing $20.3 million to nine cutting edge telehealth projects that will use the National Broadband Network to pilot new methods of health care delivery. “These exciting initiatives will help demonstrate how important high-speed broadband is to the future of healthcare and highlight why it should be rolled out to all Australians,” Senator Conroy said. The projects, to be implemented by some of Australia's leading healthcare and research organisations, will reach around 2500 patients in 50 NBN communities, and include: The CSIRO...

This is the initial part of the post - read more by clicking on the title of the article. David.

I now present the latest health IT-related podcast from Sivad Business Solutions, an interview with Suzanne Leveille, research director of OpenNotes, a project to give patients online access to the entirety of their own medical records, including the visit notes from clinicians. Leveille describes a trial at Beth Israel Deaconess Medical Center, Geisinger Health System in Pennsylvania and Harborview Medical Center in Seattle. She reported that not one of the 105 participating physicians asked for the access to be shut off after a year. In some cases, patients even discovered errors and prevented adverse events.

Here is the description from Sivad:

A pleasure to welcome Suzanne Leveille to the program today. Suzanne is a professor of nursing at The University of Massachusetts-Boston, and the research director for OpenNotes.

OpenNotes is an initiative that invites patients to review their visit notes written by their doctors, nurses, or other clinicians.

As a patient, you have the right to read the notes your doctor or clinician writes about you during or after your appointment. Having the chance to read and discuss them with your doctor or family member can help you take better control of your health and health care.

As a healthcare professional, you may build better relationships with your patients and take better care of them when you share your visit notes. Our evidence suggests that opening up visit notes to patients may make care more efficient, improve communication, and most importantly may help patients become more actively involved with their health and health care.

Some highlights from the conversation include: the dramatic improvement between patient and doctor communications; how they overcome potential push back and resistance from physicians; patients became more engaged in their personal health care; OpenNotes has been pleasantly surprised at the patient engagement; how advanced technologies and mobile technology are going to impact the future of this idea; and how they are planning to spread the word and get more patients and doctors improving communications and care with OpenNotes!

 

HHS Secretary Sebelius announces Senate confirmation of Marilyn Tavenner

The US Senate today confirmed Marilyn Tavenner as the new CMS administrator, making her the first to be confirmed to the position in over nine years.

Hospital can’t afford EMR contract, Assembly rejects funding request

City assemblymen from Juneau, AK rejects an $8.5 million budget request to pay for an already-signed Cerner contract for Bartlett Regional Hospital, saying that they were never consulted on the contract prior to its signing and that the $1.15 million in annual maintenance fees is more than they are willing to pay.

Health Care Innovation Awards Round Two

CMS announces Round Two of the Health Care Innovation Awards which authorizes up to $1 billion in awards to help fund innovative projects that will help deliver better care at a lower cost.

Marin General Hospital nurses warn that new computer system is causing errors, call for time out

Unionized nurses at Marin General Hospital are asking administrators to put its Paragon CPOE implementation on hold until glitches can be ironed out, claiming, "Orders are being inadvertently passed to the wrong patients. People have gotten meds when they’ve been allergic to them. This is dangerous.”

I recently learned about the concept of a lab formulary, an analogue of the pharmacy formulary. The latter is a list of the stock drugs carried by the pharmacy in a hospital. Prescriptions for hospital patients can only be written by physicicans for the drugs listed in the formulary. The comparable notion on the lab side is that only tests contained in the lab formulary can be ordered by physicians. Here is an article that describes the concept in greater detail (see: Constructing A Lab Formulary). Below is an excerpt from it:

Given healthcare's increasing emphasis on cost control and quality measurement, laboratorians need to reconsider their roles within healthcare organizations. A lab that provides what appears to be a commodity service may be at risk of being marginalized at best or outsourced at worst. But a laboratory that plays a highly visible role in promoting high-quality clinical care can strengthen its status within a hospital or healthcare system. One approach worth considering is to think of the laboratory test menu as a "laboratory formulary" analogous to the drug formulary maintained by a hospital pharmacy. Despite what outsiders might think, the role of the hospital pharmacy goes far beyond simply stocking drugs and fulfilling orders. For one thing, it is not feasible to stock every drug in every formulation that a physician might order. For another, it would not be in patients' best interests for pharmacists to fulfill blindly all orders they receive. 

...[T]he appropriate role of the laboratory professional goes far beyond simply maintaining analytic quality and fulfilling laboratory orders. It includes determining what test methodologies will be offered and in what forms, specifically point of care, in-house laboratory and referral laboratory. It also includes redirecting physicians when they order tests that the laboratory knows to be suboptimal....The stereotype of a lab professional, whether technologist, clinical lab scientist or pathologist, is one of an introvert who likes to hide away in the lab... But the stereotype still risks being self-fulfilling....As lab professionals find creative ways...to share diagnostic testing expertise with medical staffs, we, too, will see an increase in professional status. And more importantly, patients will benefit through more efficient and accurate diagnostic testing.

I have not heard any strident calls for the use of a lab formulary so perhaps I am stirring up controversy where none exists. One of the major drivers for the development of pharmacy formularies has been the need to switch physicians to the less expensive generic drugs to contain drug costs. If a particular generic drug is the only option available in a hospital, this goal can be more rapidly achieved. The ire prompted by such a shift from the clinicians is transferred from the pharmacist to the hospital pharmacy committee that maintains the formulary. Since there is no "generic equivalent" to lab tests, such a goal can't be used as an incentive for the development of a lab formulary.

I can envision that one major rationale for the development of a lab formulary: the desire to place some limits on the inappropriate ordering of expensive molecular and genomic tests. However, even the most expensive of these tests may be appropriate under the right circumstances. Rather than a blanket ban on such tests, it would seem more appropriate to publish the clinical criteria for the ordering of such tests and then require the approval of a pathologist when these clinical criteria are not met. In other words, publishing criteria for ordering expensive lab tests, and then enforcing them, would be a suitable substitute for a lab formulary.

EU Health Ministers, meeting in Dublin at the Ministerial eHealth High Level Conference organised jointly by the Irish Presidency of the Council of the European Union and the European Commission, today agreed a Declaration on eHealth presented by the Irish Presidency. The Declaration is aimed at prioritising the use of ICT in health among Member States to contribute to better, safer, sustainable and innovative healthcare systems for all European citizens.

Going public with her story of a prophylactic double mastectomy after testing positive for BRCA1 (a gene linked to breast cancer) via an op-ed piece in the New York Times, Angelina Jolie is clearly trying to get the message out...

David Harlow

The patient portal is becoming a really hot topic in healthcare. I think we can attribute much of the discussion to the EMR meaningful use requirements to engage with patients in a patient portal. I recently started a thread on LinkedIn based on a post by Jennifer Dennard called Opening up the Pandora’s Box of Patient Portals. The conversation in the thread was great, but David Voran, MD provided some incredibly valuable insight that I wanted to share with all of my readers. The following are Dr. Voran’s comments based on his experience using a patient portal.

Long have exploited the portal in our organization and we’ve now progressed to where the entire chart is available to patients. Can begin to list the results but here are my counter intuitive findings:
1) The more barriers a clinician erects between them and the patient the MORE work they wind up doing.
- Those of us physicians who have configured the portal to have most message types routed directly to the physician wind up answering less messages at the end of the day.
- Typically physicians will have all medication refill requests, questions about the last visit, requests for visits, etc. routed to a nurse or a pool to attempt to answer first. The majority of the time the person receiving this message can answer only part of the question and will then send a message to a physician for direction; the physician responds and then the nurse will interact with the patient; then the physician has to approve any orders or actions taken. This usually involves having the physician receive or respond in some way to 2 messages in their inbox. Those of us who receive the patient’s message directly answer one.
- Many other examples but typically those physicians who have barriers are answering or responding to 35-50% more messages than those who have no barriers.

2) The more the patient has access to the more engaged they will be and the more accurate the record will be. The patient is the best auditor of the record and will point out inconsistencies that can be corrected.

3) If the physician is the one to enroll or engage the patient. Those physicians who promote the portal will get 60-75% utilization of the portal. Those that are passive will see about 30% response rate.

4) Aggressive use of the portal will eliminate up to 8 hours of patient related phone conversations per nurse per week.

Big Day in Genomics Angelina Jolie’s very open revelation, “My Medical Choice” in the The New York Times, was brave, and a “big day for genomics”, according to Leslie Ziegler of Rock Health. Jolie, in a powerful and personal narrative, explains why she chose a preventative double mastectomy after genetic testing found the BRCA1 gene. She was estimated to have [...]

I was lucky to be asked to spend a couple of hours with a team of academics from Australia and the U.K. to explore some of the issues around the implementation of centralised National E-Health Systems  around the world - with a special focus on the U.K., Canada, New Zealand, the U.S. and Australia a little while ago. I found it very interesting that as the conversation progressed that despite the difference in starting perspectives that the conclusions reached and the perceptions of what was needed seemed to be remarkably aligned and similar. It was pretty clear from our conversation, and my own research, that there were very few, if any, top down public sector national systems that has not either failed or seemed to be heading that way. Interestingly the reasons seemed in most cases to be quite similar and to revolve around issues of the lack of any compelling value being offered by the proposed system to those who were the intended users, a considerable rigidity in approach...

This is the initial part of the post - read more by clicking on the title of the article. David.

The relevant part of the Budget is DoHA - Outcome 10. The link is here: http://www.health.gov.au/internet/budget/publishing.nsf/Content/2013-2014_Health_PBS Right at the top we read. Outcome 10 HEALTH SYSTEM CAPACITY AND QUALITY Outcome Strategy The Australian Government, through Outcome 10, aims to improve the long-term capacity of Australia’s health care system with a particular emphasis on quality and safety. To achieve this, the Department funds systemic improvement activities focused on management, performance, information, infrastructure and research. The implementation of the Personally Controlled Electronic Health Record (PCEHR) system is playing a significant role in the Government’s long-term strategy to improve the capacity and quality of the Australian health care system. The PCEHR system enables key health information to be available for individuals when and where it is needed, while ensuring that records are private and secure. In 2013-14, the Department will...

This is the initial part of the post - read more by clicking on the title of the article. David.

I posted a note five days ago about how the cost of healthcare seems to be gradually declining (see: Decrease in Healthcare Costs May Persist as Economy Revives). A reader, Ajit Alles, responded with a comment that decreasing expenditures of health my result in a lower quality of care, which I responded to in another note (see: The Correlation between the Cost of Care and the Health of a Population). He has responded to this second note with the following comment:

As follow-up, I agree that we spend way too much on end of life care, but that won't be reduced without a cultural shift. People expect miracles from medicine based on what they hear on the news and see in TV dramas. We could spend less and get better results, but people have to first start accepting that modern healthcare has limitations, not the least of which is funding. The new push for genomic healthcare is a good example of unrealistic ideas being pushed for profit. If everyone thinks that they are going to get personalized gene targeted healthcare they are dreaming! I know I'm a curmudgeon in this regard, but we first need to have good basic healthcare before we get cadillac genomics....We in for-profit medicine must share the blame for pushing "new and improved" medicine that is unaffordable and only (marginally) benefits the few people who can afford it. I recently heard of a family that wants some genomic test done on their child with cancer. The test looks at sequence variation in multiple genes and provides a "report" of very limited utility since most of the variations have no specific treatment. The test costs about $25000 and is not covered by insurance ....The family can afford to pay for this so it's being done with the encouragement of the oncologist. There are others who peddle proteomics reports to desperate patients. Enough said. This is the road to ruin.

I would like to respond specifically to his suggestion that "[those of us] in for-profit medicine must share the blame for pushing new and improved medicine that is unaffordable and only (marginally) benefits the few people who can afford it." I agree that many providers participate in "for-profit" medicine. However, the nature of the healthcare enterprise is now changing to what has been called "Big Medicine" or "Big Med" (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; The Transition to "Big Med": Need for Emphasis on Standardization and Cost; Health Systems Use Their Regional Dominance to Muscle Insurance Companies). With the rapid decline of private physician practices, many of the key decisions about the future of healthcare will be made by the federal government, large hospital systems, health insurance companies, and Big Pharma. So while we indeed have a for-profit health system in this country, most of the resources will flow from institutions like the federal government and health insurance companies to large institutions like large hospital systems. The great majority of physicians will be hospital employees. I refer to this as the institutionalization of healthcare delivery. We need to better understand the consequences of this shift.

I think that this change will have a major effect on the incentives experienced by physicians. In previous notes, I have made the point that cancer patients receive better care if the treating oncologist is salaried and does not benefit directly from selecting the most expensive treatment. This idea becomes apparent, as one example, in the treatment of ovarian cancer patients where a private oncologist is incentivised to maximize revenue from patient "chair time" whereas salaried academic oncologists seem to be more inclined in select the preferable intraperitoneal infusion of chemotherapeutic agents (see: Patients with a Cancer Should Seek Treatment in Cancer Hospitals). This is the best therapy but complicated and with lengthy patient visits. Here's are a couple of additional articles about how oncologists are compensated for additional reading (see: Will the Sequester Cause Oncologists to Lose Money Prescribing Chemotherapy?; Who Pays Your Oncologist?).

For private oncologists, the so called "oncology concession" goes to their group practice and they themselves directly benefit financially from their clinical decisions (see: The Oncology Concession Under Attack by Health Insurance Companies). For a salaried oncologist, the "oncology concession" goes to the hospital whose executives may choose to pay their oncologists the internist market salary, retaining the difference. The hospital may then choose to reward its executives at a higher level for developing a bigger cancer center (see: Cancer Business Highly Remunerative for Sloan-Kettering Executives).

I believe that health system executives will be more highly compensated and physicians will be less so as a result of institutionalization. After all, it is the executives who are making macro compensation decision and it would be natural for them to reward themselves. Moreover, these same executives will also have critical decision-making power in terms of how "new and improved" medicine is delivered. I believe that most of decisions will be based on how such care is compensated by the various institutional payers.

Agfa HealthCare's revenue remained almost stable versus last year's first quarter. Excluding currency effects, the business group posted a slight revenue increase. In the IT segment, both the Imaging IT business and the Enterprise IT business performed strongly. The segment posted strong growth figures in North America, Latin America and the North of Europe.

I don’t often turn over space on HealthBlog to other authors. An exception was during my sabbatical when Gareth Hall kindly filled in for me. Another exception is when one of my colleagues has something really cool or important to share. Then, I feel...(read more)

Last week, a number of TEDMED attendees and myself participated in a Google+ Hangout sponsored by Xerox to take a look back at our unique experiences at TEDMED 2013. The discussion included the following people:

• Markus Fromherz, chief innovation officer of Xerox Healthcare
• Benjamin Miller, assistant professor at the University of Colorado Denver School of Medicine
• Nick Dawson, chief experience officer at Frontier Health Consulting
• John Lynn, editor and founder of the Healthcare Scene blog network

We made it a really focused 15 minute discussion of the key takeaways from TEDMED. Some of the topics we discussed included: healthcare big data, multidisciplinary collaboration, citizen science, patient centered care, and a look at TEDMED topics 5-10 years from now. It was a really great discussion, and I encourage you to watch the TEDMED recap video embedded below.

Read more coverage from TEDMED from Xerox on the Real Business at Xerox Blog and follow @XeroxHealthcare.

The question was: What Do You Predict Will Be The Fate of E-Health Funding In The Upcoming Budget on Tuesday? Big Increase 0% (0) Small Increase 10% (5) No Change 10% (5) Minor Decrease 24% (12) Major Decrease 43% (22) I Have No Idea 14% (7) Total votes: 51 Looks like a 67% see a decrease of some size and the rest stable or slightly up. Again, many thanks to those that voted! David.

This is the initial part of the post - read more by clicking on the title of the article. David.

Last week in a bold and historic move (and a bitter pill indeed for many healthcare executives finding themselves explaining the obscure financial inner workings of a hospital) the HHS/CMS released the national charge master data. The release seems to be a response to Steven Brill’s epic TIME magazine article on medical billing: Bitter Pill: [...]

European Commission Vice-President Neelie Kroes has awarded prizes to eHealth SMEs from Finland, Germany, Italy, Netherlands, Switzerland and United Kingdom as part of eHealth Week 2013 in Dublin, Ireland. The winners of the 2nd EU SME eHealth Competition came up with innovations in areas such as improving cognitive behavioural therapy for mental care, improving physiological monitoring, and people facing emergencie.

Even in some of the most digitally advanced hospitals and clinics I visit, I frequently hear clinicians grousing about access to patient care data and systems. It’s not unusual for todays’ healthcare settings to have multiple repositories of patient data...(read more)

One of the longest running conversations we’ve had on this site is the shortage of qualified EMR workers. It’s a discussion that quite frankly is difficult on many levels. On the one hand you have the hospitals and clinics who are suffering because they can’t find the right people to work on their EMR. On the other hand, you have the unemployed but experienced IT worker that’s trying to crack into the healthcare IT and EMR world.

This later group breaks my heart about once a week. There stories and efforts trying to find a job in healthcare IT are hard for me to take. Sadly, I haven’t figured out a way to help them beyond pointing them to our EMR and EHR Job board which appears in the sidebar of each of our sites. Otherwise, I’m not sure how to bridge the gap between the EHR workforce shortage that many people describe and those looking for jobs in the EHR world.

Although, I was reading something recently that opened my eyes a little bit to why I hear two sides of the same story. This is what I read:

There’s always a shortage of the perfect worker.

This is a challenging idea to consider, but an important one. There are only a handful of perfect workers out there for each situation, so of course there’s a shortage of that talent. Plus, it’s amazing how the perfect workers always seem to have work. Yes, there are a few exceptions and much of job hunting is about timing and location. However, I wonder if the EHR shortage that many describe is the lack of the perfect worker and not an actual EHR worker shortage.

I thought it would be interesting to have a poll to see what people think about the EMR workforce shortage. Is there one or isn’t there? Select your answer below.

Feel free to elaborate on your poll response in the comments.

In a previous note, I discussed the hybrid teleradiology business model (see: Hybrid Model of On-Site and Remote Radiology for Enhanced Patient Workflow). In a nutshell, it works in the following way:

• A radiology department at a 370-bed acute-care hospital in Carmichael, California, utilizes both its on-site radiologists and remote radiology ("nighthawk") consultants to improve the quality of care and workflow.
• Cases are turfed to the outside consultants when the local radiology expertise is unavailable (e.g., neuroradiology), when the local number of radiologists is insufficient to handle the current case load, and during the night and weekends when the local radiology department is not fully staffed.

It occurred to me that this model would be ideal for smaller hospitals today who have deployed a digital pathology system or are interested in doing so. When outside consultation is required for a surgical pathology case, it could be scanned after primary review by the local pathologist. The volume of such cases would thus be small and a high-volume, high-throughput, expensive scanner would not be required. Moreover, such a surgical pathology consultation would require only an outside secondary opinion and thus, given my understanding of today's regulatory environment, would be acceptable to the FDA.

The Digital Pathology Association is planning a webinar next month focusing on the various business models that can be used to deploy digital pathology technology. Are there any readers of this blog who have successfully deployed such a hybrid model and wish to be considered as a faculty member for this upcoming webinar?

The FDA launched an impressive patient network website this month, after nearly four years of research, focus groups, usability testing and more. The twin goals for this website are promoting the educational mission of the FDA, and promoting opportunities for...

David Harlow

I recently had the pleasure of attending a presentation by Grahame Grieve, the originator of FHIR, on the details behind this evolving health IT standard. I have written a couple of blogs previously to introduce FHIR, including 5 Things to Know About HL7 FHIR and Review of The HL7 FHIR Session at HIMSS13. This standard [...]