Is eClinicalWorks the Next Volkswagen?

Since the Department of Justice announced the ground-breaking $155 MM settlement with eClinicalWorks (ECW) on Wednesday, industry response has been dizzying.  Let’s collect the facts and review what it means.  I reviewed it all in greater detail yesterday here.

A short summary:  EHR developer eClinicalWorks settled a legal dispute with the Department of Justice that commits them to pay $155 Million, provide free services to customers, and undergo oversight for five years.  The government found that ECW faked certification testing: the EHR software was certified as having capabilities that it didn’t have. Tens of thousands of care providers collected millions of dollars when they attested to the meaningful use of a certified EHR. DOJ therefore states that “ECW caused the submission of false claims for federal incentive payments based on the use of ECW’s software.”

Through social media and (gastp!) real-life conversations, we’ve heard:

  1. Too hot: This is evidence that ONC’s certification program isn’t working and should be rolled back
  2. Too cold:  This is evidence that ONC’s certification program is too easy and should be enhanced
  3. Just right:  This is evidence that ONC’s certification program is appropriate, and expects participants to have integrity

And we’ve heard the analogies:

  1. ECW is the health IT version of Volkswagen:  they faked a test, got caught, and have to pay the price.  Shame on them.
  2. ECW is the health IT version of Uber:  they developed shady software, used it to make millions of dollars, got caught, and have to pay the price.  Shame on them.
  3. ECW is Ray Stoller the car salesman, who sold cars that weren’t safe to unsuspecting purchasers and refused to make good on their commitments.  Shame on them.

Is this an indictment of the certification program?  Not at all.  While the program may not yet be “just right,” without certification, there would be no basis for any legal complaint against ECW, and this would all have remained hidden.  Despite the persistent calls for ONC to roll back the program, this case makes it clear that such a move would be a direct threat to public safety, and would invite more of these shenanigans.  ECW is indeed the VW/Ray Stoller of health IT (I don’t think the Uber metaphor sticks) but just as there are more car manufacturers than just VW who cheated on diesel emissions, there are more health IT developers who cheated too.  Perhaps not so boldly or carelessly as ECW, but I am 100% certain that there are other companies who have done this, and I’m confident that the government is investigating these others.

What this means for the industry

Some have argued that care providers are going to “go after” health IT developers and mimic the original plaintiff in hopes of “cashing in” or punishing these companies for “usability and design issues.”  But this is not the case.  This happened because of faked tests, not just bad design.  The industry is full of careful, thoughtful, passionate software designers and engineers who are working hard to deliver great products that improve health, and facilitate safe, efficient medical care.  Just as VW’s root problems were cultural, the root cause here is a “check the box” mindset that was pervasive at ECW.  Indeed, I had direct personal interactions with ECW staff when I was at ONC that confirmed ECW’s consistent lack of understanding of some facets of the certification program.  If one views EHR certification testing as an annoying hurdle that must be jumped, the program (and the policy goals it represents) wont’ be taken seriously, and cheating won’t seem unethical.   Would you want your EHR to be developed by someone with this mindset?

The culture that EHR developers need to maintain is one of integrity, transparency, collaboration, and humility.  This event is a great reminder for health IT companies to reinvest in the important (but sometimes forgotten) work that creates such a culture.

Purchasers of health IT who are unable access system capabilities for which their products are certified (check the certification status here) should first contact their EHR developer and insist that the capabilities be enabled.  (There may be additional cost for this – but the developer is required to publish the costs and limitations.  Here is the ECW disclosure as an example.  Find the link to disclosures on the certification status page.)  If you still can’t find a way to get the software to behave properly, contact ONC.

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meltootsMichael Chen MDNiran Al-AgbaHayward ZwerlingAdrian Gropper, MD Recent comment authors
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Michael Chen MD
Michael Chen MD

As Adrian pointed out and with my previous blog post that was referenced, it’s not surprising that events such as this have occurred with this proprietary software with certification boondoggle. Other industries have recognized the immense value of open source and it’s all around us (just not with much fanfare). When will physicians recognize there is much in common to what we do in our profession and the intrinsic ethos of open source software (which does exactly that Dr Zwerling had suggested – having the code out in the open to review, improve with physician input?). This is not a… Read more »


Interesting. Cited this comment on my KHIT blog.


“BREAKING: Cerner scores VA EHR system contract”

By Rachel Arndt | June 5, 2017

The U.S. Department of Veterans Affairs has picked Cerner Corp. to develop its electronic health record system, Secretary of Veterans Affairs Dr. David Shulkin announced Monday.

In selecting Cerner to create its EHR system, the VA leaves behind its home-grown VistA EHR, a move that’s been on the horizon since Shulkin suggested in March that the department would be moving to a commercial product…

So much for open source.

Michael Chen MD
Michael Chen MD

This is exactly the reason we can’t assume government and the political climate will do anything to change the course of our health IT destinies. However, we are not left without any options. Sure it’s a hard road the take; but the path is clear. It may not outright overthrow the entrenched systems in place, but we’ve seen quiet and incremental disruption in favor of community instead of profits and proprietary software (Linux vs Windows servers – not desktops; also Android for smartphones too which has put Linux over the top in number of installs on devices throughout the world).

Niran Al-Agba

If I don’t laugh, I will cry. Imagine what that $$$$ could have done to provide basic healthcare for millions of Americans? So glad it went to something way better than that. Technology is obviously the best way of improving patient outcomes.

Hayward Zwerling

“I had direct personal interactions with ECW staff when I was at ONC that confirmed ECW’s consistent lack of understanding of some facets of the certification program.” …As someone who has personally taken my EHR through MU stage 1 certification, and was all too familiar with the MU requirements, I can attest that rules of certification were very clear. ECW’s decision to “cheat” on the test was a deliberate decision by ECW and was not the result of a misunderstanding. Either the management of ECW is stupid (and unable to read instructions) or they are not ethical. You decide. I… Read more »


Agree with Dr Z completely. I would have selected Dr Z to represent me and my front line colleagues in any EHR cert/mandate issues. He is not only a real practicing MD, he has experience actually writing EHR systems and going through the ridiculousness of certification, when his customers really wanted what he was providing…MD/HIT working together. This most distressing part of this is that the so-called leaders still have no clue on what damage they have done and still want to double down on poking meat certification of EHRs. When does this end? Certification drove out many small VERY… Read more »

Adrian Gropper, MD
Adrian Gropper, MD

ONC policy is the root of the problem and has caused the general erosion of trust in federal health initiatives that we have today. Certification is a poor substitute for sunshine. The reason we have cheating in Volkswagen or eCW is that software that impacts our health is not open source. However, the harm of secrecy is clearer when the software can produce a medical error directly rather than just statistically impact our health through environmental damage. Certification institutionalizes the growing practice of making medicine itself proprietary and secret. Open source medical software, like medical knowledge itself, is safe and… Read more »


“gastp!” – “covfefe!”


Will ONC claw back incentive funds paid to eCW users?