8 ms·

Healthcare is less about these cool technologies and more about how do they devices and software interfaces get access to the patient data. I worked at a startu

by leak 15y ago

Healthcare is less about these cool technologies and more about how do they devices and software interfaces get access to the patient data. I worked at a startup that launched a tablet application back in 2005 for healthcare professionals to interface with patient records while walking around the hospital. Building the software was and still is the "easy" part. Getting IT to give you access to patient data is the extremely difficult part. It takes literally years. Lots of proprietary stuff that is very hard to get into. Maybe Drchrono is tackling small doctors offices and it might be easier but trying to get into major hospitals is another story. I wish them luck either way.

Skeletor 15y ago
We are going to change healthcare from the ground-up. Small 1-10 doctor practices can easily make the decision to completely move to a new solution like drchrono. Once you get every private practice doctor using better tools, you can start banging on the gates of the hospitals to let you in and adopt new technology. It's similar to how Salesforce.com started with small businesses and eventually broke into enterprise sales from the bottom up.
- leak 15y ago
  Good luck with that.
- baran 15y ago
  The problem is Epic has effectively locked-in the top end of the market. Their strategy, which is brilliant, is to only go after the biggest, most well-known clients (I know nothing groundbreaking, but it works). They say they only focus on whales, academics, and children (hospitals). Due to this, they have been able to capture 265 of the most prestigious hospitals in the country (and soon in the world). With the lock-in they have, I can't see them giving up this market. It would take a lot to justify replacing that half a billion dollar system for someone else, especially after the hell the administrators have gone through to get the systems up in the first place. Also, in many ways Epic is becoming the de-facto standard, which is leading to network effects that would have to be broken down. I don't think you can fight Epic at their game and win. Added to that they will likely begin to move downstream (recently heard a rev. projection $8.4B in 2016, up from $1.2B today) as the mid-size players would love to have an Epic install if only to mimic the respected healthcare organizations. The most secure place from Epic is the small practices. The IT/intemplmentation/costs requirements of Epic are far too high, in its current form, to sell to them. The problem becomes selling. It recently talked with a VP of Sales at a HIT vendor and he said of 10 hours spent selling a doctor, 9 hours are spent trying to get a hold of him. Difficult.
  - Skeletor 15y ago
    That's the exact way the market looked to Salesforce.com when Seibel system only went after large markets and told their salesforce to "run" not "walk" away from smaller customers. Salesforce.com definitely killed Seibel in the enterprise space after building a better product with feedback from smaller sales forces.
  - Kadrith 15y ago
    My understanding of Epic's approach, to some extent, is that they know approximately how much it will cost to support an organization. When we were going live they had reservations due to our size at the time; if we were not big enough they did not want us as a client since the cost of support would be greater than what we honestly afford. I really like how they have structured the support concerning Forums, UGM and Good Maintenance; for an enterprise software company it is the best approach I've seen.
- samstave 15y ago
  I don't agree. A little background: I am a hospital systems designer and consultant. I actually built one of the first EHR clients for iPhone, before the iPad came out (Rejected from YC in 2009), I was the technology implementation manager for the new El Camino Hospital build, I was the primary technology designer for San Francisco General's new 850MM facility. I am consulting on the UCSF Mission Bay project for technology and transition, and the same for UTSW in Dallas. I am also the transition planner for a small 100MM facility in Nome Alaska. In all of these projects I design and or consult on all aspects of technology implementation, use, training etc.. I even sent an RFP for EHR implementation to Dr. Chrono to see if you guys could step up to a larger facility ($5MM budget for that piece), I heard nothing back for weeks until after the deadline when I was then told that you couldn't respond - and then had a sales guy call me trying to get me to sign up as a physician. Anyway -- getting a private practice of ~10 physicians to use your product is in no way a gateway to hospitals. They are completely different markets. The EMR implementations in large hospitals are multi-million dollar implementations and they take ~18 months to accomplish. The sheer number of workflows needed and the integrations with various systems are daunting and non-trivial. You are going after a massively entrenched market with many many millions of dollars committed by all the customers I fully hope that there can be a serious shakeup in health IT, but having some success with 1-10 physicians and then expecting to parlay that to hospitals with thousands of employees, or even hundreds (like in Nome) is a tall tale. I think there are TONS of opportunity to disrupt healthcare, and DrChrono is a great app - it is just not mature enough or on scale enough to compete against the larger EHR market YET. EDIT: I'd like to add - that if you want to continue to build a free product, and you want to get into the larger scale EHR space - I suggest you partner with/learn from/attempt to implement on-top-of MedSphere's OpenVista EHR. DrChrono has some great features - and if you make the capabilities more robust then you can get into this market more easily. OpenVista is used widely outside the US as well, and this would be an opportunity to capture the Asian/Indian market. Also, if you take some of the features you have (Voice Notes, etc) and offer them as a stand-alone-ish product - then you can attempt to get physicians already in large hospitals to use that product - not selling it as an EHR, but a needed tool, and expand from there. If you stay away from the EHR/EMR moniker when infiltrating physicians in larger hospitals you'll more easily get under ITs radar. Every hospital has iPad users already, and most are rolling out official IT support for them - so you need to get an app that physicians can use in parallel to their epic/siemens/cerner/eclypsis solution without pissing IT off.
- caycep 15y ago
  I hope this works. As a lot of other posters have noted - hospital level deployments, where good data practices and IT are arguably the most needed due to the mission critical nature and the larger volumes of data generated, is hobbled by entrenched interests, IT policy dominated by insurance revenue concerns rather than driven by patient or practitioner needs, and being swallowed up by a oligopoly (soon to be monopoly) consisting of Cerner, McKesson and Epic. All of these companies use antiquated databases (MUMPS forms the basis of the products of these companies for the most part, a data language invented in the basement of Massachusetts General that predates FORTRAN and COBOL). The UI/UX design is nonexistent (all of them would crush any of the Daring Fireball interfaces of shame posts). More ominously - these companies protect their business AND their data formats ferociously. Epic is famous for lock ins - once you pay the $50-100 million contract for them to take over your IT, your data will not interface with any other system again, ever. They are good at generating numbers for Medicare and insurance billing revenue that make hospital CEO's giggle with glee (ignoring user experience and good data practices for the doctors, nurses, and patients on the line - which translates into lousy care administered to patients). Judy Faulkner, the CEO of Epic, is known for having much of the Wisconsin Congressional delegation in that company's back pocket, such that she sits on some congressionally mandated committee for EHR's promoting closed, proprietary systems as a means for "patient privacy" (lolwut). The system I work in actually has a reasonable setup. Not nearly as sexy as some of the advanced hadoop/linkedin/facebook/netflix setups - it was build on an Oracle back end running MS IIS and ASP. But at least it's on the web and the database isn't creaking along on a system that looks like this: http://thedailywtf.com/comments/A_Case_of_the_MUMPS.aspx?pg=7 http://thedailywtf.com/comments/A_Case_of_the_MUMPS.aspx?pg=... Yet swayed by whatever koolaid Epic fed them, they forked over the millions in contract to go 40 years back in time. I think this industry is so so so ripe for disruption. Focus on the doctor/nurse/patient user experience, make EHR software that does what every facebook/google+/linkedin, heck even blogger user takes for granted, get the adoption rates up, and kill these greedy as sons of bitches at their own game.
  - stevenbedrick 15y ago
    > Focus on the doctor/nurse/patient user experience, make EHR software that does what every facebook/google+/linkedin, heck even blogger user takes for granted, get the adoption rates up, and kill these greedy as sons of bitches at their own game. I agree 100% in principle, but I think that in reality this won't work. Why? Because the people that would benefit from that approach (focusing on the user experience, etc.) are not the people that make the decisions about which system to buy. Those people could care less about what it looks like, or how usable it is. That's the reason why so many EHRs have UIs that look like they belong up on blocks in somebody's front yard, and even worse-looking APIs- a misalignment of interests between the users of the system and the people who make the purchasing decisions. It's like a little microcosm of everything that's wrong with the entire medical system... :-)
- zeratul 15y ago
  > We are going to change healthcare from the ground-up This is so impossible! You have a great product for 1-10 general doctor practices. You should focus on that and just that. If you feel like you have a lot of free time on your hands try knocking on 1-5 pain management doctors clinic. See how you do there. If you manage to customize their workflows and menus for pain management, move to 1-5 MDs obesity clinics, and so on. I suspect that after single pain management clinic you get burned out. Have you ever looked at UMLS http://www.nlm.nih.gov/research/umls/ http://www.nlm.nih.gov/research/umls/ ? It has 2,612,024 mln medical concepts and counting. Many diseases are still poorly covered. Any time you talk with a specialist in a hospital he/she will need those terms in their documentation. Every disease has different workflow and different vocabulary. If a hospital thinks about adopting a new EMR, they will send ~100 their own IT people to EPIC/GE HQ to have them trained how to configure their system. Then, those ~100 IT people will work with ~1000 MD to have progress notes, flowsheets, and what have you configured to everyones liking. This is SO MUCH work and huge investment that has to have 0.0001% risk for the hospital and for the patients. Keep in mind that if patient dies and there are lacks in documentations someone will have to pay ... a lot. I'm sure that some day you will have ~1k engineers and ~2k support team, each encumbered with basic medical knowledge and patient workflows. But then you will notice that healthcare can be changed only top-down not ground-up.
  - chintan 15y ago
    > This is so impossible! This is exactly why I feel we need more such start-ups in this space - Naive but Bold that have a "Stay hungry Stay foolish" mentality. Having said that, I pretty much agree with all what you said. The core problem is that few years working in health IT, most people (myself included) start thinking this way. And thats why I feel we need such bold visions, which may sound stupid or "impossible" at this point but can potentially change the status quo. Its very hard to predict when, how and who will bring the change but I know it ll happen, sooner or later. PS: I disagree about the UMLS part - I don't think any company in their right mind would use Metathesaurus as their base vocabulary, may be synonyms, mappings etc but not as a coding vocabulary.
    - stevenbedrick 15y ago
- brudgers 15y ago
  >"It's similar to how Salesforce.com started with small businesses and eventually broke into enterprise sales from the bottom up." No it's not. Missteps with something like Salesforce might cost people jobs. When a hospital makes a misstep, people might die as a result. A hospital's operations are no more a scaled up version of a small group practice, than its physical plant is a scaled up version of a bungalow.

by leak 15y ago

Skeletor 15y ago

We are going to change healthcare from the ground-up. Small 1-10 doctor practices can easily make the decision to completely move to a new solution like drchrono. Once you get every private practice doctor using better tools, you can start banging on the gates of the hospitals to let you in and adopt new technology. It's similar to how Salesforce.com started with small businesses and eventually broke into enterprise sales from the bottom up.

leak 15y ago
Good luck with that.
baran 15y ago
The problem is Epic has effectively locked-in the top end of the market. Their strategy, which is brilliant, is to only go after the biggest, most well-known clients (I know nothing groundbreaking, but it works). They say they only focus on whales, academics, and children (hospitals). Due to this, they have been able to capture 265 of the most prestigious hospitals in the country (and soon in the world). With the lock-in they have, I can't see them giving up this market. It would take a lot to justify replacing that half a billion dollar system for someone else, especially after the hell the administrators have gone through to get the systems up in the first place. Also, in many ways Epic is becoming the de-facto standard, which is leading to network effects that would have to be broken down. I don't think you can fight Epic at their game and win. Added to that they will likely begin to move downstream (recently heard a rev. projection $8.4B in 2016, up from $1.2B today) as the mid-size players would love to have an Epic install if only to mimic the respected healthcare organizations. The most secure place from Epic is the small practices. The IT/intemplmentation/costs requirements of Epic are far too high, in its current form, to sell to them. The problem becomes selling. It recently talked with a VP of Sales at a HIT vendor and he said of 10 hours spent selling a doctor, 9 hours are spent trying to get a hold of him. Difficult.
- Skeletor 15y ago
  That's the exact way the market looked to Salesforce.com when Seibel system only went after large markets and told their salesforce to "run" not "walk" away from smaller customers. Salesforce.com definitely killed Seibel in the enterprise space after building a better product with feedback from smaller sales forces.
- Kadrith 15y ago
  My understanding of Epic's approach, to some extent, is that they know approximately how much it will cost to support an organization. When we were going live they had reservations due to our size at the time; if we were not big enough they did not want us as a client since the cost of support would be greater than what we honestly afford. I really like how they have structured the support concerning Forums, UGM and Good Maintenance; for an enterprise software company it is the best approach I've seen.
samstave 15y ago
I don't agree. A little background: I am a hospital systems designer and consultant. I actually built one of the first EHR clients for iPhone, before the iPad came out (Rejected from YC in 2009), I was the technology implementation manager for the new El Camino Hospital build, I was the primary technology designer for San Francisco General's new 850MM facility. I am consulting on the UCSF Mission Bay project for technology and transition, and the same for UTSW in Dallas. I am also the transition planner for a small 100MM facility in Nome Alaska. In all of these projects I design and or consult on all aspects of technology implementation, use, training etc.. I even sent an RFP for EHR implementation to Dr. Chrono to see if you guys could step up to a larger facility ($5MM budget for that piece), I heard nothing back for weeks until after the deadline when I was then told that you couldn't respond - and then had a sales guy call me trying to get me to sign up as a physician. Anyway -- getting a private practice of ~10 physicians to use your product is in no way a gateway to hospitals. They are completely different markets. The EMR implementations in large hospitals are multi-million dollar implementations and they take ~18 months to accomplish. The sheer number of workflows needed and the integrations with various systems are daunting and non-trivial. You are going after a massively entrenched market with many many millions of dollars committed by all the customers I fully hope that there can be a serious shakeup in health IT, but having some success with 1-10 physicians and then expecting to parlay that to hospitals with thousands of employees, or even hundreds (like in Nome) is a tall tale. I think there are TONS of opportunity to disrupt healthcare, and DrChrono is a great app - it is just not mature enough or on scale enough to compete against the larger EHR market YET. EDIT: I'd like to add - that if you want to continue to build a free product, and you want to get into the larger scale EHR space - I suggest you partner with/learn from/attempt to implement on-top-of MedSphere's OpenVista EHR. DrChrono has some great features - and if you make the capabilities more robust then you can get into this market more easily. OpenVista is used widely outside the US as well, and this would be an opportunity to capture the Asian/Indian market. Also, if you take some of the features you have (Voice Notes, etc) and offer them as a stand-alone-ish product - then you can attempt to get physicians already in large hospitals to use that product - not selling it as an EHR, but a needed tool, and expand from there. If you stay away from the EHR/EMR moniker when infiltrating physicians in larger hospitals you'll more easily get under ITs radar. Every hospital has iPad users already, and most are rolling out official IT support for them - so you need to get an app that physicians can use in parallel to their epic/siemens/cerner/eclypsis solution without pissing IT off.
caycep 15y ago
I hope this works. As a lot of other posters have noted - hospital level deployments, where good data practices and IT are arguably the most needed due to the mission critical nature and the larger volumes of data generated, is hobbled by entrenched interests, IT policy dominated by insurance revenue concerns rather than driven by patient or practitioner needs, and being swallowed up by a oligopoly (soon to be monopoly) consisting of Cerner, McKesson and Epic. All of these companies use antiquated databases (MUMPS forms the basis of the products of these companies for the most part, a data language invented in the basement of Massachusetts General that predates FORTRAN and COBOL). The UI/UX design is nonexistent (all of them would crush any of the Daring Fireball interfaces of shame posts). More ominously - these companies protect their business AND their data formats ferociously. Epic is famous for lock ins - once you pay the $50-100 million contract for them to take over your IT, your data will not interface with any other system again, ever. They are good at generating numbers for Medicare and insurance billing revenue that make hospital CEO's giggle with glee (ignoring user experience and good data practices for the doctors, nurses, and patients on the line - which translates into lousy care administered to patients). Judy Faulkner, the CEO of Epic, is known for having much of the Wisconsin Congressional delegation in that company's back pocket, such that she sits on some congressionally mandated committee for EHR's promoting closed, proprietary systems as a means for "patient privacy" (lolwut). The system I work in actually has a reasonable setup. Not nearly as sexy as some of the advanced hadoop/linkedin/facebook/netflix setups - it was build on an Oracle back end running MS IIS and ASP. But at least it's on the web and the database isn't creaking along on a system that looks like this: http://thedailywtf.com/comments/A_Case_of_the_MUMPS.aspx?pg=7 http://thedailywtf.com/comments/A_Case_of_the_MUMPS.aspx?pg=... Yet swayed by whatever koolaid Epic fed them, they forked over the millions in contract to go 40 years back in time. I think this industry is so so so ripe for disruption. Focus on the doctor/nurse/patient user experience, make EHR software that does what every facebook/google+/linkedin, heck even blogger user takes for granted, get the adoption rates up, and kill these greedy as sons of bitches at their own game.
- stevenbedrick 15y ago
  > Focus on the doctor/nurse/patient user experience, make EHR software that does what every facebook/google+/linkedin, heck even blogger user takes for granted, get the adoption rates up, and kill these greedy as sons of bitches at their own game. I agree 100% in principle, but I think that in reality this won't work. Why? Because the people that would benefit from that approach (focusing on the user experience, etc.) are not the people that make the decisions about which system to buy. Those people could care less about what it looks like, or how usable it is. That's the reason why so many EHRs have UIs that look like they belong up on blocks in somebody's front yard, and even worse-looking APIs- a misalignment of interests between the users of the system and the people who make the purchasing decisions. It's like a little microcosm of everything that's wrong with the entire medical system... :-)
zeratul 15y ago
> We are going to change healthcare from the ground-up This is so impossible! You have a great product for 1-10 general doctor practices. You should focus on that and just that. If you feel like you have a lot of free time on your hands try knocking on 1-5 pain management doctors clinic. See how you do there. If you manage to customize their workflows and menus for pain management, move to 1-5 MDs obesity clinics, and so on. I suspect that after single pain management clinic you get burned out. Have you ever looked at UMLS http://www.nlm.nih.gov/research/umls/ http://www.nlm.nih.gov/research/umls/ ? It has 2,612,024 mln medical concepts and counting. Many diseases are still poorly covered. Any time you talk with a specialist in a hospital he/she will need those terms in their documentation. Every disease has different workflow and different vocabulary. If a hospital thinks about adopting a new EMR, they will send ~100 their own IT people to EPIC/GE HQ to have them trained how to configure their system. Then, those ~100 IT people will work with ~1000 MD to have progress notes, flowsheets, and what have you configured to everyones liking. This is SO MUCH work and huge investment that has to have 0.0001% risk for the hospital and for the patients. Keep in mind that if patient dies and there are lacks in documentations someone will have to pay ... a lot. I'm sure that some day you will have ~1k engineers and ~2k support team, each encumbered with basic medical knowledge and patient workflows. But then you will notice that healthcare can be changed only top-down not ground-up.
- chintan 15y ago
  > This is so impossible! This is exactly why I feel we need more such start-ups in this space - Naive but Bold that have a "Stay hungry Stay foolish" mentality. Having said that, I pretty much agree with all what you said. The core problem is that few years working in health IT, most people (myself included) start thinking this way. And thats why I feel we need such bold visions, which may sound stupid or "impossible" at this point but can potentially change the status quo. Its very hard to predict when, how and who will bring the change but I know it ll happen, sooner or later. PS: I disagree about the UMLS part - I don't think any company in their right mind would use Metathesaurus as their base vocabulary, may be synonyms, mappings etc but not as a coding vocabulary.
  - stevenbedrick 15y ago
brudgers 15y ago
>"It's similar to how Salesforce.com started with small businesses and eventually broke into enterprise sales from the bottom up." No it's not. Missteps with something like Salesforce might cost people jobs. When a hospital makes a misstep, people might die as a result. A hospital's operations are no more a scaled up version of a small group practice, than its physical plant is a scaled up version of a bungalow.