Infrastructure

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who

Rudyard Kipling, 1865-1936
The Just-So Stories (1902), The Elephant’s Child

What – Infrastructure is an organizational term referring to the system by which a company or a practice is organized and the services and facilities are present that are necessary to carry on economic activity. The terms “infrastructure,” “critical mass, ” and “scale” are sometimes used interchangeably.

Why - Because “infrastructure” appears often in the health care literature, as in, “ Solo and small practices lack the infrastructure to compete in a managed care environment.” It is seldom mentioned that these practices, making up 80% of all practices, are the infrastructure that make health delivery possible.

When - The term “infrastructure” is most often cited in two situations: 1) the necessity for installation of electronic medical record systems and other software as essential tools to make medical practice more efficient and safe and capable of documenting every clinical act and satisfying every payer and consumer; 2) common complaints among physicians that they do not have resources to document every transaction and satisfy everyone outside their practice, negligible or negative return of investment of EMRs , lack of clinical relevance of current EMR systems, and loss of productivity with EMR use.. The prevailing belief is, however, even among physicians, that sooner or later, all physicians will practice on Internet time using multiple information technologies. .

How - The most common ways of introducing IT and meeting stringent infrastructure requirements are to persuade partners and staff that IT is necessary to grow and thrive, join or build a larger group, wait and see if financial incentives from payers evolve to justify the investment, forget about it and become a hospital employee, or retire. A common belief is that bigger infrastructure requires a bigger superstructure; though a few IT physician pioneers have shown they can practice with smaller staffs.

Where - Infrastructure building, also known as overhead expense expansion is going on everywhere, large practices and small, hospitals large and small, and investment therein is difficult because expenses are rising at 3-5% per year, while revenues are flat or dropping. Pressures are building to become electronically connected to payers and consumers so all transactions and clinical acts will become transparent to all. The problems are two fold: 1) most infrastructures don’t talk electronically to one another; 2) most doctors and patients don’t trust current privacy, personal, and security protections, or indeed, total transparency and electronic tracking of all human interactions.

Who - Mostly advocates of a seamless, interoperable, transparent, complex world, who believe that world can be reduced to simplicity and costs can be cut with enough software, and who conceive of the world of health care as a monolithic machine powered by algorithmic cogs and greased by aggregated data of every financial transaction and every diagnostic or treatment act. What these advocates believe and conceive, they think they can achieve. Advocates come in all managerial and technological shapes and sizes, and share thing in common – a desire to get a byte of the health care apple.