Random Thoughts from a Restless Mind

Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first  time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.

It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?

Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.

How come?

In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.

Why is this so?

The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.

And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.

It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.

A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system, and all before the 3rd party payer.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.