Christmas Wish List

The 13+ years I have spent in Healthcare have sensitized me to some things. I might have preferred to remain ignorant of many of them. In the spirit of Christmas, which is handy at this time of year, I'd like to nominate a list of gifts that would bless all residents and citizens of the U.S.A., regardless of theology or philosophy. Each item in the list relates to health care.

1. I wish that the role of technology could be clearly understood. There are a vast number of well-funded voices who want us to think that technology is health care or that health care is technology. In reality, technology is best thought of as a tool--an inert and often expensive piece of equipment, which, in the right hands, can produce wonderful results.
2. "The Patient" or "our patients" is not the same as "my patient" or "Josie Jones, patient". It may not be possible to apply technology designed for delivering care to a generic patient to Ms Jones. That doesn't mean that the technology is bad. It only means that the technology must allow for deviation in procedure. I wish that the role of abstraction is system design could be clearly understood.
3. I wish that all of the factions in the healthcare struggles were clear about their goals--with themselves and with each other. Only by being self-aware, open and open-minded can the parties negotiate a solution advantageous to all. Doctors, nurses, administrators, vendors, government and patients are currently at odds. The friction is not only between factions but within factions. Who will speak for physicians? The A.M.A.? Mayo Clinic? Who? Who speaks for government, for vendors, for patients, for nurses, for administrators? Each of these groups functions like a mob--surging to and fro as a strong voice emerges and then is drowned out. Each group must organize itself before "healthcare" can be organized.
4. Though I recognize that individuals and groups may be driven by ego to appear more knowledgeable than the next, I most devoutly wish that each of us might recognize that the person across the table might actually have some knowledge that we don't. I wish that we would listen first and assert only when necessary. I wish that we could see ourselves as occupying the same driverless bus.

There are many more things I might wish for this year but I don't want to seem greedy. May you each be showered with blessing upon blessing as one of God's beloved and may we fully appreciate each blessing as it comes.

Healthcare and Health Care

I have to revisit this subject in light of recent news and developments. It pains me to see the confusion that has caused the pollsters and pundits to be able to take shots at something that everyone wants.

There is concern about cost that is well founded. The problem is that costs come in a variety of disguises. Now discussions of cost have assumed inordinate importance in the questions of access. Once again, healthcare is about cost and health care is about access. These are two distinct issues.

There is virtually no one who advocates the denial of medical care on the basis of inability to pay. The entire health insurance industry emerged in response to a rise in costs driven by improvements in the science and technology of medicine. These improvement demanded better education for medical practitioners (added cost) and the technology has become more complex resulting in increased cost for both development and support.

While all this was happening, we became a nation of sedentary, over-eating, narcissists who believe in the idea that modern medicine can fix whatever we do to ourselves and make us all(well, me anyway) into beautiful people. We have learned to game the system to get the plastic surgeries we want and the pills we want and the therapies we read about.

Insurance coverages have been broadened continually in response to forces too numerous to mention with the result that more premium dollars go out requiring more premium dollars to come in. The insurance companies have developed bureaucratic defenses, requiring second opinions, demanding justification based on diagnostic testing, even making a practice of denial of the initial claim to filter out those who aren't really serious. The additional staffing and data handling is paid for by premium increases and forced out to the medical providers who increase their charges. Rising costs are everywhere and no one can join the debate with clean hands. Everyone wants someone else to absorb the costs.

In the midst of all of this, we sometimes lose sight of those who simply stay away from health care because they don't have enough money to pay for the other, even more basic necessities. We always lose sight of those who try to take care of themselves by buying health insurance, which they can afford only by accepting caps and deductibles or limitations on coverages. These people looks good in the statistics but rarely show up in the doctor's office because paying the premiums has put them into the same category as the uninsured in that they have no financial resources left over to pay for the visit. Further, they now have to live within the insurance bureaucracy that demands diagnostic justification, turning what might have been a $100 office visit into a $300 one.

Access to health care for everyone should be the sole topic in Washington. Access has relatively simple solutions. Let's solve that problem first, and, by the way, we have already agreed that ability to pay will not limit access.

Costs are a completely different issue and one that will require all interested parties to make substantial changes in thinking, planning and delivery.

It is deplorable (to use a word employed by a past President in a slightly different context) that we continue to allow doctors, administrators, insurance CEOs, technology vendors, pharma, and politicians to continue to point fingers at each other while the full cost of inadequate health care is borne by me and you, the patient/consumer.

Note to Sec. Sebelius

Secretary Sebelius,

I appreciate very much your stated position (according to Healthcare IT News) that technology adoption is in healthcare is not enough, that interoperability of technology is also necessary for healthcare reform. I wonder how much you know about interoperability of healthcare information systems. I wonder only because there is nothing in your published biographical information that leads me to believe that you have any background-in-depth in a technology discipline.

I don't mean for this to sound like criticism--it isn't--I think your position is a correct one and your advisers have done a good job. I wonder if you are aware, though, that there has been talk of interoperability for several years within the healthcare marketplace and there have even been claims of the achievement of interoperability. There has even been a "certification standard" published purporting to validate system interoperability.

All of this isn't worth the effort it took me to type the words. The reason for this "much ado about nothing" is simply that there is no incentive within the marketplace for the level of cooperation it would take. Technology of all kinds is the cash cow of healthcare and no one involved has any reason at all to kill that cow or even to bring it into the barn.

In the early 1980's, the Department of Defense had a very similar problem. Each branch (Navy, Army, Air Force, Marine Corps, Coast Guard) had its own procurement structure and its own pet contractors. There were no standards and all that was necessary for a contractor to be successful was to maintain some level of credibility with the procurement officer(s) involved. The result was that (for example) Army units in the field couldn't talk to units of other services because their communications equipment was incompatible. Logistics was a nightmare because of the variety of spare parts that had to be maintained and computer systems incorporated the "dialect" of the purchasing service and could not exchange information with the systems of the other services. This is the surface of the problem. The technological diversity went much deeper as well to the point where it was a major procurement effort to get two systems to cummunicate.

NASA was developing plans for an international space station and realized that they were going to have to fundamentally change the way that systems were specified, developed, and implemented if there was ever to be any hope of success.

The Defense Dept. took control of the situation through an initiative called Software Technology for Adaptable, Reliable Systems (STARS). DoD mandated that processes and methods (and their documentation byproducts) as well as tools and other technology used in the creation of systems be standardized for the purposes of reducing costs and delivering a level of interoperability.

Healthcare operations and all of their vendors--virtually everyone outside the walls of the DoD and the Software Engineering Institute at Carnegie-Mellon University remain blissfully unaware of any of this history, all the while enjoying its fruits.

I want you to know that I believe interoperablity can be obtained, but not without the institution of new paradigms and some major upheavals in the technology vendor community. I have dedicated 13 years of my life to laying some foundations where I can and I fervently hope that you have the commitment and the political will to see this through. Without that, government efforts are likely only to increase costs.

Re-Branding

Mass marketing seems to be an American (United States) invention and may be the single most impactful innovation of the last century. Please note that I made no value judgment. We each have to make up our own mind whether the impact was positive or negative.

Certainly, it has served to increase wealth so if your standard is ROI then you would have to view mass marketing as a positive development.

The downside effects are much more difficult to measure--plus virtually nobody wants to talk about the downside. Just as clearly, people have been convinced that they "need" something that they didn't even know existed. To that extent, a lot of raw materials were consumed and a lot of byproducts were produced because of the success of marketing.

Perhaps the biggest downside from my own perspective is the continual re-branding of technology practices. The effect of this is that everyone is on their heels all the time. We are bombarded with new acronyms and substantial effort must be expended to learn about them. Unfortunately, the common result of this effort is the realization that this "new" thing is really a 20 year-old concept with a new name.

Those not equipped to realize this invest even more time and energy in trying to make this new thing be their magic carpet without ever discovering what it was that kept the rug from flying the first time around. Technology folks are easy marks since they often are completely unconcerned with history--newer is obviously better after all.

Lots of money is being made but society is paying the price. Healthcare is the perfect example. Technology churn is costing billions at a time when everyone recognizes that costs are out of control. No worries though, we'll just focus all the lights on insurance premiums, thereby diverting attention away from the decision makers.

The Health Care (or Healthcare) Vision

I have a vision that can only be fulfilled from the office of the CIO. This vision is characterized by

• The patient of one is the patient of all
• The history will be available wherever and whenever the patient presents
• The patient may know immediately about the services delivered and the charges for those services.
• The revenue cycle can be reduced to same-day for covered (under contract) services
• Costs can be reduced by as much as 50% through attention to the quality of the information captured and used within the system
• People will accept a system of standards when they see that their own interests are satisfied
• The people in health care are highly motivated and need only a shared vision to be fully productive
• Alignment is possible when the vision is clear
• Good, reliable, current information is the key to all of this and getting that will demand the careful cultivation of cultural and attitudinal changes.

I firmly believe that this vision can come to pass with blinding speed in an environment of openness and honesty in which people are encouraged to care about and for each other.

Arm Waving and Obfuscation

"Pay no attention to the curtain!" "Do not look behind the curtain!"

There are two areas in which it seems necessary to ignore the Wizard. One is in the nature of "healthcare" itself. Most spell checkers refuse to recognize healthcare as a valid word, suggesting "health care" instead.

Clearly, spell checkers have not been sensitized to the politics involved. Since the dawn of the HMO nearly 30 years ago, health care has gradually given way to healthcare. What does that mean for you and me? I don't know if you've noticed, but even the physicians have been shifting attention away from their own role toward the insurance end.

More than 15 years ago, I attended a software engineering conference in Chicago at which [former] Surgeon General C. Everett Koop was a keynote speaker. I became disturbed during his speech when he made comments seeming to grant insurance companies a gate-keeping role in health care. When I got back home, I wrote him a letter mentioning my impressions and asking whether that was his intent. Some weeks later I received an envelope with Dr. Koop's return address and which contained my letter. My "gatekeeper" question was circled (red pencil) and "NO!" was written (large) in the margin.

Today, physician leaders don't even blush when they tell us that the solution to our healthcare problem is better access to [insurance] coverage.

Health care can be linked to medicine. Healthcare is a business, pure and simple. When people are talking about money and where it will come from, they aren't talking about health care.

I do not question the motives of individual physicians in health care, but I question everyone's motives in healthcare unless they are talking about profits. Even the insurance companies are being edged out for control. Today, healthcare cost is controlled by third-party (neither doctor nor patient) vendors of everything from pharmaceuticals, to technology--especially technology. This isn't necessarily a bad situation--it all depends on what the goals are. Pick your favorite goal from this list (or suggest another):

• Profit
• return on investment
• market dominance
• a healthy populace
• access to medical care
• control
• benevolence/compassion
• giving back
• ???

If you are a person who has a need for (or interest in) health care, you really do need to peek behind the curtain of healthcare to avoid wasting your time, money and energies.

Standards Dread

Healthcare in general and from top to bottom seems to have an absolute dread of standards. Physicians (many if not most) will flop about like a fish on a hook whenever the word comes up. They fight no matter how the subject is introduced. Whether it be "guidelines", "pathways" or even "best practice", it doesn't matter. As an interested consumer, I find this disturbing on several accounts.

1. It demonstrates such a me-first, tunnel vision mentality that, if I were given a clear choice, I would run as fast as I could away from this and toward anyone who could demonstrate that they do, in fact, adhere to standards.
2. It has a huge--and negative--effect on everyone else in the healthcare organization. The physician role is so central in healthcare that, if there is no reliable standard (process) for the physician, then nursing, registration, coding, billing, systems developers..., no one can predict from one day to the next or from one patient to the next what they're going to be asked to do.
3. It holds the practice of medicine back to a level not much different than was seen in the 18th century. Oh, sure, we have better drugs now and diagnostic magic is performed many times a day using the lastest technology, but the outcome for me, the patient, is so dependent on the physician I see that "bedside manner" often seems to be the most critical factor in outcomes.

In my 60+ years of life on this planet, I have seen that humanity can be put into two groups--those who appreciate standards and those who do not. Further, it has always seemed that the second group is the cause of problems not ony for themselves, but for everyone. Let's take a kind of standard that we're all familiar with--traffic laws. Those who flout the traffic laws are a hazard to everyone else on or near the road. And note that consistency and predictability are key. Traffic laws work because they produce consistency and the ability to predict with some assurance what the other guy is going to do. Those two principles keep everything flowing smoothly and with minimal (and manageable) disturbance.

We do not realize fully, the value of the standards we employ in this country. John Adams is the one who noted that we are governed by laws not men. Bribery is a recognized way to get things done in many parts of the world. Imagine having to find the right person (how do you do that?), paying to get their attention, then finding out that they weren't the right pewrson after all and having to start again. We sometimes go through that with building and remodeling contractors and it makes the evening news. Healthcare isn't much different EXCEPT that we don't get as heated about it because someone else is paying.

I constantly wonder at the inability of the insurance companies to get provider organizations to create and use standards.

Today, we are being told that technology is the key to the healthcare crisis (which is a crisis of out-of-control costs). I am going on record here that technology will only drive costs up unless the healthcare "system", beginning with physicians, learns to cherish standards, utilize standards, trade on standards.

We, the patients, must demand a system in which we can rely on standards to produce outcome and efficacy data allowing comparison of physicians and organizations. It's a sad system in which the only statistics available for comparison are mortality numbers.

Healthcare: More on I.T. Capabilities

I realize the need to be a bit more specific with respect to capabilities. I have seen a virtually unbroken string of capabilities discussed that related to the practice of medicine or the business of healthcare delivery, but in almost fifteen years of experience in healthcare I.T., I have yet to see a capability goal that is about I.T.

An example may help. Suppose you are the city planner. You could take one of two approaches.

1. You could develop a comprehensive plan for the city that takes into account various expansion directions and encourages some while discouraging others. The plan would include both residential and business expansion.
2. You could attempt to satisfy each request that comes before you. You could allow various developers and politicians to set the agenda for the next six months and continuously play one against the other for priority.

In the second approach, a deft manipulator can get by for quite a while. The city, on the other hand, will always be in turmoil and unable to staff its various departments effectively. Budget dollars will go to the current top project(s) at the time of the budget approval process. But, because project priority will be ever changing with the political situation, those projects may start and then go into hibernation. Workers with specific skill sets will find themselves with little to do while the new high priority project has tough going because there is no money to bring in the right skills. Equipment winds up sitting in a warehouse or worked far beyond recommended maintenance cycles.

In the first approach, remarkably modest effort goes into an expansion model. Productive and non-productive alternatives emerge. The productive ones are fleshed out and the unproductive are set aside for contingencies. Potential streets, sewers (storm and sanitary), gas, electric, phone, Internet, and other necessary utilities are blocked in. Alternatives and contingencies are identified and capacities are established. With all of this in place, it is now relatively simple to budget for the next year's projects and all will be well as long as we don't cave into to political expediency and begin to allow projects outside the scope of the plan.

There is no problem as long as all negotiation goes on in broad daylight. If a particular out-of-scope project has popular appeal, it will be a simple matter to say, "OK, here's what it will mean for our other projects, for our long term plan and for the budget. If it's still popular, we do it.

Back to I.T. capabilities; server capacity, mass storage capacity, network bandwidth and access points, space, cooling—these are all obvious capacity planning considerations and for that reason they are at least on the radar for everyone. More subtle but no less important considerations include the architectures (technology, network, data, and communications) that we want to have, skills required as we work within the architectures and, not least, the standards architecture that will be the governance glue that holds everything else together.

Depending on your own experience as a technology worker (rather than as a manager), you may not have a "feel" for the people, skills, and experience that will be required, nor even for the implications of various architectures. Again, this is no place to guess. Get your direct reports together. If they don't seem sure or can't tell a story that is meaningful to you, then get some outside advice. The skills and attitudes required for a successful SOA (service-oriented architecture) are much different from those needed in a more "traditional" approach.

If you intend to rely on vendors for everything, you will still need to be able to tell which vendors fit into your architecture and which don't. They will tell you that they are "architecture-agnostic" or that they can fit into any architecture--don't believe it. Know about the characteristics of things that will fit and things that won't. Attempting to force-fit something that doesn't belong is the quickest way to throw everything you've built into turmoil.

If you're uncomfortable, I apologize for being so open. The answer to getting comfortable isn't avoidance, though, it lies in making a concerted effort to bootstrap yourself. No budget, no resource plan, no allocation discussion--management of one thing is not the same as management of anything. Technology is to big, too complex, too fast-moving to be brought into line by the classic "cost management and allocation of resources" approach. It needs a team approach because there's just too much for one person to know.

Do what you're able to do and know what your boundaries are. Be honest with yourself first of all and with your peers, reports and management. You may wonder if you are the only one at times, but it is not possible to manage technology without honesty. Unlike people, technology can't be coerced or manipulated.

Advice Re; Healthcare IT

If you are a healthcare CIO or the top IT director/manager and happen to be reading this, or if someone has forwarded this post, and if you feel under some pressure more accomplished (or even to get something accomplished), I have some gentle advice. You're going to get phone calls from angry physicians no matter what you do, so you may as well do the right thing.

It is a fact that, in the history of computing (I.T.), no application or system has ever been delivered to universal acclaim (despite what the marketing people tell you). Medicine has more than its share of curmudgeons and you're going to have to let them become part of the background noise. If you're afraid of losing your job because of the indignation of a few people then you're probably on the wrong career path.

I hope you knew that already, but it can be reassuring to hear it from an "outsider".

Now, if you're still reading, you may be wondering about what the right thing is that you should do. The first thing is to get your priorities squared away. Then you you will have to work very hard to get your priorities into the cognitive space of the rest of your organization's upper management. What are your priorities? What are your 1, 3, 5 year or long term objectives? Are they written down and visible to others? If your answer is no, then your job just became much more difficult. By the way, if you are a CEO, and the only I.T. objectives you know about are the ones you handed out, you may want to re-think your approach to I.T.

What does an objective/priority look like for I.T.?

The big rocks (the ones you put into the container first) are capabilities and alignment. In my career, the most pervasive problem I have seen is that healthcare CIOs invariably focus their attentions outward from their I.T. organization. In nearly 15 years, I have yet to see a single initiative directed at developing or improving capabilities come from the top of the I.T. organization. When such things have happened, they seem always to arise from the introduction of a new application or a new technology. Just once, maybe we could spend some time to actually imagine the kind of I.T. organization we think will be needed five or more years from now. Capabilities, in the healthcare I.T. world come about by accident. The current best case is when there are a few people within the organization doing this kind of thinking on their own.

Of course, when there are uncoordinated pockets of effort, you don't get the other big rock, alignment. By the way, if one of your objectives is something like "reduce or contain costs", you may want to rethink. Cost management is like breathing if you're a manager. To call it a priority or a goal is to divert attention away from the big rocks. Similarly, any objective that includes the word "continue" is a waste of paper. Holding the gains must also be at the level of breathing for managers. You will want to keep measuring to make sure there is no backsliding and take action if there is, but holding onto gains has to be part of the original planning process and should be automatic.

Alignment begins with a picture of your organization now and five years from now. Every manager and supervisor/lead within I.T. must share that picture and understand their own specific role(s) in it. This is something best accomplished as a team. You can't mandate alignment. You will want to decide how you will recognize and/or measure the alignment within I.T. How will you know when you have it? Everyone should understand and be on board. This is the first step.

It is up to the CIO to bridge between the business strategy and the I.T. strategy to make certain that as alignment develops within I.T. it is congruent with (aligned with) the business' strategic plan.

You are fortunate in that your direct reports want all of this as much or more than you do. All they need in the way of motivation is the belief that you are committed to seeing it through. If you don't feel confident that you can produce the I.T. vision, don't attempt it on your own. This is the place for leadership that is confident and sure-footed. Start with a clear and concise vision--it has to be your vision or you won't be able to commit to it, but you can get help to create it.

Healthcare I.T. cannot get where the nation wants it to go as long as are dissociative in our thinking. Things aren't the way we want them to be simply because we say so in a presentation to the CEO or the Board. You know that buying and installing a new system is only the first step of implementation. What we're talking about here is very similar. Forming a committee or naming a Director is only the first small step. If you want to know if you have actually achieved your goals of capability and alignment, I would recommend strongly that you bring in an outside person or group to conduct an audit.

Good luck! You are the leading edge.