Disruptive innovation in healthcare

In order for technology to offer the kinds of tools that are needed to transform healthcare, it is helpful to take a step back and look at the bigger picture. Regardless of the current debate on health care reform and finances, and how the country can address the issue of the uninsured and underinsured, the healthcare delivery system is undergoing fundamental changes anyway. It is being transformed from a complicated, expensive set of products and services into a simpler more affordable one. The emergence of social networking, affinity groups of people with similar conditions or orientations, the ubiquity of information available to anyone (for free), the mainstreaming of non-traditional healthcare providers – these changes are gradually changing the role of physicians from being expert sources of information and managers of a complex system to being places that can bring interpretation, guidance and meaning to it all.

There is a parallel to the transformation of the computer industry form the 1960s to the modern era – initially, computers were very expensive and complex, requiring highly trained individuals to run them. The landscape was populated by dominant mainframe manufacturers – IBM, CDC, DEC – whose business it was to make bigger, more complex and more expensive mainframes. The advent of the personal computer was a disruptive innovation, and resulted in the downfall of these giants (except for IBM, who was able to embrace the change). And it was not because the initial PCs were better at doing what mainframes were doing, but because they addressed a different, less expert segment of consumer need, and then got progressively better and more robust with time. We are seeing similar changes occurring now in healthcare.

When looking at the role that electronic tools can serve in helping enable this fundamental change, it is important to define exactly what jobs these technologies are supposed to do. This is crucial, now that national public attention and significant moneys are being directed to encourage the adoption of such tools.

To date, the main people discussing the “job” that EHR technology is supposed to do have been vendor associations and health policy insiders. Their perspective has been from a social, macro level. The national priorities identified by the ONC’s Health IT Policy Committee are to (1) improve quality, safety, efficiency and reduce health disparities; (2) engage patients and families; (3) improve care coordination; (4) improve population and public health; and (5) ensure adequate privacy and security protection for personal health information. These goals may seem one-step-removed from the day-to-day needs of physicians, but they represent very good guidance, and should be embraced as we consider what we want our EHR technology to do.

In order to carry these out, then, an Electronic Health Record (EHR) system needs to be able to create data that is standardized, such that data from different sources can be exchanged transparently, and used to create reports and decision-support at the point of care.

In a setting where large, legacy vendors (the “health IT mainframes”) have created a landscape of separate, locally-installed, proprietary and closed systems, the only way to achieve these national health goals is to enforce a set of standards for data exchange – this means that specific pieces of clinical data need to be identified as being “important” (like medications, allergies, immunizations, demographics, and lab values), a standard format for import/export of these pieces of data needs to be required of all vendors (the CCD and CCR standards), and some data-interchange platforms need to be created where this standardized data can be uploaded to and downloaded from (regional Health Information Exchanges, or HIEs, and the National Health Information Network, or NHIN). This is especially important if one believes that “the future will be a bigger version of the past,” and that the landscape will continue to be local, segregated and proprietary.

So what does a disruptive technology look like around the “job” of creating and exchanging standardized data? A web-based, or SaaS-based (“Software as a Service”) EHR, by definition, has a standardized data architecture for everyone everywhere, and can easily enable data-exchange between practitioners using the same system. Practice Fusion is an example of such a technology. Further, connection with regional or national HIEs becomes a single-point-of-integration, rather than being the daunting task of connecting each and every physician user to a regional data hub. The result? Complicated, expensive products become replaced by simpler, affordable ones.

But the “job” of creating and exchanging standardized data is not necessarily the “job” needed by physicians practicing in the field – it is important on a national-policy level, and is a good idea from a theoretical perspective, but it is not the first thing that physicians think of in their day-to-day work. This is one of the reasons for low EHR adoption – the tools developed by legacy vendors are built to address the larger question, but miss the local one. If all that is focused upon are these high-level requirements, things likely won’t change much, there will continue to be relative apathy among EHR users (physicians), and adoption will remain begrudging (maybe moved a little by the promise of money, maybe not).

The “job” that physicians need from their EHR is (1) to display all the needed information about the patient-at-hand in order to make medical decisions (which touches on the data-interoperability question discussed above), and (2) help expedite documentation of medical encounters, to result in a high-quality medico-legal record that is effortless to create. There are other workflow “jobs” that physicians in an ambulatory setting also need from their EHR – management of lab results (and the ability to act on them if needed), review of documents as they are received, managing prescriptions and refills, and communicating messages to staff and colleagues. But for the task of seeing patients in the office, an easy way to create documentation is critical (and do so in a way that supports and is linked with billing for such services, if it is in a fee-for-service environment). The ability for an EHR to help with this “job” is the biggest determinant of adoption, even if the price question is removed from the equation.

Medical encounters have some general features that fit into groupings (like diabetes visits, or prenatal visits, or back pain visits), and some elements that are always unique. The challenge for EHR design is to balance these two factors: create flexible templates that facilitate the capture of common items, yet allow for the creation of unique text just as easily. This is critical – in an era where most medical data is still kept on paper, the competition for an EHR is not other EHRs, it is recordkeeping on paper. If it takes longer to create a chart note in an EHR than it does on paper, then there is reluctance to change. The usability of an EHR –how readily does it allow a practitioner to move through the work day and help speed it along – is the lynchpin for adoption. The Practice Fusion approach of flexible, user-modifiable “smart templates” is one example of work-in-progress toward this goal.

Disruptive innovation in healthcare is occurring on multiple levels. Regardless of the efforts of the healthcare establishment itself, consumer-driven internet-fed changes are happening every day. Patients look increasingly to each other for support and information, facilitated by the internet and social media, and look to physicians more for interpretation, meaning, and guidance through the healthcare ecosystem. The locus of care has been shifting from complex, expensive settings (hospitals) to more accessible and less costly ones (ambulatory and home settings). National policy about what is important for health IT is becoming clearer, and is organized around priorities and goals that will help the healthcare system do its job in a more meaningful and effective way – and, although a good start, it is market forces driven by the usability and effectiveness of an EHR in day-to-day practice that will influence adoption (more than HHS policy). Traditional health IT implementations that were complex, expensive and segregated have been challenged by web-based, standardized alternatives which are easier and less costly. Further, developing web-based EHR tools that focus on the “jobs” at hand allow for the emergence of technology that physicians will want to use because it makes their jobs better. As the saying goes, “the future is not what it used to be.”


Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.