Lab Soft News

Joel Saltz Appointed as Emory Healthcare’s Chief Medical Information Officer

In a previous note, I reported Fred Sanfilippo's departure from Ohio State (see: Fred Sanfilippo, Noted Pathologist, Moves to Emory). Joel Saltz, a leader in pathology informatics, is now making a similar move to Atlanta (see: Bioinformatics Pioneer Will Lead New Initiatives at Emory University). He currently serves as professor and chair of the Department of Biomedical Informatics and professor in the Department of Computer Science and Engineering at The Ohio State University, Davis Endowed Chair of Cancer at OSU, and a senior fellow of the Ohio Supercomputer Center. Below is an excerpt from the article:

Joel H. Saltz, MD, PhD, a pioneer in the fields of high-performance computing and biomedical informatics, will join Emory University’s Woodruff Health Sciences Center in September as director of the Center for Comprehensive Informatics and as Emory Healthcare’s Chief Medical Information Officer. The announcement was made by Fred Sanfilippo, MD, PhD, Emory executive vice president for health affairs, CEO of the Woodruff Health Sciences Center and chairman of Emory Healthcare....As chief medical information officer for Emory Healthcare, Saltz will direct strategic planning and implementation of the comprehensive Emory Medical Information Enterprise. He will guide recruitment, research and resource allocation for informatics programs across academic departments. Additionally, he will lead the further development of Emory’s external partnerships in bioinformatics, including those with the Georgia Institute of Technology, Children’s Healthcare of Atlanta, Morehouse School of Medicine, the Atlanta Veterans Affairs Medical Center, the Georgia Research Alliance and the Georgia Cancer Coalition.

Epic Flexes Its Political Muscle in Wisconsin with Boycott

Some of my recent notes have focused on the corporate culture of Epic Systems (see: Epic Systems and Its Corporate Culture; More on the Epic Culture: Is This a Cult or a Company?). This activity has brought to my attention a political tempest that has been brewing around Epic in its own back yard in Wisconsin (see: Epic Systems Should be WMC's Biggest Fan). Epic recently announced that it will no longer do business with companies associated with Wisconsin Manufacturers & Commerce (WMC), a Wisconsin trade and lobbying organization.  The reason for this boycott is Epic's opposition to WMC's involvement in the election of Michael Gableman to the State Supreme Court. This same article makes the following comment about Judy Faulkner, the CEO and founder of Epic (boldface emphasis mine):

Epic has always marched to its own beat.  Founded and led by Judy Faulkner, the company has blossomed into one of the top five providers of automated medical record systems in the nation....She likes telling people that the company is growing 30% annually and has zero debt.... While on paper she has a number of advisory groups, no company decision of any consequence is made without her....[She refuses to] advertise or market [and shuns] traditional business planning....But she can do that because it is her company. She has no board of directors to answer to, no proxy votes to worry about and no annual shareholder meetings where she has to explain herself.  In fact, the reclusive Ms. Faulkner feels little need to explain herself about anything.

Forbes.com had the following to say in a recent article about this same issue (see: Madison area company targets lobbying group):

[WMC's] participation in the recent state Supreme Court race won by ... Judge Michael Gableman has drawn the ire of Epic Systems, a medical records company in Verona that doesn't belong to the group. Epic said in a statement it was upset that WMC spent an estimated $1.8 million on that race and may pull business from local vendors who support the group. Those vendors included...J.P. Cullen & Sons, the contractor for Epic's more than $200 million campus expansion. CEO David Cullen resigned from WMC's board of directors on June 9 and his company dropped its membership....Epic's threat not to work with another company based on an election campaign appears to be the first of its kind nationwide, said Howard Schweber, a professor of law and political science at the University of Wisconsin-Madison. Its action is perilously close to a type of illegal boycott that typically arises in labor disputes, Schweber said. "We should be uncomfortable when private businesses have enough power to coerce businesses or other organizations to change their political views or affiliations or keep them secret," Schweber said.

Here's more about Epic's actions from Professor Schweber (see: Howard Schweber: Epic's power should not be used to silence others). He himself is very critical of WMC but makes some very interesting points about primary versus secondary boycotts and this is the basis for his criticism of Epic. In the case of a secondary boycott, an attack is mounted on the supporters of the primary target.

What I find the most interesting about this controversy is that large health systems such as Kaiser are willing to spend hundreds of millions of dollars for mission-critical clinical software supplied by a privately-held company like Epic that is so tightly controlled by its executive office and founder. This same issue may occasionally arise during the purchase of an LIS but the stakes are never as high.

More on the Epic Culture: Is This a Cult or a Company?

My recent blog note about Epic Systems (see: Epic Systems and Its Corporate Culture) seems to have stirred great interest and is currently the most popular individual entry page for Lab Soft News. Interestingly enough, many of the visitors have come from the Epic IP address. Perhaps I should label Lab Soft News as "not safe for work." Because of its strong corporate culture, Epic is not infrequently referred to as a cult. I am not the first to consider this idea -- a Google search for Epic Systems and cult yielded 779 hits.

Cult members are followers of an exclusive system of religious beliefs and practices. Describing a company such as Epic as a cult can perhaps be interpreted as an overzealous attempt by its competitors to cast it in a negative light and perhaps hinder its new employee recruiting efforts. On the other hand and drawing ideas from my original note, certain aspects of its culture may appear to be cult-like. Take the following Epic strategy, for example:

Rather than seeking experienced healthcare IT professionals, Epic relies on hiring a large corps of the brightest young, just-out-of-college IT professionals for its programming and implementation positions.

The Marine Corps has followed a similar strategy of attracting young recruits and then inculcating in them the culture of the organization. Everyone understands that young minds are generally more malleable and trainable. However, there is one major threat to establishing a cultish HIT company. After an initial training and indoctrination program, the newly minted acolytes are sent into the field to mingle with the unenlightened, otherwise know as employees of client hospitals. In such environments, there is the risk that the Epic doctrine can be questioned by more experienced hospital IT personnel. In order to avoid such confusion, it is necessary to establish a high degree of client-control. Evidence about how this is achieved can be found in three other elements of the Epic set of beliefs, copied from my original blog note with boldface emphasis mine:

Epic does retain salespeople, but they make no commissions on sales, and act more like advisers and consultants than traditional salespeople.

Epic turns away potential business. Indeed, prospective customers meeting with Epic representatives find they are being evaluated as much as they are evaluating.

Epic executives have evolved a very specific implementation process over time, one that involves intensive pre-implementation analysis and planning, but then focuses very strongly on meeting go-live dates.

Epic seems to choose its customers -- they do not choose it. Presumably this selection process is based on the willingness of the client to accept rules and processes set by the company. The company personnel function as advisers and consultants and not as a vendor at the beck and call of its customers. Finally, the specific implementation process, which is obviously enforced by the terms of the contract, imposes discipline on the client hospitals which presumably results in a successful go-live of the Epic software products in most cases. Cult of not, this is not the modus operandi of any other healthcare IT company.

For what's it's worth, here's  the opinion of Viktorcello abut Epic:

They are the devil! People get sucked into there and become totally arrogant and they change! And they really eff with you throughout the interview process, which takes like three months. And they make you work overtime all the time.

McKesson CIO Interview: What's Wrong with Healthcare IT

I have published a number of previous notes about the shortcoming of EMRs. My working theory for these chronic problems has generally been that hospital CEOs/CIOs have tolerated inadequate products and that the vendors have been happy to supply such products for the market. I have also suggested that most EMRs are too complicated and do not always increase the efficiency of the individual physicians working in hospitals (see: The Goals of an LIS Compared to Goals of a Hospital EMR). Because of my interest in this topic, I read with interest a recent WSJ interview with Randall Spratt, McKesson CIO (see: Prescription: Technology). Below is his response to the question of "what's slowing health IT down?" Boldface emphasis is mine.

MR. SPRATT: Health care, for a variety of reasons, has been the technology-adoption laggard of the U.S. Part of it is sheer complexity: The business model of health care is 100 times more complicated in terms of its information density and variability than any other business. Part of it is the economic model: Health care operates in very narrow margins, about 1% or 2% in for-profit institutions. So they don't have the resources to spend.

Randy Spratt was one of the pioneers in the LIS world. Here is an extract from his bio:

Prior to joining McKesson, Spratt held executive positions of increasing responsibility at the start-up Advanced Laboratory Systems (ALS), culminating with the role of Chief Operations Officer. ALS was acquired by HBOC in 1996, which in turn was acquired by McKesson in 1999, and Spratt took on responsibility for HBOC's laboratory systems business shortly thereafter. Following the acquisition of HBOC by McKesson in 1999, Spratt relocated to Georgia to become part of the reconstructed management team.

I think that it would be too much to expect for the McKesson CIO to be too critical of healthcare executive or EMRs in general. However, I have posted previous notes about some of the non-profit hospitals drifting from their mission and the extravagant salaries of some of their executives (see: Non-Profit Hospitals Drift from Their Mission Despite Subsidies). I have also commented about the high cost of Kaiser's HealthConnect EMR project:

Kaiser admits to a cost thus far for the EMR of $4 billion plus $1 billion yearly for maintenance. Only 13 of the 36 Kaiser hospitals have gone live with the inpatient EMR system thus far.

So, at least for Kaiser, their meager margins seemed to be sufficient to pay a very high price for a not-yet-system-wide EMR. I agree with Randy that EMRs are very complicated and that this factor contributes to many of the problems encountered when they are deployed.

The Future of the Personal Health Record (PHR)

I have posted a number of previous notes about personal health records (PHRs). John Moore over at the Chilmark Research blog recently posted on the web one of his lectures about PHRs: Evolving PHR Market: Analysis and Trends. John has been providing some of the most perceptive comments I have seen on the evolution of the PHR. Below is a short list of some of his ideas contained in this specific lecture that caught my attention:

• The PHR market has moved to a B2B model with an employer-provided PHR (35%), provider provided (25%), and health plan-provided (15%).(Slide #5)
• First generation PHRs: isolated. The target was the end consumer and most third party PHRs remain stuck here.(Slide #8)
• Second generation PHRs: Online with some data. One of the major goals was to promote healthy behavior.(Slide #9)
• Third generation PHRs: Highly networked utility. Richer data and a richer experience.(Slide #10)

John is right on target with his remarks. Much of the PHR news recently has been about Google or Microsoft cutting some deal with a large health system or major health insurance company regarding their PHRs. This is a reflection of the increasing importance of the B2B model to which John refers above. John's idea about the third generation PHR as a highly networked utility is pitch-perfect. PHRs will only provide very high value for consumers when they are populated with important medical information. Hospitals, physician clinics, health plans, and health insurance companies control most such information. Therefore, the networked utilities that John describes will serve to connect consumers to providers to payors.

A number of conclusions can be drawn about the networked medical record architecture that John suggests. First of all, the goal of practical untethered PHRs (i.e., the non-networked PHR) that I have supported (see: Implications of the Kaiser-Microsoft PHR Deal) was probably a pipe dream. Secondly, the notion of consumer-space versus provider-space on these networked healthcare utilities is going to get a little fuzzy. I think that this blending and ambiguity will be helpful in the long run. For example, a health care consumer's observations about his or her own health status can be an important component of a health record whereas they are generally not considered to have great value. In addition and starting now, we need to set up standards such that the origin and authors of all data contained in a networked health record can be clearly delineated.

"Eminence-Based" Surgical Pathology and the Digital Pathology Department

In a recent note, I commented on the new strategic alliance between GE Medical and the University of Pittsburgh Medical Center (UPMC) in the pursuit of the digital pathology department and whole slide imaging (see: GE Medical Partners with UPMC in Pathology Imaging Venture). It is often stated that digital radiology took about a decade to mature and that digital pathology will take an equal amount of time to become the accepted standard of practice. However, major incentives were available in the conversion to digital radiology such as the ability to offer new imaging procedures with attractive profit margins plus a groundswell of enthusiasm on the part of hospital clinicians for these new offerings. These same incentives do not exist for digital pathology -- there are no additional profit margins to be gained for the hospital and the pathology reports to clinicians are largely the same except for the routine integration of digital images into surgical pathology reports.

However, it you are searching for a "killer app" associated with digital pathology, it is most certainly image search. By this I mean the ability to isolate "fields of interest" in a challenging surgical pathology case, an unusual malignant tumor for instance, and then match them against a large image database of diagnosed lesions for similar lesions. For challenging cases today, this same process often takes place laboriously by searching surgical pathology atlases on the shelf. Parallel to this process, many such cases are also referred to local colleagues for their opinions and also sent to "marquee" surgical pathologists who have established reputations as having superb diagnostic skills in various specialty areas. This is the basis for what has been called eminence-based surgical pathology.

And now comes the rub. These marquee pathologists have little to gain and much to loose by the introduction of digital pathology and image searches. Image searches and pattern matching is, in fact, what is taking place in the brains of these eminent pathologists. I suspect that they will have little enthusiasm for any technology that serves to lessen their influence, prestige, and livelihood. Many of these latter pathologists are also highly placed in the hierarchy of prestigious pathology departments. I suspect that they will be leaders of the chorus opposing the conversion to digital pathology and perhaps highlighting the failures and inadequacies of digital pathology departments.

Epic Systems and Its Corporate Culture

Anyone deeply involved in lab computing needs to understand the companies supplying  LISs and EMRs to this market. Part of this understanding involves the "culture" of these companies. The term corporate culture is complex and incorporates a number of variables. As one measure of the complexity of the term, a Google search for it yields 4,450,000 hits. As only one example, some HIT companies are technology-driven whereas others are more marketing-driven. Probably no company is as interesting culture-wise as Epic Systems, currently the market leader in the EMR market. A recent article (see: Behind the Curtain) discusses the company in great detail. For me, the most interesting part of the article was the list of the differences between Epic and its competitors. Below is that portion of the article:

• Epic almost never advertises, and relies almost entirely on word-of-mouth recommendations to market itself.
• Epic does retain salespeople, but they make no commissions on sales, and act more like advisers and consultants than traditional salespeople.
• Epic turns away potential business. Indeed, prospective customers meeting with Epic representatives find they are being evaluated as much as they are evaluating.
• Epic executives have evolved a very specific implementation process over time, one that involves intensive pre-implementation analysis and planning, but then focuses very strongly on meeting go-live dates.
• Rather than seeking experienced healthcare IT professionals, Epic relies on hiring a large corps of the brightest young, just-out-of-college IT professionals for its programming and implementation positions.
• Epic never grows through acquisition, but rather relies on internal development, in extreme contrast to all its competitors among the largest clinical IS vendors.
• Most of all, Epic has a very unusual corporate culture, one that intrigues and sometimes puzzles those who encounter it or hear about it....That culture emanates to an extraordinary degree from the personality of the company's visionary, media-averse founder and CEO.

The true test of the value of any corporate culture is the success of that company in the competitive market. There are clearly no rigid rules. And by this test, the Epic culture has been, and continues to be, a successful one. My guess is that its competitors may  review this list and then probably decide that their own cultures will triumph in the end.

Who "Owns" PACS: Radiology or Central IT in Hospitals?

Veteran readers of this blog will probably know that I am a strong proponent of having laboratory professionals "manage" their own LISs. Lab tests results are a strategic asset in hospitals, underlying about 70% of hospital diagnoses and constituting about 70% of the data contained in electronic medical records. How does one determine who manages (i.e., owns) the LIS? Easy! Who makes the decisions regarding access to lab information? Who formats that information? Who has the final word on policy issues regarding that information. Who has both de jure and de facto control (i.e., stewardship) over it? If you need to pull out an org chart to answer these questions, you are in trouble. Needless to say, I was interested in a recent article (see: Who owns PACS -- Radiology or IT?) about this same question as it applies to radiology information and images. Below is a longish excerpt from the article with boldface emphasis mine:

Should radiology or the IT department take responsibility for managing PACS in a hospital? It depends on the facility's corporate culture and the level of sophistication of the IT department, an animated "debate" at the 2008 Society for Imaging Informatics in Medicine (SIIM) meeting concluded. The premise of the argument presented by Dr. Paul J. Chang on behalf of IT department ownership is that PACS technology has become a component of the entire hospital informatics enterprise rather than its own unique entity. In an increasing number of hospital infrastructures, dedicated networks for PACS are unnecessary. Thick-client workstations are facing obsolescence....Modern healthcare IT should be structured as a matrix, according to Chang, who straddles both worlds as vice chairman of radiology informatics and director of pathology informatics at the University of Chicago Pritzker School of Medicine....Because PACS is the multimedia component of an electronic health record (EHR), the EHR must be optimized to support radiology workflow. Not only is this a complex undertaking, but it logically fits as the responsibility of the IT department -- as long as the IT department has a global vision and a progressive philosophy, Chang said.

Dr. David Channin, chief of imaging informatics at Northwestern Memorial Hospital and the Feinberg School of Medicine in Chicago, disagreed. "Radiology has led informatics technology innovation in hospitals and will continue to be the source of informatics leadership in healthcare," Channin said. "Domain expertise must take precedence over IT expertise. Tools don't drive domain innovation. If controlled in a central manner, such as a matrix structure, the priorities of a radiology department will be subjected to control by an IT department juggling priorities representing multiple domains in a hospital," he said. "If you don't have budgetary control of your bucket of allocated capital dollars, you have lost control. Your critically needed PACS upgrade will be competing with acquisition of a new laser doodad for OR." Radiology departments should wield the power they have as cash cows for hospitals, define their IT domain borders, provide access to them with standard interfaces, and demand autonomy, according to Channin. He recommended that radiology departments contract with IT departments for "commodity services" such as networks, virtual operating systems, and data storage.

Well, no one can say that Drs. Chang  and Channin did not speak their minds in this spirited exchange. There is too much interesting material here to cover at one time. Here are some of my initial reactions:

• Matrix shamtrix. You either own the LIS/RIS/PACS or you don't. See my discussion above about system management/ownership. Pathology owns (or should own) lab information and pathology images and radiology owns (or should own) radiology information and images. Central IT + clinical personnel should then negotiate with pathology and radiology for access to the information managed by the latter two groups.
• According to Dr. Channin, "radiology has led informatics technology innovation in hospitals." LISs were developed and commercialized in the late 1970s and thus preceded RISs by at least five years in hospitals. AIMCL, the LIS conference that preceded Lab InfoTech Summit, was launched in 1983. Radiologists are the acknowledged leaders in hospital image management and storage. Let's call it a draw.
• I agree with Dr. Channin regarding the IT capital and operating budget for the LIS and RIS. If you don't control the information system budget, you don't control the information system.
• I have no problem with the central IT departments providing "commodity services" to pathology and radiology. They are best able to provide institution-wide services like networks and generic data storage for the entire institution. However, I believe that the latter is now a commodity and best provided via a vertical cloud (see: A Closer Look at the Vertical Cloud in Healthcare Computing; The Potential for "Sereverless" Healthcare Computing).

IT Budget Allocation Categories for Healthcare CIOs

John Moore at the Chillmark Research blog introduced one of his recent blog notes (see: Tradition Grapples with Insatiable Demand) in the following way:

Dan Nigrin, the CIO from Children’s Hospital Boston ...is struggling with the insatiable demand for HIT among care providers ...at Children’s while concurrently dealing with an industry that is so bound by tradition. On one hand he must prioritize spending across any number of categories that he characterized as infinitely long (healthcare still spends a woefully low 1-3% of revenue on IT, as a comparison, manufacturing is spending between 4-6% and financial institutions spend even more). Yet on the other-hand, he needs to find new ways to more effectively leverage this spend to insure effective adoption occurs. Not an easy task in this tied to tradition industry.

Moore then goes on in the note to provide a detailed list the following HIT spending priorities that had been enumerated by John Halamka, the other CIO on the panel. John publishes his own excellent blog (Life as a Healthcare CIO) and is chief Information Officer of the Caregroup Health System and Chief Information Officer and Dean for Technology at Harvard Medical School, among many other things. CareGroup includes Beth Israel Deaconess Medical Center. Below is Halamka's list of high level priorities in addition to the obvious support for business and clinical applications.

• Getting non-affiliated doctors on-board in using an EMR throughout the New England region
• Addressing the demand for data storage
• Insuring secure communication throughout the network
• Tackling security
• Compliance
• Creating dynamic websites
• Disaster recovery

It's a good idea to take stock of the larger set of challenges facing healthcare CIOs today. However, the list is not much different than that of the CIO of any major enterprise. The only surprise for me in his list was the first point -- getting non-affiliated doctors on-board in using an EMR throughout the New England region. Clearly, getting "outsiders wired" would not be the goal of any corporate CIO outside of the healthcare enterprise. One wonders if John is pursuing such a goal as part of his overarching interest in the improvement of healthcare IT or whether connecting such non-affiliated physicians is a strategic goal to spur admissions at his own hospitals. In a previous note and pertaining to the challenge of data storage (see: A Closer Look at the Vertical Cloud in Healthcare Computing), I discussed how some hospitals are turning to external web-based storage solutions such as InsiteOne for PACS records.

Implications of the Kaiser-Microsoft PHR Deal

A report of a new partnership between Kaiser Permanente and Microsoft regarding personal health records (PHRs) (see: Kaiser Backs Microsoft Patient-Data Plan) raises a set of interesting issues. Below is an excerpt from the article (boldface emphasis  mine):

Kaiser Permanente, the nation’s largest nonprofit health maintenance organization, is endorsing the drive toward consumer-controlled personal health records in a partnership with Microsoft. The partnership...will begin with a pilot project open to Kaiser’s 156,000 employees, which will run until November. If successful, the product linking Kaiser’s patient information with Microsoft’s Health Vault personal health-record service will be offered to Kaiser’s 8.7 million members in nine states and the District of Columbia....There are several companies offering personal health records on the Web, but the big new players are Microsoft, which entered the field last October, and Google, which came in last month....[T]he Microsoft and Google health offerings give individuals control of their own health records, as well as responsibility for them. Today, most electronic health records are maintained by health providers and insurers, allowing individuals access to their records through the Web. But those records are typically controlled by the institutions, and are not portable when a person changes insurers or health providers or moves to another part of the country. Both Microsoft and Google have previously announced collaborative pilot projects with other health providers. For Microsoft, they include the Mayo Clinic and New York-Presbyterian Hospital. For Google, they include the Cleveland Clinic and Beth Israel Deaconess Medical Center.

I have posted a number of previous notes about the Kaiser Health System, including its prolonged roll-out of the Epic EMR system, called HealthConnect, across its entire chain of hospitals with particular emphasis on the massive cost of the project (see the most recent of them: An Update on the Kaiser HealthConnect Project). Kaiser admits to a cost thus far for the EMR of $4 billion plus $1 billion yearly for maintenance. Only 13 of the 36 Kaiser hospitals have gone live with the inpatient EMR system thus far.

I have also posted a number of blog notes about personal health records (PHRs) of both the tethered and untethered varieties. Below is a quote from a recent note about HIMSS, PHRs, Microsoft's Health Vault, and Google Health (see: HIMSS President Slams PHRs: I Wonder Why?):

What's really worries [HIMSS CEO Steve] Leiber and the EMR vendors, from whom he takes his orders, is the likes of Microsoft's HeathVault and Google Health. Note that the latter company has recently created a partnership with the Cleveland Clinic (see: Google CEO Discusses New Partnership with Cleveland Clinic). What Leiber and the EMR companies fear is that Microsoft and Google will launch a fully-featured EMR/PHR combo that will deliver both value and functionality.

The recent Kaiser/Microsoft announcement brings into play three critical questions that I will summarize below:

1. Who owns/controls patient clinical information: (1) the health system that creates the information; (2) the vendor of the electronic medical record deployed within a health system such as Kaiser; or (3) the patients on whose behalf electronic medical records are generated and who pay for them, either directly or indirectly through health insurance plans? My personal vote on this question is the patients.
2. To what extent is a health system like Kaiser limited in its ability to replicate clinical information managed by an EMR supplied by a vendor such as Epic to a free untethered PHR like Health Vault? Epic has its own tethered PHR product called MyChart that It sells to its hospital clients such as Kaiser (see: The Revolution Will Not be Televised). Kaiser currently provides a tethered PHR to its patients, My Health Manager, which is based on the MyChart patient portal (see: HealthVault Signs on Kaiser). I personally think that PHRs should be free, untethered, and should also contain most of the information present in hospital and physician office electronic records (see: HIMSS President Slams PHRs: I Wonder Why?).
3. How will Epic react to the Kaiser/Microsoft announcement? Clearly, they have a lot of skin in the game. They can't be happy about this turn of events. It's hard to imagine a future scenario with Kaiser that works totally in their favor with Microsoft sitting at the table.