Sunday, April 29, 2012

Big Bad Legacy EHR Products

IBM "cloud" computing - circa 1975
There is no self-respecting innovator in Health Information Technology (HIT) who has not spoken or written about the horrific state of Legacy EHR products, which are slowly but surely being deployed in more and more health care facilities as a result of Meaningful Use incentives and changing reimbursement models. A couple of months ago I saw an EMR in a small practice. They’ve been using it for 15 years and it was a DOS based system with the ubiquitous neon green text glaring on a black and sometimes blue background. Aha! That must be a Legacy EMR, and sure enough the doctor was looking to replace it with a more modern product, but which one should he get now? After all, the last thing you’d want is to have him buy yet another Legacy EMR.

According to, a Legacy system is a “computer system or application program which continues to be used because of the cost of replacing or redesigning it and often despite its poor competitiveness and compatibility with modern equivalents. The implication is that the system is large, monolithic and difficult to modify”.  Well that little DOS EMR was anything but large and monolithic, but nobody was going to invest a penny in redesigning it, and competitiveness wasn’t a term that came to mind when you looked at it, and replacing it is sure going to be an expensive proposition. The DOS EMR is definitely out then. The only question remaining is what it should be replaced with. Which EMRs in the marketplace should be avoided since they are truly Legacy EMRs sold under false premises to unsuspecting buyers? Well, it depends on who you ask.

You could separate the various EHR constituencies based on programming technology (e.g. MUMPS vs. .NET), based on promotional labels (e.g. Cloud hype vs. everything else), based on software architecture (e.g. integrated vs. modular), and a host of other technical criteria, most of which are overlapping to various degrees. A much clearer and natural separation occurs if you divide Health Information Technology (HIT) companies into two groups: those who have lots of customers and those who don’t. According to the latter, the former are all peddling Legacy systems. It seems that a veritable tsunami of innovation is building up outside the infamous walled gardens of existing, Legacy EHR vendors, threatening to bring those walls down any minute now.

As with any worthwhile technology innovators, the newcomers to the EHR marketplace have brilliant Silicon Valley pedigrees and beautiful Web 2.0 style websites, along with iPhone/iPad/Android native (i.e. client/server proprietary) apps to complement, or even supersede, the web offering. Actually using an “old fashioned” computer or laptop is starting to feel a bit Legacy in and of itself. The innovative products themselves can be divided into two categories as well: full-fledged EHRs and a variety of self-contained pieces, or modules, of what is currently considered a complete EHR. [Note: I am not including products like athenahealth here, since they are not new, do have a respectable customer base, and had no disruptive effects on the rest of the market.]

The innovative new EHRs are all Cloud-based, intuitive and easy to use, built from scratch by user-centered designers, and are offered at a fraction of current prices, or so the ads say. These are the Southwest Airlines of health care, coming in below market pricing, with bare-bones, friendly solutions for the non-customer segment and they have two insurmountable problems. First, almost none of them are actually below market price, which in the ambulatory sector stands now at about $500 per provider/per month for a fully loaded, gold-standard integrated EHR and practice management solution. This is an extremely difficult number to beat. Second, even a bare-bones solution should have all the bones. My guess is that Southwest Airlines would not exist today if their first flight service consisted of boarding passengers in Houston and then proceeding to cheerfully shove them out of the aircraft 150 miles outside of Dallas, expecting them to arrange for their own transportation into the city. And yet, this seems to be the preferred model of our innovative HIT products, and as ePocrates (a household name in health care), painfully discovered, there are no customers lining up for this type of experience no matter how innovative it is touted to be.

In the meantime the Legacy EHR market seems to be thriving, and no, the recent Allscripts misfortune (or mismanagement) is not an indication of an impending disaster any more than this year’s snowfall in Texas is a sign of global cooling. The reason for this seemingly inexplicable prosperity is threefold: a) the government is subsidizing EHR purchase b) there are no viable alternatives to existing products c) innovation is occurring within the established market leaders. Let’s look for example at one of the more popular ambulatory EHRs, which shall remain unnamed. A few short years ago, the product consisted of a basic integrated EMR/practice management system, with very few bells and whistles and lots of bugs. Today, the product comes with a solid Patient Portal with iPhone apps for patients, a full featured disease registry, an iPad version, natural language processing, disconnected mode operations, peer-to-peer communications, and of course a much improved EHR and all sorts of other features and modules. I don’t know about other folks, but somehow this does not seem like a Legacy product to me, and there are a few more just like this one. There may be Legacy products out there, but today’s top selling EHRs do not fit the description.

A very unfortunate side effect of the forced march to HIT innovation is the confusion created by the constant barrage of misleading statements from the various Southwest Airlines wannabes. I sometimes wonder if these new folks have ever seen an EHR, let alone use one or participate in building one. A quality EHR is much more than a handful of rudimentary web pages allowing patients to communicate with providers, no matter how loud and trendy the consumer movement is. A modular architecture is much more than a collection of disparate bits of software interfaced together with duct tape, no matter how standardized the duct tape is. There is a reason why the new iEHR for the VA and DoD was allocated $4 Billion for development over five to six years. There is a reason why it took Kaiser about the same amount of time and money to take Epic from its original state to the powerhouse product it is today. There is no room for Southwest Airlines type of innovation in an industry where the routes, the meals, the fuel and the seating arrangements are regulated by the Federal Government. Innovation is coming and will continue to come from within the established systems, NASA style.

So if you are still looking to replace that little DOS EMR, or an aging and no longer supported practice management system, find a good size EHR vendor, with a hefty customer base, who develops its software in-house, instead of randomly buying shiny things, and hitch your wagon to theirs. It will not be a perfect ride because there are no perfect rides, but it will get you where you need to be. There are no miracles, there will be no miracles, and every day you waste looking for one, will make it harder to catch up, because whether we like it or not, whether it is a smart thing or not, health care is moving up the IT escalator at a very brisk pace. It’s too late for partial, gradual or “lite” solutions. The time for dabbling with a little electronic prescribing and a little email, has long since passed. You’re either all in, or all out, and your patients desperately need you to be all in.

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