Call me a cock-eyed nihilist

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).’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 may be driving the Meaningful Use announcement

I often write not because I have something that needs to be said, but to try to explain something to myself.  If I get to a point where I think I understand an issue, I’ll make it public to see if the comments reflect my understanding, or to see if I need to have another go at my own thought process.  Which leads me to this—

Let’s back up the horses for a minute and return from whence we came.  EHR.  The idea was simple.  Two groups; patients and doctors.  Create a way to transport securely the medical records of any patient (P) to any doctor (D).

For the time being, let’s keep this at the level that can be understood by a third grader.  What two things do I need to satisfy this P:D relationship?  Data standards and a method of transport.

Do we have them?  We do not.  That being the case, what fury hath the ONC wrought?  (1 Roemer 9:17)  if you don’t have what you need, and you don’t have either the authority or a plan to get what you need, you must facilitate (fund) the creation of workarounds to fill the void.

At some point, the conversation must have quickly shifted from, “We need standards and transport”, to, “Since we don’t have standards and a means of transport, we must come up with other ways to try to make this work.”  Now, I don’t believe this is literally what happened, but I think one could see how it might have evolved.

Other ways.  What other ways?  The ONC loves me; it loves me not.  HITECH.  ARRA.  Take the monkey off our back and put it on the backs of the providers.  Pay doctors to implement EHR.  Smote them if they don’t.  Write checks.  Big checks.  Lots of big checks.  Instead of coming up with a single transport plan and one set of standards, provide guidelines.  Make pronouncements.  Fund RHIOs and make them responsible for creating hundreds of unique transport plans and ask the RHIOs what progress they are making towards a single set of standards.  Get the monkey off your back.

Create artificial goalposts that get the HIT world all a twitter every time the ONC makes a proclamation.  What goalposts?  Meaningful Use and Certification.  Just so there is no misinterpretation of what I think the issue is permit me to spell it out—Meaningful Use and Certification exist because there are no standards and there is no means of transport.  Conversely, had the ONC developed standards and transport, there would be no discussion of Meaningful Use and no Certification.  Standards would have forced vendors to self-certify.

The other activity could be viewed as a feint.  Not one developed out of malice, rather one that came about from the void that resulted from the lack of a viable plan.  Meaningful Use and Certification are expensive workarounds for a failed or nonexistent national EHR rollout plan.  As are RHIOs and RECs, the six million dollars, and the forty billion dollars.

The HIT world grinds to a halt at the very mention of an announcement from the ONC.  Their missives are available in PDF or stone tablets.  Imagine someone robs a bank, and as they exit the bank, they jaywalk on their way to their getaway car.  The police missed the robbery, and focus all their efforts on the secondary issue, the jaywalking.

The chain of events has caused the focus to move away from the primary issues of no standards and no plan, and towards a plethora of secondary issues, issues for which hundreds of people are responsible and no single person has authority.

I think that by the end of 2013 pronouncements on Meaningful Use and Certification won’t be able to buy time on MTV.

If any of this is close to being correct, what are the implications for a hospital looking to select and implement an EHR?  Find the EHR that is best for your hospital.  Not the one most likely to earn ARRA money.  Not the one which will pass today’s Meaningful Use test.  Define your requirements.  What requirements?  The ones you believe will most closely align with how the healthcare industry will look in 2015 and beyond.  Meaningful Use will change.  Reform will change.  Funds will change.  Reform will change again.  Will your EHR be able to change?

The ONC’s recent Meaningful Use proclamation required 556 pages.  If you occupy the C-suite of your hospital, I hope you don’t let those pages define your selection of an EHR.  Some would argue that with so many pages that there must be a pony in there somewhere.  From what I read, I’m in no hurry to rush out and buy a saddle.

An Australian Blog worth my time, maybe yours

I had no knowledge of this until Heather Leslie wrote that I was quoted.  Independent of that nicety, it makes good presentation and argument of the pertinent issues.

As always, my best- Paul


How can EHR be made to work?

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

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

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

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

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

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

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

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

Me either.

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

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

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

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

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