Article is continued at HL7Standards.com.

The interesting dynamic with the $20 billion investment in EHRs by the HITECH act is the assumption that with absolutely no other changes in the entire healthcare system, this magic bullet will change everything. However, the data which comes together to comprise an EHR, EMR, or PHR is actually a very small slice of the information swirling around within the system. There are a lot of pieces of the "payline of healthcare" that have to come into alignment for success, and all of the fruit to win this payout can not be found in the EHR.

To understand this, think about what happens when we "present" in an emergency room. What factors must come together for a successful intervention and the saving of a life? First of all, there must be a suitable room or physical space for the team of medical professionals to come together around the patient. Then, that physical space must include all of the necessary apparatus related to the condition of the patient to be treated. If that equipment is not already present, then it needs to be found elsewhere in the hospital and delivered. Interestingly, all of these critical factors are only addressed after the patient arrives at this hospital in the ambulance. Using the Vegas-inspired analogy, hitting all fruit on the payline of healthcare assumes we have entered the right casino before we even start playing.

What if the right combination of doctors, nurses, specialists and emergency room availability is not at the hospital room to which we have been driven?  Once the patient has arrived is a lousy time to discover this. Fortunately, we've all heard stories of paramedics demanding an ambulance driver or emergency helicopter pilot go an extra 10-15 minutes to find the right hospital for a condition, like a stroke, for example. What if these stories weren't left to chance? What if the wheels of our healthcare slot machine were connected to the rich fabric of information which makes up a hospital or other healthcare facility (the way the rest of the Internet works already)?

If iTunes can connect to the iCloud and know whether a song is available or must be downloaded to my iPad or iPod, then certainly we can tag not only the equipment in a hospital but tag the people, too. Just like we are building an EHR for patients, shouldn't we build an EHR for each of the medical staff, too? As I wrote in EHRs and sheet music, it is not just important to know the notes but to have players that can play them. A clarinetist may be able to read a C note, but if the C note is to be played by a celloist, then the note on the sheet music doesn't do the orchestra much good with someone incapable of playing it.

The same is true within our healthcare system. We don't who the orchestra players are before the patient arrives or going back to the Vegas analogy, we don't know who will be dealing the cards at our table. It seems to me that meaningful use targeted at the EHR misses the point if the wrong medical professional is looking at it in the first place. We need to be thinking about linked people and not just linked data if we are going to hit "all fruit" on the payline of healthcare.  

Facebook's upcoming IPO is a good way in which to think about how a people's IPO is different. Assuming Facebook's IPO yields $10B against a valuation of $100B, as some analysts have predicted, this means that each of the 800M users of Facebook are "worth" $12.50. So, one has to ask themself a few questions. First, why is Facebook making $12.50 off of my data?  Second, if Facebook is valuable and provides useful services, why not just ask each of us for a $12.50 and take the Wikipedia approach?

CLOUD is not arguing for any of these positions specifically but is pointing out that a people's IPO not only changes how new ideas are financed but will also put the future of the Internet back in our hands. When website's come to us for the right to our data and must accept our privacy policy, it will not only be better for us but better for them, too. With privacy architected into the Internet, we can achieve a new "digital deal" to use the words of the late Nicholas Givotovsky.

As SXSW Interactive begins, we are expanding beyond our original CLOUDHealth circles and adding CLOUDPeople and CLOUDStds circles.  From #privacy to #security to #identity to #Facebook or #Google, there are a number of new ways to spread the word and support the revolution of ME 1.0 and the work of CLOUD.  Check it out here at http://www.cloudcircles.org.

For past news on CLOUDCircles:

CLOUDCircles: The Roll Out Begins (#HITsm)

CLOUDCircles: The Roll Out Continues (#HIMSS12)

CLOUDCircles: Expanding from CLOUDHealth to CLOUDPeople and CLOUDStds 

There was one particular thought that fixated my attention and forms the foundation of Part 2.  Patients are not the only ones pulling a one-armed bandit. There a large number of people in the healthcare system that also want to hit "all fruit." The challenge is that the slot machine we are playing as patients is not linked to any of the other slot machines on the gaming floor of healthcare.  This analogy becomes particularly acute when you think about the EHR (a topic I address in detail in this other HIMSS12 post - EHRs and Sheet Music.)

We have spent so much time creating the EHR and figuring out how to "move it" via HIEs, that we have forgotten about the people on the other side of the information.  Even if a patient's EHR has all the right information, if the wrong healthcare professional is looking at it, then we still haven't achieved meaningful use. This is where the systemic nature of the gaming floor of healthcare (or physical geography as I wrote at HL7Standards.com last year) comes into play. 

 

In Vegas (or Reno), I can go on to the gaming floor and choose any game I want and start gambling. I could pick the poker tables, roulette, craps or the slot machines… not so, with healthcare. No matter what my condition, I must start with my primary care physician. This isn't a bad thing. I like my doctor, and for most of the conditions with which I "present," he is the only healthcare professional I need to see. However, this isn't the case with my wife, who is battling cancer (successfully). Unless the condition with which we "present" is straightforward, we, as patients, will typically be referred to another specialist or given orders for one or more tests. 

 

In other words, there are a lot of people in the healthcare system. To increase our odds, we don't just need to look at the payline of one particular game, we need to be sure we are at the right table in the first place. This is where the "other side" of the EHR is vital. Before we even show up for our appointment, our EHR should be able "to talk," so that if we don't need to visit our primary care physician, we can instead play another table and access the necessary component of the healthcare system… better for me, the patient, and better for the system, because now the gaming floor is connected.  and, unlike Vegas, this is a gaming floor where we want to increase the odds for every player and patient!

 

To be continued….

We accept that the house always wins in Vegas and that the payline is not set in our favor, but we do not accept these same odds with our health. We always want our slot machine of well-being to come up "all fruit." In the case of health, though, we are not pulling a single one-armed bandit. There are a lot of people (and a lot of data) that must come together on our payline. With the advance of computerization, we are not actually pulling anything anymore but instead touching an electronic button. The same computerization we seek to bring to EHRs and HIEs has already washed across the gaming floors of Vegas.

As we head into SXSW next week in Austin, Texas, it seemed appropriate timing to add CLOUDPeople and CLOUDStds to the CLOUDCircles mix. The first CLOUDCircles for CLOUDPeople are: #Apple (both fans and alumni), #Facebook, #Google, #SMCAustin (social media club Austin), #TEDxAustin, #Kellogg and #Northwestern (CLOUD's Co-Founder is an alum of both these schools). We've added #privacy to CLOUDStds and will be adding #security, #identity and a few others next week. 

As is clear by the various hashtags, CLOUDCircles are a combination of topic and community-specific categories. Unlike the horizontal fundraising of a Wikipedia, the goal of these circles is allow for various user-driven groups to not only financially support CLOUD but let us know where the most energy for change is focused. You are not just voting for a new Internet but for why we need a new Internet. Whether you want privacy policies to start with your rules, rather than a website's like Google, or perhaps you want your health data to be more private and secure and not trapped in an EHR, or perhaps you just know some of the founders and supporters through our Apple, Kellogg or Northwestern connections, jump in and help us build a future built around YOU.

HIMSS12 attracted over 35,000 attendees in Las Vegas and put together 100s of education sessions, 1000s of exhibit booths, and numerous other activities that were tremendously well executed and thought-provoking. It was the perfect venue for CLOUDCircles to add topic and community-specific circles to the CLOUDHealth portion of the campaign. #ehr, #HIE and #eHealth, along with #hcsm, #hcsmca and #hcsmeu were added to our initial #HITsm CLOUDCircle for CLOUDHealth.

CLOUDCircles were announced at TEDxAustin, "Beyond Measure," on February 11, 2012.  Additional detail on CLOUDCircles and the dandelion logo can be found in CLOUDCircles: The Roll-Out Begins (#HITsm).

As I sat in my pew, I was mesmerized by all of the instruments from the voices of the altos to the tenors, as well as the violins, cellos, french horns and other assembled pieces of a small orchestra. We're not a big church, so we had to tuck our performing guests in to the nooks and crannies. The impact of this assemblage on our worship was magnificent. It also got me to thinking...

The last time I was lifted up by music was in Amsterdam, where I had just spoken at the Sibos conference. Sibos is a global financial conference hosted by SWIFT. At almost 10,000 attendees, it seemed big but pales by comparison to the upcoming HIMSS conference in Las Vegas. At almost 40,000 attendees, I am impressed by the complexity and scale of the effort of this health conference and am in eager anticipation on my flight. I was equally impressed by the opera at the Concert Begouw in Amsterdam in October 2010, where I wrote this piece about the instruments of finance, a blog later turned into an article for SWIFT's quarterly magazine, Dialogue. 

As you can tell, I like music.  So, you may be asking... what does music have to do with healthcare? To answer that question, we have to start with the sheet music from which the musicians in Amsterdam and All Saint's Episcopal Church worked.  In the case of the choral mass in C from Mozart, this piece was written and first performed in Salzburg in 1779. As I was listening to it bounce from the ceilings of our sanctuary, I couldn't help but think, "how many times and in how many places has this piece been played?" since 1779, and for that matter, "how many different places around the world was this same piece being played at the same moment?"  

Of course, the challenge with this question is the same one facing our social media and our data in healthcare and beyond. We can't connect them, because in the case of our orchestra, the notes to be played are trapped in a 2-dimensional space known as sheet music. However, what if this sheet music was capable of being multiple-dimensional? What would happen if the notes to be played were connected across space and time? Suddenly, the celloist (like my son) could be fused together with every celloist playing this same piece around the world. But for the problem of the space-time fabric, he could also be connected to the celloist playing the choral mass for the first time in Salzburg in 1779.

And, isn't this same the same problem with our EHRs? As I have written previously, our approach to EHRs and PHRs is also trapped in the limited dimensions of the sheet music of healthcare.  The evolving HIE landscape faces a similar musical challenge. The HIE is trapped in a physical geography of healthcare, much like an orchestra playing this same sheet music in a pit.  We've assumed that the only players that can play music together are the ones that are in the same physical space, but with the Internet, that isn't true. Many musicians have experimented with cyber orchestras, and I believe it is time for us to evolve the HIE and ACO in the same way. 

Just because a specific set of musicians (healthcare providers) have come together in the same orchestra does not mean that they are the only combination of players that can perform the music of health. I, as the listener (patient), should be able to dynamically bring together my own personal orchestra. However, the notes in my sheet music (EHR) are two-dimensional. I need to be able to tag these notes, so that I know who else can play them. I need to break down the physical geography of the orchestra, so that the pit in my concert hall can span the world, not just my narrow region, state or other HIE container. 

The Internet gives us the opportunity to reframe our sheet music. However, it is us, not the Internet, that is constraining the multi-dimensional capacity of this connective fabric. Our current web pages and digital EHRs are in many ways simply digital versions of our 2-dimensional sheet music. CLOUD envisions a multi-dimensional Internet that allows us to rebuild our healthcare orchestra, so that the uplifting power of the Choral Mass in C (or any music) can bring its healing power not only to the ears of its listeners but to every organ that makes us human and whole.

Before getting into the specifics, it is important to point out the genesis of the CLOUD logo. When you visit http://www.cloudcircles.org, you will quickly notice the young girl blowing on the seeds of a dandelion. As was pointed out to me by one of our newest advisory board members, the dandelion is a divine plant with medicinal and healing powers.  For those that know my personal story, CLOUD was launched because of the recurrence of my wife's cancer. I tell the story here, "Survivorship is Not a Phase." We need to harness the power of the dandelion and tap its healing powers, not only to find a cure to heal those with cancer but to heal the Internet, too.

Because of the walls of web pages and the broken paradigms around our information and data, the seeds of our future have become trapped in silos that confine us and our humanity. The CLOUD logo symbolizes the power of these seeds, not only when they are combined together, but when they are dispersed to flourish anew when they land. CLOUDCircles borrows from this same metaphor. "Reweaving the Fabric of the Internet to Transform Humanity" is a big goal, but it has many seeds, just like the dandelion. Whether your seed is health, talent, education or finace, the roots of the new Internet will be found in the combined power of our individual passions.

With HIMSS 2012 occurring next week in Las Vegas, we have decided to begin the roll out of CLOUDCircles in the health domain. Next Monday at HIMSS, we will turn on advocacy for a number of hashtags that symbolize the many seeds for the future of healthcare. From #HITsm to #bcsm to #cancer to #ehr, there are many reasons for rebuilding the Internet around people. We will capture each of those with a CLOUDCircle which you can make your own and share.

In advance of the weekly #HITsm chat that occurs tomorrow at 11am CST, we are launching the HITsm CLOUDCircle first. This community has nourished me over the course of at least the last year, and they honored us with the opportunity to make a series of guest posts last summer, discussing not only EHRs and ACOs but privacy, transparency and a virtual geography of healthcare. The participation of @CLOUDHealth in this community also led to our recognition as part of the #HIT100.  The CLOUD vision is closer to reality because of this community and its leaders at @HealthStandards. Go to CLOUDCircles, click on health, click on advocate and together let's starts to blow the first seeds of the future!

More coming soon...