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EHRs Weren’t Designed to Influence the Practice of Medicine

Posted on April 15, 2016 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 was going through some old notes from a conference and found an interesting note from a meeting I had with Ensocare at ANI 2014 (Yep, I have lots of notes like this that I’m enjoying reading) that said, “EHRs were never designed to influence the practice of medicine.” Obviously this much later I’m not sure of the context of the comment, but it still really resonates with me today. I assume Ensocare’s perspective was that EHRs weren’t designed to influence care, but that’s what they were trying to accomplish.

It’s a fascinating observation which makes me wonder how many healthcare IT companies goals are to truly influence care. It calls back to my post last month about what it really takes to move the needle in healthcare IT. It’s kind of amazing to think that EHR software wasn’t designed to move the clinical care needle. You could argue that they wanted to move the business process automation needle. You could also argue that EHRs moved the reimbursement needle. Although the problem with moving the reimbursement needle is that it might be great for doctors to get paid more than they were before, but that translates to increased costs to the healthcare system as a whole. I think we’ve largely seen that play out and now they’re trying to deal with it.

As I said in the post linked above, I think that some EHR vendors have backed themselves into a place where they can influence the practice of medicine. However, very few of them were designed to really influence the practice of medicine. It was much easier to solve the business process automation issues and plenty of money to be made by doing so. It’s much harder to actually improve the practice of medicine.

Looking forward, I’m thinking about what type of software company could come along that would disrupt the current batch of EHR software. We could have some technology or mix of technology that continues along the business process automation path. Don’t underestimate the power of a solution like this. However, I wonder what mix of technology solutions could really influence the practice of medicine. Imagine an “EHR” software that was so useful and so powerful that if you chose not to use it you’d be at major risk for medical malpractice.

That’s a really high bar to achieve. However, once you get over that bar, it makes it hard for competitors to enter that space. So, it would be worth the effort. My only fear is that given the current climate, would anyone believe a company that says they’ve created something that will dramatically improve patient care?

In the first crop of EHR software I believe there was a disconnect in the marketing. I don’t think many EHR vendors claimed to improve patient care. They didn’t need to claim it. However, the disconnect was that many of those that purchased EHR software drew their own conclusions on an EHR’s ability to improve patient care. Now, most of these people have been burnt by the idea that an EHR could truly improve patient care. That’s going to be a hard perception to change.

Coming full circle, I imagine that’s why Ensocare and hundreds of other companies that really do want to use technology to move the needle on patient care aren’t calling their solutions EHR software. They have to use a different brand. All of that said, I’m interested in finding more health IT companies that are brave enough to take on the challenge of improving patient care. Which companies do you know that are working on this goal?

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 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.

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 Zappos.com 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 (atlas.md, 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.

Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 2 of 2)

Posted on April 13, 2016 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.

The previous section of this article provided whatever detail I could find on the costs of poor communications and data exchange among health care providers. But in truth, it’s hard to imagine the toll taken by communications failures beyond certain obvious consequences, such as repeated tests and avoidable medical errors. One has to think about how the field operates and what we would be capable of with proper use of data.

As patients move from PCP to specialist, from hospital to rehab facility, and from district to district, their providers need not only discharge summaries but intensive coordination to prevent relapses. Our doctors are great at fixing a diabetic episode or heart-related event. Where we fall down is on getting the patient the continued care she needs, ensuring she obtains and ingests her medication, and encouraging her to make the substantial life-style changes that can prevent reoccurrences. Modern health really is all about collaboration–but doctors are decades behind the times.

Clinicians were largely unprepared to handle the new patients brought to them by the Affordable Care Act. Examining the impact of new enrollees, who “have higher rates of disease and received significantly more medical care,” an industry spokesperson said, “The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time…Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.” Just where the health providers fall short.

All these failures to communicate may explain the disappointing performance of patient centered medical homes and Accountable Care Organizations. While many factors go into the success or failure of such complex practices, a high rate of failure suggests that they’re not really carrying out the coordinated care they were meant to deliver. Naturally, problems persist in getting data from one vendor’s electronic health record to another.

Urgent care clinics, and other alternative treatment facilities offered in places such as pharmacies, can potentially lower costs, but not if the regular health system fails to integrate them.

Successes in coordinated care show how powerful it can be. Even so simple a practice as showing medical records to patients can improve care, but most clinicians still deny patients access to their data.

One care practice drastically lowered ER admissions through a notably low-tech policy–refering their patients to a clinic for follow-up care. This is only the beginning of what we could achieve. If modern communications were in place, hospitals would be linked so that a CDC warning could go to all of them instantly. And if clinicians and their record systems were set up to handle patient-generated data, they could discover a lot more about the patients and monitor behavior change.

How are the hospitals and clinics responding to this crisis and the public pressure to shape up? They push back as if it was not their problem. They claim they are moving toward better information sharing and teamwork, but never get there.

One of their favorite gambits is to ask the government to reward them for achieving interoperability 90 days out of the year. They make this request with no groveling, no tears of shame, no admission that they have failed in their responsibility to meet reasonable goals set seven years ago. If I delivered my projects only 25% of the time, I’d have trouble justifying myself to my employer, especially if I received my compensation plan seven years ago. Could the medical industry imagine that it owes us a modicum of effort?

Robert Schultz, a writer and entrepreneur in health care, says, “Underlying the broken communications model is a lack of empathy for the ultimate person affected–the patient. Health care is one of the few industries where the user is not necessarily the party paying for the product or service. Electronic health records and health information exchanges are designed around the insurance companies, accountable care organizations, or providers, instead of around understanding the challenges and obstacles that patients face on a daily basis. (There are so many!) The innovators who understand the role of the patient in this new accountable care climate will be winners. Those who suffer from the burden of legacy will continue to see the same problems and will become eclipsed by other organizations who can sustain patient engagement and prove value within accountable care contracts.”

Alternative factors

Of course, after such a provocative accusation, I should consider the other contributors that are often blamed for increasing health care costs.

An aging population

Older people have more chronic diseases, a trend that is straining health care systems from Cuba to Japan. This demographic reality makes intelligent data use even more important: remote monitoring for chronic conditions, graceful care transitions, and patient coordination.

The rising cost of drugs

Dramatically increasing drug prices are certainly straining our payment systems. Doctors who took research seriously could be pushing back against patient requests for drugs that work more often in TV ads than in real life. Doctors could look at holistic pain treatments such as yoga and biofeedback, instead of launching the worst opiate addiction crisis America has ever had.

Government bureaucracy

This seems to be a condition of life we need to deal with, like death and taxes. True, the Centers for Medicare & Medicaid Services (CMS) keeps adding requirements for data to report. But much of it could be automated if clinical settings adopted modern programming practices. Furthermore, this data appears to be a burden only because it isn’t exploited. Most of it is quite useful, and it just takes agile organizations to query it.

Intermediaries

Reflecting the Byzantine complexity of our payment systems, a huge number of middlemen–pharmacy benefits managers, medical billing clearinghouses, even the insurers themselves–enter the system, each taking its cut of the profits. Single-payer insurance has long been touted as a solution, but I’d rather push for better and cheaper treatments than attack the politically entrenched payment system.

Under-funded public health

Poverty, pollution, stress, and other external factors have huge impacts on health. This problem isn’t about clinicians, of course, it’s about all of us. But clinicians could be doing more to document these and intervene to improve them.

Clinicians like to point to barriers in their way of adopting information-based reforms, and tell us to tolerate the pace of change. But like the rising seas of climate change, the bite of health care costs will not tolerate complacency. The hard part is that merely wagging fingers and imposing goals–the ONC’s primary interventions–will not produce change. I think that reform will happen in pockets throughout the industry–such as the self-insured employers covered in a recent article–and eventually force incumbents to evolve or die.

The precision medicine initiative, and numerous databases being built up around the country with public health data, may contribute to a breakthrough by showing us the true quality of different types of care, and helping us reward clinicians fairly for treating patients of varying needs and risk. The FHIR standard may bring electronic health records in line. Analytics, currently a luxury available only to major health conglomerates, will become more commoditized and reach other providers.

But clinicians also have to do their part, and start acting like the future is here now. Those who make a priority of data sharing and communication will set themselves up for success long-term.

Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 1 of 2)

Posted on April 12, 2016 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.

A host of scapegoats, ranging from the Affordable Care Act to unscrupulous pharmaceutical companies, have been blamed for the rise in health care costs that are destroying our financial well-being, our social fabric, and our political balance. In this article I suggest a more appropriate target: the inability of health care providers to collaborate and share information. To some extent, our health care crisis is an IT problem–but with organizational and cultural roots.

It’s well known that large numbers of patients have difficulty with costs, and that employees’ share of the burden is rising. We’re going to have to update the famous Rodney Dangerfield joke:

My doctor said, “You’re going to be sick.” I said I wanted a second opinion. He answered, “OK, you’re going to be poor too.”

Most of us know about the insidious role of health care costs in holding down wages, in the fight by Wisconsin Governor Scott Walker over pensions that tore the country apart, in crippling small businesses, and in narrowing our choice of health care providers. Not all realize, though, that the crisis is leaching through the health care industry as well, causing hospitals to fail, insurers to push costs onto subscribers and abandon the exchanges where low-income people get their insurance, co-ops to close, and governments to throw people off of subsidized care, threatening the very universal coverage that the ACA aimed to achieve.

Lessons from a ground-breaking book by T.R. Reid, The Healing of America, suggests that we’re undergoing a painful transition that every country has traversed to achieve a rational health care system. Like us, other countries started by committing themselves to universal health care access. This then puts on the pressure to control costs, as well as the opportunities for coordination and economies of scale that eventually institute those controls. Solutions will take time, but we need to be smart about where to focus our efforts.

Before even the ACA, the 2009 HITECH act established goals of data exchange and coordinated patient care. But seven years later, doctors still lag in:

  • Coordinating with other providers treating the patients.

  • Sending information that providers need to adequately treat the patients.

  • Basing treatment decisions on evidence from research.

  • Providing patients with their own health care data.

We’ll look next at the reports behind these claims, and at the effects of the problems.

Why doctors don’t work together effectively

A recent report released by the ONC, and covered by me in a recent article, revealed the poor state of data sharing, after decades of Health Information Exchanges and four years of Meaningful Use. Health IT observers expect interoperability to continue being a challenge, even as changes in technology, regulations, and consumer action push providers to do it.

If merely exchanging documents is so hard–and often unachieved–patient-focused, coordinated care is clearly impossible. Integrating behavioral care to address chronic conditions will remain a fantasy.

Evidence-based medicine is also more of an aspiration than a reality. Research is not always trustworthy, but we must have more respect for the science than hospitals were found to have in a recent GAO report. They fail to collect data either on the problems leading to errors or on the efficacy of solutions. There are incentive programs from payers, but no one knows whether they help. Doctors are still ordering far too many unnecessary tests.

Many companies in the health analytics space offer services that can bring more certainty to the practice of medicine, and I often cover them in these postings. Although increasingly cited as a priority, analytical services are still adopted by only a fraction of health care providers.

Patients across the country are suffering from disrupted care as insurers narrow their networks. It may be fair to force patients to seek less expensive providers–but not when all their records get lost during the transition. This is all too likely in the current non-interoperable environment. Of course, redundant testing and treatment errors caused by ignorance could erase the gains of going to low-cost providers.

Some have bravely tallied up the costs of waste and lack of care coordination in health care. Some causes, such as fraud and price manipulation, are not attributable to the health IT failures I describe. But an enormous chunk of costs directly implicate communications and data handling problems, including administrative overhead. The next section of this article will explore what this means in day-to-day health care.

New HIM Social Community Tag – #HIMSocial

Posted on April 11, 2016 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.

HIM Social Media - #HIMSocial


I think this is a great idea by Brad Justus to bring together the HIM community on social media. We’ve seen such amazing benefits from the communities that have been created around the #HITsm #hcsm and #hcldr hashtags (to name just a few).

In response to Brad’s tweet, some people suggested that the HIM and HIT communities are very similar and that maybe there shouldn’t be two communities. While I agree that many of the topics discussed by the HIM and HIT communities are the same, the people involved in both communities doesn’t overlap all that much. Most HIT professionals don’t see themselves as HIM professionals and vice versa. Maybe they should, but that’s a topic for another discussion.

Like Brad, I’ve had a chance to spend quite a bit of time at AHIMA and other HIM related events and it’s definitely a distinct community that looks at the challenges of health information management from a unique perspective. That’s why I think the #HIMSocial tag could do very well.

There are a few challenges to creating a community around the #HIMSocial tag. First, there is kind of already a community of HIM professionals that use the AHIMA hashtag. Although, I think the #HIMSocial tag would feel a little more inclusive and even create an opportunity for collaboration with the health IT community. Second, there are still a lot in the HIM community that don’t want to take part in social media like Twitter. There are some incredible exceptions, but speaking generally there are still a lot of HIM professionals that aren’t likely to take part in social media. No doubt that will continue to change.

If you’re part of the HIM (Health Information Management) profession, take a second to check out the #HIMSocial hashtag and send some tweets to contribute to the community.

Should We Return to the Move from EMR to EHR?

Posted on April 8, 2016 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.

Over the 10 years I’ve been blogging about EMR/EHR, it’s been amazing to watch the evolution of the terms and how people use them. Based on most people’s usage, I’ve long been an advocate that the two terms should and are used interchangably. If you say one or the other, most people are assuming the broadest use of the term. Although, the HITECH Act’s use of the term EHR has certainly made it more popular and in vogue (even if most doctors I know still call it an EMR).

Semantics aside, now that meaningful use has matured, I believe that healthcare is ready for a return to the conceptual differences between an EMR and an EHR. Conceptually an EHR was a record that included the patient provided data along with the clinic’s data (ie. EMR data). This concept was partially included in meaningful use, but not in a very meaningful way.

What are some patient features that would constitute an “EHR”?

Medical Record Access – Patient access to the EMR data should be a core feature of an EHR. Most EMR/EHR vendors provide this feature and more and more doctors are excited to give their patients digital access to their medical record. However, along with access to the medical record we need to build features that allow the patient to submit corrections to the medical record.

Secure Messaging – Patients are increasingly demanding electronic access to their doctor’s office. This secure messaging is often done through the EHR. Most EMR/EHR software have this as an option, but many doctors are afraid of what this messaging will mean for their workflow. Luckily, more and more doctors are sharing the experience that this type of messaging makes their workflow faster and better. High maintenance patients are going to be high maintenance regardless of options they have available to access you.

Patient Generated Data – This feature is still something that many are trying to figure out. Can they allow patients to submit their own health data to the doctor? If they do, what’s the doctor’s liability for that data? How can/should the doctor use the data that’s being shared with the clinic? There are plenty of questions about how this should be executed, but there are also a lot of opportunities. It’s time we start working through these challenges.

There’s a whole suite of other services that we should look at offering patients as well such as: online appointment scheduling, online patient payment, refill requests, etc etc. However, if we could start with just the above 3 items we could truly start calling our systems an Electronic Health Record and not just an Electronic Medial Record. Regardless of what we call it, I believe these types of features and even more patient focused access are going to be the future wave of what patients will expect from their doctor.

Will Medical Billing Systems Fail Under ICD-10 Phase 2?

Posted on April 6, 2016 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.

The people at CureMD sent out this tweet and image with a pretty powerful assertion about the future of medical billing systems.
Medical Billing Systems Fail Under ICD-10

I’d like to know where CureMD got the stat in their tweet. That’s a pretty strong assertion about medical billing systems. Based on my knowledge and experience, I’m not sure I agree with them. If they’d have said that ICD-10 in general would cause 50% of medical billing systems to fail, I would have thought it was high but possible. It’s not clear to me how phase 2 of ICD-10 will be so much worse for medical billing systems. Maybe they’ll share in the webinar.

I have seen a bunch of medical billing systems that were running on fumes heading into ICD-10. There was no one really actively developing these systems and they weren’t worrying about ICD-10. They were just sucking whatever revenue they could out of their existing clients and they were going to end of life the product once they ran out of clients. They’re like medical billing system zombies.

Turns out that there are a lot more of these types of systems in healthcare than you probably realized. In fact, I’m surprised we haven’t heard more about their demise after ICD-10’s implementation last year. Whenever I’d talk to doctors, they’d often tell me which EHR they had or which EHR they were considering. Then, I’d ask them which PM system they used and they’d tell me about some software I’d never heard of before. They knew it. They liked it. Many of them would happily say that “you could pull it from their cold dead hands.”

It’s interesting to see CureMD predict that it may be time for us to start doing just that. What are you seeing? Are medical billing systems going to have trouble with the 2nd phase of ICD-10? Will we see a bunch of them finally close up shop? What do you see?

Physician Focused on Computer Screen, Not Patient

Posted on April 5, 2016 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.


Definitely sends a message to the patient. I’m still just surprised that it’s still happening, but it is:

What’s annoying to me is that there are simple solutions to this problem. Not the least of which is positioning the screen in a way that you can look at your patient while you’re working on the computer. An even better way is Dr. James Legan’s approach that he calls #ProjectedEHR. In Dr. Legan’s case he plugs in an HDMI cable so that patients can see him work in the EHR. Plus, he can show patients their results and other health info.

Plenty of other doctors just choose not to document in the exam room so they can focus on the patient. As mobile EHR interfaces develop, I could see a partial documentation done on a mobile phone or tablet and then the rest of the documentation done after the fact as well. I’m a little surprised we haven’t seen more of this already.

Of course, I’ve written for many years about the coming video EHR. That would be a game changer. Although, would certainly take a dramatic change in perspective. Scribes are also popular with many people I know. I’ve even heard of people working on remote scribes which is quite interesting.

What other solutions have you employed to combat the challenges of interacting with patients and the EHR?

Patients and Their Medical Data

Posted on April 4, 2016 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.

Sometimes they say a picture is worth a thousand words. That’s what I thought when I saw this image from Nature.com:
Patient Health Data Sharing and Big Healthcare Data

It’s great to see Nature.com talking about healthcare data. The authors are two people you likely know: Leonard Kish and Eric Topol.

This graphic shows the ideal. It’s interesting to think about what the reality would actually look like. Sadly, it would be much more complex, disconnected, and would lack the fluid sharing that this graphic shows.

It’s good to know what the idea for data sharing and understanding data would look like. Shows the potential of what’s possible and that’s exciting.

How Twine Health Found a Successful Niche for a Software Service in Health Care

Posted on April 1, 2016 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.

Apps and software services for health care are proliferating–challenges and hackathons come up with great ideas week after week, and the app store contains hundreds of thousands of apps. The hard thing is creating a business model that sustains a good idea. To this end, health care incubators bring in clinicians to advise software developers. Numerous schemes of questionable ethics abound among apps (such as collecting data on users and their contacts). In this article, I’ll track how Twine Health tried different business models and settled on the one that is producing impressive growth for them today.

Twine Health is a comprehensive software platform where patients and their clinicians can collaborate efficiently between visits to achieve agreed-upon goals. Patients receive support in a timely manner, including motivation for lifestyle changes and expertise for medication adjustments. I covered the company in a recent article that showed how the founders ran some clinical studies demonstrating the effectiveness of their service. Validation is perhaps the first step for any developer with a service or app they think could be useful. Randomized controlled trials may not be necessary, but you need to find out from potential users what they want to see before they feel secure prescribing, paying for, and using your service. Validation will differentiate you from the hoards of look-alike competitors with whom you’ll share your market.

Dr. John Moore, co-founder of Twine Health, felt in 2013 that it was a good time to start a company, because the long-awaited switch in US medicine from fee-for-service to value-based care was starting to take root. Blue Cross and Blue Shield were encouraging providers to switch to Alternative Quality Contracts. The Affordable Care act of 2010 created the Medicare Shared Savings Program, which led to Accountable Care Organizations.

The critical role played by value-based-care has been explained frequently in the health care space. Current fee-for-service programs pay only for face-to-face visits and occasionally for telehealth visits. The routine daily interventions of connected health, such as text messages, checks of vital signs, and supportive prompts, receive no remuneration. The long-term improvements of connected health receive no support in the fee-for-value model, as much as individual clinicians may with to promote positive behavior among their patients.

Thus, Twine Health launched in 2014 with a service for clinicians. What they found, unfortunately, is that the hype about value-based care had gotten way ahead of its actual progress. The risk sharing by Accountable Care Organizations, such as under the Medicare Shared Savings Program, weren’t full commitments to delivering value, as when clinicians receive full capitation for a population and are required to deliver minimum health outcomes. Instead, the organizations were still billing fee-for-service. Medicare compared their spending to a budget at the end of the year, and, if the organization accrued less fee-for-service billing than Medicare expected, the organization got back 50-60% of the savings In the lowest track of the program, the organization didn’t even get penalized for exceeding costs–it was just rewarded for beating the estimates.

In short, Twine Health found that clinicians in ACOs in 2014 were following the old fee-for-service model and that Twine Health’s service was not optimal for their everyday practices. A recent survey from the NEJM Catalyst Insights Council showed that risk sharing and quality improvement are employed in a minority of health care settings, and are especially low in hospitals.

Collaborative care requires a complete rededication of time and resources. One must be willing to track one’s entire patient panel on a regular basis, guiding them toward ongoing behavior modification in the context of their everyday lives, with periodic office visits every few months. One also needs to go beyond treating symptoms and learn several skills of a very different type that traditional clinicians haven’t been taught: motivational interviewing, shared decision making, and patient self-management.

Over a period of months, a new model for Twine’s role in healthcare delivery started to become apparent: progressive, self-insured employers were turning their attention to value-based care and taking matters into their own hands because of escalating healthcare costs. They were moving much quicker than ACOs and taking on much greater risk.

The employers were contracting with innovative healthcare delivery organizations, which were building on-site primary care clinics (exclusive to that employer and located right at the place of work), near-site primary care clinics (shared across multiple employers), wellness and chronic disease coaching programs, etc. Unlike traditional healthcare providers, the organizations providing services to self-insured employers were taking fully capitated payments and, therefore, full risk for their set of services. Ironically, some of the self-insured employers were actually large health systems whose own business models still involved mostly fee-for-service payments.

With on-site clinics, wellness and chronic disease coaching organizations, and self-insured employers, Twine Health has found a firm and growing customer base. Dr. Moore is confident that the healthcare industry is on the cusp of broadly adopting value-based care. Twine Health and other connected health providers will be able to increase their markets vastly by working with traditional providers and insurers. But the Twine Health story is a lesson in how each software developer must find the right angle, the right time, and the right foothold to succeed.