The Swarm theory of failure

According to National Geographic, a single ant or bee isn’t smart, but their colonies are. The study of swarm intelligence is providing insights that can help humans manage complex systems. The ability of animal groups—such as this flock of starlings—to shift shape as one, even when they have no leader, reflects the genius of collective behavior—something scientists are now tapping to solve human problems.  Two monumental achievements happened this week; someone from MIT developed a mathematical model that mimics the seemingly random behavior of a flight of starlings, and I reached the halfway point in counting backwards from infinity–the number–infinity/2.

Swarm theory. The wisdom of crowds. Contrast that with the ignorance of many to listen to those crowds. In the eighties it took Coca-Cola many months before they heard what the crowd was saying about New Coke. Where does healthcare EHR fit with all of this? I’ll argue that the authors of the public option felt that wisdom.  If you remember the movie Network, towards the end of the movie the anchorman–in this case it was a man, not an anchor person–besides, in the eighties, nobody felt the need it add he/she or it as some morphed politically correct collection of pronouns.  Whoops, I digress.  Where were we?  Oh yes, the anchor-person.  He/she or it went to the window and exhorted everyone to yell, “I’m mad as hell, and I’m not going to take it anymore.”  Pretty soon, his entire audience had followed his lead.

So, starting today, I begin my search for starlings.  A group whose collective wisdom may be able to help shape the healthcare EHR debate.  The requirements for membership is a willingness to leave the path shaped by so few and trodden by so many, to come to a fork in the road and take it. Fly in a new flock.  A flock that says before we get five years down the road and discover that we have created such an unbelievable mess that not only can we not use it, but that we have to write-off the entire effort and redo it, let us at least evaluate whether a strategic change is warranted.  The mess does not lie at the provider level.  It lies in the belief that hundreds of sets of different standards can be married to hundreds of different applications, and then to hundreds of different Rhios.

Where are the starlings headed?  Great question, as it is not sufficient simply to say, “you’re going the wrong way”.  I will write about some of my ideas on that later today.  Please share yours.

Now, when somebody asks you why you strayed from the pack, it would be good to offer a reasoned response.  It’s important to be able to stay on message.  Reform couldn’t do that and look where it is. Here’s a bullet points you can write on a little card, print, laminate, and keep in your wallet if you are challenged.

  • Different standards
  • Different vendors
  • Different Rhios
  • No EHR Czar

Different Standards + Different Vendors + Different Rhios + No Decider = Failure

You know this, I know this.

To know whether your ready to fly in a new direction, ask yourself this question.  Do you believe that under the present framework you will be able to walk into any ER in the country and know with certainty that they can quickly and accurately retrieve all the medical information they need about you?  If you do, keep drinking the Kool Aid.  If you are a starling, come fly with us and get the word out.  Now return your seat backs and tray tables to their upright and most uncomfortable positions.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
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paulroemer@healthcareitstrategy.com

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What should you think about HIEs

Part of the problem I have with HIEs is similar to the old Wendy’s commercial, “Where’s the beef.” Only in this case the question becomes, “Where’s the value add?”

There are hundreds of them, HIEs that is. Each one developed autonomously. Some are built within a hospital which has more than one EHR. Others are being built to serve among a hospital group, and others are geographical. Which of the HIEs is being built by a team of people who have ever built one? To my knowledge, none.

Hundreds of HIEs being built independently from one another by people who’ve never before built an HIE. Hundreds being built to transport the electronic medical records of providers using a few hundred different EHRs, each EHR operating with different standards, none of which benefits from interacting with another.

What is the purpose of the HIE? It reminds me of this children’s’ icebreaker game where the children sit in a circle. The first child starts by whispering a phrase into the ear of the person sitting next to her. She can only say the phrase once. The child she whispers it to must then whisper it to the child next to her. This continues until it goes all the way around the circle. Usually, by the time the phrase gets back around to the original person, it is completely different.

Like shuffling an EMR from one place to the next through a series of intermediaries. What does it look like when it comes out the back end?

After all, what is the purpose of the HIE? It should act like a handoff, like a mini N-HIN. It does not modify the data, at least not intentionally. If there is a more complex way to get a person’s health record from point A to point B, I have not seen it. HIEs are healthcare’s Rube Goldberg mechanism.

I think that when all is said and done, HIEs will have faded away. Until then providers should keep their focus on developing an EHR which actually serves their business model.

EHR: A billion for your thoughts

Every wonder how it is that all the billions in healthcare IT money came about?  I imagine it went something like this.

DC 1: Email those fellows over at HHS and tell them we should just make the doctors install Electronic Health Records (EHR).

DC 2: While we’re at it, how about we pay them a bonus to do it…

DC 1: …and we penalize them if they don’t.  Give them money with one hand and take it back with the other.

DC 2: How do we get EHRs to communicate?

DC 1: Make the states do figure it out.  They are looking for more money.

DC 2: I’ll email the governors and tell them we’ve got more billions to pass around.  Let them build some sort of Information Exchange.  They can set up committees and staff them with appointees.

DC 1: Then we can glue those together in some kind of national network.  Where are we going to get one of those?  Figure another ten billion for that.

DC 2: I’ll email the DOD, they are supposed to know something about building national networks.

DC 1: Just to get things kick-started, let’s email the troops and tell them we’ll sweeten the state pots a little more.  Get them to build these extension centers on a region by region basis.

All these dollars, so little value.  Most of it focused on trying to figure out how to get millions of somethings from point A to point B.

How did all those millions of emails get securely from point A to point B?  For a lot less than forty billion dollars isn’t it possible to figure out  how to get my health information to whomever needs it?  Email me, maybe we can come up with an idea for a network.

If you’re still puzzled, we can play hangman.  It has eight letters, starts with an ‘I’, and ends with ‘ternet’.

RECs, HIEs, & EHRs: Curiouser and Curiouser

Here’s a response I wrote for a very interesting conversation started by Andy Oram, though a posting, http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html

I think the very existence of the Regional Extension Centers (RECS)is but another sign that there is no workable plan for a national rollout of EHR. There is a plan, a word I use reluctantly—there may be several. Several things surrounding the rollout exist that reinforce the idea that the plan is not operational—Meaningful Use, Certification, RECs—and these things exist as a series of band-aids in the hope they will enable the plan. These band-aids have been cobbled together over time and by different parties.
There is no EHR Czar.

There is no roll out czar. I defy anyone to present their work plan for how this ties together and show where these add-ons are on the plan.

Back to RECs. Similar format to Healthcare Information Exchanges (HIEs). Political in their origin and format. Carte blanche in terms of how they are built, what they will deliver, how they relate to HIEs and standards, and how the quality of their output will be measured. Five hundred and ninety-eight hope this helps million dollars. Has anyone sought out the credentials of those running the hope-this-works RECs? Does anyone doubt that they don’t have the experience to make these of any value? Where’s the national REC work plan? The individual work plans?

Who likes the REC idea? The payors. Regionally deployed and state authorized, the payors have more than a vested interest in helping the healthcare providers in their region with their EHR efforts.

This is another lipstick on the pig effort. By now, the pig is just about covered with lipstick. Does it make it a better pig? Of course not, it just makes it red.

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