It has become politically incorrect to refer to EHRs as products. Instead, EHRs are now “technologies” as evident in all ONC and CMS published rules and regulations. This subtle change in terminology was intended to encourage, yes you guessed it, Innovation. It was supposed to signal an open market for alternatives to existing EHR products in the form of modular approaches, open platforms, mobile applications and web-based software-as-a-service. Naturally, the industry is obliging and all efforts now are geared towards creating stuff that runs on iPads, preferably “cloud” based and with minimal utility. The new stuff looks very cool and promises to become even cooler, so what’s the problem?
The problem is that these new things do not solve any problems. Traditional product innovation concentrated on identifying problems, designing solutions and then selecting technologies that were capable of enabling those solutions. New technologies were usually born out of the necessity to solve a burning problem and those with enough applicability to larger markets became blockbusters. Every frying-pan today sports technology first invented in the process of creating refrigerants and later used for nuclear destruction (Teflon). Every large enterprise embarking on cost cutting, new markets acquisition, or general improvements, should know all too well that selecting a “cool” technology first, and then attempting to find a good use for it, is recipe for failure.
As a former good friend of mine used to say, “There are three types of companies: engineering driven, sales driven and successful”. Successful companies are market driven – they look for those needs and problems that people are willing to pay to have resolved. Very successful companies create their own new markets by creating new needs that people didn’t even know they had. Sometimes, during this process, new technologies are invented for the purpose of creating products that solve people’s problems. Customers usually buy products and services. Rarely, if ever, do they buy “technology”. Moreover, technology should be transparent to the user and really good technology should feel like magic.
Back to EHRs, we are now trying to convince physicians and hospitals to buy cutting edge EHR technology, some of which has not been invented just yet. We are asking them to buy open platforms, clouds, information networks and more recently search-engine optimized data architecture. And when they drag their feet in utter confusion, we label them Luddites and technophobes. Furthermore, those supposedly concentrating on the “next generation” of health care computer tools are designing them in deference to the same cutting edge technology requirements with almost no consideration for business process. And when the business model gets in the way of the chosen technology, then the business model must go. This is why you always find criticism of our “fragmented” mom-and-pop health care system and vilification of the fee-for-service model in most health care technology reports. We have moved from the pre-HITECH sales driven approach to EMR (with an M), to an engineering driven effort to increase EHR technology adoption. I would like to suggest a third option: the market driven Product Management route.
Forget about EHR and databases and servers and networks. What problems do physicians and hospitals face today? This of course is a huge question and the answer will vary based on many factors. Hospitals are different than individual physicians; large hospitals are nothing like small rural ones; physicians’ problems vary with specialty, practice location, practice type and time of day. But why start with providers? If this is a National discussion, shouldn’t we primarily consider what Government and consumers need? Unless you are aiming at selling something to the U.S. Government, or to individual patients, my answer would be a resounding, and unpopular, No. Of course, providers’ problems will be inextricably tied to constraints placed upon them by both Government and their own customers, but the paying customer for our imaginary Product is the provider, and as all other industries that we so eagerly want to copy, already know: The Customer is King.
At this point, you would go out and talk to your customers, potential customers and non-customers. Most existing provider surveys are asking people about barriers to EHR adoption and why providers would be interested in paying for an EHR. This is not a very “innovation fostering” approach. Considering the large spectrum of customers we are exploring here, if you asked an open-ended question about pressing problems, you would most often elicit two general responses: inadequacy of reimbursement and a perpetual desire to provide better care. These two overarching requirements translate into different things for different market segments. The reimbursement issue, for example, can be looked at in two ways. How do I get more money from payers? How do I cut my costs down so I decrease overhead and increase profit? Providing better care is an even larger subject and more controversial too. For a primary care doc, this could translate into a desire for more time with each patient. For a hospital, it could mean reducing complications. For both these examples, the computer would be required to actively do something that either consumes time now, or something that is so time consuming that it is not done at all. Writing for The Health Care Blog, Dr. Steve Sanders describes a very simple vision of how computers, integrated into operations, could reduce falls in hospitals by triggering well defined sequences of human actions. This is how computers are used in manufacturing and supply chain operations.
Identifying business problems and suggesting adequate solutions requires careful examination of workflows, identification of commonalities and opportunities and constraints posed by conflicting requirements and external factors. Then, and only then, comes the time to select, or build, technologies capable of supporting your customer’s business goals. In 2006, a computer scientist thought that putting medical records on mobile phones would be pretty cool. In 2009, Eric Schmidt had the same thought, this time involving a motorcycle trip to Mongolia. In 2011, someone else had a similar epiphany. It’s not catching on. Although, the concept is very cool, it is only incrementally cooler than flinging “Angry Birds” on your cell phone and nobody has been able to locate a market segment willing to pay for implementing this concept because “pay it forward” is not a viable business strategy.
How about National strategies? After all, introduction of computers into the health care system is now a centralized Federal enterprise. On the surface, Government’s goals are very similar to providers’ goals: cutting costs and improving care by measuring outcomes, with the added lofty goal of conducting research. There is, however, a “slight” problem here because Government’s costs translate into providers’ revenue and you will be hard pressed to find a paying customer interested in software that will decrease revenues. As to measuring outcomes, just imagine trying to sell people software tools that would allow the IRS to better and more intimately measure their tax liabilities. Not much of a market there. As to research, while everybody probably agrees that clinical research is worthwhile, very few businesses, in any industry, would volunteer funds and effort to advance national research initiatives with no immediate and tangible ROI to the business itself.
We have reached a fork in the road. Either EHRs are built and sold according to free market rules, with some Government oversight and regulation, or they become regulatory, Government mandated and Government designed tools, required to be purchased and used in prescribed ways as a condition of licensure to provide health care in this country. The latter option, which seems to be where we are headed, will add another painful customer problem in need of solving: minimizing Government intrusion. For savvy HIT Product Managers, it is time to formally design a solution and begin the search for the best technology to minimize the pain created by, the yet to be agreed upon, Government technology. HIT is now a self sustaining enterprise.
Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.
Whether you use EHR/EMR or still write your notes, have them transcribed, you are ultimately responsible for the content or lack thereof, plain and simple. I have worked with physicians in both civilian and DoD settings using “Dragon” and the program doesn’t always pick things up correctly, but again, you need to review and signoff on the notes just as you do your billing. There is far too much copy forward or “auto-citing” going on due to laziness. How many times can you copy and paste “The patient was hit by a car today and suffered multiple trauma” Copying and pasting the medications is also a problem since doses change or meds are changed. This is an extremely slippery slope and if you choose to be lazy instead of vigilant then you need to pay the piper.
Other considerations for incomplete medical records–the level of service billed. If you bill a level 4, but your documentation only supports a level 2 or 3 now you’re looking at fraud on more than one level depending on how you submit your claims electronically or via US mail.
Medios EHR is certified and easily implemented. Our system can be securely accessed from any location with an internet connection helping physicians provide the best possible care for patients while helping manage a paperless practice http://ioshs.com
It is a nice blog for health.
Who’s to say EHRs are for Doctors? I’m a patient who is tired of waiting for call backs while a nurse pulls my chart. I’m tired of having to go to the pharmacy twice for every script written, once to drop off the darn thing and the second time to pick it up. I’m tired of having to say the same thing over and over again every time I go to my doctor because it is easier than him trying to find my results in the chart. I am tired of not having access to my medical records when and where I need them. I am tired of not being able to electronically contact my mom’s internist the day before her office visit to give him a list of the items needing to be addressed. Instead she needs me take off work and go with her. She can’t remember all the details. Why do doctors view EHRs as nothing more than a different place to write their notes? There is more to a patient’s healthcare experience. There is more that dictates successful healthy outcomes than what you see in the exam room. It won’t be long before your patients or your nursing staff experiences another practice that has an EHR and sees the benefits it has for them.
“The eMRs Made Me Do It”
The state Education Department has taken disciplinary action against a foot doctor, Dr. Bryan Gregory Popovici, and charged him with professional misconduct.
Meghann N. Roehl, Popovici’s attorney, said the problems stemmed from Popovici’s new electronic medical record system. “Dr. Popovici was an early adopter of electronic medical records,” Roehl said. “The earlier versions had software glitches which he is working hard to correct.”
Just a matter of time; wasn’t it.
Dr. David Edward Marcinko MBA CMP™
All – I say yes, regulate the heck out of EMR / HIT / HIE – can you imagine a more highly-regulated thing than the FAA? Sorry, I’m all about physician autonomy; but if we can develop a system that approaches a perfect safety record, can we morally justify our autonomy any more? To Margalit’s point, there will still be pilots – still real people making the decisions; but let’s hold them accountable to following protocols where such protocols are clear and well-defined; and let’s develop a system where the protocols are so clear, sound, and do-able (as they MUST be in aviation, or there would be more crashes) as to be elegantly ubiquitous. Right now, we have a situation where lapses are not the exception; they are the rule – and where good doctors can get sued willy nilly for inadvertently forgetting something: just because their job is un-do-able. As a PCP in full-time practice, I cut corners every single day; if I didn’t, I would see about 2 patients a day, and go home every night at midnight. There must be a better way…
Would be interested in comments on the Arch. Int. Med. Jan 11 article that showed no difference in meeting 20 standards of care between docs using EMRs and those using paper.
Dr. Stenes, why do you think that HIT is about replacing the current system of care?
I would say, HIT is about augmenting the current system, just like checklists are about augmenting flying airplanes, not about replacing pilots.
And to Dr. Marcinko’s point, of course EHRs are products, and they should definitely come under FDA supervision, but even drugs and devices, which have been approved by FDA, do kill people. I suspect EHRs do too, and so do clinicians.
The question Dr. Walker poses is very relevant. Do we just say that this is the best we can do, or do we try harder? And does proper HIT, in some form or shape, provide an opportunity or a hindrance?
A few years ago, Shahid N. Shah wrote that the FDA should be paying closer attention to healthcare IT systems and consider regulating those systems; in other words – regulating eHRs the same as any other drug, medical device or foodstuff.
And, of course, eMRs are products; aren’t they sold by vendors?
Dr. David Edward Marcinko; MBA
Respectfully, Dr. Stenes, I hear your point; but both intuitively and based on real examples such as the aviation industry safety record, the current system becomes indefensible. Gawande’s ‘checklist manifesto’ book cites his own research funded by WHO using surgery processes that saved lives in the study time alone. I have heard no coherent argument on the merits refuting the need for standardizing healthcare delivery, but I’m sincerely interested in listening if there is one. Even primum non nocere falls apart on the point that the medical error rate is so high; along with research such as Oestby et al in Ann Fam Med 2005 proving delivering the standard of care for chronic disease in traditional clinic systems is literally impossible. What is our alternative?
HIT does not solve this problem j. stefan: “So, so much of that process could – and SHOULD – be automated and standardized; why? because the lack thereof is killing many patients outright – and keeping too many others from the potential of many additional happy years lost from failed delivery of known preventive and chronic care guidelines.”
There is not any proof that HIT is better or worse than the systems of care it is replacing.
Margalit, more great thoughts from your pen and mind; keep them coming. I would just add that I think we are missing something here – all the cool innovations notwithstanding (metadata tags etc.), someone has got to make the rules – the real ‘holy grail’ of the HIT movement: THE ULTIMATE INTEROPERABILITY STANDARDS. Although not an expert, from Gawande and others, I ascertain that the airline industry is our best example of how to do complex systems best on a large scale. There may be 10k better and more innovative ways to run the airline grid in the USA – but for four straight years, there have been no airline fatalities in America…making me say – why the hell would we need any fundamentally different system than THAT? Again, I claim to be no expert – but why can’t the medical community study how the airline grid evolved, and just plain copy it onto healthcare delivery? I think this is where as a ‘real doctor’ I can help clarify what people want to be mystical…the idea of ‘patient care’. It isn’t that mystical; in essence, the ‘art’ is teasing the useful data from the patient history and physical data (through the convolution of subjective info, distractions, and time constraints) and then applying it to scientifically-derived algorithms to arrive at differential diagnoses and plans of care. So, so much of that process could – and SHOULD – be automated and standardized; why? because the lack thereof is killing many patients outright – and keeping too many others from the potential of many additional happy years lost from failed delivery of known preventive and chronic care guidelines. I’m all for the innovations of the EHRs and the complex intricacies of Health 2.0, 3.0, and HIE; but in the mean time, my goodness, can’t medicine agree on some basics to get things started? I guess ONC has answered this question by MU stage 1…and as a young doctor, I feel truly blessed (and excited) to be seeing this starting on my watch.
propensity, in an perfect world, we would be sitting across the table and you would tell me exactly what your vision is. Then we would be walking around as you went about your day and we would be recording points where you could articulate a wish for something to intervene and help you complete a particular task at a particular moment. Then we would sit down again and review what we recorded. Then we would brainstorm and whiteboard ideal solutions, after which we would run our ideas by a whole bunch of other doctors and nurses, who would add their own wishes and ideas. We would create a summary of functional and non-functional requirements and then, and only then, we would ask the techie guys to go out and shop for technologies to make everything possible.
I’m certain we could find a way to electronically create orders that will be helpful to you and safer for patients. It may take time, but I am 100% certain it can be done.
I suggest that you ask Tina of Weno about politically correct conduct and language as reported here: http://emrdailynews.com/2011/01/19/weno-healthcare-charges-onc-with-misconduct-in-atcb-application-process/
The government wants everyone to believe that EHRs are not devices, in order to fly under the radar of the FDA and the Federal Food Drug and Cosmetic Act.
The fact remains, few EHR and CPOE devices, if any, are any damn good at assisting doctors to achieve better outcomes and reduced costs.
The systems that works best are those that avoid electronic ordering instruments and those that put the relevant clinical information right in to the doctors’ hands at the right time; freeing the doctors from having to search and click; concomitantly allowing and facilitating their brains freedom to create solutions to complex and ambiguous medical problems.
Glen, I totally agree with your assessment. Boomers have created new markets for everything as they progressed through life, from diapers to microwaveable meals, and now to Medicare advice. Boomers are also computer savvy.
Medicare.gov has a very nice website (nicer than private insurers) and has the Blue Button too. If you take the virtual tour, you can see that the Government folks are trying very hard to be helpful (suggest and compare coverage, generics, providers, etc.).
Since Medicare fees are public, it shouldn’t be too hard to create even smarter tools with more clinical and financial decision support, actionable alerts and interaction with providers.
Instead of tinkering with metadata tags, CMS should encourage this type of interaction with providers’ EHRs.
Sine you mentioned Medicare, here is a simple example that could save quite a bit of money and human suffering: get an advanced directives form on the MyMedicare portal and allow folks to record those in the privacy of their home (with proper security & authentication – perhaps validate during the next appointment) and require EHRs to be capable of uploading such patient created documents. It is ridiculously easy for EHRs to upload documents into a chart and there are many good uses for such functionality, so why not add this to Meaningful Use?
People could upload their Blue Button stuff from Medicare or VA, they could upload consultation notes from specialists, summaries from PCPs and everything else they wish to share with their doctor.
This need not be “integrated” into the EHR structured database. Just create a “Patient Provided Documents” folder (with proper legal disclaimers) and a reverse Blue Button.
When we make regulations, we should keep in mind that extensibility without initial utility is not a good use of limited funds.
Here’s a big market opportunity: the many Boomers joining Medicare this year. We are often voiceless stakeholders in the EHR arena.
What do we Boomers want from using EHRs? We want out-of-pocket healthcare costs minimized. We want the process of obtaining timely and effective healthcare made less burdensome. Of course we want good outcomes. And we want personal involvement and at least some control over healthcare decisions that affect them and their families. What we don’t want is a government circus that draws healthcare providers’ attention away from those issues.
While the PCAST report tried to prescribe a big-IT-vendor reinvention of health IT, and ONC struggles to reconcile Meaningful Use with PCAST, Boomer healthcare recipients and their primary care providers are ill-served. And the Republican-majority House and Tea Party are not helping with their posturing. I hope the EHR market is not further stalled due to all this.
The rising tide of eHR vendors
Interesting essay but eHR software vendors aren’t churning out product profits like you might expect. You’d think that the Federal subsidies for EHR implementation would create a rising tide that lifted all boats in the EHR software industry. In reality, some product vendors are about to capsize.
Based on data points I’ve observed in the market over the past few months, I think some vendors are facing a cash flow crunch. They’re thrilled to have the wind at their backs for once, but the pace is proving hard to maintain as market evolution has accelerated under the unnatural effect of government subsidies.
Here’s the problem.
Ann Miller RN MHA