Healthcare is special. Things that work in other industries won’t work in healthcare.
If I had a dollar for every time I’ve heard that… well, I could be sitting off a beach somewhere, surfing. Though usually, this statement is immediately followed by its denial, that healthcare is not actually special, that every industry thinks it’s special (and, if every other industry thinks it’s special, doesn’t that make healthcare special all by itself?). But for every person who says that, who wishes to claim it’s not true, there’s ten people who, whether they believe it or not, act like it’s true, behave as if its truth is one of the founding principles of their lives.
But is healthcare so special? In fact, just what is healthcare?
There is a wide scope of IT systems and/or applications that may be included under the banner of “Healthcare”:
- Patient Administration systems
- Clinical Tracking and Reporting software
- Clinical Decision Support Systems
- Financial transactions for payments related to healthcare
- Population statistics and forecasting software
- Specialized variants of standard IT infrastructure
- Patient-centric healthcare data tracking software
- Bioanalytical programs or frameworks, both in research and in diagnostics
Within this wide scope, several different factors combine to make healthcare different, and potentially special.
The first and most important cause of the uniqueness of healthcare is the variability between countries. The most obvious difference between various countries with regard to healthcare is in the amount of technical sophistication, with rich countries such as USA and EU countries using high-tech high-information diagnostics and treatments, whereas these techniques are only slowly becoming available in third world countries.
Another obvious difference is how healthcare is financed. There is a huge variation between different countries, from relatively commercially based approaches such as USA to highly government financed systems such as in the UK. This same variation is seen through the whole world, not just in the rich countries. While all countries, whatever their system, share a common interest in tracking and controlling clinical costs, and relating this to population outcomes, the amount of government involvement in healthcare, and the specific details involved, can make a great deal of difference to the kinds of teamwork that are fostered, and the commercial effects that this has on interoperability. For instance, in the UK, the government has long sponsored the notion that each person has their own General Practitioner (GP) who is responsible for their care. For this reason, the government created a specification that allowed for transfer of records between GPs, and this process is gradually catching on. On the other hand, no formal arrangement like this exists in Australia, and while there is sporadic interest in exchange of records between GPs, there is as yet no prospect of a formal process existing, let alone catching on.
Another factor that makes healthcare unique is the high degree of complexity of healthcare. Actually, the problem is not so much the complexity of healthcare, but that there is no way to cherry pick the problem space. While it’s a phrase that is commonly heard in healthcare IT, that we should cherry pick the problem by “picking the low hanging fruit” (which is hardly an idea unique to healthcare), actual provision of healthcare is not really like that. Imagine, for instance, creating a special clinic that only provided renal services to renal patients, and didn’t provide care for patients with other healthcare problems. The problem is that patients with renal disease often have a number of other significant problems, ranging from depression to cardiac failure. A clinic that was unable to have these patients would exclude a significant number of patients from care. This would be either a financial problem or a patient care problem depending on the way the healthcare system is being run. So even specialized clinics must provide general medical care.
The inability to properly control the scope of the problem is a real source of the complexity of healthcare: patients get sick in all sorts of inconvenient and unexpected ways. This is a genuine difference between healthcare and most other domains. For instance, a transportation company does not provide a service that transports anything to anywhere – it can choose to restrict the scope of its service. Generally, healthcare providers do not have this choice. Of course, this is not a problem unique to healthcare. In fact, it’s true to at least some small degree of all industries, even the transportation example above. The more true this is, the more the problem space will share with healthcare. One obvious example is in the defense/intelligence space. Once you start a war, you’re committed to everything that follows, so the scope is extremely hard to limit. There are several overlaps between the informatics and interoperability concerns of healthcare and the national intelligence agencies.
Another key underlying difference is the fact that there’s always an altruism involved in the provision of healthcare: we’re here to save people’s lives. There’s no way to place a value on a life (and much published research on this problem from an economic perspective). Even just trying to make people’s lives better – we might know how much it costs to make it better, but this is not the same as how much it’s worth. This is true irrespective of how the care is funded. Of course, exactly what “better” is varies wildly from context to context, and even when the meaning is well agreed, the underlying altruism may not always be significant, or even evident; for instance, if a provider refuses to provide care when there won’t be any payment, it’s hard to see altruism at work. But if the provider isn’t paid, they won’t be to live, and then they won’t be able to provide any care (of course, a surgeon earning millions a year who never provides care at no cost isn’t displaying altruism, but this is exceedingly rare). Note that though altruism is almost always present, it’s usually considered to be very poor taste to comment on it in operational contexts (and it won’t feature in this blog again!).
A contributing factor with regards to altruism is that healthcare interoperability practitioners are generally underpaid compared to their equivalents in the other industries, such as high finance and telecommunications1. Even if this isn’t actually true, it’s certainly widely believed and in this regard, perception is reality. Many people who work in healthcare continue to do so in spite of the apparent gap because they choose to work in healthcare.
One consequence of this underlying altruism is that things that might otherwise seem simple can be very hard. When a change is proposed, in addition to the question of whether it will save money, and whether it will lead to more profitable business, and whether it’s good and/or interesting for the workers, the question arises as to whether it will be good for patient care. And because the workers are inherently more likely to be driven by altruism to some degree, they’re also (possibly paradoxically) more prepared to consider whether it’s good for themselves or not.
Again, this is not at all unique to healthcare. Most people associate a degree of altruism to why they do what they do, or more often, to how they do it (for the purposes of definition, I’m doubtful that lawyers, politicians, and used car salesman qualify as people). However altruism is more prevalent in healthcare.
Perverse Economic Incentives
Another feature of healthcare, which is partially derived from the two preceding ones, is the existence of perverse economic incentives in healthcare. These are very commonly encountered, and generally fit one of two patterns: either success leads to less funding due to decreased need, or success leads to uncontained cost due to increased utilization. Of course, perverse incentives exist in all industries where the payment cycles are not properly aligned with the costs, but this problem is particularly pervasive in healthcare because of the previous two issues.
While healthcare is not unique in any single regard, the combination of these factors does make healthcare somewhat unique. In addition, healthcare becomes unique simply because it behaves as if it is unique.
Whether any of these various possible reasons is actually proper justification or not, Healthcare in all its scope and variation is special and different enough to other industries that a there are several Standards Development Organizations specially focused on the healthcare domain, and there are several techniques that have emerged initially and distinctly in healthcare, even though their IT characteristics are not restricted to healthcare. Finally, unlike most other industries, the healthcare IT ecosystem is still characterized by a high number of very small specialist companies. In fact, it’s been called a “trillion dollar cottage industry”.
in spite of all this – or perhaps because of it – I love Healthcare Interoperability. As a discipline, Healthcare Interoperability is at the meeting point of IT, Clinical Practice, and Management. In both principles and practice, there’s nothing quite like it. To navigate the stormy waters out there, you need both passion and perspective. And you can be sure of two things: there’s an almost limitless demand for people who know what they’re doing in healthcare interoperability, and you can really make a difference for the better.