It’s Friday and time for the weekend. Here’s a little healthcare IT humor for your entertainment:
Sad but true in many EHR.
Every doctor understand this challenge. Now every patient’s starting to understand it as well.
It’s Friday and time for the weekend. Here’s a little healthcare IT humor for your entertainment:
Sad but true in many EHR.
Every doctor understand this challenge. Now every patient’s starting to understand it as well.
The New York Times recently reported that Practice Fusion is said to have hired JP Morgan Chase to evaluate an IPO. Here’s a look at the estimated IPO number for Practice Fusion according to the New York Times:
Practice Fusion later created a way to estimate its I.P.O. valuation if revenue came in at $155 million in 2018 instead of $181 million, according to one of the people. Using the lower revenue assumption, the company could command a valuation of $1.1 billion to $1.2 billion if it goes public. It is unclear if the lower revenue estimate was made in response to the market turmoil.
Practice Fusion itself is of course not really commenting on their plans for an IPO or not. However, since it has raised $149 million to date at a valuation of $635 million, you have to imagine that an IPO is in their future. However, many big silicon valley companies have stuck to the private market lately and avoided the IPO. I’m not sure Practice Fusion will be in a similar position to them though. A look at their revenue numbers is one indication of why they’re a bit different than other companies that have raised larger rounds in the private markets:
Practice Fusion’s revenue was $26.9 million in 2014 and was expected to increase by 71 percent to $46.1 million in 2015, with the company projecting it would pare losses by 40 percent to $25.8 million in 2015, according to the document prepared by bankers and the company.
At the time the document was prepared, the company estimated revenue would hit $70 million in 2016.
I personally think that an IPO is in Practice Fusion’s future. It’s just a question of when it will happen. Certainly the market volatility we’ve seen lately isn’t helping their case to do an IPO. However, I bet the bigger challenge is going to be creating attractive revenue numbers that make sense to the public markets. I believe public markets have a hard time valuing number of users and other metrics that make Practice Fusion look attractive.
Ever since the first venture capitalists asked me about Practice Fusion, I’ve said that the company has created value. The number of doctors they were able to sign up on their platform was impressive. That’s the power of offering something for free that other doctors pay hundreds of thousands of dollars to buy. No doubt their network of physician users is a valuable asset. I hope it is since they raised $149 million to build it.
The real question for me around Practice Fusion isn’t whether they created value. Instead, the question is how valuable is what they created? I once heard Peter Thiel suggest at their user conference that Practice Fusion was building the platform for healthcare. Building that would be worth multiple billions of dollars. However, Practice Fusion hasn’t built anything close to that since Practice Fusion is doing nothing in the hospital EHR space. It’s naive to think that Practice Fusion could compete in that piece of healthcare. Not to mention they have a very small part of the hospital owned ambulatory practice space where the trend is to go with the integrated hospital EHR solution.
Long story short, I think that Practice Fusion will do an IPO. I could even see them doing an IPO for a billion dollars. I’m sure that’s what Ryan Howard, Practice Fusion Founder and former CEO, wants so he can claim his startup unicorn status. Although, I’ll be interested to see how Practice Fusion’s revenue grows between now and an IPO. The golden age of EHR is over and we’re entering the dirty slog of EHR sales and EHR switching. I don’t think that makes for a compelling story for investors.
We’ve been writing a lot about Physician burnout and Physician dissatisfaction lately. This chart and tweet that Rasu Shrestha, MD shared puts some data behind what we’re talking about:
— Rasu Shrestha MD MBA (@RasuShrestha) December 23, 2015
Medical research should not be in a crisis. More people than ever before want its products, and have the money to pay for them. More people than ever want to work in the field as well, and they’re uncannily brilliant and creative. It should be a golden era. So the myriad of problems faced by this industry–sources of revenue slipping away from pharma companies, a shift of investment away from cutting-edge biomedical firms, prices of new drugs going through the roof–must lie with the development processes used in the industry.
Like many other industries, biomedicine is contrasted with the highly successful computer industry. Although the financial prospects of this field have sagged recently (with hints of an upcoming dot-com bust similar to the early 2000s), there’s no doubt that computer people have mastered a process for churning out new, appealing products and services. Many observers dismiss the comparison between biomedicine and software, pointing out that the former has to deal much more with the prevalence of regulations, the dominance of old-fashioned institutions, and the critical role of intellectual property (patents).
Still, I find a lot of intriguing parallels between how software is developed and how biomedical research becomes products. Coding up a software idea is so simple now that it’s done by lots of amateurs, and Web services can try out and throw away new features on a daily basis. What’s expensive is getting the software ready for production, a task that requires strict processes designed and carried out by experienced professionals. Similarly, in biology, promising new compounds pop up all the time–the hard part is creating a delivery mechanism that is safe and reliable.
Software development has benefited in the past decade from an incredible degree of evolving support:
Programming languages that encapsulate complex processes in concise statements, embody best practices, and facilitate maintenance through modularization and support for testing
Easier development environments, especially in the cloud, which offer sophisticated test tools (such as ways to generate “mock” data for testing and rerun tests automatically upon each change to the code), easy deployment, and performance monitoring
An endless succession of open source libraries to meet current needs, so that any problem faced by programmers in different settings is solved by the first wave of talented programmers that encounter it
Tools for sharing and commenting on code, allowing massively distributed teams to collaborate
Programmers have a big advantage over most fields, in that they are experts in the very skills that produce the tools they use. They have exploited this advantage of the years to make software development cheaper, faster, and more fun. Treated by most of the industry as a treasure of intellectual property, software is actually becoming a commodity.
Good software still takes skill and experience, no doubt about that. Some research has discovered that a top programmer is one hundred times as productive as a mediocre one. And in this way, the programming field also resembles biology. In both cases, it takes a lot of effort and native talent to cross the boundary from amateur to professional–and yet more than enough people have done so to provoke unprecedented innovation. The only thing holding back medical research is lack of funding–and that in turn is linked to costs. If we lowered the costs of drug development and other treatments, we’d free up billions of dollars to employ the thousands of biologists, chemists, and others striving to enter the field.
Furthermore, there are encouraging signs that biologists in research labs and pharma companies are using open source techniques as software programmers do to cut down waste and help each other find solutions faster, as described in another recent article and my series on Sage Bionetworks. If we can expand the range of what companies call “pre-competitive research” and sign up more of the companies to join the commons, innovation in biotech will increase.
On the whole, most programming teams practice agile development, which is creative, circles around a lot, and requires a lot of collaboration. Some forms of development still call for a more bureaucratic process of developing requirements, approving project plans, and so forth–you can’t take an airplane back to the hanger for a software upgrade if a bug causes it to crash into a mountain. And all those processes exist in agile development too, but subject to a more chaotic process. The descriptions I’ve read of drug development hark of similar serendipity and unanticipated twists.
The reason salaries for well-educated software developers are skyrocketing is that going from idea to implementation is an entirely different job from idea generation.
Software that works in a test environment often wilts when exposed to real-life operating conditions. It has to deal with large numbers of requests, with ill-formed or unanticipated requests from legions of new users, with physical and operational interruptions that may result from a network glitch halfway around the world, with malicious banging from attackers, and with cost considerations associated with scaling up.
In recent years, the same developers who created great languages and development tools have put a good deal of ingenuity into tools to solve these problems as well. Foremost, as I mentioned before, are cloud offerings–Infrastructure as a Service or Platform as a Service–that take hardware headaches out of consideration. At the cost of increased complexity, cloud solutions let people experiment more freely.
In addition, a bewildering plethora of tools address every task an operations person must face: creating new instances of programs, scheduling them, apportioning resources among instances, handling failures, monitoring them for uptime and performance, and so on. You can’t count the tools built just to help operations people collect statistics and create visualizations so they can respond quickly to problems.
In medicine, what happens to a promising compound? It suddenly runs into a maze of complicated and costly requirements:
It must be tested on people, animals, or (best of all) mock environments to demonstrate safety.
Researchers must determine what dose, delivered in what medium, can withstand shipping and storage, get into the patient, and reach its target.
Further testing must reassure regulators and the public that the drug does its work safely and effectively, a process that involves enormous documentation.
As when deploying software, developing and testing a treatment involves much more risk and many more people than the original idea took. But software developers are making progress on their deployment problem. Perhaps better tools and more agile practices can cut down the tool taken by the various phases of pharma development. Experiments being run now include:
Sharing data about patients more widely (with their consent) and using big data to vastly increase the pool of potential test subjects. This is crucial because a a large number of tests fail for lack of subjects
Using big data also to track patients better and more quickly find side effects and other show-stoppers, as well as potential off-label uses.
Tapping into patient communities to determine better what products they need, run tests more efficiently, and keep fewer from dropping out.
There’s hope for pharma and biomedicine. The old methods are reaching the limits of their effectiveness, as we demand ever more proof of safety and effectiveness. The medical field can’t replicate what software developers have done for themselves, but it can learn a lot from them nevertheless.
— Meridian HealthCare (@Meridian_MHC) January 15, 2016
Anyone that’s worked in healthcare knows that patient matching is a major problem. It’s interesting to see that ONC has quantified the problem as 7 out of 100 medical records having issues. It’s not hard to see how this can, will and does lead to medical errors. Doctors need the right information at the right time. If they are missing information or have the wrong information, then it can lead to deadly consequences.
One challenge I have with this problem is that I’ve heard many suggest that the reason this is such a problem is that we don’t have a national patient identifier. Next week CHIME is going to announce the details of their $1 million National Patient ID Challenge. We should have Anne Zieger onsite to report on the event, but here’s the challenge:
Ensure 100% accuracy of every patient’s health info to reduce preventable medical errors and eliminate unnecessary hospital costs/resources.
While I applaud CHIME’s efforts to push the national patient id forward, the issue of patient matching won’t just be solved by having a national patient ID. We’ll see what the challenge produces, but the challenge is so complex that I don’t think anyone will be able to achieve 100% accuracy. While I don’t think we’ll ever be perfect when it comes to patient matching in healthcare, I do think we can do better. Maybe CHIME’s efforts will help inspire organizations to do better.
After writing my piece yesterday on the reasons so many physicians are burnt out and my previous New Year’s post on physicians getting pissed off, I thought it might be good to add a little more perspective to the discussion.
In a perfect act of serendipity I came across this great article with quotes from Ross Koppel, scholar in the Sociology Department & School of Medicine at the University of Pennsylvania. First, he puts the situation many organizations find themselves in:
If I buy a toaster and my wife says, ‘It’s lousy; throw it out,’ to preserve domestic tranquility I throw out the toaster and buy a new one. If I spend $1.2 billion or $1.7, I am married and I don’t have a heck of a lot of options.
Then he offers what I think is a proper reality check:
There has been increasing rage on the part of physicians and others about the software not being responsive to their needs. That said, I would be the last person on Earth to argue we should go back to paper. The software is dramatically better than paper. [emphasis added]
I’m sure that some doctors will come on this post and start to point out the virtues of paper. No doubt, there were a lot of good things about paper. A long time ago I wrote a post that described the perfect interface that was infinitely flexible, multi-lingual, no training needed, etc and I was just describing the virtues of the paper chart. I get the paper chart was great for a lot of reasons, but it was awful for a lot of reasons as well. I’m reminded of this post called “Don’t Act Like Paper Charting Was Fast.” I won’t even mention how much time was wasted trying to read illegible charts or searching for the chart that could not be found. Oh wait, I just did.
The problem with all the benefits of EHR is that we quickly take them for granted and promptly forget about them. However, the problems and challenges stare us in the face and annoy us every day. Let’s just reconcile us to the fact that the Perfect EMR is Mythology. However, in many ways it’s better than paper and I don’t see anyone going back.
Here’s where I usually do my sidebar and say that doesn’t mean that EHR vendors can’t do better. They can and should. Hopefully the meaningful use handcuffs that we put on them will indeed be removed and they can focus their attention on making EHRs better as opposed to government regulation. Every EHR vendor I know would celebrate this as well!
If you can’t celebrate the small but powerful benefits of being able to read everything in your EHR and being able to instantly pull up every record. We’ve seen glimpses of other benefits coming to your EHR that are great. Take a second to talk to Jimmie Vanagon about how his #ProjectedEHR and patient portal has changed how he sees and cares for patients.
Want to see other innovation happening in the EHR space? Learn about what Modernizing Medicine is doing with EMA Grand Rounds and Watson. The grand rounds approach is genius and can really inform the care a doctor provides. Unfortunately, we don’t hear much about it, even from them, because I don’t know anyone who’s based their EHR buying decision on if it would improve care in their organization. Sure, they didn’t want it to decrease care, but did they really evaluate the EHR based on it’s ability to improve care? No. They ask if it would meet meaningful use. They ask if it will improve reimbursement. They ask if it will improve productivity. Where’s “Will it improve care?” in that list?
Chew on that concept for a minute. How many EHR systems were bought in order to improve care?
What would it take for a healthcare organization to be ready to make an EHR selection based on the care that an EHR system provided? Would the current crop of EHR vendors be able to adapt? Would it require a whole new breed of EHR software (or maybe a different name)? Will any of the current EHR vendors adapt enough that they could illustrate that their EHR improved care so substantially that it would be nearly malpractice for a healthcare organization to pick any EHR but there’s? Is this what we need to happen for doctors to love EHR?
As I wrote at the New Year, I’m optimistic for healthcare IT. There’s so much potential for us to better utilize technology to improve healthcare. There’s so much non-technology that could benefit healthcare as well. Sometimes it’s just baffling that we can’t get out of our own way. What is clear to me is that we’re not going back to paper.
Imagine someone comes to your job and tells you that if you didn’t start participating in a bunch of government programs then you’re going to get a 9% pay cut. Plus, those government programs add little value to the work you do and it’s going to cost you time and money to meet the government requirements. How would you feel?
To add on top of that, we’re going to create a new system for how you’re going to get paid too. In fact, it’s actually going to be two new systems. One that applies to the old system of payment (which has been declining for years) and a new one which isn’t well defined yet.
Also, to add to the fun, you’re going to have become a collection agency as well since your usual A/R is going to go up as your payment portfolio changes from large reliable payers to a wide variety of small, less reliable people.
I forgot to mention that in order to get access to these new government programs and avoid the penalties you’re going to have to likely use technology built in the 80’s. Yes, that means that it’s built before we even knew what the cloud or mobile was going to be and used advanced technologies like MUMPS.
In case you missed the connection, I’m describing the life of a doctor today. The 9% penalties have arrived. ICD-10 is upon us. ACOs and value based reimbursement is starting, but is not well defined yet. High deductible plans are shifting physician A/R from payers to patients. EHR software still generally doesn’t leverage technologies like the cloud and mobile devices.
All of this makes for the perfect storm. Is it any wonder physician dissatisfaction is at an all time high? It’s not to me. It seems like even CMS’ Andy Slavitt finally realized it with the announcement that meaningful use is dead and going to be replaced. It’s a good first step, but the devil is in the details. I hope he’s able to execute, but let’s not be surprised that so many doctors are unhappy about what’s happening to healthcare.
The previous segment of this article looked at the movement for patient engagement, or the patient experience. Now I’ll highlight a true reform in the health care system.
Patients Left Out in the Cold
What activist patients and doctors have been demanding for years is not engagement or a better experience, but a central role for the patient in choosing treatment and carrying it out when they leave the doctor’s office. Patient empowerment is the key to all the things doctors profess to care about, such as preventing readmissions. It’s even more critical with chronic diseases that have a lifestyle component, such as congestive heart failure and diabetes.
Some patients come to the clinical setting endowed with more education than others, or a personality suited to pushing back and demanding rights. But some fight for years for such basics as access to their records. I was dejected to read just a few weeks ago of an attempt to improve care in Rhode Island, endorsed no less by the American College of Physicians, that boasts about giving access to everybody except the patient to health records.
The American College of Physicians is concerned about the hypothetical patient who “doesn’t know the name of the peach-colored pill that the orthopedist prescribed.” That particular patient is clearly not asking for empowerment. But millions do keep track of their medications and deserve equal knowledge about the rest of the information about their medical condition. If the peach-colored pill had been recorded in a patient health record, accessible to the patient (or a responsible care-giver) wherever she goes, all the complex Health Information Exchange infrastructure praised in the article could go by the wayside. Another article describes an emerging PHR solution.
Another recent example of the disdain for patients comes in a complaint by AHIMA about the difficulties of matching records for a single patient. Duplicate records are undeniably a serious problem (as is information mistakenly entered in a different person’s record). But instead of recognizing the obvious solution of a PHR, all they can come up with is a universal identifier (which is a privacy risk as well as a target for security attacks) and more determined efforts to match patients the old-fashioned way.
Empowered patients have control over their own information. Doctors guide them to make reasonable choices that affect their health, which includes sharing those records. Empowered patients set their own goals and timetables. A grant of power and information to patients will inevitably empower and inform the other health professionals with whom those patients interact, leading to a learning health system and a true team approach to care.
What’s the difference?
As I eventually admitted, the movement for patient engagement offers many good ideas that can contribute not only to a better experience in the health care center but to patient empowerment and better outcomes. What I complain about is the motive behind patient engagement.
Let’s take patient portals. To proponents of patient engagement, it serves a few purposes related to public relations. The portal hopefully:
Indulges people’s preference for fast information, endearing them to the practice
Keeps them more “engaged,” meaning that they’ll come back and spend more money at the health care center.
Delivers information in more appealing ways (such as through video, when practices use it).
Takes routine tasks off the shoulders of staff, freeing them to do other things that improve the patient experience.
This poverty of vision is why most portals lack useful information that patients can use to actually improve their care. Discharge instructions are usually a crumpled page. Doctor notes are hidden away, available to malicious attackers more easily than to patients. Medical codes and raw numbers appear on the portal without further elucidation.
Modern health facilities use web sites along with text messaging, old-fashioned phone calls, and other tools as part of a strategy to keep patients on their treatment plans. They may have full discharge instructions, along with instructional videos for such important tasks as changing bandages, on a patient’s personal site. The patient is encouraged to report her progress along with any setbacks, and gets quick feedback when there is a change. Many face-to-face visits can be averted, and patients who can update their caretakers without leaving home are less likely to exhaust themselves at vulnerable times. The patient’s family members can easily keep up with changes and find out what they need to do, as can other professionals working on the case.
For every element of empowerment, there is a tawdry alternative that can be offered as “engagement.” That’s the risk in the patient experience movement. Unless the health care institutions start out with the philosophy of empowerment, it’s just another distraction from the work we need to do.
One can derive a certain sense of entertainment, along with a discomfort comparable to the unending alarms one hears in the background of a hospital ward, when one sees an industry fumble over a critical task and seek desperately for a solution that takes the heat off of them while freeing them from the thoroughgoing cultural and organizational change that the crisis clearly calls for. If you haven’t figured out the issue I’m talking about yet, it’s the hot topic in health care circles these days: patient engagement.
Patient engagement is starkly counterposed to patient empowerment, which is the demand issued by the activists most engaged in health care these days. This article will look at the overlap and differences.
The Elusive Hunt for the Happy Patient
Doctors and administrators must be annoyed at having take time away from busy schedules to learn new bedside manners, but articles pour out on web sites almost daily telling them they need to do so. Typical titles are Social Media 101 For Healthcare CXOs and 5 Elements of a Successful Patient Engagement Strategy. A whole new job description has been even created: the patient experience officer, adding another expensive office to the hospital bureaucracy (with a concomitant rise in hospital costs, I’m sure).
I’ll double back later and admit that many of recommended strategies could help improve care. But an initial indulgence in cynicism is still justified.
Atul Gawande contributed to the fervor for treating patients as customers through his notorious ode to the Cheesecake Factory. The strengths and weaknesses of that comparison have been intelligently analyzed by numerous articles, such as ones in Forbes and KevinMD.
Another commentary shrewdly notes that clinicians themselves suppress patient engagement through problems ranging from lack of record sharing to opaque pricing.
One can sympathize with clinical administrators caught up in the rating frenzy that has overtaken everything we buy and every institution with which we interact. People seem to listen to other people’s rants over long waits or snippy receptionists when choosing which doctor to call (that is, people, lucky enough to have a choice of doctors–a topic beyond the scope of this article). The Department of Health and Human Services has legitimized the concern for patient ratings with its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, introduced in 2006. CMS uses a hospital’s score while determining its Medicare pay rate for inpatient care. (There’s help yet again for beleaguered administrators: Five Tips to Improve Your HCAHPS Scores).
OK, patient experience is important. I certainly couldn’t argue against empathy or compassion. One study found that communicating well with patients contributes more than other “quality measures” to reducing hospital readmissions. The critical issue of patient access to records will be addressed in my next section. More minor improvements to the patient experience can have ripple effects–for instance, moving them through the waiting room and examination faster reduces their risk of picking up infections. Even the snippy receptionist contributes to stress that’s bad for health, or discourages a patient from making an important follow-up visit.
But patient experience does not equal good care. As highlighted in an article in the Atlantic Magazine, patients are easily misled by superficial conveniences. Real improvement in care, the article says, comes from more nurses and a better working environment.
If people are dropping right and left from bugs picked up in restaurants (as they did in a number of Chipotle outlets), we wouldn’t be asking customers to rate the foam on their coffees or whether the waiters smiled at them. We’d be instituting a strong restaurant inspection regimen.
That’s the position of our hospitals and clinics. We have much worse things to worry about than the lengths of time spent in the waiting room. But if we want a focus on patients, there’s another way to do it that I’ll discuss in the next segment of the article.