We received an email this week from a friend who posed some very good comments about the U.S. health information industry, and in particular, the U.S. EHR market. In the email, I was referred to key parts of an article that was published recently (discussed below).
“There was an interesting article in the International New York Times yesterday, which examined why the economic payoff from technology is so elusive, and it focused on electronic medical records. A Tennessee doctor found that switching to digital medical records lowered his productivity, as he has spent time trying to understand the new system fully, but it has made him a better doctor!”
“With $32 billion already spent in federal incentive payments to prompt doctors to use this technology however, many groups of doctors throughout the U.S. are not yet as familiar as they might be with the technology – any company that can offer a system that helps raise productivity in a short time should be able to lead the field.”
My response to these points:
It is a well-documented fact that switching from paper records to electronic healthcare records is difficult, if not traumatic, for doctors. Haven’t we all experienced the difficulty that comes with significant changes to our work processes through technology? Similarly, it is also well documented that with the addition of new technology, productivity suffers. However, history also teaches us that we will not reverse the changes that have occurred, and for anyone holding out hope they can be assured that we will never go back to paper records.
One example how technology does improve productivity: Today’s technology can now write a prescription faster than a doctor can write one. I have timed it, and they can do it in 30 seconds. The logical questions here are:
a) Can anyone read it?
b) Does the doctor document it properly in the patient’s record?
c) Is the prescription easy to find in the file?
d) Does anyone else know what was prescribed?
e) Does the prescription actually get delivered accurately to both the pharmacy and the insurance company in compliance?
In regards to the last question this implies that a patient can actually leave the doctor’s office and pick up the prescription without waiting. The overwhelming answer is frequently, no.
With an EHR platform, all the answers are an unqualified yes. The real issue is trying to convince a well intentioned and highly regulated 100-year-old industry that they can convert their patients’ paper records to an electronic solution in one single step. Until the 19th century, paper was not only hard to come by, it was expensive and the profession was just emerging. The Royal College of Surgeons in England is just over 500 years old, and the American Medical Association was incorporated in the U.S. in 1847; this truly marks a long time to be using paper.
To give you another example: Take yourself back to when you bought your first cellular phone. Okay, now that you have that picture in your mind, imagine if someone gave you an iPhone 6S during that time. What would you do with it? My first cellular phone was a Motorola, and it had much more in common to the old landline telephone than today’s iPhone. That is the progress of one product over an almost 35-year history.
Technologies are known to follow what is referred to as the S-Curve of Adoption, the Innovation Adoption Cycle and lastly, the Technology Life Cycle Path.
First, we’ll discuss the S-Curve of Adoption. We are at the beginning of the “S-Curve” of the EHR technology. That path in my opinion is 500% from the base line of the curve however, maybe 1/10 of the vertical part where the curve starts to turn horizontal. The reality is that EHR is effectively 50 years old – those first 45 years though were very shallow, and since we only saw a “forcing function” emerge in the mid-2000s (when EHRs were mandated for Medicare by 2012) and then when reinforced and funded in 2009, did that curve start to move.
That leads us to the next curve, the Innovation Adoption. Normally, EHRs would have taken longer based on the cost/benefit to providers to go mainstream (maybe only 5-6 years) when patients demanded it as they are now. From 1965 to 2000, only the “innovators” were using some kind of EHR. In 1996, when we “cobbled” together four different systems, we were an innovator. That has changed in the last five years as government mandates and penalties kicked in. This forced everyone to jump in and go directly to “a majority stage.” The markets were not, and are still not ready, and that is what is causing the stress.
Finally, this brings us to the Technology Life Cycle Path. I put that here (especially with the other two graphs) because we are also experiencing that in the EHR space – a fairly rapid cycling of technology. This is based on both changing government standards and requirements, and also the increasing knowledge and sophistication of the provider population. Additionally, the fact a technologist/coder can easily add a new screen, a new button or a new drop down menu frustrates doctors when something they use every day is changed or moved. There is a point when technology can become burdensome and hard to use when it gets too complicated.
I believe today that we are in the EHR industry where computers were in 1978 – the same year I graduated from high school and built my Heathkit computer. We have had more movement in the EHR space in the last five years than we had in computers for nearly two decades. Alan Greenspan, in his book The Map and The Territory noted that it seemed the peak of human increase in productivity over 100 years was about 3%; he deduced this was due to the fact (his opinion) that the average human brain likely could not handle more than that in change of environment. If I deduce a little, doctors have had to handle so much change in technology in such a short amount of time, they are stressing under the pressure. I know doctors who have terminated their EHR and have gone back to paper. We know entire countries that have also done that.
I would like to offer another perspective – this time the automobile. From History.com:
“Bicycle mechanics J. Frank and Charles E. Duryea of Springfield, Massachusetts, had designed the first successful American gasoline automobile in 1893, then won the first American automobile race in 1895, and went on to make the first sale of an American-made gasoline car the next year. Thirty American manufacturers produced 2,500 motor vehicles in 1899, and some 485 companies entered the business in the next decade. In 1908, Henry Ford introduced the Model T and William C. Durant founded General Motors.”
How about the first paved road?
“In 1909, the first mile of concrete highway in the world was built between Six and Seven Mile roads by Wayne County, Michigan. In 1916, the 27-mile length to Pontiac, Michigan was paved, and in 1919 the nation’s first three-color traffic light appeared on the thoroughfare. The auto industry grew up along Woodward Avenue, in Detroit, Michigan.”
So here is what the early adopters had to deal with. A “horseless carriage” had many issues, first they broke down constantly; second the entire infrastructure if you can call it that of the U.S. was not designed for cars, but for horses. You could find feed and stables for a horse nearly anywhere, but in 1901, where did you find a place to service a horseless carriage? Where did you get the fuel? “The world’s first purpose built gas station was constructed in St. Louis, Missouri in 1905 at 420 S. Theresa Avenue. The second gas station was constructed in 1907 by Standard Oil of California (now Chevron) in Seattle, Washington at what is now Pier 32.” Tires, motor oil and so many things we take for granted today.
A friend of mine shared with me a factoid from his hometown in Michigan, which still carries a law on its books that requires a runner be sent about 100 yards ahead of “all horseless carriages” entering the city limits! Just imagine enforcing that today with a city of 500,000 people! “We have come a long way baby!”
I am no historian, however I am confident that the range of a car was much less than a horse, and the mud road or even cobbled road that were designed for horses, must have been treacherous. Just think about that ride! Imagine if over a five, or even 10-year period, everyone was told they could not use their horses and had to have horseless carriages? It would have been chaos; the systems were not in place. The process not only took decades, but it migrated from cities to suburbs, and finally to rural parts. The automobile companies actually had to invest in gasoline stations to extend the range of the automobile. This is not that different from what Tesla is doing today. The good news here is that electricity is now everywhere and all we have to build is the station for the electric vehicles.
Overall, the moral of this blog is that we are still very, very early in the adoption of EHRs. If I was to compare it to the development of automobile production (effectively December 1, 1913) we are in the pre-assembly line stage. On the computer side of this example, we are definitely pre-IBM Personal Computer that was unveiled on August 12, 1981. By the way it was designed in Boca Raton, Florida, about 20 miles from our headquarters. I don’t remember the first date, but I do the second; I was at ComputerLand to buy my first PC, with more excitement than a teenager today waits in line for a new iPhone or Xbox.
So what is the solution?
We need full digitalization of health records – first for the benefit of the patient, and second for the benefit of society; the value will be incalculable. What we need are systems that are intuitive (did your iPhone come with an instruction book?) and stable, not changing every day, week, or month. We need technology that will give access to the patient, integrate it into their lives, and for overall population health. We need transparency, and we need integration of records. When a doctor can see what other doctors have done with the patient, it will all change. When we can integrate wearables and our personal lifestyle into our Wellness Record, it will all change.
I still remember my first personal assistant (PDA), a Casio 32 (as in 32K of memory). It took my assistant an entire week to input my address book on my cool new PDA; actually, it was called a digital organizer. I still have data on my iPhone that was input in 1983-84.
The estimated $200 billion (USD) spent in the last five years, is actually not enough. We should be spending $100 billion a year in the U.S., and the return on investment (ROI) would be monumental in the information, improved quality of care provided by the total and complete digitalization and engagement with consumers.
Doctor productivity will improve materially when the systems are again fully open, transparent, and the patient is totally engaged. That is starting to happen now, and 10 years in the future there will be zero doubt that this was a great move. Now the question is in this space, who are the Univac, the IBM systems, the Sperry Computer, the Commodore, the Sinclair, even the Casio 32, and who are the IBM PCs, and Dells that changed the industry? I am dreaming of the iPhone of our industry to emerge! That key player just may be a small start-up organization in a secluded city that sees the entire EHR space differently – concentrating on wellness, and placing the consumer at the center of the EHR universe!
Post Blog Note: In the International New York Times article mentioned at the beginning of this blog, it made a key note on productivity discussed in a new book by Robert J. Gordon, an economist at Northwestern University titled “The Rise and Fall of American Growth.” I am currently reading that book and will discuss in a future blog along with two other books I just finished reading. One of those books “The Rise of Robots” by Martin Ford, I have mentioned previously in this blog, and the other book by Joshua Copper Ramo titled “The Seventh Sense” are all talking about the same things, I believe, and confirm a disturbing “New Normal” in not only U.S., but global productivity and growth. I have bought many of the books by Ford and have given them to our team members and many of my friends. The good news for us and my favorite industry is that healthcare service and healthcare technology are in the best place to not only weather the concerns all those books discuss, but I strongly and without reservation believe will actually flourish in a new human (not patient, not even consumer) world.
– Noel J. Guillama, President