Lab Soft News

Cleveland Clinic Serves as Consultant with Dell for Epic EHR Deployments

The Cleveland Clinic is moving aggressively into the hospital consulting business. A previous blog note addressed one facet of this initiative (see: Cleveland Clinic Launches Consulting Relationship with ProMedica System in Toledo). Now comes news, released at HIMSS, that it's getting into IT consulting with a focus on the Epic EHR (see: Cleveland Clinic, Dell pair up to help late adopters, switchers implement Epic EMR). Here is an excerpt from the article:

The Cleveland Clinic is teaming up with Dell to offer Epic EMR consulting and implementation services to other health systems and practices.The clinic, which has been using Epic for nearly a decade, already consults with nearby healthcare systems and practices through its MyPractice Healthcare Solutions services. Now, with the addition of Dell Healthcare and Life Sciences’ technology infrastructure, it’s planning to scale those services nationwide. Together the pair will work with physician practices and health systems to plan, implement and customize the Epic EMR system to meet their needs. Customers can install the system on their own servers or use Dell’s cloud-based services to host their data, the duo said in an announcement. Under the partnership..., Epic would be paid a licensing fee, but providers and health systems would work through Dell and the Cleveland Clinic....It’s not a surprising move for the clinic, which has turned its own expertise into consulting services in other capacities, too. For example, the clinic generates revenue through the Healthcare Innovation Alliance, a seven-member consortium that leverages its commercialization expertise to help other institutions turn their employees’ medical inventions into commercial products. In the realm of electronic health records, it’s worth noting that the market for first-time buyers is narrowing. Last year, nearly 80 percent of office-based physicians had some kind of electronic health record system installed, according to the National Center for Health Statistics. But as Stage 2 meaningful use looms, vendors are facing challenges upgrading their products and obtaining certification, and market surveys have suggested some providers are switching vendors.

Very interesting news. The Cleveland Clinic is clearly one of the most innovative healthcare organizations in the country. Similarly, Epic is one of the leading EHR vendors in the country but is short on physician expertise and strategies for promoting efficient delivery of healthcare services. This new relationship places the Cleveland Clinic and Dell as key intermediaries in the deployment of Epic software with whom providers and health systems would interact. I have commented that the deployment of EHRs like that of Epic can serve as a drag on physician productivity (see: Some of the Details Behind the Maine Medical Center/Epic EHR Meltdown; Ambulatory Physicians Cite EHR Design for Their Recent Loss of Productivity). It's possible that the Cleveland Clinic's consulting efforts might help to ameliorate this problem, in part by convincing Epic to modify some of its code and screen design.

Dell has been itching to become more active in healthcare for years. Flying with the Cleveland Clinic logo will  support these ambitions. I have also been a strong advocate for wider deployment of cloud technology in healthcare (see: Google Now Supports HIPAA's BA Agreements for Cloud Computing) and this initiative should promote this goal. One more thing. I am sure that having Cleveland Clinic as an IT consulting partner for smaller hospitals can do nothing but enhance its patient referring network and super-regional reputation for complex surgical procedures (see: The Transition to "Big Med": Need for Emphasis on Standardization and Cost).

New Details about the Pathology Informatics Summit 2014 Now Available

The Pathology Informatics Summit 2014 will take place on May 13-16, 2014, in Pittsburgh. This is the only conference in the country that is devoted exclusively to pathology informatics. No lab professional with an interest in IT should miss it. The schedule for the entire conference is now available for review.  

Three workshops are offered on the first day, May 13: (1) A Comprehensive Review of Pathology Informatics; (2) HIMA Imaging Science; and (3) Informatics-Driven Molecular Pathology. A fourth workshop is also offered in the evening of May 14 entitled Digital Pathology 101. Admission to these workshops is included in the conference registration fee. 

The plenary conference begins on Wednesday, May 14, with two tracks: LIS Technology in Anatomic and Clinical Pathology. A third track will be used to showcase the best pathology informatics abstracts that are submitted as well as additional proffered lectures. Here is an alphabetical list of faculty, all leaders in the field.

There are five platinum vendors signed up for the conference at the present time: Cerner, Leica, Hamamatsu, SCC Soft, and Sunquest. Here is a list of the seven participating silver vendors with an anticipated additional dozen or more by the time of the conference: Apollo LIMS, General Data, LigoLab, Orchard Software, STS/Software Testing Solutions, Visiopharm, Xifin. 

On-line registration is offered. On-line hotel reservations at the Wyndham Grand Pittsburgh Downtown is also available.

GlaxoSmithKline Lobbies Against E-cigarettes; Motivation for Company Clear

Here's the best article I have come across about e-cigarettes from Business Week (see: E-Cigarettes: A $1.5 Billion Industry Braces for FDA Regulation). You may be aware that there is now a discussion taking place about whether e-cigarettes should be regulated and also whether they will cause non-smokers to get hooked on nicotine (see: A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It). At any rate, here's another slant on the issue about regulation of the product: GlaxoSmithKline is actively lobbying for restrictions on e-cigarettes (see: GlaxoSmithKline lobbies for restrictions on e-cigs, which compete with its nicotine products). Below is an excerpt from the article:

GlaxoSmithKline...says it's worried about adequate regulation for e-cigarettes, and it's pushing Europe to require more. After all, more red tape to cut through for e-cigarette makers can't hurt the British pharma giant, which competes against them directly with its Nicorette gum and other quit-smoking products....[E]mails from the GSK healthcare division's VP of European public affairs, Sophie Crousse, urge the European Commission (EC) to follow in the U.K.'s footsteps by requiring that e-cigarettes be licensed as medicines. The EC is currently revising its Tobacco Products Directive to regulate products, like e-cigarettes, that are linked to tobacco use but don't actually contain tobacco....Glaxo, as well as fellow smoking-cessation product makers Johnson & Johnson...and Novartis..., have good reason to care about the regulatory details, with e-cigarettes predicted to bring in $7 billion in sales by the end of this year.....Glaxo also sought assurances that the amended directive would apply to e-cigarettes already on the market and put the kibosh on e-cigarette advertising. GSK has backed other regulatory action in the past that would boost its product line; in 2011, it supported a move to nix recommendations against long-term use of nicotine gum, lozenges and patches. Still, the company insists its No. 1 priority is safety.

It's great to know that the big pharmaceutical companies are so concerned about our health. Regarding my personal opinion of e-cigarettes, I think that they will increase the number of people addicted to nicotine. I was impressed by the Business Week article cited above e-cigarettes. It was written by a former smoker and he discusses how pleasant and non-irritating is was to inhale the vapor from e-cigarettes. Different flavors of e-cigarettes are offered to increase their appeal to youngsters. Here's a quote from that article:

...[M]ost companies also have less conventional flavors [than menthol]. Blu offers Peach Schnapps, Java Jolt, Vivid Vanilla, Cherry Crush, and Piña Colada, presumably for people who don’t just like a drink with a cigarette, but in one.

Predictions for the Post-EHR IT Era; Business Continuity Challenges

The title of a recent article referred to the "post-EHR era" and caught my attention (see: New to-do lists loom for 'post-EHR era). It turned out to be a list of ten predictions about healthcare IT.  It made reference to an IDC report (U.S. Healthcare Provider Predictions for 2014) and quoted an interview of the author of the report, Judy Hanover. Here is the list of ten predictions plus some of Hanover's remarks about each of them:

1. First-generation EHR will continue to fail

...[T]he EHR as the go-to place where providers will work, in a sense, is failing. We're seeing EHRs getting replaced with other EHRs that support broader platforms, more apps, more capabilities....The EHR as the be-all, end-all for care delivery, I think that idea has failed, and we're seeing providers continue to realize that."

2. The industrialization of healthcare will accelerate

...[We are seeing] the transition of healthcare from a one-off experience with a patient to a repeatable, standardized process of care where we have more uniform outcomes and approaches to care delivery. That translates to "better-quality care with improved productivity for providers, so we can really begin to create some value in healthcare delivery."

3. Healthcare cloud adoption will flourish

... I think the security issues that have surrounded the cloud have proven to be largely unfounded. The majority of CIOs we talked to in this survey felt that they could provide better security in the cloud than they could in their on-premise deployment. And with the HIPAA omnibus rule, and the ability to sign BAAs, that reservation about security in the cloud has decreased.

4. The criticality of analytics will grow

...The analytics we have now is not as precise as we'd like, but providers are still learning a lot about their costs, doing clinical and financial analysis. They're identifying high-risk patients to better understand their outcomes. 

5. Personalized clinical decision support will become closer to reality

... [W]hat I see coming close to reality is clinical decision support moving from rules-based systems that are generalized and don't really reflect the particular patient's medical history..."So we're going to move from a rules-based CDS that fires an allergy alert for medication every time it comes up, to ones that really look at a patient's history in the system and only fire when it's appropriate. 

6. Provider consolidation will continue

...One driver...has to do with "haves and have-nots" -- smaller, under-equipped hospitals being scooped up by larger organizations. I think some of the consolidation is coming from that gap: the haves consolidating with the have-nots, to cross that gap. 

7. Revenue cycle management will become mission critical like never before

....We also see hospitals creating a lot of efficiencies by adding computer-assisted coding and clinical documentation improvement programs, and we think that's going to be critical. The provider organizations that have [better revenue cycle management] in place are going to do a lot better with ICD-10 than the ones that don't. I think we're going to have a major claims denial issue with the implementation of ICD-10, and those are great ways for providers to prepare to do a little bit better at ICD-10 than their peers.

8. Underinvestment in business continuity will come home to roost

...But providers, when [EHRs] break down now, are really having to stop work. As organizations mature and there's staff turnover, we see fewer and fewer staff in the hospital who know the process from when we used to do it on paper. So we've really come to depend on EHRs and we can't afford downtime....So investing in data recovery and business continuity tools – particularly as providers become more ready to use the cloud, and to access capabilities in the cloud that were very expensive or very difficult to install on-site, or even just the ability to have a second site for business continuity via the cloud is becoming very attractive. 

9. Security and privacy issues will drive providers to the private cloud

This is one of the things that's driving private cloud investment: the ability to better support security requirements,....Our survey results show that 67 percent of respondent say they can offer better security than the level their own IT team can provide when they use the cloud. That's starting to solve a lot of privacy and security issues and reduce risk."

10. Compliance will cost you more than you think

With all of these investments, we see providers under-budgeting for [IT compliance]....The size of their IT budgets in general – and the amount that's pointed towards business continuity and disaster recovery, and compliance with privacy and security, in particular – is woefully small. They are going to start to see penalties, and see those problems grow in importance. And they will need to budget for it. 

All of these predictions are interesting and I may return to comment about some of them later. However, I now want to focus briefly on the issue of business continuity, number eight in the list above. When I started working with LISs more than three decades ago, we viewed an unscheduled LIS "down" of an hour as a very serious problem. If an unscheduled one-hour LIS "down" is that serious, what do you call a 24-hour "down" of an EHR affecting all patient information in a hospital (see: Sutter Health System EHR Crash Reported by Nursing Union)? To quote Hanover: As organizations mature and there's staff turnover, we see fewer and fewer staff in the hospital who know the process from when we used to do it on paper. So we've really come to depend on EHRs and we can't afford downtime. So the obvious question that needs to be addressed by hospital executives is how to avoid any EHR downtime?

Lab Testing Now Being Offered in Walgreens California Stores

After a relatively long gestation period, the business model for retail walk-in health clinics is becoming clear. The  winner in the competition, in my opinion, will be the large drugstore chains like CVS and Walgreens. In previous notes, I had also discussed the "big-box store" clinics that had been launched by Walmart as part of the mix (see: Wal-Mart Launches Co-Branded Walk-In Medical Clinics in Three Cities). I also suggested that walk-in clinics developed by health systems might begin to offer lab testing beyond CLIA-waived tests (see: Health Systems Launch Walk-In Clinics). A recent article indicated that Walgreens is extending its "preventive health services" in 200 of its California stores by offering cholesterol and blood glucose testing (see: Daily cholesterol, blood glucose, body comp tests launch at Walgreens). Below is an excerpt from it:

Further expanding the scope of convenient, preventive health care services provided by its pharmacists, Walgreens is now offering daily testing for cholesterol, blood glucose and body composition at nearly 200 stores in California. Each test also includes a free blood pressure reading and personal consultation with a Walgreens pharmacist.....[A Walgreens spokesperson said] ”Tests are available to those ages 18 and over at most stores during pharmacy hours daily with no appointment necessary. Walgreens offers health testing daily at more than 4,100 stores in 41 states

Walgreens has been heavily promoting its flu shots with in-store advertising and a web page (see: Stay Well with a Flu Shot). The cost is $31.99. Here's the price list for all the other vaccinations that are offered (see: Vaccines). HPV and shingles are much more expensive than flu but I am sure that a large part of this is the cost of the vaccine. Walgreens has gone a long way toward establishing itself and its stores as outposts for prevention and wellness services. Simultaneously, it has enhanced a much broader role for its pharmacists in the minds of healthcare consumers.

In its web marketing for the shingles vaccination, the company draws a distinction between scheduling an appointment at one of its pharmacies versus its healthcare clinics (see: What is shingles?; Walgreens Introduces “Healthcare Clinic,” Rebranding its In-Store Take Care Clinics). Both offer vaccinations but the following distinction is drawn on the web site: "Your personal appointment at Healthcare Clinic will be with a board-certified Family Nurse Practitioner or Physician Assistant. Your personal appointment at Walgreens Pharmacy will be with a registered Walgreens Pharmacist."

The next question to consider is what's the next step for Walgreens and its competitor CVS in terms of diagnosis and preventive medicine. A logical progression would be blood collection and an expansion of its lab test menu in states where a physician test order is not required. I don't think that the company will move quickly  on this. Whatever the next step, however, I think that the nurse-staffed Walgreens' healthcare clinics will continue to expand and carve out an important role in basic healthcare delivery.

Keeping Tabs on Patients Post-Discharge Via Telemonitoring

Home telemonitoring of newly discharged patients by hospital personnel has a bright future as long as healthcare payers support the concept and are willing to reimburse for it. A recent article discussed a new telemonitoring initiative at the Partners health system in Boston in collaboration with Philips (see: Partners keeps tabs on patients at home). Below is an excerpt from a recent article about this topic:

With an eye on reducing hospital readmissions and boosting patient care coordination, Partners HealthCare at Home, a division Partner's HealthCare in Boston, is rolling out new telemonitoring technology. The technology, from Royal Philips, will be employed to provide improved clinical oversight for newly discharged patients and those with chronic conditions, such as congestive heart failure. Monitoring patients at home makes it possible for the nursing staff of Partners HealthCare At Home to track vital signs and intervene earlier with medical attention when it’s needed. The goal is to reduce costly hospital readmissions, and the savings can add up to millions of dollars, as Partners has shown. "Remote patient monitoring does more than improve care coordination," Sue Beausoliel, RN, vice president of operations at Partners HealthCare at Home..."It provides a tool for patients to actively engage in their own health management. As the healthcare industry focuses more on improving patient experience and outcomes while reducing costs, technologies such as home monitoring contribute toward improved quality of life. Instead of having to wait for the next appointment, this real-time data daily monitoring helps us connect with patients, track their health status, alert us to a problem and intervene earlier before it becomes full blown." ....As [a Philips executive sees it]  sees it, the Affordable Care Act, introduced a "new world order" to healthcare that has spurred many hospitals to follow their patients home, so to speak....."You can’t have this siloed care, where we're paying you for taking care of people in the hospital; we’re paying someone else to take care of patients out of the hospital. You two don’t really interact. You don’t coordinate your care." 

Here's a short quote from a article on reimbursement for home health monitoring (see: Reimbursement for home monitoring gradually expands):

Barriers to reimbursement for telehealth services are falling, slowly. One of the most recent victories came in Massachusetts, where lawmakers this summer approved a general appropriations bill that included Medicaid reimbursement for remote monitoring services in patient homes. This action...makes Massachusetts the 12th state to approve Medicaid payments for home monitoring, according to the American Telemedicine Association.The ATA reports that 19 states have mandated private insurance coverage for traditional, clinician-to-clinician telemedicine services, but reimbursement for home monitoring when a healthcare professional is not always present has been much harder to come by. In fact, the Massachusetts legislation has a bit of a catch: it applies only to home health agencies, not hospitals or physician practices, which is why the Massachusetts Medical Association declined to comment.

I believe that, slowly, hospitals inpatient services are becoming less relevant and necessary. Outpatient surgery keeps expanding its scope to encompass more complicated cases. I first ventured into a discussion of the hospital of the future with a blog note about "bedless" hospitals and virtual physician and nurse visits (see: The Future of Healthcare: Virtual Physician Visits & Bedless Hospitals; Global Study Finds Majority Believe Traditional Hospitals Will Be Obsolete in the Near Future). Home telemonitoring of recently discharged patients has the possibility of morphing into virtual inpatient stays. For the latest twist on alternatives to high-cost inpatient beds, consider an outpatient oncology infusion center coupled with an extended stay hotel (see: Top 5 things to watch for as University of Michigan's North Campus Research Complex grows). Such a facility allows cancer centers to serve a larger population of patients while offering close 24-hour monitoring and support.

Free Webinar on Integrated Disease Reporting Presented by API and Sunquest

The Association for Pathology Informatics (API) and Sunquest Information Systems will be offering a free , one-hour webinar on integrated disease reporting on February 25th at 12:30pm PST/3:30pm EST. Participating faculty members will be Monica E. de Baca, MD, of Hematologics and George Birdsong, MD of Emory University School of Medicine/Grady Health System.  

As the complexity of the data used to manage patients with chronic diseases has grown, the task of the clinician has become increasingly difficult and time consuming. At worst, patient safety can be compromised or delivery of care delayed due to the difficulty in retrieving all of the necessary data elements needed for treatment. This presentation outlines a framework that takes advantage of the capabilities of electronic reporting to create an Integrated Disease Report (IDR), a single, succinct, integrated, interpretative report comprising all data pertinent to the disease: pathology results, laboratory data, imaging correlations, risk profiles, and therapeutic implications.

You can register for the webinar here. Non-Sunquest clients should ignore the field labeled "site code."

Hyperpersonal Technology on Smartphones; A New Term for Health Apps

In a recent article in the New York Times about Intel's resident social scientist (see: Intel’s Sharp-Eyed Social Scientist), mention was made of hyperpersonal technology with regard to fitness trackers and voice recognition apps. I had never heard this term used before but it struck me as useful. Think about the term personal computer (PC) that has been used for decades. It was originally coined to distinguish between large-scale office and corporate computers and the smaller devices owned and used by individuals. PCs provide personal computing services to individuals. Hyperpersonal technology draws a distinction between apps that support communication between individuals such as voice calls and email and those that are focused entirely on individuals. The various health apps running on smart phones are perfect examples. I have discussed  health apps in detail in previous notes (see: FDA Gearing Up to Regulate Smartphone Apps and Social Media? Or Not?; The iPhone Effect: Smartphones and Their App Ecosystems Have Changed Everything; Smartphone Otoscope: Diagnosing Middle Ear Disease at Home?; FDA Begins to Regulate Smartphone Health Apps).

There is probably nothing more hyperpersonal than the management of one's own health. Medical apps running on smartphones are going to have a major effect on healthcare in the U.S. I know that inexpensive home devices such as glucometers and blood pressure monitoring devices have been available for many years. However, the linkage between such devices and smartphones, functioning as small computers, is going to be a major step forward (see: Healthcare in Developing Countries; Relationship to Smartphone Apps and Devices). Knowing one's blood pressure or blood glucose is important but combining these devices with a smartphone makes the data that is generated actionable. Such data can also be uploaded to healthcare providers for monitoring over time or to alert them if there is an emergency. Connecting a fitness armband to a smartphone can provide a fitness plan for the individual and assess progress. Health apps can also provide suggestions about the diagnosis of various ailments and when it is necessary to seek urgent care.

Google Now Supports HIPAA's BA Agreements for Cloud Computing

I personally believe that hospitals should move most, or even all, of their IT transactions to the cloud and have blogged about this idea in previous notes (see: Cloud Computing in Healthcare: Key Questions to Ask; Finally, A Clear Definition for Cloud Computing; McKesson Offers Cloud Computing and Virtualization for a CVIS; Hospitals Need to Expand Cloud Services Starting with Radiology Images; Cloud Based Genomics Launched by Baylor and Amazon Web Services). There are various reasons why the healthcare leadership has not adopted cloud computing to any substantial degree but the one I hear most frequently is that the cloud storage vendors are not HIPAA-compliant. A recent article indicated that Google has announced that its cloud platform is now HIPAA-friendly and it will support business associate (BA) agreements for its  customers (see: Google cloud gets on board with HIPAA). Here is an excerpt from an article discussing this change:

Google started inking business associate agreements back in 2013 when the HIPAA Final Omnibus Rule went into effect, making BAs accountable for violating certain HIPAA privacy and security rules. This February, the company went one step further. "To serve developers who want to build these applications on Google's infrastructure, we're announcing support for business associates agreements for our customers," wrote Google Cloud Platform Product Manager Matthew O'Connor, in a Feb. 5 company post. "We’re looking forward to supporting customers who are subject to HIPAA regulations on Google Cloud Platform." The HIPAA final omnibus rule took effect September 2013, and it made BAs directly liable for violations of HIPAA rules. The rule also expanded the definition of a BA to include health information organizations, e-prescribing gateways, PHR providers, patient safety organizations and subcontractors with access to protected health information. Moreover, subcontractors are now defined as business associates. After the rule went into effect, many covered entities reported having difficulties getting BAs to actually sign business associate agreements.... Organizations "new to the party, like cloud providers who thought they were never business associates in the first place, are having to play catch up," ...Cloud computing in healthcare is poised for explosive growth. By the end of 2013, analysts estimated the global market would hit nearly $4 billion, representing more than 21 percent growth from 2012.... "EMR is driving this market," said Bruce Carlson, publisher of Kalorama Information...."Hospitals are building great systems for gathering electronic records, but they need solutions to store all of that data, and it can't be a new server wing that might compete with needed space for care."

Obviously, the vendors of cloud services must sign BA agreements with hospitals if they want to gain their cloud business. However, I am not optimistic that this step by Google will be sufficient to convince hospital CIOs to switch to cloud computing. One reason is that such an action will reduce the number of hospital employees under the control of the CIOs as well as they space that they command. Political influence in hospitals is, in part, related to these two factors. Another consideration is that EHR vendors such as Epic have been able to keep hospital CIOs on a very short leash. Cloud computing in hospitals outside of radiology and pathology is not going to happen until EHR vendors like Epic approve of the change and decide to accept and integrate cloud technology for their hospital customers. If and when they do so, the cost advantages of cloud computing will probably largely accrue to them and not to their hospital clients.

Scribes Help to Ameliorate EHRs Deficiencies But Add to Costs

Medical scribes are physician extenders employed frequently in hospital Emergency Departments and other  units (see: Shift of Hospital EMR Data Entry Tasks from MDs to Scribes; The Emergence of EMR Scribes as a New Category of Hospital Employees; Greater Adoption of the Scribe Model for EMR Data Input). these personnel transcribe dictated notes the busy physicians into the EHR. A recent article in the New York Times discussed this new category of hospital employees (see: A Busy Doctor’s Right Hand, Ever Ready to Type). Below is an excerpt from the article:

For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer. Five years ago, only 10 percent of hospitals and doctors’ offices used electronic health records. But now the adoption rate is nearly 70 percent, thanks to tens of billions of dollars of federal incentive payments. And on the heels of electronic records has come the growing popularity of scribes. A study published jointly in October by the American Medical Association and RAND Corporation found that electronic health records were a major contributor to physician dissatisfaction, as doctors negotiate a cranky truce between talking to and examining the patient, and the ceaseless demands of the computer. And a recent article in the journal Health Affairs concluded that two-thirds of a primary care physician’s day was spent on clerical work that could be done by someone else; among the recommended solutions was the hiring of scribes.“Making physicians into secretaries is not a winning proposition,” said Dr. Christine Sinsky, a primary care physician at Medical Associates Clinic and Health Plans, in Dubuque, Iowa, who also researches physician dissatisfaction. Dr. Sinsky, who was an author of the article in Health Affairs, has visited more than 50 primary care practices over the past five years, in the course of studying ways to stem high rates of physician burnout. She has found that physicians who use scribes are more satisfied with their work and choice of careers.  The inconsistency isn’t lost on health care experts. In most industries, automation leads to increased efficiency, even employee layoffs. In health care, it seems, the computer has created the need for an extra human in the exam room.

Here's a snap one-question quiz for you:

Healthcare is the  the only business sector in the U.S. in which the wider deployment of computer technology (EHRs) is causing an increase the the number of personnel required to document patient care. One of the most common rationales for investing in IT is to reduce human work inputs and costs. Which of the following answers explains this unexpected outcome in healthcare:

(1) The delivery of healthcare is much more complex than comparable professional fields such as engineering, architecture, and finance;

(2) Inadequate training on EHRs is being provided by hospitals and EHR vendors;

(3) EHRs are poorly designed regarding clinical work flow, causing the most highly skilled and compensated hospital employees to be burdened with inefficient data input tasks.