A Call for Plug-and-Play EHRs
Nothing like great timing. In my last blog post, I suggested that electronic health record (EHR) and personal health record (PHR) technology needs to become more like an iPhone in order to achieve widespread acceptance from technology-shy physicians and patients. Yesterday I came across a great (because it agrees with me, naturally!)
blog post from Dr. David Kibbe, senior advisor to the American Academy of Family Physicians, entitled "Time for EHRs to Become Plug-and-Play." In it, Dr. Kibbe uses data from the
Nutting Report to make the case for a modular, platform-centric approach to implementing EHRs, rather than relying on bloated, everything-including-the-kitchen-sink solutions (emphases mine):
"In some industries, when the products are relatively new and not very good in terms of performance, the early entrants must provide all of the parts of the product by themselves. For example, if you wanted to be in the computer industry in 1982, you needed to manufacture a computer's operating system, the application software, the peripheral devices, the processors, etc....even the cases housing the various components came from a single producer and the product was integrated. IBM, Digital Equipment, Unisys, and Wang were all companies from whom customers had to buy the entire package, including consulting, from a single vendor.
"But over time, as the performance of the products improves, vertically integrated and proprietary companies whose approach was strongest during the early phases of the industry's development give way to a non-integrated and horizontally stratified population of companies whose products are capable of integrating, through standards, not by virtue of a single company owning all the components.
"This happens because the basis of competition changes. Customers become less and less willing to reward further improvements in functionality (e.g. adding a registry on to an existing EMR that initially doesn't have one) with premium prices. And companies that get better and better at conveniently giving customers exactly what they want (e.g. ePrescribing, or a registry) when they want it and at an affordable price, are able to earn attractive margins. And so they start to take business away from the vertically integrated firms.
"Modularity, in effect, enables the dis-integration of the industry. Which is exactly what happened in the computer industry. By 2002, virtually every part of a PC was modular and substitutable. Dell doesn't manufacture anything, it simply purchases all the components from companies in stratified groups - e.g. microprocessors, memory, hard disks, mother boards, OS, fans, etc. - and assembles them according to the wants and needs of the customer. By then, many of the leading, very top companies making computers in 1982...had gone out of business. DEC, Wang, Unisys.
"So....this same phenomenon helps to explain what is happening in the EHR technology industry. The vertically integrated, top-tier companies - GE Centricity, NextGen, Allscripts - would like to continue to sell their comprehensive EHRs to their best customers, who will pay their highest prices, and at the maximum profit margins. But they are really struggling to add value fast enough and at a price point that medical practices can afford. The proof of this is included throughout in the Nutting Report, and can be seen in countless practices and groups across the country, as they try to get these vertically integrated vendors to respond quickly to needed functionality, but find the workarounds and awkward installations maddeningly frustrating. They're quite literally screaming for the features they need, but getting a lot they don't need, at prices that seem like extortion.
"In brief, doctors have arrived at a next stage of value addition for EHR technology, one at which faster response, greater agility, convenience, and lower pricing have become as or more important than a very long list of features and functions that are no longer as useful or desirable as they once were (or were perceived to be)."
In short, Dr. Kibbe is advocating for the same "iPhone approach" that I described in my last blog post: a basic, user-friendly platform with the ability to accommodate specialized modules from a variety of vendors to meet the demands of a diversified marketplace.
Naturally, the established EHR vendors who are selling expensive, integrated systems have a vested interest in keeping things as they are, as evidenced by the recent letter from HIMSS to the Department of Health and Human Services lobbying for CCHIT to be designated as the certifying agency for EHRs eligible for government subsidy money. But the reality is that in many cases the status quo isn't serving the best interests of the customers -- you know, those pesky little folks who actually have to use and pay for the software. A modular implementation approach would benefit EHR and PHR consumers just as it has customers in other market sectors. I sincerely hope HHS will take steps to encourage this kind of innovation, and not bow to pressure from vendors who will profit by maintaining the status quo. Let consumers dictate to vendors, not the other way around.