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Will Health Systems Own Healthcare?

Posted on April 20, 2015 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.

In all of my many conversations this past week, there was an underlying understanding that health systems are getting bigger and bigger. The trends of hospitals acquiring other hospitals is having a major impact on healthcare. Hospitals acquiring ambulatory clinics is probably having an even bigger impact.

As I ponder on this trend, I really can’t imagine a way that we return to the previous status quo. Certainly some doctors will tire of being employed by health systems, but I’m sad to say that once they’re ready to leave they may not find many doors available for them to take.

Aside from a limited number of direct primary care doctors in affluent areas, I believe it’s going to become extremely difficult for a doctor to leave a health system. In some areas, this is already the case. However, value based reimbursement is going to make this an impossibility for many.

I don’t think we know all the unintended consequences of this change in healthcare. As a capitalist, I love economies of scale and you can see how healthcare could benefit from some of these economies. However, what isn’t clear to me is that health systems do a great job capitalizing on economies of scale. In fact, I bet if you studied it you’d probably find that small physician practices run much cheaper than a large health system. If someone knows of a study that looks at this, I’d love to see it.

I do think that some specialists are bonding together in some areas to create super groups in order to combat this trend. In many ways they essentially create a monopoly of sorts around a certain specialty physician service in a local area. I’ll be interested to see how this plays out. Might be a short term win, but I’m not sure they can survive long term.

I’m still chewing on all the ways that we’ll benefit and suffer in a health system owned healthcare system. I’d love to hear your thoughts in the comments on these trends and the impact for good and bad of these changes.

Where Are All the Doctors at HIMSS15?

Posted on April 16, 2015 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.

As I think about the past week in Chicago at HIMSS 2015, I’m wondering where all of the doctors are at HIMSS. Yes, I know there are actually quite a few doctors at HIMSS, but the vast majority of them are now administrators or are working for vendors. There are very few practicing doctors at HIMSS. It’s really quite unfortunate, because their voice is so important to everything that we’re doing.

I know why many doctors don’t go to HIMSS. I’ve seen multiple times where a practicing doctor comes to HIMSS and they’re overwhelmed by the disconnect between what’s being spouted by vendors and what they’re experiencing in their daily work. Most of them say, “I’m never coming back.” It’s really sad for me when this happens, but it also provides us with an opportunity to keep what’s said at HIMSS in perspective.

I wish that HIMSS would work to resolve this problem since having many practicing doctors at HIMSS would really elevate the quality of the conference. I realize that it’s hard to get a busy doctor to leave for a few days where they’re not making any money. However, with some effort and creativity they could make it a reality.

For example, they could create some sort of physician scholarship program that would help encourage more doctors to come. They could reach out to the doctors in the local area to get them to come and participate in the event. They could offer a number of quality CME options since we know that doctors need CMEs.

HIMSS has a ton of value for a large number of groups. In fact, many people have argued that HIMSS has grown so large that it needs to be divided into a number of different conferences. I don’t share that view since I like the mixing of various parts of healthcare, but HIMSS has become pretty unwieldy. As I said to someone today, I just had to let go and ride the wave. It made for a great ride. I just wonder if the ride would have been even better with more physician participants.

Mostashari’s Call for “Day of Action” Is a Double Edged Sword

Posted on April 13, 2015 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.

Neil Versel has a great article on MedCity News that covers some comments from Farzad Mostashari at HIMSS 2015. Here’s a section of his article:

Patient advocates are planning a “day of action” to generate mass demand for consumer access to medical records in the wake of a plan to roll back the Meaningful Use requirement for engaging patients in their own care.

“I think we need to show the policymakers that they’re not just pushing rope here. We need to show that there’s demand,” former national health IT coordinator Dr. Farzad Mostashari said Sunday afternoon during a preconference symposium on patient engagement before the start of HIMSS15 in Chicago.

While I think that Farzad’s suggestion is noble in idea, my gut tells me that it could backfire in a very significant way. You have to remember that a call for a “day of action” is a double edge sword. If that day goes off successfully, then it could make a great case for why we should be requiring the 5% patient engagement in meaningful use as opposed to the single patient record download that’s just been proposed.

However, the opposite can also happen too. If you call for a day of action and then patients don’t request access to their records, then it will lead many to say “We were right. Patients don’t care about accessing their patient records.” This conclusion would be incredibly damaging to the movement towards patients’ getting access to their medical records.

This would be true even if there were other reasons that the day of action wasn’t successful. For example, if you do some poor PR and marketing of the day of action, then It could very likely fail. I’m talking big boy PR and marketing to really get the word out to patients. Healthcare social media and even all of the attendees at HIMSS won’t have the power to get the word out about this idea in order to really see it take off.

While I think the goal is noble and Farzad is right that patients need to really start demanding their data, I think this idea of a “Day of Action” could end really poorly if we’re not careful about it.

Meaningful Use Reporting Period Changed to 90 Days and Other Proposed Changes

Posted on April 10, 2015 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.

In case you missed the news, CMS posted the proposed rule that modifies meaningful use in 2015-2017 (Here’s the rule on the Federal Register). The 210 page document dropped late on Friday right before HIMSS. If you think we’ve seen CMS do this before, we’ve seen it happen a lot. They love to issue the rules on Friday and often right before HIMSS. At least that’s better than when they released the rule during HIMSS, but not much.

The summary of the changes is pretty straightforward:

  • Streamlining reporting by removing redundant, duplicative, and topped-out measures
  • Modifying patient action measures in Stage 2 objectives related to patient engagement
  • Aligning the EHR reporting period for eligible hospitals and CAHs with the full calendar year
  • Changing the EHR reporting period in 2015 to a 90-day period to accommodate modifications

The patient engagement was changed from 5% to a single download, view, and transmit as it’s been called. I think many will look on this as a very favorable change since you can’t force a patient to do something and so your incentive and penalties shouldn’t depend on their action.

It also makes sense that they change the hospital reporting period to the calendar year like it’s been for EPs. The change probably has some logistical questions for many hospitals, but it will make the process cleaner.

The big one of course is the 90 day attestation period. We knew it was coming and I think everyone’s glad that it’s here. Now it will be interesting to see how many wait until October to start their attestation period. That’s pretty risky if you ask me, but that didn’t stop organizations from waiting just the same.

I don’t think there will be many issues with what’s in this proposed rule. Although, we’ll see over the next week what other things people find as they dig into the rule. I know many were waiting for this to drop and are now breathing a sigh of relief over the 90 day reporting period.

Let us know in the comments if there are other details you find that we didn’t talk about or nuances we might have missed. Enjoy the light reading on the flight to HIMSS.

Working to Understand FHIR

Posted on April 9, 2015 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.

Ever since I’d heard so many good things about FHIR, I’ve been slowly trying to learn more about it, how it will be implemented, what challenges it faces, and what’s the pathway for FHIR to have widespread adoption.

So, it was no surprise that the Corepoint Health sessions on FHIR caught my eye and will be part of my HIMSS 2015. As part of that education they sent me their FHIR whitepaper which they’ll be handing out at their booth along with their sessions on FHIR. As with most things, the more I learn about FHIR, the more I realize I need to learn.

One example of this comes from the FHIR whitepaper linked above. It talks about defining resources for FHIR:

Resources are small, logically discrete units of exchange. Resources define behavior and meaning, have a known identity and location, are the smallest possible unit of transaction, and provide meaningful data that is of interest to healthcare. The plan is to limit resources to 100 to 150 in total. They are sometimes compared to an HL7 V2 segment.

The resources can be extended and adapted to provide a more manageable solution to the healthcare demand for optionality and customization.
Source: Corepoint Health

This section reminded me of a comment Greg Meyer tweeted during an #HITsm chat about FHIR’s biggest challenge being to define profiles. When he said, that I made a note to myself to learn more about what made up profiles. What Greg called profiles, it seems Corepoint Health is calling resources. They seem to be the same thing. This chart from the whitepaper does a great job summarizing why creating these resources (or profiles if you prefer) is so challenging:

FHIR Resource Examples
Source: Corepoint Health

I still have a lot more to learn about FHIR, but it seems like it does have really good founding principles. We’ll see if the powers that be can keep it pure or try and corrupt and modify its core principles. Not to mention take it and make it so complex that it’s not usable. I’ll be learning more about FHIR at HIMSS and I’ll be sure to report back. Until then, this FHIR whitepaper provides a pretty good historical overview of FHIR versus the other healthcare IT standards.

No Cloud Based Hospital EHR of Note…Yet?

Posted on April 8, 2015 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.

Scott Mace offered this interesting intro to his article “Cloud Adoption Gains Traction” in Health Leaders Magazine:

While no cloud-based electronic health record software of note for hospitals has yet to emerge on the scene, cloud-based ambulatory EHRs continue to gain traction, storage remains a strong cloud option, and intriguing new analytics options are tapping the versatility of cloud technology.

A look at hospital EHR market share and the main EHR companies (Epic, Cerner, MEDITECH, etc) are not cloud based EHR systems. Sure, some of them might have their client server installs hosted in the cloud, but that’s not a true single database EHR cloud.

What’s fascinating to me is why cloud EHR hasn’t taken off in hospitals like it’s taken off in the rest of the world (even ambulatory EHR as the article notes). It’s worth noting that athenahealth is working on a cloud based hospital EHR. However, there still at least a couple years out from even being in the conversation when a hospital considers selecting an EHR. The small SaaS Hospital EHR vendors don’t even make a dent in the market share.

Here’s why I think cloud EHR hasn’t taken off in hospitals:

Early Adopters – Many hospitals adopted some form of EHR really early on. They made the investment before cloud was really a decent option to consider (ie. before high speed internet was ubiquitous). Now they’re stuck with a legacy investment and they’re still paying off that investment

Switching Costs are High – Switching EHR in the ambulatory world is hard. Doing so in a hospital is infinitely more difficult. If I’m a CIO at a hospital, do I want to put my organization through that process? It takes a really visionary CIO and a supportive CEO to make the change.

No Great SaaS Hospital Alternatives – Once hospitals decided they needed one all in one system, that narrowed the number of EHR options to very few. We still have yet to see a SaaS software expand their offerings to cover the full gamut of software that’s required by a hospital. For example, even Epic which has been around forever (and is not a cloud EHR for the record), still gets complaints from hospitals about their lab software. Now apply that to 100 departments in a hospital and SaaS software just hasn’t been able to provide the full suite of software a hospital requires.

Fear – I think most hospitals are still afraid of the cloud. There are plenty of reasons why they should be less afraid of cloud than their current set up, but there’s still very much fear surrounding cloud. Somehow having the servers in my data center, on site where I can touch them and feel them makes me feel more safe. Reality or not, this fear has prevented most hospitals from even considering a cloud based EHR. I think they’re starting to get past it since every hospital now has something in the cloud, but that wasn’t true even 5 years ago in many organizations.

I’m sure there are other reasons you can offer in the comments. Of course, Scott Mace’s article linked above goes into a number of the benefits of a cloud EHR. However, that’s not yet a realistic option for hospitals. I’m sure one day it will be.

1/5th of Hospital EHRs are Poor Fits

Posted on April 6, 2015 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 a really fascinating stat from Black Book. I’d like to dig into their methodology for this question. Defining what’s a “poor” fit is really hard when you realize that a poor fit is defined by hundreds and possibly thousands of EHR users in a hospital.

What I’ve found is that it’s really hard to make broad statements about EHR satisfaction at a hospital. The doctors may hate it, but the executives love it. The front desk may be annoyed by it, but the pharmacy is really happy. The nurses may love it…ok…I don’t think I know of any EHR that’s loved by nurses, but that’s a discussion for another blog post. Nurses often get left out in the EHR design and we’ll leave it at that for now.

With that disclaimer, let’s think about what it means that 20% of hospital EHRs are a poor fit. Does that mean that we’re going to see a wave of EHR switching in the hospital EHR world? I don’t think so.

The reason I don’t think so is that the hospital EHR is too expensive. Plus, changing EHR is so disruptive that you have to be really down on your EHR to actually switch. Sure, some of them are that down on their EHR that they’ll switch EHR. However, most of them don’t like it, but they aren’t ready to go through heart replacement surgery and take out their current EHR and replace it with a new one.

Some other factors at play is that they may not like their current EHR, but it’s the devil they know. That’s a powerful reason not to switch. Also, is there really a better alternative? Many who aren’t satisfied with their EHR aren’t convinced that switching to another EHR will be much better. Plus, many of these organizations are in the middle of meaningful use. If you switch EHR vendors in the middle of meaningful use, you might as well announce that you’ll be taking a year off from meaningful use (and all that entails…ask Intermountain).

While I don’t think we’ll see a wave of immediate EHR switching, once the renewal licenses come up, we’ll see more switching of EHR. Plus, if someone can come out with a high quality cloud based EHR for hospitals, then that could help with switching costs as well. However, until then, hospitals have mostly chosen their horse and now they have to ride it out. Of course, this assumes they don’t get acquired by a larger hospital system and are forced to switch EHR. That’s happening in a big way and is likely to continue.

Bringing Meaning to Disparate Clinical Data

Posted on April 3, 2015 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.

For a while, I’ve been extremely intrigued by vendor neutral archives. While they’re usually applied to the PACS and imaging world, I’ve always thought that the concept will eventually spread across all healthcare data. With that in mind, I found this whitepaper, Bringing Meaning to Disparate Clinical Data, provided an interesting view into the world of vendor neutral archives (VNA) and it was very clear to me that the problems we’re working to solve in the medical imaging world are very much applicable to the problems we need to solve with other healthcare data (ie. EHR data).

Here’s how the whitepaper suggests you evaluate VNA solutions:

  • Interoperability
  • Image accessibility
  • Disaster recovery
  • Upgradability
  • Data security
  • Ease of use

It’s quite easy to see how this same list could just as easily apply to any healthcare IT system that a hospital adopts. The image accessibility may not apply, but accessibility of data (which is what the image represents) is extremely important. I think that many organizations would be much happier with their EHR today if they’d used the above list in their EHR selection process.

The whitepaper also lists events that affect the timing and direction around enterprise image management planning:

  • Replacing a PACS
  • Joining an integrated care community
  • Accommodating new sources of images
  • Impending mergers, acquisitions, and associations
  • Storage convergence
  • Centralized management

Looking through the list, it’s very clear to me that many of the above items are going to be drivers of EHR switching as well. In fact, it’s going to make up the majority of future EHR purchases. Plus, we’re seeing a lot of changes when it comes to joining care communities and mergers, acquisitions, etc.

At the conclusion of the whitepaper, it suggests that the single most important key to choosing an enterprise solution for image management is flexibility:

  • Flexibility of connecting all kinds of devices and systems.
  • Flexibility of accessing information anywhere, anytime
  • Flexibility to scale effectively with facilities’ growing needs
  • Flexibility to meet departmental needs

We didn’t use this framework for selecting EHR vendors, but will we use it the next time around. Has our current EHR experience helped us to realize the value of flexibility with our healthcare IT software vendors? I think these will become part of the future EHR purchase process.

I don’t think the markets are that much different. The future of EHR in healthcare organizations will likely follow the path that imaging vendors have already trod. It’s just too bad we couldn’t learn from imaging’s experiences and apply them to EHR already. Since we haven’t, I think learning about the history of image management systems in healthcare will help us better understand where EHR is headed.

Epic Does April Fool’s Day – Calls Out Cloud and CommonWell

Posted on April 1, 2015 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.

You can always count on Epic for a great April Fool’s day joke. For as long as I can remember, they’ve swapped out the Epic home page and turned it into a great joke. Plus, this year, they took it to another level as they called out the cloud and CommonWell. Their cloud article titled “The Industry’s First True Cloud-Based Solution” is pretty great. Here’s an excerpt:

When dark clouds gather over the healthcare IT horizon, GOODyEHR, Epic’s new cloud-based hosting solution, will help our customers soar over them – literally. Cruising at 30,000 feet, Epic’s zeppelin-based GOODyEHR data center takes “cloud-based” to dizzying new heights. Other vendors have made similar claims in the past, but they have all been full of hot air. Epic’s solution, by contrast, is full of hydrogen.

Obviously, Epic is mocking Jonathan Bush, CEO of athenahealth who’s been harping on the advantages of cloud for years. I’ll be interested to see if Jonathan Bush brings this up on stage at HIStalkapalooza. I can’t imagine he won’t.

Although, even more likely is for Jonathan Bush to rant about CommonWell and Epic’s decision to not take part. Of course, Epic’s April Fool’s Day addresses it (kind of):

Neal Pasturesson, CEO of Churner Corp. swissmissed the initiative. “Until the Supreme Quart rules in favor of our CowmonWell healthcare infarmation exchange, all these efforts will corntinue to be a Tower of Baybel.” Alfalfahealth CEO Jugnathan Bush commented “That’s their idea? I can’t believe it’s not better.”

Good stuff. Thanks Epic for a good laugh. I’m sure Cerner and athenahealth will take this all in good fun.

I captured a screenshot of the homepage for posterity since many of you will read this tomorrow when it’s no longer up on their website (click on the image to see it full size):
Epic - April Fool's Day

Why Can’t Release of Records Be Automated Through A Patient Portal?

Posted on March 31, 2015 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 in a recent discussion with one of the leading providers of release of information services, HealthPort about EHR’s impact on the release of health records. In our discussion, I asked why the release of health records can’t be completely automated through a patient portal. In my mind, meaningful use is requiring that healthcare organizations put a patient’s record up on a patient portal, so shouldn’t that mean that the release and disclosure of patient records would become obsolete?

Of course, I was applying a limited view to what’s required when a disclosure happens and who is making the records request. In most cases, it’s not the patient requesting the record and these third parties don’t have access to the patient’s portal. Plus, the release and disclosure of patient records often requires accessing multiple systems along with assessing which information is appropriately included in the disclosure. The former is a challenge that can be solved, but the later is a complex beast that’s full of nuance.

In order to clarify some of these challenges and explain why a patient portal won’t replace all records requests, here’s a short interview with Jan McDavid, Esq., General Counsel at HealthPort.

Q: What are HIPAA requirements around “charging” for copies of records, and what are considered “reasonable” costs?

A: HIPAA is very clear that its pricing applies only to copies provided to “individuals,, which HIPAA defines as the person who receives treatment—the patient. HIPAA guidance pertains only to patient requests for medical records, approximately seven percent of all requests received by healthcare providers.

The majority of records are requested by physicians for continuing care, governments for entitlement benefits, insurers, and inquiries from attorneys, according to internal data from HealthPort’s 2014 record release activity nationwide.

Within the realm of patient requests, providers can charge patients no more than their labor costs to produce the record, plus supplies and shipping. No upfront fee to search or retrieve records may be charged to patients.

Q: Why shouldn’t records just be free now that they are electronic?

While many believe the cost to produce records should be negated once information is digital, there are misperceptions and logistics that must be understood. The process of disclosure management (release of information) involves many steps that still require human intelligence and intervention—especially on the front end of the process (receiving, validating and approving the request). Here are three examples:

  • The authorization must be adhered to strictly, which often requires contacting the requester and explaining that some of the records they requested may not be available, or may require very specific patient authorization.
  • Information is commonly pulled together from multiple sources and systems (paper and electronic) to fulfill a request. While providers are working toward completely electronic environments, almost all still have a combination of paper and electronic. Depending on who makes the request, every single page of a record may require review.
  • Staff releasing records must be trained on HIPAA, HITECH, the Omnibus Rule, state and federal subpoena requirements, and specific state and federal laws for drug, alcohol, HIV/AIDS, mental health, cancer, genetics, minors, pregnancy, etc.

Q: If the EHR is in the portal, what other records aren’t in the EHR that HIM staff has been aggregating in a records request?

A: Not all patient information is automatically included within the patient portal view, nor should it be. Each provider organization determines what EHR information is posted to the portal and what patients can do within the portal (e.g. requesting refills, scheduling appointments, viewing lab results, etc.). HIM experts are key in these decisions.