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Documentation by Exception is the Dredge of EHR Documentation

Posted on May 26, 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.

There was a very bad practice that was started thanks in large part to EHR software implementations. That practice is called documentation by exception and it’s employed by many (most?) EHR vendors. For those not familiar with documentation by exception, here’s a definition:

Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.

In the US, we all know why this type of documentation was implemented. By documenting all of the normal finding along with the exceptions, then the doctor is able to bill the insurance company at a higher level. I totally understand why doctors want to bill at a higher level. In fact, it was the argument that most EHR vendors would make when they were selling their product to doctors. The EHR was able to help doctors bill at a higher level and get paid more.

While this is going to be hard to change for this reason, there are so many unintended consequences associated with using documentation by exception in these practices. I know so many doctors that are literally embarrassed to share their chart notes with their colleagues because their chart notes are these long, cumbersome notes that are filled with normal findings that provide no value to anyone. Many of these doctors have resorted to creating a separate “short” note that only has the relevant “exceptions” detailed when they send their chart notes to another doctor.

Every doctor knows what I’m talking about, because they’ve found these long lengthy notes that are totally unusable. Plus, in many ways it puts a doctor at some risk if they documented a long list of “normal” items when in fact they didn’t actually check to see if everything was normal or not. However, more important than this is that the doctor can’t even read their own historical notes because they’re so cluttered with all these “normal” findings that it takes real work and effort (Translation: Wasted physician time) trying to search through these awful notes.

If somehow all of these normal findings that were being documented could add some value down the road, then I might change my mind about documentation by exception. However, I can’t imagine any useful clinical benefit to documenting a bunch of normal findings that weren’t actually checked or that were only casually observed. If you didn’t document something was wrong, then we can assume that everything else was normal or at least the patient didn’t complain of anything else. Why do we need to document it clinically? The answer is we don’t and we shouldn’t (except for the getting paid comments above).

We need to find a way to abolish these documentation by exception notes from healthcare. In the US this will be hard since it’s so tied to the payment system, but I’m sure smart minds can figure out a way to fix it. Every doctors I’ve ever talked to wants this solved. It almost makes the EHR notes useless to document this way. This is one more driver in the US system towards concierge and direct primary care models. In these cases, the doctors aren’t worried about reimbursement and so I can’t imaging they’d even consider documenting a patient visit in such an awful manner.

A part of me wonders if EHR vendors will work to solve this problem as well. They could have the beautiful note and the crappy, mess of a note. They’ll use less vulgar terms like the “clinical note” and the “billing note” or something like that, but maybe that’s a small step in the right direction to satisfying the clinical needs (short, concise, relevant notes) together with meeting the billing requirements note. It’s sad that EHR vendors need to do something like this, but it would be better than the current state of EHR notes.

EHR Partner Programs

Posted on May 22, 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.

Amazing Charts just announced a new EHR partner program. This isn’t something that’s particularly new for EHR vendors. They all have lots of partners. Some have formalized them into a program like athenahealth has done with their More Disruption Please (MDP) program. Others are much more quiet about the partners they work with and how they work with them.

What’s clear to me in the EHR industry is that an EHR vendor won’t be able to do everything. There are some that like to try (See Epic), but even the largest EHR vendor isn’t going to be able to provide all the services that are needed by a healthcare organization. This is true for ambulatory and hospitals.

Since an EHR vendor won’t be able to do everything, it makes a lot of sense for an EHR vendor to have some sort of partners program. The challenge for an EHR vendor is that a partner program comes with two major expectations. First, the partner has a high quality integration with the EHR software. Second, that the partner is something that the EHR vendor has vetted.

The first challenge is mostly a challenge because most EHR vendors aren’t great at integrating with outside companies. This is a major culture shift for many EHR vendors and it will take time for them to get up to speed on these types of integrations. Plus, these integrations do take some time and investment on the part of the EHR vendor. When there’s time and investment involved, the EHR vendor starts to be much more selective about which companies they want to be working with long term. They don’t want to spend their time and money integrating with a company which none of its users will actually use.

The second challenge is that EHR users assume that an EHR partner is one that’s been vetted by the EHR vendor. Even if the EHR vendor puts all sorts of disclaimers on their partner page, the EHR vendor is still associated with their partners. The written disclaimers might help you avoid legal issues, but working with shady partners can do a lot of damage to your reputation and credibility in the marketplace. I actually think this is probably the biggest reason that EHR vendors have been reluctant to implement partner programs.

I think over time we’ll see the first problem solved as EHR vendors work to standardize their APIs for partner companies. As those APIs become more mature, we’ll see much deeper EHR integrations and the costs to an EHR vendor will drop dramatically when it comes to new partner integrations.

The second problem is much harder to solve. My best suggestion for EHR vendors is to create a platform which allows your users to help you vet potential partners. Not only can they participate in the vetting process, but it can also help you know which partners would be useful to your users. Is there anything more valuable than user driven partnerships? It also puts you in a good position with potential partners if you already have users interested in the integration.

However, an EHR vendor shouldn’t just leave potential partnership requests to their users. Many of their users don’t know of all the potential partner companies. Users are so busy dealing with their day jobs that they often don’t know of all the potential companies that could benefit their practice or hospital. Certainly you should accept user input on potential partnerships, but an EHR vendor should also seed the potential partner feedback platform with a list of potential partners as well. The mix of an EHR vendor created list together with user generated partner lists is much more powerful than one or the other.

We’re just at the beginning of companies partnering and integrating with EHR vendors. I expect that over the next 5 years an EHR vendor will be defined as much by the organizations it chooses to partner with as the features and functions it chooses to develop itself.

What’s the Story on 21st Century Cures Legislation?

Posted on May 21, 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 just saw that the 21st Century Cures legislation passed the house committee process. Word on the street is that Congress probably won’t take this up even if the house passes it this summer. The legislation looks pretty interesting for those of us in healthcare IT. Blair Childs, Premier’s senior vice president of public affairs, offered the following statement on the legislation:

Members of Premier wish to thank House Energy and Commerce Chairman Fred Upton (R-MI) and Representative Diana Degette (D-CO) for their leadership to advance interoperability standards as part of the landmark 21st Century Cures legislation. With today’s vote, the vision for a fully interoperable health information technology ecosystem is one step closer to becoming a reality.

We also wish to thank Committee members Joe Pitts (R-PA), Frank Pallone (D-NJ), Gene Green (D- TX), Michael Burgess (R-TX) and Doris Matsui (D-CA) for their support of interoperability standards in the legislation, and for their efforts to ensure that the technology systems of the future will be built using open source codes that enable applications to seamlessly exchange data/information across disparate systems in healthcare.

Today’s vote is an essential step to optimize HIT investments, improve the quality of care across settings and avoid the cost burdens associated with the work around solutions that are needed today for systems to “talk” to one another. We strongly urge the full House of Representatives to support these interoperability standards and to vote in favor of moving the legislation forward as it stands today.

Many of the comments he offers about ensuring interoperability is open source and support for standards of healthcare interoperability are great things. Although, as I think we learned with the meaningful use regulations, the devil is in the details and the 21st Centure Cures legislation is not simple. I’d love to hear from people who are following the legislation. Is this a good piece of legislation? Should it be passed? Are their hidden land mines? What are the unknowns or uncertain outcomes of the legislation?

When I saw this legislation hit my email inbox it has me asking how people keep up with legislation. Not to mention, what’s the process for creating this legislation? Just thinking of the process makes me tired and overwhelmed. Is it any wonder that lobbyists are so powerful? It really takes someone whose full time job it is to track and influence legislation to really get something done. The process and legislation is so complex that a casual follower just can’t keep up. I think that’s really unfortunate. I’m not sure the solution though either.

HIMSS15: Adoption Still a Problem for Organizations Swapping EHRs – Breakaway Thinking

Posted on May 20, 2015 I Written By

The following is a guest blog post by Todd Stansfield, Instructional Writer from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield

Each year the Health Information and Management Systems Society’s (HIMSS) annual conference is the Super Bowl of health IT. No other conference boasts more attendees ranging from health IT innovators and collaborators to pioneers. This year 40,000 plus participants descended on Chicago, all eager to learn about the new direction, trends, and solutions of the industry.

As always, buzzwords were aplenty—interoperability, care coordination, patient experience, and value-based care, to mention a few. During her keynote address on April 16, Karen DeSalvo, National Coordinator for the ONC, called the current state of health IT the “tipping point.” In 2011 the ONC released its four-year strategic plan focused on implementing and adopting electronic health records (EHRs). Now, DeSalvo says the industry is changed and ready to move beyond EHRs to technologies that will create “true interoperability.”

Enlightening conversations were happening among the crowded booths, hallways, and meeting rooms between organizations looking to ‘rip and replace’ their current EHR for a new one. While some organizations are struggling to unlock data across disparate systems, others are looking to upgrade their current system for one compatible with ICD-10, Meaningful Use, analytics solutions, or a combination of these. Still others are looking to replace systems they dislike for lack of functionality, vendor relationships, etc. In many cases, replacing an EHR is needed to ensure interoperability is at the very least viable. This buzz at HIMSS is a strong indicator that EHRs are still an important and essential part of health IT, and perhaps some organizations have not reached the tipping point.

In addition to the many challenges these organizations are facing—from data portability, an issue John Lynn wrote about in August 2012, to the cost of replacing the system—leaders are agonizing over the resistance they are facing from clinician end users. How can these organizations force clinicians to give up systems they once resisted, then embraced and worked so hard to adopt? How can leadership inspire the same level of engagement needed for adoption? The challenge is similar to transitioning from paper to an EHR, only more significant. Whereas the reasons for switching from paper were straightforward—patient safety, efficiency, interoperability, etc.—they are not so clear when switching applications.

Clinicians are also making harsher comparisons between applications—from every drop-down list, to icon, to keyboard shortcut. These comparisons are occurring at drastically different phases in the adoption lifecycle. Consider the example of an end user needing to document a progress note. In the old EHR, this user knew how to copy forward previous documentation, but in the new system she doesn’t know if this functionality even exists. Already the end user is viewing the new system as cumbersome and inefficient compared to the old application. Multiply this comparison by each of the various tasks she completes throughout her day, and the end user is strongly questioning her organization’s decision to make the change.

This highlights an important point: Swapping one EHR for another will take more planning, effort, and strategy than a first-ever implementation. The methods for achieving adoption are the same, but the degree to which they are employed is not. Leadership will not only have to re-engage end users and facilitate buy-in, they will have to address the loss of efficiency and optimization by replacing the old application.

Leadership should start by clearly outlining the reasons for change, a long-term strategy, as well frustrations end users can expect. They should establish a strong governance and support structure to ensure end users adhere to policies, procedures, and best practices for using the application. The organizations that will succeed will provide end users with role-based education complete with hands-on experience completing best practice workflows in the application. Education should include competency tests that assess end users’ ability to complete key components of their workflow. Additionally, organizations must capture and track performance measurements to ensure optimized use of the system and identify areas of need. And because adoption recedes after application upgrades and workflow enhancements, all efforts should be sustained and modified as needed.

While HIMSS15 brought to the stage a wealth of new ideas, solutions, and visions for the future of health IT, the struggle to adopt an EHR has not completely gone away. Many organizations are grappling with their current EHR and choosing to replace it in hopes of meeting the triple aim of improving care, costs, and population health. For these organizations to be prepared for true interoperability, they must overcome challenges unseen in paper to electronic implementations. And if done successfully, only then will our industry uniformly reach the tipping point, a point where we can begin to put buzzwords into practice.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Emerging Health Apps Pose Major Security Risk

Posted on May 18, 2015 I Written By

Katherine Rourke 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.

As new technologies like fitness bands, telemedicine and smartphone apps have become more important to healthcare, the issue of how to protect the privacy of the data they generate has become more important, too.

After all, all of these devices use the public Internet to broadcast data, at least at some point in the transmission. Typically, telemedicine involves a direct connection via an unsecured Internet connection with a remote server (Although, they are offering doing some sort of encryption of the data that’s being sent on the unsecured connection).  If they’re being used clinically, monitoring technologies such as fitness bands use hop from the band across wireless spectrum to a smartphone, which also uses the public Internet to communicate data to clinicians. Plus, using the public internet is just the pathway that leads to a myriad of ways that hackers could get access to this health data.

My hunch is that this exposure of data to potential thieves hasn’t generated a lot of discussion because the technology isn’t mature. And what’s more, few doctors actually work with wearables data or offer telemedicine services as a routine part of their practice.

But it won’t be long before these emerging channels for tracking and caring for patients become a standard part of medical practice.  For example, the use of wearable fitness bands is exploding, and middleware like Apple’s HealthKit is increasingly making it possible to collect and mine the data that they produce. (And the fact that Apple is working with Epic on HealthKit has lured a hefty percentage of the nation’s leading hospitals to give it a try.)

Telemedicine is growing at a monster pace as well.  One study from last year by Deloitte concluded that the market for virtual consults in 2014 would hit 70 million, and that the market for overall telemedical visits could climb to 300 million over time.

Given that the data generated by these technologies is medical, private and presumably protected by HIPAA, where’s the hue and cry over protecting this form of patient data?

After all, though a patient’s HIV or mental health status won’t be revealed by a health band’s activity status, telemedicine consults certainly can betray those concerns. And while a telemedicine consult won’t provide data on a patient’s current cardiovascular health, wearables can, and that data that might be of interest to payers or even life insurers.

I admit that when the data being broadcast isn’t clear text summaries of a patient’s condition, possibly with their personal identity, credit card and health plan information, it doesn’t seem as likely that patients’ well-being can be compromised by medical data theft.

But all you have to do is look at human nature to see the flaw in this logic. I’d argue that if medical information can be intercepted and stolen, someone can find a way to make money at it. It’d be a good idea to prepare for this eventuality before a patient’s privacy is betrayed.

Hospital EHR Adoption Chart

Posted on May 15, 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 always love a good chart and this one illustrates what those of us in the industry have know for a while. EHR incentive money absolutely increased EHR adoption in hospitals. I think it also did in ambulatory environments as well, but not quite to the extent of hospitals.

Can we just put the discussion of whether HITECH helped EHR adoption to rest? It increased EHR adoption.

To me that’s not the question that really matters. What really matters is whether the EHR incentive money has incented adoption of the right EHR software. It’s great that we’ve adopted EHR software, but have we just locked ourselves in to the wrong software for the next 5+ years? Or have we implemented a great EHR foundation that will prove to be extremely beneficial to healthcare for decades to come?

I look forward to a deep discussion in the comments.

Video Demonstration of End-to-End ICD-10 Testing

Posted on May 14, 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’ve heard a lot of people suggest that an organization needed to do end-to-end ICD-10 testing in order to prepare for the switchover to ICD-10 on October 1, 2015 (we think). I came across this video demonstration of Qualitest doing an end-to-end test of ICD-10:

What do you think of the demo? Is this a valuable thing to do? Should this be done with every EHR and PM vendor and with every vendor that connects to that software?

An Important Look at HIPAA Policies For BYOD

Posted on May 11, 2015 I Written By

Katherine Rourke 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.

Today I stumbled across an article which I thought readers of this blog would find noteworthy. In the article, Art Gross, president and CEO at HIPAA Secure Now!, made an important point about BYOD policies. He notes that while much of today’s corporate computing is done on mobile devices such as smartphones, laptops and tablets — most of which access their enterprise’s e-mail, network and data — HIPAA offers no advice as to how to bring those devices into compliance.

Given that most of the spectacular HIPAA breaches in recent years have arisen from the theft of laptops, and are likely proceed to theft of tablet and smartphone data, it seems strange that HHS has done nothing to update the rule to address increasing use of mobiles since it was drafted in 2003.  As Gross rightly asks, “If the HIPAA Security Rule doesn’t mention mobile devices, laptops, smartphones, email or texting how do organizations know what is required to protect these devices?”

Well, Gross’ peers have given the issue some thought, and here’s some suggestions from law firm DLA Piper on how to dissect the issues involved. BYOD challenges under HIPAA, notes author Peter McLaughlin, include:

*  Control:  To maintain protection of PHI, providers need to control many layers of computing technology, including network configuration, operating systems, device security and transmissions outside the firewall. McLaughlin notes that Android OS-based devices pose a particular challenge, as the system is often modified to meet hardware needs. And in both iOS and Android environments, IT administrators must also manage users’ tendency to connected to their preferred cloud and download their own apps. Otherwise, a large volume of protected health data can end up outside the firewall.

Compliance:  Healthcare organizations and their business associates must take care to meet HIPAA mandates regardless of the technology they  use.  But securing even basic information, much less regulated data, can be far more difficult than when the company creates restrictive rules for its own devices.

Privacy:  When enterprises let employees use their own device to do company business, it’s highly likely that the employee will feel entitled to use the device as they see fit. However, in reality, McLaughlin suggests, employees don’t really have full, private control of their devices, in part because the company policy usually requires a remote wipe of all data when the device gets lost. Also, employees might find that their device’s data becomes discoverable if the data involved is relevant to litigation.

So, readers, tell us how you’re walking the tightrope between giving employees who BYOD some autonomy, and protecting private, HIPAA-protected information.  Are you comfortable with the policies you have in place?

Full Disclosure: HIPAA Secure Now! is an advertiser on this website.

Videos of EHR Usability Suggestions

Posted on May 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.

One of my readers sent me a link to a new site they’re developing called SaveTimeMD. This website was created as a response by an internist and EHR developer that was tired of seeing so many EHR usability problems. He decided that he’d take usability problems from users and make videos explaining how he’d resolve the EHR usability issue.

I think the concept is quite interesting. Many might ask why he doesn’t just build the perfect EHR if he’s so good at solving the usability problems. That’s the way my entrepreneurial mind would work. However, some people don’t approach problems with that entrepreneurial mindset. I’m not sure this doctor’s motivation, but I think the concept is quite interesting.

Here’s one of the videos he’s created that talks about intuitively navigating an EHR:

What do you think of the video? More importantly, what do you think of the idea of someone offering answers to your EHR usability challenges which you could take back to your EHR vendor?

Healthcare Big Data Use, Real Patient Engagement, and Practice Marketing

Posted on May 5, 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 use to do these a lot more and I think people enjoyed them. So, maybe I’ll start doing them again. It’s basically a short Twitter round up of some interesting tweets and often some pithy commentary about the tweets. Let me know what you think.


This seems about in line with my own personal experience talking to people. Although, some might argue that 100% are clueless. We’re all still trying to figure out all the data.


Great article by Michelle. I agree with her that I hate patient engagement. I love engaging patients, but I think that meaningful use requirements have forever corrupted the term patient engagement. We better move on to a new term, because I assure you that what’s happening with meaningful use is not engaging patients.


This is a little self serving, but Wednesday (5/6/15) I’ll be doing a webinar on the topic of practice marketing. I’m going to cover quite a bit of ground from a high quality practice website, to search engine optimization (SEO), reputation management, and meaningful patient engagement (sorry I had to use the term after my last comment). I hope many of you will attend and then let me know what you thought of it.