NHIN

What should you think about HIEs

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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.

Should you consider avoiding Meaningful Use?

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Where were we?

There are a few things stuck in my craw—imagine that.  One is Meaningful Use.  The other is also Meaningful Use.  Permit me to address these one at a time.  I’ll start with Meaningful Use.

Are you kidding me?  Who are these people?  To disguise that of whom I write, let’s invent some aliases, Dr. B and Dr. H.  For all the meetings, all the pronouncements, you’d think sooner or later one of them would state, “There is no way any of this makes sense.”

Why do you say that Paul?  May I?   What if you threw a party and nobody came?  What if you held a $40 billion lottery and nobody won?  Here are the rules.  A handful of people less than seven feet tall decide to buy homes in a community.  All the homes have door openings that are seven feet high.  New people move into the community.  One day the homeowner’s association mandates that all homeowners must build homes with door openings that are seven feet high.  Most homeowners ignore the mandate.  The association then decides to offer the homeowners rebates if they comply with the mandate, and penalize them if they don’t.  Most of the homeowners ignore the mandate.

Indifferent to the fact that their mandate isn’t working, the association decides to add new rules, rules that affect the homeowners who already built homes with seven foot tall doors, and those who didn’t.  One of the rules is that the seven foot tall doors must now be eight feet tall; another mandates that all roofs must be in the basement.  Homeowners who comply will win the lottery.  Those who don’t won’t.

How does the lottery pay out?  It doesn’t.  They made it impossible for anyone to get the money.   Suppose you gave a lottery and nobody won?  Suppose you made it so obtuse that nobody cared if they won.

That’s where I think we are with EHR.  The smart healthcare providers are asking themselves the question, “What if we make a business decision not to meet the Meaningful Use requirements?”  “What if we decide what is and isn’t meaningful.”

There are 2 “business models” in play—the national healthcare model, and the model your firm follows—they have different goals.  I asked my client, “When you made your selection of EHR, did you have any hint that the government was going to create rules to manage what it does?”  I assume their answer is a lot like yours—“Not at all.  We were worried about FDA oversight, but nothing like the stimulus.  The PQRI was available as an incentive to use ePrescribing, but really small potatoes.”

The national healthcare model under development will create an infrastructure such that every patient can be connected to each physician via a series of HIEs and the N-HIN.  To get there, they need you—they can’t do it without you.  What do they need from you?  Participation.  Participation by having and EHR, ePrescribing, and CPOE.

Even if it were to work, what’s in it for you?  Very little.  They know that—that’s why there are payments and penalties.  Most hospitals like the idea of implementing EHR.  Given the choice those same hospital executives would choose to listen to an entire Celine Dion CD if it would allow them to skip implementing CPOE.

If there are not many good business reasons to meet Meaningful Use, why should you build an entire strategy around it?  You wouldn’t paint your hospital pink simply because Washington said you should, although given a choice between the two ideas, pink sounds pretty good.  Let’s say you take them up on meeting Meaningful Use.  You build your strategy, drop current initiatives, implement these systems, train your people—then what?  Indeed.  What happens if the government changes its mind?  Moves the dates, changes the requirements?

In order to go for Meaningful Use you must be able to suspend your ability to think rationally.  If you do not think the HIE and N-HIN model will work—I have not met anyone who thinks it will—why even give Meaningful Use another thought.

My client is a group of 14 hospitals—they could get millions of ARRA dollars.  If you don’t have more than one hospital, your ARRA rebate will be much less.  They have already installed EHR and CPOE.  To get the millions they have to spend millions.  What happens if they spend it and the feds change their direction?  What then?  What do they do with the eight or nine figures of systems they build to follow Washington’s lead?  Take them out?  Modify them?  What happens to their business model as a result of all of this “leadership” from the ONC?

What should you do?  That’s up to you.  Here’s an idea or two.  First, ask yourself what your EHR/HIT strategy would be if there was no ARRA money.  (You do have a written HIT strategy, don’t you?)  Second, decide if you think that the current national roll out strategy will work.  Third, figure out what you won’t be able to do if you have to invest even more time and money meeting Meaningful Use.  Next, add up all the money it will cost you to meet their requirements and compare that to what they will pay you.  I bet the costs are more than the rebate.

I think Meaningful Use won’t exist in 3-5 years.  I think the N-HIN won’t be available by then either.

Here’s the real kicker for hospitals that have more than two beds.  If you have not yet selected your EHR vendor you shouldn’t even be thinking about meeting Meaningful Use for the first year because you can’t there in the time available to you.  That take’s the pressure off, doesn’t it.

Is the N-HIN helathcare’s black hole?

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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.

Call me a cock-eyed nihilist

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I offered the following comment to Kent Bottles post,

My New Year’s Resolution: To See the World Clearly (Not as I Fear or Wish It to Be).

http://icsihealthcareblog.wordpress.com/2010/01/04/kent-bottles-my-new-year’s-resolution-to-see-the-world-clearly-not-as-i-fear-or-wish-it-to-be/#comment-131

As this is the first Monday of the New Year, I had not planned on thinking, at least not to the extent necessary to offer comment on your blog.  I distilled it to three points—perhaps not the three about which you wrote, but three that tweaked my interest—happiness, counterfeit, and healthcare clarity.

Suppose one argues that happiness lives in the short-term.  It is something that one spends more time chasing than enjoying, something immeasurable, and once attained has the half-life of a fruit fly.  I do not think it is worthy of the chase if for no other reason that it cannot be caught.  As such, I choose to operate in the realm of contentment.  Unlike happiness, I think one can choose contentment.

There are those who would have us believe that contentment, with regard to healthcare, comes about through clarity, and that clarity comes from contentment—the chicken and the roaders.  Those are the ones who argue that reform, any reform, is good.  Where does the idea of counterfeit come into play?  I think it is the same argument, the one which states that any reform, even something counterfeit, is good.  The healthcare reform disciples argue that reform in itself is good; be it without objective meaning,purpose, or intrinsic value.  Therein lays the clarity, even if the clarity is counterfeit.

Call me a cock-eyed nihilist, the abnegator.  I am not content.  My lack of contentment comes not from what is or isn’t in the reform bill.  It stems from the fact that reform, poorly implemented, yields an industry strapped to change, an industry that may require greater reform just to get back to where it was.

Healthcare IT reform, HIT, will have to play a key role in measuring to what degree reform yields benefit.  Without a feasible plan, HIT’s role will be negative.  There are those who feel such a plan exists.  Many of those are the same people who believe the sun rises and sets with each announcement put forth by the ONC.

I think the plan, one with no standards, one that will not yield a national roll out of EHR, is fatally flawed.  I think that is known, and rather than correcting the flaws, the ONC has taken a “monkey off the back” approach by placing the onus on third parties, and offering costly counterfeit solutions like Meaningful Use, Certification, Health Information Exchanges, and Regional Exchange Centers.  If the plan had merit, providers would be leapfrogging one another to implement EHR, rather than forcing the government to pay them to do it.

What is wrong with the ONC’s 2010 budget?

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Some comments I wrote to ahier.blogspot.com’s posting of the ONC’s 2010 budget.

Their mission, “ONC leads, coordinates, and stimulates public and private sector activities that promote the development, adoption, and use of health information technologies to achieve a healthier Nation” although offering nice sentiments, for $61 million, ought there not be a way to measure whether or not they achieved the mission? How does one know if they led, coordinated, and stimulated, and if so to what degree?

Who certifies their work? Who determines if their work resulted in Meaningful Use? Before anyone gets excited by what they plan to do in 2010, let’s look at what they did in 2009.

1. What did the ONC accomplish, complete, put to bed?

2. What did they complete that facilitated the HIT work required of the providers?

There are no standards. There is no believable plan to obtain standards anytime soon. There is no viable national roll-out plan for EHR.

Instead of HIT/ARRA handouts, and HIE’s designed by hundreds of independent groups, and RECs designed by inexperienced appointed committees, why not use the $61 million to state that by such-and-such a date there will be a written and executable plan stating when we will have standards and a workable and believable roll-out plan?

They continue to promise funds to support an ill-conceived plan trying to get everyone on board, an approach that yields to the notion that “There must be a pony in there somewhere.” Ladies and gentlemen–there is no pony.

Should HIT make the Top 10 list for medical advances for 2009?

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Below is a reply I made to a report that HIT was one of the top medical advances for 2009.  It came from community.advanceweb.com.
Great point.  An advance requires movement.  I do not think an 8% penetration with a 60% failure rate and high churn is the type of movement that would qualify.  If anything, it appears more like a retreat or stagnation.
User acceptance is so low that the feds are offering $40 billion in incentives and penalties if that doesn’t work.
Acceptance will not be enhanced by the addition of regional extension centers (RECs); appointed committees with no more HIT expertise than the folks at K-Mart.
It will be hindered further  by similarly provisioned RHIOs building HIEs that are as different from one another as snowflakes, 400 vendors with no standards, and no incentives to create any.
Then there is the N-HIN, Meaningful Use, and Certification, all of which exacerbate the national roll out of EHR to the point where it the current plan will fail.
My take?  Meaningful Use and Certification will not exist in 3 years and firms like Apple, MS, and Google will be the N-HIN.

Interoperability-this is the problem

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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?

Why the N-HIN will be owned by public firms

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Here are a few more thoughts just to Emerilize the discussion—to kick it up a notch.  Not only do I think the national EHR market is ripe for the taking by a big three like Microsoft, Google, and Oracle, I’ll go so far to suggest that when the dust settles in 5-7 years, the N-HIN, the National Health Information Network, will be a regulated combination of a handful of those firms.

As for the other firms offering or planning to offer PHRs, permit me to suggest the following scenario.  Let’s say I am in charge of Google’s so far somewhat nonexistent healthcare line of business.  One of my goals would be to have more users of my PHR than any other firm.

Why does this model make sense?  Two ways, both of which come from the cable/telco business model.  Rule number one, content is king.  In cable, it is shows like HBO and Discovery.  In healthcare it is data; patient data, effectiveness data, disease data.

Reason number two, the cable/telco model values the businesses based on the number of assets.  What are the assets?  Subscribers.  You and me.  Each body adds somewhere between five and ten thousand dollars to the valuation model of a Comcast or Verizon.  Downstream, some valuation will be placed on each PHR subscriber.

So, back to the example of me running Google’s healthcare offering—if you don’t like Google as an example, insert your favorite firm.  If I’m Google, am I troubled by the fact that other firms are building their own solutions?  No, and here’s why.  The difficult part of the business model is adding users, adding subscribers.  Why not let a bunch of firms do the business development work for me, do the dirty work to get the users, and then just devour those firms?  Once I own them, I convert them to my platform.  Do I then get some ‘ownership’ or right to use the data?  That would certainly be the business goal.

One million users valued at five thousand dollars adds five billion in valuation.  Ten million adds fifty billion.  Ten billion is about 2.5% of the US market.  Do I stop at the border?  Of course not.

By the way, while all this is going on, Google, MS, or whoever will also be creating standards and be building or buying up EHR firms.

The Dark Side versus the Blind Side

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My take on this is probably far-afield from the mainstream. I think the Dark-Side, firms like Google, Microsoft, and Oracle look at the confusion and lack of planning in terms of what the final EHR/PHR platform will look like and they simply drool. With hundreds of EHR vendors and RHIOs and RECs and standards groups all operating independently, all aiming at an undefined target, which group is best positioned to solve this platform problem, the Dark Side, or the Blind Side?

The Dark Side’s plans are underway and visible through their PHRs. Like the tip of an iceberg, I bet that most of what they are doing to own this space is presently unseen. Practice Fusion, if their product attracts enough customers will be devoured, or they will be ignored. RECs, RHIOs, Meaningful Use, Certification, a lack of standards, and no network are large red flags from the government saying “we don’t know where we’re going, but we’re making real good time.”

Here’s a reply I drafted at the request of Brian Ahier to his blog, http://radar.oreilly.com/2009/11/getting-personal-with-health-t.html

The Dark Side knows exactly where they’re going. They don’t need a network; they have one. The Internet. There are those who argue HIPAA and security. HIPAA and security can be more readily handled on a network that’s been up and running for twenty years and was built by the military than they would be under anything developed off the cuff under Washington’s leadership.

Now for the Deathstar issue–ownership of the data. The question is are ownership and possession one in the same? I bet they will not be. I’d also bet that five years from now somehow that Dark Side will have at least access to it. I can’t prove any of this, but I’d love to sit in on the strategic planning committees of the Dark Side. I bet some or all of this is underway. The Blind Side may be blind-sided.

EHR: A billion for your thoughts

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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’.