THCB

Breaking News: Health Information Technology Sucks and it Costs too Much

“Established technology is being given a federally funded new lease on life,” athenahealth CEO Jonathan Bush said. “Traditional health software now is on Medicare, being kept alive like grandma.” Bush dubs this program as the “cash for clunkers” program for health IT leaving no doubt what his opinion is regarding the legacy vendors’ solutions.

“I know of no industry where technology is as despised as it is in health care. It’s a statement that it took government money to incentivize healthcare providers to finally do what virtually every other industry has done .”

While one might dismiss Bush’s comments because they are coming from a company with a dog in the fight, the feeling is nearly universal amongst physicians who are the most important users. The best evidence of how abysmal legacy healthIT is, is that the market leader is having trouble getting medical practices to adopt their software even with huge subsidies from large health systems.

In the course of discussions with large health systems, they share their experiences of deployments of a mega Electronic Medical Record (EMR) and how they were offering subsidies to affiliated doctors to adopt the same system. When pressed about how broadly it was being adopted by non-employee physicians (i.e., MDs who have a choice), the penetration was staggeringly low — 0.2% was the average of those who shared figures. This was despite the fact that they were subsidizing 85% of the cost (the maximum allowed by Stark Law).

When I’ve spoken with doctors who have rejected the entreaties from their affiliated health systems, it’s more than the expense (even after a massive subsidy, it’s still several thousand dollars plus monthly costs). Rather, the complexity and lack of user friendliness is the bigger driver. A common statement one hears in healthIT conversations is that doctors hate technology or are afraid of it. Hogwash. They only hate bad technology. Consider the iPad. Doctors are the biggest buyers and it’s not just young doctors.

Flawed Reimbursement Model Leads to Flawed HealthIT

This begs the question, “why is healthIT so bad that massive government and health system subsidies are required to drive adoption?” And how can this possibly be good news? Let me address the issues and then I’ll conclude with the good news. While it may seem easy to bash legacy healthIT vendors, my experience has been that vendors reflect their customers. I would take this a step further. In the case of healthcare, customers reflect the reimbursement model. It’s a reimbursement model that is so broken Americans pay nearly twice as much as other countries to get inferior outcomes.

The “do more, bill more” reimbursement model in the U.S. has been at the root of healthcare’s hyperinflation (not so fun fact: while what we spend on all other goods and services has increased 8x since the 60′s, healthcare costs have skyrocketed 274x). The byproduct is a focus on activity rather than value/outcome. Not surprisingly, the primary IT focus has to get as big a bill out as fast as possible. Despite the fact that most physicians call the patient the most important member of the care team, in reality, the “patient” as architected into most healthIT has been little more than a vessel for billing codes.

More recently, there’s been a drive to add so-called Patient Portals to involve the patient. However, these have been more driven by marketing objectives than truly rethinking the care delivery model. Making the patients central in a system designed for optimizing billing is even less likely than Yahoo or AOL surpassing Facebook in social networking. Web portals are a good analogy for the change afoot. Patient portals are similar to pre-Google web search. That is, it’s not been terribly important and not a substantive stand-alone business. Obviously, Google changed that. Likewise, the next generation patient portals will have central importance in any outcomes-based model particularly with chronic disease that makes up 75% of healthcare spend.

It will expand from simplistic provider-centric patient portal to full-blown Patient Relationship Management as one of the leading thinkers in healthIT, Shahid Shaw, stated in a recent article in a HIMSS publication.

“It will be nowhere as easy for existing legacy EHRs to simply retool their current platforms, like they did for MU.”With that said, Shah outlines nine ways future EHRs need to support ACOs.

1. Sophisticated patient relationship management (PRM). According to Shah, today’s EHRs are more document management systems, rather than sophisticated, customer/patient relationship management systems. “For them to be really useful in ACO environments, they will need to support outreach, communication, patient engagement, and similar features we’re more accustomed to seeing, from marketing automation systems than transactional systems.”

In absence of getting information from their healthcare providers, consumers/patients aren’t sitting idly by. They go to “Dr. Google” looking for information to fill the gaps left by their healthcare providers. Searching for health information is the third most common activity on the web. One site alone — WebMD — receives over 100 million unique visitors every month. Rather than fighting this, smart doctors are using low and no cost tools to harness this energy. Read Doctors Success Hinges on Transactor to Teacher Transition for more.

The best place to get a preview of how system requirements are radically changing is to look at disruptive innovators such as White Glove Health and Qliance deploying a new care/payment model called Direct Primary Care (DPC). They are already operating in the patient-centric, accountable and coordinated models that will become the norm. These venture-backed healthcare delivery organizations were forced to look beyond the traditional U.S.based technology vendors optimized around the flawed reimbursement model that will rapidly wane over the next 2-5 years. In Qliance’s case, they looked at over 240 different U.S.-based EHRs before looking elsewhere. In healthcare-wonk speak, DPC organizations are the “Triple Aim” champs. That is, they have demonstrated the most impressive health outcomes while lowering costs and improving the patient experience. It’s asymmetric competitors like these that are motivating traditional healthcare provider to look beyond their traditional suppliers.

If you would like to be notified when the seminal paper on Direct Primary Care is published this Fall, please contact me via my LinkedIn profile – http://www.linkedin.com/in/chasedave.

Great Products Killed by Convoluted Decisions Processes

When I’m asked why I didn’t get back in to healthcare sooner given my background, I share one of my past experiences. I was at a well-recognized hospital implementing their patient accounting system and we needed to decide the unique patient identifier scheme. It’s an important decision, but they were in year seven of debating what the new scheme should be! It may seem like an absurd example, but it’s indicative of how interminable the decision processes can be in a health system. It virtually guarantees that the only companies that can survive those processes are incumbent vendors — breakthrough young companies die on the vine waiting those processes out.

Consumptive User and Economic Buyer Separation

The role of Chief Medical Informatics Officer (CMIO) is relatively new and long overdue. The idea is a senior level physician plays an integral role in IT decision processes. However, there are still many scenarios where the people who will actually use software are a great distance from those who pay for the software. In other industries, the rise of Software as a Service (SaaS) has closed or eliminated this gap where you see individuals and departments not waiting around for IT to pick something that they don’t want to use. Rather, they can directly contract with the technology company. Naturally, there isn’t unanimity amongst physicians so the physician representative(s) involved in decisions will never reflect 100% of their peers.

There was a parallel scenario 10-15 years ago when multi-million dollar CRM implementations from companies like Siebel weren’t embraced the way dramatically lower-priced Salesforce.com has been embraced today. A key driver of this is the user of Salesforce.com is often the purchaser. Typically, healthIT is at least 10 years behind other industries. Fortunately, the economics of cloud-based, SaaS software are finally coming to healthcare cleaving off some zeros from what is typically spent on legacy healthIT.

One Item For Which HealthIT Vendors are Fully Responsible

Most of the items above put the root cause at the provider level driven in large part by a misaligned reimbursement model. However, there persists one insidious practice. There are various ways for tech vendors to ensure customers stick around as long as possible — lock-in or loyalty. Successful SaaS businesses are built on the loyalty model. Rather than holding data hostage or locking customers into long agreements, they believe that the more freedom you give customers, the more loyal they become (assuming you deliver the goods). In contrast, there’s still the antiquated model of lock-in used by many healthIT vendors. For example, they make it expensive and/or difficult to get access to data in a system to keep any in-house or 3rd party built system from being integrated. These vendors pull it over on naive customers by telling them that it’s a ton of work when it’s only a ton of work if that vendor is incompetent. Like escaping an abusive relationship, healthcare providers must push back on vendors’ bad behavior or else they reward that behavior.

A corollary to the vendor lock-in is healthIT still largely operates in a model akin to Wang and Prodigy where one company supplies the technology from top to bottom. Since the mid-90′s, we have seen how the web has enabled a thriving, heterogeneous model. They byproduct is a vastly expanded market for all technology vendors – old and new.

The Good News

Tectonic shifts are underway. Smart healthcare providers are trying to avoid making the same mistakes newspaper companies made in the late 90′s. For those of us used to the convoluted, interminable decision processes of the past, it is breathtaking to see the decision processes of today. As I detailed in the rise of nimble medicine, not only are entrepreneurial ventures popping up like weeds, healthcare providers are getting far more aggressive about trying new models without doing the equivalent of organizing the Roman Legions.

A great example of this is the New York Digital Health Accelerator. As you can see on their website, they have convened some of the largest and most influential healthcare providers. These organizations recognize that with all of the new requirements coming at them, they need new solutions. This program not only puts in money ($300,000), more importantly, the healthcare providers are committed to mentoring and/or piloting software. The accelerator is modeled after a highly successful program called the FinTech Innovation Lab also run by the New York City Investment Fund. Recognizing that their legacy vendors are overloaded simply keeping up with EMR implementations, each health system leader I have spoken with says they have zero expectation they will get what they need now from their legacy vendors. However, they are clear that the new systems must tie in with the old.

The best news for healthtech startups is that, by definition, legacy healthIT is optimized around the flawed reimbursement model of the past. The disruptive innovators instinctually know that they will either have to build their own software (if there isn’t off-the-shelf software) or they can work with software companies that allow them to be nimble. There is universal agreement that anything less than a fundamental redesign of healthcare will fall short in solving the most important problem the U.S. and the world faces — spiraling healthcare costs. Disruption innovation is enabled, in part, by modern technology that doesn’t have pricing models reminiscent of the 80′s.

Writing the Book on Patient Engagement

These changes aren’t lost on the trade associations for healthIT — HIMSS. Many are calling this the era of patient engagement. Reflecting this, HIMSS has commissioned a book on patient engagement that I’m honored to be co-editing and writing the chapter on patient-provider communication. A major theme of HIMSS’ 2013 conference will be patient engagement so the book anticipates that theme. It has been exciting to learn about the broad array of new companies and approaches emerging to meet the needs of healthcare providers.

More Good News

As I outlined in Mr. Obama, Tear(ing) Down This Wall, one of the rare areas of bipartisan agreement is the need to modernize the healthcare system by making more information available to patients and other providers. This is in stark contrast to the silo’ed systems of today that lead to duplicate effort and wasted money.

Not only is the public sector fostering a market expansion, private sector investors are pouring money into the healthtech sector. See Sleeping HealthIT Giant Awakens with Massive Venture Investment Growth for more.

Dave Chase is the CEO of Avado.com, a Patient Relationship Management company. Previously he was a management consultant for Accenture’s healthcare practice consulting to 25 hospitals and was the founder of Microsoft’s Health business. You can follow him on Twitter @chasedave.

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JoemidwestdocBobbyGMerle BushkinRob Recent comment authors
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Joe
Guest
Joe

I do apologize (a little) for the rant. Just in case anyone who reads this cares, there is a “big picture” consensus from my side of the canyon. And it is a canyon. The waters are violent for geeks in heath care but that is expected to change. It probably will not change before the government is totally running the show, though. What people don’t fully realize is that the government has been pretty much running healthcare since the 1960’s. They just haven’t been micro-managing in the strictest sense, which is what we are drawing closer to these days. The… Read more »

Joe
Guest
Joe

I’m still recovering from my few long years in health care IT. I do believe it would have eventually killed me to stay in that business. Health care IT sucks for a lot of reasons but I figured out there was no reason for me to stay since I was never invited in the first place. This comment section and a simple google search will easily prove that. Hospitals, doctors, administrators…almost everyone in the business WANTS it to fail. Like spoiled children, they actually believe they will prove to the world that these fancy devil boxes called computers are just… Read more »

BobbyG
Guest

“I should add that despite all the hoopla surrounding the networking of EMRs and the massive sums invested, patient records still can’t be exchanged electronically and the jury is still out regarding the viability of HIEs. Most importantly, the cost of care continues to climb and there’s little evidence that care is better or that patients are better off!” __ I am sympathetic to all of those arguments. But, there are so many moving targets in that scenario, attributing or implying cause or blame is problematic. “Clearly, the EMR systems that have been out there for years haven’t worked” And,… Read more »

BobbyG
Guest

Crowdsourcing done right:

http://tinyurl.com/98cbqtq

Merle Bushkin
Guest

You’re far more accepting than I’d be!

Can’t help but note that if your patients each had a MedKaz with all their records on it — from you and their other docs, you wouldn’t miss a beat!

Midwest doc
Guest
Midwest doc

I love it. I always wanted that. Then we would not be the burros of burden. Would put Bobby out of work. This is not a new idea. It is simple, cheap, and patient owned. Yet I think the dark side will prevail. The EHR requirements are not for us or our patients.
Good job. I wish you luck. I will pass this on.

BobbyG
Guest

You might want to check out the utter lack of traction it has gotten to date, “doctor.” Check out the “crowdsourcing” capital campaign results to date.

I’ll still be in business long after this idea has passed.

Merle Bushkin
Guest

BobbyG, since we’ve not yet offered the MedKaz for sale commercially, your conclusion that it lacks traction is a bit premature. It brings to mind Mark Twain: “Reports of my death are greatly exaggerated.” Regrettably, our crowdfunding effort didn’t succeed but that was because the site didn’t provide traffic for our kind of product. C’est la vie. We’ll know better next time! It’s reactions from the likes of Midwest Doc and others like him, however, that support our belief that we’re on the right track. Clearly, the EMR systems that have been out there for years haven’t worked and a… Read more »

midwestdoc
Guest
midwestdoc

Bien dit. I like you Mr. Bushkin.

midwestdoc
Guest
midwestdoc

Good morning all. It is 9:25 am. My EMR is down. Something about the last software update needed for QR shut us down. My waiting room is full. I have no records, cannot eRX, do my Cs and Ms. But the sky is blue, mid seventies, and dry.

BobbyG
Guest

Sounds like you didn’t establish a “disaster recovery” px as part of your HIPAA-required risk analysis and mitigation plan (45 CFR 164.308 et seq).

midwestdoc
Guest
midwestdoc

Yes i did. Why do you want to sell me something?

BobbyG
Guest

I’m not selling anything. I’m REC.

midwestdoc
Guest
midwestdoc

REC ?

BobbyG
Guest

“REC” – Regional Extension Center. C’mon, man. Click my name. Goes to my REC blog.

“My waiting room is full. I have no records, cannot eRX, do my Cs and Ms.”

Then, by definition, your risk analysis and mitigation plan (including disaster recovery/continuance of ops) was inadequate.

Midwest doc
Guest
Midwest doc

I looked at your blog. You are a salesman.

BobbyG
Guest

Midwest doc says:
September 10, 2012 at 3:59 pm
I looked at your blog. You are a salesman.

And you might actually be a doctor. Who knows?

Merle Bushkin
Guest

Sorry. I inadvertently hit Submit. To continue: The patient: * controls their records and who sees them * knows their providers will have their complete record available at the point of care, in or out of their network * knows their records are safe and secure (they’re not stored on the Internet) * can participate in their care decisions. We’ve tested the patented MedKaz with some 400 patients and their doctors and are starting to offer it commercially. It will be dispensed by physicians and HRC directly. Patients — for now — will pay for it and subscribe to our… Read more »

BobbyG
Guest

Interesting. I will have to study this. Nice way to leverage free ad space, I have to say.

One quibble. “80% of MU” = 0% of MU. While that aspect has its critics, it is the reality. Close only counts in horseshoes and hand grenades.

Merle Bushkin
Guest

It’s hard to talk about something new without describing it. But when you do, it sounds like a sales pitch! 🙂 Re: MU requirements, you’re right. You have to meet 100% but that is a total which can be met via a combination of applications. Thus, for the doc who keeps paper and embraces the MedKaz free Patient Record Manager (PRM) (described on our site but not in my comments), they’re 80% of the way there. They can use other apps to achieve the remaining 20%. This means that a doc can gradually transition to an EMR system. And when… Read more »

BobbyG
Guest

So, Merle, you’re saying MedKaz will be 2014 CEHRT verified as a “modular” product that will count for Meaningful Use Stage 2 both in the ambulatory and inpatient settings?

Merle Bushkin
Guest

Haven’t had time to review Stage 2 requirements but I’m confident the MedKaz will meet them as well.

Merle Bushkin
Guest

The docs I talk to, this blog and its commenters all say the same thing. Doctors are facing four major business issues that threaten their ability to survive — and no one seems to be listening, least of all the legacy EMR vendors and the government! * Their revenues are shrinking. * They have too little time to spend with their patients. * They are being forced to adopt medical record systems that cost too much and don’t work for them. * Irrespective of how they keep records, they can’t easily coordinate the care they give their patients with their… Read more »

Rob
Guest

As a user of EHR for 16 years (and one who is dumping this mess for a different model), I agree with the main point: most health IT sucks. The unfortunate reality, as one who has been awarded for “innovation” using IT, is that most of my innovation has been how to use IT to play the game faster so I have a little extra time for my patients on the side. Yet HIT, as Dave is trying to say, is not a transformative technology because it can’t break the rules of our system. Epic is a perfect example of… Read more »

Margalit Gur-Arie
Guest

Exactly, Rob. This is the crux.

Show me another “industry” where manufacturers are expected to booby trap their paying customers.

If we want to “transform” health care, or whatever, health IT should not be the means by which this is accomplished, any more than Boeing should be leveraged to transform the airline industry.

Make sure that the business of medicine does the right thing (like disappear) and the right IT will quickly follow. The other way around is ludicrous.

platon20
Guest
platon20

Until all EMRs can share information with each other seamlessly, they will be no more valuable than paper charts. So why arent all EMRs sharing ifnormation? Because the business model for GE and Siemens and the handful of others who make these EMRs is NOT to share information — it is to capture market share by competing against other products and trying to show superiority. Thats harder to do when you are making your EMR open to communication with other platforms. The EMR companies spend big money in Washington DC guaranteeing that there will never be a govt mandate to… Read more »

BobbyG
Guest

“Health IT is a free market that has failed”
___

See JD Kleinke, “Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System”

http://regionalextensioncenter.blogspot.com/2011/06/use-case.html

Doc McStuffin
Guest
Doc McStuffin

Margalit makes some good points – docs who have adopted EHRs are generally happy with them (or ~6/10 are). Fewer, however, are raving fans. Even fewer are able to tangibly demonstrate real triple aim impacts. And remember that the docs who have EHRs today include the docs who have had them for some time (the most mature). Expect new adopters to go through the “trough of dissillusionment” before they reach the “plateau of productivity” with associated levels of dissatisfaction. There are two sides of HIMSS: the one that represents the people of health IT and the one that represents the… Read more »

Badevaerelse
Guest

With the endorsement of bulk sum in the operational methods to simply the workload and save time indirectly affects the patients to pay more for thier medical services.

Midwest doc
Guest
Midwest doc

I think HIT and the bugs feeding on it should get a good dose of praziquantel. We do not hate tech. we want it to work. In the present form it is an expensive exercise that will make venture leeches some money. In the long run, when the pendulum beheads the parasites we can get back to work. ACOs are another venture model. There is money to be made. They will fail the patient. I agree with information sharing for better healthcare. A phone call, a fax, a working EHR, or a report should be a quality measurement. And that… Read more »

Mark Freeman
Guest
Mark Freeman

Well said.

Margalit Gur-Arie
Guest

Before I start counting the ways, let me state very clearly that I have no financial or any other interest in either “legacy” EMRs or “innovative” theoretical EMRs, or parts thereof. First of all I don’t know a single doctor, who believes that his/her patients are vessels for billing codes. Not one doctor. Of any specialty or circumstance. Nowhere. Second, the “do more, bill more” system, by which I assume you mean fee for service, works lovely in France and Switzerland, so we’d better look somewhere else rather than “under the streetlight” in this case too. Furthermore, all those reforms… Read more »

BobbyG
Guest

“Salesforce for 5 users (average small practice), costs the same.”

___

And, what a piece of shit. ONC makes us use it.

Mark Freeman
Guest
Mark Freeman

The following observation was right on target. Finally a few people are willing to accept the truth. “A common statement one hears in healthIT conversations is that doctors hate technology or are afraid of it. Hogwash. They only hate bad technology. Consider the iPad. Doctors are the biggest buyers and it’s not just young doctors…” There is no question that EHR implementation has been a disaster. In our practice, we have succumbed, implemented a common national “certified” EHR system. Our costs have escalated. Our days are punctuated by frequent software glitches with inability to enter notes and/or inability to access… Read more »

BobbyG
Guest

You utterly deserve all of your travail for not purchasing my Clinic Monkey EHR. You’re just on the wrong system.

http://ClinicMonkey.blogspot.com

Mark Freeman
Guest
Mark Freeman

Well played, sir!

Jack Lohman
Guest

Hey guys, the VA’s VistA is free for the asking… see

http://moneyedpoliticians.net/2012/09/03/healthcare-costs-and-billing/

BobbyG
Guest