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A Look at Email and HIPAA

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Disclaimer: I am not a lawyer and do not offer legal advice. The others quoted in this post are offering general information or interpretation and not specific legal advice or any statement of fact.

For more background on this topic, check out my previous post “Practice Fusion Violates Some Physicians’ Trust in Sending Millions of Emails to Their Patients

When I first started looking into the millions of emails that Practice Fusion was sending to patients, doctors were suggesting that these emails constituted a HIPAA violation. Practice Fusion has responded in my previous post that “The patient email reminder and feedback program is absolutely HIPAA compliant, under both the current and new Omnibus rules. We conduct thorough compliance research with every single new feature we launch.” I wanted to explore the HIPAA concerns regarding emails like these, so I talked to a number of HIPAA lawyers and experts. I believe the following look at HIPAA and emails will be informative for everyone in healthcare that’s considering sending emails.

Before I go into a detailed look at sending emails to patients, it is worth noting that under HIPAA emails can be sent to patients by doctors if the doctor has used “reasonable safeguards” and patients have agreed to email communication with their doctor. The following is a great HHS FAQ on use of email and HIPAA where this is outlined.

This leaves three HIPAA related questions:
1. Is Practice Fusion legally allowed to use the information in their EHR to send these emails?
2. Does the email contain Protected Health Information (PHI) that is being sent in an unsecured and not encrypted email?
3. Can Practice Fusion publish the provider reviews on their website?

Is Practice Fusion legally allowed to use the information in their EHR to send these emails?
The core of this question is whether the Practice Fusion user agreement (the version publicly available on the Practice Fusion website) allows the use of patient data contained in the Practice Fusion EHR for sending out these emails. Following are comments from William O’Toole, founder of the O’Toole Law Group regarding the user agreement:

I am not providing specific legal advice or opinion here, and I have no strong feelings about Practice Fusion one way or the other. That said, I find this issue extremely interesting and hope I can provide some direction and some interpretation of the law. Capitalized terms are defined under HIPAA and by now are familiar to all, so I will not define or elaborate.

The Practice Fusion Healthcare Provider User Agreement includes a section that, as between Practice Fusion and its customers, grants Practice Fusion the right to use a provider’s PHI (though I argue it is not the provider’s, it is the provider’s patients’ PHI, but I digress) to contact patients on the provider’s behalf, for various purposes, including “case management and care coordination” which is legally permitted. The conclusion can be easily drawn that Practice Fusion (or any other vendor doing the same) relies on this connection in claiming that its patient email is permitted under this section of the law, even if it contains PHI. Note – the topic of secure email is left out of this discussion.

Based on the user agreement, it seems like Practice Fusion is allowed to send out these rating and review emails to patients. William O’Toole does offer a reminder for providers:

For those of you that are familiar with my writings, you know what comes next. The Practice Fusion agreement clearly puts provider customers on notice that Practice Fusion has the right and option to contact patients directly on the provider’s behalf. The providers agreed when they accepted the terms of use. The most important piece of advice that I can offer to all providers is to read and understand the agreements to which you will be bound, or more appropriately, give the agreements to a healthcare technology attorney for review and opinion.

This is an important message for all providers to read and understand the user agreements they sign.

Does the email contain PHI that is being sent in an unsecured and not encrypted email?
You can see the contents of the ratings emails here (Note: The masked area is the name of the physician). Here’s Mac McMillan’s, CEO of CynergisTek and Chair of the HIMSS Privacy and Security Task Force, analysis of the emails:

The issue here is whether or not by the information included you can discern any protected information about the individual(s) involved. On the surface the email appears benign and does not include any specific Protected Health Information (PHI) and if coming from a general practitioner it would be near impossible to guess let alone determine for sure the purpose of my visit or my medical condition. Meaning I could have gone there for something as simple as a checkup, to refill a prescription, or I could have gone there for treatment of some ailment, but you don’t know and can’t tell by this simple email. Some would argue that this is no different than when Physicians communicate with their patients now via regular mail or email. The problem though is that not everyone may agree with this, and the consumer who may not be thinking rationally may take issue under certain circumstances. For instance, what if the email came from Planned Parenthood to a seventeen year old, or an AIDS clinic, or a specialty center handling a certain form of cancer, or a psychiatrists office? In these cases just the name and the identity of the covered entity potentially provides insight into the individual’s medical condition and therefore their personal health information. A patient might, whether legitimate or not, attempt to make the case that their privacy has been violated if others were to see this email who were not intended to like other family members, neighbors, employers, etc. I think this is really stretching it, but who knows how a Privacy attorney might see it?

Can Practice Fusion publish the provider reviews on the Patient Fusion website?
Assuming that Practice Fusion is authorized to contact its users’ patients, the next question is whether it is authorized to publish their responses online. When patients are posting a review, they have to agree to the terms of the “Patient Authorization.” Within that authorization it seems that Practice Fusion has done a good job making sure that they are getting authorization from the patient to publish the reviews they’ve submitted. David Harlow, a health care attorney and consultant at The Harlow Group LLC who blogs at HealthBlawg. notes that in addition to the Patient Authorization, “The Terms of Use on the review website make clear that posts on the site may be made public, and should not contain information that a patient would not want to be made public, or that a patient does not have the right to post.”

Hopefully this discussion around emails in healthcare will help more companies understand the intricate HIPAA requirements for email communication with patients. I see email communication increasing over the next couple years as more doctors realize the benefit of it. Plus, a whole new generation of patients wants that type of communication with their provider. We just have to make sure that we continue to respect patient’s privacy in the process. Making sure your emails are HIPAA compliant is not a simple task.

Practice Fusion sent me the following comment:

Practice Fusion’s goal is to create transparency in healthcare without compromise. It is critical that patients seeing any doctor on our platform understand the quality of their doctor. And, therefore, doctors using our free online scheduling application are required to make their reviews available to the public. Practice Fusion offers the only service on the market that validates a patient review was based on an actual visit. No PHI is ever shared in these communications.

August 28, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Practice Fusion Violates Some Physicians’ Trust in Sending Millions of Emails to Their Patients

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Update: At the bottom of this post, I’ve included Patient Fusion’s response to this article.

When Practice Fusion asked their users to prepare for some new “patient communication tools”, the outcry from many doctors was for Practice Fusion to stop focusing new features on patients and instead focus on unsolved physician requests that were made years previous. What I found when I started digging into Practice Fusion’s focus on patients through its launch of Patient Fusion was a much more important story where Practice Fusion’s actions were violating some physicians’ trust and might have issues with HIPAA.

The story starts in early April 2012. With little fanfare (only a generic blog post about Measuring the Patient Experience Using Surveys and two mentions in the Practice Fusion “Progress Note newsletter”) (UPDATE: Practice Fusion’s response at the bottom of this post says they did communicate more than is described here.), Practice Fusion turned on a feature that would email every single patient whenever a progress note was created in the Practice Fusion EHR. The email came addressed as being sent from the doctor and asked the patient to rate and review their provider.

In the 17 months since they started sending these emails, 1,844,718 reviews have been submitted across 29,630 providers according to the Patient Fusion website. If we’re really generous and assume a 20% response rate from the emails, then over the last year Practice Fusion has sent out over 9 million emails to patients. It’s truly an impressive feat to have been able to gather that many physician reviews in such a short period. What an amazing asset for any company to have accomplished.

Regular readers will likely remember my previous post titled Physician Ranking Websites – The Bad, The Worse and the Ugly where I discuss in detail the challenges for any physician rating website, so I won’t go into that here. The value of physician ratings aside, I don’t have any problem with Practice Fusion collecting physician ratings and reviews. What I am concerned with is how they did it.

In my research, I couldn’t find a single Practice Fusion doctor who knew from Practice Fusion’s “standard channels” (blog post and email newsletter) that every patient they charted would receive these rating and review emails. What I did find was a doctor who only discovered these emails were being sent to his patients when his brother visited his office and later asked him why the information in the email was incorrect. The doctor no doubt asked his brother “What email?” Other doctors only knew about the emails after hearing about the emails from their patients. One doctor confused a few of his patients’ comments about the ratings emails thinking that they were talking about some other rating service like Yelp, Health Grades or ZocDoc. He was later surprised to learn that Practice Fusion had been sending these ratings emails for months to all his patients and he knew nothing about them.

Imagine being a doctor who discovered your EHR vendor was sending emails to your patients IN YOUR NAME and you knew nothing about it. Shame on those doctors for not reading the Practice Fusion newsletter in more detail.

The physician response once they found out these emails were being sent isn’t surprising. Here are a few of their responses:

“We find this a MAJOR violation of our trust with Practice Fusion.”

“It demonstrates to me that PF has LOST TOUCH with how difficult it is to run a doctor’s office.”

“I just think of all the times I assured people that we would never email them with solicitations or spam, but only would use their private email addresses for emergency purposes or if they emailed us first.”

“Why were we not told? Why can’t we use the emails we enter [into] the system but you can?”

“You should NOT have to opt out of spam! This is an outrage.”

“It’s deception! Unsolicited emails to our patients from PF should never be signed off as the doctor. Where is the trust?”

“PF obviously thought of doctor’s offices more like a restaurant or retail store than the rather unique provider of personal health care and protector of personal data.”

“We were outraged!”

“No physician signed up onto PF thinking they can would treated like HealthGrades or Vitals.”

“The main point of contention has been the fact that we were not aware of the surveys being sent out IN OUR NAMES!”

“Hard to believe that the largest social site for information about my practice was created without my knowledge and I am guessing was directly solicited from my patients in the form of emails.”

“What I hope PF takes from this is that doctors, for the most part, do not like being used to advocate for a product without expressly being told in a bolded out and starred statement “hey, we’re going to use your office to send out email asking for feedback. Is this okay?”

You can read more reactions from Practice Fusion users on this forum post (Note: This post has had many of the comments removed since I posted this article.) including this comment from a patient who received the email:

I’m a patient. I received one of these emails from PF and then a follow up email from my doctor who was simply irate that PF was spoofing his email address. This just defies every email rule there is and PF owes an apology to every provider and every patient who received one.

One doctor I talked to didn’t find out about the emails being sent in his name until almost a year later. PF Staff Kristen offered the following comment in the above forum post, “The goal of patient surveys is to provide both insight and marketing materials for your practice. We will not publish, sell, or otherwise market your practice without your permission.” I think Kristen really believes this. In fact, I talked to Practice Fusion directly and they told me the goal of these ratings and reviews was to provide more transparency between physicians and patients. While I appreciate the noble goal of transparency between physician and patients, I am concerned that Practice Fusion thinks that doctors gave them permission to send these millions of emails. Practice Fusion may legally have permission to send these emails based on the fine print of their user agreement, but permission to me means that the doctor knows what you’re doing in their name.

As one doctor asked, “Why were we not told?” No where in Practice Fusion can a provider see their ratings and reviews and they weren’t published to the Patient Fusion portal until the portal went live a year after they started sending these emails. There’s no notification sent to a provider when a rating is completed. All of the emails and ratings are patient facing, so how would a provider know that reviews were happening? Oh, that’s right, they were suppose to read the email newsletter.

I wonder how many more of the almost 30,000 Practice Fusion providers still don’t know this is happening. I imagine they’ll have similar reactions when they find out.

Maybe I am wrong in my assumption that many doctors still don’t know about these emails being sent in their name. It is possible that most of them saw the newsletter and were happy with the new feature. My problem with this is that I receive the Practice Fusion email newsletters and did not recognize that this is what they were doing. It is hard for me to believe that the majority of busy doctors caught the message.

Turns out that when Practice Fusion first implemented the email ratings feature, the only way to turn it off was by contacting support. There wasn’t even an option inside the EHR to turn off the emails, but that has been added since. It seems to me that they weren’t thinking about their users’ needs when implementing this feature, but likely wanted to get as many reviews as possible in order to compete with the highly funded physician review sites: ZocDoc ($95 million), Health Grades (Acquired for $294 million) and Vitals ($26 million).

Fifteen months and approximately nine million emails later, Practice Fusion finally posted what the emails look like and what emails are sent from Practice Fusion on their new and relatively inactive forum. However, this entire time Practice Fusion could have communicated this new feature to their users directly. In one sense they are an ad platform that communicates to doctors and yet they chose not to use that platform to let their users know what they were doing. I understand there is a balance with how many alerts Practice Fusion sends doctors within Practice Fusion, but sending out thousands of emails in each doctor’s name seems like one worthy of clear notification. (UPDATE: Practice Fusion’s response at the bottom of this post says they did communicate more than is described here.)

Practice Fusion could have easily avoided all the confusion and loss of physician trust if they had just implemented this as an opt in feature as opposed to an opt out feature. Just like the pop up surveys and other notifications they display during login, they could have popped up a request for providers to opt in to this new ratings service. When I asked Practice Fusion about this, they told me that they didn’t do it as an opt out feature because it was a passion project for them and they wanted every Practice Fusion doctor to participate in more physician-patient transparency.

Maybe that was one of the goals of the project, but I think there is more to the story. Think of the value that 1.84 million reviews has created for Practice Fusion. If Practice Fusion had done these ratings emails as an opt in feature, I am sure that very few doctors would have knowingly opted into the service. With very few doctors opting into the ratings emails, Practice Fusion would have missed out on all the value that a large database of physician reviews would create.

Beyond just the forum post linked above, I know that Practice Fusion has heard from doctors who are upset with these ratings emails being sent. From my research, it seems like most doctors’ initial reaction to the emails revolves around fear of being rated by their patients. In fact, I expect this is why on the Patient Fusion website (where all the ratings and reviews are immediately published) it says “98% doctors recommended.” I have little doubt that this statement was added in response to physicians’ fear over being rated. Many doctors likely switched from anger and fear to acceptance when they saw that their patients had rated them well.

Side Note: If almost all of the provider ratings are positive, then do the ratings have any real value?

Maybe this is why Practice Fusion hasn’t had a different response to this issue. They feel that those doctors who were upset at the emails have been pacified with good reviews or the ability to disable the service. I think Practice Fusion considers those complaining in this forum post (Note: This post has had many of the comments removed since I posted this article.) the standard “complain over anything” response from users. The problem is that we don’t know how many more doctors haven’t complained because they still don’t know what is going on. Hopefully by covering it in this blog post we will see how many doctors care about this issue.

If ratings emails sent from medical doctors wasn’t bad enough, it turns out Practice Fusion has been sending ratings emails to psychiatric patients as well. Here’s what one psychiatry NP had to say about the emails:

“As a psychiatry NP I really do not think patients should be asked to rate their therapist. This is actually a conflict with the relationship with the patient. Holding the boundaries with most of my patients is VERY important. They all want to please me. So it really is inappropriate to ask a patient to rate a therapist they have.”

On July 10th this psychiatric NP asked for the emails to be turned off. On August 1st she posted that the emails were still not turned off. Why Practice Fusion’s immediate response wasn’t to reach out to this psychiatrist to turn it off and then to turn off this feature for all psychiatrists is beyond me. Sending out rating emails to mental health patients is a whole new level of trouble and legal entanglement.

Needless to say, there are dozens of other examples of bad situations that could be caused by these emails. Here’s one doctors’ comment about his patient population and these emails:

“One of the things we do is addiction. So I have people where nobody knows they are coming to see a doctor to treat their opiate problem and they are incredibly anxious about anyone finding out. We are the type of practice where people often come to keep their indiscretions hidden. Their affair, their vice, their compulsion. I realize that most just got a dumb email.”

Another doctor offers this insight into his patient population and why this could be a big issue:

“As a doctor, I don’t like this one bit. I’m in pilot country and the FAA takes medication use VERY seriously. what if a doctor mistakenly prescribed a medicine that was on the FAA “not allowed” list ( or sees a psychiatrist and then PF sends an email that the patient was seen at a psychiatrists office to their work email. Their work could be scanning their email for violations like this and BAM! someone loses their job b/c of a PF hipaa violation that reveals the private information that this person had just been to a psychiatrists office and is possibly on psychiatric medications.”

The scenarios are endless. What if the email is coming from an AIDS clinic or a Cancer clinic and no one knows you have AIDS or Cancer? What if the email was from an OB and a boyfriend stumbles upon it?

Some might suggest that this is just a bunch of FUD (Fear, Uncertainty, and Doubt). Maybe it is, but this should be the choice of the patient and the doctor and not the choice of the EHR vendor. If Practice Fusion had done this as an opt in feature, none of this would be an issue. Some doctors are now choosing to not enter emails into Practice Fusion because they are afraid of how those emails will be used. The irony is that Practice Fusion recently made a patient’s email address and phone number required fields. If a clinic doesn’t want to enter that information, they have to check the patient doesn’t have an email or phone check boxes. You just have to wonder why email and phone fields were changed to required fields.

Doctors have always had a general fear of any Free EHR. I have heard many doctors state that they would never use a Free EHR, because they didn’t know what the company would do with their data. I’m certain that actions like the ones described above will do a lot to confirm some doctors distrust of Practice Fusion’s Free EHR. Plus, you can be certain that Practice Fusion’s competitors will be sharing this information with doctors as well.

There will be some that read these physician comments and say, “Stop complaining, it’s a Free EHR. Switch EHR software if you don’t like what they’re doing.” The problem with this rationale is that it’s not “Free” to use Practice Fusion. A doctor “pays” Practice Fusion by allowing them to use their data to make money (See also my post titled “When EMR Software Became Free…Or Does It Cost?“). Turning over the right to use a clinic’s data is why it is SO important for doctors to trust the actions of their Free EHR vendor. Without that trust, many doctors will eventually leave Practice Fusion and doctors will stop signing up.

In response to this situation, one doctor commented on Practice Fusion’s need to work with MDs to avoid situations like this. Practice Fusion’s first Chief Medical Officer (CMO) parted ways with the company back in 2012. A look at their executive team shows no new CMO and no doctors in any executive position at the company. I wonder if a doctor on the executive team would have helped them understand how spoofing the doctor’s name in these emails without their knowledge would be an issue.

While I believe sending these emails in the physician’s name without their knowledge is a big issue for Practice Fusion, the bigger question is whether these actions are indicative of how Practice Fusion will treat doctors in the future. Is this the start of Practice Fusion putting company value over physician trust? Practice Fusion told me that they knew that it would upset some doctors when they rolled out these emails, but they did it anyway. Even if only 5% of doctors are upset over this, what’s to say that the next time you won’t be part of that 5%? I know there are a lot of good people at Practice Fusion, but the company also has to answer to their investors.

On a broader scale, the core question is: Do doctors trust their EHR vendor to communicate any actions they take with your data?

All EHR vendors could have similar physician trust issues to the ones described above if they’re not careful when rolling out new features. This could include vendors who may be tempted to implement a similar email rating and review feature as Practice Fusion. The problem is not with this specific feature, but with how EHR vendors choose to implement and communicate new features to their users. You can be sure we will hear more stories about the relationship of trust between EHR vendors and physicians in the future.

Approximately 9 million emails later, we’ll see the depth of impact these actions have on Physicians’ trust in Practice Fusion.

In the future, we’ll be covering the HIPAA regulations surrounding these emails.

UPDATE: Practice Fusion sent me the following response to this article:

- Practice Fusion updated our community over the course of months about the patient feedback program through numerous blog posts, forum posts, emails and messaging inside the EHR, starting in April 2012. You can read the original message from our CEO about the program online here. Despite our efforts, not every customer was aware of the program immediately. We apologize that this was not more clear and are working to improve our feature update messaging.

- The patient email reminder and feedback program is absolutely HIPAA compliant, under both the current and new Omnibus rules. We conduct thorough compliance research with every single new feature we launch.

- We are passionate about making healthcare better and proud of our work to bring almost 2 million patient voices into the conversation. Patient transparency is a key part of the national move from quantity to quality in healthcare. The patient feedback program is designed to provide your practice with a controlled, quality channel for accurate patient reviews.

- It is easy to opt-out of the patient feedback program anytime. We are happy to help you update these settings inside your EHR account.

August 21, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

EMR Market Share

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Editor’s Note: This is the first post on EMR and HIPAA by James Ritchie. James is a longtime journalist including the past eight years as a staff writer with the Cincinnati Business Courier.

Practice Fusion announced in June that it led the EMR industry in market-share gains.

Citing SK&A reports, the San Francisco-based firm boasted that it controlled 5.8 percent of the market as of May, up from 3.8 percent in July 2012. Beyond Practice Fusion, only Epic, AthenaHealth and Cerner showed gains.

In this data, which represents physician offices only, Allscripts was the market leader, with a 10.6 percent share. Not far behind were eClinicalWorks, with a 10.5 percent share, and Epic, with 10.3 percent. (The report that Practice Fusion links to is actually dated January 2013.)

But there’s more than one way to look at the EMR share picture.

Epic was the clear winner in a report by the Austin, Texas-based consultancy Software Advice on meaningful use attestations. Epic, based in Verona, Wis., accounted for 20.3 percent of attestations for a complete EHR in an ambulatory setting.

The firm’s competitors were nowhere close as of the March 2013 report. Allscripts was the system of choice for 11.6 percent of attestations by eligible professionals, and eClinicalWorks accounted for 8 percent. Next on the list were NextGen Healthcare, GE Healthcare and, with 2.7 percent share, Practice Fusion.

Software Advice claimed that the figures, based on Centers for Medicare and Medicaid Services data, might be the best around. They at least provide a standard in a market where vendors “use varied criteria to calculate their customer base,” according to the company.

Companies “might count number of users (which could include everyone from physicians to administrative staff), number of medical providers (which could include everyone from physicians to midwives) or number of practices,” Software Advice noted on its website.

Practice Fusion, founded in 2005, claimed in its press release to have doubled both its monthly active user base of medical professionals and its patient population between 2012 and 2013. The company claims to reach “a community of 150,000 medical professionals serving 65 million patients.”

The prospects for the free model that Practice Fusion uses are still up in the air. Doctors might question whether they want ads, unobtrusive as they are at the bottom of the screen, to compete for their attention when they’re entering patient data. Data, by the way, might prove to be the real revenue generator for Practice Fusion. In June the firm launched Insight, an analytics product offering a population-level view of diagnoses, prescribing patterns and other information. It’s a model worth watching. If Facebook and google can build businesses on data, maybe Practice Fusion can, too.

The SK&A figures show just how fragmented the outpatient EMR/EHR market is. The top 10 vendors accounted for only 64.8 percent of attestations, leaving about 35 percent of the market to the “other” category. By Software Advice’s count, 560 firms logged at least one meaningful use attestation.

Eager to steal share are firms like Irvine, Calif.-based Kareo Inc. It launched its own free, cloud-based EHR in February based on technology acquired from San Mateo, Calif.-based Epocrates Inc. The firm reported in June that 4,000 providers had signed on, with a third of them moving from another EHR.

Of course, ambulatory adoption is only part of the EMR story.

Epic is No. 1 among the nearly 3,000 hospitals that have received federal incentives for using complete electronic records systems, according to Modern Healthcare. The company holds a 19.6 percent share, followed by Computer Programs and Systems Inc. with 15.5 percent, Meditech with 14.1 percent and Cerner with 11 percent. The late-May report was based on numbers from CMS and the Office of the National Coordinator for Health Information Technology.

The inpatient market is far less fragmented than the outpatient space. The top 10 companies control 92 percent of share, according to the report.

No matter how you count share, the EMR space will continue to be hypercompetitive because of the dollars at stake. The market amounted to $20.7 billion in 2012, up 15 percent from 2011, according to the research firm Kalorama Information.

July 18, 2013 I Written By

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

Practice Fusion EMR Brings Patients Into The Picture

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Practice Fusion was one of the first free, advertising supported, cloud-based EMR to enter the market and has likely been the loudest proponent of free EMR software. Although, they have some interesting Free EMR competitors like Mitochon and Kareo. Since 2007, Practice Fusion has focused on offering unfettered access to its product in exchange for physicians being willing to accept advertisements relevant to the health records they’re using and the aggregate use of the EHR data.

The company, which has raked in venture capital in buckets since its founding, now says it has 150,000 healthcare providers using its EMR and records on 60 million patients, according to a piece in The New York Times.

Now, the company has taken another step in its free-for-all model with a new service it calls Patient Fusion. Patient Fusion is a new service which allows patients using the system to schedule appointments with any participating doctor who uses the EMR. It also allows patients to rate the doctors in question and to access their records with permission. So far, 27,000 of Practice Fusion’s EMR users have signed up for the service, the Times reports.

The Times columnist covering this announcement speculates that Practice Fusion has launched its new product as a means of building up patient traffic, but I don’t see how that would work. Patients may see more of their records, but this won’t necessarily do anything to increase the number of doctor-based views the network can sell to lab companies and pharmas.

On the other hand, Patient Fusion could prove to be a powerful way of attracting and keeping doctors who want to offer easy-to-administer appointment scheduling to patients. Also, getting patients engaged with their medical records is very much in the spirit of Meaningful Use and the ONC’s priorities generally, so this new patient feature could be a beacon for doctors going through MU-motivated EMR switching this year.

Bottom line, this seems like a nifty idea. I predict that most of Practice Fusion’s EMR customers will sign up over the next year or so.

April 22, 2013 I Written By

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

Some Inside Baseball for the EHR World

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I thought I’d take this moment to take a quick look at what many might consider inside baseball when it comes to the EHR world. Although, I’ve been intrigued by a couple announcements that were made recently.

The first announcement is Kareo buying the Epocrates EHR which came just in time for HIMSS. You might remember that I covered the Epocrates EHR on a number of occasions. I first saw the Epocrates EHR at HIMSS in 2010, and subsequently wrote about Epocrates “killing” their EHR immediately after launch. When that happened, I think we all wondered what would happen with the Epocrates EHR code base. You don’t just throw a meaningful use certified EHR to the curb do you?

We now know the answer to that question is no. Kareo saw fit to acquire the Epocrates EHR software and Dr. Tom Giannulli, formerly of Epocrates, is now the Kareo CMIO. I can imagine that Dr. Giannulli wanted to stay with his baby (the Epocrates EHR). I’m also quite intrigued that Kareo is offering the EHR for free (at least for now?). The funny thing is that I had written that the Epocrates EHR should be free. I guess I was sort of right, but I definitely didn’t think that the Epocrates EHR would become free since Kareo makes their money from the Practice Management and billing side of the house. We’ll see how that strategy works for Kareo. In some ways it’s taking a page out of the AthenaHealth playbook.

What might be simply an odd coincidence of timing (or not), Practice Fusion just sent out a letter (shown below) to its users from Practice Fusion Founder and CEO, Ryan Howard. In it he acknowledges Practice Fusion’s past challenges with billing, and he outlines their strategy on making the Practice Fusion billing situation better.

Does this relate to Kareo? Maybe, maybe not. What I do know is that many Practice Fusion users are on Kareo as well since it was Practice Fusion’s only major Practice Management software partner when Practice Fusion started. It seemed like a great match since Practice Fusion only had EHR, and Kareo only had Practice Management. Kareo now has an EHR, and Practice Fusion is working on billing and practice management. I guess we should have seen this coming.

Here’s the full email I got from Practice Fusion (Full Disclosure: They said Dr. Lynn, but I’m not a doctor.):

Hi Dr. Lynn,

The Practice Fusion team takes pride and appreciates your role in making us the fastest growing EHR community in the US.

We also recognize that billing has not been our strongest suit. Improved superbills and an updated payer list have been highly requested by our user community.

That’s why, by the end of March, we’re going to deliver you major new enhancements to your billing experience:

• A comprehensive, streamlined superbill, directly integrated with your workflow
• Flexible reports for billing users
• The ability to export billing data to most major billing systems
• New billing software and service partners with more economical pricing

This means you can stick with the exact billing workflow and system you use today in your practice. We’re building the ability to integrate directly by allowing you to export data to your billing system via HL7. If you prefer superbills, you’ll soon have a drastically improved superbill to work with. And if you’re looking for a new billing system altogether, we’ll also have new, low-cost partners coming soon.

We’re excited to be making your EHR faster, more flexible and easier-to-use. Lastly, our commitment to you has not changed since the day you signed on—Practice Fusion will deliver all this for free. Stay tuned for our billing revamp at the end of March!

Ryan Howard
Founder and CEO
Practice Fusion

February 22, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

EMR and EHR Ads

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It seems fitting on Super Bowl week to take a second and look at the advertisers that make what we do here at EMR and HIPAA possible. None of their ads cost $1-2 million like the Super Bowl ads, but if you’re looking for some great Healthcare IT and EHR products then you’ve come to the right place. If you like what we do here at EMR and HIPAA, then take a minute and see the advertisers who like what we do as well.

Also, I have a special ad promotion for new advertisers from now through the middle of February. If you’re interested in knowing the details, drop me a note on our Contact Us page.

New EMR and HIPAA Advertisers
Canon – I can’t imagine anyone reading this needs an introduction to Canon. In the Healthcare IT space they offer a suite of scanners, printers and copiers that are found in healthcare organizations across the country. I even have the Canon imageFORMULA DR-C125 in my house and use it regularly. The need for heavy duty scanners in healthcare isn’t going to go away for a long time. I’m glad to have Canon on board as an advertiser.

iPatientCare – EHR vendors always do well as advertisers on EMR and HIPAA and so it’s great to have iPatientCare as a new advertiser. They provide the full suite of EHR, PMS, PHR, HIE, and Mobile that you could need along with all the important EHR and meaningful use certifications. I see that they’re going to be exhibiting at HIMSS at Booth #5519 if you want to check them out at HIMSS. Plus, I love that their website has an image that says they won 9 TEPR Awards. Many of you probably won’t even know what TEPR is since it’s no longer around. However, TEPR was a conference focused exclusively on EHR (although it was probably called EMR back then since it was before EHR became in Vogue). The fact that they won awards at TEPR shows how long iPatientCare’s been doing EHR.

simplifyMD – I first started working with simplifyMD when they graciously sponsored the New Media Meetup at HIMSS 2012 (The 2013 event will be announced shortly, but save Tuesday, March 5th from 6-8 on your calendar). It was a great event and they were a great sponsor. simplifyMD is a certifed EHR vendor that strives to tailor their EHR workflow to the doctor’s current workflow. Something that dotors love to hear and experience from their EHR. They’re a web based EHR. Plus, they recently came out with these great simplifyMD and EHR cartoons. I’m sure I’ll be featuring more of their cartoons in the future.

Returning EMR and HIPAA Advertisers
Sfax – I call Sfax a returning advertiser because they first started advertising on EMR and HIPAA back in December of 2009. So, they supported EMR and HIPAA back when we were just starting to get some traction. After a short hiatus, they’re back as an advertiser. What many don’t realize is that Sfax handles the faxing for a large number of the EHR vendors out there. While I generally avoid faxing as much as possible, sometimes it can’t be avoided and so I’m always grateful I can just send a fax similar to how I send an email using Sfax. Word on the street is that they have the next version of their software coming out soon. I’m excited to check it out.

Mitochon – Similar to Sfax, Mitochon first started advertising on EMR and HIPAA back in Decmber of 2010. After a short break they’re back again as advertisers. I’ve really enjoyed watching Mitochon mature as a Free EHR vendor (They do offer the full suite of free services: PM, EMR, HIE, etc). When Mitochon first started advertising with me, they were a brand new company with a big vision and lots of ideas, but still a lot of work to do. They’ve come a long way since then with their product and their company. One example of that was in their mobile EHR solution that I wrote about previously.

Renewing EMR and HIPAA Advertisers
A big thanks to all these renewing advertisers. It’s beautiful seeing so many of them supporting us for so long.
Practice Fusion – Advertising since April 2010
EMR Consultant – Advertising since July 2009
Amazing Charts – Advertising since May 2010
Cerner – Advertising since September 2011

I’m very appreciative of those advertisers who support the work we do. As I look at the stats for the advertisers, I’m really happy that we’re providing real value to their companies.

January 31, 2013 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Health IT & EMR Advertising

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I want to take a minute to say a big Thank You to all the advertisers that support EMR and HIPAA. If you enjoy the content on EMR and HIPAA, then take a minute to look through this list and get an idea of the companies that support what we do.

The following are the new advertisers since I last posted about EMR and HIPAA advertisers, and then the list of renewing advertisers.

New Advertisers
Digital Health Conference – I wrote previously about how much I like the Digital Health Conference in New York City. So, you can imagine I’m happy to have their event advertised on EMR and HIPAA. I hope that I see many of you at the event. It’s a great one and seems to have even gotten better this year.

GE Healthcare – If any of you watched the Olympics, you have certainly seen that GE is doing a lot of work in healthcare. It is kind of cool to think that GE healthcare is advertising in the Olympics and on EMR and HIPAA. Obviously, quite a bit different goals and EMR & HIPAA might be a little more targeted to healthcare IT professionals than the Olympics.

Physia – For those of you who haven’t yet seen me talk about Physia on Twitter, this is a new venture I’m doing with Shahid Shah. Physia does really low cost physician websites. However, that’s just the beginning of what we have in mind. We plan to layer a whole set of services on top of those websites that turn your website from a glorified yellow page ad into an integral part of your office. It’s an exciting project that is going to bring physician websites into the next century.

Renewing Advertisers
Practice Fusion – Advertising since April 2010
SOAPware – Advertising since July 2010
EMR Consultant – Advertising since July 2009
Ambir – Advertising since January 2010
Amazing Charts – Advertising since May 2010
DrFirst – Advertising since January 2012
GE Centricity Business – Advertising since May 2011

I’m very appreciative of those advertisers who support the work we do. As I look at the stats for the advertisers, I’m really happy that we’re providing real value to their company.

September 5, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Hospitals Like Modular EHR, Ambulatory Likes Complete EHR

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For those reading this site that don’t know Dr. Robert Rowley, you should. He’s the original Chief Medical Officer (CMO) at Practice Fusion that recently parted ways with Practice Fusion to work on some other projects along with still practicing medicine. Along with this background, he’s a really smart guy that has a lot of knowledge about the EMR and EHR industry. Plus, he’s a downright nice guy.

The good thing is that he got addicted to blogging while working at Practice Fusion and now he’s carried over that love to his own blog (linked above). I’m sure I’ll be referencing Dr. Rowley and his blog many more times in the future. The title of this post came from a blog post he wrote about Mass Consolidation of EHR software. Here’s a quote from that post:

If one carries out a detailed analysis of 2011 Meaningful Use data, some patterns emerge. Firstly, ambulatory clinicians nearly always choose Complete EHRs – 95% of ambulatory Meaningful Use attestations were done using Complete EHRs. Hospitals, on the other hand, represent a different pattern – only 48% of hospitals attested for Meaningful Use using a Complete EHR, whereas 52% used Modular EHR components.

I found this to be a really interesting observation. It’s not all that surprising when you think about it, but it’s very interesting.

I know there’s a strong group of people that participate in the Collaborative Health Consortium that have been proponents of using modular EHR components. It looks like this is definitely happening in the hospital environment. I think that’s a very good thing.

July 20, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Meaningful Use EHR Breakout by Percentage

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I’ve seen a bunch of different websites listing the top 10 EHR vendors based on physicians who attested to meaningful use using their EHR software. This list is certainly interesting and worthy of a discussion. However, I think it’s also important to put these numbers in some context. Remember that these numbers are just for the ambulatory EHR space. The Hospital EHR numbers are a different story which I’ll probably cover on Hospital EMR and EHR.

Here are the EHR incentive numbers by EHR vendor and also the percentage of meaningful use attestations they had (Thanks to Dr. Rowley for the numbers):

EHR Vendor MU Attestations Percentage
Epic 11075 23%
Allscripts 5743 12%
eCW 4057 8%
NextGen 2237 5%
GE 2002 4%
Athena 1733 4%
Greenway 1650 3%
Cerner 1375 3%
MEDENT (Previously Community Computer Service) 1264 3%
e-MDs 1235 3%
Practice Fusion 1156 2%
Sage 1140 2%
Other EHRs (272) 14358 29%

As Dr. Rowley points out in his post, Epic is the largest vendor on the list, but they don’t market or sale their product to independent clinics or even independent physician groups. Epic’s ambulatory EHR is found in owned or affiliated clinics who use the ambulatory piece of the EHR an Epic hospital buys. So, the above Epic number actually provides an insight into how many ambulatory practices are associated with Epic using hospitals.

The numbers tell an interesting story if you take Epic out of the mix:

EHR Vendor MU Attestations Percentage
Allscripts 5743 15%
eCW 4057 11%
NextGen 2237 6%
GE 2002 5%
Athena 1733 5%
Greenway 1650 4%
Cerner 1375 4%
MEDENT (Previously Community Computer Service) 1264 3%
e-MDs 1235 3%
Practice Fusion 1156 3%
Sage 1140 3%
Other EHRs (272) 14358 38%

Once you take out the hospital dominance in the ambulatory market, the EHR market share for any one EHR vendor is quite small. In fact, the other EHR vendor category has 38% of the EHR market. The long tail of EHR software is definitely at play right now.

Plus, we have to be really careful using meaningful use attestation as a proxy for the EHR market. I recently saw a figure that only 20% of the ambulatory EHR market had attested to meaningful use. That’s right, the above numbers only represent 20% of the ambulatory market.

If my math is correct, that still leaves almost 200,000 providers that aren’t represented in the above analysis of 50k providers. Imagine an EHR vendor comes along that’s so great that they quickly capture only 20% of the 200,000 uncounted providers (no small feat). That would give them about 40,000 providers and using the above numbers they would have 45% of the EHR market (including Epic).

Of course, the current EHR vendors will continue to sale EHR software and many will switch EHR software vendors during that time as well. Plus, no doubt many of those who haven’t attested to meaningful use already have an EHR, but aren’t represented in the numbers above. They just either don’t care about meaningful use and EHR incentive money or they’re still working to get to the point where they can attest to meaningful use. However, I still think the above numbers illustrate that there’s plenty of opportunity available for an upstart EHR company to get plenty of EHR market share.

It’s going to be an exciting next couple years as we watch all of this shake out. We’ll take a look back at this post in a few years to see how far we’ve come.

June 20, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.

Interview with Dr. David Lischner Founder of Valant Medical Solutions Behavioral Health EHR

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I’ve had a somewhat unique interest in the behavioral health world ever since I started working with EHR software because the first EHR I implemented had to merge a health center together with a counseling center. As such, I was really excited to get a chance to interview Dr. David Lischner, CEO and Founder of Valant Medical Solutions. Those interested in Behavioral Health EHR software will enjoy this interview.

Can you tell us a little bit about how Valant Medical Solutions came about?
I founded Vālant with the purpose of helping behavioral healthcare providers manage their practices more efficiently. After graduating from residency in 2002 I started a group practice and became disappointed with the solutions available to psychiatrists for managing their practices. I knew that in order to successfully run and grow my practice, I was going to have to be as efficient as possible and utilize technology to my advantage. After unsuccessfully searching for software that fit my needs, I partnered with my brother who is a software developer to create the Vālant EHR.

Being a newer EHR company, what assurance can you provide psychologists and psychiatrists that your EHR is on solid footing?
First off we are the fastest growing behavioral health specific EHR on the market – and don’t plan to change that any time soon! We have been in business since 2005 and have over 1,100 providers and close to 2,000 users across the country using our product. Our product is fully certified and HIPAA compliant.

Secondly, we are 90% through a very successful round of financing, and it is clear that we have become the market leading solution for behavioral healthcare practices. We are on very solid footing.

Why do behavioral health professionals need a specialized EMR? What does Valant provide that other traditional EHR software don’t include?
It all comes down to the understanding and knowledge we have of the market. That “domain expertise” is expressed in every interaction and every feature of our product. Psychiatrists again and again tell me that we just get it, and that the product “understands how I work”, in a way that other vendors and products do not.

As an example, our new module release: Mobile NotesTM, is designed for capturing outcomes data relevant to a behavioral health clinician and using that data to not only improve care, but also auto generate narrative for the provider. That functionality is simply not present in other EHR’s and couldn’t be provided within large multidisciplinary EHR’s.

Behavioral healthcare providers want speed boats that are fast and have a very specific purpose rather than big cruise ships that have a little bit of something for everyone.

How many psychiatrists and other mental healthcare professionals do you have using your EMR?
We have over 500 psychiatrists and over 1,100 providers using our product. Including solo practices, public community health centers, mobile practices, and large group practices.

What’s Valant’s approach and thoughts on the HITECH Act and meaningful use? Do you see many mental health professionals getting EHR incentive money?
We have had over 20 providers successfully attest for meaningful use and a number of them have already received their checks. Our approach is unique in that we support “ease of meaningful use” in both our product and our support processes.

We have practice success managers that monitor the progress of our doctors and coach them along to help them achieve success. It’s not enough to simply buy a certified product. It’s important to assess the vendor and product’s ability to help you achieve success. We view the attestation process as a partnership with our doctors, treating their success as our own.

What advantages do you see for mental health professionals that have an EMR versus those that still chart on paper?
I think 3 of our biggest advantages are: greater efficiency, better patient outcomes and more revenue capture. Our newest module: Mobile Notes, delivers rapid note creation at the point of care that is faster than paper documentation. It includes automatic narrative generation from patient outcomes questionnaires and leverages an IPad’s voice recognition capability for the narrative sections of the note. It’s the perfect note creation tool for a behavioral healthcare provider and even before its release, has pried many doctors away from paper and pen.

Mobile Notes also allows practitioners to track outcomes data for their patients, providing the ability to monitor patient progress over time. This ability is not only helpful when assessing treatment plans and communicating progress to a patient, but may also become required in the future. As an example, United recently announced that over 70% of their codes would be pay for performance.

Who are Valant’s biggest competitors and what differentiates Valant from other behavioral health EMR?
I’d say that for the private practice psychiatry market, it is now mostly a race between ICANotes, Valant, and Practice Fusion.

ICANotes has been around for a number of years. I remember being impressed by a demonstration even before Valant was founded. They have had a nice system for converting check boxes into narrative. Some users are very happy with the way they can create intake notes and progress notes with just clicks. They’ve clearly developed a nice system for doing this that has generated a loyal following. It is still fundamentally a client-server product rather than a web based system. Also, when I last looked, they had not added a practice management module. [Update: Sandy Crowley commented that ICANotes does have a practice management capability.] We’ve addressed the narrative generation issue in our v5.0 release and have tied it to outcomes measures pushed from a patient portal. So we’ve combined 3 processes into one, which we think creates something much, much bigger and more powerful than check box to narrative generation alone.

The most common reason that Psychiatrists go with Practice Fusion is the price. The basic EHR without practice management is free, however the user will have to suffer through ad pop-ups and accept that your anonymized patient data is now owned by Practice Fusion. [John's Editorial Comment: Practice Fusion does have advertising, but does not use pop up ads as part of that advertising. Practice Fusion does have research rights to the data, but the doctors own the data. I'm sure many see research rights to the data as Practice Fusion owning the data, but it's worth highlighting that physicians own the data on Practice Fusion as well.] It’s an option for practices that are not bothered by this and are OK with a system that is largely text based and not optimized for behavioral healthcare.

Our big differentiator now, is our newest module release. I know that I am repeating myself. (Can you tell that I am excited about our newest release?) I really do think it is going to change the way we (clinician) practice. It will allow us (behavioral health practitioners) to get our notes done more rapidly and easily, engage better with patients, and allow us to incorporate outcomes tracking into our clinical practices.

You’ve recently launched a number of mobile initiatives, can you tell me what mobile solutions you offer mental health providers?
We were the first in our market to release a pure mobile version, which we now call Mobile Calendar. It includes a calendar with syncing to smart phones or any other calendar and key clinical information and demographic information necessary to support care when you are away from your office.

We also now have Mobile Notes, which is a more robust version of Mobile Calendar. It takes outcomes measures completed by patients on their PC or mobile devices and converts the data into narrative and then takes advantage of the iPad’s native voice recognition capabilities to support rapid note creation at the point of care.

And what mobile health options do you provide their patients and clients?
We now have Vālant Patient PortalTM. Allowing clinicians to send intake forms before the first appointment. Patients will receive push reminders to fill out intake forms before initial appointments and outcome measures before follow-up appointments. All of this is done via a secure patient platform that is branded to the practice. Patients are also able to confirm upcoming appointments, update demographic information as well as view CCDs.

5 years from now, what will differentiate Valant’s EMR?
Well it’s worth taking a step back and asking what the EHR landscape will look like in 5 years. Nearly all providers will be using EHR’s. EHR’s will be connected. Patients, hopefully, will have some control over how their data is utilized and who gets to see their data. Providers will think of EHR’s as tools that support them and work for them at the point of care. An EHR will that keep providers connected, educated and prepared. Patients will have their own set of tools that work seamlessly with EHR’s that help keep them healthy and connected to their providers. All this should be in the service of improving patient outcomes, keeping patients healthy, and improving the quality of work for healthcare providers. I believe in that vision.

By staying within the behavioral healthcare segment and not trying to be all things to all providers, Vālant will have a better chance of fulfilling this vision for our providers and their patients. It’s a big enough challenge as behavioral healthcare is 7% of the entire $2.6 Trillion healthcare market.

So in summary, we’ll be very deeply imbedded within the vertical market of behavioral healthcare and will ultimately be a platform that connects providers, patients and other areas of medicine, as they adapt to the changing healthcare landscape. We’ll continue to offer a set of tools to our providers and patients that improve provider life and work quality, the value of healthcare, and patient health.

May 4, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 15 blogs containing almost 5000 articles with John having written over 2000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 9.3 million times. John also recently launched two new companies: and, and is an advisor to docBeat. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and Google Plus. Healthcare Scene can be found on Google+ as well.