Posts Tagged ‘electronic health record systems’

The Electronic Medical Record System Innovator’s Paradox

Wednesday, December 22nd, 2010

by Adam Rothschild, M.D., M.A.

At Doctrelo we are building an electronic medical record system (EMR) for primary care that we believe is so much better than any other product out there that we don’t even like to call it an EMR system. Instead, we call it the Doctrelo Clinical Command System. Rather, I should say that we WANT to build the Doctrelo Clinical Command System, but some industry veterans tell us that we likely won’t be able to raise the capital that we think that we need to do so.

Why do they think that investors likely won’t fund us to develop our product?  Their main reason is that there already exist many ambulatory EMR products in a “competitive and crowded” market, several from large vendors with mature products and significant resources. I acknowledge that this is true… but only sort of. Yes, several large vendors do indeed have well-supported products that implement a set of features whose utilization thereof has been deemed “meaningfully useful”. I acknowledge that these products exist, but who is USING these products, or, more poignantly, who is NOT using these products? Not using these products are 90% of our nation’s primary care physicians (PCPs) in practices of 5 or fewer physicians. This comprises 120k or so physicians, which is more than 40% of our nation’s PCPs.

So we’ve now established that large companies sell “mature”, meaningful use certified ambulatory EMR products, yet the majority of our nation’s primary care physicians still prefer to use pen and paper. Why? Researchers have studied this topic repeatedly in recent years with cost consistently arising as the number one barrier. Concluding simply that cost is the main barrier, however, misses the point. The main reason why the majority of our nation’s PCPs still prefer to use paper and pen is that existing ambulatory EMR systems suck… or to put it more scientifically, they lack sufficient value. While early-adopting PCPs in small practices perceive sufficient value in existing EMR systems such that they have been willing to purchase them, the other 90% do not.

Value is defined as utility divided by price. If the goal is for all PCPs to adopt EMR systems, then there are two possible ways to overcome this barrier of lack of value: 1) increase the utility of the EMR systems (i.e., build better EMR systems) or 2) decrease their price. When the politico-economic stars aligned such that the government was looking for new ways to spend lots of money quickly (i.e., stimulate the economy), Congress passed the HITECH Act. The (large-EMR-vendor-written) HITECH Act  functionally decreased the price of EMR systems by paying physicians for purchasing an EMR system and jumping through the (admittedly reasonable and well-intended) hoop of meaningful use. In short, the government is subsidizing the purchase of EMR systems that the market, itself, has empirically shown to be of low value. So much for promoting innovation.

The large EMR vendors who wrote the HITECH Act are ecstatic that the government is subsidizing the purchase of their admittedly non-innovative products, but it is reasonably clear that universal “meaningful use” of existing EMR systems will have minimal impact on increasing healthcare quality and decreasing healthcare costs. That’s fine for stimulating the economy but not so fine for solving our nation’s healthcare woes. Along comes Doctrelo (and maybe other startup companies, too) with plans for a product that has unprecedented potential in increasing healthcare quality and decreasing healthcare costs and does so in such a way that physicians actually want to use the software that we want to build, a product whose value is high because its utility is high, not because its price is artificially low due to government subsidies (or ethically questionable practices). This leaves us with the EMR system innovator’s paradox: We can build a better EMR system that will (likely) improve healthcare quality and decrease healthcare costs, but we (maybe) can’t get the money that we need to build it. A corollary paradox: Existing EMR systems (likely) won’t decrease healthcare costs or increase healthcare quality, yet the government is spending a LOT of money to get physicians to purchase them. Again, this is fine for economic stimulus (and big EMR system vendor profits) but not so great for American healthcare.

What are we at Doctrelo going to do? First, we are going to continue with the planned release of our first product, a unique, stand-alone e-prescribing “plus” system called Doctrelo eRx+ in early 2011. Second, we are going to build the Doctrelo Clinical Command System. Thanks, naysayers, for your concern, but I’ve been dreaming about this for too long (I first started working on this during my informatics fellowship in 2003), and my team and I believe in this too much;  giving up is just not an option. If we can raise capital, great. If we can’t raise capital, then we will still build the product. We’re not going to let a few million dollars get in the way of significantly changing American healthcare for the better.

Full disclosure: My research adviser during my informatics training at Columbia was George Hripcsak, who is the co-chair of the Meaningful Use Workgroup of the HIT Policy Committee of the Office of the National Coordinator of Health Information Technology (i.e., the group that came up with the meaningful use criteria). It was with George that I first started thinking about applying the problem-driven workflow to primary care.

The 6 P’s: Who are the Users (and Re-users) of Patient-specific Clinical Information?

Friday, November 19th, 2010

by Adam Rothschild, M.D., M.A.


Electronic health record (EHR) systems are big news (and big money) these days. Our government is pushing adoption and “meaningful use” of EHR systems because computerizing patient-specific clinical information can benefit our nation’s health care system. The primary focus has been on the benefit to the care of individual patients, but computerizing patient-specific clinical information can also benefit other parties in the health care systemi. I believe that there are 6 major parties that serve to benefit from the computerization of and access to patient-specific clinical information. I refer to these parties as the 6 P’s.

The six P’s are as follow:

  1. patient
  2. provider
  3. payer
  4. public (as in public health)
  5. posterity (alternatively PhD’s)
  6. product makers (alternatively pharma).


At this juncture in the national discussion of EHR systems, it should be self-evident why patients serve to benefit from the computerization of patient-specific clinical information. I will thus not further belabor the point.


Ditto for provider. By “provider” I refer to all individuals and organizations that deliver care to patients, including but not limited to physicians, nurse practitioners, nurses, physical therapists, hospitals, home health agencies, etc.


By “payer” I refer to third parties that pay for patients’ care. I use the term broadly and include both for-profit and not-for-profit health insurance carriers, government-run health insurance programs such as Medicare and Medicaid, and even the many self-insured corporations that utilize health insurance companies solely for their administrative functions but not for their assumption-of-risk functions.

Payers will ideally be able to automatically monitor the quality of care that their patients are receiving. While many payers currently analyze claims data for this purpose, actual patient-specific clinical data will likely provide a much more precise and useful dataset. Knowledge of the quality of the goods and services that payers are purchasing should help them to design programs to improve value for their covered patients.


By “public” I refer to the population overall, as in public health, whether on a local, regional, national, or even international level. The potential public health applications of having large quantities of computationally tractable patient-specific clinical information are enormous. Examples include real-time detection of emerging infections, simplified identification of locations of environmental hazards, and real-time access to community-wide antibiograms.


By “posterity” I refer to the use of patient-specific information for clinical research. I use the term “posterity” because good research adds permanently to the scientific knowledge base, and, well, I needed a word that starts with the letter P. Since PhD scientists do a lot of research, you can alternatively think of this one as PhDs.

Product Makers

Like it or not, medicine cannot be practiced without products that health care providers use, such as pharmaceuticals and medical devices. Manufacturers of these products, of course, rely heavily on patient-specific data for FDA approval of their products but also—and possibly more relevant with respect to EHR systems—are under increasing pressure to monitor the safety of their products in the post-marketing phase.


While patients and providers benefit mostly from providers’ direct use of patients’ individual clinical information, the other 4 P’s benefit mostly from analysis of many patients’ clinical information in aggregate (de-identified where appropriate). Because patients seek care from providers who will be using disparate EHR systems, this is yet another reason to implement national terminology and communication standards for clinical information sharing; the value contained within EHR systems will likely not be realized without it.

In closing, when you are thinking about who are the users and re-users of patient-specific clinical information, think the 6 P’s.

iIn addition to the benefits of sharing and re-using patient-specific clinical information, the 6 P’s also serve to benefit from yet-unimplemented sophisticated clinical decision support. Further discussion of this topic is beyond the scope of this blog post.