IT (R)Evolutions

A lot has been said about the impact of technology on HealthCare and how 50,000 HealthCare IT jobs will be created as part of the healthcare reform debate.

Let me share an example of the reality of what is occurring due to the utter lack of transparency coming from D.C. around HealthCare reform.

Healthcare organizations are planning to run lean in 2010.  While the quality and quantity of care will continue to be emphasized and of paramount importance, the much touted impact on HealthCare IT is a different story. 

Capital expenditures are being scaled back to the absolute critical projects – and even there hard choices are being made. Maybe you can wait another year for new hardware or the next version of software.

New HIT jobs are being scaled back or eliminated directly; the money, rightfully so, goes towards clinical service and quality first. Maybe you can just buy a third party product, if you can get a pricebreak.

Healthcare Organizations just don’t know and simply cannot divine from the offal of entrails they are being thrown from D.C. as to what the impact to their bottom lines are going to be – and keep in mind, most of them struggle to stay in the black, and what profit is made is typically reinvested, not sent to line any pockets. Further many of these organizations genuinely emphasize quality care of their customers (aka patients!).

Gone is the talk of decoupling insurance, patient choice, portability standards and tort reform, replaced instead with an obfuscated miasma from the swamp that is already having a negative impact on that which can bring about efficiencies – information technology.

If healthcare organizations, even healthy ones, are scaling back on IT now, what, one wonders will occur when it finally becomes a reality?

In the process of designing and prototyping our Operational Data Store (ODS) for our Enterprise Products, we’ve noticed a couple of things that we expected but (vainly) hoped weren’t there.

First, a good number of our HL7 messages don’t follow documented standards closely. Most importantly, there are Z-segments (custom messages) in all sorts of places in a message instead of where they should be. This means our integration implementation has to be smarter and more defensive in handling these messages, such that the message transactions continue to flow when an unexpected or unanticipated message is consumed.

Second, we are replicating a lot of data with our HL7 messages. Say you change a zip code on a registration screen. You get the entire screen of data, not just the change, replete with whatever customized Z-segments. This means we’ll have some extra heavy lifting to do when consuming messages.

The key points here are two fold.

First, this is no one person’s fault – no one did a bad job – people work to their level of awareness.  What it does indicate is that HIT hasn’t evolved. We’re still making the same mistakes we’ve been making for the last few decades, and that is inexcusable.

Second, this only reinforces why HL7 and standard don’t ever belong in the same sentence.  It doesn’t matter than one vendor’s HL7 specifications may adhere to the standard, such as it is, the problem is that the HL7 message is too easily hijacked.  Z segments should be the exception, not the rule and they certainly shouldn’t cause a problem when it comes to consuming the message nor require defensive coding to accommodate it.

The only way this is going to be solved is if an alliance of HIT-centric entities, not vendors, not the government, work together to force industry adoption of standards and practices that are common place across most enterprises else. In short, HIT needs to evolve out of its current calcification by having the people that feel the pain the most do something about it

For our project needs, we knew these would be problems, we planned and allocated for them. For anyone else embarking on similar ODS or Data Warehousing projects in HIT – caveat emptor, a standard isn’t always a standard in HIT.

Fair warning, this is more of an internalized discussion written down, appropriate caveats on misinterpretations apply.

While I feel that American Exceptionalism is being apathetically eroded into guilt-ridden mediocrity, this post is going to focus on the beginnings of a sort of depressing epiphany that I’ve stubbornly fought against for the better part of my nearly 2 decade career in computing, far preferring a bloody head over what I, personally, deem an ethical compromise of commitment.

Until now.

Based on personal observation and comparison of peer experiences, exceptionalism is neither encouraged nor rewarded in corporate computing.  I’m sure the odd corporate computing environment exists out there where this may not be the case, but a very odd duck it will be.

HealthCare IT, regardless of talks of reform and funding, sadly suffers from the same issue that cancerously gnaws at the heart of ingenuity and innovation in corporate computing, but writ larger.

Unfortunately, HealthCare IT seems to have further devolved into purchasing disparate solutions and cramming them into weak integration platforms, repeated ad infinitum with insufficient focus on first, defining the problem, then designing the solution, before creating or purchasing or integrating anything. The tumor has spread to the extent that few things seem possible without the intervention or resources of a third party vendor, from defining the need to delivering the solution to supporting and training.

We’ve achieved 100% de facto outsourcing! The counterpoint of course is that you have a body of knowledge workers who have been robbed of the opportunity to gain the knowledge they need to replace that vendor mentality.

Healthcare organizations: the consultants you want are the ones who will not sell you a single license or product until they have helped you define the problem and design the solution; expect to pay for their time.

Fundamentally, this is no one person’s fault, per se, nor should this be seen as an assignment of blame, but rather a general reflection that, for all the books, talks, discussions, groups, whitepapers and consultants, corporate computing will remain mired in a necrotic momentum that seeks to continue to survive instead of thrive and grow, learning the same wrong lessons from each ancestral generation and imparting it on to each successive descendant generations in situ. What mold-breaking successes that do come, stagnate and seem to not develop into behavior that can be consistently repeated.

In considering root causes, there is one key, very lacking, cornerstone. Accountability - the accountability that speaks to a pride in ownership and a desire to excel, to step up instead of cleave to the accepted status quo, in particular by those very same computing professionals. This isn’t just a management problem, this isn’t just a business problem.

There are many understandable, wholly justifiable reasons, mostly rooted in fear and lack of support, as to why this doesn’t occur. While the parable of the tortoise and the hare teaches that slow and steady get’s you there, I have to wonder if what’s missed is that the hare likely only lost the race once, then learned a valuable lesson and modified its behavior. That tortoise is welcome to that singular gold medal, hanging lonesome on its mantle, it’s only true testament that it lead to another’s success, another who wears shades from the overpowering brilliance of its accolades.

Now replace speed with accountability in the above story. Dig deeper and realize the other lesson here is that a lesson was learned and applied.

The lesson learned for me has been that it’s not for me to expect nor to demand, except in myself and those I lead, mentor or raise, a level of accountability that I hold myself to.

For me the this leads to my epiphany. I have defined myself by my work for the better part of two decades, the cornerstone of which is accountability – from which I am convinced all other things such as delivery, flows. I can no longer afford to do so, largely for my own sanity but also because of the perception this sets.  While I take at least half of the responsibility in setting that perception, it appears that the balance of the half remains looking for a home. Sound familiar? Yes, there’s accountability (or lack thereof) again.

So, where the balance of my career in corporate computing is involved, it would appear that a reset of expectations is called for and the balance to be sought is contentment, not satisfaction nor happiness.

The sub-conclusion here is that as risky as entrepreneurial endeavors’ are it would appear that my happy professional place is there, which leads me to considered thought on my future professional growing exercises. I’m still ruminating on that; been there, got the t-shirt(s), if I’m unwilling to return to that fertile ground …

Certainly, I will not allow qualities to neither suffer nor erode, instead, they will enjoy a tighter scope!

There is comfort in this, in a way; it’s the self-inflicted globe off Atlas’ shoulders. There’s certain liberation in looking forward to not being defined by work and expelling those same energies into other avenues too long neglected.

While this still has legs to run around and finish baking, I can honestly say that I am breathing easier now than I have in years.

I will, however, shed a tear, but not for myself, but rather for the endurance of mediocrity where it already existed rather than the desperately needed elevation of excellence.

The loss here, is not mine.

I'll link here to a page which contains an email conversation, cleaned up and colored, of an email discussion between me and (apparently) a liberal around, well, many a topic.

We'll call her Miss Informed Liberal and I've colored her emails orange.
Call me Concerned American and I've colored my emails green.
Aside from some spelling corrections, I've left the content alone.

Read it from the bottom up.

The most telling part for me was the largely defensive, partisan tone she took and the lack of factual references or refutation of my references with facts of her own. Strikes me as a typical response from a liberal. To be fair, the conservatives also have their fringe, but I at least try to stay factual.

In as much a healthy shouting match is, in moderation, a necessary part of a healthy debate, it's also critical that what you are shouting is at least factual.

Ad Hominem attacks are never acceptable.
Enjoy ...

I watched with a mix of pity but also no little amount of indignation at the parade of stories today of folks who relayed stories about their struggle with cancer and health insurance. It seemed like the very real issue of under-insurance and other healthcare reformation needed was being buried under saccharine sap driven by lawyers who were our elected officials, that sought to play the heart strings instead of address the real issues head on.

Let me relay a different kind of story. I know of a sole proprietorship on the east coast of Florida who's owner, let's call him Tom, ran his own pool maintenance business for many years. He always made sure to carry health insurance and disability insurance.

He got cancer after about fifteen years in his profession. Although his prognosis was poor, his initial good health and fighting attitude (alongside with a heaping of prayers which never hurt), he survived and has been cancer free for about 3 years now.

He still drives his own car, lives in his own house, he had to shut down his business as he couldn't work, but he has income in the form of long term disability.

What makes Tom so different?

Personal accountability to research and procure health and disability insurance that would protect him in the event of a catastrophe, such as what he experienced.

This healthcare reform, for me, comes down to exactly that - personal accountability.

First, the disclaimer, there will always be citizens who can't work, can't cover themselves adequately. Personal choices aside, there should certainly be some sort of adequate and appropriate safety net, not crutches, for them. For those who cannot provide for themselves, our Republic owes it to help them provide for themselves and in as much as possible get them on a path to personal prosperity so they can provide for themselves

For everyone else ... what the hell is your excuse? I, and Tom, would like to hear why you can't, or couldn't, take enough responsibility for yourself when you could provide, to cover yourself for when you couldn't provide.

In such a vast, rich, blessed land such as America, you have no one to blame but yourself.

But for this I am now to believe that I have to make up for poor choices made by others.

Here's a very real problem: the working poor or those who work for small businesses that cannot afford health insurance. Instead of levying taxes and penalties in a manner akin to spitballs at a gradeschool classroom, why not provide some multiple of dollars in tax breaks, on some revenue-based sliding scale so that businesses will be incentivized to provide better healthcare insurance. Hand in hand with that is breaking the imaginary borders that prevent organizations in getting better rates by shopping for insurance; and much as I would be loathe to suggest this next part, additionally, yes, some sort of public supplemental assistance should be made available, where government and small business work hand in hand. This is just one idea.

But there are no powerful lobbyists for small businesses. There are no lobbyists for you, the American people.

You only have your own voices that you sit mutely on.

When you're tired of being mute, start here: Senators of the 111th Congress and Representatives of the 111th Congress

If you want some very good reading, read Doc Searls article on e-patients.net AND read all the associated comments. Agree or disagree on the direction that your elected officials are taking your healthcare reform in, there's a lot of very good information.

As an aside, if you're anywhere near business and technology, you owe it to yourself to read The ClueTrain Manifesto. Keep in mind, there is no such thing as bad data (back in your corner ETL chuckleheads, you know what I mean)

In a recent interview, I was asked a good question - do I consider my self an Innovator or an Entrepreneur?

An innovator is a dreamer, an entrepreneur finds ways to make the innovator and himself wildly successful.

Whereas most innovators might be focused in a subset of activities, an entrepeneur can reach across many of them, but in that way he too is an innovator. 

For that reason I would say I am an innovator who has grown into an entrepeneur. I find ways to make current tech do new tricks, come up with new tech for new problems, and I'm always thinking about ways to convert that into dollars, then forwarding a strategic plan with tactical milestones to build or extend, and market, sell and support.  So much so that I'm evangelizing the idea that more often than not, it may be a good idea to view some projects as products from the get go.

No matter the type or size of your org, there's always opportunity to take your good ideas and make money from them OR to somehow better the lot of those around you.  The latter is especially important as the world shrinks in size and the old Donne saw about no man being an island is writ large in the virtual Pangaea of the current age.

A twitter friend (and high content value tweeter) @daphneleigh recently asked if she could get a HealthCare IT (HIT) primer. Sure I said, shoot me some questions - and what good questions they were. I've answered these below.

Note that I consider this post a bit of a work in progress and will stamp it final at some later date.

Comments welcome.

1. What, exactly, does HIT include? Are we talking EHR/EMR/PHR, or are we talking beyond these technologies (which I assume we are, but don't know what the "beyond" is...medical devices and equipment? hospital tech infrastructure? etc., etc.).
HealthCare Information Technology – is a catchall category for information technology and systems used within HealthCare. Although some folks use it and healthcare informatics interchangeably, I believe there is a differentiation. HIT is more technical\technology in nature and informatics is more about the acquisition, accumulation and assessment of information, data, having to do with healthcare, for example, quality on episodic care. I think it’s critical this distinction exists because all too often HIT is not approached with the sensible, strategic approach as it should be (more on that below) in healthcare.

a) By extension, HIT covers EMR, EHR and PHR, Medical Devices, Mobile Medical Devices, server systems and other infrastructure used in the conveyance of healthcare – that’s all HIT (not informatics). Note that in many instances the technology is the same for healthcare as it is in any other vertical. For example, server, network and telecom systems are the same. Business Intelligence, Data Warehousing tools remains the same. The key different systems are EMRs, PHRs, EHRs, medical devices and other clinical (lab, radiology) systems – those are unique to Healthcare.

b) I think that sometimes EMR, EHR and PHR also get muddied, I think the differentiation is as follows:

i. EMR’s are used by healthcare organizations to assist in the practice of healthcare, being an electronic medical record of all pertinent demographic, clinical and billing data, surrounded by a (clinical) process automation system and, in better systems, having strong clinical heuristics and analytics around clinical data. Hospital Information Systems (HIS) and Physician Office Management Systems (POMIS) are types of EMR’s

ii. EHR is a more generic term mean to refer directly to the clinical data for a patient that resides in some system, be it an EMR or PHR

iii. PHR is a system that allows users, or users and certain slices of the healthcare vertical, to share, collaborate and otherwise act on electronic health data

2. Alot of back and forth about whether HIT can reduce healthcare cost? Does it? How? And for whom? Patients? Docs? Hospitals? All? Others?
HIT, correctly implemented with a plan and a strategy, using best practices standards and systems, CAN reduce the cost of doing HealthCare business. MOST of these systems are fairly significant in cost and time to implement. We’re talking, for example, seven years and $250M, or more for larger multisystem orgs or around $50k and about three of months for a smaller practice – and that’s just the licensing cost. Extra interfaces to other systems carry a cost as does annual maintenance and support. I’ll reference additional points about HIT in point 4. HIT is one component but not the leading component to bring about change in HealthCare. As with any properly run business it means the difference between surviving and thriving, but herein is the rub: properly run business. A LOT of hospitals aren’t run as a business, in terms of process and fiscal discipline, in terms of strategic planning not just for growth and services but also for infrastructure and IT. Although I can’t comment as to why this would be the case, it’s likely one that has to do with a complex culture that’s inherited the good (process focus) with the bad (emotion, not facts based decision making). When you DO have a properly run hospital – and there are many – where compassion and enterprise thinking work well together – a properly implemented HIT strategy\system can cut costs for all parties concerned. Data is more readily available, transportable and consumed by all parties that need it while respecting the appropriate security needs – this is why something like HealthVault succeeds but most EMR’s fail (more in point 4). This is the reason most enterprises survive or thrive – they know where and how to get to the data they need to run their business effectively. The magic of Amazon is not in their pricing (although that helps) – it’s in how data driven their business is. Hospitals, in particular, need to evolve to the point where they are more data driven as well.

3. Who should care about HIT and why?
Everyone who is or will one day be a patients, should care about HIT. Hospitals likely have their hands full with quality initiatives, patient safety, physicians satisfaction and fighting government contractors on Medicare\Medicaid denials – contractors who get paid a percentage of the takebacks! Smaller orgs and practices also have the added concern of defensive medicine, liability issues and staffing and the cash-flow challenges of being a small business, dealing with third parties (insurers) for their cash flow. Who’s left minding the (data) bank? It should be patients, empowering patients. A patient should care that HL7 is a standard in name only and that almost every single EMR or HIT system out there does not play well with each other. Getting data from system A to system B requires either paying one, or both, vendors a custom interface fee or having an in-house interface team. Two issues crop up here

a) On a simpler basis, the in-house team is typically using HL7 specific tools and technologies that have not evolved in 20 years, or more

b) On a more complex basis, the concept of charging a custom interface fee is a little disingenuous, after all, isn’t HL7 supposed to be a healthcare data exchange standard? The vendors might defensively, and correctly, state that the nature of the beast compels such custom interfaces because the business of providing healthcare is so diffracted and disjoint. My counterpoint to that is that Healthcare is series of repeatable processes and steps – yes every sick patient is unique but a lot of the processes around the sick patient – labs, radiology, treatments fall within established guidelines meant to enforce standard, repeatable processes.

i. This is where running like a business comes in and the needs for an umbrella industry standards (think ISO) comes in not just for the business of running a hospital but also for the systems that supports them to come into play. While I’m not espousing assembly-line medicine, what I am suggesting is that healthcare take a long hard look at itself as industry. It is in that way, an industry like no other where it is responsible for saving lives. As such it lacks the maturity to hold itself accountable to a standard greater than itself, on a local basis. Remember, standards don’t restrict thought or creativity, they govern the known and give freedom to explore the unknown, identify it and codify it. I have little illusions that this is easier said and done – there are a LOT of different opinions on standards of care and they’re likely all right to some extent. The industry owes it to itself to at least try.

ii. As an example, I know of a multisystem organization that had several thousand order sets. They recently started an initiative to reduce those to hundreds. The wailing and gnashing and lamentation of teeth was smoothed over and the effort proceeded regardless. They are on their way to meeting that goal.

iii. It can be done.

4. Is HIT on par with other industry technology? How? Or how not?
Which brings us to HIT – first, a caveat, I’ve been in Healthcare\HIT for 7 of my 17 years and, others from the “outside” who’ve come to work within HIT can attest to what I attest to here. Succinctly, HIT is at least 20 years behind where other IT verticals are. You will be hard pressed to see a more disjoint, backwards, insular, silo’d mindset, which, being an IT professional at heart, is morally and ethically repugnant to me at least. IT exists to codify, encapsulate, secure and transport data for the betterment of some entity, be it a person or a business. HIT exists to force the client into an expensive silo and paint them into a corner. A LOT of the systems are poorly written with a horrible user experience and neither themselves nor their interfaces scale well. In part this is due to the fact that HIT traditionally hasn’t been able to attract a lot of talent (pay being a prime cause, IT strategy akin to aimless wandering being another) so they’ve not had the talent on staff to call bullshit on these vendors – and so, the traditional vendors have gotten away with highway robbery. The other aspect of the problem is that most orgs don’t have time to pay attention to IT or deprecate it (reference running your business as a business) and so buy something off the shelf from a vendor, pay a lot of money to implement it, pay more money for interfaces, then either by more of that vendor’s product or some other vendor’s product for another segment of their business, pay more money for more interfaces, ad naseum. Seeing that most healthcare orgs spend 2%-4$% of their revenue on IT where most other verticals spend closer to 8% and up, it’s not a surprise. In those scenarios it is easier to justify and expend on a capital basis than it is on an operational basis. A nurse takes care of patients and helps doctors who bring in revenue. What’s an IT guy do?

a) This is starting to shift and the smarter, traditional vendors have picked up on it and started to become a lot more part of the solution than the problem. We’ll see. As more attention has focused on healthcare and HIT over the last decade, more folks from other industries have come into the HIT space, motivated by the profits to be made, justifiably. But along the ways we’ve inherited more disciplined folks and folks who work FOR the org or for a vendor who knows that the money to be made isn’t in the traditional Big Blue silo’ing of their customers.

b) Add in some of the newer technologies and platforms, such as Google Health and Microsoft HealthVault, and you’ll see that most vendors want to get on board with the rest of modern IT principles.

5. What are biggest challenges facing HIT right now, and how/why is it important to the whole healthcare reform debate?
The biggest challenge to HIT now is that it get’s incorrectly labeled as the #1 way to save on costs. It simply isn’t. No IT system in the world will help if you can’t run a business properly and, most importantly, don’t have good interoperability between systems. Throwing money at docs to implement HIT systems, or worse throwing money at vendors, isn’t going to help the situation. There are fundamental, process-based & cultural changes that need to occur before IT even enters into the picture. A good example, I know of an in-house development shop at a large org that has demonstrably shown that it can deliver value and products far faster than the org can absorb them. In a recent project 40% of the time was spend on product development and 60% on making up for the failure of clinical leadership on integrating that product, which they asked for\demanded, into their clinical workflows. The product was very well received and is now in active use, yet talk about a lot (60%) of effort expended outside of development and deployment. You could have the best EMR system in the world with every feature under the sun – clinical transformation is still required, and cultural adjustment, before it will be meaningful enough to make change.

a) For what it’s worth, clinical transformation and cultural adjustment are change. Change is scary. I understand that. IT changes every day, sometimes twice a day. So while I don’t expect change overnight I do expect that change does at least start to occur and that folks compartmentalize their fear. Folks should be allowed to fail and be encouraged to learn from those failures. Finally, at some point, after the healthy debate is over, someone needs to make a decision and folks be held accountable to follow in that decision.

b) There is an aside here that begs to be talked about which is process. The development and deployment process is all too often also mired in decades old processes or heavyweight processes that do not work. There are newer, more up to date HIT processes that should be leveraged.

6. What are biggest myths/misperceptions about HIT among general public?

This is a good question. I think most folks, especially these days, would be aghast to find out how backwards HIT is and how non-transportable and paper based their health information is. When’s the last time you wrote a paper check? Or got a paper utility statement? Or got a letter in the mail or sent a roll of film in to get developed? Sure you can still do those things but you can just as easily do without them. ebanking, paperless statements (save the tree’s and my filing cabinet please!), email (grandma sends emails to her grandkids!), Flickr to Walmart. Yet more clinicians than you would guess are stubbornly married to their paper. And you can’t, not if you are a large hospital beat them over the head (they are revenue streams remember!) nor can you easily incentivize them (Stark law). If there’s an ugly secret anywhere, it’s how distinctly Cro-Magnon HIT is when it’s surrounded by Homo Sap Sap examples of cogent IT around it.

So, what’s the bottom-line then, right?

The bottom line is that HIT is sclerotic and backwards and everyone owns and is accountable to it being so. Patient’s for not demanding more and that it keep pace. Clinician’s for some of the same but also for being resistors to change instead of change agents. Organizations for not making IT strategy part of their life blood. But especially vendors, vendors who should be living, eating and breathing technology, who know better, but who have like a drunk driver who knows he’s drunk, gotten behind the wheel and wrapped the industry around a tree.

But there is a silver lining. The driver didn’t cry, turns out they only side-swiped a sapling and the car, the industry, is repairable. Folks from outside Healthcare are coming into HIT. There are CEO’s, CIO’s and CFO’s cropping up internally and from other verticals that understand that Healthcare fundamentally only succeeds when it’s run like an enterprise business. Docs, usually younger, are demanding more electronic mediums for healthcare and the older docs are glomming on as they get fed up with the fragmented continuity of care. Vendor’s, perhaps driven by crowdsourcing, open source and the twin titans of Google and Microsoft are realizing they need to bring about a change in how they structure their solutions. Finally, the consumer, the Alpha and the Omega, the Patients, are waking up, connecting, getting educated and, lead by Mom’s everywhere, are asking tough questions and demanding more.

The pity of it is we didn’t have to get to this point, but at least we can recover from it and are starting too. Now, if only the government will listen to what works instead of throwing money around and focus on universal process guidelines, liability reform and enforce real interop standards, well, we might see a change for the better sooner rather than later.