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Monday, March 08, 2010

For My Sins...

The push is on to get doctors to use electronic medical systems (current catchy acronym is EHR), and no doubt realizing that it is Lent, and that my soul needed penance, SuperDoc asked me to help him out with his transition.

After much research, which I am now writing up, I must sorrowfully return tomorrow to discuss the very penitential situation with him. The Chief had suggested that I not spoil SuperDoc's weekend by giving him the bad news on Saturday, since the weather had turned.

ARRA (stimulus bill last year) mandated stuff to do with electronic health records. The theory is that doctors and hospitals will get payments based on meaningful use of EHRs meeting the standard. It all sounds so wonderful, as in this industry coverage of a speech:
Dr. David Blumenthal introduced himself to the IT community yesterday in a talk in which he told the story of his first experiences using health IT and shared his convictions about its future.

Speaking to a crowd of thousands for a keynote address at the Health Information and Management Systems Society annual conference, he had the tone of a gracious outsider in the IT community.
“As long we keep the patient as our North Star we will not go astray,” he said.

In giving the history of this first 10 months in the job, Blumenthal reminded the crowd they were involved an experiment that had no equal in the history of healthcare, “or any other industry,” he said.

“It’s a huge and unprecedented ambition,” he said. “No one in the history of healthcare has tried to do something as complicated and difficult and in such a large diverse country with the kind of independence of spirit and professional autonomy that we have."

Of the “meaningful use” plan, he was as positive: “This is the first time I believe anyone has laid out in black and white what it should expect of a modern electronic health care system.”
It was at that point that I cracked and started hurling epithets at the screen. There is nothing patienty-North Star-ish about what is going on, and in fact, one of the main problems is that the regs governing this "complicated", "difficult", "diverse" "unprecedented ambition" which is also an "experiment" have not in fact been written yet.

Any of you who have been involved with this sort of thing realize that conforming to a standard which has not yet been explicated is extraordinarily difficult and promises to be extraordinarily expensive. After a lot of time and money, failure is almost guaranteed. That is why anyone who has a successful track record in IT flees from such projects as if harpies were devouring their entrails. Those of you who have no background in such matters and wish an independent opinion might do well to ask Snarky Mark, who does have this background, and can think. Also see this excellent post at Photon Courier reviewing another grand governmental initiative based on "radical ambitiousness" that just did not work.

This experiment is all the more worrisome because no one has worried about the inherent RISKS of these systems. But they exist. Anybody who gave this half a thought would realize that a hasty adoption of such systems would magnify those risks. But that is our plan.

Word has it that Joseph Heller's "Catch 22" was heavily consulted by those who have been hired by the government to write the regulations and, well, just supervise and makes speeches in a leisurely fashion while collecting healthy and satisfying salaries with excellent health benefits. Dr. David Blumenthal was hired as the National Coordinator for Health Information Technology by President Obama. Bio.He has all the qualifications - including a complete lack of understanding of actual IT, costs, etc. In short, no idea of what is achievable, and the glorious academically accumulated indifference to believe that practical limitations don't matter.

I will later post some of what I am writing up for SuperDoc. I can embed the links and it will be a useful resource later for me, since I am probably going to be spending many gloomy hours hanging out at the health regulatory websites over the next few months.

Good Luck! I mean that sincerely.
I don't mean to minimize your point here, M_O_M, but consider yourself and SuperDoc lucky if there's no criminal penalties attached to these regs. I know far more than I wish to about the effect of CPSIA on children's clothing product development. It's been what, 18 months since that law passed, the felony sentence for infractions has been in place for a year or so, and they still have not "clarified" the regulations so that one can know what might land one in jail!

This wouldn't be so bad if it were possible to conform to the law itself through common-sense best practices, but the law appears to prohibit said common-sense best practices. It's just good d**n luck that no camera-hound District Attorney has decided to make an "example" of some random small-business operator.

I really, truly, don't think they care anymore what effect their laws have outside the DC cocktail party circuit. To the extent they do care, I think they welcome the chaos for the power it brings them. And note that this law was a bi-partisan effort, hardly anybody voted against it. This kind of stuff is why there's Tea Parties, and why the Tea Partiers don't care which party attends their concerns, just that at least one does.
Neil - Your rant is quite accurate, IMO.
If you haven't seen it, MoM, you might "enjoy" my post on the FAA computer system project that was known as the Advanced Automation System.
David - thank you. I have put the link in my post because I think it helps to get the point across to those who do not have this background.
Strangely enough, when I read MOM's post, I thought about the FAA system. I knew it had gone badly, but I didn't know the details. I'm glad David was psychic enough to complete my thought!

Any of you who have been involved with this sort of thing realize that conforming to a standard which has not yet been explicated is extraordinarily difficult and promises to be extraordinarily expensive. After a lot of time and money, failure is almost guaranteed. That is why anyone who has a successful track record in IT flees from such projects as if harpies were devouring their entrails.

Hahaha! Indeed!

I nearly posted a very long rant here about the importance of standards. It became so long that I put it on my blog instead.



"Advanced Automation System"

Oh my. I'm reminded of yet another story. One programmer managed to convince management to let him work on "Generic AI". He had them convinced that artificial intelligence could be black boxed and all our products could use it.

I just wanted to know the answer to one question. Would it be smart enough to snipe me with a sniper rifle AND beat me at chess? If so, maybe I was obsolete. Maybe it could program games instead of me, lol.

I can imagine that there might be some *core* AI functions which would be useful both for sniping and for chess IF there was a lot of domain-specific software wrapped around them. But it sounds like the guy you mention had something much more galactic in mind...

Congress is a decent Generic AI simulator in my opinion.

1. Every decision takes a really long time.

2. http://www.despair.com/meetings.html

Can you imagine what it would be like to play Congress in a game of chess?

"We're getting nothing done. Let's try a new approach. First we'll vote on which piece to move and then we'll vote on where to move it. And no more filibusters!"

Later that day...

"I would be willing to move your state's horse out of harm's way this turn if we could later move my state's bishop out of harm's way next turn."

Hahaha! :)
This reminds me of what happened with CPSIA. Congress passed this grand law in August 2008, in knee-jerk response to the Lead Paint Toy Scare of 2007. CPSIA not only banned pretty much all lead content in everything sold or distributed for children 12 and under, but it also mandated an expensive third-party laboratory testing regime, a labeling system, and a bunch of other stuff. Congress also conveniently forgot to clarify such things as whether used items would have to be tested (at ~$100 per test) before being sold, whether library books could be checked out to children without being tested, and whether the input materials could be tested in lieu of testing the entire finished object. Not only that, but nobody had been able to convince Congress that there are certain children's objects, such as the valve stems in their bicycle tires, that have to contain lead in order to be machined, but are so small that in order to poison himself with them a child would have to roam the neighborhood removing and eating the valve stems from hundreds if not thousands of bicycles. And they didn't consider that some parts of kids' motorbikes have to contain lead in order to meet crash safety standards, e.g. to crumple instead of shattering, so that removing the lead would make the bikes less safe-- the likelihood of crashing being much, much greater than the likelihood of a child licking the fender enough to poison himself.

So Congress passed this bold wonderful new law and patted themselves on the back for how bold and wonderful they were in leading the country into a new era of safety. Oh, and they gave the CPSC and the entire nation six months to work out all the details and implement them (which as everyone knows is a far shorter length of time than the retail cycle). At the same time as retail was in a slump. Oh, and a court decision made it retroactively illegal to sell any soft plastic stuff that hadn't been tested for phthalates, four days before the deadline. And by the way, Congress also passed two other major laws (one of which required some ungodly proportion of the nation's swimming pools to be inspected by the CPSC) that were also to be implemented by CPSC in the same six month time window. Which CPSC also had to work out all the details of. Based on "peer-reviewed science" of course. 'Cause that stuff just grows on trees! Oh, and they promised CPSC a budget increase, but it wasn't going to happen just yet. In a recession, natch.

Result: nobody knew what the hell was going on with CPSIA compliance. Some people went out of business because they couldn't afford what they thought they'd have to do to comply. Others did stuff that turned out later to be a waste of money. People argued about whether CPSC would require permanent tracking labels to be affixed to children's post earrings and how to properly label a set of marbles and whether clothes with rhinestones could be resold at thrift shops. I kid you not. Children's boutiques and resale shops were being very cautious about what they bought, which meant that those of us who supply these things were getting very poor. Some retailers (Burlington Coat Factory, I'm looking at YOU) were asking for retroactive proof of lead testing on everything their vendors had sold to them for years before the law was even conceived and threatening to charge them if such proof was not forthcoming. Many of my friends went out of business entirely because they couldn't survive the chaos this law unnecessarily imposed with its short time frame. Vintage children's books, whose inks stand a remote chance of containing enough lead to be dangerous should a child decide to eat his entire bookshelf, were thrown out by the boxful lest their sale bring the wrath of government down upon them.

I don't like this new trend of Congress waving their magic wands around and declaring It Shall Be So, All You Peons Work Out The Details.
The bad news is the project will never be successful. The good news is there will always be IT work on projects like this.

What winds up happening is people who take pride in doing a good job abandon these projects as fast as they can. That leaves the project staffed with nothing but people who really don't give a damn.
Wacky Hermit...one of the most irritating things about the CPSIA debacle is CongressCreatures who posture about how the "bureaucrats" at the agency are to blame for the problem, rather than fixing their own incompetently-written legislation.
EMRs is something I know a tremendous amount about- tell SuperDoc to use this one.

Way better than the others
David, I hate that too. But you really can't blame them as much as you can Reprehensible Henry Waxman. After all, it's not that much of a stretch to think that a Congressperson who passed a law assuming CPSC would work out the details would be upset when said details haven't yet been worked out. But Reprehensible Waxman wrote an entire book on how if the process of writing a law was perfect, then the law itself would be perfect, and declared on that basis that CPSIA was perfect. I'm not sure on what planet CPSIA is perfect, but I do know that I'm mightily pissed that the only way Congress would then hear of its imperfection is if the Committee on Energy and Commerce decided to have a hearing on it, and that decision lay with its chair... you guessed it... Reprehensible Henry Waxman. Somebody I can't vote out of office and on whom my Congresspeople can have no influence. Talk about your unfalsifiable hypotheses!

Honestly, that's what propelled me into the Tea Party movement. You can't have a system of representative government that's designed to completely ignore the voice of the people.
M_O_M, I work on databases and work with several software vendors in the healthcare industry. Having seen what software vendors write and knowing how easy it would be to get into patient records just by querying the database, the thought of this huge no-direction experiment makes my hair stand on end. To top that off, much of what these vendors write as code leaves a lot to be desired in the area of performance. You can only do so much with poorly written code along the spaghetti of legacy code and apps.

I can just see how much the general public is going to love to be standing at the doctors office waiting on a computer to respond because of all of the overhead of the unknown regulations that have to be applied to their medical information. That is going to be one pissed of North Star. It's already bad enough waiting on the doc at the office let alone their computer system.

And, what docs office can afford to properly set up servers and network and staff to support this ambitious experiment? Can you imagine what would happen if the app that hold the EHR's breaks or is broken into? You have no idea how open some medical records are because vendors do not think about what they are doing. And making something like that secure??...you must be kidding!!!! Who at a doc's office is going to maintain security and make sure that their data is not stolen? How about proper backups and redundancy of these systems?

Just thinking about this makes me want to break out the Jack Daniels to dull the madness. These kinds of projects\experiments with no direction are the kiss of death. No IT person worth anything wants to be a part of one.

-- Army Mom
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