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Making Health Data Patient-Friendly

Posted on May 6, 2016 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 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.

Most of the efforts designed to make healthcare processes more transparent hope to make patients better shoppers. The assumption is that better-informed patients make better decisions, and that ultimately, if enough patients have the right data they’ll take steps which improve outcomes and lower the cost of care. And while the evidence for this assumption is sparse, the information may increase patient engagement in their care — and hopefully, their overall health.

That’s all well and good, but I believe too little attention has been paid to another dimension of transparency. To wit, I’d argue that it’s more than time to present patients with clinical data on a real- or near-real-time basis. Yes, shopping for the right doctor is good, but isn’t it even more important for patients to see what results he or she actually gets in their particular medical case?

Patients rarely get a well-developed look at their clinical data. Patient portals may offer access to test and imaging results from today through 10 years ago — my health system does — but offer no tools to put this data in context. If a patient wants to take a good look at their health history, and particularly, how test results correlate with their behavior, they’ll have to map the data out themselves. And that’s never going to work for your average patient.

Of course, there are obstacles to making this happen:

  • Physicians aren’t thrilled with the idea of giving patients broad healthcare data access. In fact, more than one doctor I’ve seen wouldn’t let me see test results until he or she had “approved” them.
  • Even if you set out to create some kind of clinical data dashboard, doing so isn’t trivial, at least if you want to see patients actually use it. Significant user testing would be a must to make this approach a success.
  • To my knowledge, no EMR vendor currently supports a patient dashboard or any other tools to help patients navigate their own data. So to create such an offering, providers would need to wait until their vendor produces such a tool or undertake a custom development project.

To some extent, the healthcare IT industry is already headed in this direction. For example, I’ve encountered mobile apps that attempt to provide some context for the data which they collect. But virtually all healthcare apps focus on just a few key indicators, such as, say calorie intake, exercise or medication compliance. For a patient to get a broad look at their health via app, they would have to bring together several sets of data, which simply isn’t practical.

Instead, why not give patients a broad look at their health status as seen through the rich data contained in an EMR? The final result could include not only data points, but also annotations from doctors as to the significance of trends and access to educational materials in context. That way, the patient could observe, say, the link between blood pressure levels, exercise, weight and med compliance, read comments from both their cardiologist and PCP on what has been working, and jump to research and education on cardiovascular health.

Ultimately, I’d argue, the chief obstacle to creating such an offering isn’t technical. Rather, it’s a cultural issue. Understandably, clinicians are concerned about the disruption such approaches might pose to their routine, as well as their ability to manage cases.

But if we are to make patients healthier, putting the right tools in their hands is absolutely necessary. And hey, after paying so much for EMRs, why not get more value for your money?

P.S. After writing this I discovered a description of a “digital health advisor” which parallels much of what I’m proposing. It’s worth a read!

New Payment Model Pushes HIT Vendors To Collaborate

Posted on April 20, 2016 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 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.

CMS has launched a new program designed to shift more risk to and offer more rewards to primary care practices which explicitly requires HIT vendors to be involved at advanced stages. While the federal government has obvious done a great deal to promote the use of HIT in medical practices, this is the first I’ve seen where HHS has demanded vendors get involved directly, and I find it intriguing. But let me explain.

The new Comprehensive Primary Care Plus payment scheme – which builds upon an existing model – is designed to keep pushing risk onto primary care practices. CMS expects to get up to 5,000 practices on board over the next five years, spanning more than 20,000 clinicians serving 25 million Medicare beneficiaries.

Like Medicare payment reforms focused on hospitals, CPC+ is designed to shift risk to PCPs in stages. Track 1 of the program is designed to help the practices shift into care management mode, offering an average care management fee of $15 per beneficiary per month on top of fee-for-service payments. Track 2, meanwhile, requires practices to bear some risk, offering them a special hybrid payment which mixes fee-for-service and a percentage of expected Evaluation & Management reimbursement up front. Both tracks offer a performance-based incentive, but risk-bearing practices get more.

So why I am I bothering telling you this? I mention this payment model because of an interesting requirement CMS has laid upon Track 2, the risk-bearing track. On this track, practices have to get their HIT vendor(s) to write a letter outlining the vendors’ willingness to support them with advanced health IT capabilities.

This is a new tack for CMS, as far as I know. True, writing a letter on behalf of customers is certainly less challenging for vendors than getting a certification for their technology, so it’s not going to create shockwaves. Still, it does suggest that CMS is thinking in new ways, and that’s always worth noticing.

True, it doesn’t appear that vendors will be required to swear mighty oaths promising that they’ll support any specific features or objectives. As with the recently-announced Interoperability Pledge, it seems like more form than substance.

Nonetheless, my take is that HIT vendors should take this requirement seriously. First of all, it shines a spotlight on the extent to which the vendors are offering real, practical support for clinicians, and while CMS may not be measuring this just yet, they may do so in the future.

What’s more, when vendors put such a letter together in collaboration with practices, it brings both sides to the table. It gives vendors and PCPs at least a marginally stronger incentive to discuss what they need to accomplish. Ideally – as CMS doubtless hopes – it could lay a foundation for better alignment between clinicians and HIT leaders.

Again, I’m not suggesting this is a massive news item, but it’s certainly food for thought. Asking HIT vendors to stick their necks out in this way (at least symbolically) could ultimately be a catalyst for change.

Direct Primary Care Docs And EMRs

Posted on April 14, 2016 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 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.

For those that haven’t stumbled upon it, direct primary care is an emerging model for changing the relationship between primary care docs and their patients. Under this model, patients pay primary care practices a flat fee per month which covers all services they use during that month. From what I’ve seen, fees are typically between $50 and $100 per month, depending on the patient’s age.

The key to this model — which borrows from but is emphatically not a concierge set-up — is taking insurance companies out of the relationship. And investors seem to be excited about this approach, with VC money flowing into DPC companies and startups like Turntable Health, which is backed by CEO Tony Hsieh.

I bring this up because I wanted to lay out a theory and see what you folks think. The theory doesn’t come from me; it was tossed out in a blog item by Twine Health, which makes a collaborative care platform. In the item, Twine blogger Chris Storer argues that the DPC movement is enabling doctors to junk their EMRs, which he suggests have been put in place to handle insurance documentation.

While the notion is self-serving, given that Twine seemingly wants to replace EMRs in the healthcare continuum, I thought it gave rise to an interesting thought experiment. Are EMRs mostly a tool to placate insurance companies? It’s worth considering. While Twine may or may not offer a solution, it’s hard to argue that existing EMRs “have empowered both physicians and patients in developing relationships that result in better healthcare outcomes.”

In the blog item, Storer argues that primary care practices largely use EMRs as a means of capturing data, and by doing so meeting insurance claims requirements. Though he offers no evidence to this effect, Storer suggests that DPC practices are dumping EMRs to focus better on patient care. There’s actually at least one direct-primary-care oriented EMR on the market (, which is backed by a DPC practice in Wichita, KS), but that doesn’t prove the blogger wrong.

For Twine and its ilk, the question seems to be whether switching from EMRs to another care management model would actually improve the patient experience in and of itself. I’m sure that Twine (and others who consider themselves competitors) believe that it will.

As I see it, though, they’re talking around some key issues. no matter how user-friendly a platform is, No how laudable its goals are, I doubt that even a direct primary care practice unfettered by insurance requirements could seamlessly shift their practice to a platform such this. And no matter how good next-gen collaborative tools are — and I’m optimistic about them, as a category — the workflow issues which have alienated patients in the EMR age won’t go away entirely.

So while I’ll believe that DPC practices want to pitch their EMR, my guess is that the odds of their replacing it with an alternative platform are slim. Now, if collaborative care players catch practices when they’re being formed, that may be a different story. But for now my guess is that any practice that has an EMR in place is unlikely to dump it for the time being. The alternatives (including going back to paper charts) are unlikely to make sense.

Dumb Question 101: What’s Workflow Doing in an EHR?

Posted on March 29, 2016 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

This was going to be a five year relook at Practice Fusion. Back then, I’d written a critical review saying I wouldn’t be a PF consultant. Going over PF now, I found it greatly changed. For example, I criticized it not having a shared task list. Now, it does. Starting to trace other functions, a question suddenly hit me. Why did I think an EHR should have a shared task list or any other workflow function for that matter?

It’s a given that an EHR is supposed to record and retrieve a patient’s medical data. Indeed, if you search for the definition of an EHR, you’ll find just that. For example, Wikipedia defines it this way:

An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format.[1] These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.[2]

Other definitions, such as HIMSS are similar, but add another critical element, workflow:

The EHR automates and streamlines the clinician’s workflow.

Is this a good or even desirable thing? Now, before Chuck Webster shoots out my porch lights, that doesn’t mean I’m anti workflow. However, I do ask what are workflow features doing in an EHR?

In EHRs early days, vendors realized they couldn’t drop one in a practice like a fax machine. EHRs were disruptive and not always in a good way. They often didn’t play well with practice management systems or the hodgepodge of forms, charts and lists they were replacing.

As a result, vendors started doing the workflow archeology and devising new ones as part of their installs. Over time, EHRs vendors started touting how they could reform not just replace an old system.

Hospitals were a little different. Most had IT staff that could shoehorn a new system into their environment. However, as troubled hospital EHR rollouts attest, they rarely anticipated the changes that EHRs would bring about.

Adding workflow functions to an EHR may have caused what my late brother called a “far away” result. That is, the farther away you were from something, the better it looked. With EHR workflow tools, the closer you get to their use, the more problems you may find.

EHRs are designed for end users. Adding workflow tools to these assumes that the users understand workflow dynamics and can use them accordingly. Sometimes this works well, but just as often the functions may not be as versatile as the situation warrants. Just ask the resident who can’t find the option they really need.

I think the answer to EHR workflow functions is this. They can be nice to have, like a car’s backup camera. However, having one doesn’t make you a good driver. Having workflow functions shouldn’t fool you into thinking that’s all workflow requires.

The only way to determine what’s needed is by doing a thorough, requirements analysis, working closely with users and developing the necessary workflow systems.

A better approach would be a workflow system that embeds its features in an EHR. That way, the EHR could fit more seamlessly its environment, rather than the other way around.

Could Blockchain Tech Tackle Health Data Security Problems?

Posted on March 25, 2016 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 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.

While you might not own any them, you’ve probably heard of bitcoins, a floating currency backed by no government entity. You may also be aware that these coins are backed by blockchain technology, a decentralized system in which all participants track everyone’s holdings on their own individual systems. In this world, buyers and sellers can exchange bitcoins untraceably, making bitcoins perfect for criminal use.

In fact, some readers may have first heard about bitcoins when a Hollywood, CA hospital recently had all its data assets frozen by malware hackers, who demanded a ransom of $3.4 million in bitcoins before the hospital could have its data back. (The hospital ended up talking the ransomware attackers down to paying $17K, and when it paid that sum, IT leaders got back control.)

What’s intriguing, however, is that blockchain technology may also be a solution for some of healthcare’s most vexing health data security problems. That, at least, is the view of Peter Nichol, a veteran healthcare business and technology executive consultant. As he sees it, “blockchain addresses the legitimate previous concerns of security, scalability and privacy of electronic medical records.”

In his essay posted on LinkedIn Nichol describes a way in which the blockchain can be used in healthcare data management:

  1. Patient: The patient is provided a code (private key or hash) and an address that provides the codes to unlock their patient data.  While the patient data is not stored in the blockchain, the blockchain provides the authentication or required hashes (multi-signatures, also referred to as multi-sigs) to be used to enable access to the data (identification and authentication).
  2. Provider: Contributors to patient’s medical records (e.g. providers) are provided a separate universal signature (codes or hashes or multi-sigs). These hashes when combined with the patient’s hash establishes the required authentication to unlock the patient’s data.
  3. Profile: Then the patient defines in their profile, the access rules required to unlock their medical record.
  4. Access: If the patient defines 2-of-2 codes, then two separate computer machines (the hashes) would have to be compromised to gain unauthorized access to the data. (In this case, establishing unauthorized privileged access becomes very difficult when the machines types differ, operating systems differ and are hosted with different providers.)

As Nichol rightly notes, blockchain strategies offer some big advantages over existing security, particularly given that keys are distributed and that multiple computers but need to be compromised for attackers to gain access to illicit data.

Nichols’ essay also notes that blockchain technology can be used to provide patients with more sophisticated levels of privacy control over their personal health information. As he points out, the patient can use their own blockchain signature, combined with, say, that of a hospital to provide more secure access when seeking treatment. Meanwhile, when they want to limit access to the data it’s easy to do so.

And voila, health data maintenance problems are solved, he suggests. “This model lifts the costly burden of maintaining a patient’s medical histories away from the hospitals,” he argues. “Eventually cost savings will make it full cycle back to the patient receiving care.”

What’s even more interesting is that Nichols is clearly not just a voice in the wilderness. For example, Philips Healthcare recently made an early foray into blockchain technology, partnering with blockchain-based record-keeping startup Tierion.

Ultimately, whether Nichols is entirely on target or not, it seems clear that health IT players have much to gain by exploring use of blockchain technology in some form. In fact, I predict that 2016 will be a breakout year for this type of application.

EMR Issues That Generate Med Mal Payouts Sound Familiar

Posted on February 8, 2016 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 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.

When any new technology is adopted, new risks arise, and EMR systems are no exception to that rule. In fact, if one medical malpractice insurer’s experience is any indication, EMR-related medical errors may be rising over time — or at least, healthcare organizations are becoming more aware of the role that EMRs are playing in some medical errors. The resulting data seems to suggest that many EMR risks haven’t changed for more than a decade.

In a recent blog item, med mal insurer The Doctors Company notes that EMR-related factors contributed to just under one percent of all claims closed between January 2007 through June 2014. Researchers there found that user factors contributed to 64% of the 97 closed claims, and system factors 42%.

The insurer also got specific as to what kind of system and user factors had a negative impact on care, and how often.

EMR System Factors: 

  • Failure of system design – 10%
  • Electronic systems/technology failure – 9%
  • Lack of EMR alert/alarm/decision support – 7%
  • System failure–electronic data routing – 6%
  • Insufficient scope/area for documentation – 4%
  • Fragmented EMR – 3%

EMR User Factors

  • Incorrect information in the EMR – 16%
  • Hybrid health records/EMR conversion – 15%
  • Prepopulating/copy and paste – 13%
  • EMR training/education – 7%
  • EMR user error (other than data entry) – 7%
  • EMR alert issues/fatigue – 3%
  • EMR/CPOE workarounds -1%

This is hardly a road map to changes needed in EMR user practices and system design, as a 97-case sample size is small. That being said, it’s intriguing — and to my mind a bit scary — to note 16% of claims resulted at least in part due to the EMR containing incorrect information. True, paper records weren’t perfect either, but there’s considerably more vectors for infecting EMR data with false or garbled data.

It’s also worth digging into what was behind the 10% of claims impacted by failure of EMR design. Finding out what went wrong in these cases would be instructive, to be sure, even if some the flaws have probably been found and fixed. (After all, some of these claims were closed more than 15 years ago.)

But I’m leaving what I consider to be the juiciest data for last. Just what problems were created by EMR user and systems failures? Here’s the top candidates:

Top Allegations in EMR Claims

  • Diagnosis-related (failure, delay, wrong) – 27%
  • Medication-related – 19%
    • Ordering wrong medication – 7%
    • Ordering wrong dose – 5%
    • Improper medication management – 7%

As medical director David Troxel, MD notes in his blog piece, most of the benefits of EMRs continue to come with the same old risks. Tradeoffs include:

Improved documentation vs. complexity: EMRs improve documentation and legibility of data, but the complexity created by features like point-and-click lists, autopopulation of data from templates and canned text can make it easier to overlook important clinical information.

Medication accuracy vs. alarm fatigue: While EMRs can make med reconciliation and management easier, and warn of errors, frequent alerts can lead to “alarm fatigue” which cause clinicians to disable them.

Easier data entry vs. creation of errors:  While templates with drop-down menus can make data entry simpler, they can also introduce serious, hard-to-catch errors when linked to other automated features of the EMR.

Unfortunately, there’s no simple way to address these issues, or we wouldn’t still be talking about them many years after they first became identified. My guess is that it will take a next-gen EMR with new data collection, integration and presentation layers to move past these issues. (Expect to see any candidates at #HIMSS16?)

In the mean time, I found it very interesting to hear how EMRs are contributing to medical errors. Let’s hope that within the next year or two, we’ll at least be talking about a new, improved set of less-lethal threats!

#HIMSS16: Some Questions I Plan To Ask

Posted on February 1, 2016 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 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.

As most readers know, health IT’s biggest annual event is just around the corner, and the interwebz are heating up with discussions about what #HIMSS16 will bring. The show, which will take place in Las Vegas from February 29 to March 4, offers a ludicrously rich opportunity to learn about new HIT developments — and to mingle with more than 40,000 of the industry’s best and brightest (You may want to check out the session Healthcare Scene is taking part in and the New Media Meetup).

While you can learn virtually anything healthcare IT related at HIMSS, it helps to have an idea of what you want to take away from the big event. In that spirit, I’d like to offer some questions that I plan to ask, as follows:

  • How do you plan to support the shift to value-based healthcare over the next 12 months? The move to value-based payment is inevitable now, be it via ACOs or Medicare incentive programs under the Medicare Access and CHIP Reauthorization Act. But succeeding with value-based payment is no easy task. And one of the biggest challenges is building a health IT infrastructure that supports data use to manage the cost of care. So how do health systems and practices plan to meet this technical challenge, and what vendor solutions are they considering? And how do key vendors — especially those providing widely-used EMRs — expect to help?
  • What factors are you considering when you upgrade your EMR? Signs increasingly suggest that this may be the year of the forklift upgrade for many hospitals and health systems. Those that have already invested in massiveware EMRs like Cerner and Epic may be set, but others are ripping out their existing systems (notably McKesson). While in previous years the obvious blue-chip choice was Epic, it seems that some health systems are going with other big-iron vendors based on factors like usability and lower long-term cost of ownership. So, given these trends, how are health systems’ HIT buying decisions shaping up this year, and why?
  • How much progress can we realistically expect to make with leveraging population health technology over the next 12 months? I’m sure that when I travel the exhibit hall at HIMSS16, vendor banners will be peppered with references to their population health tools. In the past, when I’ve asked concrete questions about how they could actually impact population health management, vendor reps got vague quickly. Health system leaders, for their part, generally admit that PHM is still more a goal than a concrete plan.  My question: Is there likely to be any measurable progress in leveraging population health tech this year? If so, what can be done, and how will it help?
  • How much impact will mobile health have on health organizations this year? Mobile health is at a fascinating moment in its evolution. Most health systems are experimenting with rolling out their own apps, and some are working to integrate those apps with their enterprise infrastructure. But to date, it seems that few (if any) mobile health efforts have made a real impact on key areas like management of chronic conditions, wellness promotion and clinical quality improvement. Will 2016 be the year mobile health begins to deliver large-scale, tangible health results? If so, what do vendors and health leaders see as the most promising mHealth models?

Of course, these questions reflect my interests and prejudices. What are some of the questions that you hope to answer when you go to Vegas?

Time For A Health Tracking Car?

Posted on December 30, 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 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.

Several years ago, I attended a conference on advanced health technologies in DC. One of the speakers was Dr. Jay Sanders, president and CEO of The Global Telemedicine Group. And he had some intriguing things to say — especially given that no one had heard of a healthcare app yet and connected health was barely a vision.

One of Dr. Sanders’ recommendations was that automobile seat belts should integrate sensors that tracked your heart rhythm. After all, he noted, many of us spend hours a day behind the wheel, often under stressful conditions — so why not see how your heart is doing along the way? After all, some dangerous arrhythmias don’t show up at the moment you’re getting a checkup.

Flash forward to late 2015, and it seems Dr. Sanders’ ideas are finally being taken seriously. In fact, Ford Motor Co. and the Henry Ford Health System are co-sponsoring a contest offering $10,000 in prize money to employees creating smartphone apps linking healthcare with vehicles. While this doesn’t (necessarily) call for sensors to be embedded in seat belts, who knows what employees will propose?

To inspire potential entrants, the Connected Health Challenge sponsors have suggested a few ideas for possible designs, including in-vehicle monitoring and warnings and records access from the road. Other suggestions included appointment check-ins and technology allowing health data to be transmitted to providers. The contest kicks off on January 20th.

In some ways, this isn’t a huge surprise. After all, connected vehicles are already a very hot sector in the automotive business. According to research firm Parks Associates, there will be 41 million active Internet connections in U.S. vehicles by the end of this year.

At present, according to Parks, the connect car applications consumers are most interested in include mapping/navigation, information about vehicle performance, Bluetooth technology and remote control of vehicles using mobile phones. But that could change quickly if someone finds a way to interest the well-off users of wearables in car-based health tracking. (A possible direction for Fitbit, perhaps?)

Ordinarily, I’d have some doubts about Henry Ford Health System employees’ ability to grasp this market. But as I’ve reported elsewhere on Healthcare Scene, Henry Ford takes employee innovation very seriously.

For example, last year HFHS awarded a total of $10,000 in prizes to employees who submitted the best ideas for clinical applications of wearable technology. Not only that, the health system offers employees a 50% share of future revenues generated by their product ideas which reach the marketplace.

Now, it’s probably worth bearing in mind that the wearables industry is far more mature than the market for connected health apps in automobiles. (In fact, as far as I can tell, it’s still effectively zero.) Employees who participate in the challenge will be swinging at a far less-defined target, with less chance of seeing their ideas be adopted by the automotive industry.

Still, it’s interesting to see Ford Motor Co. and HFHS team up on this effort. I think something intriguing will come of it.

Are EMR Templates Really That Bad?

Posted on December 16, 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 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.

Recently, I read an interesting blog item by healthcare veteran Bobby Gladd, kicking around the notion of whether structured EMR data is killing medical practice. In the item, Gladd makes as good of a case as I’ve seen that while open text has its place, the lack of same is NOT single-handedly killing medicine.

In the blog item, Gladd ribs critics of template-driven medicine such as Margalit Gur-Arie, who has called structured data “the one foundational problem plaguing current EHR designs.” Gur-Arie argues that templated data controls clinical interviews, a phenomenon she calls “Bingo Medicine”:

“When your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say.”

Gladd does concede that templates for Meaningful Use can be “simply stupid,” for example in the case of the MU Core 9 measure of smoking status. But do free-written EMR entries support the care process better?  Maybe we do actually need “open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal ‘structured data,'” Gladd notes wryly.

Ultimately, perhaps critics of templates have gone overboard, the blog contends. Gladd suggests that Gur-Arie’s “bingo medicine” argument is more sound than substance: “I have to be a bit skeptical that (it) is anything more than a motivated-reasoning assertion of opinion lacking evidentiary underpinning comprised of adequate psychometrically valid studies of physicians’ cognitive processes while at work, perhaps using docs on paper charts as the differential ‘control’ group.”

As Gladd sees things, the real issue with templates isn’t their existence, as such. For one thing, as readers are likely to know, EMRs almost always come with free-text narrative options from many different points in the workflow. So it’s not that there’s no opportunity for clinicians to write detailed prose about their patient encounters.

Also, the issue isn’t necessarily that doctors are having templates forced upon them, either. As Gladd rightfully points out, at least the Meaningful Use-related data gathering requirements have been extensively vetted by the public, with each stage generating thousands of recommendations from physicians. And both CMS and ONC incorporated as much as possible from that flood of commentary.

Ultimately, the problem isn’t that physicians are being asked to adhere to digital documentation styles at times, Gladd contends. The true problem is the “productivity treadmill” requirements that push doctors to see 25-30 patients a day. “If the typical physician only had to see an average of one patient per hour…adequate documentation would be way less onerous,” Gladd concludes.

And there you have it. Overwork is the bane of any profession requiring brain work, and turning back to all narrative-style documentation does little to remedy the problem. (In fact, it could make things worse — for if doctors don’t have time to use templates, how good are their long-form notes going to be?)

Maybe templates have some downsides. In fact, if someone tried to get me to practice blogging with word templates I’d probably object. But it’s worth bearing in mind that template medicine may be a symptom rather than a cause.

Significant Articles in the Health IT Community in 2015

Posted on December 15, 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 ( 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.

Have you kept current with changes in device connectivity, Meaningful Use, analytics in healthcare, and other health IT topics during 2015? Here are some of the articles I find significant that came out over the past year.

The year kicked off with an ominous poll about Stage 2 Meaningful Use, with implications that came to a head later with the release of Stage 3 requirements. Out of 1800 physicians polled around the beginning of the year, more than half were throwing in the towel–they were not even going to try to qualify for Stage 2 payments. Negotiations over Stage 3 of Meaningful Use were intense and fierce. A January 2015 letter from medical associations to ONC asked for more certainty around testing and certification, and mentioned the need for better data exchange (which the health field likes to call interoperability) in the C-CDA, the most popular document exchange format.

A number of expert panels asked ONC to cut back on some requirements, including public health measures and patient view-download-transmit. One major industry group asked for a delay of Stage 3 till 2019, essentially tolerating a lack of communication among EHRs. The final rules, absurdly described as a simplification, backed down on nothing from patient data access to quality measure reporting. Beth Israel CIO John Halamka–who has shuttled back and forth between his Massachusetts home and Washington, DC to advise ONC on how to achieve health IT reform–took aim at Meaningful Use and several other federal initiatives.

Another harbinger of emerging issues in health IT came in January with a speech about privacy risks in connected devices by the head of the Federal Trade Commission (not an organization we hear from often in the health IT space). The FTC is concerned about the security of recent trends in what industry analysts like to call the Internet of Things, and medical devices rank high in these risks. The speech was a lead-up to a major report issued by the FTC on protecting devices in the Internet of Things. Articles in WIRED and Bloomberg described serious security flaws. In August, John Halamka wrote own warning about medical devices, which have not yet started taking security really seriously. Smart watches are just as vulnerable as other devices.

Because so much medical innovation is happening in fast-moving software, and low-budget developers are hankering for quick and cheap ways to release their applications, in February, the FDA started to chip away at its bureaucratic gamut by releasing guidelines releasing developers from FDA regulation medical apps without impacts on treatment and apps used just to transfer data or do similarly non-transformative operations. They also released a rule for unique IDs on medical devices, a long-overdue measure that helps hospitals and researchers integrate devices into monitoring systems. Without clear and unambiguous IDs, one cannot trace which safety problems are associated with which devices. Other forms of automation may also now become possible. In September, the FDA announced a public advisory committee on devices.

Another FDA decision with a potential long-range impact was allowing 23andMe to market its genetic testing to consumers.

The Department of Health and Human Services has taken on exceedingly ambitious goals during 2015. In addition to the daunting Stage 3 of Meaningful Use, they announced a substantial increase in the use of fee-for-value, although they would still leave half of providers on the old system of doling out individual payments for individual procedures. In December, National Coordinator Karen DeSalvo announced that Health Information Exchanges (which limit themselves only to a small geographic area, or sometimes one state) would be able to exchange data throughout the country within one year. Observers immediately pointed out that the state of interoperability is not ready for this transition (and they could well have added the need for better analytics as well). HHS’s five-year plan includes the use of patient-generated and non-clinical data.

The poor state of interoperability was highlighted in an article about fees charged by EHR vendors just for setting up a connection and for each data transfer.

In the perennial search for why doctors are not exchanging patient information, attention has turned to rumors of deliberate information blocking. It’s a difficult accusation to pin down. Is information blocked by health care providers or by vendors? Does charging a fee, refusing to support a particular form of information exchange, or using a unique data format constitute information blocking? On the positive side, unnecessary imaging procedures can be reduced through information exchange.

Accountable Care Organizations are also having trouble, both because they are information-poor and because the CMS version of fee-for-value is too timid, along with other financial blows and perhaps an inability to retain patients. An August article analyzed the positives and negatives in a CMS announcement. On a large scale, fee-for-value may work. But a key component of improvement in chronic conditions is behavioral health which EHRs are also unsuited for.

Pricing and consumer choice have become a major battleground in the current health insurance business. The steep rise in health insurance deductibles and copays has been justified (somewhat retroactively) by claiming that patients should have more responsibility to control health care costs. But the reality of health care shopping points in the other direction. A report card on state price transparency laws found the situation “bleak.” Another article shows that efforts to list prices are hampered by interoperability and other problems. One personal account of a billing disaster shows the state of price transparency today, and may be dangerous to read because it could trigger traumatic memories of your own interactions with health providers and insurers. Narrow and confusing insurance networks as well as fragmented delivery of services hamper doctor shopping. You may go to a doctor who your insurance plan assures you is in their network, only to be charged outrageous out-of-network costs. Tools are often out of date overly simplistic.

In regard to the quality ratings that are supposed to allow intelligent choices to patients, A study found that four hospital rating sites have very different ratings for the same hospitals. The criteria used to rate them is inconsistent. Quality measures provided by government databases are marred by incorrect data. The American Medical Association, always disturbed by public ratings of doctors for obvious reasons, recently complained of incorrect numbers from the Centers for Medicare & Medicaid Services. In July, the ProPublica site offered a search service called the Surgeon Scorecard. One article summarized the many positive and negative reactions. The New England Journal of Medicine has called ratings of surgeons unreliable.

2015 was the year of the intensely watched Department of Defense upgrade to its health care system. One long article offered an in-depth examination of DoD options and their implications for the evolution of health care. Another article promoted the advantages of open-source VistA, an argument that was not persuasive enough for the DoD. Still, openness was one of the criteria sought by the DoD.

The remote delivery of information, monitoring, and treatment (which goes by the quaint term “telemedicine”) has been the subject of much discussion. Those concerned with this development can follow the links in a summary article to see the various positions of major industry players. One advocate of patient empowerment interviewed doctors to find that, contrary to common fears, they can offer email access to patients without becoming overwhelmed. In fact, they think it leads to better outcomes. (However, it still isn’t reimbursed.)

Laws permitting reimbursement for telemedicine continued to spread among the states. But a major battle shaped up around a ruling in Texas that doctors have a pre-existing face-to-face meeting with any patient whom they want to treat remotely. The spread of telemedicine depends also on reform of state licensing laws to permit practices across state lines.

Much wailing and tears welled up over the required transition from ICD-9 to ICD-10. The AMA, with some good arguments, suggested just waiting for ICD-11. But the transition cost much less than anticipated, making ICD-10 much less of a hot button, although it may be harmful to diagnosis.

Formal studies of EHR strengths and weaknesses are rare, so I’ll mention this survey finding that EHRs aid with public health but are ungainly for the sophisticated uses required for long-term, accountable patient care. Meanwhile, half of hospitals surveyed are unhappy with their EHRs’ usability and functionality and doctors are increasingly frustrated with EHRs. Nurses complained about technologies’s time demands and the eternal lack of interoperability. A HIMSS survey turned up somewhat more postive feelings.

EHRs are also expensive enough to hurt hospital balance sheets and force them to forgo other important expenditures.

Electronic health records also took a hit from ONC’s Sentinel Events program. To err, it seems, is not only human but now computer-aided. A Sentinel Event Alert indicated that more errors in health IT products should be reported, claiming that many go unreported because patient harm was avoided. The FDA started checking self-reported problems on PatientsLikeMe for adverse drug events.

The ONC reported gains in patient ability to view, download, and transmit their health information online, but found patient portals still limited. Although one article praised patient portals by Epic, Allscripts, and NextGen, an overview of studies found that patient portals are disappointing, partly because elderly patients have trouble with them. A literature review highlighted where patient portals fall short. In contrast, giving patients full access to doctors’ notes increases compliance and reduces errors. HHS’s Office of Civil Rights released rules underlining patients’ rights to access their data.

While we’re wallowing in downers, review a study questioning the value of patient-centered medical homes.

Reuters published a warning about employee wellness programs, which are nowhere near as fair or accurate as they claim to be. They are turning into just another expression of unequal power between employer and employee, with tendencies to punish sick people.

An interesting article questioned the industry narrative about the medical device tax in the Affordable Care Act, saying that the industry is expanding robustly in the face of the tax. However, this tax is still a hot political issue.

Does anyone remember that Republican congressmen published an alternative health care reform plan to replace the ACA? An analysis finds both good and bad points in its approach to mandates, malpractice, and insurance coverage.

Early reports on use of Apple’s open ResearchKit suggested problems with selection bias and diversity.

An in-depth look at the use of devices to enhance mental activity examined where they might be useful or harmful.

A major genetic data mining effort by pharma companies and Britain’s National Health Service was announced. The FDA announced a site called precisionFDA for sharing resources related to genetic testing. A recent site invites people to upload health and fitness data to support research.

As data becomes more liquid and is collected by more entities, patient privacy suffers. An analysis of web sites turned up shocking practices in , even at supposedly reputable sites like WebMD. Lax security in health care networks was addressed in a Forbes article.

Of minor interest to health IT workers, but eagerly awaited by doctors, was Congress’s “doc fix” to Medicare’s sustainable growth rate formula. The bill did contain additional clauses that were called significant by a number of observers, including former National Coordinator Farzad Mostashari no less, for opening up new initiatives in interoperability, telehealth, patient monitoring, and especially fee-for-value.

Connected health took a step forward when CMS issued reimbursement guidelines for patient monitoring in the community.

A wonky but important dispute concerned whether self-insured employers should be required to report public health measures, because public health by definition needs to draw information from as wide a population as possible.

Data breaches always make lurid news, sometimes under surprising circumstances, and not always caused by health care providers. The 2015 security news was dominated by a massive breach at the Anthem health insurer.

Along with great fanfare in Scientific American for “precision medicine,” another Scientific American article covered its privacy risks.

A blog posting promoted early and intensive interactions with end users during app design.

A study found that HIT implementations hamper clinicians, but could not identify the reasons.

Natural language processing was praised for its potential for simplifying data entry, and to discover useful side effects and treatment issues.

CVS’s refusal to stock tobacco products was called “a major sea-change for public health” and part of a general trend of pharmacies toward whole care of the patient.

A long interview with FHIR leader Grahame Grieve described the progress of the project, and its the need for clinicians to take data exchange seriously. A quiet milestone was reached in October with a a production version from Cerner.

Given the frequent invocation of Uber (even more than the Cheesecake Factory) as a model for health IT innovation, it’s worth seeing the reasons that model is inapplicable.

A number of hot new sensors and devices were announced, including a tiny sensor from Intel, a device from Google to measure blood sugar and another for multiple vital signs, enhancements to Microsoft products, a temperature monitor for babies, a headset for detecting epilepsy, cheap cameras from New Zealand and MIT for doing retinal scans, a smart phone app for recognizing respiratory illnesses, a smart-phone connected device for detecting brain injuries and one for detecting cancer, a sleep-tracking ring, bed sensors, ultrasound-guided needle placement, a device for detecting pneumonia, and a pill that can track heartbeats.

The medical field isn’t making extensive use yet of data collection and analysis–or uses analytics for financial gain rather than patient care–the potential is demonstrated by many isolated success stories, including one from Johns Hopkins study using 25 patient measures to study sepsis and another from an Ontario hospital. In an intriguing peek at our possible future, IBM Watson has started to integrate patient data with its base of clinical research studies.

Frustrated enough with 2015? To end on an upbeat note, envision a future made bright by predictive analytics.