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Shinseki's Successor Should Use Technology To Rehabilitate VA
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SeniorMoment
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SeniorMoment,
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5/31/2014 | 10:48:08 AM
Can the VA Automate Successfully
The VA has even proven itself incomptent to do a relatively simply task of converting data from one database, the Defense Department's system for discharged service personnel, and its own system to eliminate mountains of tree use for paper.  The only computer software I woud trust the VA with is off the shelf software already being used by another health care organization.   The only allowed difference until internal to the VA technical and adminstrative competency can be absolutely proven is that every patient will have the same health insurance information.  It is fair to assume such programs have a place to enter the name of the business, which in this case is the USA Veterans Adminstration.

Information Week about 25-30 years ago printed an article that said the federal government had contracted out so much system development work that it no longer had in its agencies enough technical competence to even specify data system needs, and this even proved true with the Affordable Care Act enrollment system, one of the highest federal priorities, so it is apparently little has really changed.

To circumvent purchasing rules and legal requirements for competitive bidding of all purchases that dragged on with appeals past the generational life expectancy of the equipment to be purchases, federal agencies started writing software development contracts that required only an evaluation of Requests for Proposals that included delivery of all the computer hardware necessary to run the software.  To cost justify such decisions the agencies had to reduce their own information systems staff, and that was a huge mistake that has haunted the federal government ever since.
JimS826
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JimS826,
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6/1/2014 | 8:54:17 AM
Re: Can the VA Automate Successfully
The 'people served' have to Pay For It, Decades now and wars from of ignoring the many issues so they don't have to!!!

Travesty For Us Veterans': Especially if another Conservative Executive Administration oversee's, we already have them in Congress and State Houses talking but doing nothing but obstruction!

Finally a Non-Political VA Secretary That Was Addressing Long Ignored, and Newly Ignored Combat Theater Veterans, Issues By Those They Served and Through Their Representatives, With Help From the Full Executive Branch and Accomplishing For the Surviving Veterans of Those Issues!!

As Veterans, and especially us looooong time Veterans Activist and Advocates: WE ARE PIS*ED ! ! !
and what we are pis*ed about is that senior VA mangers are setting Shinseki up to take the blame for their own back-stabbing, incompetency and bullsh*t {thanks to llbear for this}

Patriotism Posers!! Sen. Sanders to bring back veterans bill GOP previously blocked - Put Up or Shut Up!!!!!!!

Conservatives got what they've long sought, and attempted to do prior, since he was nominated and confirmed as VA Secretary!

The General was like most of us Veterans, though we really know better but when them served are a wavin them patriotic symbols there's just a maybe they really mean it, others like those served, like their representatives, quickly lay all blame on the VA, no demand they sacrifice, especially conservative led Vet orgs., who think that Politics and Greed wiil be kept out of the many area's of the VA agency and the total focus within would be to fulfill the countries contract in caring for the very few who served them. Most do, especially the unpaid many many volunteers, but it only takes a few employee's, especially looking to help the conservative ideology, when under democratic executive administrations especially, in wanting to privatize for corporate profit off the people's treasury and added fee's legislated for same.

Long Past Time, Decades and War Of, Those We've Served Stand Up and Take Blame For Lack of Sacrifice From:

PTSD, Agent Orange, Chemical Exposures, Gulf War Syndrome, Homelessness, National Cemeteries, Veterans Courts getting help for instead of just throwing a Vet into jail or prison, to Name But Only a Few, Including Issues From These Two Present Long Occupations, Totally Ignored Now Being Addressed by This VA and the Executive Branch Cabinet Helping the Long Under Funded Peoples Responsibility, the VA! Thankfully the only Government Branch, this Executive and it's Cabinet, doing anything for not only Veterans but Military and their Families will continue working with the VA to fulfill what the peoples representatives, Federal and States, aren't as those served like that!

"Why in 2009 were we still using paper?" VA Assistant Secretary Tommy Sowers "When we came in, there was no plan to change that; we've been operating on a six month wait for over a decade." 27 March 2013

It isn't a VA 'scandal', it's the Country served and through their Representatives 'SCANDAL', decades long and wars from as they ignore the issues so they need not pay for! Wars over no need to wave them patriotic, patriotism posers, flags! Nothing more to see or need to do here, move along!

That spending, like most of the budget is still mostly borrowed, especially in the last decade plus and two wars of choice, with two tax cuts as they started especially for the wealthy with costs for the wars rubber stamped off the books with no bid private contracts and and all borrowed, as this VA started addressing long ignored issues of previous decades and wars from, since Korea and even WWII issues, with interest and problems created by the people and their reps taking from those budgets to fix. Instead of the flag wavin country building and just maintaining and advancing the Agency that should have always been, thus costing less to operate and with quality!!

Long Time Example of just one Long Ignored Military, and wars, Veterans' issue:

Conservatives Pro-Business right-wing Think Tank American Enterprise Institutes own Sally Satel, Still Selling Care for PTSD Veterans is Waste of Money! Nemesis of us Vietnam Veterans who fought for recognition of for the brothers and sisters suffering with and not only as to Vietnam and war PTS but the Civilian personal from their traumatic life experiences as well! She, and some others, have made very lucrative livings writing and speaking in denial of, giving reason to country and politicians serving them to ignore, and thus have the blood of hundreds of thousands of not only military, military veterans but civilians who suffer the ravages from extreme trauma's, on just one long of many ignored issues by those served issue so they need not pay for care!

USN All Shore '67-'71 GMG3 Vietnam In Country '70-'71 - Independent***

Alison_Diana
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Alison_Diana,
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6/2/2014 | 9:10:53 AM
Re: Can the VA Automate Successfully
You are absolutely right, @SeniorMoment. As we saw with Healthcare.gov (and many other examples, too long to list), the government's entire approach to purchasing, managing, and implementing complex solutions is broken. I'm not sure what the reasons are and don't want to get into a big political debate, since this isn't the forum (and from what I can tell, this problem extends across multiple parties' leadership). But the end result is that taxpayers spend a lot of money needlessly; our systems are years (or perhaps decades) behind, and - in the case of the VA - heroes are dying.
MedicalQuack
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MedicalQuack,
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6/1/2014 | 12:04:50 PM
Any Coders commenting here?
I love these types of articles that say "what so and so should do"..we see it all over the web.  First off there's the disability rankings that are done for VA Vets with LHI, a subsidiary of United Healthcare for tose who will be receiving those benefits and enrolled in the VA, United has quite a few military contracts with the VA and DOD.  There's a a front runner to the system before they even get into the VA system that adds more time..anyone aware of that?  That uses another EMR system that LHI has and then those records need to get put into the VA ViSta system.  Has anyone seen ViSta? I have and it's actually very good. 

Well the employees at the VA found a bug on the schedules so time drag out some code modules and fix it as well as an over all audit of the audit trails to find out who, where, time stamp of those gaming the system.  I used to hate that as a former developer when I missed something like that too as it's code bug that needs to be fixed and in this case they gamed it instead of reporting it, happens all the time with software development and there's no way around finding every bug as that's the software world.


The VA is fractured and does us a lot of different technologies too, you can look at Picis if you want, anesthesia software used throughout, another subsidiary company of United Healthcare.  Integration, easier said than done, folks coding is freaking hard..if it were that simple the DOD and VA would have had that done by now.  I'm sure they have a burial ground of sandbox applications they have worked with over the years to test integration too, as they don't just do nothing but integrating two massive systems is not easy.  Actually using a middleware app such as Zoeticx is becoming a better solution and cost sustainable as well so not only the VA but others are looking at middleware as integrator.

Actually the "real" problem with the VA is a big culture change needed all over as we have become a nation of "stat rats" and you can see it failed here with being out of touch with the real world and if you look around and read the news you are starting to see more models fail as we need both but we need balance on how technology is used so to say they just need to use technology and line up a a list of things to do doesn't mean a lot as it's monster project by all means.  I understand non coders and the general public don't understand the complexities for the most part and I keep telling everyone "the short order computer code kitchen burned down years ago and there was no fire sale"...

http://ducknetweb.blogspot.com/2014/05/va-crisis-just-tip-of-iceberg-as-us.html

We have had a few years of the Sebelius Syndrome we have all had to live through with her searching for the "algo fairies" she thought was the cure and wanted to "hurry up health IT" as well...so again it's balance and not leaving the human out as that's what happened here with the stat rat effect, sadly.  I'm in tech and I would not stick my nose out there and tell the VA what to do as you can't be a Monday morning quarter back and you have to really be there.  Again the perception of non code folks and folks who create code and software will always differ, I had that when I wrote my medical records program and once I sat down a couple of MDs and showed them how complex coding changes are, we a got along great as they saw the difficulty and structures i had to work with at as well from my side, so no algo fairies rushing in for a fix.

 

SeniorMoment
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SeniorMoment,
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6/2/2014 | 6:15:39 AM
Re: Any Coders commenting here?
I concur that the core problem at VA, based on the experiences I had with my parents, is cultural.  The VA does not function as a whole organization but as an amalgam of its component facilities which even have different eligiblility standards which I woudl have thought woudl be a violation of equal access regardless of state and equal due process of law.  Management has to feel like they are part of a team with the actual health care providers and veterans at the core of their world--not internal management philosophy disputes and office politics that go on in every bureaucracy, including business ones. I have never observed that existing in VA, whch most nurses for example regard as an employer of last resort, just above a rural county hospital.  Unless it has changed the annual turnover in doctors is unaccetable high.  I once paid for a veteran's prescription because he was new to town and although he had only asked for a ride to the VA,  I didn't want him to spend hours waiting to establish local eligibility and see a doctor all to fill a $10 for 90 day prescription because I had waited that long myself with my mother.

It takes doctors more than one visit to understand all but the simplest patient's problems and past treatment attempts, and each new doctor comes with a new set of medical opinions too.  I once saw 4 lipid specialist.  It turned ut the first 3 were students.  I told the 4th one what the others had said, and he replies (as it turned out they were his students) didn't they learn anything at all from me.  I felt just a VA patient then.

From a long past article from Information Week, 90% of the computer programing is done by 10% of the programmers.  I personally wrote over a quater million lines of code over a decade, so computer programming is only hard for people to whom it does not come naturally.  For me it was much easier than learning Spanish, Zoology, or English Literature was in college.

The real problem with computer programming comes when it is done by people who know only computer programming and not actually how the business or agency processes work by having physically done the work or closely supervised or watched it unobtrusively. I once threatened to kill a multi-year project unless they delivered part of their proposed system within a year.  They did and learned the hard way I was right that they approached the problem poorly all because the Team Leader way back then did not want to learn how to write a single interface page in CICS and insisted on doign everything in Natural which magnified the total number of programming modules needed.  Of course by now CICS probably does not exist and Natural having come from Software AG probably doesn't have such tiny program size requirements on today's faster computers and storage devices.

When Windows NT was written it was done by a small team of good programmers working over a reasonable number of months, and now the development tools are greatly improved, yet advancements are much slower and no less error prone.  In fact the recent Heartbleed smart phone security vulnerability was introduced by accident to a computer program that did not have it, yet 2 or 3 levels of review did not catch it because everyone was treating old code as unlikely to have changed any except where intended revision was made.

If you want to know what is hard in programming, it is finding a logic or non-obvious syntax error, so it is really important the first run at the code is great.

 
Alison_Diana
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Alison_Diana,
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6/2/2014 | 9:16:16 AM
Re: Any Coders commenting here?
You're right, @MedicalQuack: It is very easy to sit at a desk and write an article about what "should" be done. We both agree, as you said, that a lot of the change is cultural. I had hoped that my feeling this is a HUGE, DIFFICULT undertaking would come through. No one in their right mind would ever suggest improving the VA is something that could happen overnight, or even in a year. Writing code is not easy, especially when you're looking to integrate different vendors' systems. That's not something they necessarily want you to do! If it was easy, then healthcare alone would be a much smoother (and less costly) industry.

Thanks for sharing some of the details of why there are so many challenges facing the VA. What do you think can be done to improve the system? I don't think anyone disagrees that there are major problems here, when so many folk are coming forward to show veterans had been shelved without appointments, wait-listed for months, and some execs received bonuses for allegedly falsifying records. How would you start this process? What resources would you want?
MedicalQuack
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MedicalQuack,
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6/2/2014 | 10:16:49 AM
Re: Any Coders commenting here?
There's plenty of talent at the VA that knows what they need to do without me:)  Last year both of the head IT folks left as well.  I keep telling all we are a nation of stat rats with math models and software beginning to fail with an over reliance and VA is just the tip of the iceberg.

http://ducknetweb.blogspot.com/2014/05/va-crisis-just-tip-of-iceberg-as-us.html


I have full respect for coders and last thing they need is someone like me telling them on a blog what to do.  In meantime I'm much more concerned about our novice Consumer Financial Protection Chief and his case of Algo Duping right now with building a federal data base on all US consumer credit data.  This problem keeps repeating itself over and over with executives with no data mechanics logic saying stupid things and putting weird data perceptions out there and these executives are duped over and over again, just as was the head of the VA.  Cordray is just like Sebelius suffering from the Sebelius syndrome. 

http://ducknetweb.blogspot.com/2014/05/richard-cordray-yet-one-more-algo-duped.html

 
TerryB
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TerryB,
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6/2/2014 | 1:37:21 PM
Not an IT Issue at VA
Like most old government agencies, their problem is bureacracy. Way before this serious story came to light, it was obvious that mgmt is disconnected and internal policies are more important than people. My wife has been a nurse for a very long time, and a very good one. She recently left Prevea to work for VA in the spirit of giving something back, her Dad was a Marine and served in Korea. She was so good that top HR person at Prevea personally asked to see her when she heard my wife was leaving, asked if they could do anything to keep her. She said no because it wasn't about money or wanting to leave Prevea, she wants to help vets. Her job is to travel to home of vets in area and coordinate their care, getting them appointments in clinics when necessary.

After her first year and review time came to evaluate whether her GS grade, the major pay driver in government jobs, should be increased, her immediate supervisor gave her an over the top evaluation, saying she was incredible at her job for a person of any tenure, much less a 1st year employee in the job. She even covered the slack when her partner was in bad car accident and could not work for months.

But whoever this evaluation was sent to up the mgmt chain, she was denied a promotion in GS stating she only met 3 out of 5 criteria they have. I still don't think she even knows what this criteria is. It certainly had nothing to do with satisfaction and feedback from the Veterans, and obviously nothing to do with people who actually manage her local work. How can a system like that possibly work? It's all about manipulating budgets, especially when budgets get connected by metrics in evaluating the higher level managers.

I work in Mfg, so one of our biggest metrics is shipping to our customers on the date we said we would. It connects directly to any bonuses paid out. So there is high motivation to make that number look good. Managers at other business units of our company have been fired for manipulating that data.

The difference to VA is no process seems to be in place, maybe because they hide behind paper processing when they can, to audit the process. That's a mgmt failure at much lower levels than this Shinseki who took the fall. They need to clean house at top manager level in every VA unit implicated in this. Which, by the way, is not in this area where my wife works. She was as shocked as anyone this could even happen. I've seen her extend her workday to make sure any of her Vets who need to see her get to do so. It's not the people actually providing the care who are the problem here.
Alison_Diana
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Alison_Diana,
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6/2/2014 | 3:57:51 PM
Re: Not an IT Issue at VA
There are some absolutely wonderful, dedicated people working at the VA and it sounds as though your wife is one of them. Thank you so much for all she does to help the brave men and women who served our nation. The people actually working in the hospitals themselves are to be commended. From what i've read, it's the beaurocrats behind the scenes who need to be replaced and to use the kinds of tools i detailed in order to avoid some of the very things you described here. 

It's appaling to hear that great employees don't get raises when, elsewhere, we read about paper pushers who get undeserved bonuses for lying about wait times. There's obviously something wrong with the system and somehow we owe it to our vets (and the many great employees within the VA) to do something about it.
AmandaInMotion
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AmandaInMotion,
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6/3/2014 | 11:03:23 AM
Re: Not an IT Issue at VA
Let's just hope that whatever new "technology" the VA pushes doesn't turn out to be like this: (http://tinyurl.com/mmnphhk). Apparently there have been more medical device recalls in the past decade than ever before.

I fear that the structure of government healthcare - that is, where lobbying corporations have more sway than veterans themselves - means that giant government contracts will be granted to medical device companies who may be pushing out faulty products.

The problem, it seems to me, is the institution of socialized medicine itself. Bureaucracy making health decisions for individuals instead of individuals making them seems to breed these kinds of consequences.

Thanks for the informational article, Alison.
Alison_Diana
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Alison_Diana,
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6/5/2014 | 9:35:28 AM
Re: Not an IT Issue at VA
Once again you bring up some great points, @AmandaInMotion, and it's one reason I'm so glad I wrote this piece: I wanted to spark a conversation about this horrendous situation because it made me so upset about the treatment of these vets. We may not solve the problems in this forum, but it's a great place to discuss some options, alternatives, and I'm definitely learning new insights.

The fact that lobbyists are involved in the VA is ridiculous, IMHO. Politics has absolutely no place in a medical setting and doctors, nurses, and other medical professionals are the only people who should be deciding which treatments, which equipment, and which vendors are involved at VA hospitals, clinics, rehabs, etc. Lobbyists, politicians, aides, and anyone else from DC shouldn't be there -- unless they're a veteran in need of care. From what I've read, some of the VA's problems stem from the involvement of lobbyists; others stem from the unions' demand for more jobs and its baulking at allowing vets to seek treatment at non-VA facilities, even when vets have Medicare or other insurance. With the non-VA focus on "population health" and "patient engagement," there's a real opportunity for the VA -- with its captive population -- to be a leader, not a laggard. The VA has tons of information on its patients, plenty to create a system of PERSONALIZED care yet it appears to have done the opposite and treated at least some veterans as indistinguishable pawns by not providing them with appointments, and allegedly causing at least some deaths due to that lack of timely care. In other words, the exact opposite of what the government's requiring of healthcare providers that accept Medicare/caid.

There are far more medical devices now implanted in patients so there will be more recalls. That said, there's been a lack of oversight on these devices which have been found to be easily hacked. This is one area I believe the government needs to get more heavily involved in to ensure patient safety, not only from the device components but from external threats from hackers and bad code. 
ICU_DOC
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ICU_DOC,
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6/4/2014 | 9:32:29 PM
IT to help the VA
I agree with Barbara that better technology is key. One way we can spend more time on the needs of patients is if EMRs were integrated and not silos of disparate data. Doctors like me waste a great deal of time working with systems that are not compatible. A patient's lab data could be stored in one database while data from a surgery in another EMR database and a file of past prescriptions still somewhere else. 
 
By the time I search three different databases, I could have been attending to a patient to help ensure the best possible outcome. Barbara is correct in looking to solutions that go beyond the same old EMRs. Technology like that being offered by visionary EMR leaders like Zoeticx will help make a difference. 
 
Hospitals need to move forward with these types of new solutions and ways of doing business that helps hospitals do more with less.
 
Howard Nearman, MD
ICU Physician

 
Alison_Diana
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Alison_Diana,
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6/5/2014 | 9:53:42 AM
Re: IT to help the VA
Being forced to search through three EMRs is a big waste of your time, doctor. When you add up the time spent doing that for patient after patient, that adds up to many hours per week or month. A lot of hospitals face that issue because they choose a best-of-breed approach to EMRs, using one for the main hospital, one for the ER, one for radiology, etc. From conversations I've had with CIOs, CMOs, etc., I'm seeing a shift toward standardization on one EMR across an organization, although this may well cause problems for hospitals' departments if that EMR doesn't resolve the needs of the ER, radiology, surgery, etc.

One thing the ONC now plans to address is integration. Now, I'm not certain how the government intends to do this or if this is the best approach, but the ONC certainly has a big stick to help hospitals and doctors address this time-consuming issue and, hopefully, help physicians like you do what you want with your time. What has your IT department done to try to help you with this issue, Dr. Nearman?
PedroGonzales
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PedroGonzales,
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6/5/2014 | 4:26:55 PM
Re: IT to help the VA
I think all the points you have indicated are the correct strategies to find various ways to fix the current problem the VA has.  But, I wonder whether whether the next person in charge will define clear goals and be accountable to how they are accomplishing the suggestions you have made.  Also, lets take into account that such and other changes will take years to acomplish.  People have to understand that as well. 
Alison_Diana
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Alison_Diana,
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6/6/2014 | 9:31:30 AM
Re: IT to help the VA
Oh yes, @Pedro. Unfortunately, this will NOT get resolved overnight -- or even in a year. Whoever takes over this position should have brilliant leadership capabilities; extensive knowledge of healthcare, perhaps from the ground up (with a medical background as well as being a veteran, him/herself), and the abiilty to see the big picture and clear-cut goals. This leader must have the resources and backing they need without outside lobbying or political battling, although it's doubtful s/he will get that liberty! I'd suggest they conduct visible pilots across several sites, sharing the results to demonstrate a new transparency. Those employees found guilty of gaming the system to get bonuses should be fired, if union rules allow; if not, they must be demoted and retrained, moved to positions with little to no authority that have nothing to do with patients. 
don voltz
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don voltz,
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6/5/2014 | 12:47:04 PM
Re: IT to help the VA
Clearly there are issues in the VA that have been recently highlighted. They do not stop there, however. As pointed out by MedicalQuack, development of software is hard. Developing software using the typical waterfall methodology presents its own issues, especially in healthcare where requirements, processes, and workflows are not completely understood, standardized and regulatory issues continue to change with new initiatives including the latest Affordable Care Act and all the IT requirements that go along with it.
 
One needs to ask the question, can a single platform effectively address the needs of healthcare practitioners, offices, clinics, hospitals, health systems and governmental agencies? The current model of EHR development, deployment and implementation is clearly moving in this direction. With the continual expansion of EHR functionality to add new requirements, we make these systems more complex, add inter-dependencies, setting ourselves up for potential catastrophic failure of systems we are becoming more dependent upon. As each EHR vendor continues development and is in competition with other providers, we need to address the big question of why interoperability is good for their business model. The short answer is it is not and will only be added to comply with federal regulations and mandates. One has to wonder if this will be the concept of interoperability many of us have in mind from the provider as well as the patient consumer. Is there another solution?
 
At the core, all EHR's are databases, albeit, built on platforms and database technology from the 1960's, MUMPS. My concern is many of these have been developed and consist of millions of lines of code making re-factoring and expansion a difficult, if even possible solution. I agree with MedicalQuack in the concept of a middleware platform to interact with the data and allow for expanding these systems to meet local, regional, federal and evolving requirements. In exploring the Zoeticx platform and their recent announcement of an API allowing others to build applications and services on top of a platform, we open up development far beyond the EHR vendors (Zoeticx's New API Allows for Faster Medical App Development). Much as iOS brought innovative ideas as well as major flops to the marketplace, a middleware platform connecting disparate EHR systems while maintaining security and integrity of the data being stored by these systems and the development of customized applications to address the needs of providers, clinics, hospitals, health systems, and governmental agencies. This moves the development from the waterfall process to a more agile one where ideas can be tested and the market can respond to the solution without having to rip and replace expensive EHR systems for a niche market within healthcare. 
 
We have amassed a significant collection of healthcare IT failures and are likely to uncover many more. As with the art of medicine, we need to develop a system for healthcare IT that can be treated and managed with novel and creative solutions.
 
Donald M Voltz, MD
Anesthesiologist
Alison_Diana
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Alison_Diana,
User Rank: Author
6/6/2014 | 9:27:50 AM
Re: IT to help the VA
You are right, Dr. Voltz, that for vendors it typically is in their best interest not to promote interoperability. It's like the olden days of earlier enterprise systems, where proprietary solutions battled for tenure: Once they had a foothold, it appeared too costly, too career-damaging to oust the incumbent, the reasoning was. That did change, of course, but it took time and lots of very expensive failures. With the ONC's announcement yesterday of its 10-year plan and focus on interoperability, I wonder whether that will change. Given the challenge of change, I think a decade is optimistic, particularly as this is a political office and roles (and funding) change, there will be privacy concerns, and we all know there'll be a ton of lobbying by multiple factions.

Middleware would seem to be the most cost-effective approach since it wouldn't require ripping and replacing, something few healthcare organizations rightfully would be loathe to do after spending perhaps millions in software, hardware, staff, training, and more. In hindsight, interoperability should have been part of the equation from Day One -- but it wasn't, so now the industry and vendors must address it in order to move forward. 

So many people believe healthcare is in an age of disruption and some organizations definitely seem to be trying to break the mold. Other than a desire to improve patient care, cut costs, and be viewed as a leader, do you think there should be additional financial incentives for those willing to experiment with tech (not just the VA. As you say, this is a more extensive issue.)? And if so, what sort of parameters should there be? Or is trial and error part of the cost of doing business, something healthcare orgs should be willing to pilot whether they succeed or fail? 
don voltz
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don voltz,
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6/9/2014 | 3:43:01 PM
Re: IT to help the VA
Clearly interoperability continues to plaque EMR's and is a complex, not well understood issue with multiple proprietary systems implemented and a lack of standardization between them.  Lack of interoperability slows innovation in healthcare since it is the road block for cost effective IT solutions in support of care providers.  One of the best ways to address the VA challenges is to scale up care providers bandwidth since it is a zero sum game on the number of care providers available to extend more coverage for patient care.

With the amount of stimulus funds that has been invested in a national implementation of EMRs, I think the issue of interoperability needs to be implemented in a shorter time frame.  From the ONC 13 page document on their 10 year vision, it is clear that this needs to be accomplished, 

"To ensure that individuals and care providers send, receive, find, and use a basic set of essential health information across the care continuum over the next three years, we need to migrate policy and funding levers to create the business and clinical imperative for interoperability and electronic health information exchange," 

But why wait ten years when we can do this today with healthcare 2.0 vendors like Zoeticx. They provide the ability to view patient medical information from different EMRs from one type of media. This type of technology will cut down potential errors, while at the same time, giving back precious time to care providers so they can take care of additional patients. (I can prove this to you through a simple WebEx demo if you have time next week.  I would be happy to volunteer to help arrange a demo through web ex. We believe a healthcare Ninja must always be well armed.) ☺  

EMR vendors have a conflict of interest with widespread access and use of their systems by physicians and other hospital systems where there is no license agreement in place or business relationship with their product.  Patient's past medical data, collected by EMR's, is absolutely required for physicians and other healthcare providers to care for patients in a safe, efficient and cost conscious way. 

This discussion on interoperability has been focused on HIE (Healthcare Information Exchange) where duplicated patient medical data records add to the overall complexity. On the other hand, leading EMR vendors advocate for a rip-and-replace effort, as you cites in your response as 'too costly to oust the incumbent'. Why do healthcare institutes have to rip-and-replace its deployed EMR, or create additional database layers in order to achieve interoperability? Or do they really offer interoperability, or yet another roadblock to a true interoperability solution. Would one entertain solutions focusing on patient medical information (not data) sharing (not exchange)? Why not leverage data from the existing deployed EMR solutions (its strength in data) to dynamic patient medical information?

I think we should step back and look at what would be feasible and practical for healthcare and care providers. 
  1. Achieving interoperability by adopting standard patient medical data format (ONC) in the EMR: This 'train' has left the station. As EMRs are deployed in most US healthcare facilities, to roll out the next generation of EMRs using a new patient medical format standard is mostly equivalent to a rip-and-replace of an EMR system, which would lead to another wave of service disruption and severely impact care providers' bandwidth.
  2. Achieving interoperability by data duplication (HIE approach): Basically, it is about duplicating patient medical records and presented in an additional new data base layer adopting a new standard format. This approach does leverage existing EMR deployments, but it is costly and not sure to really address care providers' needs. It does address a number of needs such as patient medical data analysis, but faces the challenges of operating on potential stale data due to its batch mode synchronization approach. 
  3. Providing access to patient medical record as single source of truth: This approach leaves the patient medical data at its source, puts an emphasis on a middleware infrastructure to provide an 'information highway' for patient medical data. It focuses on multiple data sources, mapping patient medical data into information on a near-time approach. This approach leverages deployed EMRs, avoids a rip-and-replace, and addresses care providers' collaboration needs. Coupled with an open architecture, this approach would be ideal for inspiring innovation in healthcare, addressing care providers efficiencies by extending their bandwidth. 

Would you like to witness a scenario where a physician can retrieve patient medical information from both hospitals and clinics (different EMRs / different vendors) on the same media, have the ability to collaborate on patient care (patient care continuum) and using the most up-to-date data from its sources (point of data collection)? Would it be good if I could consult with you on a patient medical condition similar to a web-ex session where there is no miscommunication? 

To sum up, the challenge is not about realizing and agreeing on the problem. It is interoperability, but how to solve the problem without any disruption of service, contain the cost, and protect healthcare institutes investment on EMRs. The recent ONC announcement acknowledges the challenges and outlines the steps to address the challenges. It is the 10-year road map with another major disruption. As I pointed out previously, such a solution exists today and is available now. We can't just wait for another 10-years with billions re-investing in another form of EMR deployments. Let's leverage it and get healthcare IT moving forward!


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