Sunday, April 29, 2012

Big Bad Legacy EHR Products

IBM "cloud" computing - circa 1975
There is no self-respecting innovator in Health Information Technology (HIT) who has not spoken or written about the horrific state of Legacy EHR products, which are slowly but surely being deployed in more and more health care facilities as a result of Meaningful Use incentives and changing reimbursement models. A couple of months ago I saw an EMR in a small practice. They’ve been using it for 15 years and it was a DOS based system with the ubiquitous neon green text glaring on a black and sometimes blue background. Aha! That must be a Legacy EMR, and sure enough the doctor was looking to replace it with a more modern product, but which one should he get now? After all, the last thing you’d want is to have him buy yet another Legacy EMR.

According to, a Legacy system is a “computer system or application program which continues to be used because of the cost of replacing or redesigning it and often despite its poor competitiveness and compatibility with modern equivalents. The implication is that the system is large, monolithic and difficult to modify”.  Well that little DOS EMR was anything but large and monolithic, but nobody was going to invest a penny in redesigning it, and competitiveness wasn’t a term that came to mind when you looked at it, and replacing it is sure going to be an expensive proposition. The DOS EMR is definitely out then. The only question remaining is what it should be replaced with. Which EMRs in the marketplace should be avoided since they are truly Legacy EMRs sold under false premises to unsuspecting buyers? Well, it depends on who you ask.

You could separate the various EHR constituencies based on programming technology (e.g. MUMPS vs. .NET), based on promotional labels (e.g. Cloud hype vs. everything else), based on software architecture (e.g. integrated vs. modular), and a host of other technical criteria, most of which are overlapping to various degrees. A much clearer and natural separation occurs if you divide Health Information Technology (HIT) companies into two groups: those who have lots of customers and those who don’t. According to the latter, the former are all peddling Legacy systems. It seems that a veritable tsunami of innovation is building up outside the infamous walled gardens of existing, Legacy EHR vendors, threatening to bring those walls down any minute now.

As with any worthwhile technology innovators, the newcomers to the EHR marketplace have brilliant Silicon Valley pedigrees and beautiful Web 2.0 style websites, along with iPhone/iPad/Android native (i.e. client/server proprietary) apps to complement, or even supersede, the web offering. Actually using an “old fashioned” computer or laptop is starting to feel a bit Legacy in and of itself. The innovative products themselves can be divided into two categories as well: full-fledged EHRs and a variety of self-contained pieces, or modules, of what is currently considered a complete EHR. [Note: I am not including products like athenahealth here, since they are not new, do have a respectable customer base, and had no disruptive effects on the rest of the market.]

The innovative new EHRs are all Cloud-based, intuitive and easy to use, built from scratch by user-centered designers, and are offered at a fraction of current prices, or so the ads say. These are the Southwest Airlines of health care, coming in below market pricing, with bare-bones, friendly solutions for the non-customer segment and they have two insurmountable problems. First, almost none of them are actually below market price, which in the ambulatory sector stands now at about $500 per provider/per month for a fully loaded, gold-standard integrated EHR and practice management solution. This is an extremely difficult number to beat. Second, even a bare-bones solution should have all the bones. My guess is that Southwest Airlines would not exist today if their first flight service consisted of boarding passengers in Houston and then proceeding to cheerfully shove them out of the aircraft 150 miles outside of Dallas, expecting them to arrange for their own transportation into the city. And yet, this seems to be the preferred model of our innovative HIT products, and as ePocrates (a household name in health care), painfully discovered, there are no customers lining up for this type of experience no matter how innovative it is touted to be.

In the meantime the Legacy EHR market seems to be thriving, and no, the recent Allscripts misfortune (or mismanagement) is not an indication of an impending disaster any more than this year’s snowfall in Texas is a sign of global cooling. The reason for this seemingly inexplicable prosperity is threefold: a) the government is subsidizing EHR purchase b) there are no viable alternatives to existing products c) innovation is occurring within the established market leaders. Let’s look for example at one of the more popular ambulatory EHRs, which shall remain unnamed. A few short years ago, the product consisted of a basic integrated EMR/practice management system, with very few bells and whistles and lots of bugs. Today, the product comes with a solid Patient Portal with iPhone apps for patients, a full featured disease registry, an iPad version, natural language processing, disconnected mode operations, peer-to-peer communications, and of course a much improved EHR and all sorts of other features and modules. I don’t know about other folks, but somehow this does not seem like a Legacy product to me, and there are a few more just like this one. There may be Legacy products out there, but today’s top selling EHRs do not fit the description.

A very unfortunate side effect of the forced march to HIT innovation is the confusion created by the constant barrage of misleading statements from the various Southwest Airlines wannabes. I sometimes wonder if these new folks have ever seen an EHR, let alone use one or participate in building one. A quality EHR is much more than a handful of rudimentary web pages allowing patients to communicate with providers, no matter how loud and trendy the consumer movement is. A modular architecture is much more than a collection of disparate bits of software interfaced together with duct tape, no matter how standardized the duct tape is. There is a reason why the new iEHR for the VA and DoD was allocated $4 Billion for development over five to six years. There is a reason why it took Kaiser about the same amount of time and money to take Epic from its original state to the powerhouse product it is today. There is no room for Southwest Airlines type of innovation in an industry where the routes, the meals, the fuel and the seating arrangements are regulated by the Federal Government. Innovation is coming and will continue to come from within the established systems, NASA style.

So if you are still looking to replace that little DOS EMR, or an aging and no longer supported practice management system, find a good size EHR vendor, with a hefty customer base, who develops its software in-house, instead of randomly buying shiny things, and hitch your wagon to theirs. It will not be a perfect ride because there are no perfect rides, but it will get you where you need to be. There are no miracles, there will be no miracles, and every day you waste looking for one, will make it harder to catch up, because whether we like it or not, whether it is a smart thing or not, health care is moving up the IT escalator at a very brisk pace. It’s too late for partial, gradual or “lite” solutions. The time for dabbling with a little electronic prescribing and a little email, has long since passed. You’re either all in, or all out, and your patients desperately need you to be all in.

Sunday, April 1, 2012

Hypothetical: Tofu at the Broccoli Court

The year is 2018 and President Tofu is fortunate to have a majority in both houses of Congress. America elected President Tofu when it became weary of partisan politics and developed a taste for a President with no preconceived notions and fully capable of absorbing the flavors of whatever surrounds him at the moment; a pragmatic, businesslike President for tough and fast-changing times. American small businesses are still hurting from the lingering effects of the Great Recession, but its larger bastions of business savvy are thriving in a booming global economy bringing cheap products to the impoverished masses armed with $5 cell phones, $10 netbooks and empowered by a Khan universal education system (the other Khan, not Genghis).

Many Americans are also benefiting from this expansion in some ways. For example, after the 2016 passage of the historical and liberating Student Protection and Affordable Education Act (SPAEA), many parents decided to take advantage of the Khan system, now owned and selflessly maintained by Google, and use the Government Education Voucher (GEV, pronounced give), minus the $15 for a cell phone and netbook for each child, to pay for the mandated health insurance penalty of 2010, thus breaking even on child mandates. This trend caught on like wildfire after some knucklehead libertarian tweet went viral on every social media outlet practically overnight, as a suggested measure to counteract the Constitutional, but still unpopular individual mandate to buy health insurance.

America’s Health Insurance Plans (AHIP) did not take very kindly to this popular trend, since most folks buying health insurance from US Health were now either elderly or sick. It should be noted that the other three health insurance providers, Liberty Health which insures elected public servants, Glamour Health which insures most sports and entertainment personalities and the Health Division of Goldman Sachs which provides discrete insurance to industry captains, were not affected by this phenomena, limited to some sectors of the currently or previously wage earning class. Most workers though, were provided health insurance through self-funded multi-national employers, as part of their wages. Unlike the misguided Liberal government of Mexico, who struck down in 2012 an early attempt by Walmart to pay their Mexican employees with store vouchers, the pragmatic administration of President Tofu, welcomed the business oriented solution of paying American workers with vouchers for the company health insurance store.

Seeing how by definition President Tofu found himself in close proximity to US Health executives, some since early childhood, he absorbed the pain and suffering caused to this worthy corporate citizen and decided that something must be done to ensure that elderly and sick Americans can afford US Health premiums and Khan Academy freeloaders don’t dump their health care costs on the rest of society. There were several options for President Tofu and his administration. He could have mandated that GEV should be spent at one of the few private prep schools, but that would impose undue burden on those brilliantly elite institutions of education, who were also very close to President Tofu’s heart. He could have mandated that all Americans not otherwise covered by health insurance, must purchase insurance from US Health at the ongoing premium rates, but some lesser representatives in his Party were deeply concerned with backlash from voters in the upcoming midterm elections, and President Tofu as close as he was with his colleagues, immediately absorbed their pain as well. Luckily there was another way out of this impasse.

In the summer of 2018, the landmark Life Protection and Perpetual Health Act (LPPHA) was passed in both houses with crushing bi-partisan support, and signed by the ever smiling President Tofu into law. Americans were very happy with this legislation, since all media outlets were running headlines informing the people that Congress in its wisdom is now guaranteeing health and long life for every American by 2020. For the skeptical 2012 audience, no, President Tofu was not miraculously transformed into a futuristic Indiana Jones marching out of the crumbling ancient temple with the magic challis in his raised hands, but science, particularly statistical analytics, has advanced to new heights in 2018, partially fueled by Khan Academy graduates.

A RAND corporation study conducted in December 2017, at the behest of a global retail industry giant, clearly showed that Americans employed by multi-national corporations are healthier and projected to have a much longer quality adjusted life expectancy than their peers who were not paid with company store vouchers. After careful adjustments of all measures designed to infer worker health status from corporate economic indicators, RAND concluded that multi-national workers and their dependents have a whopping 92 quality adjusted life years expectancy, thus leaving all OECD Socialized medicine countries in the dust. Other than using innovative study measures, clearly the multi-national corporations have identified the secret sauce to long life and perpetual health. In a follow-up study commissioned by AHIP, RAND identified the preventive health measures taken by self-funded employers as the indisputable cause for the longevity and excellent health of their charges.

Thus the LPPHA contained several provisions to spread the health amongst the rest of the Nation, which would dramatically reduce US Health costs and significantly contain taxpayer expenses for those who chose the 2012 penalty over buying health insurance. At the heart of the LPPHA (or PHA, pronounced phe or F), was a mandate for all citizens to purchase body weight, physical activity and happiness monitors, sold and administered by the corporation insuring their health. Since, most citizens insured by multi-nationals were already purchasing those monitors at the company store, as required by their employer, and since workers’ poor health clearly affects Commerce, and since all Commerce now is at least interstate Commerce, this seemed to be a very logical provision and its benefits to the millions of sedentary, overweight and demoralized Americans were self-evident. Hence the monitoring mandate gained enormous public support, according to the media. Of course, the Government would provide subsidies to those who cannot afford to pay for their own monitors, and monitors would be free to households under 200% FPL, which is really most of the unmonitored citizenry. In order to uphold the monitoring mandate a clever penalty will be imposed, modeled after the large employer health insurance rules, where people with a larger than the approved Body Mass Index (BMI), and/or a smaller than indicated daily activity level, and/or larger than normal depression quotient (as defined by the U.S. Preventive Services Task Force), would have to pay a penalty proportional to their income levels. Exceptions and voluntary drug treatment options are available for all categories.

For a fleeting moment after the beautiful ceremony of the LPPHA signing, by an obviously trim, fit and happy President Tofu, there were some thoughts in some old Liberal quarters that perhaps the LPPHA is unconstitutional and should be challenged in Court, but apprehensions died down quickly after experts read the 4562 pages of the statute and found that the Federal Government is not forcing us to buy broccoli. And America lived happily ever after. The End.