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Tuesday May 01, 2018

EHR Market Needs Competition, Innovation

"I get sick when I'm around; I can't stand to be around; I hate everything about you."
-- Ugly Kid Joe

I spend a fair amount of my days engaged in conversations with family physicians and policymakers on how to improve our nation's health care system. These conversations and the feedback they generate are the engine that drives the AAFP's advocacy. There are dozens of pertinent issues impacting family physicians and their patients, but there are two themes that emerge in every conversation. The first is the disdain family physicians, really all physicians, have for electronic health records. The second is how the EHR industry, to date, has failed in its core mission.

[physician typing on laptop]

Let's take a little walk down memory lane.

On Jan. 20, 2004, President Bush made the following statement as part of his State of the Union Address: "By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care."

On April 26, 2004, the Bush Administration formally launched the Promoting Innovation and Competitiveness campaign(georgewbush-whitehouse.archives.gov), which was aimed at accomplishing the goals outlined in his SOTU address. The campaign made several observations and had several goals, but I would like to highlight three:

  • A patient's vital medical information is scattered across medical records kept by many different caregivers in many different locations – and all of the patient's medical information is often unavailable at the time of care.
  • Innovations in electronic health records and the secure exchange of medical information will help transform health care in America -- improving health care quality, preventing medical errors, reducing health care costs, improving administrative efficiencies, reducing paperwork, and increasing access to affordable health care.
  • Within the next 10 years, electronic health records will ensure that complete health care information is available for most Americans at the time and place of care, no matter where it originates.

Within the next 10 years?

Guess what? Time's up, and none of this happened. It is reasonably safe to say that in the 14 years since President Bush issued his call to action, the promise of EHRs has failed epically to meet the expectations outlined in the SOTU speech -- avoid dangerous medical mistakes, reduce costs and improve care. Some would argue that we have digressed in each of these areas.

I struggle to find an articulate and elegant way to describe what is so frustrating about electronic health records, but I think I have found a way to do so succinctly -- they suck. They suck as products, and they suck the life out of everyone that uses them.

Ponder this, since President Bush issued his 2004 challenge, the following innovations hit the market -- Facebook (2004), Reddit (2005), Twitter (2006), iPhone (2007), Airbnb (2008), Thumbtack (2008), Rent the Runway (2009), Uber (2009), Instagram (2010), Pinterest (2010), Snapchat (2011), Alexa (2014), Bumble (2014), and dozens of others targeted at specific industries or activities. Each of these platforms changed an industry or changed the way we communicate and share information with each other. They have made positive contributions to our economy and our lives.

It is a shame that the efficiencies realized from these platforms have not translated to health care via EHRs. Instead of streamlining the health care industry, EHRs have created a plethora of cottage industries and consultants; required physicians to incorporate "work-arounds;" and, most sadly, the EHR has contributed significantly to the onset of an actual epidemic -- physician burnout.

A few weeks ago, I was in San Francisco and had the opportunity to meet Andrew Hines(canvasmedical.com),  an engineer who has spent his professional career working in and around the technology industry, including work for a major EHR company. During our conversation he said something that really stuck with me, both for the boldness of the statement and the fact that, deep down, I think we all know it may be true. He said, "I used to think we could improve the electronic health record from within, but now I realize the only way to truly improve electronic health records is to start over."

Let that sink in.

Clayton Christensen, M.Phil., M.B.A.(www.claytonchristensen.com), a Harvard professor known for his work in disruptive innovation, describes this as sustaining versus disruptive innovation. Incumbents focus on incremental improvements in their products where as new entrants succeed with disruptive innovations. The problem with health care and EHRs specifically, is that incumbents have all the market power.

Steven Waldren, M.D., director of the AAFP Alliance for eHealth Innovation, summed it up as follows: "The reason EHRs suck is not due to a lack of innovation in technology but rather in a lack of innovation in health care. It seems that the health care industrial-complex, unlike other industries, is insulated from such innovative challenges from new players."

Waldren summarized his thoughts in a simple statement, "Without competition, we will not see the technology innovations in health care we have seen in other industries."

There are no easy solutions in health care, and improving EHRs is no different. However, we desperately need innovation and meaningful competition in the health information technology and EHR space. The following are three objectives the AAFP is pursuing to increase competition and spur innovation:

  • Make it easier for new companies to enter the health IT marketplace -- The AAFP continues to work on expanding interoperability to allow appropriate access to data stored in EHRs, in a timely manner. The AAFP is aggressively advocating for policies that force EHR vendors and other health IT products to be interoperable based on a defined set of standards. We also believe that all data in the EHR should be available for use by third-party vendors, of course with appropriate privacy.
  • Make it easier for innovators to design smarter health IT products -- One of the differences between health care and the general IT space is the complexity and fuzziness of the semantics of clinical data. The AAFP is committed to working with others to model clinical data in standard ways that allow developers to make health IT systems that can reason about clinical data and therefore help automate tasks physicians must perform.
  • Eliminate or reduce administrative requirements placed on health IT products -- The poor usability of EHRs is often due to external requirements established by regulators and payers, such as clinical documentation, which do not add clinical value. The AAFP is actively promoting policies that eliminate or, narrow, those requirements. We believe a reduction in administrative burden will help physicians, and also allow health IT developers to focus on features and functions that add clinical value.

Closing Thought

As you can tell, I am frustrated with the performance of current EHRs and the negative impact they are having on our health care system and each of you personally. The dominant companies in the market have produced products that have largely failed at the core goals established in the early 2000s. As I have noted, technology in every other industry tends to result in rapid improvements to function and efficiencies. Health care simply hasn't seen the same improvements, and the companies that make these products have seen windfalls in the billions, yet their products continue to underperform and fail to meet expectations of patients, physicians and policy makers.

I remain a strong supporter of the broad use of EHRs in our health care system. The EHR still stands to improve the aggregation and distribution of medical information, which would improve our health care system. Without a doubt, the ability to access and transmit medical information among care sites and physicians would improve care and result in efficiencies for patients and the system overall.

Posted at 08:00AM May 01, 2018 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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