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Unpacking the Unholy Mess of EHR in America

April 29, 2019 • News • Heidi Jannenga

Recently, Fortune published a nearly 9,000-word story on the “unholy mess” of EHRs in America titled, “Death by a Thousand Clicks: Where Electronic Health Records Went Wrong.” It’s an incredibly well-written, well-researched piece that is, quite frankly, utterly depressing. In fact, if you’re still seething over the effects of the opioid crisis, you may want to hold off on reading the article in full until you’ve had a chance to recover. In it, authors Erika Fry and Fred Schulte paint a dismal picture of how a short-sighted government and profit-centric healthcare IT industry failed an entire profession, and the people that profession should be serving.

In the past, you may have heard me lament about what a shame it was that physical therapists were excluded from the Health Information Technology for Economic and Clinical Health (HITECH) Act. Well, now I’m conclusively saying the opposite: thank goodness we were spared. It might just be what saves our entire profession.

Looking Backward

During the financial crisis of 2008, a newly elected President Obama gave a radio address in which he announced his plan to improve the economy: “We will make sure that every doctor’s office and hospital in this country is using cutting-edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year,” he said. While he wasn’t the first politician to suggest digitizing health care, he was the first to put serious money behind it.

In early 2009, the US passed the HITECH Act, which, as the article explains, “carved out a hefty chunk of the massive stimulus package for health information technology.” In this “carrot-and-stick approach,” eligible providers “would qualify for federal subsidies (a sum of up to nearly $64,000 over a period of years) only if they were ‘meaningful users’ of a government-certified system.”

“Utterly Infeasible”

But, because this was a push to help the economy recover, it had to be done quickly. Thus, software vendors had to choose between creating systems that actually met the needs of their customers, and, in many cases, worked properly, and ones that met the government’s laundry list of requirements. Obviously, they chose the latter. After all, it wouldn’t have been possible to stay in business otherwise. In the article, the authors paraphrase Farzad Mostashari, the director of The Office of the National Coordinator for Health Information Technology (ONC), as saying, “The ideal, creating a useful, interoperable, nationwide records system, was ‘utterly infeasible to get to in a short time frame.'”

And yet, no one stopped the train. No one even pumped the brakes.

A Race to the Bottom

Instead, EHR companies raced to the finish line, or the bottom, depending on how you look at it, with subpar, ineffective, buggy solutions that didn’t communicate with one another and, in some cases, caused catastrophic and even fatal consequences. (Seriously: Fortune and Kaiser Health Network “found that alarming reports of patient deaths, serious injuries, and near misses, thousands of them, tied to software glitches, user errors, or other flaws have piled up, largely unseen, in various government-funded and private repositories.”)

According to the authors of the article, “The EHR vendor community, then a scrappy $2 billion industry, griped at the litany of requirements but stood to gain so much from the government’s $36 billion injection that it jumped in line.” According to Rusty Frantz, CEO of NextGen Healthcare EHR, “The industry was like, ‘I’ve got this check dangling in front of me, and I have to check these boxes to get there, and so I’m going to do that'”, at the expense of all the other boxes that should have been checked, including usability, reliability, interoperability, and ethical business practices.

Government-Mandated Problems

According to one Rhode Island ER doctor, “It’s not that we’re a bunch of Luddites who don’t know how to use technology. I have an iPhone and a computer and they work the way they’re supposed to work, and then we’re given these incredibly cumbersome and error-prone tools. This is something the government mandated. There really wasn’t the time to let the cream rise to the top; everyone had to jump in and pick something that worked and spend tens of millions of dollars on a system that is slowly killing us.”


While the vision for bringing technology to health care might have been a good one, the rush to implementation was a big, fat mistake, one that everyone seems to be paying for now, although, certainly none more than those patients and families who have been harmed. And while a truly interoperable network of systems was always the end-goal, we don’t seem to be any closer to achieving that on a large scale.

After all, no one considered the “business incentives working against it.” According to the article’s authors, “A free exchange of information means that patients can be treated anywhere. And though they may not admit it, many health providers are loath to lose their patients to a competing doctor’s office or hospital. There’s a term for that lost revenue: ‘leakage.’ And keeping a tight hold on patients’ medical records is one way to prevent it.”

Looking Forward

Apparently, many EHR systems included “gag clauses” in their contracts, preventing providers from talking honestly about the systems, but legislators are now beginning to unravel those clauses, which means we’re probably going to be seeing a lot more on the impact of these rushed-to-market systems. And I don’t think we’re going to like what we learn.

People Over Profit

Legislators are also apparently working to improve information sharing, and “in one sign of progress last summer, the dueling sharing initiatives of Epic and Cerner, the two largest players in the industry, began to share with each other, though the effort is fledgling.” High-five, guys; it’s about time. Now, it’s up to all of us to continue to demand a push toward interoperability. It won’t happen overnight, but this lack-based scarcity model of putting profit above people, and holding people hostage by hoarding their data, must come to an end. And the only way that’s going to happen is if all of us stop accepting it as status quo. It’s got to be people over profit, every single time.

A Climate of Consolidation

Interestingly, the pressure to integrate disparate systems has led to a climate of consolidation. If you think about it, this is similar to the evolution of the physical therapy market: once HealthSouth dissolved, the “giants” started to disappear, making room for small, independent practices to flourish. Now, we’re seeing the pendulum swing back the other way, with private equity coming in to consolidate those small practices. This is the natural cycle, the ebb and flow, and we’re seeing it with EHRs as well.

Niche, Purpose-Driven Systems

If this wasn’t a call to support niche, purpose-driven technology platforms that actually serve their customers, I don’t know what is. After all, the medical community has finally arrived at the conclusion that large, one-size-fits-all systems are terribly inefficient for even generalist providers (the average ER doc has to make about 4,000 mouse clicks in one shift), let alone niche ones. As a result, we’ve seen a rise in systems designed specifically to support specialists, WebPT included.

There’s a reason WebPT has remained dedicated to only serving rehab therapy professionals. We just don’t believe that you can be all things for everyone. Instead, we’ve intentionally kept our customer base small and niche, so we know who we’re serving, and we’ve done our best to create a system that meets their actual needs. And because we never had to adhere to HITECH criteria, we were able to focus our attention on getting the certifications that are meaningful to our Members. For example, in 2018 we obtained the BSI ISO 27001:2013, which is the platinum standard of excellence in protecting and ensuring all information is secured in a consistent manner.

Opportunities to Do the Right Thing

We all have opportunities in our lives to do the right thing (or not), to uphold our integrity or to allow ourselves to compromise. This is especially true for healthcare providers and companies. Let this “unholy mess” be a reminder for all of us to continue to choose the path that we believe will truly do no harm, and for all of us EMR companies to place our focus on driving efficiency, enforcing compliance, and supporting clinical decisions. In other words, let us prove ourselves as more than an EMR, but as a partner in every aspect of business for the providers we serve.

Speaking of clinical decisions, a few years ago, a number of EMRs and EHRs began implementing technology that drives decision-making, essentially putting providers in the backseat with respect to clinical judgment. We took a stand against that trend, and we took some flack for it. But, we knew in our hearts (and our guts) that doing anything less would be a slippery slope, one that could end up undervaluing the rehab therapy profession and endangering patients. Instead, we’ve taken care to ensure that our users, rehab therapists, are still the mind behind the technology. In other words, our software does not, and will not ever, drive decision-making. Instead, we provide clinical decision support, with “support” being the key word. Ultimately, the clinician, not the software, is still calling the shots, and that helps guard against errors that could potentially compromise patient safety.

You know what else guards against compromised patient safety? A thoughtfully built and operated solution. Please don’t ever settle for anything less.


What are your thoughts about the current EHR crisis? Are you as relieved as I am that PTs were left out of the HITECH Act? Share your thoughts in the comment section below.


About the Author

Heidi Jannenga, PT, DPT, ATC/L, is the president and co-founder of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi leads WebPT’s product vision, company culture, and branding efforts, while advocating for the physical therapy profession on a national scale. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has since guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

An active member of the sports and private practice sections of the APTA, Heidi advocates for independent rehab therapy businesses, speaks as a subject-matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. In 2014, Heidi was appointed to the PT-PAC Board of Trustees. She also serves as a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice rehab therapy professionals.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a lifelong fan of the Aggies. She graduated with a bachelor’s degree in biological sciences and exercise physiology, went on to earn her master’s degree in physical therapy at the Institute of Physical Therapy in St. Augustine, Florida, and obtained her doctorate of physical therapy through Evidence in Motion. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.

Heidi Jannenga

Heidi Jannenga, PT, DPT, ATC, is the co-founder and Chief Clinical Officer of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi advises on WebPT’s product vision, company culture, branding efforts and internal operations, while advocating for the rehab therapy profession on a national and international scale. She’s an APTA member,...

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Paul Potter

Commented • May 1, 2019

Heidi, the Fortune EHR article caught my attention as well. Thanks for your commentary. The stat that doctor's spent 5.9 hrs on EHR and 5.1 hours with patients in an 11.4 hr day says it all. I found it insightful that the EHR article was preceded by the brief stating that nearly every Democrat running for president supports some form of universal health care. Thus eradicating the $600 billion insurance industry; the private health insurance industry may end up going by the wayside.

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