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Do Vendor Business Models Discourage EMR Innovation?

Posted on April 4, 2017 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Despite the ever-mounting levels of physician frustration, in some ways EMRs have changed little from their mass-market rollout. EMR interfaces are still counterintuitive, data sharing possibilities are limited, important information still lives in isolated silos and endless data entry is the rule rather than exception.

In theory, we could do better if we had a reasonable vision of what should come next. For example, I was intrigued by ideas proposed by Dr. Robert Rowley of Flow Health. He describes a model in which EMRs draw on a single, external data source which isn’t confined to any one organization. Providers would access, download and add data through a modern API.  Given such fluid access to data, providers would be able to create custom front-ends based on a collection of apps, rather than rely on a single vendor-created interface.

Unfortunately, EMR vendors are unlikely to take on a completely different approach like Rowley’s, for reasons inherent to their business model. After all, they have little reason to develop new, innovative EMRs which rely on a different data architecture. Not only that, the costs associated with developing and rolling out a completely new EMR model would probably be very high. And what company would take that chance when their existing “big iron” approach still sells?

Not only that, EMR vendors would risk alienating their customers if they stray too far off the ranch. While an innovative new platform might be attractive to some buyers, it might also be incompatible with their existing technology. And it would probably require both providers and vendors to reinvent workflows and transform their technical architecture.

Meanwhile, in addition to finding a way to pay for the technology, providers would have to figure out how to integrate their existing data into the new system, integrate the platform with its existing infrastructure, retrain the staff and clinicians and cope with reduced productivity for at least a year or two. And what would become of their big data analytics code? Their decision support modules? Even data entry could be a completely new game.

Smaller medical practices could be pushed into bankruptcy if they have to invest in yet another system. Large practices, hospitals and health systems might be able to afford the initial investment and systems integration, but the project would be long and painful. Unless they were extremely confident that it would pay off, they probably wouldn’t risk giving a revolutionary solution a try.

All that being said, there are forces in play which might push vendors to innovate more, and give providers a very strong incentive to try a new approach to patient data management. In particular, the need to improve care coordination and increase patient engagement – driven by the emergence of value-based care – is putting providers under intense pressure. If a new platform could measurably improve their odds of surviving this transition, they might be forced to adopt it.

Right now, providers who can afford to do so are buying freestanding care coordination and patient engagement tools, then integrating them into their existing EMRs. I can certainly see the benefit of doing so, as it brings important functions on board without throwing out the baby with the bathwater. And these organizations aren’t forced to rethink their fundamental technical strategy.

But the truth is, this model is unlikely to serve their needs over the long term. Because it relies on existing technology, welding new functions onto old, clinicians are still forced to grappled with kludgy technology. What’s more, these solutions add another layer to a very shaky pile of cards. And it’s hard to imagine that they’re going to support data interoperability, either.

Ultimately, the healthcare industry is going to be bogged down with short-term concerns until providers and vendors come together and develop a completely new approach to health data. To succeed at changing their health IT platform, they’ll have to rethink the very definition of key issues like ease of use and free data access, care coordination, patient engagement and improved documentation.

I believe that’s going to happen, at some point, perhaps when doctors storm the executive offices of their organization with torches and pitchforks. But I truly hope providers and vendors introduce more effective data management tools than today’s EMRs without getting to that point.

Taking a New Look at the Lamented Personal Health Record: Flow Health’s Debut

Posted on June 8, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

After the disappointing lack of adoption suffered by Google Health and Microsoft HealthVault, many observers declared personal health records (PHRs) a non-starter, while others predicted that any progress toward personal control over health data would require a radically new approach.

Several new stabs at a PHR are emerging, of which Flow Health shows several promising traits. The company tries to take advantage of–and boost the benefits of–advances in IT standards and payment models. This article is based on a conversation I had with their general counsel, David Harlow, who is widely recognized as the leading legal expert in health IT and health privacy and who consults with companies in those spaces through the Harlow Group.

Because records are collected by doctors, not patients, the chief hurdle any PHR has to overcome is to persuade the health care providers to relinquish sole control over the records they squirrel away in their local EHR silos. Harlow believes the shift to shared risk and coordinated care is creating the incentive for doctors to share. The Center for Medicare & Medicaid Services is promising to greatly increase the role of pay-for-value, and a number of private insurers have promised to do so as well. In short, Flow Health can make headway if the tangible benefit of learning about a patient’s recent hospital discharge or treating chronic conditions while the patient remains at home start to override the doctor’s perception that she can benefit by keeping the patient’s data away from competitors.

The next challenge is technically obtaining the records. This is facilitated first by the widespread move to electronic records (a legacy of Meaningful Use Stage 1) and the partial standardization of these records in the C-CDA. Flow Health recognizes both the C-CDA and Blue Button, as well as using the Direct protocol to obtain records. Harlow says that FHIR will be supported when the standard settles down.

But none of that is enough to offer Flow Health what the doctors and patients really want, which is a unified health record containing all the information given by different providers. Therefore, like other companies trying to broaden access to patient data, Flow Health must deal with the problem that Dr. Eric Topol recently termed the Tower of EMR Babel. They study each format produced by different popular EHRs (each one using the C-CDA in slightly incompatible ways) and convert the data into a harmonized format. This allows Flow Health to then reconcile records when a diagnosis, a medication list, or some other aspect of the patient’s health is represented differently in different records.

What’s next for Flow Health? Harlow said they are preparing an API to let third parties add powerful functionality, such as care coordination and patient access from any app of their choice. Flow Health is already working closely with payers and providers to address workflow challenges, thus accelerating the aggregation of patient health record data for access and use by clinicians and patients.

A relative of mine could have used something like Flow Health recently when her eye doctor referred her to the prestigious Lahey Clinic in the Boston area. First of all, the test that led to the referral had to be repeated at the Lahey Clinic, because the eye doctor did not forward test results. Nor did anyone provide a medication list, so the Lahey Clinic printed out a five-year old medication list that happened to hang around from a visit long ago and asked her to manually update it. There was also confusion about what her insurer would cover, but that’s a different matter. All this took place in 2015, in the country’s leading region for medical care.

It seems inevitable that–as Flow Health hopes–patients will come to demand access to their medical records. A slew of interesting experiments will proliferate, like Flow Health and the rather different vision of Medyear to treat health information like a social network feed. Patient-generated data, such as the output from fitness devices and home sensors, will put yet more pressure on health care providers to take the patient seriously as a source of information. And I’ll continue to follow developments.