TCS Daily

Are Newt and Hillary on to Something? Sort Of...

By Arnold Kling - May 19, 2005 12:00 AM

"Longtime political foes Newt Gingrich and Hillary Rodham Clinton joined cheerfully yesterday to promote legislation on healthcare changes...

The 21st Century Health Information Act would create regional health information networks to help transfer health data quickly among doctors, hospitals, and nurses, and ensure that hospitals adopt compatible technologies."
-- AP News Story


Putting medical records into a computerized database has bipartisan political support. The goal is to reduce medical errors and reduce overall costs in the health care system. My guess is that this will prove to be difficult and expensive.


I spent much of my business career at the intersection of business processes and computer systems. I know how business units complain about information systems departments without understanding how large-scale systems evolve. Conversely, I have seen information systems departments try to run the business ("driving from the back seat," as one former colleague calls it). Overall, I have arrived at this conclusion:


Information systems reflect their organizational setting


If organizational roles and boundaries are not well defined, then computer systems will have gaps and overlaps, also. If a business process is overly complex, then the computer systems will share that complexity. If a management structure has too many layers, then the computer system will be bloated by effort to meet competing demands.


In my experience, problems that are blamed on computer systems almost invariably can be traced back to organizational characteristics. Any attempt to fix the information system without doing anything about the organizational issues is likely to fail. Information system weaknesses are more often a symptom than a cause of an organizational problem.


Who Owns Your Medical Records?


One reason that medical care records are not well digitized is that there is no clear owner of the data. An "owner" in this case is someone who is clearly responsible for creating, retrieving, updating, and deleting information (the acronym for this is CRUD). In management jargon, the owner of a business process has authority and accountability for that process. When a process lacks a clear owner, the organization typically fails to execute that process effectively. The flaws of such a process often include weak information systems.


The owner of a process is the natural owner of the data used in that process. For example, with my checking account, my bank is the owner of the data. It is true that I own the money in the account, and I certainly double-check my bank by balancing my checkbook. But the bank is ultimately responsible for the database that contains the information about my checking account. The bank sets the rules for when my account is incremented or decremented.


The bank owns the data in my checking account because my bank is involved in every transaction that changes my balance. There is no comparable actor in the health care system. My doctor is not necessarily involved in every transaction that affects my medical record. Neither is my insurance company.


The Clinton-Gingrich proposal includes the creation of regional health information networks. Presumably, the network will have to handle every data transaction in which a medical record is involved -- all data CRUD. But if there is no owner of medical records, there is no way to ensure that a database will be definitive.


Who is responsible for making sure that the regional health information network is supplied with data, and that this data is timely and accurate? The regional health information network is probably going to require some organizational analog. Is government going to create new regional health bureaus? What powers will a bureau have? Will it be illegal to obtain medical care without informing the bureau?


The dilemma is this: if the bureau has no powers, then there is no reason to expect that the bureau will have accurate data. On the other hand, if the bureau has strong powers, so that no medical transactions elude the database, then it will represent a new and potentially intrusive entrant into the health care delivery system.


I have seen arguments in favor of re-organizing health care to improve accountability. One of the alleged benefits the concept of a Health Maintenance Organization was that the HMO would be accountable for every aspect of the consumer's health care. If HMO's are not the solution, then another possibility is that your primary care physician should be accountable for all your health care, and the actions of all other providers ultimately should be under his or her direction. If the health care process were re-organized to create a single owner for your health care, then that would provide a natural owner for your medical records.


I believe that the absence of computerized medical records largely reflects the lack of a single owner for those records. This in turn reflects a system in which there is no single owner for an individual's health care. If we change the organization of health care to provide single-point accountability, then my prediction is that computerized medical records will follow. On the other hand, if we attempt to computerize the data without changing the way that medical care is organized, then we will run into great difficulties.


Interfaces and Transaction Types


Another reason that computer systems for health care are difficult to develop is that they require a large number of interfaces. I discussed this in The Mythical Health Care Man-Month.


A bank checking account requires relatively few interfaces. The way that check clearing traditionally works is that banks clear checks on one another and for their own customers. As a bank, you need a system to track flows of funds to and from other banks, and a system to maintain the data for your customers' checking accounts.


Only recently have banks added electronic payment, which allows for direct interface between the customer and a payee. Because this is so much more complicated than interfacing with other banks, many banks have outsourced electronic bill payment to third-party service providers.


In health care, the number of interfaces is much more daunting. There are various types of providers. Hospitals operate very differently from small physician practices. There are different regulatory structures -- a procedure that can be performed by an optometrist in one state may require an ophthalmologist in a different state.


With a checking account, there are only a few types of transactions. Basically, you either deposit money, withdraw money, or write a check. With the health care system, there are many different types of transactions. There are evaluations, which can include hard numerical data, such as blood pressure, but also subjective reporting by both the patient and the physician. There are many different procedures, both diagnostic and therapeutic. There are referrals, recommendations, and plans for follow-up. The data structure for medical records is going to be many times more complex than that for a checking account. Moreover, the elements are not nearly as well defined as the dollars and cents that constitute banking transactions.


Costs and Benefits


I do not question the logic that supports the benefits of digital medical records. My point is that obtaining those benefits is not as simple as politicians might make it appear. It will be quite costly to build and maintain the system that Senator Clinton and former Congressman Gingrich are proposing.



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