Changing the World

Why startups rarely change the world" says that Google, by building a better search algorithm to organize the world’s information, did not bring foundational change to the world. The foundational change, according to the author, was brought about by the government that funded — without concern for revenue, profits, and a potential exit — the development of a network of interconnected networks that we lovingly today call the Internet.

I don’t necessarily agree. I think technology like Google has also changed the world. So have Facebook and Twitter, to name the obvious.

I do see the author’s point. Google, Facebook, and Twitter would not exist if public funds and years of research had not gone into building the Internet and enabling founders like Brin, Page, Zuckerberg, and Dorsey. The Internet is the foundation of many of the world-changing startups that are built upon it. We wouldn’t see private enterprises gearing up to take consumers to space if the government hadn’t spent the time and money to sort out some of the peskier details of space travel. The government — because it doesn’t have equity investors, revenue targets, or exit strategies — can play the long game, and the long game is required to change the world.

In healthcare, we’ve seen breakthroughs that have changed the world, like Fleming’s discovery of penicillin and Jenner’s discovery of a vaccine for smallpox. Both of these discoveries are the foundations for many therapeutics that have changed public health and healthcare delivery, saving millions of lives in the process. It’s hard to imagine living without antibiotics and vaccines. Really smart, well-funded efforts continue to make breakthroughs in bio-pharma. I’m not talking about incremental improvements to existing drugs that might give some marginal improvement in outcomes with a substantial increase in cost. Today, a medication list is as big a part of a person’s medical record as a problem list.

Then I look at technology in healthcare. People like me talk about technology as a tool in the providers toolkit, we write about prescribing apps to patients. Has healthcare technology changed the world? No, not yet. Taking a narrow view here in the US, it is certainly changed the practice of medicine. EMRs are a big part of the daily workflow of most providers today. I’ve talked to three 60-something doctors in the last month who told me they are retiring in the next 12 months and EMRs are among their top two reasons. EMRs are impacting providers,not always in a good way, but they aren’t changing the world.

Another area of health technology involves services and apps that are meant for patient use and engagement. EMRs are separate and distinct from this side of health technology, though EMR vendors don’t always agree. The tie-in is EMR-owned PHRs such as MyChart. PHRs also won’t change the world. Both EMRs and PHRs provide valuable data about an individual, and harnessing the power of that data through analytics will be part of the technology that may eventually change the world.

EMRs are the major repositories of healthcare data today. But we’re seeing other sources of data that may be more relevant to changing health. The first is genetic data. Our understanding of the human genome will bring fundamental changes to the world. Just as the government funded space travel and the development of the Internet, so to has public money funded much of our understanding of genetics. As more companies like 23andMe and pharma leverage genetic data and knowledge, we will see the next wave of world changing therapeutics and a shift to truly personalized care.

The second relevant source of data is self-tracking data, the massive amounts of data we are now able to collect both passively and actively from individuals. Some people call it quantified self data (QSD). On the sensor side, I’m sure the government has helped gather much of the early knowledge we now have that companies are leveraging. But what’s interesting — and this is true about companies like 23andMe as well — is that for-profit startup companies are building technology and tools for the motivated healthy. It makes me wonder if some of these startups can play the long game in health like the government by targeting initial groups of motivated (and willing to self-pay) users. I’m skeptical, because startups — at least funded, successful ones — will likely be acquired at some point by an existing big fish. Startups don’t usually play the long game.

I’ve broken down health data into three buckets — EMRs, genetics, and QSD. The integration of these sources of data is exceptionally powerful. It’s always assumed that the EMR will be the integrator or the hub. I’ve lost count of the number of times I’ve been asked about the potential of integrating QSD into an EMR. Partners is already doing some of it.

But I’m curious why an an EMR has to be the hub for health data? EMRs were built to collect point-of-care data, and the successful ones have tightly integrated billing. They were made for those provider-patient transactions. EMRs now integrate labs and other sources of data into the medical record, but it’s provider focused. Care is being shifted beyond the four walls, patients are being given more access to data, patients are becoming more involved in decisions, and the definition of what data is meaningful for a patient is changing. Why are we trying to bolt on new data sources and workflows onto EMRs that were never designed to support them?

What if EMR information, collected as it is today, was integrated into patient-centered platforms using emerging standards like CCDA? These new platforms would then be the drivers of decisions, analytics and big data efforts, and ultimately care. The EMR remains the medical-legal and billing layer, but only provide a usable subset of data to other systems that are more nimble and purpose-built for shifting models of care.

Is it required for the EMR to be the hub for data, or can it just be the point-of-care spoke?


Travis Good is an MD/MBA involved with health IT startups. More about me.

  • Mobile Man

    Very interesting question!

  • PHRs also won’t change the world.

    Couldn’t agree more. Seems like some incumbents have convinced themselves that the way things were is the way things are is they way they will be. This isn’t always a bad thing because you can still innovate on the side and try to pull discoveries into your main product lines or generate new ones.

    In the medical industry, though, this has resulted in not only lack of attempted innovation but conscious rejection of innovation by others. Every day the major EMR providers choose to not make their data universally interoperable, to not push the envelope, is a day real people continue to live with real issues that could really be helped.

    If the top doesn’t innovate, the bottom will.

    (I wrote some more thoughts on this here too, mostly about PHRs, Microsoft, and Apple: )

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