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Re: [Gnumed-devel] Re: Gnumed-devel Digest, Vol 91, Issue 51

From: Jim Busser
Subject: Re: [Gnumed-devel] Re: Gnumed-devel Digest, Vol 91, Issue 51
Date: Sun, 27 Jun 2010 13:57:21 -0700

On 2010-06-27, at 11:15 AM, richard kim wrote:

> Setting up a server-fat client model can be difficult for physicians, even 
> just to experiment and test the product.

Richard makes excellent points, but if I remind us of the iPhone, iPad and also 
Android it is not all about "the browser" because increasingly "there's an app 
for that".

Let me come at it from another angle as to how decisions get made:

1) doctors as employees:

        Their paradigm *could*, from freedom of worry over fee items, be built 
around patient outcomes but such doctors are often voiceless to *define* the 
outcomes and how to best achieve them. That includes the software selection(s). 
Software choices are made by senior management (or in a public system, the 
government) based usually on business operational measures deemed important. 
The US VA's Vista may be among the few exceptions.

        Do we think that browser vs non-browser based will affect the above 
choice? I suppose it might, if an IT Department would regard it easier to 
maintain. There is also the question of how to get such doctors to argue for 
better software than what their employers choose. Employers, however, tend to 
require one-size fits-all software for all their employees.

2) doctors as self-employed:

        Self-employed doctors become driven by the revenue model for their 
"business". Their definition of success becomes "income > expenses". The payer 
is typically *not* the patient but, instead, a government or insurer which will 
pay (or withhold to pay) based on "allowed activities" rather than value 
(outcomes). Doctors having any choice over their own activity will sub-select, 
from what is available to them, activities with the highest payment-to-cost 
ratio (where cost is time / risk / unpleasantness) in preference to lower-rated 
items until the the latter either cannot be ignored, or until they are all that 
remain. Revenue maximization, and "charge capture", become the drivers, 
typically unlinked to the provision of quality care, which explains current 

Ironically the billing software for many doctors is single-user or (if it is 
client-server) fat client, local server. Doctors mostly leave the billing to 
the non-doctor staff who, not having to access it from outside the office, do 
not as much need web-based. But I most doctors have a poor understanding and 
will ask "why can't it be in a browser" and then desire to just use any 
malware-loaded, coffee shop machine to log into their patient database.

-- Jim

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