Apr 17 2013

Chuck Hagel’s Assessment of IEHR: “I didn’t think we knew what the hell we were doing.”

Published by at 2:52 pm under AHLTA,VistA

Secretary of Defense Chuck Hagel testified before a Congressional hearing yesterday about the Integrated Electronic Health Record project: “I didn’t think we knew what the hell we were doing.” I’m glad that he put the stop to the effort after only $1 billion, the UK National Health Service blew an incredible $17 billion before pulling the plug.

This ratchet ups the rhetoric of Assistant Secretary of Defense for Health Affairs’ Ward Cascells’ 2009 assesment that DoD’s AHLTA system is “Intolerable”

Not to kick a dead horse, but this has been going on for nearly 40 years now.  The DoD had spent $250 million prototyping the TRIMIS system, a collection of incompatible demonstration systems, while we at the VA were delivering a working, integrated hospital information system (DHCP) for 172 hospitals for $82 million.  House Veterans Affairs Committee Chairman Sonny Montgomery hit the roof over this, and partially triggered by the successful VA/DoD integration prototype declared that one of the competitors for the CHCS system would propose an adaptation of DHCP (now called VistA).  I went to SAIC to help with the effort, and we ended up delivering a very successful CHCS system, which is still the core of the DoD EHR system today.

The fundamental problem with the DoD is that they do not understand how to deal with systems of the complexity of a modern health care system.  They understand how to build an aircraft carrier, make sure that the troops have the supplies they need, and other activities from a linear perspective: the whole is equal to the sum of the parts.  Break the carrier into pieces, design all the pieces, and put them back together again to make a whole carrier.  This is (kindof) well and good for things that have this whole-equal-sum-of-parts quality.  Toasters can be taken apart and put back together again, and will still be the same toaster.

But health care is far more complex and dynamic than an aircraft carrier.  The hospital, Peter Drucker said, is the most complex organization in modern society.  Like a cat, we cannot dissect a hospital and put it back together again.

In a lesson straight from Humpty Dumpty, DoD wanted to break the electronic health record system into 17 “best of breed” applications, then hire a “systems integrator” to put Humpty together again.  This is like trying to build the world’s best car by trying to integrate the engine from a Corvette with the seats from a Rolls Royce and the chassis from a Porsche.  But despite how lucrative it is to be one of “all the king’s men,” it is simply not going to happen.

Yesterday, a friend of mine with many decades in the health IT industry called to tell me that he had just signed up with the VA in San Diego.  He said he was amazed at how well coordinated his care was – and this is from someone trying to do this in the private sector for 30 years.  This is the result of a fundamental approach taken from the earliest days of VistA – we were “integrated” by virtue of the fact that we never “disintegrated” into pieces.  We build a tool kit from which we composed the system over time, instead of the DoD’s approach of decomposing the system into pieces and then trying to put them back together again.  In that sense, VistA is remarkably similar to Wikipedia in this sense.  (See my discussion with Wiki inventor Ward Cunningham on this topic.)

So the fundamental issue is that we are dealing with a cat-like problem with toaster-like thinking.

Here’s my proposal: Fund a Skunkworks to get us out of this mess:

I’ve been developing VA/DoD interfaces since 1985.  They were technically correct, but politically incorrect.  I would hope that in the future, we can get past all the political nonsense of the past few decades, and just settle in to getting the technology working.

1.  Give me a contract to form a skunkworks.  I’ll collect 8-10 of the smartest people I know to develop the simplest solution that is “good enough” to get started.  I’ll also define an approach for “making it better.”

2.  I would like a couple of hospitals to work with (preferably in the San Diego area), at least one VA and one DoD.

3.  Connect me with teams of folks (both in the VA and DoD) who are passionate about making this thing work.  Create a bonus pool (for DoD as well as VA) against which I can make recommendations for bonuses for their contributions to the success of the skunkworks.

4.  Run interference for me to keep the bureaucracy out of the way.  We’ll be doing this in San Diego, far outside the beltway.

This can be a parallel activity to whatever the inside-the-beltway thinkers want to mull over.  Just ramp up a small, talented team working on the problem, independent of what is formally happening.  Think of it as portfolio diversification. The skunkworks funding would be just a fraction of what the IEHR-style aproach has been.








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