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Are Limited Networks Necessary to Reduce Health Care Costs?

Posted on September 10, 2014 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.

Among the dirty words most hated by health care consumers–such as “capitation” and “insufficient medical necessity”–a special anxiety infuses the term “out-of-network.” Everybody harbors the fear that the world-famous specialist who can provide a miracle cure for a rare disease he or she may unexpectedly suffer from will be unavailable due to insurance limitations. So it’s worth asking whether limited networks save money, and whether they improve or degrade health care.
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Why Accepting Patient Email is a Practical Requirement of the Affordable Care Act

Posted on July 31, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest post by Zachary Landman, M.D., Chief Medical Officer for DoctorBase.
landman fb
With the infusion of 30 million patients into the U.S. healthcare system in the coming years, the physician shortage is only going to worsen. In Massachusetts, which has had a similar healthcare legislation enacted since 2006, improvements in healthcare coverage and access are highly associated with physician shortages. Prior to the implementation of the health law in Massachusetts, internal medicine and family practice physicians were in deemed to be in “adequate” supply. Almost immediately following the legislation and in nearly every year since, however, the specialties have listed as “critical.”  While the percent of covered patients in the system has reached upwards of 95%, the result has been that physicians are increasingly difficult to visit. Appointment wait times have soared into weeks and months for some specialties and there has been frustration from both patients and providers regarding access.
MMA workforce 2006 and on
An even direr scenario is expected to play out on a national scale when 55 million people currently without insurance enter the healthcare market through subsidized exchanges. Economists predict that the current shortage of physicians will balloon to 63,000 by 2015 and escalate to 130,600 by 2025, due to both increasing demand and dwindling supply. To add salt the wound, a 2012 Physicians Foundation survey demonstrated that nearly half of the 830,000 doctors in the U.S. are over 50 meaning that as the number of patients swell, the supply of physicians will conversely retract.

Clearly, the way healthcare is provided will need to fundamentally change in order to accommodate the three main tenants of the Patient Protection and Affordable Care Act: Access, Quality, and Cost. One potential way is to simply force physicians and healthcare providers to see more patients in the current set of time or work longer or more frequently to maintain their level of reimbursement. Physician time, however, especially for chronically ill and complex patients has become a relatively “inelastic product.”

Physicians already experience significant rates of burnout, are feeling overworked, and have increased the frequency of patient visits to between and 6 and 9 minutes per encounter. Some studies suggest that trying to reduce this amount of time further may actually cause an increase in costs due to inadequate care, counseling, and increased frequency of complications. I would therefore argue that we have reached a point at which physicians cannot increase the volume and frequency of patient care without a fundamental alteration to the paradigm of healthcare.

Secure email may just be the answer. Securely messaging patients can provide a way to fundamentally alter the type and scope of care provided remotely leading to a maintenance or even reduction in the amount of patient care conducted in the office. The fundamental “if” in this scenario, however, is that it must save physician time. For example, physicians have known the value of hand hygiene in patient care for nearly two centuries, but only recently has widespread adoption been shown in an inpatient setting. What led to the main change? Time.  It takes considerable time to cleanse hands thoroughly between each visit. Only when the practice became a time-neutral or time saving event were physicians keen to alter practice behavior. With the inclusion of quick, visible, and easy to use dispensers outside each patient room, these two principles finally coincided.

It’s the same with email. Many physicians worry that by accepting patient messages, their already inelastic time will continually be stretched, forcing them to work longer and harder for a non-reimbursed activity.  After studying more than 11,000 physicians over three years, I have found that the effective use of secure messaging saves physicians on average 45 minutes per day.

Three hours and forty-five minutes per week. That’s a lot of time. And here’s where it comes from.

#1 – Triage. Physician messages should be directed to a practice manager or physician extender who triages the messages and forwards to the appropriate individual. In our case, we found that nearly two-thirds of “physician” messages could actually be handled by office staff. These messages were typically related to hours, availability, insurance coverage, consultant phone numbers, or other back office functions. Our surgeons found that by including a nurse practitioner or physician assistant could also further reduce the number of “MD-level” messages.

For example, minor concerns regarding wound or incision appearance, follow-up timing, suture removal, or questions from visiting nurses were all routinely and commonly handled by the midlevel provider. The exact nature of each question was handled in accordance with physician comfort and expectations. Ultimately, the number and quality of the messages that were directed to physicians were important, timely, and appropriate which led to fewer ED visits, sameday appointments, and phone calls.

#2 – Mobile. Physicians who are able to read, review, and send messages from their mobile device were able to find a considerable amount of “lost” time in their day. Physicians are constantly on-the-move: between patients, rounding, to the hospital and back, to lunch and back, on the elevator, etc. We found that these “micro-minutes” in each day added considerable effectiveness to mobile messaging. As discussed in #1, physician messages were already screened to be important and relevant and so a timely response is indicated. Physicians were able to answer these questions on-the-fly, leading to further confidence in the system on behalf of the patients and fewer voicemails or messages to return at the end of each day.

#3 – Voicemail. Voice messages are the bane of nearly every provider’s life. They are difficult to understand, slow, and take considerable time to review, record, and answer. Through points #1 and #2, the volume and frequency of voicemails decline considerably. The top competitor to patient portals and secure messaging is the phone. It’s universally understood, easy to use, and an immediate response is obtained. Only when patients have an easy to use portal that they can easily access anywhere (and from any device), send a secure message with confidence that it will be reviewed by the provider in a timely manner, and rewarded with a response will patients choose a new system. That’s exactly what our experience has been and there’s absolutely no reason that this cannot be replicated on a national scale.

Whether secure patient email (and ultimately our healthcare legislation) is a failure or a success relates to the patient and provider experiences and our ability to create a harmonious interplay of accessibility, ease of use, and time.

Zachary Landman, M.D. is the Chief Medical Officer for DoctorBase, a San Francisco mobile health technology company considered to be the leader in mobile cloud-based health messaging services that serves more than ten thousand providers and nearly five million patients. Landman is a former resident surgeon at Harvard Orthopaedics and graduate of University California San Francisco School of Medicine. During his career at the intersection of healthcare, technology, and industry, he has developed interactive online musculoskeletal anatomy modules for medical students, created industry sponsored resident journal clubs, and published numerous peer reviewed articles on imaging and outcomes in spine and orthopaedic surgery. Currently, he is leading the development of DoctorBase’s pioneering patient engagement and automated messaging suite, BlueData.

Fee for Service is Dead

Posted on July 9, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In a recent call with the Collaborative Health Consortium, Mark Blatt, MD, Director of Intel Health made some pretty strong statements as a front end to the Healthcare Unbound conference happening this week. In his comments he essentially predicts the end of Fee-For-Service, calling it a dinosaur that will not survive and saying that “this is like a 30-day eviction notice…and it’s happening faster than anyone thinks.”

I find this really interesting because he’s the second high level leader in healthcare that I’ve heard say that the switch away from Fee for Service is happening faster than any of us realize. I wonder what the consequences will be of us not realizing this change is happening. Plus, the odd thing is that we can all see this change happening. Is is that we’re just not understanding the consequences the change will have on the healthcare business?

I also was really intrigued with Mark Blatt’s list of thing you need for a successful transition from Fee for Service:
1. Patient empowerment
2. Mobilize data
3. Share data
4. Gather and store data

When I first considered this list, I realized that EHR could help to enable all of these things. In many ways it already is working to make many of these things possible in an organization. Without the EHR’s involvement, many of these objectives will fall flat.

Although, I also realize that many of these objectives require something outside of the EHR. Will they eventually integrate with the EHR, that’s the vision of some EHR vendors. However, I believe it will take years for us to get there. Until we get there, I think it’s going to create a really tough integration challenge for organizations.

You can hear all of Mark Blatt’s comments in the video below.

Stand-Out Themes at HFMA #ANI2013

Posted on June 24, 2013 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

My third trip to the HFMA ANI show was by far the best yet, for a number of reasons. I found the overall event to be easily manageable in terms of way finding, session offerings and overall organization. Every HFMA volunteer I encountered had a smile on their face, and that’s saying something at 7:15 three mornings in a row. This positive attitude was also evident in the brief keynotes given by the association’s executives and board members, including Ralph Lawson, Steve Rose, Melinda Hancock and Joe Fifer. Each exuded an air of gratefulness at being put in a position of leadership, and seemed optimistic – yet realistic – about the future of healthcare.

Rose was particularly realistic in his comments, noting that the event’s theme of “Whatever it Takes” is one that he applies to his own life, most notably (visually at least) in the area of weight loss. I have to admit, it’s always nice to see healthcare professionals being healthy. (I didn’t see many taking advantage of the doughnuts during the continental breakfast each morning, though everyone does seem to love their caffeine and a few even snuck a cigarette – yuck!)

The only tone of dissension I detected amongst HFMA’s ranks was a result of the keynote given by Joe Gibbs, a celebrated football coach and racing team owner unknown to me before the event. As Gibbs spoke about leadership and picking the right players, I wondered how his testosterone-fueled keynote would compare to the first “Women as Leaders” session held a few days later. While Gibbs’ presentation was so-so, the female-centric session held a few days later was amazing. It was at times confessional in tone, always blunt and occasionally tear-inducing. Five HFMA board members shared their struggles, their triumphs and advice around working, parenting and trying to juggle both. It was refreshing to hear each of them go off script – touching on faith, values, husbands, kids and extended family.

I had the chance to attend most of the keynotes, a session on the challenges faced by small, independent hospitals, and the Women as Leaders panel. I spent a ton of time in the exhibit hall, and will cover that part of the show in next week’s post. For now, I’ll cover some high-level themes I gleaned from talking with attendees and exhibitors, and share a few pictures.

1. It’s time for hospitals to be more proactive in reaching out to payers and physicians, especially when it comes to sharing data. I had no idea that the “H” in HFMA once stood for Hospitals, so this inclusiveness has been in the works for some time. My thinking is that as the industry consolidates and hospitals try to become payers, payers buy hospitals, and physicians get caught in between, it’s only natural that an association like HFMA broaden its horizons to better serve its constituents.

2. Value-based care seems to the new name for accountable care and/or coordinated care. It’s certainly a phrase that will resonate better with consumers, which leads me to number three.

3. Everyone is aware of the need for more transparency into healthcare costs. Consumers have become more vocal in demanding it, and some hospitals are beginning to see the light, offering pre-service estimates. In fact, Fifer announced that HFMA has formed a task force to address the issue of price transparency in healthcare. You can view his announcement below:

4. Health insurance exchanges were covered copiously in sessions I was unable to attend. The “what ifs?” certainly outnumbered the “without a doubts.” I’ll be interested to see how these conversations go next year, once every state is in deep.

5. I did not hear one mention made of mobile health during the entire conference. I realize the attendee demographic is more finance than IT, but I would have thought at least one or two sessions would have addressed mobile health and the benefits this concept and technologies bring to healthcare’s bottom line. Isn’t mobile health key to cost containment and patient engagement?


I’m beginning to think Orlando is my favorite city for conferences. This picture pretty much says it all – beautiful area of town, sunny skies with the typical once-a-day shower, and definitely warm. Even though it was humid, the outside atmosphere was a welcome respite from the absolutely freezing temperatures inside the convention center.


Joe Gibbs gave Monday morning’s keynote. He kept referring to “salesmen,” which made me wonder if he’d been properly debriefed.


This was a pretty interesting panel on the fate of small, independent hospitals. It helped paint a much clearer picture for me of the competitive markets these types of hospitals face.

Berwick slide

Dr. Don Berwick, former head of the CMS, gave my favorite keynote on Tuesday morning. It was fairly high level in nature, but he presented seven or eight examples of healthcare organizations that were taking the term “value-based care” to new levels. He referred to the much venerated “Triple Aim” often, and shared a number of slides, including the one above on “The Structure of the Affordable Care Act.” Notice the word “partial” at the end. To me, this slide conveys the complexity and somewhat confusing nature for the ACA.

That’s all for now. I’ll follow up next week with observations from the exhibitors hall. I’d be interested to hear from anyone else who attended what they took away from the event.

EHRs Don’t Support Key Parts of Practice

Posted on June 3, 2013 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 @annezieger on Twitter.

Ideally, EHRs make the clinical exams more efficient and effective, ultimately saving or even making more money for medical practices.  But the reality is that they bypass other parts of the patient encounter where much of the costs and inefficiencies are generated, according to a whitepaper by athenahealth, “The Economics of Patient Workflow: Cracking the Code of Successful EHR Design.

As the paper notes, 100 percent of practice revenue is generated by the patient exam. Other stages of managing a practice, such as orders and results management, generate 30 percent to 40 percent of costs but no revenue at all. So having an EHR in place which does little to improve exam efficiency — or actually reduces it — is a dangerous thing to do to a practice.

Worse, as the paper points out, there are some major flaws with typical, software-based EHRs:

* They’re too expensive:  Typical cost is $33,000 per physician plus $1,500 per doctor per month for maintenance.

* They don’t save money because they slow doctors down:  Most EHRs force physicians to do a lot of data entry, much in time-consuming, structured formats.

* They aren’t designed to manage the P4P cycle seamlessly:  With most EHRs, doctors have to dig out the data needed to create pay for performance reports.

* They usually don’t offer an efficient, closed-loop solution to the problem of monitoring paper and electronic orders and results:  Remember, orders and result management generates as much as 40 percent of practice expenses.  EHRs’ failure to make such tracking efficient is a major obstacle for medical practices.

Few EHRs support follow-up work from orders and results effectively:  Most EHRs don’t include built-in management and tracking of patient communications, forcing providers to do inefficient and potentially risky manual follow-up.

The white paper goes on to make the argument that there are several reasons why Web-based EHRs solve these problems, largely by requiring no up front cost, using up less physician time on data entry, optimizing collection of data for P4P programs, digitizing all paperwork and tracking practice results.

EMR Value Diminished If Patients Can’t Access Care

Posted on November 16, 2012 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 @annezieger on Twitter.

A new study from the august Commonwealth Fund has just come out, offering a portrait of primary care practices in ten countries. The study had a lot of interesting data to offer, including news of primary care reforms to meet the needs of aging populations and improve chronic disease care.

One of the key data points drawn from the CF study was that two-thirds of U.S. PCPs reported using EMRs in  2012, up from 46 percent in 2009. That’s obviously a big improvement, though the U.S. still lags behind the U.K.,  New Zealand and Australia in EMR implementations and use of IT generally.

At the same time, it seems that U.S. citizens still face serious financial obstacles in getting primary care. Fifty-nine percent of U.S. physicians surveyed said that their patients often have trouble paying for care. That’s a big contrast with other countries included in the study, including Norway (4 percent), the  U.K. (13 percent) and Switzerland (16 percent). These numbers make sense when you consider that the U.S. is the only country surveyed that doesn’t offer universal health coverage.

Putting aside humanitarian reasons to be troubled by money obstacles to PCP access, there are other issues to consider. To me, the most obvious is the selection bias imposed by financial barriers to care.

Consider one of the big goals a medical home hopes to accomplish, managing chronic conditions effectively across the primary care practice’s population.  PCPs can make great use of an EMR to work on such goals, from issuing reminders to get preventive care to tracking patient progress across different demographics to test the impact of new interventions.

The thing is, the power that is a well-tuned EMR is not at its best if the interventions are mostly aimed at those who fit a certain socio-economic profile.

Admittedly, few small PCPs need to be worried about selection bias from a scientific standpoint, as they’re seldom gunning for the next journal article presentation, but looking at the country as a whole, we’re missing out on the collective learning we can generate with clinical data analytics.  It seems to me that we’re going to have to address this problem directly if we want to leverage EMRs for the greater public good.

SCOTUS Decision, Combating Mobile Health Threats, and a Video from RockHealth: This Week at

Posted on July 1, 2012 I Written By

Katie Clark is originally from Colorado and currently lives in Utah with her husband and son. She writes primarily for Smart Phone Health Care, but contributes to several Health Care Scene blogs, including EMR Thoughts, EMR and EHR, and EMR and HIPAA. She enjoys learning about Health IT and mHealth, and finding ways to improve her own health along the way.


Medicaid Doctors and Dentists Gaming the EHR Incentive Program

In order to get the EHR incentive money, Medicaid Doctors and Dentists are only required to purchase the equipment. They can, technically, just buy it and do anything with Meaningful Use. Recently, Dentrix recently partnered with Henry Schein to get access to this money. In this post, the legality of doing this, with no intention of actually passing Meaningful Use standards, is discussed.

SCOTUS Decision and Healthcare IT

The recent decision on the “Affordable Health Act” has gotten the attention of many people across the country. Will this decision affect the IT and EHR world? This post delves into that question, as well as addresses how the SCOTUS decision will impact healthcare reimbursement.

Wired EMR Doctor

My Presentation Submission to 2012 mHealth Summit

Many doctors are hesitant to embrace mHealth. Dr. Michael Koriwchak submitted a talk to the 2012 mHealth Summit, explaining why he feels this is the case. This post gives a basic overview of his talk, which is split into three sections: 1) addressing practicing physicians concerns about mHealth, 2) addressing the culture differences between physician and HIT communities and, 3) outlining the concessions both physicians and the HIT community need to make in order to facilitate communication, promote adoption of mHealth, and improve the quality of mHealth products.

Smart Phone Health Care

Combating Mobile Health Threats: 13 Tips Everyone Should Read

There is a big concern for the security of mHealth, and rightfully so. With all the intelligence to create this technology, there’s people out there wanting to steal information from it. An article a created a list of 13 tips for “combating mobile health threats”. Read the tips and other commentary this week over at Smart Phone Health Care.

App Created to Connect Patients With Doctors Immediately

Consult-a-Doctor is a program designed to connect users with a doctor without ever leaving their home. This cloud-based program is available for the iPhone and requires a subscription. Patients are able to access live medical consultations, treatment, and even receive prescriptions through this program.

EHR and EMR Videos

RockHealth Startup Elements: Product Design with Dave Morin

RockHealth has created a series of videos concerning the elements of starting up a healthcare company. The video featured this week on EHR and EMR Videos features David Morin talking about Product Design. To check out other videos in the series, some of them are posted here.

EMR and EHR Thoughts

$34 Million Series C Funding for Practice Fusion

Practice Fusion brought their total funding to over $64 million, with $34 million coming from recent Series C Funding. Although Practice Fusion seems to be one of the major players in the EHR world, there are some complications that may make it difficult to live up to this $64 million financing.

Physician Adoption of EMRs Growing, But Don’t Expect A Landslide

Posted on February 26, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

About 30 years ago, when cable television hit its stride,  pundits watching the industry assumed that home adoption would quickly climb to near 100 percent. Instead, for a variety of reasons, consumer adoption more or less froze at the 50 percent mark for many years.

Maybe the industry didn’t their pricing strategy right; maybe consumers were perfectly happy with broadcast television; or  maybe the existing broadcast networks greased a few palms and helped regulators slow down its growth in subtle ways.

In any event, the cable industry has improved its performance enormously; in fact, it hit 70% in the late 90s, though that number has fallen significantly as satellite providers have horned in.

So, why bring up cable TV in a forum aimed at dissecting the EMR business?  Because I think the cable industry’s experience is instructive in how we think about EMR adoption.

First, some data points.  According to study released in January by the CDC’s National Center for Health Statistics, 50.7 percent of physicians were using EMRs in their offices in 2010.  That’s a dramatic upswing from previous years, the agency noted.

Of course, practices are eager to collect Meaningful Use incentives if they can.  Also, as older physicians retire, younger, more-wired MDs are taking up the EMR banner. (In fact, CDC data concludes that the younger a physician is, the more likely they were to adopt EMR technology.)

Not only that, hospitals are helping to grease the skids, with one-third offering to subsidize EMR buys and 60 percent offering doctors access to the facility’s EMR, the CDC found.

All of that sounds great, particularly if you’re an EMR vendor.  But I think it’s a bit early, as it was for cable pundits, to predict that EMR adoption is at some kind of tipping point.  Whiz-bang technology always looks great from the peanut gallery — especially to analysts and editors — but it often looks different on the ground.

Not only do I think exponential growth is unlikely, I’d argue that adoption by physicians will be painfully slow for at least a few years more, gaining say, 5 to 7 percentage points a year at best.

Why do I feel that way?  Here’s a few reasons:

*  Few (if any) vendors can honestly say that introducing their product won’t bog down a practice and trash its productivity for months at least.  Doctors know this.

*  Smaller practices don’t, and aren’t likely to, have full-time IT staffers.  Even practices that want to adopt don’t have the reassurance of a dedicated IT brain that knows their needs. Under these circumstances, buying an EMR is a scary investment.

* Other trends that might spark EMR adoption — such as the emergence of RHIOs/HIEs — are moving at a snail’s pace.  If a doctor doesn’t have the added incentive of sharing patient data to spark adoption, that’s one more reason to delay.

Look, maybe I’m being pessimistic, or short-sighted. But I simply don’t think the EMR vendor market nor the physician buyer side have gelled enough to spark a revolution. I guess we’ll just have to wait and see.