Mr. H posted the results of a recent poll asking whether it’s OK to ask emergency department patients to pay before treating them for non-emergent problems. The vast majority of HIStalk readers responding thought it would be OK.

Since I’ve spent the better part of the last week working the ED, I have to say I agree. Normally I don’t work this many shifts, but the combined stresses of recent changes in our nursing ratios that resulted in some “blue flu” among the nursing staff seems to have inspired an unusual number of call-ins among the medical staff as well. (Either that, or my partners just want to get a jump on their summer vacations.)

Most of my shifts were on the lower acuity side of the ED, which suits me just fine. The full-time docs can handle all the gunshots, “fit for confinement” exams, strokes, heart attacks, and major trauma, thank you very much. I’m perfectly happy to handle fractures, asthma exacerbations, lacerations, and minor trauma. This week, however, we had a boom in patients who simply should not have been in the ED.

This was a bit of a bummer from an electronic documentation standpoint. Our recent upgrade brought us the ability to have condition-specific defaults, and I had spent a fair amount of time building out my personal templates for the conditions I typically see. I did not, however, spend any time building templates for problems that might be best handled at home with a wet paper towel and a nap. The highlight reel:

• A teenager with an insect bite. His mother wrote a note giving permission for a neighbor to bring him in. He noticed the bite in the morning before school when it wasn’t bothering him at all, but mom decided at 10 p.m. that she wanted to know what kind of insect it was that bit him. Unfortunately, I am not an entomologist.
• A high school senior with mild sunburn who wanted to know what she could put on it to make it go away before graduation (which was the next day.)
• An adult male with a 0.5 cm lump on his arm that had been there for six months. That prompted him to arrive at 1 a.m. “just to get checked out,” although he couldn’t say why he was coming in NOW.

I’m pretty sure that if someone in the waiting room would have told them it would be a minimum of a two and a half hour wait and a $200 charge, these three musketeers (and the dozens like them) would probably have chosen to go home. I wish we could have a seasoned registered nurse stationed in the waiting room, administering simple first aid and counseling patients to follow up with a primary physician or a walk-in clinic in a day or two rather than using scarce ED resources. While I was dealing with them, we had an elderly woman with a complex fracture of her upper arm, several patients with lacerations, and a chap with a knee the size of a grapefruit that needed my attention.

Unfortunately, fallout from the Emergency Medical Treatment and Active Labor Act (EMTALA) makes it difficult for us to employ creative strategies to reserve the ED for appropriate use. Becoming law in 1986 as part of the COBRA legislation, EMTALA seemed like a good idea at the time. Although EMTALA was intended to ensure that patients presenting with emergent conditions were not turned away for inability to pay or other discriminatory reasons, the unintended consequence is a generalized fear of saying “no” to anyone who walks in the door.

The Code specifically defines an “emergency medical condition.” More than half of my patients this week failed to meet that standard, yet they had full visits anyway. We had to document each visit in detail, including a full review of systems, counseling on advance directives, nutritional screening, and more. (We also had to arrange transportation home for the mom who brought her daughter by ambulance for a splinter, but that’s another story entirely.)

I wasn’t in practice prior to 1986 so I can’t say what it was like, but I can’t imagine it was as chaotic and soul-sucking as it is now. I was, however, in the trenches when E&M Coding appeared on the scene, and I experienced first-hand the ridiculous make-work that ensued.

Looking at the track record for federal meddling in health care, it’s hard for me to think that the changes occurring as a result of Meaningful Use will turn out well in the long run. I may have Certified EHR Technology and full command of the Meaningful Use program. I can cite all the measures verbatim even after a couple of glasses of wine. I have more timely access to old charts (which are now actually legible) and better drug interaction checking, but other than that, the benefits still seem elusive.

How do you think we’ll feel in 25 years when we look back at Meaningful Use? E-mail me.

E-mail Dr. Jayne.

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Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The Art of Medicine: Unlocking the Power of Patient Data
By Nick van Terheyden, MD

We are awash with information and choices in every aspect of our lives, from the selection of our morning coffee to the choice of painkiller in our local pharmacy. Worth noting, Starbucks currently offers 30 variations of espresso beverages, and each comes in three sizes with four types of milk. That’s 360 choices — enough to potentially make you want to not get out of bed in the morning.

This problem is magnified in medicine with a deluge of new information, studies, treatments, and the explosion of genome understanding and its impact on patient care. Based on current estimates, medical information is doubling at least every five years. Cyril Chanter encapsulated today’s medical information challenges best when he said, “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”

There is general agreement in the medical profession that the delivery of quality medical care is no longer possible based on recall and applying what individuals can remember at the point of care. In fact, according to the Kaiser Permanente Institute for Health Policy, “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable.”

The digitization of medical records, accompanied by the requirement imposed on the care team to capture discrete data, is setting the healthcare system up for failure. We’re promoting the incomplete capture of the patient note. Discrete data is much like a black-and-white drawing — it contains some of the data, but much of the critical information and nuances are missing. In order to ensure the complete capture of the patient note, discrete data and the clinical narrative must coexist.

The key transport mechanism for medical intelligence is the clinical narrative, which provides the detail that is essential for the execution of intelligent, high-quality medical care. From there, language understanding offers a legend for these pieces of information – the narrative and discrete data – which allows us to view the complete work of art, also known as the patient note.

We are a long way down the path to enabling clinicians to capture complete patient information using the latest advances in voice recognition, which converts spoken word into text. Still, it is with language understanding that we unlock the true meaning of this information, offering a “Rosetta Stone” to tap into the insights of this information and allowing us to connect the dots in our expanding picture of patient care in a digital world.

It is this unlocked data that will link the subtle details of the patient record to vast mountains of medical intelligence; allowing for a guided, evidence-based approach to medicine alongside integrated decision support. This in turn will offer care takers a more complete picture from which they can guide individual care, while enabling possibilities surrounding large health population analysis and insight.

As we unlock the capabilities of clinical data in healthcare, we open the door to new discoveries, associations, and yet-unimagined treatments that will directly affect the care of those we love and look after now and into the future.

Nick van Terheyden MD is chief medical information officer of Nuance of Burlington, MA.

I once heard it said that successful device connectivity in a hospital is like implementing a universal remote on your TV. The consolidation of controls allows for easier training of new users, fewer steps to execute a command, and less room for error. But in today’s age of accountable care and new care delivery models, the health systems that are still operating in the “universal remote” mindset will be left behind as the industry progresses.

It’s great that my DVD player can talk to my TV. But what about when I want to watch the same movie on my laptop in the other room? And while this entertainment glitch is a little frustrating, it’s actually criminal when we think of a similar scenario in the healthcare world. We don’t need to just connect one point solution to another. We need to be able to effectively care for patients, regardless of where they are within the hospital; what systems the hospital has in place; or how many physicians, nurses or other staff are involved in the patient’s care. The sooner hospitals begin to think beyond individual technologies and develop an overarching strategy to connect people and processes, the faster we’ll start to see a real change in patient care.

Historically, hospitals and health systems have approached medical device connectivity tactically, focusing on how to connect a nurse call device to a smart phone, a monitoring device to an iPad, or data from a smart bed to an EMR. Often purchased by IT departments as middleware, a range of IT solutions have been viewed as a solution to one or two key problems, and have typically been implemented one department or one facility at a time.

Because many of these technology investments were made to solve only singular, point-in-time problems, providers still struggle to deliver care that focuses on the patient across the entire care continuum. They need to get smart about implementing solutions that cater to the unique workflow of their personnel – not their hardware – if they want to drive efficiency and improved patient care.

It’s not really the provider’s fault, though. The vast majority of vendors have played into this universal remote mindset by building point solutions that connect a small subset of devices or departmental systems to one another, rather than focusing on the entire system. Providers need solutions that both cater to a department’s unique workflow and enable collaboration from one department to the next, making it possible to efficiently serve patients as they move between these diverse care settings. They need to come to the table with customizable solutions, and with services that help hospitals implement these solutions as part of a broader workflow strategy. It’s not enough to drop off a box and wish them well. Providers need partners to help them learn and improve for years to come.

We need a new movement in healthcare, one that takes a system-wide view to clinical workflow design and leverages clinical technology solutions to both connect devices and foster collaboration across the entire system. This includes everyone from patients to clinical teams to ancillary groups (biomedical engineering, dietary, environmental services, IT, and pharmacy). Clinical workflow is about more than hardware and software. It’s about the clinicians who use these solutions and need them to promote — not hinder – high-quality patient care. Vendors need to offer their customers something better than stale point solutions. 

As an industry, we need to map to the bigger picture, driving teamwork and collaboration among every individual and across the entire care continuum in order to drive dramatic performance improvements for healthcare organizations.

Mary Baum is chief healthcare officer of Connexall USA of Boulder, CO.

When hospitals choose a healthcare IT provider, they too often just focus on the same questions many of us consider when buying a car: “How fast does it go?” and “How much does it cost?” But for a successful project, these are just two of the many factors to consider. Another key decision point should be a vendor’s suitability as a long-term partner.

We’re not just talking the equivalent of a 100,000-mile power train warranty, whereby the vendor will fix your system if it breaks, though of course responsive support is important. But beyond that, you’ll be better off working with a company that not only understands its products and services, but also your processes, your staff, and your goals, and will do its best to unite these elements to give you maximum performance and value.

The first thing to consider before getting on the road is your hospital’s needs, both now and for the next few years. What are the pain points you’re trying to overcome, what new compliance mandate are you struggling to satisfy, or which facet of your EMR/EHR project are you finding most troublesome? This then defines the focus of your solution search, which will in turn narrow your list of prospective vendors.

Next, ask for references from facilities like yours and see how they’re solving the very issues you want to solve. Then ask them what else they’ve been able to do with the product. A hospital sometimes picks a solution because it fits neatly into whatever box they’re trying to fill, but yet leaves the full potential of that solution untapped. One of the reasons is that an IT team is typically tasked with solving a very narrow problem, and once they’ve done it, they must move on to putting out the next fire lit by clinicians or the CIO. They then go out and look for other vendors to meet the very needs that could be met by the product they’re already using – a waste of time, effort, and money for everyone involved.

Executives tend to chase the next “shiny object” or respond to the newest tech trend, and this leads to the misconception that something ‘new and improved’ is required. Just like we all want the next iPhone or iPad, many hospital users hanker after the latest IT toys on the market, following the hype rather than putting in the effort to explore the full capability of the applications already deployed.

Despite the need for hospital project managers to be proactive in working with vendors to get the most from their systems, the burden cannot fall solely on the facility. A responsible vendor that cares about its customers and the staff and patients they serve should dedicate time and resources to helping hospitals get the most out of its solutions. A regular onsite “checkup” with both a customer advocate and a member of the vendor’s executive team can provide the hospital with a view of what its products can do now, and what the roadmap is for upcoming functionality. The vendor can explain and even demonstrate how other customers are using its offerings in new ways, and can then help the IT staff put this knowledge into action. Executive buy-in is also crucial on the hospital side, as the CIO and IT director will be key in both understanding the full potential of vendors’ products and services, and then in driving widespread user education and adoption.

The challenge to such leaders: push your IT analysts/project managers to explore each product’s entire feature set and get involved in engaging your vendors to see what else you could or should be doing. Yes, it requires accountability and an upfront time investment. But it will yield the benefits of doing more with existing tools, moving further toward achieving your facility’s goals, and, most importantly, of improving care and service to your patients. Time to start your engine!

Chad Morrill is an account manager at Access of Sulphur Springs, TX.

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The 79-member HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news development and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a provider organization (hospital, practice, etc.), you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

For this report, I asked panel members what advice they would provide to Allscripts after the company’s recent earnings disappointment and board shakeup. Their responses have been edited for brevity and to ensure their anonymity. Your comments are welcome.

Vision and Strategy

• The anti-takeover defense made them look weak in my eyes. They need to communicate their go-forward strategy with large clients as soon as possible. People here are worried that our vendor is going out of business.
• Phil Pead was all about the stock price and less about the product, integration, and ease of use. Allscripts tried to tell the integrated story with several different legacy flavors of PM/EMR – too many products, too many moving parts. The Eclipsys purchase was 2-3 years too late since Epic and Cerner have already beaten them and Epic is the only one with a real story of true integration. On the low end, they are most likely getting hurt bad by eClinicalWorks, athenahealth, Greenway, and similar companies. My advice: sell Eclipsys and use the money to pick a lane with one or two flavors of product and just kill it in that space. They cannot be all things to all people.
• They need to re-examine their market and whether this Eclipsys thing is really going to work. Seems like Glen did not learn anything from McKesson and GE.
• Post-acquisition is difficult and companies sometimes make all the parties feel good by including all the legacy resources – people and products – in the path forward. That leads to lack of vision, resource mismanagement, and excessive costs. I think Allscripts got caught in that vortex. They need to clarify what they want to be, then clean up the operation despite painful changes and bruised egos. A change at the top may be necessary to keep the institutional shareholders and analysts at bay while they right the ship.
• Put a plan in front of your most important customers and enlist them to create a public statement of support. Customers trump boards of directors every day.
• Come clean to everyone with what the problem is. Replace the corporate audit firm. Either replace the management team or give them a 12-month notice to clean up their own mess and then get out, assuming there is a belief they can clean it up. Appoint an external firm to work with the board to identify the issues and to decide which board members should stay. Make sure key intellectual capital employees are willing to stay and reinforce your need for their services.
• Allscripts is a finalist in our inpatient EHR selection. The recent news has raised concerns about the company’s viability. Show the market you can recover and succeed since partnering with Allscripts at this point represents significant risk. The failure to integrate Eclipsys products is a key issue since companies like GE and McKesson promised it after an acquisition and failed miserably, leaving customers in a lurch.
• A trick of publicly traded companies is to reveal all your bad news at once, let the market kill you, then build back up. I assume this is the case and future revenues will come with a clean slate. I think they will have some good upcoming quarters.
• They have had a pretty successful ambulatory product offering. They need to leverage that business model to tackle new accounts. With the internal politics hopefully behind them, they can concentrate on integration. They have a good product – I hope they understand that. It’s their execution that’s hurting them.
• Senior management, led by the CEO, need to be transparent if they’re going to put this turmoil behind them. They need to communicate clearly, thoughtfully, and comprehensively what the plan is, with no BS and PR. Humbly admit past mistakes, acknowledge vulnerabilities, reiterate its strengths and lay out the plan to recover. Spend 30-60 days to do a thorough, honest self-assessment – including consideration of the complaints of its critics – and play out best- and worst-case scenarios. If past decisions (i.e. integration) are criticized, those can’t be changed, but they should be acknowledged and addressed. The market is still large and I don’t believe it’s too late for Allscripts to get its share. It may not achieve a #1 or #2 market position, but it can still emerge as one of the winners. It has good products, a sizable customer base, and many talented employees. The message should be positive and encouraging, but above all, credible. In the absence of an ability or willingness to do this, Allscripts should fire Glen Tullman and hire a CEO with the determination and commitment to turn the company around, like fresh leadership did at IBM with Lou Gerstner.

Sales

• The sales team needs better access to technical resources. When they do a dog and pony show for our executives, our technical team is always invited and the sales team can’t answer their questions. I want to be sold, but they can’t bring it.
• Closing deals is the way to show viability. We’ve evaluated their products for our clinics and they didn’t stack up well. One group we’re associated with uses Allscripts and they have not been happy with the product for some time, but I don’t see them moving away from it.

Products

• They need to focus on clean integration of products they are selling as integrated. The last few times we purchased ‘integrated’ solutions from Allscripts, we had to take over the integration because we were getting nowhere with the company.
• Articulate the vision of the combine Allscripts-Eclipsys platform and provide a well thought out plan on how they will get there.
• They may want to take the approach McKesson used for Horizon Clinicals – sunset Eclipsys and focus on ambulatory. They carved out a nice space in the ambulatory area and the R&D dollars going into Eclipsys integration could have been used to further the ambulatory product line. Ambulatory clients are confused. This plays right into the hands of Epic.
• Allscripts needs to stop talking about an integrated record as though they can compete with Epic. They need to find a way to leapfrog Epic. Take what Sunrise customers are developing using Objects Plus/Helios (some of which knocks the socks off Epic) and incorporate it into the product.
• We were a long-time Misys client who left after Allscripts dropped the ball. They couldn’t deliver on support. They decimated their personal relationships by replacing dedicated professionals by a different nameless person every time we made a support call. Their salespeople couldn’t even present a proposal for community integration without innumerable failures in the demo. The ‘free upgrade’ from Misys EMR to Allscripts Professional turned into a morass of fees for training that would have cost more than  buying a competitor’s product. Not surprisingly, small practices in our area have turned to eClinicalWorks and Greenway and never looked back. Simply merging individual products repeatedly without true integration and delivering on promises is not sufficient for success.

Services

• The India-based support we were getting from Eclipsys and then Allscripts was horrible, but they have really taken the bull by the horns and cleaned it up. Recent responses to our problems were clean and focused and I have been pleasantly surprised.
• Outsourcing support to India was a bad idea. Docs like me call and we get people who don’t know the product. The same is true of their patient portal – it is a Babel Tower.
• We have seen deteriorating support and turnover amongst the sales/support team that crosses product lines. Physicians are losing confidence in the product.
• We’re a large Allscripts Professional client and it’s been frustrating to watch them struggle to grow and try to compete with Cerner and Epic. Their overall support and quality has suffered, especially with new releases.
• Please care about me and provide support. I know life isn’t the best for you right now, but I still have to work and I need you to fix the support structure. Keep current customers from being so put out with you and fewer of use will become someone else’s customer.
• Hire more qualified staff. They are hiring high school graduates for implementation consultant positions and giving them only basic training before sending them out to clients at $205 per hour.

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From Determinant: “Re: Cerner. Have you heard of them trying to sell ProFit patient accounting for both hospitals and practices? Looks like Cerner wants to complete head to head with Epic by offering one combined solution set for hospital, professional, and physician clinic billing.” I haven’t heard that. Anyone?

From The PACS Designer: “Re: Samsung Slate. One of the drawbacks of the iPad when it comes to viewing healthcare legacy apps is its small size. This hampers the effort to move these apps to a tablet display. Samsung has released a tablet called Slate with a 11.6 inch form factor, which should make the legacy app transition effort easier.” Samsung seems to be leading the “bigger than Apple is better since we can’t beat them otherwise” charge with its 3×6” Galaxy smart phone (or “smablet”) and now the 11.6” Slate. You’re going to look like a tool yapping into the bigger-than-your-hand Galaxy that covers the whole side of your head like Gordon Gekko’s 1987-era cell phone in Wall Street (which in turn looked like a Vietnam War walkie talkie), so I suggest budgeting for a headset and to arrange tailoring services for pocket expansion. The Slate will basically be the size of the entry level MacBook Air screen without the keyboard, meaning you’re back to a laptop size again other than the touch screen and a lot more money. Wasn’t portability the whole point of these devices? All of this makes me think that Windows 8 could be a really big deal since it seems that everybody wants some features of iOS (apps, touch, crisp display) but doesn’t care too much otherwise, and Win 8 will of course run on cheaper commodity hardware.

From Real Doll: “Re: former Cerner COO Paul Black on the board of Allscripts. The other new board member is from UPMC, which has close Cerner ties. Could be a merger in the works.” Unverified. I suppose anything is possible and Cerner isn’t all that strong on the ambulatory side, but that would be an ugly marriage.

Listening: Material Issue, a Chicago-based guitar-heavy power pop trio from the mid-80s. The frontman-founder killed himself in 1996, but the band left behind some great music. I also looked back to my February 13 post as Van Halen started their tour, when I said, “Check out their tour, but I’d be cautious about buying tickets for anything after the Boston show since tours seem to bring out the squabbling between the Van Halen brothers and whoever their lead singer is at the moment (Roth, Hagar, Cherone, lather, rinse, repeat) and the whole thing could go down in flames (think The Eagles without the concert-dollar greed that makes them pretend to get along.)” Sure enough, the band has postponed the remainder of their tour, although I missed the date — the Boston show was March 11 and it lasted a few weeks longer than that.

It’s OK to ask ED patients with non-emergent problems to pay before treating them, say 82% of respondents. New poll to your right, from the next story down: will Cerner and Epic be the only hospital information system survivors?

Cerner CEO Neal Patterson says at Cerner’s shareholder meeting that the company could be pulling in $10 billion per year in revenue by 2020, almost five times today’s total. He also says he’ll probably retire before then. When asked about the complexity of meeting provider technology needs, he said Cerner and Epic might be the only companies left standing. The “and Epic” part is not very Neal-like, so maybe he’s already mellowing on his way to the rocking chair.

Long-term care provider Deseret Health Group chooses HealthMEDX Vision to manage patient records across its 20 locations.

On HIStalk Practice, Inga interviews John McConnell, who sold more than $1 billion worth of companies that weren’t Eclipsys (Medic and A4) to what is now Allscripts.

Eight physician groups in the Kingsport, TN area start the OnePartner HIE, which will use the Siemens MobileMD platform.

The Twin Cities paper profiles the use of SafetyPad by Hennepin County paramedics. The tablet app, developed by Open Inc., receives 911 information, records vital signs, provides checklists, and notifies the ED that the patient is inbound. The hospital’s server receives a copy of the chart, looks for trends that may signal an epidemic, and bills insurance companies quicker than on paper (10 days vs. 90).

Here’s your weekly dose of HIS-tory, in which Vince talks about product names.

The FCC will vote this week on allocating a chunk of the wireless spectrum to Medical Body Area Networks, in which wearable patient sensors would communicate wirelessly to a local base station to send information back to physicians. FCC Chairman Julius Genachowski lauded the technology, citing examples such as remote EKGs, smart pill boxes, and diabetes management devices, also pointing out that half of hospital inpatients aren’t monitored and could potentially be with MBANs. If the rules are approved to reallocate the spectrum formerly used by commercial test pilots, the US would be the first country in the world with a dedicated spectrum for MBANs. He specifically mentioned that GE and Philips are working on the technology.

The results of Dr. Oz’s 15-minute physical on 1,000 Philadelphians using Practice Fusion’s free EMR: 43% were obese, another 29% were overweight (meaning a total of 72% weighed more than they should), 43% had high blood pressure, and 40% had pre-diabetes. Two patients were found to have significant problems (blood chemistry, hypertension) and were admitted to the hospital. Practice Fusion compared the data from its records on 40 million patients to conclude that more of those 1,000 patients were hypertensive than in several other large cities. The article says the Dr. Oz show chose Practice Fusion over several other EMRs that were considered, including Epic and drchrono.

Reading Hospital (PA) reports that a now-fired employee exposed the medical information of 12 patients by printing their billing information and using it in a training class.

A Department of Homeland Security bulletin warns that connecting medical devices to wireless networks is risky, and organizations that do it need to implement a really good security program. They mention the VA’s use of virtual LANs with access control lists as one way to keep unauthorized users out. A problem is that more devices are using commercial operating systems rather than custom-developed embedded ones, meaning they are more susceptible to malware.

A team of electrical engineering students from Portland State University wins Cornell Cup USA Presented by Intel for its prescription drug identification device, which provides near-instantaneous identification of tablets and capsules from their image. The students came to the university through the Intel Vietnam Scholars Program, in which interns from the Intel’s Ho Chi Minh City factory study engineering at Portland State.

In Australia, the government of Victoria finally kills off the HealthSMART project that was to have provided hospitals with software from Cerner, iSoft (now CSC), and InterSystems. The initial $318 million budget had run up a $557 million tab before funding was ended. Only four health services are live today of the 10 the government had promised would be running by 2007. Most folks blame mismanagement and poor planning rather than the vendors.

The Chicago business paper reports that Merge Healthcare Chairman Michael Ferro and companies he’s invested in have earned $9.3 million in side deals from Merge. Only four of the 11 related-party transactions were reviewed by independent directors. Shares have dropped 61% in the last couple of months.

The former assistant dean of Temple University’s medical school, along with the university, will pay more than $1 million to settle Medicare fraud charges in which $4.5 million in plastic surgery work was billed to Medicare but performed by unsupervised medical residents. The doctor is serving a seven-year term in federal prison for 150 counts of fraud.

The Tucson newspaper recognizes Sunquest Information Systems interface programmer Kenny Wickert, who throws annual  cookouts at work to collect co-worker donations for a Tucson child protection organization. Each event raises around $5,000. Says Kenny, who has worked for Sunquest for 21 years, “I see people dropping 20 and 30 bucks in the jar for a burger … We grew up just dirt-poor, and she always made it work with what we had. It’s kind of fair that I give back now that I can.” The award was given by Ben’s Bells, a kindness recognition program started by the mother of two-year-old Ben, who died when a respiratory infection caused his airway to swell shut while he was playing.

I lauded HealthNovation President and CEO Mike Mosquito at HIMSS in Las Vegas after observing his sartorial splendor, explaining as I asked to take his photo that Inga would be impressed with his truly sharp-looking outfit. Here’s a shot of him taken by Jennifer Dennard at last week’s Georgia HIMSS golf tournament, pulling off a great look despite what might appear to a highly questionable choice of trousers even in the “go to hell pants” world of golf clothing (I’m thinking Rodney Dangerfield’s Al Czervik in Caddyshack). I found by searching that I ran a photo of Mike from the same tournament last year, in which he was equally resplendent. I should get him to take a pic of his closet contents.

The event funded $2,000 scholarships for Ana Alston (Georgia Health Sciences University), Tiffany Formby (Georgia Tech), Laura Griggs (College of CoastalGeorgia), Lars Moen (Georgia State), and Laura Sims (Georgia Tech).

E-mail Mr. H.

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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 May 2007.

Incompetence by Committee: How Customers Dumb Down Vendor Software
By Mr. HIStalk

We software customers often complain that our vendors lack vision. Maybe so, but what goes unsaid is that we ourselves are largely responsible.

Many or most vendors do their best work before their second customer comes on board. Their bright and dedicated employees, along with perhaps a development site’s subject matter experts, work from a blank slate and do some really innovative work.

Once customers sign up, however, the once-fresh product is dumbed down. Every new customer has their list of must-have enhancements, almost entirely (a) a smorgasbord of unrelated bells and whistles they saw in some other vendor’s demo; or (b) a feature of questionable necessity that exists only in the product they’re replacing. Consider the irony in either case.

That’s why software turns into a crazy quilt of unrelated and immature ideas. Too many customers come up with lame ideas that vendors are scared to ignore.

Customers, you see, are terrible visionaries. They always have a punch list of minor productivity tweaks and site-specific changes that move the product sideways at best. Vendors who ignore these suggestions, often with good reason, are considered unresponsive.

No wonder quality assurance, product documentation, and integration are so bad in healthcare software. Applications aren’t an integrated software platform with a clear focus – they’re a collection of unrelated product features and emergency tweaks held loosely together with the unreliable glue of a common user interface, customization switches, and a single database, all voted on by committees of self-interest.

Too many cooks in the kitchen indeed. We blame customers or poor training when only 20% of software capabilities are used. Maybe it’s because only 20% of a scattershot of functionality applies to a given site.

The enhancement process encourages this. A bunch of customers – heavily overweighted by those from big hospitals with travel money – sit in a room and vote on enhancement ideas. What’s wrong with that democratic approach?

• The larger the committee, the less likely anything bold or innovative will result.
• The voting process ensures that only safe, universally acceptable enhancements will be chosen. Products that were created through risk-taking and creativity get watered down by dull, uninspired changes that neither enrage nor delight anyone.
• Small, obviously beneficial changes never get done. Why waste your user vote on something less than a sweeping change that no one else wants?
• Customers have no idea what they want or need. They’re also unwilling to expend any more effort than to toss out off-the-wall suggestions.
• Customers will provide crudely drawn screen mockups (users think only in terms of screens). They don’t employee critical thinking skills until the enhancement arrives on their doorsteps, at which time they suddenly get engaged and loudly proclaim its imperfection and refuse to use it.

Ample evidence exists that hospitals have few original thoughts and little ability to think strategically. Putting hospital staff in charge of product design and strategic direction is a bad idea.

Once a product has evolved into a Frankenstein-like set of unrelated product appendages, testing and integration get geometrically more difficult. A great niche product with a fanatically loyal customer base becomes an unwieldy fibrillation of disjointed ideas with an indifferent audience and mediocre KLAS scores (sound like anybody you know?)

Vendors don’t help. Is the intended product audience a 50-bed rural hospital, a 1000-bed academic medical center, or an IDN with a big ambulatory business? "Yes!! We want a product that is universally cherished and appreciated." Fat chance.

I see nothing to challenge the basic premise that innovation will come only from small, cheeky vendors willing to break the rules and provide leadership, not contract programming to customer specs. At the other end of the product life cycle is the elephant graveyard, those publicly traded vendors and multi-industry conglomerates where once-interesting products go to die slowly and painfully.

What happens in between is up to us customers.

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