As hard as it is to believe, electronic health record (EHR) development started in the 1960’s. By the 80’s industry leaders began to implement national standards and supported the creation of organizations such as the Computer-Based Patient Record Institute (CPRI). You would think that 50 years of research and design would have yielded a robust crop of extremely effective EHR systems. Why then are we finding a growing backlash surrounding the use of electronic health records systems?
Show me the money:
Up until 2009 EHR vendors were attempting to improve the healthcare system, and turn a profit, with little or no governmental investment. To accomplish this they had to design products for entities that had financial incentives to purchase their systems. Most of the EHR systems I have worked with started out as practice management systems (PM) used for scheduling and managing appointments while also serving as billing and reporting systems for hospitals and large clinics. ROI was tied to increased efficiencies found in billing and scheduling. Providers enjoyed increased patient loads and faster billing which drove revenue up and decreased the time it took to receive payments from insurance carriers. In most cases these systems were created with a payer focus as the goal was efficient revenue cycle management. The clinical portion of a patient’s chart continued to be maintained on paper while the financial pieces were electronic.
Slowly but surely more of the paper chart was transitioned to electronic records driven by regulatory requirements and vendors attempting to differentiate themselves from their competitors. For example: When a large hospital system considered the purchase of a new system it was routine for the hospital to demand certain new functionality be added prior to authorizing the purchase (I am reminded of the old adage, “sales drives development”). Vendors hastily made the code changes to comply with the client’s request allowing them to complete the deal and book the revenue. The new functionality was labeled a “feature” and was made available to subsequent potential clients. Sounds like a win-win situation right? Not so much. After hundreds of deals like these vendors found themselves with bloated-difficult-to-use-memory-hogging-systems that were nearly impossible to integrate with other products. The bolted on functionality did not fit into a unified plan for streamlining and/or improving the overall product and as such the whole system suffered. Remember the Abby Normal scene in Young Frankenstein?
The product managers for these systems recognized they were stuck between a rock and a hard place. With hundreds of clients depending on their software, starting over on a modern platform including all the knowledge gained along the way was not feasible. Maintenance costs for the current system ate up the majority of their revenue and “fixing” the product was too expensive. The best option was to hire a separate team of developers to create a more efficient product and then move current clients over to it. However, as the market saturated there were not enough new software deals to pay for it. Vendors just continued to bolt on new functionality to keep potential customers happy and hope for the best.
In 2009 with the passage of the American Recovery and Reinvestment Act (ARRA), standards for EHR design and interoperability were defined and funds made available to help providers offset the cost of installing or upgrading an EHR system. Healthcare providers were required to purchase, install and meaningfully use a certified EHR by 2015 or face reductions in Medicare & Medicaid reimbursement. Boom, the market just expanded!
Unfortunately, the timetable for creating, certifying, selling and implementing products that met the new standards forced most existing vendors to continue the bolt on strategy rather than start over from the ground up.
Enter the startup:
Free from the limitations imposed by managing hundreds of clients entrenched in outdated systems, new companies could finally do EHR right. By employing clinicians early in the design and development process and leveraging the latest cloud and touchscreen technologies developers could create systems that truly benefited all stakeholders including for the first time – the patient.
One example of this is UroChartEHR founded by a practicing urologist. UroChart is a clinical system that may be integrated with practice management systems (scheduling and billing), labs (Quest, LabCorp, Bostwick, etc.), hospital systems, health information exchanges, diagnostic machines and proprietary web sites via standard HL7 interfaces. Rather than attempting to cover all possible bases, perhaps the future of EHR is to be exceptional at a few specific things and integrate with the best of the rest (full disclosure: I am a former employee of UroChart’s parent company).
UroChart includes the desirable traits of a modern EHR (touchscreen, mobile enabled, patient portal, etc.) but with a focus on how these features may be used by urologists without all of the unnecessary bolt-ons (see video overview).
Unfortunately, the extremely ambitious timetable for implementing the meaningful use provisions of ARRA, and thereby qualifying for incentive funds, prompted most providers to sign with well-known names in the EHR industry. Established companies could guarantee their products would be ready for meaningful use and had the assets necessary to back up those claims. Several years have gone by and providers are beginning to lose patience with their vendors’ Frankenstein strategy and are demanding more.
The Bride of Frankenstein:
Sadly, it’s not so easy to replace EHR software as contracts are typically written for multiple years and may include provisions for withholding patient data for non-payment as well as hefty fees for extracting data that may then be imported at substantial additional cost into a new EHR. Not to mention the phases of set up, content customization and training that could take months if not years to complete.
In order to remedy this situation we must look to discard the Frankenstein approach of the past and develop lean, specific, scalable, open solutions. I believe the time has come for providers to begin working directly with startup companies in an effort to create more products similar to UroChart. However, there are many potential downsides.
For instance, ROI for startup EHR companies appears non-existent when considering virtually all healthcare providers are already locked into multi-year EHR deals and do not have the money or time to make the switch even when a superior product is available. It makes sense that many providers feel trapped in a bad marriage, because they are.
Grab your torch & pitchfork:
Healthcare organizations from the smallest single doctor practice to the largest integrated health network are being required to purchase systems and attest to the meaningful use of an EHR. Once their product is certified however, the EHR vendor’s pain ends. There are no attestation phases or penalties for failing to comply or threats of future audits for software developers.
Maybe it’s time to start easing up on healthcare providers a bit and begin requiring EHR companies to get a little more skin in the game. Possibly offering incentives for the companies doing things right and fines for those reluctant to throttle the Frankenstein’s EHR they have unleashed.