The Human Computer

Recently I was asked to review an article about IBM and the Mayo Clinic's recent decision to release natural language processing or NLP code to the open source community and comment on how likely the open source development model and delivery mechanisms like Software as a Service (SaaS) or Service Oriented Architecture (SOA) will become the preferred models for delivering healthcare IT solutions. I've pasted my response below...

Alright, here are some observations but be prepared, it's a bit out there......

I think that it's kind of important to draw a distinction between the FSF/OSF development model and SasS/SOA etc... as delivery model. Linux was sort of special in that it really set a new visible standard for collaborative development in a community. That's not to say that it never occurred before. DARPA/ARPA and the military contractor/technical academic community were the real pioneers for this in many respects. Think of BSD UNIX vs AT&T System V for example. You basically have academia, big R and D shops in new markets (Bell Labs) and military contractors setting up collaborative environments with tons of freedom for brilliant people who want to use their creativity. Richie and Thompson invented UNIX almost in their spare time. Ritchie invented C because he couldn't write UNIX in B (true story) and C was the great grand daddy of a ton of 4th generation languages and definitely set the standard for compilers.

The point is that Linux wasn't the prototype model. It's just that over time the companies that fostered these communities got a grip on their intellectual capital and switched the focus to selling them. Once money is attached to an idea it's no longer psychologically possible to maintain an open flow of ideas and creativity around that idea. This is a system that rewards true brainstorming where no idea is a stupid idea and the person who helps his brother/sister find an answer is more valuable than the person who builds a silver bullet to feed an ego. This I think is a key concept, more on that below.

Linux and GNU revolutionized things by understanding that a large number of brilliant creative people care more about the free and open flow of creativity and ideas than making money. CPA finance best practices don't seem to mix easily with people who are wired to understand things and solve them because it's satisfying. It creates a kind of cultural dissonance and a myth that there is a choice (albeit a suckers choice) between having either the open flow of ideas/creativity OR the efficient and effective financial principles of selling in a market. There are more and more companies though who recognize this as a suckers choice and know that it's not an OR but an AND to be successful. Red Hat supports the open source community, fosters and respects it while making buck. IBM's transformation from big iron hardware vendor to services company was enabled by their willingness to embrace the FSF community, contribute generously and then fill a niche helping their business partners deploy these far cheaper and high quality solutions to a variety of business problems. I suspect their real target in considering a purchase of sun is MySQL (the fabled open source database that does 80% of what you need a database for REALLY REALLY fast) and Java. I can imagine them turning Java loose in the FSF community and watching it blossom into capabilities that make their consulting services that much more valuable.

We're moving from an industrial age and economy into a knowledge and information age. The winners are no longer going to be defined by who can protect and sell "things" or products. Instead it's going to be more effective to foster people's built in desire to be creative, productive and, well, human. I think this is an important concept and yes, more on that below.

SaaS and SOA can be thought of as architectures. What people generally call Web 2.0 are also. They're the next layer of abstraction in the evolution of computing. Just as punch cards evolved over time into 4th generation languages each evolution brings ease of use to computing and generally amplifies our ability to solve problems more naturally. I think it's easy to forget just how unnatural it is that we rely on a bunch of signals traveling through solid state logic gates to synthesize meaning on a CRT or LCD display truly is. The real work is done at the end of the day by the person who reads and interprets those images and uses the most powerful computer known (the human brain) to translate those abstractions into action. While SaaS, SOA and Web 2.0 types of technologies can ease the burden of that translation and make it easier for us to use technology to communicate they are still terribly crude compared to the richness of human interaction. There will be successors to SaaS and SOA. So I think the REAL benefit that they provide is in simplifying the common understanding and language of how we interact with computers. Music is a pure and natural human language in many respects. Emotion and meaning can be conveyed in a very real and raw state through composition and arrangement. SaaS and SOA help us get closer (even if we're still light years away) to that quality of communication by giving us standard mechanisms to arrange how we interact with each other through technology. I think this is the link between SaaS/SOA and the cost of technology. As technology evolves towards allowing us to spend more time on the message and less time on constructing it the flow of ideas becomes easier. This is a key concept.

If the keys are that creative collaboration is becoming more valuable than proprietary protection, fostering creative collaboration will be the key to being sustainable in the future and that the evolution of technology is moving towards enabling the communication required for collaboration then where in the heck is healthcare as an industry and healthcare IT going to have to go? Here are my predictions...

1. Healthcare's cost is driven by it's complexity and variability. The need for standardization in healthcare will be both drive and be driven by the need for easy interoperable exchange of patient information across the continuum of care.
2. SaaS and SOA are most effective when dealing with the standardized exchange of data (think RSS) so if standardization continues to gain traction via HITSP, IHE etc then they will become even more viable delivery options.
3. The need to exploit our most efficient and powerful resources, the minds of countless doctors, nurses, technologists, patients and other stakeholders, will drive us to converge on technologies that simplify the creative process.

I think that the end-point is likely to be SaaS, SOA or something that comes along later that fits this bill. Creative collaboration (aka the FSF model) is gaining momentum and will reach a tipping point once the pain of doing it the way we've always done it is greater than the pain of what will come next. I think that we're on the cusp.

So here's the deal. You can't just let me ramble like this without giving me some feedback. Help me develop this idea into something useful....

P.S. I think that NLP technology (as referenced in the article) has a ton of potential and could even break down some of the barriers and challenges associated with traditional business intelligence. In the short term though structured data and standards will serve us better since they help drive down the variability that is the root cause of our countries high cost of healthcare. The decision to open source it's development is both intelligent and responsible.

To centralize or decentralize, that is the question...

I found the following article by Kevin Crowston and James Howiston about the Social Structure of Free and Open Source Software. It explores the implications of measurable communication patterns on the assertions of the Cathedral and the Bazaar metaphor, namely that highly decentralized and somewhat chaotic social structures are capable of creating higher quality and more generally useful products than traditional closed projects that focus on creating competitive advantage through protecting intellectual property. This is a crude definition so I highly recommend following the link above.

Crowston and Howiston examine data associated with bug tracking on a variety of open source projects and develop a methodology for measuring the degree of decentralization of a given project. Some of their conclusions are very very fascinating and made me think.

In The Wisdom of Crowds and Wikinomics the concepts around mass collaboration, ala Linux and the Cathedral/Bazaar metaphor, are explored and the potential benefits of these models are sorted and categorized. This is giving rise to some interesting conversations about organizational operating models and competitive advantage via collaboration. There is the potential here for lots of c-level executives to hop on a very popular but tricky bandwagon. Like everything else the trick is in the execution.

How many companies have adopted the tenets of process engineering or continuous improvement through six-sigma and lean techniques? Many of these companies are seeing the benefits of these tools and methods but they don't really translate to a competitive advantage because their competition deploy them as well. Like these tools mass collaboration, and it's enabling technology, is likely to become a necessary standard of operation rather than a revolutionary competitive differentiator with a few exceptions. As with all things that comprise the standard book of operating principles and tricks execution will be the real test and therein lies the trap.

The real lesson of Crowston and Howiston is that mass collaboration is not a well defined thing with clear boundaries and a cookbook for success. It's an enabler for truly inspirational and robust organizations. If the apple is rotten at the core then you're only enabling more rapid decay. If the apple is strong and fresh then you're getting ready to bake a mighty good pie. The core of any good organization is it's people.

So beware the seduction of techniques, tools and processes that claim to be the key to competitive advantage and cookbook success. Just like late night infomercials it's snake oil. Instead look to your people and the rest will come. In their minds, voices and inspiration lies the real wisdom, centralized or decentralized.

Why do we pay for software again???

VistA is a HIS system developed by the government and made freely available. It's used outside of the VA as well. It's built on the same Mumps or M platform that McKesson uses for STAR and Epic uses for their EMR technology. Mirth is a freely available HL7 interface engine. There are several other open source EMR products out there. Bulletin boards, web servers, wikis, content management systems and J2EE servers can all easily be found freely available under the GPL.

Per the Wikipedia entry...

"The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA.[6]"

It also states that most organizations that implement see an approximately 6% improvement in efficiency and that the cost of the implementation can be covered by reducing a few unnecessary lab tests.

So why are we paying for software again? A full 60% of our IT budget is spent on support maintenance agreements (SMA) every year. We get the following benefits from these dollars...

• The right to actually use the software, usually in the form of licensing.
• The ability to call a help desk or support organization for help.
• Updates and patches.

All of this even if we don't call the help desk or upgrade the software. Furthermore all of this comes with caveats that basically void any guarantee that the software will work if we don't stay up to date version wise.

VistA and Mirth both have developers that contribute to the system, user and support groups that assist when there are problems and all of this is available for FREE. There are no guarantees, unless you want to pay someone for the support.

A full 30% of our budget is labor. The lifeblood of any knowledge based industry and at our company they are the mission alive. We have been told by our biggest vendor partner that we are sometimes a challenge to support because of the quality of our technical folks. We challenge them in ways that they usually aren't on a consistent basis. Our server, application, process, data, network, development, desktop, telco and database staff regularly find bugs and fixes that our vendors struggle to tackle.

Hmmmmmm....

What if we converted to a total Open Source solution. We could dedicate half of the existing SMA budget to grow our staff. Better yet dedicate a third to labor and a sixth of it to training and deployment of (Open Source) collaboration tools. The remainder of that money gets reinvested in the hospitals and clinics. With our new staffing model and skill set we improve the products and feed the improvements back into the industry. We push the products to easier and easier to support so that smaller facilities and clinics can afford to implement an EMR. We contribute to and participate in the support forums and train other IT professionals to use the model so that all of healthcare in this country can benefit.

No more SMAs......

Blueberries

Not far from where my family lives there is an abandoned blueberry farm. It's not actually abandoned. It was purchased by a group that preserves farmland and now people are free to pick the blueberries. We go there nearly every year and my wife's blueberry cobbler is heaven in a bowl ala mode. There are volunteers that come in and trim back the lilacs that are trying to take over. Some years there are fewer volunteers and we trudge through boggy mud up to our calves to find unpicked berries. It's sort of a hidden community garden.

Open Source software is that way too. There are hundreds or thousands of projects developed mostly by volunteers and usually offered for free via a licensing model known as the GNU Public License (aka the GPL). Wikinomics is a great book about how open source, idea markets and the knowledge economy is being accelerated by software such as the LAMP (Linux, Apache, Mysql and PHP) stack and other technology innovations. Just as more and more farmland is preserved for future generations by passionate volunteers who see and feel the potential for a better future there are passionate volunteers who imagine, propose and participate in the development of new tools to make peoples lives better. It's inspiring.

I came to healthcare through my families love of service. I came to healthcare IT through Open Source Software so I naturally try to see our industries opportunities, challenges and possabilities through that same lens of realistic optimism. It's not always easy. The challenges are not trivial but when we get it right the blueberries are delicious and when we have a good partner to help us cook the cobbler life is good.