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Another Look: The Wal-Mart and E-ClinicalWorks Deal

Portrait2The New York Times reported this week (Wal-Mart Plans to Market Digital Health Records System) that 
the company’s Sam’s Club division will bundle eClinicalWorks
electronic medical record software, Dell computers, installation,
maintenance and training to offer to small physician practices. Pricing
is about $25,000 for the first physician in an office, and $10,000 for
each subsequent physician. Annual maintenance and support costs will be
about $4,000 to $6,500 (though it doesn’t say whether that’s per
physician or per practice).

Wal-Mart says its package deal of hardware, software,
installation, maintenance and training will make the technology more
accessible and affordable, undercutting rival health information
technology suppliers by as much as half…

Dell will be responsible for installation of the computers, while
eClinicalWorks will handle software installation, training and
maintenance. Wal-Mart is using its buying power for discounts on both
the hardware and software.

This program has promise, but it isn’t revolutionary and is by no
means certain to succeed. Interestingly, the Wal-Mart PR people, who
usually send me a heads up about any new Wal-Mart move in health care,
didn’t tell me about this one. It makes me wonder what’s really going
on. There are a couple of very promising aspects of this program:

  • The company partnered with eClinicalWorks (eCW), which based on my
    experience is the best system for small and mid-sized practices. The
    software is easier to install and use than competitors’ programs, and
    has a lower total cost of ownership. eCW has done an excellent job with
    the Massachusetts eHealth Collaborative, for example.
  • The program addresses one of the key bottlenecks of EHR adoption
    for small practices: distribution. It’s painfully difficult and
    expensive to sell EHRs to physicians and that’s a big part of a
    vendor’s costs. I don’t know what Sam’s Club plans to do in that
    regard, but if they figure how to sell to physicians efficiently that
    could be a big deal. Physicians are starting to realize that they need
    an EHR, so perhaps it will be easier than in the past to make the sale.
    Having said that, I’m not convinced Wal-Mart has any idea how to do
    this.

There are also unanswered questions and some key elements that the program doesn’t address:

  • It’s hard to tell if the pricing is attractive or not. It’s
    notoriously difficult to make an apples to apples comparison of EHR
    costs and there is not nearly enough information in the article to know
    whether there will be any savings at all from the typical eCW pricing.
    The claim of “undercutting… by as much as half” can be said about eCW
    anyway, with or without Wal-Mart. This is not like the $4 Wal-Mart
    generic program where Wal-Mart really did undercut existing pricing
    dramatically.
  • After cost-effective distribution (mentioned above) the main
    bottlenecks in EHR adoption are finding enough good technical people
    and change management people to help physician practices transition to
    the new workflow patterns that EHR adoption brings. Successful
    companies like eCW already strain to find enough talent to meet the
    demand. And it looks like eCW will still be responsible for all of
    those activities –not Wal-Mart. I don’t think Wal-Mart adds any value
    to this part of the equation.

So overall, thanks Wal-Mart for giving this a go. At least you
picked the right EHR vendor to work with and are raising awareness
among small physician practices. If you make this program a big success
I’ll be impressed and surprised.

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14 replies »

  1. I can’t see buying an expensive system like this for my 10 doc, 10 PA group unless I can reduce my coding and billing staff to offset the costs.

  2. As someone who installed eCW in a number of small to medium sized offices, it’s kind of stunning to see that WalMart’s pricing isn’t that much lower than I’d charge. The difference is in the “service” fees, which I’ll wager pays for not very personal service, compared to a small vendor.
    This may have the OPPOSITE effect from what the conventional wisdom desires. Poor service will drive practices away, after they’re done being seduced by the idea they’re getting a deal.
    Pity.

  3. The article in NYT about WalMart selling a pre-packaged Dell-eCW EHR package, actually didn’t come from WalMart – it came from an interview with eCW (http://www.histalkpractice.com/2009/03/11/eclinicalworks-to-sell-pmemr-package-through-sams-club-girish-kumar-interview/). Since the source did not come from WalMart (as you mentioned, you didn’t get a heads-up from them about this), the Washington Post, who also picked up the NYT story, later retracted the story ( http://www.washingtonpost.com/wp-dyn/content/article/2009/03/11/AR2009031101740.html).
    Regardless of all this, the question still exists: is the packaging of an EHR for $25,000 sold via WalMart a good thing for healthcare? Firstly, $25,000 per MD is fairly pricy – perhaps less than some systems, but certainly more than others (our own web-based EHR (http://www.practicefusion.com), for example is free to physicians, paid for by alternative revenue sources, including advertising). Is WalMart where physicians will go to purchase a high-end, mission-critical system? I am dubious. WalMart is more known for offering low-cost staples, and has no experience in EHR support, training, uploading of legacy data, etc. I certainly can’t envision eCW putting in support people in WalMart stores all over the country. So how is this to be implemented?
    The problem that this is addressing is the low EHR implementation rates seen in this country. Cost is a major factor, and (as noted), this is not that much of a “deal.” Usability – the ability to work effectively, efficiently, and learn the interface with a minimal learning curve – is not really addressed here either. eCW offers a client/server installation, as well as a hosted, ASP-model deployment – my understanding is that most of eCW’s installations are client/server. As with any client/server enterprise solutions (built in the era when client/server was the leading edge of software, prior to web apps being emergent), the issue of true interoperability is there – how do you connect with other practices, with hospitals, with labs, and with pharmacies? Buying a “box off the shelf” does not really address these things.
    I am doubtful that this marketing move by eCW will impact EHR adoption on the U.S. healthcare scene very much. It is interesting, from a marketing perspective, but is not the kind of solution that will really move the EHR adoption issue forward in a meaningful way.
    Robert Rowley, MD
    Chief Medical Officer
    Practice Fusion, Inc.

  4. I don’t see how Wal-Mart owns this data. The physician maintains the data, the patients have the right to access and share it (or prevent it from being shared, except in emergency), and it will be physically held on eCW servers. From what I can tell, Wal-Mart will no more own the data than it owns the content of cell phone conversations just because it sells a cell phone. Or does it monitor what you watch when it sells you a TV?
    I’m not a fan of Wal-Mart. In fact, I refuse to shop there because they are so virulently anti-union and treat their employees so poorly from a financial perspective (for proof that you can treat them better and still be a discount retailer, see CostCo). That said, I think it really does veer into paranoia to think Wal-Mart has some nefarious plot to own everyone’s medical data.
    I second David’s take on eCW. It would have been hard to pick a better partner for implementing in small practices on a large scale.
    As for what Wal-Mart brings to the mix, the price mentioned may be pretty much the same as eCW normally charges, but in this case it seems to include the hardware. Just based on that press release, it seems that the advantage for a physician to purchase through Wal-Mart is that they get the equipment for free compared to other channels. Just a guess.

  5. I’m a techie… I have but one question no one seems to ask or note, but which is _essential_ with respect to EMRs:
    Q: Does eCW offer a “cloud computing” type of solution?
    Me thinks not… as if so, why would Dell or -any- hardware provider be specified?

  6. Here’s hoping Walmart doesn’t do to health care what it has done to American manufacturing.
    Good grief, how anyone can be pleased about this company getting involved in the space is a mystery to me. And no one has noted the irony that this is a company that still leaves the overwhelming majority of its own workers without health coverage.

  7. David –
    So yes, you anticipated that Wal-Mart is angling to become physician employer. And EHR would be “a platform they can leverage” towards this goal – or an enticement.
    But it is not too hard to imagine how ownership of clinical data could become tool to pressure physicians into a relationship they may not necessarily desire. Again, that may not be part of the plan, but I think to downplay that potential is to exhibit a certain amount of “trustanoia”.
    And what’s with “thanking” Wal-Mart for “giving this a go”? That’s very revealing. Since when do we thank corporations for doing what they normally are supposed to do: maximize profit. You make it sound like they are doing this for altruistic/humanitarian reasons for which we should express gratitude. I am not at all criticizing Wal-Mart here for pursuing profit – but I’m leery of a culture that lauds corporate interests as a matter of reflex, confuses that with the public good, and puts undo trust in corporate good will.
    We don’t need to reject out-of-hand Wal-Mart’s ehr gambit as necessarily nefarious – but I think we’d be well served to be very skeptical of their motivations.

  8. Good marketing ploy by eCW, but overall bad strategy.
    1) EMRs are not yet a commodity, perceived or otherwise. Hooking up with Wal-Mart conveys a commodity product. Personally, would not want to see my product commoditized.
    2) Wal-Mart certainly is a big brand name, but they are not a brand name in selling solutions. Will eCW need to put a trained staff person in each Sam’s Club similar to what Apple does today at Best Buy?
    3) And most important, what does this change in channel strategy do to existing partners/VARs. If I were a reseller, I may well be looking for a different HIT partner to take their wares to market. Many an eCW competitor is probably calling on those VARs worth their salt as I write.

  9. When Walmart gets involved, things happen. However, there is a lot of work to be done to tie the clinics, the pharmacies and the patients.
    One of the fundamental need of the time is to create the EHRs patient owned.
    Clinical process etc of course remains to the ownership of hospitals
    rgds
    ravi
    http://www.biproinc.com
    blogs.biproinc.com/healthcare

  10. Parley, you may be right about this. Here’s what I said on the topic back in 2006: http://www.healthbusinessblog.com/?p=910
    “I wouldn’t be at all surprised to see Wal-Mart start to hire significant numbers of doctors and put them to work in its stores.
    If Wal-Mart can spur significant reductions in the cost of routine services and products, it will go a long way to cutting overall costs.”
    I don’t think Wal-Mart will actually suck doctors in the way you’ve described –by controlling their EMR data. However it may provide a platform they can leverage.
    As far as I’m concerned it would be a good thing.

  11. Is selling and profiting from ehr’s really the extent of Wal-Mart’s business model here?
    The press I’ve read about the Wal-Mart/eCW partnership has tended to focus on questions of technical mechanics, clinician adoption, cost analysis, is ehr a retail commodity?, etc. These are all important areas to examine and debate, but I’m wondering if we are missing the bigger picture here.
    Lets just start off with the value-neutral observation that Wal-Mart’s interests and the public interest only occasionally (and coincidentally) coincide. Then consider what the rise of Wal-Mart has meant for small, independent businesses in communities across the nation. In any case, whatever your opinion of Wal-Mart’s business practices, I think we’d be wise to treat any initiative like this with some skepticism, and to ponder what Wal-Mart might really be trying to do here.
    Is Wal-Mart merely aiming to become an ehr retailer? Maybe, but I don’t think it would surprise anyone if their strategy were far broader. A key question here is: once Wal-Mart connects these physicians into an ehr, who then owns and controls the clinical data? (Of course, the standard answer will be “The Patient!” – and technically that might be true, but in the proprietary ehr world where standards and portability are mostly a mirage, is it practically the case that patients own their emr?)
    Now, if you are a physician in a small, private practice (which this program ostensibly is targeting), and Wal-Mart wants you to work directly for them, would it be easy to decline such an offer if all of your patients’ medical histories reside in Wal-Mart’s system? What Wal-Mart might really be aiming for is an employed physician model, converting Wal-Mart into not just an ehr retailer, but a major provider network.
    I surely don’t have any insight into Wal-Mart’s ultimate business plan – but I think we need to at least start asking these questions of who will control the patient data, and start to ponder the potential here that ehr could easily be (ab)used as leverage to bind physicians to a nation-wide network of Wal-Mart owned or franchised clinics.

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