I’ve long been a fan of open source technologies. My blogs are run and created almost entirely on open source software. In fact, I first wrote about open source EMR on this blog back in January of 2006. We’ve come a long way since then with Vista being the top open source EHR in the hospital world and OpenEMR leading the pack in the ambulatory world.
We’re starting to see more and more application of open source technology in other areas of healthcare IT beyond EMR as well. There are some really amazing advantages to a thriving open source community. I think the key there is to have a thriving open source community behind the project. It’s not enough to just say that your software is open source. If you don’t have a great community behind the project, then the open source piece doesn’t do too much for you.
With that said, I was really intrigued by this whitepaper from Achieve Health that talks about why they are applying the popular open source Drupal framework to healthcare. While I’ve mostly used WordPress for the things I’ve done, I’ve had a chance to use Drupal for a few projects and I’m really intrigued by the idea of applying the Drupal framework to healthcare.
This section of the whitepaper describes their vision really well:
Drupal is not a replacement for legacy IT systems from EMRs, Billing, Practice Management etc., but rather an extension to these systems. Through sophisticated integrations Drupal can enhance the functionality of each system concurrently. While there is no one panacea for the trials ahead, Drupal is highly capable of rising to meet many of the existing and future challenges the industry has to offer.
In the whitepaper they mention open source success stories like Pfizer, Florida Hospitals, Amerigroup Health Services, and Alliance Imaging. I think we’ll continue to hear of more and more open source success stories in healthcare for the reasons outlined in the whitepaper Harnessing Open Source Technology to Drive Outcomes in Healthcare. It takes a bit of a different mentality to go the open source route, but those who do are usually very satisfied. I think healthcare IT could really benefit from this shift in mentality.
Living in Las Vegas I likely have a skewed idea of what customer service means. In the tech world, we have Zappos headquarters in downtown Las Vegas. Most of you are likely familiar with Zappos unique approach to customer service. They really have taken customer service to the next level and created an entire company culture around the customer service they provide. The same could be said for the experience that the various casinos on the strip offer their customers. They do a really amazing job at most casinos providing an amazing customer service experience.
With this background, I find it really smart of Kareo to open an office in Las Vegas. Although, that’s not really the point of this post. Instead, I want to focus on the idea that most EHR vendors need expand their idea of customer service.
As I look at the world of EHR customer service I see so many organization lacking. Certainly we see examples of terrible EHR customer service that include calling into a call center in another country where the person doesn’t speak English and has no power to actually solve a user’s problems (Disclaimer: I don’t have a problem with call centers in other countries if they are well trained and can actually solve problems). Of course, the same thing can apply to a call center in the US who can’t solve the users’ actual problems. Both are terrible customer service and a problem in the industry. However, there’s a far more painful problem that I don’t think most EHR vendors consider a part of their customer service plan and 99% of EHR vendors have done terrible at this.
Adding new features and accommodating an EHR user’s feature request is just as much a part of the EHR customer service experience as the person who answers the phone. I can assure you that every EHR vendor out there would get rated an F the past few years when it comes to this form of EHR customer service. Why do I know this? I know this because every EHR vendor has been focused on meaningful use that they haven’t had the time to add any meaningful EHR user feature requests and features outside of meaningful use.
This isn’t EHR vendors’ fault. The end users have required it and EHR vendors have had to spend the time doing it. However, EHR customer service has suffered as a consequence. Don’t believe me. Look through all the EHR press releases that have been released over the past couple years. Find me the plethora of press releases that talk about the innovations that EHR vendors have created for their end users that aren’t related to meaningful use. I get the press releases and they’re MIA.
That’s not to say that EHR vendors have done nothing for end users. They’ve made some incremental progress on a few things, but meaningful use has zapped their development time. Stage 2 was even worse. I look forward to the new day where EHR vendors can focus on great customer service and EHR features and not just MU.
I recently had lunch with an EHR vendor that had an extremely small number of providers. I’ve known this EHR vendor for about 5 years, so this isn’t a new EHR vendor that’s trying to establish themselves in the industry. Instead they’ve focused on having a small, nimble team that’s focused on making the EHR work the right way for the doctors. It’s a novel approach I know, but pretty interesting that his business can survive with so few providers. Also worth noting is that the EHR is certified for meaningful use stage 2 as well.
Now think for a minute how the development process of an EHR vendor would be better if your EHR only had 25 doctors (For the record, the EHR vendor above has a few more than 25 doctors). Would it be much easier to satisfy just 25 physician users? Imagine the personalized service you could provide your users.
One of the real challenges I’ve seen with EHR vendors is that when they’re small, they are extremely responsive to their end users and the end users are very happy. As the EHR vendor grows, they lose that personal touch with the end users and many of those originally happy end users become dissatisfied with their EHR experience.
The problem with scaling an EHR user base is that you can’t make everyone happy. You have to make compromises that will be great in some people’s eyes and terrible in another person’s mind. What large EHR vendors do to try and solve this problem is they create configurable options that allow the end user to customize their system to meet their personal needs. Problem solved, right?
The problem with these configurations is two fold. First, you can’t make everything configurable. Once you go down the path of making everything configurable, it never ends. There’s always something else that could be made more configurable. So, the culture of configurability leads to unsatisfied users who can’t customize everything (even if what they want to customize shouldn’t matter).
Second, if everything is configurable, then it makes the implementation that much more complex. I’ve written before about the need for EHR vendors to have great “out of the box” user experience, but balancing that with allowing the user to configure everything that’s needed. This is a real challenge and most fail. Just look at the number of high priced EHR consulting companies out there. Many of them could better be defined as EHR configuration companies since the configuration needs are so large and complex.
Returning to where we started, when you’re an EHR vendor with 25 doctors you don’t have to build in all the flexibility and configurability. You’re small enough that as an EHR vendor you can do any needed customizations and configurations for the end user. Plus, with this kind of personalized service you can charge a little extra as well.
When you look at EHR development, there’s a spectrum of approaches starting with a fully in house, custom designed EHR through a fully outsourced EHR that can apply to any organization or specialty. In many ways a 25 doctor EHR has a lot of the same benefits of a fully custom EHR software, but spreads the costs of development across more doctors.
As a business, maybe a 25 doctor EHR company won’t dominate the world. Maybe they won’t have a huge exit to some other company or an IPO. However, that doesn’t mean it’s not a great small business if it’s doing something you love. Once you get World Domination out of your sites, it changes a lot of things about how you do business.
Like many other enabling-technologies in healthcare, telemedicine has vast unrealized potential.
If we make location completely irrelevant and can deliver care virtually, we can address the supply and demand imbalance plaguing healthcare. The benefits to patients would be enormous: lower costs and improved access in ways that are unimaginable in the analog era.
However, one of the many roadblocks to adoption is the cost of the legacy technology powering clinical telemedicine use. In this post, I’ll outline why the telemedicine systems are so expensive, even in the era of Skype and other free video-conferencing systems.
The Telemedicine Industry Is Old…School
Telemedicine as an industry has existed for about 15 years, although uses of telemedicine certainly predate that by another 10-20 years. A decade and a half ago, the foundational technologies that enable video-conferencing simply weren’t broadly available. Specifically, early telemedicine companies had to:
1) Develop and maintain proprietary codecs
2) Design and assemble hardware (e.g. proprietary cameras) and device drivers
3) Deploy hardware at each client site and train end users on its management
4) Build an expensive outside sales force to carry these systems door-to-door to sell them
5) Endure long, grant funding-driven sales cycles
Though some of these challenges have been commoditized over the years, many of the legacy players still manage and maintain the above functions in-house. This drives up costs, which in turn must be passed onto customers. Since many customers initially paid for telemedicine systems with grant money (that telemedicine technology companies helped them write and receive), the market has historically lacked forces to drive down prices. Funny how that seems to be a recurring theme in healthcare!
But, there’s a better way
Today, many startups are building robust telemedicine platforms with dramatically lower cost overhead by taking advantage of a number of technologies and trends:
1) Technologies such as WebRTC commoditize the codec layer
2) The smartphones, tablets, and laptops already owned by hospitals (and individual providers) have high quality cameras built into them
3) Cloud providers like Amazon Web Services make it incredibly easy for young companies to build cloud-based technologies
4) Digital and inbound marketing enable smaller (and inside) sales forces to succeed at scale.
5) To reduce the cost of care, providers are increasingly seeking telemedicine systems now, without wading (and waiting) through the grant process of yesteryear.
In short, telemedicine companies today can build dramatically more cost-effective solutions because they don’t have to incur the costs that the legacy players do.
Why don’t the old players adapt?
The simple answer: switching business models is exceedingly difficult. Consider the following:
1) Laying off hardware and codec development teams is not easy, especially given how tightly integrated they are to the rest of the technology stack that has evolved over the past decade
2) Letting go of an outsides sales force to drive crafty, cost-effective inside sales is an enormous operational risk
3) Lobbying the government to provide telemedicine grants provides an effectively unlimited well to drink from
Changing business models is exceedingly difficult. Few companies can do it successfully. But telemedicine is no different than all other businesses that thought they were un-disruptable. Like all other technologies, telemedicine must adapt from legacy, desktop-centric, on-premise solutions to modern, cloud based, mobile and wearable-first solutions.
The following is a guest blog post by Jennifer Bergeron, Learning and Development Manager at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
The closest I’ve come to experiencing a house call was watching Dr. Baker on “Little House on the Prairie” visit the good folks of Walnut Grove. Today, most people have no choice but to trek to their doctors’ offices and hospitals for health maintenance, diagnoses and check-ups. But new technologies are returning the personalized attention of the house call and will need to be adopted to retain the convenience and accessibility they offer.
I haven’t met anyone with a practice like Dr. Baker’s, though I recently read a news article that highlights the comeback of the house call. Some practitioners are banding together to provide round-the-clock care to patients who benefit from the fast response and lower cost: If a deductible or copay is higher than the price of the doctor’s visit, the patient may opt for the home visit.(1) The updated versions of the house call, however, are born of the technology used for telehealth, mobile health and health stations.
Telehealth allows a person to connect with a provider via the Internet. Patient and doctor can video conference, share informational media, and experience a face-to-face interaction without either party traveling from his or her home or office.(2) This allows patients better access to specialists who may have been too far away to visit and more frequent care at the right time to reduce the chances of serious complications or hospitalization. For patients who require frequent care over time, telehealth enables them to receive the medical attention they need while staying near their support network.(4) For providers, access to networks of specialists who can provide remote consultation helps them retain and ensure the highest level of care for patients rather than refer patients to another location.(3)
Both patients and providers also save time and money when there is no commute to an office or to a patient’s home. This is especially true of patients who live in rural areas and have to travel long distances for care. The quicker a patient can connect with the right specialist to treat or prevent serious illness, the lower the overall cost of care. (3)
Mobile health, or mHealth, takes technology one step further by allowing providers to track and monitor patient health on mobile devices such as tablets or phones. This includes monitoring devices that measure heart rate, blood pressure, oxygen levels, blood glucose and body weight. mHealth can be used in the office or taken on the road the way mobile clinics do. When healthcare is mobile, the ability to bring a doctor’s office to a neighborhood gives access to communities that otherwise wouldn’t seek or know how to find care. Currently, all 50 U.S. states have mobile clinics.(4)
Another trend in the making is the health kiosk. These look like private pods, about the size of four phone booths side by side. Think of it as telehealth combined with a mobile clinic. HealthSpot, a provider of health kiosks, describes them as “the access point to better healthcare.”(5) In addition to providing interaction with healthcare professionals via video conferencing, each station has an attendant and an automatic cleaning system. HealthSpot aims to give patients a private, personal, efficient experience.
Healthcare is on the move to better accommodate our lives, schedules, family structures and communities, which have vastly evolved from the “Little House on the Prairie” days and even from a decade ago. At the same time, our industry faces challenges in making the new technologies simple to use in order for them to be effective. With telehealth, for example, people typically need help setting up a home system and technical assistance. Meanwhile, providers face communicating and documenting in a new environment.
As we enter this new, modern, faster era of healthcare, both patients and providers will need to learn how to implement and adopt new systems, technologies and ways of interacting. Easing adoption is what we are prepared to do at The Breakaway Group. Once the learning-and-comfort curve is overcome, patients can experience the convenience of Dr. Baker’s updated home visit.
(1) Godoy, Maria, (December 19, 2005). A Doctor at the Door: House Calls Make Comeback.
(2) Health Resources and Services Administration Rural Health, (2012). Telehealth.
(3) Hands on telehealth, (2013). 15 Benefits of telehealth.
(4) Hill, C., Powers, B., Jain, S., Bennet, J., Vavasis, A., and Oriol, N. (March 20, 2014). Mobile Health Clinics in the Era of Reform.
(5) The HealthSpot Station.
Xerox is a sponsor of the Breakaway Thinking series of blog posts.