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Specialty Specific EHR

Posted on June 29, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve long been a fan of the specialty specific EHR vendor. I’ve seen over and over again how much of a difference a specialty specific EHR can make in a practice. It’s a slippery slope when a specialty specific EHR starts entering other specialties. We’d like to think that every doctor is the same, but the variation in the needs of different specialties is rarely given the attention it deserves.

What scares me is that if we’re not careful, the specialty specific EHR vendor might be a dying breed. This isn’t because the specialty specific EHR vendors aren’t loved by their users more than the alternatives. Instead it’s the shift towards hospital owned medical practices that puts the specialty specific EHR in danger.

While hospital systems would love to support a best of breed approach to EHR software and allow each specialty to choose their own, I’ve never seen it actually happen. When push comes to shove, the hospital system starts rolling out an EHR vendor that “supports” every one of their specialties. It’s hard to blame an executive for making this choice. The logistics of supporting 20+ EHR vendors is onerous to put it lightly. The efficiency of one EHR vendor for a large multi specialty organization is just impossible to ignore. Long term however, I wonder if the downsides will cause major issues.

I should also declare that I don’t think a specialty specific EHR is always the best option. Some specialty specific EHR software aren’t very good either. In fact, I was recently thinking through the list of medical specialties and there were a lot of specialties where I didn’t know of a specialty specific EHR for them.

The one that struck me the most was that I didn’t know of an OB/GYN specific EHR. Is that really the case? I’ve seen hundreds of EHR and I couldn’t think of ever seeing an OB/GYN specific EHR. Maybe I’ve missed it, and if I have then I’d love to learn about one. I imagine the reason there isn’t one is because many of the larger All in One EHR vendors have put a decent focus on OB/GYN functionality. So, maybe no one wanted to compete with what was out there already? That’s speculation. What’s odd to me though is that OB/GYN seems like the perfect case where a specialty specific EHR could really benefit that specialty. They have some really unique needs and workflows. I’d think there would be massive competition around their specific challenges.

What I’ve also found is even the EHR vendors that are happy to sell to any specialty and probably have a few templates for that specialty (Yes, that’s how many EHR vendors “support” every specialty), even the All In One EHR vendors work better for certain specialties. This is often based on which specialties the EHR vendor had success with first. If 80 of your first 100 EHR sales are to cardiologists, then you can bet that your EHR is going to work better for cardiologists than it will for podiatrists.

With this in mind, let’s work as a community to aggregate a list of specialty specific EHR vendors. I’ll be generous and say that if an EHR vendor works with more than 10 EHR specialties, then it’s not a specialty specific EHR (5 is probably a better number). If you’re an EHR vendor and want to admit which specialties you work better for, then I’d love to hear that too.

Can we find a specialty specific EHR for every medical specialty? I look forward to seeing if we can in the comments.

EMR and EHR Goes Mobile

Posted on June 26, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I know. I’m a little late to the party. Ironically I created the first mobile version of EMR and EHR about 3+ years ago, but the options that were available weren’t very good and so I abandoned it and went back to the general theme. Plus, phone sizes got so big that I’ve always felt like most websites could be viewed on a modern smartphone without issue.

The people at Google (who are much smarter than me) have chosen otherwise and have started penalizing websites (in their search ranking) that aren’t mobile optimized. I still don’t think it’s a huge deal for my readers since only 10-15% of them read it on mobile devices and a big portion of that is on an iPad or tablet which is large enough to enjoy the normal website. Plus, an even larger portion of the EMR and EHR readership reads it in their email and that’s optimized for mobile already.

Of course, now that you’ve heard my excuses for why it took so long to create a beautiful mobile version of EMR and EHR, I’m happy to say that I’ve finally bit the bullet and rolled out a nice mobile theme for EMR and EHR. In fact, if you’re reading this post on your mobile device, then you’re experiencing the mobile optimized goodness already.

I’m still working on a few more changes to the mobile version of EMR and EHR, but I think you’ll enjoy reading our great content on your mobile device much better now. Let us know what you think in the comments. We’re happy to hear any problems, suggestions, and any praise (who doesn’t like a little ego stroke?) you have about the new mobile version of the site.

Above all else, thanks so much for reading and all your support!

Some Methods For Improving EMR Alerts

Posted on June 25, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study appearing in the Journal of the American Medical Informatics Association has made some points that may turn out to be helpful in designing those pesky but helpful alerts for clinicians.

Making alerts useful and appropriate is no small matter. As we reported on a couple of years ago, even then EMR alert fatigue has become a major source of possible medical errors. In fact, a Pediatrics study published around that time found that clinicians were ignoring or overriding many alerts in an effort to stay focused.

Despite warnings from researchers and important industry voices like The Joint Commission, little has changed since then. But the issue can’t be ignored forever, as it’s a car crash waiting to happen.

The JAMIA study may offer some help, however. While it focuses on making drug-drug interaction warnings more usable, the principles it offers can serve as a model for designing other alerts as well.

For what it’s worth, the strategies I’m about to present came from a DDI Clinical Decision Support conference attended by experts from ONC, health IT vendors, academia and healthcare organizations.

While the experts offered several recommendations applying specifically to DDI alerts, their suggestions for presenting such alerts seem to apply to a wide range of notifications available across virtually all EMRs. These suggestions include:

  • Consistent use of color and visual cues: Like road signs, alerts should come in a limited and predictable variety of colors and styles, and use only color and symbols for which the meaning is clear to all clinicians.
  • Consistent use of terminology and brevity: Alerts should be consistently phrased and use the same terms across platforms. They should also be presented concisely, with minimal text, allowing for larger font sizes to improve readability.
  • Avoid interruptions wherever possible:  Rather than freezing clinician workflow over actions already taken, save interruptive alerts that require action to proceed for the most serious situation. The system should proactively guide decisions to safer alernatives, taking away the need for interruption.

The research also offers input on where and when to display alerts.

Where to display alert information:  The most critical information should be displayed on the alert’s top-level screen, with links to evidence — rather than long text — to back up the alert justification.

When to display alerts: The group concluded that alerts should be displayed at the point when a decision is being made, rather than jumping on the physician later.

The paper offers a great deal of additional information, and if you’re at all involved in addressing alerting issues or designing the alerts I strongly suggest you review the entire paper.

But even the excerpts above offer a lot to consider. If most alerts met these usability and presentation standards, they might offer more value to clinicians and greater safety to patients.

Doctors, Not Patients, May Be Holding Back mHealth Adoption

Posted on June 24, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Clearly, mHealth technology has achieved impressive momentum among a certain breed of health-conscious, self-monitoring consumer. Still, aside from wearable health bands, few mHealth technologies or apps have achieved a critical level of adoption.

The reason for this, according to a new survey, may lie in doctors’ attitudes toward these tools. According to the study, by market research firm MedPanel, only 15% of physicians are suggesting wearables or health apps as approaches for growing healthier.

It’s not that the tools themselves aren’t useful. According to a separate study by Research Now summarized by HealthData Management, 86% of 500 medical professionals said mHealth apps gave them a better understanding of a patient’s medical condition, and 76% said that they felt that apps were helping patients manage chronic illnesses. Also, HDM reported that 46% believed that apps could make patient transitions from hospital to home care simpler.

While doctors could do more to promote the use of mHealth technology — and patients might benefit if they did — the onus is not completely on doctors. MedPanel president Jason LaBonte told HDM that vendors are positioning wearables and apps as “a fad” by seeing them as solely consumer-driven markets. (Not only does this turn doctors off, it also makes it less likely that consumers would think of asking their doctor about mHealth tool usage, I’d submit.)

But doctors aren’t just concerned about mHealth’s image. They also aren’t satisfied with current products, though that would change rapidly if there were a way to integrate mobile health data into EMR platforms directly. Sure, platforms like HealthKit exist, but it seems like doctors want something more immediate and simple.

Doctors also told MedPanel that mHealth devices need to be easier to use and generate data that has greater use in clinical practice.  Moreover, physicians wanted to see these products generate data that could help them meet practice manager and payer requirements, something that few if any of the current roster of mHealth tools can do (to my knowledge).

When it comes to physician awareness of specific products, only a few seem to have stood out from the crowd. MedPanel found that while 82% of doctors surveyed were aware of the Apple Watch, even more were familiar with Fitbit.

Meanwhile, the Microsoft Band scored highest of all wearables for satisfaction with ease of use and generating useful data. Given the fluid state of physicians’ loyalties in this area, Microsoft may not be able to maintain its lead, but it is interesting that it won out this time over usability champ Apple.

We’re Hosting the #KareoChat and Discussing Value Based Care and ACOs – Join Us!

Posted on June 23, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

ACO and Value Based Reimbursement Twitter Chat
We’re excited to be hosting this week’s #KareoChat on Thursday, 6/25 at 9 AM PT (Noon ET) where we’ll be diving into the details around Value Based Care and ACOs. We’ll be hosting the chat from @ehrandhit and chiming in on occasion from @techguy and @healthcarescene as well.

The topic of value based care and ACOs is extremely important to small practice physicians since understanding and participating in it will be key to their survival. At least that’s my take. I look forward to hearing other people’s thoughts on these changes on Thursday’s Twitter chat. Here are the questions we’ll be discussing over the hour:

  1. What’s the latest trends in value based reimbursement that we should know or watch? #KareoChat
  2. Why or why aren’t you participating in an ACO? #KareoChat
  3. Describe the pros and cons you see with the change to value based reimbursement. #KareoChat
  4. What are you doing to prepare your practice for value based reimbursement and ACOs? #KareoChat
  5. Which technologies and applications will we need in a value based reimbursement and ACO world? #KareoChat
  6. What’s the role of small practices in a value based reimbursement world? Can they survive? #KareoChat

For those of you not familiar with a Twitter chat, you can follow the discussion on Twitter by watching the hashtag #KareoChat. You can also take part in the Twitter chat by including the #KareoChat hashtag in any tweets you send.

I look forward to “seeing” and learning from many of you on Twitter on Thursday. Feel free to start the conversation in the comments below as well.

Full Disclosure: Kareo is a sponsor of EMR and EHR.

Marketing Predicted the Failure of Meaningful Use Stage II Patient Engagement

Posted on June 17, 2015 I Written By

The following is a guest post by John Sung Kim, General Manager of DoctorBase, a Kareo Company.
John Sung Kim
Marketers knew far ahead of CMS and the ONC that certain components of Meaningful Use Stage 2 (MU2) were simply not attainable. Thankfully, one of the original components of MU2, whereby 5% of a provider’s patients have to exchange secure messages, is now being relaxed to the simple ability to have secure messaging as an available option for patients.

When MU2 was first drafted, the original threshold was 10%, which was met with a wave of criticism from vendors, analysts, and providers who pointed out that forcing patients to adopt a new technology was outside of a provider’s control.

Yet, even the subsequently reduced 5% goal was difficult to achieve for most organizations, especially smaller independent practices that were dealing with a confluence of changing competitive markets, new billing codes, and mandated technological updates. Any digital marketer with two years of experience running ad campaigns could have told us this would become the case.

There were several marketing related reasons why 5% (or 1 in 20 patients) was simply not achievable for many practices, even with many modern EHR systems:

  • Activation Energy: Most patient portals are too difficult to register for. It’s a well known marketing rule that the number of fields a user has to fill in to register for a service is inversely proportional to the completion rate. Marketers call the amount of effort that users are required to obtain a desired action on a computer or mobile device the “activation energy.” Quite simply, the activation energy required to register for most patient portals is too high.
  • The Funnel: The most common way that patients look for the address or phone number of a provider is to enter permutations of the doctor’s name in search engines. This is what marketers call the “top of the funnel.” If a patient portal is not optimized for search engines (very few are) patients won’t enter the funnel, in other words—what can’t be seen at the top of a Google search result simply doesn’t exist to the patient.
  • Call to Action: Any modern digital marketing campaign has a “Call to Action,” commonly referred to as a CTA. In healthcare, it’s rare that any brochure, office sign, or practice website has a CTA asking patients to engage or interact, and that’s a shame since colorful, visible (and often large) buttons directing the user to click have interaction rates that are often on an order of magnitude greater than collateral without a clear CTA.
  • Email Marketing: Having worked in both digital health and digital marketing, I know how important collecting email addresses of users is, and how poorly most practices actually do this in a routine fashion. A “typical” small or group practice will have no more than 20% to 25% of their patients’ email addresses. So when a marketer does the math of registering 5% of their users through emails, the true number becomes much larger. For example, a practice with 20% of their panel with an email address would need a 25% engagement rate—not 5%! That’s an incredibly aggressive target, even for the biggest brands and best marketers.

Is it time for the Office of the National Coordinator and CMS to start hiring more marketers?

About John Sung Kim
John Sung Kim is the founder and founding CEO of Five9 (NASDAQ: FIVN) widely recognized as the leading company in the contact center industry. He’s acted as a consultant to numerous startups including LGC Wireless (acquired by ADC), Qualys (NASDAQ: QLYS), RingCentral (NYSE: RNG), Odesk (merger w/ Elance), 6connect (funded by Hummer Winblad) and M5 Networks (acquired by ShoreTel). Follow him @JohnSungKim.

Kareo, the leading provider of cloud-based software and services for independent medical practices, is a sponsor of EMR and EHR. Find out more about Kareo’s award-winning solutions at http://www.kareo.com/.

Is Meaningful Use For Mental Health Providers On The Way?

Posted on June 10, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

If you look at the policy statements issued by ONC, it sounds as though the organization is a big fan of putting behavioral health IT on the same footing as other aspects of care. As the agency itself points out, 46% of Americans will have a mental health disorder over the course of their lifetime, and 26% of Americans aged 18 and older live with a mental health disorder in any given year, which makes it imperative to address such issues systematically.

But as things stand, behavioral health IT initiatives aren’t likely to go far. True, ONC has encouraged behavioral health stakeholders on integrating their data with primary care data, stressed the value of using EMRs for consent management, supported the development of behavioral health clinical quality measures and even offered vendor guidelines on creating certified EMR tech for providers ineligible for Meaningful Use. But ONC hasn’t actually suggested that these folks deserve to be integrated into the MU program. And not too surprisingly, given their ineligibility for incentive checks, few mental health providers have invested in EMRs.

However, a couple of House lawmakers who seem pretty committed to changing the status quo are on the case. Last week, Reps. Tim Murphy (R-Pa.) and Eddie Bernice Johnson (D-Texas) have reintroduced a bill which would include a new set of behavioral health and substance abuse providers on the list of those eligible for Meaningful Use incentives.

The bill, “Helping Families in Mental Health Crisis Act,” would make clinical psychologists and licensed social workers eligible to get MU payments. What’s more, it would make mental health treatment facilities, psychiatric hospitals and substance abuse mistreatment facilities eligible for incentives.

Supporters like the Behavioral Health IT Coalition say such an expansion could provide many benefits, including integration of psych and mental health in primary care, improved ability of hospital EDs to triage patients and reduction of adverse drug-to-drug interactions and needless duplicative tests. Also, with interoperable healthcare data on the national agenda, one would think that bringing a very large and important sector into the digital fold would be an obvious move.

So as I see it, making it possible for behavioral health and other medical providers can share data is simply a no-brainer.  But that can’t happen until these providers implement EMRs. And as previous experience has demonstrated, that’s not going to happen until some version of Meaningful Use incentives are available to them.

I imagine that the bill has faltered largely over the cost of implementing it. While I haven’t seen an estimate of what it would cost to expand eligibility to these new parties, I admit it’s likely to be very substantial. But right now the U.S. health system is bearing the cost of poorly coordinated care administered to about one-quarter of all U.S. adults over age 18. That’s got to be worse.

Industry Tries To Steamroll Physician Complaints About EMR Impact On Patient Face Time

Posted on June 9, 2015 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Some doctors — and a goodly number of consumers, too — argue that the use of EMRs inevitably impairs the relationship between doctors and patients. After all, it’s just common sense that forcing a doctor to glue herself to the keyboard during an encounter undercuts that doctor’s ability to assess the patient, critics say.

Of course, EMR vendors don’t necessarily agree. And some researchers don’t share that view either. But having reviewed some comments by a firm studying physician EMR use, and the argument an EMR vendor made that screen-itis doesn’t worry docs, it seems to me that the “lack of face time” complaint remains an important one.

Consider how some analysts are approaching the issue. While admitting that one-third to one-half of the time doctors spend with patients is spent using an EMR, and that physicians have been complaining about this extensively over the past several years, doctors are at least using these systems more efficiently, reports James Avallone, Director of Physician Research, who spoke with EHRIntelligence.com.

What’s important is that doctors are getting adjusted to using EMRs, Avallone suggests:

Whether [time spent with EMRs] is too much or too little, it’s difficult for us to say from our perspective…It’s certainly something that physicians are getting used to as it becomes more ingrained in their day-to-day behaviors. They’ve had more time to streamline workflow and that’s something that we’re seeing in terms of how these devices are being used at the point of care.

Another attempt to minimize the impact of EMRs on patient encounters comes from ambulatory EMR vendor NueMD. In a recent blog post, the editor quoted a study suggesting that other issues were far more important to doctors:

According to a 2013 study published in Health Affairs, only 25.8 percent of physicians reported that EHRs were threatening the doctor-patient relationship. Administrative burdens like the ICD-10 transition and HIPAA compliance regulations, on the other hand, were noted by more than 41 percent of those surveyed.

It’s certainly true that doctors worry about HIPAA and ICD-10 compliance, and that they could threaten the patient relationship, but only to the extent that they affect the practice overall. Meanwhile, if one in four respondents to the Health Affairs study said that EMRs were a threat to patient relationships, that should be taken quite seriously.

Of course, both of the entities quoted in this story are entitled to their perspective. And yes, there are clearly benefits to physician use of EMRs, especially once they become adjusted to the interface and workflow.

But if this quick sample of opinions is any indication, the healthcare industry as a whole seems to be blowing past physicians’ (and patients’) well-grounded concerns about the role EMR documentation plays in patient visits.

Someday, a new form factor for EMRs will arise — maybe augmented or virtual reality encounters, for example — which will alleviate the eyes-on-the-screen problem. Until then, I’d submit, it’s best to tackle the issue head on, not brush it off.

Taking a New Look at the Lamented Personal Health Record: Flow Health’s Debut

Posted on June 8, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://radar.oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

After the disappointing lack of adoption suffered by Google Health and Microsoft HealthVault, many observers declared personal health records (PHRs) a non-starter, while others predicted that any progress toward personal control over health data would require a radically new approach.

Several new stabs at a PHR are emerging, of which Flow Health shows several promising traits. The company tries to take advantage of–and boost the benefits of–advances in IT standards and payment models. This article is based on a conversation I had with their general counsel, David Harlow, who is widely recognized as the leading legal expert in health IT and health privacy and who consults with companies in those spaces through the Harlow Group.

Because records are collected by doctors, not patients, the chief hurdle any PHR has to overcome is to persuade the health care providers to relinquish sole control over the records they squirrel away in their local EHR silos. Harlow believes the shift to shared risk and coordinated care is creating the incentive for doctors to share. The Center for Medicare & Medicaid Services is promising to greatly increase the role of pay-for-value, and a number of private insurers have promised to do so as well. In short, Flow Health can make headway if the tangible benefit of learning about a patient’s recent hospital discharge or treating chronic conditions while the patient remains at home start to override the doctor’s perception that she can benefit by keeping the patient’s data away from competitors.

The next challenge is technically obtaining the records. This is facilitated first by the widespread move to electronic records (a legacy of Meaningful Use Stage 1) and the partial standardization of these records in the C-CDA. Flow Health recognizes both the C-CDA and Blue Button, as well as using the Direct protocol to obtain records. Harlow says that FHIR will be supported when the standard settles down.

But none of that is enough to offer Flow Health what the doctors and patients really want, which is a unified health record containing all the information given by different providers. Therefore, like other companies trying to broaden access to patient data, Flow Health must deal with the problem that Dr. Eric Topol recently termed the Tower of EMR Babel. They study each format produced by different popular EHRs (each one using the C-CDA in slightly incompatible ways) and convert the data into a harmonized format. This allows Flow Health to then reconcile records when a diagnosis, a medication list, or some other aspect of the patient’s health is represented differently in different records.

What’s next for Flow Health? Harlow said they are preparing an API to let third parties add powerful functionality, such as care coordination and patient access from any app of their choice. Flow Health is already working closely with payers and providers to address workflow challenges, thus accelerating the aggregation of patient health record data for access and use by clinicians and patients.

A relative of mine could have used something like Flow Health recently when her eye doctor referred her to the prestigious Lahey Clinic in the Boston area. First of all, the test that led to the referral had to be repeated at the Lahey Clinic, because the eye doctor did not forward test results. Nor did anyone provide a medication list, so the Lahey Clinic printed out a five-year old medication list that happened to hang around from a visit long ago and asked her to manually update it. There was also confusion about what her insurer would cover, but that’s a different matter. All this took place in 2015, in the country’s leading region for medical care.

It seems inevitable that–as Flow Health hopes–patients will come to demand access to their medical records. A slew of interesting experiments will proliferate, like Flow Health and the rather different vision of Medyear to treat health information like a social network feed. Patient-generated data, such as the output from fitness devices and home sensors, will put yet more pressure on health care providers to take the patient seriously as a source of information. And I’ll continue to follow developments.

Evolutionary Timeline of Medical Documentation

Posted on June 5, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been kicking up some dust over on EMR and HIPAA about the awful EHR documentation that most EHR vendors produce (Full Disclosure: It’s not really the EHR vendors fault, but billing and other regulations). In response to my post, Peter Elias provided a great look at the history of medical documentation and how we got so far off track when it comes to using documentation as a clinical tool. Here’s his comment:

Evolutionary time-line…
In the earliest days it was sparse/terse and mostly for the benefit of the clinician:

1. Document the decision and treatment. (Otitis media – amoxicillin.)
2. Document the decision, supporting evidence, and treatment. (Bulging red R TM, OM, amox.)
3. Then it became necessary to document why other decisions and treatments were not elected.
4. The SOAP note and problem oriented recording developed to encourage tracking problems over time. Still a clinical approach.
5. The medical record slowly became a legal document. If you didn’t say you examined the calf and found no evidence of DVT, it meant you hadn’t done it and were liable.
6. The medicolegal record slowly became a billing record. In order to prove how hard you worked, you needed to document two from column A, three from column B, level 37 decision making, an explicit statement of risk. This required documenting lots of negative detail. ‘Pertinent negative’ in a ROS became a laundry list of clinically irrelevant but coding-dependent negatives.
7. Add meaningful use and other audit requirements, and there is another layer of information that must be acquired and recorded.

In all this process, sadly, the note stopped being primarily a clinical tool. I fantasize about a system that allows recording of all that clinically unnecessary flotsam and jetsam, but does not require including it in a clinical note. It goes into the database and is accessible for those who want it when they want it, but it doesn’t get between me and my patients.

Reading Peter’s comments made me wonder if we’re going to start having two types of notes. A clinical note and a billing note. That’s sad to consider that EHR vendors would spend their time coding their applications around the challenge of quality documentation.