As a computer engineer pioneering computer applications and services in healthcare, I am never surprised to uncover yet another domain where computer technology can further enhance the efficiencies of healthcare delivery. Equally surprising is how accessible these enhancements could be with the intelligent application of existing technologies, technologies have been available in other "more sexy" industries for years.

Nine years ago, coming out of Silicon Valley as a computer designer, I made an observation in my father’s office (an Otolaryngologist). I noticed how much information was there, and how relatively little technology was available. I was acutely aware of the technologies that existed in other industries. It seemed that access to healthcare information systems had been committed to be unnecessarily expensive and deficient. What has been provided for the price was embarrassingly inadequate and expensive when compared to the technologies available to other industries.

The healthcare industry has been stifled with overpriced low technology being forced onto an industry literally willing to pay anything that promises some solutions in the area of streamlining operations and containing costs. Most of the traditional vendors of this technology come from either lower end office management systems or higher priced hospital based "legacy" systems.

In desperation and by vendor familiarity, decisions are often made to select from these two alternatives. Often, within months of purchase, the solution is found to be disappointing and less than what was promised. Institutions and practices end up "making due" with what they have, always wishing for more of what they thought they were getting.

The purchase decision for these systems is very confusing in today’s transitional market. Misinformation and overzealous sales and marketing add to the confusion. The features that are really needed often do not emerge as promised in the smaller office systems. The larger, more expensive systems have the features, but are unattainable to any organization smaller than a very large group practice. After the purchase, the customer is "locked" into the selected vendors "total package" solution.

In this climate, the vendors keep selling, and the healthcare industry keeps buying, and often the buyer is left "working around" the inadequacies. Year after year there is the promise of newer "open architecture" systems, but they never seem to make it to the show floors. What we often see is new brochures, new materials, new features and new user interfaces, usually tied to the same old "tired" core architecture.

I have been observing this phenomenon for the last nine years. It amazes me to this day how slow progress has been towards providing some reprieve or alternative.

Vendors are getting rich selling overpriced solutions that often don’t even address the most obvious requirements of medical office management systems. If they do, it is under the vendor’s terms, with a "once you go with us, your stuck with us" attitude.

The major players are quite literally duping the industry. They have been around so long that they are viewed as the "experts to listen to". In reality, these overpriced systems are often "legacy" or "older architecture" systems, written a long time ago, with a Graphical User Interface put on to make it look "Windowish". Sad but true!

Many of these systems, when you drill down past all the hype and marketing are similar in their "closed" nature. By this I mean that they do not integrate well with other systems. The primary reason for this is most often the underlying architecture. These systems have been written using older software technologies that are hard to adapt without major rewrites that are expensive and slow to market. Another reason is that by keeping the industry believing "this is the way it is" allows these vendors to market "only their products" to their customers once they are "hooked in".

My voice may sound harsh, but it expresses the frustrations of the many CIO’s and Medical Group Managers who suffer with the decision of what to buy. There is so much confusion, misinformation and ignorance in the healthcare information industry. Sometimes it is really sad to speak to some of the unhappy prospects or victims.

At a time when the intelligent application of relatively inexpensive and easily integrated database systems could serve an industry so well, why do we see the "old" way persist? Why is the industry still so driven by legacy systems? Why have not fourth generation language based, wide area networkable, true multi-dimension relational databases and open architectures proliferated the market? The technologies have been around for some time, just not in healthcare systems (at a reasonable price).

The answer is simple, money, greed, and ignorance. The vendors say "If we can get rich selling overpriced products to a technology starved industry, we should". There is no motive by the vendors to make healthcare more streamlined. They are being unfair to the industry, adding unnecessary cost and confusion. I have never seen such a vendor driven market as in healthcare information systems.

The U.S. healthcare industry stands at a critical juncture. While facing a significant increase in the number of customers who will need to be served, the healthcare industry is being tasked by the nation to increase the quality of results, to be accountable for outcomes, to provide accurate measures of success, and to accomplish all of these with lower costs.

Information technology can and will form an essential role in the resolve of this challenge, but only when the industry gets involved. It is time to speak out and start letting the industry drive the vendors rather than the reverse. It is time to say collectively "Enough is Enough!".

By my observations, the time has come where the healthcare industry is entering the information age. There are beginning to appear bright rays of hope from intelligent and forward looking companies. These newly written (within the last four years), cleverly designed systems are based on modern software technologies. In the same way IBM opened up the architecture of the PC and fostered a revolution in the computer industry, so will these new players impact the healthcare information market.

These systems are based on true open architecture and multi-dimensional relational databases. As such they allow for ease of portability and integration. They allow for data sharing and migration. These "open architectures" allow standardized query methods and data sharing. Automated and integrated functions can easily and naturally occur (as they should). Products from different vendors can be seamlessly placed together, each to perform it’s respective area of expertise.

With the ability to support centrally shared data warehouses, true master patient indices, and standardized data portability methods, systems can finally pass information from application to application, or from platform to platform. With active X controls, SQL, HL7, and vendor supplied API’s (Application Program Interfaces), tools from different vendors can be easily integrated and perform together, in harmony.

This new breed of available systems has an advantage that will kill off the "legacy" solutions that have been the sole option for so long. With ease of modification and integration, "best of breed" products can be placed together easily by systems integrators. The need for "re-invention of the wheel" each time will be forever eliminated. This translates to quick time to market.

With this fast turn around, functionality can finally be user driven rather than vendor driven. Customization, added functionality and lower prices will be a natural outcome. More and more of our technology hungry healthcare institutions will finally gain access to systems that cater to their needs at a price that is approachable.

This new breed of products, as they gain acceptance into the industry, will alter once and for all the way medical information systems are evaluated and purchased.

Having open architecture systems based on relational databases, in a fourth generation language will allow CIO’s and medical groups looking to purchase software, to more readily seek out the integration of "best of breed" sources. Finally selecting suites of software that make sense to their practice rather than being forced to make one "major" decision putting them at the mercy of one "sole source" vendor. This will foster a new accountability to every vendor.

If you are frustrated with the whole prospect of buying a system and look towards outsourcing as a solution, be equally aware that the billing service you select faces the same system selection and purchasing issues that you do.

Insure that the system your billing service utilizes is also secure, open and wide area distributable. This will insure that you can readily access the system from your practice. It will also insure that you can utilize it’s "in-office" features such as appointment scheduling, queries and reports, on-demand statements, C4’s, on-demand statements, encounter forms and the like.

These systems will allow you to slowly absorb functions into your office such as patient demographic entry, cash and co-pays, eventually charge entry, leaving your billing service to do the claims processing, statement processing, and follow-up. These tiers of service can only be facilitated if the core architecture of your billing service system is open, and based on a multi-dimensional, partitioned and secure data architecture.

Eventually you may want to take your billing back into your office (in whole or in part). If your billing service utilizes a system that is based on these technologies, migration of functionality from their office to your practice can be easily facilitated.

New technologies of this dimension are emerging at a rapid pace in healthcare. Pay attention to what "was" versus what "is". Look closely at the new vendors. Pay attention to the details. Learn the questions to ask. Ask what the software was written in. Ask about the core database architecture.