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March 04 2010

Report from HIMMS Health IT conference: toward interoperability and openness

Yesterday and today I spent once again at the href="http://www.himss.org/">Healthcare Information and Management
Systems Society (HIMSS) conference in Atlanta, rushing from panel
session to vendor booth to interoperability demo and back (or
forward--I'm not sure which direction I've been going). All these
peregrinations involve a quest to find progress in the areas of
interoperability and openness.

The U.S. has a mobile population, bringing their aches and pains to a
plethora of institutions and small providers. That's why health care
needs interoperability. Furthermore, despite superb medical research,
we desperately need to share more information and crunch it in
creative new ways. That's why health care needs openness.

My href="http://radar.oreilly.com/2010/03/report-from-himms-health-it-co.html">blog
yesterday covered risk-taking; today I'll explore the reasons it's
so hard to create change.

The health care information exchange architecture

Some of the vendors I talked to boasted of being in the field for 20
years. This give them time to refine and build on their offerings,
but it tends to reinforce approaches to building and selling software
that were prominent in the 1980s. These guys certainly know what the
rest of the computer field is doing, such as the Web, and they reflect
the concerns for interoperability and openness in their own ways. I
just feel that what I'm seeing is a kind of hybrid--more marsupial
than mammal.

Information exchange in the health care field has evolved the
following architecture:

Electronic medical systems and electronic record systems

These do all the heavy labor that make health care IT work (or fail).
They can be divided into many categories, ranging from the simple
capturing of clinical observations to incredibly detailed templates
listing patient symptoms and treatments. Billing and routine workflow
(practice management) are other categories of electronic records that
don't strictly speaking fall into the category of health records.
Although each provider traditionally has had to buy computer systems
to support the software and deal with all the issues of hosting it,
Software as a Service has come along in solutions such as href="http://www.practicefusion.com/">Practice Fusion.

Services and value-added applications

As with any complex software problem, nimble development firms partner
with the big vendors or offer add-on tools to do what health care
providers find too difficult to do on their own.

Health information exchanges (HIEs)

Eventually a patient has to see a specialist or transfer records to a
hospital in another city--perhaps urgently. Partly due to a lack of
planning, and partly due to privacy concerns and other particular
issues caught up in health care, transfer is not as simple as querying
Amazon.com or Google. So record transfer is a whole industry of its
own. Some institutions can transfer records directly, while others
have to use repositories--paper or electronic--maintained by states or
other organizations in their geographic regions.


HIE software and Regional Health Information Organizations
(RHIOs)

The demands of record exchange create a new information need that's
filled by still more companies. States and public agencies have also
weighed in with rules and standards through organizations called
Regional Health Information Organizations.

Let's see how various companies and agencies fit into this complicated
landscape. My first item covered a huge range of products that
vendors don't like to have lumped together. Some vendors, such as the
Vocera company I mentioned in yesterday's blog and href="http://solutions.3m.com/wps/portal/3M/en_US/3M_Health_Information_Systems/HIS/">3M,
offer products that capture clinicians' notes, which can be a job in
itself, particularly through speech recognition. href="http://emdeon.com/">Emdeon covers billing, and adds validity
checking to increase the provider's chances of getting reimbursed the
first time they submit a bill. There are many activities in a doctor's
office, and some vendors try to cover more than others.

Having captured huge amounts of data--symptoms, diagnoses, tests
ordered, results of those tests, procedures performed, medicines
ordered and administered--these systems face their first data exchange
challenge: retrieving information about conditions and medicines that
may make a critical difference to care. For instance, I saw a cool
demo at the booth of Epic, one of
the leading health record companies." A doctor ordered a diuretic that
has the side-effect of lowering potassium levels. So Epic's screen
automatically brought up the patient's history of potassium levels
along with information about the diuretic.

Since no physician can keep all the side-effects and interactions
between drugs in his head, most subscribe to databases that keep track
of such things; the most popular company that provides this data is href="http://firstdatabank.com/">First DataBank. Health record
systems simply integrate the information into their user interfaces.
As I've heard repeatedly at this conference, the timing and delivery
of information is just as important as having the information; the
data is not of much value if a clinician or patient has to think about
it and go searching for it. And such support is central to the HITECH
act's meaningful use criteria, mentioned in yesterday's blog.

So I asked the Epic rep how this information got into the system. When
the physicians sign up for the databases, the data is sent in simple
CSV files or other text formats. Although different databases are
formatted in different ways, the health record vendor can easily read
it in and set up a system to handle updates.

Variations on this theme turn up with other vendors. For instance, href="http://www.nextgen.com/">NextGen Healthcare contracts
directly with First DataBank so they can integrate the data intimately
with NextGen's screens and database.

So where does First DataBank get this data? They employ about 40
doctors to study available literature, including drug manufacturers'
information and medical journals. This leads to a constantly updated,
independent, reliable source for doses, side-effects,
counterindications, etc.

This leads to an interesting case of data validity. Like any
researchers--myself writing this blog, for instance--First DataBank
could theoretically make a mistake. Their printed publications include
disclaimers, and they require the companies who licence the data to
reprint the disclaimers in their own literature. But of course, the
disclaimer does not pop up on every dialog box the doctor views while
using the product. Caveat emptor...

Still, decision support as a data import problem is fairly well
solved. When health record systems communicate with each other,
however, things are not so simple.

The challenges in health information exchange: identification

When a patient visits another provider who wants to see her records,
the first issue the system must face is identifying the patient at the
other provider. Many countries have universal IDs, and therefore
unique identifiers that can be used to retrieve information on a
person wherever she goes, but the United States public finds such
forms of control anathema (remember the push-back over Read ID?).
There are costs to restraining the information state: in this case,
the hospital you visit during a health crisis may have trouble
figuring out which patient at your other providers is really you.

HIEs solve the problem by matching information such as name, birth
date, age, gender, and even cell phone number. One proponent of the
federal government's Nationwide
Health Information Network
told me it can look for up to 19 fields
of personal information to make a match. False positives are
effectively eliminated by strict matching rules, but legitimate
records may be missed.

Another issue HIEs face is obtaining authorization for health data,
which is the most sensitive data that usually concerns ordinary
people. When requesting data from another provider, the clinician has
to log in securely and then offer information not only about who he is
but why he needs the data. The sender, for many reasons, may say no:

  • Someone identified as a VIP, such as a movie star or high-ranking
    politician, is automatically protected from requests for information.

  • Some types of medical information, such as HIV status, are considered
    especially sensitive and treated with more care.

  • The state of California allows ordinary individuals to restrict the
    distribution of information at the granularity of a single institution
    or even a single clinician, and other states are likely to do the
    same.

Thus, each clinician needs to register with the HIE that transmits the
data, and accompany each request with a personal identifier as well as
the type of information requested and the purpose. One service I
talked to, Covisint, can query
the AMA if necessary to verify the unique number assigned to each
physician in the us, the Drug Enforcement Administration (DEA) number.
(This is not the intended use of a DEA number, of course; it was
created to control the spread of pharmaceuticals, not data.)

One of the positive impacts of all this identification is that some
systems can retrieve information about patients from a variety of
hospitals, labs, pharmacies, and clinics even if the requester doesn't
know where it is. It's still up to them to determine whether to send
the data to the requester. Currently, providers exchange a Data Use
and Reciprocal Support Agreement (DURSA) to promise that information
will be stored properly and used only for the agreed-on purpose.
Exchanging these documents is currently cumbersome, and I've been told
the government is looking for a way to standardize the agreement so
the providers don't need to directly communicate.

The challenges in health information exchange: format

Let's suppose we're at the point where the owner of the record has
decided to send it to the requester. Despite the reverence expressed
by vendors for HL7 and other
standards with which the health care field is rife, documents require
a good deal of translation before they can be incorporated into the
receiving system. Each vendor presents a slightly different challenge,
so to connect n different products a vendor has to implement
n2 different transformations.

Reasons for this interoperability lie at many levels:

Lack of adherence to standards

Many vendors created their initial offerings before applicable
standards existed, and haven't yet upgraded to the standards or still
offer new features not covered by standards. The meaningful use
criteria discussed in yesterday's blog will accelerate the move to
standards.

Fuzzy standards

Like many standards, the ones that are common in the medical field
leave details unspecified.

Problems that lie out of scope

The standards tend to cover the easiest aspect of data exchange, the
document's format. As an indication of the problem, the 7 in HL7
refers to the seventh (application) layer of the ISO model. Brian
Behlendorf of Apache fame, now consulting with the federal government
to implement the NHIN, offers the following analogy. "Suppose that we
created the Internet by standardizing HTML and CSS but saying nothing
about TCP/IP and DNS."

Complex standards

As in other fields, the standards that work best in health records are
simple ones. There is currently a debate, for instance, over whether
to use the CCR or CCD exchange format for patient data. The trade-off
seems to be that the newer CCD is richer and more flexible but a lot
harder to support.

Misuse

As one example, the University of Pittsburgh Medical Center tried to
harmonize its problem lists and found that a huge number of
patients--including many men--were coded as smoking during pregnancy.
They should have been coded with a general tobacco disorder. As Dr.
William Hogan said, "People have an amazing ability to make a standard
do what it's not meant to do, even when it's highly specified and
constrained."

So many to choose from

Dell/Perot manager Jack Wankowski told me that even though other
countries have digitized their health records far more than the U.S.
has, they have a lot fewer published standards. It might seem logical
to share standards--given that people are people everywhere--but in
fact, that's hard to do because diagnosis and treatment are a lot
different in different cultures. Wankowski says, "Unlike other
industries such as manufacturing and financial services, where a lot
can be replicated, health care is very individual on a country by
country basis at the moment. Because of this, change is a lot slower."

Encumbrances

The UPMC coded its problem lists in ICD-9-CM instead of SNOMED, even
through SNOMED was far superior in specificity and clarity. Along with
historical reasons, they avoided SNOMED because it was a licensed
product until 2003 whereas ICD-9-CM was free. As for ICD-9-CM, its
official standard is distributed as RTF documents, making correct
adoption difficult.

Here are a few examples of how vendors told me they handle
interoperability.

InterSystems is a major
player in health care. The basis of their offerings is Caché,
an object database written in the classic programming language for
medical information processing, MUMPS. (MUMPS was also standardized by
an ANSI committee under the name M.) Caché can be found in all
major hospitals. For data exchange, InterSystems provides an HIE
called HealthShare, which they claim can communicate with other
vendors' systems by supporting HL7 and other appropriate standards.
HealthShare is both communications software and an actual hub that can
create the connections for customers.

Medicity is another key
HIE vendor. Providers can set up their own hubs or contract with a
server set up by Medicity in their geographic area. Having a hub means
that a small practice can register just once with the hub and then
communicate with all other providers in that region.

Let's turn again to Epic. Two facilities that use it can exchange a
wide range of data, because some of its data is not covered by
standards. A facility that uses another product can exchange a
narrower set of data with an Epic system over href="http://www.epic.com/software-interoperability.php">Care
Everywhere, using the standards. The Epic rep said they will move
more and more fields into Care Everywhere as standards evolve.

What all this comes down to is an enormous redundant infrastructure
that adds no value to electronic records, but merely runs a Red
Queen's Race to provide the value that already exists in those
records. We've already seen that defining more standards has a
limited impact on the problem. But a lot of programmers at this point
will claim the solution lies in open source, so let's see what's
happening in that area.

The open source challengers

The previous sections, like acts of a play, laid out the character of
the vendors in the health care space as earnest, hard-working, and
sometimes brilliantly accomplished, but ultimately stumbling through a
plot whose bad turns overwhelm them. In the current act we turn to a
new character, one who is not so well known nor so well tested, one
who has shown promise on other stages but is still finding her footing
on our proscenium.

The best-known open source projects in health care are href="http://openmrs.org/">OpenMRS, the Veterans Administration's
VistA, and the href="http://www.connectopensource.org/">NHIN CONNECT Gateway. I
won't say anything more about OpenMRS because it has received high
praise but has made little inroads into American health care. I'll
devote a few paragraphs to the strengths and weaknesses of VistA and
CONNECT.

Buzz in the medical world is that VistA beats commercial offerings for
usability and a general fit to the clinicians' needs. But it's
tailored to the Veterans Administration and--as a rep for the href="http://www.vxvista.org/">vxVistA called it--has to be
deveteranized for general use. This is what vxVistA does, but they are
not open source. They make changes to the core and contribute it back,
but their own products are proprietary. A community project called href="http://www.worldvista.org/">WorldVistA also works on a
version of VistA for the non-government sector.

One of the hurdles of adapting VistA is that one has to learn its
underlying language, MUMPS. Most people who dive in license a MUMPS
compiler. The vxVistA rep knows of no significant users of the free
software MUMPS compiler GT.M. VistA also runs on the Caché
database, mentioned earlier in this article. If you don't want to
license Caché from InterSystems, you need to find some other
database solution.

So while VistA is a bona fide open source project with a community,
it's ecosystem does not fit neatly with the habits of most free
software developers.

CONNECT is championed by the same Office of the National Coordinator
for Health Information Technology that is implementing the HITECH
recovery plan and meaningful use. A means for authenticating requests
and sending patient data between providers, CONNECT may well be
emerging as the HIE solution for our age. But it has some maturing to
do as well. It uses a SOAP-based protocol that requires knowledge of
typical SOA-based technologies such as SAML.

Two free software companies that have entered the field to make
installing CONNECT easier are href="http://www.axialexchange.com/">Axial Exchange, which creates
open source libraries and tools to work with the system, and the href="http://www.mirthcorp.com/">Mirth Corporation. Jon Teichrow
of Mirth told me how a typical CONNECT setup at a rural hospital took
just a week to complete, and can run for the cost of just a couple
hours of support time per week. The complexities of handling CONNECT
that make so many people tremulous, he said, were actually much easier
for Mirth than the more typical problem of interpreting the hospital's
idiosyncratic data formats.

Just last week, href="http://www.healthcareitnews.com/news/nhin-direct-launched-simpler-data-exchange">the
government announced a simpler interface to the NHIN called NHIN
Direct. Hopefully, this will bring in a new level of providers
who couldn't afford the costs of negotiating with CONNECT.

CONNECT has certainly built up an active community. href="http://agilex.com/">Agilex employee Scott E. Borst, who is
responsible for a good deal of the testing of CONNECT, tells me that
participation in development, testing, and online discussion is
intense, and that two people were recently approved as committers
without being associated with any company or government agency
officially affiliated with CONNECT.

The community is willing to stand up for itself, too. Borst says that
when CONNECT was made open source last year, it came with a Sun-based
development environment including such components as NetBeans and
GlassFish. Many community members wanted to work on CONNECT using
other popular free software tools. Accommodating them was tough at
first, but the project leaders listened to them and ended up with a
much more flexible environment where contributors could use
essentially any tools that struck their fancy.

Buried in href="http://www.healthcareitnews.com/news/blumenthal-unveils-proposed-certification-rule-himss10">a
major announcement yesterday about certification for meaningful
use was an endorsement by the Office of the National Coordinator
for open source. My colleague and fellow blogger Brian Ahier href="http://ahier.blogspot.com/2010/03/meaningful-certification.html">points
out that rule 4 for certification programs explicitly mentions
open source as well self-developed solutions. This will not magically
lead to more open source electronic health record systems like
OpenMRS, but it offers an optimistic assessment that they will emerge
and will reach maturity.

As I mentioned earlier, traditional vendors are moving more toward
openness in the form of APIs that offer their products as platforms.
InterSystems does this with a SOAP-based interface called Ensemble,
for instance. Eclipsys,
offering its own SOAP-based interface called Helios, claims that they
want an app store on top of their product--and that they will not kick
off applications that compete with their own.

Web-based Practice Fusion has an API in beta, and is also planning an
innovation that makes me really excited: a sandbox provided by their
web site where developers can work on extensions without having to
download and install software.

But to a long-time observer such as Dr. Adrian Gropper, founder of the
MedCommons storage service,
true open source is the only way forward for health care records. He
says we need to replace all those SOAP and WS-* standards with RESTful
interfaces, perform authentication over OpenID and OAuth, and use the
simplest possible formats. And only an enlightenment among the major
users--the health care providers--will bring about the revolution.

But at this point in the play, having explored the characters of
electronic record vendors and the open source community, we need to
round out the drama by introducing yet a third character: the patient.
Gropper's MedCommons is a patient-centered service, and thus part of a
movement that may bring us openness sooner than OpenMRS, VistA, or
CONNECT.

Enter the patient

Most people are familiar with Microsoft's HealthVault and Google
Health. Both allow patients to enter data about their own health, and
provide APIs that individuals and companies alike are using to provide
services. A Journal of Participatory
Medicine
has just been launched, reflecting the growth of interest
in patient-centered or participatory medicine. I saw a book on the
subject by HIMSS itself in the conference bookstore.

The promise of personal health records goes far beyond keeping track
of data. Like electronic records in clinicians' hands, the data will
just be fodder for services with incredible potential to improve
health. In a lively session given today by Patricia Brennan of href="http://www.projecthealthdesign.org/">Project HealthDesign,
she used the metaphors of "intelligent medicines" and "smart
Band-Aids" that reduce errors and help patients follow directions.

Project HealthDesign's research has injected a dose of realism into
our understanding of the doctor-patient relationship. For instance,
they learned that we can't expect patients to share everything with
their doctors. They get embarrassed when they lapse in their behavior,
and don't want to admit they take extra medications or do other things
not recommended by doctors. So patient-centered health should focus on
delivering information so patients can independently evaluate what
they're doing.

As critical patient data becomes distributed among a hundred million
individual records, instead of being concentrated in the hands of
providers, simple formats and frictionless data exchange will emerge
to handle them. Electronic record vendors will adapt or die. And a
whole generation of products--as well as users--will grow up with no
experience of anything but completely open, interoperable systems.

March 02 2010

Report from HIMMS Health IT conference: from Silicon Valley technology to Silicon Valley risk-taking

I'm in Atlanta for the biggest US conference in health care IT, run by
the Healthcare Information and
Management Systems Society (HIMSS)
. This organization, along with
the branch of the federal government responsible for dispersing funds
for a medical records overhaul, has to do a huge job in an extremely
short time. I'll report what I hear (and how I interpret it) over the
next few days, aiming both at people who care in general about the
future of health care at particularly at readers who are wondering
whether their next career move may be into health care.

Although many people have been saying that the medical field would
benefit from a Silicon Valley approach to technology, it's coming to
seem that even more important would be a Silicon Valley approach to
risk-taking. I'll look at the events that created this imperative.

Where the pressure comes from

Why are most doctors in the U.S., some thirty years after IT became
ubiquitous in American offices, still working with paper records? The
main reason is that they work in small offices instead of large
institutions, as I describe in href="http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html">an
earlier blog about electronic health records. Most economically
advanced nations have centralized, government-administered health care
systems, and therefore electronic records. Large institutions in the
U.S. also have them--the Veterans Administration's VistA is a famous
example--and more hospitals have made the move than small physicians'
offices.

A crisis in costs and achievements provides a nice impetus for change
( href="http://www.nytimes.com/2010/02/28/weekinreview/28abelson.html">an
article in last Sunday's New York Times lays out the stakes), but
cold cash does even better. Few things can make an industry perk up as
much as a sudden infusion of twenty billion dollars. Thus the impact
of a provision in the federal stimulus bill (properly known as the
American Recovery and Reinvestment Act of 2009 or ARRA) that mandates
the adoption of electronic medical records.

The framers and implementers of the stimulus bill were both ambitious
and idealistic, but they weren't naive. They know that the adoption of
electronic health records, like any computer system, can be botched
and can turn out to miss the benefits that it's supposed to bring. So
in this part of the act, called Health Information Technology for
Economic and Clinical Health (HITECH), they lay out a demanding list
of practices that clinics and hospitals must carry out to qualify for
government money. In other words, HITECH is really about behavior and
workflow, not technology.

What does HITECH call for? Some requirements seem fairly easy to meet,
such as tracking key clinical conditions on patients. Others get quite
complex, even at Stage 1 of the implementation. For instance, doctors
are supposed to use their electronic systems to help check their
treatment plans for errors and suggest best practices, a field called
clinical decision support. Stages 2 and 3 require complex data
exchanges with other organizations, which in turn requires
interoperation among different systems from different vendors. I'll
return to interoperability in a later blog. Other rules include
evidence-based order sets (which bring up suggested treatment regimes
based on research) and reporting treatments and results to registries
to foster the further development of best practices.

All these requirements are put forward under the buzzword
meaningful use, an ironic choice given that the requirements
aren't even completely defined yet. Still, whether it's meaningful or
not, the term has instantly leapt to the forefront of discussion among
vendors and providers, because of the financial rewards attached to
them.

In principle, the meaningful use criteria are good. The government bodies
creating the requirements got stakeholders involved early and often.
It's well understood that these things are needed to improve care and
reduce inefficiency. As in any major attempt at social change,
doom-sayers predict disaster. (I'm not necessarily saying they're
wrong; in this case they include href="http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&type=Blog&tier=7&id=B98FF5D2B2E34463A550B2407329FC6C">CIO
Anthony Guerra and href="http://blog.srssoft.com/2010/02/government-ehr-program-potentially-harmful-unintended-consequences/">IT
company CTO Evan Steele, both featured at the HIMSS conference.)
But for the most part, the health care industry is lined up behind
meaningful use--or at least behind the promise of the money that
health care providers will be paid to implement it. Grumbling among
vendors and practitioners focuses on the timetable for implementation,
not on the practices themselves.

If you've gotten the impression from this summary that Congress and
the Administration have bypassed all the political bickering around
health care reform bills and implemented it under the guise of a
financial recovery, I'd say you're right. HITECH doesn't directly
address the health care industry or other controversial issues such as
how to pay doctors. And those issues still need to be resolved. But
HITECH does try to reform the health care system around better
practices.

So the HIMSS conference is taking place at the height of a suspenseful
moment in U.S. health care history. The Administration has released
proposed final rules, but they're in the middle of a 60-day comment
period. Meanwhile, working from the drafts that have been released
all along, vendors are feverishly bringing their tools into
conformance and claiming (how could they not?) that the tools will be
ready soon for adoption.

The pressures extend to other players all throughout the health care
industry. A certification body called the Certification Commission
for Health Information Technology (CCHIT) is design certifications for
vendors' systems as well as the hospitals and individual providers who
adopt them, matching the meaningful use criteria "no more and no
less," as said today by the outgoing CCHIT chair, Dr. Mark Leavitt.
The pressure will then be on the providers--and here is where I'm
seeing the most resistance.

Suspicion and silos

Given that many clinicians never adopted electronic systems, and
others who did regretted doing so, we don't have to be surprised to
hear that some don't think it will work or don't believe that they can
make the change.

It would seem that heath care IT is hot right now. HIMSS is sprawled
across three buildings in the Georgia World Congress Center (whose
address completely confuses Google Local, by the way). Getting from
one place to another between sessions means forcing my way through
hundreds and hundreds of attendees. To walk from one corner of one
show floor to the other would take several minutes. I picked up half a
dozen magazines on health care IT.

But even here--among people who paid to attend a health care IT
conference--dissent can be felt. There's a lot of anger at electronic
systems and their vendors, complaints ranging from high costs and
inflexible templates to user interfaces that slow down busy staff and
problems with data exchange. A few observers claim that HIMSS and
CCHIT are just vendor-controlled consortia who want to milk providers
and walk away with government money. I must say, though, that debate
here ranges across many points of view. I was impressed to see an
HIMSS book on patient-centered records, which--if made the basis of
health care--would produce a bigger revolution than anything discussed
so far. (I'll explain why in another blog this week.)

Although attendees want to make the move to electronic records, many
talk about other people who won't. And a typical session on clinical
decision support was devoted, not to ways of using electronic medical
systems, but to persuading the attendees that electronic medical
systems would be worthwhile.

The timetable does seem like a forced march. Even though the systems
that meet the meaningful use criteria are still under development--and
so is the certification--providers will be rewarded as early as 2011
for installing them and using them heavily. (The records have to be
used for 80% of some practices in order to get the money.) And each
year that providers wait before meeting the meaningful use criteria,
they get less money. A stick also accompanies the carrot; providers
that accept Medicare and Medicaid will actually be penalized if they
don't demonstrate meaningful use.

Furthermore, implementing the rules will require the hiring of more IT
staff and telling clinical staff to take time to serve on committees.
These considerations contributed to a href="http://www.healthcareitnews.com/news/chime-airs-critical-concerns-about-ehr-incentive-program">declaration
by a consortium of Chief Medical Officers that the timetable was
too aggressive. Some Congressmen have recently href="http://www.himssconference.org/daily/tuesday.aspx#1">made the
same request, so you know someone has been talking to them.

But many others in the field--including the vendors, confident in
their ability to deliver, and some hospital managers in the forefront
of implementing electronic records--urge the government to stay the
course. Their attitude is that the need is great (because health care
costs are rising so precipitously), the schedule is demanding but
still feasible, and "if not now, when?"

I stated earlier that HITECH was more about behavior and workflow than
technology. The push to implement the meaningful use rules brings
this to the fore. Old silos between IT, doctors, and other staff won't
work; neither will silos between doctors, billing, labs, and other
departments.

Providers trying to achieve meaningful use must talk to their staff:
not just doctors, but also nurses, technicians, and anyone else who
touches a record. They have to examine their workflows and be willing
to admit when they don't conform to health care standards or are
inefficient. They have to make some of the same mistakes offices and
factories made when they computerized in the 1980s, and learn from
those mistakes. To some extent, implementing an electronic system is a
bottom-up activity.

That's why I say that a Silicon Valley approach to risk-taking is even
more important for this field than a Silicon Valley approach to
technology. I'm not so concerned with the famous Silicon Valley
tolerance for failure. Health care is not a social network, and
failure there has serious consequences. I'm more interested in a
Silicon Valley willingness to cross organizational boundaries and to
encourage people's opinions on things where other people are the
recognized experts.

Overall, I don't think the money offered by HITECH will really drive
the decision to change. I think providers will move as they hear of
others running awesome applications to make life easier--and save
lives. I've stopped using the phrase "killer app" in the health care
field for obvious reasons, but the standards, protocols, and storage
mechanisms won't have much impact until applications follow.

So I'll end with a nod toward a company for which I have a fond spot
because it happens to be the href="http://www.oreillynet.com/pub/wlg/3961">first health care
company I talked about in a blog, over six seven years ago. href="http://vocera.com/">Vocera is still going strong, providing
mobile devices with health care applications to over 600 sites.
Medical staff can issue orders, call for help, or scan medications
using these tiny clip-on devices.

Although Vocera doesn't work on the immensely popular iPhone, it does
have partnerships with the makers of several other handhelds,
including the Blackberry and one from Motorola. It collects scads of
statistics about things such as the number of contacts made and the
success of speech recognition software, to help sites judge its
effectiveness. I find it an example of the kind of product that will
drive electronic medical systems, because it will please not only a
Chief Medical Officer, regulator, or insurance claim processor, but
someone doing clinical work on the floor of the hospital.

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Don't be the product, buy the product!

Schweinderl