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A dark wind is beginning to blow through the tortured landscape of health care in America. At the confluence of the corporate cold front with the warm front of technology innovation, a storm is brewing. A storm that may grow into gentle and much needed rain showers, or the grandest tornado ever experienced by mankind, and unlike the wondrous works of nature, the path taken here is completely within our control. The US government and all its federal, state and local branches spent over 1 trillion dollars of our tax money on health care for the poor, elderly and disabled last year and we spent well over 1.5 trillion dollars of our own on health care for everybody else. Most of these monies are going to medical service delivery systems, some is going to financial management intermediaries and a fraction is going to companies providing services to these corporate entities.

Obviously, this level of expenditure is unsustainable, and when we look at other developed countries, we realize that we could be spending a lot less for similar results. However, this is America, and while we must find a way to reduce the number of dollars spent on health care, we must do so without adversely affecting our health care corporate citizens.  This leaves us with two options. One is to simply not provide care to some of us some of the time, i.e. lower the volume and increase profit margins, and the other is to find cheaper ways to provide health care at higher volumes with lower margins. As long as the sum total of corporate profit remains unchanged (or happily improves), any combination of the above should work well for our purpose. Since we are a monetary democracy, we will have to carefully combine strategies so that moneyed citizens continue to enjoy the same levels of service, while the less savvy voting masses do not perceive significant rationing or cheapening of their health services. The non-voting folks are obviously free to perceive whatever they want.

The first thing to do is to change the discourse from all antiquated and touchy feely definitions of health care to a more modern conversation about consumer goods and services, which in a free society implies well understood variations in quality, availability and ability to purchase, based on one’s socio-economic status, closely mirroring our three groups of citizens described above.
  
The second thing to do is engage the fiery wave of information technology sweeping the planet. In the realm of consumer goods, information technology is accomplishing nothing short of magic by transforming traditional goods, like books, into electronic services, and by orchestrating the manufacturing and distribution of everything else. Many service industries, such as banking and travel, have also been transformed from labor intensive enterprises to largely computerized electronic transaction hubs, with very little human intervention needed, and mostly insensitive to geographic location. These transformations resulted in lower prices, lower expectations, increased availability and convenience for paying consumers, paired with record profits for corporations. Seems like the perfect solution for our health care puzzle.

So we begin by transitioning medical record keeping from paper to electronic format, and by standardizing medical transactions so they can be eventually captured by predictive algorithms that will accept standard inputs from consumers and industry knowledge bases, resulting in the dispensation of standard medical advice pretty much on demand. Very much like using Travelocity to book a vacation. If you are a physician, you are probably growing a bit uncomfortable at this point, because this is precisely the type of work you do now.  But wait, we are not as ignorant as you think. We completely understand that some medical transactions require human touch and that even the best medical algorithms still need some form of supervision, but do we really need an overeducated doctor for every routine medical encounter? For very simple things, the autonomous algorithms should be just fine, for medium complexity a trained technician oversight should do the trick, and for complex stuff, or for people with lots of money, a doctor can be added to the mix. This model of operations kills two birds with one stone. It immediately solves the artificially induced shortage of educated physicians, making more of them available for the wealthy, and it drastically reduces the cost of medical care for the masses because technicians don’t need formal education and uneducated workers can be both cheap and plentiful. We just need to secure a good supply of people without any formal education, by convincing everybody that absence of education is now the ticket to a good job and middle class status. And here is where our ominous meteorological event is now unfolding.

In a JAMA article almost a year ago, Drs. Emanuel and Fuchs began by defining the “obsolete” physician, “an incisive diagnostician and empathetic clinician, a productive researcher, and a scintillating teacher”, as a “triple threat” and terrified us all at the mere thought of encountering such a dangerous creature in real life. They then propose a new model based on the assumption that people are incapable of excellence, and “no physician can be a competent triple threat”, therefore why bother trying. Instead, we should apprentice most medical students to be practitioners of a narrow trade, and leave scientific research activities and critical thinking (a.k.a. autonomy) to a select few. This should shorten training periods, lower costs of training, and obviously we wouldn’t have to pay these guys as much, once the “threat” is eliminated. In a more recent article in the Atlantic, Jonathan Cohn is advancing the thesis one step further. After exploring the emerging wonders of algorithm driven medicine, and drawing from the expertise of medical quality beacons, such as Tanzania, India and Brazil, Cohn is suggesting that health care will prove to be the salvation of the “middle class”, because “[i]f technological aids allow us to push more care down to people with less training and fewer skills, more middle-class jobs will be created along the way”.  Middle class jobs, according to Mr. Cohn, are those that “don’t require college or a bachelor’s degree, just a technical program”. So our uniquely American solution to the health care problem is two pronged: eliminate as much expensive education from medicine as possible, and simultaneously ensure that the vast majority of citizens are devoid of enough education to know the difference.

This pioneering stance in health care is reverberating through other realms as well, and reinforcing the notion that technology has freed us from the need to educate ourselves and our children. The Economist for example is taking on the legal profession, which may not be as education intensive as medicine, but it still commands large consumer prices. Instead of educated attorneys, why not use computerized algorithms provided by ZumbaLaw.com at a fraction of the price? And most importantly we should allow investors to buy legal firms and employ (uneducated) lawyers so they can create a more efficient legal system for consumers. Sort of like the miracle solution now applied to health care, where professional people are forced to surrender their autonomy, and now their education, to shareholders and managers. The term efficient here, as in health care, means that ethics and obligations to put clients/patients first are superseded by financial needs of the few, and cheapness needs of the impoverished many. Having professionals stripped of their education and economic power is only half the job to be done. If we are to be successful in reducing prices of everything down to the new "middle class" levels of affordability, without significant civil unrest, we have to make sure that we maintain the ratios of educational attainment, between our new professionals and the typical consumer, constant. To that end, we must convince everybody that we are in an education “bubble” and sending our kids to college is detrimental to the realization of the American Dream in this technology era. Or as Mr. Charles Murray gently puts it in a CATO institute Quarterly Message on Liberty “the BA is the work of the devil”.

In a letter to Charles Yancey dating from 1816, Thomas Jefferson stated that “If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.” The education Thomas Jefferson thought was necessary in his times had very little to do with picking cotton and making nails. Similarly, in our current “state of civilization” the prerequisite education to freedom has nothing to do with learning a technical trade to better serve the corporate masters of computer algorithms, which seems to be the preferred prescription of the educated elite, liberal and conservative alike, for everybody else. The only question remaining, before we swallow the pill of voluntary ignorance, which has been shown to work for the benevolent tyrants ruling the United Republic of Tanzania, is whether the long term side effects of this treatment are congruent with our expectations, or what’s left of Thomas Jefferson’s hopes for the nation.

The Destructive Recreation of Health Care

The Edwin Smith papyrus ca. 1500 BCE
In Part I of this series, we engaged in a design exercise for an imaginary software product that has no stated (or hidden) purpose other than to improve patient care. Following our initial definition of patient care, we formulated three general requirements and several constraints, none of which were specific enough to start building software tools from. The next step in our journey will break down each requirement into more specific tasks. What follows below will seem like an unnecessary and laborious statement of the obvious to some. However, I would submit that the careless bypassing of fundamental analysis is precisely what led us to where we are today, and even if we are forced to cut corners eventually, it is imperative that we define all corners prior to cutting them, instead of feigning shock and surprise after the fact. So without further ado, let’s start where we left off.

System shall assist with gathering information from various sources (TBD) at the point of care

The first thing we need to do before we begin gathering anything is to figure out the sources of information that may be able to contribute to patient care, and the essence of each contribution, which will serve as a guide to any prioritization efforts that may be required down the road.
  1. The Patient – You cannot provide patient care without a patient, and any activities undertaken without adequate input from the patient (or proper surrogate) do not fit our definition of patient care.  Therefore the patient is the primary and most important source of information. Information gathered from the patient can be subjective or objective. Subjective is not a derogatory term that implies lack of importance, and quite the opposite is true in most cases. Subjective information is the patient’s point of view, without which it would be quite impossible to do anything that qualifies as patient care. Objective information is something observed or measured by someone other than the patient, but the lines can be blurred when observation depends on patient voluntary response (e.g. range of motion). Information from the patient is available through several modalities and can be solicited or unsolicited.
    1. Narrative – This is the patient’s story, historically delivered in person, but more recently also available through phones and now through electronic communications over the Internet. Originally, large parts of the patient story were known to the doctor who was part of the community he served, but to compensate for societal lack of wisdom, increasingly larger portions of the narrative are being solicited through paper forms, clerical assistants to physicians and most recently computer software (see below). In most cases, the patient still has the opportunity to relay unsolicited and unstructured information to the doctor, but the allotted time for this activity is shrinking by leaps and bounds. The patient narrative delivered in person has value beyond the story itself, as it exposes other forms of information that can be processed by humans, such as demeanor, tone of voice, body language, general appearance and even smell. It is worth noting here that this sensory exchange of information is bi-directional and the patient is also gleaning important information about the physician. Therefore, at this point in our analysis, we will make a note to consider this expanded definition of narrative when addressing our third general requirement dealing with patient-doctor relationship building. 
    2. Examination – The physical examination of the patient, once the hallmark of practicing medicine, is somewhat diminishing in its diagnostic importance nowadays. Palpation, auscultation and manual handling of the patient is being surpassed by machines that can accurately “see” inside the patient and analyzers measuring biophysical markers and functions that could only be hypothesized by inference or educated guess. Here we are going to use this new and expanded definition of patient examination to include input from any available equipment at the point of care (others will be considered in #3 below). However, as was the case with the narrative discussion above, the traditional “laying on of hands” has implications to our third general requirement. Since we are after all a type of animal, consensual agreement to intrusion by another person into our personal space (and beyond) implies the establishment of an uncommon level of trust and, in some cases, may have healing effects in and of its own. Therefore, we will make the same note as above.
    3. Remote asynchronous – Although historically doctors acquired quite a bit of information about their patients asynchronously, and largely unsolicited, by virtue of being part of the same social community as their patients, those days are mostly gone, and here we will consider newer electronic forms of communication. From email to text messages to patient portals and direct transmission of monitoring data, patients today have multiple asynchronous venues to relay information to their physicians. These communication channels are used, when available, mostly for inquiries and requests for service, but they can also contain information pertinent to patient care. Monitoring data in particular (e.g. glucose levels, blood pressure, peak flows, etc.), whether in electronic or paper format, and subject to our constraint stating that patient care is not equivalent to lifestyle coaching, is obviously pertinent to caring for an individual patient, and in all cases this form of communications has implications for our third general requirement. We note this, and move on to the next item on the list.
  2. The Chart – Before the chart, we had “papers”, ledgers, index cards and other less common methods of recording the most salient points of encounters with patients over time. This source of information forces us to consider the corollary to information gathering, which is the voluntary recording of information by the user. This is a fork in our design road. We can assume that information created as a byproduct of patient care is recorded by an external product, or we can add this capability as another requirement for our patient care software. We choose the latter and therefore add a requirement as follows: System shall assist with information recording at the point of care. This requirement will need to be further broken down, in a future iteration, to account for information sources as outlined in #1 above.
  3. Other Facilities – In the world of modern day medicine, and primary care in particular, physicians providing patient care must bring into account information generated by others currently or previously engaged in the same activities. This information may be solicited by the physician, in the form of orders to diagnostic facilities or specialty consults, or unsolicited if the patient sought and received treatment at other facilities in the past, which may or may not be pertinent to the care provided by our user. There are two general categories of medical information generators that should be considered:
    1. Diagnostic, Ancillary and Administrative Facilities – These include laboratory and imaging services purveyors as well as pharmacies and any other existing or future holders of information pertinent to patient care. Our product will be required to both solicit and accept unsolicited information from these entities.
    2. Care Providing Entities – This is the entire universe of medical service providers surrounding our physician and patient interaction. Inpatient facilities, long term care facilities and other physicians, are included in this category and we become acutely aware of the need to build our software in a way that it can communicate with a large and extremely ill defined spectrum of other software and traditional partners. Summarizing both categories leads us to state that the System shall retrieve and accept information from external sources.
    This item introduces another requirement originally put forward in the Holy Bible as “…all things whatsoever ye would that men should do to you, do ye even so to them” [Matthew 7:12]: System shall respond to all external legitimate requests for information. Note that here, and immediately above, we are not requiring the system to merely assist the user with this task, but instead we are requiring that the system takes full responsibility for exposing and/or sending appropriate information to other entities (the term appropriate or legitimate is an important constraint).
  4. Literature – The final source of information pertinent to caring for patients is of course the science of medicine and the recorded experience of those similarly engaged in providing or receiving care from a medical professional. This body of knowledge is approaching magnitudes and velocities that are impossible to collect, analyze and entrust to human memory, particularly on the fly while caring for any one patient. We classify reliability and importance of clinical information, based on accepted practices, in descending order as follows:
    1. randomized controlled trials
    2. controlled trials, no randomization
    3. observational studies
    4. opinion of expert panel
    5. clinical practice guidelines & recommendations
    The first thing to note here is that unlike information to be gathered from all other sources, literature is not patient specific. To satisfy our fourth constraint prohibiting us from treating patient care as a commodity, information gathered from literature will require significant processing to make it useful when caring for an individual patient. We will therefore split this requirement into two parts: the first, System shall have the ability to access general published information, to be addressed here and the second, involving analysis and processing, to be addressed through our requirement pertaining to synthesis of gathered information. Although this is not the proper time to make technology decisions, we are noting here that gathering information from published materials is probably something we are going to buy off the shelf, instead of building our own module from scratch, as long as we can impose our requirements and, most importantly, our constraints on any commercially available software package. We will make a note to that effect here, and elaborate on it when considering our next general requirement which deals with information synthesis.
To summarize, our first requirement yielded several insights for future consideration and four sub-requirements as follows:
  1. System shall assist with information recording at the point of care (needs more specificity)
  2. System shall retrieve and accept information from external sources
  3. System shall respond to all external legitimate requests for information
  4. System shall have the ability to access published clinical information (consider buying)
Funny how certain things rise to the top and impose themselves on the software if patient care is the driving concern, and an orderly design process is undertaken.

And on this note, let’s pause, since we are quickly exceeding the boundaries of polite imposition on readers’ time. If you were expecting to be knee deep into buttons and font sizes by now, please understand that the user interface is the last thing to address in proper software design. If you paid close attention to the narrative so far, you should have noticed that we never mentioned buttons, screens, fields or anything of the sort. We cannot, and should not, define the problem in terms of its solution, just like you are not defining the patient complaint in terms of currently available prescription drugs. We will apply solutions, like buttons and pick lists, or maybe build new things that don’t exist just yet, after we completely understand the problem and the preferences of our users. The same can be said to those expecting discussion on standards, transport protocols and terminologies. We are not at a point where we should constrict our analysis to existing technology solutions, which by the way, are not serving us very well currently, this being the rationale for engaging in this thought exercise in the first place.

With this in mind, we will move on to Part III: A Better Haystack, where the need to synthesize and present the information we are gathering will be examined, forcing us to add specificity to our existing requirements (#1 should be most enlightening), before concluding our first design iteration in Part IV: Continuous Healing Relationships.

De Novo EMR Design Part II: The Quest for Information

IBM’s Dr. Watson of Jeopardy! fame has finally completed its residency and fellowships and, presumably to its creators’ utter delight, is now a practicing Oncologist. The prodigy “cognitive system” completed its training in less than a year at the illustrious Memorial Sloan-Kettering Cancer Center, and although only proficient in lung cancer right now, Dr. Watson’s career as an advisor to oncologists everywhere is off to a great start. A recently released video demonstration shows Dr. Watson in action, researching, evaluating and treating a 37 year old woman with newly diagnosed stage IV lung cancer in his advisory capacity to a hurried and pretty uninspiring human oncologist. Regardless of the slightly weird scenario, it is worth noting that in a fraction of a second Dr. Watson, scours 3,469 text books, 69 guidelines, 247,460 journal articles 106,054 other clinical documents and 61,540 clinical trials, and evaluates their contents against the patient’s EMR to identify need for further diagnostic tests and treatment options for this patient. Being an exceedingly helpful advisor, Dr. Watson quickly reads the entire EMR and uses his trained processing power to eliminate all the clutter in the EMR, presenting to the human doctor only information pertinent to this particular diagnosis. Ouch.

On the other side of town, ONC is busy apologizing for the sorry state of what it calls “interoperability”, blaming everything from the lack of standards to people’s inability to agree on a restricted set of vocabularies for the medical profession. According to the ONC philosophy of interoperability, only “computable” data can be exchanged or analyzed in a meaningful way. In other words, all medical professionals must learn to express themselves in a standardized way which computers can understand.  To that end we have ICD-9, ICD-10, SNOMED-CT, LOINC, RxNorm and all sorts of other terminologies and vocabularies aimed at restricting the English language to the limited computational abilities of available EMR software. How do you say “Mr. Smith is a pleasant 82 year old gentleman with a sad demeanor” in SNOMED? You don’t. You dispense with the pleasantries (pun intended) and diagnose Mr. Smith with depression. The Sapir-Whorf linguistic relativity hypothesis is by no means a settled subject, but if it contains any truth and vocabulary does affect cognition, then how will restricting clinical vocabulary affect the cognitive abilities of its users over time? We don’t know, and frankly I am not interested in finding out.

The folks at IBM took a different route. Paraphrasing Sir Francis Bacon, loosely quoted as, “If the mountain won't come to Muhammad then Muhammad must go to the mountain”, Dr. Watson’s creators must have decided at some point that if the doctor won’t come to the computer then the computer must go to the doctor. Instead of framing the problem by asking how we can change human communications to better enable the current generation of computers to “understand” humans, IBM began by figuring out how to change computers to better enable them to understand current forms of human communications. Thus, Dr. Watson learned to read books and articles and all sorts of “unstructured” information, because no matter how hard the powers to be are trying to fit the square peg of human language into the round hole of computer language, and tragically vice versa, most information generated by people is in their natural language and Dr. Watson was programmed to process natural language. So if Dr. Watson is able to “read” half a million pieces of text of various heft in a second or so, how long would it take for it to read an old fashioned paper chart, or an electronic rendition thereof? I am pretty sure that if you ask nicely, Dr. Watson would be happy to rearrange it for you in any way you choose, while pointing out the most pertinent parts to your current objective, highlighting discrepancies, missing and redundant information, all in a picosecond or less. And interestingly enough IBM developers thought it wise to take a generalized path to Watson’s education, instead of creating specialized Watsons each with linguistic abilities specific to a domain. Seems more human friendly that way…

The IBM Watson software line is not an EMR, but it can process and analyze information in an EMR. It is really an attempt at artificial intelligence consisting of a gigantic contextual search engine, coupled with lots of very sophisticated and self-generating algorithms to both analyze and inform the search itself. Watson doesn’t need to have the smoking status check box clicked in order to infer that the patient is or is not a smoker and doesn’t need to have a new standard defined before it can read a patient’s family history. True, Watson is pretty new software and folks have been tinkering with natural language processing and artificial intelligence for half a century without much success, but things are beginning to coalesce now and technology in the next decade will look very different. Is it really wise for our government to spend so much money and invest so much effort in building and enforcing the use of tools that are becoming obsolete faster than they are created? My hat is off to the VA and DoD who gave up on the strange and expensive idea of building their own EMR from scratch (better late than never). I think it’s high time that other governmental agencies got out of the EMR design business as well, because there are companies out there whose core competency is technology and who have large enough innovation budgets to build the next generation of health IT. Consider this: What if Dr. Watson had a few less educated siblings serving as medical secretaries, summarizing, abstracting and relaying information back and forth, on demand? All of a sudden the shape, form, functionality, standardization and all “meaningful” bells and whistles in an EMR are rendered irrelevant, and using Microsoft Word for typing or dictating your note is as good as using a “certified” EMR, or much better, because the context is so much clearer and so much more forthcoming.

Whether it can pass a Turing test or not yet, Dr. Watson is not a real doctor, and it will not be one in our lifetime. Dr. Watson has no free will and everything it knows is dictated by the corpus of knowledge made available to it by its creators or employers. There will be huge ethical and legal questions raised by software capable of supplanting human decision making processes, and software that can be centrally deployed and manipulated to this end. Even before that future arrives, it is worth noting that Dr. Watson is simultaneously employed in oncology clinics and by payers, and in my opinion, Dr. Watson has one button too many – the direct button to the insurance company, which will automatically approve payment for Dr. Watson’s top recommendations, but presumably not so much for other choices. Like all technologies, Watson embodies hope for the greater good along with great new perils for ordinary people. Leaving these philosophical questions aside for a moment, the only certain thing is that Dr. Watson is starting its brilliant new career by introducing a cure for one very painful disease that is reaching pandemic proportions amongst medical professionals: clicking boxes.

Dr. Watson is Not a Meaningful User

Our ancestors began using tools millions of years ago and humanity assumed control of the planet it lives on through a succession of tools ranging from sticks and stones all the way to iPhones and drones. The basic process for discovering or inventing tools hasn’t changed much over the millennia, and it follows two basic patterns. Either an existing artifact is examined for fitness to various purposes until one such purpose is discovered accidentally or through organized efforts, or a problem is identified and a tool is then invented, or located, to solve the problem. The problem itself could be something that was thought impossible before, such as flying, or a more mundane desire to reduce the effort and expand the capabilities associated with an existing activity, such as moving goods from one place to another. Tools can have limited effects, revolutionize an entire economic sector or can change history, and some tools can have harmful effects that must be balanced with the benefits they offer for the intended task. Tools usually undergo long processes of change, improvement and expansion, and sometimes the evolving tool looks nothing like the original invention. Why are we talking about tools here? Because programmable computers are tools. The computer hardware is like the hammer head and the programming software is like the hammer’s handle (more or less). And EMRs are one such handle.

Let’s imagine that we are software builders and we have a desire to help doctors deliver patient care. And let’s further assume that we, and our prospective customers, examined all the existing tools out there and found them not quite fit for purpose. Let’s also assume that we are not suffering from delusions of grandeur, have the humility to admit that we don’t know how to cure disease and have no interest in global social engineering initiatives. Let’s imagine that we are the misguided founders of a small social business interested in doing well by helping others do good things.

The following is a theoretical exercise in software product design for the shrinking market niche still subscribing to Sir William Osler’s views on medicine. Therefore our starting point will be fixed by the assumption that medicine is “a calling, not a business” and that medicine is to remain a “humanitarian and respected profession” concerned with “diminishing human suffering”. Since we are not out to develop drugs or devices, the overriding goal for our imaginary software is to improve patient care. But in order to improve something, we first need to at least understand what that something is. So what is patient care? For simplicity of illustration, let’s further constrain ourselves to primary care, because it is probably the most common and best understood type of patient care.

Patient care is a longitudinal activity occurring over varying periods of time, but it is not continuous; instead it is a chain of discrete units of service usually called encounters, which may or may not be dependent on each other. Encounters can be proactive, reactive, physical or virtual. The mechanics of a patient encounter in primary care is very simple. Patient comes in (or not), patient relates problems (if any) to physician, physician formulates diagnosis based on patient narrative, physical examination, diagnostic measurements and finally suggests therapies to resolve, alleviate or prevent suffering from problems. Patient may or may not agree with suggestion. There are three major parts to this process - gathering of information, synthesis of information and relationship building - and each part has a very clear purpose. Note that documenting the events is just a corollary to the main process. Sounds simple? Not quite.

While this is the current practice, many product designers are designing software for what they think patient care should be, adding and removing parts to and from the current process, or disregarding the existing process in its entirety. To understand why this is a problem, let’s think about Microsoft Word. Manny decades ago, writing consisted of a blank sheet of paper and a writing instrument, quill, pen or pencil. First the typewriter removed the work needed to shape each letter by hand, and then the computer removed the need to have a physical piece of paper, and instead gave us an infinite number of blank sheets, with obvious benefits to the user. What neither of these inventions did is to redefine the authoring process; you still have to pick something to write about, do your research and “write” it down. The word processor makes it easier and cheaper to write, to fix mistakes and to make your masterpiece look appealing. Now imagine what would have happened if the creators of Microsoft Word would have decided to be a bit more helpful and gave you a series of dropdowns and buttons to choose and refine the subject of your writing and then plopped in a prewritten article, which you can now edit to your liking. Who would have used this contraption? People who have no business writing in the first place. As is true with medicine, in software design sometimes less functionality is better functionality, particularly when the extra functionality is paternalistically dictated by the purveyors of software.

Back to our little project, what do we have so far in the way of requirements?
  1. System shall assist with gathering information from various sources (TBD) at the point of care
  2. System shall assist with synthesis of said information
  3. System shall assist with patient-doctor relationship building
Note that since we are not building a replacement for the user, our system is an assistive technology system and nothing more. These requirements are not granular enough to start programming from, but are there to always look up to, and see if everything we do serves one of those basic goals. If it doesn’t, then it should not be built. Note also that we are not questioning the user’s “workflow”, wisdom or professional decisions. We are aiming to provide a limited service, and will leave “fixing health care” to more ambitious folks. To any set of basic requirements, I like to add the prime directive of software development, which is a general warning for subsequent designers, architects and programmers:  
  1. System shall not make the task harder to perform for the user
The next phase of design will take our primary set of requirements and break them down into concrete software tasks (and no, #3 is not a joke). To do that, one should understand in minute detail, and preferably practice, patient care, particularly for the purpose of observing the constraint imposed by #4. The creators of Microsoft Word, and all other direct to consumer software builders, have a much easier time with this portion, since everybody writes. Those who build software tools for domains that they are not familiar with have a tendency to make too many assumptions based on random and infrequent encounters with said domain (e.g. I take my kids to doctors all the time, I had to go to the ER once and I know how it works, etc.). Translating the above requirements into concrete specifications should entail many months of research. Assuming we have that under our belt, we are ready to move on to the next step.

Even to the untrained eye, our first three basic requirements speak volumes. #1 looks like something computers can do very well. #2 looks like something that computers may be able to do very well in the future, but right now it embodies lots of difficulties and temptations best avoided. #3 looks ridiculous to some, but very promising to younger folks who define relationships through software apps. Another nifty thing that practically jumps out of the page is that we don’t have to satisfy all 3 requirements all at once in order to have a useful product. Thus our little project lends itself very well to an agile development model where we can have successive series of small releases that are useful to our users from the get go.  Another look at those general goals reveals that we could benefit from placing some boundaries on the magnitude of our project to avoid the number one pitfall of all software projects – scope creep, or consistently succumbing to the temptation of adding one more little thing. To do that we should look, within our scope of service, at what patient care is not.
  • Patient care is not a synonym for public health.
  • Patient care is not a financial transaction.
  • Patient care is not lifestyle coaching.
  • Patient care is not a commodity (at least until people become a commodity as well).
And just in case we were not specific enough in our definitions, this software is for physicians administering care to an individual patient. We are not designing tools for staff, billers, payers, employers, federal or state agencies, and no, we are not building tools for patients. Although requirement #3 may drive us to address the patient perspective to the extent that it is pertinent to physician activities, our (paying) customer persona is the doctor (we’ll expose some APIs for the rest of the world…).

So let’s tackle the biggest bang for the buck first, and get started from the top. Part II will attempt to define a manageable set of specifications for our imaginary product. In the meantime, feel free to contribute to this thought process….

De Novo EMR Design - Part I: Stating the Obvious

Somewhere between the 20th century Bank ATM and the 25th century Tricorder, lays the EMR that we should have today. Somewhere between the government-designed Meaningful Use EMR and the Holographic doctor in Star Trek, there should be a long stretch of disposable trial-and-error cycles of technology, changing and morphing from good to better to magical. For this to happen, we must release the EMR from its balls and chains. We must release the EMR from its life sentence in the salt mines of reimbursement, and understand that EMRs cannot, and will not, and should not, be held responsible for fixing the financial and physical health of the entire nation. In other words, lighten up folks…..

A patient’s medical record contains all sorts of things, most of which diminish in importance as time goes by. Roughly speaking, a medical record contains quantifiable data (numbers), Boolean data (positive/negative), images (sometimes), and lots of plain, and not so plain, English (in the US). The proliferation of prose and medical abbreviations in the medical record has been attacked a very long time ago by the World Health Organization (WHO), which gave us the International Classification of Disease (fondly known as ICD), attaching a code to each disease. With roots in the 19th century and with explicit rationale of facilitating international statistical research and public health, the codification of disease introduced the concept that caring for an individual patient should also be viewed as a global learning experience for humanity at large. Medicine was always a personal service, but medicine was also a science, and as long as those growing the science were not far removed from those delivering the service, both could symbiotically coexist. Fast forward to today. Medicine has developed significant heft and doctors are now mere “frontline” workers in the “trenches”. This implies the existence of something large and controlling behind those frontlines, and everybody comfortably positioned away from the trenches has been watching Moneyball. So the health care chameleon, morphing from an ATM into an airplane just to shrink back into a cheesecake, is now curling up into a baseball, and demanding all sorts of data so Billy Beane can miss the World Series more efficiently. There is of course a slight problem preventing medical ex-players turned general managers from gathering data for medicometrics. In health care, the players have to record their own stats, and they don’t like doing that because it is a bit difficult to hit and run while holding a computer.

Another reason why gathering data in health care seems to be a tall order is the lack of something called “interoperability”, or in layman words “EMRs don’t talk to each other”. But talking is not a good analogy, because this is America and everything should be likened to a car. So using the car analogy, it seems that the government is buying everybody a big huge SUV and making sure the proud owners load it to the hilt with health care data, but in its infinite lack of wisdom, the government neglected to build suitable interstate roads and bridges, so all those lovely SUVs are idling in people’s garages, raring to get out and hit the open roads. This governmental failure is inexplicable considering that we have a long history of building infrastructure first. So first we built the oceans and then we built the ships; we created the trails just before we tamed horses; we first built all the railroads and then someone built a train; we built the Autobahn and then they invented cars for it. Makes perfect sense…..

There is only one problem with this convenient version of history. Those SUVs supposedly sitting idle in health care’s garages are making very profitable night runs all over the place, because the roads and the bridges are really there already, and all sorts of other cars and trucks are jamming the interstate of technology all day and all night, and some funky contraptions are even flying. Imagine that. But imagination doesn’t seem to be the strong suit of health care analysts and advisors, so the attacks on government failure to build infrastructure for interoperability are incessant. We have technology savvy Congress members writing selfless indictments and the folks at the RAND corporation who at the behest of EMR manufacturers, predicted seven years ago that EMRs will save the nation, just came out with an explanation for the failure of their prophecy to materialize, blaming the same lack of interoperable infrastructure. The AMA in its thoughtful comments on Meaningful Use proposals is reiterating the need for government to pave the roads because its members cannot possibly be expected to bear the expenses of building highways from scratch. Using all the right words and a proper measure of righteous indignation, the government is reaffirming its commitment to build said infrastructure any day now. And round and round we go. As long as there is the faintest chance that the government will allocate a little more taxpayer money to build health care interoperability infrastructure, the chorus of complaints will not be silent.

In the meantime, out on the existing slick networks of interoperability for all but health care, activities are bustling with seemingly something new every day. What if the government just told all complaining and procrastinating health care stakeholders to literally take a hike and hit the road? What if the government told EMR vendors to go figure out what their customers want on their own, instead of providing a sanitized version of what the government believes EMR customers should want? What if instead of spending the newly minted trillion dollars coin on a brand new interoperability system for health care, the government would allow EMRs to travel on existing technology highways, and leave well enough alone?

Here are a few things that could happen:
  • Nobody would need to “send” prescriptions electronically to pharmacies. If you had the dubious pleasure of flying somewhere lately, you would know that ticketing is now very different. No, they don’t send your ticket electronically to the gate. They just send it to your mobile phone as a 2D barcode that is scanned at the security checkpoint and again at the gate. A patient friendly EMR could generate the same type of barcode for your prescription and send it to your email so you just have the pharmacist scan your mobile device. All security information can be embedded and you can get a refill at a pharmacy of your choice. If you are now formulating objections in your mind because of possibility of fraud and abuse (and because you are invested in the current system), relax, all your worries can be addressed.
  • You don’t like barcodes? No problem. Instead of killing half the Amazon forest in an attempt to give you “clinical summaries” and instead of whining about interfaces with other facilities, what if your doctor swiped a magnetic card and “loaded” it with your clinical summary, while at the other end the hospital or specialist would use one of those Intuit or Square gizmos to read it in, and then “reload” it for your follow up visit with your PCP? Perfectly doable, and applicable to prescriptions, lab tests and even imaging.
  • Still not convinced? Buy a Samsung Galaxy phone and find a friend that has one too. Try to exchange some information with your friend, like pictures, files or music. It’s called S beam and all you have to do is gently bump the phones. Would you like to bump the doctor’s mobile device on your way in, and bump it again on your way out to collect all the new information? This is not fully baked, but it could be if our well-meaning government relaxed its grip on EMRs just a tiny bit.
Comic relief: Not directly related to interoperability, but instead of having to choose between looking at your patient and looking at your computer, what if you could do both at the same time? A couple of years ago Samsung came up with transparent AMOLED displays (see through screens). There didn’t seem to be any good use for the technology, but they forgot health care. Right now if you have a laptop in the exam room, all you can see is the screen and all your patient can see is the cover of your laptop. What if you could see the patient through the screen and what if the patient could see (and touch) the same things you are seeing? Would be pretty cool if liberated EMRs would be allowed to find creative ways to take advantage of such hardware, and there must be hundreds and thousands of better ideas out there, suffocated by pre-adjudications and pre-authorizations and slowly withering away under the Meaningful Use lid.

Does government have a role in health care technology and interoperability in particular? Of course it does. First the government is the largest health care insurer in the country, and as such it has an interest in reducing costs, and since this is (still) a representative government, it should also have an interest in the wellbeing of its citizens. Governmental agencies should rightfully expect a certain level of (reasonable) electronic reporting from those it pays for services and it makes perfect sense to require that certain levels of service be provided, including coordination of care between facilities, which may involve interoperability to various degrees. And finally it is incumbent upon the government to ensure that tools used to provide health care, including software tools, should be safe, just like it ensures that drugs, devices and all other medical paraphernalia are safe (and using the same agency for this purpose). Public health is another domain where a government concerned with the health of the nation can find opportunities to affect positive change. And that’s about half the work required.

The other half should be left to professionals in the “trenches”, whether doctors providing direct patient care or (deep breath here) technology people who can actually write code to support patient care, if patient care is what we want to support. These folks with massive expertise in navigating the all too real interoperability highways are currently wasting their talents on making your washing machine interoperate with your Twitter account. Can you imagine what they could do with your charts and your “workflows” if we let them lose in health care? It’s not the data that needs to be liberated. It’s our collective imagination that must be set free, or at least half free.

Half Gov Half Degov Venti EMR Lite

“Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs” [ihi.org]

If you stop to think about the holy grail of health care reform, also known as the Triple Aim, it sounds like a grand challenge involving wizardry or wishful thinking or worse, propaganda for the masses, particularly the last part. It’s like attempting to build a better driving machine, with better fuel efficiency at lower cost. Or maybe it’s like trying to make a chocolate cake that is most scrumptious, quicker to prepare and has very few calories. Yeah, right…. You can have one of the three, and maybe two, but certainly not all three. Not that there is anything wrong with trying…. And when it comes to health care it is actually imperative that we try, and failing will have dire consequences for all but the very few who are always shielded from consequences.

The Institute for Health Improvement (IHI) who introduced the Triple Aim philosophy, now adopted by the government, is also proposing a methodology for achieving this, larger than the moon landing, challenge.  The IHI will be having a seminar this spring, where those engaged in achieving the Triple Aim will presumably share success stories and strategies with those interested in doing the same.  IHI believes this learning event is “ideal” for folks working for insurers, employers, government, integrated health systems and other businesses and organizations. Individuals, populations and their doctors don’t seem to be part of the IHI target market. It seems that IHI believes that the Triple Aim of research institutions should be achieved by corporations, for the people of this country and the world in general. It also seems that this particular view is shared by our government, who is feverishly pushing for the creation of corporate health care entities (a.k.a.  ACO), and, patient-centered rhetoric notwithstanding, is largely ignoring doctors and their patients, who are assigned to care corporations sometimes unbeknownst to them.

In addition to a slew of financial incentives/disincentives, Health Information Technology (HIT) is one of the most powerful levers applied to the system in order to change its fabric from a multitude of small and varied health care establishments to a unified landscape of large standardized health services entities, which as IHI, and obviously all other “decision makers”, “thought leaders”, etc., believe are best suited to build a system for achieving the Triple Aim in an orderly and measurable fashion. A health care system as opposed to a sick care system; a system where populations get all their shots and screenings for every imaginable disease, carefully tabulated and monitored to show progress, and a system where care for the sick is optimized for “value” to the IHI “ideal” stakeholders; a system that requires massive computation power to constantly drive costs down by feeding millions of digital histories of people to complex algorithms; a sophisticated supply chain system that replaces continuity of care with electronic coordination of services, and generally keeps the proverbial trains running on time; a system powered by billions of dollars of computers, software and IT guys.

And here is where the “official” strategy gets really weird, wasteful, and luckily for all of us individuals, populations, and our doctors, it also contains the seeds of its own eventual demise. How so? Big business will always be saddled with expenditures on big technology, which is useless for small business, but technology has its own way of growing and advancing, independent of political whims, and independent of governmental master planners. Technology today is on a path to ever shrinking size (and price) and ever growing power, and as such it has morphed itself into a tool that truly empowers individuals and small business because those much maligned programmers, who don’t know anything about health care, are expert at building cool things for people and are some of the most nonconformist and visionary out-of-the-box inventors around. And they are now coming to health care seeking fame and fortune.  But we have to give them time and we have to do our part in this dreadful game of world domination.

If you are a primary care physician in private practice, here are some things to keep in mind:
  • Don’t buy technology that does not serve your patients and does not serve your business. Don’t be tempted by incentives and don’t be afraid of penalties. If you collect say, $500,000 per year and 40% of that is Medicare, a 1% penalty amounts to $2,000 per year or $40 per week. Even if all your billings are Medicare, this still amounts to only $100 per week. Would you buy a stethoscope outfitted with sharp little nail heads (to improve the grip), if someone threatened to charge you $8 a day for using your old stethoscope? Would you hire an assistant to hold the prickly stethoscope for you and a steel worker to sharpen the nail heads periodically, just so you are in compliance with Prickly Use?
  • Do buy technology that serves you and your patients. If you are convinced that a particular EMR will help you provide better care and make your work more efficient, then by all means, go for it. Make sure you understand the total cost of ownership over the next five years or so, and make sure you’re not buying the cow just to get a glass of milk. If all you want is to store your paper charts in a computer, you don’t need a certified EMR. If you just want to communicate electronically with patients and business partners, including labs & pharmacies, you don’t need a certified EMR. If you want to track your chronically ill patients and make sure all are taken care of, you still don’t need a certified EMR. You do need a certified EMR if your patients routinely end up at the ER unconscious, alone and naked, halfway across the country, which seems to be the preferred use-case of those who build “infrastructure” for health care.
  • Today’s technology renders physical location and business affiliation irrelevant to in-person collaboration. You should explore using some of this technology, and much of it is nearly free. A three-way video call with a home-bound patient, a neurosurgeon and you is as simple and cost effective as sending a fax. Heck, you can even conduct the entire thing on your mobile phone while on vacation somewhere nice and warm. This is not a futuristic “tricorder instead of doctor” type of thing. This is an example of real and tangible benefit you, and your patients, can derive from technology this afternoon.
  • Selling your practice to a hospital system because the “business” is too complex and because technology is too expensive (and because you’re scared) is most likely something you will live to regret, bitterly in some cases. Consolidation of health systems is not driven by a desire to achieve the Triple Aim. It is happening in defensive reaction to it, particularly the part about lower costs. You are not being courted (or pressured) because you are a great doctor. The coveted asset is your client list, which once integrated into the massive computerized system of the hospital, renders you irrelevant. There are cheaper ways of providing services in a system not designed for sick care than employing a physician, and those will eventually be put in place, because technology is like nuclear power: it can be used to do a lot of good things, but it can also be used for pure destruction.
  • Look around you. Most people in this country are hurting financially. Way more than you do. People are cutting down on food. Do you think you can cut down on inefficiencies inherent in most practices? Do you think you can use cheap or even free technology tools to accomplish that? Do you know what’s available out there? Are you way too busy seeing patients, and cannot be bothered with details? Instead of hiring accounting firms to valuate your business and lawyers to make believe that you are actually “negotiating” with the hospital, how about hiring a bright business consultant specializing in turning bloated small businesses into lean and mean survivors? We all know that there is a shortage of primary care physicians, which is projected to get much worse over the next couple of decades. If you owned a little gold mine, and the markets projected a shortage of gold lasting well beyond your life expectancy, would you sell your small enterprise to the Newmont Mining Corporation for next to nothing, because upgrading mining equipment is too complicated and way too irritating for your lifestyle? 
  • Stand up and step forward. Keeping your head down and hoping that this too shall pass is not going to work this time around. You have more power than you realize. Speak up, and use technology to make your voice heard. If you are one of those business savvy physicians who figured out how to maintain a sustainable private practice, share your knowledge. Teach. Start a blog. Build a community. Publish a paper. Write a case study (or let me know and I’ll write it for you... ). Every time an independent practice gets swallowed by a system, and every time another physician is forced to abandon his or her patients at the hospital door, something is taken away, from you personally, and from the people you wanted to help when you chose this profession. Your silence is harmful to your patients.
If you are a patient or think that someday you may need to be a patient, consider this:

When you find yourself in a strange room, partially covered by a large paper towel, and otherwise completely naked, contemplating the upcoming prodding of your most private body parts by shiny instruments and strange hands, what do you want to know most about the person about to enter the room? Would you feel better knowing that the stranger turning the knob on that door has an iPhone compatible website for you to peruse from the comfort of your cubicle at work? Would you feel safer knowing that he or she has financial responsibilities and commitments to a faceless corporate office for which your naked body is just a line item on the balance sheet, perhaps a socially responsible balance sheet, but a balance sheet nevertheless?  If it’s your small child under that paper towel, would you be comforted knowing that this person’s prime directive is to minimize your child’s “per capita” cost (not price) of care? And when you’re done making imaginary deals with your God or the devil, would you experience great relief knowing that the doctor walking into the room now is not really “your” doctor, but the shepherd of “populations” and the averter of deficits and fiscal cliffs?

Don’t answer these questions now, or right after you finish your morning run. Answer them when you are actually sitting in that room because Google said that the pesky little thing you found last week is most likely nothing serious, or of mild concern, or a cancer that will kill you in a year or two. Depending on your answers, you may want to seek out an independent physician for your next appointment, because the opposite of “independent” may be hazardous to your health.

The IHI concludes the promotional blurb for its Triple Aim seminar by proudly stating that these seminars were attended by “senior leaders, vice presidents or directors” in the past, and although individuals are welcome, ”experience has shown that Triple Aim implementation is dependent on the collaborative effort of leaders and strong program involvement”, so according to the IHI "leaders", if you’re not a corporation or powerful enough organization, don’t waste your time (and $1,975) and don't worry your little head about it, because individual people cannot make a difference in health care.
It’s probably high time that we took some triplicate aims of our own, don’t you think?

The Crosshairs of a Triple Aim

Adam Smith would disagree, Karl Marx would be appalled, and heck even Milton Friedman and Ayn Rand would be raising objections. But for some peculiar reason, there are enough contemporary lesser economic minds scattered throughout the entire philosophical spectrum, that are advocating for, and enabling the execution of, a government induced transition of our health care system to an oligopoly model of business. It all started with someone stating that our health care system is broken, and my guess is that a multitude of otherwise very intelligent people took that to mean literally broken into a multitude of useless shards of uneven size and quality. Hence the frantic attempts to glue the “fragmented” Humpty Dumpty system together again, and unlike the legendary efforts of all the King’s horses and all the King’s men, it seems that we are well on our way to putting together something that never was, and arguably never should be.

Consolidation is the name of the game. Health systems are buying each other and are morphing into insurers. Private equity is buying whatever it can buy. Insurers are buying each other and are buying health systems and everybody is buying physician practices. In health care nowadays, either you are buying something, or you are selling yourself, and sometimes you do both. While these unholy matrimonies are executing, those who sell technology for health care are following a similar consolidation path, because small firms are rarely able to service large corporations adequately. The government who initiated, or wholeheartedly endorsed, all this fragmentation rhetoric, kicked off the consolidation bonanza by chartering Accountable Care Organizations (ACOs) and by imposing a slew of regulations favoring large health systems, not the least of which is the acquisition and prescribed use of very expensive and very complex health information technology.

And the early, anecdotal, results are beginning to trickle in. Last week the New York Times published an article about the consolidation battles of two saintly health systems in Idaho (St. Luke and St. Alphonsus), waging holy war on each other for the right to acquire more physician practices, and with them, more patients to refer to more services within the system. Area doctors seem distraught and the prices of medical services in the larger St. Luke system seem to have tripled following each acquisition. The hundreds of comments to the article include many more similar stories from all over the country. The NYT article is not the first one to highlight the inflationary effects of mending our broken health care system, and you can find plenty more anecdotal stories here, here and here, and for those insisting on being surprised, there is always the early 2010 Health Affairs study of California-style defragmentation effects on the price of health care, and a grim warning regarding the implications to health care reform.

The fascinating part of this process is that health information technology is being cited by all players as a major driver for consolidation itself and also for the subsequent increase in costs of services. Information technology, if you remember, was supposed to reduce costs for the health care industry just like it did for other industries. Instead, it seems that the complexity and unaffordability of technology is driving small providers to sell themselves to the highest bidder, and the ensuing oligopoly is then justifying its immediate price increases by the need to outfit its newly purchased assets with state of the art information technology.  It seems that the fancy brand-name buckets of glue used to put the health care Humpty together are way too expensive. The apologists for the consolidation trend observe that this is just an upfront investment and soon we will be reaping the benefits just like all those other industries. These editorial opinions ignore the fact that Walmart never increased its prices to account for the world’s most sophisticated supply-chain software system and neither did anybody else in those other industries. They also ignore the Kaiser experiment in our own backyard, where billions of dollars in technology, over many years, may have resulted in better quality (according to Kaiser), but had no beneficial effect on consumer premiums for Kaiser plans, which are keeping pace with all other less integrated and less technologically advanced entities.

Many health care technologists are accusing doctors of misusing technology to emulate the inefficient paper chart process and hence are failing to realize the benefits of new technology. My guess is that we have a very similar problem with health care reformers, who are envisioning technology as the glue needed to create 19th  century business models for health care, because it worked so well for railroads, banks and car manufacturers. And to that end, the technology paradigm forced on health care is big, heavy, slow, expensive and in every way corporate and duly regulated by government. It feels like iron from an era that has ended about 10 years ago. The disgruntled physicians, who are complaining about health information technology not being like their iPhones or their Facebook, are instinctively recognizing that both the technology and the business models it enforces are dead.

From a technology point of view, the information age is over. This is the collaboration age and information availability is assumed, just like electricity is assumed. When I can sit in my kitchen and casually chat with a colleague in Karachi, while we are both working on the same Google document and can see each other’s edits in real time, as if we were in the same room, huddled around the same table, and at zero cost to both of us, there is suddenly no ability to comprehend why having two (or seventeen) physicians coordinate patient care necessitates the formation of a new corporate structure supported by technology yet to be built and standards yet to be defined. We have the technology to support all the lofty goals of true health care reform, and the technology itself is dirt cheap, which makes economies of scale, once available from physically owning and controlling as many means of production as possible, insignificant in modern service industries. Those dwindling economies of scale are of course outweighed by the monopoly’s age old ability to set prices, which may be nice for the conglomerate, but not so nice for the rest of us.

The assumption that a corporate office must control everything, including customers, through computerized means, in order to create efficiency and accountability is only true if that efficiency is to be reflected in the corporate bottom line, and said accountability is to corporate shareholders, or the corner office. The assumption that government must dictate and regulate every aspect of the business and its technology tools in order to protect consumers is only true if the business is a large monopolistic corporation. It doesn’t matter how greedy you think doctors are, a million doctors running hundreds of thousands of small businesses cannot do a fraction of the damage one monopoly can do with a proverbial stroke of a pen. Thousands of hospitals operating independently, largely as contractors for those independent doctors, can never muster the necessary clout to unilaterally raise prices or hoard information, and hundreds of insurers (or fund administrators) negotiating separately, can never drive hospitals, doctors or patients into bankruptcy. And government’s job is to ensure that everybody plays by a clear and simple set of rules.

This is what we mean when we say that health care is local. This is what Adam Smith’s books were all about. And this is what we should be doing (with or without a single payer). Instead of erecting regulatory barriers to simple collaboration, we should be smashing any large pieces left over from times when Humpty Dumpty was ruling the walls on which it was sitting, because health care is not literally broken or fragmented. It is distributed.

The Arithmetic of Health Care

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