How can EHR be made to work?

I’ve never been mistaken as one who is subtle.  Gray is not in my patois.  I am guilty of seeing things as right and left and right and wrong.  Sometimes I stand alone, sometimes with others, but rarely am I undecided, indecisive, or caught straddling the fence.  When I think about the expression, ‘lead, follow, or get out of the way,’ I see three choices, two of which aren’t worth getting me out of bed.

I do it not of arrogance but to stimulate me, to make a point, to force a dialog, or to cause action.  Some prefer dialectic reasoning to try to resolve contradictions, that’s a subtlety I don’t have.  Like the time I left the vacuum in the middle of the living room for two weeks hoping my roommates would get the hint.  That was subtle and a failure.  I hired a housekeeper and billed them for it.

Take healthcare information technology, HIT.  One way or another I have become the polemic poster child of dissent, HIT’s eristical heretic.  I’ve been consulting for quite a while—twenty-five plus years worth of while.  Sometimes I see something that is so different from everything else I’ve seen that it causes me to pause and have a think.  Most times, the ball rattles around in my head like it’s auditioning for River Dance, and when it settles down, the concept which had led to my confusion begins to make sense to me.

This is not most times.  No matter how hard I try, I am not able to convince myself that the national EHR rollout strategy has even the slightest chance of working as designed.  Don’t tell me you haven’t had the same concern—many of you have shared similar thoughts with me.  The question is, what are we going to do about it?

Here’s my take on the matter, no subtlety whatsoever.  Are you familiar with the children’s game Mousetrap?  It’s an overly designed machined designed to perform a simple task.

Were it simply a question of how to view the current national EHR roll out strategy I would label it a Rube Goldberg strategy.  Rube’s the fellow noted for devising complex machines to perform simple tasks.  No matter how I diagram it, the present EHR approach comes out looking like multiple implementations of the same Rube Goldberg strategy.  It is over designed, overly complex.  For it to work the design requires that the national EHR system must complete as many steps as possible, through untold possible permutations, without a single failure.

Have you ever been a part of a successful launch of a national IT system that:

  • required a hundred thousand or so implementations of a parochial system
  • has been designed by 400 vendors
  • has 400 applications based on their own standards
  • has to transport different versions of health records in and out of hundreds of different regional health information networks
  • has to be interoperable
  • may result in someone’s death if it fails

Me either.

Worse yet, for there to be much of a return on investment from the reform effort, the national EHR roll out must work.  If the planning behind the national ERH strategy is indicative of the planning that has gone into reform, we should all have a long think.

I hate when people throw stones without proposing any ideas.  I offer the following—untested and unproven.  Ideas.  Ideas which either are or aren’t worthy of a further look.  I think they may be; you may prove me wrong.

For EHR to interoperate nationally, some things have to be decided.  Somebody has to be the decider.  This feel good, let the market sort this out approach is not working.  As you read these ideas, please focus on the whether the concept could be made to work, and whether doing so would increase the likelihood of a successful national EHR roll out.

  • Government redirects REC funds plus whatever else is needed to quickly mandate, force, cajole, a national set of EHR standards
    • EHR vendors who account for 90%–pick a number of you don’t like mine—use federal funds to adapt their software to the new standard
    • What happens to the other vendors—I have no idea.  Might they go out of business?  Yup.
    • EHR vendors modify their installed base to the standard
  • Some organization or multiple organizations—how many is a tactic so let’s not get caught up in who, how many, or what platform (let’s focus on whether the idea can be tweaked to make sense)—will create, staff, train its employees to roll out an EHR shrink-wrapped SaaS solution for thousands and thousands of small and solo practice
    • What package—needs to be determined
    • What cost—needs to be determined
    • How will specialists and outliers be handled—let’s figure it out
  • Study existing national networks—do not limit to the US—which permit the secure transfer of records up and down a network.  This could include businesses like airline reservations, telecommunications, OnStar, ATM/finance, Amazon, Gmail—feel free to add to the list.  It does no good to reply with why any given network won’t work.  Anyone can come up with reasons why this won’t work or why it will be difficult or costly to build or deploy.  I want to hear from people who are willing to think about how to do it.  The objective of the exercise is to see if something can be cobbled together from an existing network.  Can a national EHR system steal a group of ideas that will allow the secure transport of health records and thereby eliminate all the non-value-added middle steps (HIEs and RHIOs)?  Can a national EHR system piggyback carriage over an existing network?

We have reached the point of lead, follow, or get out of the way, and two of these are no good.


4 thoughts on “How can EHR be made to work?

  1. my 2 cents
    Phased approach
    Start with the data points which are available in existing data streams (ie HL7)** yes here someone will have to decide on the format. we know each facility is a “snowflake” but the data will have to be standardized in/out of the PTP nw
    Feed a peer-to-peer network which is searchable based on several layers of matching criteria (exact and fuzzy)
    Authentication and logging is handled within each facility with proper audit measures in place.
    What’s next? Ideally something like medication or radiology reports, not sure which would be easier!
    labs data
    cardiology waveforms
    other stuff i know nothing about!
    free-text narratives.

    I’m not sure a nationwide repository is necessary,it would be a duplication of data. Perhaps it would open a business model for EHR backup services.
    yup, still lots of unanswered questions.


  2. Have you ever been a part of a successful launch of a national IT system that:
    * required a hundred thousand or so implementations of a parochial system
    * has been designed by 400 vendors
    * has 400 applications based on their own standards
    * has to transport different versions of health records in and out of hundreds of different regional health information networks
    * has to be interoperable
    * may result in someone’s death if it fails

    Yikes, I’m almost tempted to inquire about that ad in the back of Popular Science on Locksmithing, but I do like a challenge.

    Kinda brings it all home. I’m wondering what the folks at NextGen and Greenway are telling their clients when it comes to the upload part of all this. Am I buying the capability as they envision it today or as it *will be* at some future set of temporal coordinates. Perhaps that’s part of the wonderful 20% service contract.

    Probably the best example of what works today in healthcare is the various registries. These proprietary systems all have one thing in common; they accept a single data set in a very rigid format. If you want to play, it has to be by their rules. If your data is hosed up, it gets bounced. There are tools that help you scrub it before the upload, so rejection is rare. Of course this is all batch-based, and an EMR to EHR transfer should be more of a real-time single record arrangement – but other than that it’s quite similar.

    As far as examples of a good transport system, I think you must turn to a Google or some other entity that can handle mass transactions with low risk of failure. The Automated Clearing House (ACH) is an electronic network for financial transactions in the United States. This system moves more than 10 billion transactions per year – albeit in batch. But if you look at the proprietary sub systems like the ATM networks, thy work very well and appears to be real-time, otherwise you could take a trip around town to 10 different ATM’s and clean out your account a few times over. I’ve never had a bogus transaction via ATM in more than 25 years. Credit cards are another story of course.

    Yes it can be done well and at a reasonable cost, but rigid standards and simplicity in the design of the transport and storage architecture must be at the top of the priority list.


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  4. Pingback: Why I differ with Mr. Halamka’s EHR strategy « EHR: How difficult is it without the correct strategy?

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