I’m watching ads during the ballgame (I watched the kick-off and the ads—the rest, not so much) and who should be declaring itself a “cloud solution” but Microsoft?!

See the ads here and here, in case you don’t own a TV or computer or newspaper.

OK, I’ve gotta admit my gut reaction was: Microsoft in the cloud? Seriously? But my next thought was…YES! FINALLY! I’m watching evolution unfold before my very eyes, and it’s oh so comforting to see others walking upright on two feet, using modern tools, and cooking their food.

What am I talking about? Well, let me explain. Gather round kids for a quick tour of the museum of ancient computing history. There will be time for a bathroom break later.

Here in the lobby is a giant diorama like you see in other ancient history museums. (For a larger version, click here.)

In the lower left corner, on four legs and covered with hair, is the software product (Latin, Rebootus-maximus). The Latin root designates high up-front costs and a low relationship between the maker of software and the benefits received by the user. Also, since maker and user sit on different instances of the application and can’t see what the other is doing, the only way this species ever evolves is through primitive gatherings called “user groups.” Here cave drawings are put on flip charts by pained customers and users thump their chests in desperate efforts to get future generations of software to improve.

Then, draggin’ the occasional knuckle but proudly waving a stick that he has learned to use as a weapon, is the ASP (Latin, Rebootus-less, Payus morem). Here, the Latin indicates higher overlap between buyer and seller and lower up-front costs. This is because the seller BUYS the software and the hardware for the users and rents the whole finished thing as a package. Ongoing costs are much higher, and, as before, the maker of the software and the user can’t see what each other is doing and have no shared responsibility for business outcomes. The ancient user group antics and chest thumping continue in this era, with a little less body hair.

Moving up and to the right from there, proudly wearing a helmet and a (smallish) chainmail skirt…and looking surprisingly like Marc Benioff…is the SaaS company! This is the first true use of cloud-computing. Here, the maker of the software maintains a single instance of software on the web. It is fully hosted in a web-native setting, and there is no cost for it. Ongoing costs for the users decline compared to the Payus morem species, but, most importantly, innovation happens at a massively higher pace with Payus servicum. The reason for this is that software maker and ALL software users are on the same instance of the same application. The programmers watch users suffer through bad reporting models or clunky workflows. The web-logs from these weaker members of the species flow through to the hive and are killed off quickly. Also, the idea of an “interface” becomes effortless. Meanwhile, species of applications can intermingle and cross-mate in a new tribal ritual called the Appus storem. The resultant functionality and reporting still has the data integrity of the original species, and the pace of innovation spikes as many tribes are unconsciously moving along the same path in different ways. While one or another version may be unsuccessful, it is easy for it to die without harming the tribe.

Finally, in the upper right corner, wearing a stylish sweater and looking like a more dashing and fully upright version of, let’s say…Jeff Bezos…is the cloud-based service (Latin: Payus resultum). Here the idea of the shared application in the cloud gets taken to another level. Now, other terrestrial things enter the cloud, like knowledge and work. The ongoing cost of the software has receded almost completely from view. Here the vendor sells only outcomes. The software sits in the cloud as a common “store” that customers enter to get their goods. For athenahealth, these goods are electronic medical records, medical billing services, and a patient portal. We’re responsible for keeping the fires burning with cloud-based computing and security and we also take on the hunter-gatherer work of processing documents, posting claims, tracking down payments, etc. We continuously inject knowledge into the cloud, tracking and updating payer and clinical rules, formulary requirements, and P4P program incentives for everyone at once.

That’s my tour folks. So now, I hope, you know what athena means when we talk about this newfangled thing called “the cloud.” And that’s where health care is heading—or being dragged kicking, screaming, and knuckle-dragging.

Welcome to the clan, Microsoft!

Sunday Blues to Big Monday News: Congress makes sure the “doc fix” is in and avoids Medicare payment cuts…

More News from the REC Front! The regional extension center for central Florida has selected athenaClinicals as a preferred EHR partner.

A Bloodbath on the Horizon: Frequent blogger and also CEO Jonathan Bush is quoted in this wide angle piece about HIT from The Economist.

AHA Says Hospitals Facing MU Hurdles: Check out this letter from the American Hospital Association to HHS Secretary Kathleen Sebelius.

Air Warfare: The battle for domination of the cloud is underway. More on that later… a lot more.

AMA on ACOs: And if you aren’t tuned in already you will also hear more and more about accountable care organizations.

The Guy Who Kicks Hornet Nests: A post by Jonathan Bush that appeared here first but was picked up by The Health Care Blog has stirred up a few of the regulars.

An Echo of the Baby Boom? And finally, just in time for the weekend, Harvard finds out there may be other reasons for the popularity of the ‘early bird special’ among seniors.

What if one doctor could “friend” or “link in” with another for the purpose of patient exchange? Today when we hear people talk about clinical integration, they’re talking about financial integration…literally owning every stage of the treatment of a patient just so that the data created from that care can be integrated. That kind of thinking has fostered a proliferation of miniature Kaiser Permanente-like health organizations across the country–each with their own multi-hundred-million-dollar proprietary system to hold their data all in one place.

I think owning a lab is an expensive way to integrate the data from that lab into a common view of a patient—let alone “owning” a cardiologist! Furthermore, as the nexus of health care moves ever further away from the hospital ward and towards the home, owning every point of health care delivery will become increasingly difficult, if not impossible. So what’s the alternative? It’s the same one that gives us integrated credit ratings and the ability to walk up to any ATM in the world and still get money from our own account. It’s a market for clinical information exchange enabled by social networking-type technology.

When you think of it, Facebook and LinkedIn present integrated pictures of all the people you’ve touched in your life or work as soon as you log in. And over time you see how that integrated picture of your life or work life improves.

I know there’s something like this for clinical integration.

I know because, at athenahealth, we just had a physician client in Texas perform our very first “friending.” This doctor friended a major health care network in Texas and it went like this:

• Our client had a patient that needed a certain procedure, and this particular health care network was the ideal provider choice.
• To perform the procedure, the health care network needed the patient’s insurance eligibility, key medical records, and financial information.
• We’re building a pipeline from our cloud-based medical record into the big health care network’s proprietary system.
• We reached an agreement that every time athenahealth performs an injection of the exact, pre-formatted clinical and financial information that the network needs to care for a patient, it would pay us for that service. The service fee would be a few dollars, significantly less than the big network’s administrative costs to verify insurance and clinical information and get that patient scheduled. This presents a new opportunity to change the way EHR technology is paid for and should encourage wider implementation through lower costs for EHRs on the front-end.
• Now, any time that anyone we serve sends a patient to this Texas network, that patient’s chart will reflect what happens at both places.

It sounds nascent because it is. In fact, it’s the first time it’s happened anywhere.

Next year we’ll be doing more friending and more patient exchanges.

It’s health information exchange, or HIE, as a verb instead of a noun.

We think that it will result in confederated patient information—that is, the ability to consolidate a patient’s information while allowing that patient to receive treatment from a broad array of places…including (over time) his or her home.

Doctors are going to be able to friend each other. And when they do, the receiving doctor can expect to get exactly what he or she wants from the sending doctor. The charts in the athenahealth EMR from the sending doctor are going to automatically shape shift to make sure that the data the receiving doctor wants is being captured and transferred.

Finally, no matter where you go in the world, a doctor you authorized will be able to find you on athenaNet…but that’s another story.

Ryan Champlin is the vice president of operations for Cook Children’s Health Care System, an athenahealth client. Based in Fort Worth, Cook Children’s is a non-profit network with 393 pediatric providers and more than a thousand staff in 50 locations across Texas. For more information go to their website.

We brought more than a thousand providers live on athenahealth’s network in February, 2010 after a seven-month implementation. We now have 100% physician adoption. Our first year as a partner with athenahealth has taught both of us some valuable lessons that I’d like to share with the providers who are just behind us in moving to an effective electronic health record. 

Here’s my Top 10 list for success with a new EHR at the enterprise level:

1. Make patient care your goal and then clarify how the EHR project will make that goal achievable.  We’re focused on the ability to give each of our patients a lifetime medical record that will be accessible via the web. Since the effort is focused on patient care, the ability to bring frustrated physicians back to that cause helps everyone get through the tight spots.

2. Know your first go-live will generate the most energy and you will want to use that energy to build momentum. Plan your implementation to bring rainmakers live first and set up some friendly competition to see who can have the smoothest go-live. After all, physicians are a competitive bunch.

3. Use the flexibility of athenaClinicals to your advantage.  Short, more efficient templates—and being able to improve them on the fly—really impressed our providers.

4. Guard against being too flexible.  This is the old double-edged sword because the flexibility of athenaClinicals helped make it the KLAS number one choice for pediatrics. But if they build it too flexible, the record can get cluttered in an enterprise environment like ours.  Now that we are almost fully live, we are naming a team of physicians to go back through the record and streamline it.

5. Set clear expectations at the outset and broadcast them across the organization.  Our project leadership understood that we chose athenaClinicals because of its efficiency but this message was not conveyed very well throughout the organization.  This led some physicians to question “missing” functionality – the old “if we are going electronic, why do we have to do anything on paper?” discussion.

6. Create an executive steering committee to manage the politics of the project.

7. Use a project management consultant to keep the entire effort on track. 

8. Pick input devices early and let the providers get familiarized with them before the go-live.  We sometimes forget that most physicians are not very comfortable with laptops.

9. Build your wireless connectivity for speed.  Overnight, users can go from being amazed by a wireless connection to becoming frustrated with slow refreshes.

10. Start finding important things to send to physicians via email before the project kicks off.  We sent out a lot of project information via email before we found out that many of our physicians never checked their messages.  You need them to be in the habit of using email to communicate so that project news and updates can be conveyed effectively.

Remember that helping large organizations move to a better place is not easy and it can be very frustrating but it is worth the effort.  Also, remember that you have the ability to improve the life of every patient you care for with an athenahealth medical record. Unlike traditional EHRs, athena’s is evolutionary and keeps changing and improving to meet the needs of care.

Hopefully you already follow us on Twitter, the mini-blog where we provide readers—including industry leaders—with quick and helpful news links on health IT, dispatches from the sizzling hot EHR front, as well as the latest on medical billing, practice management and broader health care issues.

But in case you miss our tweets, check out this blog through the week for a short collection of info items, articles, and stories we find worth sharing:

–Of recent interest was this letter from the National Coordinator for Health Information Technology, Dr. David Blumenthal, asking the industry to prevent a ‘digital divide’ when it comes to serving minority populations with EHRs. At athenahealth, we feel like we’re already there. We offer physicians in underserved communities a low-cost path to adoption. We harness the power of the Internet to give them the exact same tools that we provide to the biggest and best-funded practices we serve. We’ve found that our patented rules engine lets physicians navigate the common Medicaid problems that so often result in physicians turning away these at-risk populations—and we offer a broad range of population management functionality that serves communities that struggle with diabetes, asthma, etc.

–In the days following the Nov. 2 midterm elections, many want to know what will happen to all the major shifts in health care initiated by the Obama administration. The Wall Street Journal’s health care blog has some answers. You also might want to check out the comments there.

–Now to go back a few days. Even before the official work day started one morning in October, several of us paused mid-sip from our coffee to listen more closely to this NPR story about the struggle between independence and acquisition among hospitals and medical practices.

–That piece had us tuned in the next morning, coffee in hand, for the second half of the NPR reportage.

–And again from the Wall Street Journal, reporter Katherine Rosman explains the latest findings on trends in cell phone, text message, and social media use. This is ground we covered extensively in our whitepaper and webinar on patient communications.