# Healthcare IT’s Black Hole

Last year scientists turned on the largest machine ever made, the Hadron Collider. It’s a proton accelerator. This all takes place in a donut-shaped underground tube that is 17 miles in circumference.

Fears about the collider centered on two things; black holes and the danger posed by weird hypothetical particles, strangelets, that critics said could transform the Earth almost instantly into a dead, dense lump. Physicists calculated that the chances of this catastrophe were negligible, based on astronomical evidence and assumptions about the physics of the strangelets. One report put the odds of a strangelet disaster at less than one in 50 million, less than a chance of winning some lottery jackpots—what they failed to acknowledge is that someone always wins the lottery, so negligible risk exists only in the mind of the beholder.

If I understand the physics correctly from my Physics for Librarians mail-order course—and that’s always a big if—once these protons accelerate to something close to the speed of light, when they collide, the force of the collision causes the resultant mass to have a density so massive that it creates a gravitational field from which nothing can escape. The two protons become a mini black hole. And so forth and so on. Pascal’s triangle on steroids. Two to the nth power (2ⁿ) forever. Every proton, neutron, electron, car, house, and so on.

The collider could do exactly what it was designed to do. Self fulfilling self destruction. Technology run amuck. Let’s personalize it. Instead of a collider, let’s build a national healthcare information network (N-HIN) capable of handling more than 1,000,000 transports a day. What are the rules of engagement?  Turn on the lights and let’s see how it functions.

Let’s say we need to get anybody’s record to anybody’s doctor.  That’s overly simplistic, but if we can’t make sense out of it at this level, the N-HIN is doomed.  The number of possible permutations, although not infinite, is bigger than big.  Can you see what can happen? Strangelets.  The giant sucking sound comes from ARRA and stimulus money as it is pulled in to the black hole.

So what is the present thought leadership proposing to fight the strangelets? Healthcare information exchanges (HIEs)—mini N-HINs.  Regional Exchange Centers (RECs).  A few million, a few billion.  Not only does their plan have them repeating the same flawed approach, they are relying on embedding the same bad idea, and doing it using hundreds of different blueprints.

Einstein defined insanity as doing the same thing over and over and expecting different results.

Stop the craziness. I want to get off.

It’s the end of the world as we know it…and I feel fine. R.E.M.

# Redux–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.

(I published this post one year ago, just after the Orlando HIMSS.  It appears to still be valid today. Comments?)

# How the Grinch stole healthcare

Not much has changed since I wrote this two years ago…or has it?

Every Congressman Down in Congress-ville
Liked Health reform a lot…But the Payors,
Who lived just North of Congress-ville,
Did NOT!

The Payors hated Health Reform! The Congressional reform season!
And as everyone’s heard there is more than one reason.
Was it the fear of losing their monopoly right?
Worried, perhaps, that Congress might indict.
But I think that the most likely reason of all
May have been that the uninsured took them all to the wall.

Staring down from their man-caves with indemnifying frowns
At the warm lighted windows below in the town.
For they knew every Congressman down in Congress-ville beneath,
Canted an ear to hear Congress gnashing their teeth.

“If this reform passes, they’ll kill our careers!”
“Healthcare reform! It’s practically here!”
Then they growled, the ideologues’ fingers nervously drumming,
“We MUST find a way to keep Reform from coming!”

For, tomorrow, they knew…

…Stumbling home from the tavern at a quarter past two What each Congressman, intern, and page just might just do And then all the milieu. Oh the milieu, the milieu
Which the Payors hated more than their mom’s Mulligan stew.

Then all the Congressmen, the left and the right, would sit down and meet.
And they’d meet! And they’d meet!
And they’d MEET! MEET! MEET! MEET!
Implement full provision; cover pre-existing…how sweet
That was something the Payors couldn’t stand in the least!

And THEN they’d do something Payors liked least of all!
Every Congressman down in Congress-ville, the tall and the small,
Would stand close together, their Healthcare bells ringing.
With Blackberrys-in-hand, the Congress would start pinging!

They’d ping! And they’d ping!
AND they’d PING! PING! PING! PING!
And the more the Obligators thought of the Congressman-Health-Ping
The more they each thought, “I must stop reform-ing!
“Why for all of these years we’ve put up with it now!
We MUST stop health Reform from coming!
…But HOW?”

Then they got an idea!
An awful idea!
THE Indemnifiers
GOT A WONDERFULLY, AWFUL IDEA!

“I know what to do!” The CEO Payor laughed in his throat.
And he made a quick Congressional hat and a coat.
And he chuckled, and clucked, “What a great Payor raucous!
“With this coat and this hat, I’ll look just like Saint Bacchus!”

“All I need is a pass…”
The Payor looked around.
Since Congressional passes are scarce, there was none to be found.
Did that stop the old Payor…?
No! The Payor simply said,
“If I can’t find a pass, I’ll make one instead!”
So he called his aide Max. Then he took some red paper
And he dummied up the pass and he started this caper.

THEN
And some old empty sacks
On a Benz 550
And he rode with old Max.

Then the Payor called, “Dude!”
And the Benz started down
To the offices where the Congressmen
Lay a-snooze in their town.

All their windows were dark. Quiet snow filled the air.
All the Congressmen were dreaming sweet dreams of healthcare
When the Payor came to the first office in the square.
“This is stop number one,” The old Warrantist – a winner
And he slipped passed the guard, like sneaking to a State Dinner.

Then he slid down the hallway, Harry Reid was in sight.
Reid was chumming Pelosi, he planned quite a night.
He got nervous only once, for a moment or two.
Then he found the Congressional stimuli all hung in a row.
“These Stimuli,” he grinned, “are the first things to go!”

The Payor slithered and slunk, with a smile somewhat mordant,
Around the old Cloakroom, looking quite discordant!
There were copies of the bill stuffed in jackets and on chairs, Why, he even found a copy tucked under the stairs
And he stuffed them in bags. Then the Payor, very neatly,
Started humming the jingle from Blue Cross; rather Cheeky!

Then he slunk to the Senate Chamber, the one facing East
He took the Senators’-copies!—didn’t mind in the least!
He cleaned out that Chamber and almost slipped on the floor.
Saw an Internet router, and thought of Al Gore

Then he stuffed all the copies in the trunk of his Benz.
And he thought to himself, “Why don’t I have friends?” “There’s always Tiger,” he said with no jest But TW’s being chased by reporters, those pests.

The Payor spotted the Grinch having trouble with his sacks
And he lent him a hand—he offered him Max Max was quite pleased, for he knew this December,
That the Grinch would become the Payor’s newest board member.

The Grinch was all smiles–he’d made quite a killing
Offering to help pillage if the Payor was willing.
He stared at the Payor and asked, “New glasses?”
The Payor simply smiled, saying “These people are such (You did that to yourself, not me.)

And, you know, that old Payor was so smart and conniving
When he next saw Pelosi he found himself smiling!
“Why, my dear little Nanc’,” the Bacchus look-alike stiffened,
“Botox in this light makes you look like a Griffin.”
“I’m taking these bills home,” he said pointing to the copy.
“There’s a comma on one page that looks way too sloppy.”

And his fib fooled the Griffin. Then he patted her head
And he gave her a wink, and he sent her to bed
And as Speaker Pelosi shuffled off to her army,
The Payor said to himself, “What a waste of Armani!”

The last thing the Payor needed to do,
Was to mess with these records systems, all four thousand and two.
So he drove to HHS, the DOD and the VA,
And stuffed mint jelly in their servers so their networks would not play

And the one EHR, that still worked in the DC
Was the one bought from CostCo and tucked under the tree.

Then he did some more damage
To HIEs, and the N-HIN,
Making the idea of a healthcare network
Just a has-been!

It was quarter past dawn…
None in Congress were his friends
All the Congressmen, still a-snooze
When he packed up his Benz,
Packed it up with their copies of reform in those bags! Stacked to the leather ceiling,
Manila envelopes with name tags!

Three miles away were the banks of the river,
He was poised with the bags all set to deliver!
“Pooh-pooh to the Congressmen!” he was Payor-ish-ly humming.
“They’re finding out now that no Reform is coming!
“They’re just waking up! I know just what they’ll do!
“Their mouths will hang open a minute or two
“The all the Congressman down in Congress-ville will all cry BOO-HOO!”

“That’s a noise,” grinned the Payor,
“That I simply must hear!”
So he paused and the Payor put a hand to his ear.
And he did hear a sound rising over the snow.
It started in low. Then it started to grow…

Why, this sound sounded merry!
It couldn’t be so!
But it WAS merry! VERY!

He stared down at Congress-ville!
The Payor popped his eyes!
Then he shook!
What he saw was a shocking surprise!

Every Congressman down in Congress-ville, the tall and the small,
Was singing! Without any health reform at all!
The Congress didn’t care, a few were disgraces,
All they wanted, it seemed, was TV with their faces

And the Payor, with his Payor-feet knee deep in the muck,
Stood puzzling and puzzling: “Man, there goes my bucks.
It could be about healthcare! It could be global warming!
“It could be Al Qaeda, Afghanistan and desert storming”
And he puzzled three hours, `till his puzzler was sore.
Then the Payor thought of something he hadn’t before!
“Maybe Congress,” he thought, “simply needs a free ride.
“Maybe Congress,” he thought…just needs to look like they tried.

And what happened then…?
Well…in Congress-ville they say
That the Payor’s small wallet
Grew three sizes that day!
And the minute his wallet didn’t feel quite so tight,
He zoomed in his Benz passing through a red light
And he brought back the copies of the bill for reform!
And he……HE HIMSELF…!
The Payor calmed the whole storm!

# AP reports national EHR rollout will fail-now what?

I just fell out of the stupid tree and hit every branch on the way down. But lest I get ahead of myself, let us begin at the beginning. It started with homework–not mine–theirs. Among the three children of which I had oversight; coloring, spelling, reading, and exponents. How do parents without a math degree help their children with sixth-grade math?

“My mind is a raging torrent, flooded with rivulets of thought cascading into a waterfall of creative alternatives.” Hedley Lamar (Blazing Saddles). Unfortunately, mine, as I was soon to learn was merely flooded. Homework, answering the phone, running baths, drying hair, stories, prayers. The quality of my efforts seemed to be inversely proportional to the number of efforts undertaken. Eight-thirty–all three children tucked into bed.

Eight-thirty-one. The eleven-year-old enters the room complaining about his skinned knee. Without a moment’s hesitation, Super Dad springs into action, returning moments later with a band aid and a tube of salve. Thirty seconds later I was beaming–problem solved. At which point he asked me why I put Orajel on his cut. My wife gave me one of her patented “I told you so” smiles, and from the corner of my eye, I happened to see my last viable neuron scamper across the floor.

One must tread carefully as one toys with the upper limits of the Peter Principle. There seems to be another postulate overlooked in the Principia Mathematica, which states that the number of spectators will grow exponentially as one approaches their limit of ineptitude.

Another frequently missed postulate is that committees are capable of accelerating the time required to reach their individual ineptitude limit. They circumvent the planning process to get quickly to doing, forgetting to ask if what they are doing will work. They then compound the problem by ignoring questions of feasibility, questions for which the committee is even less interested in answering. If we were discussing particle theory we would be describing a cataclysmic chain reaction, the breakdown of all matter. Here we are merely describing the breakdown of a national EHR roll out.

What is your point?  Fair question.  How will we get EHR to work?  I know “Duh” is not considered a term of art in any profession, however, it is exactly the word needed.  It appears they  are deciding that this—“this” being the current plan that will enable point-to-point connection of an individual record—will not work, and 2014 may be in jeopardy—not the actual year, interoperability.  Thanks for riding along with us, now return your seat back and tray table to their upright and most uncomfortable position.

Even as those who are they throw away their membership in the flat earth society, those same they’s continue to press forward in Lemming-lock-step as though nothing is wrong.

It is a failed plan.  It can’t be tweaked.  We can’t simply revisit RHIOs and HIEs.  We have reached the do-over moment, not necessarily at the provider level, although marching along without standards will cause a great deal of rework for healthcare providers.  Having reached that moment, let us do something.  Focusing on certification, ARRA, and meaningful use will prove to be nothing more than a smoke screen.

The functionality of most installed EHRs ends at the front door.  We have been discussing that point for a few months. When you reach the fork in the road, take it.  Each dollar spent from this moment forth going down the wrong EHR tine will cost two dollars to overcome.  To those providers who are implementing EHR I recommend in the strongest possible terms that you stop and reconsider your approach.

# “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?

# HIT: The Change Keeps Changing

Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of \$10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• PMO
• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

# 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.

# Why should HIEs be scrapped, and what else might work

“Just because Jimmy’s mom lets him do it does not mean I am going to let you do it.  Would you jump off a cliff if he did?”

This argument is the best one I can make extolling the merits of the Healthcare Information Exchanges (HIEs) and the National Health Information Network (N-HIN).  The strategy behind the HIEs and the N-HIN are somewhere between killing a mosquito with a tank.  As the camel is a horse designed by a committee, so may be the goal of having HIEs serve as the cog of the N-HIN.

Why?  Because I think the architecture needed to make this happen exists in a far simpler form.

For example, let us look at iTunes.  To be transparent, I do not have the knowledge to describe or explain the technical underpinnings.  But what if we look at the business strategy around what makes iTunes work for Apple and its customers, perhaps there is something relevant worth borrowing.

Like physics for librarians, permit me to oversimplify the idea to see if a similar set of underpinnings could work in healthcare.

For purposes of explaining the analogy as a business network, what if we equate the major components thusly?

• Apple (iTunes)                                  Government

o   HIEs

• The tunes                                            Patient records
• The Internet                                      N-HIN
• Customers                                          Patients

While it is never as simple as it seems, especially given Apple’s success with iTunes, here is the simplified version.

There a millions and millions of songs (patient records).  For Apple, the songs exist digitally—ones and zeroes—and are stored digitally.  No LPs, no tapes, no CD (no paper charts).

Apple never physically touches a single song.  What does Apple do if it doesn’t sell CDs?

• Apple brokers the entire transaction to its customers
• The tunes move securely and unaltered from one entity, Apple, to one customer, millions of times
• Apple secures all parts of the business

o   Nobody has hacked into Apple to steal tunes

o   Nobody has stolen customer information

o   Nobody who does not own the songs has been able to alter their content wheter they are in transit or with their owner

• In the iTunes business model the iPod is no more important than a toothbrush has to do with Crest’s business model
• The business model’s success is based upon a new delivery system for music
• Apple’s business model did not necessitate creating hundreds of disparate and separate distribution systems to link tunes from Apple to its customers.
• Apple did not create a new way of moving ones and zeroes from virtual point A to millions of virtual Point B’s.
• Apple was successful using and existing, and inexpensive transportation network, thereby keeping overhead much lower than it would have been

So, if we equate the two paradigms, and buy into the fact that a model such as iTunes—if you prefer you can substitute aspects of financial services, airline ticketing, GPS (On-Star), EBay, and Amazon—in its most basic form, is nothing more than the secure transport of billions of ones and zeros, it is not a big stretch to see how one can argue that the transport of millions of electronic health records may not require a solution as complex as the HIE—N-HIN model.

And if that is true, can a business argument be made to justify building hundreds of HIEs?  I do not believe it can.  The HIEs are designed to act as middlemen.  Their purpose is to hand ones and zeros from one network node to the other, and they way they will do this is by building more nodes.  They will not so much as add a one or a zero to a patient record.

Rule One of engineering a business process is that if a process does not add value to the whole, the process adds cost and complexity without adding any value.  Under the current national EHR rollout, I think HIEs are such a process.

Before discounting this notion, what would be required to make an iTunes’ model work for electronic health records?

# The National Health Information Network explained

How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class?  Ideas?  Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is.  your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B.  It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A).  Now, find your doctor, any doctor (Point B).  Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course.   That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the national HIE-NHIN plan will work?  It is complicated enough without adding all those HIEs each developed independently of one another each to their own standards.  Why not simply use the same National Information Network (NIN) we already use–the Internet?

# Interoperability-this is the problem

How does one depict the complexity of the mess being presented as the national roll out plan of electronic health records (EHR) via the national health information network (N-HIN) using Health Information Exchanges (HIEs) designed by Regional Health Information Organizations (RHIOs), with the help of regional extension centers (RECs) without Standards (Standards) and with N too many vendors?

Class?  Ideas?  Class?

If this looks dumb, undo-able, unimplementable, uninteroperable–it’s because it is.  your vision is fine.

Remember the idea behind all this is to get your health record from point A to point B, any point B.  It’s that little word ‘any’ that turns the problem into a bit of a bugger.

Find yourself in the picture below, pic a dot, any dot (Point A).  Now, find your doctor, any doctor (Point B).  Now figure out how to get from A to B–it’s okay to use a pen on your monitor the help plot your course.   That was difficult. Now do it for every patient and every doctor in the country.

Now, do you really think the DC RHIO-NHIN plan will work?  If EHR were a Disney park, who’s playing the Mouse?