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2013-04-22

SwitchPoint 2013


I attended the SwitchPoint Conference as a guest of IntraHealth last week. It is the second such gathering to find solutions that will save lives and improve the health of the poorest regions on earth. 

One of the things I promised my host was to provide some reflections on what I saw and heard. My reflections are my own, based on what I could experience, and informed by my past, So, I may get situations wrong and misinterpret some encounters. My apologies in advance.
Front of the Saxapahaw General Store

First and Lasting Impressions

Funky surroundings. Music. Art. Ubiquitous technology. Ubiquitous. Set in the Saxapahaw Ballroom (it's a dye house that was part of an old mill with remnants of antique machinery here and there), the meeting had an air of 1900 meets the 21st Century. The group's diversity was striking with every continent represented--based on the names and accents in evidence. Everyone had a smartphone and everywhere someone was looking at a personal screen. Lots of tablets--usually iPads. A few laptops, but very few. 

Music permeates and punctuates everything. Usually a mix with a wide variety of sampled sounds. It's not an add-on, it's organically integrated into the experience. During presentations, visual art--usually digital--is included and occasionally incorporated into presentations or musical interludes. There is an activist aesthetic in play, often with stylish logos or icons as well as personal fashion. As one participant put it, "Art is the common language of technology now." 

Undercurrents are still working, however. Attendees have an underlying passion, a drive to find the solution to vexing challenges in global health and recognize the substrata of challenges in economic development. Economic determinists would find that gratifying, but these are people who are combating those realities. They are seeking solutions that rely on available resources in their host environments and find the patchwork solutions delightful and beautiful--no matter how many paper clips and how much duct tape (literally!) are involved. These anti-cool solutions of low-tech are the best responses as reckoned by these high-tech enthusiasts. While personal styles reflect the global village and the insouciance of tech, these are determined people. Listen for even a few minutes and the movement culture begins to emerge. 

Conference or Chautauqua?

They are all learners. Again and again are presentations where they experimented, failed, prototyped, deployed, failed, and cycled iterations as they closed in on the solutions. "Africa has more pilots than the United States"--referring to projects not aviators--was a refrain either said out loud or implicit in many conversations. Several times, the more experienced people talked about the growing maturity of the movement as these lessons percolated and spread from group to group. 

The conference reminded me of the American chautauqua of a century and more ago, where people of diverse backgrounds and ages came together to share what they have learned and learn what they share. Like the American Populists of the late 19th Century, these people live in a movement culture. (Many thanks to Larry Goodwyn's The Populist Moment to describe the phenomenon.) Activism, art, music, and a post-industrial infusion of technology--a lot of technology--combine in a heady brew. The audiences listen in rapt attention to the presentations (mercifully short and pointed) to find out what was done here and there. 

Between presentations and "ensembles" (essentially panel discussions) are musical interludes that do more than provide a stretch break for the audience. The music comes from the shared evolution of rhythm and beat of the urban West and rural areas in the developing countries. These connections work at an intellectual and visceral level simultaneously. The beat supports the body moving and the emotions flowing, paradoxically taking the edge off and allowing everyone to return with determined, aware mindfulness. 

Lessons Drawn 

We're on our own was a theme that lasted from front to back. The situation of people short on resources, knowledge, and know-how could be glimpsed by those who came to understand that a home-made hammer was the high-technology solution available for some. The iron age and wireless routers can rest side-by-side in a collapsing of epochs that is the modern world. The notion that if it can work in Africa, it can work everywhere was proudly offered as proof of the utility of these solutions. 

The open question was how could these solutions and approaches be brought to serve industrialized communities with their own systems of economic production and distribution. The issue of convergence was not brought up--meaning the narrowing of means and outcomes as the rest of the world catches up in material circumstances with the industrialized regions. I guess the distance is so great to the people working in sub-Saharan Africa or south Asia that it has yet to appear. Yet, some of the people living there are more advanced in the use of texting than even 12-year-old Americans. It might be an interesting area of exploration. 

One take-away notion was the rise of the app. It was not a dominant feature of the conference, but was an enticing idea by one presenter/musician who is finishing a book on it. The app seems to have all the characteristics needed for success in the regions these folks hope to serve. It can be platform-independent; with the latest tools for creation the barriers to entry are low; it can provide its own sustainability through low pricing and wide deployment; it can work over wifi, cellular, or no network; and it is battery-powered when the electricity inevitably goes off. Watch this space. 

How to scale solutions was a repeated theme, but the solutions still remained merely promising. The inventions and innovations were still in gestational stages of evolution and not fully ready for deployment. Sustainability was another open question, but some seemed to think that government policy was one of the paths. Several times the notion of a shift in policy or investment would change the issue on the ground at scale. Few, however, seemed to see entrepreneurship as an answer--even social entrepreneurship. Maybe I missed that discussion. 

Underlying Meanings

Everything is Local. 
The underlying theme of the conference was figuring out how to make do with local materials and local effort--assisted with tips and tools from agencies in the developed areas of the planet. Repeatedly, speakers and participants offered stories of ad hoc remedies and solutions that could scale if the right circumstances arose. (See Von Hippel, Eric.) 

Keep It Simple.
While the challenges are staggering, there is faith in the simple solution if taken to scale. In fact, the assertion is that if the solutions are not simple they will fail. Simplicity mirrors the material conditions of the challenge and must be heeded. If the tools and resources are not at hand, keep looking to find them. 

Build for Scaling
No matter how small and seeming insignificant the idea, it needs to be scaled to address the mountain of challenge facing the people in need of solutions. The question is how to do that. Often people voiced the need for a policy shift or initiative to get governments to back an initiative, whether workforce development or shifting economic incentives. But some did see a potential network effect, depending on situations and circumstances. Information creation and access was the quiet message. 

Fail Fast
Few used the word "failure" to describe pilots and other efforts that did not achieve the hoped-for results. But the word hovered in the air during many sessions, but with more of the sense that entrepreneurs use it as the pathway one travels. My guess is that the term has such emotional freight and connotes such despair that many avoided it. Yet, the most successful and scalable approaches told stories of revising and even starting over before progress was achieved. 

Final Words
I was privileged to encounter these hundreds of people who work to raise the health circumstances of billions. They admit they have not found the solutions, yet. But they are relentless in trying. Read more at The SwitchPoint Reader. I recommend it highly. 

2013-04-17

The Alphabet Soup of HIEs

I've been looking into HIEs (that's Health Information Exchanges) lately to prepare for a lecture to my students. I've been tracking the area since the late 1990s and have tried to keep up with all the acronyms. Here's my initial stab at the pre-history: 


The current initiatives coming out of the ARRA and HITECH legislation are a collection of standards, protocols, legal agreements, specifications, and services that enables the secure exchange of health information using the Internet as the pathway and technology. Getting even to the point of talking about a national HIE has grown from a number of starting points.

Back in 1990 the Hartford Foundation offered grants to several states and cities to set up community health management information systems to create central repositories for individual-level demographic, clinical, and eligibility information. Those data were to be used by stakeholders such as local agencies, payers, employers, and researchers for assessment activities. Secondarily, they were to create transaction systems to facilitate billing and patient eligibility information to reduce costs. Hampered by primitive technology, especially to costs for networks and related technology but also discovered that the lack of standards for data integration hampered their efforts. Moreover, they ran into political resistance from some providers who even got a law passed in Iowa to prevent the exchange from succeeding because of privacy and security concerns as well as ultimate control of the data—issues that persist even today. Finally, they never grew beyond the grant-funded approach to become self-sustaining.

Another effort was the community health information networks, CHINs, that were primarily commercial endeavors. The prioritized savings rather than quality assessment objectives. They took a very different approach and emphasized data transfer as their mode of sharing rather than having a centralized repository. Nevertheless, most did not make it out of the 1990s. The transaction costs, when affordable, could not support the system or meet business objectives. The costs needed to be borne by a larger market.

RHIOs were the first effort to start getting notice, and support, by the federal government. Because they offered services across a wider area, many linking communities together, they spread the risk. Nevertheless, they took millions to start and millions more to keep operating—difficult to raise and sustain. Competitive pressures between hospital systems kept the bar of mistrust high and stymied many efforts at data collaboration. Again, the issue of who controls the data tended to limit access and therefore success of the exchanges. Finally, the fear of legal liability from unlawful disclosure added another chilling effect.

To Err Is HumanIn the mix of these efforts was the 1999 NIH report, To Err Is Human, that suggested that as many as 98,000 people die as a result of preventable medical errors—issues that sharing health information should be able to mitigate. In fact, they followed up in 2001 with a supplemental report advocating the sharing of healthcare information in some sort of exchange.

The above initiatives were focused on community and regional collaboration. Why not reverse the direction and focus on the patient? A big boost to the idea of personal health records as the lingua franca of health information exchange was started by the Markle and Robert Woods Johnson foundations in the mid-2000s. (I attended the first couple of meetings they had and felt some of the enthusiasm.) The idea was to empower patients to have their own “personal health record” that contained all information relating to their healthcare. Generally, these efforts were started by individuals who were patients with serious chronic conditions, their family members who needed to care for someone, or they were started by behemoths like Microsoft or Google. The legal issues were potentially eliminated because the patient controls their own data in the first-person, but the approach would not provide societal benefits of aggregating the data for improving clinical outcomes or reducing costs. Finally, there were the persistent technical and logistical issues of providers tapping into the PHRs.

HIEs attempt (through the HITECH Act and Meaningful Use) to provide a set of incentives and penalties for non-compliance in adopting a standards-base EHR as well as strike a balance between personal information security and community information use. Some have called this a utility model similar to past regulated monopolies in electrical power and telephony. 

I'll explore the path traveled so far in a future post.