Thursday, September 2, 2010

The Elephant (HIT) Inside the Boa Constrictor (Government)

When it comes to physicians failing to adopt and install electronic records, I think of the Saint-Exuperty’s story of The Prince, in which a boa constrictor is trying to digest an elephant.

The story says, “"Boa constrictors swallow their prey whole, without chewing it. After that they are not able to move, and they sleep through the six months that they need for digestion."

With electronic health records, this metaphor holds true. But it going to take five years, probably a decade if you count the last five years, for the boa constrictor, government, to digest the elephant. It may have byten off more than it can chew.

In a piece in The Health Care Blog, “ Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT,” David Kibbe, MD MBA, a Family Physician and Senior Adviser to the American Academy of Family Physicians, and Brian Klepper health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc., describe the essence of the digestive problem.\

All or Nothing

“Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment.

Three HIT Trends

They then go on to describe three trends likely to take place over the next five years.

"1. The expanding uses of structured health data using XML. EHR vendors, HIE companies, consultants, and other middlemen are used to making fortunes on one-off health data interfaces between an EHR and sites of care (e.g., hospital) or service (e.g., lab)."

"2. Point-to-point sharing of health data, securely, over the Internet. Local and regional health information exchanges are proliferating, but they still face the problem of communicating beyond their own boundaries."

"3. Platforms+modular apps+network services. Almost everyone is familiar with this model: it’s the iPhone app store and the Android Market. It’s the use of the Internet without as much dependence on the web browser, with multiple mobile devices for platforms, and with the emphasis on replaceable apps and re-useable technology that offers up data from many sources simultaneously."

This is the kind of technocratic language most physicians, particularly those in marginal small practices, find hard to swallow and digest. This physician indigestion process reminds me of two other elephant metaphors.

The Elephant in the Room

Before resigning in frustration as the first “HIT Czar,” David Brailer observed in a 2005 in a New Times Times interview , “The elephant in the living room is what we’re trying to do is the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.”

The Blind Men and The Elephant

The second metaphor is the Blind Men and the Elephant. Our health care system is an elephant. Everyone feels the elephant’s parts differently. Doctors hanging on to the tail feel the system is an encircling rope, purchasers touching the leg feel it is an immovable tree, plans holding the trunk feel it is a squirming snake, and government officials riding on the head feel it as a global positioning satellite devices, capable of controlling the direction of the elephant.

What concerns me is what will come out the distal end of the boa constrictor once the digestive process ends.