I have a sad story to tell you.  Sit down and grab a tissue.

It was 10pm on a cool night in September 2005.  Somewhere in Grapevine, Texas, a junior SQL Server professional was sitting alone in a hotel room watching TV.  He was tired but not exhausted, having spent all day learning his trade at the Super Bowl of SQL Server conventions, the annual PASS Summit.  Although he had met a few people, he didn’t really get to know them or try to meet up with anyone the normal conference hours.  He attended a couple of parties, but left early and didn’t get beyond chit-chat with others.

Across town, much fun was being had.  Stories were told, laughs were shared, and personalities bonded.  People went out on a limb and introduced themselves to others they’d never met.  Some people would literally change the trajectories of their careers through the relationships that were built at this conference.  Sadly, the guy in the hotel across town is missing out on all of this.

As the conference wore on, he saw all those people chatting between sessions and at dinner, laughing and getting to know each other, and secretly he wished to be connected to some other professionals.  You see, since he was the only SQL Server professional at his place of employment, he didn’t have a lot of opportunities to talk shop in person with others.  He longed for what they had, but couldn’t find the initiative to start up meaningful conversations with others.

As the conference wrapped up at the end of the week, he was appreciative of the technical knowledge he’d be taking home, but couldn’t stop dwelling on the fact that he’d done little networking at this event.  It was almost as if he’d missed out on half of the conference.

The man goes back to his job and reads the blogs of those who also attended the summit.  He begins to think, “I’m no different than those people, I just need to be more assertive.”  He realizes that networking is as big a part of career success as is technical knowledge, and that it’s easier than he’s made it out to be in his mind.  He vows then never to again sit on the sidelines; he promises to himself that he will take full advantage of these functions by getting involved in related events outside the scope of the conference.

The story does have a happy ending.  “That guy” was me, and I did indeed waste a huge networking opportunity four short years ago.  With that lesson in mind, I swore off being the wallflower and now take the initiative to be more assertive at each technical event I attend.  Though I don’t set specific numeric goals, I make it a primary mission to get connected with people, to learn what they do and to share a little about what I do.  I’ve come to learn that getting to know fellow SQL Server professionals at technical conferences is at least as important – and quite possibly even more so – as the technical content.  I can tell you firsthand that the relationships I’ve built since then have led to many opportunities in my career I wouldn’t have otherwise found, and I’ve built some friendships along the way as well.

So the takeaway is, don’t be me – at least the Me In 2005.  Don’t be lonely hotel room guy: use your hotel room for one thing – sleep – and spend the time with others getting to know them.  At next week’s PASS Summit, there are official events scheduled for every night of the conference, along with numerous unofficial events.  There are vendor breakfast presentations, lunchtime meet-and-greets, and various other opportunities to press flesh and get to know your fellow SQL Server professionals.  One of the people you meet could be your next boss, employee, business partner, client, or even a good friend.

In the first installment of this discussion, I talked about the challenges facing database professionals and others with respect to healthcare data integration.  In this post I’ll talk about the first part of the problem: a lack of adoption of the required technologies and/or methodologies.  I’ll also describe when an electronic health record really isn’t.

We’ve all seen it; it is still the de facto standard of medical documentation.  You sit in the reception area and the nurse or clerk gathers the initial information: demographic information to confirm your identity, insurance information, the reason for your visit, and  metrics such as your blood pressure, pulse, or weight.  He also asks you about any medications you’re taking and any other physicians you are currently seeing, which you provide from memory as best you can.  This information is written down on your chart, a collection of dead trees that is then hung on the door.  You wait for a while and the doctor arrives, writing still more information on your ever-growing paper chart.  She writes your prescriptions on yet another piece of paper.  You’re then dismissed with a stack of papers – your prescriptions, a carbon of your hand-written visit record and diagnosis, a scribbled referral to a specialist, and a business-card size reminder for your next appointment.

Several concerns come to mind in this scenario.  If the patient forgets to remind the physician about another medication she’s taking, the doctor fails to note a stated medical condition, if a portion of the paper record is lost or destroyed (or simply illegible), or if a required piece of information is not collected, the system can break down.  Further, recording information in this manner will restrict significantly the ability to index, search, aggregate, or mine the data.  What if the provider wants to find out how many patients required hospitalization after presenting with a particular symptom?  Perhaps ER staff need to know if an unconscious patient has a particular allergy or medical condition?  Somebody’s going to be surfing through paperwork to answer these questions.  The most frightening part about that is that those answers are often needed immediately, and no dead-tree storage system can provide that.

What’s The Problem?

The problem is not a technological one, nor is it new.  So why does it still exist? Simply put, this archaic way of storing and accessing healthcare records usually works, and it has for decades.  Patients usually receive the care they need, providers almost always get paid, and most of the time the records workflow does not negatively impact patient safety. 

Why Change?

I’ve encountered a small number of physicians and other healthcare professionals who prefer to keep things the way they are.  Paper records work fine, so why change?  On the other side of the fence are those who see value in collecting and analyzing patient data, individually and in the aggregate, to improve patient care and overall process flow.  Support of EHR implementation is especially prevalent in the under-40 crowd, though there are exceptions that transcend every age demographic.

The chief arguments against implementing an EHR system are that 1) it’s expensive, and 2) it won’t bring much additional value.  The first point is true; EHR systems don’t come cheaply, and usually require significant soft costs as well (staff retraining and system upkeep among them).   To the second argument, there is rarely an immediate return on investment, but the long-term return can be significant.  With a fully electronic record system, staffing needs may be reduced because sending a patient’s health records to another provider requires only a few clicks and keystrokes rather than the time-consuming manual retrieval of paper and film.  Billing and collections can be streamlined by eliminating multiple points of data entry, further reducing workload and the potential for human error.  Patient safety is enhanced by allowing the rapid analysis of a patient’s data when making treatment or medication decisions.

Electronic Health Records that really aren’t

In my experience, there are few shops that are fully reliant on paper.  Healthcare providers often use a hybrid approach, tracking information such as patient demographics and scheduling with a modern database application but retaining the paper-based workflow of documenting diagnoses, procedures, and prescriptions.  Others modify this workflow and scan in the paper records after the fact, sometimes calling this an EHR.  Paper-to-electronic scanning solves a few of the problems (storage space and portability among them), but other challenges still remain.  To research a patient’s treatment history, someone still has to place eyes on each document in the person’s record, and it’s almost impossible to aggregate this information.  Even though these records are stored in an electronic form, they do NOT represent a true EHR system.  Scanning of hand-written paper records is a half-step toward the solution, but doesn’t cure the problems at hand.

Government Intervention

Finally realizing the importance of electronic health records, the federal government has mandated and is in the process of defining rules which will govern EHR adoption and usage.  Although they won’t be forced to use a true EHR system, providers will see their payments from Medicare slashed significantly if they fail to comply.  Further, there are significant short-term financial incentives for providers who implement EHR systems by the 2011 deadline.

The Future

In the next 20 years, we’ll see the use of paper healthcare documentation come to an end; shops that work on paper will be as common as crank-handle cash registers.  Government regulations and consumer demand will bring on a level of data availability and transparency not currently available in healthcare data; patients will have immediate, on-demand access to their own health records, and more importantly, will have the ability to research aggregated healthcare data to help take charge of their own treatment and evaluate the quality of their providers.  Further, healthcare outlets will be required to share information with one another for the benefit of all patients (I’ll talk more about sharing data in the future).

To Be Continued

In my next post in this series, I’ll discuss the sharing of healthcare data, including the challenges it presents and the possibilities it brings along.

Anyone who has an Internet connection has kept up with PASS-related news during the past couple of weeks is keenly aware of the fallout surrounding this year’s Board of Directors election.  I’ve been associated with PASS for a number of years now (though admittedly I wasn’t as connected or involved as I am now), but I can’t recall there ever having been a BOD election that was more talked-about than this one.

Two Problems

At the root of the controversy was one big issue, or if you think like I do, there were actually two.  The first and most forefront was the selection by the nomination committee of Matt Morollo, a media executive with a strong record of success but zero experience with PASS and seemingly little knowledge of the membership.  Much of the discussion occurred in the comments of one of Brent Ozar’s blog posts in which he published an interview of this candidate (as he did for the other candidates as well).   Matt’s responses to the interview questions led many to believe that he was not in touch with the mission of PASS; he referred to PASS numerous times as a media organization but avoided addressing the topic of new media, Web 2.0, etc.  In the flurry of comments that followed, concerns were raised, positions defended, a few accusations were thrown, and the collective blood pressure of our organization spiked for a while.

The other issue that bothered me was the fact that there were 3 board positions but only 4 candidates offered up for the general election.  I’m sorry, but when those numbers are presented, I can’t help but think of musical chairs.  The small number of final candidates coupled with the lack of transparency in the whole process was, for me, more bothersome than the introduction of a candidate who appears to be an outsider.

The Results

In the end, the three candidates selected for the board were new directors Brian Moran and Jeremiah Peschka, and current board member Tom LaRock.  I offer congratulations to the three who were selected, and I tip my hat to Matt Morollo, who underwent a tough vetting process and even tougher trial-by-mob on Brent’s blog.  Whether you supported Matt or not, you have to give it to the guy for hanging in there.

I will say for the record that I don’t have a problem bringing in someone with fresh ideas to the board.  But to do so at the expense of other qualified candidates with a long history of service to the community is a poor decision, in my opinion.  A lot of folks, myself included, have expressed concern about the exclusion of Tim Ford from the final pool of candidates; although he admitted that he had not done well on the interview portion, it’s my opinion that the nominating committee put too much weight on that interview without accounting for his other community contributions and successes.

There were a lot of peripheral discussions on the topic during and immediately after the election, and I won’t begin to try to summarize all of them.  I will point out a blog post by Kevin Kline, who chaired this year’s nomination committee; in his post, he acknowledged the controversy around the process and this year’s nominees, explained some of the current processes and goals of the committee, and offered up the opportunity for the community to have their voice heard on this topic.  This well-worded and thoughtful response did not attempt to take the side of any person or group, but gently offered some insight into the establishment, and expressed a willingness by the leadership to change the structure if the community so chooses.

I’m Not Without Blame

Now here’s the part where I admit complicity in the problem.  I’ve complained about both the lack of transparency and the nomination process as a whole, yet, I must confess that this year’s election is the first time that I’ve paid significant attention to these goings-on.  The only candidate from last year’s election that I could name is Andy Warren, and that’s only because he and I have had a number of conversations about his work at PASS and the possibility of my candidacy for a board position in the future.  As a voting member with an equal voice, I have some ownership in any problems that arise, and if there’s something I don’t like, it’s up to me to either bite my lip and support it or actively work to change it.  I consider this to be a learning experience for me, and I hereby commit to increase my involvement in PASS and will do what I can to improve the effectiveness of this organization and its impact on the SQL Server community.

The Upside

If there is some good that has come from all of this controversy and chatter, it’s that people are actually talking about the board of directors and the organization as a whole.  Those who have followed the conversations know a great deal more about PASS and its inner workings than they did two weeks ago, and my hope is that this heightened interest will carry on for years to come.

If you meet me at PASS, you can win prizes!

OK, so maybe there’s a little more to it than that.  Quest Software is hosting a SQL Bingo game, where players will meet various “squares” and log each person’s code word onto a randomly generated bingo sheet.  There will be daily drawings for prizes, and the game, like the smoky bingo halls back home, will get progressively more difficult (one bingo, then double bingo, then a blackout to win) as the week progresses.

The goal, of course, is not really the stuff but the interaction.  Anything that helps people to break the ice and get to know other SQL professionals is a good thing in my book.  I’m looking forward to participating, and to meeting all of you.  See you there!

Last week, I had lunch with an old friend who is, by his own definition, technologically ignorant.  While we caught up, he asked me to explain in terms he could understand what I do for a living.  I went through one of my spiels (the one usually reserved for relatives who only know that I work “with computers”), delivering a high-level talk about systems integration and ETL and some of the challenges involved in intersystem communications.  Since most of my time is spent in the healthcare sector, our discussion wrapped back around to healthcare data integration and the initiatives to integrate personal health data electronically across platforms and providers.  My friend, being a non-technologist and an outsider to the healthcare world, asked a revealing question: 

“So, you’re just talking about lining up the different fields to make sure that they match?  If so, what’s the big deal?”

Alas, if only it was that easy.

There is a great deal of noise surrounding electronic health records right now, and for good reason.  Everything is electronic these days: my local grocery outlet can analyze my purchasing history to generate customized coupons at check-out; local law enforcement systems are integrated with auto insurers which allows officers to immediately verify insurance coverage; my local dealership tracks my Explorer’s mileage and, based on my estimated milestones, automatically sends me reminders to change my filters and have my transmission checked.  Common sense would dictate that our healthcare systems would have at least as much capability as the local Ford dealer, but in practice it seems that this isn’t the case.  A visit to the local clinic often requires that I provide the same information several times at various points of care, and this drill must be repeated at each encounter.  My family doctor is unaware of any information gathered or treatment performed by my podiatrist, and vice versa.  Further, and most irritating, is that a single doctor visit or trip to the hospital will generate a handful of different bills from numerous entities, which often cross over and bill several times for the same specific procedure.

While it may sound like there’s a real dysfunction with healthcare information systems (HIS), the truth is that the situation is not as bad as it appears.  I’ve dealt with some outstanding HIS products, and, while they all have their quirks and shortcomings, many of them are mature and highly stable.  In my analysis, there are two key issues that cause the most headaches: lack of adoption and system interoperability, each of which bring along their own problems and opportunities.  I’ll discuss each of these in turn in the next 2 posts in this series.

As an aside, it’s clear that the electronic health record challenge is not new.  I recently developed a networking friendship with a retired physician who spent several years as a hospital chief of staff, and he tells me that he was providing counsel to EHR vendors almost 25 years ago.  Even though the issue of electronic health records spans the generations, it’s still a very exciting time to work in this field because of the challenges and opportunities to be a part of some creative solutions.

In my next post on this topic, I’ll discuss the issue of technology adoption, and talk about when an electronic record really isn’t.