4. Healthcare Repositories – Their Care and Feeding

Healthcare Repositories – Their Care and Feeding

It was in those days that there came a decree from the leader of the free lands that all providers shall submit records of their care for patients to a repository.  And they shall foot the bill because we can’t find anyone else to do it (there were those who suggested that the government foot the bill but they were immediately recognized as socialist spendthrifts and were booted out one cold November day).  And it was good.

And so it came to pass, in a land purchased from the Lenape Indians in a historic transaction, there was a provider Dr. William Robert who decided he could be his own repository (there being no provision against it, the assumption was it must be legal).  He bought (with his own money) computers, hard drives, cabling, and other stuff too technical to be listed here.  With these he established the required security and confidentiality controls and voilá it was done.  And it was good (according to applicable state and federal regulations in effect at the time but subject to change without notice).

In the land of the Super Bowl (as it was known at that time) there lived a provider Dr. Billy Bob.  Dr. Billy Bob wasn’t technically proficient (he only liked to see patients and care for them) so he googled to find an organization named Healthcare Repositories Be Us.  They offered to store his contributions to the healthcare records for $1/MB/month.  That is, each megabyte of data he submitted would be kept available for a month for only $1.  If at any time he no longer wanted to keep those data available he could cancel and they would kindly delete the data from the repository.  They even had an option to automatically deduct the payments from his bank account each month.  And it was good (good enough to satisfy meaningful use which was all that seemed to matter at the time).

In the land of the Great Fault there lived Dr. Willy Robert (the “t” was silent).  Living in the constant threat of breaking off and being shoved into the Pacific Ocean, the local repository (Cool Dude Repositories) had adopted a more long term perspective for the pricing of their services.  They charged a one-time fee in exchange for which they would store the record and make it available forever (or until an Act of God should make forever meaningless).  They offered this at the rate of $10/MB but finance options were available.  And it was good (and it is expected that the bankers that had been forced to leave the east and settled in this area would arrange for a new financial instrument called a healthcare derivative to resell those financed data).

As time passed, there came a day when all three of our providers reached the mandatory age for retirement.  When our friend in New York retired he turned off his computers and (after scrubbing the hard drives to preserve confidentiality) donated them to a local charity (amazingly his tax return suggested they seemed to be worth more at that point than they had originally cost).  Our friend in Texas closed his office and his bank account taking the cash and heading for Bermuda.  As for the third, they say there is an old guy who looks a lot like him who now has a small agricultural concern in Humboldt County.

From that day on, the people in California were healthier and spent less on healthcare than in any other state.  It is said that this might stem from the fact that they still have access to their healthcare records but that is mere speculation.  Some would say that the only rational model for healthcare repositories is that they should be other than the provider and should be priced as a one-time fee.  But what do they know?

I know dear reader, you are saying “but wait, give me more!”  Be patient.

Continue Reading Next Post: Healthcare Repositories – Belt and Suspenders

5. Healthcare Repositories – Belt and Suspenders

Healthcare Repositories – Belt and Suspenders

You may or may not trust a man who doesn’t trust his own pants but never trust just one copy of healthcare data.  This note seems almost nonsensical or at least obvious to the most casual of observers but here it goes…

One of the lesser quoted benefits of electronic health records, is that they can be copied (not in the illegal way).  So the days of a patient’s record lost in the trunk of the doctor’s car (admit it guys, you have been guilty of this at some point) can now be banished to the scary stories of our healthcare childhood.  And since they can, they should.  The prime directive in data management is that any important data should be duplicated.  In the old days we did this by making backup tapes each night and methodically storing them in a safe place (in my trunk always seemed like a good option to me).   The problem was if the original ever actually died (like that Sunday morning when the oil depot next to the data center blew up in Hemel Hempstead, England),  then it might take a while to find the copy and then find out if it was the latest and if it really worked (fortunately that copy was in a cave in Wales).

The days of tape backups are behind us (no one actually still uses that, do they?) and we have raised the bar.  In the old days, having a backup as of yesterday was sufficient.  That meant we could lose up to one day’s data which is fine if it isn’t your data.  I mean how would you feel if the results of your colonoscopy were lost? Today, the maximum period of data loss can reasonably be down to a few minutes or seconds.  So real-time replication to another location (preferably in another part of the power grid) should now be part of the minimum performance expectations (or service level agreements).

That should give us a nice belt but do we still need suspenders?  I am afraid it is so.  The focus of any high availability plan is first to eliminate every single point of failure.  To find the one thing that if it failed would render the data (even briefly) unavailable.  We do this routinely with redundant switches, power supplies, RAID drives, and as we just discussed data centers.  So what single point of failure remains to be eliminated?  The company.  If the company providing the healthcare repository fails (in financial terms, it bites the dust) then those data may be lost.  If we are to achieve high availability we must require redundancy in the company.

This will be awkward.  Company A offers healthcare repository services but as part of that service we require it to provide redundancy; meaning find another (unrelated or they may die at the same time) company (read competitor) to keep a copy of any data it stores.  We could ask someone else to take care of this (like the provider of course, since we always dump things we don’t want to deal with on them) but if we are serious about the value of these data then supplying redundancy should be the responsibility of the repository service.

Redundancy in company is the suspenders we need to complement our belt.

Continue Reading Next Post: Healthcare Repositories – Role of the FDIC

6. Healthcare Repositories – Role of the FDIC

Healthcare Repositories – Role of the FDIC

I recently had the opportunity to review proposed state legislation grappling with the prospect of what to do if an entity integral to the state’s plan for healthcare exchanges becomes “unsustainable”.  In technical terms that means “goes belly up.”  That prompted me to write a proposal for this very problem.  This is a potential problem for data repositories as well as data registries but we will focus this discussion on the problem of the repositories.  It is a problem for the “old paradigm” of the EHR/HIE model as well as the “new paradigm” of PCAST.

It is important to make sure that we understand the context in which any such legislation should be written.  To that end I emphasize the following assumptions to keep in mind:

• Having healthcare data with a high degree of availability has value to society.
• Having value doesn’t mean we want to pay for it.
• Government can’t be trusted with something as important as healthcare.
• Murphy was not a lawyer.

I have never heard anyone suggest that if we could only find a way to spend a larger percentage of our GDP on healthcare we could really compete in the global marketplace.  Nor have they ever suggested that we need more unhealthy people on the dole rather than earning a living and paying taxes to really energize our economy.  So I have made the leap that we, as a society, think there is value associated with having healthcare data available whenever and wherever we need it.

One never hears from rational politicians (who are not ready to retire) that we need to raise taxes to pay for what we value as a society.  It seems far more rational to make the costs vanish into the free market pricing models.  Out of sight, out of the budget, as my mother always said.  If it isn’t a line item in our budget then we don’t have to pay for it.

Wars, water, and food safety are one thing but there is no way we should ever let government get involved in healthcare.  This is the land of unlimited bounty and fast food.  We should get whatever we want and we should get it when we want (if we have the money to pay for it or have a good insurance policy).  No governmental death committees for us.  No rationing.  No planning.  Let the laws of supply and demand not be trumped by the laws of the land. Ok, this is hyperbole.  I really never thought that the healthcare bill advocated death committees.

The best laid plans.  If something can go wrong it will.  And if it does, we must make sure there is someone to sue.  That should make them be more cautious.  Although, the lobbyists do have a point about the need for caps on environmental damages.

So what was the problem in the first place?  Well.  there is a data repository that has valuable healthcare data for which it is responsible..  In the course of modern business, sometimes the forces of nature conspire to bring down a company.  When that happens they might (just might you understand) stop making those data available.  If that happened we are sorry for them (kinda) but we don’t want to be inconvenienced.  What should government do about that (without getting involved in healthcare)?  The legislation mentioned above and in question didn’t offer an answer but did suggest that government should conduct a study to figure out an answer.

As the reader no doubt remembers from a prior note, the only reasonable pricing scheme for healthcare data repositories is a one-time fee charged to the provider for which the repository will make the data accessible forever.  The reader also fondly recalls our statement of the obvious (in a prior note) that for every piece of data there should be two unrelated repositories.  These two items mean that the data are not subject to the sustainability of the source (provider) or the repository.

But we still have a problem (or I wouldn’t have written this note in all likelihood).  In our model, the provider paid a one-time fee to have the data stored in perpetuity.  In reality they had to pay that one-time fee twice (once to each of the redundant repository services).  But if one of those repositories vanishes then we again have only one copy of the valuable data.  That will never do.

The good news is that we still have a copy of the data and can find another repository service to take on holding the duplicate copy.  But perchance, here is the rub (and dreaming will not make it fade) who will pay for the new third repository to hold the duplicate?  It seems unlikely it will be free (there are some downsides to depending on the free market).  Can we get the provider to pay again (that may be just a bit too far to push this idea)?  How about the patient?  Don’t think so?  How about the government? I know that sounds like the socialist spendthrifts again.  Never mind.

Wait. By Jove I think he’s got it!  What do we always need in disasters?  Insurance.  And, in this case, one that will pay when there is a valid claim.  I therefore propose the creation of the FDIC (Federal Data Insurance Corporation).  There is another obscure agency that may need to change its acronym but that is a minor detail.  How it will work is that each repository service will be required to pay a premium for all of the data it stores so that in the event it fails the FDIC will have the money to pay the third repository service to take up the task.

And you were there.