Source of Social Division and Dysfunction: People-Appraisal Judgments and the “True Nature” Myth

A very common psychological phenomenon which I call “people-appraisal” occurs when we make judgments, typically without conscious awareness, about the intrinsic worth and goodness of someone’s true nature. 

This judgmental tendency is a root cause of divisiveness in societies which manifests in problems at many levels in our lives—fractured families, personnel problems in organizations, and inequities that create many other serious issues in across the world today.

There' s consensus in the field of psychology and sociology, that almost everyone in the world wants certain things including to be valued, to feel cared for (loved), and to matter in the world. Everyone also shares the same planet and has an imperfect human body, a fallible human nature, and a perplexing human mind that mystifies science.

Despite these very important similarities, we’ve been told stories our whole lives about ways we’re different from each other. We’re told that this knowledge helps us know the kinds of people to admire and approach, and which ones to dislike and avoid.

The things we learn from these stories form our perceptions, thoughts, and feelings about people. We are taught how to use people-appraisal to judge people by what they have and what they do. These judgments enable us to define not only who they are, but also the essence of what they are.

Judgments like these would be beneficial if they were to promote health, wellbeing, positive outcomes, and an adaptive path to our species’ future. Unfortunately people-appraisal and the stories about them far too often promote social division, failures, harm, and foster unwarranted fears and hostilities. This is a huge problem for individuals, organizations, and humanity as a whole. 

The mindsets people develop about judging the intrinsic worth and goodness of self and others is so fundamental to how human treat each other that I consider this issue one of the most important things for humanity to address, yet it is rarely discussed. Yes, a difficult thing to change, but awareness is the first step, and together I'm optimistic we can help nudge humanity to follow a more adaptive (less self-destructive) path in all aspects of life. 

An overview of people-appraisal is published at this link.

An extensive presentation is my People Appraisal blog

Human Potential

Humanity has much potential to evolve along a virtuous path of compassion, empathy, love. We also have the proven capacity to go in the opposite direction. Our values and beliefs--learned from family, culture, religion, etc.--is what builds our character and guides the direction we take through life.


Even when strongly influenced (traumatized) by some of the worst aspects of human nature, those experiences do not define who we are and need not forever dictate our thoughts, emotions and actions.


Humans have resilience characterized by our ability to learn and adapt to life’s problems and challenges; to change our maladaptive beliefs, feelings and behaviors; and to expand our awareness and understanding of the unseen foundations of reality.

My hope is that this wonderful positive potential of human nature will be the most powerful guiding force of our species world-wide. Striving to realize/achieve this vision is one way to define life’s purpose and meaning.


Wishing you all the best in 2020 and beyond.

Culture and Health: Part 2

In my previous post, I discussed how many Americans believe that a wealth is earned through hard work and poverty is a consequence of laziness. This cultural view implies that if the poor worked more diligently they could become wealthy. It doesn't matter if a person grew up in a disadvantaged community where a good education, healthcare, nutrition and housing were tough to come by, or if s/he was born into wealth privilege where those opportunities were abundant and easily accessible. All that really matters is one's effort. And since poor people's laziness is a personal failing, they do not deserve social and economic programs such as welfare; after all, it's their own fault they are poor. All they have to do is stop being lazy and they would get a good paying jobs that would bring them out of poverty. This includes the working poor...they just have to work harder.

So, as I understand this way of thinking, the assumption is that poor people don't mind being poor because it's easier than hard work. Sure, they'll probably die younger from disease, violence, poor nutrition, pollution and the like. Sure, they can't afford to travel for pleasure, go to fine restaurants, see Broadway shows, buy nice clothes, purchase a home in a good neighborhood, make investments and watch their money grow, etc. Sure, they might have to live in fear of lives, confront gang violence, grow up in broken families, have a history of being ridiculed, experience prejudice, become disheartened and hopeless, etc. But these things don't really matter to people in poor communities since they can take comfort and rejoice in being lazy. The joys of doing nothing productive--not earning a degree, not going to work and earning a good living--are so wonderful that the pain of poverty means nothing to them...they actually welcome it!

Is my understanding of poverty accurate? Am I missing something? If a few people come out of poverty, does it mean everyone in their community can if they just try hard enough? Is thie a logical view of reality?

How our Culture Influences Health

Things a culture considers important strongly influence the health of its people. Some cultures promote beliefs and values that adversely affect the health and well-being of people in certain communities. For example, in a culture that equates the degree of a person’s worthwhileness and deservingness with one’s material wealth, power, status and race is likely to judge poor, weak, “lower class” people of color as unworthy and undeserving and treat them accordingly. Conversely, it would be unlikely for people in a culture that values the virtues of empathy and self-sacrifice for the common good to judge others as less worthy and deserving.

One recent survey found that the U.S. “…public overall is about evenly divided over which has more to do with why a person is rich: 45% say it is because he or she worked harder than most people, while 43% say it is because they had more advantages in life than others.” The results differed by respondents’ income, educational level and party affiliation.

Likewise, many believe that people are poor because they have personality characteristics such as laziness, which is a personal failure that results in poverty. They believe that people who are worthy are rewarded, so those who fail to reap rewards must lack self-worth. This meritocratic view is entrenched within U.S. thought and results in resistance to social and economic programs such as welfare. After all, the belief that a poor person’s lack of prosperity shows a personal failing means that s/he should not be rewarded by public benefits. https://tinyurl.com/y8h7yjhz

Are these beliefs valid? Is it true that people in poor communities don't have adequate nutrition, healthcare, housing, etc. because they have in-born personality flaws that prevent them from getting a decent job and living a healthy lives? Are they just getting what they deserve?

Or should our society do more to help improve the social and economic conditions of disadvantaged communities that deny people healthy lives? Should we, for example, consider social determinants of health--such as good healthcare, nutrition and education--to be a right for all?

Social Determinants of Health

Social Determinants of Health (SDH) are being recognized as important factors in people health and well-being. They include:

• Economic stability: Poverty, employment, food insecurity, housing instability
• Education: Language and literacy, early childhood education and development
• Social and community: Social cohesion, civic participation, discrimination, incarceration
• Neighborhood and built environment: Access to foods that support healthy eating patterns, quality of housing, crime and violence, environmental conditions
• Health and healthcare: Access to quality healthcare; health literacy.

I’ve been thinking about a useful way to examine SDH in terms of prevention and treatment of health problems that requires patient self-management and engagement.

It seems to me that a good way to begin is by answering two basic questions: What would be the current reality IDEALLY? How does the current reality DIFFER from the ideal and why? How can current realities be transformed to be more reflective of the ideal.

How’s this for a start – Ideally, everyone should:

• Understand their health risks, problems, and suitable ways to deal them
• Have healthy eating patterns and healthy foods
• Exercise properly in a suitable place
• Access a PCP for physical exams, health risk assessments, advice, treatments, referrals
• Have a multidisciplinary care team (as needed) who follow a care plan that improves physical and psychological health through high-value methods
• Have beliefs, emotions and behaviors that result in wise health-related decisions and beneficial actions • Monitor themselves
• Deal with distressing life problems rationally and effectively
• Live in a safe neighborhood with low crime, healthy environmental conditions, and stable housing
• Have competent, compassionate care givers (formal and informal)
• Have good social support from family, friends, community, etc.

Determining what can be done to overcome the obstacles to the ideal should consider the positive and negative qualities of human nature and cultural values, as well as biomedical factors.

Design Thinking for Health IT

Design Thinking is a recent topic discussed on the AMA's Physician Innovation Network. Following is a comment I posted there.

We have been using design thinking since the 1980s, before I knew what design thinking is. As a practicing clinical psychologist with an strong interest in IT, I envisioned that computers could be used to collect and analyze patient-generated data to help with treatment planning and delivery, as well as outcomes evaluation. I’ve been working for the past three decades to develop and evolve health IT apps through an intuitive process that closely mirrors the five-step design thinking model:

1. Empathize. Through my clinical training, research, observation and questioning my patients, I gained understanding of the information patients could provide and computers could use to support clinical decisions aimed at behavioral and emotional change.
2. Define. This understanding led to insights that defined possible health IT solutions.
3. Ideate. I used these insights to develop more detailed ideas about these defined solutions and discussed them with my patients and colleagues.
4. Prototype. I built prototypes based on these ideas and showed them to others for their feedback.
5. Test. I continually tested and refined the prototypes based on my own observations, assessments, and feedback from others.

This process yielded important benefits. One was my realization our solution should extend to address the relationship between physiological and psychosocial factors since people’s thoughts, emotions and behaviors can affect their physical health and biomedical symptoms can present as psychological problems. As such, I developed a biopsychosocial ontology that categorized and associated physiological/biomedical and psychological concepts; it provided a blueprint that we used to incorporate medical and psychosocial data within the solution. Related benefits are that this solution is relevant to social determinants of health (SDH), and to patient engagement and activation.
We now plan to offer this solution in an open environment for its continued evolution through collaborative design thinking processes.

Practices for Comprehensive Health IT Systems

Following are practices for developing comprehensive health IT systems.

Something I realized early on is that such systems should be flexible enough to continually adapt to new healthcare knowledge and concepts; data models; value sets; data format, terminology and transport standards; use cases; workflows; and diverse user needs.

It should be able to accommodate the needs of PCPs and all clinical specialties, approaches and user roles, as well as patients, with highly useful and useable tools.

It should be able to work in centralized, distributed, point-to-point, and tightly- and loosely-coupled networks using client-server and standalone (desktop) tools.

It should be able to leverage cloud-based storage and computing (all flavors), as well as the local resources of untethered devices that may connect to the internet occasionally.

It should be able to work with third-party tools that provide additional relevant capabilities.

And if it provides decision support, it should focus on enabling knowledge-feedback loops among diverse groups of collaborators who build, share and refine models aimed at continually increasing the value of care patients receive through systematic process and outcomes research that cross organizational and geopolitical boundaries. These models should include ones that focus on the whole person (biomedical and psychosocial), social determinants of health (SDH), precision medicine, clinical workflows, population health, finances, and prevention (wellness care) as well as treatment and self-maintenance of chronic conditions.

Is the Biopsychosocial Approach a Scientific Model?

The biopsychosocial (BPS) model integrates a full range of biological, psychological, and sociocultural perspectives. A Critical Review of the Biopsychosocial Model states that BPS “provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care…[However, science] operates within a system that asserts there is nothing in the universe beyond matter and energy interacting in a time/space matrix...[and] we don't have a rational, empirical way of investigating non-observables...this restrictive view excludes from scientific consideration a great deal of what we regard as quintessentially human.”

Furthermore, scientific models must have “true predictive value…[e.g., predicting] a man's psychological state from his biological data or vice versa [and it must unite ] the disparate elements of human life in such a way as to legitimize a holistic approach [in which] materialism involves more than just matter and energy. Today, we accept that information, its transfer and manipulation…is a material matter…[so] manipulation of brain-based information…is a materialist theory of mind.”

As such, BPS can be considered a scientific model. I contend it also has predictive ability, e.g.:

• It can be predicted that a certain medication may have side-effects that present as psychological/psychiatric symptoms 
• Mental disorders may predict physical disease and vice versa
• Brain patterns may predict psychiatric problems
• Mental disorders make a substantial independent contribution to the burden of disease worldwide.

Reimagining spreadsheets:The incredible capabilities of spreadsheet cells

Our Spreadsheet-based Software Framework (SSF) is used to build apps that reimagine what spreadsheets can do. SSF apps provide new ways to take advantage of a spreadsheet’s power, flexibility, and simplicity. At the core of an SSF app are grids composed of millions of spreadsheet cells. Each cell is a content container with a built-in computation engine that provides a rich set of capabilities for inputting, storing, modifying, calculating and displaying data (described below). SSF apps organize cells into different data models that: (a) harmonize disparate data for aggregation and integration using maps, (b) perform analytics and create charts using data arrays, and (c) enable data inputs and report outputs using lists and tables. These cells are embedded in worksheets, and the worksheets reside in workbooks. The workbooks also provide macros for process automation that includes data access, transformation, organization, storage, transmission, analysis, and rendering, as well as utilization of user forms and integration with third-party tools. The diagram below depicts the many capabilities of a spreadsheet cell, something that few people realize.

A sampling of what we've done with spreadsheets is available at this link and this link.

Wellness: A Proposed Definition

There has been much written about the importance of promoting "wellness" in value-based care. Yet there is no definitive definition of the concept. In this post I offer a conceptual framework for discussion in which I attempt to delineate many of the key factors discussed in the literature, along with my observations as a clinical psychologist. 

Proposed definition: Wellness is a measure of a person’s overall state of health, which is greatest when a person has and uses a set of abilities, desires, behaviors, and resources to avoid, manage, and cope with physiological, psychological (mental and emotional), and mind-body health problems to the extent possible.

The Following delineates some of the concepts in this proposed wellness definition.

1.      Health problems include (but not limited to):

1.1.   At-risk, acute, subacute, chronic, catastrophic, and end-of-life conditions.

1.2.   Illness, injury, dysfunction, disability, disfigurement, and debilitating distress with associated causes (e.g., contagion, trauma, genetics, etc.) and signs and symptoms (physical, emotional, behavioral, and cognitive).

1.3.   Mind-body (biopsychosocial) health problems in which psychological distress adversely affects a person’s physical health and vice versa.

2.      Requisite abilities, resources, and desires include:

2.1.   Abilities:

2.1.1.      Psychological capabilities that enable people to cope effectively with their health problems in a way that reduces the likelihood of denial, ignorance, self-deception, debilitating depression, irrational despair/discouragement and fear, hostility, blame, shame, and self-destructive behavior. These capabilities include focused awareness, rational and adaptive beliefs/thoughts/cognitions, open-mindedness, adequate drive/motivation/will and impulse control, self-determination, reasonable self-confidence, self-understanding, self-acceptance, sound/logical reasoning, reliable knowledge, and intelligence.

2.1.2.      Behavioral capabilities characterized by proactive, competent, and responsible actions that include adherence to evidence-based care plans/guidelines and making recommended lifestyle changes.

2.2.    Social, economic, and environmental resources (e.g., having access to quality healthcare, good health literacy, money, time, a healthy/safe living environment, social/family support, education and access to useful information, access to foods that support healthy eating patterns.

2.3.    Desire to live and develop one’s potential for a fulfilling life characterized love, learning, accomplishment, and other positive activities, experiences, and feelings.

Whole Person Integrated Care (WPIC) IEEE Presentation

A Healthcare Transformation Strategy Supported by a Novel Spreadsheet-Based Software Framework

I will be presenting at the IEEE Global Humanitarian Technology Conference (GHTC) in San Jose on Oct. 20, 2017. GHTC focuses on bringing together people to address critical issues for the benefit of the people around the globe through the deployment and application of humanitarian technologies.

The presentation will describe a healthcare transformation strategy called Whole Person Integrated Care (WPIC). I will discuss how WPIC couples a novel Spreadsheet-based Software Framework (SSF) and a care delivery model that focus on increasing efficiency and effectiveness through evidence-based knowledge and action.

This strategy: 1) integrates “sick care” (treatment of health problems) with “well care” (prevention and self-management) and 2) addresses both physical and psychological problems affecting a patient’s health. The SSF currently utilizes Microsoft Excel to create simple, low-cost, and flexible software solutions that capture, import, export, transform, integrate, organize, store, analyze, render, and exchange data and information. Using a node-to-node (point-to-point) network architecture, clinicians, researchers, patients, and others can connect securely and resiliently, anywhere and anytime, across national and organizational boundaries. This allows collaborators to build, share, evaluate, and evolve evidence-based knowledge and analytic models. The shared knowledge and models are used to make projections, reveal existing problems, identify risks, and offer solutions that support decisions for clinical and business process improvement. 

Included will be a live demonstration of an SSF application recently piloted in a Federal health information technology program, a review of existing SSF tools, and a proposal for an open source community to enable the SSF to develop apps that work on all platforms and devices.

Small Independent Practices - Big Transformative Potential

A post by Dr. John Brady titled My oasis of care is being threatened examined the dilemma small practices (the "little guys") are now facing. Should they become extinct, being consumed by large organizations (the "big guys")? Or does the little guy have an important place in the healthcare? How can the little guys autonomy have the power to transform our healthcare system in very positive ways, especially when centralized control by the big guys is so prevalent these days? Here's what I wrote ...

As a clinician and health IT software architect working in several Federal (ONC) workgroups over the past three years, I can confirm that government focus has been on the “big guys,” i.e., large provider organizations and EHR vendors participating in health information exchanges (HIEs). I’ve been fighting to have the focus extended to supporting the needs of small practices and EHR vendors (the “little guys”).

Having had a solo practice in NY for twenty years (as a clinical psychologist), I empathize with Dr. Brady’s sentiments about the importance of autonomy and independent practices in terms of clinicians’ quality of life and the well-being of their patients. This extends to primary care practices and specialists of all disciplines.

While I contend that care coordination and next-generation decision support are important to increasing healthcare value to patient, it is unwise to ignore or destroy the little guys in the process.

A case can be made for the government’s centralized, top-down, tightly-coupled network (TCN) model that it benefits larger organizations. Primary benefits of the TCN are control and consistency because this model limits participation to people within the same discipline, department, region, organization, etc.; who have access to the same information sources, share similar experiences; who do things in similar ways; and who are under the control of central authority.

An equally valid though opposite model can be made for decentralized bottom-up loosely-coupled network (LCN) of independent collaborators that benefit small practices and organizations. In addition to the professional autonomy benefit, the LCN’s other benefits include creativity, innovation, and attention to differing needs and circumstances of different parties. This is because collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of resource intellectual pools, and offers access to a greater variety of non-redundant information and more content on which to base decisions. As such, the LCNs provide the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative clinical and economic solutions.

An example of an LCN is the communities of referral that form patient centered medical homes/neighborhoods in which a primary care physician and specific specialists and facilities collaborate in the care of a specific patient. These LCNs can interconnect with each other on a nation-wide and even world-wide basis, as well as connect with TCNs. Given the political will and adequate business incentives, this global interconnectivity can be achieved rather quickly, easily and inexpensively. It can be done using a software architecture in which pub/sub nodes exchange information via simple encrypted e-mail (such as the ONC Direct Project).

Realization of this vision would enable independent-minded individuals to maintain their autonomy, while at the same time enabling them to collaborate in regional and international LCNs for the purpose of improving clinical decision support to increase value to healthcare consumers and reward providers who do so.

Dealing with EHR Dissatisfaction (Part 5)

This post is a continuation; Part 1 is at this link. In this post, I describe a examine the question: When it comes to EHRs, whose satisfaction is important?

Someone commented that EHR “satisfaction is in the eye of who? The physician? patient? government? business?... I only hope it is the patient that wins out.” This comment is intimately tied to the question: Who should gain the most VALUE/BENEFITS from EHR/health IT use?

I contend that if they improve clinical outcomes and quality-of-life (through prevention and treatment), while they contain or lower costs to providers/clinicians and prices to consumers/patients (i.e., increasing value/benefits to the providers and receivers of care), then our society (and species) wins in the long haul. A business model that focuses on short-term gains for “me & mine,” rather than on realizing a longer-term vision that focuses on the common good, inevitably harms consumers and those who care for them.

Beneficiaries of this dysfunctional business model are manufacturers, politicians, lobbyists, providers, consumers and others who line their pockets by “gaming the system” through all sorts of unscrupulous (and at times illegal) tactics. Some might conclude that this is just “the American way,” but based on the huge waste of money and resources in the in the UK's health IT system (NHS IT system one of 'worst fiascos ever'), I believe it’s a consequence of capitalism that has lost its way, along with its sense of virtue.

I contend that the underlying cause of our broken healthcare system is our pathologically mutated form of capitalism —a term coined by John Bogle, named by FORTUNE magazine as one of the four giants of the 20th century and by TIME magazine as one of the world's 100 most powerful and influential people—which he said is a “fundamentally a blight on our society…It says something very bad about American society…ultimately, the job of capitalism is to serve the consumer. Serve the citizenry. You're allowed to make a profit for that. But, you've got to provide good products and services at fair prices…What we've done is have…a pathological mutation of capitalism” (see this link).

The rational way forward with regards to EHRs, I contend, is for clinicians to demand health IT tools that enable them to increase value to the consumer and demand fair compensation for doing so (Pay for Value). These tools should be low cost, flexible, ever-evolving, interoperable, and highly useable & useful for the clinician, patient, and researcher/informaticists. It should combine the best (and simplest) methods for data entry, analytics, decision support, and presentation (display), as well as secure transport and storage. They should also be efficient and accommodate workflows (including referral point-of-care, and mandatory reporting processes), and they should include the capabilities that include clinical concept parsing & processing (i.e., tools that improve the use of clinical notes and aid in inductive and deductive reasoning). In addition, they should provide ongoing risk-adjusted information to clinicians about their individual patients and population (cohort) outcomes.

The use of innovative EHR add-ons (companion applications) is a sensible way forward, even though EHR vendors may resist for business reasons that run contrary to the goal of increasing value for patient and provider, which is not surprising as per Bogle’s criticism and the need for "real capitalism, not crony capitalism that we have now in many industries, especially healthcare.” And while EHRs should be able to incorporate information directly from patients, it should also be able to associate and substantiate it with clinical technicalities.

These capabilities are simply way too much for any EHR today, but they can be achieved over time through collaboration that expresses our views and needs, embraces creative destruction, and suppresses regulatory capture that increases complexity, cost, and inefficiency.

Dealing with EHR Dissatisfaction (Part 4)

This post is a continuation; Part 1 is at this link. In this post, I describe a vision of an ideal EHR system that can developed today.

Based on the complaints about EHRs, one can conclude that there would be increased satisfaction if EHRs are thought to be a component of an all-encompassing HIT system. This next-generation computerized system would manage clinical information, as well as administrative data, in a way that increases provider efficiency, enables providers to deliver high-value (cost-effective/safe/quality) preventive and acute care and rewards them for doing so, assists patients/consumers in taking better care of themselves (self-maintenance), and promotes population health.

So, imagine coming together to build a novel EHR-based HIT system that continuously improves clinical and economic outcomes by (in no particular order):

• Capturing clinical information accurately and automatically at point-of-care in real time in a way that requires little effort and workflow change

• Clearly presenting—to clinicians and patients—the biomedical, psychosocial (biopsychosocial) and economic information they need to: (a) bridge the knowledge gap (http://wellness.wikispaces.com/The+Knowledge+Gap) ; (b) make wise prophylactic, diagnostic, and treatment decisions; and (c) promote patient-centered cognitive support (http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html)

• Enabling networks of collaborators to: (a) perform clinical research in the field and lab through the streamlined collection, sharing, and analysis of large quantities of diverse clinical data; (b) build evolving health science knowledgebases with for clinical research, which transform this knowledge into evidence-based practice guidelines/protocols/pathways; (c) promote the continuity and coordination of care; (d) share observations, lessons learned, and best practices; and (e) effectively run PCMHs and ACOs

• Integrating sick care with well care (see http://wellness.wikispaces.com/Tactic+-+Well-Care+Sick-Care+Integration)

Also imagine that this next-generation EHR system:

• Facilitates ongoing biosurveillance and post-market drug & medical device surveillance

• Streamlines mandatory regulatory reporting.

• Connects providers/clinicians to one another in (a) loosely-coupled, occasionally connected, near-real-time, asynchronous, peer-to-peer mesh networks (e.g., DIRECT e-mail) and (b) tightly-coupled, continuously-connected, real-time networks (e.g., corporate VPNs)

• Secures PHI while it’s being exchanged (in transit) and while stored in a device (at rest), as well as protecting patient privacy

• Provides a hybrid approach to information access and exchange that includes Web-based tools, services and deidentified information stores in the cloud, along with standalone applications on users’ devices

• Provides useful business intelligence

I claim that, by working together, we can realize the vision described above by adding common off-the-shelf HIT tools and custom-built applications to EHRs. I know how this can be done!

Part 5 examines the question: When it comes to EHRs, whose satisfaction is important?

Dealing with EHR Dissatisfaction (Part 3)

This post is a continuation; Part 1 is at this link. In this post, I discuss what's needed to make EHRs more satisfactory and answer questions about my claims.

I wrote:

What’s needed is a paradigm-busting shift in which clinicians and software developers collaborate to create tools that are truly clinically useful and promote (rather than destroy) efficiency. We can start by redefining Meaningful Use – see my blog post at http://curinghealthcare.blogspot.com/2009/05/defining-meaningful-use-of-health-it_02.html

I then answered a question about my claim that over-reliance on XML and Web services is a big problem with HIT standards:

I'm not saying that XML can't work; just that XML is being over-used. When data sets are rather simple or XML is used for sending messaging operation instructions for web service, I have no problem with it. But when it comes to representing complex data, as in a CDA-based document or a complex form definition file, XML sucks!  

Here’s why: When you use XML in such cases: human readability is a joke, verbosity is huge, and parsing requirements and complexities are immense. It also forces conceptual incongruities just to keep data in hierarchies when such parent-child relationships are unnecessary. See http://curinghealthcare.blogspot.com/2009/12/dueling-data-formats.html and http://c2.com/cgi/wiki?XmlSucks.In fact, I’ve seen XML-related complexities bring the Query Health initiative to its knees (see http://curinghealthcare.blogspot.com/2012/08/disruptive-innovation-in-health-it-path_8.html).

I fought against this "let's use XML for everything" mentality since the mid-90's, but to no avail. Now the crap is hitting the fan!  

Bottom line is that there are much easier/simpler and more rational ways to represent complex data than XML, even hierarchical data. We've got to start busting maladaptive paradigms.

Regarding the web services issue, I have no problem with this architecture for the most part, but bringing SOAP and RESTful into the DIRECT Project, and relying on them exclusively in other Federal initiatives, adds similarly increased complexity, as well as vulnerability, as I discuss at http://curinghealthcare.blogspot.com/2012/07/oncs-direct-project-in-defense-of.html.

What we need is a hybrid approaches that balances web services and XML with simpler elegant methodologies.

These issues came to a head during the standards-making process at the S&I Framework Structured Data Capture (SDC) initiative where I fought for the inclusion of a much simpler approach to capturing data using electronic forms, but was voted down by the community (see http://wiki.siframework.org/Canddiate+Standards+List+Feedback). To their credit, however, they are allowing our team to pursue a pilot (on our own dime) even though it will demonstrate use of technology/methods that aren’t fully compliant with the implementation guide they are developing.

In any case, the kind of change we need isn't going to happen by EHR industry lobbyists or the Feds ... As I said before, it's got to be led by clinicians and researchers working closely with creative software developers (including nimble EHR/HIT vendors) who focus on designing and deploying clinical tools that are truly useful and useable.

In part 4 at this link, I discuss a practical vision of a next-generation EHR system that can be built today, which addresses the many criticisms of what is happening today.

Dealing with EHR Dissatisfaction (Part 2)

This post is a continuation; Part 1 is at this link.

The next issue turned to who should ultimately control a patient's data. Should it be the patient (patient access control), provider/clinician, care team/ACO/PCHM, HIE/gov't/CMS?

Here's what I wrote:

Some believe patients should have granular control of who gets to see their health data and, if de-identified and aggregated for population health research, that the patient should be compensated financially for authorizing such use of their data.

Concerns about PHI privacy and gov't control are certainly warranted and, I agree with Randall, that legacy systems have been incapable of doing what's needed to give patients peace of mind that storing their PHI in the cloud provides a high enough level of privacy protection. We cannot achieve the Triple Aim unless we have wide deployment of a secure, low-cost, always available, and simple way to exchange data from EHR to EHR, EHR to PHR, EHR to Population Health and After Market Surveillance repositories (with de-identified data), and from Person to Person (patient to clinician, clinician to patient, and clinician to clinician).

A pub/sub, loosely-coupled, mesh node network, with identity management and endpoint-to-endpoint encryption, is one way to achieve this.

The next issue raised is whether the actual goal of healthcare reform is to make it fail. I responded by saying:

I've heard from more than one person that current healthcare reform efforts were designed to fail. While I'm not sure about that, I AM confident that the cost, complexity, inefficiencies, and insecurities built into current implementation regulations are too big NOT to fail.

Nevertheless, the underlying goals of ARRA HIT--to improve care quality and contain costs/prices (i.e., increase value to the consumer)--are absolutely essential. We have a real big problem if all the spending and hassles are just a manipulation to funnel taxpayer's money into the coffers of certain big corporations under the guise of helping the common good.

As such, I believe physicians and other clinicians, researchers/informaticists, and HIT developers have a duty to participate in loosely coupled collaborative networks focused on ensuring that the HIT being developed is designed and used to improve patients' health and wellbeing, to minimize the burden and maximize the competency of providers, and to reward delivery of high value care.

I then went on to describe my experiences as a committed member of the government's HIT standards bodies:

Having been involved over the past few years in a half dozen HHS/ONC technical workgroups that determine EHR/HIT standards, my associates and I have been like David facing an arena of Goliaths. I've been dealing with the biggest EHR vendors, as well as Federal contractors and agencies. It's been a very frustrating and enlightening experience. We entered the arena with the faint hope that the powers-that-be would compare our simple, low-cost, highly capable, disruptive innovations to the complex, convoluted, expensive mainstream technologies currently being adopted.  

What we’ve found is that the standards-making process is rife with regulatory capture in which new standards are built on top of old standards without due consideration of modifying those standards in light of new and better technologies. Simplicity, efficiency, and usability are an afterthought. The result is an extraordinarily complex set of monolithic processes that few (if any) can implement and few are willing to use.  

Examples include, in no particular order: (a) an over-reliance on XML data representations and Web services, (b) long delays due to HL7 voting processes, (c) changes to DIRECT taking it from what was supposed to be one step above the fax to a convoluted amalgam of HISPs that make PHI vulnerable with exposure to man-in-the-middle attacks, (d) incestuous relationships between vendors and ONC that block innovation from “outsiders,” (e) reticence to deal with difficult clinical workflow issues, and (e) the natural tension between making huge leaps in EHR system capabilities and the “let’s just keep crawling until we can walk” mentality. The result is that money continues to be spent with dismal progress in enabling HIT to increase value to the consumer while enabling and rewarding providers for delivering such value.

It seems to me that most of these problems are due to business strategies and tactics supported by regulatory capture; it is not a technology issue, per se.

In part 3, at this link, I elaborate about the problems identified above.

Dealing with EHR Dissatisfaction (Part 1)

For the past few days, I’ve been involved in a very good conversation at LinkedIn HIMSS titled: Can we turn EHR dissatisfaction around?

Here’s a comment from person that struck a chord:

It took the doctor 2 minutes to dictate as opposed to 30 minutes to use speech, edit and/or type. In addition, if the text is not edited in most cases except for those of you have it down perfect, you get crappy documentation that is (oh my goodness) actually used down the road to treat a patient. I can also introduce you to several law suits filed due to the poor documentation of a physician who refused to edit his dragon speech and just let it go into the chart. I can also introduce you to a neurologist who spends 4 ADDITIONAL HOURS a day documenting in an EHR. He has been at it for over a year so apparently this brain surgeon is an idiot who can't be trained. All of your responses to this, even the "this is off topic" are very revealing as to one source of the problem. Like typical programmers, no one wants to hear they have a bad design or the product actually needs more work.

So, to stay on topic, "Can we turn it around?" yes but only when you listen to the experts in the field you are dealing with - medical record specialists and physicians - they seem to be the people you have left out of the equation.

I'm a clinician (clinical psychologist) and HIT software inventor/architect/developer with 33 years’ experience in both areas. What I've noticed is that programmers routinely rely on healthcare subject matter experts regarding product content, the same is often not true regarding workflow adaptation, usability and usefulness issues.

It's relatively easy to create databases and forms for data entry and presentation, but it's quit difficult to construct the inputs and outputs in ways that streamline workflows, integrate and organize complex interdisciplinary data in clinically meaningful manner, generate clinically useful information that supports decisions at point of care, and present that information in ways that promote knowledge and understanding that lead to greater value for the consumer/patient.

Herein lies the problem, imo, and it is where disruptive innovation is sorely needed!

Unfortunately, such creative destruction is often hindered by governmental regulatory capture in which big bucks direct the regulators who dictate the rules that constrain innovation, focus on appeasing big business, and drive up complexity and cost.

A short while later, Randall Oates, MD posted a comment that ended with:

It is time for more enlightened physicians to step up and assist/collaborate the transitions to processes generating EHR notes that are more clinically useful, while meeting basic billing/legal/reporting needs of others as well. Otherwise, physicians have to mainly blame themselves for systems that don't meet their needs.

To that I replied:

Randal, I'd to add to your excellent statement: "...and present, in a concise integrated view, the relevant interdisciplinary information needed to support their clinical decisions, at point of care, that is focused on continually improving outcomes and care value.

For past year and a half, I've been volunteering my time in a Federal workgroup (WG) called the 360X initiative and work alongside Cerner, Epic, and several other large EHR vendors and HIEs on implementing closed-loop referrals. In the WG, I'm a "little guy" offering novel ideas and methods to the "big guys."

I sincerely believe that the clinical and technical folks in the workgroup do want to improve their products, despite the fact that I have had to repeatedly insist that instead of focusing on doing the minimum; we focus on dealing with the big, complex issues, especially regarding workflows.

I'm also involved in several other Fed workgroups that create HIT meaningful use standards. What I've noticed is a general tendency to keep things complicated, while at the same time, minimizing the scope of their efforts. Many times, when I’ve tried “push the capabilities bar” higher--and even offered innovative ways to do it)--I’ve heard the phrase: “We should first crawl and then walk before we try to run.” Unfortunately, after all these years, when it comes to enhancing EHR systems' clinical usefulness and security, there's too much crawling under the "low bar," and a general aversion to trying to "leap over the high bar."

I believe there are many reasons for this and they mostly relate to the “business layer” supported through regulatory capture by HHS/ONC.

After three decades of HIT involvement, I’ve come to the conclusion that what we need is to transform EHR products into “EHR systems” (a term I helped add to the Fed’s lexicon and workgroup charters). These EHR systems would be enhanced through integration with low cost, easy-to-use “companion applications” that fill in gaps in EHR usability, usefulness, interoperability, and protection of PHI.

The companion apps are likely to be disruptive innovations created by loosely-coupled collaborative networks of small nimble companies and individuals with diverse backgrounds and experiences, who share, discuss, evaluate, and continually evolve models (types of apps) focused on different use cases and types of end-users.

 [Continued in Part 2 at this link]

Should "Value" Be the New Mantra in Health Care?

On  the Commonwealth Fund blog at this link is a new post titled: "Should "Value" Be the New Mantra in Health Care?"

 

This is good to see! I began blogging about the need to focus on Value to the Consumer back in 2007, starting with a post at http://curinghealthcare.blogspot.com/2007/10/path-to-profound-healthcare.html.

 Value is a complex issue that brings into light the notion of cost-effectiveness and how to compensate providers who demonstrate a commitment to high-value care via Pay for Value (P4V) models.

 I contend that a firm focus on value is the ONLY way to solve the daunting problems plaguing healthcare delivery. If we don't, costs will continue to rise without corresponding quality improvements, and cost reductions will likely result in worse care outcomes.

Defining a Rational Healthcare Value Network

A value network is a marketing concept that describes the social and technical resources (supply chain) within and between businesses. They account for the overall worth of products and services, including the collection of upstream suppliers, downstream channels to market, and ancillary services that support a common business model within an industry. The kind of value network that the healthcare system needs focuses on bringing increased value to healthcare patient (consumer) and reward providers for delivering high-value care.

Such a value network has four primary interacting components, as depicted in figure above. These components enable cyclical data flows—affected by drivers and impediments—that increase care value to the patient:

1. The green box refers to three types of data required to build the information and knowledge people need for increasing value across the supply chain. The education data refers to formal and informal ways that people share their knowledge, ideas, and experiences. Research data, on the other hand, is used in controlled clinical trials, outcomes and performance studies, various types of biosurveillance (e.g., post-market drug and device, public health), preferred clinical guideline development, and other types of research. Technology data refers to the date collected by EHRs and other health IT (HIT) tools, as well as streamed through durable medical equipment.


2. The five blue boxes refer the transformation of the data using a variety of HIT tools and clinical processes that promote the kinds of knowledge and understanding that fosters more effective and efficient care (services and products). They include (a) use of evidence-based guidelines, personalized care plans, decision support tools, and communication networks; (b) methods of information sharing and care coordination; and (c) patient empowerment. Each activity (process) in the blue boxes supports value by requiring quality handoffs and continuous measurement, assessment, feedback and acceptance at each breakpoint (the gap between each activity) to ensure value creation via continuous quality improvement (CQI).


3. The red box on the bottom refers to the technological, psychological, economic, and regulatory factors that promote or inhibit value to patient by influencing (driving or impeding) the blue box processes. Some of the key influences are listed in the box.


4. The purple box represents good patient outcomes; it is the desired result of using the data, tools and processes to increase value to the patient. The curved purple arrow pointing to the Data Types box indicates the need to provide data about the process, influences and outcomes of care across the entire supply chain via continuous feedback loops. The blue box activities and their related influences that help achieve the goal of higher quality at lower cost are reinforced; those that do not are modified or eliminated.

Leveraging health IT to promote value through CQI is a strategy that focuses on (a) learning from our past, current and futures practices to determine what results in the best outcomes at reasonable cost and (b) transforming this knowledge into high-value healthcare. This solution fosters greater care quality and affordability through (a) use of appropriate evidence-based guidelines and lessons learned; (b) implementation of personalized care plans and decision support tools; (c) information sharing among collaborative teams in social and technology networks; (d) informed decision-making; and (e) fostering patient compliance and responsible behavioral choices.

This CQI solution does not strive for zero defects (no errors of omission and commission) because perfection assumes infinite resources and knowledge, both of which are unrealistic. Instead, it is based on the Michael Porter’s value chain model, which assumes defects (errors) will occur and, therefore, we had better accept some reasonable level of tolerance, reconcile mistakes and poor outcomes, and strive to ensure ever-better outcomes at reasonable cost for a given condition.

Ensuring patient access to high-quality healthcare at reasonable cost through the value-driven CQI solution requires adherence to these critical process transformations:

• Supporting value for each primary activity through quality handoffs (the transfer of information, as well as authority and responsibility, during transitions in care across the continuum) along with ongoing measurement, assessment, feedback, and acceptance at each breakpoint (the gap between each primary activity).
• Assuring that all infrastructure or support activities (a) promote a seamless support relationship that benefits the primary activities, (b) avoid impeding the primary activities, and (c) follow CQI rules for each component across the entire healthcare spectrum.
• Operating with awareness of current healthcare system shortcomings that focuses on areas with quality improvement is warranted.
• Addressing the problems associated with defining quality in real time versus retrospective analysis, for both individual patient and aggregate data.
• Focusing on root cause identification to determine the factors preventing clinical outcome and cost improvement, instead of playing a “blame game,” which only exacerbates the problem.

ONC’s Direct Project: In Defense of Simplicity

Over the past year or so, I’ve been deeply involved in various Federal gov’t health IT initiatives, including the Direct Project and Query Health. This is first time, I believe, that the public (private sector “outsiders”) has had access to the inner-workings of the Office of the National Coordinator for Health Information Technology (ONC). While I’ve been delighted with this new level of transparency, I’ve been dismayed by the way the process tends to transform simple ideas and sensible goals—aimed at improving care quality and efficiency—into overwhelmingly complex, convoluted and costly technical specifications and requirements!

One of the reasons for situation is that people often “come to the table” with preconceived notions of what is possible and how do it. These narrow/closed mindsets are either unaware or prone to reject  technologies that provide simple inexpensive solutions through the “novel combinations of existing off-the-shelf components, applied cleverly to a small, fledgling value network”) in favor of conventional technologies (commodities) that lack those positive qualities. Following is just one example.

A few months ago, Dr. John Loonsk (CMO of CGI Federal) wrote a widely cited article at this link in which he criticizes the Direct Project’s reliance on SMTP (Simple Mail Transfer Protocol)—the simple method for transporting e-mail messages that’s been widely used since the early 1980s. His criticism is based on the fact that SMTP uses a “store and forward” process in which messages are stored locally (in the user's computer) and then sent to the recipient. He claims that SMTP is insufficient and thus should be augmented by types of Web Services, such as SOAP or RESTful methods, which tend to be considerably more complex than SMTP.

In his critique, Dr. Loonsk takes a “closed inside-the-box” view of SMTP-based e-mail. Following are my responses to his key issues. In contrast to his narrow conventional point of view, my replies take an “open outside-the-box” perspective of SMTP’s capabilities that incorporates a novel publish/subscribe (pub/sub) node-to-node desktop architecture (see this link for technical details).

Issue 1: Dr. Loonsk wrote that “the store part of SMTP…introduces new security concerns even with encrypted data.”

My reply: Since when is the encryption of stored files not enough? These days, it is free and easy to encrypt not only individual files, but even entire hard drives (or partitions) can be protected with bit-locker encryption. With this kind encryption of stored files, along with encryption of e-mail in transit (e.g., using PKI), Protected Health Information (PHI) is protected end-to-end (in transit and at rest), which is about as secure as you can get!

In contrast, the Web Services approach can leave PHI exposed at the web server, e.g., when Web Services provide the in-transit encryption and when they transform the PHI format as it passes between disparate EHRs. With the SMTP pub/sub node-to-node architecture, on the other hand, all encryption and PHI transformations are done by the sender prior to transporting the e-mail.

One more thing about XML security: Encryption vulnerabilities. According to an interesting (and technical) blog post by a cryptographic engineer, encrypting XML securely requires extra steps to prevent a "ciphertext" attack that exposes the encrypted XML content. The author concludes: "If your system is online and doesn't have a solid, well-analyzed protection against them, don't pretend that you're doing anything at all to secure your data. I wish I had a funny, pithy way to sum this all up. But honestly, I'm just a little depressed."

Issue 2: Dr. Loonsk wrote that “Because SMTP store and forward infrastructure can only do the push transaction, it is a limited platform standard and a technical dead-end in trying to address other transaction needs…a true U.S. health system all seem to need more [which does] not stop with the data that one provider anticipates another provider will need…[nor] with the assumption that providers will reliably initiate a store and forward SMTP transaction to move the right data to all that need them.”

My reply: The SMTP pub/sub node-to-node architecture actually enables both “pull” transactions whereby the request for the transmission of information is initiated by the receiver, as well as “push” whereby the request for a given transaction is initiated by the sender. To perform a pull transaction, the party who wants to receive the PHI (1^st party) e-mails a request for it to the party with whom the PHI resides (2^nd party). Upon receipt of the request, the 2^nd party responds by sending the requested PHI to the 1^st party. Either or both parties can do his manually or have it done programmatically (automatically) by the software. This simple solution resolves the SMTP push-pull issue. Nevertheless, as reported by ONC in 2009, push messaging is crucial because it is "...less complex and will be far more readily available to a broader range of providers than so-called 'pull' technologies.

Issue 3: Dr. Loonsk wrote that, unlike Web Services and REST, the SMTP infrastructure does not support HIE functions such as “unanticipated needs, unanticipated providers, reliable data access from unreliable senders, accumulation of data into longitudinal and population records, accessing registries and data for decision support, accumulating quality reporting data, querying to get more data when needed, a raft of directory services, and with team care, the shared management of care plans, problem lists and other data.”

My reply: The SMTP pub/sub node-to-node architecture actually does support these functions and we’ve demonstrated such capabilities with our software tools using SMTP.

Issue 4: Dr. Loonsk wrote that “One argument for SMTP has been that it is more accessible to small providers. In practice, implementations to date have involved more complexity than predicted and…[rely] on an outside organization – a Health Information Service Provider (HISP) to carry the technical load. If a HISP is necessary, a more robust platform standard like Web services or REST would seem to be just as achievable as SMTP.”

My reply: Unlike Web services or REST, the SMTP pub/sub node-to-node architecture I’ve been describing does NOT rely on a HISP since the desktop e-mail client (MS Outlook in our case) carries the technical load, not the HISP. To comply with the Direct Project requirements, however, we use a HISP for PKI certificate management and provider registries, but the actual e-mails pass right through the HISP from senders (publisher) to their recipients (subscribers).

In conclusion, the view of Dr. Loonsk and many others fail to realize how breakthrough innovations, like our novel SMTP architecture and apps, can accomplish what seems impossible to folks focused conventional technology. Though no doubt well-intentioned arguments by intelligent people, their criticisms do not provide good reason for denigrating the simple, sensible, survivable solution SMTP provides.