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Readers Write: Ignorance of the Major EMR Software Vendors is Not Bliss

March 23, 2015 Readers Write 10 Comments

Ignorance of the Major EMR Software Vendors is Not Bliss
By Tyler Smith

11-6-2013 12-24-41 PM

We in healthcare IT have found ourselves in a pretty sexy industry. You know that is true when Silicon Valley is practically banging down the doors to get in and KPCB’s John Doerr states that he would really like to see an open source competitor to Epic created. Damn, so Valley money admits it is losing to a slowly built behemoth in Madison – not a brand spankin’ new startup it missed an angel round on.

Needless to say, HIStalk’s Startup columns are a quite timely addition to the blog. I particularly enjoyed reading Marty Feisenthal’s explanation of the elite JPM conference. Having heard about the conference from banker friends (not HIT colleagues), his column removed much of the mystique. Being a fellow Atlanta resident and having visited the Atlanta Tech Village before, I also have greatly appreciated Michael Burke’s articles on the experiences of an HIT founder in Atlanta.

I recently co-founded a startup that aimed to bring efficiency to the Epic staffing arena by using very simple tools already in place in other industries. I do not want to call it the Uber of Epic staffing – for fear of sounding like a hack – but the basic idea was a connection platform with ratings for Epic certified consultants. While we have put the project on hold due to some shakeups on our technical team and also due to slow buy-in from provider organizations (our target clients), the pause in the action has given me time to reflect on the current state of HIT startups – particularly those looking to nibble on the enterprise EMR vendors’ scope of services.

Along with Mr. H and most readers here, when anybody from the outside comes and brings a new idea to the HIT table, I am usually skeptical. For starters, most entrants do not understand the complexity of the hospital / provider organization buyer or the provider organizations’ importance in the system. In theory, I love the idea of patient advocacy and patient-centric apps, but if providers or the systems that house them aren’t buying it, you better have something that patients see as life or death (read: an HIV curing drug, not a sleep tracking app) if you want them to fight the entrenched stakeholders for you or with you to make your startup relevant or widely used to truly create positive clinical outcomes.

Secondly and most importantly, many of these outsiders do not understand the current state of the EMR vendor landscape, and if they do, they arrogantly think they can steal market share while the enterprise systems watch from the sidelines. True, Epic and Cerner’s UX can appear very basic from an end user stand point and it often appears that the enterprise systems do not appear to be covering even close to all the functions that could be automated in a hospital or healthcare delivery organization. However, it would be naïve to think that these vendors have no big plans to tackle all of these remaining un-automated functions in the near future. When they do, unlike many of the new startups, these vendors will be able to simply make an additional sale to their already heavy client lists instead of having to undergo the arduous process of breaking down the doors to just get on the approved software vendor list at a major healthcare system.

The truth is that healthcare IT is a B2B market, not a consumer market. Organizations do not make purchasing decisions overnight, and thus while an app may actually do something better than an organization’s EMR, it better be a lot better for a healthcare provider organization to consider even meeting with the startup’s sales team.

This is not to say that I think that clinical apps which could be potentially developed and which will lead to improved clinical outcomes should not be attempted. What I am really saying is that before delving into development, HIT startup founders should take a much more serious look into EMR current state.

Even more importantly, startups should also consider what logical next steps vendors will be taking in their product offerings and research timelines as the massive implementation phase winds down and optimization becomes a priority for the vendors’ in house development teams. If there really is a competitive advantage which the startup has over these behemoths in the development of an EMR related application, then by all means go for it. But if not, it is probably best developing something far outside of the current or near future EMR vendor scope.

Easy for me to say as I sit on the sidelines and consult on EMR projects, I know. And you can object and say I’m siding with the status quo. Regardless, it pays to do your homework on the massive vendors. They aren’t going to crumble and they certainly aren’t going to let their clients get on products that encroach on their turf without a very solid battle.

In closing, I would ask any hopeful HIT entrepreneur: what is your startup doing that an established EMR vendor could not accomplish without a system update or by adding a new application which would seamlessly integrate with their current lineup?

Tyler Smith is a consultant with TJPS Consulting and co-founder of Hitop.co.

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Currently there are "10 comments" on this Article:

  1. That barriers to entry to the inpatient EHR game are high was all part of the strategy by the oligarchs.


  2. So is the advice to startups to basically save yourself the heartache and stay out of the space of big HIT vendors since they will ultimately eat your lunch? It sounds like you are saying “You startups may be nimble but the big dogs will crush you eventually”. As I see it, a startup can quickly disrupt the status quo, establish a niche where the big EMR vendor has yet to capitalize upon and set the bar.

  3. @startup:
    If there really is a competitive advantage which the startup has over these behemoths in the development of an EMR related application, then by all means go for it.

  4. I’m curious, when did John Doerr express that he wants to take on Epic? I haven’t come across anything like that online.

  5. >As I see it, a startup can quickly disrupt the status quo, establish a niche where the big EMR vendor has yet to capitalize upon and set the bar.

    That’s the kind of vague sentiment filled with buzzwords I’ve come to expect from people guzzling the startup Kool Aid. The kind of statement that reeks of someone with little or no experience in medicine or HIT. It’s like they spend half their time pontificating pseudo-intellectual buzzwords, the other half of their time figuring out how to trick investors into believing their startup provides value.

  6. Tyler, you make some good points.
    Two thoughts (from someone who actually built a HIT company before we heard the magic moniker EMR.)

    1- You are correct in saying it is a B2B market. But what the Valley is trying to do is what the drug companies did last decade by advertizing drugs to the consumer. Get consumers to ‘ask’ the doc what about this drug. It’s called pull through marketing, and I guess it must be working since there are adds all day, all over the media for meds. I guess Apple figures that if every one has an Apple watch telling them their heart rate is askew health providers and institutions will have to buy Apple system products also? The second part of the Rx success was getting the laws changed so drug companies could advertize. If you haven’t noticed, Apple, Google, MS, etc have been trying to do just that via the MU rules changes and heavey lobbyng.

    2 – Attacking intrenched big companies head on, in a limited market, is suicide. See the “Art of War”.
    You need to be in a very unique niche and leverage the heck out of it.

  7. @HealthcarePundIT – LOL you couldn’t be more wrong! I personally have 30 years of health IT experience and would be happy to swap resumes and credentials if you would like! “Pontificating pseudo-intellectual buzzwords” and “tricking investors into believing their startup provides values”. I must admit that I did dash off a quick reply to this article when I used terms like “disrupt the status quo”, “establish a niche” and “set the bar”. It was my attempt to be brief but get to the point of the value I see that startups bring to the industry. Please allow me to a expand a bit on what i was trying to say:
    – Disrupt the status quo – Legacy vendors have been in this space for decades and in some cases have a near monopoly. Also, due to contractual obligations with their legacy vendors, HCOs are often unable to try out a new solution from a new vendor. They would be in violation of their contract if they attempted to integrate or swap out functionality with some other vendor. A startup vendor might have a new, innovative way to accomplish a task but because the HCO is locked-in to their vendor it makes it very difficult for that new idea to see the light of day
    – Establish a niche – Startup vendors typically don’t try to boil the ocean. They often see a compelling business or market challenge and try to solve that one issue with new thinking. If they can make inroads with their idea and push the envelope a bit on the conventional thinking then it is possible that they can carve out a new space and as a result they can “set the bar”.
    Facebook wasn’t the first to come up with the idea of social networking – but as a startup they figured out how to do something different that the consumer wanted and that’s why we have Facebook pages and not MySpace pages
    Uber wasn’t the first to come up with the idea of ride sharing or taxi service – but as a startup they figured out a new way to link the driver with the customer and that’s why many use the Uber app when needing to get across town and don’t call Yellow Cab.

  8. @Startup – I think you raise fair points, I just think you under-value the importance of integration. Success in HIT goes beyond creating excellent solutions for niche problems. As a consumer, the impact of niche products has changed my life. Uber for transport, Venmo for money exchange, all of these things make my life significantly easier. But when I’m with a patient, I don’t want to go to one app for radiology results, one app for the rest of the clinical documentation, and another app to post charges for everything. While there will be some opportunities, in challenging the legacy vendors who DO have largely integrated products: 1) good luck convincing healthcare organizations that there is value worth the overhead of maintaining another system; and 2) good luck convincing the rest of the vendors that you’re worth integrating with.

  9. Isn’t that why so many are focused on practices? Whether large PHOs/IPAs or the zebra-like solo practitioner?

    While all this is going on, simultaneous to HIT, is a real rebellion by physicians against the never-ending payor demands whether commercial or CMS:to me, the most significant is the primary care docs eliminating the middleman and making financial arrangements/establishing costs directly with the patients, and we’re also seeing the development of “boutique” practices (smell the disdain) where for an exorbitant fee you’re guaranteed 24/7 access – and probably the ability to jump the line over the rest of us plebes.

    What I despair of ever seeing is input from nursing prior to – and this is important – the first scratch of a designer’s pen. We realize that MDs rule the ambulatory setting, but what software out there doesn’t take into account is that it’s the nursing workflow that’s important.it will only become more important now, with the advent of ACOs. Everyday I see ACOs posting jobs for a “scribe”, sometimes with a more important title like “documentation improvement coordinator”, but it’s really just a handmaiden type thing.

    These people will follow a doc around taking notes etc for him/her, and one purpose of this is to eliminate EMR contact by the doc, as much as humanly possible. And nurses are going to be in charge of them as well. In some ways, this is “back to the future” in two ways: everyone hates to have to document thoroughly. Most of all MDs. Some view it as a serious affront to the PRACTICE of medicine. Some just want to examine a patient, be handed all pertinent data, make a pronouncement and scribble a signature.

    Can’t blame them. And I also understand that many nurses can be Luddite-like. I’ve trained them.

    I’ve seen too many UX to know that it cannot have sought out nursing input. Including a huge company employing over 100K. This was the end result: a claims system WITH A NOTEPAD SLAPPED ON for documentation. Seriously. A UI that represented nothing that nurses need,want,and understand. Instead,a claims system had to be mastered to WORK ON THE NOTEPAD. In this day and age. No ability to track anything…

    Even with ACOs,where outcomes matter, and quantity won’t,it’s the workflow of everyone else that matters. Docs want their lives made easier, and it’s largely the nurse’s workflow that matters in most daily tasks.

    The exceptions to this will be in clinical data management: predictive modeling, population health, reporting to all payors, HEDIS measures,complex case and disease management, cloud storage,etc.
    You may be able to train a $10~15/hour scribe to hang onto and record every word, but…there’s no replacing critical thinking skills,so that part of practice – the nurse’s – will only continue to expand. Inpatient or outpatient settings.

    How can I leverage my expertise to be involved with all these exciting changes in healthcare and HIT? I’ve never seen such change as what’s occurring now, my expertise and knowledge is in nursing,but my passion is in HIT. And using it to manage outcomes, and all its possibilities for all stakeholders. Our primary purpose is optimizing consumer health and everything is about making that happen quickly,efficiently and cost-effectively,and using outcome-based research to get there. That’s the role HIT can do better than anyone.

    Consult us! Please!

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