Imagine an EMR without Billing

For today’s weekend post, here’s a thought provoking comment:

Imagine what EMR software would look like if it didn’t have to worry about billing, insurance and reimbursement. Would we then see much higher quality EMR software in regards to patient care and physician workflow?

I look forward to reading your thoughts.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Small world; I started writing a very similar article after web conferencing a couple of days ago with a vendor who has a great EMR for ophthalmology but that does not handle billing. I’ll write more on my blog but my question is can an EMR be so good that it is worth getting if you need to use another program to handle the billing?

  • hmmmmmmmmm…… Its a thought provoking question; in our case, we can redploy the resources to focus on EHR as opposed to the logistics of billing. Billing is part of the territory; comes with it. At the end of the day, we consider Ambulatory Care Physicians and Clinics as small businesses that do not have to be burdened with multiple vendors; rather have one throat to choke…………… Ideal to have an excellent EHR system with required billing functionalities that can be improved over time.

  • The fact that the question is even asked is a measure of how dysfunctional the system is.

    Ask yourselves: Would anyone even consider the needs of ticketing or salaries or other business considerations when writing software used by the pilot to fly a commercial jet?

    Different problem. Different needs. Different risks and benefits. Different mindset. Different vocabulary. Should be a different system. Full. Stop.

  • @pheski –

    Nice analogy.

    I guess the salient difference — where the analogy breaks down — if that you don’t file a claim for reimbursement for your airline ticket. Yeah, I know; that’s somewhat implicit in your observation.

    One of my own REC medical directors expressed some irascible dubiety regarding the HITECH initiative, in that “these systems are all really about the billing.”

  • Most current EHR are full software suites focused on general medicine with great practice management/billing options, but the specialty EHR (e.g. psychiatry) portion is merely added on as an after thought (for instance, rudimentary word document templates, etc) and do not address the needs for specialty EHR/workflow of a psychiatric medical record. Hence private practice offices are leery to give up their practice management software which keeps the billing/revenue generating stream up and running, and end up compromising on hanging on to the watered down medical record portion that is tacked on to it. With inter-operability criteria maturing as well as health information exchange getting standardized, more modular EHRs may be the route to go…. rather than one package being jack-of-all trades with inherent compromises.

  • @Umar-

    “With inter-operability criteria maturing as well as health information exchange getting standardized, more modular EHRs may be the route to go”

    One thing we learned during a HITRC conference put on by ONC in Salt Lake City last week is that, if you go modular and wish to retain your current Practice Mgmt system to be interfaced with your EMR, the front/back-office PM system itself must ALSO be ARRA Certified. They were unequivocal on this point.

  • I agree with Pheski. I wrote a post about this a few months ago and separating billing from workflow is exactly our plan with Ankhos.

    Our client LOVES their billing software, but hates their current EMR. The EMR they use is old, clunky and the employees actually requested to go back to paper.

    Our philosophy is to let the billing guys do what they do best and let us make the best Oncology EMR possible. Like pheski said… “full stop”.

    Not only do you get better usability, but you also spread the risk of software, server and user errors.

  • I see some interesting and valuable comments and each of them have their own merit. From practicality stand point, we do have some issues related to modular EHR, PMS, Billing/Financials. Besides certification of PMS there are other practical concerns. In Ambulatory Care, especially with smaller 1/2/4 physician clinics – the bandwidth to integrate disparate systems is simply not there; add to it, is the unwillingness or lack of cooperation from the legacy system vendors to open up their systems for interfacing with EHR. Also the finger pointing that ultimately happens when multiple systems are involved resulting in confusion which the small businesses can seldom afford. Finally the TCO of maintaining multiple systems is much higher especially when each system is upgraded and interfaces need to re-tested.
    For a PCP or any other smaller Ambulatory Care clinics, a single system is a simpler way to go, avoiding the pit falls associated with integration of multiple systems.
    I do appreciate the purety of thoughts such as Nick’s and I believe such endeavors will lead to best of class products in specialties such as Oncology, which well afford to have the IT Team to admin/maintain multiple systems. But coming down to the PCPs and lesser financially attractive specialties, all-in-one may provide the better TCO.
    And as John points out all the time, there is no one solution that fits all; each has its advantages. This is a discussion that will be on for a long time.

  • @ peski – love your analogy.

    Taking the billing requirements out would allow developer resources to focus on EMR usability, workflow and patient care. All the complexities of billing would be eliminated but a practice would still need to handle billing in some other way which can lead to another entirely new set of problems to deal with.

  • Interesting discussion (which was the point of this post). Anthony is right that this type of discussion is going to go on for a long time to come.

  • In another time in another industry there was similar dialog relating to need for integration of several different modes of operations, customer service, and billing functions.

    Of course one vendor wanted to supply it all and other vendors just parts touting ‘best in the World accolades.

    What we ended up with was a common data core warehouse and then ‘snap on’ applications for the various functional centers. Functional data developed fed the core and had to meet core data standards. Functions did not feed functions.

    Suggest those who want to build self standing EMRs might want to spend some time with the top PM providers and figure out how to effectively share data and then comarket yourselves.

    If you don’t and practices are going to have to deal with the data gap … your EMR may be the best in the World … but few will want to buy it.

    Who would buy a computer workstation that is not networked?

    Practices are businesses first.

  • The primary impetus and reasoning for the legacy PM vendors to get involved with the clinical side was to capture new revenues from old customers.
    These same vendors have achieved remarkable success in influencing legislators and administrations into adopting their vision of Healthcare Information Technology.
    For example, the meaningful use criteria requires that an EMR system be able to transmit claims files and that an EMR system need not concern itself with the “Clinical Note”.

    Practice management systems manage TRANSACTIONS. (Round Hole)
    Clinical records systems manage DOCUMENTS. (Square Peg)

    The current EMR offerings of the legacy PM vendors is an exercise in converting complete formatted documents into discrete data elements. The result is a disappointment at best.

    Get the best PM system you can afford that works and your office manger will be happy.
    Get the best Clinical Record system you can afford and your doctors will be happy.

  • @Dr Robert Schertzer – What makes this EHR product so amazing that it’s worth the hassle of integrating disparate systems? It could be worth it.

    The problem with demo’s as they can razzle dazzle but without time in, it’s hard to know what questions to ask. Functionality issues crop up after implementation after you’ve taken care of 80% of the stuff and your ready to move on to the next level.

    You want to make sure you have flexibility with your software so that when you get to this point, you are able to address them. So powerful software with a vendor who understands your environment are certainly important. A great vendor also knows enough about your environment to know what questions to ask you to make sure they really are a good fit. Sometimes this means the vendor should walk away from an engagement. Alfred–

  • Alfred,
    It’s so true that demos can really pull the wool over people’s eyes. I haven’t written about EMR demos lately. I might have to pull out some of my old posts and some content from my EMR selection book and do some more posts on it. It’s an important topic.

  • The broader problem is that the billing aspects have many more insidiously negative effects than simply sending a charge transaction across an interface.

    They actually degrade the quality of the documentation by requiring certain elements to support specific levels of billing. The whole issue of needing to have a certain number of elements done and documented to bill a particular E&M code is one example. A particular visit may have extremely complex history/assessment/decision-making but to get “credit” one also has to document a certain number of irrelevant review of systems items.

    It is no surprise that the places that have used EHRs most effectively such as Kaiser and the VA are incentivized to give care that will produce better outcomes. They are less beholden to bureaucratic insurer-driven documentation demands that do not aid in patient care or communication.

    Eliminating all of these items (and similar demands for information to fulfill PQRI and other measures that are irrelevant to a particular patient or that fragment thought processes) would improve workflow and efficiency in any system, paper or electronic. It would certainly make it easier to develop an EMR that would support patient care needs.

    But just having distinct EMR and billing software isn’t going to do the trick in our current dysfunctional health care system. It is only if an EMR can be designed (and insurer/payor/regulatory demands can be synchronized) so that the health care system looks like a single payer system to the EHR user and clinicians can go about the business of treating patients.

  • Thanks Ariella for bringing this older post back to life. I love when people do that. Great analysis too. In fact, you reminded me that I wanted to ask the question about what could replace E&M coding to make healthcare and EMR better. Watch for that post tomorrow.

  • Good point. My thought was thats what clearinghouses were suppose to be to electronic claims. You push one button and the software sends all the info. to all the insurance companies in one standard format. It seems that every insurance company wants to deny claims because one or another field and usually not the same fields, are filled or not filled in the prescribed way.
    One thing that would simplify thing is one pricing structure. The retail industry figured this out a long time ago. If I by an apple at Safway in Washington, it is the same price as an apple in New York Safeway. If insurance companies published their pricing nation wide and competed this would help. Back to the codeing. Why ICD 10. ICD 9 is complicated enough. ICD 10 is suppose to be more cause and effect related, what ever that means. I always wondered if we all billed from quickbooks on an invoice and payment was due in 30 days or you could charge interest, how much that would save the whole industry. If you are audited, the EMR documentation should support your charges. I know pie in the sky, but that is what were doing right? Just dreaming. JW

  • I think the most fundamental question that a physician should ask is “who do I want to answer to?” Most have chosen one of two options – payors or health systems (i.e., being an employee). Both are perfectly reasonable options but they have direct implications on the viability of the question you pose. The third option is the patient — i.e., the “Marcus Welby” model of a direct relationship between a patient and MD unfettered by insurance bureaucracy.

    If the answer is the payor, this requires playing by their rules. Even if you are answering to the health system, you are indirectly answering to the payor. Having reviewed or implemented 100+ different healthIT systems, they have one thing in common — their main purpose is to get bills out as big and fast as possible. That is a rational response to the legacy reimbursement model we have today. Fundamentally, the “patient” in those systems is really not much more than a vessel for billing codes. [Google “Patients are more than vessels for billing codes” for more.]

    The most professionally satisfied MDs I know have decided to answer, first and foremost, to patients and have jettisoned insurance billing altogether. At most, they’ll produce a super bill that a patient can use to file for reimbursement. The most common model there is Direct Primary Care (think of it as concierge medicine for the masses — i.e., typically 1/3 of their patients are uninsured) — see for more. It’s two parts Marcus Welby, one part Steve Jobs. In some sense, it’s a bit of a mini-ACO/IDN in terms of payment.

    Outcomes studies of these models have been very impressive (e.g., 40-80% reduction in surgeries, hospital admissions, etc.). Guess what, when you have a model such as that, the centrality of billing in legacy healthIT gets in the way. Thus, those orgs have often either built their own (Iora Health, WhiteGlove Health, Qliance, etc.) or more recently have used off-the-shelf EHRs that aren’t about billing. [Disclosure: my company, Avado, has that as one module of a broader Patient Relationship Management system.]

    This is all a very long way of saying. Start with the goals of the practice and it will be self-evident whether an EMR without billing makes sense. If you follow the link above, you can see that Direct Primary Care is “hidden” in the PPACA which is why they are quietly exploding in popularity right now.

  • Dave Chase,
    That’s an interesting analysis of the industry and how it’s changing. How do you think this movement will play out? Do you think it will start to take over the insurance companies for primary care?

  • How will this play out? Naturally, in U.S. healthcare that is a difficult thing to predict but I will outline one way that it could play out.

    One of the things that is starting to play out is insurance companies are realizing that direct primary care (DPC) can actually be something that helps them, rather than threatens them. Why? In the insurance exchanges, one of the ways to compete will be on price. When one combines a DPC model with a high deductible wrap-around (that is clause in the PPACA for DPC), it is typically 20+% less than a conventional health insurance program. In the last couple months, I’ve seen an uptick of interest around that combo coming from insurance companies.

    Other factors that could drive it include the following:
    * A vocal opponent of Obamacare (Rep Bill Cassidy, MD – GOP Louisiana) has proposed HR3315 to expand DPC to Medicare showing that DPC is one bipartisan facet of PPACA.
    * A California GOP legislators is proposing DPC legislation similar to what is in places like Washington state to expand DPC.
    * States such as West Virginia are looking at DPC for their Medicaid population which would be fulfilling the vision of this article –
    * Employers & unions are increasingly realizing that the best bang for the buck there is for their healthcare dollar is increasing primary care access. This is driving the explosion of onsite clinics and to a lesser degree DPC (best for smaller employers…thus why it isn’t happening as quickly).
    * For orgs wanting to play in the ACO world, DPC is sort of a mini ACO so it’s a great place to get one’s feet wet so some providers are also driving this.

  • […] While it’s hard to argue that Dr. Nash is wrong — that a focus on billing for “doing stuff” turns EMRs into billing software — my question is, what is the alternative?  Or rather, what is the best alternative (as EMRs will inevitably have some connection to the billing process even if my colleague John Lynn asked us in 2010 to imagine an EMR world without billing)? […]

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