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.
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.
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.
I agree that the lack of data standards and interconnectivity is on of several big problems that have traditionally crippled health IT innovation. But, advanced technology is becoming so cheap, and the pain points have become so large, that companies are changing.
Technologies that can compensate for inconsistencies between existing systems (like my company's product, http://comprehend.com) are enabling health IT to do things previously unthinkable.
I would argue that it is the crippling lack of appetite for change and innovation that stifles breakthrough technology that would create a data standard and a thriving interoperable service ecosystem.
The success of an innovative idea will attract the other members of a data ecosystem. ( Your example proves that!) So you need to have innovation first - not standardization. Standardization may follow.
You were right to abandon IT as a VC --- this is an industry that is not about ROI. The only reason I do it is I can afford to subsidize it, fueled by the letters we get from patients thanking us for making their lives better, or saving them a tremendous amount of pain and suffering.
The MDs at the hospitals I know don't do it for the money. Despite the outrageous prices in US healthcare, they get paid pennies on the dollar for 24X7X366 work (they take it home!) and little thanks (and lots of lawsuits). Often their own institutions don't support them. I would never recommend my child be an MD in the US, at least not for profit. (Advice a family friend and physician once told me when contemplating med school, which I took to heart.)
HL7 is a data interchange format, not a data storage format. You can't code to that spec the way you can to DICOM. EHRcon and CDA are jokes.
And, of course, the vendors who stitch together siloed datasets from proprietary vendors make a killing. So that's yet another group who loves the status quo.
HL7 is often characterized as a "70% standard," meaning that instead of getting complete agreement from vendors, they decided to standardize most of it. (HL7 3.0 is an 80% standard, but no one really uses HL7 3.0, at least not in the U.S.)
Think of HL7 as a language with many dialects. As a result there are whole industries for translating feeds both within hospitals (integration engines) and between institutions (RHIO/HIEs).
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.
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.
In my experience with HL7 it's a standard, but every single system you talk to you need to write custom code to handle them, because everyone talks the "standard" a bit differently.
[edit] and as for the XML v3, nobody uses it. Nobody.
Absolutely (for both points). I found HL7v2 to be more of a 'standard of communication of data' as opposed to a 'standard of data'. A lot of the work I did in my last job was dealing with these differences... I think the best investment of my time was the code I wrote to more easily interact with the messages, just to help alleviate those differences.
you could also say Cache (it's a post-relational database... whatever that means) is a standard database used in medical systems, but it sure isn't a postgres.
It is an object database which was all the rage back in 1996-ish. I had to use it outside of the medical market once and the sales manager was shocked!
HL7 V2 actually defines two standard encodings: ER7 and XML. They are both logically equivalent. The ER7 encoding is similar to old EDI standards and typically uses the '|' character as the field delimiter (although certain other characters can be used instead). Unfortunately the XML encoding is poorly supported and most applications use the ER7 encoding.
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.
"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.
> DrChrono has it quite good, because the government will pay their customers
Only if their customers can document, attest, and verify that they meet the standards for Meaningful Use as required by federal law to receive their subsidies. And this can be a considerable burden for the smaller practices that DrChrono targets.
Plus consolidation within the industry means their market is shrinking as larger hospital systems buy up small practices and move fold them into to their hospital-grade EMR systems such as Epic, Cerner, and MEDITECH - all while these larger EMR companies are concurrently giving their products to small practices in order to become regional standards.
Plus, for those remaining practices they have a LOT of competition - there are literally thousands of outpatient EMR solutions, including Practice Fusion, which is well established and free, meaning providers can pocket the subsidies.
DrChrono is a great technology, but don't think they don't face their own challenges.
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.)
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.
"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.
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.
> the sad truth is that medical industry doesn't welcome software disruptions
This is a message that really needs to stop being regurgitated around the technology start-up space.
The medical industry DOES welcome software disruptions. The past two years have been the two biggest years in healthcare software disruption, in terms of VC dollars invested in that sector[0], the number of accelerators that have accepted healthcare related start ups (YC has now invested in a several) and the rise of accelerators focused on healthcare (e.g. Rock Health, Health Box) that have graduated over 100 'small and agile' teams that have established product-market fit, and raised institutional funding.
Healthcare is a space that does require a significant understanding of industry-specific knowledge (third party payment models and regulations are examples), but I feel that many other industries that are being disrupted have similar barriers to entry.
In my experience, most developers ignore the medical industry, citing similar complaints as yours, but neglect to mention the incredible growth that has been demonstrated in that industry for a while now...
Raising funding is one way to punch through the hurdles discussed in the article. I think the point is that if you want to innovate, why should it take $5M in funding if you can demonstrate a good idea working. Answer: all the reasons mentioned in the article.
Small and agile is a function of penetration in the healthcare market --- the regulatory friction and customer requirements will slow them down considerably as they (hopefully) move past initial pilots. There a hundreds of small startups in HIT that get 1 or 2 pilots, but then never get past that point, likely due to the points in this article.
I welcome more and more funding in this space to help educate the buyers and realign priorities toward efficiency vs. status quo. But the industry does not welcome disruptions of any kind. VCs do, in terms of VC dollars invested.
I would make a guess that the ROI YC makes on its HIT investments will pale in comparison to other industries in the long term. Only PG will know.
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.
I recommend not trying - not for profit anyway - unless you directly influence (did they come to your birthday party?) multiple people at the C-Level at 2 or 3 major hospital prospective customers, ideally academic research centers, depending on your idea
This is one where, if you had the contacts, you could at least try to do a lot of good, for everyone - but definitely one where you should expect to receive staunch, and ugly, opposition.
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.
This is going to be quite challenging as long as things are under government control. In fact, the best solution may be some sort of rapid transport that allows people to leave the government's jurisdiction fast enough to be treated and return rapidly. I'm still waiting to hear about Musk's hyperloop, but if it's for real, it could make a difference in this industry (among many, many others).
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.
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!
I'd also like to throw myself into the ring as someone with significant medical and IT experience curious and keen to do something here. Perhaps contact me (and anyone else is welcome to, too), if you'd like to talk further.
Shoot me an email. I paid health insurance claims for over five years and would love to chat, hear what you are contemplating and all that. (my gmail account: talithamichele)
Hi FireBeyond, your email is not listed, but I'd appreciate it if you could email me as I have a few questions. I am curious as to what companies you may have meant when you said, quote:
"There are entire companies devoted to nothing more than this - taking a ICD9/10 diagnosis, some procedure codes and massaging the bill to get the biggest possible bill".
I had searched before for exactly this and found very little to lead me. Any help would be appreciated.
When castles were everywhere, the bigger castle won. Then airplanes came along and essentially made castles obsolete as an aspect of war. The future solutions in health IT will likely appear to be orthogonal to current conceptualizations of the problem.
I am curious what type of solution you have been pondering, if you don't mind me asking. (If you don't want to post it publically, my email adress is in my profile.)
Well, you made me smile. But my point is I am trying to build a "first airplane" and I don't much care what the 900lb gorillas controlling the healthcare castles are up to.
But now I am wondering if I need to work on my metaphor. :-/
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.
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.)
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.
> 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?
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.
I very much disagree with this moral view. Just because something is legal doesn't make it moral.
See, when I'm being up-sold almost anywhere, in a store, eating place, etc., I can make good judgement on whether it makes sense to agree to a sale. However, when it comes to medical procedures, I can't make the same good judgment, because I lack the knowledge. So I trust the doctors to make good decisions, firstly medically, but secondly financially.
If I knew that they are adding many of these "reliability" checks, it would break the trust, and I would need to start making much more judgement on my own, this way probably making the matters even worse.
You would be shocked to know how some physicians would like to speed it up and quickly give you a diagnosis and have you out of the hospital, or just plain don't know stuff.
Like you, I do believe most people can not make a good judgement, because they lack the medical knowledge, so they expect a professional to make the decision for them.
Yet medical science is evolving - very quickly, with an ever reducing half-life for medical knowledge. Financial decision OTOH have a strong incentive (likewise for reliability checks)
I'm sorry if it would break your trust, but for someone who has been on the both sides of the hospital business, "Doctor Doom" scenarios are far more worrisome, and unfortunately not that rare.
There was a story on the NYT IIRC about a doctor his colleagues called "doctor doom and destruction" because his failings were so obvious. Yet he had a medical license and a great reputation, because of his excellent bedside skills.
There are some parts of the business I'm not comfortable with (diverting MDs from patient care to billing - that's a negative externality)
But this is something I now fully believe to be in the interest of both the patients and the hospital - ie something I would personally be very happy to pay for (or to have charged to me) if I was incapacitated and unable to take a decision by myself.
Here are additional takeaways from your statement: things that sell in healthcare include 'time savings' and 'empathy extension factor' in addition to financial factors.
> 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 a somewhat emotional reply, but: as someone with a pre-existing, chronic condition -- this disgusts and terrifies me. I'll never get cover for it. I'm resigned to that, and am fine with dealing with it. I've put a lot of effort into establishing a reasonable savings account that can help to cover me; something's that not easy due to my dietary requirements and constant medical expenditure.
However, because the medication I'm on is an immunosuppressant, there's a very real chance that other illnesses -- bacterial infections, for instance -- can ultimately be said to be caused by my preexisting condition. I might be able to buffer myself against immediate medical malady, but invalidating all of my insurance due to that condition is gross.
"First do no harm" means to me having everyone perform efficient medicine - going by the book, not cutting corners or adding useless tests (they won't be billable)
I am very sorry if you feel that the system works against you, but IMHO the consequence of the financial incentives is your physician will make sure you have no actual infection if you are in the hospital for any other reason. he will also check for possible bad consequence of your immunosuppressant - something otherwise he might have forgotten, say for a wrist problem.
It's an incentive. It has bad sides and good sides. I believe there is more good than bad.
Regarding providing coverage, the French market is different from the US system. It will certainly be changed soon, so I don't think I can provide an interesting/useful comment.
The french system is interesting and had many strengths, but it need some serious tweaks. Putting a big chuck of the US system (medicare) was a great idea - 8 years ago. Now we have to keep evolving it.
> Reducing profits is also immoral in the belief system I have.
People who tie up profit with morals utterly baffle me. Whether it's "profit is evil" or "profit is morally good", it's all nonsensical. It's just fucking money. Are your actions helping people or hurting them?
Profit is a synonym for efficient. I couldn't care less about the money part.
Yet where there are no profits, efficiency is also generally lacking. (and don't mention free software, because the profits are just different - just not directly financial, but bankable - like reputation, experience, passion - people write free software for good selfish reason, "to scratch their own itch")
> 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".
No medical system charges the average patient as much--legally--as the U.S. system does. When it comes to ethics vs. legalities of patient payments, U.S. doctors have the shortest legs in the world to stand on.
The French system, for all the praise it gets in the U.S., is a fiscal mess. That system does need to find a way to charge their patients more, or it will eventually go bankrupt. Conversely, the U.S. system needs to find a way to charge its patients less.
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.
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?
> 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.
By making patients pay as much as legally possible you are effectively denying medical attention to all the ones who otherwise could pay for it; not to mention many diseases come back (as cancer) so the patient may eventually run out of money for their treatment; making you partly responsible for their pain and death.
Not to mention the country with the best health care system is also the one with the highest taxes; so by increasing the cost for the patient and consequently decreasing the amount of money that he can pay in taxes you are indirectly hurting the quality of overall health services.
You are also encouraging the market to produce more of the relevant test in the future, and encouraging more competition to go for those treatments because they can make it profitable at a lower cost.
The problem with your very static analysis is that you end up breaking both of those second-order effects, so while you may get to feel good in the short term, in the long term you are doing much more harm. You have to analyze this problem dynamically. It's the more subtle approach, but more fruitful long term.
(Of course hypothetical situations can be constructed in which this general principle does not hold... but nevertheless, it is the general principle and you will be producing exceptions.)
> and encouraging more competition to go for those treatments because they can make it profitable at a lower cost.
They can make it more profitable but only helps a smaller subset of people because is better to sell 1000 $10 needless than 10000 $1 needles (transportation, packaging, liability, etc); plus is a strong incentive to use any procedure that makes the patient believe that he is getting better even if he actually don't; because ultimately is the profit margin that matters. And that is not an exception; is the number one rule for business.
And data also goes against your view; the country I am talking is Denmark, the health system is 100% subsidized by the government itself; it haves a 95% health services satisfaction rate because all those events generated from the need to generate profits are non-existent.
"They can make it more profitable but only helps a smaller subset of people because is better to sell 1000 $10 needless than 10000 $1 needles (transportation, packaging, liability, etc);"
You implicitly make the error that the same person faces the choice of selling a few expensive needles or lots of cheap ones. In a free market, if one person tries the former, someone else can do the latter.
The medical market is not very free, unfortunately, and the proposed solutions to the resulting problems are always to make it even less free. The results are so boringly predictable it hardly seems sporting to talk about them. Shortages, inefficiencies, you name the usual consequence of centralized planning and meddling and our medical systems are full of them, but ever and always the solution is to increase centralization. Pity we must once again grind ourselves to dust on the alter of government control en masse again.
The data I see does not match your assertion. For all people bitch about the US, and for all our neutering of the free market advantages we are desperately trying to jam into our system to keep up with the Euro-Joneses, it still has better outcomes than Europe in many key areas. I'm sure that will change soon enough, though.
I am living the consequences of this in my country itself; they make you wait months for one date, even if they suspect cancer; you know why they make you wait so much time? Because they want to make sure you health insurance payments are the ones pre-paying for the specialist service (or at least a good part of it) before you stop paying or before you die. There is people with cancer standing long hours in queues just because some guys through it was really smart to overprice common medical resources and lobby in the congress for laws that help them abuse their clients (aka patients) and government subsidies.
"they make you wait months for one date" - that is unacceptable, just like overpricing is.
The medical market has far too much friction and rent seeking behaviour. I do not agree with the short version, but I agree with your long version.
I dream about the day when (if?) the medical market become a perfect market in the economical sense - price taking behaviour, pure and perfect competition, factors of production being paid at their marginal productivity
I believe that, among other things, the financial incentives are a step forward. We apparently have different ways, but a same goal.
"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."
There are entire companies devoted to nothing more than this - taking a ICD9/10 diagnosis, some procedure codes and massaging the bill to get the biggest possible bill (and vice versa, as an insurer, minimizing the same).
Yes, that's the easy part - massaging the bill, testing.
Providing an accurate estimation of the expected gains however require both domain knowledge and statistical analysis.
Ie if your hypothesis is to add "morbid obesity", and you know how much it will gain in the bill, how likely are you to find that in the patient file, given the patient history and (hopefully) some text from the release letter?
Enough to send an unqualified worker who does not understand medical speech?
(you won't get paid for ideas, but for actual results - and too many false positives cost money, because humans have to do the fact checking)
Do you believe it's worth putting a MD on the case? It will cost more in fixed costs, and thus reduce potential gains.
Can you automate that for one patient file consisting of multiple inputs? Can you still do that for 100'000 files? How long does it take for your software to produce its result? Can it still work when it is missing some critical information you believed in your early development would never be missing - like the release letter?
Textual analysis, datamining, Bayes, even sentiment mining (see http://news.ycombinator.com/item?id=4908056) etc - everything is fair game (ex: "the patient did not seem morbidly obese, but upon calculating BMI score, was")
Then you have to convert the lead to a sale. I'm talking about having money in the bank. This requires more than a nod and a signature for hospitals. I know firsthand - in the end, only one hospital paid.
Interest and traction are irrelevant. What matters is how much money you get in the end, and how satisfied the customer is to recommend you to others (it's a small world, especially in the health-IT field)
Very true - on a slightly different note, my company cleans up in the insurance / claims management side by implementing a system of policy management not based on table lookups but by allowing our providers to build rules and flows of their own. You wouldn't (well, perhaps you would) believe how many claims processors rely on database tables hundreds of columns wide to cover every permutation for a policy possible, and how (relatively) easy it is to convert those into boolean logic and simple rules along the lines of "IF AmountPaid > Deductible THEN" etc.
We achieve auto-adjudication of claim rates into the low-mid 90th percent, whereas most of our competitors are in the 60s to 80s (and some clients, inefficiently using those competitors, are as low as 30% auto-adjudication when they come to us).
But working on the insurance side of things increasingly tweaks my moral compass the wrong way...
Indeed, there are many things that can be done simply at first, then you have to reach for the higher hanging fruits.
However I would not call that "the wrong way" - for me, it's moral and logical. Maybe I'm too zen about that, but for me it's about increasing efficiency.
Generally speaking, if somethings feels wrong to you, you shouldn't do it. Works for every topic - because we each have our own morals, and it's soul damaging to go against it.
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.
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.
Hi rficcaglia, I would like to buy you a pint, or lunch, or coffee or something. Are you in the Silicon Valley area? Your email is not listed, but mine is. I am interested in natural language processing and machine learning in the medical field. Would you know anything about this?
How do you find your sales lead? Specifically, my question is how do you identify a potential sale target? Is it through your connections. call calls or online ads?
Publish peer reviewed journal abstracts with data showing efficacy --- yes for software, not only for devices. Then present data at major conferences (though, you cannot be a presenter directly as it conflicts with vendor conflict of interest restrictions).
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.
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).
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.
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.
What I've observed is that it's hard to get the decision makers listen to you and often, they're unwilling to invest any more than they've already done towards any solution. Granted these conversations were mainly concerned with a SaaS based solution targeted towards HR & Administrative Operations vs. the field techs.
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.
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.
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.
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.
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.
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.
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 ;)
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...