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.

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.

The Health IT Nerd

I’m a Health IT Nerd. It’s all I ever do: living, breathing and sleeping Healthcare IT until I dream about it: patient records, diagnosis codes, web services, and Snomed expressions. I’d much rather dream about nurses (who wouldn’t?). Hell, I’d be happy to dream about the clerical staff. But no, it’s all bits and bytes and needles and XML for me: it’s not even worth it for me to sleep at all. So I hole up in my hovel with my computer, spending all my time on the internet pretending I know how to make Healthcare better.

That’s all anyone can do: pretend. No one has the faintest idea how to make things better, although you’d never know it, listening to the way the experts go on about how clever they are. But don’t be fooled: they’re either dishonest or just plain dreaming. Or deranged, that’s always possible with these people. The fact is: no one has any idea how to actually fix all the problems that exist with Healthcare or even just Healthcare IT.

Rest assured: it’s not like there’s any doubt about the problems. Any fool can see them, even with their eyes shut and their brain turned off, just the way everybody goes about these days. And most fools do see the problems. The trouble is, the problems are so big, no one knows how to fix them. Everywhere you turn, you can see lots of smart ideas floating around, but even a quick look will make it obvious that they won’t actually work. All they’ll do – if anything – is make someone a quick buck.

Of course, you’re thinking, that’s the problem: it’s all about the almighty dollar, profit for the fat pigs, making money off poor sick people. But even that’s not true. Healthcare is just so stuffed up, it’s pretty much about the only industry where you can say, “let’s do this, it’ll make us money” (or “it’ll save you money”), and half the audience sits around saying, “Like, so, what do we care? What we want to know is, is it good for the patients?”

As if the patients get to have any say in it.

In fact, it’s the patients that are the whole problem. If we took patients right out of the system, we could have unbelievably efficient healthcare. Heck, we could run the operating costs right down to zero, and the system would no longer produce “totally negative healthcare outcomes” (that’s somebody dying, to you and me).

But we can’t get rid of the patients, or their stupid addiction to their own positive healthcare outcomes, so instead, healthcare systems around the world gradually consume ever greater amounts of money on a scale that beggars the imagination. You can join in the game of figuring out how much it costs too – just think of a number, and keep adding zero’s until you run out of space: it’ll be about right (or not any more wrong than any other number you read). Every country is trying to figure out how to protect themselves from this monster, this rampaging beast that just keeps gorging itself on an ever bigger GDP slice. And USA, that paragon of economic efficiency, it spends even more on healthcare than any other country as a % of GDP, and with worse outcomes than many, so free-market economic efficiency is no answer.

It just gets worse too, when you consider what the economic outcome of a successful healthcare system is: an even more expensive Healthcare system in the future. The only way is up, baby, this is a one-way growth industry. Healthcare is the real Rocket Science.

One of the most commonly discussed ways to reduce the cost of healthcare is to leverage the efficiencies that IT can introduce. So it makes total sense – I’m sure you guessed it yourself: Healthcare spends less on IT industry as a percentage of total costs than any other industry.

But even a small percentage of a gob-smackingly large amount of money is still more money than you can poke a stick at, and there’s a huge stack of dollars going down. And all the vendors, from super-small one-man expert consultancies through to mega-large my-turnover-is-bigger-than-your-country’s-GDP multigalaxial corporations, they’re all positioning to get themselves a piece of that river of gold. And the trough is so big, there’s plenty of space for all of us (because yes, my nose is in the trough too – I know what I am. Oink Oink), no matter how ignorant we are. Even if you can’t spell EHR (and a big thanks to Microsoft Word for always correcting EHR to HER).

What all this means is that there’s a lot of real interesting things happening right now in Healthcare IT. That’s “interesting” as in the old Chinese curse, “May you live in interesting times”. And we do, so I just can’t sit back and keep my mouth shut anymore. So I’m going to sit in my hovel, run off at the mouth, and be the Health IT Nerd.

Note that I’m not the original Nerd. Oh no, that’s the War Nerd himself. Compared to the War Nerd, I’m nothing. I’m not even worth to tie his shoelaces and all that sort of thing. Even so, I’m honored to follow in the Esteemed Masters’ footsteps. Particularly because war is just like Healthcare – it’s not driven by any sensible financial outcomes.

You might say, war - that’s a really interesting subject! How boring is Healthcare? Who’s interested in that? Well, think on this: you might be able to avoid a war – if you're lucky – but two things are sure in life: death and hospitals (though not usually in that order). (If you thought I was going to say taxes, where do you think all your taxes are going to go in the future?) Anyway, I spit on war. Healthcare guzzles far more money than war, and we kill far more people in hospitals than die in war (and I don’t even have to count the freebies, the do-it-yourself deaths people accidentally prescribe to themselves at home). And unlike war, just about every country plays at having a healthcare “system”. Well, nearly every country. There are a few conspicuous exceptions in Africa. And I’m told I should mention Canada at this point, too, from what I’m always reading in the US media (and that must make it right).

So, healthcare IT: it’s the piggy in the middle between clinicians, managers, bureaucrats, patients, academics, corporations and technology. It’s chock full of crazy behavior, and the whole shebang is fueled by the biggest pile of dollars anyone has ever imagined.

So sit back, buckle in, and hold on tight, because the Health IT Nerd is gonna show you round.