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©2018 BY ERIK ON MEDICAL INFORMATICS.

Medical Software is Hard

August 29, 2016

 

Software developers and entrepreneurs think medical software is the same as any other kind. They set themselves up for heartbreak and me for smugly chuckling.

 

Healthcare has long been considered an industry in desperate need of software magic. When I was young buck it seemed that software for healthcare was 15 or 20 years behind the rest of civilization. As the first internet boom was cranking into high gear and we were learning the rules of web browsing, our hospitals were the realm of “roll and scroll”. Don’t know what “roll and scroll” was? Never seen the ass end of a terminal crackling with green phosphor madness? You’re young, so very young.

 

Anyway I’m exaggerating because “roll & scroll” terminal applications were the advanced stuff. Most relevant clinical information, the data about patient conditions and treatment and the key to successfully diagnosing and managing those patients across a long and complicated healthcare process, was on paper. Not legible laser printed paper either. Nope, we wrote that data into paragraphs using handcrafted ballpoint pen technology. Sure some systems like lab and billing were computerized and some places even had electronic medical records. But we were behind, way behind and everyone knew it.

 

Then in the late 1990s I read an article in “Wired” magazine about Jim Clark, one of the founders of Silicon Graphics and Netscape. He was starting a new company to do something about the primitive state of medical software. I don’t recall many of the details but the takeaway was that the reason medical software was in such a state was because up until that point, only dopes, fools, idiots and lunatics had worked on it. Now that Jim Clark and his fellow geniuses were on the case, they should have this all wrapped up lickety-split. I imagined him clap-swiping his hands together as if shaking off the dirt from a job well done.

 

I didn’t get the impression these guys knew much about healthcare or the specific challenges of making software for it, but I understood they were smart and well financed and I figured they would do what they said. They intended to start by streamlining insurance something or other. I kind of zoned out at that point because it was not a problem that interested me and struck me as a bit of a punt. Still as we all know and history records, the company he founded, Healtheon went on to solve almost all the problems in healthcare and dominates the industry to this day.

 

Or rather, it completely failed to do anything like that.

 

Around this time I was working on my own entrepreneurial dreams. I was focused on transforming the medical record from a set of stories into a well-modeled data structure. I was enthusiastic, optimistic, and naive and I believe all of these are necessary to being a successful entrepreneur. I was also quite easily swayed by the confident pronouncements of more experienced…well, anybody. When I would present my proposals and early designs and sad little business plans in their clean grey binders (back then I believed it when people advised me to write business plans) the older experienced guys with the money would tell me that if this were valuable or if this were possible Microsoft would just do it so give up. I mean quite literally they recommended I  give up. That’s what people said to just about anything back then. Microsoft was the dominant company  and they employed a critical mass of the worlds software geniuses (ask them; they’d tell you). If you had a good idea, better keep it a secret cause if Microsoft got a whiff they’d do it themselves before you had a chance to print a sales brochure. I protested to an older potential investor/partner that Microsoft lacked the domain expertise and couldn’t just do what I was working on. In frustration he exclaimed “Oh, c’mon, Erik!!!”. I never felt quite so put in my place before or after. But he was right. Microsoft had all the genius of Healtheon and a track record of creating great software and entering and dominating new business domains. Healthcare in the late 1990s and early 2000s was recognized by everyone as the next big software goldmine. Microsoft got into it and using their hordes of superior developers and dominance in computer operating systems they were able to…do jack shit.

 

Of course years later they tried again and, uh, jack shit again!?! Third times the charm? I’ve lost track. It’s 2017 Microsoft has lost its luster. Who are the super genius software monkey ranchers (or whatever they are called) today? I know it used to be Google. Is it still Google? Surely Google Health had some…oh right. My group actually had a meeting with the group at Google that was taking the second (or third?) swipe at healthcare. It was run by the guy who knocked it out of the infield on their Facebook killer. My impression of them was they were the perfect expected blend of arrogance and aimlessness. Maybe they fixed healthcare. This wasn’t that long ago and I’m just bitter because they didn’t want to work with us.

 

I was in contact with a guy who was the first engineer at Skype and was investing in healthcare. I did not dig his idea for his startup and declined to participate. I caught up with him a few years later and he sounded like he had PTSD from the experience. He said he would never start a healthcare company again (though, now that I think about it, I think he was investing in one which is how I happened to get back in touch with him but that really kind of detracts from my point. For the purpose of this blog post the guy was traumatized, ok?).

 

After I shut my own startup down I was looking for a job and my Y-combinator alum pals got me in touch with some healthcare oriented startups. I had some interviews with some swell kids, most of whom had no background in healthcare but had faith that new software development methodologies and lean start-up and Y-combinatorism would enable them to fix this healthcare mess. I demonstrated my own software for one of them to show my technical chops and because I am proud and wanted someone to say “my god, man, you’re a genius! How could this have failed?” Of course no one said that. They said “Oh yeah, they were really amazed you were able to get that to work”. I was still looking for a job and I’m a professional so I said the following only to myself in my head: “Amazed I could get it to work? You arrogant pups! You have no fucking idea what you are doing and you have the nerve to patronize me? And I have to just take it because I am looking for a job and you are riding a wave of loose investor funding and Y-combinator hype?”.

 

So yes I just stood there and took it and went home and kicked the dog (I kid, my dog died years before). I forgot the name of the company. I don’t need to remember it. They failed. I don’t even need to check.

 

So anyway, it’s 2017 and a succession of software geniuses with immense funding and prestige and hype have been working on the problem of "medical software sucks donkey balls" for 30 years or so and the dominant software in the US market is one that was written back in the 1970s on MUMPS. Even that is only the case because the government bribed everyone to start using electronic medical records. If you allowed the users of the systems to choose their own tools they would probably vote for pen and paper (old people) or word processors (younger people). It makes no sense. It’s like a huge cosmic level running gag. Everyone is motivated to solve the problem. Insane level smart people work on the problem. Minor progress is made. People are irritated. Where is the Excel of healthcare? Where is the iPhone of healthcare? Where is the Amazon of Healthcare? Where? Why? Please explain.

 

All I can say is, medical software is hard. In followup posts I’ll provide my opinions about why this is.

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