There are two ways to improve quality measures. The most important way is to improve quality (duh). But your good quality can be diluted if you don’t manage the denominator.

Most physician practices don’t manage their panels. Panel management is the key to top P4P results. If your panel includes patients that are no longer seeing your physicians, then ultimately they will be non-compliant with you health management targets (e.g., diabetic eye exams, annual physicals, chlamydia screenings, etc.).

My experience is that a physician practice takes no action when a patient leaves their panel (moves, switches insurances, dies). In fact, they often don’t know. But these people will pull down your P4P results. Physician practices need to introduce new processes to actively track down patients that they have not seen and flag when they have left their panel. Their IT systems also need to be able to flag them as out of the panel. So they can be excluded from the P4P denominator.

Ideally the system will allow the practice to document why and when the patient left as well. This information could come in handy if we get to the point that these results start getting audited.

At HIMSS this year I spoke in the Dictaphone booth regarding our experience with their EXSPEECH voice recognition system. It was a good project that had a solid ROI (less than a year). We implemented the system while their then parent company, Learnout & Hauspie, was going through bankruptcy in 2001. This turned out to be a good move since we got a great deal of support. Like your financial portfolio, your IT portfolio should have some agressive, high risk investments.

This year there was a sense of deja vu in the Dictaphone booth as they were being acquired by Nuance. Nuance holds much of the same assets held by Learnout & Hauspie (e.g., Dragon Naturally Speaking) when they acquired Dictaphone in the 1990s. The primary difference in the 21st century is that Dictaphone sold out for 1/3 the price.

A couple of years ago I had dinner with Rob Shwagger, the president of Dictaphone. Rob was on a low-carb diet. As he ate a cheese platter for dessert he told me a great story about the Learnout & Hauspie acquisition that really captured the spirit of the Internet boom. This is the story as I remember it:

Apparently Rob and another Dictaphone exec were meeting with the L&H principles in a Belgium outdoor cafe. The L&H dudes wanted to know the selling price for Dictaphone. Rob threw out an amount he considered to be outrageous, just to test the waters: $1B, as I remember it.

The L&H executives excused themselves and walked into a nearby farmer’s field. After a few minutes they returned to tell the Dictaphone executives that they accepted their offer.

I am starting to study IT infrastructure frameworks such as ITIL. The idea is that you have a standard way of handling most aspects of IT service management such as change management, continuity, capacity management, incident management, etc.

In my research I found the IT Service Management Forum whose mission is to “enable member organizations to achieve measurable operational excellence by introducing, developing and promoting IT Service Management Best Practices. ” However, I wasn’t able to order any publications from them because their online ordering page is down. How ironic is that?

Still, the notion of IT frameworks is more appealing to me as Ministry Health Care begins to consolidate its IT services into a single service organization. Ideally, we will develop a framework that addresses these elements of infrastructure management from an enterpise perspective. Otherwise, they will only be as good as each person assigned to manage a specific technology. For example, we can set some standards for managing availability. Those standards will be a guide for the rollout of services at the enterprise level. When we consolidate email, the email guru will have some guidelines for addressing availability. S/he will be given direction on assessing availability requirements; develop an availability plan; monitor availability; etc.

I don’t think this apporach makes sense for most community hospitals. But for larger networks that have 10,000 plus employees there is value in this level of discipline. Especially as more mission critical applications are brought online.

Well, I guess I am on a Microsoft bashing streak (the folks at the Leapfrog Group will appreciate the repreive). I read Dr. Bill Crouse’s blog with regularity and generally find it to be quite good. But this post makes me crazy.

Dr. Crouse is employed by Microsoft. In this post he blogs about a a Micorsoft partner, HealthUnity, that has developed something called a RHIO In A Box. The name alone makes me crazy. Anyone that has tried to exchange data between healthcare providers knows this is a huge challenge that cannot be solved with software or technology alone. All of the problems in creating a RHIO are outside the box. Posts like this only serve to make CEOs think that creating a RHIO is as easy as buying software.

I picked up this marketing gem from the vendor’s web site:

“A hospital that wants to tap into the HealthUnity™ network can do so using our low-cost, plug and play solution. Once deployed, this solution will enable your physicians to collaborate with internal as well as external parties over secure and HIPAA compliant mechanisms. We provide all the services required to maintain smooth operation of the system. This keeps your IT investments minimal while increasing the returns on your investment.”

When I got to “plug and play” I began to involuntarily heave.

Neither the HealthUnity web site, nor Dr. Crouse’s post, address the complexities of patient matching. For example, how does the RHIO know that John Smith with Medical Record Number 123 is also Jack Smith in another provider’s database with another medical record number?

Then we have the fact that most physician offices don’t collect allergies in a codified manner. In fact, many don’t even have the free form text online. The solution to that problem is not going to be in a box.

Dr. Crouse points out that the product has the ability to exclude parts of a patient’s chart from automated access, yet make it available for case by case requests (e.g. an AIDS test result). Driven by patient privacy and state laws. How does the RHIO In A Box know which of the lab tests are for AIDS tests? While there are some emerging standards for univerally coding lab tests (i.e., LOINC) less than 5% of health care providers use them. How does the box know what my hosipital lab system calls an AIDS test?

My mission in writing this blog is to add some realism into the healthcare IT debate. Healthcare IT has over-promsied and under-delivered. We have been selling unrealistic dreams. These are complex topics. To pretend they are not is the worse thing we can do to forward the IT cause in healthcare.

One of the great things about being in the same industry for 20 years is that there are some people that I have known for a long time.

It is great to see them at HIMSS. I was going through some pictures and found some that reminded me just how much things have changed. I guess these pictures are a metaphor the maturation of the entire healthcare IT field. Here are some examples:

Me and William Greskovich (left) in 1987 when we were FCG
consultants working on a gig at St. Mary’s – Evansville.
William is now the Vice President of Oerations and
Chief Information Officer for St. Agnes Hospital in Baltimore.

Mary Pat Fralick is currently the co-president

I haven’t seen Bobbi Coluni in 15 years. But I believe she is still the
Director of Product Development at Thomson Medstat. This is us circa 1985.
I have no idea what we were doing here, but it wasn’t as intimate as it appears.

I have identified the single greatest contribution that Microsoft can make to healthcare.

They need to remove the Auto Correct option in the office applications that turns “EHR” into “HER”. I am so tired of correcting Microsoft’s correction. I realize that this can be turned off through options. But, I use many computers (including Citrix). And everytime I get a new one I have to make this change.

I also know that this could probably be fixed globally with some good desktop management tools and a registry change (let me know if you know where this resides). However, my desktop management fokls have not figured this out yet.

It seems like Bill Crounse would have enough pull to have Microsft make this fix globally.

Here are the results from a recent web poll that asked: “What is your favorite scripting tool:“

• Boston Workstation: 546,465,355,300,154
• Summit Healthcare: 546,465,355,221,355

Let me know if you get it.

I was just reading at Mr. HISTalk’s blog how much he enjoyed the entertainment portion of the opening keynote. I thought I could count on him for sarcasm and a jaded point of view? Personally I thought the entertainment portion was very cheesy. Being from Wisconsin I know 8-year old cheddar when I see it. I didn’t come to HIMSS to be semi-entertained.

Brailer’s speech was the first opening keynote that I ever fully attended. I sat in the front-most section. Clearly the message was that Brailer and the president only want to “prime” the capitalism pump. They are going to let the free markets lead us forward to an interoperable EHR. One of the ways that this would be done is through “standards harmonization.” Which sounds like new standards on top of standards. Cool, I was hoping for more complexity.

Meet The Bloggers turned out to be as big of a nerdfest as I expected. It was great to meet the folks that share my interests. They were genuinely nice people that really wanted to discuss healthcare IT at a meaningful level. But if a fight broke out I didn’t have anyone I could hide behind. Thanks guys, I had a great time.

I have vowed not to mention the weather when calling back home. Too cliche.

Everything is going smoothly in my travels, unlike those on the East coast. It sounds like many MEDITECHers won’t arrive until Tuesday due to the weather.

When I travel my goal is to keep my expenses so minimal that it isn’t worth submitting them for reimbursement (other than lodging and airfare). Ground transportation is an expense that can really add up. The great thing about San Diego is that you can take the city bus from the airport to downtown for 2.25. I had about a half mile walk to the Hyatt from there.

Speaking of the Hyatt…I made my lodging reservations way too late. The hotel problems for this conference are well known. Luckily CHIME books a block of hotels for member CIOs. That saved my bacon.

I worked at the University of California – San Diego Medical Center in my consulting days. During that gig I remember waking up every morning and saying “this is the most beautiful day God ever made.” That is still the case. It is a beautiful day. I went for a run along the harbor and I loved every minute (except the running part).

Now I am getting ready to head over to the HIMSS welcoming reception (I will be fashionably late). My big decision is clothing. I am torn between business attire and a shorts/Hawaiian shirt combo. Maybe I will compromise.

Then it is off to the Meet The Bloggers event. It will be great to see my friends in the blogosphere.

The best kept secret in Healthcare IT may be St. Clare’s hospital in Weston, WI. St. Clare’s opened in October 2005 without a single file room. It is Wisconsin’s first digital hospital. Some hospitals have received tons of recognition, including the one in Birmingham that probably will never open. St. Clare’s, however, has flown under the radar despite being a state-of-the-art facility with everything from e-learning to full CPOE.

The entire project is the vision of Steve Pelton, the CIO for Ministry Health Care’s central region (Ministry and Affinity are sister organizations). The project enjoyed comprehensive project management support from the Ministry PMO. As a result, there are some good numbers regarding the total overall effort. St. Clare’s is a new hospital, so there weren’t any conversions or worries regarding existing paper records.

In total, the IT effort for this digital hospital has been just over 100,000 hours (including intense post-opening support). I calculate that to be just under 50 man-years. If you are going to take on the effort alone you will want to get an early start.