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.

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.