And Caesar’s spirit, raging for revenge,
With Ate by his side come hot from hell,
Shall in these confines with a monarch’s voice
Cry “Havoc!” and let slip the dogs of war,
– Julius Caesar, Act 3, Scene 1

If ever there was havoc in the boardroom of a health IT company, this is it. Over the last several days, chairman Phil Pead (bio still up for now), CFO William Davis and three board members unceremoniously and promptly departed the management team at Allscripts Healthcare (MDRX), a company which, it’s hard to argue, otherwise seems to have been on a reasonable course for the past year or so.

By the way, this seems to have been as much an Eclipsys purge as a board purge, as all of the departing members were with the company, which Allscripts acquired in September 2010 with “a vision for a Connected Community of Health.”

Within a few days, the Board announced that it had elected board member Dennis Chookaszian as Chairman. No word yet on which unlucky CFO will be hired to face the fires of investor displeasure over the stock’s performance (see below).

It’s bad enough when a chairman and three board members split — allegedly in support of now-ex chairman Phil Pead — but when your CFO leaves, a girl’s gotta wonder whether financial improprieties will turn up later. Now, let’s be clear, I’m not suggesting that there are ANY financial issues that I know of myself, directly, but it’s never a nice thing to see Mr. CFO shove off so quickly.

What we do know is that Allscripts was slapped with a suit in 2009 alleging the company broke federal securities laws when it went live with the latest version of its EMR. Current CEO Glen Tullman and now departed CFO William Davis were named as defendents. The  accusations in the 2009 suit seem to boil down to that Allscripts failed to let customers know that it couldn’t afford to install its Touchworks 11 software properly on customer sites.

It gets even better

And now, even more fun. Perhaps to contribute to the gladiatorial atmosphere, one of Allscripts’ largest shareholders demanded Monday April 30 that its chief executive Glen Tullman resign.  (If I were Tullman I’d say “the heck with that,” gather a group of investors and buy the darned thing out from under them. Mr. Tullman, go for it!)

Anyway, it seems that HealthCor Management LP, which owns about 5 percent of Allscripts outstanding shares, thinks execs have done a bad job building the value of the stock. The fund said the stock  is “being valued well below any reasonable acquisition price,” at its Friday close of $10.30.  Other investors seem to agree with HealthCor, as the stock went  up 7.73 percent to $11.10 at the close of trading on Monday April 30.

To make sure nobody panics, the company has hurriedly announced a $200 million stock repurchase  plan, adding to a plan announced a year ago which still contains $148 million for repurchase. That should do something to keep the stock from careening down a greased slide.

Why, oh why?

Now, to the real question. Why the big shakeup in the boardroom at a time when EMR/EHR companies are extremely vulnerable to market shifts and missteps? I can’t say I’ve found any concrete reason in my research, other than storied “differences of opinion over the direction of the company.”

The financials, while they could probably be much stronger, aren’t exactly pathetic. We’ve got a 5.1 percent profit margin, quarterly revenue growth year over year of 25.5 percent and a P/E (ttm, intraday) of 28.52.  The only obvious disappointment is the big drop in share price, which fell nearly 50 percent over the last 52 weeks of trading.

And in a somewhat ironic twist, it seems that Allscripts is touting some variant of the software Eclipsys had (Touchworks) when it first ran into SEC trouble.  Allscripts may not like the guys behind the technology, but it likes the technology for sure. (Actually, I’m eager to learn more what Allscripts is doing there — drop us a note on our contact us page if you have more information.)

P.S.  In the view of your friend and mine Mr. HISTalk, “No matter what explanations are provided, the casual observer might conclude that Glen (Tullman) staged a coup that cost the company four board members and its CFO at the worst possible time.” What do you think?

Change is in the air when it comes to venture capital (VC) investment in healthcare. I wrote about this a few days ago on a post on EMR Thoughts called VC Investment in Healthcare. The final paragraph is a nice summary of my thoughts:

I think we’re seeing a shift in healthcare investment into a large number of smaller companies who can innovate as opposed to larger sums of money into medical device and biotech companies. In some ways we’re seeing the costs associated with a startup company in healthcare starting to come down the way they did in the IT side of things.

I was amazed by the timing of a post from my favorite venture capital blogger, Fred Wilson, called Can The Crowd Be More Patient?. His first paragraph provides a similar sentiment:

One of the most noticeable changes to the VC business over the past decade is the movement of investment allocation from capital and time intensive sectors like biotech and clean tech to capital efficient and fast moving sectors like internet and mobile.

Although, Fred offers an interesting twist on where sectors like biotech might get their funding in the future: crowd funding.

The idea of crowd funding is definitely beginning to take shape. Websites like Kickstarter and IndieGoGo have started the trend with no equity involved and the latest jobs act has opened up the door to allow crowd funding to happen with equity involved. For those who don’t know what crowd funding is, it could be 1000 people all “investing” $100 into a company that needs to raise $100,000. That means that 1000 people are all at very little risk, but the company gets a relatively large sum of money. Those who invest the $100 would own a very small part of the company and benefit in any upside the company experiences. It’s going to be a game changing way to fund entrepreneurship and will be an incredibly important investment trend.

The interesting thing is that we’ve seen this funding trend in healthcare for a really long time. Ok, they haven’t gotten equity for the investment, but how many of you have supported cancer research or diabetes research through a donation? That’s basically an investment in the companies that are doing that research.

I heard an interesting statistic a few days ago during a very informative webinar – “The Future of Meaningful Use, EHRs and Accountable Care” – hosted by Greenway Medical’s Justin Barnes. He shared a huge amount of information during the hour-long presentation, but the fact that most stood out to me was that, according to Barnes, between 35 and 50 percent of EMRs will eventually be replaced after just one year of use. (Don’t quote him on the “year,” but I’m pretty sure that’s what he said.) His point being, of course, that providers need to think long and hard about what type of solution they need to fit their workflows before they spend time and money implementing an EMR.

This sentiment was echoed by Kimberly Harding of BCBS Florida in a panel at the iHT2 Summit in Atlanta. As part of a greater discussion on Meaningful Use, she made the comment that just because a healthcare IT product is certified doesn’t mean it’s the best fit for a particular facility.

My takeaway from both of these statements is that providers looking to adopt new healthcare IT tools like EMRs need to take a long, hard look at what their current needs are and what their future needs might be before they even think about demoing products.

They also need to adopt technologies that fit their workflows, not necessarily technologies that have a ton of bells and whistles. Added features won’t do anyone any good if they’re never used properly, never used at all, or used to the detriment of a physician’s productivity.

I kept this sentiment in mind when I read the results of a recent study of 250 hospitals and healthcare systems by consulting firm KPMG. The survey found that “71% of respondents’ organizations are more than 50% finished with their EHR adoptions. Will this 71% be satisfied with their EMRs once fully installed and adopted? How many will realize their product of choice wasn’t the right call? If we apply the Greenway statistic, that could be as many as 125 facilities!

So where is the disconnect? Why are providers making poor choices with presumably the best of intentions? Why has the term “rip and replace” become so well known in healthcare? Are physicians misinformed, or not educated enough? Are they feeling so rushed by Meaningful Use deadlines that they don’t perform proper due diligence? Are vendors part of the problem? If so, shouldn’t they be part of the solution? What role do regional extension centers have to play in all this?

If you have answers, please let me know in the comments below.

I must say this headline from Fierce Health IT gave me a great many giggles today: Healthcare social media a ‘moral obligation’. No shred of irony in the article either, which quotes Farris Timimi, M.D., medical director for the Mayo Clinic Center for Social Media, thusly:

“Our patients are there. Our moral obligation is to meet them where they’re at and give them the information they need so they can seek recovery,” Timimi said. “You’ve got to be ready for it. You build it for the patients; not for yourself.

“This is not marketing,” he added. “This is the right thing to do.”

Are you sure it’s not just a way to log in to Facebook while you’re on the clock, Dr. T?

Not to come down too hard on Dr. Timimi, but I can think of plenty of other medical things which are “moral obligations”: saving patient lives, or low cost accessible healthcare for all. Being able to find a condesed tweet about bunions – um, not so much. I mean, healthcare is already quite a messpool to be in without doctors and hospitals flogging themselves over not being social media savvy enough. And not everyone can be a social media rockstar John D Halamka.

I know I’m being wilfully dense tonight. And the esteemed Dr. Timimi probably had stuff like Facebook pages and cancer blogs in mind when he talked about healthcare info via social media. But I scoured Twitter for “medical advice” and “cancer” and found that there’s some accidental giggles to be had:

Tim Brookman ‏ @T_Brookman
Next person that texts me for medical advice is getting told to apply icyhot directly to their genitals

nicole west ‏ @NicNac19
I love when friends come to me & ask medical advice & I actually know the solution… just don’t quote me, lol.

saintseester ‏ @saintseester
will not be giving free medical advice on anonymous social media. You’d be an idiot to take advice like that anyway.

Official Cancer Page ‏ @Cancer69_
#Cancer is big on trust and if you lie to them they will make sure you regret it
(yeah, yeah, I getit.. they’re talking about the sun sign)

Anybody catch the recent Mashable.com or CNN articles on the feedback Facebook COO Sheryl Sandberg has received because she makes it a point to leave work at 5:30 pm every day? (You can read them here and here.) In a nutshell, Sandberg has always left the office around that time – a practice she started when she first had kids, but has only felt comfortable talking about it now that she is in upper management and (presumably) somewhat immune to corporate push back. ( Don’t confuse leaving work with not working, by the way. Sandberg, like many others, checks email at all hours.)

Mashable CEO Pete Cashmore, who authored the CNN.com story, summarizes the mini-controversy that has evolved in the tech world as a result of Sandberg’s coming clean: “In a competitive industry where your work is never truly complete, has it become socially awkward to leave work at a time that used to be the standard? And are those working eight-hour days that end at 5 p.m. being quietly judged by their co-workers? Whatever happened to “work-life balance”?

Good questions, to be sure. So good, in fact, that I felt compelled to pose a similar query to a panel of current and former healthcare CIOs – all guys, by the way – at the recent Women in Technology International (WITI) / GAHIMSS event, “Women in Healthcare IT Talk.”

Piedmont Healthcare CIO Mark Pasquale was refreshingly candid in his response: “I don’t have a work-life balance.” His point being that, as a CIO overseeing a near-future EPIC ERP system go-live, his work day never really ends, especially given how connected he is via multiple mobile devices. He also pointed out that, as 85% of Piedmont’s install team is internal, Piedmont spent copious amounts of time preparing that staff for the time commitment required to travel to Epic headquarters in Madison, Wisc., for training. Pasquale kept an open door, and said many staff members came by multiple times to hash out whether committing to such an intense project was the right move for them.

From left to right: Christopher Kunney, The BAE Company; Sonny Munter, Georgia Dept. of Community Health; Mark Pasquale, Piedmont Healthcare; Praveen Chopra, Children's Healthcare of Atlanta

Fellow panelist Christopher Kunney, HIT Strategist at the BAE Company and former CIO of Piedmont, made the point that you have to be aware of what you’re signing up for when you enter healthcare’s executive ranks. Long days aren’t unusual; they are the norm. Children’s Healthcare of Atlanta CIO Praveen Chopra concurred, adding that his wife makes him limit use of his Blackberry on vacation to just one hour a day. Sonny Munter, CIO of Georgia’s Dept. of Community Health, joked that he leaves his job everyday at 4pm – but gets going around 6 in the morning. Munter added that he makes it a point to surround himself with good staff members, which also helps in balancing his work and family obligations.

From left to right: Lisa McVey, McKesson; Gretchen Tegethoff, Athens Regional Medical Center; Patty Lavely, CIO Consulting LLC; Deborah Cancilla, Grady Health System

A second panel of healthcare executives – all female – pretty much agreed with their male counterparts. Patty Lavely, founder of CIO Consulting LLC and former CIO of three different health systems, did echo Facebook’s Sandberg just a bit in her comment on the subject: “There comes a time when you have to say, ‘This [work] will be here for me tomorrow. I need to go home and have dinner with my family tonight.”

All of the panelists mentioned the need to prioritize workplace projects and challenges in a way that is suitable to the particular balance they need in their lives. They have triaged, so to speak, their commitments, priorities, deadlines, etc. to fit their schedules.

So, can healthcare IT folks – providers or vendors, executives or otherwise – ever be off the clock, never mind leave the office between 5 and 6? Share your stories and advice in the comments below.

Not long ago, American Medical News ran an article on training up medical practice staffers for EMR use. The piece concluded that while practices may save some bucks on the front end, they generally end up regretting it later.  An anecdote from the piece:

Nine months after All Island Gastroenterology and Liver Associates in Malverne, N.Y., went live with its electronic medical record system, practice administrator Michaela Faella realized things had not gone as smoothly as planned.

Even though the staff had used other health information technology systems for many years and considered itself tech-savvy, it had taken everyone six months to learn how to use the new EMR system. Several months later, the staff still had not become proficient at it.

The problem was not with the staff, but that the practice cut training short to save time and money. “Training was not placed high on the priority list, and we paid the price for it,” Faella said.

As the piece notes, many practices assume that the training bundled into the cost of their new EMR will meet their needs, and find out to their regret that this isn’t the case.  (In fact, I’d argue that this is more the rule than the exception, based on anecdotes I hear in the field and in conversations with physicians.)

A consultant quoted in the piece suggests that practices should consider three main issues when planning for training:

1) How much data they’ll be dealing with, which can vary greatly depending on whether all data is imported in advance or done patient by patient

2) Whether the practice will be integrating new systems into the EMR, such as e-prescribing, or conversely, adding an EMR to existing systems

3) Whether using the EMR will call for using new hardware such as tablet computers

Personally, I’m not satisfied by that list at all.

What about, first and foremost, assessing the staff’s existing skills more precisely, walking staffers through the various layers of the EMR on a daily basis, forming teams of superusers within the organization to help the less skilled and taking steps to be sure EMR problems don’t interrupt critical functions (a backup/workaround plan for the short term)?

What do you think?  Does the list above cover the critical EMR practice integration issues?  Am I just being testy?

I got just a glimpse yesterday of what clinicians must feel like when they log into an EMR for the first time – giddy with anticipation, hopeful that its use will ultimately lead to better patient outcomes and easier workflows for all. On the flipside, there was also frustration, impatience, and a bit of confusion.

Just before bedtime, I fired up Calorie Counter, my newest iPad app. As with any community you join, I first had to fill out a member profile, which took some time. I then had to learn through trial and error how to navigate through the program – search for, find and choose the foods I had eaten earlier that day, make adjustments for portion sizes, then log the data. The app’s drop-down menus included some of the foods I ate, but not all. “How do I add foods to the stock menu?” I wondered, thinking at the same time that this must be what doctors feel like when they can’t find what they need in an EMR.

It didn’t take long, and I’m sure now that I’ve at least done it once, future data entry will be more intuitive, and quicker. I do wonder about the rate of retention for this type of app, though. Do people stick with it for more than a few days or weeks?

I’ll have to either keep a running paper list of the foods I eat throughout the day, or bring my iPad with me wherever I go in order to log my calories. I was bummed that I couldn’t find this particular app for both the iPad and iPhone. (Those that were developed for both just didn’t seem to be as robust.) Perhaps this twinge of disappointment has been felt by doctors who have fallen in love with their new EMR, only to realize they can’t access it via their chosen mobile device.

It will take dedication on my part to keep up with daily logging of calories and activity, but I am convinced it will be worth it. After just one day, I’ve already had a nutritional wake-up call: Just seeing how much cheese I eat has made me decide to cut back before bathing-suit weather.

The beauty of the app isn’t the comprehensive list of foods already plugged in from which to choose from, but the calorie recommendations it makes based on members’ profiles (weight/height/activity level/age/gender, etc.) and the analytics that will result after I have a few days/weeks/months logged. Patterns will emerge that will give me a clearer picture of my diet – foods I should keep eating, those I should eat in moderation, and those I should avoid all together as long as I’m trying to reach a certain daily caloric intake. Not quite as important, but still similar in my mind to the aggregating power EMRs have when it comes to clinical data.

Other than keeping up with the daily log, I also have the option of joining the Calorie Counter community on Facebook, and I think there’s a brief tutorial out there I can take a look at. Depending on my time available, I may not do either – a course of action I’m sure a few doctors also opt to take with their EMRs, which I assume is ultimately detrimental to the results they’ll see with the technology.

In addition to trying to get a bit healthier, I’m overcoming my resistance to change (as if I really want to eat less cheese!), which as my colleague John pointed out in a recent post at EMRandHIPAA.com, is “the number one reason doctors aren’t adopting EHR software.”

But change is usually good, and as John also points out, “resistance to change is going to be the reason why EHR adoption will become the norm.” I’ll let you click over to his post to find out why. In the meantime, I’m going to try and resist the bagel with cream cheese that seems to be calling my name from the kitchen.

New research is drawing to attention to a critical subset of  ”alert fatigue,” a problem which has dogged medical devices since well before EMRs/EHRs rolled into the picture.  The research, which appears in this month’s issue of the International Journal of Medical Informatics, finds that providers are becoming particularly numb to the high volume of EMR-based medication alerts they get.

To draw this conclusion, researchers followed 30 doctors, nurse practitioners and pharmacists as they treated 146 patients in outpatient settings run by the Indianapolis VA center. The study took place from August 2008 to August 2009.

After watching providers for a year, researchers came up with several different features characteristic of a poorly designed alert:

*  The system generates too many alerts
*  The alert provides far more information than the clinician needs
*  The system produces alerts that appear to go against standard clinical practice
*  The alert doesn’t apply to the patient
*  The alert isn’t needed (such as a warning about a drug a patient has already received and responded to safely)

Another failing found by researchers — which seems particularly acute in my opinion — is that alerts are typically designed to meet the needs and training of pharmacists, even though physicians and nurse practitioners were doing the prescribing.

Yet another issue that stood out was timing. On the one hand, alerts often interrupted the prescribing process, and wouldn’t go away until addressed.  Meanwhile, other alerts disappeared once addressed, and couldn’t be retrieved once they’ve left the screen.

As most readers know, I’m not a clinician, so I’m just reacting to the research data, but the situation sounds pretty dire. If an EMR is guilty of half of these medication alert “sins,” much less all of them, I’d bet it increases the potential for patient harm significantly.

Maybe this is a good place to start addressing the kind of potentially harmful design flaws identified by NIST. After all, virtually every patient takes meds, and  most every clinician touches them. Why not address some of these nagging problems before someone gets hurt?

I’ve been writing about and commenting on the plight of healthcare IT students for a few months now, and the recent HIT job fair I spoke at gave me a great chance to talk one-on-one with folks finishing up their course work and getting ready to enter the job market. One – Helen Murphy, who is currently Director of Sonographic Education at Worldwide International Emergency Medical Services in Atlanta – was nice enough to share her experience with me first-hand.

What educational program are you in right now?
I have recently completed the Health Information Technology (HIT) Workforce Development Program Trainer Role being offered through the Atlanta Technical College.  Atlanta Tech is one of the Community College Consortia designated to educate HIT professionals.

What prompted you to enter a healthcare IT curriculum?
I understand the value of Healthcare information technology, and the benefit EHRs will bring with regards to patient safety, workflow efficiency and return on investment.  The opportunity to use my healthcare education along with my training experience was a perfect combination to me. Educating and/or training have been a part of all of my work experience, and this program is an opportunity to be a part of a profession that is in its infancy.

What did you find to be the most challenging in your studies?
My background is healthcare-based, so understanding some of the IT areas are challenging to a degree.

When do you anticipate graduating?
I have completed the course and I am now studying to take the competency exam.

How is your program helping you with system training? Apprenticeships/internships/co-ops, etc.?
Atlanta Tech has initiated a six week program/internship where students who have completed the curriculum will have the opportunity to work with Pristine Technology Solutions – an Atlanta-based technology company that focuses on EHR application sales, implementation, training, support and understanding the steps to help providers reach the goals of Meaningful Use.

How has your school helped you in looking for a job?
The school has had one job fair that I attended prior to me completing my curriculum.  The internship that I am currently in made us aware of the Technology Association of Georgia Health IT Job Fair where I met you, and where the students from the Atlanta Technical College program were able to see what companies are looking for in a health IT workforce graduate. This is helping me to understand how to align my education and experience with the needs of the employers to create a tailored perspective that will show the immediate value I can provide for them in health information technology.

What do you anticipate your chances of finding employment to be right after graduation?
I anticipate employment in the very near future because the Atlanta Tech program has provided us with an internship that gives us direction in the job search.

Do you get the feeling it’s a competitive field?
I do not think there are enough trained HIT workforce individuals. Employers in some cases at this point are not completely sure what they need in potential employees, and until the field of healthcare IT has developed further, there will be a continued need for HIT trained professionals.

What are you doing to stand out from the pack?
I am developing a presence on Twitter, upgrading my LinkedIn Profile, and starting a blog about my process of becoming a health information technology professional.  I am also gaining as much knowledge and experience as possible through the internship that is being provided by Atlanta Technical College. I also understand the importance of training, and am building a strategy that will allow me to understand the needs of the providers so that I can learn to create targeted engagement methods to meet their individual needs.

Do you have any other tips for those seeking employment in HIT?
Of course, updating your professional profile to highlight your HIT experience and education is critical. Attend job fairs where a job seeker can become aware of the types of positions that are available and how they would best qualify for those positions.  It is also crucial that the job seeker understand the HITECH Act and be able to speak knowledgeably about Meaningful Use.

Most of the critiques I read of EMR design ding the EMR for its difficulty to use or its inability to accomodate the workflow of the institution that bought it — and of course, sometimes both. What I’ve never heard suggested, however, is the following idea proposed by Chuck Webster, a guy who clearly doesn’t stop short when he decides to study something. (He’s an MD, an MSIE and an MSIS in intelligent systems design, which is only one of the reasons I think he’s onto something here.)

In a thoughtful and nuanced blog entry, Dr. Webster outlines the work of a pioneer in usability design, Donald Norman, and comes away with the conclusion that the current trend toward “human-centered design” might actually be a mistake.  What a pain — health IT limps along catching  up with a trend from the 1980s, and now may be too late to catch the bus.

In any event, Dr. Webster argues instead of focusing on human/user-centered design, EMR vendors should be focused on activity- or process-centered design. I love what he says about one of the potential problems with human-centered UIs:

Optimization around a user, or user screen, risks the ultimate systems engineering sin: suboptimization. Individual EHR user screens are routinely optimized at the expense of total EHR system workflow usability…I’ve seen EHR screens, which, considered individually, are jewel-like in appearance and cognitive science-savvy in design philosophy, but which do not work together well.

It’s better, he suggests, to have EMRs model “interleaved and interacting sequences of task accomplishment” first and foremost. For example, he writes, key task collections that should be considered as a whole include workflow management systems, business process management, case management and process-aware information systems.

While there’s much more to say here, of course, I’ll close with Dr. Webster’s words, who once makes his point with wonderful clarity:

User-centered EHR design does help get to good EHRs. Good isn’t good enough. If EHRs and HIT are going to help transform healthcare they need to be better than world-class (compared to what?). They need to be stellar. Traditional user-centered design isn’t going to get us there.

The question I’m left with, readers, is whether you can have your cake and eat it too. Does one side of UI/UX design literally have to be jettisoned to support the other?