Canadian Healthcare EHR

I participated on a panel at a conference in Canada last week that was thoroughly enjoyable on several levels, including skiing. :-) The conference was an international gathering, focusing on Canada's plans to deploy a national EHR and maximize the secondary use of clinical data for quality improvement and research. I found myself daydreaming, “If I had responsibility for leading the adoption of EHRs and secondary use healthcare data in Canada, what would I do? How would I approach the challenge?” Of course, I don’t pretend to understand the intricate details and issues in Canada which would impact an actual strategy-- but sometimes, naivety in situations such as this, is not a vice. The eyes of the innocent see fewer barriers, prejudices, and biases, I suppose.

These are the thoughts I summarized and shared with our Canadian colleagues:

Leverage the Early Adopters: There are usually three camps of physicians and their willingness to adopt an EHR-- (1) Those that pull technology into their practices and welcome EHRs into the care of their patients; (2) Those who are ambivalent; and (3) Those that strongly resist. I think none of us question whether EHRs will be used ubiquitously, but only question when that will occur in time. If the culture of Canada is not willing to be more pushy about the issue, then simply leverage the physicians in the first camp. Pull them closely into the CIHI/Infoway mission and team. Offer them hard and soft financial subsidies for early adoption of EHRs. Trumpet their adoption and hold them up nationally as role models. Eventually, the ambivalent and resistant camps will either be marginalized and/or acquiesce.

Educate the Patients: Inform and market the value of EHRs to patients by sharing anecdotes of EHR success with them in other healthcare systems, such as Intermountain, Sentara, Northwestern, e.g. Grab their attention first with metrics—e.g., number of avoidable patient deaths and safety events (this was the tipping point issue in America, initiated by the Institute of Medicine Study); cost of their healthcare now vs. later and how that tax money can be better spent on things such as health prevention, primary and secondary education, and the environment. In a recent poll in the US, 87% of patients said that they would be more likely to choose a physician who used an EHR in their practice than one who did not.

Data Tariffs and Financial Incentives: This is harder to execute in Canada, but money talks in healthcare. In the US, the Federal government is rewarding physicians under a “Pay for Performance” (P4P) program in which physicians submit de-identified clinical data in a standardized format to a national data warehouse. This data includes indicators which suggest that best practices in chronic disease management are being followed by the physicians. Technically, an EHR is not required to submit the data. It can be hand-abstracted and manually entered in the Federal database, but realistically, it’s not possible without an EHR. In return for submitting this data, the Federal government provides higher reimbursement rates for treating patients with chronic diseases. This P4P model is not economically extensible—i.e., if suddenly every physician in the US participated, healthcare costs would actually go up due to the higher reimbursements. However, at this stage, it is having an impact, if nothing else, as a portending gesture of the future. There are similar models being adopted and piloted under private payers, too. In the UK presentations, I noticed that they use a tariff-based system, which is a more extensible long term economic model and does not drive up costs. If physicians do not submit their data in a complete and timely fashion, they are taxed at a higher rate.

Physicians, Airline Pilots, and Generational Issues: At one time, airline pilots ruled the airline industry. Flight schedules were actually scheduled around the conveniences and preferences of the pilots. They commanded huge salaries and pensions. It was the most sought-after profession in the US. In 1978, airlines were "deregulated" by the US government, essentially removing the barriers to competition and free market efficiencies. Competition ensued and suddenly the pilots weren’t the tail wagging the dog of the airlines anymore. A few years earlier, anticipating the impending deregulation, Lamar Muse started Southwest Airlines and completely changed the nature of the business. Southwest hired pilots under a completely new set of expectations. The passenger’s value and convenience were the most important priority, not the pilots’. The rest is history. Pilots in Southwest Airlines now participate in any activity, including baggage handling and trash pick-up, which make Southwest more attractive and efficient to the paying passengers. With this new generation of Southwest pilots and airlines, the expectations across the entire industry have changed, though the pain of change is still not over in the older cultures such as American Airlines and Delta. I see the same inevitable events in the case of healthcare. Our medical students and residents have a completely different set of values on issues such as patient involvement in their care plan and patient conveniences, and in particular, the role of an EHR in modern healthcare. I oversimplify here for the sake of dramatic effect, but the younger physicians ask of me, “Where is my EHR?” The older physicians demand, “Don’t bother me with your EHR” (of course there are numerous exceptions to this stereotype, so don't be offended). The younger physicians disdain healthcare settings which are not computerized. They would no rather admit to paper medical records than admit to their friends with iPods that they still listen to 8-track tapes—not cool. Culturally, paper-based records are not an acceptable option anymore to this generation. I think, unless Canada is willing to push the issue harder, you may face a timeline of EHR adoption that requires a generational turnover before rapid progress can be achieved. The cultural and political pressure on US healthcare to become more computerized is much higher than in Canada, I sense, and our adoption rate is ramping up.

The Tao of Buy-In: Sometimes, I would rather be a philosopher than a CIO in healthcare, but reality being what it is, I have to blend the two together in order to eat. When I sense resistance against a fundamentally sound project or idea, rather than increasing my efforts at buy-in, I reduce them. I assume a low-profile, and slowly chip away at the project quietly, while acquiring key buy-in when it comes easy-- but I take the project off the radar screen. Often times I have found that the suspicious side of human nature becomes even more suspicious when attempts to achieve buy-in become more intense. It’s the same phenomenon in romantic relationships, right? Sometimes, the harder you chase and court a mate, the more suspicious that mate becomes that you are desperate for love, and must therefore suffer from some sort of hidden character flaws or dreadful disease which make you generally unattractive to others. As a Taoist philosopher would say: In order to achieve maximum buy-in, be less convincing. Try less to achieve and simply do.

Canada’s Unique Opportunity: Canada is in a truly unique opportunity to achieve in clinical data collection, management, and analysis—more and better than any other country in the world. You are standing at the brink of opportunity in which you can apply all the right and wrong lessons from other countries to achieve incredibly more effective solutions. You have the culture and the economy to do it right.

Engage the Employer Groups: Ultimately, as I mentioned in my presentation, the employer pays for either good or bad healthcare in the form of a productive—or unproductive—workforce. Employers know this, too, but struggle for a place to gain a foothold of influence, I suspect. Reach out to them from CIHI and Infoway. Look for opportunities to work directly with employers to flex their economic muscle and engage physician adoption of EHRs and secondary use of healthcare data. I need to learn more, but it sounds as if you have a model of this in Group Health?

Leverage and Publicize Early Victories: There are clearly pockets of success in Canada. I heard numerous stories. These stories need to be collected and publicized—treat them like a commercial marketing plan or a political campaign strategy.

Make this a National Issue: I agree that a national EHR will not likely reelect a Prime Minister on its own merits, but it can play a major role. In the US, the voting population is disillusioned with the high cost and the poor quality and safety of healthcare. The populace is also, now, reasonably well-informed about the poor state of computerization in healthcare and how EHRs and secondary use of data can help reduce costs while improving quality. Numerous news articles in print and TV have helped enormously with this education. As a result, computerization of healthcare in the US is now a nationally recognized issue and a major part of every political campaign strategy. The topic of EHRs in healthcare even made it into President Bush’s State of the Union speech last night. With the right sense of Federal charisma, leadership, and education of the populace, Canada can make this a national issue and push the adoption of EHRs along faster. Access to care will, in fact, improve over time with the expanded utilization of EHRs in Canada. As the population’s health is better managed, patients will place fewer demands on the bottleneck areas of providing care.

A Poem Wrapped in a Song

Below are the lyrics to a poem/song by a band named “The Call.” The name of the song is “Let the Day Begin” and I think it came out in the late 80s or early 90s. I had heard the song many times before and appreciated the lyrics, but I never REALLY appreciated the words until I heard the song played in Denver during the Procession of Survivors at the Susan B. Komen Race for the Cure against breast cancer in about 1999. To see my sister Darlene and all those women, of every age and demographic… their smiles and tears… the tears and smiles of their families… hands waving, smiles smiling, flowing into the park by the hundreds… a river of pink…and these lyrics were playing in the background… you could feel a collective sense of fear overcome by courage… yet the fear still lingering slightly, gone for this moment in the sun…the joy overcoming sadness for that tick of the clock. The lyrics took on a new meaning. They move me deeply still, and now when I hear this song as I did this morning, I think of it in yet another way, as Darlene with Gary-- afflicted with Lou Gehrig's Disease-- face another moment of fear overcome by courage, sadness overcome by joy, uncertainty clarified by comfort.

Life’s a big adventure… :-)

DRS
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Let the Day Begin

Here's to the babies in a brand new world
Here's to the beauty of the stars
Here's to the travelers on the open road
Here's to the dreamers in the bars

Here's to the teachers in the crowded rooms
Here's to the workers in the fields
Here's to the preachers of the sacred words
Here's to the drivers at the wheel

Here's to You my little loves with blessings from above
Now let the day begin
Here's to You my little loves with blessings from above
Now let the day begin, let the day begin

Here's to the winners of the human race
Here's to the losers in the game
Here's to the soldiers of the bitter war
Here's to the wall that bears their names

Here's to You my little loves with blessings from above
Now let the day begin
Here's to You my little loves with blessings from above
Let the day begin, let the day begin, let the day start

Here's to the doctors and their healing work
Here's to the loved ones in their care
Here's to the strangers on the streets tonight
Here's to the lonely everywhere

Here's to the wisdom from the mouths of babes
Here's to the lions in the cage
Here's to the struggles of the silent war
Here's to the closing of the age

Here's to You my little loves with blessings from above
Now let the day begin
Here's to You my little loves with blessings from above
Let the day begin

Here's to you my little loves with blessings from above
Let the day begin
Here's to you my little loves with blessings from above
Now let the day begin, let the day begin, let the day start

Services Oriented Architectures

While I’m thrilled to see SOA momentum, my cynicism tells me that many of the headline grabbing initiatives in health care are poorly conceived, based upon what I’ve read and heard from those involved. I see a gold rush to SOA in health care, but many people still don’t “get it” when it comes to fully grasping SOA concepts. Ironically, we are over complicating the basic software engineering issues and overlooking the simple lessons-learned from previous similar frameworks and building blocks like JCL, DCE, RPC, OOP, CORBA, and COM. More than any other point, I emphasize that SOA concepts are not new, nor revolutionary. They are very much evolutionary, and the more we in the health care industry understand about the history of events, methodologies, and technologies which preceded the current attention on SOA, the more likely we are to be successful and avoid the mistakes of the past. Kevin Chamberlain in Harvard Business Review On-Line wrote: “Leaders often fail to consider history because they have an unhealthy sense of their own uniqueness, and they have a sense that the events around them are 'peculiar' to their time and therefore history is of little value.” I see young and inexperienced software engineers and marketing representatives from vendors who tout the heroics of their capabilities in SOA, yet can't answer basic questions like:

• What led to CORBA's poor adoption rate?
• Which companies have grasped the essence of SOA and are leveraging it best and how?
• How do you balance fine and coarse granularity of services in an overall design strategy?
• What principles of granularity have you developed for your software engineers?
• What's the value of UDDI in a smaller organization with no intent to publish?
• How does an entire industry manage UDDI without the content imploding over time?

One of the most important and first SOA steps in health care is simply the development of a semantic list of services and the basic API's for services associated with our industry. This exercise is equivalent to defining the message types in HL7, but at the software services layer, not the messaging layer. To use another metaphor, think of data modeling at the software services layer. I believe HL7 is the best governance organization for this new "SOA Standard" to reside, but I'm not encouraged by HL7's embrace of or progress on the topic so far. I'll keep my fingers crossed.

I was a chronic agonist to my friends and colleagues at Intermountain Health in the late 1990s about this topic. Arguably, the failure of our relationship with 3M and the Care Innovation Suite can be traced to a poorly designed services layer. In 1998 or 1999, we finally held a retreat at the local Marriott and documented the list of core software services, and their behaviors, which would define a future path for our development efforts. I'm not sure what happened to that list-- I would love to have a copy-- but the 3M relationship was eventually replaced by GE, and the development of the 3M services fizzled. I hope the current development agreement between GE and Intermountain has somehow resurrected those core services, at least conceptually. Developing the list of services does not represent a "rocket science" endeavor. It's a day-long affair with a handful of bright people who understand software engineering and healthcare processes. Iterative improvements on the list will go on forever, but getting started is not that complicated.

Anyway, the bottom line is: We are transitioning from a "buy and maintain" to a "buy and develop" culture at Northwestern and we plan on making tangible progress with our SOA in 2008, but we likely won’t be looking to any of the early headline leaders in health care for positive role models unless I see a greater appreciation for the history that got us here.