
Thinking of starting a Health IT company? Here are top three industry challenges - rmorrison
http://pandodaily.com/2012/12/19/thinking-of-starting-a-health-it-company-here-are-the-top-three-industry-challenges/
======
mcphilip
> 2\. Good enough is not good enough

I don't think this really sinks in until you work in the industry. As an
example, I knew of a developer who accidentally forget to make a list page
scrollable and it got through QA that way. I heard rumors that ultimately the
bug resulted in a patient being given the same immunization twice since the
user was unable to scroll down the list page.

And that's a relatively benign example...

~~~
jordan0day
I'm not sure the point the original article was trying to make -- in reality,
a lot of HIT software is _terrible_. "Good enough" would be significantly
better than a lot of the crap that is out there.

------
sachinag
This article understates the issues delivering software solutions to patients,
providers, or payers. The lack of data standards has completely crippled the
ability for new companies/products to innovate and break through. When I
worked at a healthcare VC, we deemphasized IT in favor of medical devices
because the path for success is much clearer and easier to trod.

The reason I can be so confident that it's the data standards, BTW, is because
the DICOM data standard exists for medical imaging. IIRC, the founder of
Heartlab invented the format, it somehow escaped a proprietary home, and
dozens of companies innovated on top of it. The existing EMR vendors - GE,
Cerner, Epic, etc - all have proprietary data standards for storage and
interchange. My due diligence on this revealed that the companies would each
have to spend three years re-writing their software against a common data
standard. Of course, they should have to. It would help patients immensely and
all sorts of innovations would spring forth, just like after DICOM.

~~~
drstewart
What about HL7?

~~~
lucidrains
it's delimited by pipes... i mean, it is a standard, but it's far from ideal.

~~~
narcissus
Technically it's delimited by whatever character is decided to be the
delimiter, which is even better :)

Having said that, it still seems to get data between all sorts of systems in
the hospital.

~~~
daigoba66
That I think is the key distinction: HL7 works okay for a group of tightly
coupled systems, usually internal to a single organization. The biggest
problems today are with data interchange between providers, networks of
providers, 3rd party vendors (cloud based or whatever) and the like. The
finance and insurance industry have, I think, figured this out. Healthcare has
not.

~~~
narcissus
That's a good point and to be honest, I didn't deal much with things outside
of the hospital itself (I mainly worked in the ADT 'sphere') but I could see
how the 3rd party stuff could get hairy... especially if they're trying to
deal with different message formats within the same facility.

------
eclipticplane
4th challenge: what's legal in one state may not be legal in another and may
change with every legislative session.

If your customers are physicians and other practitioners, the state laws are
even more complicated as to who any data belongs to. In some areas, any data
about patients is technically owned by their physician.

If you're contacting patients, your attorneys will debate at length whether
something is legal under the rules of HIPAA. In the end, it will be a much ado
about nothing, because HIPAA is barely policed or litigated over. So you'll
end up with a large legal consulting fee, a confusing legal opinion, and no
clear direction on whether to move forward or not. The next attorney will have
a wholly different opinion.

Healthcare law in the US is absolute shit.

------
FireBeyond
Some quite good points:

"For example, inside a hospital, operating rooms (OR) are often profit
centers, and emergency departments (ED) are often cost centers. The hospital
may be receiving subsidies to maintain its EDs based on its ratio of OR
profits to ED losses, in which case a product that ultimately makes ORs more
profitable may not be worthwhile to the hospital."

To an ambulance service (emergency and pre-hospital medicine is my
area/passion), IFT (Inter-facility Transport) is a near guaranteed paycheck,
911 response is generally a cost center.

DrChrono has it good, because the government will pay their customers (the
doctors and facilities) for the implementation.

But it's definitely an area that could do with some work in unseating some
entrenched and ultimately complacent incumbents.

~~~
xxpor
Is 911 response REALLY a cost center? Around here, to get an ambulance, it's
$500 (IIRC) up front + $16(!!!!!) a mile. And the closest hospital might be 10
or 15 miles away. And I dont think this includes material costs (any drugs,
etc.)

~~~
FireBeyond
911 response, unless ran very well, and / or miserly, is absolutely often a
cost center. You have "frequent fliers" who you may see several times a week,
without insurance. Billing sends them a bill, but there's no realistic
expectation of payment.

You can't, even as a private agency (and should 't - for better or worse, I'm
a proponent of "socialized" medicine, even in bastardized form) refuse a
patient transport, though about the best you can do is advise a patient that
their insurance is unlikely to pay if the ambulance transport does not have.
"medical necessity", even with (especially with) Medicare (who requires us to
get a document from the physician stating the necessity of "transport in a
fully equipped BLS/ALS ambulance").

Add to that Maintenance, drug purchase (must be kept stocked and current, even
if rarely used), fleet Maintenance (driving code in a truck carrying N extra
10-15000 lb at high speed places a lot of strain on a vehicle), insurance
(likelihood of an accident), insurance (malpractice in this area is usually
carried by the agency, not individual), regulatory and other costs, costs of
maintaining sufficient crews on duty so you can respond even when others are
out doing long distance transports (hospitals to nursing homes, home, or
stabilized patients to bigger or more appropriate hospitals) or transporting
your frequent fliers, and it begins to add up.

------
lekanwang
"Your customer’s incentives are not straightforward."

So true.

Don't mean this to be cynical, but if you actually want to have a chance of
upending the healthcare system, always clearly identify the flow of money (are
costs paid by carriers? providers? Medicare? consumers? are the prices
negotiated?), regulation (are fines built into the cost structure? what
regulations are relevant? are they incentivized to be ignorant?) , and
decision-making (e.g. how billing departments more often decide on the EMR to
go with rather than the docs). Then check again, because it's likely you
missed a huge underground river.

Then the tricky part is to align your business plan with your customers'
incentives.

------
lucidrains
i've been thinking about how to create something that can disrupt the medical
industry for a long time, ever since beginning medical school. the sad truth
is that medical industry doesn't welcome software disruptions. software
adoption is usually a bureaucratic process due to the direct risk to human
health, not to mention HIPAA and other regulations. quality of the software is
not as important as selling the software while offering strong credibility and
insurance, which makes it significantly harder for the typical small agile
team to succeed. i am at the point where im wondering if i should sacrifice my
time and efforts on a medical startup or just settle for other challenges that
are not so messy. regardless, software will fix our healthcare system one way
or the other. it's probably just going to take a long time.

~~~
rmorrison
I would recommend trying, especially if you have medical training and know the
space. While it is difficult, with the appropriate go-to-market strategy and
determination you can get a foothold and grow from there.

~~~
lucidrains
thanks! i will try, at least for a little while. honestly, at this point, i
think a true disruption can only happen if diagnostic tests are put into the
consumer's hands instead of being held hostage at the hospital, and we just
aren't there yet.

~~~
robbiep
Hi - As a fellow med student I'm interested in what you mean here.. Are you
suggesting that patients should be able to order their own tests?

~~~
lucidrains
hey robbie, don't know what year you are in, but basically yeah. a physician
in a hospital basically looks at data on a patient to assess the state and
then make decisions on management to affect the state. the problem is that
these tests are hard to find off-the-shelf and often costs an obscene amount
of money as well. i would look into the efforts of companies like scanadu,
alivecor, cellscope. once we can get data to the consumers, then us developers
can immediately start creating knowledge based systems that utilize the data
to give the patient a clearer picture of their internal state.

~~~
robbiep
Im just entering my final year.

Like you I think there's plenty of room for disruption, not just on the
medical devices side but also in terms of efficiencies.

So the three companies you reference are basically disrupting devices that
cost thousands of dollars (ECG and otoscopes/dermatoscopes) - great for
bringing down the costs of clinics or solo practitioners. A lot of these
devices I think are probably being angled at the home user as well
(particularly ECG) but the clinical relevance of giving a patient their own
rhythm is pretty minimal... I mean if they have a dicky heart they likely have
a pacemaker or ICD which will record suspect rhythms themselves.

I'd be fascinated to talk more to you and see where you are taking this
because I think you are really saying is that if we give patients their
results or order their own (bloods, EUC, any ELIZA etc studies) then we will
be empowering them to make better health decisions. I have my own opinions on
this based on what i've seen and if you're interested in discussing further my
email is in my profile - although seems like you have a lot that would like to
talk to you!

------
intractable
In my experience, one of the most significant hindrances has been access to
and communication with medical personnel:

\- Medics, especially specialists / surgeons, have extremely busy schedules,
often holding down both public & private patient responsibilities as well as
performing duties for their specific colleges etc.

\- The level of IT-savvy amongst healthcare pros is generally low.

\- They seem to have a different logic to us IT folk, answers are nebulous for
non-medics and hard rules are very difficult to pin down. Ask the same
question n times and you will get n different answers, from the same
respondent.

When you find a medic who is willing / able to help and towards the positive
on all the above axes, you must hold onto them with a death grip.

~~~
rficcaglia
Surprisingly I work with a lot of MDs who think communication and lack of
professionalism and thoughtfulness in software engineers is a significant
hindrance to success.

\- Medics have extremely busy schedules and so they don't want to have their
time wasted by lack of data, lack of rigorous testing, and risk to their
patients. Software pros work in cozy offices not splattered in patient fluids,
from 11AM - whenever, and yet don't expend the extra effort to statistically
test data, design efficient algorithms and user interfaces, etc., before
throwing something over the wall as a MVP. \- The level of healthcare savvy
among software pros is generally pretty low \- MDs seem to have a logic that
focuses on quality, meticulous attention to detail, going the extra distance
without added compensation, acceptance of hard and legally binding rules about
ethics, data collection, privacy, security, efficacy, peer review, etc.. Run
the same software program n times and you will get n different bugs, from the
same software developer.

When you find a software pro who is willing / able to help on all the above,
you do need to hold on to them (and pay a high market salary, with good health
care benefits, and reward them for quality and precision vs. MVP attributes.)

------
guylhem
As a health IT professional who did try, and will try again in 2013, this
article is spot on.

There are differences between France and the US - especially in the mindset -
but the payment system is very similar. In fact, the current french system
(used for hospital billing since 2004, and tested for 10 years before that)
was based on the US medicare DRG approach.

My job is to make patients pay as much as we can legally make them pay, using
any mean necessary as long as it is legal.

In the past, my unit was the single most profitable in the whole hospital, by
large. So I tried to sell things, and failed.

I would like to insist on the "incentives" topic with a quick example: I
previously developed production analysis software to find and exploit the
cases where an hospital could be more efficient and thus make more money (long
story short, see one of my previous posts on
<http://news.ycombinator.com/item?id=4826314> for more details)

As I like to say, this is as good as printing money - I can say precisely what
should be changed in a billing statement, why, how much it will gain, and the
probability to find matching evidence in the patient file.

I can calculate an expected return, so that on small cases you can use
unqualified personnel, while it might be worth to have a doctor study every
page of the patient file for high profile cases (since, if you don't have
evidence to back your billing claim, you are legally liable - it's not unusual
for a large hospital to be fined sums with 6 digits if during an audit
mistakes are found)

I tried to sell the software, with a commercial partner. In a year, we could
only find a single client in the whole french public hospital system!!

Want to know why? The improved productivity - short term financial gains - can
be used to demonstrate that the civil servants in charge were not as efficient
as they should have been, or that they should hold to that level of efficiency
in the future.

That's just like the OR example in the article - they don't want to be more
efficient because basically, making more money is a liability to the top
management personal career.

I was quite disgusted by this twisted way of seeing things. Medical
credentials did not help me. Efficiency was not welcome. Improving one's
profile, even at the expense of whole hospitals profitability, was.

I did not explore that much, but there seemed to be a demand for a service to
selectively reduce profits, to maximize government subsidies in some units -
something utterly disgusting for a libertarian. I didn't think I could do
that, so I stopped.

I will try again very soon, but now I will make sure to carefully study the
incentives, and do something I can morally agree with.

~~~
trhtrsh
> My job is to make patients pay as much as we can legally make them pay,
> using any mean necessary as long as it is legal.

> I did not explore that much, but there seemed to be a demand for a service
> to selectively reduce profits, to maximize government subsidies in some
> units - something utterly disgusting for a libertarian.

So your morality teaches that it's OK to scam patients, but not OK to scam the
government?

~~~
guylhem
If it is legal it is no scam. Making patients pay as much as legally possible
is legal.

For ex, on preexisting conditions, the burden of proof is almost reversed. I'm
simplifying, but more or less in an audit the opposite party has to _prove_
the charge could not have been caused by the preexisting condition. It is
almost impossible (good luck if you are trying to prove say that the chest
x-ray had absolutely nothing to do with a physician making sure a cancer did
not relapse - so I'll add that preexisting condition to the bill. it has a
multiplier effect on the whole bill after a threshold)

This is also moral, according to my beliefs, since it helps improving
reliability (here, giving a financial incentive to always check for relapses)
and efficiency.

Reducing profits by accounting trickery is illegal. Reducing profits is also
immoral in the belief system I have.

You have different beliefs - good for you.

~~~
logjam
> If it is legal it is no scam. Making patients pay as much as legally
> possible is legal.

Really.

M.D. in U.S. here. Your profile page says you're an M.D., too.

Please reassure me that you are not a licensed physician and that you have no
patient care responsibilities.

However, if you do see patients (or ever have), please comment on your medical
licensing board's "belief system" on unethical (but legal) practices (even
"business practices") as they pertain to the practice of medicine.

Maybe we're just having a little language breakdown here. Your parent comment
sounds like you advocate for the use of "unqualified personnel" if it improves
the profit margin. You comment below about "massaging the bill". Just above
you seem to be winking and nudging your way to the idea that it's ok "legally"
exposing your patients to the risks of certain tests like chest x-rays even if
they're driven more by your own pocketbook or client's pocketbook (or your own
paternalism) than by what's best for the patient, or perhaps what the patient
chooses.

Unless there's some misunderstanding here, your actions are taking place in
the wrong field. Medicine isn't a business.

Trying to turn it into a shady profit center is driving your actions toward
grave difficulties with ethics, if not "legality".

~~~
guylhem
Really, it's legal in France. We have a mixed public and private for-profit
system. And studies have revealed a tendency to underbill - ie forget codes.

FYI, I am licensed, board member, and I do see patients.

However I strike a line between patient care and billing analysis. And I love
both.

For patient care, my consults are provided for something like $30/consult.
Keep in mind these are lengthy consults (~30/45 min per patient) in a
demanding specialty. I do them far below costs, in a public hospital, to help
- because I know how much the only alternatives in town costs.

For billing analysis, however that's another story. If it is legal (as in
allowed by the law and the code of deontology) it goes.

But given your message, there might in fact be a language difference. I'll try
to clarify my terms.

Regarding "unqualified personnel", I call anyone who is not a nurse or a
practicing physican "unqualified". Ex: a medical coder or medical secretary.
They do not see patients, so they are "unqualified". I see it as a good thing
if they can do this work, considering the alternative is putting someone
"qualified" (ie who could be with a patient providing actual medical care) on
an administrative job, something that worries me as a waste of rare resources.
If it actually improves the profit margin, that is great : it will provide
excellent arguments against wasting rare resources! Anyway, that doesn't make
a lot of differences. The laws might be different in the US than in France,
but here physicians are legally personally responsible for anything the law
call their "subordinates" do. Your nurse leaks medical info about a patient?
Your fault by default, unless you can prove otherwise.

Regarding "massaging the bill", that's not the language I use, but it seems to
be what the other poster was using. I guess that's how it's called in the US.
If it has a negative connotation, I'm sorry. I personally call that billing
analysis. There is no need to do anything shady - it would be stupid to do so,
given how profitable just following the law can be.

Regarding "tests", it is not about exposing patients to the risks of certain
tests - however, if the tests have _already been performed_ and adding them to
the bill results in a higher bill, it's about making sure they are not
forgotten in the bill. Just like preexisting conditions.

The laws in the US might also be different, but here it's the prescribing
physician responsibility to order tests and exams. Billing happens after the
patient has left, and therefore can't directly influence the patient care ex
post facto.

The medicare inspired system was adopted in France for a lot of reasons -
including to help standardize care a little more.

I have had a patient I send to an hospital for chest pain _in an ambulance_
with a case highly suggestive of infarction leave the hospital without
troponin, even while he had a antecedents. I've had a patient _I personally
brought to the ER_ (we call that medical transfert) with a diagnosis of
pulmonary embolism and a prescription for nuclear medicine returned after an
echography and a written note saying 'there was no embolism' (how can you tell
that with an echography???) - and subsequently dying of pulmonary embolism.

IMHO, this is totally unacceptable - I came to that conclusion, when as a
patient I also experience such grave inefficiencies, with consequences. Some
people will try to slither their way out of responsibility and consequences.

I take a great pride in bearing full consequences of my actions. I have seen
patient wishes completely disregarded, something I decided to refuse - and
therefore got more involved in the administrative side than the clinical side,
even if I still do both.

There is a quality problem with some colleagues, one that only financial
incentives or legal liability can solve. The US system is far from perfect,
but it can give us some inspiration on these points.

~~~
StavrosK
I think there's a misunderstanding here. From what you said here:

> As I like to say, this is as good as printing money - I can say precisely
> what should be changed in a billing statement, why, how much it will gain,
> and the probability to find matching evidence in the patient file.

I understand that you, or your system, adds items to patients' bills for tests
that either have never been performed, or that have been performed
unnecessarily.

Is that the case, or does your system check what _probably_ was performed, and
makes sure that it wasn't left out of the bill?

~~~
guylhem
> I understand that you, or your system, adds items to patients' bills for
> tests that either have never been performed, or that have been performed
> unnecessarily.

The first one would be illegal. You can't bill for things that were not done.

The second one is a matter of interpretation : I do not judge whether it was
necessary or not. If it was performed, I try to see how it logically could be
argued, using the probability of finding matching evidence, that it was
necessary given the case or preexisting conditions - and thus bill for it.

> Is that the case, or does your system check what probably was performed, and
> makes sure that it wasn't left out of the bill?

The third one, making sure things that were performed were not left out of the
bill, is most of the work. The files are incomplete and it requires a
probabilistic and interpretative approach, before sending in a human for fact
checking.

It's all about providing incentives. The billing rules are complex, but there
is some logic in them, and physicians see that too - it change their
behaviour. #3 and #2 will directly result in other physicians becoming very
careful that everything which should have been performed was - because doing
this is highly lucrative, "it is as good as printing money". No need to do
anything but following the law and the billing rules.

Truly useless tests won't increase the bill, and therefore they will be weeded
out.

I see that as a financial incentive to change behaviours.

------
tel
I'm in the 7th month of starting a Health IT company and would be happy to
answer (some) questions if anyone has any.

~~~
rficcaglia
I'm in the 41st month of a Health IT startup and I'd be happy to give you a
preview of the questions you havent even thought of :)

Honestly if you can't fund full speed (dev, QA, support, sales, mktg, ops,
clinical studies) for a _minimum_ three years before the first hospital _sale_
, assuming you are selling to hospitals, then get out now.

Happy to shar war stories over a pint!

~~~
wging
Your HN profile says you're at CloudAmp, which doesn't seem to be a health IT
startup at all. What am I missing?

~~~
rficcaglia
I'll spare the HN community self promotion, but I am worker bee and other
roles at a few startups. Interestingly enough, Salesforce (CloudAmp's
specialty) is being used in hospitals! scary, eh.

------
ryanteo
Hi everyone, happy to chime in from an Asian perspective. I'm Ryan, based in
Singapore and tried to co-found an online platform for procurement of medical
supplies for private clinics. Faced many of the industry's frustrations as
expressed in this discussion too. Would be happy to share my experience too.

~~~
yen223
Hi,

I'm curious, how big, do you think, is the medical IT market in Singapore?

~~~
superchink
I'd say it's pretty big. I'm somewhat familiar with a national project for
exchange of clinical data and it's in the hundred million dollar range.

------
error54
As a current developer for a health IT company, much of this is true. Even
with the current incentives to go electronic, many doctors just simply prefer
paper charts and are willing to forgo the $40k a year just to keep things the
status quo. My particular company is growing by leaps and bounds because we
started with a very simple Practice Management model and grew out from there
whereas I see a lot of startups try to jump directly into EMR's which can be a
tough market to crack.

But for anyone looking to get into Health IT, I highly recommend it.
Healthcare is a multi-billion dollar industry that is in dire need of some
disruption and the programming challenges are both interesting and rewarding
(shameless plug: we're hiring).

~~~
FireBeyond
You should also consider the pre-hospital field - a paramedic/EMT in the field
with a Toughbook, etc (where they're not still with paper) is typically using
horrible software, with little flexibility to what by nature can be a rapidly
changing encounter. I see this every day, and hear the cursing that
accompanies it, and think to myself that there is so much that could be done
to improve this.

~~~
error54
That's a really great idea and honestly, our biggest problem now isn't a lack
of work but rather a lack of programmers. The entire health care industry from
the EMT's up to the hospitals really needs an overhaul as some of the software
used is decades old.

------
ams6110
I would add that "agile" development is a hard sell to institutional
customers. They want one or two releases a year, tops. Certainly not monthly
and absolutely not continuous. "Change management" committees will become your
own little hell.

------
Mz
For those saying they would like to chat, I have started a posterous group
called Health IT:

<http://health-it.posterous.com/>

Consider yourself invited.

~~~
Mz
For those interested in joining, you may have to shoot me an email to be
added. My gmail account: talithamichele.

------
sgarg26
In the current environment, health care IT solutions will go further if they
help professionals and patients do 'more with less' instead of 'more with
more'. The dynamics in the article are real, but there are tons of way around
the challenges posed. The article to me says that the market has yet to be
cracked, but the opportunity is still pretty huge.

~~~
rficcaglia
Unfortunately the entrenched attitude is do 'less with more'. There are ways
through the challenges posed - but not 'around'. YMMV.

Until patients pay directly for their care and have transparent pricing, I
don't anticipate real innovation. (of course examples exist of innovation
within the current system: Athena Health, One Medical, PracticeFusion, ZocDoc
- but all of these took quite a lot of time and effort and funding to punch
through the barriers noted in the article...so yes, it is possible, you are
correct).

That said the current (US) system rewards existing thinking and does not
encourage efficiency and outcomes and patient satisfaction.

------
anon6567
I got this pitched to me a couple of months back, but why not start a Yelp-
like medical tourism service? Americans can save a ton of money going to S.
Korea or anther country with similar healthcare standards at the fraction of
the price. It would have to be elective surgery, but you can save a ton of
money.

------
dawson
OT: There are a lot of people in this thread thinking about starting or
joining a Health IT company. I'm hiring (> 7) engineers, happy to help
(answers questions, make introductions etc) or hire, email is in profile.

------
pionar
This could really be for any enterprise IT company.

~~~
wging
Eh. If you send out two shipments of Doritos, nobody dies. If you administer a
med twice, a patient very well could die. Consequently, if you make it even 1%
more likely that a med will be administered twice, patients will die.

~~~
rficcaglia
Absolutely true. That said, software should never replace human thinking
(until the singularity, Ray) and the clinician must be the final authority.

Same goes for pilots - the software can help, but as too many pilots have
discovered, looking only at the instrument panel (especially one instrument)
is a bad idea, speaking from experience ;)

