High Tech people are very enthusiastic people. We are optimistic, confident and creative and if I may be allowed to say so, really, really smart. We start out by saying “Hello World!” not “Hi, I’m Jack or Jane”. We hail the entire Universe and assume it knows who we are, or that it will soon find out, because the sky is not the limit and we are going to change the world, all at once. We don’t wear pocket protectors or duct tape on our spectacles. We wear defiantly baggy clothes; have tattoos and piercings in all the right places, ride motorcycles and listen to the latest music. Actually many of us are former or part-time musicians, or at least dabble in painting, spiritual philosophy and sometimes even a little writing. We don’t make telephones or missiles or coffee makers, but we make your phone smart, your missile guided and your brew master programmable. We solve problems and sometimes we get carried away.
Back during the heyday of the Certification Commission for Health Information Technology (CCHIT), a grumbling sound began to emerge from the medical community moaning and groaning about the Big Boy EMRs certified to meet CCHIT’s standards. Those who underwent the onerous CCHIT certification process which began in earnest in 2006 were said to be nothing more than “bloatware”, expensive, cumbersome and useless software developed by programmers who know nothing about the practice of medicine and forced on physicians by an emerging semi-governmental effort and greedy, unscrupulous EMR vendors. This of course gave birth to the most ridiculous slogan in EMR advertising: built by doctors for doctors. Every fledgling new entrant to the EMR market and every retrofitted DOS program with less functionality than Microsoft Office seemed to have been built by doctors, presumably by the one MD usually introduced at the beginning of the “About Us” inspirational story. Obviously there were some true stories too, and some MDs ended up specializing in C++. The CCHIT wars have ended and even the great CCHIT era crusader, Dr. Al Borges, seems to have gone silent somewhere around 2010, but the notion that EMRs, or EHRs now, are falling short of expectations because they were built by programmers has become a widely accepted “fact”.
Very few products successfully sold for mass consumption are ever built by end users, software included. A retrospective look at the EHR market would indicate that regulations and certifications and now also incentives and penalties were applied too soon in a normal market cycle. EMRs were never allowed to evolve, just like any other product, based on user preferences as manifested in buy/no buy decisions. Try to imagine what would have happened to the cell phone market if during the first years of its existence someone would have mandated, for quality and consistency reasons, that the antenna should always be on the left side and it should be between 1” and 2.4” in length and no less than 0.25” in diameter. And then the Department of Motor Vehicles in collaboration with the Department of Homeland Security and Motorola would have provided everybody with a hefty tax deduction for buying a certified cell phone. It wouldn’t have mattered much who actually built those cell phones. Since High Tech people are more enthusiastic than most, we are now not only fixing in amber the size and shape of our software product, but also endeavoring to prescribe how it should be changed and how it should be used. To use the early cell phone analogy, we are standardizing the button sizes, adding a 911 auto dial button and mandating users to push that button after an accident if they want Progressive to honor their claims.
ONC is short for the Office of the National Coordinator for Health Information Technology. It is the highest office in the land for High Tech people working in health care, and enthusiasm should probably be its middle name, rainbows, stars and all. ONC is not really writing EHR software, but from its high perch it is guiding programmers on what to build, in what order to build things and recently began dabbling in advising on how to build EHRs. Many veteran EMR programmers weary of the built-by-programmer vs. built-by-doctor fight are probably breathing a sigh of relief right about now, because customers, who don’t like what they see in the product, can now be redirected to log their complaints with the powers to be at ONC. Fortunately, for every veteran EMR programmer laying down his arms, there are dozens of brand new and experienced High Tech people enthusiastically answering the call to arms for solving the national crisis posed by our health care system.
Old EMR programmers assumed that they know nothing about medicine, and although believing that doctors are equally ill-equipped to architect software, programmers recognized that doctors are their customers and mighty tough customers at that. EMRs were a tool & die business, something one sells and another buys, if needed. The new and very enthusiastic High Tech people in health care, unburdened by any previous EMR scars and bruises, have a different mindset (or so they say), most likely brought about by ONC’s very successful public relations efforts. EHRs and Health IT in general are now a cause, something you advocate for, something you believe in, something you write about, something to be fostered, promoted, or adopted. Health IT is an ideology. Health IT is a political issue that should support governments. Health IT is a social issue that should reduce disparities. Health IT should change medicine as we know it. Well, not that we actually know medicine in the classic meaning of the term, but we just know better in general.
After all, we changed the world already. Just look at the Internet. We have no money to buy books, but we have Facebook. We have no food to speak of, but we have democracy in Egypt. We can’t afford tuition, but we have Khan. We have no jobs, but we have passionate blogs and tweets that reach billions in an instant. We make no saleable products, but we can market with laser accuracy. We have no money for doctors, but we have Google. We have no friends, but we have Siri to keep us company in big old empty houses. We have no worldly possessions, but we own the world of Zynga. We have no clue, but we have data. We can do the same for medicine. We can make it virtual, free, fun, engaging, personalized, simple, participatory, democratic, pain-free and expertise-free. We don’t know what DNA stands for, but sequencing the genome sounds like something we can write software for. We don’t care if observations are prospective or retrospective, as long as we have plenty of data points. We feel strongly that double blinding something is cruelly medieval, in an age of transparency and visibility. We have created a world where babies can manage hedge funds, lizards can sell insurance, everybody can run an agribusiness and every barefoot, malnourished child in Rwanda has a fair shot at the Nobel Prize. We can fix health care once and for all, and we know exactly how to do it.
“There were two men in one city: the one rich, and the other poor….. “
(II Samuel 12:1-12)
Thus begins the story of King David’s punishment for robbing a simple man of his life and of his one beloved wife. I have had the incredible fortune of being taught the Bible in the City of David, probably a stone throw away from where he perpetrated a sin that haunts his people to this very day. I was taught the Bible not as a divine text, but as a political, historical and philosophical manuscript written by ancient sages, and David’s story was not about the perils of philandering. It was about the disastrous results of social injustice. The story is not a Socialist manifesto. The Bible in its entirety accepts the fact that there are rich men and poor men and David was not admonished for not redistributing his riches equally amongst the poor. The line of decency is crossed when the rich and powerful wantonly decide to take away the poor man’s “one little ewe lamb”, not to love and cherish as the poor man and his family did, but to carelessly slaughter and serve at some casual meal. The predicted future for such rich men and for their people is that “the sword shall never depart from thy house”. Of course, this is just a story, but over the thousands of years since Nathan the Prophet delivered his indictment, many nations and great kingdoms came to experience gruesome violence and ultimately collapsed due to excesses of the rich and powerful, and careless disregard for basic social justice.
Today, America is taking the first step towards joining the pantheon of cruel nations doomed by history to crash and burn. The Grand Old Party of Abraham Lincoln, who went to war with itself to rectify social injustice, is asking the American people to elect the Romney/Ryan pair to the highest offices in the land, based on their solemn promise to hunt down all remaining little ewe lambs of the poor and serve them up butchered and dressed as an afternoon snack for the rich men they represent, because the only way for poor people to survive and avert the wrath of the rich is to make the sacrifices necessary for feeding the rich men’s insatiable appetite for tender shish-kebab.
I am not an economist or a financial expert of any sort, and I have no appreciation for the fine differences between long term and short term capital gains, or the multitude of tangled terms used to obscure intended and unintended realities from common folks who have not experienced any type of gains in half a century. I am perfectly willing to accept the obvious fact that the US is spending more than it’s making and that we must make more and that, at least temporarily, we must tighten our collective belts. The Romney/Ryan notion of fiscal responsibility is placing the rich folks, each with his own private belt, at the soft center of the beltless masses of poor people, all surrounded by one national belt, which is to be tightened at the same time as the epicenter of wealthy individuals loosen their belts by a few notches. The incredibly well calculated idea is that the circumference of all of us can be reduced while the wealthy center is actually increasing its girth. Millions of faceless and nameless poor people will of course suffocate to death during this geometric wizardry if allowed to proceed, but the captains and titans in our midst will thrive, and promise to eventually share a bit of their good fortunes with the surviving cannon fodder in their immediate vicinity.
If you are one of the fewer and fewer citizens who are not poor, and if you think that when the Great Republican belt tightening exercise commences, you could wrestle yourself a cozy place close enough to the center to allow you to keep your belt where it is today, or if you’re lucky maybe even relax it a notch or two, while shielding your eyes and ears from your neighbors getting crushed at the periphery, remember that this great nation was created as “one nation under God, indivisible, with liberty and justice for all”, and God has spoken on this matter over five thousand years ago, and regardless of your beliefs, history is teaching us that nothing that was built on social injustice and “that which is evil” can stand for very long, and no matter how many fortunes were bestowed on a man or a nation in the past, once “the poor man’s lamb” is not safe from the selfish greed of the rich and powerful, sooner or later calamity always follows.
The 2012 Presidential election is not about different fiscal approaches to the national deficit. It’s not about efficiency of private markets as opposed to incompetence of public solutions. It’s not about health care or Obamacare. It’s not even about gay marriage or abortions. This upcoming election is unfortunately about politics as usual versus sheer evil. And it is your decision to make on November 6th. Please vote.
Like most home buyers, I toured the house with my family, checking closet space and bathtubs and finally descended into the basement to see if it has any potential. It was a very large and dark basement mostly unfinished, but the scene in front of us was breathtaking. Thousands of glass jars and bottles of every conceivable shape and color, sparkling clean and neatly stacked in groups by size and shape, some in small pyramids, on a myriad of shelves, small tables and wooden crates. There were no labels on any of them and there were no tops. The ex-Marine Sergeant who built the house in the fifties and lived there ever since, must have spent a lot of time cleaning, processing, sorting and arranging glass containers for what seemed like an awful lot of years. Why did he do that? What did he see in those glass mazes he built in his basement? I never found out. We bought the house almost eight years ago, and had a “guy” come by and remove everything that was not nailed to the walls before the painters and floor refinishers showed up. Sgt. C.’s big collection of empty glass shells ended up as Big Trash, because although empty containers may hold certain fascination, particularly for those who lived through the Great Depression, there is absolutely nothing useful you can do with a basement full of glass.
We as a species are now collecting data. We’re not sure exactly why or how we’re going to use it, but we are convinced that we cannot, should not, discard any electronically recorded piece of information. You may clear your browsing history on your own computer, but somewhere, somehow, someone retains that information. You may delete all your text messages from your own phone, but they may still exist in some database somewhere in some cloud. You may delete your old emails, but somewhere there will still be a record for them. Your tweets, your Facebook messages, all other social media participation, every syllable you ever typed and every tag or image you touched, all these things are being neatly catalogued and stored in some data basement somewhere. And now we have apps that most of what they do, other than show you that cheesecake has more calories than turnips, is to collect even more bits and pieces of information and add them to that big basement in the sky.
Previous generations of human beings created as much data as we do. They shopped and traveled and engaged in conversations. They kept diaries and every single one ate, slept, walked, breathed in and out, had a heartbeat, loved and hated things, experienced profound happiness and despair, and when all was said and done, discarded the containers of life without a second thought. We are the generation of the Great Information age, and just like Sgt. C. we feel compelled to keep everything that was scarce and hard to come by only a few years ago. We talk about treasure troves and are so very certain that all those mountains of carefully scrubbed and meticulously arranged pieces of information will yield some miraculous result any day now. And if it’s not clear what miracle exactly, that’s because we need more data and we need to arrange it in other ways. I wonder if Sgt. C. was consciously shopping for foods packaged in glass containers, just so he can add another shiny piece of the puzzle to his collection.
I’d like to imagine that when Mrs. Sgt. C. whipped up a batch of her famous tomato sauce, she would stroll down to the basement and pick a nice jar to store the sauce in, or when Sgt. C. brought her flowers for her birthday, she would pick the nicest blue glass container to put the fresh daisies in. She probably never had to buy those ugly plastic Tupperware things either. There was some utility in Sgt. C.’s glass collection, but did it really warrant giving up an entire basement and countless hours of maintenance work? There is some utility in our big data collection too. When we need to sell tomato sauce or flowers to people, we can dig through our data basement and find just the right message and the right people to send that message to. Today’s Mad Men need not be as “creative” as Don Draper had to be in order to increase sales and profits for clients.
If Sgt. C. could have collected all the glass jars in the world and if he could have shared them with all people in this world, nobody would have needed to worry about storage for their secret recipe potato salad ever again. If we could listen to, collect and analyze every heartbeat in the world, we could instantly identify impeding disaster, and correct the problem. We could be saving lives judged worth saving. If we could know in real-time when people are sad, we could make them happy in real-time. If we could know in advance which people would become ill and exactly when, we could tell them and maybe treat them if it made economic sense. Eventually, we could ensure that all our babies are born healthy and with proper monitoring live long, productive and happy lives.
Mrs. Sgt. C. died at the turn of the new millennium, and Sgt. C. died a few short years after that. He never knew what eventually befell his glass containers collection. I am grateful for that. Perhaps if someone other than us would have bought his old house, those beautiful glass jars would still be there today and perhaps more would have been added. Perhaps a pattern would have emerged and something great would have happened. But it did not because I trashed his life’s work. We will most likely all die before our collection of digital shells of life will yield any benefits or alter the definition of humanity in any significant manner, and we will never know if our data basements will be preserved or relegated to the Big Trash pile. I am grateful for that too.
Dr. Gawande has a new article in the New Yorker suggesting that hospital chains may very well be the solution to our health care problems. Dr. Gawande has a very engaging writing style and in addition to writing for the New Yorker, he writes books and delivers memorable speeches and he is also a surgeon at Brigham and Women’s hospital in Boston. In recent years, Dr. Gawande’s writings have become the cornerstone of health care policy and none more so than his 2009 New Yorker article explaining the inexplicable health care cost explosion and the variability of medical expenditures across the nation. As the New Yorker itself proudly noted, President Obama himself had a most fortuitous epiphany after reading the New Yorker article, and summarily decided that “This is what we’ve got to fix.”
In “The Cost Conundrum” Gawande explored the differences in expenditures for Medicare beneficiaries in two Texas towns whose names became synonymous with our health care issues, the expensive McAllen and the rather cheap El Paso, concluding that “across-the-board overuse of medicine” induced by “a culture of money” was the root cause for the “extreme” expenditures in McAllen. The article, accompanied by an illustration of a patient dressed like an ATM machine, quickly became the foundational axiom at the base of health care reform efforts, and Peter Orszag (the then OMB Director) immediately adopted this axiom and translated it into hard dollar amounts: “The result is an estimated $700 billion a year spent on health care that does nothing to improve patient health, but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful – not to mention wasteful.”
One could identify here the beginnings of the currently undisputed rhetoric about a 30% waste in health care, the associated slogans of “more care is not better care”, “pay doctors for value not volume”, and the need to rein in greedy doctors who are knowingly harming patients to enrich themselves through the unfortunate fee-for service payment model. It didn’t matter much that respected researchers like Drs. Robert Berenson and Jack Hadley from the Urban Institute repeatedly disputed the findings of the Dartmouth Atlas on which the Gawande axiom was based. It didn’t even matter that Medicare itself came up with different numbers which show that McAllen is not really that expensive after all. Once the President decided that “this” is what we’ve got to fix, by golly “this” is what we are going to fix, whether it needs fixing or not.
Next Dr. Gawande turned his attention to learning from other industries and applying lessons learned to the troubled health care system. The first such industry was Agriculture, which has come a long way from “strangling the country” at the turn of the 20th century to today’s seemingly bottomless pit of cheap, genetically altered, antibiotics, pesticides, preservatives and other carcinogens laden foods, produced by sub-minimum wages illegal immigrants, and pushed by vertically integrated agribusinesses to every supermarket and every 7-11 across the land. Dr. Gawande is crediting this major development to Government intervention in the form of local extension services to diffuse experimental technology innovations to uneducated and initially resistant farmers, and to various assistive regulations. He sees a similar experimental approach being taken by the Affordable Care Act (ACA) and is hopeful that current health care initiatives will have the same beneficial effects as observed in agriculture.
Aviation with its almost perfect safety track record was the next industry to attract Dr. Gawande’s attention. The checklists used by pilots in commercial aviation seem to have some applicability to medicine. Although checklists were used by others with great success in health care, Dr. Gawande published an entire book on the subject and called it a Manifesto. Next came the race car industry, and in a commencement address at the Harvard Medical School, Dr. Gawande informed the class of 2011 that medicine needs them to be “pit crews” instead of traditional “cowboys”. I don’t know if Dr. Gawande watches too many John Wayne movies or too few car racing events, but old-time cowboys, although versatile and capable of performing many tasks, always worked in coordinated groups of various sizes and compositions, depending on the size of the outfit that employed them. By contrast in a pit crew, one member’s responsibility, which is strictly defined by regulations, starts and ends with the left rear lug nut even if the entire car is on fire. Despite the poor choice of words, the message is the same: standardized, repeatable protocols of care delivered by “medical systems” are superior.
In this month’s issue of the New Yorker, Dr. Gawande takes the systems approach to its logical conclusion. We need Big Medicine. We need chains of hospitals and clinics. Big chains, like the Cheesecake Factory. It seems that health care can also learn from the restaurant industry or retail in general, since CVS and Walmart are also fondly mentioned in the article. According to the story, Dr. Gawande and his children had a lovely dining experience at the local Cheesecake Factory establishment, ergo chain restaurants when managed well, can deliver a fantastic culinary experience for a rather affordable price. Of course, we all know that there are hundreds of other chain restaurants that cannot, and Dr. Gawande himself seemed very protective of his reservations at Per Se, but maybe the reason the Cheesecake Factory is so successful is the automation and team approach to food preparation. No Iron Chefs here. A well-oiled (no pun intended) machine of managers and sub-managers and workers at various stations of cooking, cleaning and learning on the job, eerily similar to pit-crews, each responsible for a prescribed piece of work, manage to create in aggregate a consistently repeatable faux upscale dining experience for people who have no idea what Per Se is.
Exploring the excellence of chain establishments is not unique to Dr. Gawande, although he may have just turned it into official policy. Similar arguments were made recently by Dr. Peter Pronovost, comparing health care to the exclusive Capella hotel chain, an offshoot of the Ritz-Carlton glitzy chain, and reached similar conclusions. One could wonder how these learned essays would address what most people recognize as hospitality chains, such as Applebee’s, Chili’s, Holiday Inn or Motel 6. One could also observe that anybody with no particular credentials could open a restaurant or a Bed-and-Breakfast, or work at such “one-of-a-kind” place, just like there are no particular education and licensing requirements for working on a farm or for becoming a cowboy. A very interesting experiment would be to require that each mom-and-pop restaurant should have a Parisian Cordon Bleu graduate in order to open its doors, or that every Bed-and-Breakfast would need a Glion graduate on staff. I wonder if in that case, anecdotal evidence from hand-picked hospitality chains would still compare favorably to the one-off little establishments. I suspect not.
Dr. Gawande is proposing that medicine should become Big Medicine and doctors become broiler “chefs” with a computer monitor controlled by “headquarters” hanging above their “station”, or perhaps we don’t even need those super educated doctors and scullery maids can work their way up to “management”, just like his protagonist in the New Yorker story did, because he knew of no other place where he “could go in, know nothing, and learn top to bottom how to run a business”. They used to teach medicine that way before we had medical schools too.
So based on one dining experience at one chain restaurant, “liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight”. Just like we had to accept the growth of Big Farms, Big Banks, Big Automotive, Big Retail and Big Corporate everywhere, all with strong lobbying oversight and strong public subsidies and bailouts as necessary, and a slowly evolving definition of quality to mean cheap enough to keep the nouveau poor from jumping out of the experimental pot of boiling water.
If you are a Primary Care Physician and would like to express a thought, an opinion or describe an experience, this blog page is at your disposal. It could be a short note, a long dissertation or anything in between. Write it down and email it to me. It will be promptly posted here as is, unedited, uncut and anonymously if you so desire. You can send one or as many notes as you need. All are welcome!