“FaceBook” EHR –Visionary, or is it time for me to take a nap?

This is what happens when my mind is allowed to free-associate when I run. I was watching a show on the science channel on the mathematics behind the principle of “6 degrees of separation and Small World”. The show demonstrated that very simple networks can be developed to get person A to any other person or entity, B.

This got me thinking–always a dangerous proposition–why couldn’t Small World networks be developed for EHR on a national level?  One Super EHR. Cradle to grave healthcare records, one person (patient) and at time via a Small World network. Super EMRs, patient owned, to a single, repeatable, standardized EHR.  Eliminate the RHIOs with their multiplicitous standards, eliminate hospital’s mini-EHRs.  Document the functionality required of the specialist practices and enable the data to be captured at the EMR level.

EHRBook; but with real privacy controls.

What do you think?

What is the future of the EHR/N-HIN landscape?

One may argue it is possible to build the real Brooklyn Bridge with nothing but toothpicks, and a lake filled with Elmer’s Glue.  Difficult yes; prudent, no.   Urban legend is when the United States first started sending astronauts into space, they quickly discovered that ballpoint pens would not work in zero gravity.  To combat the problem, NASA scientists spent a decade and $12 million to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C.

The Russians used a pencil.

The ability to do something is not justification for doing it.  Nor is that fact that someone has put it forth as an idea.  The willingness to do something merely because everyone is doing it or because someone instructed it be done probably has nothing to do with a business strategy, or if it does, it shouldn’t.

In the next five to seven years the business of healthcare at the provider level will have the opportunity to change markedly—the unanswered question is, will it have the ability?  To answer that at the provider level—primarily hospitals and clinics—I believe one must distinguish between the business of healthcare (how the business is run) and the healthcare business (how the care is delivered).

In many respects, the business of healthcare and the strategy surrounding it is pinned to a 0.2 business model.  Certainly there are exceptions to any aphorism, but taken as a whole, there is plenty of room for improvement.  As one hospital CEO told me, “What we really lack is adult supervision.”

So, how exactly does the toothpick bridge apply to healthcare?   Here’s my take on the situation.

  1. It may be possible to build and roll out a national network of EMRs through EHRs connected by HIEs to an N-HIN—I don’t think will happen in the next five to seven years, especially if to be effective the network requires a minimal participation of somewhere between 70 to 80 percent of healthcare providers.
  2. Even if I am wrong, why would anyone build a national EHR network out of toothpicks?  Could they possibly have devised a more complex and costly approach?
  3. The government arrived late for the party, has only limited authority, and chose to provide cash incentives instead of direction or leadership.  They passed the responsibility of the success of the national EHR roll out to hundreds of thousands of healthcare providers.
  4. The providers are burdened by having no experience in the sector, hundreds of EHR systems from which to select, no standards, hundreds of HIEs, no viable plan, no one with singular authority, a timeline that cannot be meet, and an unwritten set of Meaningful Use requirements.

The plan sounds like something designed by Rube Goldberg.  Could it be done this way?  I do not think we will ever know.  Not necessarily because it will fail, but because I think the plan will be supplanted by a more realistic one from the private sector.

The government’s plan relies on a top-down approach—albeit with a missing top; from the government, to the providers, to the patients.

The private sector plan will come from firms like Apple, Google, and Microsoft.  It will work because it will be built from the bottom up; from the patients, to the providers, and back.  Personal Health Records (PHRs) will become EMRs.  This approach will allow them to flip their PHR users to EMR users, and will be adopted quickly by millions of customers (patients).  Their approach will have a small handful of decision makers calling the shots instead of hundreds.

This model’s other component will be driven from another direction, by large hospitals and clinics that connect to small hospitals, small practices, and ambulatory physicians via a SAAS model.  Something like this is underway today at the Cleveland Clinic using their offering, DrConnect.

I believe the approach will be refined even further as the distinction between PHRs and EMRs erodes.  Instead of requiring remote care providers to have their own mini-EHR integrated with their practice management system, they will be able to use the EHR of a large hospital.  I anticipate that they will be able to log on to the system to access their patients’ EMRs as though they were actually resident in the large hospital.  This will all but eliminate the role of Health Information Exchanges (HIEs).  It will also extend the reach of those large hospitals, and aid in the retention and recruiting of physicians.

Why is this important?  Because the federal plan, which won’t be viable for several years, is designed to use software solutions which address a current business issue.  By the time their networked solution is fully functional it will be well on its way to obsolescence.  The government is forcing the expenditure of more than a hundred billion dollars on a static offering to address a non-static issue.  Their approach will not be able to keep pace with the changes demanded by market forces.  It reminds me off building a plan to go to the moon based on where the moon was instead of where it will be.


HIEs: Too Many Cooks Spoil the Broth

Is the number of people working on developing Health Information Exchanges (HIEs) is greater than the total number of people who attended HIMSS in Orlando; more than 30,000?  Why are five hundred HIEs are being built?

Let us assume for a moment that there is a set of standards somewhere, a blueprint perhaps, for what a good HIE should be able to do.  Granted, if we are going to be honest, an HIE does not have to do very much; does it?  It does not change the data in a health record.  It does not add data.  And, it neither creates nor destroys health records.

In its simplest form, a health record comes in from some place, and that same record goes out to some other place.  And what is in that health record?  If we are trying to keep it simple in order to show the problem is in fact solvable, what is in the health record is a formatted collection of ones and zeroes.  And how does the HIE “move” the ones and zeroes?  The movement is caused by writing computer applications; code—ones and zeroes.

The blueprint for an HIE is nothing more than a pipe to move formatted zeroes from point A to point B.  Now in reality, we have about five hundred HIE teams working hard to build disparate HIEs.  To what end?  To move ones and zeroes from point A to point B.  So, the 500 HIE teams are writing 500 different HIE applications using ones and zeroes to move ones and zeroes.

Doing the math—500 HIE teams * 1 HIE application per team = 500 different HIE applications.  If done correctly—which is an entirely different conversation—we will have 500 HIEs, each of which are capable of doing the exact same thing; which is—moving ones and zeroes.

Let us dissect the ones and zeroes concept for a moment.  When Al Gore created ones and zeroes he did so with the premise that all ones were created equal, all zeroes are created equal, and that ones and zeroes are equal.

Now, what makes the one and zero concept particularly great with regard to HIEs and all of healthcare IT is there is never a need for a “two”.  No CIO worth his or her salt will ever sit at a steering committee meeting and state, “If I only had a 2, this whole problem would go away.”

If one looks correctly at the issue of HIEs by breaking it down to its simplest elements, it is a unique problem to solve.  Unique—as in singular.  Two HIEs do not solve the problem better than one HIE.  Once you have two, you no longer have a unique solution, and when you have 500 HIEs, you have a mess.

Here is the kicker to this argument.  What else do you have when you have a single HIE capable of reading the data from all of the various EHR platforms?  Exactly.  You have the N-HIN—the Nationwide Health Information Network.  Why?  Because when push comes to shove, the N-HIN is nothing more than a glorified HIE.

However, once you have more than one HIE, you then need an HIE for the HIEs, which is the only reason there is any discussion about building an N-HIN.

So, in addition to the fact that 500 HIEs are 499 too many, do they create any other problems?  Of course they do.  They add a very high and unnecessary degree of additional complexity to the healthcare IT systems of every healthcare provider.  Some providers offer services within many different HIE footprints.  Every provider will need to adapt their systems so that the provider’s healthcare records can be accepted by their corresponding HIE pipe.

Instead of building 500 HIEs, and forcing them to some semblance of a standard, why not just build one HIE and have that be the standard?


HIE: Are two HIEs one too many?

The is my most recent post at healthsystemcio.com

According to Wikipedia, Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations within a region, community or hospital system. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged.

That seems really straight forward, at least to me. I find it helpful to whittle complex ideas down to a point that enables me to explain them to my parents, without either of us having to reach for the Tylenol.

In its simplest form, an HIE is a pipe, a pipe that transports ones and zeroes. Back in the days when I still had hair, one of my clients was the CEO of a large cable television company. He explained his business this way; “We are just like the water department. We put a pipe in the ground, send something through it, and every month people mail me money.”

He also sent ones and zeroes.

Now, there are those around us, apparently thousands of them, who have made it their mission to convince those in the minority that HIEs are far more complex than they really are. Maybe I just do not understand the concept of ones and zeroes.

You probably know that several hundred HIEs are in the process of being built—and they are all being built by people who have little to no experience building HIEs. Now, here is where everything gets a little hairy. Let us look back on the definition of an HIE and let us focus our conversation on building just one HIE. The tricky part about getting the HIE to work is that pesky little word “disparate,” as in disparate health information systems, and the last time I counted EHRs, I hit 300 before giving up.

That is where all that disparate clinical information comes from. However, when push comes to shove, the information from all of those different EHRs is pretty much the same, but the various EHR vendors just line up their ones and zeroes differently, thus enabling them to prevent others from playing in their sandbox.

There is another disparity surrounding HIEs, one that is unspoken. Suppose you and I decide to build an HIE, a good one. After some period of time, we get rid of all the little disparities among the various EHR vendors and are able to zip those little ones and zeroes from one end of the HIE pipe to the other. Let us also suppose we used a very long pipe, so we could use this HIE anywhere. It would work for a hospital, or at an Integrated Delivery Network (IDN), or across a region.

Our HIE is able to move our individual healthcare information from one end of the pipe to the other wherever the other end may be.

I forgot to mention the disparity. The unaddressed HIE disparity is the one created from having hundreds of HIEs, each designed in its own vacuum by people who have little experience filling vacuums. And when those HIEs have been built, what will they do? Exactly. They will move clinical information among disparate healthcare information systems. In laymen’s terms—ones and zeroes from EHR vendors who do not play well together.

The new ones are identical in functionality to the one we just built, only now there are 500 of them.

Now to the meat of the issue. If we build an HIE correctly, and build it to be able to handle any disparity, is there any more need for HIE 2, since in theory HIE 2 will be able to do the same things as HIE 1?  Let us extend this same thinking from HIE 1 through HIE 500. At some point—irrespective of certain technical issues—can it be concluded that the total number of HIEs needed to move ones and zeroes is one?

Other than the redundancy and expense of building a few hundred things that each perform the same function, the real problem of having multiple HIEs is that each new HIE greatly increases the complexity of moving a personal health record from point A to point B. If HIE 2 is the same as HIE 1, we do not need HIE 2. If the two HIEs are not alike, when we try to transport a personal health record from a patient in HIE one and move it to a doctor in HIE 2, the disparity created between the two almost requires a new HIE to resolve the problem. We will have infinitely compound the complexity of moving ones and zeroes by deploying 500 HIEs and hundreds of thousands of healthcare providers and a few hundred million patients, and we have designed quite a mess.

And why does the mess exist? It exists to move those same ones and zeroes we were moving quite nicely by the HIE we built. One can argue that scale may create its own design issues, but those issues do not make this idea dead in the water. Issues of scale are solvable; those of compounded complexity are self-imposed due to an overzealous design.

The proposed way to solve the upcoming problem of compounded complexity is to build the National Health Information Network, the NHIN. We need the NHIN to act as a super HIE, to remove the disparities that result from having multiple disparate HIEs.

Adding further unwarranted complexity to the multi-HIE model is the fact that each HIE has resulted in several hundred providers designing and retooling their healthcare IT systems to adapt to these anomalous HIEs.

Sometimes the most difficult solution to envision is the least difficult one to implement.


What people at HIMSS were afraid to say

One image of HIMSS that will not escape my mind is the movie Capricorn One—one of OJ’s non-slasher films.  For those who have not seen it, the movie centers on the first manned trip to Mars.  A NASA Mars mission won’t work, and its funding is endangered, so feds decide to fake it just this once. But then they have to keep the secret…

The astronauts are pulled off the ship just before launch by shadowy government types and whisked off to a film studio in the desert.  The space vehicle has a major defect which NASA just daren’t admit. At the studio, over a course of months, the astronauts are forced to act out the journey and the landing to trick the world into believing they have made the trip.

Upon the return trip to Earth, the empty spacecraft unexpectedly burns up due to a faulty heat shield during reentry. The captive astronauts realize that officials can never release them as it would expose the government’s elaborate hoax.

I think much of what I saw at the show was healthcare’s version of Capricorn One.  Nothing deliberately misleading, or meant as a cover-up or a hoax.  Rather more like highlighting a single grain of sand and trying to get others to believe the grain of sand in an entire beach.

The sets for interoperability and HIEs served as the Martian landscape, minus any red dust.  There was a wall behind the stage from where the presentation interoperability was shown.  I was tempted to sneak behind it to see if I could find the Wizard, the one pulling all the nobs and using the smoke and mirrors to such great effect.  It was an attempt to make believers, to make people believe the national healthcare network is coming together, to make us believe it is working today and that it is coming soon to a theater near you.

After all, it must be real; we saw it.  People wearing hats and shirts emblazoned with interoperability were telling us this was so, and they would not lie to you.

The big-wigs, and former big-wigs—kudos to Dr. B. for all his hard work—were at the show for everyone to see, and to add a smidgen of credibility to the message.  They would not say this was going to happen if it were not—Toto, say this ain’t true.

The public relations were perfect, a little too perfect if you asked me.  Everyone was on message.  If you live in Oz and go to bed tonight believing all is right with the world, stop reading now.  If what you wanted from HIMSS was a warm and fuzzy feeling that everything is under control and that someone really has a plan to make everything work you probably loved it.

Here is the truth as this reporter saw it.  This is not for the squeamish, and some of it may be offensive to children under thirteen or C-suiters over forty.  In the general sessions nobody dared speak to the fact that:

  • Most large EHR implementations are failing.
  • Meaningful Use isn’t, and most hospitals will fail to meet it.
  • Hospital productivity is falling faster than are the Cubs chances of winning a pennant.
  • Most hospitals changed their business model to chase the check
  • Most providers will not see a nickel of the ARRA money—the check is not in the mail and it may never be.

The future as they see it is not here, and may never be, at least until someone comes up with a viable plan.  Indeed, CMS and the ONC have altered the future, but it ain’t what it used to be.  People speak to the need to disrupt healthcare.  Disrupt it is exactly what they have done.  The question is what will it cost to undo the disruption once reason reenters the equation?  What then is the future for many hospitals?

  • Hospitals on the whole will lose more much more money due to failing to be ready for ICD-10 than they will ever have seen through the ARRA lottery.
  • It make take years to recover the productivity loses from EHR and the recoup those revenues.
  • Hospitals spending money to design their systems to tie them into the mythical HIE/N-HIN beast will spend millions redesigning them to adapt to the real interconnect solution.
  • The real interconnect solution will be built bottom-up, from patients and their primary care physicians.
  • Standardized EMRs will reside in the cloud and patients will use the next generation of smart devices.  And like it or not, the winners will be Apple, Google, and Microsoft, not the ONC and CMS.  Why?  Because that is who real people go to to buy technology and applications.  A doctor still does not know which EHR to buy or how to make it work.  Give that same doctor a chance to buy a solution on a device like an iPad and the line of customers will circle the block.

And when doctors are not seeing patients they can use the device to listen to Celine Dion.  This goes to show you there are flaws with every idea, even some of mine.


Blazing Saddles: the original HIE-NHIN model

Several have inquired as to why I came down so hard in yesterday’s post regarding the CMS-ONC’s approach to link our physicians and hospitals through the development of HIEs and the N-HIN.  I think, as do others, the goal is worthwhile but, is the current strategy going to work?

I think the current plan is fatally flawed, and is racing ahead like a herd of turtles.  Just because everyone is working hard, and has good intentions, does not necessarily mean the outcome will deliver what is needed.  It seems over engineered to the point that it is like trying to put ten pounds of turnips into a five-pound bag.

Unfortunately, until the leadership of the CMS and the ONC come to that realization the CMS, the ONC, and healthcare providers will continue to spend hundreds of millions of dollars to support an infrastructure that:

  • Unnecessarily complex
  • Is not necessary nor sufficient
  • Cannot be built
  • Will not work

Call me Deep Throat.  The perspective that the HIE-NHIN plan will not work is only spoken of in the bowels of the Watergate Hotel’s parking garage in hushed voices late at night.  Many of you have shared with me that you are of the same opinion but, like vampires you shudder that your voice on this matter would see the light of day.  It would be less antagonistic to open a kosher deli in Tehran than to say the CMS-ONC needs to be rethunk but, sometimes a little antagonism is what is needed.

Do you recall the scene in Blazing Saddles when Harvey Korman’s horde of bad guys is racing through the desert on horseback to get to the town of Rock Ridge only to be halted in the middle of a wide open prairie by a lone toll gate?  Instead of being able to go directly to where they wanted to go they are forced to go through the toll gate, and their progress is stopped entirely because nobody has any spare change.

What makes it nonsensical, and quite funny, is their failure to realize that all they had to do was o ride around the toll gate.  Maybe it is just the way my mind works, but trying to get electronic health records to a national network via several hundred disparate HIEs reminds me of the toll gate.  Why not just go around it?


EHR, HIEs & N-HIN; a prophecy of doom

Whether it’s vendors, RHIOs, HIEs, or the N-HIN, where is a plan that will work?  Is not this what it’s all about?  Perhaps it is time that the rest of the national HIT leaders at CMS and the ONC who devised this plan, and who have lead physicians and hospitals down this ill-fated path promising them riches at the end of the journey should acknowledge their mistake and look for other ways to pass their time; pursue something more achievable, like gardening.

If the plan of of nationalizing healthcare by using HIEs, RHIOs, Meaningful Use, and the N-HIN had any real chance of working, don’t you think we would see a lot more organizations lining up to collect their EHR rebate?

In 1-2 years Meaningful Use will have been replaced by something else or done away with entirely.  In 3-5 years the HIE-NHIN plan will have changed dramatically.  That does not help people who are spending money today chasing ghosts.

As a side note, many hospitals will miss the ICD-10 conversion date.  Not for lack of interest, but because so much of their attention is focused on chasing the banshee known as EHR.

HIEs remind me of hand-to-hand fire bucket brigades.  It’s time we agree to use a truck.