Policy types have been whining about the slow uptake of electronic health records (EHR) for ages.  One conference I attended, a number of years ago, featured Newt Gingrich proclaiming, “Paper Kills.”  David Brailer, MD, was crowned the first health information czar during the Bush administration.  He was charged with “rewiring” American medicine.  Fast forward to 2010, and we still have not reached the goal of an EHR in every doctor’s office.

Why not?

Here is what I learned from some very smart people at the Inaugural Digital Office of the Future conference (expertly hosted by The Center for Business Innovation in Las Vegas, September  9-10, 2010).

  • First of all most docs practice solo or in small groups.   The most popular EHRs are server based (or if accessible on the web, a closed system), monolithic, one size fits all products that are very expensive.  The small guy simply cannot afford it.
  • Next, even if they were willing to make a major investment in the technology, these doctors know it is risky.  Depending on how you define “failure,” 30 to 40% of large system EHR implementations fail.
  • Further,  implementations are time-consuming and disrupt daily practice routines.  Docs make money seeing patients.  Time spent bringing up the EHR is time away from patients.
  • Finally, doctors are experts in clinical decision-making.  They did not train in IT.  Deciding which EHR is right for their practice is quite complicated.

So what ‘s  to be done?

Some say the answer is to ‘app-ize” the components of the EHR and let docs “Plug and Play,” adding the components they need and want into an open platform.  Now, two weeks ago, I couldn’t have written such a sentence, so let me see if I can translate it.  (Steve Adams, Keith Toussaint, and Vince Kuraitis, leaders in the Clinical Groupware Collaborative,  I am writing about your stuff, so correct me if I didn’t get it right).

What is being proposed – and what is already being developed – are platforms that will ultimately reside in “The Cloud,” not on an individual company’s server.  The Cloud is an on-demand self-service IT infrastructure that is owned and managed by a Cloud Service company.  That company can sell chunks of service, to another company – say your doctor’s office  – as needed.  Demand can scale up without the doctor’s office having to make additional investments in hardware.   This allows those IT services to be provided at a more affordable price since you aren’t buying or licensing hardware and software and you don’t have to hire staff or consultants to help you manage.

The individual components of an EHR, say clinical decision support, health information and data management, administrative tools and so forth, are developed by others.  There may be multiple companies, for example, providing a Patient Connectivity module.  Each one may offer different features and functionality.  One may meet the needs and price point of your practice better than the others:  “Plug it and Play it.”  When you are done “constructing” your EHR, it is customized for your practice, rather than being a one-size-fits all software solution.  Just as we have seen Apple and Droid create a robust and dynamic market for smart phone apps, this open model of  EHRs should accelerate innovation, the usefulness of apps, and bring down costs.  What could be better?

If Newt was right and “Paper Kills,” then a Plug and Play EHR may be just the antidote.


  1. You are partially right.
    The problem is also change. Doctors, like everyone, dislike change and if there is no advantage to them personally, why would they switch. I run a solo practitioner’s office and there is no reason for us to make any changes, so we have no plans to.

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