Tom Munnecke’s Eclectica

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.