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Thursday, June 14, 2012

Those Damn Vendors — Escaping the EHR Trap

Before I start, I need to remind you that what I write here represents my own opinion, not that of my employer or any other organization I represent.

Vendor - A supplier of any good or service.

Ken Mandl and Zak Kohane's provocative opinion piece on Escaping the EHR Trap — The Future of Health IT in the NEJM is getting a lot of attention this morning. There are nearly 50 tweets of the article listed below, and plenty more to come.
@alexmeshkin
Escaping the EHR Trap — The Future of Health IT http://www.nejm.org/doi/full/10.1056/NEJMp1203102
@pjmachado
Buyers need to define the solutions & interoper RT @ahier: Escaping the #EHR Trap — The Future of #HealthIT http://bit.ly/LblSn6 #hitsm
@hashem25
RT @ahier: Escaping the #EHR Trap — The Future of #HealthIT http://bit.ly/LblSn6 via @NEJM
@Tim_Stapleton
Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/LMDG7L
@ahier
Escaping the #EHR Trap — The Future of #HealthIT http://bit.ly/LblSn6 via @NEJM
@Richard_Dabbs
Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/LMCscF
@TPCaruso
Escaping the #EHR Trap — The Future of #HealthIT http://ow.ly/bzJQa : EHR vendors have systems that are decades behind
@AppSecPundit
Top story: Escaping the EHR Trap — The Future of Health IT — NEJM http://goo.gl/YOJHj, see more http://goo.gl/SCVIP
@kostaMakroDimi
Escaping the EHR Trap — The Future of Health IT. HIT vendors should adapt modern technologies http://www.nejm.org/doi/full/10.1056/NEJMp1203102
@emrninja
#healthIT Escaping the EHR Trap — The Future of Health IT: Source: Mandl KD, Kohane IS. N Engl J Med, 366(24) Co... http://bit.ly/LaLRes
@icmccupdate
Escaping the EHR Trap — The Future of Health IT http://shar.es/soyg4 #healthit #ehr
@decisiondawn
Interesting perspective in this weeks NEJM: Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/LLLA12
@urigoren
Escaping the EHR Trap — The Future of Health IT — NEJM | @scoopit http://bit.ly/MQ9Oqj#ehealth
@CitiusTech
A different perspective: Escaping the EHR Trap — The Future of Health IT | http://bit.ly/MPAmYE | #HealthIT #EHR #healthcare #ONC
@ElinSilveous
Wasn't it? Thank you. RT @jbselz Great article! RT Escaping the #EHR Trap, The Future of #HealthIT via NEJM http://ow.ly/1NGDpv
@Health_IT_India
Escaping the EHR Trap — The Future of Health IT http://dlvr.it/1jh915 #hcsm via @nrip
@AaronNeinstein
An important read in @NEJM "Escaping the EHR Trap — The Future of Health IT" http://bit.ly/L9Leln #EHR #HCT #HIT
@pat_rioux
Escaping the EHR Trap — The Future of Health IT -"their systems' inability to work together has not helped drs or pts." http://www.nejm.org/doi/full/10.1056/NEJMp1203102
@michaelwcraige
Escaping the EHR Trap — The Future of Health IT http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC&#t=article
@JimNHansen
'Ten Principles ... Dev of an 'iPhone-like' Plat. for #HealthIT ' http://chip.org/platform b4 'Escaping the #EHR Trap' http://www.nejm.org/doi/full/10.1056/NEJMp1203102
@jbselz
Great article! RT @ElinSilveous: Escaping the #EHR Trap, The Future of Health IT via NEJM http://ow.ly/1NGDpv #HealthIT #HITsm #HCSM
@k1h
電子カルテの罠 Escaping the EHR Trap — The Future of Health IT NEJM で全文pdfダウンロード可能 読みたいけど時間ないです。
@pyramidmedicine
Escaping the EHR Trap — The Future of Health IT - http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC (NEJM)
@nrip
Escaping the EHR Trap — The Future of Health IT http://vsb.li/DOpmBJ #hcsm #hcsmin #healthIT
@l_scott_brown
EXCELLENT critical analysis of the problems with #EHRs today. Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/K3uwP3
@Health_IT_Feed
#hcit via @nrip Escaping the EHR Trap — The Future of Health IT http://ow.ly/1kxtVJ
@healthyrx
Escaping the #EHR Trap — The Future of #HealthIT http://www.nejm.org/doi/full/10.1056/NEJMp1203102
@jmichaelslocum
Escaping the EHR Trap — The Future of Health IT — NEJM: http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC via @AddThis
@plus91
Escaping the EHR Trap — The Future of Health IT - It is a widely accepted myth that medicine requires complex, highl... http://vsb.li/3wpLMX
@drmalpani
#hcit Escaping the EHR Trap — The Future of Health IT - It is a widely accepted myth that medicine requires complex,... http://ow.ly/1kxzKY
@health_medical_
Escaping the EHR Trap — The Future of Health IT - It is a widely accepted myth that medicine requires complex, highl... http://ow.ly/1kxzL0
@health_care_IT
Escaping the EHR Trap — The Future of Health IT - It is a widely accepted myth that medicine requires complex, highl... http://ow.ly/1kxzL1
@IAMItweets
Escaping the EHR Trap — The Future of Health IT: It is a widely accepted myth that medicine requires com... http://bit.ly/LYgAcT #hcitin
@paragvr
#hcsmin via @nrip Escaping the EHR Trap — The Future of Health IT http://goo.gl/2eynQ
@simonmcbride
Excellent NEJM paper exposing the #healthit industry #fail > Escaping the EHR Trap http://nej.md/Kozr1H
@mtmdphd
Escaping the EHR Trap — The Future of Health IT — NEJM http://bit.ly/M4ZmJ6
@websitesfordocs
Escaping the EHR Trap — The Future of Health IT http://dlvr.it/1jfQFn
@technicaldr
Escaping the EHR Trap — The Future of Health IT http://dlvr.it/1jfQFg
@rsm2800
NEJM Perspective: Escaping the EHR Trap — The Future of Health IT http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC#references
@moorejh
#informatics RT @westr Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/Kot2DQ #pm101 Let Apple Do It!
@westr
Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/Kot2DQ #pm101 Let Apple Do It!
@joeketch
Escaping the EHR Trap — The Future of Health IT — NEJM http://ow.ly/bz8lI
@cdocwong
Escaping the EHR Trap — The Future of #Health IT — NEJM: http://nej.md/KorYzJ - #EHR #ACEP - HIT vendors locking in your data? Don't let 'em
@geekintraining1
Interesting, discussion-inspiring NEJM article: Escaping the EHR Trap — The Future of Health IT http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC
@SurvivorshipHIT
Interesting, discussion-inspiring NEJM article: Escaping the EHR Trap — The Future of Health IT http://www.nejm.org/doi/full/10.1056/NEJMp1203102?query=TOC
@daborbolla
Reading: "Escaping the EHR Trap — The Future of Health IT — NEJM"( http://twitthis.com/cl94gg )
@johnrgraham
Escaping the EHR Trap — The Future of Health IT — NEJM: http://nej.md/K2JXqC

The first thing that popped into my mind as I read the article was that it was troll baiting, looking for a response.  And the pretty negative attitude about "vendors" that the article was written would seemingly guarantee a trollish response.  I'll try to avoid it though, because there are far too many billy-goat gruffs out there.

I've got a lot of complaints about the article: The authors' make their claims about a whole industry, including all 700 certified EHR vendors and certified EHR products.  The brush they paint with is very broad, and with it they make numerous unsupported assertions about vendor behaviors and product designs.  Some of their claims (e.g., vendors blocking new entrants, locking up the data) are internally inconsistent with other statements in the article (e.g., EHR vendors have proliferated, data was exported to SHRINE from numerous systems).  I could go on in great detail on each.

But perhaps the most faulty argument in the article is this section, and I want to spend most of my time on it:
A healthy IT marketplace would favor disruptive innovations (simple products and services that initially serve the bottom of a market and then move up to displace established competitors) for improving patient engagement, communication, and care coordination. Improved population health obtained at a lower cost would result. 
I'd suggest the authors reread Christenson's series on Innovation.  I'll quote (emphasis mine) from page 187 of Clayton Christenson's The Innovator's Prescription to illustrate the real problem:
The Co-opting Power of the Present Value Network in Health Care
  When disruptive innovators attempt to commercialize their innovations within the established value network in the industry — essential trying to cram it in the back plane of the competition in Figure 6.1— that system will either reject it (as it did with Sony's transisterized products) or co-opt the potential disruption, forcing it to conform to the existing value network in order to survive.
The idea that disruptive innovations can fit into the current healthcare value network, as suggested by the authors', ignores this key point that Christensen expands on further (again, emphasis mine):
The very same ... process is at work within every company, and within the value networks in which each company is ensconced.
Going back to The Innovators Dilemma, the value network in which hard drive manufacturers that were ensconced was the mini-computer marketplace.  It was the new value network brought about by the microcomputer revolution which brought about the innovation and the disruption in the hard drive industry.

The real challenge is not providing disruptive technology in Health IT, but rather, in providing a new value network in health care that will enable disruptive innovation. When that happens, the new value networks will have the necessary technology to support it, and indeed, the current EHR industry will either adapt, or die, just as hard drive manufacturers did.

But to get there, we might need to looking at the behaviors of a very different set of "vendors".


6 comments:

  1. Keith, you nailed it on the head. A disruptive business model requires and engenders a disruptive value network. Unfortunately "disruption" thinking often gets stuck at the "technology" level, and when it breaks through then it then gets stuck at the "business" level. In this industry, as in most networked markets, the value network is the minimal level of granularity for engendering change, which means that incumbents (and folks who cater to incumbents, like the government) are usually challenged beyond their mental/structural means to actually shape it.

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  2. I am expecting a disruptive value network to emerge from the patient-centered view, not the current EHR market nor its cohorts. Current EHR value is focused on providers and "meaningful use" incentives for them. A new value network will directly engage patients and provide explicitly measurable value to them. It may displace EHRs as we now know them, assuming interoperability with clinical data systems. The current payment value network is so broken that it does providers and patients a disservice; interoperability with it is best avoided.

    I hope that the changes can occur in the private sector. IMHO, the US government has proven to be an ugly partner, despite what political party is in power.

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  3. Keith, I don't disagree with your quibbles on some of the points in the article, but to me the most critical point you make is in the second-to-last paragraph. I totally agree with you that changes in health care (particularly reimbursement) must necessarily be the drivers of IT innovation. To this end, I think Mandl and Kohane make some great points, and we should not get lost in the weeds of their words.

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  4. Keith,
    My friends and colleagues who wrote the article lead one to believe that the vendors are the cause of the insane complexity of health care financing and administration. Rather, they are merely reacting to this complexity. The terms "apathy" and at times "opposition" can be more generally applied to the healthcare industry - including academic medical centers and many of the "Informatics Illuminati" who focus on small goals rather than at ambitious transformation. So I agree with friend Bill here: we should not get lost in the weeds of their words.

    Thanks for your post...and even more for your book. It's great.

    Mark Frisse
    Vanderbilt University

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  5. Good Grief. Do you guys really understand what challenges we developers face? Gee, just WHAT standards shall we follow? (See all the articles above) Oh, and what validator should be used. Oh, yes, the validator that was modified to ignore deviation from the standard.... Then let's agree with each other how we "use" the standard, then let's generate a few hundred quality reports whose results we can't prove and no one uses at great expense until we figure out that we should use CDS to start with THEN test the quality outcomes that we all generate from the CCD's we all need to generate and share anyway. As a regional developer, we love the fact that we can meet and exceed what the national EHR's can provide and we add stellar service and training. But the certification fees, challenges to obtain regulation clarification from "anyone, anyone" has not been fun. Could it be we are we a bit mis-understood and possibly under appreciated? Did I mention that nobody wants to pay us for those added aggregators, certificates, interfaces that we must build? Do you really think those incentive payments are going to us? Hmmm? Thanks for the blog and info. You have been one of our most appreciated resource! (OK, so I took the bait)

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  6. Hi Keith/Mark/Bill et al.,

    I think Ken's/Zak's piece should be interpreted as an opinion piece designed to stimulate discussion, not as a whole lot more. Technology is only one piece of the puzzle (and sometimes, a very small piece). Professional, cultural, economic and structural issues loom much larger many times, as already implied here.

    I think our main challenges from a data management perspective include these: (1) help healthcare providers and patients record high-quality data in non-intrusive and efficient ways; (2) make sure data flow through the "system" at large to support care-related decision-making and workflow in meaningful ways; and (3) ensure that we can use the data for meaningful secondary purposes (like public health, research, system improvement, etc.).

    I do think that healthcare value propositions must change in many ways for us to be able to implement (and benefit) from improved information management: from discipline/care setting-centered to patient-centered; from procedure and volume-focused to outcomes-oriented; and from platform-specific and siloed to open and shared.

    That is a task that faces the healthcare enterprise as a whole. One challenge is to get all the individuals involved in healthcare onto the same page (or at least the same book or library) so we can make progress on this in the long term.

    The posting of "Anonymous" right above is emblematic of one of our ailments: We don't spend enough time talking to each other (as, for instance, in "vendors and informaticians") in order to surmount the most basic disconnects. How can we work towards the bigger vision if that is the case?

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