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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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34 replies »

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

  2. 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.

  3. 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 clinician’s unaided mind would probably depend on the complexity of the situation, the clinician’s knowledge base, and the software’s competency. But that’s not the point, imo. When I speak of the need for patient-centered cognitive support, I’m saying that mainstream IT does NOT yet provide PCCS because there’s been little incentive for IT developers to use virtual patient models the way I’ve described. Nevertheless, it is something that we had better start doing if radical and sustainable improvements in healthcare cost-effectiveness are to be realized! When PCCS becomes a widespread reality, clinicians would be able to use their knowledge and heuristics more efficiently and effectively, which would result in better decisions and clinical outcomes.
    None of this is meant to diminish the importance of collaboration! In fact, people-to-people correspondence is a necessary prerequisite for PCCS. One example is an IT system we designed for a major company in another industry. Knowledge workers input their lessons learned (i.e., experiences and observations), categorized them, and shared and discussed them with each other. The lessons learned are then sent to subject matter experts who evaluated them, compared them to other lessons learned and existing best practice guidelines, and passed them along through a systematic process in which groups of experts would determine whether certain of them should be established as new best practices; those that are would then incorporated into the decision support software system. If applied to the PCCS process in healthcare, the best practices would become part of domain of knowledge that the virtual patient algorithms would access and evaluate for its pertinence to the particular patient. This iterative process is an example of how IT can facilitative communication and collaboration to improve decisions.

  4. 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, as Dr. Kibbe said, will represent “Innovative business models.”

  5. 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 human mind can has limitations. I discuss this at http://wellness.wikispaces.com/The+Knowledge+Void.

  6. 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.

  7. 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 addition of third-party applications that can interact with the classes. methods, etc. “exposed” but the API.
    Contracts between users and vendors invariably stipulate that any third-party additions that interact with the proprietary system invalidate warranties. Part of that stipulation is commonsensical and correct, but mostly it is there to ensure lock-in and associated limitations or high cost or both. Principle number 5 deals with that issue. It is a crucial point.
    The concept of “hiring” some outside service or product to perform a “job” that the user wants done is a key insight (although the same as earlier business jargon about “paying attention to the customer”) as outlined in point 10.
    Certification is useful to the extent that helps to limit choice of computer technology to the most efficacious products or services, but certification should not be designed to protect the entrenched and exclude the innovative. That is a characteristic of much “certification” or “licensing” schemes.
    All the more power to Drs. Mandl and Kohane, Prof. Christensen, Dr. Kibbe and others who drafted the principles.

  8. 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 for the Dossia venture that was launched a few years ago.
    I have not read the 10 principles yet, so do not know how those fit in the statement above.
    I have little faith that Microsoft’s Health Vault venture will do anything positive socially or will even do much otherwise. The Microsoft mindset is and will forever more be that of a proprietary monopolist. Google on the other hand … And who knows who else is out there.
    I have a hard time understanding the fuss about social networking and do not see anything particularly socially useful from that phenomenon in regard to improving health status or reduction in medical service cost to the average person.

  9. 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 combo.
    It is the application that has the healthcare specific capabilities.
    It is the application that serveso as a “platform” for plug-and-play of other small software applications. So the platform is really a software product, and a proprietary one at that.
    A better example for a plug-and-play platform in this sense is Force.com, where developers can build and connect various applications to the salesforce.com application or even have stand alone apps. The force.com Platform-as-a-Service is providing CRM like capabilities out of the box. I assume, and please correct me if I’m wrong, that this is what you are trying to promote for health care applications.
    If so, then there are some discrepancies between the 10 Principles you published and the Force.com paradigm. First and foremost would be that the platform vendor is totally in control of all applications running on that platform. Second, applications built on the platform are proprietary to the platform (Apex language for Force.com). You can have other applications communicate with the platform using connectors, but again, the platform and the data stored on it are proprietary to that one platform vendor.
    A software platform like this one will not be free to either consumer or developer, unless the platform owner has another way to monetize the platform (data mining). Force.com is certainly not free.
    As to substitution of components, the main component that makes the platform and allows it to produce revenue to its creators will most likely not be replaceable. I doubt that Microsoft will allow an IBM Health Vault to actually run on its platform and collect all the data.
    At this point, I doubt very seriously that a robust, health care platform, similar to the CRM Force.com platform is an easy thing to build from scratch. There is no resemblance between what needs to be programmed into a decent clinical application and what Force.com can do, not to mention iGoogle and Facebook. These are recreational apps that mostly do not interact with each other and if they do it’s on a very basic level of contacts and emails.
    All that said, I would love to see this level of interoperability in the health care software market. I would be thrilled to see, say, a NextGen to GE connector that is developed by a third party vendor. I can even see stand alone modules, like registries and CDC that can be interconnected to other vendor offerings. This is already happening now anyway.
    I’m not so sure that this is about platforms really. It is about communications, published APIs and data exchange.
    I am sure you understand, and particularly Mr. Christensen, that nothing ever gets innovated, built, and widely adopted, unless there is a profitable business case for both the innovator and the consumer.

  10. 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. The innovations in technology that turn out to be “disruptive” are also innovative business models, something that Andy Grove pointed out to Clay Christensen several years ago. So, it’s really the play between technology and business model, both of which have inherent sophistication, that combines to create disruptive change in a market.
    Thanks. Kind regards, DCK

  11. 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 decision support HIT tools.

  12. 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 communication tools such as phone and text (SMS) notification for appointment reminders and billing communications. There are Web Services vendors in the marketplace that offer other services applicable to health care practices, and organizations can build their own fully integrated systems efficiently and affordably in a model that requires only an Internet connection to work once it’s implemented. I appreciate that these services do not cover every aspect of the issues being discussed, but I wanted to make practitioners aware that there are alternatives to the black and white problem of expensive total solutions vs. inferior products.

  13. 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 and how Facebook apps work. Moreover, as the web developed, the interoperability standards community followed after rather than led the developers who were constructing components of functionality in servers and browsers.
    viz:
    http://en.wikipedia.org/wiki/History_of_the_web_browser
    It can be easily argued that making a standards effort precede this competition on loosely coupled functionality could have delayed the advance of the web.
    Ultimately this is an issue that gets resolved in practice and not in debate. We surmise our contributions will positively affect the practice of medicine but regardless we hope that judicious use of IT will improve the efficiency and quality of healthcare delivery.
    Ultimately this is an issue that gets resolved in practice and not in debate. We surmise our contributions will positively affect the practice of medicine but regardless we hope that judicious use of IT will improve the efficiency and quality of healthcare delivery.

  14. 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 curious to see whether those clinics can make money over time. The concept of “precision medicine” that can permit pricing of clinical outcomes as opposed to intuitive diagnosis that has to be paid on a non-outcome basis is an invaluable insight by Prof. Christensen and colleagues in my estimation. Also the idea of chronic care paid for on a “subscription basis” is very insightful. All three are valuable for policy setting, it seems to me.
    Somewhat puzzling to me is mention by Dr. Kibbe in his essay of the announcement by the AMA concerning a “portal”. The AMA already sponsors through initial funding and presumably on-going partial ownership an excellent portal, the Medem website, which has been available for several years as an excellent, web-based PHR for patients and a somewhat useful web-hosting site for physicians.

  15. Wendall: I really appreciate your comment about Luddites. I stand corrected.
    What bothers me about client-server technology is its unit cost and lack of scale. Here also, I’m not opposed to client-server or PC-based or computer-resident software. Use these all the time.
    But when it comes to distributing software at increasingly lower cost to customers, and offering less hassle for maintenance, security, and upgrades, and connectivity/communications ease, I think there are some very powerful reasons for EHR technology to evolve towards Internet-based systems.
    Again, I’m for choice and innovation. Community not control.
    Kind regards, dCK

  16. An addendum: I just read the essay by Dr. Kohane and Mandle, Tectonic shifts …, which I thinks is superb in every way.
    I will check out the 10 principles reference.

  17. Margalit and others: I’d like to add that I’m NOT an opponent of the single-vendor EHR technologies from companies like NextGen, eClinicalWorks, Allscripts, Amazing Charts, SOAPware, etc. People shouldn’t take my comments about Clinical Groupware and the contrast with these comprehensive single-vendor products as an “either/or” position. Rather, I think the likely outcome is that both approaches or models, the interdependent and vertically-integrated, and the modular architected, will do well over the next few years. PCs did not obliterate the market for mainframe computers. Clinical Groupware will not replace comprehensive EMRs from single vendors. What’s up for grabs is the non-consuming portion of the market. Make sense? Kind regards, dCK

  18. Mr. Bosworth’s comments cited by Dr. Kibbe are on target, it seems to me. This is also consistent with the idea of the value proposition or “a service that helps customers do more effectively, affordably and conveniently a job they have been trying to do” that is a key concept in the Christensen, et. al. book.
    “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.”
    One of the problems with many current EMR/PM products is not so much the client-server nature of them that seems to bother Dr. Kibbe for reasons unknown to me, but a mixture of relatively high to exorbitant cost of most and not doing “the job that that physicians have been trying to do” along the lines of what Mr. Bosworth describes in the quotation.
    Most physicians are Luddites I am sorry to say. Luddites were primarily opposed to machinery that supplanted their skilled work because it took away their incomes. They were not opposed to the technology per se. Much of the Ludditism of physicians is for a similar reason, although some is also disparagement of computer technology out of disinterest in learning how to exploit it combined with no incentive to invest because physicians by and large simply do not feel “normal” competitive pressure.

  19. Margalit: I’ve asked Ken Mandl and Isaac Kohane to respond to your question, which is quite valid. What is the difference between the “iPhone apps platform” and the old Microsoft Windows “platform?” My own answer: about 30 years.
    Seriously, it’s a good question. The OS for Windows was the first almost universally-accepted “platform” that supported third part apps through an SDK and APIs, although for a while there the Apple IIe OS gave it a run.
    Technically, I think there are significant differences between a cell phone OS and a PC OS, but I”m not going to quibble with your basic point, which I believe is that these are both examples of device “platforms” for third party developers, and they’re both proprietary OSs, as opposed to FOSS.
    What Ken and Isaac and Clay Christensen have brought attention to, however, is not that the iPhone is some revolutionary new kind of platform, but rather that the iPhone apps model is a powerful metaphor for the way that some health IT, particularly EHR technology, ought to be designed, integrated, and marketed in 2009-11. And they have described the benefits of that approach, as have I.
    No one is claiming that this is the only approach or model. But examples of an open API, modular architecture for the EHR technology market would almost certainly be disruptive of the dominant single-vendor, monolithic, high interdependency products that give the customer virtually no choice whatsoever as to the component services they want or need to purchase. It’s the one-size-fits-all and take-it-or-leave our product/price/performance that the platform approach — whether Windows or iPhone — offers an alternative to.
    Not for everyone. But it’s nice to have a choice if you’re the customer.
    Regards, dCK

  20. I give up….. I don’t even know where to begin…
    Can someone, please, go through the “Ten Principles..” above, one by one, and explain to me what is the difference between the novel “iPhone Platform” and the old Microsoft Windows “platform”?

  21. David,
    Great post — it’s great to see this discussion flourish at such an important time.
    For those interested in the platform/app idea, Ken Mandl and Zak Kohane just posted a set of “Ten Principles for Fostering Development of an “iPhone-like” Platform for Healthcare Information Technology” (see http://chip.org/platform), developed with input from David and also Clay Christensen.

  22. Dr. Dussia,
    I agree that a good consultation with a competent clinican is essential! PCCS is not, however, about optimized coding and scheduling. Instead, it’s 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.

  23. I agree with Margarit and a few other commenters. “Groupware” is much like “cloud computing” – almost entirely marketing hype. The concepts and practices of both have been around for decades.
    I might note that I took a look at Margarit’s company’s EMR/PM product – quite good in my opinion. Those physician commenters who continually disparage current EMR technology cannot have had any experience with a good-quality EMR. There are many that function well. Pricing is another matter.
    “One example is Glostream, an upstart vendor that is using Microsoft Office (used by hundreds of millions of information workers around the world) as the integrated foundation of the company’s EMR solution.”
    How Dr. Crounse can hype any third-party EMR product based on Microsoft Office is beyond me. That is one of last software “foundations” that anyone should consider for developing an EMR product. FOSS is the antithesis of Microsoft strategy, and of much of Microsoft’s software development. To be note however that Microsoft, like other large vendors such as IBM in particular, has contributed significantly to various FOSS projects.

  24. Dr. Kibbe, I am skeptical of promises to pay for “certified” applications that do not solve problems. The EMRs that are available today do a good job of supporting the office and hospital office staff, but have little to offer busy clinicians. The money isn’t designed to go to me anyway, just to the “certified” vendors.
    Dr. Beller, I really don’t want “patient-centered cognitive support” (PCCS). I really want a good consultation with a clinician I know and trust. On June 10, I posted a blog http://www.drdussia.com/my_blog/ about what a clinician needs most. It is not an ASP that will “optimize coding” and give me scheduling nirvana.

  25. Evidence-based decision support and effectiveness – Clinical Groupware and “lite” systems — If one looks at evidence of what improves care, getting decision support to the point of care workflow is the critical element – note, this is distinct from getting physicians hands on keyboards as the first step for improvement.
    A great example of the evidence is the Kawamoto et al article in the BMJ from 2005…
    http://www.bmj.com/cgi/content/full/330/7494/765
    “Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P less than 0.00001) provision of recommendations rather than just assessments (P = 0.0187), provision of decision support at the time and location of decision making (P = 0.0263), and computer based decision support (P = 0.0294). Of 32 systems possessing all four features, 30 (94%) significantly improved clinical practice. Furthermore, direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.
    Some specific examples across settings come to mind in thinking about DocSite users over the years –
    1) Improvement within rural small practices engaging in a diabetes care enhancement initiative – the practices moved from 42% to 57% of patients in good control (A1c<7) in a six month period, using a web-native clinical groupware product.
    2) A 300+ physician PHO moving A1cs in poor control (A1c greater than 9 or missing) from 26% to 12% in 4 months in original clinics and 29% to 15% over a similar timeframe in spread clinics. AHIP published an analysis showing a decrease in hospital admissions of 26% in patients with team-based care using decision support and population management with a web-native clinical groupware product.
    3) Asthma controller meds from 43% to 76% (equivalent of moving from the lowest to the highest decile of quality, as evaluated against a national benchmark) in primary care practices within a multi-month period – the IPA turned this into enhanced reimbursement rates over a 3 year period resulting in a multi-million dollar rate improvement across the 125 physician IPA in a particular managed care contract.
    4) Paper-based clinical groupware physicians, using computerized decision support within their office workflow, out-scoring on quality measures and P4P rewards hands-on complex legacy EMR users in a hospital-based family practice department. This example occurred within a Connecticut IPA participating in the Anthem P4P program.
    Another example, not so much on immediate improvement of quality, but rather on demonstrating the feasibility of new participants in quality processes and programs:
    In 2008 thousands of physicians successfully submitted quality measures for Medicare PQRI using clinical rather than billing data. In 2008 CMS created a method where simple systems, including clinical groupware systems, can be used to let a physician qualify for Medicare Quality Bonuses. The collection, analysis and submission using clinical measures typically takes a few hours over a few days in the office for the 2008 Medicare pay for performance program.
    Sitting in the "meaningful use" discussion at the HIT policy committee meeting in Washington right now (10:45 a on June 16), Paul Tang is presenting proposed measures for "meaningful use" for HIT and for getting the $44K ARRA incentive funds. He and the group are offering a concept of "HIT derived Quality Measures – including such things as the measurement with clinical data from electronic systems, such things as % of diabetic patients with A1c or LDL assessment and control.
    The bottom line, reliably getting decision support into the point of care workflow – whether in a paper or electronically documenting office improves care.
    Dr. Kibbe's less is more hypothesis is spot on, based on the evidence in the literature and through experience – at least on this end over the last decade – simple, evidence-based systems make it easier to deliver better care.
    David, thanks for shining the light!
    John Haughton MD, MS
    DocSite

  26. Steve: I think you’ve articulated the goal very, very well for patient-centered decision support, or PCCS. It’s really important to have your list of capabilities, and I’ll keep it handy as I think and write.
    Margalit: So many issues! Please don’t over-read my post about Clinical Groupware to imply that I have this all figured out. I don’t! The point is to let the developers and the market offer “a hundred flowers of disruption,” meaning many new products, some of which will be very good, and others that may not be.
    With regards to the plug-and-play aspect, I think the most important thing is the open APIs. You’re perfectly right, the iPhone’s operating system is closed and proprietary, and I fully expect some Clinical Groupware entrants to choose this route. It’s already happening. But Android (cell OS from Google) is both open sourced and open API. There are people in the FOSS already working on a “core platform” for EHR technology which they hope will be successful as open source code.
    And remember, I said that I think Clinical Groupware will occupy a niche, not take over the market. The single-vendor, monolithic products will continue to sell into this market, particularly for those who prefer this option. But as David Blumenthal said yesterday in the WSJ, if someone builds an EHR technology that works more like the iPhone and its apps — and if it works — then he’s fine with that.
    You may be right that I’m wrong about this trend.
    Kind regards, dCK

  27. Hi David,
    Since our nation’s goal is drastic improvements in care efficiency and effectiveness (i.e., value to the consumer), it seems to me that mainstream HIT—be they EHR/EMRs, CPOEs, or even PHRs—have minimal usefulness because they don’t provide robust decision support. Cost is not a factor in this regard…I did not mean to imply otherwise.
    EHEs that could provide truly useful decision support would bring about dramatic improvement in care quality and affordability. This means doing much more than offering warnings and alerts (which is the bulk of decision support provided by mainstream HIT systems).
    The kind of HIT tools I’m envisioning would promote profound holistic understanding of each patient’s particular problems, needs, and preferences; enable a keen awareness of the pros and cons of appropriate treatment, prevention, and self-management alternatives; and supply reliable guidance and useful feedback over a person’s entire lifetime.
    The missing ingredient for such robust decision support is what the National Research Council of the National Academies calls “patient-centered cognitive support” (PCCS). PCCS is a computerized process that uses a “virtual patient model” to:
    • Save clinicians time and energy by automating searching and sifting through a patient’s clinical details and related research guided by a virtual patient model.
    • Promote a deep and broad understanding of a patient’s health status, including the interplay of biological, psychological, and social (i.e., biopsychosocial) influences—past, present, and future.
    • Provide effective, personalized decision support regarding diagnosis, treatment, prevention, and health promotion. And this decision support would help:
    o Account for patient preferences, qualities, and circumstances
    o Help improve overall care value
    o Continually evolve.
    If an EHR, alone or connected with next-generation clinical decision systems, were to be PCCS-enabled, then I would consider the decision support it provides exemplifying “meaningful use” … and the lower the cost of such an EHR’s deployment and ongoing use, the better!

  28. Dr. Kibbe,
    As you know, I don’t necessarily agree with the notion that clinical software needs to be fragmented in order to qualify as groupware. Fragmented software is harder to use, harder to maintain and much more expensive when you add it all up.
    Let’s take for example the quote from Adam’s blog. Having an application that chats with patients and another that records home monitoring and later on add some charting sounds great in principle. However, such disparate portals or web apps will require either complex context management/single sign-on ala CCOW, or plain old multiple data entry. In either case obtaining a good unified longitudinal record for a patient will be difficult, not to mention that it’s not clear to me where exactly the medical record is residing and how the “group”, other providers and the patient, is accessing it.
    I do agree that most existing EHRs are not communicating with each other. The question is why? Is it a technology issue? Considering that most EHRs are communicating with a variety of entities, such as labs, diagnostics centers, payers, pharmacies, I think the problem lies elsewhere. Groupware is a mind set and if the “group” required that their EHRs be able to communicate, I’m pretty sure that plenty of interoperable EHRs would be made available. Sadly, there was/is no business case for interoperability between EHRs. There is no Groupware mind set in the clinical community. Hopefully ARRA will change all that.
    I am not at all convinced that the path to software innovation is the creation of smaller, less capable software modules to replace a comprehensive product. I am not familiar with any software product that followed this particular path and achieved success. Again, there is no business case for a software vendor to develop small bits of an application and there is no business case for a physician to purchase software that way, no matter how dirt cheap each nugget is. The cumulative cost of utilization will be too high. This is not to dispute the fact that today’s crop of EHRs is by and large obscenely overpriced.
    I believe we should concentrate on innovations that will create more usable, nimble and interconnected software at an affordable price, instead of whether it is an integrated package or something that the physician has to assemble from disparate sources. Most small practices don’t have the ability, or the time to do that and the end result is mostly guaranteed to be less efficient.
    Now to my private little crusade, the mighty iPhone and its platform. Yes, the iPhone has an OS platform; a proprietary OS platform. It is not open in any sense. Linux OS is open and so is MS Windows (not to be confused with open-source). You can install those OS on almost any hardware and anybody can freely write applications that run on Windows or Linux and deploy or sell them anywhere. The iPhone OS only runs on Apple iPhones and you can only deploy your iPhone applications through the Apple store. Not very open at all.
    The iPhone is more computer than phone and that may be its major appeal, other than being very cool, of course. You could always have multiple apps on your MS Windows computer, but that is hardly exciting anymore.
    So what are we really saying when we advocate an open EHR platform like the iPhone? Are we suggesting one proprietary EHR framework that runs on one proprietary hardware from the same vendor, which allows guys in garages to sell tiny modules that only work on this proprietary hardware/OS combo?
    Maybe it should even be a government owned proprietary “platform”. Would this qualify as “socialized” HIT :-)?

  29. Dear Rob: I strongly agree with you that Clinical Groupware is unlikely to succeed if physicians using it aren’t willing to collaborate and coordinate their care. Part of the expected Obama health reforms, however, may be to increase the likelihood that physicians and their practice gain higher levels of financial integration, and will be rewarded for clinical integration. And I also agree with you that this isn’t mostly about the IT itself, never has been for me. Kind regards, DCK

  30. Dear Steve: You raise an important point. However, I don’t think that low cost necessarily implies poor decision support, although I agree with you that many of the lower cost legacy EHR technologies don’t offer much DS. However, in a plug-and-play architecture, a decision support module ought to be able to interface with several other components to “grab” the data needed for robust DS. This is the way I’m seeing people visualize it, and, although a challenge, I think it can become a reality soon. Perhaps someone from the Clinical Groupware space wants to comment on this? It’s a legitimate concern.
    Regards, DCK

  31. Low cost EHR alternatives make wonderful sense! One serious problem with all EHR/EMRs, however, is that the decision-support they provide are unimpressive and, as such, they are unlikely to much positive impact on quality and costs. Since our nation’s goal is drastic improvements in care efficiency and effectiveness (i.e., value to the consumer), then we should make patient-centered cognitive support a requirement of “meaningful use.” I just posted an in-depth discussion of this issue at http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html
    Steve Beller, PhD

  32. David,
    Thank you for your thoughtful comments on Clinical Groupware. As you know, I am a huge fan of “disruptive innovation” and like you; I think the time is ripe for a little disruption in healthcare.
    There is evidence all around that this is happening. I see hospitals overseas building very robust hospital information systems using off-the-shelf commodity IT solutions and doing so for pennies on the dollar compared to the “big iron” solutions we use in America. More important, the doctors and nurses who use these systems actually like them because they are intuitive, contemporary, flexible, and work the way clinicians want to work.
    I see an uprising of EMR vendors in America who are starting to use more commodity, open standards components in the solutions they build. One example is Glostream, an upstart vendor that is using Microsoft Office (used by hundreds of millions of information workers around the world) as the integrated foundation of the company’s EMR solution.
    I see a rallying cry from consumers who are embracing web-based platforms for personal health records and medical devices such as Microsoft HealthVault. In fact, I believe these web-based and SAAS platforms that aggregate health data around the consumer are a model for the so-called “national health information network” that is actually achievable at a price this country can afford.
    I look forward to participating in next week’s Healthcare Unbound conference where I’m sure we’ll have some lively debate. Thanks for sharing your wisdom. We need a few more “disruptors” in our ranks.
    Bill Crounse, MD
    Senior Director, Worldwide Health
    Microsoft

  33. Groupware as a concept has been around for a couple of decades now. Having had a lot of experience in global groupware implementations in the early ’90s, I can say this:
    Groupware isn’t technology; it’s a mode. Adding groupware to people who are competing just gives them all something to agree about: Groupware doesn’t work.
    For those already cooperating, it’s a marvelous way to take advantage of a computer’s basic abilities: it can remember things a long time, and look them up after. It’s electronic smart-paper, and a cooperating team will intuitively know what to do with it.
    This is about intent and priorities. It has very little to do with what technological artifacts you choose. I fear we will once again focus on the fetish of machine instead of the mind of care. Ah well. Maybe in 2030 our new computer overlords will straighten it out…

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