Change we can believe in

Look, this blog isn't supposed to be about healthcare politics. It's supposed to be about healthcare IT. But the intersection between the two is enough that I feel justified in commenting about this blog entry that one of my spies alerted me to.

The Kennedy-Dodd bill would create an individual mandate requiring you to buy a “qualified” health insurance plan, as defined by the government.  If you don’t have “qualified” health insurance for a given month, you will pay a new Federal tax.

And then it continues with a whole lot of analysis, which my spy aptly summarized as:

Take all the things that are off about US healthcare, ignore them, and heave a corporate subsidy into place as a solution.

Well, I think that's a pretty good summary. But that's what they did with the wunch of bankers, so why would you expect anything different in healthcare?

As I said, I had hoped that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid. But it looks like that's what we're getting, and what we're going to continue to get. 

I say that because just like every 'reform' proposal is stupid, every criticism has its own built in time bombs. Take, for example, this:

Those who keep themselves healthy would be subsidizing premiums for those with risky or unhealthy behaviors

Just think that one through. Who's going to say, 'well, you know, someone else is going to pay my healthcare costs, so I'll drink myself into the ground'? Look, I know plenty of people who are drinking themselves into the ground, but for most of them, the availability of healthcare sure doesn't factor into that choice (and for the few that it is, it's the fact that they can't get the healthcare they need that means they have no reason not to drink).

And just how do you think any form of healthcare coverage works, from pay-for-yourself-as-you-go through to a fully collectivized economy? The healthy pay for the sick, either by saving up for when they're sick, or entering into some cost sharing scheme known as "insurance" or "tax" whereby their sickness risks are shared to the mutual benefit of all. 

So, the real question here is, do people indulge in risky or unhealthy behaviors because their consequential healthcare is subsidized? Economists believe this sort of stuff as a matter of religion, but real people don't make health decisions like that based on financial considerations. They're far more... emotional. Anyway, it's not as if private insurance schemes are really successful at preventing those with risky or unhealthy behaviors from getting coverage. No, what they're good at is preventing those with risky or unhealthy heritages or histories from getting coverage, which is a whole different kettle of fish (usually called discrimination).

Another typical claim of the opponents of national healthcare services is this:

force patients to accept what a bureaucrat deems “proper” healthcare regardless of what the patient deems proper care

Yes, I can see why people are skeptical about accepting what a government bureaucrat thinks is best. I sure can. After all, the government bureaucrats have no stake in the outcomes either way, what would they care?

So I've got a heaps better idea: instead, we'll let some company decide what proper healthcare you should get, and you can pay them for that instead of relying on the government. After all, they have a stake in the game, which is that the less healthcare you get, the more profit they make. Yep, definitely an all-round better idea! I can see why everyone wants to go for that. (at least, that is, it's a better deal for the people who own the insurance companies, who seem to be the only ones at the table)

Ahh, but wait, the economists will be saying right now, you've missed the key point, which is that it's all about choice. If the consumer has choice, then the insurers will be forced to compete to give us the best deal, and that'll be much better than if the government takes that choice away. 

Well, my response to that is three-fold. 

1. if you are economist, have you actually heard about transaction costs? (and see also this about free market efficiency)
   
2. for the rest of us who live in the real world, does the word "cartel" sound familiar? At least you vote for the government (and round the rest of the world, governments routinely get voted out over the state of their health systems)
   
3. yep, choice itself is a good thing, but the mere fact that the government is going to provide healthcare doesn't mean choice goes away. 
   

Just to reinforce that last point, to my knowledge only Canada prohibits a private healthcare system. Because only Canada has USA as a realistic option for providing the second-tier healthcare system- because everyone needs a two-tier system (everyone important anyway). 

Not that any of this matters anyway - as long as the government is paying, then nothing will change. The costs will keep climbing like a rocket. In addition to the reasons I explained earlier, also because as long as the government is just paying, people (I guess we have to call those beasts running the health insurers that) will be just ripping the government off, and we've just been shown how to do that on a grand scale in a real expert fashion. That's why in other countries, the government is not only payer, it's also provider. 

Anyhow, as long as morons are running around making these kinds of claims, and voters are listening, then there won't be any real progress on healthcare in USA. But it seems to me that these kinds of concerns are built into the very fabric of USA, part of the basic social contract enshrined in the constitution: what's good for me is what's good for everybody. And, therefore, vice versa: what's good for everyone can be judged by whether it's good for me. USA is a country founded on a very different set of principles than other countries. Accordingly, it can't have the kind of healthcare system other countries can have, and comparisons with other countries (such as seen here on The Big Picture) are pointless and misleading. Because USA isn't ever going to achieve the outcomes other countries can - and neither can the other countries achieve what USA does. 

See, if you choose individual wealth over shared wellness, then that's what you're going to get.

Patients = Patience

You hear at all the time: the problem with socialized healthcare is that it leads to waiting lists, people waiting too long for operations. Months, I hear, people have to wait months for operations you shouldn’t have to wait for, and sometimes they even die before the operation can happen.

Well, I say that’s crap.

Let’s start with some mathematics. Let’s say that we have a population P, and D, the rate occurrence of a particular condition that requires treatment.

Now let’s, for the sake of argument, assume that P is large enough – major city size,> 1,000,000 – to provide some constancy in statistics. So you can tell right away that we’re dismissing rural medicine. Stupid hillbillies who still live out in the boondocks, what the hell do we care about them anyway? All decent people live in slums cities with at least that number of people in it.

A P that large means that the rate of D is basically fairly constant, with the daily rate of Dd having a standard distribution around the mean D, and an approximate Standard Deviation of √D.

Look, these are rough statistics, and you know the drill: lies, lies, and statistics. But if I had a polished statistician go over this stuff, instead of the weird Health IT Nerd, the picture wouldn’t change that much.

So we have this condition occurring Dd number of times per day in the city. Now let’s say that this condition requires treatment on the same day. If this treatment is not provided, the patient will die. Perhaps the condition is extreme exhaustion from exposure to the political shenanigans associated with the bail-out, and the treatment is to be forced to read the War Nerd. Or we could try taking life seriously and posit that the condition is a renal stone, and the treatment is ultrasonic destruction of the stone. (Not that this is generally highly successful, but I’ve always though it’s the perfect procedure: we’ve got a problem – a real painful one, so what we’re going to do is have a good scream at it for a little while, and see if it goes away all by itself.)

Whatever, there’s a rate T, the number of treatments for the condition that can be provided in a day. Unlike D, this number is not subject to a normal statistical variation. Instead, it’s influenced by the availability of staff and long term institutional policies (which often produce unexpected results on the value of T). So for the sake of argument, let’s assume that T is a fixed constant.

If T is less than D, then this is a disastrous outcome - the queue for services will rapidly grow longer and people will die. The queue will get shorter on some days, but in general it will grow longer. However the length of the queue is limited by the number of people who die before they get to the front of the queue. So eventually the queue will stop growing. (So next time you hear of a long queue, understand: the people waiting aren't dying like flies while they're waiting...)

If T = D, then the queue will quickly reach a steady state – but roughly 50% of people will still have to wait until the next day. (Actually, it starts out much lower than that – a small number miss out on some days, say when Dd = D + 1 * √D. And they get carried over to the next day, where they compete with Dd for that day. The eventual outcome of this, what the average carry over is, depends on a variety of modeling and simulation assumptions, but as a rule of thumb, about 50% get carried over the next iteration.)

So when T = D, only 50% of the target is met. Note that like the previous case, the actual length of the queue depends on the number of people who die before treatment.

As T > D, and the gap increases, the percentage chance that a patient will have to wait until the next day drops – but T has to be quite a bit bigger than D before it approaches 0. (How much bigger depends on the value of D, given that the standard deviation of D was posited to be √D, but a useful rule of thumb is T = D + (3 x √D) gives 1% missed targets)

This is well and good, but what does it mean?

If you want to have immediate treatment available, you have to build considerably more than the average required treatment capacity into the system.

This is true for almost all kinds of treatment, whether obstetrics, oncology, cardiology, or what. You just plug different numbers in, and different requirements, but the same basic principles are in play.

Note that it’s mostly not as bad as it sounds because many treatments share a common set of resources, particularly facilities and staff. By pooling these things, the overall size of D increases, and the ratio of D/√D goes up, and the built in waste is ameliorated.

Nevertheless, you need to have excess capacity built into the system. Now this is hardly a radical conclusion – it arises in other industries all the time, particularly in telecommunications and transportation, and it’s a pretty well understood problem.

But people seem to forget this when they start talking about health, and we have these stupid debates about resources and waiting lists. In these, people not only ignore the simple principles above, they also ignore the fact that no society on earth can afford to pay for unlimited healthcare, let alone have excess capacity in the system.

So, how do you limit the resources available without creating waiting queues? Want a hint?

You can’t.

Well, actually, I lie. You can. But only if you deny some people access to the queue at all. Then they turn into a “totally negative healthcare outcome” instead of screwing up your statistics (i.e. they screw someone else’s stats up. Since funding is linked to statistics in most jurisdictions, this is just a way of externalizing the costs).

So, you choose: the immoral or the distasteful? Which is it to be?

Though there’s a third option. The way this works is simple: You know that a queue has to exist, but you personally don’t want to wait. So you create a two-tier system that ensures you don’t have to wait when you need the treatment, that someone else will wait. Or miss out altogether.

This only really works well if you can arrange that everyone who matters is in the top tier, and people in the second tier are such losers that they either don’t have representation (e.g. communist paradises)  or don’t have the wit or leverage to be heard anyway (say, UAW members ;-). Note that this can only work if the second-tier people fund the first tier some way or other (kind of socialism in reverse).

I’ll leave it to you to decide for yourself how well your country manages this issue, whether you’re happy with the way the case-by-case decision is made, whether it’s going to be the immoral or the distasteful for you and your loved ones.§

But next time you hear someone discussing the disgraceful state of waiting lists in [country/system/state] as compared to [other country/system/state], ask yourself: how are the statistics lying this time? How many people had a totally negative outcome before the possibly positive outcome got counted? And who were they?

§ The correct answer to the question above is ‘no, I’m not happy’. It doesn’t matter which country you live in. Tricky huh?

p.s. Here’s an excellent example of this stuff in practice, quoted from
http://tedstumor.blogspot.com/2009/03/natasha-richardson-epidural-hemorrhage.html

“It's important to ask this question, because this is precisely the situation where the Canadian-type health care system -- much touted by reform advocates -- tends to fail Canadians.”

Yes, the Canadian government makes one set of decisions. These weight some situations preferentially over others. And then:

“In the United States if someone falls and hits her head and then an hour later is rushed to the emergency room you can bet she will get a STAT CT scan and immediate neurosurgical attention.”

This is another set of decisions. Because there’s a word or two missing from this paragraph – this doesn’t apply to all citizens, only to those with “coverage” – a number steadily decreasing at this time. Both of these are two-tier systems. The Canadians just outsource their first tier to USA – works well for everything but emergency medicine.

All I want for Christmas

It’s Christmas time. [Well, okay, it’s not anymore. This was written before Christmas, but the one friend I do have reviews these posts first, and he disappeared on holiday beforehand, so I’m only getting to post it now].

It’s a hard time of year for everyone, especially if you have any sense of the ridiculous. After all, what’s the basis for Christmas? The Son of God came to the world, and told everyone that God was angry because of everyone’s injustice and greed. So naturally, we remember Jesus by giving gifts to anyone who’ll give us stuff back, and by eating and drinking far too much. We can’t even get the time of year right – though maybe it’s best that Christmas is just a pagan feast at heart.

Of course, when I’m stupid enough to say something like this to my friends, they tell me that the best part of Christmas – what it’s really all about – is spending time with my family. Well, they’re quite welcome to spend time with my family. Though if they think that’ll be fun, they don’t know my family as well as I do. So I’m back hiding in my hovel, thinking about healthcare and IT (and not before time too. Apologies for the long delay between posts – apparently our customers expected me to get some actual work done before they got to go on their family fun-time holidays).

And what I’m thinking about right now is, what will you and your loved ones – if you have any – what will you be talking about this Christmas once you’ve had too much to eat and drink, and all the presents are opened? Well, I can’t think of anything better than to talk about healthcare system reform. 

“Umm, yeah,” you’re saying, “right. What else would we talk about?”

Well, don’t blame me. Instead, you can blame Senator Tom Daschle:

Daschle wants Americans to host “holiday-season house parties to brainstorm over how best to overhaul the U.S. health-care system,” the WSJ reports.

Don’t believe me? Check out the WSJ for the whole outrage. And thanks to my spies in the USA who alerted me to this gem.

At first I laughed at this. I was pretty disappointed too. I was certainly hoping for more from the incoming administration. After eight years of the Bush power slide, we’re in desperate need of a responsible approach to prevent the inevitable, though a quick survey shows that the Democrats have quite happy competed with the Republicans to see who offers worse government (it’s a US thing: governments are bad, so we vote for bad governments). Nevertheless, I found myself hoping that “Change we can believe in” didn’t mean that kind of change the Health IT Nerd believes in, the kind that I usually see in the healthcare system – namely, just a different kind of stupid.

As I said, I thought, who’d be stupid enough to talk about healthcare policy over a Christmas meal? But the more I thought about it, the more I realized that we always talk about healthcare policy when my family gets together. It starts easily enough, talking about our family’s latest encounter with the healthcare system. What with the many little accidents of life – backyard, kitchen, and bedroom - and getting old (also accidental; at least, it certainly seems to happen while you’re looking the other way), the extended families of the Health IT Nerd and his suffering wife have regular encounters with the healthcare systems across the world, and whichever side of the family we have the “luck” to spend the festive season with, the subject is sure to come up.

And once the subject does come up, you can be sure of one thing: everyone is going to start complaining about how terrible the healthcare system is. After all, it’s never our fault that we needed healthcare. Actually, it’s not our fault. Since the only thing that’s sure in life is death and hospitals, it’s just because we were born. So the fact that we need healthcare is our parent’s fault – it’s important to know who to blame for all life’s ills. For this reason, the best time to talk about how to reform the healthcare system is when you get together with those whose fault it is. 

It doesn’t matter what country you’re in, either. You can be sure that everyone’s going to be complaining about the quality of the healthcare system. And also how much we have to pay for it. Again, it doesn’t matter how it gets paid for, directly, indirectly through insurance, or indirectly through taxation. We pay too much, and the quality of service sucks. 

So, this year, when you get together as families, do your patriotic duty, and brainstorm how to overhaul the U.S. health-care system, because, as Daschle points out:

There is no question that the economic health of this country is directly related to our ability to reform our health-care system

For a start, you can tell by looking at the way we celebrate Christmas, you can tell for sure that it would be a waste of time asking us to consider the healthcare system from some altruistic perspective about what would actually be good for our health. No, we definitely need to talk about money. And since there’s a war or two to fight, and the worst financial crisis this century, we need all the money we can get. 

So this year, instead of simply complaining about how poor the system is, instead, try and figure out how to pay less, either by defrauding someone, or perhaps by setting up some kind of ponzi scheme to raise enough money to pay for it (as if any kind of savings plan isn’t a ponzi scheme in the end). If that doesn’t work out for you, see if you can figure out how to overhaul the US healthcare system. And the best kind of overhaul is one that saves money – in other words, one that makes the system poorer. 

It’s kind of a game, see. Basic level, you get to plan a healthcare system assuming no constraints, like worrying about how much it costs. But anyone can design a pretty good healthcare system that way. At the intermediate level, factor in real world constraints like costs, staffing levels, and inefficiencies like organizational dysfunction. There’s a special advanced level where you also get to make allowances for things like liability funding, and on-going educational resourcing. If your family wins at that level, then you move onto wizard level, where you get to figure out how to overhaul the US healthcare system to make it better, while factoring in unreal world constraints like eating long lunches with friendly lobbyists.

No one wins the wizard level. Ever.

But it’s Christmas, so there’s no harm in hoping for the best. After all, wishes can come true. So what does the Health IT Nerd wish for?

Of course, I wish for world peace, justice for all, the end of famine, an end to bad governments, and that people would stop sponging off their richer neighbors. And in healthcare, I wish that people would stop getting sick, and that everybody would be happy to let their poor sick neighbors sponge off them.

Hmm. This isn’t going well. Though at least Bush the Second is going to be gone. I guess that’s not much a Christmas present though, since it was all organized years ago. 

No, other than a bit more of that river of gold, what I really want for Christmas is that everyone would finally come to really understand: Interoperability – it’s all about the people.

[Belated Christmas note: I sure hope you got what you wanted for Christmas. Because I didn't)

Europe’s turn to waste money

The Health IT Nerd has spies all over Europe, so I got showered with notifications when a new report was released by the EU last week.

These reports are nothing new. Governments need to commission these reports every so often, to make sure that they’re not on track in their programs. And it doesn’t matter which government, it always works the same way. The government announces it wants a report, and invites all and sundry to bid to do it (usually this is called and RFP or something similar). Then the government ranks the bids, and either picks the one it was going to pick anyway, or chooses the cheapest, from the dumbest least informed clown that bothered to respond.

If it was a pre-selected winner, then, surprise: the report spins things how the government wants. Or, if it’s the cheapest respondent, then the report might say anything at all. If it’s sufficiently crap, the government throws it to the wolves (whoops, I mean the relevant industry), and everyone feels better for having canned the crap that the government needed canned anyway.

This happens everywhere in every industry. I think it gets taught in Government 101. But everyone plays the game dutifully, because you never know quite which variant of the game is on until later. Hindsight is 20/20 (or maybe just 20/10 or something).

In spite of that, I’ll bet all the monopoly money I can find in my hovel that this one is being thrown to the wolves. One thing you can be sure of: it’s utter crap. Check the extensive and thorough preparations undertaken to prepare this report:

In November 2007, empirica conducted an online survey of e-health experts from ICT industry, user organisations, public authorities, university and research, SDOs, and consultants. 94 experts responded

94 experts? Wow, that’s thorough. For all we know, 90 of them were French, and the French don’t know anything about anything. Also, it lists OpenEHR as a standards organization. Now while the openEHR guys seem to be trying to do something useful, they ain’t no standards group (actually, I think I'll make a report of my own about them in the future). 

If I hadn’t already had turkey for thanksgiving, this report would’ve done nicely for a late consolation prize.

So, let’s see what their extensive research yields in terms of conclusions:

Current situation in e-health standards: Nearly all interviewees agreed that there is a lack of widely used e-health standards.

There’s a lack of widely used e-health standards? Have they not heard of HL7? Or perhaps “widely” has a different meaning in Europe? So maybe the respondents were French after all.

Impacts of current situation: Nearly three quarters of the respondents indicated that within a single health service provider the overall situation is supportive, but the majority found the situation unsupportive for cross-border care provision.

Well, the outcome certainly wasn’t the ability to write meaningful sentences (this might demonstrate that they understand the essentials of interoperability properly after all). 

Barriers to adopt common e-health standards in hospitals: Hospital IT managers may first of all find internal process functionality more important than commonly used standards.

Well, duh. That’s exactly the real problem (maybe I did respond to this survey after all). Everyone in the industry is in the same boat: my process functionality is more important than commonly used standards, and I’m not going to waste money on them. 

Hang on: “waste money on standards”?

Isn’t the whole point of standards that they save money? Well, yes. And no. Rather more no than yes, unfortunately, in the healthcare industry. If everyone adopts standards over the industry as a whole, then they will pay off. But only if everyone does. It’s a two-edged sword.

For vendors, in the absence of standards, they get paid to do the same work again and again – nice safe money. But that sucks. No one enjoys it, and it’s damn hard to hold on to staff as it is without making them do the same thing again and again. For care providers, adopting standards might offer the ability to purchase cheaper software, but it also means behaving in a standard fashion. Where’s the business ego differentiator in that?

If you look across other industries, and see which ones have rapidly adopted standards, it’s the ones where the adoption of standards has drastically increased the size of the whole pie, so everyone benefits. But in health, the pie is already as big as it can get. So the result of using standards is just to reallocate parts of the pie.

It’s not for lack of trying, but the governments can’t impose proper standards on the industry, because the industry just doesn’t want them across the board. It’d rather adopt them in a piece meal fashion – the patient will pay, one way or another.

And how can healthcare get away with this? Politics. It’s always politics. See, doctors have unbelievable power in society, and they’re tremendously conservative when it comes to how things are done. Sure, that’s got it’s bad side, but hands up anyone who wants to volunteer to be the guinea pig for a new way of doing things. And everyone, even El Presidente or whatever they’re calling themselves this year, eventually everyone is going to be a patient.

Anyhow, back to the report. It seems to me that they demonstrate a complete knowledge of the current state of the industry when they say:

In January 2008, the US Department of Health and Human Services recognised certain interoperability standards for health ICT which federal agencies have to include in procurement specifications for certain fields of health. This could be a step towards mandatory use of a confined number of standards for principal e-health applications. Such a regulation by the US government could have considerable impacts in the EU. In order to prevent unfavourable developments, the EC and the Member States may be well advised to develop a common strategy and roadmap for e-health standards development.

Let’s see if I understand this correctly: USA did something, so in response, the EC and it’s member states better go and do their own thing. 

Interoperability: it’s all about the people. And it doesn’t look like there’ll be any change soon.

What we have here is a failure to communicate

IT is the great white hope for healthcare, the healthcare administrator’s wet dream: we’ll be able to reduce the cost of this monster using IT and improve service at the same time. And like all fantasies of this type, what you get in the cold light of day just isn’t quite the same – that sensuous young woman turns out to be a withered old hag with a sour disposition (or, for my female readers – if I still have any: that buff young man turns out to be a crotchety old jerk with a hairy back).

One of the principles is easy to grasp. Anywhere between 50% and 80% of healthcare professionals’ time is spent tracking down information so they can provide proper healthcare. That’s right – that doctor who’s getting paid a million smackers a year: he spends most his time finding the right pieces of paper. That's not all - almost all of the preventable deaths that occur relate to missing information one way or another.

So, if you stick all that information on computers, and they can talk to each other, then the information will just be right there, exactly when and where the healthcare professional needs it. Magic! And we could get twice as much work for the same amount of money, and with less “totally negative health outcomes”. So you can see how seductive this idea is – up there with the supermodels. Also, see the Turkey I had for thanksgiving.

Actually, it would be magic if it worked that way, but the real magic is in the innocuous words “they can talk to each other”. In the healthcare IT industry, this is called “interoperability”, and it’s the Holy Grail. It bears startling resemblance to the Holy Grail too. Not only has no one ever seen it, we don’t even know what it actually is.

In order for computers to be able to talk to each other, they need to understand each other in a deep and meaningful way. At least that’s what the experts say.

I’m not so sure. I’m married, and I know that once you understand each other, you no longer need to talk anymore. Yeah, yeah, everyone laughs when I say that, and pities Mrs. Health IT Nerd. And I mean, I understand their pity, because I know me even better than they do, but they’ve missed the point: Mrs. Health IT Nerd and I are never going to understand each other (any of you that are married will know exactly what I mean). So our lives are full of interesting times, and we are forced to keep talking to each other.

So this is what makes interoperability so much fun: we’re never going to understand each other fully, but we have to get along anyway. I think this is one of the craziest things that happens in health IT, that the industry so seriously misunderstands what will enable interoperability, and what the results might be.

Classic interoperability theory says that in order for two computers to talk to each other, you need the following things:

• A transmission channel between the two (usually, but not always, bidirectional)
  
• A common set of terms (words) with meanings that both parties understand
  
• A common set of information models (grammar/story plotlines) to allow the pieces of meaning in terms to be assembled into a coherent larger structure
  
• An agreed process (who says what when, and what happens next)
  

This is called the “interoperability stack” (I presume “stack” like as in “Dad, I totally stacked your car”).

It’s the same requirements for humans to talk together, on any scale, from my two small kids arguing about who gets to be the doctor and who is the patient, to diplomats from two large countries resolving which side of the border their soldiers will get to acquire their need for emergency healthcare on.

Actually, that stack above is incomplete. There’s something else that most interoperability wonks don’t stress, but I can’t stress enough:

• The two parties need to share an agreed context of operations
  

Like Mrs Health IT Nerd and I, no one knows how to even agree on what this “context of operations” thing is, how wide and deep it is.

Take a simple case: in Isaac Asimov’s Foundation, one of the characters says: “Violence is the last refuge of the incompetent”, by which he means, only the incompetent will use violence because it doesn’t solve anything.

Well, I have a friend (Yes, I *do* have one), and he’s a wingnut, so he says that this means that competent people would have resorted to violence long before it’s time for the last refuge. While that interpretation is the polar opposite of the one that was intended, the actual words and the grammar are understood the same way. It’s the different background values people use when evaluating the meaning of the phrase that make the difference here. (Which interpretation is correct? It’s not like it matters for this column, but I figure that what happened in Iraq - or any other war - shows the statement is wrong and stupid however you want to read it.)

This is why interoperability is so hard: there are so many layers to understanding. A whole industry exists to define interoperability based on standards that provide meaning for that stack, a whole alphabet soup of them, such as HL7, CEN, ISO, IHTSDO, ASTM, ANSI, WHO, W3C, OASIS, WS-I…. a never-ending profusion of standards bodies. You know what? These standards bodies, these definers of interoperability, they can’t even interoperate amongst themselves, so it’s the proven-blind leading the probably-blind.

These standards are all going to fail. Well, not so much fail (though it might be best if, umm, if we all don’t actually look too closely at them when we say that), as not quite deliver all the things people are demanding from them – just small things, like life, the universe, everything, and also world peace as well. These things won't happen, but there will be some outcomes: life will get better, healthcare will improve. But you know should know by now what happens when healthcare improves: costs go up; so even if these interoperability standards deliver everything anyone dreams of, the outcomes won’t be what they desired in terms of cost-cutting.

Even if the healthcare administrators and those who pay for healthcare (i.e. you!) scale back the expectations of what interoperability can achieve to something reasonable, these standards are not going to deliver, because they’re all based on the expectation that if you solve the technical problems, interoperability will just happen.

It’s people who insist on doing things differently, calling the same thing by different names or vice versa. It’s people, who, given the same patients, the same healthcare problems, and the same computer systems, find completely different ways to achieve roughly the same outcomes. And for all these people – both healthcare professionals, and healthcare informaticians (horrible word!): there’s my way of doing things, and all the wrong ways to do it. There’s even a step beyond that, people for whom there’s my way of doing something, and all the other ways that I am dedicated to destroying. These people are methodological terrorists, and they are attracted to standards. This is part of why the healthcare standards wars are such fun.

So the fundamental problem of interoperability, of getting the information to the right person at the right time, is the first and last steps – getting it out of the first person who has it, and into the other person who needs to understand it in the appropriate context, how it relates to all the other information they have. Compared to these two problems, everything else is just plumbing, though we can’t even get that right. Interoperability is about people, not technologies.

Perhaps the healthcare industry isn’t so stupid to spend below average amounts on IT after all.

However we’re clearly going to spend what we do have on chasing the chimera of getting computers to fully understand healthcare – that is, us. Well, that will never happen.

So I think that we need to start focusing on enabling interoperability without trying to understand each other. See, if we all focus together on trying to achieve something perfectly useless, there’s a reasonable chance that we might actually succeed, especially since we've already achieved one of the desired outcomes – we’ll never understand each other.

The Mightiest Champion of Them All

Roll up, Ladies and Gentlemen, Roll Up, Roll Up!

Welcome to the grandest heaviest longest fight you’ll ever see. The fight is being fought between two implacable foes, two of the heaviest grandest contestants you’ll ever see, marshalling their entire forces on the side of good. At stake is nothing less than the very heart and soul of the people of the earth. You’ll never see anything like this again: a fight of good vs. good, a war of attrition with both sides grinding each other slowly down with no quarter given.

People laugh at cricket, such a slow game with weird rules. And the rules are weird, almost as weird as any country’s legal system – with the same kind of happy outcomes too. Seriously, a game that lasts five days? How can anyone be interested in that? But, you see, the longer the game lasts, the tougher the tussle, the more there is at stake. Imagine that your team has spent five days building a winning position, and then, right at the last moment, you drop the ball? That’s real drama – the longer and slower, the meaner it gets. Anyone living in one of ex-British colonies – wish I could write that with the proper upper class pronunciation – will have seen the headlines that follow when their team loses.

Well, this fight I’m talking about has been going for more than a generation, and the losing side has just struck back for the first time.

In the one corner, we have the Cardiologists, with their array of complicated and expensive diagnostic machines (positively military priced, in fact), and their flag-ship open heart surgery campaigns. Over in the other corner, ragged and beaten, but still fighting hard, it’s the Oncologists and their friends, with their terrifying array of “therapies” lead by their nuclear, chemical and biological weapons. Yes, that's right folks, just like some other fight that’s currently taking place, the side with the nuclear weapons is losing.

Between them is their boxing ring, the canvas that they fight on, the people of the earth. Somewhere between 70 and 85% of all the people on earth die from heart/vascular disease or cancer. (Aside: You know the drill: lies, lies, and damn statistics. How much of a lie is this one? It all depends who you listen to, how you count, and how definitions are done.)

The cardiologists landed the first really effective punch back in the sixties, and open battle has been on since then. It seems that they didn’t really know exactly how devastating a thrust they were making when they declared war on cholesterol back in the 1960’s, didn’t know just how much a blow that was to the oncologists. Let’s check a replay of the action back then.

By the early 1960’s, enough evidence had accumulated to show convincingly that cholesterol – specifically, dietary cholesterol and fats – was one of biggest causes of heart disease. Heart disease alone was the biggest people killer, even ahead of the World Wars. And they declared war: not only with steady improvements in weaponry, but also in some long, slow, hearts and minds things: in this case, dietary cholesterol. That’s right – they declared war on all the good foods, the stuff that we really like. Like my favorite food, fried chocolate bars (it’s got all the key food groups all wrapped up in one package - sugar, fat, salt, chocolate. What’s not to like?)

The grand assault on cholesterol was much more effective than they hoped, a real knock-out blow. Over a forty year period, the rate of most forms of heart disease has slowly but surely dropped, and just as significantly, the age at which people start having problems has slowly but surely been rising. So – a great outcome - people are living longer and better.

As a result, they started dying like flies from cancer. See, if your ticker lasts long enough, and nothing else goes wrong, you’re going to get cancer. The older the body, the more likely it is to contain small amounts of cancer (and a big hello to my weird friends the autopsy technicians). It’s just a question of time until one of the little cancers cuts loose and tries to take over from it’s host: you.

So the unexpected outcome of people not dying from heart disease was that the rate of cancer started rising. It’s rather a pyrrhic victory for two painful reasons.

The first reason is that dying from cancer is a horrible way to go. The terrifying NBC weapons-of-mass-desperation that the Oncologists use against the tumors are bad enough, but losing is even worse. People forget just how a relative died if the ticker gives out, but they don’t forget cancer, no way – not that long slow horrifying decline to a painful death.

The second reason is that for all the dizzying expense of the Cardiologist’s diagnostic hardware and spectacular operations, they’re just cheap dates compared to total cost of treatment for cancer.

So the Cardiologists won the first round, and we’re still paying for it now. That’s right: healthcare is so screwed up that the price of a victory is an increase in costs. Note also another consequence of the Cardiologists’ victory: more Oncologists and less Cardiologists. There’s nothing else like healthcare for producing perverse incentives.

Well, the Oncologists have just struck back! At a meeting of American Cardiologists last month, it was reported that for the first time in fifty years, the number of people dying due to heart disease has gone up (no apparent on-line reference to this, though I found this).

There’s lots of reasons why the rate might be going up, but one contributing factor must be that the rates of death due to cancer are dropping. The Oncologists have been fighting back: early diagnosis, more targeted treatments, the same kind of preventative war against cancer risk factors as the Cardiologists’ war on cholesterol. And they’re starting to make real progress. You can check out this summary for more information in careful government-type language (as in, boringese. Translated for the rest of us it says “Yay! We’re starting to win! Give us some more money, or you’ll die horribly!”).

So, the Oncologists are doing well, and this is magnificent news for all of us.

Except for our wallets. Welcome to the healthcare system, where the consequence of better healthcare is more expense. As long as the Cardiologists and Oncologists are duking it out, trying to run their statistics down, they’re going to spending more of our money doing it. And how can we say no? Do you even want to?

And as they get better, the population will get older, and that's a whole different ball game, one that makes the ticket price for our current fight look positively family-friendly.

More old people who don’t contribute to the economy, what are we going to do with them all? How can we look after them? I’ve got a great idea: you look after my old folks, and I’ll go surfing (on the internet, not the real thing).

Everyone knows that while we can’t afford to buy or provide unrestricted healthcare now, that's nothing compared to where we’re heading. It’s common to blame the baby boom, or falling birth rates. But I say the biggest factor of all is the improvement in positive healthcare outcomes resulting from the Cardiologists vs. the Oncologists.

So that’s how it’s gone in the first world, the so-called “civilized” countries. Actually, some European countries didn’t buy into the whole population anti-cholesterol thing at first, and didn't get the population health benefits till later – but they’re catching up. And in fact, the rest of the world is rapidly catching up, some trading off between different diseases, but ending up with the same outcome: if you save someone’s life, that means that they live on to get sick with an even more nasty and expensive disease. From the perspective of a healthcare system, this is what should be known as a “totally negative healthcare outcome”.

Well, I think that the time has come for the governments to bring back cholesterol. It’s my new public health policy: for the first 50 years of your life, eat well, keep sober, stay fit, have your two kids, be good. Then, on your fiftieth birthday, go on a big spree for the rest of your life. Eat whatever you want, stop exercising, drink as much as you can. Hell, sleep around as much as you want. Really enjoy your twilight years. And then, when you die in your mid-sixties, it’ll be quick and painless. And most importantly, cheap. It’s just a matter of thinking of your children.

Like that’s going to happen.

So forget the Cardiologists vs the Oncologists: that’s just a side show. The real champion, the mightiest of all, the one that will always win all the fights: that’s the healthcare system. It’s rocket science, baby, the only way is up.

Turkey for Thanksgiving

The Health IT Nerd has spies all over the world, and one of them sent me this from Australia.

Ahh, Australia. You know, I could stop right at this point, but I doubt anyone outside New Zealand would get the joke.

Anyhow, back to the article:

SPECIAL commissioner Peter Garling has prescribed a massive dose of IT to fix NSW's troubled public hospitals, and recommended a watchdog oversee e-health.

I found myself at a loss trying to figure out what parts of the article to quote. Only the crazed funny bits, I said to myself. Well, that didn’t eliminate any of it. So put down anything that you might spill, drop or snort, and read the article in full.

Peter Garling is a turkey, and he’s the main course for the Health IT Nerd’s Thanksgiving special. Like I said, any fool can figure out that Healthcare is completely screwed. And this fool did. And just like I said happens, he’s proposed a whole lot of IT programs that will fix healthcare up. I hope you like your turkey flavoured with stupid.

Let’s start with his proposed programs.

He says that NSW should have “critical infrastructure, hospital and community information systems and a statewide e-health record system”. Before I go on, I’ve heard about NSW. In a country full of blow-hard states with ever more obnoxious politicians, NSW tops the lot in venal corruption and plain buffoonery. In fact, the NSW politicians are now almost qualified to graduate to US Congress. But I digress.

So this Peter Garling fellow says that NSW should provide all these things – which probably comes as a surprise to their existing critical infrastructure and hospital systems – and it should do that in a timeline of four years, not the eight to fifteen (actually thirty) year timeframe. Because, you know, if you just wish for things and strike a pose, that’ll make it come true. I’ve heard this is called “Creating Your Own Reality”, and we've all see how well that works out.

So not only has our Thanksgiving Turkey already decided that it can just happen in a four year time frame, he’s already priced it out: $705 million – accurate to the third significant place. Unbelievable.

If that wasn’t funny enough, there’s this: “Mr Garling has called for an independent Bureau of Health Information -- separate from NSW Health -- to be established to access, interpret and report on all data relating to safety and quality of patient care”. Ahh. So, this is where the 4 years and $705 million comes from – creating a new government department. And since government departments don’t have non-negotiable contractual goals, you can fix the budget before hand, with total assurance that the money will be spent, exactly as planned. You can even tell right now that there won’t be any actual money for patient services here.

What goals does our Turkey have for his little stack of gold?

There will be no feel-good moment which comes from cutting the ribbon to open a new facility. However, it will surely save many lives, and protect many, many more from harm.

I’m at a loss for words. As I’m sure you’ve figured out, this is not something that happens to me very often. Even in the land of Nod Healthcare IT, you don’t often see someone proposing to spend that much money for no measurable outcome.

Ahh, Australia.

Anyone who had the misfortune to attend international Health IT conferences about 10 years ago will probably remember various chief high lord this and that from Australian governments giving serious presentations about how Australia was going to the lead the world in the use of IT to reduce the costs of healthcare while improving services.

So they should. Australians are tough, pragmatic people, and it’s not very easy for someone else to pull a smart one over them. Oh no. They’re too busy pulling a smart one over themselves to be caught like that. Put five Australians in a boat, and you’ll have five people with the hand on the tiller, all going in different directions. But they’ll actually only have their hand on the tiller when someone’s looking. Not for nothing do Australians use the Koala for their national symbol – an animal that sleeps for 23 hours a day, and is permanently stoned from the eucalypt leaves it eats.

The only thing that saves Australians from themselves is that they don’t know how to take themselves seriously. Which is why no one else does either. Are they a mini-America? Or just Euro-Wannabies? Do they have a socialist healthcare system, or a private free-market healthcare system like USA? Well, Australians sure can’t make their mind up, and no else can figure it out either. Anywhere else it would actually matter, but, hell, this is Australia. They’ll all just go and throw some prawns on the barbie, and whine about the government over one or two (or many) beers.

I only feel sorry that Thanksgiving is not an Australian thing – our turkey will probably just miss the fun.

I recommend that readers keep an eye out for mention of this in the next week or so. The first thing to know is that anyone with half a brain will instinctively know everything I’ve had to say, and will know just how stupid our Turkey is. So they’ll consider themselves free to take a self-serving position on it. How will the politicians posture to leverage the most advantage off the notion before they kill it? How will the technocrats try and stay away from any consequent project? Which vendors reckon they can get a piece of the action?

Well, it’s healthcare IT, and it ain’t meant to be pretty. I sure hope your turkey tasted better than this one.