Moving at the Speed of Software

Your company, regardless of industry, is now controlled by software.

People are still the underlying foundation of any company, but the best people can be no better than the software they use to perform their jobs.  You can only move and adapt as fast as your software can move and adapt.  Likewise, if you are building bricks and mortar facilities, they too must be adaptable to the changes in business models that are being driven by the Speed of Software.  In other words, heavy investments in bricks and mortar can inhibit the ability of a company or industry from leveraging the benefits of delivering their products and services through rapidly adaptable software.  I was touring a healthcare organization recently that is building a beautiful new "Cardiology Services Tower" in anticipation of the aging baby boomers and their needs.  The thought that kept running through my mind as I reviewed the plans:  You are building an enormously expensive structure here that will last at least 40-years, but is based upon the old way delivering healthcare, including the relatively new and already outdated notion that a hospital should be a 5-star resort.

The future of all industries is defined by software, not bricks and mortar.  Don't buy software that can't adapt, and don't build buildings that paint you into a corner and that can't leverage the Speed of Software.

The Importance of Disease Registries

This article underscores the importance of using disease registries for proactive management of chronic disease. These registries are not the same concept as traditional disease registries used for reporting to government and public health authorities. These are disease registries which are integral to the day-to-day workflow of patient care and functional use of the EMR. Registries such as this are still woefully under-utilized in healthcare, and should be a standard functional element in EMRs, but yet are a common concept in other industries such as telecom and retail which maintain customer relationship registries based on demographics, buying habits, etc. Disease registries are the first step in creating a standard, data-driven definition for a particular disease, and then proactively managing patients who meet that definition. You can't manage or measure what you haven't defined.

"DENVER – An intensive population management program that matches heart disease patients to personal nurses and clinical pharmacy specialists is able to save lives, reduce hospital visits and drive down costs, according to a new study from Kaiser Permanente Colorado."

Heart Disease Management at Kaiser Permanente Colorado

True Healthcare Reform

I will trust that true healthcare reform has arrived, when doctors stop wearing stethoscopes like a policeman wears a pistol... At the ready, all the time, just in case a violent heartbeat breaks out or a congested lung tries to hold up a 7-11.

That was a friendly jab at my physician friends...like they jab me for wearing a pocket protector.

;-)

Evidence-Based Medicine’s Giant Leap

Cerner and the British Medical Journal (BMJ) have teamed to provide evidence-based medicine (EBM) embedded in the electronic medical record in a manner that is as exciting and encouraging a development in healthcare IT as anything I’ve ever seen — I repeat, as exciting as anything I’ve ever seen. Coming from a noted cynic and critic of healthcare IT, this flash of optimism is a significant change in the wind.

I was attracted to healthcare by the huge greenfield opportunity to apply the lessons I learned in military command centers (the Universe loves irony) about embedded computerized decision support. I’ve been searching for a sustainable piece of grass in that green field ever since.

One of the factoids I enjoy throwing around is the length of time that elapsed before US healthcare providers widely adopted and routinely practiced EBM for the treatment of community-acquired pneumonia —17 years. The Mean Time To Improvement (MTTI) in healthcare is abysmal, but not because clinicians are unwilling to change, rather because the clinicians don’t always know how to change or whether they should change at all.

The BMJ methodology provides clinicians with a trustworthy and convincing source of evidence upon which to justify a change in clinical behavior; and the integration of the BMJ knowledge into Cerner’s EMR gives clinicians an easy avenue for practicing that change in a fashion that can drive the MTTI in healthcare from decades to days. That’s not a dramatic overstatement — this collaborative effort between Cerner and BMJ, and what I hope will be similar efforts in the future, can radically lower the MTTI in healthcare.

As I mentioned in previous blogs, one of my major challenges in this relatively new position as CIO is to squeeze more value — measurable and perceived — from the Cayman Islands’ substantial investment in Cerner’s products. At the same time, we are undertaking a new care delivery model here that looks and feels very similar to the concepts evolving in the United States under an Accountable Care Organization (ACO) and Medical Home.

Among other commitments, our new model (known as CayHealth) is contractually committed to practice and measure EBM. The challenge, of course, is to enable EBM, that is, make it as easy as possible for clinicians to practice true EBM and then measure that practice somehow. This marriage of BMJ’s EBM content with Cerner’s Millennium application suite is an opportunity to do both — derive more value from the Cayman Islands’ Cerner investment, as well as support the imperatives of CayHealth.

Historically, there have been several barriers that were too high for EBM to hurdle:

• Governing the definition and content of EBM
• Updating, maintaining, and disseminating EBM to clinicians in a timely fashion
• Efficiently integrating EBM into the clinicians’ workflow
• Achieving all the above while making EBM affordable

The Cerner-BMJ collaboration knocks every one of these hurdles to the ground.

BMJ’s methodology for defining and maintaining a clinical practice as “evidence based” is Gibraltar solid. Likewise, the clinical content that is developed and governed is not based exclusively upon BMJ articles — BMJ knowledge engineers are collecting evidence from 110 of the premier medical journals across the globe. Their “Grading of Recommendations, Assessment, Development and Evaluations” (GRADE) working group is insightfully well-conceived as a means of removing as much subjectivity as possible from the governance process for declaring a fact to be “evidence.” As I studied in preparation to write this blog, my admiration for what BMJ has managed to organize and achieve kept growing.

While the governance and management of EBM is an enormous achievement for BMJ, all of their work would likely sit on the shelves of dusty Web pages, as is the case with many other sources of EBM in the world today, were it not for their collaboration with Cerner.

Knowledge engineering always suffers from this “And a Miracle Occurs” cloud between the knowledge management system and the computer systems supporting the decision maker. Converting human knowledge into a computable decision-support system for use by another human being is the Achilles Heel of knowledge-based systems, especially in the complex world of healthcare. To highlight only two of numerous examples, rules-based systems are too fragile and Bayesian neural networks too challenging to build and train to support the entire healthcare industry.

Cerner and BMJ found a way to convert the human knowledge derived from scouring 110 medical journals into a format that Cerner can import into Millennium and present to the clinician. This will enable the right decisions at the point of care — the EBM decisions. When you see the presentation of BMJ’s knowledge in Cerner, you’ll probably say the same thing I said — “Is that all there is?” — feeling somewhat underwhelmed. Then, however, you’ll realize, “That’s all we need.”

If you are a Cerner customer and you’re not looking into this collaboration with BMJ, I encourage you to do so. As CIOs and healthcare leaders, we need to nurture and encourage these types of developments in the market.

If you are aware of other similar collaborations between clinical knowledge engineers and EMR vendors to co-develop EBM of this type, please share.

Here are a few reference links for more details:

• BMJ and Cerner Action Sets: http://group.bmj.com/products/evidence-centre/cerner/
• The BMJ Methodology:http://clinicalevidence.bmj.com/ceweb/about/put_together.jsp
• GRADE Scoring of Evidence: http://clinicalevidence.bmj.com/ceweb/about/about-grade.jsp
• Updating and Maintaining Evidence:http://clinicalevidence.bmj.com/ceweb/about/updating-process.jsp

Don't Be Strangled By Process-Improvement Black Belts

In ITIL, we healthcare CIOs are acting in predictable fashion by following the “Most Popular Practice” as opposed to the “Best Practice.” Before we pull the trigger on yet another silver bullet savior of process, I urge all of us to look closely at the contribution of burdensome process in the woes of Toyota…and GE…and Motorola. Try though we might to fix the problems of healthcare IT with rigorous process-- most recently ITIL-- we’re only putting lipstick on a pig.

Fat processes like ITIL will only make matters worse for us until we fix the core issues: (1) Stop buying poorly designed software systems and insist on something better from vendors; and (2) Hire and mentor engineers, computer scientists, mathematicians, and musicians into healthcare IT and stop microwaving nurses, doctors, registrars, and technicians into overnight software developers and IT professionals.

Background
Those of you who know me, know that I’ve admired Toyota for many years, particularly their philosophies of leadership, employee relations with management, Lean manufacturing and the Toyota Production System. My faith in Toyota is taking a beating as I watch it struggle with one recall after another, even though, I’m betting, the problems with runaway acceleration will more likely be associated with driver error than faulty design. We’ll see what the Failure Modes and Effects Analysis (FMEA) team at NASA has to say when they release their report in the next few weeks.

Even so, there’s no getting around the fact that Toyota is losing its edge in quality and innovation—they’ve been out-Toyota’d by Hyundai and Kia. In fact, at the rate they’re going, Toyota is going to be out-Toyota’d by Ford. The root cause of Toyota’s problems is, of course, a tangled web of roots, but I see a common thread that crosses the fabric of other companies across 30 years—and the common thread is Process Overkill.

In the Air Force, I was one of Motorola’s biggest customers for their new products, notably spread spectrum and CDMA networking (but many other radio-based systems as well). I was around when Six Sigma was a Motorola baby — that was in the early 1980s when quality and reliability were more important to the military than product agility and innovation. I thought Six Sigma was the coolest thing around. Everyone thought Six Sigma was awesome … including Motorola … they burned Six Sigma into their hiring, organizational structure, and the DNA of the company.

Then they started believing their own press or, as my granddad would say, started drinking their own bathwater. Fast forward to the mid-1990s, when it wasn’t enough to produce reliable products anymore … you had to produce reliable and innovative products, faster than ever before. Mean Time Between Failure (MTBF) was replaced by Mean Time to Improvement (MTTI) (that’s a Sanders Theory and phrase…so don’t bother to Google it). Six Sigma bogged Motorola down like a Mississippi mud walk, and they still can’t get it off their feet. Motorola might be able to produce a fairly reliable product, but you couldn’t possibly describe Motorola as innovative. They’ve been strangled by the Black Belts of Six Sigma.

Jump to the late 1990s and early 2000s … cut and paste the exact same story at Motorola, then do a global replace with “GE” and “DMAIC”. Jack Welch was to GE what Steve Jobs is to Apple, and without either leader the company identity is completely different. Nevertheless, the weight of DMAIC on GE has them stuck in the mud walk of innovation, too — Jack Welch or not. Drive the time machine ahead to 2009 and do the same cut and paste, but this time insert “Toyota” and “Lean” into the story. Lean’s gone Fat at Toyota and their arteries are ready for a CABG.

In love with their own success and thirst for their own bathwater, Toyota over-applied Lean concepts, creating a bureaucratic environment that squeezed innovation to death (only the Chevy Citation was uglier than the current Toyota Camry), and cultured apathy in their design teams and production lines. Toyota might be salvageable, however, because their leadership still exudes humility and accountability. It’s going to be interesting to watch.

Do you believe for one second that Google’s search engine was the product of a DMAIC session? Or Apple uses Six Sigma or Lean Gone Fat in their product development? You could argue that a dose of better process would have prevented the worm in Apple’s recent 4G antenna problems, but the 4G, iPad, and iPod are the most innovative, best quality products to be produced in the US since the Apollo space program. It’s amazing to me that the 4G antenna problem is the only problem they’ve had in a string of pioneering, revolutionary products. Take away Apple and Google, and the only claim to major, society-wide impact and innovation we can claim in the U.S. since the late 1960s are hedge funds and credit debt derivatives.

The best processes are worthless in the hands of the wrong people. Does a good change-control process in the hands of a bonehead make a genius of that bone? No. Even worse, Processes Gone Wild — such as ITIL, Lean, Six Sigma, and DMAIC — are a disaster in the hands of great people. Good people trump everything. EVERYTHING. But the best people … the most innovative people … will not stick around if constantly force-fed ITIL, Lean, Six Sigma, or DMAIC. They’ll go to work for Apple and Google. The force-fed people and organizations left behind will end up as so much foie grais.

Sip from the cup of ITIL Kool-Aid, don’t gulp it.

DARPA for Healthcare: An EMR Shootout

Building on a recent post about Peter Orszag's resignation, and stimulus funding for healthcare IT...As long as we're throwing money around by the billions...

If I were Dr. Blumenthal, I’d dangle $500M in front of Amazon, Google, Nintendo, Facebook, salesforce, eBay– or any other capable body– and sponsor a shoot out: Build an inpatient/outpatient EMR and financial management system that will rock our world.

In the rush to incentivize adoption and certification of EMRs, there is a commensurate rush to purchase known and “safe” products– the market leaders with typical solutions–and that will be a disaster. Many of the top EMR vendors themselves will tell you behind closed doors that they are not necessarily proud of their products, but they keep selling, so there is no incentive for them to stop producing.

The current HITECH focus on investment in integration is putting the cart before the horse….we need better horses, first. The measurable and sustainable value provided by HIE’s is the reduction in redundant lab tests. That’s as far as we need to go with HIE’s at the moment, and that’s a relatively simple technical solution that the insurance companies offered to providers many years ago, but providers rarely accept.

We are taking on massive federal debt to invest in a crop of mediocre products. Here’s the ironic scenario that I see: Five years from now, when almost everyone is running on EMR products designed around paper charts; and inflexible client-server, message oriented architectures, there will be a new and better product on the market, probably produced in another country, which is better than anything else on the US market… but no one in the US will have the money or willpower to adopt and adapt it for the US, because they exhausted themselves under the current HITECH strategy of Now, Now, Now. Let’s ensure and accelerate the development of that better product in the US and hold-back some funding to make its adoption possible.

We don’t need more medical informaticists. We need hardcore computer scientists and engineers, like the kind going to work for salesforce.com, Nintendo, Facebook, Amazon, and Google. It’s much faster for the supply chain of labor to teach great healthcare to a computer scientist, than it is to teach great computer science to a physician or nurse. No offense to my many doctor and nurse friends, most of whom would agree.

I’m not saying that we will receive no innovation from HITECH. I’m saying we won’t get as much innovation as we need or could, unless we set aside more funding and manage it properly to stimulate true innovation in healthcare IT.

Peter Orszag’s Resignation: Why CIOs Should Care

Before I levy my criticisms on Orszag and the mess that his philosophies will leave behind for healthcare CIOs, you need to understand that I’m as politically liberal as they come. I voted for Obama and celebrated in Grant Park when he was elected. However, while I’m a spendthrift with my money, I’m a tightwad when it comes to spending other people’s money, and therein resides the problem that Peter Orszag created for healthcare CIOs.

Unless we pause now and deliberately change course, Peter Orszag’s economic policies are going to leave healthcare CIOs with a crop of under-performing, over-priced electronic medical records and surrounding products. While Osrzag leaves his current position at OMB to chalk up another score on his glowing resume, his think-tankish, economic behaviorist policies are going to leave the rest of us with a giant mess and healthcare in the US will suffer.

Orszag is the outgoing Director of the Office of Management and Budget under the White House. He was in that position for a very short period—not even two years–starting in November 2008, but in that time frame, drove the economic policies behind the White House and designed the Obama budget, including HITECH funding. His background is as academic as they come– and I would give my right leg to share—Exeter, Princeton, London School of Economics. Orszag believes that healthcare spending is at the root of the US economic meltdown, which may not be entirely true, but I concur it is to a large extent. He was also a key architect in the bailout of the banks and automotive industry. In a recent interview with John Stewart, the non-academic Stewart asked the highly-academic Orszag to explain why more of the ARRA funding didn’t flow directly to the consumer—why must the money pass through the banks first, in the hope that it would eventually make its way into the hands of the average citizen with a failing mortgage? Orszag replied, “Because you don’t want to create an incentive [in consumers] for defaulting on their home loans.” Stewart’s eyes illuminated at the irony and he howled in laughter. The brainy Orszag was caught with his economic pants down.

There are two extremes of political-economic thought—democratic capitalism advocates think that hands-off, free-enterprise business will eventually benefit the populace and world—less government is better. Socialism believes in cooperative ownership and governance of wealth and business, all for the common good—more government is better. It’s pretty clear to me from empirical evidence that neither extreme works, and that the most successful countries in the world today are a mixture of both, with the socialist-leaning horses leading the race by half a length.

I would assert that Orszag’s $19B in HITECH funding, a cornerstone of his strategy for addressing the ever-increasing costs of healthcare, has gone too-far socialist and will strangle the efficiencies and creativity of free-market capitalism out of the EMR market…unless we pause now to withhold some of those funds and invest them– venture-capital style– to seed development of a new generation of EMRs that reflect a new model for healthcare delivery. There are numerous models in government for successfully funding innovation—DARPA is the best example. DARPA takes advantage of government power and free-market ideas, balancing capitalist and socialist economics extremely well.

Dr. Blumenthal—Return some free-market balance to the healthcare IT economic model. Don’t let Peter Orszag’s economic policies drive healthcare IT into the mud of mediocrity for the next 20 years. Withhold some of that HITECH money and invest it in innovation—create a DARPA for healthcare IT please!!