Time for EHRs to Become Plug-and-Play

by David C. Kibbe MD, MBA

The remarkable report, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” published in the May/June issue of Annals of Family Medicine, the Nutting Report, makes this point about the state of primary care IT offerings:

Technology needed in a PCMH is not “plug and play.” The hodge-podge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system.

Surprise!  Well, actually, no surprise.  We all recognize that health IT implementation in family practices, even under the best conditions and with the best of planning, is difficult and can be an ongoing challenge.   

What is surprising to us, however, is that Dr. Nutting and co-authors make this comment in their recommendations section:

…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR.

This is real wisdom, borne of collective AAFP experience, here placed under the microscope, and is the key message that I (David Kibbe) have been delivering to audiences of physicians and administrators for the past year or so, in my talks entitled “Confessions of a Physician EMR Champion: A Conversation with Physicians About Health IT in the Age of Google Health and Microsoft HealthVault.”

But things change, and the above findings of the PCMH evaluation team that it is “possible and sometimes preferable” to implement components or modular applications instead of a comprehensive EHR from a single vendor is a brilliant recognition of how our changing business models in primary care intersect with a major shift in the health IT market of products and services aimed at primary care practices.  

Conservation of Modularity

First of all, the shift from a firm-centric or vertical company-centric approach to technology, to one that is platform-centric and modular, is well known and has been described in length in the business and computing literature.  Clay Christensen, the noted Harvard Business School professor and author of several books on innovation, describes this evolution in the computer industry at length, even coining a “law of the conservation of modularity” to help in the description. 

What he tells us is the following:  in some industries, when the products are relatively new and not very good in terms of performance, the early entrants must provide all of the parts of the product by themselves.  For example, if you wanted to be in the computer industry in 1982, you needed to manufacture a computer’s operating system, the application software, the peripheral devices, the processors, etc….even the cases housing the various components came from a single producer and the product was integrated.   IBM, Digital Equipment, Unisys, and Wang were all companies from whom customers had to buy the entire package, including consulting, from a single vendor. 

But over time, as the performance of the products improves, vertically integrated and proprietary companies whose approach was strongest during the early phases of the industry’s development give way to a non-integrated and horizontally stratified population of companies whose products are capable of integrating, through standards, not by virtue of a single company owning all the components.  Clay Christensen says this “looks like the industry got pushed through a bologna slicer.” 

This happens because the basis of competition changes.  Customers become less and less willing to reward further improvements in functionality (e.g. adding a registry on to an existing EMR that initially doesn’t have one) with premium prices.   And companies that get better and better at conveniently giving customers exactly what they want (e.g. ePrescribing, or a registry) when they want it and at an affordable price, are able to earn attractive margins.  And so they start to take business away from the vertically integrated firms.

Industry Dis-Integration

Modularity, in effect, enables the dis-integration of the industry.  Which is exactly what happened in the computer industry.   By 2002, virtually every part of a PC was modular and substitutable.  Dell doesn’t manufacture anything, it simply purchases all the components from companies in stratified groups — e.g. microprocessors, memory, hard disks, mother boards, OS, fans, etc. — and assembles them according to the wants and needs of the customer.   By then, many of the leading, very top companies making computers in 1982….had gone out of business.  DEC, Wang, Unisys.

So….this same phenomenon helps to explain what is happening in the EHR technology industry.  The vertically integrated, top tier companies — GE Centricity, NextGen, Allscripts — would like to continue to sell their comprehensive EHRs to their best customers, who will pay their highest prices, and at the maximum profit margins.   But they are really struggling to add value fast enough and at a price point that medical practices can afford.  The proof of this is included throughout in the Nutting Report, and can be seen in countless practices and groups across the country, as they try to get these vertically integrated vendors to respond quickly to needed functionality, but find the workarounds and awkward installations maddeningly frustrating.  They’re quite literally screaming for the features they need, but getting a lot they don’t need, at prices that seem like extortion.

In brief, doctors have arrived at a next stage of value addition for EHR technology, one at which faster response, greater agility, convenience, and lower pricing have become as or more important than a very long list of features and functions that are no longer as useful or desirable as they once were (or were perceived to be). 

EHRs Ought to be Plug-and-Play

Let’s repeat the Nutting Report quote, seeing it now as a new value statement:  “…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR.”   This is an explicit recognition of a shift in demand, a sharpening of the focus of what capabilities are most important for primary care IT offerings to support, and at the same time a call for us all to recognize that circumstances have changed.  The other important part of the new value statement is that these components ought to be “plug-and-play.”   Makes perfect sense. Modularize and integrate through standard interfaces.

And yet as of right now, most of these components aren’t “plug-and-play.”   That is, the market is in a state of transition away from one model, towards another, but not yet stable.

In fact, it’s worse than not stable.  The established top tier vendors like Allscripts and GE Centricity are digging in, entrenching, and fighting back hard against the shift to plug-and-play modularity that is recognized as valuable in the Nutting Report.  They’re doing this primarily through a campaign organized by HIMSS that is pouring money into lobbying efforts to lock in federal policy that will discriminate against new entrants into the EHR technology market.  They want ONC to mandate that HITECH incentive payments can go only to CCHIT certified EHRs, that is, comprehensive applications from single vendors. 

Robert O’Harrow Jr. writes in today’s Washington Post:

A Washington Post review last week showed that the group, known as HIMSS, worked closely with vendors, health-care researchers and others to create nonprofit advocacy groups and generate research data to convince policymakers that such a system could save tens of billions of dollars, and that the government needed to subsidize Medicare and Medicaid providers to buy the equipment.

It’s time for a more deliberate approach, one that recognizes the experience included in the Nutting Report, and which tries to accelerate the rate at which modular and component EHR technology becomes interoperable and substitutable, e.g. “plug-and-play.”

Your comments and questions are very welcome.

16 thoughts on “Time for EHRs to Become Plug-and-Play

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  2. Plug-and-play is already available as an open-source platform, Vista EHR Core. Again, it is a platform with million users globally. We keep reinvent the wheel when the Veteran Affairs have spent billions to implement in >170 Medical Centers……..

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  4. Interoperability is the key to plug and play. If each component is designed to use interoperability standards they you can literally plug it in and it will work.

    Ideally, your e-prescribing application would be able to find your master patient index, your drug lists, your medication history, etc. Likewise for point of care decision applications. This can be done with interoperability standards but not with current models of the EHR which are ‘integrated’ systems. There is a big difference between integrated systems and interoperable systems.

    Unfortunately, CCHIT certification is focused on integrated monolithic systems, not interoperable components. CCHIT needs to adopt an interoperable component approach to certification or it will only impede adoption of HIT.

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  9. Well, I read the Nutting report (twice) and I find it a bit confusing in general. I’m not sure I understand the bottom line. For example, “Everyone should have a PCMH, and it should be developed primarily to improve health care; payment reform should remain an important secondary goal”, immediately followed by “Having practices front the cost of transformation with the hope of more appropriate reimbursement in the future is unlikely to succeed.”

    As to technology, first the existing “hodge-podge” array of applications and lack of integration is bemoaned, followed by a suggestion to adopt bits and pieces of technology.

    Implementing plug-and-play pieces of functionality is never as simple as the very enticing term of plug-and-play, which really belongs to the hardware world. Having disparate registries and lab modules for example, begs the question of where does the data reside. Do we have multiple data stores across the disparate systems, each storing fragments of data? Do we have one master vendor with a master data store that the other (smaller) suppliers of plug-and-play extensions access? These extensions will be vendor specific.
    As opposed to the iPhone or the iGoogle page, which are hosting completely disparate applications, EHRs are transactional applications that must combine information from all parts and pieces in order to offer a useful tool to the practice.
    The term “platform” when it comes to software has very different meaning then when applied to iPhone firmware. In software it means something like salesforce.com or IBM Websphere portal. These are proprietary applications (not platforms) that allow users to write their own extensions and trade or sell them to other users of the same application. I’m pretty sure that this is not what you had in mind here.

    Regarding dis-integration, the hardware industry cannot really be compared to the software industry in this way. Hardware is basically a manufacturing sector, where specialization brings production cost reductions. Even then, note that consumers are not buying motherboards and sound cards and putting together their computers. It takes a Dell to do that and the consumer still buys a complete product.

    Software, on the other hand, is more like a service. No one buys software because they want to own a shiny disc and a big box. They want their accounting done or their word processing done, etc. Indeed the software industry is moving towards the service model, instead of the off the shelf box model. All the “cloud” and web 2.0 talk and all the SaaS companies mushrooming out there indicate just that. Software is moving from being a product to being a service.

    So how about the service industry? Is it subject to the same dis-integration trend as manufacturing?
    A few years ago, when you took the afternoon off to “run some errands”, you went by the bank, got some stamps at the post office, picked up some milk at the grocery store and maybe splurged on a new camera lens. You had to drive and stop at 4 different places to get all these services. Today it’s one stop.
    Service companies benefit from consolidation, particularly if the services are very similar and can be performed by the same resources. This will drive prices down and provide convenience to the customer. Just imagine that you would need to hire one person to do your windows, another to wash floors, a third for bathrooms….

    Software is the same. The resources required to write registry code are exactly the same that can write ePrescribe code. There is no need for a differentiated assembly/production line. Thus, a company that offers integrated services, can do so at much lower prices than a specialized vendor and with much less discomfort to the customer and with higher quality, since it has more resources to move around and much more opportunity and ability to innovate.

    Now, should these integrated applications be able to communicate with each other, or be interoperable? Absolutely! I think that is where our focus should be and it is much easier to have the “cleaning service” as a whole coordinate schedules with the “home security” service, instead of having the window washer call, and the floor washer call with a different time, and the bathroom person forget to call at all…….

  10. There is always a vigorous debate on the strengths and weaknesses of the monolithic integrated approach versus the ‘best of breed’ interoperable approach.
    Since Margalit seems to be connected with the vendor of an integrated approach, she is defending it by pointing out the ‘one stop shopping’ benefits.
    However, health care software is a very diverse and complex field and it is just not possible for any vendor to have high quality offerings in all possible areas. When you consider that medical practices potentially need software that does billing, patient records, disease registry, electronic prescribing, best practice alerts, point of care decisions, laboratory and radiology ordering and reporting, and other functions I think that one can see that the skills involved in developing these functions are unlikely to be strong in all areas.
    In addition, as the Nutting report points out, implementation and change is difficult and it is better to take a path of gradual modular implementation rather than try to digest a large application all at once.
    Interoperability is difficult because most of our software is not designed for it. The standards exist in HL7, ICD, SNOMED, LOINC, etc but they are not well supported by the integrated software that is currently available.
    If you look at the case of the internet standards HTTP, FTP, SMTP, IP, etc. you can see that interoperability works well when you have software that supports the standards. The Internet, web browsing, email, etc all works well using software from thousands of vendors running of a wide variety of platforms.
    Unfortunately, medical software has been developed on a closed proprietary, monolithic model with poor support for standards. If physicians understand and demand interoperability, it will appear and vendors who support interoperable systems will prosper.
    Unfortunately, the CCHIT seems to be perpetuating the monolithic integrated model of software. Hopefully it can be persuaded to open up to focus on interoperability.

  11. Mark, health care software is indeed very complex, but not as complex as ERP or the software that NASA uses. All those bits and pieces mentioned here are on their own, just tiny software modules by comparison, and one vendor can provide quality products that do more than just one thing. Look at SAP or Oracle or Microsoft or Intuit….
    The best of breed notion should not be applied to code fragments.
    You get MS Office, or Open Office, not spreadsheets from vendor A and slides creator from vendor B, etc. It is inefficient for both customer and vendor.

    The notion of interoperability as envisioned by all of us, is not interoperability inside one office. It is interoperability with other providers. That is where the value is. I really don’t quite understand where the idea of breaking EHRs into various sub-modules is coming from or what its purpose is. It’s not like there are hundreds of little apps like that floating around looking to break into the big, bad “monolithic” market.

    BTW, I think it’s probably a good idea for a clinic to start using their EHR in phases. Starting with ePrescribe is always easier, particularly for large clinics.

    Now to the standards, you are mixing and matching protocols, terminology and data specifications. There are three interoperability standards that are extremely well supported by everybody in the industry: HL7, X12, NCPDP, and CCR is gaining some traction as well.
    CPT and ICD9 are supported by every single vendor.
    As to internet protocols, HTTP, SFTP and others, you can’t really be in the software business without supporting those.
    The other terminologies that you mention like SNOMED and LOINC are not really ready for prime time, but are being adopted nevertheless. I can tell you from recent personal experience that LOINC is not even close to being what it’s touted to be.

    And, Mark, whatever my presumed motives are, I think CCHIT is a major distraction and even a barrier to what’s in the best interest of the customer and health care in general.

  12. Good discussion and comments, all. I don’t have any disagreements with what has been said, and I think that the market will ultimately be the proof of what works and what doesn’t for those who pay the bills. For some, a monolithic app from a vertically integrated firm is a source of comfort. But I think the smaller medical practices are having to be more nimble and more efficient in their operations than ever, and that this model doesn’t sever them as well. It’s up to the innovative companies to fill the need, and I see this is starting to happen. As to CCHIT, well, we’ll see what David Blumenthal and Secretary Sebelius decide to do. DCK

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  16. I see David already said what I also think about this matter, that the final decision is to be made by the market.

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