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Software Is Dramatically Better Than Paper – Even if EHR Is Far from Perfection

Posted on January 14, 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.

After writing my piece yesterday on the reasons so many physicians are burnt out and my previous New Year’s post on physicians getting pissed off, I thought it might be good to add a little more perspective to the discussion.

In a perfect act of serendipity I came across this great article with quotes from Ross Koppel, scholar in the Sociology Department & School of Medicine at the University of Pennsylvania. First, he puts the situation many organizations find themselves in:

If I buy a toaster and my wife says, ‘It’s lousy; throw it out,’ to preserve domestic tranquility I throw out the toaster and buy a new one. If I spend $1.2 billion or $1.7, I am married and I don’t have a heck of a lot of options.

Then he offers what I think is a proper reality check:

There has been increasing rage on the part of physicians and others about the software not being responsive to their needs. That said, I would be the last person on Earth to argue we should go back to paper. The software is dramatically better than paper. [emphasis added]

I’m sure that some doctors will come on this post and start to point out the virtues of paper. No doubt, there were a lot of good things about paper. A long time ago I wrote a post that described the perfect interface that was infinitely flexible, multi-lingual, no training needed, etc and I was just describing the virtues of the paper chart. I get the paper chart was great for a lot of reasons, but it was awful for a lot of reasons as well. I’m reminded of this post called “Don’t Act Like Paper Charting Was Fast.” I won’t even mention how much time was wasted trying to read illegible charts or searching for the chart that could not be found. Oh wait, I just did.

The problem with all the benefits of EHR is that we quickly take them for granted and promptly forget about them. However, the problems and challenges stare us in the face and annoy us every day. Let’s just reconcile us to the fact that the Perfect EMR is Mythology. However, in many ways it’s better than paper and I don’t see anyone going back.

Here’s where I usually do my sidebar and say that doesn’t mean that EHR vendors can’t do better. They can and should. Hopefully the meaningful use handcuffs that we put on them will indeed be removed and they can focus their attention on making EHRs better as opposed to government regulation. Every EHR vendor I know would celebrate this as well!

If you can’t celebrate the small but powerful benefits of being able to read everything in your EHR and being able to instantly pull up every record. We’ve seen glimpses of other benefits coming to your EHR that are great. Take a second to talk to Jimmie Vanagon about how his #ProjectedEHR and patient portal has changed how he sees and cares for patients.

Want to see other innovation happening in the EHR space? Learn about what Modernizing Medicine is doing with EMA Grand Rounds and Watson. The grand rounds approach is genius and can really inform the care a doctor provides. Unfortunately, we don’t hear much about it, even from them, because I don’t know anyone who’s based their EHR buying decision on if it would improve care in their organization. Sure, they didn’t want it to decrease care, but did they really evaluate the EHR based on it’s ability to improve care? No. They ask if it would meet meaningful use. They ask if it will improve reimbursement. They ask if it will improve productivity. Where’s “Will it improve care?” in that list?

Chew on that concept for a minute. How many EHR systems were bought in order to improve care?

What would it take for a healthcare organization to be ready to make an EHR selection based on the care that an EHR system provided? Would the current crop of EHR vendors be able to adapt? Would it require a whole new breed of EHR software (or maybe a different name)? Will any of the current EHR vendors adapt enough that they could illustrate that their EHR improved care so substantially that it would be nearly malpractice for a healthcare organization to pick any EHR but there’s? Is this what we need to happen for doctors to love EHR?

As I wrote at the New Year, I’m optimistic for healthcare IT. There’s so much potential for us to better utilize technology to improve healthcare. There’s so much non-technology that could benefit healthcare as well. Sometimes it’s just baffling that we can’t get out of our own way. What is clear to me is that we’re not going back to paper.

Clinical Decision Support Should Be Open Source

Posted on January 26, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://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.

Clinical decision support is a long-standing occupant of the medical setting. It got in the door with electronic medical records, and has recently received a facelift under the term “evidence based medicine.” We are told that CDS or EBM is becoming fine-tuned and energized through powerful analytics that pick up the increasing number of patient and public health data sets out in the field. But how does the clinician know that the advice given for a treatment or test is well-founded?

Most experts reaffirm that the final word lies with the physician–that each patient is unique, and thus no canned set of rules can substitute for the care that the physician must give to a patient’s particular conditions (such as a compromised heart or a history of suicidal ideation) and the sustained attention that the physician must give to the effects of treatment. Still, when the industry gives a platform to futurists such as Vinod Khosla who suggest that CDS can become more reliable than a physician’s judgment, we have to start demanding a lot more reliability from the computer.

It’s worth stopping a moment to consider the various inputs to CDS. Traditionally, it was based on the results of randomized, double-blind clinical trials. But these have come under scrutiny in recent years for numerous failings: the questionable validity of extending the results found on selected test subjects to a broader population, problems reproducing results for as many as three quarters of the studies, and of course the bias among pharma companies and journals alike for studies showing positive impacts.

More recently, treatment recommendations are being generated from “big data,” which trawl through real-life patient experiences instead of trying to isolate a phenomenon in the lab. These can turn up excellent nuggets of unexpected impacts–such as Vioxx’s famous fatalities–but suffer also from the biases of the researches designing the algorithms, difficulties collecting accurate data, the risk of making invalid correlations, and the risk of inappropriately attributing causation.

A third kind of computerized intervention has recently been heralded: IBM’s Watson. However, Watson does not constitute CDS (at least not in the demo I saw at HIMSS a couple years ago). Rather, Watson just does the work every clinician would ideally do but doesn’t have time for: it consults thousands of clinical studies to find potential diagnoses relevant to the symptoms and history being reported, and ranks these diagnoses by probability. Both of those activities hijack a bit of the clinician’s human judgment, but they do not actually offer recommendations.

So there are clear and present justifications for demanding that CDS vendors demonstrate its reliability. We don’t really know what goes into CDS and how it works. Meanwhile, doctors are getting sick and tired of bearing the liability for all the tools they use, and the burden of their malpractice insurance is becoming a factor in doctors leaving the field. The doctors deserve some transparency and auditing, and so do the patients who ultimately incorporate the benefits and risks of CDS into their bodies.

CDS, like other aspects of the electronic health records into which it is embedded, has never been regulated or subjected to public safety tests and audits. The argument trotted out by EHR vendors–like every industry–when opposing regulation is that it will slow down innovation. But economic arguments have fuzzy boundaries–one can always find another consideration that can reverse the argument. In an industry that people can’t trust, regulation can provide a firm floor on which a new market can be built, and the assurance that CDS is working properly can open up the space for companies to do more of it and charge for it.

Still, there seems to be a pendulum swing away from regulation at present. The FDA has never regulated electronic health records as it has other medical software, and has been carving out classes of medical devices that require little oversight. When it took up EHR safety last year, the FDA asked merely for vendors to participate voluntarily in a “safety center.”

The prerequisite for gauging CDS’s reliability is transparency. Specifically, two aspects should be open:

  • The vendor must specify which studies, or analytics and data sets, went into the recommendation process.

  • The code carrying out the recommendation process must be openly published.

These fundamentals are just the start of of the medical industry’s responsibilities. Independent researchers must evaluate the sources revealed in the first step and determine whether they are the best available choices. Programmers must check the code in the second step for accuracy. These grueling activities should be funded by the clinical institutions that ultimately use the CDS, so that they are on a firm financial basis and free from bias.

The requirement for transparent studies raises the question of open access to medical journals, which is still rare. But that is a complex issue in the fields of research and publishing that I can’t cover here.

Finally, an independent service has to collect reports of CDS failures and make them public, like the FDA Adverse Event Reporting System (FAERS) for drugs, and the FDA’s Manufacturer and User Facility Device Experience (MAUDE) for medical devices.

These requirements are reasonably light-weight, although instituting them will seem like a major upheaval to industries accustomed to working in the dark. What the requirements can do, though, is put CDS on the scientific basis it never has had, and push forward the industry more than any “big data” can do.

Is Your EHR Stupid?

Posted on March 20, 2013 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.

Yes, I know it’s a bit of a salacious title, but I think it’s an important question. Although, the answer to the question is completely obvious. Yes, your EHR is stupid.

At least the current state of EHR software is a bunch of dumb data repositories of healthcare information. That’s not to say that EHR software today doesn’t have value. The current EHR software can have tremendous value as I’ve been highlighting in my EHR benefit series. Although, just because something is useful and beneficial, doesn’t make it smart and also doesn’t mean we’re anywhere near the potential benefits that EHR will provide.

It’s worth considering a quick look back at how we got to where we are in the EHR world. First, EHR’s (really EMR if we’re splitting hairs) were created to be big billing engines. Since that was their goal, they got really good at it. In fact, the ugly spew of information that we know as templated notes came out of this desire to meet billing requirements easily.

In the next stage of EHR’s history, we layered on EHR certification and meaningful use. That’s right, EHR vendors went from coding software to increase a doctor’s ability to bill to now creating software that meets a set of government regulatory requirements.

Considering this history, is it really any wonder why we’re having a discussion of the EHR backlash that we see happening today?

While many might think this is a doom and gloom perspective. I’m actually incredibly optimistic about the future of EHR and the impact for good it can have on healthcare. Why am I optimistic?

My optimism stems from a number of different areas. First, I have tremendous respect for the creativity of people. I’m certain that we as a people will come up with EHR solutions that benefit healthcare greatly. Second, I think the “stupid EHR” that we have today lay the groundwork for all of the future benefits that will come.

This second point is a very important one. Most of the time people look at innovative ideas and think that they just came out of no where. Instead, when you start to study innovation you realize that most of the very best innovations have come from a mixture of small changes that are put together in a way that no one could have conceived before. I think we’ll see this applied to the EHR world.

The best example of this is what the IBM Watson technology is doing in healthcare. It’s great that a technology like Watson can take in so much information. However, Watson wouldn’t be able to learn anything about healthcare if the data wasn’t in digital form. That’s right, the simple process of having medical knowledge available in electronic form is an essential building block for something as powerful as Watson. The same is true for Watson’s analysis of a patient’s chart. How could Watson analyze a patient if all of their patient information was stuck in an offline world? Each move into the electronic world facilitates the next layer of innovation.

Yes, your EHR is stupid, but that’s ok. Just wait until you see the creative ways entrepreneurs and innovators will take your stupid EHR and make it smart.

If you have examples of this, I’d love to see them. If you have ideas of how to make a smart EHR, I’d love to hear them.

Health Sensors Panel at SXSW

Posted on March 13, 2013 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.

If you’ve been following @ehrandhit on Twitter, then you know that I’ve spent the past few days at the SXSW conference in Austin. It’s been quite the experience and I’ll no doubt write a lot more about my experience at the conference. For now, let’s take a look at many of the top takeaways from the health sensors panel.


While this doesn’t necessarily apply to sensors, I found it interesting that only 5 people raised their hands when asked who in the audience were patients. It’s kind of a stupid question since we’re all patients. I think most of us that heard the question assumed he meant patient advocate or possibly chronic patient. At least I bet that the 5 that raised their hands fit into those categories. Someone on Twitter said that maybe it’s because many of us don’t see ourselves as patients since we’re “healthy.”


Fascinating to consider all the data that our brain is processing. Plus, it should give us hope for what is possible with sensors. Needless to say, we have a long way to go.


This is really sad to consider and applies to many diseases. I think they’re point was that sensors can help us get at some of these diseases.


I’d never consider integrating environmental sensors in your healthcare. Those sensors could be indicators of why our health suffers. Interesting idea.


Seriously amazing technology…assuming it really works. I love people trying even if it doesn’t work out.


This was an important takeaway from my time at the mHealth Summit. We need new study methodologies that match the speed with which we can collect data using sensors and other tech.


I can’t wait for data to point out when we’re lying to ourselves and others.


People always say the wrong thing about Watson. At least right now, it’s not diagnosing. It’s just assisting and supporting the diagnosis.


This is definitely true and we haven’t even started to tap into the health data that’s possible. We’re going to need some amazing technology created to be able to make sense and filter the data down to only what matters.


It’s amazing how important the context is to the data. This is part of the challenge with the Watson technology and the volume of data mentioned above.


This is a fascinating differentiation. I think we’ll see this start to merge over time, but it is interesting to consider the various types of sensors and their intended use. I think until now we’ve focused mostly on sensors for disease. The idea of sensors for health is still such a nascent field of study.

EHR Company Funding Risks – Large EHR Companies

Posted on May 29, 2012 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.

This is the fourth post in my EHR Company Funding Risks series that was started in response to my original post about the The Current Health IT & EHR Bubble. In this series, we’re looking at the following EHR company categories: Seed Funded, Well Funded, Positive Cash Flow, Large EHR Company, and Large Company Backed EHR. Next up is Large EHR companies.

Large EHR Companies
Most of the EHR companies that fit into this category are publicly traded EHR companies (with a few notable exceptions). Each of these EHR companies has their own story, but the majority include some mix of EHR acquisition or EHR merger to get into or expand their EHR market reach. Often this means that the EHR company has more than one EHR software under their purview.

Many of the larger EHR group practices and particularly the multi specialty clinics look to the larger EHR companies because these large EHR companies have usually worked to try and cover every EHR specialty in their EHR. In most cases the EHR software has been around for a very long time. This is good because then the software is often mature, but it’s also bad because it’s often built on old technology.

The large complaint against these large EHR companies is that they’re large and impersonal. That they are out of touch with the customer. Of course, this is kind of the nature of being a large company and having a large user base. Plus, you can imagine the challenge listening across a half dozen different EHR software products.

The risks associated with these large EHR companies software usually has much less to do with cash flow and much more to do with the decisions of the EHR company executives. With multiple EHR software under their umbrella, will they choose to close the one you use down and focus on their other EHR products? Will your EHR product get lost in the corporate shuffle of priorities? Sure, they’ll still support your EHR product if there’s an issue, but have they dedicated the company resources to your EHR or to another product in the company’s portfolio?

One argument that larger EHR vendors have made is that they’re the only companies that have the resources available to create the EHR software of the future. Some argue that many of the smaller EHR companies won’t be able to meet meaningful use stage 3, because they don’t have the resources available to do that. Not to mention when we eventually have to do Watson like Smart EHR software integrations across large data sets. I think the first part about doing MU is overstated. I think the jury is still out on how smart EHR software will become over time and how smart physicians require their EHR to be.

Next up, we’ll look at Large Company Backed EHR. Read all the posts in the EHR Company Funding Risks series.

An EMR Point of Differentiation – Watson

Posted on May 17, 2012 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.

Michael Dale has an interesting post I came across discussing IBM’s Watson in healthcare. Here’s one piece of the post:

You may know Watson best for its performance on the Jeopardy game show. Watson demonstrated swift decision making after indexing over 200 million pages of data. Watson would only answer if the system crossed a certain confidence threshold. The confidence threshold was a predefined percentage set inside the system. When Watson referenced the data, it determined the percentage to which it was sure the top three answers were correct. If the percentage of the top answer crossed the confidence threshold, Watson would signal for the answer. The IBM machine proved itself successful against two humans competing in the game show by winning both rounds.

Certainly physicians and members have much to gain from the assistance of a machine that can reference millions of pages of data to ascertain a diagnosis or treatment. While physicians may always hold the upper hand to interpret the context of the situation for a presenting patient, Watson’s assistance can certainly supplement any decision using vast amounts of data in a quicker time frame.

My immediate reaction to reading this post was the following:

Reading what you wrote made me wonder if the Watson like technology could become a strong differentiation between EHR vendors. It has been extremely challenging lately to differentiate between the various EHR vendor offerings. It seems like having a Watson like brain assisting you in the process could become a differentiation point.

So many physicians are trying to sift through the overwhelming number of EHR companies, that they are looking and wanting for some sort of major EHR differentiation. I wonder if some smart Watson like technology would be amazing enough to blow physicians away so they start saying, I have to have that.

Michael Dale also discusses in the post how Watson would essentially use an EHR to access the data. Sounds a lot like my comments about EHR Being the Database of Healthcare.