Monday, August 20, 2012

Curb Your Enthusiasm…

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.

“Hello Health Care!”


  1. 'nailed it' Margalit!

    As I tweeted:

    We have no clue, but we have data....' via @margalitgurarie >> Don't you just love event horizons beyond 6 months ago!

  2. Great post.

    I'm more than willing to give the High Tech people a break. It's actually people with M.D. behind their names who have grotesquely over-stated the immediate and long-term benefits of HIT, throwing evidence to the winds. They're the ones who have turned HIT into a faith-based initiative, and have done tremendous damage to health care in this country.

    1. Thanks, southern doc.

      I think we are all at fault here. Those who want profit, those who want fame, those who choose not to listen, and also those who choose not to speak up.
      You may recall my pet peeve with practicing physicians not organizing themselves... :-)

  3. Excellent post. Thanks for the share. Analyzing Healthcare data must be given first priority.