Mar 27 2013

There’s Gotta Be a Better Way

Published by at 4:23 pm under Uncategorized

100,000+ pages of federal legislation controls our health care system today.  We are increasing the number of disease categories 10-fold, moving towards a disease coding system (ICD-10) that names 150,000 categories, including categories such as W59.83D “Subsequent encounter of being crushed by other nonvenomous reptile.”  An enormous array of standards committees seek to define coding systems, exchange mechanisms, privacy and security, and medical knowledge bases.

One way to look at this is to marvel at the scale of it all.  Perhaps when we reach 200,000 pages of legislation and 1.5 million terms for how to be sick, we will finally get a handle on the US health care system.

Another way to look at it is that we are trying to get out of hole by digging it deeper.  What we see are the symptoms of the Humpty Dumpty syndrome: we have broken health care into so many pieces that even with “all the kings horses and all the kings men” we can never put it together again.

There has been a huge federal push towards the Electronic Health Record in recent years, and sharing it through information exchanges.  The problem is that hospitals consider this information to be core to their business, and would no sooner share it with competing hospitals than a Ford auto dealer would share their customer contacts with a Chevrolet dealer.  The AMA earns $70 million/year licensing their Current Procedural Terminology Codes (CPT) coding system that doctors must use according to a government-mandated monopoly.  There are hundreds of classes of stakeholders in healthcare who thrive by this kind of “rent-seeking” behavior – profiting not from creating value or improving health, but rather by serving as a tollbooth at some point in the flow of health care activities or information.

The complexity of this array of perversely incentivized stakeholders carries over to the information systems we seek to use to manage our health care systems.  Standards bodies are often dominated by the biggest industry players, who are motivated to either favor their technology or block approaches that may be damaging to their position.

In the past few decades, we have see a remarkable shift in how value is creating through the use of networks.  Rather than the hierarchical, top-down approach dominant in the health care industry, companies have emerged that thrive on the “network effect” – connecting vast numbers of people through modern communications capabilities.  These companies presented new visions of how to meet the needs of their markets.  When Tim Berners-Lee set out to create the World Wide Web, he didn’t go to Compuserve and AOL to try to integrate their services.  When Jimmy Wales created Wikipedia, he didn’t try to integrate World Book, and Encyclopedia Britannica.  When Craig Newmark started Craigslist, he didn’t try to integrate local newspaper classified advertising.  Google didn’t try to integrate libraries, nor did eBay try to integrate auction houses.

None of these network-based success stories would have happened if the old-guard stakeholders had their ways.  If the Department of Education had contracted with Encyclopedia Britannica to create on online encyclopedia, Wikipedia would have never happened.  They would have protested that only their hierarchical control of knowledge would be acceptable.  The notion that an open, network-based model could overtake their approach would have been unthinkable.

Similarly, Tim Berners-Lee’s model of creating a world-wide web of information was seen as a “chaotic mess of URLs” – no one would ever be able to find things if it wasn’t organized and curated.  See this inteview of Mark Frisse’s early review of Berners-Lee’s original paper describing the web.  Yet it was just this simplicity that allowed the web to take off:

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.” (From his book, “Weaving the Web”)

Rather than trying to apply a “Dewey Decimal System” to the web, he let the web itself figure things out.  Yahoo emerged, trying to superimpose a hierarchical coding scheme, Alta emerged as an early search engine.  Eventually, Google emerged to what it is today.

Today, we can search Google for Clostridium difficile, and Google returns C. diff, C. difficile, C-diff or even Bacillus difficilis, it’s early name.  This happens as part of the Google search process.  The more people search for this term (or related terms), the smarter Google gets by examining their search behavior.  The network is creating “order for free” – without requiring hierarchical control structures, such as librarians managing card catalogs with Dewey Decimal Systems.

The transition from the traditional stakeholders controlling (or being controlled by) hierarchies to a modern network-based model is not going to be hotly resisted by those stakeholders.  The New Health Project seeks to engage unencumbered thinkers and doers, who are not tied to the existing perversities of the current system.  Our initial efforts are focused on creating webinars and workshops to build a community of like minded thinkers to explore the issue and identify technologies that can be used to carry out the shift to a network-based model.


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