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Why BIDMC Is Shunning Epic, Developing Its Own EMR

Posted on July 31, 2013 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Though its price tag be formidable and installation highly complex, the Epic EMR is practically a no-brainer decision for many hospitals.  As Beth Israel Deaconess Medical Center CIO John Halamka notes, things are certainly like that in the Boston metro, where BIDMC’s competitors are largely on Epic or in the process of installing Epic.

Why are Halamka’s competitors all going with Epic?  He proposes the following reasons:

*  Epic installs get clinicians to buy in to a single configuration of a single product. Its project methodology standardizes governance, processes and staffing in a way that hospitals might not be able to do on their own.

* Epic fends off clinicians’ request for new innovations that the hospital staff might not be able to support. IT merely has to tell clinicians that they’ll have to wait until Epic releases its next iteration.

* Epic is a safe investment for meeting Meaningful Use Stage 2, as it has a history of helping hospitals and providers achieve MU compliance.

* CIOs generally don’t get fired for buying Epic, as it’s the popular move to make, despite being reliant on 1990s era client-server technology delivered via terminal services that require signficant staffing to support. (Actually, it does happen but it’s still rare.)

*  These days, hospitals have moved away from “best of breed” EMR implementations to the need for integration across the enterprise.  As Halamka notes, such integration is important in a world where Accountable Care/global capitated risk is becoming a key factor in reimbursement, so having a continuous record across episodes of care is critical. Epic seems to address this issue.

But BIDMC is a holdout. As Dr. Halamka notes in his blog, BIDMC is one of the last hospitals in Eastern Massachusetts continuing to build and buy components to create its own EMR. He’s convinced that going with the in-house development method — creating a cloud-hosted, thin client, mobile friendly and highly interoperable system — is ultimately cheaper and allows for faster innovation.

In closing, Halamka wonders whether his will end up being one of the very last hospitals to continue an ongoing EMR development program.  I think he’s answered his own question: it seems likely that BIDMC’s competitors will keep jumping on the Epic bandwagon for all of the reasons he outlines.

Will they do well with Epic?  Will they find later on that the capital investment and support costs are untenable? I think we’ll have the answers within a scant year or two. Personally, I think BIDMC will have the last laugh, but we’ll just have to see.

Develop Your Own EMR – Crazy, But This Guy Did It Anyway

Posted on July 30, 2013 I Written By

James Ritchie is a freelance writer with a focus on health care. His experience includes eight years as a staff writer with the Cincinnati Business Courier, part of the American City Business Journals network. Twitter @HCwriterJames.

When I read John Lynn’s post “Develop Your Own EMR – You’re Still Crazy!” the other day, I thought of Dr. Terry Ellis. I talked to him in 2005 when I worked for the daily Leaf-Chronicle in Tennessee. He had developed his own EMR, and I wrote about it.

Dr. Ellis operates Ellis Oral & Maxillofacial Surgery and Implants in Clarksville. Another surgeon, Dr. Ted McCurdy, practices with him. He wrote his EMR after teaching himself Visual Basic 6.0. I thought that was cool. His only other programming experience had been a one-semester college course in 1977. Dr. Ellis started using the software in his own office in 2002. He started a firm called DescriptMed and began licensing the product, The Chart, to other practices.

Dr. Terry Ellis, an oral surgeon in Tennessee, developed his own EMR called The Chart.

Dr. Terry Ellis, an oral surgeon in Tennessee, developed his own EMR called The Chart.

I wondered where Dr. Ellis’ EMR journey had taken him since we last talked, so I got in touch. The story had an interesting turn. Dr. Ellis still uses a descendant of his EMR every day, but it’s from a different company, and it has a new name. Here’s what he had to say.

How did you develop your EMR?

I spent many hours from 2002 to 2007 improving this EMR. Many nights, weekends and nearly all of my spare time was spent either programming in VB6 and SQL or thinking of coding problems that would come about from a “fresh idea.”

Why didn’t you go with an established vendor?

Primarily the EMRs that were available were obviously written by non-practitioners and did not enable me to effectively use the product in my practice. Most of the products were rigidly programmed or “hard coded.” Most had limited flexibility and really didn’t offer bang for the buck. I only looked at a few, and the closest that ever made it was Amazing Charts, but it still was not what I needed.

Did you have any software development experience?

No. I had taken Fortran IV in college at Murray State University in 1977. I had to learn VB6, VB.Net & C# as well as SQL with database programming on my own. I bought several good books and did a lot of searching online.

How well has it worked for your practice?

It has been the best thing I have done for record keeping. We would never go back to paper.

You eventually expanded it beyond your own practice. How successful has that effort been; how many practices are using it now?

I had users from New York to Georgia, Oklahoma, California and Washington. A cardiologist in Pomona, Calif., still uses it. He even flew me out there to help him get started. My longest user is an internist in San Jose, Calif.

What’s different about your EMR compared with others on the market?

The biggest thing was the flexibility that users had. They could put almost anything they wanted in their own words into the H&P elements. Thus things like complex counseling or treatment statements/paragraphs could be entered in one or two clicks. Other products did not offer this approach. By the way, I hold a copyright on my product.

How has it changed over time?

I moved it from Access database to MySQL and MS SQL. It has numerous features that can support multiple specialties

How has it fared in Meaningful Use?

Not well. I haven’t tried to keep up with that rat race.

How do you keep it updated?

Currently my EMR is embedded in a product out of Washington state. We work together to produce a full-featured PM/EMR for oral and maxillofacial surgeons. I don’t know how many are using it, but I believe there are several hundred oral and maxillofacial surgeons using the EMR under the Oral Surgery-Exec name. This is being marketed by DSN Software in Centralia, Wash. They have a strong following.

Do Hospitals Need an EDW to Participate in an ACO?

Posted on July 29, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The following is a guest blog post by Dana Sellers, Chief Executive Officer of Encore Health Resources. Dana’s comments are in response to my post titled, “Skinny Data Solves Specific Problems While BIG DATA Looks for Unseen Problems.” For more context, also check out my post on Skinny Data in Healthcare, and my video interview with Dana Sellers.
Dana-Sellers-Encore-Health-Resources
You did a great job of nailing down the kinds of problems our industry can tackle with BIG DATA on the one hand and smart, skinny data on the other in your blog last Thursday, “Skinny Data Solves Specific Problems While BIG DATA Looks for Unseen Problems.” We here at Encore Health Resources were particularly intrigued when you asked whether skinny data would be enough for ACOs, or whether hospitals will need full enterprise data warehouses – EDWs – to meet the demands of ACOs.

I’d love to take a shot at that. As I’m sure lots of your readers know, an EDW is a collection of enterprise data based on the best guess of what an organization thinks it will need over the long run. So it’s bigger than skinny data (only what we know we need now) but smaller than Big Data (every bit of data available). So now we get to your question…do hospitals need an EDW to meet the demands of participating in an ACO?

If you’ve got one, great! In large part, we know what measures ACOs want a hospital to report. If you already have a mature, well-populated EDW — fantastic! Pull the needed data, calculate the required measures, and go for it.

If not, start with skinny data. Many organizations find that they are jumping into ACOs before they have a mature EDW. So this is a great example of where skinny data is a great idea. The concept of skinny data lets you focus on the specific data required by the ACO. Instead of spending a long time trying to gather everything you might need eventually, focus on the immediate needs: quality, readmissions, unnecessary ED visits, controlling diabetes, controlling CHF, etc. Gather that quickly, and then build to a full EDW later.

Think about a skinny data appliance. One of the problems I’m seeing across the country is that organizations are rarely talking about just one ACO. These days, it’s multiple ACOs, and each one requires a different set of metrics. I talked with an organization last week that is abandoning its current business intelligence strategy and seeking a new one because they didn’t feel the old strategy was going to be able to accommodate the explosion of measures that are required by all the ACOs and commercial contracts and Federal initiatives coming down the road. The problem is that you don’t have to just report all these measures- you actually need to perform against these measures, or you won’t be reimbursed in this new world.

One way to deal with this is to establish a sound EDW strategy but supplement it with a skinny data appliance. I doubt that’s an official term, but my mother never told me I couldn’t make up words. To me, a skinny data appliance is something that sits on top of your EDW and gives you the ability to easily extract, manipulate, report, and monitor smaller subsets of data for a special purpose. As the demands of ACOs, commercial contracts, and Federal regulations proliferate, the ability to be quick and nimble will be critical — and being nimble without an army of programmers will be important. One large organization I know estimates that the use of a smart skinny data appliance may save them several FTEs (full time equivalents) per year, just in the programming of measures.

Bottom line – I believe skinny data will support current ACO requirements. Eventually, an EDW will be useful, and skinny data is a good way to get started. Many large organizations will go the EDW route, and they will benefit from a skinny data appliance.

John, as always, I love talking with you!

Where’s the Imagery in EHR?

Posted on July 26, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of my readers recently asked me, “Where’s the imagery in EHR?”

It was a fascinating question. At the core of their question was the implication that there was real value in images that wasn’t being leveraged in EHR software. This is not to say that EHR software doesn’t do any imagery, but it could do so much more. Pretty much every EHR software I’ve seen has some sort of image documentation available. Sometimes it’s just uploading an image to the EHR, but in most cases you can incorporate an image into the documentation itself. Usually you can do some sort of Paint like editing of the image as well. Although, that’s about the extent of imagery in most EHR software.

Of course, when most people hear imagery and EHR, they likely think of DICOM images from radiology. This is definitely missing from most EHR software as well. The excuse is usually a mix of the DICOM images being too large and having the right software to view the DICOM images. With that said, I think this imagery will eventually be part of the images available in an EHR.

I’d love to see much more imagery available in the EHR. It should be as simple to add a photo into your EHR as it is to post it to instagram. We’re not there yet, but we should be. There are hundreds of situations in healthcare where an image provides incredible benefit to your documentation. Imagine having images or video from the Otoscope stored in the EMR. The technology is there to be able to store this type of imagery in an EHR. In fact, back in 2006 I predicted that one day an EMR would store a video recording of an entire patient visit.

Why don’t we see more imagery in EMR?

The simple reason we don’t see more imagery in EMR is that reimbursement doesn’t require it. In fact, you could make a case that reimbursement discourages the use of imagery in documentation. The same goes for physician liability. You can make a case that more imagery in an EHR can make for more physician liability. Unfortunately, healthcare is heavily influenced by both reimbursement and liability.

Meaningful use doesn’t do anything to encourage the use of imagery as well. In fact, the healthcare interoperability standards do almost nothing to consider the transfer of image based documentation. They basically didn’t take this into account, because so little documentation includes it.

There are a few EMR vendors that are taking imagery seriously. Modernizing Medicine’s EMA EMR is one example. They use images to document the whole visit. Although, ironically they take all this amazing image work and translate it into text because that’s what’s required for reimbursement. How twisted is that? Of course, the EMA EMR is designed for specialties that really benefit from images: dermatology, opthamology, optometry, plastic surgery, and orthopedics.

I’d love to see more imagery used in EMR. Unfortunately, I see nothing driving the use of images in EMR.

HIPAA Fines and Penalties in a HIPAA Omnibus World

Posted on July 25, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Lately I’ve been seeing a number of really lazy approaches to making sure a company is HIPAA compliant. I think there’s a pandora’s box just waiting to explode where many companies are going to get slammed with HIPAA compliance issues. Certainly there are plenty of HIPAA compliance issues at healthcare provider organizations, but the larger compliance issue is going to likely come from all of these business associates that are now going to be held responsible for any HIPAA violations that occur with their systems.

For those not keeping up with the changes to HIPAA as part of the HITECH Act and HIPAA Omnibus, here are a couple of the biggest changes. First, HITECH provided some real teeth when it comes to penalties for HIPAA violations. Second, HIPAA Omnibus puts business associates in a position of responsibility when it comes to any HIPAA violations. Yes, this means that healthcare companies that experience HIPAA violations could be fined just like previous covered entities.

To put it simply, hundreds of organizations who didn’t have to worry too much about HIPAA will now be held responsible.

This is likely going to be a recipe for disaster for those organizations who aren’t covering their bases when it comes to HIPAA compliance. Consider two of the most recent fines where Idaho State University was fined $400k for HIPAA violations and the $1.7 million penalty for WellPoint’s HIPAA violations. In the first case, they had a disabled firewall for a year, and the second one failed to secure an online application database containing sensitive data.

Of course, none of the above examples take into account the possible civil cases that can be created against these organizations or the brand impact to the organization of a HIPAA violation. The penalties of a HIPAA violation range between $100 to $50,000 per violation depending on the HIPAA violation category. I’ll be interested to see how HHS defines “Reasonable Cause” versus “Willfull Neglect – Corrected.”

I’ve seen far too many organizations not taking the HIPAA requirements seriously. This is going to come back to bite many organizations. Plus, healthcare organizations better make sure they have proper business associate agreements with these companies in order to insulate them against the neglect of the business associate. I don’t see HHS starting to search for companies that aren’t compliant. However, if they get a report of issues, they’ll have to investigate and they won’t likely be happy with what they find.

The message to all is to make sure your HIPAA house is in order. Unfortunately, I don’t think many will really listen until the first shoe falls.

Improving Financial Performance By Accelerating Cash Flow

Posted on July 24, 2013 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

In IT circles, revenue cycle management isn’t the sexiest assignment, but collecting revenue is the lifeblood of your hospital nonetheless. In this e-book, Relay Health offers several suggestions for speeding up cash flow by being proactive about when and where cash is collected.

Right now, as the book notes, hospitals rely on collecting co-pays at the time of service, while determining and collecting the balance post-service. However, the likelihood of patients paying goes down after they leave the hospital.

To address collections pre-service, Relay Health suggests hospitals use technology to screen patients for eligibility for benefits and their propensity to pay bills, verify their personal data and identity information to avoid fraud and speed the claims process, and screen them for charity assistance.

There’s also several steps the e-book recommends which can increase the propensity of patients to pay post-discharge, including leveraging patient data to customize statements with relevant messages; using visually-appealing statement formats; offering online bill  payment and management; and integrating an estimation/verification tool to help focus the discussion of patient responsibility.

Another important step  hospitals can take is to evaluate their claims management processes and shift effort to areas where the greatest impact can be felt, the book suggests.  As of the first half of 2012,  the average service-to-payment velocity industry wide was 45.3 days from patient discharge to resolution. This can be helped by finding process delays in key areas of claims performance, including service to release of claim, service to submission of claim, submit to Transmit and Transmit to Payment, Relay Health suggests.

Still another way in which hospitals can improve their revenue cycle management performance is to engage in comparative analytics, benchmarking their financial performance to improve decision-making.  The e-book notes that while traditional benchmarking presents several issues — not the least of which being that comparing performance indicators between organizations may be an “apples to oranges” comparison — benchmarking using comparative analytics avoids these issues.

Ultimately, the e-book notes, healthcare providers will transition from a focus on internal data repositories for performance information to a more outward-facing, patient-centric model integrating data from claims, EMRs, PHRs, analytics technologies, CRM systems and health insurance exchanges. In the mean time,  it suggests, it’s definitely worth the effort to fine-tune RCM systems using the data you have.

Bring Your Own EHR (BYOEHR)

Posted on July 23, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Nerd Doc recently offered a new term I’d never heard called Bring Your Own EHR (BYOEHR). Here’s the explanation:

As a tech nerd doc, the best advice I can give to CIOs/CMIOs is to find a framework for ambulatory practices that embraces a BYOEHR (Bring your own EHR) in the same vein of BYOD (Bring your own device). What I mean by that is allow providor choice in purchasing and implementing their own EHR while insuring that a framework is set up for cross communication to interlink records.

This is to fend off the trend to a one size (Epic) fits all approach in which no one is happy. C-level management needs to realize that if users (providers) are not happy, the promises of savings via efficiency simply will not happen.

I think we’re starting to hear more and more examples like this. We saw evidence of this in my previous post called “CIO Reveals Secrets to HIE.” That hospital organization had created an HIE that connected with 36 different EMRs. Think about the effort that was required there. However, that CIO realized that there was a benefit to creating all of those connections. The results have paid off with a highly used HIE.

I’m sure we’ll still see hospitals acquiring practices and forcing an enterprise EHR down their throats for a while. However, don’t be surprised if the cycle goes back to doctors providing independent healthcare on whatever EHR they see fits them best. Those hospitals that have embraced a BYOEHR approach will be well positioned when this cycle occurs.

A Patient’s View of Meaningful Use Questions

Posted on July 22, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The creativity of humans will never cease to amaze me. If you’re someone who works in the EMR world, you’ll love this video. I honestly don’t know whether to cry or cry laughing. I’m sure many doctors and nurses reading this will have had some first hand experiences like this. Enjoy a nice patient view of meaningful use thanks to Ashley Fuller.

Health IT Tweet Roundup – Neil Versel Edition

Posted on July 21, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As you know, each weekend I like to do a roundup of interesting tweets and add a bit of commentary. This time I thought it would be fun to grab some tweets from just one person, Neil Versel. Neil has been doing a number of really great posts on his blog Meaningful Health IT News lately (Full Disclosure: Neil’s blog is part of the Healthcare Scene blog network). The following tweets highlight some of Neil’s recent blog posts.


I agree that Blue Button Plus is a great step forward for Blue Button. This post is particularly interesting because Neil didn’t see the promise of Blue Button before the changes were made and it was called plus.


This is a great discussion on the meaningful use requirements and Blue Button’s role in them. Join in if you have some knowledge on the area about what your EHR is doing.


Neil’s right about people who don’t cover healthcare regularly not understanding many of the true dynamics at play. I do find it interesting that Neil is such a fan of clinical decision support. I still think it’s in such an infant state. I can’t wait for much more advanced clinical decision support.

Patients Eager To Access Medical Images Online

Posted on July 19, 2013 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

A new study suggests that making medical images accessible online to patients might be a fruitful method for getting patient engagement up in time for Meaningful Use Stage 2, reports EHR Intelligence.

The study, by IDR Medical and Carestream Health, surveyed 1,000 patients who had recently had an imaging study done, in an effort to examine patient views of patient portal use prior to engagement requirements falling into place with MU Stage 2.

It found that patients were very interested in accessing medical images — as well as the clinical notes accompanying the images — with 68 percent saying it was “extremely likely” they would do so if given the opportunity, according to EHR Intelligence.

Survey respondents were particularly interested in using a portal to access their children’s medical images, with 90 percent saying that they would do so if they could. Meanwhile, 82 percent of people wanted to view their own images.

The researchers assumed that older patients would be less likely to use an online portal, but that other patients who frequently get images taken or already access health data online would probably access a portal often.

While elderly patients aged 71 and above were indeed less likely to be interested in portal use, patients aged 50 to 70 had the most positive attitude toward patient portals.

Not surprisingly, patients who already had access to a patient portal were also very positive about access imaging studies online, the site notes. When given a choice of methods by which they could review imaging studies, 79 percent of patients said that an online portal would be their first choice, either by itself or in addition to hard copies of images and reports.

While some providers have worried that they’ll have trouble getting patients to interact with online patient portals, it seems clear that putting images and interpretative notes online can help, if this data is any indication.

Now, some clinicians have worried that at the extreme — an overly-engaged patient who raises time-consuming questions over trivial details — online patient portals will turn out to be a headache.

But to date, as my colleague Jennifer Dennard notes, the portal-fueled pesty patient isn’t materializing. Perhaps both the portal and the patients have matured to the point where they can support each other.