to the top of this file.
Pyxis Systems Helped Catch Murderer...
Psycho Killers Like Computers, Too
Clinical information systems from Cerner and
Pyxis are key to the case of Charles Cullen,
the registered nurse who is accused of, and
who admitted, overdosing patients at 315-bed
Somerset, N.J., Medical Center.
One can reasonably ask why the reporting
capabilities in these systems didn't
highlight his deadly behavior sooner. But on
the other hand, officials investigating the
case say documentation from the two systems
has helped to make their case. Given the fact
that another case against the slippery
alleged serial killer failed last year for
lack of evidence, that's a big benefit.
Mr. Cullen was charged last month with one
murder and one attempted murder after lab
records showed drastically elevated levels of
the heart-regulating medication Digoxin in
half a dozen patients. He then briefly began
to talk, claiming responsibility for 30-40
deaths over 16 years, including 12-15 in a
year at Somerset.
The killing spree spurred calls for state and
national databases to keep background
information on healthcare workers. He had
been fired from six positions and quit three
others, and had been criminally investigated
in Pennsylvania in 2002 for similar behavior.
However, hospitals that hired him said
background checks on him turned up nothing.
The bad news for IT departments: he seems to
circumvented the security system
for Somerset's Pyxis pharmacy cabinets.
Somerset's new $10 million Cerner HNA
Millennium package also was apparently wide
open to Mr. Cullen, who used it to obtain
records on patients who were no longer his.
The good news: it was Somerset, rather than one
of the other nine facilities, which was
actually able to finger him. St. Luke's
Hospital in Bethlehem, Pa., had reported him
to the State Nursing Board in 2002 after
twice finding full boxes of heart medication
in a used-syringe bin. A cardiologist hired
by St. Luke's combed records of 69 patients
who died while Mr. Cullen was an employee,
but uncovered no actionable evidence. The
case was also investigated by a forensic
pathologist retained by the Lehigh County
District Attorney's Office, but was closed
for lack of evidence in early 2003.
Somerset went live on Millennium CDR and
ancillaries in June, 2002, several months
before his arrival. Its application security
system uses a single sign-on. Somerset
implemented 14 Cerner applications in 11
months, according to a presentation at the
2003 HIMSS meeting.
The electronic footprints Mr. Cullen left in
the Cerner and Pyxis systems were
instrumental in the law enforcement
investigation. County Prosecutor Wayne
Forrest--who told us he doesn't even use his
own e-mail address--focused heavily on
The suspect alleged gained access to the
critical care unit's Pyxis station on the
evening shift last June 15, and ordered
Digoxin for a patient who was not prescribed
the medication. "He obtained the Digoxin
and then canceled the order on the computer
system in an attempt to conceal his theft of
the drug," the prosecutor's office
That same night, Cullen got access to his
victim's medical records in Somerset's Cerner
system, even though he had "no
legitimate reason" to review them. Three
days later, an inventory of the CCU Pyxis
unit came up short by two bottles of Digoxin.
That victim, Jin Kyung, 40, survived the
overdose, then died later of cancer.
Two weeks later, Cullen is alleged to have
followed exactly the same pattern, but this
time, 68-year-old Catholic priest Florian
Gall died after a Digoxin overdose. A July 1
inventory of the CCU Pyxis station came up
four bottles of Digoxin short.
During his year at Somerset, Mr. Cullen
accessed the "medication dispensing
system for Digoxin at an abnormally high
rate," the arrest warrant said.
As we went to press, the Somerset Count
prosecutor's office was examining records on
nine patients from Somerset Medical Center.
At least two patients overdosed on Digoxin;
at least four appeared to have overdosed on
insulin. Prosecutors in other counties were
checking into records of at least five other
Did computer records alert Somerset to the fact
it had a problem in the first place?
Prosecutor Forrest said he doubts it. He said
a hospital investigator uncovered records of
patients with Digoxin levels "higher
than any human being should ever have,"
and then began digging deeper.
Mr. Forrest's office also noted that following
the overdoses, Somerset tightened its
medication access procedures, whereupon "Mr.
Cullen's accesses ceased." That seems to
suggest that Somerset could have used tighter
security procedures to begin with. Mr.
Forrest encouraged us to ask the medical
center, but officials there are not yet ready
Before Somerset, Mr. Cullen worked at:
- St. Barnabas Medical Center, Livingston,
N.J., June 1987 to January 1992;
- Warren Hospital, Phillipsburg, N.J.,
February 1992 to December 1993;
- Hunterdon Medical Center, Raritan
Township, N.J., April 1994 to October
- Morristown, N.J., Memorial Hospital,
November 1996 to August 1997;
- Liberty Nursing Home, Allentown, Pa.,
February 1998 to October 1998;
- Easton Hospital, Easton, Pa., November
1998 to March 1999;
- Lehigh Valley Hospital, Bethlehem, Pa.,
December 1998 to April 2000;
- St. Luke's Hospital, Bethlehem, Pa.,
June 2000 to June 2002;
- Sacred Heart Hospital, Allentown, Pa.,
for 18 days, July, 2002.
He told prosecutors he was "alleviating
suffering." He is being held at a New
Jersey mental hospital.
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Hospitals, Vendors Gouged On Travel By Some Major
HIS Consulting Firms?
...No Vendor Yet
Known To Have Played This Game
Lawsuits have been filed alleging that
PriceWaterhouse Coopers (PWC) secretly
profited by changing its travel discount
plans from price discounts to a plan under
which it charged clients -- including health
care IT clients -- face value for airline
tickets, then took and pocketed back-end
rebates during the late 1990s and early
Some other major consulting firms may have had
similar practices. Both Ernst & Young and
KPMG acknowledged that they had used
end-of-term rebates for some time before
2002, and were switching back to the visible,
up-front discounts for travel. Both said
their past practices benefited clients.
In September, 2003, we warned electronic
subscribers in a brief e-mail opinion piece
about these practices. In retrospect, that
brief opinion piece, titled, "Scrutinize
Your Vendors' and Consultants' Travel Claims
And Tighten Up Your Terms," should
have gone to all subscribers. It referred to
a prior W.S. Journal news report saying that
such rebate schemes had turned travel to
client locations from a basically break-even
function into a significant profit center at
Yes, it did happen in health care...
A Jan. 5, 2004 Wall Street Journal article
quotes documents from lawsuits over Price
WaterhouseCoopers' travel rebate schemes. The
article also quotes a former director of
PWC's' health care practice in Chicago, Jean
Joslyn -- an Inside Healthcare Computing
We contacted Ms. Joslyn for this article and
commentary. In health care, she said, PWC
consulting proposals promise in writing to
make every effort to seek travel savings, and
say that these savings will be passed on to
When PWC changed from ticket price discounts to
back-end rebates, fares on many of Ms.
Joslyn's frequent Chicago-to-Philadelphia
trips to a large health care client (not a
hospital, she told us) rose $200 each.
In February 1999, she contacted the PWC travel
director, James F. Lennon, and asked how the
rebates would be allocated back to clients.
His response, in part: "We negotiate
these discounts, not our clients."
Dismayed by that answer, she contacted the
firm's corporate ethics department. Her
ethics complaint led to a meeting of PWC's
top management in New York on March 19, 1999.
These executives reinstated a 12.5% up-front
discount on ticket prices charged to clients.
PWC execs didn't tell either Ms. Joslyn or
clients that "total discounts, including
back-end rebates, in some cases would
continue to be as high as 40%," so the
firm continued to reap big profits on
tickets, the Journal article said.
Then, in 2000, a lawyer in a PWC office in Los
Angeles, Neal Roberts, began raising the
issue anew. His complaints led to lawsuits
and a federal civil investigation. Then,
starting Jan. 1, 2001, PWC again changed its
policy, to a flat 28% front-end discount on
air fares charged to clients, saying it would
keep 8% in year-end rebates to cover its
costs. PWC again decided not to reimburse
clients for millions of dollars in rebates
from prior years. So the lawsuits continue.
Other major firms may have had similar
practices. The Journal article said that both
Ernst & Young and KPMG changed their
practices away from end-of-term rebates in
2002; both claimed that their former
practices benefited clients. The Journal
reports E&Y said it now charges face
value and also charges clients a surcharge
for "administrative" costs of air
Ms. Joslyn is now with Cardinal Consulting, a
small but fast-growing firm of long-time HIS
consulting professionals organized by Frank
Cavanaugh, former head of healthcare IT
practices at both Coopers & Lybrand and
PWC. Cardinal's policy: it negotiates the
lowest travel costs it can, passes on these
discounts in full to clients, and doesn't
charge administrative fees or keep a back-end
percentage, Mr. Cavanaugh said. "Travel
is just a cost of doing business...I think
most small consulting firms operate this way."
Cardinal: (708) 645-1235, http://www.cardinalconsulting.org.
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Allscripts, Misys Helped Sharp
Our Dec. 15 article on vendor charity mentioned
that the folks at Picis Corp. collected money
for fire victims who are employed by Sharp
Healthcare, San Diego, Calif. CIO Bill
Spooner asked us to add that Sharp also
received substantial contributions from IDX,
Allscripts, and Misys.
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Have Best Job In Healthcare
At a recent regional HIMSS meeting, someone
asked panelists what their experience as
hospital CIOs had prepared them for in their
next career moves. He might as well have
posed the question to a panel of Supreme
"This is the best job in healthcare,"
said Mike Sauk, CIO, City of Hope National
Medical Center. Tim Kirk, CIO, Huntington
Memorial Hospital, echoed the sentiment, as
did Bob Blades, CIO, Loma Linda University
Medical Center. "I wouldn't want to do
The three were among the five veteran CIOs who
spoke about their CIO careers at a recent
meeting of the Southern California Chapter of
the Hospital Information Management and
Systems Society. The others were Tim Moore,
IT outsourcing account executive; Saint
Joseph Health System, Anaheim; and Dan
Robins, CIO, Providence Healthcare, San
Fernando Valley. The panel was moderated by
Jack Schlosser, who heads the health services
practice at Spencer Stewart, a Los
Angeles-based executive search firm. Here's
- No particular degree or training
track. Not one was classically
qualified for his big early career
advancements into healthcare IT. Mr.
Blades's background was in aerospace
engineering and software sales. Mr.
Robins had an advanced degree in
finance and marketing. Mr. Kirk had an
advanced degree in computer
technology, but knew little about
- It's almost as if the way to become a
CIO is to "not to be qualified
for any of the promotions along the
way," said Mr Sauk, who once
aspired to be a high school speech
teacher. "The common thread"
is that "somebody once saw
something in us that gave them faith
we could do the job."
- They all took risks. Mr. Moore
was an RN, who'd worked a while for
SAIC when he was offered a project
management job implementing a revenue
management system at Northridge
Hospital. "What did I know about
project management?" Mr. Sauk was
once offered a job as an accounting
manager. "I had never had an
accounting course in my life." He
Mr. Kirk has a
degree in math, and earned the first
graduate degree in computer sciences
at the University of Washington. He
went to work n the small computer
department at Sacred Heart Hospital,
Eugene, Ore. (now part of Peace
Health.) Three years later, the
department needed a manager. "I
went up to administration and said --
`Hey, I'm your man. I'm the best you
could get.'" He got the job. "My
entire goal was to just survive for 18
It is when
you take on the difficult challenges
that the outcome, positive or
negative, that your results are most
noticed, noted Mr. Moore.
- Surviving. The world of
a CIO is treacherous. "In the
house of Cs (CEO, COO, CFO, CIO) you
become very political," Mr.
Blades said. "One big failure,
and you're gone." Everyone wants
your job. Physicians want it. Hospital
administrators want it. COOs want it.
Tips for hanging on to CIO job
From Mr. Kirk: Read Leading Geeks, by
Paul Glen and David Maister. It deals with
the difficulty Fortune 500 companies have
with dealing with the creative and technical
side of business. "I really recommend
From Mr. Blades: Before you plunge into a major
project, make sure you have "all of your
Cs lined up," Mr. Blades urged. He is
trying to get a clinical systems back on
track "for the second or third time."
The CFO is on board. The operations staff has
bought into it. The CEO has issued a memo in
support. But the CMO has reservations. Mr.
Blades is waiting and wooing her. "It
takes time and patience and skill."
He also says: Learn to speak in the language of
whomever you are addressing. "When I am
talking to the board, my message is very
positive." When it is finance "I am
value- driven." "I have used every
sales trick, gimmick, technique that I ever
learned in my current job."
From Mr. Sauk: Hospitals change CEOs often.
Evaluate each regime change as a new job
opportunity. Whatever you've done up until
now "doesn't matter...You reinvent
yourself every time you get a new boss."
Advice for those on the way up
Choose the right job to begin with. Corporate
culture varies widely, warned Mr. Kirk, who
has worked for seven different healthcare
organizations. Some of it is "very bad,"
and whatever it is, you are not going to
change it. "You must fit in, or get out."
Mr. Robins agreed. Scandals that brought down
management at Enron and HealthSouth might
have been predicted by a close examination of
those companies' corporate cultures, he said.
But you, as a job applicant, can't possibly
assess a corporate culture in a 60-minute job
His advice: Find the right people beforehand,
and ask the right questions to get an honest
assessment of the corporation's culture.
What they look for in the people they hire:
"A global view," Mr. Moore said. He
said he "often" turns down
exceptional individuals if all they offer is
"niche talent." Results-oriented
people, Mr. Sauk said. CIOs who survive
deliver their project on time and on budget,
so "I look for people who have a history
Clinical background is also becoming more
important in IT. Two of Mr. Kirk's four
managers are clinicians. Nowadays "clinicians
drive business decisions," Mr. Robins
said. "I keep my license current,"
Mr. Moore said. It is not clinical
understanding that helps him, as much as a
thorough understanding of the business
processes that nursing goes through.
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E-Mail Catching On
Under pressure from patients, many MDs are
overcoming resistance to electronic
communication, but encountering complex
choices in selecting the right tools, says a
new report, "Online Provider
Communication Tools," written for the
California HealthCare Foundation (CHCF) by
First Consulting Group.
"Contrary to persistent misconceptions,"
many MDs find that "online communication
is manageable, improves productivity, and can
even generate revenue," said the
report's author, Keith MacDonald.
Half a dozen payers are pilot-testing payments
to physicians who communicate with patients
by e-mail. Aetna and United Healthcare, Blue
Cross-Blue Shield of Massachusetts, Blue
Shield of California, ConnectiCare, First
Health, and Horizon Blue Cross-Blue Shield of
New Jersey have recently completed or are
planning projects to test reimbursements for
e-mail consultations. CIGNA, Health Net
(Connecticut) and Pacificare (California) are
Blue Shield concluded that it could save up to
$4 million per year in office-visit claims if
more physicians adopted e-mail communication
All of the pilot programs reimburse $20-$25 per
e-visit. Blue Shield of California reimbursed
at a flat $20 per e-mail during a 2002 pilot
involving 250 MDs and 2,000 patients.
Inside Healthcare Computing dug into its own
records and learned that during 2003, Blue
Cross of California was reimbursing as little
as $33 for an office visit by a family
practitioner. A neurological exam, including
a brief physical, earned a board-certified
neurologist just $55. At these rates, it
seems quite likely that an MD could make more
money answering patient e-mail, when it's an
appropriate alternative to seeing the
patient, particularly factoring in
The 30-page report also provides a detailed
review of electronic communication tools;
case studies on how single, multi-site, and
integrated delivery systems use these tools;
and lists of vendors providing e-mail
communication. It also gives a detailed look
at roadblocks that prevent MDs from hopping
on board more enthusiastically. It's
available at no charge from California
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Electronic Medical Record System Offers PDA Support
If you're looking for an electronic medical
record system, be sure to question your
vendor closely on the issue of PDA support. A
number of vendors offer EMR functionality
which is top-drawer for desktop, remote, and
wireless users, but either don't have
portable-device support or offer very limited
This information comes AC Group's 2003
Electronic Medical Record Survey. The data is
consistent with its 2002 results, when 47% or
vendors didn't offer PDA devices with their
AC Group's assessments are based partly on
self-reports by 34 vendors, which answered
product inquiries on more than 3,400
functions. Mark Anderson, the former CIO who
heads AC Group, then applied his own testing
matrix to the top 10 finishers. The result is
120 pages of system selection guidelines and
product ratings. Some results track well with
KLAS Enterprises (both, for example, give
high ratings to NextGen), but they're derived
differently; KLAS relies almost exclusively
on user reports, while AC Group seeks vendor
assessments of their own products. Some
- Top honors: For the second year in a
row, Mr. Anderson gives top honors
overall to EMRs from NextGen
Healthcare Information Systems, Inc.,
and Allscripts Healthcare Solutions.
JMJ was also among the top three
finishers. Each had 93-94% of the
functionality required by the AC
- MedInformix, Praxis, eClinicalworks,
Imedica, and A4 Health Systems make
the second tier, in that order.
- PMSI, Greenway, GE Medical, and Misys
come in next, again in that order.
- Chartcare, eMDS, and Cliniflow anchored
the bottom of the top 15 finishers.
- The sixteenth place finisher, McKesson
Corp., also made it into some charts
with its MediNotes product. (To put
things into perspective: Products were
rated only if they have at least 75%
of the functionality the researchers
sought, which means that 18 products
that were submitted for rating did not
make the cut at all.)
- Top honors notwithstanding, the ideal
choice for an EMR depends on practice
size. Among systems sold to MD groups
of more than 50, the top
feature/functionality finishers are
NextGen, Allscripts, Imedica, and A4.
For practices of 16-49, top rated
vendors are NextGen, Allscripts, JMJ,
and A4. Practices of 5-14 MDs should
take a hard look at JMJ,
MedInformatix, Praxis, and
eClinicalworks, he concluded.
- Epic Systems, widely viewed as the top
EMR vendor for big organizations,
isn't included in the survey. Nor is
Cerner Corp., which has a relatively
new EMR called PowerChart EMR.
- MediNotes, McKesson's Horizon Ambulatory
care system is sold to almost any size
practice, according to the report.
- Costs: EMRs are typically
licensed on a per workstation basis.
Factoring in hardware, training and
implementation, and software, hardware
and network support, systems are
typically priced from $15,000-$30,000
per physician user.
- Of the EMRs marketed to large group
practices (50-149 physicians), GE
Medical's Logician is most widely
installed, with 20,000 MD users. It
ranks seventh in functionality,
according to this report. Imedica
ranks third on the same chart, but has
only 800 users.
- Some vendors said they will
substantially increase system
functionality within the next year.
They include MDAnywhere, WebMD Intergy
and Monarch Medical International
Mark Anderson, AC Group, Inc,
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Chink in HIPAA Privacy
In a Dec. 28 letter to the National Committee
on Vital and Health Statistics (NCVHS), the
American Hospital Assn. (AHA) recommends that
hospitals be permitted to respond to payer
requests for claims attachments by sending
the plan an "entire document or record."
Currently, under the "minimum necessary"
provision of the HIPAA Privacy Rule, only the
information that is necessary to adjudicate a
claim may be shared with payers. The rule
may, however, undo a key advantage of XML,
which is newly under consideration as a
claims attachment standard that might allow
relatively unsophisticated organizations to
communicate electronically with payers
without complex coding schemes.
"The rule must state clearly that when a
provider uses the XML standard to forward to
the health plan an entire document or record
containing the information the health plan is
looking for, the provider is compliant with
the privacy rule's `minimum necessary'
requirement," AHA said.
NCVHS, a citizen advisory group to the
Department of Health and Human Services,
meets later this month to formulate its
recommendation to the government for a claims
attachment standard. HHS is expected to issue
a draft claims attachment standard shortly.
The AHA also complains that payers make far too
many attachment requests. Attachment requests
should be a "rare event" rather
than a "routine request," AHA said.
Payers routinely come to providers for
information they should be digging out of
their own records, AHA said. They also
install computer systems that lack
programming logic that can associate related
data elements within a claim.
AHA also seeks a requirement that providers be
informed in advance of the questions that
could be sought on claims attachment
requests. That way, providers can collect
answers to all possible questions up front,
rather than chasing down answers to surprise
questions after the patient is long gone. HL7
is defining standards for various kinds of
claims attachments, and the questions that
may be asked for each.
If the notion of using XML for a claims
attachment standard catches you by surprise,
it's probably because until recently,
discussion has centered around requiring that
claims attachment data to be sent in an HL7
message. The new plan is to allow XML
transmission of claims attachment data. The
approach is supported by HL7 and by ANSI's
Accredited X12 Standards Committee.
Either way, the message would be embedded in
X12 275 message format, but allowing XML
would be technically easier, especially for
smaller organizations. XML would give
organizations the option of transmitting
unstructured, human- readable data -- hence
AHA's interest in allowing organizations to
send entire records or entire documents. We
haven't yet seen much response to AHA's
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Gets `Best Bang For Buck' Award From Frost &
Superior Consultant Co. is living up to the "superior"
part of its name, says the international
business consulting firm Frost &
Sullivan, which has singled it out for its
best "Bang for the Buck" award.
This is only the second time Frost &
Sullivan has given the award, and the first
time it has gone to a healthcare technology
firm, said analyst Vivek Subramany.
As far as we can tell, this is not one of those
"nominate yourself and hope nobody else
bothers to apply" deals, but a genuine
honor. Mr. Subramany said he contacted 14
competing firms and then selected Superior,
which won on the basis of the flexibility and
scalability of its offerings. The firm also
scored points for offering packages that
appeal to smaller hospitals, where Frost &
Sullivan sees an increased demand for
outsourcing services. Superior stacked up as
a "premier provider of IT services and
solutions" within healthcare, he said.
The research also contributed to a new Frost &
Sullivan report, "US IT Outsource
Markets for Healthcare." The report
finds an overall trend toward increased
healthcare outsourcing. The demand is being
federal regulation and hospitals'
lack of in-house expertise. Turnover rates
for hospital IT staffs are up around 17%, the
The other firms Frost & Sullivan contacted
for the report were Cap Gemini Ernst &
Young (CGEY), Cognizant Technology Solutions,
Computer Sciences Corp. (CSC), Daou Systems
Inc., Eclipsys Corp., Electronic Data Systems
Corp. (EDS), First Consulting Group (FCG);
McKesson Information Solutions, Perot Systems
Corp. (PHNS), Premier Sourcing Partners;
Science Applications International Corp.
(SAIC), Siemens Medical Solutions, and
TriZetto Group Inc.
The report may be valuable to vendors, but we
are guessing that from a hospital
perspective, it will have some limitations.
It lists market share leaders, but does not
otherwise rank vendors. Also, Mr. Subramany
said he did not interview any outsourcing
clients. What about the cost-benefit
information? He described his trove of vendor
pricing information as "holistic."
It's available on the Web, at
The price is $3,950.
KLAS Enterprises is also preparing an
outsourcing report, which will include client
feedback. Clients either love their
outsourcing vendors or they hate them, said
KLAS VP Karen Ondo in a late October 2002
presentation. "We have received no
survey from somebody in the middle." She
emphasized that KLAS's research on the topic
was just beginning.
to the top of this file.