Tom Munnecke’s Eclectica

The details for the Integrated Electronic Health Record (IEHR) are just now beginning to roll out.   It’s pretty much a replay of the “Best of Breed” marketing approach that I’ve seen been pitched for decades.  Basically, collect all the parts and the whole will fall together with “just a bit of integration.”  They are issuing dozens of RFPs and RFIs describing all the pieces they seek; how it all fits together is a lot of hand-waving at the moment, with an inordinate faith in the role of an Enterprise Service Bus to magically make everything work together.

This is a little like someone selling you the world’s best car, based on “best of breed” components from all the best manufactures.   An engine from a Corvette, seats from a Rolls Royce, transmission from a Ferrari, etc. To make it all fit together, they would say it is all “standardized” – every part would use metric nuts and bolts, 12 volts electricity, and a common electrical harness (equivalent of the Enterprise Service Bus), to make sure that all the parts could work together.

We took an opposite approach in VistA, starting with a conceptual model of a system driven by active metadata – a common roadmap to patient database.  We were “integrated” by virtue of not “disintegrating” into pieces in the first place.  We had an overarching Conceptual Integrity to the design that gave us a common foundation from which to grow, climbing up the ladder of abstraction rather than falling down it.

This turns out to have been a good decision.  The President’s Council of Advisors for Science and Technology (PCAST) issued a report the report—Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward— that specifically pointed out VistA as one of the success stories for large scale EHR systems.  It also advocated greater use of metadata: tagging data dynamically through meta rather than “pigeonholing” it into pre-defined, previously synchronized slots.

This argument can be very abstract to some people, particularly to bureaucrats whose entire life has been engulfed by hierarchies and “pigeonhole” systems thinking.  The notion that systems can associate dynamically, spanning hierarchies (or not even being associated with a hierarchy) casts them into unfamiliar uncharted territory.  To them, complex systems require complex organizations to manage and regulate them. They seek efficiency, rather than resilience, adaptability, or robustness.

In order to make this a bit more understandable, I am proposing a theme song for the IEHR architecture: Johnny Cash’s One Piece at a Time.  Think of the IEHR vision as Johnny Cash’s Cadillac.  I’ll let the viewer draw their own analogies.  Of course, Johnny didn’t have billions of taxpayers dollars to spend, nor did he have a gaggle of consultants ready to reap huge contracts to do the “little bit of integration.”

It really pains me to post this kind of stuff, but I fear that we are entering an era of unprecedented Health IT fiascos.  After the $4 billion Department of Defense AHLTA fiasco, (AHLTA is Intolerable), and the $17 billion UK National Health Service fiasco, here is a A scathing report on the eHealth Ontario spending scandal charges that successive governments wasted $1 billion in taxpayer money. Carpet bagger consultants have arrived in full force, with flimsy-if-no experience in the complexities of medical informatics, but a deep, abiding concern for their own income.

The head of the Ontario disaster “billed thousands of dollars for limousine rides… before she resigned from her $380,000-a-year job in June. She was given a $317,000 severance package and received a $114,000 bonus after just 10 months on the job.”  This payment was made for leading the fiasco, not delivering a product.  The Canadian auditor found the agency had fewer than 30 full-time employees but was engaging more than 300 consultants. they also said the effort was ”lacking in strategic direction and relying too heavily on external consultations.”

The idea behind eHealth is to create electronic health records for Ontario, something the auditor says could save $6 billion if implemented in every province and territory.  Instead, Ontario “is near the back of the pack” when it comes to electronic health records, having wasted millions on underused computer systems and untendered contracts.

EHealth was set up in 2008 to create electronic health records after Smart Systems for Health spent $650 million but failed to produce anything of lasting value. Smart Systems for Health was quietly shut down last September.

And then there is politics: “the Conservatives and New Democrats complained the agency gave out $5 million in untendered contracts to consultants.   Documents released by the government since then showed the value of those untendered contracts was closer to $16 million, with the biggest ones going to companies the opposition parties say have ties to the Liberal government.”

These kinds of shenanigans are not unique to Canada, of course.  Here is a letter from a group of Wisconsin congressfolk blatantly meddling in VA and DoD internal IT decisions:
Wisconsin reps try to derail VA/Defense open source health records system which happens to be the home of Epic Systems, who hope to provide one of the most proprietary, closed systems in the nation.  Epic denied hiring lobbyists, but a quick search on OpenSecrets.org showed over $1m in political donations from Epic CEO Judy Faulkner and Epic, much directed to the very Congressfolks who took the time to write the letter.  Epic don’t lobby; I guess it’s more efficient just to send cash to their Congressfolks.

This isn’t just about money… Bad health IT software kills people.  When I worked at the VA Loma Linda, I routinely rode in the staff elevator with the gurney of a patient headed towards the morgue.  I would be in meetings when a code blue sounded, and docs would rush out of the room, only to come back breathless, saying, “now, where were we?” This was a sobering and constant reminder of the significance of what hospitals do.  The wrong information, or delays in getting the right information, can kill.  Installing patient software (e.g. the VA’s bar coding of patients for medications) can save lives.

At the core of this – around the world, not just the US – are self-righteous bureaucrats who persist in top-down, centralized, waterfall development, “one-correct-way” thinkers who see their bureaucracy, not the patient, as the center of the IT universe.  We are not creating an “accounting system for disease” as if it is a banking transaction system.  We need to building communities of health, with the individual at the center of the world.  We need to overcome the “failure to communicate” in health care; the Electronic Health Record is but one aspect of a much broader need for transformation in our health care thinking.

I don’t see this shift happening.  Instead, I see self-righteous indignation on the part of the bureaucrats who perpetuated the fiasco in the first place.  It’s as if a carpenter builds a crooked house, and blames his hammer.  All he needs is a another, more expensive hammer, and he’ll build a house twice as expensive.  The US Department of Defense is now on its fourth generation of crooked houses/more expensive hammers, and is in the process of repeating the process all over again, full of self-righteous indignation that VA’s VistA is continuing to evolve while their break-and-replace models continue to fail.  DoD continues to blame “the software” for their failures, oblivious to the fact that they were the ones who perpetrated the fiasco in the first place.  Governments continue to pour money onto the fire, paying for new hammers even when bureaucratic incompetence has been repeatedly demonstrated.

My current Health IT fiasco report card:  I hope this is the extent of the list, but I fear that there are many others to be listed.  Please email me with any links.

UK National Health Service:  $17 Billion

US Department of Defense AHLTA: $4 Billion

Canada: Ontario eHealth System: $1 Billion

(tip of the hat to Joseph Dal Molin for some of these links)

I had thought that DoD’s AHLTA held the record for being the world’s greatest health IT fiasco, spending $4-5 billion of taxpayer’s money on a system that was deemed Intolerable by the GAO and an Assistant Secretary of Defense.  It was so bad that it is cited as one of the leading reasons physicians are leaving military service.  One user told me, “The worst part of AHLTA is when you actually have to read some of the documentation it generates…. there is rarely a coherent statement in a 3 page clinical note.”

I knew that AHLTA would be a failure the instant I saw a diagram of it – a giant, centralized single point of failure that ignored everything that I had found successful in doing the VistA architecture.

This is not just dollars we are talking about, or missed opportunity costs.  Bad software kills people.  I don’t know if we’ll ever know how many patients AHLTA has killed, but it has to be significant.

But enough about AHLTA: I just read this article NHS IT system condemned about the UK National Health Service is in the midst of a far greater fiasco:

In a jaw-dropping condemnation of the NHS National Programme for IT, the National Audit Office has exposed a white elephant in the final stages of collapse.

In what read as a final pronouncement, the NAO reported that after nine years and £2.7bn, (US $4.5 billion)  the NHS has failed to deliver its primary aim of an electronic care record for everyone in the country.

The situation looks so dire the system might continue leeching money from the NHS for another decade if the whole scheme and all its software is not seized by state liquidators.

They go on to say that they don’t think its worth going forward with the remaining US$7.7 billion:

The NAO (National Audit Agency) said CSC would likely fail to deliver the rest before its contract runs out in 2016. DoH had been in dispute over its contract with CSC for 18 months, trying to claw back some of the £5bn (US $8.2b) it had promised the supplier.

What is particularly galling about this situation is that both the US DoD and the UK NHS had access to an award-winning, open source hospital information system that has been running at this scale for 25 years… the VA’s VistA system.  As one of the original software architects of this system, I have seen an endless stream of novice health IT folks appear on the scene, thinking that because they know some other aspect of IT that they can apply this to health IT.  In the past, these folks would slink away after losing $100m or so.  But now, it seems the stakes have been raised to the tens of billions.

We took an innovative approach in designing VistA, and it worked…  So, why are people continuing to pour money down the same failed approaches?

The answer is to follow the money:  A $5 billion fiasco is extremely lucrative to the beltway bandits.  Sure, they have to weather a few editorials and a couple of roastings before the various legislators.  But this can all be fixed with a little lobbying effort.  They’ll apologize, promise never to do it again, change the name of the project, and double the price tag of the next round of funding.  And laugh all the way to the bank with the profits they made on the fiasco.  It’s likely that a successful implementation would have probably earned them less profit.

Tthis isn’t just about an atrocious waste of taxpayer’s money.  People die from bad software.