From The Editor | April 16, 2014

Stirring The Health IT Pot

ken congdon

By Ken Congdon

Ken Congdon, Editor In Chief of Health IT Outcomes

This article is the 200th opinion column I’ve penned for Health IT Outcomes. Needless to say, there has been no shortage of things to write about. The past few years have been tumultuous and transformative ones for health IT, and I hope I captured a small piece of this journey in the pieces I’ve written. To me, the most rewarding articles I author are the ones that elicit a response from our audience or start a discussion. One surefire way I’ve done this over the years is to pose an intriguing question or take a stance on a controversial topic in my columns. When I do this effectively, the comments undoubtedly roll in. Sure, some of these comments are less than helpful — they simply either praise my post or imply that I’m an idiot. However, most of the comments I receive are extremely well thought out and articulated. These comments are pure gold. I’ve always believed that good comments are more valuable than the content of the article itself. They add clarity, insight, and alternate viewpoints to the topic being covered, and truly take the piece to another level.  The following are a few of my opinion columns that provide the best examples of this dynamic in action.

If Not Obamacare, Then What? — 11/18/2011

What better way to strike a nerve with our audience than to offer my opinion on one of the most controversial pieces of legislation to be drafted over the last century? In this column, I express the need for U.S. healthcare reform and explain why I support the Affordable Care Act (ACA) even though I feel it is an “imperfect” solution. Needless to say, Obamacare is an extremely polarizing issue, and readers were quick to offer their own opinions on the subject. Here are a couple comments that I felt helped round-out the argument:

“The problem here is simple. A bad law is no substitute for a good, proper law. Obamacare is too rife with politics to accomplish much. Here are 3 simple things to be done after repeal of Obamacare.
1- Allow every health insurer to sell across state lines, to all 50 states and American territories.
2- Enact medical tort reform. The Texas model has worked well, and served to reduce malpractice premiums to tolerable levels, instead of their current multi-million dollar premiums.
3- Pro-actively stop fraud and wasteful Medicare/Medicaid spending. There is a bi-partisan bill in the Senate that can address this issue, if only Harry Reid will allow it to be debated. It is the Breaux-Tauzin initiative. It would replace the $60 billion annually spent to 'chase' fraud after it is paid. Breaux-Tauzin intends to verify and vet payees before the check is sent. Rarely is any money recovered under the current 'backwards' scheme.”

“I agree that the healthcare reform law is far from perfect but it will achieve some long overdue changes. We can't stay on the current trajectory. SPXZ is wrong about his suggestions. Selling insurance across state lines would just cause a race to the bottom while insurance companies move to the states that allow the most pitiful excuse for coverage and payment. Tort reform has been done in several states and had almost no impact on availability or price of medical care. Waste, fraud, and abuse don't need a new law. Emphasizing prevention and quality may help to bring down costs. We've been incentivizing quantity over quality for too long and at least ACA gets us started on path to cost containment. The act will change and improve over time, but we have to start somewhere.” — js714

Why Are Patients Anti-EHR? — 8/16/2012

In this article, I express my concern over a Xerox Healthcare and Harris Interactive survey that revealed only 26% of patients stated that they wanted their medical information recorded electronically. I write that patients clearly don’t understand the benefits that EHR technology can have on their care. I also argue that many of their negative perceptions about EHRs are the direct result of poor experiences they’ve had with clinicians using the technology. Not everyone agreed with my assessment.

“I disagree with this analysis strongly. The EHR takes an ENORMOUS amount of time away from the doctor-patient relationship. The physician spends 5 minutes doing an H&P and 15 minutes battling with filling in code categories so he can COMPLY with CMS, avoid licensure infractions, and maintain a revenue stream to support his office and family — all because he is forced to do things the way the GOVERNMENT wants. Doctors who live in the "ivory tower" of medicine love the EHR for various reasons. PCPs and similar practitioners "in the trenches" on-average hate the fact that they have to deprive the patient of a thorough H&P. Remember, a good H&P is responsible for a most accurate diagnosis. EHRs deprive docs of the "luxury of time,” which will have adverse consequences on patient and doctor.” — Joseph Guida, MD

“I think that patients are resistant because some are smart enough to realize that all of this data collected on them will no doubt be used in ways they certainly wouldn't agree to. Once this info ends up in an electronic record that is exchanged, all bets are off. While my doctor might have his security act together, who knows about the other physicians, hospitals or government agencies that are authorized to access my health record? Most practices are lax on network security. HIPAA is not changing their behavior in this regard, despite what the EHR folks would like you to believe.” — Guest

Is Healthcare Entering An Era Of Technology Discrimination? — 1/8/2013

In this column, I share a personal experience where my visit to a local lab was expedited through my use of an online scheduling portal. While my experience was enhanced as a result of the technology, the seemingly preferential treatment I received only served to outrage the masses of waiting patients that didn’t preschedule their appointment via the portal. These patients cried foul because they were either unaware of the portal, didn’t know how to use it, or didn’t own the technology required to access it. As a result of this experience, I question whether or not the healthcare technology revolution will provide all patients with an even playing field. Readers seemed genuinely moved by this story, and one even offered suggestions on how this uproar could have been averted.

“Ken, as you pointed out, most patients don’t know about the online scheduling portal. It is not enough to let disturbances promote awareness and adoption of the portal. The lab should have a big sign in the waiting room announcing that patients can save time by making appointments online through the portal. In a large font it should say something like “Don’t waste your day waiting… Schedule an appointment online!” In a smaller font, it should say that those who do not have access to a smartphone or computer can use a computer for free at any of these nearby places (and of course it should list the places with their addresses). The sign should also have an image of the interface – preferably with numbers and arrows to show the steps to take to schedule an appointment. In addition, the lab could hand out a flyer that shows the image with instructions for use. The sign would not only inform the patients, but would also save the receptionist the time and aggravation of dealing with irritated patients who see someone who had made appointment get taken care of before them.” — Beverly Wachtel

The Truth Behind “Free” EHRs — 1/25/2013

In this article, I go beyond the hype and take an in-depth look at two of the most popular “free” EHR platforms on the market today (Practice Fusion and Hello Health). I examine their respective capabilities and business models and attempt to provide readers with the unbiased information necessary to effectively evaluate these “free” options as part of their EHR selection process. As it turns out, a lot of our readers had something to say on this topic as well.

“Free is good, but buyer beware! The companies you mention in the article make it easy for doctors to implement EHR with one click of a button. The 2 things that concern me most about these companies are data security and ownership of patient data. I tend to trust an EHR provider that has its own data center more than a vendor that stores your patient records somewhere in the cloud. Ask yourself the following question before clicking that Download button — ‘Do I own the patient data?’ Read your Terms & Conditions carefully and you will be able to answer that question yourself.” — George

The EHR Honeymoon Is Over — 7/23/2013

In this column, I react to the 2013 State of the Ambulatory EHR Market report by Black Book Rankings. The report revealed rampant dissatisfaction with ambulatory EHR software among providers. I examine the shortcomings of the ambulatory EHR products currently on the market and suggest steps vendors should take to enhance their offerings. Several of our readers offered their own theories and suggestions.

“I obtained my AHIMA HIT Pro IM at the end of 2011 and what I have seen in the EHR market reminds me of the late 80s when document imaging was an immature market.  Only this one is far more costly. I have had several discussions with the ONC about "certified" EHR products that were just terrible to implement because the developers were unable to support the way a licensed and experienced physician practices medicine.  So many clinicians believe having an EHR is a mandate, and that is a myth. If you don't have one, you simply miss the incentive payments and CMS threatens to withhold 2% on Medicare reimbursement. Ask a practitioner who has been burned by a bad EHR and he will likely tell you he’d rather opt for the Medicare penalties than go through another EHR implementation.
Vendor consolidation needs to settle down just like it did for imaging in the 90s and it will be the companies that do more for less and listen better than their counterparts that remain competitive.
I have more success by adding electronic charts while extending the capability of a Practice Management System that is installed, well used, and understood. Denials can be worked and reimbursement is faster so the clinician can wait for the dust to settle in the EHR community. They need an ROI that is quick and a certified EHR system was never intended to pay for itself. It was just intended to reduce medical errors and improve patient safety. Great intention, but this needs years before the deliverable can be successful and cost justified.”
— Kim Frasch

“While there are plenty of EHRs that fail due to design/technology, I would venture to guess that, with other products, as much dissatisfaction is the fault of the user as it is the fault of the EHR. While many people might just assume that charting is charting, whether paper of electronic, EHRs are a different beast. It has been my experience that many people make their own problems by expecting the software to do things as they feel they should be done. When the software doesn't respond as they think it should, they blame the software. Proper training and a commitment to knowing your software is an important piece of the puzzle that is currently missing in many cases.” — Michael Annicelli

Why Another ICD-10 Delay Stinks — 4/2/2014

In this column, I am vocal about my opposition to the ICD-10 transition delay that was included in the recently passed SGR “Doc Fix” bill. I offer several reasons that support my contention that another ICD-10 delay is bad news. Not everyone agreed with me. For example, one physician added the following, seemingly sarcastic, comment to my article:

“And ICD-10 is so full of useful codes, which will no doubt improve certain injury-related outcomes such as V91.07XA – Burn due to water-skis on fire, initial encounter.” — Doug Roberts, MD   

However, other readers had my back.

“The current Oxford English Dictionary is full of funny, seldom used words. Doesn't stop it from being a more useful dictionary than one printed in 1970.” — mloxton

“Dr. Roberts offers a good example of why ICD-9 doesn't work anymore. The only ICD-9 codes available to describe the patient he presents would be E002.6 — Activities involving water skiing and wake boarding and in addition, you would have to also include the only code available to describe the external cause of the burn, so E899 — Accident caused by unspecified fire is your only choice. Unfortunately, ICD-9 doesn't allow specific codes to accurately identify whether the patient is being seen for the first time or months later for follow-up so no other codes would be assigned. I completely agree how the CDC, NCVHS and others who actually track these codes would have better tracked the injury related outcomes with ICD-10 in this example.” — Heidi Kollmorgen

Is Epic Future Proof? — 4/9/2014

Finally, this article I penned just last week clearly resonated with readers. In it, I question the long-term viability of the reigning EHR leader, Epic Systems, given its client-server architecture and MUMPS-based programming language. I speculate that these characteristics could prevent the platform from being as flexible and innovative as it needs to be in a rapidly changing healthcare industry. Here are a couple comments that added clarity and depth to the article.

“Actually the use of MUMPS is a red herring — it can be easily made accessible to the new breed of JavaScript developers and can play as a highly effective and modern JSON database (see and ). The real problem, as I see it, is the client-server architecture that uses a near obsolete technology, with business logic embedded in the thick-client instead of at the MUMPS back-end, preventing it from being easily leveraged into a browser-based alternative.” — Rob Tweed

“You make some excellent points here, but some aspects of the discussion are missing. No cloud-based EHR has yet made the steps to fully support complex medical decision making across an enterprise. Best-of-breed integration sounds fantastic but the standardization of data is a huge challenge that the cloud does not fix. A client with multiple source systems (lab for example) needs to harmonize data internally so similar tests are correctly identified as the same test when the methodologies are the same. That level of certainty is a challenge when that work needs to be done externally. Choosing Epic now cannot make it future-proof but everyone is learning now that the hurdle to move from one EHR to another is very costly and overwhelming. If a product cannot meet your needs now, you are not going to be able to look to it as the next best thing in the near future.” — Michael Lee