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VA May Drop VistA For Commercial EHR

Posted on July 12, 2016 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.

It’s beginning to look like the famed VistA EHR may be shelved by the Department of Veterans Affairs, probably to be replaced by a commercial EHR rollout. If so, it could spell the end of the VA’s involvement in the highly-rated open source platform, which has been in use for 40 years. It will be interesting to see how the commercial EHR companies that support Vista would be impacted by this decision.

The first rumblings were heard in March, when VA CIO LaVerne Council  suggested that the VA wasn’t committed to VistA. Now Council, who supervises the agency’s $4 billion IT budget, sounds a bit more resolved. “I have a lot of respect for VistA but it’s a 40-year-old product,” Council told Politico. “Looking at what technology can do today that it couldn’t do then — it can do a lot.”

Her comments were echoed by VA undersecretary for health David Shulkin, who last month told a Senate hearing that the agency is likely to replace VistA with commercial software.

Apparently, the agency will leave VistA in place through 2018. At that point, the agency expects to begin creating a cloud-based platform which may include VistA elements at its core, Politico reports. Council told the hearing that VA IT leaders expect to work with the ONC, as well as the Department of Defense, in building its new digital health platform.

Particularly given its history, which includes some serious fumbles, it’s hardly surprising that some Senate members were critical of the VA’s plans. For example, Sen. Patty Murray said that she was still disappointed with the agency’s 2013 decision back to call of plans for an EHR that integrated fully with the DoD. And Sen. Richard Blumenthal expressed frustration as well. “The decades of unsuccessful attempts to establish an electronic health record system that is compatible across the VA in DoD has caused hundreds of millions of taxpayer dollars to be wasted,” he told the committee.

Now, the question is what commercial system the VA will select. While all the enterprise EHR vendors would seem to have a shot, it seems to me that Cerner is a likely bet. One major reason to anticipate such a move is that Cerner and its partners recently won the $4.3 billion contract to roll out a new health IT platform for the DoD.

Not only that, as I noted in a post earlier this year, the buzz around the deal suggested that Cerner won the DoD contract because it was seen as more open than Epic. I am taking no position on whether there’s any truth to this belief, nor how widespread such gossip may be. But if policymakers or politicians do see Cerner as more interoperability-friendly, that will certainly boost the odds that the VA will choose Cerner as partner.

Of course, any EHR selection process can take crazy turns, and when you grow in politics the process can even crazier. So obviously, no one knows what the VA will do. In fact, given their battles with the DoD maybe they’ll go with Epic just to be different. But if I were a Cerner marketer I’d like my odds.

Harnessing Open Source Technology to Drive Outcomes in Healthcare

Posted on July 22, 2014 I Written By

John Lynn is the Founder of the 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 and 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 long been a fan of open source technologies. My blogs are run and created almost entirely on open source software. In fact, I first wrote about open source EMR on this blog back in January of 2006. We’ve come a long way since then with Vista being the top open source EHR in the hospital world and OpenEMR leading the pack in the ambulatory world.

We’re starting to see more and more application of open source technology in other areas of healthcare IT beyond EMR as well. There are some really amazing advantages to a thriving open source community. I think the key there is to have a thriving open source community behind the project. It’s not enough to just say that your software is open source. If you don’t have a great community behind the project, then the open source piece doesn’t do too much for you.

With that said, I was really intrigued by this whitepaper from Achieve Health that talks about why they are applying the popular open source Drupal framework to healthcare. While I’ve mostly used WordPress for the things I’ve done, I’ve had a chance to use Drupal for a few projects and I’m really intrigued by the idea of applying the Drupal framework to healthcare.

This section of the whitepaper describes their vision really well:

Drupal is not a replacement for legacy IT systems from EMRs, Billing, Practice Management etc., but rather an extension to these systems. Through sophisticated integrations Drupal can enhance the functionality of each system concurrently. While there is no one panacea for the trials ahead, Drupal is highly capable of rising to meet many of the existing and future challenges the industry has to offer.

In the whitepaper they mention open source success stories like Pfizer, Florida Hospitals, Amerigroup Health Services, and Alliance Imaging. I think we’ll continue to hear of more and more open source success stories in healthcare for the reasons outlined in the whitepaper Harnessing Open Source Technology to Drive Outcomes in Healthcare. It takes a bit of a different mentality to go the open source route, but those who do are usually very satisfied. I think healthcare IT could really benefit from this shift in mentality.

Epic Builds Lab Installations At Oregon University

Posted on November 27, 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.

Epic Systems has agreed to build two lab installations of its EpicCare EMR at the Oregon Health & Science University, one to be used for medical informatics education, and the other giving the school access its source code on the research side, reports Healthcare IT News.

Though the school’s OHSU Healthcare system already runs EpicCare for its hospitals and clinics, students and teachers have had to rely on a basic installation of the open-source VistA system for OSHU’s EMR laboratory course.

According to HIN, this is Epic’s first partnership with an academic informatics program, and potentially an important turning point for the company, which has conducted research and development almost exclusively on its Verona, Wis. campus. (It does release its source code to commercial customers.) And the agreement didn’t come easily; In fact, the school spent several years persuading Epic to participate before it agreed to commit to an academic partnership, Healthcare IT News said.

In a press statement, OSHU notes that the EpicCare research environment should allow students to delve into usability, data analytics, simulation, interoperability,  patient safety and more. The school also expects to prepare prototypes of solutions to to real-world healthcare problems.

Students in both OHSU’s on-campus and distance learning programs will pursue coursework based on the Epic EMR, with classes using the live Epic environment beginning March 2014. Work students will undertake include learning to configure screens, implementing clinical decision support and generating reports.

While this isn’t quite the same thing, this agreement brings to mind a blog item by John in which he describes how prospective programmer hires at Elation are required to shadow a physician as part of their hiring process. In both cases, the people who will be working with the software are actually getting an idea of how the product is used in the field before they’re out serving commercial clients. Sadly, that’s still rare.

I think this will ultimately be a win for both Epic and OSHU. Epic will get a fresh set of insights into its product, and students will be prepared for a real world in which Epic plays a major part.

New Open Source (Free) EHR Offering Developed by A Doctor

Posted on October 25, 2012 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In a recent comment, a physician told me they were developing their own open source EHR called New Open Source Health (or NOSH) ChartingSystem. As a huge fan of open source and also since I consider myself a Physician advocate, I had to learn more about what this doctor was doing. The following is an interview with Michael Chen, MD who is developing this new open source EHR.

Tell us a little about yourself and your open source EHR software.

Briefly, I’m a board-certified family physician and I spent 9 years as
a solo practitioner in a low-overhead, micropractice model where it is
just me without any additional ancillary staff. I was not able to
make this possible without the maximum use of technology to help me.
That is why having a robust EHR system was vital for my practice from
the beginning.

I began development of my own open source EHR software in 2009 in
response to the changes in the EHR landscape following the 2009 HITECH
Act and the pending changes to Medicare reimbursement that would
directly affect my practice.

My open source EHR software is called the New Open Source Health (or
NOSH) ChartingSystem. It is a web-based EHR where the user interfaces
the program through any web-browser that is connected to the network
where the NOSH ChartingSystem is installed. It is a based off a MySQL
database and programmed using PHP, HTML5, and Javascript. Many of the
components are based off of other open-source code (the PHP framework,
Javascript framework and plug-ins) It is meant to be run on an Apache
web server.

Why did you choose to develop your own open source EHR software instead of going with the other open source EHR out there?

I initially started work on contributing to the OpenEMR open-source
EHR that has been in development since the late 1990’s. However, over
time, I became disillusioned with the underlying project and the fact
that no matter how I wanted to improve the user interface (which was
my ultimate criticism of the project, even though the rest of the
project was exemplary), it required that I entirely “redo” the whole
system – you can’t fix a user interface as a piecemeal project. I
began to understand that the user interface (like the adage that form
follows function) really starts from the fundamental core of how the
system is developed. OpenEMR, like the other EHRs that I have used,
is designed with the hospital administrator and biller in mind and the
physician interface was a mere afterthought.

My other job before I embarked on my EHR project, besides being a solo
physician, was a medical director of a child abuse assessment center.
Part of my job is to review chart notes from other physicians in the
community and I can tell you that the ones that used EHRs were very
difficult to read at a glance. Even though the information appeared
complete, it was difficult to sort out all the “useless” information
that was contained in the record and to get to the core of clinically
relevant information. That really speaks to where the focus of EHRs
are designed. It really was not for the physician in mind.

After my frustration, I decided to expend my energy more wisely in
starting a new project from scratch as it was already envisioned in my
own practice and in my experience as a physician how a electronic
health record should be.

How far along are you in the development of your EHR software?

It is fully developed for real-world use right now. The Ubuntu
installer and source code has been available to be downloaded and
installed since October 15, 2012. Of course, with all projects, there
are new features, updates, and specific modifications that are a part
of the project life cycle.

Do you think that an open source EHR software can keep up with the well funded EHR vendors out there? Will your EHR software be able to keep up with the changing EHR landscape?

I think there is one specific challenge that will determine if an open
source project can keep up with the well funded EHRs. That challenge,
of course, is the financial means to maintain a project. There is a
second challenge that I’ll go over in more detail regarding your
question about certification.

Regarding the financial component, this project for me started out as
a pro-bono thing for me, with the aim that I could practice medicine
the way I want. I didn’t initially envision that I would release it
for others, but after I spoke to a few other physician colleagues and
saw my project, they were in awe with the simplicity and
user-friendliness of the system and wished they could use an EHR like
mine…of course, they were working in larger organizations that
already have an EHR implemented already. However, as I re-looked at
the landscape of physicians who were satisfied with their EHR system
since the meaningful use incentives began (after I came out of my
developer’s “hole” for a couple of years), I realized that there was a
“great divide” among physicians and the health IT community. If you
look at the Sermo forums and even talking to physicians one-on-one,
many are not happy with the EHR systems they are using. Most feel
that the EHR’s they used affected their workflow negatively and they
have to recoup their cost and efficiency in other ways, all in trying
to not affect patient care, which is very stressful. Most doctors
are angry that this is somehow being “forced” on them and they have no
choice but to comply. This leaves many of my colleagues
disillusioned, not just in the EHR realm, but for the whole profession
as well. Many keep asking (most without any answers, unfortunately),
“why can’t Steve Jobs build an EHR for them”? The key part of that
question, to me, is “for them”. That has been the missing piece that
no amount of incentives can rectify. The process of incentiviation
for lackluster products to doctors is going to lead to a dissolution
of the profession (especially those in primary care) and throwing out
the talent that is out there who really want to make a difference in
healthcare…unfortunately, it is already happening.

One thing that a vibrant, community-supported open source project can
do (that is a significant advantage compared to other EHR products) is
that the open source EHR can be continuously improved upon and adapted
to the needs of physicians, not just now, but in the future. There
are many examples of open source projects that have really done well
over the life-span of the project (Linux and its distributions, but
also Firefox, Android, Drupal and Puppet). I hope and envision NOSH
ChartingSystem to head in the same trajectory with the community
support coming from medical providers and developers alike.

The best open source software projects involve a community of developers and users. How far along are you in building the Nosh EHR community?

Since I just released my project in October, 2012; building my
community is at its infancy stage right now. I hope that having
medical professionals actually try out my project, know that it is
“real” and that they too can be a part of a movement and a project
that will work for them, will continue to build that community.

I’m also planning on working with individuals who are in the forefront
of health care reform to see where this project can go and how it can
work towards those goals. I feel that the EHR, if implemented with
the medical provider in mind, can transform health care in subtle, but
also profound ways, with physicians in the driver’s seat instead of in
the back seat.

Does the trend of hospitals acquiring physician practices concern you since there will be fewer doctors who can use your products? Or do you plan to scale your open source EHR for acute care?

Yes, the trend that there are few and fewer smaller or physician owned
practices does limit my project potential, but on the flip-side, I see
this as a possible way that my EHR can impact health care reform in a
bigger way, if the community support grows significantly and
physicians have voice again.

My focus right now is to make sure EHRs are accessible to the doctors
least able to afford them, even with incentives programs out there.
Those would be the smaller and solo-practice doctors, likely in the
primary care sector and also those in the rural setting, or any
physician or clinic that does not have the means to afford one. That
was why I ended up making my own EHR…because I couldn’t afford the
one I used to have since certification was “needed” for meaningful use
incentives, and even thought I met all the meaningful use criteria
with my older system and my own “modifications”, I would not have been
able to get reimbursement because my system was not “certified”.

I am betting that if a physician sees a truly user-friendly EHR, it
doesn’t need to take incentives for them to jump on board. Because I
feel that most physicians are already ready to jump on board…there
just isn’t something for them to jump on board to that they feel good

One key point, and one that physicians who have implemented an EHR or
thinking about implementing an EHR have noticed, is that the EHR is
not just a product…it’s creating a level of service to make sure a
transition to the EHR is as minimally disruptive as possible to their
practice. It’s not realistic to assume that any switch will not
impact, but I think most physicians have been given a false hope that
with one EHR product is claimed to be overly superior to another that
it would not cause those impacts. I think that too many physicians,
hospital systems, and statewide health systems have been “burned” by
the process and so I’m focusing on offering this EHR project (which
does not cost anything to use and that one can modify it to their
heart’s content without penalty) alongside with consultation services
(which would be my source of revenue) to best incorporate my system to
their practice. EHR implementation is definitely not a
one-size-fits-all approach, so I think the value of these consultation
and personalization services in addition to the physician being a part
of a community, will make happier physician clients overall.

How do you balance the need for an EHR to complete sophisticated tasks, but still keep the interface simple?

It really goes back to the adage of form follows function. You don’t
have to sacrifice function for form. In fact, most of the functions
that NOSH ChartingSystem has is very much what most other EHRs have,
its just presented in a very different way and in a way that (I think)
makes sense to most physicians. Even though I designed this system
for physicians, I know that there are certain non-clinical information
that is important. For instance, if you’re a clinic administrator or
a solo physician like me, there is information in NOSH ChartingSystem
that shows monthly statistics for how many patients have been seen and
how much each insurance company is reimbursing for each visit type or
what has not been paid yet so you can keep track of those accounts
receivables. You can also quickly query a list of all active patients
who are male and have diabetes so you can keep track of your practice

It’s not just even what type of information is being presented or how
it is entered, the whole system was meant to evoke the feeling of
calmness. As a physician, the last thing I need is a system that
looks like you’re operating a military-grade dashboard with
multi-colored panels with tons of information, and I have decide at
that moment what is important or not without fearing that I’m going to
do something catastrophic with the system. I don’t want to be playing
the “Where’s Waldo” game when I’m working one-on-one with a patient.
As a physician, I’m there to listen, examine, and diagnose…not
figure out minute-by-minute how to enter this finding or locate a
medication allergy or issue for this patient. It just has to be,
almost literally, at my fingertips.

What is the best feature you’ve created in your EHR that others don’t have?

I think I mentioned it before, but it bears mentioning again, a user
interface that is familiar to physicians. One that does not need a
book, tutorial, or class to learn how to use. That is the best
feature of my EHR. For busy doctors, the last thing they need is to
learn something new that takes a lot of time to learn. My philosophy
is that the EHR should be an everyday tool, like a pen, so that
physicians can do the work of physicians. If a patient that you treat
does not know that you are using an EHR while you’re in the middle of
an encounter, that is an example and a testament of a great EHR. If I
can do my part to let physicians be physicians again, I can say that I
successfully accomplished my goals with my EHR project.

What features are still on your EHR roadmap that you haven’t been able to create yet?

My next priority is to port my project to a mobile application; it’s
not a daunting task given the structure and framework that this system
already has, but it just takes a little more time. I think there are
always different customizations one physician would like over another,
which one could consider them as features, but I like to present them
as options rather than adding unnecessary overhead to the core project
over time.

Do you plan on getting your EHR certified? Can a doctor show meaningful use and get the EHR incentive money with your open source EHR?

That is very good question. At this point, I’m hesitant for getting
my EHR certified for the following reasons. I feel that the current
EHR certification process, at its core, is not compatible to the
open-source philosophy. Certification, in it of itself, is a good
idea for any software or service, but the devil is in the details. If
an open-source developer cannot afford certification (like myself),
there’s something to be said about exclusion and giving the upper hand
to already established entities that have a foothold in the EHR
marketplace. For instance, the cost of certfication only applies to
the specific version that is being tested. Updates need to be re
certified, at the same cost of initial certification. Over time, that
can be very costly to a small developer. Certification ought to
promote and encourage innovation (which the current process does not).
I see this issue as a potentially huge challenge for my project as
meaningful use incentives are tied to certified EHR products. I think
there are many examples where a practice or physician is able to meet
meaningful use in a defined and measurable way, but because they
didn’t use a “certified” product, they will get penalized (like me
when I was in practice). What is the point? All the process did was
to disincentivize me into using EHRs as it would cost me nothing if I
used a paper and pen and I stopped seeing Medicare/Medicaid patients.
Is that really want the government wants? Is that good public health

I believe most physicians are unaware that certification means that
the costs get passed down the physicians and practices. I knew that
it happened to me in 2009 before I started my own project. But most
physicians don’t own their own practice so the issue isn’t even in
stream of consciousness. But as they become more disillusioned with
the MU incentives program as time goes on, it’ll be clear to them that
the real winners here are the established EHR system providers and the
certification bodies and not to the doctors and the patients. This is
where I am actually outraged, from a physician standpoint.

So, I’m not sure I’m going to go the certification route (both
financially and philosophically).

Like I’ve said before, I think a good EHR product should stand on its
own merits without incentives. Physicians are savvy enough to know
what works and most have already caught on to smartphone technology.
Why? Because it’s intuitive to use. Like other human beings,
physicians don’t like to be patronized and told to adapt to a system
that doesn’t make sense to them. Physicians are really looking for
something that works for them. There are just not many options out
there, but I’m offering mine to see where it goes.

What do you see as the future of EHR in healthcare?

Recently, I came across these “10 Commandments of Healthcare
Information Technology” by Dr. Octo Barnett, who penned these way back
in 1970. You can see them on my project website. I found it
fascinating that these concepts are very much what I envision
healthcare information technology to be even now. I found it
disturbing, though, that a lot of what has been happening in
healthcare IT, unfortunately, goes against these concepts. I feel
that for EHRs to succeed in healthcare, we really have to go back to
these concepts. Only then, will EHRs be accepted and used by
physicians. After all, the physicians are the ones that enter the
information in these systems. The value of EHRs and the information
provided is only as good as how the information is entered. We’ve
totally missed the boat on this, from a health IT standpoint in my
opinion…leaving the physicians behind so to speak, but I don’t think
it is too late to change course and start over again. Generations of
younger physicians are craving for a good functioning EHR (I was
astounded that my first job over 20 years ago as a cash attendant at a
cafe involved these touch screen systems that were really easy to use
and then to find that my stint as a medical student, I had to resort
to using paper charts and pens…it’s really telling how far behind we
are on EHR implementation…and that was 15 years ago!). I think it’s
about time that there is something real for physicians to use.

VA Hospitals Had Big EMR, BCMA Implementation Problems, Study Says

Posted on April 12, 2012 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 done at a group of seven VA hospitals has concluded the hospitals rolled out their EMRs with far too little planning, leading to problems that tied staff members and clinicians in knots.

The study, which was published in the American Journal of Managed Care, drew on interviews with doctors, IT staffers, nurses, pharmacists and managers.  The interviews were done several years after the VA had implemented its computerized patient record system (CPRS) and its bar code medication administration system (BCMA).

The respondents told interviewees that for most of them, the new technology created big difficulties. Many of the interviewees didn’t start out familiar with computer use, making the inevitable workflow disruption even worse than in other hospitals.

BCMA was a particualrly sore spot for the VA clinicians and staff, as it was phased in more rapidly and with little training for users.  Staff members at the hospitals essentially had to implement and use the system on their own, according to a story appearing in Information Week.

As if this wasn’t challenging enough, the hospitals ran into major issues in selecting and rolling out hardware to support these new technologies.

For one thing, some of the hospitals had little idea how to  build a wireless network capable of supporting the myriad of computer cards in use at their facility. In some cases, they faced major connectivity problems after failing to test the wireless systems prior to rollout of CPRS and BCMA.  Other hospitals in the seven had great difficulty figuring out how many computer terminal to order.

As I read the situation, the hospitals’ BCMA rollout led to the biggest problems and greatest possibility for harm.  All seven of the hospitals reported having major BCMA issues, including miscoded medications, empty unit-dose packages being delivered items not scanning.

Perhaps even worse, nurses sometimes had to cut the ID bands off of patient wrists just to scan them, or scan from extra wristbands in patient charts. “At some VA hospitals, staff were implicitly or explicitly permitted to use various workarounds with BCMA, such as…doing all scanning after medication administration,” the magazine reports, quoting the research report.

Not only that, many workarounds remained in place years after the BCMA rollout — a testimony, if there ever was one, to getting things right the first time.

Apparently, according to IW, BCMA is at stage 5 in the maturity scale HIMSS Analytics has established for measuring the maturity of a hospital EMR rollout. HIMSS says that 8.4 percent of hospitals are at this stage.

The thing is, a maturity scale shows its own weakness when you can laud a hospital for getting there even if their implementation has disrupted workflow greatly and even put patients at risk.  And I’m not aware of any ratings scale from HIMSS (or a similar entity) that grades quality of execution.

Do you know of other ratings systems for hospital EMR rollouts that do more to adjust for poor planning or implementation problems?  If you do, I’d love to hear about them.  This story is pretty scary.

OpenEMR Passes HITECH EHR Certification

Posted on August 20, 2011 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

LinuxMedNews just posted the announcement that OpenEMR is now a certified EHR. Here’s the quote from their announcement:

It’s official! OpenEMR has passed all ONC certification tests as a fully qualified emr that can be used to attest for incentive moneys. The official posting: appeared on the website 2011/08/19. Congratulations to all involved! OpenEMR 4.1 should be ready for download in a few weeks.

This is a really big announcement for the open source ambulatory EHR community. A number of other open source EHR are certified, but they’re mostly for the hospital EHR space. So, it’s a great thing for OpenEMR to provide an open source EHR to the ambulatory space.

Plus, I have to admit that it’s pretty great that an open source community can pull together the funds to actually be certified. The programming and development time is one thing, but getting the $20-30k to be certified is a big deal that I’m sure took a lot of effort. I actually wish I knew more about the process they used to achieve the EHR certification.

Now, OpenEMR users better start digging into resources like Meaningful Use Mondays. EHR Certification is the first step, but showing meaningful use of that certified EHR is the next one.

Big thanks to an avid follower of OpenEMR – Jojo the HITMAN who informed me of the news.

The Risk of Free EHR Starting to Cost

Posted on May 10, 2011 I Written By

John Lynn is the Founder of the 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 and 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 been writing about Free EHR since I first started this blog in 2005. Initially I was mostly writing about the “free” open source EHR model like I did in this Open Source in Healthcare post in 2006. I still remember when I found out about Free EHR vendor Practice Fusion and wrote this post in 2008 about Free EHR Software and Some of the Hidden Costs. I think it’s fair to say that I was a bit more skeptical of the Free EHR model then than I am now. Practice Fusion and Mitochon Systems are both Free EHR vendors that advertise on this site (Full Disclosure). So, I’ve had a chance to talk at length with both companies. I must admit that the more I talk with them, the more intrigued I am with the Free EHR model.

However, there are still challenges that are faced by the Free EHR model. This struck home quite strongly when I saw the relatively recent news about Free accounting software vendor, Outright, changing from a free model to a paid model. Funny thing is that I was really close to using Outright for my accounting, but then opted to go instead for the Free open source software Gnucash. However, this change in direction made me pause and wonder what would happen if a Free EHR vendor chose to switch from the free model to a paid model.

No doubt that any change in Free EHR business model would likely be similar to Outright where they provide a fair amount of time for users to remain on the free model. They’d also have to provide some way to get your data out of the EHR or else their paid model would not likely survive. The bad will that would be created from holding the practice’s data for “ransom” would be terrible for a company. Although, switching from a free EHR model to a paid one would be even more detrimental I think.

Of course, the EHR company could easily argue that at some point they’re faced with only a couple options: close the company or switch from the free to a paid EHR model. Faced with those options, would you rather have your EHR company go under or be able to pay them for the services you’re receiving? Although, as I’ve discussed in other Free EHR posts, just closing the company down completely wouldn’t likely be an option. Instead, the company would instead be acquired for some discounted rate by another EHR vendor. So, the real options would be to switch EHR companies since the acquiring company would likely want you to switch to their EHR or start paying for the EHR services. I think in most cases, EHR users would prefer to start paying for the EHR services. Even if deep down they’d feel like it was wrong and unfair.

As I argued in the post above, the real problem with all of this is that transferring EMR and EHR data isn’t as simple as even accounting data (like the Outright example above). Moving from one EHR to another is a pretty intense process and leaves much to be desired. Although, it’s not like Free EHR software are the only EHR companies that could go under, be bought out, be merged, etc. Everyone says that EHR company consolidation has to happen and so the transfer of data from one EMR and EHR company to another could happen for all sorts of EMR companies large (see Misys) and small.

Also, I think one other difference between the Free EHR companies and the Outright example above is that Free EHR companies aren’t just an ad only business model like Outright. For example, there’s a lot more value in aggregate healthcare data than there is in aggregate accounting data. Even anonymous healthcare data is incredibly valuable if done right. Not to mention a number of other possible business models that could be placed on top of a Free EHR offering.

As always, I’m not trying to scare people away from the Free EHR model or drive people to that model either. My point is to just bring to light all of the possibilities of what can happen if someone should choose to go with the Free EHR model. I’m sure there are even more angles to this which will be brought up in the comments. I look forward to the discussion.

I also sent an email to my contacts at Practice Fusion and Mitochon Systems saying I was going to write an article about this and asked them for a response. Here are their responses and I’m quite sure they’ll join us in the comments as well.

Practice Fusion’s response:
It’s hard to see a young company like Outright struggle with their pricing, but the truth is that being a free, web-based business is not for everyone. Practice Fusion does not succeed by being free alone. Our dedication to delivering the easiest to use product, our phenomenal support team, the support of 80,000 healthcare providers across the country, our sustainable platform – these are the elements that have made us the largest EHR community in the country. We are 100% committed to bringing free EHR technology to every doctor in the country and that will never, ever change.

Mitochon System’s response
There are two key differences between Mitochon’s free EHR model and the small software service company you cited, Outright.

First, Outright offers its services directly to individual consumers. There is no third-party payer involved and the service does not provide value-added for anyone but the individual purchaser. In contrast, healthcare is often compared to a three-legged stool: patients, providers (physicians, hospitals) and payers (health plans, employers). When a physician provides care to a patient, a third-party usually picks up all or part of the bill. Free EHRs can potentially add value for all three parties involved. Our experience has been that both payers and providers are willing to subsidize or support free EHRs through paid clinical messaging (ads, health message reminders).

Second, it appears that Outright tried the ad-supported model and it failed for them. Although the article does not state exactly why the advertisers were dissatisfied, it might be that the user demographic was poor. Perhaps the Outright users just didn’t buy enough of the advertised products.

In contrast, physicians are major purchasers of goods and services for their patients and their organizations. According to Dr. John Eisenberg, a leading medical economist, physicians’ professional fees alone represent about 20% of all health care expenditures and they are responsible for decisions that govern how 90% of each health care dollar is allocated. With annual health care expenditures in the U.S. now topping $2.5 trillion, clearly physicians are a highly desirable audience for paid messaging delivered by many different organizations.

In conclusion, we know for a fact that the free EHR model works now and we believe it will grow and expand dramatically in the future.

Terrible Forbes Article – “Open Source Debut in Healthcare”

Posted on December 13, 2010 I Written By

John Lynn is the Founder of the 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 and 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 still have a hard time calling myself a writer or even press (although it’s convenient for getting into conferences). Plus, I think I reach, influence and interact with as many or more people than the traditional healthcare journalist. However, there’s something liberating about being called a blogger instead of a journalist because the standard and approach is different.

At least I thought that was the case until I read this article on which declares Allscripts new API as “Open Source’s Debut in Healthcare.” Ok, to be fair, it was written written on a Forbes healthcare blog and not their magazine, but as a blogger I’m embarrassed that a Forbes blogger would write such a terrible article.

Let me set the record straight. Allscripts launched an interesting API (which they call an “Application Sote & Exchange”). It’s a sort of app store for healthcare IT. This is interesting news and worthy of a story. What it’s not is open source entering healthcare.

Maybe there is some sliver of open source software that’s part of the Allscripts API/App store (or maybe not), but that’s backed by a heavy set of proprietary Allscripts software. It’s not like Allscripts has open sourced their MyWay or Allscripts Professional EHR. Then, you could really talk about Allscripts entering the open source EMR world. This is NOT!

Besides the fact of saying that is open source when it’s not, is the blogger’s headline that this is the first open source in health care. That’s just absolutely silly. Here’s just a few of the Open Source EMR on the EMR and HIPAA wiki page that have been around for quite a while and led I believe by OpenEMR and the various flavors of Open Source Vista EMR.

Honestly, Zina Moukheiber should be embarrassed by what she wrote. Even a blogger should be held to a higher standard than what she wrote. Of course, the sad part is that her mistakes likely drove a ton of traffic to the post. It’s her top post with 51 people tweeting the post and 15 people sharing it on Facebook. Too bad she lost all credibility in the process so the short term spike won’t turn into long term readers.

EMR Platform

Posted on March 26, 2010 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

After I wrote my post about 50 EMR markets instead of 1 EMR market, I started to wonder what an EMR might look like that was just an EMR platform.

The basic idea would be that some vendor would create a platform where other vendors could build on top of their platform. They’d offer the core elements and foundation needed for an EMR and then companies could build applications on top of those core elements that focus on the 50 different EMR markets (or whatever the number actually is).

The easy part is seeing someone who builds some specialty specific applications like growth charts for pediatrics or a drawing application for dermatology. The hard part is to decide which elements of the EMR are “core elements” that can act as a foundation for every type of specialty, practice, location, etc.

I guess the question of core elements really comes down to whether we can define any part of the EMR to be something that EVERY doctor could use. I think of the iPhone as the example of a platform that people have taken and expanded with applications. The core elements are the phone, the GPS, the accelerometer, etc. Then, various companies have created applications using that platform that can cover a wide range of markets. Making the comparison of EMR features with iPhone features is not an easy one.

I honestly don’t think any EMR vendor has done something like this yet. Sure, some of them have some API’s where some customizations can be done. However, I’m not sure I’ve seen the full embrace of creating an EMR platform. The closest I’ve probably seen is some to the open source EMR software that’s out there. It seems like some of them have done a good job modularizing the software so that many different people can iterate on the software.

What do you think? Is an EMR platform possible and what would it look like?

VistA EHR Polarizes People

Posted on January 16, 2010 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was recently quoted in an article in Federal Computer Week about the VistA EHR. I think the first paragraph of the article summarizes the article quite well:

Is VistA a diva in disguise? The Veterans Affairs Department’s renowned electronic health record (EHR) software is touted as one of the premier systems in the world. But it also has a reputation as a star performer who’s difficult to manage.

My part of the article is them quoting me saying, “It is amazing how polarizing VistA can be”

A small contribution for sure, but it’s so true. If I want traffic to this site, all I have to do is rip MUMPS and they’ll come out in mass to tell me why it’s great and why it sucks. People have strong opinions both ways. The crazy thing is that both groups are probably right.

P.S. I think we’ll make next week Meaningful Use week. Hopefully time will permit. Lots to still say about it. In the meantime, you should check out my Meaningful Use posts on EMR and EHR.