I want to begin by sharing well-known information for the sake of comparison. Both the Apple and Google Android platforms welcome the introduction of new and (sometimes) highly valuable functionality through plug-n-play applications built by completely different companies.
You know that already.
Healthcare IT companies welcome you to pay them great sums of money for enhancements to their closed systems. This is on top of substantial maintenance fees that may or may not lead to hoped-for updates in a timely fashion. (With all due respect to the just-announced CommonWell Health Alliance, Meaningful Use does mandate interoperability. The participants are, in effect, marketing what they have to do anyway to try to differentiate themselves from Epic.)
The respective results of these two divergent approaches are probably also familiar to you.
Consumer technology has taken over the planet and altered almost every aspect of our lives. These companies and industries have flourished by knowing what customers will want before those same customers feel even a faint whiff of desire. We are both witnesses to and beneficiaries of dazzling speed-to-solution successes.
Back on planet health IT, the American College of Physicians reports that the percentage of doctors who are “very dissatisfied” with their EHRs has risen by 15 percent since 2010; in a poll, 39 percent said they would not recommend their EHR to colleagues and 38 percent said they would not buy the same system again.
I will argue that the difference between health IT and every other progressive, mature industry is the application of open source, open standards and, most importantly, open platforms. These platforms supporting interoperability and substitutability have enabled Apple and Google—and NOAA weather data, the Facebook Developer Platform, Amazon Web Services, Salesforce, Twitter, eBay, etc.—to drive innovation and competition instead of stifling it. They have created markets where everyone wins—the client, the application developer and the platform company.
The keys to open platforms are application programming interfaces (APIs) through which a platform-building company (i.e., Apple, Google) welcomes the contributions of clients and other companies. The more elegant the API, the more it can support true interoperability.
Almost 20 years ago close to 4,000 people from 200 companies gathered in San Diego for a conference to discuss the future of health-care information technology. This was before the Web. This was back when computers in physicians’ offices, to the extent they were present at all, were used only for scheduling and billing patients. Paper charts bulged out of huge filing cabinets.
It was one of the first big conferences held by the Healthcare Information and Management Systems Society (HIMSS). I was among a grab bag of physicians, technologists, visionaries, engineers and entrepreneurs who shared one idealistic goal: to use information systems and technology to fundamentally change health care.
We didn’t just want to upgrade those old systems. We imagined a future that looked a lot like what we were being promised throughout the economy as it sped into the Internet era. Computers would enable improvements in the practice of medicine—and make it safer, higher quality, more affordable and more efficient—all at the same time. We wanted people to be healthier.
For the record: I am a geek. I love technology. I adopted EMR when all the cool kids were using paper. Instead of loitering in the “in” doctors lounge making eyes at the nurses, I was writing clinical content and making my care more efficient. I was getting “meaningful use” out of my EMR even when nobody paid me to do it.
But now who’s laughing? While they are slaving away trying to get their “meaningful use” checks, I’ve moved on to greener pastures, laughing at their sorry butts! It’s just like my mom promised it would be. Thanks mom.
Really, for the record, I am not so much a technology fan as a “systems” guy. I like finding the right tool for the job, building systems that make it easier to do what I want, and technology is perfect for that job. I am not so much a fan of technology, but what technology can do. Technology is not the goal, it is the best tool to reach many of my goals. There are two things that measure the effectiveness of a tool:
1. Is the tool the right one for the job?
2. Is the person using the tool properly?
So, when answering the question I posed at the end of my last post, what constitutes a “good” EMR, I have to use these criteria.
In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in – well, actually, poured in not that much money at all when you think about it – lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.
Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.
The actual scandal is more complicated and scary. It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.
I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.
This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.
Early this week Greg Masters and Pat Salber chatted with me for a fun convo about EMRs, NOLA, HIMSS, and alot more. It’s part of their overall series for the HIBCtv (Health Innovation Broadcast Network Consortium). And be warned they are giving me keys to the car for 90 minutes at HIMSS next Weds! You should be able to click on the player above to hear. If not click to this.
I’m well aware that a good fraction of the people in this country – let’s call them Rush fans – spend their lives furious at the New York Times. I am not one of them. I love the Grey Lady; it would be high on my list of things to bring to a desert island. But every now and then, the paper screws up, and it did so in a big way in its recent piece on the federal program to promote healthcare information technology (HIT).
Let’s stipulate that the Federal government’s $20 billion incentive program (called “HITECH”), designed to drive the adoption of electronic health records, is not perfect. Medicare’s “Meaningful Use” rules – the standards that hospitals’ and clinics’ EHRs must meet to qualify for bonus payments – have been criticized as both too soft and too restrictive. (You know the rules are probably about right when the critiques come from both directions.) Interoperability remains a Holy Grail. And everybody appreciates that today’s healthcare information technology (HIT) systems remain clunky and relatively user-unfriendly. Even Epic, the Golden Child among electronic medical record systems, has been characterized as the “Cream of the Crap.”
It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.
I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and x-rays. I could give better care, and that was a good enough reason to use it.
But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered). So we made a compromise: since it was easier to format printed data, we took that data and made a printed template. Continue reading…
I am not sure if my lack of blogging is a good sign or a bad one. It’s been a week and a half since I started my new practice and I finally am getting this chance to come up for air. It’s been an über hectic and very draining time, but I am happy to report that the end of the week was significantly better than the beginning.
Here are some things I am learning.
1. Starting a business is really, really hard
I did my best to make my business as simple as possible, mainly because I understand my own deficiencies when it comes to business-related activities. Of course, being in a leadership role of a practice for the past 16 years helps me understand incredibly confusing concepts like accounts receivable, budgets, paying bills, and avoiding going to jail for spending all the collections on lottery tickets and reporting it as “research.” I purposefully designed the business to require as little accounting as possible, and in general I think I accomplished that. People come in to see me, pay me by swiping their card on the nifty card-reader on my iPhone, and I email them the receipt. That’s not the hard part (aside from people touching the “skip signature” button with their hand while they are signing).
The hardest part of starting a business for me is knowing what overhead items are necessary and what are not. Building the office took a month longer than I expected and cost twice as much. Yet I signed “yes” to all of the things that added cost. Some of them were necessary, like doing the things needed to comply with ADA, compliance with electrical code, and having furniture. But where to draw the line? I want the office to send a message of “professional, yet welcoming,” which means it can’t look cheap but doesn’t look posh either. I want the office to be consistent with my logo, a door opening that says “come on in,” and “welcome.” But everything adds cost, and mounting cost is tough when delay in opening means I am earning nothing.
Everyone is willing to give advice, but most of the advice given has little foundation in my reality. People say “it will all work out,” or “you’ll do great,” reassuring me that I don’t have to fret about things. It’s as if I can sit back and relax while things “work out.” The reality is that the reason they will work out is that I will spend most of my waking hours (and some while I’m not awake) working, worrying, thinking about details, and trying to plan for a very uncertain future. Continue reading…