[mxwll]

There are some major hurdles for these SV companies to overcome if they want any level of success in this arena. EPIC and Cerner together hold over 50% market share of EHR systems in American hospitals. Their interoperability and patient facing applications are a joke. EPIC actively makes it difficult for third parties to build on top of their system.

Sure, these SV companies have figured out how to build great tech at scale but transitioning an entire hospital network to a new EMR is a massive undertaking -- both technically and organizationally. Many doctors had their world rocked by the forced transition to using EMR systems and they run the other way from those claiming a novel technology will solve all of their problems.

There are much greater issues at play here and IMO the organizational problems within hospitals are far greater than the technical ones. To be successful hospitals will have to become tech companies. They aren't exactly the hottest place for top tech talent to end up.

I think the patient first approach that Apple and Samsung have been taking are likely to win out. If they can build a system that captures an individual's personal health record doctors will want that data. Hospitals will have no choice but to begin integrating that data even if it lives outside of the walls of EPIC, Cerner, et al.

[nikanj]

EPIC and Cerner are doing their best to, simultaneously:

1) Appear to be open, ready for innovation and playing fair (so hospitals don't replace them)

2) Maintain their position as gatekeepers, and use that position to extract as much revenue as possible. New startup wants to deploy tech at your hospital? Hospital probably will end up paying more to Cerner for the integration, than the new tech.

[mxwll]

You hit the nail on the head.

Building anything on top of EPIC is unbelievably painful. You either pay EPIC engineers to access their "Dark API's" or pay $$ for their certifications.

Very few of these big medical device start-ups are actually integrating with patient records at a significant scale. Every instance of EPIC or Cerner is different and there is a lot of manual work needed to get up and running with live data in the patient record.

[grwthckrmstr]

Sounds EXACTLY like an industry ripe for disruption

[nradov]

The EMR market for hospitals and large clinics really isn't ripe for disruption. This isn't an industry where a startup can quickly hack together an "80% solution" as an MVP and sell to some early adopters. Due to regulatory requirements and legitimate patient safety concerns any new entrant needs to be a 100% solution from the start. Otherwise they'll never make it past the first vendor down select.

There may be some limited opportunities for disruptive innovation in niche markets like smaller medical specialties with unique requirements, concierge medical practices, genetic counseling, etc.

[tim333]

>Sure, these SV companies have figured out how to build great tech at scale

Their tech is much disliked by most doctors. There's even a protest group LetDoctorsBeDoctors with a humorous song video (https://www.youtube.com/watch?v=xB_tSFJsjsw)

There is also a fully functional heavily tested free open source solution that most doctors prefer in surveys, called VistA or Openvista.

> Doctors at the VA really like VistA. In Medscape’s 2016 EHR Report, VistA was the top rated EHR overall and the most preferred solution for use as a clinical tool. http://hitconsultant.net/2017/05/10/reasons-not-to-replace-v...

I think that what Epic and Cerner have figured out is how to crack the corporate sales process. Doctors and patients don't choose the EHR system, managers do, and I guess Epic and Cerner are good at selling to them.

If any startups want to do a Red Hat type model building on top of VistA I hope they do well.

[jeremylee]

Both Epic and Cerner are making at least some strides toward opening up their platforms (Epic with App Orchard, and Cerner with Ignite, SMART on FHIR etc.) Athena has MDP ("More Disruption Please.") I get the feeling these organizations have at least come to the realization that they need to open up--granted their denial up to this point leaves them with a lot of catching up to do. But access to the data that exists in those systems is a pretty big carrot for integration partners to help push adoption.

[methehack]

Sorry, dude, but I think you fell for it. These entities try to make you think they're open, but really they are keeping entrants at bay.

Here's an interesting episode of the weeds podcast that gives some context by exploring why the fax machine is still so prevalent in US healthcare.

https://player.fm/series/voxs-the-weeds/fax-reform-bonus

[nradov]

You haven't addressed the point that jeremylee made about the SMART on FHIR platform now available in those EMRs. It's not a complete solution but it works today and people are building real applications on it. Take a look at the demos from the latest HL7 FHIR Applications Roundtable. https://www.hl7.org/events/fhirapps.cfm

[marktangotango]

But access to the data that exists in those systems is a pretty big carrot for integration partners to help push adoption.

The scary reality is, they don't even have access to the data in those systems. I had a friend contracted at cerner working on a FHIR api end point. Something as simple as answering the question "what medications have been administered to a patient" was extremely difficult to pull out of their system. One would think there'd be a simple report for that information, but they didn't have it. The domain/system knowledge wasn't there either. That one simple api endpoint drug on for months as new data was "found" in the 5000+ table schema. Oh, and they don't use foriegn key constraints in production either.

[NoNotTheDuo]

I can vouch for some of that as well, although I disagree with some of it. The domain/system knowledge is there, but there's likely a relatively small group of people that know all of the ins and outs. And the group that knows about inpatient medications likely isn't the the same that knows about outpatient medications. And maybe the ordering of meds is different from the administration of meds.

I think the point about FK constraints is perhaps a little too generalized. In a 5000+ table schema (which is entirely accurate!), I'm sure there are some tables which don't have FK constraints enabled. But I know for a fact that there are FK constraints on some of the tables (because I created them!)

[PakG1]

There are much greater issues at play here and IMO the organizational problems within hospitals are far greater than the technical ones. To be successful hospitals will have to become tech companies. They aren't exactly the hottest place for top tech talent to end up.

You could say that about a LOT of organizations. Hospitals are perhaps another level though.

[opportune]

Apple and Samsung entering the healthcare space to compete with Epic (their name isn't all-caps) and Cerner, in reality, is going to be closer to this: https://xkcd.com/927/

Most of the employees at Epic and Cerner in the healthcare space are actually operations. Like, at least 60% of their workers are operations. Not only that, but they're not traditional IT workers who go out and get certs, they're really closer to devops professionals who are able to provide both IT support and have an intimate understanding of what they're working with. Last time I checked, Apple and Samsung don't really even have this tier of customer facing support. It's going to take organizational shifts for them to break into this sector, and it's not so sure a thing.

That said, I completely agree with your observation that hospitals need to become tech companies. My parents are medical professionals and I have also worked at a medical software company in the past, so I think I'm pretty well grounded when it comes to saying this: hospitals hate developers, and developers hate hospitals. From the perspective of the hospital worker, developers make overly confusing systems and as soon as the worker gets used to it, they completely change everything and make it even more complicated than before. From the perspective of developers, most hospital professionals are luddites who oppose all change and progress as a matter of principle. If the two roles were more closely integrated, these severe communication issues would be mitigated. Medicine needs to be redesigned form the ground up with these two fields learning each others' skills and understanding how and why the other field does what it does.

[mxwll]

Fair points - I don't believe that Apple / Samsung are necessarily going to build out their own EMR systems. Rather I think the bottom up approach they are taking by creating an enormous amount of personal health data -- heart rate and exercise activity now with a growing ecosystem of third party devices -- that is up to FHIR specs is a step in the right direction.

Your second point really resonates with me. I have spent the last few months working within a large healthcare organization and it is extremely difficult to make necessary changes. There is a lot of distrust of our team to the point of hostility. Very frustrating