I found a fun new web site at http://www.netdisaster.com. It allows you to virtually deface someone’s web site. It is a great way to take out some vendor and competitor frustrations.

Likewise, a vendor may use this site as a way to take out their frustrations with me.

I had toyed with the idea of using my competitor’s web site with for this demonstration, but I was afraid the press would mis-interpret that as being something other than healthy competitive spirit.

Also, I don’t have any vendors that currently deserve such treatment.

Updated with event details…

I really enjoy being part of this emerging Healthcare IT blogosphere. Better than the exposure that I have gotten is the fact that I am exposed to a lot of ideas.

Several of us bloggers have decided that HIMSS will be a great chance to meet the faces of those ideas. Please consider joining us to share your insights and reactions to the hot topics.

If you are looking for free food and drink then this is the wrong place. This is an unsponsored event to preserve the independent spirit of blogging. This is the place to come if you thirst for knowledge (poetic, eh?).

The event will be on Sunday, Feb. 12 at 8:30 p.m. at Hennessey’s Gaslamp, 708 4th Ave., San Diego. That’s walking distance from the convention center and most of the HIMSS hotels. Click here for a map. So far we have 36 attendess. A manageable number.

If you think you might be able to join us, visit the HIMSS 2006 Blogger and Reader Meetup Registration site. Your e-mail addresses and private comments are not shown to the public.

I couldn’t seem to get my hands on good numbers regarding Computerized Physician Order Entry (CPOE). So, I have decided to do my own research. These numbers are based upon the Leapfrog Group survey reported on their web site.

You may ask “but Will, what if there are hospitals that have implemented CPOE but have not reported it to the Leapfrog Group?” I cannot imagine that someone would go through the effort of a CPOE implementation and not report their success to the Leapfrog Group. At many hospitals “Leapfrog” is the reason to do CPOE.

Is it possible that a lot of hospitals have gone live on CPOE since that last survey submission deadline? After all, each large HIS vendor claims they have hundreds of hospitals implementing CPOE. Well, it is possible that some new CPOE installations have recently gone live but, according to the Leapfrog site, only 58 hospitals claimed they were within 12 months of bringing their CPOE system live.

The other cautionary note is that all of the Leapfrog Group surveys are self-reported. I am going to write a separate post on why I am skeptical about many of these self-reported surveys.
So, how many hospitals claim they have implemented CPOE, as defined by Leapfrog?

68 hospitals operated by 43 different health systems claim to have fully met the CPOE leap. This represents 1.7% of all hospitals in the US according to my database.

Here is a breakdown by Type:

• Academic Medical Center: 30
• Community Hospitals: 26
• Government Owned Facilities: 6
• Children’s Hospitals: 5
• Heart Hospital: 1

This means that only .08% of American community hospitals have implemented CPOE (according to my database). But, I would be the first to admit that the definition of a “community hospital” is open to interpretation. I think this is a more important number, because Academic Medical Cetners can rely on residents to enter orders online without much regard to their desires. Community hospitals risk losing their top admitters to the competition.

I also think it is interesting to look at these hospitals by bed size (staffed beds):

• 101 – 249 beds: 14
• 251 – 400 beds: 14
• >400 beds: 34

The fact that most of the hospitals are big is no surprise. The real eye opener is the 6 that are under 100 beds. Again, I will write about this in a future post (we will have some fun with that).

I also plan to run the numbers by software vendor in a future post.

I hope this is helpful. I think the numbers can help set some expectations.

I am pleasantly surprised that my blog receives 30 – 60 unique visitors a day. I have to admit that I have become a bit addicted at looking at the logs to see what I can learn about the visitors and how they arrived here.

I had to laugh out loud when I saw one person arrived here by searching “i hate meditech” on MSN’s search engine. I can only wonder what caused such an action. BTW, I am ranked 6th on that search even though that exact phrase (or any such connotation) does not appear on my blog.

Speaking of MEDITECH, they are frequent visitors here. I am sure my account exec is keeping an eye on me (Hi Priscilla). But, it appears other MEDITECHers are visiting too. Maybe even Howard Messing, who I have never met.

Some of my other vendors that have stopped by include Valco, McKesson, Quadramed, and Wellogic.

I have also received some visits from organizations that may have been less than thrilled with the attention that I gave them. Even though the Leapfrog Group and Avaya have been here, they did not respond to my posts.

I also get emails from people that discovered me through my blog and want to sell me something. I am slightly more open to listening to somebody that took the time to learn about me, than someone mis-pronouncing my last name off of a call list. Still, that isn’t very interested.

But, it appears that most visitors are like-minded healthcare IT professionals looking for an exchange of ideas and some fresh thinking on tricky topics. A few visitors are from my own organization. Some visitors are with competing organizations (Aurora, not ThedaCare yet). But most from hospitals and health systems in other parts of the country and the world.

Traffic really began to become noticeable when I became a part of the healthcare IT blogoshpere. Other, more established sites linked to me and referenced my posts. I appreciate the attention they have brought my posts. If you want to be exposed to other healthcare IT bloggers the best starting point is Shahid Shah’s HITSphere.

I hate software demonstrations. They are nearly useless. Here are my primary gripes…

Suspension of disbelief
I cried when I saw ET. That is the magic of movies. Somehow a perfectly rational person can believe that a lost alien has been rescued by children. I think that same aspect of human nature betrays us when we watch software demonstrations. People want to believe. I have seen people swear that they saw something in a demonstration that I know was impossible. Somehow, people see what they want. Perhaps people are too optimistic.

“Cannit”
I know I am trapped in a bad demonstration when a volley begins between participants and demonstrators. Each question begins with “Can it…” Of course each response is “Yes.” Or my favorite “Yes, with customization,” which is vendorspeak for NO.

There are so many problems with this approach I don’t know where to begin. Actually I do. The vendor is lying through his/her teeth until proven otherwise. Any simple question that someone asks can be interpreted in a way to illicit a positive response. Usually the questions are too poorly thought out to really capture the intent. Furthermore, if the vendor is not demonstrating, but just volleying back positive responses is anyone really learning anything?

Watching TV
I guess Americans would rather watch TV than read a good book. That is the true when it comes to the software selection process too. Everyone would rather crowd into a room to see a fraction of the functionality demonstrated than read through the documentation to really learn how the system works. See my earlier post about reading documentation.

Why are we here?
When we do have software demonstrations (which is as seldom as possible) I always make sure we start the meeting by telling everyone why we are gathered. There are two reasons for demonstrations: education and acquisition. Everyone assumes that a software demonstration will lead to a purchase decision, so it is important to strongly emphasize to all parties if you are just window shopping.

It is OK to have software demonstrations just to spark ideas and expand your understanding of what is possible. When that is the case it is critical that the participants and vendors know this and that the message is clear that there is NO commitment beyond today. These demonstrations should have a very limited internal audience.

If the demonstration is part of a selection process at my organization that will be self evident. The demonstrations will be tightly scripted. Everyone participating will have assignments, including:

• completion of evaluations that are tied back to the features/functions required to achieve the project goals;
• documentation feature/functions that need to be pursued; and
• identification of possible gaps.

Bottom Line
If there is no written documentation that is attached to the contract than this whole exercise has limited value. There is no obligation on the vendor’s behalf to provide the client with anything discussed during a demonstration.

In my previous post I emphasized how important it was to have a vision for an electronic health record before you head into a selection process. One should not buy their requirements from a consultant, they should develop them based upon a clear business purpose.

So, I present to you the most recent draft of Affinity’s Electronic Health Record (EHR) Manifesto:

Preface: For the first time in the 100+ year history of Affinity, and it’s predecessors, we are fundamentally changing the way that we practice medicine. This new model is based upon the Affinity Health Management Vision.

How we practice medicine will be hard-wired into the patient encounter: Good care will no longer be dependent upon the physician’s ability to remember the guidelines that vary by patient’s age, gender and existing conditions. Instead, the guidelines will be pushed to the physician via the exam room computer. These will not be generic guidelines, they will be specific to each patient. Consequently, the patient and the physician will know every patient is being treated by the most current and up to date evidence-based guidelines every time without anything being missed due to memory lapse or a lack of guideline awareness. This zero-defect approach will make good doctors great and great doctors even better.

Information systems will support efficient, thorough care: Valuable physician time will not be wasted searching the abyss of today’s electronic medical record. Instead, a new generation of electronic health records will assemble the most relevant test results and vital signs in a way that facilitates the practice of medicine using the guidelines. This presentation of the patient’s electronic health record will be the centerpiece of the exam room visit.

The management of the patient’s health will no longer be limited to the clinic setting: Population management tools will be used to monitor patient compliance with their guidelines and to intervene before care is overdue. These efforts will be coordinated across the system (AMG, NHP disease and case management, Occupational Health, Nurse Direct, etc.) to ensure the most efficient use of resources. As a result, AMG patients will receive all of the appropriate primary care and screening exams, improving their health.

Furthermore, our interactions with the patient will extend to their homes through WISDOM mailings and AffinityConnect, the patient portal.

How patients perceive Affinity will be greatly improved because patients will see us proactively reaching out to them, not just waiting for them.

The patient experience will be more open and personalized: Our WISDOM initiatives will provide patients access to the same personalized health information as the physician. They will more fully understand their plan for care and patients will be more engaged in the physician/patient partnership. AffinityConnect will provide access to their information when they want to review it. Constant feedback will engage the patient and enrich the physician/patient partnership.

Our interactions with the patient will be personalized using the data and new electronic tools. Ironically, the result of this high tech approach will be perceived by patients as more human and caring.

I am going to leave the CPOE topic this week. But, it was a good week to point out that our industry is pursuing CPOE without the proper planning or evidence that it will improve patient safety. So, I will move to the other phrase maxing out the “hype meter.”

I have a new rule. I am forbidding anyone to discuss “Electronic Health Records” unless they can describe three clear expected benefits of an EHR system and how the EHR will accomplish that. Furthermore, “Going paperless” does not count as a benefit.

Luckily, we are pretty much past that phase at Affinity. Certainly at the executive level. I still have some others ask me when I am getting an Electronic Health Record. My standard response is: “You are not allowed to use that phrase.”

I see some CIOs pursuing Electronic Health Records without any vision regarding what they want to accomplish. This is usually in the form of a CIO sending an email to a CIO list-serve asking if anyone has a EHR RFP. There is so much wrong with that request I don’t know where to begin. It is like asking if anyone has a good recipe. Well, I have great recipe for a Green Bay Packer tailgate, but if your medical staff is expecting a 5-course meal you are both heading for disappointment.

I truly believe folks need to develop their own functional requirements. At least the core requirements. But, that should only take place once they have developed a common vision with the leadership and medical staff. Once you know what you are trying to accomplish, then you can decide what features/functions you will need.

We have put together an Electronic Health Record manifesto. I love it, but I love my own cooking. I will post it later in the week to continue the EHR theme.

If CPOE was such a promising technology to improve patient safety, why has the Leaprog Group failed to deliver its CPOE evaluation tool? In November of 2001 Leapfrog promised to collaborate with FCG to deliver an evaluation tool in 2002.

The first version of the CPOE evaluation tool may still be coming. In mid-2005 Leapfrog promised that the tool would accompany the next survey. I believe that is due in April 2006. This is over THREE years after it was initially promised. Even my worst projects are not delivered this far off schedule.

Why does Leapfrog expect 100-bed community hospitals to implement technologies that it can’t seem to master, even with all of the financial backing of its members / funders and the intellectual capital of the country’s largest healthcare IT consulting group (FCG)?

Was Leapfrog premature in suggesting that CPOE was an immediate opportunity to improve patient safety? Sure CPOE is great in theory, but then again, so are flying cars.

I do appreciate that Leapfrog has provided a definition of true CPOE, which they say includes three elements:

1. Assure that physicians enter at least 75% of inpatient medication orders via a computer system that includes prescribing-error prevention software;
2. Demonstrate that their inpatient CPOE system can alert physicians of at least 50% of common, serious prescribing errors, using a testing protocol now under development by First Consulting Group and the Institute for Safe Medication Practices [this is the missing evaluation tool]; and,
3. Require that physicians electronically document a reason for overriding an interception prior to doing so.

Despite this clear definition health systems continue to claim that all kinds of things are CPOE, like clinic e-prescribing systems. Ambulatory CPOE is an oxymoron.

Most CPOE implementations that I see don’t even try to tackle 2 and 3. For that matter they can’t meet the threshold of the first criterion. What is the value in that?

And even though the Leapfrog survey instructions are clear there are many instances where hospitals submit CPOE claims that are, at best, overly ambitious. It will be interesting to see how many hospitals report true CPOE success in their 2005 survey after reporting that they were a year away from full CPOE in the 2004 survey.

Update: a few hours after posting this I was heading to the bathroom (I know, TMI) and I grabbed whatever was on top of my mail pile. That turned out to be the HIMSS 2006 materials. As I was flipping through it I saw that FCG and University of Pennsylvania Health System will present the benefits of the CPOE Evaluation Tool (Education Session Number: 58). Perhaps Penn is the beta site.

It appears, by the title of the seminar, that the intent is for the tool to be available before HIMSS. So, Leapfrog and FCG may be making some headway. Then again, since the HIMSS submission deadline is in May this may have been wishful thinking.

I have sat through a few presentations with titles such as “What Went Wrong With Our CPOE Implementation.” A recurring theme in those powerpoint slides is a perceived “lack of strong senior managment support.” In my opinion, this is an incomplete analysis.

Is it really the case that senior leaders are too lazy or uncaring to champion these new information systems? I don’t think so. I think the trouble lies a little deeper. I suspect the scenario goes like this:

1. The project folks go to senior management to dsiscuss adoption problems with the hope that they will “force” the physicians to use the system.
2. The CEO or COO approach the top admitters to discuss the situation.
3. The physician responds by stating that the system sucks and s/he would rather practice at the competing hospital than use the system.

Is it really strong senior leadership that would turn away a significant amount of patient revenue and jeopardize the ability to fund the mission of the organization?

I think the real issue is that the planning and anlysis failed to ask some real hard questions about the risk of physician resistance and the limited options the organization may have in that event.

I also think that usability has to be a primary focus and it may be that most products are not to a state that they are easy to use.

Hospitals with hospitalists and teaching staff have an advantage. But even those will have a large number of physician customers that can take their business elsewhere.

I believe a key to a successful IT project is ensuring that it has a clear business purpose. In my opinion, this works best when the project is being lead by someone outside of IT that has a stake in the long term success. At Affinity we strive to assign a non-IT Project Champion to each project and make them accountable for the results.

In an earlier post regarding statements of work someone commented: “In my view a SOW included the commitments (read “promises”) that the internal personnel are making to each other. I submit that it is MUCH more important to make the promises to ourselves before we make them to vendors! “

This is my view too and I appreciate that I am not alone. The first draft of that internal agreement is developed by the Project Champion using our Project Champion Agreement.

Feel free to borrow from this liberally. Please tell me what you think.