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Clinical Groupware: When Not-As-Good Is Actually Better

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In a February 13, 2009 blog post I introduced the idea of Clinical Groupware as a low cost, modular, and cloud computing alternative to traditional electronic health record technology for physicians and medical practices. Central to the concept of Clinical Groupware is IT support for care coordination and continuity, achieved through shared access to personal care plans and point-of-care decision supports. In this post I’d like to put a few more ideas on the table, specifically with respect to the market niche that Clinical Groupware may ultimately fill, including comments by several individuals whose opinions or work may be crucial to the success of Clinical Groupware over the next 1-3 years.  (Anything farther out than that is simply dreaming.)  Consider this an interim report on an emerging story with an indefinite timeline.

Interest in this topic has been, of course, heightened by the recently passed federal AARA/HITECH, provisions of which will provide incentive payments to physicians of as much as $44,000 over a five year period commencing in 2011, provided that the physicians can demonstrate the “meaningful use” of “certified EHR technology.” It’s always more exciting when there’s real money in the mix. Will Clinical Groupware qualify as “certified EHR technology?”  Many physicians and developers are hoping it will. Here’s why.

I see Clinical Groupware as a disruptive, low cost but high capability technology, an alternative to the costly EHR technologies that are now implemented in about 15-20% of ambulatory care settings; the rest of the market has not become consumers of these products.  When 80% of potential customers aren’t buying, one thing you can say for certain is that non-consumption is an important characteristic of that particular market. And that’s what we have here. Doctors have taken a long look in the vendors’ shop window and overwhelmingly decided that the combination of cost and performance characteristics offered there don’t warrant a “buy now” decision.

Notice, there is no Apple iPhone adoption problem among doctors. To the extent that there does exist an “EHR adoption problem” for physicians, we should look to the characteristics of the products on the market for the sources of the problem, and not simply blame the purchasers out-of-hand.  In my own experience most physicians are not Luddites, nor are they frightened by or confused by information technology in general. They purchase and use technologies they see as valuable to them and their patients, and that offer the performance characteristics they want at the price point they deem reasonable. It’s just plain silly to get angry at physicians for being prudent shoppers. No one blames auto consumers for not having liked the Edsall or the Pontiac Aztek.

But this is all in retrospect. What’s likely to happen in the future?

Of course no one can predict the future; all we have to go on is the past, and things don’t always repeat themselves. But there is sound business theory based upon study and research over many decades, that can help us make educated guesses about future health IT product offerings, as well as about purchaser buying behavior. Clay Christensen, the noted Harvard Business School professor and author of several books on innovation, has described situations that favor the development of disruptive innovation in any industry.  His ideas about change and innovation are worth a careful read:

The initial products and services in the original “plane of competition” are typically complicated and expensive, so that the only customers who can buy and use the products…are those with a lot of money and a lot of skill. In the computer industry, for example, mainframe computers made by companies like IBM comprised that original plane of competition from the 1950s through the 1970s… The same was true for much of the history of automobiles, telecommunications, printing, commercial and investment banking, beef processing, photography, steel making, and many, many other industries. The initial products and services were complicated and expensive.

Occasionally, however, a different type of innovation emerges in an industry — a disruptive innovation.  A disruptive innovation is not a breakthrough improvement. Instead of sustaining the traditional trajectory of improvement in the original plane of competition, the disruptor brings to the market a product or service that is actually not as good as those that the leading companies have been selling in their market.  However, though they don’t perform as well as the original products and services, disruptive innovations are simpler and more affordable. This allows them to take root in a simple, undemanding application, targeting customers who were previously non-consumers because they lacked the money or skill to buy and use the products sold in the original plane of competition. By competing on the basis of simplicity, affordability, and accessibility, these disruptions are able to establish a base of customers in an entirely different plane of competition…In contrast to traditional customers, these new users tend to be quite happy to have a product with limited capability or performance because it is infinitely better than their only alternative, which is nothing at all.

…When a disruptive technological enabler emerges, the leaders in the industry disparage and discourage it because with its orientation toward simplicity and accessibility, the disruption just isn’t capable of solving the complicated problems that define the world in which the leading experts work. (The Innovator’s Prescription, 2009, pgs. 5-6)

Is it accurate to compare the emerging Clinical Groupware with disruptive innovations in other industries, with the early PCs, the transistor radio, and Southwest Airlines, for example? Are we about to enter another “plane of competition” beyond the one that was established by EHR vendors like NextGen, GE Centricity, Epic, and Allscripts?  And, perhaps most importantly, will the new EHR technology compete “on the basis of simplicity, affordability, and accessibility” with the older products in way’s that establish “a new base of customers and disrupt the market?”

Well, one consistent sign of disruption is visible opposition and protectionism from companies who sell top tier products at the highest profit margins.  And we are certainly seeing that! As reported in the Washington Post and elsewhere, the industry is attempting to raise barriers to new products characterized by simpler, more accessible, and less expensive EHR technology, mainly through regulatory control that would constrain the features and functions used to “certify” these products; through complex standards that make it more difficult for small companies to bring their products to market; and, most recently through state legislation that would ban non-certified products from being bought, sold, or used. (I understand that New Jersey state legislators with close ties to top tier vendors have introduced a bill that would make it illegal for anyone “to sell, offer for sale, give, furnish, or otherwise distribute to any person or entity in this State a health information technology product that has not been certified by CCHIT,” and which would levy heavy fines on anyone who did. This would make it illegal, in effect, for Google Health or Microsoft HealthVault to operate in the state of New Jersey.)

But it is less the disparagement and discouragement to innovation, and more the enthusiasm and hopefulness attached to new health IT models, that indicates to me there may be a surge in popularity for Clinical Groupware during 2009 and 2010.  A growing number of experienced engineers, technologists, patient advocates, and health professionals have indicated common support of the basic innovative ingredients in Clinical Groupware.   These include: low cost, simplicity of use, interoperable modularity, software as a service, a focus on coordination, and engaged communications with patients and among providers.  Here, for example, is Adam Bosworth of Keas, formerly Google VP in charge of Google Health, writing in a recent post on his blog:

…[M]ost small practices can’t really afford to use big iron EHR’s. Even if it is free, they can’t really afford to do it because it will still require training, more time per patient potentially, and so on. Lastly, most EHR’s don’t work with other EHR’s so that coordinated care across practices isn’t supported and most people who are elderly or who have serious illnesses have more than one physician treating them.

The way around this is to build systems that don’t just duplicate what physicians do today during their face to face meetings with their patients, but rather provide new capabilities that will help with continuous and coordinated care and can generate additive revenues for physicians and then evolve by adding those features that automate the current physician activities as demanded by the physicians.

What would such systems support? They would support having a way to chat with or exchange messages with a patient for a fee so that unnecessary office visits can be removed and the patient is more likely to reach out for help. Think eVisit-lite. They would support a simple way to monitor the health of a patient who either has a chronic disease or is on path to developing one, again for a fee, so that physicians are actually getting paid instead of punished for keeping their patients healthier since, ideally, healthier patients will generate fewer visits/procedures over time. In short these systems will support physicians managing an ongoing paid relationship with the patient rather than an episodic one measured only by in-office visits.  What should be done about helping physicians who are afraid of losing time to retraining? These systems should be as easy to use as a Southwest airlines reservation page. These systems should have a cost so low that physicians don’t care. Most of these points aren’t typical of most of the big EHR’s currently being sold. Again, hence our fear that a de-facto monopoly of the incumbents will lose this opportunity to let 100 disruptive innovations flower. (May 29, 2009 http://adambosworth.net/)

Adam isn’t the only one interested in letting “100 disruptions flower.” Steve Downs and John Lumpkin at the prestigious Robert Wood Johnson Foundation have recently blogged about the need to develop an “interoperable and substitutable web-platform” for EHR technology that is akin to the Apple iPhone apps model, an idea that is foundational to Clinical Groupware, and which was first described in detail by Ken Mandl and Isaac Kohane in a NEJM editorial in late March, 2009. Downs and Lumpkin write — their enthusiasm nearly jumping off the page — in part:

Perhaps the key is to put more money behind companies that offer EHRs that allow 3rd party app development. Will seeding a fund convince other investors to get in? Are there startup ventures out there that could take advantage of the fund? A venture fund for app developers.  Apple and Kleiner Perkins did this – they set up a $100 million fund to invest in companies that would develop applications for the iPhone.  (June 4, 2009 https://thehealthcareblog.com/the_health_care_blog/2009/06/catalyzing-the-app-store-for-ehrs.html)

Meanwhile, over at ZDNet, noted business journalist Dana Blankenhorn is hopeful that David Blumenthal of ONC will come through as a supporter of innovation.

CCHIT changes its certification criteria every year, and every year it becomes more detailed. While the 2009-2010 standards have now been unveiled only 40 ambulatory EHRs have been approved under the 2008 standards, and only six are approved for emergency departments. By making all vendors jump through these hoops CCHIT imposes an enormous tax on all vendors and limits competition to those large enough to deal with it. What reformers …seem to want is a more basic process, one that assures interoperability and encourages innovation. Placing that authority in the government instead of CCHIT does not guarantee this result, but it is certain CCHIT is not going down that road. What I expect to happen now is for the newly-appointed ONCHIT advisory committee to seek a compromise, and David Blumenthal will try to craft a solution that keeps all options open. (May 21, 2009 http://healthcare.zdnet.com/?p=2318)

Representatives from the medical specialty societies are also beginning to understand the value to their members of component-based EHR technology and software-as-a-service.  For example, a senior team of researchers from the American Academy of Family Physicians, led by Paul Nutting at the University of Colorado Health Sciences Center, recently reported on initial lessons from 36 patient-centered medical homes.  In their report in the May/June issue of Annals of Family Medicine, the authors highlighted as a common problem in medical home transformation the lack of a “plug-and-play” platform for EHR technology, and the slowness of response and high costs associated with some single-vendor EHR/EMR technology vendors.  Among its findings and recommendations, the panel of authors stated:

…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR.

The AMA has just announced, in an appearance at the Microsoft Connected Health Conference, June 11, 2009, “..a new physician Web-based portal the AMA is developing … will provide physicians access to practice-related products, services and resources in a single location. The AMA plans to launch its new portal nationally in early 2010.” The platform will help physicians exchange health information with their patients through Microsoft’s HealthVault application, and will include an ePrescribing module as well.

And then there are the open source folks. Fred Trotter, an expert in online security and a leader in the free and open source, FOSS, movement in health IT has recently discussed in his blog how momentum is growing towards a disruptive set of innovations:

The ‘Clinical Groupware‘ people want to see the certification of a suite of technologies that may or may not add up to a traditional EHR. The EMR-lite people want to see faster and lighter tools. The PHR people and consumer advocates want EHR systems that empower the patient instead of the provider. The Health 2.0 people want to see completely different models of finance and care become possible. Of course, the FOSS people (like me) want FOSS EHRs to get equal footing. (June 2, 2009 http://www.fredtrotter.com/2009/06/02/can-cchit-move-beyond-problem-ehr-certification/ )

One of the nice things about blogging is that people respond with their thoughts and opinions, and sometimes with new information that adds value to an idea, making it a collective — rather than a merely personal — concept. This is what appears to be happening with Clinical Groupware. I’ve received hundreds of emails and telephone calls from people who have connected the dots around this concept in their own way; most simply want me to listen to and understand their approach or, in some cases, discuss their innovative products. But a few commenters have asked the necessary, hard questions about what will make Clinical Groupware a successful disruptive innovation in a marketplace — medical practice health IT — that has been notoriously difficult, even fickle, to sell into. These questions, in turn, have forced me to think more deeply and to reach out to experts and innovators whom I trust to test the ideas.

Next week, at the 6th Annual Healthcare Unbound Conference in Seattle, I’ll be moderating a panel on Clinical Groupware with a number of representative companies, and discussing their business models with the audience. Should be very interesting, and I hope to report back to you as developments warrant.
David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

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Jayakanth DornadulaMike McBrideGraham Chiu MRCP, FRACPEvan Earl Dussia, II, MDElizabeth Rack Recent comment authors
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Jayakanth Dornadula
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Jayakanth Dornadula

Hey David,
Will Clinical Groupware be the next Blue Ocean Strategy in Healthcare IT?

Mike McBride
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Graham Chiu MRCP, FRACP
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EMR usage in some countries reaches 100% ( see http://stanford.wellsphere.com/healthcare-industry-policy-article/ehealth-2006-10-country-review-of-emr-systems/462087 ). The cost of US EHR software appears to be considerably greater than for similar products available in other countries, and certification costs will only drive the price upwards. One solution is to drive the pricing downwards so that the cost and performance characteristics are aligned, and that can only occur with free and open standards supported by the government.

Steve Beller, PhD
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In response to Dr. Dussia’s last post: I suppose the idea that business models can be disruptive is, well, a disruptive idea! I’ve been of the mindset that disruptive innovation referred to discontinuous leaps of technology. I don’t mind that the definition has been expanded. And please realize that I respect Dr. Kibbe and other original thinkers, such a Dr. Larry Weed, who have the courage to take on the status quo with novel ways to improve our healthcare system in radical ways. The results of a cpu-to-mind comparison between an experienced clinician using decision support tools and an experienced… Read more »

Evan Earl Dussia, II, MD
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Dr. Beller and I agree that the human mind has limitations. However, I am willing to put up my carbon based computer (or any number of my clinician colleagues carbon based computers) against your silicon based computer any time you want. Be advised that your silicon based computers don’t get any help collecting information from carbon based units and vice versa. 😉 It seens that there are only IT solutions offered here and that any other non-IT options are not options at all. Disruptive solutions may require no specific application or platform, but rather a change in mind set that,… Read more »

Steve Beller, PhD
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I agree with Dr. Dussia’s recommendation that it is essential for clinicians to share their thoughts and lessons learned through collaboration! I’d also add that such collaboration between clinicians and researchers (e.g., through practitioner-researcher networks) and between clinicians and patients (e.g., shared decision making) are also very important [see http://wellness.wikispaces.com/Tactic+-+Collaborate%5D. Nevertheless, this doesn’t negate the need for patient-centered cognitive support to improve decision making even among well trained, experienced, and highly competent clinicians. Why? Because despite drowning in oceans of information, there is serious a knowledge void in our healthcare system. Why? There are several reasons; one being that the… Read more »

Evan Earl Dussia, II, MD
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Dr. Beller writes that PCCS is “a process that enables clinicians to make the best possible decisions using a virtual patient model to help them sift through, select, and analyze enormous amounts of data pertinent to the patient.”
I thought that process is what I learned and perfected with “real patients” during 4 years of medical school and 5 years of residency training. Plus 27 years of sifting, selecting and analyzing in my home town.
What I miss is having access, at the point of care, to what the other clinicians, participating in the care of our common patient, are thinking.

Wendell Murray
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Just read the 10 principles. Good. The paradigm is not the iPhone alone. It is FOSS in fact and the concept has been around since UNIX at least and other fundamental software applications. In general the 10 principles argue for avoidance of so-called lock-in and the ability to easily (“no programming required” caveat too vague however) integrate enhancements, otherwise known as “extensions”, onto proprietary or non-proprietary software. That is crucial because lock-in is achieved through closed, as opposed to open, software. Open either in the sense that the source code is available or there is an API that permits the… Read more »

Wendell Murray
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Excellent commentary from Margarit, as usual. I agree with her again. Margarit: read the brief article by Drs. Kohane and Mandl entitled Tectonic Shifts … in the NEJM in April 2009. Remarkably astute and much clearer, it seems to me, than the iPhone analogy to their thinking. That pair of physicians/researchers (with others) apparently developed a software PHR product (FOSS) called Indivo at Childrens’ Hospital in Boston as a concrete realization of their thinking. I have just started to look at the product, so do not know much about it, although I know it has been used as the basis… Read more »

Margalit Gur-Arie
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Dr. Mandl, Dr. Kohane and David, First, thank you for taking the time to address my questions. I believe that we may have a confusion of terminology here. Health Vault and Amalaga are not platforms in the same sense that the iPhone is. As I said before, the iPhone platform consists of nothing more than a piece of hardware and an OS, just like a server consists of some hardware and, in this case, a Windows server OS. Neither one have any healthcare specific capabilities. Both Amalga and Health Vault are applications that run on top of the basic hardware/OS… Read more »

David C. Kibbe, MD MBA
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David C. Kibbe, MD MBA

Elizabeth: Thanks for your comment, and your characterization of the “black and white problem of expensive total solutions vs. inferior products.” As Clay Christensen has so nicely helped to explain, sometimes “good enough” is where the market wants product offerings to be, and he sort of jokes about disruptive products like Southwest Airlines being “crummy” compared to the upscale, uptier products. You know, you only get peanuts, never any meals or first class service. Or the transistor radios of the 1960s that were full of static, and only got one or two stations. But, of course, this is somewhat deceiving.… Read more »

Steve Beller, PhD
Guest

Although I wouldn’t necessarily call it a “disruptive innovation,” per se, it seems to me that Clinical GroupWare is a decent centralized web-based information exchange communications architecture, regardless of the particular HIT tools being deployed on/through it. The lower the cost the better! I suggest, however, that it should be augmented with a secure, decentralized (peer-to-peer), Internet-based communications architecture deploying offline HIT tools that support (a) patients and providers lacking continuous broadband connectivity (including rural areas with dial-up service only and mobile users) and (b) researchers, clinicians and model-builders in loosely coupled professional networks who collaborate to develop and evolve… Read more »

Elizabeth Rack
Guest

As a provider of Web Services useful for the healthcare industry, I would like to add that XML Web Services integrated with software applications and Web portals avoid the problem of interoperability as they are compatible with the various programming languages. Medical practices can purchase more affordable software and add Web services that cater to their individual practices on a pay-as-you-go basis (per transaction), saving a great deal of money. The company I represent, CDYNE, offers fraud prevention tools that aid in compliance with the FTC’s Red Flags Rule (411 lookup services and Death Index, among others), as well as… Read more »

Ken Mandl and Isaac Kohane
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Thanks to Stephen Downs for his post about the 10 principles. Margalit raises some questions which we address briefly here. We think, concisely, the difference between Windows and the proposed “iPhone-like” platform is that Windows does not support a healthcare data model nor healthcare transactions. Microsoft itself does not use Windows as the operating system for its health applications–it uses Health vault and Amalga. Healthvault and Google do recognize that relatively small autonomous, encapsulated bits of functionality are the best way to assemble customized functionality, for their health applications. But this is also exactly how Google and Yahoo widgets work… Read more »

Wendell Murray
Guest

One more addendum: I just finished The Innovator’s Prescription, which I also think is superb in almost all ways (but not all) and very relevant as direct and indirect references to its ideas have been made in this and other postings. It seems to me the “disruption” from current and evolving Internet/networking and generally computer technology that will lower medical service delivery costs will likely come from the “job being done” as defined above in the quotation from Mr. Bosworth. Somewhat related is the example of the “disruption” caused by retail walk-in clinics that the book discusses, although I am… Read more »