Feds Approve $44K Doctor Reimbursement for Using Drchrono (YC W11) iPad App | Hacker News Reader

Feds Approve $44K Doctor Reimbursement for Using Drchrono (YC W11) iPad App

techcrunch.com

136 pointsSkeletor49 comments

I showed this to a friend who has created software for the medical industry and has close ties with/knowledge of the industry. He allowed me to copy his thoughts here, with some very minor edits for privacy:

Regarding Drchrono app:

> a) [...] compared to PAPER it's pretty good! but its not built with speed in mind, iits built to tackle other things like billing, and assumes a more traditional practice. it aint gonna make you more $$ in an office as it does nothing to speed up the workflow and allow a doc to cut staff, which is THE overhead in a practice.

> b) that 44k comes with a lot of strings. main one is that you have to have 30% medicaid patients. that alone can bankrupt a practice, as medicaid pays a fraction of what insurance/medicare pays for visits. an efficient practice, for example, would look at the 44k and say 'f that'.

> other strings is what [some doctors] refers to as the 'thought police ' - you have to regularly submit reports on your patient stats to the gov't. not nec.a bad thing, but few doctors want some beauracrat to be eyeballing their stats without knowing anything about the actual patients. i'm not sure how the data will be used... i generally dont think "outcome based" compensation is a great way to pay either bc its hard to quantify health and management of chronic stuff etc.

And opinion on medicine more generally:

> medicine has been, and ought to be, a relationship business - which defies a lot of efforts to quantify it. a lean practice [with] deep personal relationships with patients (as opposed to a clinic style 35 patients/day practice, which is mayhem and prone to problems) ought to be what ppl strive towards. thats not the trend... trend is towards big groups bc individual docs are dumb and cant run their practices well.

> anyway, its' a long discussion... :-) not clear what the next 10 years will bring. hunch is we'll be big losers when primary care is mostly atrophied and big groups with salaried docs are common. remember how much innovation comes from large entities. [a certain private practice he knows of] is 10 years ahead of anyones bc [it is] lean and innovative.

Nice going, guys. As a med student, this sort of stuff really excites me. It seems like the government is willing to incentivize the adoption of electronic mobile technologies in clinical practice.

To all who are making quips about the $44k incentive: the amount of money that is spent on resolving logistical, administrative, and medical errors because of disorganized, incomplete health records, yearly, is astronomical. Doctors are often very technologically stubborn and those who run their own practices will usually opt for implementing whatever traditional, paper-based system they're accustomed to as they have concerns that lie elsewhere. $44k (or less) in government incentives could prove to be an amazingly cost-effective investment if adoption of these technologies can truly reduce the risk of error.

I've been eager to play around with Dr. Chrono, but I'm not practicing yet, so is there a demo I can play with? I suppose I could just sign up for a free account.

Unfortunately most institutions choose to simply automate their bad processes. The studies that were originally done to justify this incentive were based on hospitals such as Mayo that are simply better hospitals. Their use of electronic systems is not the reason why they are better.

One relevant study:

http://www.ajmc.com/publications/supplement/2010/AJMC_10dec_...

Another:

http://archinte.ama-assn.org/cgi/content/short/170/17/1578

Interesting. I'll take a look at the links you just posted. Thanks.

Even so, implementing EHRs in a way that qualifies as meaningful use still improves patient care for the worst institutions.

[citation needed]

At this point it's downright comical. It seems like a significant percentage of startups these days go to market on a design that is directly copied from Shopify.com

pricing page:

http://www.shopify.com/signup https://drchrono.com/pricing/

Or worse, look at that little badge in the top right and compare it to the one at www.shopify.com frontpage.

Wow, that front page badge is a blatant copy.

I mean, that's how you sell SaaS, right? Why reinvent the wheel? Good artists copy, great artists steal, etc.

If you're selling SaaS, you've probably got more pressing concerns than coming up with a unique way to present your pricing tiers.

Agree that the corner badge is a bit much, though.

I don't think there's anything wrong with taking a layout/framework... but at the very least, change the colors, button styling... make it yours instead of copying every single detail.

That style substantially pre-dates Shopify. It's a fairly inevitable consequence of the tools available and A/B testing. Everyone is working from the same basic starting point and testing everything for conversion. Convergent evolution is remarkably powerful when you can iterate quickly. Whether people work it out for themselves or just copy it wholesale, that layout is used for a reason - because it drives conversion.

Copying the layout is one thing. Copying very specific details is another. Look at the tops of each pricing tab in both sites. The tabs with rounded corners. The subtle fades behind the pricing numbers. The 1-pixel-line-highlight above the price. The colors. (I know I'm basically describing the popular "letterpress" effect, but these examples are remarkably similar, even considering that they are both using a popular graphic style.) And clearly the corner badges are almost identical.

I'm sorry, but are you seriously implying that because Shopify uses gradients, rounded corners and shades of green that no other website can use those styles?

Look at the badges on the front page, it's kinda hard to argue that they weren't copying the design.

And you effectively copied the way 37signals structured their pricing page.

Out of curiousity, who was first with a design like that, 37signals or shopify? http://campfirenow.com/signup the structure is also very similar.

I seem to recall pretty much every webhosting company using a similar layout of different plans they offer since the early 2000s. I'm sure it was used other places before that as well.

If they were like shopify they would take a % of the doc's gross revenue. And fail to support basic features like having a customer/patient account on launch.

Why is my tax money subsidizing software that should have to fight in the free market like the software most other developers write?

I think you might have misunderstood the article. Doctor's aren't being paid to use this particular software. Doctor's are being paid to convert to electronic records. To be eligible for that payment, they have to use systems that have been certified. Drchrono has been certified.

Anyone else is free to write a competing application, get it certified, and compete in the same market.

Ah, that makes more sense. I can see how the public good would be served by having doctors use electronic records; having them use this specific software (which is what I thought was being subsidized) seemed too specific to justify in terms of the public good.

https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.a...

Certification isn't cheap though. It's a definite barrier to entry at the outset. CCHIT seems to be structured to favor monolithic companies with deep pockets, and startups with lots of funding. The certification process also dictates to a degree the functionality of the app, which to my way of thinking may inhibit innovation.

I believe it runs around 20k.. which is a pretty small number compared to cost of labor to build something that would pass the certification. That said, I'd certainly love it if it were cheaper :)

Certification costs have been going down as the Federal government has become the accreditor of new certifying bodies. Previously there was only 1 certifying body. Now there are 6 that all have to conform to the same standards. As a result, certifying costs have come down and will likely trend down for sometime.

Medical service providers work in something that's only vaguely like a free market.

Why should I have to pay for-profit pharmaceutical companies, hospital companies, and insurance companies for worse quality healthcare than I could be getting for pennies on the dollar from my taxes?

Medical records being computerized imposes short term costs on the providers (who are small offices -- the big guys moved to EHR years ago), bur provides private and public goods.

I'm basically a libertarian, but this is one of the least wasteful government programs. As a plus, it was built around open standards vs. trying to have a government standard ehr.

I'd like to see insurers match the meaningful use payments.

Personally I don't think the 44K incentive has ever made any sense. All it has done is allow existing EMR providers to charge more for their poorly designed software. Physicians would have switched over on their own, if the reason were compelling enough - and that reason would be user friendly software at a reasonable price. Startups would have had more opportunities without the incentive. Now they have to offer it just to compete.

One aspect of getting government certification is that all vendors are required to support government approved standards like HL7/CCR/CCD for the exchange of health information.

So forcing all vendors in the space to get certified has forced all of us healthcare IT vendors to cooperate and adopt a fixed set of standards for exchange of data. Without the government stepping in and forcing vendors to adopt these standards, the disparate vendors would never have agreed on any standards and followed them.

This is the type of industry that really needs that type of standardization and enforcement of it. I can fully understand why the government wanted to step in and help enforce that standardization for a greatest benefit of all involved, and I can not really think of an alternative to the cash incentive to get people to do it. Can anyone else offer up a reasonable alternative?

Getting certification and offering a $44K incentive are different things. I can understand the former being required of software companies - but the medical providers aren't the one who have to seek certification, they have to purchase the software and are being given an incentive to do so, because there isn't otherwise an obvious cost benefit for them to switch over. I feel the software company should provide the cost benefit for the medical provider to switch over. Free market competition, without incentives thrown in, would eventually allow that.

Wow... incentives for making the doctors life easier? What a deal. Just what the medical industry needs... more breaks.

I can't tell if this is serious or not. Either way, it seems like we all benefit from devices that make doctors more effective.

> Either way, it seems like we all benefit from devices that make doctors more effective.

The problem with your statement and approval is in no way justifies the magic $44K number. Why not a $2 billion incentive for each doctor that switches?

I'm assuming it's based on the perceived cost of the software in question(not just Dr Chrono but all EMR system). I was surprised that Dr Chrono doesn't charge around that for it's software. A lot of those packages have so few clients that it needs to be priced ridiculously to make it viable. This is mostly due to over kill design by committee that makes it's expensive to develop. Dr Chrono as a small shop probably has the advantage here.

theclay is right - the benefit is to make physicians more efficient and to allow them access to tools that benefit the public as a whole. They shouldn't have to spend the majority of their time trying to negotiate insurances and medicare/medicaid (which, by the way, rarely pay the amount it can cost the physician) - they should be focusing on practicing medicine. Using EMRs/EHRs allows physicians to automate part of that process, as well as giving them more analysis of patients.

I think many older physicians would disagree with you that EHRs make their life easier.

To clarify, these subsidies come in the form of medicare/medicaid reimbursements. The reimbursements are also PER DOCTOR. For the doctors to receive the full amount, they'd have to be seeing medicare/medicaid patients and to start using the EHR system in the next year. After 2018 these incentives turn into penalties, in the form of less medicare/medicaid money received per patient.

Smart way to get it picked up. Use an app and get paid what some people earn in a year? Amazing strategy.

Am I right that the meat of this product is a back-end web application, rather than an iPad App? Anyone know if the web service may have existed as a fully fledged EHR business prior to the mobile app being created?

I don't think this is really right for Dr Chrono -- they're very iPad focused, although there is a lot of hidden complexity on the server side.

There are plenty of free EHRs and SaaS EHRs which are web based -- Practice Fusion (Salesforce) is the big SaaS one, and . They all kind of suck from a UI/UX perspective.

The big EHRs are really mostly proprietary (e.g. the Vista system used mainly at the Veterans' Administration, MC4/TC2/etc. used in the Army, whatever Kaiser uses...).

There's also a long tail of utter crapware out there -- systems with 0-100 installations built with foxbase, hypercard (!!!), ms access, filemaker pro, ... .

Dr Chrono has the best UI/UX of any of them (a lot of which is "free" because the iPad is so great compared to alternatives, but part of it is the quality of the Dr Chrono app, and the benefit of being a later entrant vs. a legacy app).

Makes you wonder about identifying similar government grants/reimbursements and building apps to fill a related need. Would make for a very easy sales pitch and maybe give a new venture a bit of a running start.

I wouldn't get too excited. Does anyone have any first hand knowledge of the Federal government actually paying out this incentive? I say this because I have medical professionals in my own family, and at least from their experience and from every physician they have spoken to - the incentive is promised again and again, but never materializes despite physicians and medical professionals jumping through the myriad hoops. Like many government incentives, it looks great on paper - but actually getting the thing is entirely different story.

Is it just me who finds this 'rebate' quite preposterous. Without sounding too critical about the government measures to reduce healthcare costs, I want to point out to this TED video about a chain of hospitals in India and how they have made quality eye care affordable by cutting costs.

http://www.ted.com/talks/thulasiraj_ravilla_how_low_cost_eye...

It's interesting that they decided to go with InfraGuard for certification rather than CCHIT. My graduate research involves healthcare certification standards (and computer security) but when I asked InfraGuard details about their certification process, they asked me to sign an NDA first (which I wouldn't/couldn't do).

CCHIT is more open, but unfortunately, it's controlled by large vendors in the the healthcare space.

CCHIT is in no way controlled by large healthcare vendors. For example, on the Ambulatory work group only 3 of 11 members work for vendors. http://www.cchit.org/workgroups/ambulatory (I am a former member of another CCHIT work group and work for a large healthcare vendor.)

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