Welcome to the HealthCare Information System (hcinfosys) Researcher Resources website of Nelson King that intends to share the (primarily) academic resources I've gathered since 2004 for my healthcare information technology (HCIT) research.  My research focuses on social and technical implications of process change in healthcare information systems including e-prescribing, location tracking and verification systems, hand-held nursing tools, and pharmacy dispensing systems.  This website focuses primarily on resources addressing the socio-technical aspects of e-prescribing and electronic medical records.  Recent health care articles or blog posts on related topics are also included.  Your first stop should be the
Literature page (see sidebar) which has a table of contents of topics addressed.
If you want to see the latest blog postings on healthcare take a look at HITSphere which aggregates posts from the leading blogs. 
The website is a work in progress that was started with the assistance of a 2009/10 University Research Board Grant from the American University of Beirut is acknowledged for the development of this website.

Visit my profile at ResearchGATE

Medical Benefit (Loss) Ratio

posted May 5, 2017, 10:35 PM by Nelson King   [ updated May 6, 2017, 9:14 AM ]

I updated the Medical Loss Ratio page of this website given the recent interest in #agetax. The debate seems to ignore the value-added of the premiums that go to the insurance company rather than for medical services rendered. If the MLR is 80%, then health insurers take 20% of a very large number. Some fraction of the $3.2 trillion in US health care spending (2015) paid by insurance companies. Even if only half of the $3.2 trillion was covered by insurance companies (i.e., $1.6 trillion), that means roughly $320 billion (depends on the actual MLR of an insurer) spent on administering claims, marketing, overhead, and profits. I'll work on a better number in the future. The number is in billions of dollars! Yet little research on how this chunk of healthcare premiums being spent.

Call For Papers on Human-Computer Interaction in Health and Wellness

posted Mar 18, 2014, 4:12 PM by Nelson King

2014 Research Workshop on Human-Computer Interaction in Health and Wellness jointly Hosted by AIS SIG-Health and SIGHCI with an associated Special Issue of AIS Transactions in Human-Computer Interaction.

For more details go to AMCIS Research Workshop - SIGHCI

The research workshop promotes the creation and refinement of scholarship that addresses the intersection of Human-Computer Interaction (HCI) and Health and/or Wellness fields. Several selected papers from the workshop will be invited for further development toward publication in a special issue of AIS Transactions on Human-Computer Interaction (THCI) to be titled “HCI in Health and Wellness”.

All related research topics and methods are welcomed; priority will be placed on selecting papers that:
-    Clearly address topics relating to HCI and Health and/or Wellness
-    Incorporate development and/or empirical evaluation of theory that is testable (i.e., falsifiable)
-    Are submitted in substantially complete form

A Systems Approach to Clinical Informatics Research

posted Mar 18, 2014, 12:05 PM by Nelson King   [ updated Mar 18, 2014, 12:06 PM ]

My paper is currently free on the Palgrave website of Health Systems.  I provide heuristics based on the systems approach to aid multi-disciplinary clinical informatics researchers 

KING N  (2014)  Expanding the boundaries of clinical informatics for interdisciplinary systems research. Health Systems  3(1), 1-11.

Health-care organizations and the information they exchange are increasingly complex and difficult to understand necessitating fresh methodological approaches on the part of clinical informatics researchers. Looking at the interplay between health-care information technology (HIT), clinical workflow, and the surrounding organization requires some notion of a system and an interdisciplinary orientation toward research. The paper offers practical advice grounded in the systems approach to researchers who wish to view HIT holistically and part of an integrated system. Examples from literature describe the importance of expanding system boundaries, looking for relationships within those boundaries, simplifying complexity, and accounting for social behavior.

E-prescribing Workflow Resources

posted Dec 26, 2012, 3:34 AM by Nelson King

E-prescribing has taken a back seat to other healthcare initiatives in 2012.  However, valuable resources have been generated during the year to aid medical practices and pharmacies in communities or states move forward on e-prescribing implementation.

E-prescribing Workflow is the newest page in Healthcare IS/IT resources that provides a list of toolkits that help in assessing and planning an e-prescribing implementation.  There are also a number of articles (primarily academic) that have examined e-prescribing or medication management work practices.

If you understand your workflow, you will be in a position to assess the impact of a particular e-prescribing vendor solution on your processes.

EHR Satisfaction Survey Comparison

posted Dec 22, 2012, 4:03 AM by Nelson King

There have been three major EHR surveys in the past year. 

I tried to make a direct comparison but the questions are different.  I provide the questions and the equivalent (not direct) response.

EHR Usage

Physicians Practice




My practice has a fully implemented EHR or use a provided one

EHR adoption result

Are you using an EHR?

Equivalent Response

37% +17% = 54%




The second compilation reflects EHR satisfaction (broadly) but in two of questions speaks to efficiency.

Related to EHR Satisfaction

Physicians Practice




Would you say your EHR has made your practice’s work flow more efficient overall?

How satisfied are EHR users with their systems?

How EHR affects practice


Yes (66%)

No (19.1%)

Same (14.9%)

Very satisfied (38%)

Somewhat satisfied (47%)

 Somewhat dissatisfied (10%)

Very dissatisfied (5%)

More efficiency (23%)

Decrease productivity (26%)

 The negative responses are always of concern to me since one in three are are dissatisfied.  We need to dig deeper into understanding why.  I'm still going through the surveys and hope to get more common insights.

EHRs Increase Billing: Why the Surprise?

posted Sep 24, 2012, 11:38 PM by Nelson King

The Center for Public Integrity published an article Growth of electronic medical records eases path to inflated bills.  News organizations have also picked up on the story.  EMR and EHR vendors have long promoted their technologies to medical practices on the basis of more complete billing.  This is one way that medical practices can recoup the investment in these systems.

Whether this news should have been a surprise is debatable.  Jaan Sidorov in a Health Affairs article "It Ain’t Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs" questioned the premise that the EHR would reduce the cost of health care.  In particular, Dr. Sidorov said "Not only are the EHR’s labor savings questionable, but increased billings are another likely outcome."

One reason for maintaining this website is to make the health community aware of the unintended consequences of technology including e-iatrogenesis in e-prescribing and the failures experienced in HCIT.  This information is critical to design HCIT that take a systems-oriented view of technology operated in an organizational and societal context.

Ohio E-prescribing: Helps But ...

posted Sep 1, 2012, 12:36 PM by Nelson King

The E-prescribing Task Force of the Ohio Health Information Partnership published its survey results in the form of a Improving E-prescribing in Ohio white paper.  While the majority of physicians and pharmacists agreed that e-prescribing helps, the large minority that did not is worthy of noting.

Do you believe that e-Prescribing has improved patient safety? Physicians saying no (41%), Pharmacists saying no (47%). 

The top three problems reported by physicians: missing prescriptions at the pharmacy (45.51 percent), difficulty choosing the correct drug from the list of choices (44.8 percent), and duplicate pharmacy refill requests (39.1 percent).

For 35% of pharmacists who did not consider e-prescribing generally accurate, 40% reported errors 11%-50% of the time.

The survey results are worth reading.

EHR Surveys: Adoption but Hesitation

posted Jul 21, 2012, 10:03 AM by Nelson King

The National Center for Health Statistics updated its 2011 survey on Physician Adoption of Electronic Health Record Systems and Physicians Practice released its 2012 Technology Survey that focuses primarily on EHR adoption.  These EHR surveys are relevant to e-prescribing since Surescripts 2011 National Progress Report on E-prescribing and Interoperable Healthcare shows that 82% of active prescribers use an EHR.  Now that 58% of office-based prescribers can route prescriptions electronically, going the last mile to reach a critical mass depends on further deployment of EHR.

The two surveys have slightly different results on adoption.  Physicians Practice reports 28% of respondents do not have an EHR.  NCHS reports 45% have not adopted an EHR.  However, adjusting the NCHS data to PP's "do not have an EHR" shows that 32% have "no intent to purchase within 12 months" and 20% "undecided on purchasing within 12 months" or 45% X (20%+32%) equals 23%.  These surveys show that 1 in 4 respondents (don't know if they solely represent their organizations) will not be implementing an EHR in coming year despite the CMS penalties.  The data doesn't say if these organizations are using standalone e-prescribing.  However, as the 2011 data shows standalone e-prescribing has decreased substantially since 2008 (62%).  These numbers are consistent with a 2010 Medscape online survey on e-prescribing adoption that found 20% of practice/hospitals "has no plans to use an e-prescribing system" (albeit only 67 responses).

Whether 75% adoption is sufficient to reach critical mass for e-prescribing should be the question being asked.  If CMS penalties haven't swayed physicians to adopt, then the economic penalty may not be a sufficient motivation.  While Physicians Practice survey did not provide an average cost to implement and maintain, they reported that majority are paying between $250 and $500 per month.

The surveys are a worthwhile read and the conversation should be a) what level of adoption to truly benefit from e-prescribing and b) what will it take to get there.

EMR Enough for Care Coordination?

posted Mar 28, 2012, 6:29 AM by Nelson King

The Journal of the American Board of Family Medicine published in its March-April 2012 issue a mixed method study on care coordination.  The authors concluded:
" We demonstrate that the difficulties inherent in collaborative care are independent of the patient population being cared for. Regardless of the patient population and sector of health care, developing collaborative relationships and learning to work collaboratively is difficult and takes time. What many of these teams need is ongoing support and education about how to make these collaborative care practices work."

The real value of this care coordination initiative was that coordination tasks were transferred from family physicians (FP) to nurse practitioners (NP).  This transfer and time-savings to FPs took place once trust was established among members of the team.  The authors point out that the contributions of various actors were not expected (e.g., pharmacist and NPs).

Interestingly, the EMR contributed little to care coordination.  The EMR had been in place for four years but the electronic "To Do" note did not offer a means of adjusting care plans (scanned into system) so current information was not available.  Taken together (roles of team members and impact of EMR), this suggests that future EMR/EHR designs should be more chart-based (i.e., coordination artifact) rather than role-based as currently done.


Legault, F., Humbert, J., Amos, S., Hogg, W., Ward, N., Dahrouge, S. & Ziebell, L. (2012) 'Difficulties Encountered in Collaborative Care: Logistics Trumps Desire', The Journal of the American Board of Family Medicine, Vol. 25, No. 2, pp. 168-176.

1st Fill Adherence Reduces Costs?

posted Feb 23, 2012, 7:59 AM by Nelson King

The blogsphere is abuzz about Surescripts February 1 press release announcing increased adherence with e-prescribing.  The study does not appear to be publicly available so my impressions from press release may not accurately reflect the study.  That said my initial impressions are that the term "costs" used loosely.  Cost to whom should be asked?  One should also ask if e-prescribing is the only way to improve adherence?

Surescripts relies upon the Roebuck et al (2011) study which estimated that adherence for four vascular conditions reduced medical spending by the ratios cited by Surescripts (3 to 10 times less).  We will need to see what kind of medications have increased first fill adherence in the Surescripts study.  These ratios are based on vascular diseases and Fischer et al (2010) reported adherence less than 30% for chronic diseases even though the overall adherence was 78% (similar to Surescripts study).

The Roebuck et al study also says "one should not necessarily expect to see immediate reductions in medical costs from improved medication adherence. This is a particularly salient point for insurers with short time horizons."  Can improvements in first fill adherence rates be generalized to continued adherence, especially if costs to patient becomes an issue?

The Roebuck et al (2011) study summarized its study: "Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings."  What is the cost of e-prescribing?  Why has the elimination of patient co-payments for chronic medications, known to increase adherence, been lost in the discussion?  See Sipkoff (2004) which includes quoting Mark Fendrick that "We believe that some people should indeed get their drugs for free, and for a small class of people, should even be paid to take them".

It seems e-prescribing just shuffles the costs around to different categories that may or may not be included in a "cost" number.  Higher adherence means more medication costs to the patient to save payers the cost of hospitalization.  E-prescribing means medical practices and pharmacies pay for the cost of systems and transaction fees to increase adherence so that payers avoid the cost of hospitalizations.

Given that Surescripts press release is claiming the benefit ratio from chronic vascular diseases, one must ask if payers paying the co-pay of an at-risk population might be cheaper than the billions already spent on e-prescribing.  I hope someone does the math.


Fischer, M, Stedman, M, Lii, J, Vogeli, C, Shrank, W, Brookhart, M & Weissman, J 2010, 'Primary Medication Non-Adherence: Analysis of 195,930 Electronic Prescriptions', Journal of General Internal Medicine, Vol. 25, no. 4, pp. 284-90.

Roebuck, MC, Liberman, JN, Gemmill-Toyama, M & Brennan, TA 2011, 'Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending', Health Affairs, Vol. 30, no. 1, pp. 91-9.

Sipkoff, M 2004, Not So Much of a Reach: Let Sick Pay Less for Drugs, October, January 18, 2007, <http://www.managedcaremag.com/archives/0410/0410.benefitbased.html>.

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