Monday, September 27, 2010

Change Has Come

My apologies for the long silence. It has been a very busy year for everyone. When this blog was started more than a year ago, it was to begin a discussion about disappearing borders in human experience and the related issues in healthcare and technology. A lot of people joined that discussion, and they expressed an interest and a desire for something to serve the rapidly growing needs of businesses and  providers in the cross-border healthcare space. And so we became very busy creating IHITA, the International Health IT Association. Our attention was on those matters of concern to our immediate members in the US and Canada—as expressed in the blog USCanadaHealthTech. And then IHITA, like the world, got busy. We began to see that the issues we were looking at were only examples of much larger, global issues. Cross-border licensing of nurses is unique to neither the US-Canadian relationship nor the profession of nursing. Medical records are transmitted across every border, not just the 49th parallel. Almost immediately, we re-examined our scope, our mission and even the name. Happily, we are back —bigger, and eager.

USCanadaHealthTech is now GlobalHealthITblog. Because Health IT, just like the healthcare industry, is global and no longer bound to contiguous economies. This blog is now part of, and as such is dedicated to driving and enabling the global conversation about technology, healthcare and how the two can combine to serve people and businesses on all sides of all borders.

Please continue to follow GlobalHealthIT as an organization at and on our blog at

Monday, November 9, 2009

What’s A Smile Worth These Days?

Medical personnel, like anyone else, like to get paid for what they do--usually as much as possible. Historically, the more “free-market” sentiment of the US has resulted in higher pay rates south of the 49th for the same work done north of the border. Canadians have long complained about the “brain-drain” of the US market on Canadian knowledge workers. Canadian industries lose technologists taking their education at UBC to Seattle and Cupertino; Phd geologists running to Texas after a winter in Edmonton, and; doctors porting their Quebecois licenses to join partnerships in New York. Stories are told in all fields--well, almost all fields. Nurses seem to stay where they are. But then, a nursing license does not mean the same thing across a border---or even across a state line. For a role so valued by society, this lack of portability is unusual. Do nurses do the same thing north of the border that they do in the States?

Nurses are famously underpaid, overworked and underappreciated. They are in the middle of pretty much anything going on in healthcare. Wherever you go they are there with you--from intake to invasive surgeries. Nurses have long held forth that “Nothing would happen without nurses;” yet, they are financed like an appliance--as just one more overhead cost of a doctor’s practice.

“If it cannot be measured, it cannot be managed,” say the MBAs. In this case, if it cannot be measured, it cannot be monetized. There is no way to accurately measure and to compare what nurses do in modern medicine. No standard CPT codes exist to document the work of nursing staff--nor of the services asked of them. No CPT codes means no reimbursements--not by insurance companies, not by governments. And so, while nurses are indispensable like lights and heating, they are paid the same way--as overhead to be managed by the accounting department.

If one asks, nurses will tell you that nursing is an artform--a creative, more intuitive, less rigid service bound to the fixed tasks of physical care. Like any artform, those who know it best often have trouble reducing it to descriptors and numbers. The choreographer Merce Cunningham left notes that are an unintelligible collection of stick figure drawings. They fail to capture the essentials of his work, and it is feared that his dances will be lost forever. Like modern dance, nursing is very much about the people involved; and like dancers, nurses are often compensated as fixed-price resources (“members of the Company”) without consideration of quality or breadth of performance.

Treating skilled human resources as commodities is not the best way to enable retention or quality. But if nursing staff are to be managed as anything other than a poorly defined “support service” to “real” providers, then their tasks and skills need to be measured. And coded. And billed. And reimbursed.

That means CPT coding of nursing services. With clear coding, nurses would be able to justify their salary expectations. The profession could better classify and qualify nursing skills. Facilities could better manage care by controlling nursing skills against better projected patient-care requirements. And patient care could be better standardized across facilities, across regions and across borders. Nursing could be portable.

But what would be coded? Can the delivery of just the right smile and touch of a hand to calm a hyperventilating child be measured? Would there be a triple-sub code for “touch:with gentle squeeze:lower extremity:upper?”

Human interaction studies, time-and-task research and human-factors studies are making the tools for these measurements more available and easier all the time. Codes can be developed and standardized. So why are they not ready now?

In the US (the largest market for coding and coding resources), insurance companies have little interest in documenting nursing services. In the fee-for-service model used by these businesses, coding nursing would just result in more services to be paid. While nursing goes undocumented, the costs are passed along to the providers and the facilities. Provider groups like the American Medical Association see no upside in coding nursing services, as an expected result would be a reduction in those fees paid the member doctors.

Still, there have been a number of efforts to code nursing in various ways. Mostly, these efforts have been by hospitals and provider groups working to manage nursing skills against patient-care requirements. Coding has also been developed to try to measure performance against outcomes. None of these coding schemes has been pervasive or standardized in any way.

And there may be another reason why not--nurses themselves. Some nurses are quick to declare “without nurses, the hospital would collapse.” Yet they will also refuse to describe what they do in detail. “Nursing is an art,” they will say, “and you can’t just break it down into widgets and codes.” Might it be--and this is a serious question--that nurses do not want their work measured and coded? Might some be afraid that if nursing were broken down into a documentable craft, instead of an inchoate art, it would reduce nurses to replaceable technicians? Are nurse afraid of becoming machinists?

What do you think?

Tuesday, October 20, 2009

Borders are for Crossing...

Over the past 20 years, The US and Canada have shared an increasing number of patients and an equally growing investment in health information technology, culminating in the parallel creation of Canada Health Infoway and The Office of the National Coordinator for Health Information Technology.

Despite this past decade’s dramatic increase in the health information technology (HIT) industry, borders throughout the world have become less traversable and the sharing of technology more difficult. People are uneasy or even unable to transfer of data across borders because of complicated and often conflicting security measures. Trade regulations are poorly documented and ill-suited to modern technology. Many technologists are afraid to attempt crossing borders because of anti-terrorism measures and ever-changing documentation requirements.

In discussions with vendors and CIOs on both sides of the US-Canadian border, a constant theme is “The Border.” The government policies of the past 8 years have made the border, in the words of one CIO, “sticky and opaque.” Americans are unsure about export regulations being rushed out by the Department of Homeland Security. As many Canadians in technology are of Southeast-Asian descent, they are often afraid to try crossing the US border. Even carrying a laptop in from either country is now seen as a potential risk to the sensitive patient data it might contain.

Organizations involved in cross-border trade are confronted with differences in culture, practices and expectations. Vendors cannot successfully deliver to healthcare providers’ expectations, and organizations have increased management overhead with every cross-border supplier. All of these inefficiencies of culture and commerce drive costs up and productivity down for all parties on all sides of any border.

Very good work is being done by groups like HIMMS and OHITX to facilitate technological sharing issues. But the issues of cultural dissonance, tangled government protocols and the common human factors have been ignored. Now there is an organization to address these human issues of cross-border sharing--The International Health Information Technology Association, IHITA.

IHITA is a trade association of healthcare technology professionals for healthcare technology professionals; developers, providers, administrators and technologists. Members are in government, business, clinical care and academia across the US and Canada.

IHITA is dedicated to;

Business Support: helping the HIT industry successfully deliver products that improve patient care and healthcare delivery systems within and across all borders by offering members and member organizations education, partner/resource introduction and cultural-knowledge services

· Published studies

· Partnership guidance

· Research and development of cultural commerce knowledge resources

Government Relations: improving patient care options and resources by reducing the negative impact of borders on the HIT industry’s ability to deliver by Educating and advocating governments and government personnel for tools and regulations to enable cross-border trade and transfer of HIT products, personnel and data.

· Better documentation of NAFTA visa requirements for transiting personnel

· Treaty enhancement to enable electronic transfers of clinical data across borders

· Clarification of Ex/Im regulations for technology

Philanthropy and Research: building the global HIT knowledge base by developing learning and solutions to pervasive healthcare delivery problems by working concurrently with multiple governments and NGOs in identifying and researching solutions to common, “borderless” problems.

· Studies to deepen insights into strategic trade challenges in the global HIT marketplace

· Joint US-Canadian technology solution for First Nations chronic, at-home care issues

These challenges impact patient care and safety every day. IHITA is looking to clear these hurdles and make The Border simply “invisible.” We’ll keep you posted….

Monday, September 21, 2009

Nat'l Health IT Week from DC

I'm here at the National Health IT Collaborative for the Underserved in Washington today. The meetings are lasting all day, and I am a member of the Policy workgroup. Members of the workgroup come from a variety of places; provider networks in Californiaand Michigan, Morehouse, The Office of Minority Health and Capitol Hill. Much of this morning's discussion was about ARRA funds and how the remote, rural and underserved community providers would access those funds.

Those at the table from the Hill were pretty energetic about the ARRA funding allocations to regional health networks. They feel that the RFPs have been written to such a tight profile as to be "self selecting." It is already known which big players in health management will qualify. There are now discussions in California to enable access to these funds through "subcontracting" to local networks. There is a requirement that for a Regional network to qualify, it must have a minimum of 100,000 people. By aggregating these "local"'s numbers, the big players can then have the qualifying numbers, and the local clinics can access funding.

There was also a strong sentiment about bringing the smaller, rural/remote providers together to examine their HIT wants and needs. By documenting this aggregate market, vendors can be educated to develop and deliver more integrated and interoperable technologies---This is very reminiscent of last week's article on the Canadian market. MORE ON THAT LATER.....

Wednesday, September 16, 2009

The Seven Myths of Healthcare Technology
6. Health IT is just a product

And as a product, it is subject to the same market drivers and business strategies as any other commodity.

This was the point of a rather difficult conversation I had the other day with a very smart, very senior business-management consultant at a major firm. I had asked his thoughts on cross-border IT and the difference in implementation costs between the States and Canada. I brought up the idea of the cultural differences and the market limitations these impose on vendors. I posited that there might be value to both customers and vendors alike in having some sort of "cultural/market versioning support." He did not think so. Smart software developers, according to my friend, only deliver one version of their products for the largest single market or buyer. These "large-target" versions are sold across the board and the additional customization and implementation costs are passed down to the smaller buyers and the smaller markets. The Canadian market is much smaller than the US.

And while the number of people in Canada is one-tenth that in the US, the market for HIT is even smaller. After all, my friend noted, because of National Health, there are only a few buyers--the Provincial and regional health authorities; So, maybe 6 in all of BC? One in Alberta? Who would build a special version for only a few dozen customers when there is the US market with hundreds of facilities?

Now, this friend of mine is very smart, and he has been very generous with his insight and time. But on this I am not sure I can agree. Yes, in business, as in the US, healthcare is a commodity. The Cato Institute just said so in US News and World Reports. In Canada, however, this is not the case. Healthcare here is a community responsibility (and the best thing the government has ever done, according to some surveys. As a community, the Canadian HIT market population (providers) is about 8% the size of that in the US--about the size of California, and no developer is writing off the Gold Rush State. Healthcare providers are also different from consumers of other softwares. They are not shopping for something to give them an "edge" over their competitors. Healthcare providers, including the technologists, are always aware that their work is about someone's life--someone in their community. This very non-business value structure makes them companions, not competitors. As companions, they can work together to pressure US vendors to fulfill requirements of the Canadian market (as is already done for bilingual functionality).

As to there being so few buyers, shouldn't that be a good thing? HIT software is usually licensed by the number of users, not the number of contracts. So shouldn't managing a few large sales be better than making and managing a lot of small ones? Imagine selling to all of California with only 50 sales, instead 1050.

Maybe US software companies just have trouble understanding the Canadian customer. Perhaps Canadians have trouble communicating their values to American vendors successfully. The culture gap is certainly wider than people might think, and it appears in the most unexpected places.

What are your thoughts? Is Canada big enough to get more "ready-to-use" software? Are developers only successful if they follow a Keynesian model? Is healthcare just a commodity? And is HIT just a product like any other?

I grew up in one country and have lived and worked in both the US and Canada. But this is a real puzzle to me--and to many people I speak with every day. So let me know your thoughts. Maybe my friend is right.....