The Seven Seeds Deadly Sins of EMR Success
December 27, 2012

After some forty plus years in the healthcare IT world, and reading Vince Ciotti’s extensive history of
HIT published in HISTalk during the past year, I asked myself, “What have we learned? What does it
tell us?” Or is it just the ramblings of old war horses that can’t stop running down the history trail.
From my forty years in the trenches coupled with Vince’s extensive anthology I’ve distilled it down to
two simple rules:

1. HIT/EMR  buyers just love the fair haired boy, or new glamour model, and
2. Like all glamour models, they have an on runway life of about a decade.

Just look at the history, decade by decade (my apologies to Vince for the being so brief).

Decade                              Glamour model
            1960’s                                IBM
            1970’s                                SMS (Siemens)
            1980’s                                Technicon (Alltel/Eclipsys)
            1990’s                                HBOC / McKesson
            2000’s                                Cerner
            2010’s                                Epic

These vendors were/are the dominant top tier vendors in each decade, not necessarily in terms of
the largest number of installs, but when a major vendor selection was made during that decade, it
usually went their way.  Then after about a decade they start to stumble, not collapse, but stumble
and it’s downhill from there.  Well maybe in some cases preceded by a long plateau, but soon
enough they hit the down slope. Some hit it faster and harder than others, such as HBOC, others
have a very long and slow downhill run, like Siemens (SMS).

Glamour models don’t blossom overnight. It took SMS maybe ten years to hit their stride and HBOC
at least twenty when you include the life cycle of the companies they acquired. EPIC, our new darling,
and Cerner started in the 1980’s. Not surprising, it takes at least a ten or fifteen years to blossom.

Of course there were/are many second and third place vendors such as McAuto, Saint, Baxter, and
the various mini system vendors. And there were ones that stayed away from the top tier of the
market and focused on smaller facilities, like Meditech and CPSI.  

Now why is it that the top tier glamour model always seems to fatten then fade? Why couldn’t IBM,
SMS, Technicon, McKesson, hang on to the brass ring for more than a decade? My theory is their
demise is in the DNA of HIT/EMR. Nothing lasts forever, least of all top tier HIT companies.  They are
destined to sow the seven seeds of their own destruction, which are:

1. Constantly changing regulations.
       The plethora of health care regulations is innumerable. It all started with Medicare
       and its complex billing and reporting in 1967. Then TEFRA, Price Controls, DRGs,
       CHINS, RIOs, JCAHO, FDA, CLIA, HIPAA, FLSA, and on and on.  Today it’s MU, ARRA,
       P4P, ACO, HIE, ACA, EBM, Outcomes, and more to come. And that’s not to mention
       the many state and local regulations starting with Medicaid.

       All these mean more software modifications and updates. Every update will generate
       at least a dozen bugs that will come back to bite you when you are least prepared.

2. Moore’s Law
       The law has been great for hardware, maybe not so great for software developers.
       Just about the time our glamour model has everything together out comes a new
       style (technology). Remember mainframes, minis, micros, dumb terminals, lunch
       box computers, notebooks, client server, peer to peer, thin clients, fat clients, chubby
       clients, internet, web based, PDAs, and so it goes. That’s just the hardware. Now add
       to that a tsunami of software languages and tools. IBM promoted at least twenty
       languages and core development tools during its healthcare reign. Oracle and
       Microsoft are not far behind.

3. More installs equals more costly support
    As the successful company grows its geographical foot print grows and meanwhile it extends
    its application portfolio. All this success makes for more complex and costly support. Things
    are bound to go wrong, and the market will hear about it. It starts with small pimple, then some
    wrinkles, and then grows into lesions. The only way to slow or stop the pox is to significantly
    invest more in support, fix code problems before they fester, increase quality control, or maybe
    do a full rewrite. That can take tens of millions of dollars and decades of years as witnessed by
    Siemens (Soarian) and McKesson (Paragon). And all are non-revenue generating (see the
    capital seed).

  4. Medicine – science or art or both?
    Information technology to automate the science piece can be complex, yet it’s more
    straightforward than applying IT to the art component. Then add to that the ever changing
    nature of medicine. The majority of today’s protocols, procedures and medications did not exist
    ten or fifteen years ago. Medicine is a moving target and the information it generates is orders
    of magnitude beyond 1980. Changing medicine also means more enhancements, more
    support, and more fixes.

  5. Pursuit of the perfect design becomes no design.
    Some firms get mesmerized by the latest tools then get caught up in the perfect design
    syndrome. While they are immersed in designing the perfect evening gown, the glamour model
    is sent down the runway half naked. Technology perfection becomes the enemy of good.  
    Then after missing too many delivery dates, their back is against the wall and they fall into the
    next trap; ‘Code now, ask questions later.’ It's all down hill from there.

  6. Need for capital, or who’s in charge here?
    To keep your systems up to speed and address all the mammoth medical, regulatory,
    operational, and technological changes you need capital. There are only two ways to get it.

    From profits (via more installs- see seed 3), and that gets more difficult as you grow and deal
    with size and industry changes. The second is from investors, either private of public. If you
    prefer private investors there may not be enough sources. The public stock route has its own
    unique problems. To keep feeding this monster you’ll need more and more investments. But
    after your outside investors are on-board it’s not uncommon for them to have a change of
    vision /plan /agenda. It’s a marriage, and like some marriages you won’t know your
    real partner until the honeymoon is long over.  

  7. Pride before the fall.
    As the glamour model nears the end of the runway her eyes are blinded by the light and her
    head is in the clouds (no pun intended). So much so she loses her footing and falls off the
    stage.  In the HIT world this is usually described as ‘marketing got way ahead of development’.  
    As an old friend once told me; ‘When you start eating your own marketing b.s., death can’t be
    far away’.

Any one of the preceding can be assigned to any of our past leading models and in most cases more
than one. Any one seed can be the beginning of the end with some more deadly than others. Usually
it’s a combination of several that cause our glamour model to fall off the runway.

At this point you may ask, ‘Who will be the glamour model of 2020?’ Stay tuned for the next chapter
you may be surprised.

(Too read the full ‘HIS Story’ covering over 50 HIT vendors go to

Frank Poggio
                 The Kelzon Group

All rights reserved.

This article first appeared in
HISTalk on 01/02/2013

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