Home Forums Discussions General Discussion Does the new company affect AC in a good way? bad way?

All living systems are required, as a condition of being alive, to reverse the second law of thermodynamics and decrease entropy locally-- as long as there is a supply of energy from outside the living system.

So, necessarily, a fundamentally simple, functional system like Amazing Charts will develop increasing complexity as time and energy do their work.

In the Saga of Amazing Charts we are experiencing the inevitable development of increased complexity, resulting in a desirable increasing functionality. As in all complex systems, this process will finally pass some limit of decreasing marginal return on the energy investment-- at which point functionality will decrease and finally the whole system will collapse back to a simpler state. Pri-Med is essentially an additional external source of energy, allowing the system to increase complexity, and in the short run, functionality.
In my opinion, it is less important that Pri-Med be a good fit (which is hard to imagine, since that organization is really a pharmaceutical marketing scheme, not a tool for improved medical care) than the liklihood that it will drive AC to a level of complexity beyond the marginal return on energy invested.

At that point, conventional thermodynamics takes over and the Second Law operates as usual. (See Joseph Tainter, The Collapse of Complex Societies) http://www.amazon.com/Collapse-Complex-Societies-Studies-Archaeology/dp/052138673X

There is a reason why cyanobacteria are the most successful group of living things on earth -- they have just the right amount of complexity to adapt to any situation. Of course, beyond that, they aren't particularly interesting or beautiful, like people, for example

Pretty fascinating concepts in Tainter's book (read some excerpts on Amazon preview), Tom. I wonder whether parts of a society (i.e., our healthcare system), can become so complex as to experience the same decline? Would explain a lot of why increasing successes in medicine also is leading to its failure to deliver value.

John--

There is no doubt in my mind that a complex system like "western civilization" doesn't just collapse in one piece, and all in place.
Parts of it are quite resistent -- they are very conservative, like cyanobacteria, and will not reach the limit of complexity.

Other parts, like the medical system just can't continue to function in a "business as usual" manner. It's anyone's guess how it will play out, but when 20% of the GNP is devoted to an enterprise that produces worse results than any number of other societies -- at 2 or 3 times the cost-- it doesn't seem like it can continue.

Of course, I said that in 1975 when people were complaining that medical costs were 8% of GNP and employer-based insurance was far more secure. So my sense of the timing of the collapse is not correct.

Tom

Interesting discussion. And, I probably know less about the overall macroeconomics of healthcare than anyone. Any while pharmaceutical companies and insurance companies are a huge part of the problem, there are many, many small things that add up. Except for poor reimbursement and prior authorizations for prescriptions, MaineCare does little to curb costs. You could order two MRIs and a CT scan in one week, and MaineCare will cover it.

A classic example of a misuse of the system, which happens all the time is a patient with Medicaid (I am not trying to single them out -- it just doesn't work the way I am describing with private insurance)calls out office at 12:30 pm because her daughter has hives. We give her a 3:15 pm, but she can't wait that long. So, she goes to the Walk-In Care where they diagnose her with hives, prescribe Benadryl (which is covered) and do a Pertussis swab. She then drives over to the office at 3:15 pm thinking it may still be open so she can be seen so "I can explain the cause of the hives better." Now, when she went to the WIC during office hours, WIC calls for a referral. We, of course, refused to give it, but WIC has to see her anyway. Even though WIC will tell them they will get billed, it is illegal to charge MaineCare for anything. MaineCare will possibly send a letter teaching them, "how to use the healthcare system better."

I know this is a outdated term, but we really need to get some tough love in these situations. WIC, simply, should refuse to see them, or if WIC deems the visit not urgent, the patient should be required to pay.

We are supposed to be working on that one in Oregon, with the Coordinated Care Organizations -- which aim to "transform the way medical care is delivered". We'll see.

The biggest driver of cost is our insurance system -- which guarantees complete non-transparency of cost, and which insulates both the doctors and the patients from the financial impacts of their choices, except in that grand lottery of the Medical Malpractice system.

As you noted, it isn't just medicaid -- until recently, employer based insurance didn't charge any co-pays for ER use, just like Medicaid. People would go to the ER for a sprained ankle because it was covered -- not to my office, where they had to pay. It is a little different now, but not much. Now, the ER costs something, but it is perceived to be more convenient. And of course, the ER tells them they must follow up with an orthopedic surgeon, but of course, they need a referral, so they have to come in to our office for the referral. This is the sort of thing that I mean by the "decreasing marginal return on increasing complexity."

But we all know this -- and it is totally resistant to change, because there are so many vested interests.

Of course, the ED will also tell them to follow up the next day for conjunctivitis.

I always thought the best way (though not very workable) would be to only allow ED docs to write one days of antibiotics for sinus, ear and throat infections. Or give a sample. Then the patient would HAVE to come to the office the following day to get the remaining nine days. It wouldn't take too long for the patient to figure out, I guess it's sort of stupid to go to the ED, wait four hours, get diagnosed with an ear infection by someone who is seeing you at 2 am, doesn't specialists in looking at ears and probably doesn't want to piss you off after four hours. Then, have to go to the doctor anyway. Of course, for things like cellulitis, it would be different.

The factors leading to the higher costs and worse outcomes are diverse however it appears in the short term the 'fix' on the cost side will be on our backs.
Does the PM/AC merger have any impact on the cost side? Not likely.
On the outcome side maybe some better integration of best practices into the flow of documentation and plan but if you are like me anything that slows me down is not looked upon too favorably.
I somewhat anxiously await to see where the merger takes AC, no popup infomercials PLEASE!

I read the above insightful posts with interest, and was tempted to jump in on several occasions. I decided to wait until the dust settled a little and I had a bit more information. Yesterday at the Baltimore Pri Med meeting, a group of us had a chance to speak with Jon Bertman and representatives of Pri Med (including Dr. Marc Mossier; I was late so unfortunately I didn?t get the names or roles of the others there). Now I feel more comfortable weighing in. For those of you who have spent any time talking to Jon B, some things have not changed. The discussion seemed to be as open as above board as it always has been in the past. Hopefully the Pri-Med people are equally comfortable with this approach.
I will try to summarize some of the facts we heard (which as usual, are colored by my own opinions). If I get anything wrong, I am sure that someone will step in and correct me. Hopefully others that were in attendance will add their take.

We heard something of the history of Pri Med (which has some interesting elements) and little about their parent company (to briefly paraphrase? ?they will leave us alone?). Jon B?s explanation for the sale to Pri Med is on the AC site, so I won?t repeat it. The financial viability of AC was never an issue, but the hope is to gain resources from the acquisition that will allow AC to a). better address challenges in program development, and b). better deal with logistical issues related to meetings (ACUC and regional conferences) and marketing/sales. The latter would occur by accessing the Pri-Med program network.
There was some discussion about ?what?s in it for Pri-Med?. I think that some of us are still a bit hazy about that. Of course it isn?t our business, so we don?t need to understand it in detail? but some of the skepticism comes from our concern about their use of our patient care data in AC. Some of those concerns were allayed with two statements from Drs. Bertman and Mossier:
1. We will always have the choice to share or not share our data with the company. In fact, to do so will require us to proactively ?opt-in? (as opposed to information gathering unless we opt-out).
2. The information we do pass on will never be shared with anyone outside of Pri-Med. Not with pharma, not with their parent company, not with anyone.

For those of us who are waiting for some delayed program improvements, the good news is that there will be a version 6.5 released ?probably in late January? that will incorporate a few long requested changes. These were not detailed at the meeting, but the one that I am most excited about is a new letter writer that looks to be a significant upgrade (and may represent a fix to perhaps the most longstanding complaint on the AC board). There are other improvements as well; I am trying not to steal too much of AC?s thunder. The bad news regards practice management; the summary on the release date is ?no time soon?. Jon B. said he plans to make an announcement about this in the near future.

In summary, I think it will be some time before we really know how this acquisition plays out for us, as users. We heard that pricing will not change, our data is secure, the direction and culture of the company will not be affected, customer support will remain strong and perhaps improve, and product development will be accelerated. Jon B. didn?t sell to a bigger EMR company (which many of us dreaded) and in theory, Pri-Med should be a good partner (well, owner, actually). What we are hearing generally sounds good; let?s hope the reality meets the promise.

Hi Jon,

Thanks for the update. Your insights and perspective are greatly appreciated!

Gene

I think Jon's post above is an excellent summary of information presented at the Baltimore meeting. One thing that I would add is about what is in the deal for Pri-Med, and the impact that it may have for our future.

Pri-Med's business is providing medical education at low cost to providers. This has been possible because much of the funding came from the pharmaceutical companies who paid for exhibit space and sponsorships. The pharma revenue stream has shrunk dramatically. So, if PriMed is to continue, they need a new source of revenue. They have connections to a network of over 200,000 providers who have attended their CME programs. They now have acquired the EMR with the highest satisfaction rating, and they intend to promote it. Software development cost is the same whether the program has 1000 or 100,000 users. Thus, the purchase price can stay reasonable, but the return for AC/Pri-Med should go way up if many providers buy AC.

For existing users, this will give us strength in numbers. There have been discussions about whether AC would continue to be viable going forward with all of the coming changes and pressures. A large user base, providing cash flow, makes it much more likely that AC will have the resources to continue to adapt and succeed.

Only time will tell how this aquisition plays out. I think all parties realize that much of the strength of AC is the open, fair and reasonable atmosphere that Jon Bertman has created, and a loyal user base. Although we may gain many more users, I hope these core principles can be maintained. It is a culture that is all too rare in today's world. I know that I am not alone in feeling like AC (especially this user board) has given me back a sense of belonging to a medical community of like minded individuals where we can share and help each other. It may be a virtual community, but it is incredibly important. And, with our local user group,we have a real community.It is to AC's credit that open dialogue is encouraged, even when things are not smooth sailing.

And, yes, PM has been greatly delayed, and we have all been disappointed by that. It is a very complex undertaking, and I think it was underestimated what resources would be needed to accomplish it. Hopefully, the additional resources provided by this merger will get it to the finish line.

Thanks for your comments Donna and Jon. You have brought much greater clarity to the whole situation. Overall, I'm hopeful and encouraged. Even on those days when I'm frustrated with some AC glitch, it's nothing compared to the hassles associated with our hospital EMR (I still care for my patients in and out of the hospital).

The cautious part of me agrees that while software development costs will not change, the more users, the more support will be required. Supporting 1000 users vs supporting 100,000 users is a significant difference. [my 2 cents... or less]

Yes, Les, they addressed this, and have the intention of upscaling staff to meet the need. Hopefullly, they can keep up to maintain the level of support that we have enjoyed. Implementation of rapidly adding and training support staff will be key.

They also intend to use the regional Pri-Med venues to hold AC meetings for training. This will allow users across the country to attend, versus ACUC which has always been held in the northeast.

It is unfortunately easy to grow yourself out of a niche market. I would feel much more reassured if AC had sold itself to a larger software development firm than to a company that does educational programs. The only expertise they got for this was in marketing. Software developers don't grow on trees, and new ones don't hit the ground being productive as they first have to educate themselves on how the package works. Code is a language, and different programmers "say" things differently. (I have had to hire help for development of parts of my own software, and most of his time was spent figuring out how I had written the code in the first place).

I worry about small companies getting ambitious. "The noble Brutus has told you that Caesar was ambitious; if it were so it was a grievous fault, and grievously has Caesar answered for it...."

"I had rather be first in a village than second at Rome" (Julius Caesar)

Yes, I never understood the combination of Pri-Med and AC. I think the merger of Medisoft or Lytec with AC would have been a match made in heaven.

I also agree wtih David and John as I do not wish to see AC continue to grow and move out of the niche market THAT IT CREATED.

I think David's point is very valid as what AC needs now is top notch programmers. The hope is that the returns from marketing will provide the funds for such.

I think Bert's point is also a good one, that rather than trying to create PM from scratch, AC perhaps should have partnered with an existing PM program. I am guessing that it may not have been possible to find a company with the right mind set for JB. I love Lytec (which I use now), but it is owned by McKesson.

The harsh reality is that we all grow or die, and I think that that is choice AC faced going forward. It needs more users to be viable. I'd like to be 30 again, but that's not happening either..... We are all uneasy, but hope for the best.

Hiring developers is both art and science. With the advent of social coding (ala GitHub), there is much more opportunity to assess their work product, how they document their code, and even how they take feedback/critique.

My guess is that part of how Pri-Med will help AC is bring in some outside development expertise to review process, resources, logistics, infrastructure, and execution. A fresh set of eyes and perspective can be a game changer.

The fact that they have switched from a massive undertaking (v7) to a incremental release to pick up several languishing issues is very promising.

This would be a good time for AC to re-think the whole re-invent the wheel PM approach from a business perspective. AC and their users might be better off if AC got serious about interfaces or integration for PMs. I can think of a few RCM companies who would welcome AC collaborating so that the practices get what they need.