Sunday, July 17, 2011

Electronic medical records and the muddle of government initiatives

In a recent position, I worked in the health technology sector. A repeated challenge that I tried to impress on the team was that digitizing medical records, medical practices, and healthcare is not as simple as technologizing existing practices. One of the physicians with whom I spoke insisted to me that the best technology for her work was a pen and paper. Actually, I think she might have said a crayon and paper.

The U.S. government recently initiated a program to motivate physicians to start using electronic medical records (EMRs). The government is offering cash back incentives, up to many thousands of dollars, for MDs who meet certain basic criteria in their digitization. As is the wont of the U.S. marketplace, many many business have proliferated to "facilitate" the transition. Unfortunately, while the government provided a list of criteria that have to be met to receive the incentives, they did not really do a very good job at creating a standard format for EMRs. This means that doctors' offices need to evaluate competitors to determine which application will best work for their practice. The transition is daunting and overwhelming for many doctors' offices, which already perceive their workload to be more than they can handle (for the money that they believe they should receive).

This Sunday's Business Section of The New York Times has a cogent article about this problem. [Yes, I know I reference this periodical disproportionately.] I hadn't articulated this point as well as I'd like to have done, but I think the medical records dilemma is a great example of the limitations of innovation. We hurdle ahead to make things fancier, shinier, and purportedly more streamlined. But in the process critical details get lost.

During my last project, I repeatedly reiterated that we needed to really understand workflows and the processes in place. Digitizing practices is great for something that is repetitive and cumbersome, at least early on, as the technology becomes integrated into actors' needs. It also needs to capture tasks with a predictable workflow. This sounds like such a simplistic perspective on technology, missing all the amazing and fantastical things technological innovation might offer. But in industries in which data remain non-digital, you can't simply waltz in and show off the fancy things that might be possible. It's simply far too daunting and impractical.

Thus far, I have yet to see a platform or computerized set of practices that really address the needs of healthcare practices. These still remain too piecemeal and focused on the future to really meet the demands of the people who will use the tools. While one might be tempted to say that the healthcare industry is a particularly complex arena (and it is in some ways) because of the competing users' priorities (healthcare payers, for example, have a very different end goal than the users of the system [patients]), this is an overly simplistic explanation for why the tech industry hasn't gotten it quite right in the healthcare field. I would suggest that many of the people in the tech industry simply haven't done due diligence in understanding the problems.


  1. I agree with you in principle on this one. I'm occasionally surprised, however, at phenomena/innovations that cut through all of the process-documentation that you're describing.

    Things like the Palm, the iPhone, the iPad, etc. jumped over the hurdle that you're describing by being SO smooth/pretty/easy that their users were/are willing to work around a number of limitations that the same users would probably call 'critical' otherwise. I've seen it happen on literally dozens of web projects that involved translating existing business workflows into webpages. If the thing *feels* smooth enough to use, things that seemed critical no longer do.

  2. True, Alex, and I like your optimism (and thanks for your feedback!). But I think what has happened is that there is the assumption that all doctors are ultimately doing the same thing. There's stuff that requires some individualization (which is why we go see a physician, rather than just look things up online) and there are a lot of actors involved in the care of one patient (nurses, medical assistants, billing offices, transcribers, doctors, referrals, insurance companies, pharma companies, diagnostic services, etc.), so trying to streamline a digital solution that spans all those steps is pretty challenging. I don't think it's impossible, but there needs to be some kernel of standardization.

    One of my favorite stories (because I'm kind of an old person, deep down, or not so deep) is the Baltimore fire story -- where the lack of standardization for fire hydrants actually prevented the fire from being contained. Lots of neighboring towns came to help put out the fire, but their hoses didn't fit the hydrants in Baltimore. There are some things that really do benefit immensely from a standard formatting. And while the government's main reason, I think, for incentivizing EMRs comes from the ability to collect a ton of epidemiological/population data, there's an accountability, too, to generate a baseline from which everyone can work. And the iPhone/android PC/Mac divide is really a huge time waster. I'm not arguing for Communist-era limited choice, but there are places, I think where the branding of tools actually hampers innovation quite significantly. I'm mostly arguing that there are times when the branding/distinctive attributes that don't play well with others can really harm true innovation (not just "novelty").