MU stage 2 is making everyone miserable. Patients are decrying lack of access to their records and providers are upset over late updates and poor system usability. Meanwhile, vendors are dealing with testy clients and the MU certification death march. While this may seem like an odd time to be optimistic about the future of HIT, nevertheless, I am.
The EHR incentive programs have succeeded in driving HIT adoption. In doing so, they have raised expectations of what electronic health record systems should do while bringing to the forefront problems that went largely unnoticed when only early adopters used systems. We now live in a time when EHR systems are expected to share information, patients expect access to their information, and providers expect that electronic systems, like their smartphones, should make life easier.
Moving from today’s EHR landscape to fully-interoperable clinical care systems that intimately support clinical work requires solving hard problems in workflow support, interface design, informatics standards, and clinical software architecture. Innovation is ultimately about solving old problems in new ways, and the issues highlighted by the current level of EHR adoption have primed the pump for real innovation. As the saying goes, “Necessity is the mother of invention,” and in the case of HIT, necessity has a few helpers.
Helper #1 – Technological change
In 2009 when HITECH went into effect, LAN-based client/server was the standard for EHR systems. And, in 2009, this meant using a desktop computer. Accordingly, EHR systems were still being designed with desktop computers and their feature set in mind. The keyboard, mouse, and sometimes voice were the only reliable input choices. Laptops provided some portability, but brought additional issues (e.g., battery life) and did nothing for interface improvements.
In 2009, the iPad was still a year away, and the iPhone was still a novelty. Five years later, we have reliable mobile computers with 64-bit processors that are also able to act as communications devices with video chats and text-messaging. The library of reliable input methods now includes gestures and more sophisticated voice interaction capability. Together, they open up new ways of interacting with clinical applications that were simply impossible in 2009.
The cloud cannot be overlooked as a major infrastructure advance. It offers scalability and access to both storage and computing power on-demand, making LAN-based client/server seem… well, primitive. In concert with mobile computers, cloud technology provides the underpinnings for anywhere access, in real time, to even the most sophisticated software. Consequently, software development and deployment have changed.
Helper #2 – Lower entry barriers
Back in the 1980s, I remember working on a DOS application that required a database. Initially, I tried writing my own disk access routines, which was not fun. Later, I grabbed a copy of the Turbo Pascal Toolbox, which provided the disk writing routines I wanted. It never worked; I could not get it to compile. Many hours were wasted on something as mundane as saving data to a floppy disk. Back then, relational databases were very expensive, assuming you had a network to run one on (I didn’t). Today, databases of every genre are free–relational, document, object, graph—all free. Operating systems are free (Linux), and there are free frameworks for developing applications in every major language. Professional-quality programming languages and integrated development environments are free. Many cloud providers even offer free development accounts for a year or longer. Finally, collaboration between developers is simple using the cloud, version control, and communication tools.
Delivering a solution to market is easier as well. One can make provisions for a cloud-based web application during a coffee break–no IT department required. The practical effects of these changes? The cost of turning an idea into software has decreased greatly in the last seven years. This means more money allocated to talent and R&D and less to tools and infrastructure. In a 2011 WSJ article, Marc Andreessen, uber-venture capitalist, stated that the cost of running a basic web application in 2000 was about $150,000 per month. In 2011, this cost had shrunk to $1,500. It is even less now. Make it less risky to take chances, and more people will take more chances, which means more entrepreneurs entering healthcare to solve the problems every one is complaining about.
Helper #3 – Educated consumers
I have seen an interesting and much welcomed change in my medical colleagues when it comes to buying EHR systems. Fifteen years ago, the main question I was asked concerning EHR systems was which system was the best. My answer was always, “It depends…” No one ever liked that answer. When I explained that implementing an EHR was not just about selecting a system, instead it was actually about changing everything about the way one practiced, no one liked that either. One clinician who sought my advice, when told that he would have to map the workflows in his practice to make sure the EHR would not disrupt everything, looked at me incredulously, and said, “Are you joking?” These days there are enough horror stories and communal misery that it is no longer necessary to convince docs that there is no one-size-fits-all system or that detailed planning is essential—everyone gets it. The upside is that healthcare professionals now have plenty of hands-on experience with EHR systems, and it has made them become much better consumers.
Clinicians are demanding readable notes, ease-of-use, productivity enhancement (or at least no loss), and lower ownership costs. Even better, not only are they demanding better systems, but they are also beginning to discuss software requirements. Clinicians will not get better systems until they demand them. Fortunately, these voices are growing louder, and I am very happy to see it.
Helper #4 – The MU certification death march
Renovations are more costly and take more time than doing the same thing from scratch. Changing requirements over the course MU are, once again, proving this to be true. Vendors are being forced to change their products at a breakneck pace (at least in software engineering terms), and the effects are showing up in the form of delayed updates, bugs, and lagging performance.
Vendors have to serve too many masters. They have to keep up with MU certifications, and still provide high quality customer service. In trying to do both, it seems many are doing neither. As a result, they have less time to concentrate on business imperatives such as market share and new product features. Angry clients who are willing to switch products, and vendors that are treading water, make Helper # 2 even more of a threat.
New market entrants with products that are stable, mobile-friendly, and available can compete for customer loyalties without the liabilities of vendors already in the market. For one, they can build a system from scratch and not have to deal with backward capability woes. Finally, vendors that have been around for awhile are more likely to stick to what is working than try something completely new, which always provides an opening for a new entrant—Google vs. Yahoo, Apple vs. all phone manufactures, Amazon vs. Borders–you get the idea.
Helper #5 – Clinical informatics research is more varied and plentiful
Even though electronic record systems have been around for years, today there is more research on implementation, interface design, usability, workflow, and security than ever before. Reports from AHRQ and NIST provide very useful information that is helpful to designers as well as to those implementing systems. Data quality has become a research focus, as has extracting data for clinical research. Today we have more information than ever before on how to design good systems.
Workflow technology, which is important for decision support and usability, has matured significantly over the past 15 years. Business process management suites and workflow modeling tools are plentiful, and there are good open source tools available. Companies seeking to enter the clinical care systems market now have access to informatics, human factors, usability and workflow research that has never existed before. So, contrary to what one might think, companies designing products from scratch have a leg-up. They can readily take advantage of information that is difficult for companies with legacy products to incorporate.
Current EHR systems are from an era that considered electronic access to information as being the key paradigm for clinical care support. Now, five years into a national experiment that has resulted in substantial adoption of certified EHR systems, we find that patient engagement, team collaboration, information exchange, usability, and workflow capability are just as important as information access in supporting clinical work and quality care. Times have changed and so must the systems that support clinical care.
New technology, eager entrepreneurs, discerning clinicians, distracted vendors, and plentiful research have set the stage for the debut of the next generation of clinical care systems. Expect the curtain to go up within the next five years, maybe sooner.