Wow! I do not know how I should feel about this. Heather Leslie of Ocean Informatics wrote on Twitter that MS is leaving the HIS market, and as you can read here, it is true.

Now I’ve written about Amalga more than 2 years ago,  and I was excited about what it may become. I was hoping that with support and competition from Microsoft, the hospital information system business would go forward. Competition in this kind of very high cost markets is important, and only actors with lots of resources can push this kind of competition.

It appears Microsoft was not big enough! I’ve always felt that it was almost impossible to sustain a business model with a HIS product, and solutions in HIS market would survive only if they reach a really large scale. Reaching that scale is very hard on the other hand, since HIS software is no small piece of software, and its entry into a new hospital always takes a lot of effort in every way you can imagine.

It appears the amount of difficulty I kept observing in HIS business was not overestimated. Microsoft has sold lots of products with no profits at all. They have been selling xbox consoles for years now, and I’m not sure they started making profit in that market, but they still push it for the future value.

They won’t be doing this for HIS market. This is a very important sign for many stakeholders. If MS can’t dare to scale up its operation in such a well known domain, what does it tell you?

What it tells me is: do not attempt to build healthcare IT products with large scope. The cost of creating such products is incredibly high, and it can easily take you down. Everybody has a lot to gain from building smaller, well connected, specialized solutions. Clinicians, software developers, and even patients. Microsoft’s exit from HIS market is not the only sign. CSC having lots of trouble in delivering Lorenzo in UK, NHS slowly walking away from the idea of big contracts for the whole country..

These are the signs that show that gigantic, magical all in one solutions are simply not affordable, not for UK government, not for MS. So what makes you think you can afford it?

Instead we need to focus on systems using the agreed, open standards, specializing in various clinical domains, but sharing information to help with the whole operation of healthcare services. HIS market is way too expensive for newcomers, and even the well established players are having trouble in addressing the needs of customers. It looks more and more like airline industry: economies of scale with thin profit margins, with survival depending on addressing as many customers as possible.

I can’t claim, with full confidence that the future of health services lies in small web based applications, but there is certainly enough signs to claim that the market is going to give this approach a try.

Wow! I can’t believe I have not written anything for two months.Well, time to catch up then.

Ibelieve that EHR implementation is not taking off because of some fundamental problems, and I’ve written about them before. Check out my previous posts for anti-patterns in  EHR implementation.One of the things I have not mentioned (or maybe I did) is the lack of commercial motivation for investment in EHR implementation. Pretty much any project has a commercial aspect, and it offers some profit to one or more stakeholders. Sometimes though the offer is not significant enough to attract big players into the project, and at the end, unexpected costs lead to financial constraints and less then desired level of implementation.The big players are governments, private insurance companies, trusts (for UK) and private practices, and large IT domain players like Accenture, IBM, Oracle and Microsoft. However, if you have these names on the table, you have to be very careful to not to create a monster instead of a project. Unfortunately, what happens most of the time is that grand visions (with grand bills) emerge, and billions are spend while actual results turn into fairy tails.If you go for smaller projects like PHRs, the commercial driver, the motivation that comes from profits is hard to build and harder to keep alive.

People can’t really provide convincing business models for PHRs, unless the PHR is some sort of side benefit in a larger system. It is almost always about patients having access to their own records, which are kept in a bigger system.Don’t get me wrong, there is nothing wrong with PHRs, it is just that they are not very easy to commercially justify, especially if they are disconnected from other systems.What we need is smaller (read my anti-patterns posts), but commercially attractive targets for implementation. Smaller pieces of software, connected to major flow of money. GP software is a good example of this, especially for USA.

I’ve been thinking about  medical tourism for some time. It is normal for me to think about this: a visit to a dentist costs you hundreds of pounds for a very simple procedure in London, and if you have a fairly complex operation or a series of operations to have, good luck with that. Meanwhile, flying to Turkey, having the operations in Istanbul, staying at a nice hotel and coming back can easily cost you much less, and you’d probably feel much better at the end. Especially if you do not have huge amounts of money.The level of clinical care in many countries including Turkey, is surprisingly good, and the difference in cost is even more surprising. I can see a huge potential in establishing a proper “medical outsourcing” network among various countries. It would work for everyone, including payers, care providers and finally (and obviously) patients.The amount of cost savings would be huge, and many practices would love to offer prices which would be cheap for patients living in other countries, but still leave them a nice profit, quite likely to be higher than their domestic operations.

The thing is, pulling this kind of setup off would take serious investment. Ensuring that the practices performing the outsourced medical procedures provide proper care, dealing with legal issues around privacy and location of data (still matters a lot), and integrating financial operations is a much larger task than an EHR platform for shifting medical data. The benefit is huge though.Governments (think EU here) can cut off so much spending, they can avoid long waiting times for many procedures, and therefore improve care.Unlike many other use cases for EHRs, medical tourism can very easily justify the investment in money turns, and I think this is what makes it different. If you are a clinician or a developer you may argue that money is not everything, and EHRs should not be implemented on the basis of commercial aspects. Well, you may be right (you probably are), but in this world, money turns most, if not all the wheels, and if your approach is not adopting to the way the financial workings of the healthcare market is organized,  you are going to have a very, very hard time.I know I am not the only one who has thought about this, Professor Kalra mentioned months ago a project they have been involved in. I am not sure if anyone has focused on the huge commercial aspects of medical tourism (I’d rather call it medical outsourcing actually).From a clinical point of view, it is very hard to discuss priorities, and I’m not equipped to do this anyway. However, actual financial figures may get very powerful actors interested in projects which are quite small in clinical scope, which is hard to do. When a medical outsourcing network offers a couple of billions in savings, suddenly the funding for the core EHR system becomes incredibly small, especially compared to administrative work that must be done.

So maybe we are supposed to include these kind of use cases in our presentations and discussions more, to attract the financial support we need to build the better systems we want to build.Having seen many EHR projects fail even to get started, no matter what the clinical benefits are, I am more and more inclined to focus on services which would earn us the resources we need. Otherwise, I can’t see how we can break the cycle of half implemented, budget constrained, isolated projects.Medical outsourcing may allow us demonstrate all the benefits we have been promising, and it can help all stakeholders justify their investment much better than other setups.