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Sunday, June 17, 2012

Cloud computing, EHRs, and other disruptive innovations

Jim Manzi has written an interesting piece in the Atlantic Monthly regarding the history and development of cloud computing:
When some friends and I started a software company in 1999, we used current software development languages and tools that were designed to allow access via the Internet. This was entirely incidental to us, since we assumed that we would ultimately install our software in the traditional manner. When we delivered a prototype to an early customer, they didn't have IT people to install it, so we allowed our customer temporary access to our software via the Internet -- that is, they could simply access it much as they would access any web site.
As they used it, two things became increasingly clear. First, this software made their company a lot of money. Second, despite this, the IT group had its own priorities, and it would be very difficult to get sufficient attention to install our software any time soon. 
I look at my own institution (which shall remain unnamed) and review all its attempts to deploy software in an enterprise fashion, including its EHR. We have very smart people at multiple levels, all working diligently to accomplish their respective tasks. These are not stupid or incompetent  people..far from it. However, almost every attempt to deploy software systems in an enterprise fashion has been fraught with major problems. These challenges were highlighted by Mandl, et al this week in the NEJM in a piece entitled "Escaping the EHR Trap - The Future of Health IT" . In this piece the authors note:
Early health IT offerings were cutting-edge,1  but contemporary EHRs distinctly lag behind systems used in other fields. In 1966, members of Octo Barnett's laboratory at Massachusetts General Hospital invented a highly efficient programming language for the earliest EHRs; the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) partitioned precious computer memory so parsimoniously that with only 16 kilobytes, the earliest personal computers could run an EHR supporting multiple users. But nearly a half-century later, most EHR vendors not only have failed to innovate but don't even embrace existing modular architectures with interfaces that allow extension of product capabilities, innovative uses of data, and interoperation with other software.
Loss of technological leadership reflects apathy and even opposition by EHR vendors to promoting liquidity of the data they collect. This attitude has thwarted medicine's decades-long quest for an electronic information infrastructure capable of providing a dynamic and longitudinal view of the health care of individuals and populations. EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.
The authors go on to identify specific areas which EHR vendors fall short - the inability to work with other systems, private storage, fostering communications between providers and between providers and patients, documentation tools, analytic tools, and decision support. Why does this persist? One of my colleagues made the observation that in the present environment the deployment of an EHR is like drug development. It involves huge costs and risks and is constrained by all sorts of regulatory issues. I think a flawed payment system coupled with a constraining regulatory environment is the cause. 

It does not and should have to have this structure. EHR's have evolved primarily in response to a series of regulatory mandates, not in response to the needs to patients or health care providers. Furthermore, where IT has impacted other industries (retail, banking, travel, entertainment), it has created whole new series of products unimaginable before IT tools could be deployed. These products ended up being deployed because smart people created business plans where these new ideas and products could me monetized. Thus the public was served, new products were created, and entities that took the risks became wealth creating engines. 

The payment systems linked to health care are much less capable of adapting to such new products. Thus, we have failed to create pathways whereby new products, which could be created by novel IT tools, can be monetized. The payment system makes such activities not into risky business ventures; it is business suicide to make investments in new systems and approaches which cannot be monetized readily and paid for. 

We are left with large organizations health care organizations, attempting to deploy EHRs primarily to collect meaningful use monies, pushing basically dysfunctional systems on providers. They call upon us to become expensive data entry clerks using work processors which no clerk would put up with (NO SPELL CHECK!).  We would not be in the quandary and the industry would be developing modular and light weight applications to meet many more real needs of patients and providers if the payment system allowed us to create new products and use creative approaches to monetize them. 

 The culture within organized medicine has been hostile to financial innovation in general. For example, people and entities that bypass the usual payment system such as those who develop concierge practices are often viewed a unethical. Legal constraints also make it very difficult to experiment with innovative approaches to care delivery, that might come as a consequence of using new technology. And we wonder why everything except health care gets cheaper and better. 

In some sense by focusing on what what we call the EHR, we miss a bigger picture, that being that health IT is not limited to EHRs. It is about how technology will change how we interface with patients, collect and analyze information, and make decisions. Here again, the payment system (and licensing system) by and large prevents healthy innovation and development of software tools that will allow us to do what is essential to caring for more people for much less money. We know we are not incentivized to that now and we anticipate that we may be provided with the incentives at some point in the future. We just have no real idea of when that future will be upon us. 

For the small and lightweight medical applications and EHR world to thrive, it needs a different business model, one that allows new products and care practices to evolve and support themselves. 

1 comment:

  1. This was a very interesting take on these innovations. I have been reading a lot lately about EHR and EHR Companies but don't know a lot about it. Your article was very informative and helpful, thank you for sharing this with us!