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Cloud-Based EHRs With Analytics Options Popular With Larger Physician Groups

Posted on April 20, 2018 I Written By

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

Ever wonder what large medical practices want from the EHRs these days? According to one study, the answer is “cloud-based systems with all the bells and whistles.”

Black Book Research just completed a six-month client satisfaction poll questioning members of large practices about their EHR preferences. The survey collected data from roughly 19,000 EHR users.

According to the survey, 30% of practices with more than 11 clinicians expect to replace their current EHR by 2021, primarily because they want a more customizable system. It’s not clear whether they are sure yet which vendors offer the best customization options, though it’s likely we’ll hear more about this soon enough.

Among groups planning an EHR replacement, what appealed to them most (with 93% ranking it as their preferred option) was cloud-based mobile solutions offering an array of analytical options. They’re looking for on-demand data and actionable insights into financial performance, compliance tracking and tools to manage contractual quality goals. Other popular features included telehealth/virtual support (87%) and speech recognition solutions for hands-free data entry (82%).

Among those practices that weren’t prepared for an EHR replacement, it seems that some are waiting to see how internal changes within Practice Fusion and eClinicalWorks play out. That’s not surprising given that both vendors boasted an over 93% customer loyalty level for Q1 2018.

The picture for practices with less than six or fewer physicians is considerably different, which shouldn’t surprise anybody given their lack of capital and staff time.  In many cases, these smaller practices haven’t optimized the EHRs they have in place, with many failing to use secure messaging, decision support and electronic data sharing or leverage tools that increase patient engagement.

Large practices and smaller ones do have a few things in common. Ninety-three percent of all sized medical and surgical practices using an installed, functional EHR system are using three basic EHR tools either frequently or always, specifically data repositories, order entry and results review.

On the other hand, few small to midsize groups use advanced features such as electronic messaging, clinical decision support, data sharing, patient engagement tools or interoperability support. Again, this is a world apart from the higher-end IT options the larger practices crave.

For the time being, the smaller practices may be able to hold their own. That being said, other surveys by Black Book suggest that the less-digitalized practices won’t be able to stay that way for long, at least if they want to keep the practice thriving.

A related 2018 Black Book survey of healthcare consumers concluded that 91% of patients under 50 prefer to work with digitally-based practices, especially practices that offer conductivity with other providers and modern portals giving them easy access to the health data via both phones and other devices.

EMR-Based Alert System Can Identify Possible Child Abuse Victims

Posted on February 21, 2018 I Written By

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

Sometimes, it’s pretty easy for a physician to tell that a child might be experiencing physical abuse at home. However, sometimes physicians are rushed and may not do an adequate screening for abuse, the signs of which aren’t always available at first glance.

However, a group of researchers has developed an algorithm, drawing on patient records in the EMR, which it says can improve screening rates for physical abuse and identify such cases earlier.

The project, the write-up of which appears in the Journal of the American Medical Informatics Association, coded triggers to identify children less than two years old at risk for physical abuse into the EMR using a freestanding pediatric hospital with a level 1 trauma center. The researchers embedded 30 age-specific triggers in the EMR.

During the test, the system ran a “silent mode,” in which study personnel saw data on children whose clinical symptoms triggered the alert system but physicians did not. During the period between October 21, 2014 through April 6, 2015, 226 children triggered the alert, the mean age of whom was 6.5 months.

During the pilot the system detected 98.5% of children less than two years of age with signs of probable or definite child abuse, according to the study authors.

If these algorithms are that successful in identifying at-risk children, one would hope that the system moves from pilot to widespread rollout fairly soon. In theory, the system should help clinicians who encounter children in potential danger, especially ones presenting with serious injuries in the emergency department, be better prepared to identify these children and take appropriate action.

Ultimately, this study suggests that even if such clinicians are alert and careful, triggers generated by an EMR might be more effective at detecting these cases. After all, while clinicians must juggle multiple patients in an extremely hectic environment, especially in the ED, EMRs don’t get tired and they don’t need to check a signs and symptoms list manually to detect signs of trouble.

Of course, while these triggers can be very helpful in investigating signs of abuse, clinicians would be ill-advised to rely on them entirely, as there’s no substitute for experience and medical judgment. Also, there’s always a risk that adding another alert to the cacophony of existing alerts could lead to it going unnoticed. Still, it seems certain that if nothing else, this is a promising approach to protecting children from harm.

AAFP Proposes Tactics For Reducing EHR Administrative Burdens

Posted on February 12, 2018 I Written By

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

The American Academy of Family Physicians has proposed a series of approaches it says will reduce the administrative burdens EHRs impose on primary care doctors.

The recommendations, which come in the form of a letter to CMS, address health IT simplification, prior authorization and standardization of quality measurement. However, the letter leads off with EHR concerns and much of the content is focused on making physician IT use easier.

Few would argue that the average physician spends too much time struggling with EHR-related administrative work. The AAFP backs this assertion up with a couple of studies, including one finding that primary care physicians spend almost 6 hours per day interacting with EHRs. It also cites research concluding that four types of specialist spent almost 2 hours using the EHR for every hour of direct patient care.

To address these concerns, the AAFP recommends taking the following steps:

  • Eliminating HIT utilization measures in MIPS: The group argues that such measures are not needed anymore now that MIPS includes quality, cost and practice improvement measures.
  • Updating documentation requirements: With the agency’s Evaluation and Management recommendation guidelines having been developed 20 years ago, prior to the widespread use of EHRs, it’s time to rethink their use, the letter asserts. Today, the group says, they have a negative impact on EHR usability and hinder interoperability. The group recommends eliminating documentation requirements for codes 99211-99215 and 99201-99205 entirely and allowing any care team member to enter medical information.
  • Rethinking data exchange policies: The AAFP is asking CMS and ONC to focus on how and when data is exchanged rather than demanding that specific data types be included. The group also urges CMS and ONC to penalize healthcare organizations not appropriately sharing information, using its authority granted by the 21st Century Cures Act.
  • Creating standardized clinical data models: To share data effectively across the healthcare ecosystem, the AAFP argues, it’s necessary to develop nationally-recognized, consistent data models that can be used to share data efficiently. It recommends that such principles be developed by physicians and other clinicians rather than policymakers, vendors or engineers.

I don’t know about you, but I find much of this to be a no-brainer. Of course, the decades-old E/M guidelines need to be reformed, consistent data models must emerge if we hope to improve interoperability and physicians need to lead the charge.

Unfortunately, it’s hard to tell whether CMS and ONC are willing and prepared to listen to these recommendations. In theory, leaders at ONC should be only too glad to help providers achieve these goals and CMS should support their efforts. But given how obvious some of this is, it should have happened already. The fact that it hasn’t points up how hard all of this could be to pull off.

Three-Quarters Of Medical Practices Aren’t Getting Full Value From Their EHR

Posted on February 6, 2018 I Written By

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

Given how many EHRs seem to feature position-hostile designs, it’s hardly surprising to learn that many medical practices aren’t getting the most from them. However, I was taken aback by how deep this underutilization seems to run.

A new study appearing in the American Journal of Managed Care has concluded that a whopping 73% of practices weren’t using their EHRs to the fullest extent and that another 40% make little or no use of health IT functions. Even given the obstacles to using EHRs, this seems like a big waste of money, time and potential, doesn’t it?

To conduct the study, researchers used data from a relevant HIMSS Analytics survey. The data included responses from 30,123 ambulatory practices with an operational EHR in place, most with fewer than seven affiliated doctors in place.  Researchers sifted the data to determine the extent to which these practices were using EHR-based health IT functionalities.

Of course, some medical groups were on top of their game. Researchers found that 26.6% of practices could be classified as health IT super-users that squeezed every benefit from their systems. As you might guess, the likelihood that a practice was a super-user grew as the number of affiliate doctors increased, as well as when the practice was located in a metropolitan area. But far more groups seem to have fallen well behind the leaders.

According to the data, among practices using CPOE tools, only 36% used them for more than 75% of orders. Also, while groups commonly used basic functions such as data storage, with 100% of practices storing transcribed reports electronically and 61% using the EHR for nursing documentation, most lagged in other areas. For example, only 29% used tools allowing them to find and modified orders for all patients on a specific medication.

To address this gap, researchers say, policymakers should consider how to address the barriers PCP and specialist practices face in using the health IT tools more fully. Understanding how this disparity has emerged and how to address it is critical, they suggest, as less sophisticated use of EHRs may have an impact on care quality and also on groups’ ability to participate in community efforts such as HIEs.

The truth is, if the under-utilizer practices don’t get some kind of help or support, it’s unlikely they’ll step up their use of EHR functions. Particularly if they’ve had the system in place for a while, the workflow is baked into the system and physician habits established. Maybe the pressure to provide value-based care will do the trick, but it remains to be seen. This is a problem that won’t go away quickly.

Big Gap Exists Between Wearables Hype And Physician Use

Posted on January 12, 2018 I Written By

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

Not long ago, I wrote an article describing some major advances in wearables and health tracking technologies. Standout technologies included Grail, a cancer detection startup, Beddit, which makes sleep tracking technology, and Senosis Health, which developed apps using smartphone sensors to monitor health signals.

In the article, I argued that we’re past the question of whether wearables are valuable and that it’s time to focus on what we want to do with next-generation of superpowered health tracking devices instead. I was driven by stats like the ones produced by the Consumer Technology Association, which asserted last year that by 2020, physician use of patient-generated data will reach critical mass. It noted that wearables are being used more often in clinical trials and that some health insurers offering free wearables to patients, trends which it predicts will cause the market to explode.

But at least to some extent, I think the CTA (and I) were both wrong. As impressive as the new patient trackers are, they won’t be that valuable if nobody on the frontlines of medicine uses them. And even if trackers are being used in clinical trials or given away by health insurers, that doesn’t mean physicians are on board. The issue is not just whether devices work well, but whether doctors can actually use them in their daily care routine.

Recent stats suggest that few physicians actually use patient-generated data in their practice. In fact, the Physicians Practice Technology Survey found that just 5% of respondents reported that they use such such devices as part of their care routine.

I’m not surprised by this research. My own informal discussions with physicians suggest that the number of practices that actively use patient-generated data may be even lower than 5%.

Why are so few medical practices leveraging patient-generated data? The reasons are fairly straightforward:

  • Few of devices offer measurements that are consistent, predictable and valid
  • Vanishingly few are FDA-approved, which does little to inspire clinicians’ confidence
  • In most cases, the data produced by wearables and related devices isn’t compatible with practice EMRs

For what it’s worth, I do believe that many physicians — especially those with an interest in health IT– know that patient-generated health data will eventually play a valuable role in their practice. After all, in principle, there must be ways that such data could inform patient care.

But right now, the simple devices patients own aren’t sophisticated enough to serve practice needs, and most of the advanced patient tracking devices are at the idea or testing phase. Until patient tracking devices become more practical, and offer reliable, valid, usable data, they’re likely to remain a dark horse.

Coping With The Loss Of Your Ambulatory EMR

Posted on December 13, 2017 I Written By

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

Despite the struggles involved, most practices seem to have settled in with an EMR they can at least tolerate. Their workflows are, well, working, the practice management features seem to connect with the clinical ones and most clinicians are complaining about using it.

Yes, your practice may have had to go through a few systems before you found one everyone liked, wasn’t too expensive and had decent technical support to offer.  By this time, though you may have been a little scarred by the experience, hopefully practice leaders have gotten comfortable with the central role the EMR plays in the practice.

Then, you decide it makes sense to sell your practice to the local health system. It could be because it’s an irresistible deal financially, or you feel you can’t survive without their help and partnership, or any number of additional reasons. Everything looks good, but then you take a hit: your new “partner” wants to dump the EMR you worked so hard to find and customize. They want you to work on the same enterprise system they do.

Now, from a hospital’s perspective that may make sense. Here’s how one consulting firm lays things out:

“[When acquiring a medical practice] one critical issue is how to transition the workflow of these physicians and their staff from the practice-owned ambulatory EMR to the centralized hospital-owned EMR to ensure the efficient and safe delivery of care to patients,” it tells its hospital customers. In other words, it’s a question of when and how, not IF the hospital should require acquired practices to make the switch.

The thing is, while the hospital may have a comparatively large staff dedicated to integrating and managing the data pulled in from your ambulatory EMR, the reverse is probably not true. Unless your practice is particularly large, it probably only includes 5 to 10 doctors. In such practices, having even a single data expert on staff would be unusual. (Not to mention that hiring one part-time or as a consultant wouldn’t be cheap.)

In other words, for a while you may be fishing for your patients’ data as you transition to the larger team to which you will belong. Also, until the hospital health system completes integrating the data from your practice into its enterprise system, you may or may not have access to quality metrics important to running a practice these days, and the effect on your billing practices could turn out to be a disaster too.

At this point, I’m supposed to stop and tell you that all this can be handled efficiently if you take one step or the other. Unfortunately, I’m not sure there is any great happy ending to suggest at this point. If you have to give up your own ambulatory EMR, it’s probably going to be painful.

However, it doesn’t hurt to be prepared. There probably are some strategies, perhaps unique to your practice, that can blunt the impact of some of these problems if you’re prepared. That said, the move to a new EMR is always painful, even if the change ends up being a good one.

EHRs and Keyboarding: Is There an Answer?

Posted on November 28, 2017 I Written By

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

One of the givens of EHR life is that users, especially physicians, spend excessive time keying into EHRs. The implication is that much keyboarding is due to excessive data demands, poor usability or general app cussedness. There’s no end of studies that support this. For example, a recent study at the University of Wisconsin-Madison’s Department of Family Medicine and Community Health in the Annals of Family Medicine found that:

Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. The study broke out times spent on various tasks and found, unsurprisingly, that documentation and chart review took up almost half the time.

Figure 1. Percent Physician’s Time on EHR

This study is unique among those looking at practitioners and EHRs. They note:

Although others have suggested work task categories for primary care,13 ours is the first taxonomy proposed to capture routine clinical work in EHR systems. 

They also make the point that they captured physician EHR use not total time spent with patients. Other studies have reached similar EHR use conclusions. The consensus is there too much time keyboarding and not enough time spent one to one with the patient. So, what can be done? Here, I think, are the choices:

  1. Do Nothing. Assume that this is a new world and tough it out.
  2. Use Scribes. Hire scribes to do the keyboarding for physicians.
  3. Make EHRs Easier. Improve EHRs’ usability.
  4. Make EHRs Smarter. Adapt EHRs to physician’s needs through artificial intelligence (AI) solutions.
  5. Offload to Patients. Use patient apps to input data, rather than physician keyboarding.

Examining the Alternatives

 1. Do Nothing. Making no change in either the systems or practioners’ approach means accepting the current state as the new normal. It doesn’t mean that no changes will occur. Rather, that they will continue at an incremental, perhaps glacial, pace. What this says more broadly is that the focus on the keyboard, per se, is wrong. The question is not what’s going in so much as what is coming out compared to old, manual systems. For example, when PCs first became office standards, the amount of keyboarding vs. pen and paper notations went viral. PCs produced great increases in both the volume and quality of office work. This quickly became the new norm. That hasn’t happened with EHRs. There’s an assumption that the old days were better. Doing nothing acknowledges that you can’t go back. Instead, it takes a stoic approach and assumes things will get better eventually, so just hang in there.

2. Scribes. The idea of using a scribe is simple. As a doctor examines a patient, the scribe enters the details. Scribes allow the physician to offload the keyboarding to someone with medical knowledge who understands their documentation style. There is no question that scribes can decrease physician keyboarding. This approach is gaining in popularity and is marketed by various medical societies and scribe services companies.

However, using scribes brings a host of questions. How are the implemented? I think the most important question is how a scribe fits into a system’s workflow. For example, how does an attending review a scribe’s notes to determine they convey the attending’s clinical findings, etc. The attending is the responsible party and anything that degrades or muddies that oversight is a danger to patient safety. Then, there are questions about patient privacy and just how passive an actor is a scribe?

If you’re looking for dispositive answers, you’ll have to wait. There are many studies showing scribes improve physician productivity, but few about the quality of the product.

3. Make EHRs Easier. Improving EHR usability is the holy grail of health IT and about as hard to find. ONC’s usability failings are well known and ongoing, but it isn’t alone. Vendors know that usability is something they can claim without having to prove. That doesn’t mean that usability and its good friend productivity aren’t important and are grossly overdue. As AHRQ recently found:

In a review of EHR safety and usability, investigators found that the switch from paper records to EHRs led to decreases in medication errors, improved guideline adherence, and (after initial implementation) enhanced safety attitudes and job satisfaction among physicians. However, the investigators found a number of problems as well.

These included usability issues, such as poor information display, complicated screen sequences and navigation, and the mismatch between user workflow in the EHR and clinical workflow. The latter problems resulted in interruptions and distraction, which can contribute to medical error.

Additional safety hazards included data entry errors created by the use of copy-forward, copy-and-paste, and electronic signatures, lack of clarity in sources and date of information presented, alert fatigue, and other usability problems that can contribute to error. Similar findings were reported in a review of nurses’ experiences with EHR use, which highlighted the altered workflow and communication patterns created by the implementation of EHRs.

Improving EHR usability is not a metaphysical undertaking. What’s wrong and what works have been known for years. What’s lacking is both the regulatory and corporate will to do so. If all EHRs had to show their practical usability users would rejoice. Your best bet here may be to become active in your EHR vendor’s user group. You may not get direct relief, but you’ll have a place, albeit small, at the table. Otherwise, given vendor and regulatory resistance to usability improvements, you’re better off pushing for a new EHR or writing your own EHR front end.

4. Make EHRs Smarter. If Watson can outsmart Kent Jennings, can’t artificial Intelligence make EHRs smarter? As one of my old friends used to tell our city council, “The answer is a qualified yes and a qualified no.”

AI takes on many, many forms and EHRs can and do use it. Primarily, these are dictation – transcription assistant systems. They’re known as Natural Language Processing (NLP). Sort of scribes without bodies. NLP takes a text stream, either live or from a recording, parses it and puts it in the EHR in its proper place. These systems combine the freedom of dictation with AI’s ability to create clinical notes. That allows the theory maintains, a user to maintain patient contact while creating the note, thus solving the keyboarding dilemma.

 The best-known NLP system Nuance’s Dragon Medical One, etc. Several EHR vendors have integrated Dragon or similar systems into their offerings. As with most complex, technical systems, though, NLP implementation requires a full-scale tech effort. Potential barriers are implementation or training shortcuts, workflow integration, and staff commitment. NLP’s ability to quickly gather information and place it is a given. What’s not so certain is its cost-effectiveness or its product quality. In those respects, its quality and efficacy is similar to scribes and subject to much the same scrutiny.

One interesting and wholly unexpected NLP system result occurred in a study by the University of Washington Researchers. The study group used an Android app NLP dictation system, VGEENS, that captured notes at the bedside. Here’s what startled the researchers:

….Intern and resident physicians were averse to creating notes using VGEENS. When asked why this is, their answers were that they have not had experience with dictation and are reluctant to learn a new skill during their busy clinical rotations. They also commented that they are very familiar with creating notes using typing, templates, and copy paste.

The researchers forgot that medical dictation skills are just that, a skill and don’t come without training and practice. It’s a skill of older generations and that keyboarding is today’s given. 

5. Offload to Patients. I hadn’t thought of this one until I saw an article in the Harvard Business Review. In a wide-ranging review, the authors saw physicians as victims of medical overconsumption and information overload:

In our recent studies of how patients responded to the introduction of a portal allowing them to e-mail health concerns to their care team, we found that the e-mail system that was expected to substitute for face-to-face visits actually increased them. Once patients began using the portal, many started sharing health updates and personal news with their care teams.

One of their solutions is to offload data collection and monitoring to patient apps:

Mightn’t we delegate some of the screening work to patients themselves? Empowering customers with easy-to-use tools transformed the tax reporting and travel industries. While we don’t expect patients to select what blood-pressure medications to be on, we probably can offload considerable amounts of the monitoring and perhaps even some of the treatment adjustment to them. Diabetes has long been managed this way, using forms of self-care that have advanced as self-monitoring technology has improved.

This may be where we are going; however, it ignores the already crowded app field. Moreover, every app seems to have its own data protocol. Health apps are a good way to capture and incorporate health data. They may be a good way to offload physicians’ keyboarding, but health apps are a tower of protocol Babel right now. This solution is as practical as saying that the way to curb double entering data in EHRs is to just make them interoperable.

What’s an EHR User to Do?

If each current approach to reducing keyboarding has problems, they are not fatal. I think that physician keyboarding is a problem and that it is subject to amelioration, if not solution.

For example, here’s Nordic’s Joel Martin on EHR usability:

… In reality, much of this extra work is a result of expanded documentation and quality measure requirements, security needs, and staffing changes. As the healthcare industry shifts its focus to value-based reimbursement and doing more with less, physician work is increasing. That work often takes place in the EHR, but it isn’t caused by the EHR’s existence.

Blaming the EHR without optimizing its use won’t solve the problem. Instead, we should take a holistic view of the issues causing provider burnout and use the system to create efficiencies, as it’s designed to do.  

The good news is that optimizing the EHR is very doable. There are many things that can be done to make it easier for providers to complete tasks in the EHR, and thereby lower the time spent in the system.

Broadly speaking, these opportunities fall into two categories.

First, many organizations have not implemented all the time-saving features that EHR vendors have created. There are features that dramatically lower the time required to complete EHR tasks for common, simple visits (for instance, upper respiratory infections). We rarely see organizations that have implemented these features at the time of our assessments, and we’re now working with many to implement them.

In addition, individual providers are often not taking advantage of features that could save them time. When we look at provider-level data, we typically see fewer than half of providers using speed and personalization features, such as features that let them rapidly reply to messages. These features could save 20 to 30 minutes a day on their own, but we see fewer than 50 percent of providers using them.

Optimization helps physicians use the EHR the way it was intended – in real-time, alongside patient care, to drive better care, fewer mistakes, and higher engagement. Ultimately, we envision a care environment where the EHR isn’t separate from patient care, but rather another tool to provide it. 

What does that mean for scribes or NLP? Recognize they are not panaceas, but tools. The field is constantly changing. Any effort to address keyboarding should look at a range of independent studies to identify their strengths and pitfalls. Note not only the major findings but also what skills, apps, etc., they required. Then, recognize the level of effort a good implementation always requires. Finally, as UW’s researchers found, surprises are always lurking in major shake-ups.

Join us for this week’s #HITsm chat on Using Technology to Fight EHR Burnout to discuss this topic more.

In The Hot Seat Again: eClinicalWorks Faces Billion-Dollar Suit Over Alleged Software Problems

Posted on November 27, 2017 I Written By

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

Earlier this year, eClinicalWorks agreed to pay $155 million to the U.S. Department of Justice to resolve allegations that it had faked its conformance with Meaningful Use criteria. The DoJ suit alleged that by withholding information needed for certification, eCW violated the False Claims Act.

Now, the vendor is facing what could be an even more serious legal threat, according to a news report appearing in Becker’s Hospital Review. BHR is reporting administrator of the estate of a deceased cancer patient is suing the vendor over data display errors that may have affected the patient’s care.

What makes the stakes so high in this case is that the complaint is asking the court to certify the case as class action, with members to include “all persons residing in the United States whose physicians used eCW to record and store their medical records at all dates relevant.” The suit is asking the court to award plaintiffs $999 million in damages, Becker’s Hospital Review reports.

According to the complaint, which was filed by Kristina Tot, administrator of the estate of the deceased Stjepan Tot, errors with eCW software began to appear before the cancer patient’s death. For example, “he was unable to display his medical history or progress notes,” the complaint reportedly states.

The cancer patient’s problems were far from unique, however, the suit asserts. According to the complaint, important eCW software functions didn’t work or violated regulatory guidelines. The filing claims the vendor didn’t provide accurate and reliable health information, displayed incorrect panels and didn’t record EHR user actions in audit logs.

The bottom line, the suit claims, is that millions of patient records were compromised, leaving patients and physicians unable to rely on the eCW platform.

I am not qualified to speak on whether there’s any merit to the latest suit against eCW, though I think it’s reasonable to assume that the company may not have its act together. (You might also want to check out the angry eCW critiques on this site — whose publisher, like our fearless leader John Lynn, I know to have an impeccable reputation for honesty.)

Ultimately, it’s hard to say whether this latest suit is largely blowback from the previous certification problem or yet another (extremely) costly headache. Either way, if I were part of its leadership team I’d be more than a little shaken by recent events even if the recent complaint gets dismissed.

Elderly Doctor May Lose Medical License Due In Part To Lack Of Computer Skills

Posted on November 10, 2017 I Written By

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

Do physicians need to be computer-literate to run a safe and effective medical practice? The question has come into high relief recently as an 84-year-old New Hampshire physician fights to get her medical license reinstated.

Dr. Anna Konopka, who recently lost her license due in part to a lack of computer skills, is suing the New Hampshire Board of Medicine in an effort to get it reinstated.

Back in September, Konopka had signed an agreement to surrender her license with the medical board. The agreement settled pending allegations regarding her “record-keeping, prescribing practices, and medical decision-making,” according to an article in Ars Technica. The agreement reportedly permits her to apply to regain her license, but to succeed in doing so she’d have to prove that she did no wrong.

In her interview with the publication, the elderly physician denied any misconduct and said she was under duress when she voluntarily surrendered her license previously. She has said that she wants to continue practicing medicine, but does not want to participate in what she calls “electronic medicine.”

“I am getting the patients from the system [her term for the medical bureaucracy surrounding the use of EMRs today], and I see how badly they are mistreated and misdiagnosed or not diagnosed at all,” she told Ars Technica. “Therefore, I am not going to compromise patients’ lives or health for the system.”

For what it’s worth, Konopka’s troubles with the state medical board didn’t arise from computer use or lack thereof. They were triggered when a formal complaint was filed with the board alleging that she treated a young patient with asthma incorrectly.

The dispute resulted in a formal reprimand from the medical board in April 2017. The board also required her to undergo 14 hours of medical training as a condition of continuing to practice. After that, other investigations followed, including disputes over the scope of her original agreement with the medical board.

Ordinarily, Konopka’s struggles for reinstatement might never have come to public view. What differentiates them from others is the role her unwillingness to use computers has played in the process. Specifically, unless she learns to use the Internet, she won’t be able to comply with the state’s new law requiring her to access an online opiate monitoring program. (As part of her attempts to regain her license, she’s agreed to do so.)

It’s hard to tell who is right in this particular case, but the situation does raise interesting questions about the role of computer use in medical practice generally.

Should physicians be required to use computers as part of their practice in this day and age, and if so, what level of competency should they be required to attain? Are there specific pieces of software, such as EMRs, they have become as important to medicine as a stethoscope was in a prior era? Should use of health IT software be a required part of all medical training at this point?

I don’t have any answers to these questions, and you may not either. But if a doctor’s license can be threatened, even in part, by failing to use computer technology, we’d better work on finding some.

Patient Generated Data, Workflow and Usability Coming Into Focus for EHR Vendors

Posted on October 16, 2017 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

At the recent Medical Group Management Association annual conference (MGMA17), I made a point of visiting as many of the EHR vendors in the exhibit hall as I could so that I could ask them two questions:

  1. What are you working on right now, given that there is a bit of a lull between ONC requirements?
  2. How do EHRs and EHR vendors need to evolve over the next 5 years?

Below are some of the best responses I received.

Steve Dart, Senior Director of Product Management at AdvancedMD believes that both EHRs and EHR companies need to fundamentally change their paradigms in order to thrive over the next five years. “EHRs should facilitate the job that needs to get done rather than serve as a documentation repository,” says Dart. “What is that job? Helping patients live healthier lives while at the same helping physicians be happier at work. We really missed the boat during the Meaningful Use (MU) gold rush. We neither helped patients be healthier nor did we make physician lives easier. In fact, as an industry we generally made things more difficult for doctors.”

AdvancedMD is charting a new path forward, instead of just fixing their user interface (UI), they are rethinking their entire approach to their EHR. The company is taking full advantage of the lull in MU requirements by using the time to bring together designers, UI experts, physicians and office managers to design a brand new EHR. Dubbed the “connect the dots” strategy, AdvancedMD is centering their next generation on clinical and administrative workflows.

“When you think about it, healthcare is really just a journey of sequential workflows,” Dart explains. “A patient starts by experiencing symptoms, then moves to research physicians online, schedules an appointment, comes in for their visit, goes to get lab tests done, comes back to discuss the results and fills a prescription. What EHR companies have done is create whole bunch of point solutions for each one of these situations. What we haven’t done well is connect these all together with technology. We siloed everything. Instead what we need to realize is that each situation is actually a complex workflow and we journey from one workflow to another as patients. What we need now, and what AdvancedMD believes, is that we should build technology that enables these workflows – make them easier and more seamless for patients and physicians. Data collection, for example, should happen on devices that both doctors and patients already use and in a way that doesn’t detract from the visit.”

To illustrate that AdvancedMD is doing more than just giving their theory lip-service, Dart showed an early design prototype of an EHR interface that provides a longitudinal view of a practice. Instead of clicking down into one patient to order labs or renew prescriptions and then clicking down into the next patient to do the same, the new interface groups all lab orders together and all the prescriptions together. One click and the physician can see all that they need to do and clicks once to push the orders ahead. The new interface is highly intuitive and functional.

Juan Molina, VP of Strategy and Business Development at CareCloud also believes that EHRs need to radically change. “EHRs need to allow doctors and their staff to do their jobs better,” says Molina. “We have to stop asking doctors to be data entry clerks and documentation specialists. They need to go back to being 100% focused on the patient and providing care. As an industry we have focused too much on checking the box. We need to move beyond that through better use of technology – especially modern cloud-based architectures.”

Mollna is most excited about the potential of real-time analytics and Artificial Intelligence (AI) at the point of care. He feels that the promise of precision medicine and true personalized care will only be possible if “massive amounts of health data is crunched and context from that data delivered to the doctor at the time when they are seeing a patient.” CareCloud is using the freedom from compliance requirements to work on new partnerships for deep analytics, AI and patient experience (read about their partnership with First Data here).

It is refreshing to hear EHR companies talk about collaboration. Over the past several years it was frustrating to see vendors attempt to build everything themselves only to end up with inferior solutions to what was readily available in other industries from other vendors. Partnership and collaboration are a welcome shift in EHR strategy.

athenahealth is actively pursuing partnerships as part of their More Disruption Please (MDP) program. “We are constantly expanding and improving our cloud-based platform to align with our vision,” says Stephanie Zaremba, Director of Government and Regulatory Affairs at athenahealth. “We want to see a healthcare industry free from administrative burden, enabled to care for diverse and disparate populations, and one that ultimately lets doctors be doctors. We believe that the current paradigm of federal regulations hinders, rather than helps, our industry from making this vision a reality. The innovation we so desperately need can’t flourish in the confines of check-the-box requirements that do not grow and evolve with technological advances. But even if we’re stuck with the regulatory status quo, in the next five years, we hope that vendors will continue to embrace their collective potential, shifting from competitors to collaborators in an effort to create a more provider-friendly, patient-facing, and connective tech landscape that captures the full continuum of care.”

The announcement of the partnership between Pulse Systems and InteliChart at MGMA17 is a prime example of this newfound collaborative spirit. For years Pulse offered a perfectly serviceable patient portal, yet they recognized that they would never pour as much time and effort into that area of their solution versus a company like InteliChart.

“We are pursuing an open-EHR strategy,” explains Chris Walls, President & CEO of Pulse Systems. “Although we provide a comprehensive solution, we recognize that clients may not want every component from our stack. They may want to keep a best-of-breed solution that they already have in place. Rather than force our clients to change, we are working to ensure we can integrate and play nice with others.”

Pulse arrived at this open approach by listening closely to clients and prospects. What they found was an under-current of a best-of-breed approach. Physician offices wanted to use different tools and applications from different vendors but the lack of integration and internal IT resources forced them to go with a single monolithic solution instead.

Through this listening exercise, Pulse also realized that it was more than an EHR vendor to its clients. Many of their clients are smaller practices which do not have ready access to technical support. Rather than deflect their client’s calls for help with mundane things like anti-virus updates, internet connection issues and printer failures, they leaned into it. They created a dedicated IT Field Support team that handles calls for routine IT issues and will even fly out to help a client if needed.

By proactively helping their clients in this manner, Pulse has found that they reduce EHR issues down the road and they engender tremendous loyalty. When you think about it Pulse is essentially applying a Population Health approach to their own clients – offering preventative maintenance to avoid more costly support calls in the future.

Most impressive is how Greenway Health is using this lull in compliance requirements. “Now that we are freed from working on ONC compliance work, we are putting focus on customer requested enhancements” says Mark Janiszewski, EVP of Product Managmeent & Corporate Development at Greenway. “Much to the delight of our customers, we can now apply resources to the enhancements that they have asked for, but that were lower in priority compared to what was needed to comply with regulations and the Meaningful Use program.”

Greenway is also using their “found time” to take a serious look at EHR usability. They recognize that there is tension between physicians and EHR makers caused by the endless clicking and confusing user interfaces. Greenway is hoping to relieve that tension by collaborating with clients to improve their system. According to Janiszewski, the company has planned a series of customer visits where a team of designers and engineers can observe how people interact with their system over a 2-3 day period.

The team has already identified several areas of improvement after observing how admin staff were copying down ID numbers from one screen onto post-it notes in order to key it in on a different screen to bypass a lengthy click-path. The team is hard at work to ensure data is transferred across the system more seamlessly.

Over the next five years, Janiszewski believes that EHR companies will have to embrace the concept of multiple care settings and multiple data sources: “EHRs will need to have a higher degree of interoperability as patients move between care settings – from acute care to rehab to home care or from acute care to elder care. EHRs will also need to solve for Patient Generated Data. We are all wearing fitness trackers and using apps to track our health. This data needs to be incorporated in a meaningful way into the EHR. “

The responses from MGMA17 demonstrates that companies are well aware of the negative feelings healthcare providers have towards EHRs. What is very encouraging is that fixing the user interface is only one of many different solutions being pursued by EHR companies. Rather than myopically focusing on the shiny object in front of them, companies like Greenway, Pulse, athenahealth, CareCloud and AdvancedMD are taking a step back and looking at healthcare with a broader perspective in order to identify opportunities for improvement. It will be interesting to circle back with them a year from now to see what progress has been made.