Remember the Past or be Doomed to Repeat It

I had to Google that quote to figure out who said it first. Apparently the proper quote or original quote from George Santayana is, "Those who cannot remember the past are condemned to repeat it." "Doomed" is often used in place of "condemned," but I prefer the ring of condemned because it’s more like a punishment for forgetting.

Why should we be thinking about the past? Health IT is booming and more is coming to healthcare. In many respects, healthcare is at a crossroads, with large shifts taking hold. Many of these shifts will be powered by new technology, technology-enabled services, and data-enabled services. Layer on top of all of this new rules — I’m hesitant to say “standards” because of the track record of HL7 standards being implemented in a standard way for data exchange and interoperability — and we’re at a crossroads as an industry.

If we’re trying to recreate healthcare or recast it with new incentives (pay for quality, bundling, ACOs) and models of care (telemedicine, retail medicine) powered by new technology, we would do well to learn from what has been successful and what has not in the past. One of the biggest and most obvious challenges in healthcare has been access to data, especially clinical data.

To me, "access to data" means third-party access to data with the permissions, blessing, authorization of the owner of the data. Today there are lots of reasons given for why access to data has to be restricted – protected data fields, integrity of data, cooperation of vendors. Certain fields in information systems need to be protected, but that’s a problem that can be solved by restricting write access.

Typically today the challenges to third-party access to clinical data are overcome when two things happen: (a) a customer asks, escalates, or insists on access from their EHR vendor;  and (b) somebody, usually the EHR customer, pays for access or an interface. This two-step process is slow and fleeces customers who have already spent millions of dollars on your product and only want to be able to use third-party tools that access the customer’s own data. I would think the market, at the insistence of customers, would have corrected this a long time ago, but it has not to date.

I expected newer vendors into the health IT space — and I’m talking mostly about new, cloud-based EHR vendors — would have different practices. Some certainly do. Kareo is an example of a PM company I’ve heard great things about, especially in terms of customizing and access to data, both in and out of Kareo. I’ve heard similar good things about Drchrono on the EHR side. But I’ve been surprised in talking to friends and family who are evaluating newer, cloud-based EHRs for their practices. Time and time again, if a connection to data for a third-party is needed, the costs for each connection are exorbitant  — $5-10k for each connection.

It feels like we’re making the same mistakes. Sadly, due to lack of choice, the market is allowing it to happen. Maybe it’s something we can get away from, and maybe it’s just part of the cost of doing business, but it makes pricing a lot more confusing and unpredictable.

The best example I had was of a mobile, cloud-based EHR company. The EHR product was specialty-specific and only the EHR, no billing or scheduling. Presumably if you’re running a medical practice and looking at a Meaningful Use-certified EHR, you’re going to need some type of scheduling (scheduling into PM to EHR) and billing (billing from EHR to PM) software, so you have to have a PM system. This EHR company had pre-built, "seamless connections" to several PM systems for billing and scheduling. These integrations between EHR and PM did not require anything from the PM company.

Despite that, the cost to the customer to turn on the "seamless connection" is $5,000. I understand that the EHR company spent time and money creating the seamless connection, but that’s the cost of doing business. The EHR customer is still paying them close to $1,000 per provider per month for a SaaS product.

Looking outside of healthcare might be helpful for comparables. Newer SaaS companies with an enterprise angle are Box, Dropbox, Asana, and Github.

Box does most of its business on the enterprise side, including in healthcare. It is subscription-based and the cost is per user. If you want to get real value from Box, you have to download the desktop version (Mac and Windows), which interfaces with the underlying local desktop file systems. Box had to create these apps so people could use its product. The apps were the part of the cost of doing business. If Box was acting like a healthcare company, it would charge $15 per user per month and then $100 for each desktop app, not to mention the mobile apps. Would anybody use Box if that was the case?

What do you think? Are we learning from our past mistakes or are we doomed to repeat history?


Travis Good is an MD/MBA and co-founder of Catalyze. More about me.

  • David Brooks

    I agree. This has always been standard operating procedures in healthcare IT. That’s not to say it’s acceptable, because it’s not. But prior to HITECH, we sort of just dealt with it. The evil of the business. The nature of small-minded business people who think the path to success is through control, exclusion, and proprietary silos.

    Today, it’s not only absurd, but arguably criminal. How much money have EHR vendors gained directly from public funding? How many vendors exist exclusively because of the government’s decision to pour billions of tax payer dollars to subsidize the industry by promoting the adoption of inadequate technology?

    What did we (taxpayers) ask in return? I don’t know… that maybe to meet certification these systems support open protocols to enable data exchange. Yet, somehow, some genius decided it was sufficient that an EHR demonstrate the mere ability to support open standards in a one-off version in some laboratory. Don’t worry about making it required in a standard deployment.

    The end result is the government not only propped up companies that should have gone away years ago, they gave them the ability to continue to milk this position ad infinitum. And it’s not just about repeatedly charging interface fees. The government also gave them – in the world of healthcare IT – the prized real estate at the corner of Main and Broadway.

    In the real world, it wouldn’t be so bad. Undeserving recipients would quickly be crushed by better, more competitive options. Healthcare, on the other hand, is a completely different story. Take a system that comes with inherently high-switching costs, throw on top of that a growing mound of government regulations, and voila, you didn’t just give them the prized real estate, you ensured a minimum hundred year lease.

    Any startup or entrepreneur looking to make a difference in healthcare either knows, or should know, that before you change the world you will need to stop by the major EHR vendors, hat in hand, and ask for their blessing. The implications of this are EPIC where innovation is concerned.

    If we limit our frustration to the issue of interface fees, there are really only two possible explanations for EHR vendors charging, and I genuinely do not know which is true. The first is that they refuse to support the intent of HITECH (and thus, the origins of their own existence), and absolutely will do everything possible to prevent data sharing as it might lead to merit-based competition. Or, the second possibility, which poses a very strong argument, is that the systems are truly so god-awful, customized, non-scalable, non-repeatable, non-compatible, garbage, that it really does require full-time interface engineers to customize “standard” interfaces that were required in the first place. I think it’s probably a bit of both.

    I would like to give props to Athenahealth and Drchrono (and I’m sure there are others) because I think they really do believe in innovation and open competition. When the other wolves come dressed as sheep claiming to be supporters of “openness” (and yes, they are coming), tip your hat not to their generosity or altruism, but to yourselves because you have FORCED them. In the meantime, complain, kicking and screaming every time they blackmail you for another interface fee.

    …that’s what I think about it.

  • Mobile Man

    Wow. Love it. Even those of us that make our living in the world of interfaces would like to see this change. It’s not just money either, but time, effort and resources. All mostly “wasted”…

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