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Epic and other EHR vendors caught in dilemmas by APIs (Part 2 of 2)

Posted on March 16, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first section of this article reported some news about Epic’s Orchard, a new attempt to provide an “app store” for health care. In this section we look over the role of APIs as seen by EHR vendors such as Epic.

The Roles of EHRs

Dr. Travis Good, with whom I spoke for this article, pointed out that EHRs glom together two distinct functions: a canonical, trusted store for patient data and an interface that becomes a key part of the clinician workflow. They are being challenged in both these areas, for different reasons.

As a data store, EHRs satisfied user needs for many years. The records organized the data for billing, treatment, and compliance with regulations. If there were problems with the data, they stemmed not from the EHRs but from how they were used. We should not blame the EHR if the doctor upcoded clinical information in order to charge more, or if coding was too primitive to represent the complexity of patient illness. But clinicians and regulators are now demanding functions that EHRs are fumbling at fulfillling:

  • More and more regulatory requirements, which intelligent software would calculate on its own from data already in the record, but which most EHRs require the physician to fill out manually

  • Patient-generated data, which may be entered by the patient manually or taken from devices

  • Data in streamlined formats for large-scale data analysis, for which institutions are licensing new forms of databases

Therefore, while the EHR still stores critical data, it is not the sole source of truth and is having to leave its borders porous in order to work with other data sources.

The EHR’s second function, as an interface that becomes part of the clinicians’ hourly workflow, has never been fulfilled well. EHRs are the most hated software among their users. And that’s why users are calling on them to provide APIs that permit third-party developers to compete at the interface level.

So if I were to write a section titled “The Future of Current EHRs” it could conceivably be followed by a blank page. But EHRs do move forward, albeit slowly. They must learn to be open systems.

With this perspective, Orchard looks like doubling down on an obsolete strategy. The limitations and terms of service give the impression that Epic wants to remain a one-stop shopping service for customers. But if Epic adopted the SMART approach, with more tolerance for failure and options for customers, it would start to reap the benefits promised by FHIR and foster health care innovation.

Epic and Other EHR Vendors Caught in Dilemmas by APIs (Part 1 of 2)

Posted on March 15, 2017 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The HITECH act of 2009 (part of the American Recovery and Reinvestment Act) gave an unprecedented boost to an obscure corner of the IT industry that produced electronic health records. For the next eight years they were given the opportunity to bring health care into the 21st century and implement common-sense reforms in data sharing and analytics. They largely squandered this opportunity, amassing hundreds of millions of dollars while watching health care costs ascend into the stratosphere, and preening themselves over modest improvements in their poorly functioning systems.

This was not solely a failure of EHR vendors, of course. Hospitals and clinicians also needed to adopt agile methods of collaborating and using data to reduce costs, and failed to do so. They’re sweating profusely now, as shown in protests by the American Medical Association and major health care providers over legislative changes that will drastically reduce their revenue through cuts to insurance coverage and Medicaid. EHR vendors will feel the pain of a thousand cuts as well.

I recently talked to Dr. Travis Good, CEO of Datica that provides data integration and storage to health care providers. We discussed the state of EHR interoperability, the roles of third-party software vendors, and in particular the new “app store” offered by Epic under the name Orchard. Although Datica supports integration with a dozen EHRs, 70% of their business involves Epic. So we’ll start with the new Orchard initiative.

The Epic App Store

Epic, like most vendors, has offered an API over the past few years that gives programmers at hospitals access to patient data in the EHR. This API now complies with the promising new standard for health data, FHIR, and uses the resources developed by the Argonaut Project. So far, this is all salutary and positive. Dr. Good points out, however, that EHR vendors such as Epic offer the API mostly to extract data. They are reluctant to allow data to be inserted programmatically, claiming it could allow errors into the database. The only change one can make, usually, is to add an annotation.

This seriously hampers the ability of hospitals or third-party vendors to add new value to the clinical experience. Analytics benefit from a read-only data store, but to reach in and improve the doctor’s workflow, an application must be able to write new data into the database.

More risk springs from controls that Epic is putting on the apps uploaded to Orchard. Like the Apple Computer store that inspired Orchard, Epic’s app store vets every app and allows in only the apps that it finds useful. For a while, the terms of service allowed Epic access to the data structures of the app. What this would mean in practice is hard to guess, but it suggests a prurient interest on the part of Epic in what its competitors are doing. We can’t tell where Epic’s thinking is headed, though, because the public link to the terms of service was recently removed, leaving a 404 message.

Good explained that Epic potentially could track all the transactions between the apps and their users, and in particular will know which ones are popular. This raises fears among third-party developers that Epic will adopt their best ideas and crowd them out of the market by adding the features to its own core system, as Microsoft notoriously did during the 1980s when it dominated the consumer software market.

Epic’s obsession with control can be contrasted with the SMART project, an open platform for health data developed by researchers at Harvard Medical School. They too offer an app gallery (not a store), but their goal is to open the repository to as wide a collection of contributors as possible. This maximizes the chances for innovation. As described at one of their conferences, control over quality and fitness for use would be exerted by the administrator of each hospital or other institution using the gallery. This administrator would choose which apps to make available for clinical staff to download.

Of course, SMART apps also work seamlessly cross-platform, which distinguishes them from the apps provided by individual vendors. Eventually–ideally–FHIR support will allow the apps in Orchard and from other vendors to work on all EHRs that support FHIR. But the standard is not firm enough to allow this–there are too many possible variations. People who have followed the course of HITECH implementation know the history of interoperability, and how years of interoperability showcases at HIMSS have been mocked by the real incompatibilities between EHRs out in the field.

To understand how EHRs are making use of APIs, we should look more broadly at their role in health care. That will be the topic of the next section of this article.

April Fool’s Day – Health IT Edition

Posted on April 1, 2016 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.

Most of you know that I love a good April Fool’s day joke. I don’t like those that hurt people, but I love good humor (ask me about the time my wife said she was going into labor and wasn’t). You may remember my past years’ pranks about the #HIT100 Health IT Company, the ONC Reality TV show, and my personal favorite where we announced we’d be selling our own EHR software. Good memories all around.

This year I’ve been busy organizing the Health IT Marketing and PR Conference, but that doesn’t mean I can’t enjoy other people’s work. I’m sure I’ve missed some of the great health IT related April Fool’s day jokes, so let me know of others in the comments.

The big winner for April Fool’s 2016 for me was SnapChart from Twine Health. You’ll particularly enjoy it if you’re a SnapChat user, but it’s a great one either way. This video should demonstrate what I mean:

Well done Twine Health! I think even patient privacy advocates would appreciate SnapChart. “We all know that EHRs suck. Well this EHR only sucks for 7 seconds….BOOM”

Another honorable mention goes to Epic who has a long standing tradition of offering something entertaining on April Fool’s Day:
Epic April Fool's Day 2016
*Click on the image to see a larger version

Nice work by Epic to keep it topical with reference to Clinton and Sanders. However, the one that takes the cake is Jonathan Bush using MyChart. The only thing that would make me laugh more would be if athenahealth put out a video response from Jonathan Bush. Please?!

Cureatr decided to go old school with a new technology called the Faxenatr:

Howard Green, MD posted this announcement from Alphabet Inc and Google Inc’s company Verily Life Sciences about the UHIT (Universal Health Information Technology).

So many others I could mention outside of health IT. This one from Samsung about a 3D holographic projection was cool:


Although, when you look at what’s happening with VR, maybe it will be more reality than we realize.

Gmail’s Mic Drop is pretty funny. Well, at least it was until people starting losing their job because of it. The concept of a mic drop on email or social media is pretty interesting though. I wonder if there’s a way you could really implement something like it.

What other April Fool’s day jokes have you seen. It’s Friday. We all need a good laugh.

My Prediction for the Epic App Store

Posted on March 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.

Today I was talking with a healthcare IT vendor which really needs to integrate deeply with an EHR to be valuable. Without that integration the product is not nearly as useful for doctors. Therefore we started talking about their current EHR integration and the potential for future EHR integrations. At that point he asked me what I thought about the coming Epic App Store (officially called the Epic App Exchange).

In case you missed it, I wrote about the Epic App Store over on Hospital EMR and EHR. I cover what’s been said about the Epic App Store (not much from Epic itself) and make some predictions. However, today’s conversation solidified my predictions.

Epic has always been open to working with their customers and a tech partner to integrate something with Epic. Basically, the customer is king and so if the customer wants the integration, Epic will provide the SDK that’s needed for the integration and make it possible for the customer to do what they need. Everyone’s known that if you want to integrate with Epic, then you need to work through a customer.

With this in mind, I believe the Epic app store is a way for Epic to allow for distribution of these apps that have been created by their customers (often with a tech partner) to other Epic customers.

Basically, this is in line with Judy’s focus on the customer. Some might say that this focus is great. Hard to argue with Epic’s success. However, this approach misses out on the opportunity of the Epic app store facilitating entrepreneurial innovators to build something on top of Epic that their customers didn’t even know they wanted yet.

Epics current strategy is more in line with staying the entrenched incumbent. Real transformation comes when you provide a platform for innovation that goes beyond yourself and your customers. I hope one day Epic sees this vision and really roles out an open app store. Until then, the Epic connected customer applications are going to have a bit of a monopoly selling their add on services to Epic customers.

Understanding Apple Health

Posted on June 17, 2014 I Written By

Kyle is CoFounder and CEO of Pristine, a VC backed company based in Austin, TX that builds software for Google Glass for healthcare, life sciences, and industrial environments. Pristine has over 30 healthcare customers. Kyle blogs regularly about business, entrepreneurship, technology, and healthcare at kylesamani.com.

Apple recently announced Health and Healthkit as part of iOS 8, and initial responses have been mixed.

At one extreme, the (highly biased) CEO of Mayo Clinic called Apple Health “revolutionary.” At the other, cynical health IT pundits claim that Apple Health is a consumer novelty and won’t crack the enigmatic healthcare system. As a cynical health IT pundit myself, I’m more inclined towards the latter, but have some optimism about Apple’s first steps into healthcare.

For the uninitiated, Apple Health is a central dashboard for health related information, packaged for consumers as an iOS app. Consumers open the app and see a broad array of clinical indicators (e.g. as physical activity, blood pressure, blood glucose, sleep data). You can learn more about Health and Healthkit from Apple.

The rest of this post assumes significant understanding of modern health IT challenges such as data silos, EMPIs, HIEs, and an understanding of what Health and Healthkit can and can’t do. I’ll address what Apple Health does well, ask some questions, and then provide some commentary.

Apple Health does a few things well:

1) Apple Health acts as a central dashboard for consumers. Rather than switching between five different apps, Health provides a central view of all clinical indicators. In time, Health could help patients understand the nuances of their own data. By removing friction to seeing a variety of indicators in a single view, patients may discover correlations that they wouldn’t have observed before. With that information, consumers should be able to adjust behaviors to lead healthier lifestyles.

2) Apple Health provides a robust mechanism for health apps to share data with one another. Until now, health app developers needed to form partnerships with one another and develop custom code to share information; now they can do this in a standardized way with minimal technical or administrative overhead. This reduces app lock-in by enabling data liquidity, empowering consumers to switch to the best health app or device and carry data between apps. This is a big win for consumers.

Unanswered questions:

1) How does Apple Health actually work? Apple provided virtually no details. Does the patient need the Epic MyChart app on their phone? Is there custom code integrating iOS to Epic MyChart? Is there a Mayo Clinic app that is separate from Epic MyChart? If not, how does Apple Health know that the consumer is a Mayo patient? Or a Kaiser Permanente patient? Or a Sutter Health patient?

2) Does the patient give consent per data value, or is it all or nothing? How long does consent last? Must consent be taken at the hospital, or can the patient opt in or out any time on their phone? Who within the health system can access the consented data?

3) Given that there are hundreds of EpicCare silos and dozens of CareEverywhere silos, how does Apple Health decide which silo(s) to interface with? Does data go to an HIE or to an EMR? If to an HIE, can all eligible connected providers access the data with consent? If a patient has records in multiple HIEs and EMRs (which they likely do), how does Apple Health determine which HIE(s) to push and pull data from?

4) Does Apple Health support non-numerical data such as CCDAs? What about unstandardized data? For example, PatientIO allows providers to develop customized care plans for patients that can include almost any behavioral prescription. Examples include water intake, exercising at a certain time of the day, taper schedules, etc.

5) Can providers write back to a patient’s Health profile? Given that open.epic doesn’t allow Epic to send data out, how could Apple Health receive data from Epic?

7) How will Apple handle competing health apps installed on the same consumer’s phone? For example, if I tap “more diabetes info” in Apple Health, will it open Mayo Clinic’s app (and if so, to the right place in the Mayo Clinic app?) or the blood glucose tracking app that came with with my blood glucose meter? Or my iTriage or WebMD app?

8) Is Apple Health intended to function as a patient-centric HIE? If so, what standards does it support? CCDA? FHIR? Direct?

Comments:

1) The Apple-Epic partnership is obviously built on open.epic, which Epic announced in September of 2013. It’s likely that Apple and Epic reached an agreement around that time, and asked the public for ideas on how to shape the program to get a sense of what developers wanted.

2) The only way to succeed in health IT is to force the industry to conform to one’s standards, or to support a hybrid of hybrids approach. Early indicators show Apple (predictably) trending toward the former. Unfortunately, Apple’s perennially Apple-centric approach inhibits supporting the level of interoperability necessary to power an effective consumer health strategy. Although Apple provides a great foundation for some basic functions, the long term potential based on the current offering is limited. What Apple has produced to date provides for sexy screenshots, but appears to fall short of addressing the core interoperability and connectivity issues that plague chronic disease management and coordination of care.

3) In a hypothetical world at some indeterminate point in the future, there would be a patient-facing, DNS-like lookup system for provider organizations (Direct eventually?). Patients should be able to lookup provider organizations and share their data with providers selectively. Apple Health provides a great first step towards that dream world by empowering patients to see and, to some extent, control their own data.

Epic – Future Proof, EHR Prenup, and Intelligent EHR

Posted on May 25, 2014 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.


Nope! But it has quite a few years of prosperity left in it.


I think it’s funny to call it a prenup. Translation: Read and understand your contract. A lot of people are starting to pay the price for this one.


Let’s be honest. EHRs today aren’t intelligent.

EpicUGM Insights, Announcements (Epic API), and Pictures

Posted on September 18, 2013 I Written By

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

This week has been the annual user group for Epic EHR users, otherwise known as Epic UGM. @VinceKuraitis aptly noted that the Epic user conference had 15k attendees and yet it only produced 188 tweets the first day of the conference. I’m not sure if this is a reflection of Epic users view of social media or Epic users fear of sharing what’s happening. The limited tweets aside, there were still a number of interesting tweets and pictures coming out of the event. Plus, some interesting quotes from the Madison paper I think you’ll enjoy.


Look at the crowds for registration. I wonder when Epic will outgrow Madison and need to move the event to Las Vegas. We’d certainly welcome them here. Although the local paper said that the event is the second biggest tourism engine in the area (World Dairy Expo beats it out).


Deep Space was the theme of the conference and also is the name of the enormous 11,400 seat underground auditorium on Epic’s campus. More pictures of the auditorium below. It’s also worth noting that Judy did the keynote dressed as a Na’vi from the movie “Avatar.”

Now for some tweets with pictures of the auditorium:


Soon the Epic conference will pass HIMSS on attendance. Not likely, but it is interesting that there were only 297 healthcare organizations. I wonder how many people organizations like Kaiser brought to the event.


This is a really interesting tweet. First, it’s interesting that Judy is talking about meaningful use stage 4. Does this mean there will be an MU stage 4? Second, what happened to MU stage 2? I’m pretty sure most aren’t worried much beyond MU stage 2 right now.


This likely deserves a blog post of its own. Although, this comment is really interesting in the context of Epic. Does this mark a fundamental shift in the products that Epic develops?

What I think will be the biggest announcement coming out of Epic UGM 2013 is the new Epic API. While it definitely falls short of what most of us would love to see Epic do with an API, at least it’s a start. The focus of the API seems to all be around getting all of the various health and wellness app data into the EHR. Here’s a good description of who they want to use the Epic API:

Are you a manufacturer of a consumer-facing monitoring device? We have an API for that.

Have you developed a health or wellness-related tracking app or portal? Clinicians need that information.

We’ve designed open.epic to make it gosh-darn simple to integrate the data you collect into your patients’ medical records. Interested?

I believe this will be a great opportunity for many developers. We’ll see how it plays out long term. I’m a little surprised that the Epic API doesn’t include interoperability which Epic is doing more and more. I guess they see it as a separate initiative.

The local newspaper covered the Epic UGM event as well and offered a few other insights into what was said at the conference:

“We’ve just gone over the 51 percent mark. You take care of a little over half of the patients in this country,” Faulkner said. Worldwide, nearly 2.4 percent of the population is covered by electronic health records created by Epic.

I’m sure we’ll be hearing Epic users quote this 51% number a lot more.

Epic, with $1.5 billion in 2012 revenue and 6,800 employees, will keep growing as its customers grow, Faulkner said, adding that clients are loyal. “To us, it’s a lifetime relationship,” she said.

I think Judy might be right for many Epic customers. The lock in to Epic for many of these large organizations is strong.

I guess the 15,300 attendee number is interesting when you think that 6,800 of them could be employees. Although, no doubt it is a really important and interesting event in the healthcare IT world. Judy seems to be softening on media coverage of Epic. It seems like Judy and Epic have decided to start becoming a larger part of the conversation. I wonder if a blogger could attend the event next year.

Why BIDMC Is Shunning Epic, Developing Its Own EMR

Posted on July 31, 2013 I Written By

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

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

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

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

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

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

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

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

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

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

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

Kaiser Permanente Accused Of Using EMR As Smokescreen

Posted on March 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.

Kaiser Permanente, California’s largest healthcare provider, has been cited by state officials for using its EMR to work its way around requirements to see mental health patients promptly, reports EHR Intelligence.

Potentially risking their own jobs, Kaiser’s own mental health team brought the discrepancies to the attention of the state.  Their complaint not only slams Kaiser’s practices regarding wait times, but also its overall clinical approach to treating mental health patients, going so far as to accuse the giant HMO of defrauding Medicare by upcoding cursory visits as complete.

According to the California Department of Managed Healthcare, Kaiser has been keeping two sets of records, one in its official EMR and another on paper that hid violations of the state’s law mandating short wait times for mental healthcare. The EMR also fails to retain a record of booking dates, so if an appointment date is changed, the wait time is being calculated from the most recent booking date, not the original date, the state charges.

The dual record keeping procedure allowed Kaiser to hide the fact that mental health patients may have waited weeks longer than the state’s “timely access” law requires, for illnesses such as schizophrenia, depression and suicidal ideation, as well as other serious conditions.

In defiance of the state-required two days between contacting an enrollee and booking an appointment, Kaiser had been recording initial contacts on paper, then asking patients to call back during the next window for appointments, up to four weeks later.  The EMR would then record the initial contact as taking place during the later booking windows, leaving out completely the weeks of waiting mentally-ill patients endured.

Kaiser has said that it addressed the discrepancies noted by the government, which were first brought to its attention last August, but the Department of Managed Healthcare has concluded that the changes needed have not yet been made.

Health IT Q&A with Scott Joslyn, CIO and Senior Vice President, MemorialCare Health System

Posted on September 13, 2012 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.


Tell us a little bit about yourself and your organization.
I’ve been the CIO at MemorialCare for about 16 years and with the organization for some 33 years. My training as a pharmacist has allowed me to bring a clinical background into my work as CIO. A subsequent MBA allows me to approach today’s challenges from both a clinical and business perspective.

MemorialCare, based in California, is a private, not-for-profit integrated delivery system that includes 1,500 beds across six hospitals, and a medical foundation with 400 physicians in an IPA model and 150 physicians in a staffing model. MemorialCare is listed among the top 20 percent of health systems nationwide by Thomson Reuters and in 2011 the organization was identified as one of the top 100 integrated healthcare networks nationwide.

What have been the benefits and challenges associated with EHR adoption to date?
Today, we live with Epic across five of six hospitals and 175 physicians. In addition, approximately 300 physicians use the NextGen EHR. Epic replaced an early-generation EHR (TDS, now Allscripts) installed in 1991. The experience with that system – CPOE, alerts, order sets, best practices, etc. – was immensely helpful as we configured, installed and supported the rollout of the Epic system. We know from that experience, for example, the critical role of physicians and nurses as the key leaders and champions of change, patient safety, and system design cannot be overemphasized. Apart from that experience, we also benefited from all that had been learned by other organizations that had gone before us with EHR rollouts, both successes and failures. We went live with Epic at our first hospital six years ago. We completed implementation of Epic’s clinical and revenue cycle systems over the ensuing four years.

We’ve learned that rather than being done with our EHR journey, we are actually just beginning. We are currently live with high levels of physician adoption and have largely eliminated paper-based records in our care for patients. Nevertheless, we find ourselves expanding the Epic system and exploiting its power in an environment where care process and healthcare financing are undergoing a revolution as a result of healthcare reform. Challenges included keeping pace with advances in the features and functions of Epic, increasing cost pressures, the anticipated organizational changes associated with accountable care, a transition from fee-for-service out outcomes focused financing, and the basic operational needs of accountable care.

Other challenges we faced were developing a system that would work well for everyone – from specialist to internist to hospitalist and beyond. Many different but interrelated workflows are involved, some that emphasize content while others are built for procedural speed. Another challenge is ensuring system reliability, speed, and near-constant availability. While we have “downtime” procedures, we are not terribly productive reverting to paper when the system is not available. We simply must take steps to minimize and protect against system failure.

What role has voice recognition played as it relates to your organization’s EHR adoption?
Today, we’re moving from an era of dictation and transcription to an era of voice recognition. As a result, the role of the transcriptionist is shifting from one focused on transcribing to one focused on editing the text captured by voice recognition.

Our EMR captures data in two forms – structured and narrative data. Increasingly, EMRs are incorporating functions and tools that help streamline the capture of both types of data. Voice recognition, specifically Dragon Medical 360 | Network Edition and Dragon Medical 360 | eScription, play a large and growing role in the capture of the patient narrative. Voice recognition helps make our physicians more productive, as the capture of narrative is integrated with structured data gathering tools such as forms and discrete data fields. This will be especially important and helpful as we shift to more elaborate coding under ICD-10.

How has meaningful use influenced your development roadmap? Have you found meaningful use to be very “meaningful”?
We invested in the Epic EHR well before the HITECH Act and Meaningful Use incentives and embraced MU along the way as part of our adoption and use of Epic. We have already attested for Stage 1 for MediCal (Medicaid in California). We believe in Meaningful Use and think it represents the best interests of patients, providers and payers. Currently, we’re in the process of digesting Stage 2. While we find it daunting as it relates to the breadth of the information provided, we’re confident that we’ll be able to tackle these new requirements over time. So yes, we do find Meaningful Use “meaningful” and generally the right thing to do.

What type of involvement do you see your organization having in Accountable Care Organizations (ACOs) and what role will technology play in it?
EMRs are a foundation of ACOs and increasingly taken for granted – table stakes for participation in an ACO. While we’re still ironing out the details of what an ACO means for our organization, the reality is we’re living in a post-EMR world. ACOs are the next frontier and, clearly, EMRs will play a major role in the making the ACO model a reality. Other technologies, such as analytics, interoperability and data warehousing will play an equally big part in this shift toward the focus on population health and outcomes-based care.

What’s are your thoughts on HIE? What will it take to have a truly successful HIE?
New policies and regulations need to be put in place at the Federal level for HIE to truly work. Today, providers are reluctant to consider or embrace HIE because of the financial and reputational risks associated with the idea of sharing patient information. Issues of patient consent management, opt-in vs. opt-out, and privacy create both real and imagined barriers. We need to create a legal and regulatory environment that is receptive and supportive of HIE rather than potentially risky and punitive. As an organization, we participate in local, public HIE efforts while we endeavor connect our systems to affiliated providers to safely and securely make available patient information as our physicians and patients currently demand and expect in the current environment. We’re encouraged by the progress and ongoing regional and national dialog with regard to HIE though we do think it will evolve slowly and unpredictably.

What’s the most beneficial IT program that your organization has implemented? What benefits were achieved?
Our EMR. It’s had the most dramatic impact on the patient care we provide and how we run our “business” efficiently with substantially higher levels of patient safety. It is a vital go-forward “platform” on which to build new tools and capabilities to survive and thrive in a rapidly-changing healthcare environment.

What are your biggest challenges as CIO?
Figuring out what it really means to be an ACO and what it means to manage the health of a population. I find myself constantly thinking about these questions:

  • What do we really mean by population health?
  • How do we restructure our business to provide population health services, and with which organizations will we need to affiliate to carry out population health initiatives?
  • What tools and technologies will we need beyond the EHR to make population health a reality?

Which IT project doesn’t get enough attention and why?
Establishing social media tools and technologies that can help facilitate internal collaboration – beyond email and our intranet.

Effectively engaging patients in their health care, likely using social media, apps, etc. I’m constantly wondering what patients really need from us in order to manage their health and wondering what role apps or other technology might play in making an effective connection between provider and patient.