Tom Munnecke’s Eclectica

I’m researching a op-ed piece on federal health care software, and am browsing through my old proceedings from the early days of the MUMPS Users Group meetings.  These meetings were quite an entrepreneurial incubator: Judy Faulkner was starting Epic Systems,  Paul Egerman, founded Interpretive Data Systems, which then became  IDX and sold to GE HealthCare systems for $1.2 billion, Terry Ragon started Intersystems, and I had just started working for the VA to work on what was to become VistA, and spread to the Department of Defense as CHCS and the Indian Health Service as RPMS.

Here is scan of Judy Faulkner’s 1979 paper called PISAR: A Time-Oriented Data Management System.  Judy’s Epic Systems went on to become a powerhouse in the Electronic Medical Record space.  It is remarkably similar to the architecture I was developing for the VA VistA’s system with George Timson and others called the File Manager.

It’s interesting to look at these systems 30 years later.  Judy’s company, Epic, has become a giant in the electronic medical record world.  VistA has gone on to power the transformation of the VA documented in Phil Longman’s Best Care Anywhere.

Rumors abound that EPIC is the lead contender for replacing AHLTA.  An alternative is the Open Vista Initiative.

I have great respect for what Judy has accomplished over the years, but at the same time, I think it would be a travesty for the government to turn to a closed, proprietary system instead of a roughly equivalent open source, publicly available one.

Isaac Newton said, “If I have seen farther than others, it is because I have stood on the shoulders of giants.”  In today’s Federal health care IT world, it’s getting hard to see anywhere, because everyone is standing on each other’s toes.  The VA’s VistA system has been in constant evolution since 1978 – and continues to thrive today.  The DoD’s uses a “break and replace” model, running one system into the ground until it breaks, only to replace it wholesale with another, more expensive system.  (It spent $250 million on TRIMIS until it threw it away to spend $1.6 billion for CHCS, which it tried to replace for $5 billion with AHLTA, which it is now throwing away to be replaced by something else.)

How will DOD pull itself out of this bureaucratic disaster area?  Will it spend billions more on a closed, proprietary system, or will it join the VA to create an evolutionary open source approach that benefits all?

Stay tuned.

P.S. I’m digging out all my old papers from the era and will be posting them in an archive Real Soon Now.

I watched an hour or two of the Health Care Reform Summit at the White House today.   My overwhelming reaction to it was how much effort was being expended on just a tiny part of the whole equation.  First of all, it should be called Health Insurance Reform, for it has little to do with the health process at all.  Second, it treats health care as an industry, as if it were a factory taking in sick people and producing well people.  All that we need to do is figure out faster/better/cheaper ways to run the assembly line, and make room for more people to get on it.  It is firmly locked in to the notion that health care is something the system does to the person, patients are “consumers” and doctors are “providers.”  We have transactionalized health care – defining disease/billing codes that shape doctor behavior.  If someone cures their depression by taking up running on the beach, they generate no transactions, incur no medical costs, and improve their health in many other ways.  If they get an antidepressant and go back to sit on a couch to wait for their depression to clear, this generates many transactions, incurs potential side effects, and may diminish their health in other ways.  Unfortunately, our health care system only recognizes the latter… things that don’t get transactions don’t get recognized.  Things that cause health transformations (such as running on the beach) are lost below the radar of the disease industrial complex.

Addiction is one of the great health problems of our time, and Alcoholics Anonymous is the premier organization for treating it.  I recently had dinner with a man celebrating his first year of sobriety, and he was glowing about AA, and has turned his life around.  He is an enthusiastic mentor for 5 others.  AA generates no medical records, no master patient index, and incurs no costs.  The more members it gathers, the more members it can support – members help themselves stay sober by helping others stay sober.  AA in San Francisco has over 700 active groups meeting weekly, yet is has only a tiny staff of 10 to organize it.

So, here is one of our most pernicious health care problems that is being solved virtually cost-free in a self-organizing, self-propagating manner.  It is a transformational approach to health – utterly outside of the transactional provider/consumer model that dominates all health care reform discussion.

The 600 pound gorilla in our health care system is ourselves.  Obesity, smoking, drugs, alcohol, and sedentary lifestyle drive a huge portion of our health care costs… and these are personal life-style issues, not things that “providers” do to “consumers.”

People don’t necessarily “consume” health care when they get healthier.  AA members help others when they become sober – its “baked in” to their 12 step process.  People can get healthier, and in so doing, make other people become healthier.  The fact that your immune system fought off TB today makes everyone else around you a little healthier.

AA attributes their success in part to the fact that that they were underfunded when they got started:

Mr. Rockefeller decided to turn down the request for the money requested by Frank Amos. He reiterated, “I am afraid that money will spoil this thing”… Both Bill and Dr. Bob could access this account and funds could be withdrawn as needed. Rockefeller warned them that despite his help, the movement must become “self-supporting” in order to eventually become a success.

Jonas Salk (in Anatomy of Reality, Columbia University Press, NY, 1983, p. 122) spoke of the need for health care reform to be framed as “Creating an Epidemic of Health.  Only a few are needed to visualize and to initiate a process that would become self-organizing, self-propelling, and self-propagating, as is characteristic of evolutionary processes.”  AA could be viewed as an example of the kind of transformational, “viral” models of health that Salk was talking about.

Are there other self-organizing, self-propelling, and self-propagating models of health out there?  I don’t know.  But I do know that the transaction health industry would not be the place to look for them.  Pharmas are not going to fund products that decrease their dependency on them.  Nephrologists who are sitting on dialysis “gold mines,” despite stated good intentions, would worry about the financial ramifications of a treatment that diminished the need for dialysis.  A approach based exclusively on the notion of health as something the system does to the consumer would not see much virtue in their “consumers” running off and doing things independently of them.

This dependency relationship is exactly what Rockefeller saw when he refused to fund the local chapters of AA… and yet it is the glue that our system is based on.

I participated in a health care reform effort called Valeo about 10 years ago.  It was an effort to apply Dee Hock’s theory of “Chaordic” organization to health care reform, coupled with David Cooperrider’s “Appreciative Inquiry”   We ended up in a summit meeting of about 180 stakeholders from the entire health care field.  My Duh! moment from this event was that gathering all the stakeholders in a perversely incentivized system and asking them to self-organize into a more efficient system is not a recipe for success.  Asking some to jump off the gravy train so that others can ride more comfortably is not going to attract many volunteers.

I don’t recall any political stakeholders in the group – certainly nothing like I saw today at the White House.

Health insurance reform is but the tip of a very large iceberg of reform.  Given the enduring complexity of the problem, I have to wonder whether its humanly possible to come up with an effective solution.  Perhaps we need to declare a “complexity crisis” and rethink ways of minimizing complexity, rather than fixing problems.  Maybe adding 2700 pages of legislation to 125,000 pages is not going to create a workable system.  If so, how much is too much?  If we got to 1 million pages of legislation, would we have solved the crisis?  Or would it be an indicator of intractable complexity?

Here are some thoughts towards simplifying health care:

1.  Decouple the employer relationship from the health care system.  Employers don’t buy our car insurance, why should they buy our health insurance?  This would remove a huge load of issues relating to insurance portability, privacy, unemployment, big- vs small business, and taxes.

2.  Give up on the notion that we have a “system.”  It is just too big and too diverse to think of it in the factory model – that there is One Correct Way to push things down the assembly line.  Rather, we should frame things as a Health “Space” – much in the way that the web was designed as a “space for information to exist” rather than a “system for retrieving information.”

3.  Start with a communications-oriented approach rather than a records-oriented approach.  The problem is that we have a failure to communicate, not that we haven’t standardized, organized, and shared our file cabinets in the proper way.  One form of communication is the medical record,  but not the only one.

4.  Start with the transformational notion of health.  Health is something we all do, and are primarily responsible for it ourselves.  Providers are the edge, people are the center.  Let’s discover all kinds of new approaches to this, to communities of health, to buddy-systems, and the like.  Patients Like Me is a great example of this kind of thinking.

5.  Free up telemedicine.  While its nice to have the super hi res, high bandwidth hi-tech telemedicine systems I’ve seen pitched for decades now, the fact is that a lot of good can come from a simple cell phone photo or video.  There are lots of legal (and some would say ethical) issues to be dealt with, but I think that this should be a basic notion for any future system of health.  We need to design from a state of connectivity.

So, my advice to President Obama: make whatever simple changes that can be agreed upon today, but declare a complexity crisis and move to a new model specifically designed to be a simpler, more adaptive, and more resilient health care system focusing on the transformational rather than the transactional nature of health.

I had three very similar emails this morning, so I thought I’d post my response on my blog…

the basic question was: “What are the driving forces behind this inflexibility? (in Health Care IT)”

and here is my response:

1. In the federal govt, civil service are largely to blame… fed employees’ salaries and job security are based on the number of people below them in the bureaucratic pyramid. If you do your job less efficiently, you end up sitting on a larger pyramid and get a raise. If you do your job more efficiently (replace labor with computers, collaborate with another agency, cut costs), you threaten your salary, job security, and retirement. (I was demoted for my work on VistA, because I worked with peers across the system, rather than supervising a local staff). The VA has had a horrific backlog for accepting new veterans for decades. What the vets see as “delays,” VA employees see as “job security.” Its an on-going beltway drama – going on decades now – for congress to huff and puff about the issue, but things just plod along as another batch of civil service employees march to retirement.

2. Proprietary information systems. Imagine trying to build the “best of breed” automobile with the engine from a Corvette, the chassis of a Porsche, the seats from a Rolls Royce, and the suspension of a Hummer. “All it takes is a little integration” says the salesman as he takes your check. This is basically what is happening in Health IT at the moment, with all these incompatible systems being sold for tiny portions of the overall pie, “all it takes is a little integration” at the hospital level to make it happen. Now imagine the Feds (or UN) saying that we need to standardize our car manufacturing to insure the best of breed Corvette/Porsche/Rolls/Hummer is “interoperable” and meets the criteria for “meaningful use.” And they throw hundreds of billions of dollars at the manufacturers to make it happen, so that all can enjoy the benefits of the best of breed automobile. We’d have lots of jobs and profits at the manufacturers, but the chance of coming to a simple but practical vehicle would be nil. Folks would laugh at the 50 mpg tiny car that had none of the declared virtues of the best of breed car. Similarly, people laugh at VistA because it doesn’t have the “best of breed” (read proprietary) paraphernalia of the commercial systems. And this criticism somehow prohibits folks from working together on an open source stack of technology, allowing folks to stand on each others shoulders instead of their toes.

3. A fundamental mistaken metaphor about Health IT … the very notion of the “health record” is too primitive a notion… The vision should be about health communication. The “filing cabinet” role of medical record is but one form of communication. Simply streamlining communication about health – and not necessarily link it to hospital – patient relationship. In my dream world, I would base this communication around the notion of an “ensemble” focusing on a specific health transformation. This ensemble might involve be a doc and a hospital, or it might involve a mother offering chicken soup. But to “bake in” a filing cabinet metaphor into today’s tangled web of enterprise/hospital/employer/malpractice is a great way to burn through $100 billion and dig ourselves into the very hole we are trying to dig ourselves out of.

4. A fundamentally mistaken metaphor about health care as a “system.” Hospitals are like factories, admitting sick people and discharging cured people, not unlike a car assembly line. If we just “optimize” our outcomes assessment process, we will have an ever-improving factory for health. Yes, there are certainly some health care processes that work this way, but they are a minor portion of the overall health “space” of activities that is a much richer vision of the health process. I worked with Tim Berners-Lee in the early days of the web.. I had been scheming an idea I called “Universal Namespace” for VA/DoD integration, a naming convention for naming every information object in both agencies as a tool for integration. When I saw Tim’s URL (Universal Resource Locator) concept, I immediately realized that he was on to something big. This became even more important with REST architecture ( http://en.wikipedia.org/wiki/Representational_State_Transfer ) Tim went on to write about his design of the web, “What was often difficult for people to understand about the design of the web was that there was nothing else beyond URLs, HTTP, and
HTML. There was no central computer “controlling” the web, no single network on which these protocols worked, not even an organization anywhere that “ran” the Web. The web was not a physical “thing” that existed in a certain “place.” It was a “space” in which information could exist.”

Note that there were very powerful proprietary networks at the time (Compuserve, AOL, Tymnet, Prodigy), and he could have gone the “integration” route, perhaps seeking a UN commission to provide “meaningful” interoperability between them. Pierre Omidyar could have gone Southebys and Christies to “integrate” their auction systems instead of starting eBay. But each went off and created their own “space” for things to happen, independently from the powers that were at the time.

I think we need to take a similar “space” approach to health.

I just ran across this disgusting article Favoritism fears halt major military health upgrade:

Work on a high-priority project to integrate the Pentagon and Department of Veterans Affairs health care systems has been delayed by up to two years because of a “potentially unethical” relationship between a government staffer and a contractor, according to an internal Pentagon report….

This month marks the 31st anniversary of the 1978 Oklahoma City conference that was the kickoff for the software architecture that lead to the current VA’s VistA system, the DoD Composite Health Care System (CHCS), and the Indian Health Service’s Resource and Patient Management System (RPMS).  (I have several boxes of papers from the conference that I am going to scan and post online Real Soon Now).  I took it as a given that we would design a single architecture that would seamlessly integrate all of the federal health IT systems.  I reviewed the state of the art in database management systems at the time, and rejected SQL as being too “pigeonhole” oriented… it expected everything to be nicely laid out in a predefined structure: a place for every datum and every datum in its place.  I used IBM’s IMS (Information Management System) as a counter example for the design of FileMan: whenever I was in a quandry about how FileMan should work, I asked myself, “How would IMS do it?” and then did it the opposite way.  We designed the Kernel architecture as a device- and vendor-independent layer built upon an amazingly simple core MUMPS technology: one data type, 19 commands, and 22 functions.

This approach was amazingly successful, it was eventually used in all federal health care facilities – about 10-15% of all hospital information systems nation wide.  By 1982, we were deploying the system throughout the VA, and in 1984, I implemented my first of many VA-DoD interfaces between the VA hospital at Loma Linda California and March Air Force Base in Riverside.   The system worked very well, and it only took a team of 2-3 programmers less than a year to make it happen. We had staffers from Congressman Sonny Montgomery’s office visit, and it became a major impetus to require one of the bidders for the DoD’s Composite Health Care System “fly off competition” to propose an adapted VA solution.  We had a similar integrated system operating at Fitzsimmons Army Medical Center in Colorado.

My first inkling of the power of the Beltway Bandits came when DoD hired a consultant from Arthur D. Little to study the system.  I discovered that they had a budget several times greater to STUDY the interface than I had to DO the interface.  And I wasn’t convinced that the study was necessarily looking for the benefits of the interface, but rather seemed politically motivated with “push polling” style of interview looking for the negative.

March AFB was closed down, and the interface forgotten.  After I moved to SAIC, I did another interface between the DoD (which went nowhere), and then set up a lab running an integrated version of VA, DoD, and Indian Health Services systems.  Again, this got nowhere.

Now that the interface had surfaced in the world of beltway economics, it rapidly escalated to a multi-million extravaganza.  I’m not sure of the cost of the GCPR (Government Computer Patient Record) in the mid 1990s to integrate the systems – it was in the hundreds of millions.

After 31 years now, I see a recurring pattern.  Someone in congress gets upset about the disintegration of VA and DoD information systems, and huffs and puffs about doing something.  The call hearings, and various secretaries and program managers pledge to make things happen.  Big bucks are allocated, committees are formed.  However, by the time it gets down to the worker-bee level, folks suddenly realize that if they integrate their information systems, their health care facilities might follow as well.

This violates Munnecke’s First Law of Bureaucracy: Never stand between bureaucrats and their retirement program.  Successfully integrating an interface between the VA and DoD – increasing efficiency – would result in someone losing their job security.  Bolixing up the interface, creating a backlog of work to do – decreasing efficiency – results in greater job security.  Meanwhile, the huffing and puffing at the top has been directed at other causes, and folks have probably moved on to other jobs.  And so the cycle continues.

Meanwhile, we pour more money down the drain, feeding the beltway, ethically or not:

the mishandling of the project has delayed the military’s effort by “a minimum of one year up to two year [sic]” and could leave the military with nothing to show for the $13 million it has already spent, the internal report says.

To further compound the problem, we are trying to interface other systems to the VA, such as the Kaiser-VA interface which strikes me as a very brittle architectural approach.  Now, all of VA is trusting all of DoD and all of Kaiser to do the right thing with their medical records.  The trustworthiness of the extended web of interactions is only as trustworthy as the weakest link.  And as we see here, weak links do appear.

The way out of this mess is to reframe our information architecture around the individual, not the enterprise, something that I concluded 10 years ago.  We should reframe health information technology around then notion of a Space, rather than an absurd presumption that we have a health care “system” akin to a car factory, taking in sick people and spitting out healthy ones at the other end.

I think that there are many foundation issues that need to be addressed regarding our health care system that are being ignored in the rush to “pave the cowpaths” of the very practices that most desperately need changing.