I turned down offers from 3 large healthcare systems to become their Chief Medical Informatics Officer and walked away from a blossoming health tech startup that I had founded to return to life in clinical medicine. I reached this difficult decision just over a year ago. Before that, I was spending most of my waking hours writing code with one foot in San Francisco and the other in NYC.   The differences between startups and hospitals are dramatic and have their roots in organization (or lack thereof).


1. If hospitals were run like startups, electronic medical records such as Cerner’s Powerchart and eClinical Works would be laughed at, not adopted.
(I recently counted how many mouse clicks it takes to write a patient note in  Cerner’s Powerchart. Each “progress note,” of which physicians can write two dozen or more each day, takes about 250 mouse clicks to navigate (not including the textual content of the note!). A “history and physical” takes about 350 clicks to document — this again does not include the actual textual content of the note, just navigating awkward menus.
(Would anyone use Facebook if updating one’s status took 350+ clicks?)
2. If hospitals were run like startups, they wouldn’t adopt software so poorly designed and non-intuitive that it takes months to train people how to use it.
Can you imagine holding a week-long training course to teach employees how to use an iPhone, hiring a team of full-time employees to “support” these captive users, and constantly reinforce how to use tragically chosen hardware and software?
3. If hospitals were run like startups, there would be transparency in how organizations operate and how decisions are made.
Scrum would be the name of the game, and yes, even the Scrum Master can be overthrown as spectacularly as the most entrenched Middle Eastern dictator.
I speak from personal experience both as a startup guy selling hospitals software, and now as a hospital employee, when I say that politics frequently predominate an organization’s decision to purchase particular enterprise software. “IT committees” don’t choose the best piece of software for the job; much of this decision-making is based on kick-backs and sales that lead directly or indirectly to an individual(s) gains.
(The authors have no conflicts of interest to declare.)
4. If hospitals were run like startups, decisions regarding the implementation of technology in the workplace would be made by experts and thought leaders.
Instead, this critical task is relegated to IT committees headed by retired nurses and physicians with little to no grasp of how modern web and mobile technology works.
5. If hospitals were run like startups, no one would hesitate to invest in sound software and hardware because this is the highest-yield investment an organization can make in the year 2015.
6. If hospitals were run like startups, they wouldn’t spend hundreds of thousands of dollars for enterprise software only to realize a few months later that it doesn’t run on any of the hospital computers. 
(Yes, I’ve seen this happen. Seriously.)
7. If hospitals were run like startups, personal merit, not seniority, would determine who is allowed to call shots. 
8. If hospitals were run like startups, machines would run Unix-based operating systems.
Many hospital PCs have not been upgraded in decades and still run Windows XP (or older versions of Windows).
Yes, I’m serious.
(why Google when you can call the Operator?)
9. If hospitals were run like startups, they would nourish and celebrate innovation from its employees.
Large companies like Google and small startups alike give their employees ample time to learn new technologies and cultivate side projects.
Realizing how inefficient one hospital’s current paging system is, I started writing a web app while working the night shift to make this process more efficient. In that particular hospital, nurses randomly page one of the on-call MDs at night, ask if they are responsible for patient John Doe, and hope that they reached the correct physician. The page consists of a 4-digit “callback” number that gives no information on how emergent or non-urgent the call is (which is important in hospitals, as you can imagine). Making things more interesting, the hospital contains many “black holes,” such as the emergency department, where pages can’t be received, and critical pages can disappear into cyberspace.
Our app lets users look up a room number and send a prioritized, SMS-based message within seconds. The recipient can then acknowledge receipt of the message or respond via SMS (which is not possible with the current antiquated pager system). Building the app was the easy part. Our physician, pharmacist and nursing colleagues were thrilled to start using it, but we were asked to get formal approval from the “IT Committee” before using it. The app was 100% HIPAA complaint, in fact more HIPAA compliant than the hospital’s legacy Windows PCs running versions of IE that predate Javascript. It took months to get a meeting set up, and 15 minutes for the IT committee to shoot it down.
One of my physician-coder friends makes a living running a gaming website. He avoids healthcare like the bubonic plague. Now I understand why.
10. If hospitals were run like startups, they would use their resources to do more inspiring things than set up firewalls and encrypt hard disks.
“IT” in most hospitals is synonymous with internet security. What about apps that engage patients, monitor patients with chronic illness at home using wearable technology and apps, help patients engage with physicians, and help healthcare professionals do their work more efficiently — so they can spend more time doing the most important, and enjoyable, part of their work: listening to their patients?
I’ve come across a small handful of physician-coders since moving to San Francisco. There aren’t many of us. We are idealists. We love the practice of medicine. We are deeply frustrated that hospitals are run more inefficiently than the most poorly run post offices. We can build things and are effervescing with ideas and enthusiasm.
Our battle with uninspired hospital administrators constipating the flow of innovation may be perpetual. So should our hunger to re-invent this industry.
Omar Metwally

12 thoughts on “If hospitals were run like startups

  1. Also, if hospitals were run like startups, they’d hire people to do extraordinarily important jobs on the basis of how well they “culture fit” with the existing staff, patients that looked like they might not make it would be dumped outside (fail fast), and the primary goal would be to get purchased by a bigger hospital.

    1. And hospitals wouldn’t select residents through the National Residency Match Program’s “Residency Match” process. Can you imagine applying for a job by ranking a list of companies you like, companies ranking desirable candidates, and then having an having an algorithm decide who gets what job?

  2. Enlightening and infuriating.

    At the same time, it seems like companies such as One Medical Group ignored the route of trying to convince hospitals to buy their software and started creating their own practices with modern IT systems. More should follow in their footsteps.

    1. I admire One Medical Group’s approach. We had reached an analogous conclusion at PulseBeat. Why sell to antiquated healthcare systems that will cycle through one free pilot after another but ultimately refuse to pay when you send them the bill 18 months later? Why not start our own home healthcare company? In retrospect, I wish we did this from the start. We were fortunate to have met a very progressive, forward-thinking home healthcare group, but they were exceptional. I think that some of the most interesting health tech companies we’ll see in the first decade or two of this wave will be companies that revolve around optimizing the delivery of a healthcare service.

  3. You missed #1: if hospitals were run like start-ups, the winners in the market would be the providers of the greatest value for the lowest cost. Instead, everybody gets a brand-new MRI machine and our costs are through the roof.

  4. One of the reasons I chose to work at a VA was the computerized medical record system which we rather unimaginatively call CPRS (VistA, to be precise). Clearly, the effort was put into software development and not into marketing. Indeed, CPRS was designed by physicians in the first place some 40 years ago (Suggested reading for more details: Best Care Anywhere). When I started at the VA full time about 10 years ago, CPRS was by far the most powerful and physician-oriented EMR available. This apparently remains the case. CPRS seemingly anticipates the next step during a patient encounter. After learning a couple keyboard shortcuts, I can complete a simple patient encounter with a handful of clicks. Medication renewals can be done with a click or two. I have easy access to a veteran’s most recent notes and labs whether the visits occurred in Manilla or Philadelphia. As CPRS is public domain, I can only conclude that there is a lot more money to be made selling white elephants than stuff that actually works.

    1. CPRS is wonderful. Freetext is much faster than clicking through mind numbing menus and makes for more accurate documentation. When it comes to EMRs, less is more. Thanks for your thoughts, toaster.

  5. Great article.

    I’ve worked in healthcare in Australia for 15 years – many of your points are valid to our side of the world.

    I do have a couple of theories as to why health IT is in an interesting state:
    1. healthcare is difficult and needs specialised expertise
    2. healthcare is not at a stage where IT is “trusted” like other industries e.g. airlines have autopilot (IT), transport has GPS (IT), communications no longer have operators (replaced by IT)
    3. healthcare systems are developed to support decisions made by experts (clinicians) and not replace clinicians
    4. sometimes clinicians have input into new systems (item 3), typically the “design” associated with other modern tech like iPhones is missing or de-prioritised – businesses need to start prioritising design


    1. Great points Thomas. By the time end-user input is sought, it’s already far too late: the software has been built and end users are beckoned to design templates or order sets, whereas they should be involved from the earliest stages of design. And absolutely, expertise is critical here.

  6. Saying hello Omar because we’re kindred spirits…
    The primacy of billing/RCM in the hospital system environment needs to be understood to sell to that group. The EHR exists for compliance/billing purposes, not to empower physicians and streamline care. That’s why Cerner/EPIC have the lions share of the market – top administrators will usually come from or at least through finance, and IT is beholden to them (& would usually like to keep their jobs). The back end, not the front end, is what the purchasers care about.
    From an IT/EHR standpoint, I’ve been saying for a few years now as IHE’s continue vertically integrating and physician practices corporatize, that these kludgy UI’s in the legacy EMR’s are going to be unacceptable from a workflow standpoint. You can have a scribe to smooth it over, but at some point cost saving administrators are going to ask, “Why do we have to have a scribe? Why can’t the vendor provide something that works?”. And change will be demanded, because it will impact the enterprises’ bottom line.
    Come over and visit me as well. I have a bit of a different tact, but I think you would agree with much of what I’m saying:

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