Why is Health IT so hard?
December 28th, 2008 andrewEvery now and again someone decides that health IT is obviously doing something wrong and they are going to fix it. This is a familiar call, often made by well meaning bureaucracy and its part of the problem and not part of the solution.
Health IT is hard and its become much harder with the involvement of well meaning bureaucracy. They often regard (and even refer to!) health it people as a bunch of “nerds”. If only there were more nerds and less bureaucracy we may be further ahead. Yes it is possible for the banks to have ATM machines working in a global sense and interoperating but they are only adding and subtracting figures from a balance and tolerate a fair bit of fraud as part of the cost. I am sure it all we wanted to do was maintain long term records of patients blood pressure and have this interoperate, with low levels of security it could be done quite easily. If we did this for the same transaction fees as the banks charge for ATM transfers there would also be a funding model!
Health IT is hard because the problem that we are trying to solve is huge, changes rapidly and cannot be modelled completely at any one point in time. It also rightly needs to be done with a very high level of security and even low levels of fraud and security breaches are intolerable and cannot be assigned to an “acceptable level of fraud” – which is what happens in the banking industry. It is also either starved of funds or funds are wasted in large treasure chest sized amounts by giving it to the large corporate software pirates who conduct yet another study or review the “state of the art” and sail on to their next victim.
Meanwhile standards bodies try and pull together workable standards with volunteer labour and laughable budgets. The standards meeting have also been invaded by bureaucracy and modellers with the “nerds” having been left at home.
What health IT needs is an army of smart technical people (ie nerds) and smart clinical people who can get together and actually try and pull together the technologies needed to make it work in the real world.
As the guardian of a million lines of very technical HL7 orientated source code I am acutely aware of the difficulty of the problem. Medical-Objects has some top class technical brains at its disposal but you know that even with someone who is exceptional you have to try and partition their problem space off to a small subsection and do a lot of hand holding if you want any useful work done. It takes years to get a top class technical person to see the whole picture as it’s all interlinked. They may be a database/internet/user interface guru but to make it work together a lot of balls need to be in the air and aligned at the same time. Any model needs to be serialiseable in HL7, security and digital signatures/authorisation appear at all sorts of levels. The model has to support not only the HL7 model but also the Snomed-CT model and this model has to be addressable by the GELLO code in a standard way. In many cases the number of patient/records may be huge so performance issues are critical and it has to operate in a secure distributed fashion in software environments that are totally uncontrolled and often unreliable. No matter how well you model it it will have to go to systems that are quite basic so it needs to gracefully downgrade to a simple text document on demand. At some point a dicom image might appear so this needs to be supported as well. Finding people who can function over a landscape dotted with landmarks like HL7, Dicom, PKI, GELLO, SQL, XML, XML-Schema, SOAP, HTTP, HTML, RTF, SNOMED-CT, Archetypes, BNF, RDF etc is no small task. Then of course you have the clinical knowledge that is so vital to build systems that are actually useful. This clinical knowledge is changing and variable, and sometimes contradictory between institutions.
Meanwhile the bureaucracy is being wined and dined by the salesmen of the latest wizz bang technology and engaging well dressed consultants to come up with a plan… Working proven scalable technologies must be replaced by new unproven and less scalable technologies… Of course these plans fail, and the whole process restarts with a new bureaucracy who go through the same process yet another time.
Its time they actually looked at working Health IT technologies and tried to emulate them. Pathology has been delivering electronic results for over 10 years. The system would not cope if they did not. The quality is patchy but it works and there is lots of room for enhancements. This has been done without any significant government handouts. Australia has standards in place that could be enforced, but no one seems to have the balls to do it. If the government wants to throw money at it then they could reward the use of standards, standards that we know work and not some “almost ready” latest greatest thing that is unproven. It is impossible for the government bureaucracy to come up with their own new “standard” and possibly have it work, its just to hard to get it right until you have been doing it for 10 years and even then you get it right a little bit at a time. Organisations such as NEHTA need about 10 years to actually get their finger on the pulse and government can’t see that far ahead. They also need 10 years of actually trying to make it work rather than 10 years of whiteboard scribbling. They need to be highly concerned when “nerds” who are making some things work actually disagree with their plans and alas this is not the case! NEHTA needs to become a promoter and enabler of proven standards and a funder of standards work and true R&D, it cannot “solve” the problem on its own and unless they feel totally across all the acronyms above they should not be trying.