Is there such a thing as international in Healthcare IT?

When I talk to investors, one of the most common question about healthcare IT is “how international is HIT”. The background to the question is of course simple: can you scale an HIT business beyond national boundaries or is the ceiling to growth what used to be the border bars before there was Schengen?The answer is simple. And complex. Almost like in real life.

It is simple, because in theory it should not be a problem to take a healthcare IT solution international. At the end of the value chain there is always a patient. There is always biology. And that is, with all its complexity, variability and unpredictability, the same wherever you come. It is complex and difficult everywhere. But it is the same complexity and difficulty everywhere too. If the French, the Germans, the Australians, Americans, to name but a few from which I have heard it, say: “we are so, so different!” – the truth is: they are not. Clinical practice, in my experience, is sometimes more different between one hospital and the next, between one ward (or senior physician) and the next, than it is between one country and the next. In other words, the true workflow differences are nominal in reality.

But then, why has hardly any EPR company achieved to go global? Why is there almost not a single seriously global platform? Even those, that earnestly tried to take a one-platform-strategy global, in all reality have failed. They may be in a handful of countries but have stopped to go further. Some are even backtracking. The companies that actually have a more global footprint – they do not have a one-platform-strategy. More a type of one-platform-per-country-strategy. Which gets us back to the question of why does it seem to be so difficult to go global?

The hidden reality is that it is not clinical practice, patient safety or workflow efficiency that drives EPR adoption. It is, sad and sober truth, reimbursement regulation. No hospital can run without being reimbursed for its services. And a hospital that does not comply with the way reimbursement is handled in a country, will not be able to live. Easy to comprehend.

Every country however – sometimes even different regions in the same country – has a different reimbursement system. Case based, DRG, volume based, KPI based, fee for service, mixtures of everything, you name it. Even the same thing is not the same. DRGs are to be found in most countries. How to calculate them however is different again wherever you look.

As payment for medical services is the textbook classic for a principal-agent-dilemma, what regulators do, in order to retain a level of (perceived) control over incoming bills and their relation to services rendered (note: not quality delivered), is to increase the documentation requirements to an ever more complex and detailed level. It is almost an arms race: helped by digitalisation, documentation has become easier, which led to regulators to ask for ever more documentation. Of course clinicians blame that vicious circle on EPRs and their cumbersome documentation routines. However, the real challenges comes from the reimbursement driven statutory documentation requirements, which are different in every country, unpredictable and grow in random pace and random areas – which makes it so difficult to bring structure, reason and simple workflow concepts to bear. The complexity is such, that not even flexible template tools are enough, architecture matters! Where cases are enough in one country, case sub-segments are needed in others.  

Now, back to the question of internationalisation. If my theory is true and reimbursement drives documentation routines, which drive workflows, which drive layout and customisation of EPRs, then it is very difficult indeed to internationalise an EPR. You would have to design a catch all architecture and granular datamodel with a very flexible workflow and template engine and at the same time hardened rigour around design principles, terminology and data concepts. And then it would be possible to have one platform for the world. In theory not a problem. In practice however… in practice all EPR platforms have been built for a home market with all its design decisions and restrictions, and then, because they work well, you try to take it global. That has proven very tough to anyone who tried.

There is another truth in this though. The further you stray from billing rules and reimbursement-driven documentation, the more consistent workflows become across country boundaries. Departmental systems that are very close to the reimbursement cycle are still almost as local as EPRs usually are. Theatre solutions, A&E and the like are still very local businesses. Yet procedures, that are not really part of the reimbursement calculation, like imaging, labs, cardiology, and many other specialties, are areas, where systems become more and more international and even global.

The answer to the question hence is simple: if you have a catch-all datamodel with a powerful and flexible documentation engine, internationalising an EPR is possible. If you designed it with the end in mind. And provided you acquire the necessary local knowledge on reimbursement requirements and intricacies.

If you work in specialty areas, whose workflows are a distance away from billing cycles, then you can deploy global best practices much more easily. And clinicians, who are otherwise hesitant to change their workflows, will be interested in how to improve their processes. When billing is not impacted, clinical practice actually does become innovative.

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