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Death of the Solo Practice

April 27, 2009
by Anthony Guerra, Editor-in-Chief
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HITECH has swept the small physician practice into the dustbin of history

Most scientists believe the dinosaurs were killed by a meteor that hit the Earth, spewing a cloud of ash that blotted out the sun for years. While the dinosaurs perished, smaller, more adaptable microbes and tiny mammals survived, giving rise to the diverse ecosystem we see around us. That meteor had been on its trajectory for a long time, and depending on how Zen you want to get, it had been on its way forever.

For many small, independent physician practices, HITECH is an extinction event. They just don't know it yet.

Dozens of conversations with industry insiders have changed my thinking around the problem of independent physician CPOE adoption and documentation (in the acute setting) and EMR adoption (in the ambulatory setting). “You can't force them to use it,” I used to say. “They are the revenue generators, they bring in the money.”

But HITECH has changed those dynamics. And unless something is drastically changed in the regulations, physicians will lose their “I'll-just-admit-my-patients-to-your-competitor” card, which has traditionally made CEO/CFO-types go wobbly.

With nowhere to go and scribble orders into frequently misplaced three-ring binders, independent docs will have to play ball. And once they play ball in the hospital, it will only be a short time before HITECH sticks and carrots induce them to stop at Sam's Club on the way home for Iron Man and an EMR.

The only model, however, which seems to make sense from a technology point of view is one which has the ambulatory EMR/PM software hosted by someone else, somewhere else, ideally at the hospital where the practice sends most of its patients. But what if the local hospital, and I've talked to CIOs who work at such facilities, can't find a business reason for providing those services? What's a doc to do?

If physicians can't sign up for an ASP/SaaS EMR with a low monthly subscription fee that offers them access to practice and hospital-created data, while simultaneously safeguarding their financials from the prying eyes of hospital administration, and offers them easy import/export portability should they want to switch EMRs, or port their data (in the same EMR) to another hospital's servers, the chances of significant adoption are low.

To understand what can be done to foster physician adoption, we must first understand these physicians. Fiercely independent, and to a lesser extent, entrepreneurial, these docs do not like being told what to do. They are phenomenally educated and know how much they know. They have tempers and egos and they are brilliant and save lives. They have terrible manners and at times a seeming lack of compassion, but when they wheel your loved one into the OR, none of that matters. These doctors are largely not interested in being slowed down, making less money or sitting on the phone listening to an EMR vendor help-desk's Muzak while a waiting room full of patients transitions from simmer to boil.

What these physicians need is a technology infrastructure to handle what the next century will demand of them. And what HITECH will require, they cannot afford, install or maintain in their small practices without third-party hosting and maintenance. One person cannot start and run a factory because the infrastructure required to do so is beyond the revenue generating ability of that person to sustain. Companies run factories and, soon, companies will be the only entities running physician practices. We see this today, when physicians join into single or multi-specialty practices of 10, 50 or 100 doctors.

We will see more and more of this - more doctors banding together, more hospitals hiring their physicians instead of credentialing community docs, and more practices buying hospitals. The future of healthcare, you see, is all about understating the implications of the new infrastructure required to sustain it, required by law. HITECH, and the infrastructure it mandates, constitutes an extinction event. At least we have the chance to see it coming.

Anthony Guerra, Editor-in-Chief
Healthcare Informatics 2009 May;26(5):8

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