As most regular readers know, on the weekend I’ve been doing a weekly Twitter round up of interesting tweets about EMR and EHR. Well, this week I came across all sorts of odd tweets. Also, it seems that someone with EMR in their Twitter name has been talking about the Giants making it to the Super Bowl. On that note, I’m not sure I really care whether the Giants or the Patriots win the Super Bowl. Although, I think it will be a fun game to watch. Push came to shove, I’ll take the Giants defense for the win. Enough football, back to the health IT and EMR talk.

This tweet is going to blow your socks off a little bit. We all know this type of technology is coming, but it’s crazy to think that it’s actually starting to be done. I might have to do a full post on this type of technology later:

UK: Edible Microchip Tracking Device goo.gl/fb/xdo5I #news #cellular #emr #politics

— Why Fry (@WhyFryWiFi) January 23, 2012

For those who didn’t go read the article, it talks about an edible microchip that reports patient compliance with medication. Seems a bit extreme no? It’s still quite a ways off, but is interesting to consider.

This next tweet is fascinating and the landing page it goes to is even more fascinating. Mostly because the tweet and landing page feel more like spam than they feel like a legitimate company. So, tread lightly if you click:

Post Edited: AAYUWIZ – is a state-of-the-art complete healthcare solution bit.ly/yUrcGm #aayuwiz #ehr #emr

— Sphata Systems (@sphatasystems) January 23, 2012

As best I can tell this is a legitimate company. Although, I can’t understand why someone would think naming EMR software AAYUWIZ. Really? You’ve got to be able to do better than that. This looks like one of the MANY (and I mean many) EHR software that have been developed by Indian companies.

I don’t know the entire process these companies go through, but so many of these Indian (and probably other countries as well, but all the ones I’ve seen have been from India) development houses see an opportunity to create EHR software. After developing the EHR software, they reach out to people like myself asking for help on bringing their EHR software to America. Seems like a really risky business model to me. At least a couple of them do have Indian healthcare strategies as well, but many seem to be solely focused on the US market with no way of actually entering the market.

@tnhimss Nursing informatics project # 2: EMR+ Analytics, to increase notifications (and faster) of organ donors. “auto triggers.”

— Lawrence Lin (@larrylin) January 19, 2012

I like this idea. In fact, I’m a little surprised that I haven’t seen anyone do this before. What kills me is that there are probably 100-200 projects like it in healthcare that could benefit from better use of technology, but for one reason or another we haven’t gotten to it…yet(?). Seems like Lawrence Lin is working on it. Too bad he’s working in China, but from Nashville, TN. Now, I’ve got to meet Lawrence to hear his stories.

In a post done in 2009 that’s still getting comments, Diane G. offered some interesting commentary that I think is fair warning for those purchasing an EHR (names removed since it could apply to a lot of EHR vendors):

We use Software A for our EMR, but Company A provided the equipment and installation quote for Software A and I can tell you, you’ll want to look at EVERY line they bill to your company. We have been billed for equipment that we never received and interfacing that was never launched. I have spent hours explaining to them what services they have billed us but didn’t provide. I am extremely grateful that we did not purchase their EMR and/or Practice Management product!!

Definitely a good warning for all purchases, but applies to EMR software as well. A number of EHR software companies have really simplified the way they bill and so this is less of a problem with those EHR vendors. However, many EHR vendors still try to pilfer doctors for the extras which can often add up to more than the core product. It’s ugly and unfortunate since it leaves a bad taste in doctors mouths.

Along these same lines is making sure your EHR contract is sound. There’s a whole section on EHR contracts in my EHR Selection e-Book that is worth looking at if you’re going through the EHR process.

As I said in my previous EMR and Health IT in 2012 post, I’m going to create some of my own lists for 2012. I decided to tackle the first one on the list: My 2012 EMR and Health IT Wish List. This was kind of fun to think about. I’m also sure that I’ll come up with other ideas once this is posted, so don’t be surprised if I add things to this list in a future post.

I should also note that I’m not sure any of these things are going to happen in 2012. In fact, I bet that many of them aren’t, but this list isn’t about what is going to happen. This list is about what I wish would happen.

EHR Companies Would Embrace Interoperability – It’s an incredible shame that in 2012 we still don’t have interoperable health records. EHR companies need to get off the stump and make this a reality. The technology is already there and has been there for a while. EHR companies need to start making this dead simple because it’s the right thing to do. Sometimes doing the right thing is more important than the bottom line. Plus, doing the right thing ends up often being the best long term strategy for your bottom line as well.

Start doing what’s right and making your EHR interoperable!

Meaningful Use Would Go Away – I’m actually certain that this one won’t be happening in 2012, but I wish it would. I guess there’s a small chance that it could go away if Republicans take control of Washington and start slashing everything Obama related. However, I have a feeling that even then meaningful use will find its way back into Washington. There’s too much invested in it.

My reasoning for wanting meaningful use gone is clear. It provides a perverse incentive to providers and often incentivizes them to choose an EHR software that doesn’t work well for their practice. As I’ve mentioned in some recent posts, far too many clinics are so focused on meaningful use and EHR incentive money that they’re ignoring the real and tangible business cases for implementing an EHR in their clinic. I think this is a bad thing for healthcare and EHR software in general. The short term bump in EHR adoption won’t be worth the cost of EHR implementations focused on the wrong criteria.

I also really hate how meaningful use has hijacked the software development cycle of pretty much every EHR vendor out there. This is a real travesty since rather than developing for user/customer requirements EHR vendors are developing for a criteria. Talk about a perfect method for destroying innovation. This is a real travesty in my opinion.

Of course, I’m a realist and realize that meaningful use isn’t going away. We have to make the most with what we’re given and live with the realities that exist. However, in this New Year Wish list, I wish that meaningful use would be a past memory.

New Healthcare Model that Provides Care, Not Reimbursement – I’m sure many of you might be thinking that I’m calling for ACO’s in this wish list item. We’ll see how ACO’s evolve, but my gut tells me that the ACO model still won’t make the fundamental change that I wish would happen in healthcare. There’s far too much focus on reimbursement the way our healthcare is structured today. I’m not arguing that doctors and other healthcare professionals not get paid what they deserve. I’m just wishing that there was more focus on care for patients and less worry on maximizing the reimbursement.

How does this have to do with health IT and EHR? I’ve long argued that the biggest bane to EHR systems is the onerous reimbursement requirements. I can’t imagine how much healthcare could benefit from fabulous EHR systems if the energy spent on maximizing reimbursement were spent on improving patient care.

Diabetes Prevention App – I’ll admit that this is a little personal. I come from a long line of diabetes in the genes and I love sweets far too much. I’m pretty much destine to be a diabetic. I think that mHealth apps can have amazing power if done correctly. My wish is for someone to create a Diabetes app that will help me overcome the seeming destiny I have in this regard. The key will probably be illustrating in a profound way the impact of the choices I’m making.

Of course, you could insert hundreds of other chronic illnesses into this wish list too. I’d love to see mobile health work to solve those as well.

A True Patient Identifier – I realize that America is a large place, but we’re also a really creative country that can figure out creative solutions to problems. The lack of a true patient identifier is a challenge and a problem in healthcare. I’d love to see this problem finally resolved. I think every EHR company would rejoice at this as well.

Real EMR Differentiation – My heart absolutely goes out to doctors, practice managers and others who have the unenviable job of trying to sift through the 300+ EMR companies. I’d love for some EMR companies to really do something so innovative to differentiate themselves from the rest of the pack.

No doubt part of this problem is what I stated above about meaningful use. Hard to create innovation and differentiation in EHR when you have to develop for a government list of requirements.

EHR Data Liberation – I’ve wanted EHR data Liberation for a long time, but I think in 2012 this is one thing on the list that could become a reality. It’s a bit of a long shot, but I think there’s potential for this to happen.

My gut tells me that if we can find a way to liberate the data that’s stored in EHR software, then we’d see a dramatic increase in adoption of EHR. One of the major concerns doctors have with selecting an EHR is that once they select an EHR they know they’re locked in with that EHR for the long run. If a doctor knew that they could switch EHR software if they made a bad choice, then they’d be much more likely to pull the trigger on EHR adoption.

We need a wave of EHR vendors that aren’t afraid of liberating their EHR data, because they:
1. Know that their EHR software is so good users won’t leave
2. Know that if someone wants to leave their EHR software it’s better that they find one that’s good for them than the few extra dollars the EHR company will make off an unhappy user.

How’s that for a wish list? I think achieving these things would do an amazing amount of good in healthcare and EHR. Of course, I won’t be holding my breathe on any of them happening any time soon. That doesn’t mean I won’t keep holding out hope.

Today I opened up a web browser and eventually made it to Twitter to see what was going on. I was greeted by the not so friendly Twitter site redesign. If you’re on the Twitter page at all, you won’t miss it. To be honest, it felt like going to a foreign land. I use a number of tools for Twitter, but my favorite is just going to the Twitter website to consume and send my @techguy tweets. Although, maybe I should say it WAS my favorite place.

Yes, change is always hard, but isn’t that kind of the point? Was there any announcement about the change before it happened? Nope! Did they give users a chance to try the new interface before they made a wholesale swap to the new interface? Nope. Google’s actually done this really well recently with things like Gmail. They’ve made the new interface available, but you can always click back to the old interface if you don’t like. That way they can solicit feedback and improve the new interface while still not alienating those that love the old interface.

In my example on Twitter, I quickly was able to identify the thing that annoys me most. When I click on someone’s Twitter name it gives me a pop up box for that person. Before it use to have that appear on the side. It’s a small subtle change, but makes a huge difference since on the side I can continue consuming tweets, but in a pop up box I have to remove it before I continue on.

I could go on about the new Twitter, but the point is that software vendors have to be careful when they change the user interface. Maybe this new Twitter interface will even grow on me. I didn’t like the last time they changed the Twitter interface either, but once I found some of the secret features I came around for the most part. Maybe I’ll come around on this too, but it would have been nice if I knew it was coming.

What does this have to do with EMR?

The connection seems quite clear to me. EMR and EHR companies have to be really careful and considerate when they change their EHR interface. Give users options to be able to try it and to adapt to it over time. With a sort of limited opt in release of a new EMR interface to an active user base, you’ll likely get a lot of pointed feedback for the new EMR interface. Certainly you’ll get the useless “I hate the new look” emails without any value. However, you’ll also get the pointed emails that provide constructive ideas on things you probably didn’t realize were important in the old EMR interface.

Most SaaS EHR companies are constantly considering this since they’re rolling out changes to their software all the time. Client server based EHR software also takes it into account, but this can be shown and taught as each client is upgraded.

The main point is to be thoughtful of and upgrade to your EHR user interface. Get feedback and whenever possible let them opt in and out of the new interface so you don’t alienate your users.

While I may not be totally enamored by the new Twitter interface, I do always love new features in software. For example, as part of the new Twitter interface there’s a feature that lets you embed tweets. Here’s a few EMR related tweets to see how it works.

Need marketplace to reward good design & doc reimbursement for social@jacthong @AtlasMD How to close gap between EMR & consumer tech? #hcsm

— borborygmi (@nickgenes) December5, 2011

And then some big news from GE and Microsoft that just came out:

G.E.-Microsoft Venture to Create ‘Windows’ for Health Care. #ehr #emrnyti.ms/u8ttTu

— Andrew Herman Heller (@andrewhheller) December8, 2011

Hmmm…still looks like they have some work to complete on their embedded tweets (UPDATE: The preview looked different from when it’s posted. It’s not too bad in the actual post). Sounds like many doctors talking about EHR features that get rolled out.

One of my all time favorite posts I’ve done was called “Develop Your Own EMR….Are you Crazy?” Hard to believe that was back in May of 2006. I should go back and check out the content of that post, but the title still rings very true to me. Of course, every entrepreneur that I know is a little bit crazy, so it should come as no surprised that I’m hearing all the time about new EMR software getting ready to hit the market.

Today’s encounter has to be one of the most unique. I was going to church in another state (visiting family for the Holidays) and I ran into one of my high school friends at church. We caught up and I learned that he’s the owner of a software development company. Then, as he learned what I was doing he just mentioned off hand that they were developing an EMR.

After I picked myself up off the floor, the meeting at church started so I didn’t really get a chance to talk to him. Since he’s my friend on Facebook (you know, a real friend that I know in real life type of Facebook friend), I sent him a message and hopefully we can connect. I’m really intrigued that his software development house is doing an EMR for someone. Obviously, now I have a ton of questions for him about the project. He did say before the meeting started that “it’s a BIG project.”

Of course, the message here is that there are a lot of people out there that are crazy (no offense intended) enough to start building another EMR. The problem is that there are so many doctors that are dissatisfied with the EMR software that’s out there, I’m sure until that’s resolved we’ll see more and more EMR software entrants. Oh, if only these brave souls knew what they were getting themselves into. I guess maybe that’s the beauty and key to entrepreneurship and why I love it so much.

There’s a really interesting article on Nextgov that talks about a CSC report that looks at the role of health IT and EHR software in Accountable Care Organizations (ACOs). The most valuable part of the article is this list of items that an EHR must enable or allow to support an ACO:

• Clinical information and point-of-care automation, with integrated ambulatory and inpatient records and a central repository for clinical data.
• Enterprise master data management and integration, with a population management repository, a master person index and a master provider index.
• Tools to enable participation in a health information exchange.
• Patient engagement tools, including secure messaging, e-visits and tele-visits, social media, patient portals and mobile health applications.
• Care management and coordination tools, including referral and request tracking, provider-to-provider communication, medication reconciliation and case- and disease-management applications.
• Performance management tools, including integrated business and clinical intelligence and analytics.

To be honest, as I look through this list of EHR items, I can’t say that any of them really stick out to me as impossible for any EHR to achieve. In fact, I’d say that they’re quite achievable by almost all EHR software vendors.

The only partial fear I have reading through the list is that some of the points depend on an EHR vendor working with other EHR software vendors. In most of the cases, these are large hospital EHR vendors that have often worked in very closed environments.

The reason this is a cause for concern is that even the best EHR software in the world won’t be an effective ACO and won’t meet the above requirements if the large EHR software vendors don’t work with them to connect their system.

Maybe this isn’t something we should be too concerned about since the hospital client will be motivated to get their EHR vendor to work with the other even small EHR vendors in order to make the ACO happen and get access to the extra reimbursement. However, my gut tells me that this won’t be the case and there will be stories where EHR software is basically shut out of the ACO based on the large EHR vendors decision to not work with them.

The other day I was browsing the EMR Update forum (where I started my EMR education) and found this interesting comment about the e-MDs iphone app.

EMDs is charging $250 to “install” it even though the phone does the installation for you and then they are charging $35 a month per device for “support”. I guess they are trying to lose all of their long term customers to other EMRs that are free like Practice Fusion. I find these charges to be outrageous.

Note: I tried to verify this pricing on the e-MDs website, but it’s conveniently not listed on their mobile page. Although, they do have a “free trial.” Is that a $250 install to get the free trial? I also found their website tagline ironic: “Affordable EHR software”

I find this comment really interesting on a number of levels. First, it comes from someone who has indeed been a long time e-MDs user and long been a fan and vocal spokesperson for the e-MDs EHR software. The above seems like such a small amount of revenue to alienate your happy EHR users over.

Second, $250 to help the user install the EMR iPhone app? Really? That just feels wrong on every level.

Third, $35/month for support? Of course, this is on top of the doctors existing e-MDs support contract. Such a terrible plan by e-MDs. If they felt like they needed to get some money for the support that would be required for their iPhone EMR app, then they should have rolled it into the existing support contracts. Then, no one would complain. At least not as loudly.

Now I’m starting to wonder what other EHR vendors are charging for their apps. Let me know what you’ve been charged for your EHR app. A while back I posted about all the various EMR Android apps. All of them were free.

UPDATE: In case you couldn’t tell, this was an April Fool’s joke.

Over the past year myself and the other people here at EMR and HIPAA have been working like crazy on a very exciting new project. We’ve obviously seen first hand the many doctors that are dissatisfied with their current EMR and the current EMR vendors. We kept wondering how we could fix this problem. In the end, we decided that the best way to solve this problem would be to fix this problem ourselves. So, I’m really pleased to announce the launch of a new EMR software product by EMR and HIPAA called DoctorEZ (cool name huh?).

We’re still in beta right now working with only the best doctors we know to refine the product. Although, here’s the goals for our EMR software:

• No Cost for the EMR – Why should doctors have to pay for software? Haven’t you ever heard of a free lunch? That’s what we’re offering here.
• Zero Implementation Time – If you think you want DoctorEZ, it’s already installed. Doctors don’t want to take the time to implement the EMR software and so we decided to take out the implementation time.
• No Training Needed – Doctors have an MD after their name. That means they were basically professional students for most of their life. Why burden them with more training? That’s why we don’t.
• Universal Device Domination – Some people like their iPad. Fine we do that. Blackberry Playbook. It’s not released, but we support them too. Desktop. Check. Laptop. Check. iPhone, Droid, Blackberry, iPod touch, Pay as you Go phone. Check, check, check, check, check. Xbox, PS3, Tivo and Wii. You got it!
• Standards Based – SNOMED, ICD-9, EZ, ICD-10, 23%, ICD-11, SMRT, ICD-666, CPT, 1040-EZ, 5010, 90210, ACO, 867-5309, ieee, HAL-0999, etc. You bet!
• Supports All Specialties – Some people like to say that specialties have different needs. Not with the DoctorEZ EMR. It satisfies every specialty with a unique Specializer (TM) system.
• Easy – Did I mention that this was easy? (That’s why we called it DoctorEZ after all)
• Interoperability – As if other EMR are sophisticated enough to integrate with us.
• Increase Billing – Of course we do. Why else would you buy us? It’s not about the patient after all…speaking of which…
• Patient – We thought about some great features to help patients, but our beta test doctors asked us why. They then told us patients were a dime a dozen and it was all about the reimbursement. At DoctorEZ we listen to our customers.
• Interplanetary Hosting – I’m sure many of you are wondering if the new EMR will be a SaaS based EMR or client server based EMR. We decided since we were offering this for free that neither of those options was good enough for our doctors. Instead we launched a new interplanetary hosting option. That’s right. Your EMR data will be safely stored on our own personal network of data centers located on Mars, Saturn and Venus (we tried Pluto, but it lost its planet status and so we had to change direction). We had Neil Armstong sign a HIPAA business associate agreement, so you’re all covered if he heads to Mars and happens upon your patient’s info.
• EMR or EHR – Maybe you missed the part above about patients. Plus, did you see us use the word EHR in this article. I didn’t think so.
• EHR Certification – Are you kidding? Of course we are. Our business wouldn’t survive without it. Although, since we’re not an EHR we had to create our own certification called EZ Certification. Let’s just say it was easy to do. Will it get you access to the government handouts for EHR? Probably not, but you didn’t pay for the EMR and we didn’t pay for the EMR certification so it all works out. You will get to put up an DoctorEZ Certification sign on your door with our cute little bunny rabbit logo.
• Support – We’re from Las Vegas, the city that never sleeps. Neither do our support people. That’s why we’ve spared no expense on chaining them to their chairs and installing the shock collars to make sure they don’t sleep. In fact, the top DoctorEZ EMR feature is the “Shock My Support Person” EZ button.
• EMR Usability – At DoctorEZ we alpha tested a direct brain to EMR input. Basically if you think it, we record it. Only problem was we found out what the doctor was really thinking. Let’s just say I was surprised how many doctors play Farmville. To solve this problem, we’ve integrated Farmville into our EMR in a really fantastically usable way. Now doctors are no longer distracted thinking about Farmville since they’ll actually be playing it.
• Doctor Flattery Module – How many other EMR software really focus on the doctors? We’re taking it to a whole new level by randomly displaying a flattering comment about the doctor on the screen. In back office mode, a lovely male or female voice (configurable) will sound to compliment the doctor on their incredible skill, beautiful hair or amazing technique. Repeat Compliment button is available.

There’s so much more to the DoctorEZ EMR, but I think you get a feel for where we’re going. Who’s ready to sign up? Sorry. We’re in beta. However, I do like a nice piece of Cheesecake with hot fudge on top from Cheesecake Factory *wink* *wink*.

Natalie Hodge MD posted an interesting list on Quora of what she considers a strong EMR system:

I am a pediatrician. Here is what I must have in 2011.
1. Usability. When I say usability, I mean I decide the definition of usability.
2. Patient Health Record. nuf said.
3. Lab interfaces that help my patients get convenient and timely blood draws that flow directly into their medical record.
4. Eprescriber that is easy to use and hosted within the same platform so I don’t have to worry about a third parties server being slow.
5. Secure messaging.
a. I need to be able to email patients in a secure fashion, and they need to be able to email me.
b. Text. I need to have secure text messaging visits with patients.
c. Video. I need to be able to do video visits with patients at times.
d. I need to be able to communicate with my team securely.
6. Inbound fax that brings any external communication directly into my emr system. Seriously it’s 2011.
7. Ecommerce. I do membership practice so I can’t be running to the bank all day long depositing checks.
8. Web based. I have to work in a web based world, because I don’t like the expense of maintaining servers and I have to be able to access my data from anywhere.
9. Iteration. I have to have a rapid feedback loop with the developers of the application. If I can’t continually give feedback that makes the emr better, then I may as well go buy an old dell desktop computer from 2004 and start using that.
10. Mobile. I must be able to access all of this on my mobile, right now, I’m Iphone 4 but next week I might be android.
11. Open. The EMR must continually create further opportunities to help physicians manage health of their patients, whether it’s by integrations with loseit.com, imoveyou.com or nike training camp’s iphone ap. Self tracking may be a key tool physicians may use to solving our nation’s health crisis.

So what I am saying is I have to be able to function in an entirely paperless loop, despite the distractions of reform, medicaid, medicare, meaningful use, and payors.

I’m sure many will have a lot to say about this list. Here are a few of my comments:
1. I wonder how Dr. Hodge defines usable. Of course, that’s the problem. She wants it usable, but likely can’t really define it.
5. I love a number of these ideas. Just a few HIPAA/security issues to deal with. Back in March 2006 I wrote a post with the idea of just having the full video recording from a visit in the EMR. I think it’s the long term future of healthcare. It is interesting that in many companies they want more video recording to protect them from liability. In other cases like many in healthcare, they don’t want video recording since it adds to their liability. I’ll be interested to see EMR vendors text message strategies going forward.
7. You don’t like the checks? Imagine that. Online bill pay. Amazing!
9. This is INCREDIBLY INCREDIBLY valuable. It’s one of the reasons why a smaller, but stable EHR vendor is often more desirable than one of the big name EHR vendors.

What do you think about this list? Is it reasonable? What’s it missing?

I’ve now had two people send me links to a study coming out of Stanford University that says that EHR software doesn’t improve patient care in the US (Here’s one story about it from Reuters). So I figure that it must be a topic that my readers would enjoy me discussing. Here’s a portion of their summary:

A team from Stanford University in California analyzed nationwide survey data from more than 250,000 visits to physicians’ offices and other outpatient settings between 2005 and 2007.

They found electronic health records did little to improve quality, even when there was “decision support” software that gives doctors tips on how best to treat individual patients.

I’ve always found it a bit off to talk about EMR software as a means to improve the quality of care that a doctor provides. For the vast majority of healthcare, more information, clinical decision support, drug to drug interaction checking, drug to allergy checking, etc aren’t going to improve the care a doctor provides. First, because the doctors have been well trained to do many of these things already. Second, because if I come in as a generally healthy patient with a common cold, then of course the doctor doesn’t need any of these advanced EMR functionality.

Now in more advanced and complicated cases, there is potential that an EMR software could offer some benefit. I remember a doctor commenting back in 2009 on my blog about how the Body of Medical Knowledge could become to complex for the human mind to process it all. Whether we’re there or yet, is open for debate, but the concept is interesting. Although, this still only applies to the outlier cases.

I remember one time hearing a clinician tell me about how the Drug to Drug interaction alerts informed her of some medical knowledge that she hadn’t known previously. So, there are instances where various parts of an EMR software can provide better patient care, but is it dramatic enough difference to really improve the quality of care? I think that’s a hard argument to really make. At least with the current iteration of EMR software.

Other EMR Benefits
Quality of Care aside, I think the thing that studies like this (and their related headlines) miss is the other benefits of having an EMR system (see also my list of EMR benefits in my EMR Selection e-Book).

I can’t tell you how many times I’ve heard doctors talk about how they love the legibility and accessibility of patient charts in the EMR. No difficult to read handwriting (others or their own). No waiting for chart pulls. These are guaranteed benefits to having an EMR system. Sure, it’s hard to quantify them when it comes to dollar signs or improved quality of care. However, they’re a real tangible benefit to having an EMR. Not to mention that I still think there’s long term benefits to widespread adoption of EMR that we can’t even imagine yet.

I could go on about many of the other benefits. It’s just unfortunate that studies and those who report on these studies don’t take into account these other benefits of EMR software.

UPDATE: Over at HIStalk, Mr. H also points out that the study only focuses on a couple quality measures. So, it doesn’t actually say that EHR doesn’t improve quality of care, but instead it says that it doesn’t improve quality of care when it comes to the couple simple measures that the study used to measure it. There could be many other quality measures where EHR does improve the quality of care. We just don’t know.