Cash for Clunkers?

“Cash for Clunkers”? Hot diggity dog! What a great new idea to adapt into the whole new ARRA/HITECH EHR adoption drive!

I mean, think about it...we’re trying to drive users to EHR adoption, right? We’re hoping to encourage “meaningful use” which could sort of be interpreted as improved mileage, yes? We want every new EHR driver using a system which will participate and share safely on the health information sharing multilane highway, no? And, ultimately, we’d like to see all those non-CCHIT-certified, non-government-approved EHR clunkers off the road, eh?

So, if you read or watch any news lately, you know the auto-selling industry has had a landslide success with the government’s “big bucks for your trash trade-in program” formally known as the Car Allowance Rebate System or CARS. (Cute, huh?) Intended to run until November, the billion dollar budget appears to have been blown in only one week. Talk about end user adoption!!!

Such blazing success should not go unimitated. You want an EHR in every provider pot? Let’s take a lesson and forget the whole 44K reimbursement nonsense. Here’s the new deal:

• First, we pick a catchy name like “Every Human Receives Something” or EHRs.
• Next, we choose a cute-ish informal moniker, say, “Moolah for Medicine.”
• Third, we decide upon a set of high mileage models worthy of reimbursement...of course, CCHIT-certified systems will likely be the defacto choice.
• Finally, we offer cold, hard, trade-in cabbage to all clunkers out there – those notoriously antiquated non-CCHIT systems and, obviously, anyone still driving the prehistoric pen-and-paper monstrosities.

If $4,500 for a running, drivable, used car inspires sufficient adoption of new, high-mileage models to burn through a billion bucks in one week, I’ll betcha an upfront $44K to turn in old, gas-guzzling EHR junkers or paper-based jalopies for sleek, new, energy efficient health record roadsters will tear through 19 billion greenbacks in two, three days, tops.

First posted on HIStalk, August 11, 2009.

What I lack in decorum, I make up for with an absence of tact. - Don Williams, Jr.

Drink To Me Only With Thine Eye(s)

- or - The Window to the EHR Soul

I’ll betcha Ben Johnson, back in 1616, never dreamed his sweet, though somewhat melancholic “To Celia” would ever become the basis for the musings about a relationship with a machine. Yet, here it is almost 500 years later and as I stare into the giant baby blue of the EHR with whom I have become so enamored (or at least familiar), that is the love song I hear swimming betwixt my ears.

It isn’t just the soulless machine or LCD whom I find myself adoring in virtual and intellectual romance; it is the essence within which drives my love and from which her true beauty derives. It is her spirit, her life force, her anima, her élan vital. It is her software GUI, from her EHR underpinnings, which inspires my adoration and supplies the muse to my mental poetry – for she, her eye, is beautiful.

The first thing that attracted me to her was her eye. Beautiful blue with gorgeous splashes of color, clear whites with few lines, and an aura of serene simplicity which almost belied the wonderful depth of her inner complexities. She was stunning. Still is.

She is still the only eye I want to look into every working day. She still fulfills most of my manly medical needs. The soul I see within as I am constantly drawn to her never-wavering gaze each day is still one of passionate concern trying to be my all, to meet my every desire. Her countenance still pleases my gaze, her eye still beauteous to mine.

But, just as with every great love, time and familiarity reveal undeniable cracks in the veneer of loveliness which first bedazzled completely. Not that she isn’t still beautiful and not that there is another out there who has caused my eyes to wander; it’s just that all of the promise, both implied and assumed, never quite matches fully with time-revealed reality. The talents presumed and the best-foot-forward finesse of the early infatuation days yield to the actuality of the true.

Will this beautiful eye, this rectangular optical window to the true soul of my EHR machine, ever fulfill all of my desires? Will she grow with the refinement of age and experience into the dream with which my mind’s eye beheld her when infatuation first flowered?

Or, will I join the ranks of the unfaithful, becoming enamored by the sultry lines and sinuous curves of a younger, newer beauty? Will one with the flexibility of youth and the promise of new love distract my eye from my first, now aging, love?

Frankly, I don’t know. Our cohabitation, after all, is solely at my discretion. I do know that it was love at first sight with my first EHR love. The beautiful GUI, her “eye,” drew me in helplessly. Her understanding of my needs was deep, but her visual splendor captured my soul. This was an eye I knew I could gladly gaze into daily for many, many years to come. (Others before – and most, so far, since – appear lifeless and cold and uncaring of my visual happiness.)

While many are perhaps far more pragmatically oriented, I believe beauty engages us all. If you’re going to spend years, perhaps a professional lifetime, gazing upon a quadrangular “eye” to your EHR machine’s soul, it should be a gaze returning pleasure and visual “vavoom.” Superior EHR GUI design can lead to love.

First posted on HIStalk Practice, August 11, 2009.

Talent hits a target no one else can hit; genius hits a target no one else can see. - Arthur Schopenhauer

The Elegant Palm Pre Cereal Box Top EHR

Yep. Pretty happy with the new Palm Pre. Simple, nonetheless powerful. Stylish, yet practical. Hip, though perhaps not iHip. Zen, and so much so, that I quit maintaining my motorcycle.

But, regardless of the number of contemplatory eggs gracing Palm developer desks, it isn’t perfect. Battery life is abysmal unless you keep all the apps closed. This kind of diminishes the glamour of being able to keep a bunch of ‘em open and switch in and out at will. Of course, if you have a bunch of chargers scattered around, you can keep up and the new magnetic grab-n-go charger helps this. (Thank you, yet again, Mr. Tesla.) Still, I’m used to having my digital six-shooter on my hip and jumping about at will. Remembering to grab the little beauty when I run off to an emergency or bathroom break proves challenging.

Also, the Palm Data Transfer Assistant could use some work. You’ll find lotsa online tales of woe about Palm Desktop or Outlook data migration. (Thank you, Chapura PocketMirror.) Another noticeable weakness is Sprint’s cellular coverage, at least here in my little burg. Verizon had me covered and I could always hear you now. Sprint doesn’t want me getting calls in the surgery center or even sitting at my office desk. (I won’t bore you with why Sprint doesn’t want new business customers to have AIRAVEs to enhance their signal, but will freely give them to established customers – I have to endure crap coverage until them deem me worthy, I guess.)

Still, challenges and foibles aside, I realized the other day that I could pretty much do every common little computer thing I need from wherever I happen to be (within cell tower range.) This is phenomenal! The integrative nature of the Pre and the beyond-iPhone-friendliness of my new pocket-sized phone-calendar-contact database-camera-GPS locator-weather center-web browser-videocam-pager-planner-game system-younameit tool made me realize the future had hit. This was a, “Wow, I can actually do what I’ve always wanted to do,” light bulb moment.

Then, this morning, I was putting my Raisin Nut Bran cereal box away when I noticed the box top. Remember how cereal boxes always had that little semi-cut-out slit you had to punch open to stick the opposing flap’s tab into? Remember how it invariably would not be well cut and your attempt to pop it apart would, also invariably, lead to the little connector piece tearing such that the tab would never hold the flaps closed as intended? Well, some cardboard engineering whiz kid has figured how to cut the tab and its opposing flap indentation such that the punch is eliminated and my little box top stays untorn and closes right every time. Genius, though it took decades to discover.

So, a two-and-two flash strikes. That’s what I want from my EHR. I like my system well enough; it has lots of the gadgets and gizmos I need. The problem is it isn’t Pre slick yet. Close. Kind of like the difference between the Palm Treo and the Pre. Functional, but kludgy. Close, but still not quite brass ring worthy. Missing the box top simple solutions for functionality. I’m guessing many EHR users feel similarly. We know what we need, but no one has the truly elegant answer yet.

I would like to know if anyone out there knows the “Geniuses of the Box Top” and a couple of Palm Pre developers who might be interested in constructing the new Palm Pre Cereal Box Top EHR? To make the next generation EHRs, the ones we really need, it’ll take these types of Zen master geniuses, those who can make all the work underneath appear simple and elegant. Maybe I should ask Fred Astaire.

First posted on HIStalkPractice, August 4, 2009.

You don't get anything clean without getting something else dirty. - Cecil Baxter

Postscript : Since submitting this piece, I came across a tremendous article, The EHR ‘killer app’, by Jeff Marion on EHRWatch.com. If you haven’t seen it, it is well worth a read.

The Six Degrees of Integration

Tipping points and network theory. Malcolm Gladwell and Kevin Bacon. If short books and the Science Channel have taught me anything, it’s these: While I may not have all the answers, it is only a hop, skip, and a jump to where the answers lie and simple things may have the biggest impact. (T.V. and the Web reaffirm this daily.)

Have you noticed that no matter where you look, someone is promising the grand digitization of healthcare in the oh, so near future. I’m starting to chafe from the tipping point upon which we’re supposedly perched. However, a look at the percentages of full-blown HIT users, either provider side or consumer, doesn’t seem to tilt the impression that mass adoption is all that imminent.

Still, with Facebook at nearly a quarter of a billion users and Twitter plotting their plan to become the first Internet site to reach a billion users, it is apparent that providing people with a tool they: a) understand; b) find simple to use, and: c) find real, immediate use for has major power to quickly topple a tool over into mass adoption. If healthcare IT could get off its high horse and learn a lesson or three from these more “common” contrivances, maybe we could actually reach the Promised Land of Healthcare Information Integration.

Enter Kevin Bacon. HIT struggles virtually non-stop to understand how to integrate all the data we derive daily, be it patient care info, new medical knowledge, or business numbers management. And, from Kalamazoo to Cocoa Beach, everyone is trying to figure it out almost independently. Well, Kevin says we are all only separated by some six degrees or less. What if we take a part of Mr. Bacon’s recipe, sprinkle in some of Facebook’s Gladwellian success spices, stir it all up within the HIT pot, and then dump the whole stew out upside down?

Instead of Six Degrees of Separation, what if healthcare information integration chose to focus upon the reverse view that we are all within “Six Degrees of Integration”? We are not separated so much anymore as we are integrated. A quick breeze about the HIT blogs brings up some pretty interesting observations along these lines from both the more notorious as well as some lesser known HIT brainstormers. Many of them are now bandying about notions related to direct-to-consumer healthcare information integration management beyond PHRs and EHRs. After all, every person on the planet has health which needs care at some point or another, just as most everyone has social networks with whom they want to keep connected. If simple social networking tools are able to empower such rapid adoption and end user deployment, then haven’t they demonstrated the fast, focused force available for integration of healthcare info if we only harness similar motivating energies?

To promote this reverse view of the Six Degrees for HIT, I propose a new organization: Pursuers of Integration’s Six Degrees, to be more affectionately known as PISD. If you don’t want to wait for the trickle down of big, siloed systems, consider becoming a PISD member. Help all of America, even all of the world, become PISD so we can get beyond the abrasive point upon which we tip.

The unwitting modern day Moses, Kevin Bacon, has shown us the Promised Land past the HIT Tipping Point. Now, if we could just pass over.

First posted on HIStalkPractice, July 20, 2009.

“If you're not scared or angry at the thought of a human brain being controlled remotely, then it could be this prototype of mine is finally starting to work.” - John Alejandro King

You Have To Let It All Go, Neo

Just for fun, let’s say you have 19 billion dollars and a tremendously philanthropic heart. Let’s say you decide to devote your vast fortune to solving the healthcare crisis in America. As you also have a geeky soul, you settle upon healthcare information technology enhancement as the vehicle you deem most likely to have give you that big bang for your many, many bucks.

You look around the HIT realm and see many, many players providing many, many digital solutions, but realize that the vast majority of them are siloed, they don’t work and play well with others. There are some really wonderful systems, many of which have the potential to provide the electronic underpinning to your truly national health care project; however, very few, if any, have all of the tools with all of the interoperability you seek. Virtually none have the diversity of user interface that end users’ widely divergent personal preferences demand. (People do want their own style.)

It appears to you that no current system can provide the be-all-end-all tool that works for everyone, no system yet has the easy and highly individualized personal customization required to entice everyone into adoption with a tool that works for their unique needs and their unique eyes. Thus, you begin to ponder, “I wonder what kind of a broadly attractive system I could build from scratch for my 19 billion dollars?”

Pursuing this thought train, you muse:

• How many top notch developers could I hire? (2,000 X $150K = $300 million)
• How many designers could I employ to make user interfaces that are easy with thousands of skins so everyone can look at whatever suits their eyes? (2,000 X $150K = $300 million)
• How many educators could I deploy throughout the country to make sure “no child is left behind” – or any adult? (10,000 X $150K = $1.5 billion)
• How much of my money pile could I afford to give to individual smaller communities across the nation to help them step across the digital healthcare divide? (Micropolitan areas: 577 X $3M = $1.73 billion)
• How much could I give to schools to help educate the young so that, going forward, this digital healthcare stuff becomes second nature? (94,000 X $100K = $9.4 billion)
• How many really great support personnel could I hire and deploy to every corner of the land in an effort to insure uptime? (10,000 X $250K = $2.5 billion)
• How large a chunk would be left over for various loose nuts and bolts, including quality CEOs, COOs, CIOs, and all the little “o”s? ($3.27 billion)

2,000 developers; 2,000 designers; 10,000 support personnel; 10,000 educators; big, no huge, chunks of money to help small communities join the party and teach our children how to be digital healthcare thinkers using existing Web and cell phone technologies which already reach every knook and most every cranny? “Hmmmmmm...,” you further muse, “I bet this money could really do some good.”

First posted on HIStalkPractice, July 13, 2009.

“You have to let it all go, Neo...fear, doubt, and disbelief. Free your mind.” - Morpheus

KISS, Please

Simplicity. As complex as healthcare is, if we try to add the density of technology to it, perhaps it is counter-intuitive to think of ‘simplicity’ as a key operating principle of the NHIN construct. However, I believe this is the must have nuclear core for the successful initiation of the broad masses of both consumers and providers to the adoption of healthcare information technology. It is also key to their subsequent and sustainable utilization of these tools.

Everyone who has been listening to the widely broadcast cachet attributed to HIT has at least some appreciation for the extensive list of advantages we all envision for our future digitally-enabled healthcare provision. Seeing what tech has done for shopping, banking, communications, social networking, political campaigns, and general information sharing, it is virtually impossible to imagine that such benefits would not also transcribe well into the realm of healthcare. Indeed, it is the very complexity of healthcare that makes it seem such a likely candidate for technology enhancement.

Therein lies the rub: We know what technology can achieve, yet we are seemingly overwhelmed by its application to so complex an arena as healthcare. We want all the benefits which we know it can provide, yet we are stymied by the vastness of healthcare as well as the currently available information technology solutions, most of which have trouble working and playing together.

I propose we let the big players continue to duke it out over who shares what with whom and how they’re going to solve their big center issues. I mean, while they have helped to push HIT along the past quarter century or so, they’re also the ones who have enabled the ‘silo-ization’ with which we are now hamstrung. They have oodles of money and should be the ones to fix the dilemmas they’ve enabled.

In the mean time, for the rest of us (consumers, small providers, ancillary healthcare delivery providers,) let’s do simple. Already familiar tools. Real, immediate value. Attractive, intuitive user interfaces. Internet as the backbone, no silos. Easy-to-use cell and smart phone push-pull data collection and dissemination apps. Work with the individual end user in mind, both consumer and provider – together, not separate. Important pieces first, add complexities as mastery grows. Small sips to start; avoid the overwhelming drink-from-a fire-hose phenomenon.

As John Gaule said, “A complex system that works is invariably found to have evolved from a simple system that works.” Couldn’t agree more.

Keep it simple, stupid? No...Keep it stupid simple.


First posted on HIStalkPractice July 8, 2009.

It is almost a miracle that modern teaching methods have not yet entirely strangled the holy curiousity of inquiry; for what this delicate little plant needs more than anything, besides stimulation, is freedom. - Albert Einstein

A Willing Suspension of Magical Thought

Actors and playwrights know that “a willing suspension of disbelief” is essential for the successful acceptance of any fiction. Such faith allows us to enjoy the greatest of entertainment, be it Samuel Beckett’s “Waiting for Godot” or Matt Groening’s “The Simpsons.” Without a willingness to forego our skepticism and socially inculcated, rules-based orientation, we would forever be ingrained in a world of columns and rows and formulaic drudgery.

This is the essence of “magical thinking.” It allows us escape from our cubbyholed, preconceived mindsets. It enables flights of fancy, free association, and the perception of the possible. It is enabled from birth (genetically programmed?) as evidenced by watching any child at play. It allows us some of our greatest kidhood fantasies and fears. (Think: Santa, Tooth Fairy, Easter Bunny, Boogey Man, and all those monsters under your bed.) Magical thought allows magicians to amaze us and artists to enthrall us.

Unfortunately, that same ready power of mental delusion is what also allows us to believe that politicians really do mean what they say this time, that bankers really can self-regulate themselves adequately, that insurance companies are there for our protection, that technology can solve our healthcare crisis. It permits the fantasy that ARRA money will wind up helping heal healthcare and not just bulking the bankrolls of EHRco bigwigs and bolstering Insco bottom lines.

I love my fantasies as much as anyone. I would absolutely love to believe that information technology will put a period to my pen-and-paper-based problems, end my seemingly ineluctable non-electronic errors, provide instant access to the information I need as I need it, give me gobs of great evidence-based new brain power, and stop the shrinkage of my already skinny sliver of practice profit. However, I am unable to relinquish the disappointing deduction that the current rush toward IT as the “end all, be all, cure all” for healthcare is poorly planned at best and an impending catastrophe at worst.

For those who live and work in highly technical worlds, where the people you see daily are digitally oriented and adept, it is probably not an unreasonable reach to assume all things digital are possible. But, when I drive around my little corner of middle America, I see loads of folk whose electronic skill sets are likely limited to TV remotes and ATMs...at best. Where I work, I encounter colleagues who would love the aforementioned techno-advantages, but who barely have enough time to unravel the mysteries of CPTs and ICD-9s, no less the quandaries of an entirely new EHR-demanded workflow. Where I practice, I live the daily dilemmas of bringing the non-techno-literate along as we endeavor to navigate our way across the digital divide.

In considering this piece, I Googled “magical thinking” which brought me immediately to a great article by

Gilles Frydman with comments and links to related pieces by such HIT notables as David C. Kibbe, Sarah Greene, John Halamka, and e-Patient Dave. Agree or not, all are worth a read, though perhaps the best, from the view of a grunt in the trenches, was a shorty by e-Patient Dave where he highlights the neglect of the everyman in this HIT stampede.

I want this brave, new, digital world for healthcare as much as anyone, but authentic and concrete, with real value for everyone, not just the fat cats and CEOs. Let’s suspend the magical thought and deliver truly “meaningful use” to my neighbors, Joe and Josephina Sixpack, not just the technorati.

First posted on HIStalkPractice June 27, 2009.

Delusions of grandeur make me feel a lot better about myself. - Jane Wagner