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Moving Hospital EHR to the Cloud

I’ve long been interested to see how hospitals were going to handle the shift to “the cloud.” Obviously, most hospitals have made a big infrastructure investment in huge data centers and so I’ve always known that the shift to the cloud would be slow. However, it also seemed like it was inevitable.

I was interested to hear Jason Mendenhall talk in our Healthcare Data Center Google Plus hangout about healthcare entities moving their technology infratructure into their data center. Plus, I pair that with the smaller rural hospital CIO I met who balked at the idea of having a data center or really even having any sys admin people on staff.

Plus, I’m reminded of this quote I heard Dr. Andy Litt tell me about when hospitals will start using Dell to host their Epic EHR:

The opportunity to host an Epic or other EHR is in first install, not for existing ones that have invested in a data center already. -Andy Litt, MD, Dell

I can’t imagine that many institutions really want to move their Epic EHR hosted locally into the cloud. That just doesn’t happen. At least it doesn’t right now. Will we see this change?

I think the answer to that is that we will see it change. There’s a really good argument to make that hospitals shouldn’t be building data centers and that there’s tremendous value to using an outside provider. Plus, many of these “data center” companies are becoming more than just a set of rails, power, and cooling. They are now working with a variety of cloud providers that can provide you more than just a place to put your own servers.

I’ll be interested to see how this plays out, but I think we’ll see fewer and fewer hospital data centers. The outside options and connectivity to those outside data centers is so good that there’s going to be no need to do it on your own.

March 24, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

2013 Hospital EHR and Health IT Trends

There are a number of amazing milestones and trends happening with EHR and Healthcare IT. I think as we look back on 2013, we’ll remember it for a number of important changes that impact us for many years to come. Here are a few of the top trends and milestones that I’ll remember in 2013.

Epic and Cerner Separate Themselves – This has certainly been happening for a couple of years, but 2013 is the year I’ll remember that everyone agreed that for big hospitals it’s a two horse race between Cerner and Epic. There’s still an amazing battle brewing for the small hospital with no clear winner yet. However, in the large hospital race the battle between Cerner and Epic is on. Epic had been winning most of the deals, but Cerner just gave them a big left hook when Intermountain chose Cerner.

I expect we’re living in an Epic and Cerner world until at least a few years post meaningful use. The job listings on Healthcare IT Central illustrate Cerner and Epic dominance as well.

Near Universal EHR Adoption in Hospitals – I can’t find the latest EHR adoption (meaningful use) numbers from ONC, but the last ones I saw were in the high 80′s. That basically leaves a number of small rural hospitals that likely don’t have much tech infrastructure at all, let alone an EHR. Every major hospital institution now has an EHR. I guess we can now stop talking about hospital EHR adoption and start talking about hospital EHR use?

The Cracks in the Healthcare Interoperability Damn Appear – Interoperability has always been a hard nut to crack in healthcare. Everyone knew it was the right thing to do, but there were some real systemic reasons organizations didn’t go that direction. Not to mention, there was little financial motivation to do it (and often financial disincentive to do it).

With that background, I think in 2013 we’ve started to see the cracks in the damn that was holding up interoperability. They are still just cracks, but once water starts seeping through the crack the whole structure of the damn will break and the water will start flowing freely. Watch for the same with interoperability. Some of this year’s cracks were started with the announcement of CommonWell. I think in response to being left out of CommonWell, Epic has chosen to start being more interoperable as well.

Skinny Data Happens – I was first introduced to the concept of skinny data vs big data at HIMSS 2013 by Encore Health Resources. While I’m not sure if the skinny data branding will stick, the concept of doing a data project with a slice of data that has meaningful (excuse the use of the word) outcomes is the trend in data analytics and it’s going to dominate the conversations going forward.

As I posted on EMR and EHR, Big Data is Like Teenage Sex, but skinny data is very different. Skinny data is about doing something valuable with the data. Sadly, not enough people are doing skinny data, but they all will in 2014.

Hospitals Ignore Consumer Health Devices – Consumer health devices are popping up everywhere in healthcare. We’re quickly reaching the point that consumers can monitor all of their vital information at near hospital grade quality using their smartphone and sometimes an external device. This is a real revolution in medical devices. Many are still making their way through FDA approval, but some have passed and are starting to work on traction.

With all of this innovation, hospitals seemed to have mostly ignored what’s happening. Sure, the larger ones have a few pilot projects going. However, most hospitals have no idea what’s about to hit them upside the head. Gone will be the days of patients going to the hospital to be “monitored.” I don’t think most hospitals are ready for this shift.

December 31, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Epic to Epic Conversion

Gabriel Perna has a great article on Healthcare Informatics discussing an EHR conversion that I hadn’t considered. What happens when a hospital system acquires another hospital system and they both use the Epic EHR? Here’s the challenge as described in the article:

“As we got into it, we realized Epic had done [a conversion from] IC Chart [InteGreat from Med3000] before, they had done Cerner-to-Epic conversions, they had done McKesson-to-Epic conversions. They had done those before, and they do them well. They hadn’t done Epic-to-Epic before. That was the area where they were least experienced in. It was a lot more work to do,” says [Bob] DeGrand, who assumed the position of CIO [of Froedtert Health] in January of 2009, a few months after the West Bend affiliation became official.

As we continue on our path of hospital system consolidation, this is going to become more and more of an issue. As those familiar with Epic know, every Epic installation is unique. I was recently told by someone that even within the all Epic Kaiser there are multiple Epic installations and they have a challenge communicating with each other. Now think about what that means if you’re trying to merged two different Epic installations.

The article also points out that one of the biggest challenges in a merge like this is overlapping patients and ensuring that you merge them properly. Patient identity is a big challenge in any hospital system, but even more important when you’re looking to merge two large hospital systems that have relatively close proximity with similar patient populations.

I’d be interested to hear from other people who might have gone through an Epic to Epic conversion. What challenges did you face? Would you have rather had a Cerner to Epic conversion?

December 30, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Kaiser Permanente Branch Joins Epic Network

Though it apparently held out for a while, Kaiser Permanente Northern California has signed on to Epic Systems’ Care Everywhere, a network which allows Epic users to share various forms of clinical information, Modern Healthcare reports.

Care Everywhere allows participants to get a wide range of patient data, including real-time access to patient and family medical histories, medications, lab tests, physician notes and previous diagnoses. The Care Everywhere network debuted in California in 2008, and has since grown to a national roster of more than 200 Epic users.

Many of the state’s major healthcare players are involved, including Sutter Health, as well as prominent regional players such as Stanford Hospital and Clinics, USCF Medical Center and UC Davis Health System, according to Modern Healthcare. Kaiser Permanente Southern California also participates in the network.

According to Epic, the Care Everywhere system allows patients to take information with them between institutions whether or not both institutions use the Epic platform. Information can come from another Epic system, a non-Epic EMR that complies with industry standards, or directly from the patient.

But of course, the vendor likes to see Epic-to-Epic transmission best, as it notes on the corporate site: “When an Epic system is on both sides of the exchange, a richer data set is exchanged and additional conductivity options such as cross-organization referral management are available.”

Care Everywhere also comes with Lucy, a freestanding PHR not connected to any facility’s EMR system. According to Epic, Lucy follows patients wherever they receive care, and gathers data into a single source that’s readily accessible to clinicians and patients. Patients can enter health data directly into Lucy or upload Continuity of Care Documents from other facilities.

While connecting 200+ healthcare organizations together is a notable accomplishment, Care Everywhere is not going to end up as the default national HIE matter how hard Epic tries. As long as the vendor behind the HIE (Epic) has a strong incentive to favor one form of data exchange over another, it cuts down the likelihood that you’ll have true interoperability between these players. Still, I’ve got to admit it’s a pretty interesting development. Let’s see what healthcare organizations have to say that try to work with Care Everywhere without owning an Epic system.

P.S. It’ll also be interesting to see whether Epic is actually “best” for ACOs, as a KLAS study of a couple of years ago suggested. More recent data suggests that best-of-breed tools will be necessary to build an ACO, even if your organization has taken the massive Epic plunge.

December 26, 2013 I Written By

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

What Can Go Wrong With An Epic Implementation

With Epic owning the lion’s share of new EMR implementations — it has as many in progress or planned as all other major vendors combined — it’s good to stop and look at just what can go wrong with an Epic implementation.

After all, while Epic installations are a fact of life, all of the news they generate isn’t good. In fact, a growing number of stories of botched Epic installs and institutional fallout are beginning to mount.

In an effort to do learn more about Epic’s strengths and weaknesses, researchers at The Advisory Board Company interviewed some of Epic’s most experienced U.S. hospital customers, as well as some of the busiest Epic implementation consultants, writes senior research director Doug Thompson.

As Thompson points out, the problems Advisory Board identified could impact any big EMR install, but with Epic in the lead, it doesn’t hurt to focus on its products specifically.  (By the way, according to the Advisory Board, there were 194 Epic installs in process or contracted for 2012 and 2013; the closest competitor, MEDITECH, had 59 and Cerner came in at 55.)

So what’s behind the stumbling? Thompson names several limitations to Epic’s own approach to implementation, including the following:

* Its young implementation staffers may be enthusiastic, but some lack operational experience in hospitals or medical practices, which means they rely heavily on Epic’s standard methods and tools –and that may not be adequate for some situations.

* Though Epic’s recommended implementation staffing numbers are higher than that of most other EMR vendors, their estimate nonetheless falls short often by 20 percent to 30 percent of the need.

*Epic’s “foundation” (model) installation plan limits customization or extensive configuration until after the EMR has gone live, which can lead to less physician buy-in and end-user cooperation.

To address these concerns, Thompson offers fourteen techniques to help hospitals get the value they want.  Some of my favorites include:

Begin with the end in mind: Make sure your facility has specific, measurable benefits they hope to achieve with your Epic implementation, and prepare to measure and manage progress in that direction.

Governance: Make sure you assign appropriate roles and responsibilities in managing your Epic rollout and ongoing use. While IT will serve as the linchpin of the project, of course, it’s critical to make sure the appropriate operations leaders have a clear sense of how Epic can and should affect their areas of responsibility.

Get outside input on project staffing: While Epic is upfront about the need for extensive staffing in its implementation, as noted its estimates still come in rather low. It’s a good idea to get in objective outside estimate as to how big the project staff really needs to be.

For more information, I highly recommend you read the full Advisory Board brief. But in short, as  the report concludes, it seems that relying too much on Epic’s approach, staff and tools can lead to problems. Surprised?

December 9, 2013 I Written By

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

Has Epic Grown Too Big, Too Fast?

We’ve written a lot of posts over the years about some of the challenges that Epic has faced as it’s grown its EHR business. In fact, Anne Zieger’s post yesterday about a Hospital Credit Rating Lowered due to their Epic Project is one example. However, I was really struck by this reader submitted article on HIStalk.

The article is written by a “Long-Time Epic Customer”. You don’t get the sense that this customer is bitter or has any real dog in the fight. In fact, if anything this customer seems to have a love for Epic and they want Epic to win the EHR battle. However, they’re concerned by the changes that they’ve seen in Epic as its grown. His a paragraph from the article:

We installed Epic years ago, but have seen a vast difference between our prior experience and a recent rollout of newer products. The method where time was taken to help us build our own system has been replaced by a rushed, prefab Model system installed by staff where even the advisers and escalation points at Epic have little knowledge of their applications. Epic has always had newer people, but it was much more common to have advisers during the install who did have experience to watch for pitfalls.

The writer then goes on to describe how Epic seems to be investing in the wrong things. “We’re getting answers, solutions, fixes, and reports slower than ever.”

I think the reason many of things really struck a chord with me is that they’re matching up with many of the things I’ve seen and heard. Based on some real anecdotal things I’ve heard I won’t be surprised if Judy decides to get out of the day to day work at Epic sometime soon. We’ll see how it plays out, but an Epic without Judy at the helm will be quite different.

November 8, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Billionaire Patrick Soon-Shiong Shares NantHealth Details

I’m really glad that I didn’t hear about the Forbes Healthcare Summit, because I would have wanted to attend and I’m already traveling too much as is. With that said, it’s great that Forbes has put all of the sessions from the Forbes Healthcare conference online. I’m interested in checking out more of the videos, but I was quite intrigued by the interview with billionaire, pharmaceutical inventor, and entrepreneur Patrick Soon-Shiong, Chairman and CEO, NantHealth.

One stat that’s really intriguing is it takes “47 seconds versus 60 days for a personalized genetic analysis.” One thing I love about billionaires is that they don’t know how to think small. They could certainly be wrong in their approach, but they always go after big goals.

Also, about 30 minutes in Patrick Soon-Shiong talks about whether NantHealth will replace the Epic and Cerner EHR.

Thanks to Pat Rioux for pointing out this video to me.

October 23, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Should Hospital Associations Choose EMRs?

Today I read a press release trumpeting the new relationship between the Texas Hospital Association and Enterasys Networks, which is now the THA’s preferred provider for wired and wireless network infrastructure products.

When I read this I found myself thinking “wow, is it really that easy?” Will hospitals rely on intermediaries like the THA to do the due diligence and sort out what sort of networking gear they should buy?

To me, this is an intriguing concept which could easily and logically extend to EMRs. After all, state hospital associations could do an analysis of an EMR’s technical strength, usability, interoperability and features as well as a  health system or hospital could.

It would certainly upend the industry if hospital associations routinely got down and dirty with EMRs, went through a selection process and put their “recommended” stamp on a small handful of systems.

If nothing else, it would be a shock to vendors, who would have to create new channel relationships with the associations, quickly and well. Marketing to associations wouldn’t superceded marketing to individual hospitals completely, but it would add a new layer of effort.

It would also give some attention to lesser-known EMR vendors. I’d argue that in an honest process, it’s unlikely that all — or even most — of the hospital associations would only choose as “winners” the enterprise EMRs that dominate the market today.  This is not to say that giants like Epic and Cerner would never be selected; it’s just that as I imagine it, a thorough hospital association selection process would identify some underdogs that deserve hospitals’ business.

The truth is, though, that most hospital associations wouldn’t want to go down the road of officially putting their stamp of approval on a small collection of EMRs. The task is enormous, the political costs high if members don’t agree with their choices, and the downside is considerable if a recommended vendor completely flames out in some way.

No,  it seems to me that while the THA has put its credibility on the line for Enterasys, I don’t see it (or its peers in other states) sticking an oar in the EMR selection business. There’s just too much at stake. They’ll spend their last penny fighting regulatory battles — particularly as Meaningful Use steams along — but hospital trade groups are not going to become the EMR Fairy.

October 10, 2013 I Written By

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

EMR Upgrade Cycles are Painful – Are You Prepared for Them?

Everyone gets so excited and worked up about the initial EMR implementation, but so many discount the effort that’s required for every EMR update cycle as well. Dr. Jayne from HIStalk gave a great first person perspective on EMR update cycles:

I figure I’ve got about two weeks of the good life left and then I’m going to be back in an upgrade cycle with all the standing meetings that entails. I’ll be back in the trenches testing workflows and trying to find defects as quickly as possible so that our vendor can roll them into patches before we go live. Every time we upgrade it reminds me more and more of some kind of military assault. I’m not sure if it’s just the way we run them or a little bit of post-traumatic stress. Maybe it’s a little of both.

I’m also reminded of Heather Haugen’s comments about EHR upgrade cycles: “software upgrades erode adoption over time and so with every upgrade you need a commensurate effort to retrain adoption.” Far too often organizations underestimate the impact and challenge associated with EMR upgrades.

Over the next couple years, those upgrades will likely be tied to an organization’s meaningful use plan. So, those will likely go better than some nebulous EMR upgrade plan. However, those organizations who underestimate the impact of EMR upgrades on their organization will pay the price later.

I know that many believe that in the large hospital space it’s a two horse race between Cerner and Epic. However, when you consider the challenges and costs associated with upgrading those software, don’t be surprised if some smaller scrappy startup can exploit the EMR upgrade opportunity. I don’t think it will happen until after meaningful use and EHR incentive money run their course, but it will happen.

October 7, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.

Lessons Learned from Sutter’s EHR Implementation Challenges

One of our more popular recent posts was published on EMR and HIPAA and was titled, “Adding Insult To Injury, Sutter’s Epic EMR Crashes For A Day.” When the post was shared on LinkedIn, it prompted a really insightful discussion on EMR training and Sutter’s approach to EHR implementation. A few of the comments were so good that I wanted to share them for more people to read and learn.

The first comment is from Scott Kennedy, an Epic Stork Trainer:

I was an Epic training consultant on the E. Bay Sutter EHR implementation and I can tell you first hand that Sutter Admin, and the Nurses are at odds. This unfortunate relationship made it difficult to train the staff. Epic itself is not to blame. Those who are using the Epic EHR are not as trained as they should be.

Sutter used an “in house” training team rather than bringing on a full consulting team with much more experience in training and educating end users. The “in house’ trainers included some nurses, RTs, and the like as well as a host of newly graduated college students who had less to no experience with conducting a formal training presentation on a multidisciplinary EHR.

Hiring and training “in house” is a great addition to bringing on an experienced, skilled, professional team of Epic credentialed trainers, like myself who do this as a profession all over the country.

We were also directed by Sutter EHR implementation Administration to “facilitate” rather than “train.” “Facilitate included passing out exercise booklets to the clinical end users and having them work on their own, rather than conducing concise, lectured, guided practice prior to each exercise. Hands on exercises are an essential part of the training, but should not be the complete focus of training.

The learner is left on their own to figure out the system, which is counter productive. That approach only builds anxiety, confusion and eventual resentment for the system and the administration who have chosen the EHR they are fumbling through.

I empathize with the clinical end users. There training experience could have been much more instrumental in getting them off on the right foot with their new EHR, had the training approach been more adult learning theory based rather than self-learning based.

I only wish I could come back to Sutter and retrain the nurses and other clinicians from the proven, consistent, progressive, successful adult learning approach, which enables and empowers the end user to grasp, comprehend and assimilate the EHR system into their daily shift work flow. That is not to say that there are not implementation bumps and optimization needs that have to be addressed, but they are far less impactful when the clinician is properly trained.

I am so sorry Sutter nurses and staff that I trained, but I was firmly told to “facilitate” your learning rather than “train” you. I tried to implement adult learning methodology, but was told by your EHR administration to “stop talking and let them do it on their own.”

Epic EHR is not to blame here. Epic is a sound, EHR system that is serving the needs of millions of patients and their care providers around the world, without incidents such as those being experienced at Sutter.

There is a right way to implement and train and a wrong way. Sorry Sutter EHR implementation administration, but “I told you so!”

I asked Scott Kennedy if he’d thought of leaving the project since it was being done the wrong way and he offered the following response:

@ John, yes I did come very close to leaving the project. As a matter of fact after I was verbally “scolded” for lecturing to much I phoned my recruiter and asked to be placed on another project, but then, after careful thought, I decided to stay on the project and attempt to train and support as much as I could. But it seems that my individual efforts were not enough to counter the original training “facilitation” focus.

To add insult to injury those of us trainers who were there for the Sutter E. Bay implementation were told not to return for the W. Bay implementation. The EHR administration wanted an entirely new outside consulting team.

I got a fellow colleague on the project, hoping that the E. Bay administration would have learned from and the current W. Bay implementation would be better. The training colleague I got on the W. Bay project shared with me that it was worse than the E. Bay implementation. They kept the experienced Epic trainers as support and utilized them as little as possible for actual front end training. So sad, really.

The EHR administration at Sutter tried to cut every financial corner possible and lost sight of the long run implications of improper front end training. Now they are paying the price.

Michael A. P., an EMR consultant offered this insight as well:

I’ve also had the misfortune of working with Sutter for a (thankfully) brief period. In their long history of attempting to implement Epic, they could be counted on to make the wrong decision in almost every situation. Their internal politics trump the advice they receive from vendors and highly experienced consultants. The result is an implementation that serves neither the patient or the users best interests.

Then, Ryan Thousand, an IT Architect at Athens Regional Medical Center, offered a broader view of what’s happening in health IT and EHR:

I hate to say it but most large healthcare organizations are getting like this as well…. There are WAY too many layers in these organizations and sometimes to get work done can mean 4 weeks of executive meetings and in the end no decision or 100% opposite of the recommended direction given. That being said, with the rapid change in healthcare and the mergers and acquisitions occurring right now, I fear the worries for Healthcare in general over the next couple of years. We cannot continue to try to meet mandates the government is making while still ensuring 100% utmost patient care; and in the end that is really all I care about.. the patient in the bed who is BENEFITING from my implementation. Change is always tough but done the right way with the right people (as you all stated above was not done correctly) we will continue to see great things happen on the HIT side. But unless Epic/Cerner all the big players in the markets as well as the local clinician and providers work together and decide the best outcomes for our patients, we will all one day suffer, as we will all one day be patients.

In all the years I’ve been writing about EMR and EHR, the biggest problem with most EMR implementations is lack of EHR training or poor EHR training. It’s really amazing the impact quality EHR training can have on an implementation. However, many organizations use that as a way to save money. If they could only see the long term costs of that choice.

September 25, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: InfluentialNetworks.com and Physia.com, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus.