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.

Survival, Error & Technology

I'm going to pass on some wisdom here. It's not very often that we encounter wisdom today, especially where technology is concerned, and it's often the case that we don't recognize or acknowledge wisdom until we're looking back over the wreckage and trying to figure out what we should have done. I'm probably also setting myself up by labeling this as wisdom but I am so weary of seeing the same ads with different acronyms and talking to the same people with different names.

You will never find your way out of the current mess you're in or about to be in by searching for and hiring someone with recent experience on a specific product. To put it another way, a specific product, no matter how much buzz it enjoys, is never the answer.

I will be among the first to acknowledge that the use of absolute language (never, always...) and even the use of unqualified superlatives (best, worst, fastest...) is a habit to be avoided, nevertheless, decades of experience have proven that the absolute statements in the preceding paragraph represent wisdom and that failure to heed this wisdom will produce cost overruns, timeline disasters, confusion, stress, employee turnover and a host of other undesirable outcomes.

In large part, the success of the human race has been due to our ability to recognize exceptions without necessarily understanding the rule. My own take on this is that, with today's reliance on technology, we may have reached the point where the process of natural selection that has honed this skill over countless generations has now produced a liability. "Something's different," is enough to put us on guard and may be enough to launch a complex defensive reaction to preserve the safety of the individual or group.

First of all, while it is still good to recognize exceptions, it is now absolutely essential (that's an absolute absolute) that we develop the ability to recognize the underlying rule. A study of human error (Human Error, Set Phasers on Stun...) shows that leaping to conclusions about the rule is what produces the error condition. In fact, if we can't describe the rule in terms of the logic of the computer (if... then... else...), we can't rely on technology at all.

You might ask, as I did, how we might acquire this ability. The time tested way is known as [survivable] experience. There are a host of cause-and-effect analysis tools and techniques that have the appearance of rigor and reliability and are an improvement over experience, especially when combined with exhaustive testing, but you will find that even these are more productive when used by people with experience in the world being analyzed.

Tools are great and another critical human enabler, but--and this can't be over-emphasized--no tool is so advanced that it runs itself. Every tool, no matter how advanced the technology requires human hands and a human mind to guide it. If you were to be presented with the greatest woodworking tool in the world or the most advanced sewing machine or fishing gear or computer, would you immediately become a master cabinetmaker or designer or fisherman or software developer? You might note that the only immediate change is one of expectation.

An experienced person with rudimentary tools is more likely to produce a quality result than the inexperienced person using the "best" tools. The fact that I used a tool just yesterday says nothing whatsoever about the level of my experience in producing the required outcome. I have made the mistake of looking for help and focusing too narrowly on what amounts to recent experience with the tools in my shop. I have learned (through experience) that I will enjoy better results if I'm learning while interviewing my prospective employee. If I'm talking with someone whose knowledge stops at the tool's user interface, then I had better be prepared to devote myself to directing the employee's work. If I have a staff composed of such employees, then I need to possess all of the requisite experience myself or else be prepared to conduct a project whose principle product is more experienced workers.

The challenge is to find the right mix of experienced people in supervisory or team lead roles and people who possess dexterity but are in need of experience. If I'm in a director or management role, I have to have experience producing a product with that scope. A technology "system" has a complexity that is beyond human comprehension. The only way to design and build it is through a process of identifying smaller and simpler pieces, building those and then assembling them into the final product. You need to look for people who have an appreciation for the amount of effort this takes and the discipline--both personal and organizational--that it takes.

Stop looking for Oracle or CRM or Rational or even "use case" or "data model" experience except as clues about the approach that the candidate might be expected to take. I understand that these things are ideal as targets for a logic rule processor, but the rule ("find resumes that include these terms") is so simple-minded as to be useless. If your only goal is to turn 1000 resumes into 100, then proceed, but if your goal is to find someone who can get you out of the predicament you're in, then you should spend more time on your rules so that the exceptions are more productive.

Business, Information and Technology

Are you in management? Do you have annual/quarterly goals? Will you be held accountable for achieving those goals? Is the accountability expressed in bonus dollars? Is there any possibility of a zero bonus?

Are you still with me?

How will the achievement of your goal(s) be measured? Please note here that "how" has two dimensions: one is related to process and the other to a unit of measure. In all of my vast personal experience, all of the attention has been focused on the unit of measure part (when there has been any attention at all), and the process part has never even been part of the conversation.

Please understand that what follows is not intended to sling mud at any individual or organization. My purpose is to clear the air so that we can talk about how we're really going to achieve our goal(s).

I am going to generalize based on extensive, though anecdotal, experience. In other words, I have not conducted a survey, scientific or otherwise, and cannot produce data to back up anything I'm about to say here, so I'm leaving it up to you, the reader to determine whether it feels like truth or not. Should you feel that this does not ring true, or should you wish to fault me for not being more objective, I would ask that you produce a study or at least a body of experience in support of your position.

Awards of bonus dollars tied to achievement are based solely on whether the holder of the dollars wishes to give them away or not. There is rarely, if ever, any protocol defined for defining metrics, units of measure or measurement process. You will go into an "annual assessment" meeting with your boss and he or she may discuss your level of achievement in very general terms before announcing the amount of your bonus or a recommendation for an increased level of compensation.

Why is this important, you ask? Well, it is important because it's the the way things are done. Despite vigorous protests to the contrary, the business world is set up to run on subjective assessment supporting subjective decisions. What, you say that your decisions are "data-driven" (objective)? I would love to hear the story behind the data that was used to arrive at your most recent decision.

All of this is background for understanding why "data" initiatives so frequently become mired in a swamp of politics and personality. Let's walk back from a data-driven decision.

1. You are able to make the decision because you trust the data.
2. You trust the data because you are familiar with and trust its source.
3. You trust the source because you know that it is reliable.
4. You know that it is reliable because it consistently produces information that can be relied upon.
5. The source has been consistent because it always uses a tried and true methodology (set of processes) to produce its product.
6. The consistency is possible because the methodology includes steps designed to validate the source's inputs.
7. The validation decision returns us to #1.

How do you feel about standards (e.g., standard operating procedure or SOP)? If you don't currently support the creation, implementation auditable use of standards or, at any time in the past have not done so, you have no right to and almost certainly do not have access to reliable information and therefore no claim to data-driven decisions. Just to drive the point home, when your boss decides that you won't be getting that bonus or increase you were counting on, your only acceptable response is to smile and say thank you.

By the way, if you notice that your bank account (or budget) is suddenly much bigger (or smaller) than it was yesterday, what is your responsibility? Who are you accountable to? How much trust can you afford? Now you have some insight into compliance.

The use of technology introduces an additional huge portion of uncertainty into the trust equation. Take another look at the decision walk-back above and note the points where the use of technology means adding additional paths and complexity to the validation process. This is what your data governance people are trying to get their arms around.

To summarize:

• data-driven or intelligence-driven decisions demand trust
• trust demands reliability
• reliability demands consistency
• consistency demands compliance
• compliance demands governance

OK, you can go back to work now.

Managing Technology and People

The thing about management is that it works great for money, time or countable things, but management of complex, uncountable things is at best a dream. You say "people are countable" and I'll agree, but only to the extent that the management is about bodies (head count).

Technology and its applications are so complex as to be unmanageable. Edsger Dijkstra spent much of his career trying to get that message across to the business world and the budding computer industry. Today, he is remembered more for optimized search algorithms. If that isn't the industry in a nutshell...

Many years ago I tried to tell people that technology must be controlled, not managed. My slogan was "control technology or it will control you." We are so in love with the notion of management and have so much antipathy for control, that this message, like Dijkstra's, falls on deaf ears. I am not, in any way, comparing myself to Dijkstra. I am comparing his "audience" to mine. Today, the tag line on my web site (www.m2dxtx.com) is "Leadership for change, Management for effectiveness, Governance for stability." The three are not mutually exclusive but the probability of finding all three in one person is quite small.

Control is not a bad thing--it is an essential thing. Automobile travel without control would involve so much risk that no reasonable person would attempt it. The control starts with the design and production of the machinery itself. An automobile is designed to be controlled. It is also designed to function within a larger system of controls. Awareness of this allows the designers to prioritize their efforts and focus on differentiators suggested by the system rather than on mere "performance" factors. For example, it would be a waste of time designing a vehicle for mass production that could negotiate a 90-degree turn at 80 mph. The system of controls insures that this level of performance is unnecessary.

Use of technology without controls is also fraught with risk. We require control over the design and production of technology to insure that the product is useful and usable within the larger control framework that is our business context. Control over the use of technology is needed to insure reliability and safety for all just as our traffic laws and their enforcement produce a sense of safety and predictability for those of us on public roads.

Because no one likes the idea of control, we are calling this "governance" but make no mistake, governance must be about controls or any effort is wasted. People want and need consistency. Consistency produces contentment and the role of government, according to SunTzu (The Art of War) is a contented populace.

So, if by management, you mean counting (or accounting), you won't have success applying it to personalities or to technology. If, by management, you mean coercion, you can, for a brief time, deliver the appearance of consistency and contentment with personalities or technology, but you will only be masking a growing problem. If, by management, you mean a system of controls (governance) that produces consistency, predictability and reduced risk, only then will you be able to say that your technology (and your people) are being managed.

Fortunately, the controls necessary for effective implementation and application of technology are well understood (if largely ignored). The Software Engineering Institute's CMMI and ITIL are but two specifications for a system of controls. These are thorough and consistent and understanding them will enable you to create a system tailored to your organizational needs.
The future starts when "control" is accepted and welcomed.

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.

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.

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.

Information or Systems?

For those of you who work in I.S. or I.T. or any of the variants, a question. Is your organization about information or is it about systems or maybe it's about technology?

My sense is that many more people are in it for the systems (programming) or the technology (networking, servers, wires, boxes) than for the information.

Just to get all the cards on the table, I'm asking this from the perspective (there's that word again) of someone who has been having his nose bloodied for years because of a stubborn streak that keeps on insisting that it is about the information and that everything else is supporting cast, walk-ons and extras (the Academy Awards are a recent memory).

The term, ontology, has become trendy in the relatively recent past. It simply means a specification for a concept. A concept is an idea and many times it never progresses beyond that. Rarely, an idea like freedom or liberty needs little or no specification to make it useful, Many ideas, like stewardship, on the other hand, need quite a lot of specification before they become useful.

Information Systems/Technology appears to be in need of some onological work. I.S./I.T. are ideas that require a context. They are found in the context of a business. The business, in turn, has a context but we don' need to go that far for the purposes of this discussion.

Businesses need to produce, dispense, store, manage many kinds of things and all of them are physical save one--information. Because information is a concept in its own right, it quite often gets pushed out of the way in favor of the physical things that compete for our attention by virtue of form, color or sound. These things require physical space and unless we do something, they will soon pile up and make it impossible to get anything done.

Quiet information or data, on the other hand makes no demands and is consequently ignored. Remember, though, that the business has an I.S. or I.T. organization because every now and then someone needs a specific piece of data or a chunk of information and needs it now. Sometimes the data has just come into existence and other times it has been languishing in a "data file" for days, months or years.

How do we find that set of ones and zeros and turn it back into the concrete abstraction that the business needs? Friends, that takes data as well. Device names, drives, folders, files, instances, records, fields, indices, values--all of that is data. In I.S., we understand the need to keep that kind of data reliable. We create systems and they are data as well. We understand the need to maintain our system data: product, version, build, component, QA status... and the implications of not doing so.

Frequently the Data people (data administration, data architecture, data stewardship, data governance, database administration...) are part of I.S. or I.T. and we're content with that as long as they are directing their attention outward, toward the business. As soon as they begin to exhibit interest in us and our handling of our own data, we start to feel resentment, frustration and even anger. "Who are they to tell us how to do our job?"

Friends, and I am sincere in my use of the term, programming is programming and data is data. The Data people can help you and they want to help you and, most of all, they need to help you in order to close the loop. They are being held responsible for the quality of the data resource and the processes that create and manage the resource. You represent a huge exposure as far as they are concerned. When you re-learn to associate your system with the information that flows through it, I hope you will also learn to value what the Data people are offering.

Information Systems, Information Services, Information Technology: let's refocus on the reason and purpose of those efforts. You can benefit from the consistency that results from standard processes. You can benefit from better data management capabilities. We can all benefit from understanding our shared purpose--the best information for the business we're part of.