
Feds Approve $44K Doctor Reimbursement for Using Drchrono (YC W11) iPad App - Skeletor
http://techcrunch.com/2011/07/28/feds-approve-44k-doctor-reimbursement-for-using-drchrono%E2%80%99s-ipad-app/
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LiveTheDream
I showed this to a friend who has created software for the medical industry
and has close ties with/knowledge of the industry. He allowed me to copy his
thoughts here, with some very minor edits for privacy:

Regarding Drchrono app:

> a) [...] compared to PAPER it's pretty good! but its not built with speed in
> mind, iits built to tackle other things like billing, and assumes a more
> traditional practice. it aint gonna make you more $$ in an office as it does
> nothing to speed up the workflow and allow a doc to cut staff, which is THE
> overhead in a practice.

> b) that 44k comes with a lot of strings. main one is that you have to have
> 30% medicaid patients. that alone can bankrupt a practice, as medicaid pays
> a fraction of what insurance/medicare pays for visits. an efficient
> practice, for example, would look at the 44k and say 'f that'.

> other strings is what [some doctors] refers to as the 'thought police ' -
> you have to regularly submit reports on your patient stats to the gov't. not
> nec.a bad thing, but few doctors want some beauracrat to be eyeballing their
> stats without knowing anything about the actual patients. i'm not sure how
> the data will be used... i generally dont think "outcome based" compensation
> is a great way to pay either bc its hard to quantify health and management
> of chronic stuff etc.

And opinion on medicine more generally:

> medicine has been, and ought to be, a relationship business - which defies a
> lot of efforts to quantify it. a lean practice [with] deep personal
> relationships with patients (as opposed to a clinic style 35 patients/day
> practice, which is mayhem and prone to problems) ought to be what ppl strive
> towards. thats not the trend... trend is towards big groups bc individual
> docs are dumb and cant run their practices well.

> anyway, its' a long discussion... :-) not clear what the next 10 years will
> bring. hunch is we'll be big losers when primary care is mostly atrophied
> and big groups with salaried docs are common. remember how much innovation
> comes from large entities. [a certain private practice he knows of] is 10
> years ahead of anyones bc [it is] lean and innovative.

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kyro
Nice going, guys. As a med student, this sort of stuff really excites me. It
seems like the government is willing to incentivize the adoption of electronic
mobile technologies in clinical practice.

To all who are making quips about the $44k incentive: the amount of money that
is spent on resolving logistical, administrative, and medical errors because
of disorganized, incomplete health records, yearly, is astronomical. Doctors
are often very technologically stubborn and those who run their own practices
will usually opt for implementing whatever traditional, paper-based system
they're accustomed to as they have concerns that lie elsewhere. $44k (or less)
in government incentives could prove to be an amazingly cost-effective
investment if adoption of these technologies can truly reduce the risk of
error.

I've been eager to play around with Dr. Chrono, but I'm not practicing yet, so
is there a demo I can play with? I suppose I could just sign up for a free
account.

~~~
absconditus
Unfortunately most institutions choose to simply automate their bad processes.
The studies that were originally done to justify this incentive were based on
hospitals such as Mayo that are simply better hospitals. Their use of
electronic systems is not the reason why they are better.

~~~
absconditus
One relevant study:

[http://www.ajmc.com/publications/supplement/2010/AJMC_10dec_...](http://www.ajmc.com/publications/supplement/2010/AJMC_10dec_HIT/AJMC_10decHIT_Jones_SP64to71)

~~~
absconditus
Another:

<http://archinte.ama-assn.org/cgi/content/short/170/17/1578>

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xal
At this point it's downright comical. It seems like a significant percentage
of startups these days go to market on a design that is directly copied from
Shopify.com

pricing page:

<http://www.shopify.com/signup> <https://drchrono.com/pricing/>

Or worse, look at that little badge in the top right and compare it to the one
at www.shopify.com frontpage.

~~~
jdietrich
That style substantially pre-dates Shopify. It's a fairly inevitable
consequence of the tools available and A/B testing. Everyone is working from
the same basic starting point and testing everything for conversion.
Convergent evolution is remarkably powerful when you can iterate quickly.
Whether people work it out for themselves or just copy it wholesale, that
layout is used for a reason - because it drives conversion.

~~~
jbenz
Copying the layout is one thing. Copying very specific details is another.
Look at the tops of each pricing tab in both sites. The tabs with rounded
corners. The subtle fades behind the pricing numbers. The 1-pixel-line-
highlight above the price. The colors. (I know I'm basically describing the
popular "letterpress" effect, but these examples are remarkably similar, even
considering that they are both using a popular graphic style.) And clearly the
corner badges are almost identical.

~~~
timerickson
I'm sorry, but are you seriously implying that because Shopify uses gradients,
rounded corners and shades of green that no other website can use those
styles?

~~~
fletchowns
Look at the badges on the front page, it's kinda hard to argue that they
weren't copying the design.

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jemfinch
Why is my tax money subsidizing software that should have to fight in the free
market like the software most other developers write?

~~~
tzs
I think you might have misunderstood the article. Doctor's aren't being paid
to use this particular software. Doctor's are being paid to convert to
electronic records. To be eligible for that payment, they have to use systems
that have been certified. Drchrono has been certified.

Anyone else is free to write a competing application, get it certified, and
compete in the same market.

~~~
harold
Certification isn't cheap though. It's a definite barrier to entry at the
outset. CCHIT seems to be structured to favor monolithic companies with deep
pockets, and startups with lots of funding. The certification process also
dictates to a degree the functionality of the app, which to my way of thinking
may inhibit innovation.

~~~
bbbwater
Certification costs have been going down as the Federal government has become
the accreditor of new certifying bodies. Previously there was only 1
certifying body. Now there are 6 that all have to conform to the same
standards. As a result, certifying costs have come down and will likely trend
down for sometime.

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dr_
Personally I don't think the 44K incentive has ever made any sense. All it has
done is allow existing EMR providers to charge more for their poorly designed
software. Physicians would have switched over on their own, if the reason were
compelling enough - and that reason would be user friendly software at a
reasonable price. Startups would have had more opportunities without the
incentive. Now they have to offer it just to compete.

~~~
Skeletor
One aspect of getting government certification is that all vendors are
required to support government approved standards like HL7/CCR/CCD for the
exchange of health information.

So forcing all vendors in the space to get certified has forced all of us
healthcare IT vendors to cooperate and adopt a fixed set of standards for
exchange of data. Without the government stepping in and forcing vendors to
adopt these standards, the disparate vendors would never have agreed on any
standards and followed them.

~~~
rysulliv
This is the type of industry that really needs that type of standardization
and enforcement of it. I can fully understand why the government wanted to
step in and help enforce that standardization for a greatest benefit of all
involved, and I can not really think of an alternative to the cash incentive
to get people to do it. Can anyone else offer up a reasonable alternative?

~~~
dr_
Getting certification and offering a $44K incentive are different things. I
can understand the former being required of software companies - but the
medical providers aren't the one who have to seek certification, they have to
purchase the software and are being given an incentive to do so, because there
isn't otherwise an obvious cost benefit for them to switch over. I feel the
software company should provide the cost benefit for the medical provider to
switch over. Free market competition, without incentives thrown in, would
eventually allow that.

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thesis
Wow... incentives for making the doctors life easier? What a deal. Just what
the medical industry needs... more breaks.

~~~
theclay
I can't tell if this is serious or not. Either way, it seems like we all
benefit from devices that make doctors more effective.

~~~
cma
> Either way, it seems like we all benefit from devices that make doctors more
> effective.

The problem with your statement and approval is in no way justifies the magic
$44K number. Why not a $2 billion incentive for each doctor that switches?

~~~
nkassis
I'm assuming it's based on the perceived cost of the software in question(not
just Dr Chrono but all EMR system). I was surprised that Dr Chrono doesn't
charge around that for it's software. A lot of those packages have so few
clients that it needs to be priced ridiculously to make it viable. This is
mostly due to over kill design by committee that makes it's expensive to
develop. Dr Chrono as a small shop probably has the advantage here.

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iends
To clarify, these subsidies come in the form of medicare/medicaid
reimbursements. The reimbursements are also PER DOCTOR. For the doctors to
receive the full amount, they'd have to be seeing medicare/medicaid patients
and to start using the EHR system in the next year. After 2018 these
incentives turn into penalties, in the form of less medicare/medicaid money
received per patient.

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jamesteow
Smart way to get it picked up. Use an app and get paid what some people earn
in a year? Amazing strategy.

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whileonebegin
Am I right that the meat of this product is a back-end web application, rather
than an iPad App? Anyone know if the web service may have existed as a fully
fledged EHR business prior to the mobile app being created?

~~~
rdl
I don't think this is really right for Dr Chrono -- they're very iPad focused,
although there is a lot of hidden complexity on the server side.

There are plenty of free EHRs and SaaS EHRs which are web based -- Practice
Fusion (Salesforce) is the big SaaS one, and . They all kind of suck from a
UI/UX perspective.

The big EHRs are really mostly proprietary (e.g. the Vista system used mainly
at the Veterans' Administration, MC4/TC2/etc. used in the Army, whatever
Kaiser uses...).

There's also a long tail of utter crapware out there -- systems with 0-100
installations built with foxbase, hypercard (!!!), ms access, filemaker pro,
... .

Dr Chrono has the best UI/UX of any of them (a lot of which is "free" because
the iPad is so great compared to alternatives, but part of it is the quality
of the Dr Chrono app, and the benefit of being a later entrant vs. a legacy
app).

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prawn
Makes you wonder about identifying similar government grants/reimbursements
and building apps to fill a related need. Would make for a very easy sales
pitch and maybe give a new venture a bit of a running start.

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phunel
I wouldn't get too excited. Does anyone have any first hand knowledge of the
Federal government actually paying out this incentive? I say this because I
have medical professionals in my own family, and at least from their
experience and from every physician they have spoken to - the incentive is
promised again and again, but never materializes despite physicians and
medical professionals jumping through the myriad hoops. Like many government
incentives, it looks great on paper - but actually getting the thing is
entirely different story.

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deepGem
Is it just me who finds this 'rebate' quite preposterous. Without sounding too
critical about the government measures to reduce healthcare costs, I want to
point out to this TED video about a chain of hospitals in India and how they
have made quality eye care affordable by cutting costs.

[http://www.ted.com/talks/thulasiraj_ravilla_how_low_cost_eye...](http://www.ted.com/talks/thulasiraj_ravilla_how_low_cost_eye_care_can_be_world_class.html)

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iends
It's interesting that they decided to go with InfraGuard for certification
rather than CCHIT. My graduate research involves healthcare certification
standards (and computer security) but when I asked InfraGuard details about
their certification process, they asked me to sign an NDA first (which I
wouldn't/couldn't do).

CCHIT is more open, but unfortunately, it's controlled by large vendors in the
the healthcare space.

~~~
nradov
CCHIT is in no way controlled by large healthcare vendors. For example, on the
Ambulatory work group only 3 of 11 members work for vendors.
<http://www.cchit.org/workgroups/ambulatory> (I am a former member of another
CCHIT work group and work for a large healthcare vendor.)

