EMR

EHR: How to purchase an EHR

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Are you really going to where that?  Do these pants really make my…

Did you ever have one of those non-halcyon days when you felt the need to ask someone “Did a house fall on your sister?”  Try to stay with me, it will come to you.  Enough about falling houses Toto.

I sought the counsel of a friend before heading down this path, and I’ve decided to choose the road less traveled anyway.

I may have written that I have observed differences between men and women.  You too?  Here are a few examples from my side of the gated compound.

  • We are willing to make mistakes as long as someone else is willing to learn from them
  • A good excuse is almost as good as getting it right
  • Good intuition will often make up for a lack of any facts
  • We refine our personality flaws, for without them we may not have a personality
  • Peter the Great heard the voices too

I regret that I am unable to share my list about women, for I am a coward.

While shopping the other day, I noticed that women shop for clothing differently from men.  For women, shop is a participatory verb—whatever that is—involving all twelve senses, for men it’s something we’d rather do online while watching the game.  From what I’ve observed, in fostering the she-conomy women:

  • Do their homework—what’s in, what’s not, what’s on sale
  • View shopping as a competitive sport, for some, a blood sport
  • Try on things, often more than once
  • Buy something they may need in case they someday find some other thing they may need that may go with it
  • There is no rule about having too many shoes—buy in volume
  • There is no rule about having too many black shoes

So, let’s see if we can segue beyond this jingoistic tractate on one to something more in line with the lofty subscription fee you paid for this site.

Permit me to employ two definitions which help me keep my ideas cogent.

  • IntraEHR—EHR statements that relate mostly to the healthcare provider
  • InterEHR—EHR statements that relate mostly to the movement  or transport of the EHR record from point A to point B

EHR and shopping.  Can one be at one with this duality?  How can one not be?  From having spoken with a number of healthcare providers about their IntraEHR selection, my take on a lot of the process is that more often than not there is no process.  It’s a lot like watching men shop.  It’s over and done with without much reasoned or substantiable—I was afraid I’d have to invent this word but I found it on Google—thought.  Over and done with, now back to the game.

Maybe EHR scholars will one day be able to trace speed buying of IntraEHRs back to that whole Neanderthal hunter gatherer thing in the Pleistocene epoch.  Sort of a think fast on your feet or you’ll be eaten approach to software selection—an awful metaphor, however CNN ran a feature with that title, so it has some legitimacy.  Maybe the hospital’s executive committee will be able to trace the hastily made IntraEHR purchase back to a lack of a plan, the lack of business requirements, and the lack of an adequate request for proposal RFP.  Maybe your successor will figure it out.

For those who haven’t contracted for their IntraEHR, it may be better to approach this like a woman.  To those who are women—you should know who you are—you are probably already approaching it that way.

Now, where did I leave my black pumps?  And no, I am not going to finish my thought about the pants.

You now know which ERH you should have bought

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This occurred to me while listening to a report on NPR that was comparing the Kindle to the iPad.  The comparison made regarding a study conducted to assess the viability of using the devices in universities as e-Textbooks instead of paper textbooks.  The Kindle was tested for a year; the iPad was tested next.

The traditional textbook prevailed over the Kindle; iPad may have reinvented the textbook.  A winner and a loser for what many consider being the same device in different packages.  Apple did the same thing for MP3 players and the cellular phone.

The conclusion about that Kindle was it was a bad imitation of its paper counterpart, saying it was simply a copy of what was on the paper but not as effective.  To me, this sounds like the conclusion many physicians have made about their EHRs—a poor automation of a poorer set of processes.  This is why user acceptance has been poor and why in many places productivity has fallen off the charts.

The study concluded some of the issues with the Kindle for both the students (think patients, and the professors (the physicians)—the analogous EHR function is noted within the parentheses has the following negatives.  The Kindle:

  • is less interactive than a piece of paper
  • does not follow the layout of a textbook or the flow of the discussion (navigation)
  • cannot easily handle full color illustrations and photographs (imaging)
  • is more difficult to annotate (SOAP notes)
  • takes longer to load the material, input data, and to search for information (clicks and drop downs)
  • the users stopped reading Kindles as scholarly texts and began reading them as novels (how physicians read and chart)
  • the students learned less and required additional time to learn the same amount (productivity)
  • did not maintain pace with the discussion or activity (process)

The textbook winner, the iPad, creates multimedia functionality out of a book.

Just because you search for electronic book readers online, and up pop both the Kindle and the iPad, does not mean they are equal.  You cannot expect a search engine to distinguish between them.

Here’s the punch line.  Just because you Google EHRs and get a list of vendors does not make them equal.  I know you know that.

I think most of EHRs are equal, equally dysfunctional.  Sticking with the analogy of the Kindle and the iPad, most EHRs are Kindles.  Most EHRs—in fact almost all of them; 99% of the 400—are to healthcare what Kindle is to textbooks; not much.  For many, the chart is better.

If you already implemented EHR you learned your EHR, how well is it performing?  I am willing to bet more than half have not met expectations, or expectations have been lowered to meet the performance.  Let us look at the same scorecard we used above.  If your EHR…

  • is less interactive than a piece of paper
  • does not follow the flow of the patient/doctor narrative
  • cannot easily handle full color illustrations and photographs
  • is more difficult to annotate than a paper chart (SOAP notes)
  • takes longer to load the material, input data, and to search for information (clicks and drop downs)
  • does not allow doctors to review notes and images the way they read charts
  • requires additional time to read and document the same amount of information than paper charting (productivity)
  • does not maintain pace with the patient discussion or activity (process)

…you have quite a mess on your hands.  If this makes you a little weak in the knees, what does this type of performance imply about your chances of meeting Meaningful Use?  Having a certified EHR will not make these problems disappear; you will simply have certified problems.

If you disagree with this assessment, please tell me why.  If you agree with the assessment, what are you doing to try to fix it?  I am willing to bet you a bag of licorice that it will not make things better.

Those who have read this far did not need to read this to know your EHR has not done what you needed it to do.  The strange thing is very few know what to do about it.

Those who have yet to complete their EHR or have yet to begin the process will come to the same conclusion unless they find the hidden jewels that make up the one percent of EHRs that actually function better than a paper chart.

EHR productivity need not be awful

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I wrote this in response to a question I posted on a LinkedIn discussion group.

I have met with CIOs and CMIOs who have spent well over $100 million on name-brand systems-wide EHRs whose productivity in the exam room after more than two years is 20-30% less than it was before they implemented the EHR.  Two of those hospitals are replacing their EHR and expecting different results.

I watch some physicians spend more than half their time with a patient sitting at a keyboard clicking and navigating while the patient sits there.  I watched it happen to me in an exam.  My physician knows what I do and asked me if there was a way to improve his face-time.

That got me thinking about how to do that.  Most hospital EHRs are very broad and complex systems.  They are designed to do a multitude of things that go well beyond the  interactions needed to document what occurs during the exam.  My review of those systems indicates that in many cases their breadth makes it difficult for them to render effective and efficient service during an exam–too many clicks, and difficult navigation.
Most physicians are much more effective writing than typing, selecting options from a slew of drop-down menus, and finding their ways around a maze of screens.

My reference to the term GUI is meant as a placeholder, perhaps I should have called it an ambulatory EMR front-end.  Whatever its label, I believe there are inexpensive solutions that can be implemented alongside large EHRs that can make the doctor more productive.  The fact that nobody is doing this does not mean it cannot be done.

I have seen EHRs that serve ambulatory care providers that are highly effective and do not neutralize the patient-doctor interaction.  I have seen a doctor be fully functional in as little as 30 minutes.  Some physicians use the increased productivity to spend more time with patients, and some use it to see more patients.

I think it is also an important cost and ROI consideration.  If a hospital spends $200 million on an EHR, and their result is a productivity decrease of twenty percent, the total cost of their EHR is substantially higher than $200 million.

How can EHR be made to work?

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I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.

Why bother with an RFP for EHR?

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HIT Strategy; without one, do not take out your checkbook.  Buying what your neighbor bought, and assuming they did their homework, is not a strategy.  Buying something because the sales-rep told you they had an amazing list of client references is not a strategy.  These are shortcuts.  Have you noticed none of the EHR providers were not wearing “I love my EHR” T-shirts at the last HFMA meeting?

My rule of thumb about Google is that if I cannot find something it is because it does not exist.  There are no good EHR RFPs available on Google.  Here are a few thoughts on RFPs in case you want to use one—by the way, a good RFP makes a great addition to a vendor contract as it provides a written audit trail of what they contracted to do.

  1. The RFP should have an exhaustive list of requirements.  It is designed to separate one vendor from another, not make them all appear to be equally capable.
  2. The requirements should be addressed in a way to help a provider know what business capabilities the vendor offers, not to show how pretty their screens are.
  3. The RFP should not mirror your current business.  Your goal is not to simply automate what you do, but to do it better.  That means change.  Without change your EHR will simply be an expensive scanner.
  4. Along that same thinking, I have yet to see an RFP that mentions a single requirement about making the provider’s business more efficient or more effective.  Here’s why.  if each provider tells you their system can perform the same tasks as the other systems, you have not learned anything to cause you to pick one vendor over another.  If they say their system is efficient, make them supply you with details about the number of clicks, screen navigations, and times needed to do the ten tasks you do most often.  If they say they are twice as fast as Vendor A, make them prove it, make them prove it in your office.  Contact vendor A and find out who is telling the truth.  If they each have the same functionality, and one vendor takes half the time to perform a task, that fact should be included in your decision.  How important is 30 seconds?  How many 30-second improvements are there with each patient?  If there are four, and you see 30 patients a day, and your practice has eight doctors, you’ve either just saved a total of eight hours a day to spend more time talking to your patients, or to add patients.
  5. The other important part of the RFP that is often either overlooked or under assessed is the specialization of the EHR.  Warning: A large vendor has probably has at least one implementation covering each specialty; cardiology, orthopedics, urology.  Having one or a few clients in a specialty does not mean their product was designed to serve that market.  It may mean their clients did not do a very good job selecting tem as their vendor.
  6. That brings us to references.  A large vendor may have a thousand or more providers installed.  When you ask to check their references, which ones are they likely to parade in front of you—the ones who like their product.  The other 990 are kept in their lock-box.  Whoever they give you to talk to will be those who they feel are least likely to say something negative.
  7. How should you check references?  Most vendors will give you as a contact either a top administrator or someone in IT.  That will tell you very little.  Once you learn the name of the organization, call them.  “This is doctor so-and-so, and I am calling to speak with one of your physicians.”  Whatever this person tells you will be of much more value than having someone who not use the system tell you how much they like it.

Anyway, those are my thoughts.  There are a range of savings available if you have a good EHR strategy, pick a good system, and implement it correctly.  If you pick the wrong one, you do not need to worry about calculating your ROI—there won’t be one.

Should you meet Meaningful Use?

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Here are links to two presentations I wrote on the topic.  Please let me know what you think.

http://www.slideshare.net/paulroemer/should-you-meet-meaningful-use

http://www.slideshare.net/paulroemer/nyc-health-20

Best – Paul

Failed EHRs: Maybe it’s the jeans

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There I was listening to NPR while driving home from the airport.  Their lead story was about Levis’ announcement of a new line of custom-fit jeans for women.  They developed the line after studying the shapes of more than 60,000 women—I guess that is good work if you can get it.  Levis somehow determined that 80 percent of all the women on the planet fall into three distinct categories, Curve IDs.  (Does that mean the other twenty percent fall into roughly 3,752,841 body types?)

Why did Levis go through all this effort?  Apparently 87 percent of women say they can’t find a pair of jeans that fits them.  Fifty-four percent stated they try on at least ten pairs of jeans before deciding on a pair.  I concluded from a few of the things I read on Google that for those whom believe the jeans don’t fit—must be a lot of bad jeans out there.

There are a lot of failed EHR implementations out there.  How do I know that to be true?  I studied the shapes of more than 60,000 failed EHR implementations and, guess what?  They fall into three failure categories—EHR Failure IDs—lack of due planning, lack of process change, and lack of user involvement.  I guess it’s difficult to get an EHR to fit…Kind of like finding a good pair of jeans.

Here’s my take on the matter.  Chances are that whatever EHR does not seem to fit in Provider A is fitting just fine at Provider B.  How could that be?  Same system.  Same code.  The functionality of the system has not changed in the time since it was selected.  Maybe the reason the EHR does not fit is not the fault of the EHR.

That said, there are those of you who think I may tie this discussion back to the discussion of the jeans, and write something like, “Maybe the reason the jeans do not fit is not the fault of the jeans.”  I may be dumb, but I am not that dumb.
Kind Regards,

Paul

Paul M. Roemer
Managing Partner, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942
paulroemer@healthcareitstrategy.com

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How to Revive a Failed EHR Implementation

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My latest post on www.healthsystemCIO.com.  Here’s an idea I think merits consideration.

http://healthsystemcio.com/2010/07/30/how-to-revive-a-failed-ehr-implementation/

What do you think?

Finally, an EMR worthy of a T-shirt

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Those who are regular readers know I’ve commented on more than one occasion that you never see anyone at the HIMSS convention walking around wearing a T-shirt imprinted with the slogan, “I love my EPIC”, or one stating, “McKesson forever”–unless they were talking about the implementation plan.

Today, my perspective changed–I’m going to start selling T-shirts printed with the phrase, “SRS-Soft Rocks my Docs.”

You may ask, ‘Who is SRSSoft’?  Fair question.  I could not have given an adequate response to that question prior to today.

I spent some time with them, ran their demo–I played doctor but they stopped me before I was able to insert a chest tube.  I ran the demo.  Why is that important?  It went like this.

“So, if you were a doctor, what would you do?”

With enthusiastic anticipation, I searched for my scalpel–that wasn’t what he meant.  “I’d see who my next patient is.”

“Do it.”  (Mind you, all of what I am doing happens on one screen faster than a sneeze.)  I clicked the schedule and up popped all the patient’s information.

“Next?”

“I’d probably want to review their chart.”

“Do it.”  (Don’t try this at home unless you are a devotee of Scrubs or other medical training.

Same screen, up pops the chart.

“Next?”

I click on the notes from their last visit, compare their labs by pulling up a comparison chart–new versus old; scan the X-RAY, and review their list of medications.  I did this all on one page and figured out in less time than it took you to read this.  We did the demo using two screens.  That way, if I am describing what I am seeing to the patient on their X-RAY, instead of holding the film up at the ceiling and hoping my patient understand what I am talking about, I point to it with my mouse and let the patient see it one their screen.

Tomorrow I was going to issue an EHR RFP for a small clinic.  Not any more.  No point in having them pay me to hunt down a solution when I’ve already found one.  Did I mention you can also get it with a world-class practice management system?

So what makes me think this EMR can handle a practice size of up to a few hundred doctors?  Let me try to summarize its benefits with the following.  If we separate healthcare into two arenas–the business of healthcare (the business side) and the healthcare business (the clinical side)–this EMR is so well designed, it makes the mundane business tasks almost invisible to the doctor.  Instead of spending twenty percent of each day moving charts, filling out forms, sending faxes, dictating and transcribing notes, the clinical team can either spend more time with their patients or see more patients.

Now, let me tell you about their secret sauce, part of what makes it so special.  You are going to think I’ve lost my mind when you read this.

One of the first questions most doctors are going to ask a vendor is whether or not the system is certified.  (Do not repeat this to anyone–that is why I am writing in parentheses–this system is not certified.  They have no plans to get it certified.)  Why?  Because certification is as relevant to the value of an EMR as agriculture is to bull fighting.  Certification will not improve care, will not enhance the doctor patient relationship, it will not improve the patient experience, it will not increase productivity.  Certification does one thing.  It enables you to get a check provided that your EMR implementation does not fail, provided that you pass the Meaningful Use audit, and provided you are willing to upgrade your existing system to your vendor’s new and improved certifiable version.  That certifiably makes little to no business sense.

Anyway, if you want a system that makes the stuff you hate doing go away, take a look at this.

I’ve also written about way hospital EHRs fail.  A big reason for their failure is the drop in productivity they experience, and a lack of acceptance from the doctors.  Sort of makes me wonder if they could use this tool as a front-end for those big pricey EHRs.

Me, I printing T-shirts.  PayPal accepted.

Why Google, Apple & Microsoft will win the EMR battle

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In the next few years, brick and mortar, immobile physician-centric EMRs and EHRs—those large EHR systems implemented by healthcare providers residing on large systems will be supplanted by portable patient-centric EMRs residing on a next generation of super smart devices—we call them smart phones today.  The limited functionality of today’s Personal Health Records (PHRs) will be replaced by these portable patient-centric EMRs; EMRs that are cloud-based and accessed through super functional next generation smart devices—the grandchildren of the iPhone and the Droid.  Why do I think that is the case?  Please keep reading.

Five billion people voluntarily purchased cell phones.  Initially, consumers had to be convinced they needed cell phones.  The uptake was slow.  Something changed, compelling us to buy cell phones.  We initially bought cell phones not because we needed phones, but because we wanted convenience—we bought convenience.  What made it convenient?  Portability.

Not much changed for several years—not until Palm created a phone-sized portable device that could do other cool things.  Then Blackberry took it one step further—a device that could handle basic email and phone calls.

Very recently, piggybacking on the success of the iPod, Apple redefined the market for smart devices.  They did not set out to build a phone, or a web browser, or a MP3 player, or an email client, or a SMS device—or a device designed to do all of those specific tasks.  Instead they built a device capable of doing just one thing—securely and wirelessly sending and receiving ones and zeros.  Those ones and zeros became emails, faxes, internet interaction, downloading and playing music, videos, images, calls, text messages, and data.  Apple also paved the way for other firms to have customers download thousands of other ones and zeroes applications.  The iPhone device simply sends, receives, reads and writes ones and zeroes.

Phone calls on the smart device (the iPhone) are but a small subset of the device’s total usage.  This breakthrough is what I think of as the “Transport Phase,” moving ones and zeros from point A to point B, reassembling them, and recreating the same thing on the other end.

In the last two years, we have seen the maturing of the Transport Phase whereby the device is even smarter, faster, has more storage and actually performs tasks.  It appears to infer and learn.  It is capable of gaming and GPS functions.  It performs more tasks than the computer on the Saturn rocket.  Last year Google made its debut with the Droid.  It is open and operating in a cloud.  The smart device’s features and usage are so ubiquitous that the pricing model commoditized.

Today’s devices can operate more than one hundred thousand apps—including hundreds of medical applications.  The vast majority of the healthcare applications are for doctors and clinicians.  Very few healthcare applications are available to customers (patients) and there is no PHR for any of the devices.

This will change, and change in a big way.  The smart device many call a phone can do things nobody envisioned ten years ago.  Those “experts” were wrong.  We have a new set of experts today.  They claim:

  • PHRs offer little value
  • PHRs have been slowly accepted by the mainstream
  • There are no good healthcare apps on smart devices for patients
  • There are no PHR apps on smart devices
  • There is no such thing as an EMR on a smart device

My take?  They are correct on all five claims—today.  What else of note is underway?  The launch of the iPad.  Bad name choice.  I would have called it the iGoogle, but neither firm would go for that.  Why the iGoogle?  Stick with me on this.  Google is in the process of transcribing every written word and digitizing the great works of art—ones and zeroes.

What did Apple do?  Apple did one thing—their new smart device made Google’s library potable.  Portable.  Ones and zeroes, colored text and images can now reside on a one and a half pound tablet one a device with a thickness of one half inch.  Complaints—it’s not a computer, it cannot take pictures, it cannot make calls.  Not yet.

Yesterday calls (ones and zeroes) were made portable, as were text messages, emails, videos, and GPS.  Tomorrow, today will be yesterday.  Look forward a thousand tomorrows.

What exactly are the electronic medical records flying around in ERHs costing hundreds of millions of dollars?  Ones and zeroes.  Nothing more.  Oh, did I mention these institutionalized EMRs are immobile.  The plan calls for them to be portable—a billion here and a billion there.  Maybe it comes down to what kind of portability you think Americans will adopt.

I think two things are in store for healthcare.  In the near-term, stationary hospital-centric EMRs and EHRs will begin to be replaced with portable patient-centric EMRs residing on super smart devices owned by individuals.  Point two; the limited functionality of today’s immobile Personal Health Records (PHRs) will be replaced by portable patient-centric EMRs, EMRs that are cloud-based and accessed through super functional next generation smart devices.  These devices will be the offspring of the iPhone, the Droid, and the iPad.  EMR functionality will be available, along with the existing functionality on these super smart devices.  Customers will not need to buy a separate device to make their EMRs portable.  They will simply gain access to that functionality when they purchase the next generation phone-camera-notebook-tablet-MP3-EMR.

Just because PHRs can’t do much today doesn’t mean PHRs won’t evolve to become tomorrow’s EMRs and EHRs.  PHRs will be replaced by EMRs in the same way mere voice applications have been supplemented by multitudes of additional powerful applications.

What business drivers will make this happen?  Apple, Google, and Microsoft are huge corporations, corporations with which almost everyone currently does business.  They are not healthcare companies.  They do not operate like the government.  They know how to build and market very high-tech, glitzy devices packed with the functionality their customers demand.  Customers line up outside of stores for days to be the first to have one.  Hospitals and physicians are not doing that to install EHRs.

Why do PHRs exist?  They exist as a way for these companies to establish a foothold in healthcare, to have their customers begin to associate their healthcare records with the likes of Apple and Google.  They know there is very little money to be made with PHRs.  The revenues will come to them as the functionality evolves the PHR into the EMR.

Measured in today’s dollars, the average US resident will spend about $650,000 on healthcare during their life, or about $8,000 a year.  Eight thousand a year doesn’t seem like much until you extrapolate it.  Eight thousand a year times three hundred and fifty million people comes out to an annual healthcare expenditure of about three trillion dollars.

Let’s compare that $8,000 a year figure to what we spend in other areas.  The average annual phone bill is around $700.  The average cable bill is $1,000; electric—$1,200.

What if these companies developed a way to build a secure, HIPAA compliant, portable EMR application that could be accessed using the next generation of the super smart device we get in line to purchase?  In addition to everything else it can do, the device will have secure access to clouds to access, update, and transport electronic medical records—combining the future functionality of the tablet and open architecture of smart devices like the Droid.

What if firms like Apple and Google made these next-gen super smart devices available for free?  This approach is almost identical to the current model of highly discounting smart phones to lock customers into service agreements.  Why would Apple and Google give away the super smart device?   The reason to give it away only makes sense if the real business opportunity is so large that the money they would have earned from the device is a drop in the bucket compared to the downstream revenues.

What if firms like Apple, Google, and Microsoft devise a way to earn a transaction fee of one percent for each dollar of healthcare services that either comes in through their device or goes out over it?  That is how phone usage is billed.  Companies bill for ones and zeroes sent and received.  They do not care what information those ones and zeroes contain.

The model of providing devices to consumers for free is no different than giving away toothbrushes to sell toothpaste.  The bulk of the revenues come not from the device; but from what consumers do with the device.  A one percent transaction fee applied to the three trillion dollar healthcare market is a thirty billion dollar business.  That’s a pretty good chunk of change for coming up with another service facilitated by moving around ones and zeroes.

Let’s suppose for a minute that as consumers adopt this model that these same corporations, using cloud computing, succeed in building an interoperable healthcare network, the same network the federal government plans to spend billions to develop.  The companies do not need to build it, it exists today—the internet—and it exists wirelessly.  The government just announced the development of a supercharged internet.

This makes Health Information Exchanges (HIEs) and the National Health Information Network (N-HIN) obsolete before they are even built.  As a result of having built the network, and having equipped customers with these EMR capable devices—next generation super smart devices—these firms then own the entire EMR food chain.  Might these firms then be able to garner some kind of usage rights to clean medical data, data that has been scrubbed so as to make it anonymous, data which they can sell to payors, providers, the government, and pharma?  It’s all about the healthcare data, or at least it will be.

The business opportunity is data usage, transporting ones and zeroes.  Data usage is what Apple and Google sell—the portable devices are simply a means to an end.  According to gigaom.com, Apple’s revenues just from its App Store exceeded $2.4 billion in 2009—pretty good money for a start up, a start up that uses a super smart device.

Microsoft doesn’t sell computers.  It sells ideas.  Microsoft is an enabler.  It sells the ability to allow people to do more and more things.  The idea about which I write is no different from Microsoft’s, Apple’s and Google’s current business models.  The smart devices, sell data, data transport, and data usage—ones and zeros.

The difficulty healthcare providers have with today’s approach to EMRs and EHRs is they are focused on now, on today.  They are costly, immobile, hurting productivity, and are driven from the top down—the government.

What if this idea comes to pass, or even something close to it?  What does that mean for physicians?  More than anything else it means physicians will face patients who will take more responsibility for their health, patients whose medical records are stored on the same smart device as their Rolling Stones records.  Physicians will be able to beam the patient’s EMR to their own EMR capable super smart device.  The demand for EMRs will shift from building immobile EHRs that may meet today’s business requirements—to a patient driven demand for portable EMR devices that will meet tomorrow’s requirements, devices which in addition to containing EMRs will meet there other smart device requirements.  It is those other requirements which will drive consumption, the EMR functionality will be a bonus.

I think in five years terms like Meaningful Use, Certification, HIEs, and incentives will be outdated.  The C-suite should be looking at what lies ahead, not at what will be outdated by the time a monolith EHR-NHIN has been implemented.

What do you think?

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

paulroemer@healthcareitstrategy.com

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