Edmund Billings, MD
Chief Medical Officer
Medsphere Systems Corporation
Well into the computer age, healthcare lags badly behind other industries in the adoption of comprehensive information technology that facilitates greater efficiencies and improves vital functions. Despite more than sufficient evidence that clinical systems help improve care, save lives, reduce costs and increase revenue, right now only 15 percent of health organizations use advanced clinical systems and electronic health records (EHRs). Be it a hospital, an ambulatory clinic or a physician office practice, fully 85 percent of providers have not automated their care processes. The obvious question is why not.
The answer lies not in technology itself but in the proprietary software business model and how it fails to serve the mainstream healthcare marketplace. The acceptance of the Open Source business model across other industries and the proliferation of Open Source companies—e.g., Linux, Red Hat, MySQL, JBoss—offers healthcare a roadmap to use in transforming health IT and improving the level of care provided.
Of course, the roadmap has existed for many years but healthcare technology remains a Rube Goldberg operation held together by the tireless efforts of clinicians and other personnel, as well as a little chewing gum and bailing wire. Enter 2009, an economic crisis, and a new presidential administration. The confluence of all three forces has brought healthcare to a new place where the way forward is neither mapped nor illuminated. The industry has no choice but to venture forth, trying new approaches to enduring challenges and leaving behind what has clearly failed to satisfy.
Of course, efforts to address what can safely be called America’s healthcare crisis must be thoughtful and deliberate with extensive review. Healthcare in general and health IT in particular require a scalpel, not a hammer. Thankfully, Congress should be able to effectively wield a scalpel at this juncture given the specific knowledge of health IT available.
The Three Major Barriers to Technology Adoption
The transformation of healthcare using health information technology (HIT) is hindered by three primary barriers:
• Affordability: Proprietary systems remain prohibitively expensive and the vendors who peddle them ignore interoperability issues because they have no financial incentive to relax the chokehold they maintain on individual hospitals.
• Interoperability: While many systems support some interoperability through Health Level 7 (HL7), this interface standard often requires a great deal of time and money, as well as thousands of dollars, per interface. And there remains the challenge of getting different vendors to cooperate in pursuit of interoperability when it is not in their business interest or proprietary business model.
This scenario creates islands of automation and data, and stifles information sharing and collaboration.
• Clinical Adoption: While the proprietary business model is based on getting the system up and running, getting clinicians trained and using the system is another matter; organizations are often on their own for this. With the cost of IT so high, many organizations cannot invest in adoption
and most systems are written to maximize functionality, not enhance workflow.
Healthcare and Disruptive Innovation
When industries wares are not available to the bulk of the market as a result of prohibitive cost, then that the market is ripe for disruptive innovation. Clayton Christensen describes this situation in The Innovators Dilemma:
A disruptive innovation is a technology that brings a much more affordable product or service that is much simpler to use in the market … and so, it allows a whole new population of consumers to afford to own and have the skill to use … whereas historically, the ability was limited to people who had a lot of money or a lot of skill.
Christensen cites an interesting and representative example of this phenomenon. When televisions were expensive and required costly service and replacement of tubes, only a fraction of the market could afford them. Then Sony invented the transistor, which shook-up the predominant business model and made it possible for low cost retailers like Kmart to sell televisions. Both decreased cost and increased access expanded the television market to the mainstream middle class.
Proprietary vs. Open Source
The legacy business model, the proprietary approach, is defined as follows:
– Merriam Webster’s Collegiate Dictionary
In practice, this definition is unsatisfying and requires explanation. The proprietary business model promotes a capital software sale requiring an upfront licensing payment and a roughly 18 percent annual maintenance fee for support. Services and associated fees to implement, configure, install, and train the system are required, and added complexity naturally leads to higher fees. Every enhancement or upgrade
requires the customer to write another check. The ultimate goal, making the customer dependent on the vendor’s proprietary wares and ways, generally yields low customer satisfaction and what customers call vendor lock or vendor fatigue.
Proprietary technology in the healthcare market clearly creates three segments: the ‘have-a-lot’s,’ the ‘have’s’ and the ‘have not’s.’ Since the 1990’s, when work on the clinical applications that make up an EHR really grew, the industry has focused primarily on the have-a-lot’s, the early adopters with significant resources who make up roughly 15 percent of the market. As the industry progressed, every usage model and automated workflow became available as proprietary technology. These systems were developed by vendors working with the early adopters who had the necessary resources and wanted every bell and whistle. Not surprisingly, the industry responded to their best customers and the feature/function, beauty contest, bake-off culture of the software industry as a whole gained a foothold in healthcare.
Without question, feature functionality predominates in healthcare IT today. Because software development is expensive, the successful corporations create hugely expensive systems that only the most wealthy hospitals and integrated delivery networks can afford. The majority of providers are left with minimal or no electronic support.
The bake-off culture also rewards complexity and longer, harder implementations. It makes selling software the highest priority and incorporates no incentives for helping customers realize specific clinical and procedural goals unless an hourly development fee is associated. The bake-off vendors wanted then and still seek now to be the single source of IT for their customers. Indeed, lack of interoperability and
vendor lock are not unfortunate byproducts of an efficient system; they are crucial to the dependence business model, creating islands of automation and data that are difficult to use to improve processes. Proprietary healthcare IT may be good for generating revenues, but it has not been good for market share or expansion. This is a classic “Crossing the Chasm” problem (http://en.wikipedia.org/wiki/Crossing_the_Chasm).
In short, the proprietary model provides technology, but without a financial incentive it cannot provide what the customer really wants and needs: the transformation of care and business. Healthcare organizations must have some control over their systems to be able to transform operations and the provision of care.
The innovation healthcare requires must address the major barriers identified previously, support mainstream health organizations in transforming the care they provide, and promote value-based competition.
Open Source offers healthcare the control and disruptive innovation the industry needs by supporting the affordable development of system software.
Open source is an approach to design, development, and distribution offering practical accessibility to a product’s source (goods and knowledge) … The open source model of operation and decision making allows concurrent input of different agendas, approaches and priorities, and differs from the more closed, centralized models of development. The principles and practices are commonly applied to the peer production development of source code for software that is made available for public collaboration. The result of this peer-based collaboration is usually released as open-source software …
– Wikipedia
In the Open Source model code is either free or very affordable and usually includes no upfront capital investment in the software technology. The client pays an ongoing subscription to the partner (vendor) for support and all future upgrades. Clients have full access to source code and can enhance it themselves with an eye toward both individual gain and contributing to the Open Source project. The access and transparency empowers healthcare organizations to use the system in transformative ways and reinvest money saved on proprietary licenses. In the Open Source model, healthcare facilities can invest in development and redesign, hire consultants, and focus on getting the results they desire.
Why Open Source Is Ideal for Healthcare
Simply put, the provision of healthcare is a collaborative process and both the development of proprietary systems technology and the underlying business model are not. Intuitively, improvement of healthcare processes and clinical transformation also require coordinated collaboration efforts. “Open source software is well suited for health care, as it mimics the evidence-based health model; it, too, engenders better outcomes and continual improvement.”
