Using DevOps to Save Healthcare

The following is an abstract for a presentation I hope to give in October to the DevOps Enterprise Summit conference in Las Vegas.

I went to Caltech to become a world class mathematician but decided for family reasons to train as a doctor instead. I spent nights picking the lock and programming the old Burroughs 220 vacuum tube computer, learning years later that its daytime job was to do the math on dark matter in our galaxy. I graduated BS Ch ‘65.

I went to UTMB Galveston for med school and was immediately recruited to do a PhD in physiology. Between drinking too much and spending too much time writing Fortran code to calculate my data, I got an ABD instead – All But Dissertation. By age 40 I was a sober Family Practice doctor with a rapidly growing practice, but I suffered from severe depression and burnout. I went through two expensive and lengthy hospitalizations, sober and suicidal. All this therapy and meetings taught me to understand my patients and their sicknesses better, and I became amazingly good at getting them well. One of my patients was a world-class teamwork trainer. He took on my practice as a pet project, teaching my staff of 10 to talk to each other with respect. I wrote a productivity incentive spreadsheet that effectively made them all financial shareholders in the practice. I made money billing insurance and Medicare with a commercial electronic billing product written in MUMPS code. At the end of 2003 I finally burned out and sold the practice for a nice profit. For years the employees would hold a reunion dinner to thank me for changing their lives.

American doctors die of suicide at the rate of 300-400 a year, or about one a day. Their Electronic Medical Record is a top burnout complaint.  The two hours they spend each evening checking boxes on the EMR and NOT spending time with spouse or children, they refer to as“Pajama time”.  The American Foundation for Suicide Prevention concluded that “drivers of burnout include work load, work inefficiency, lack of autonomy and meaning in work, and work-home conflict.” These are all symptoms of low performing IT operations.

In 2007 I discovered WorldVistA, a nonprofit formed by a core group of VA developers in 2003 to take VistA to the world. VistA is the server side of the VA electronic medical record. Written in MUMPS, it launched at 20 VA hospitals in 1978 and has been up and running since then. It is documented to save lives, and it doesn’t slow productivity. But politics forked the VA version from the Department of Defense version, so that veterans could not transfer their health data from the military to the VA. This is a huge technical debt, whose resolution gets high priority but no significant progress, and now the whole VA-DoD medical record system is being outsourced to Cerner Corp. The new 10 billion dollar effort went live at four test locations and promptly collapsed.

Meanwhile, VistA code is public domain, open source and available for free. At semi-annual VistA Community Meetings I would meet developers and operations people from all around the world. I gave a couple of presentations, did some support work, and started my own two-man company to sell and support VistA to small primary care offices. I ran out of money after two years. I applied for a federal Small Business Investigative Research grant to fund the idea, didn’t get it but learned a lot in the process. Three years ago I learned of a small group of family doctors in West Virginia trying to bring up VistA to replace their commercial EMR. I drove over to say hello and was hired the first day; in a week I was promoted to “Project Director”. I had never in my life made a dollar off of IT. The CEO kept firing people who couldn’t deliver a usable product in 2 weeks. I kept using the skills from my old team-building mentor to get everyone to laugh and work together. In 6 months we had launched VistA in beta, and it was working. Winter came to West Virginia and I was unprepared for 30” snowfalls, so I asked permission to go home and return in the spring. The project fell apart within a month after I left.

It was a good team, and there were many reasons for the sudden demise, but I kept thinking about a WorldVistA talk I gave on the “Clinical Champion”. This is an individual with clinical medical expertise who seems to be necessary for the success of any EMR installation. Perhaps, even though I didn’t really think of myself as an IT leader, I had actually been essential to the project.

Then my former IT employee told me about “The Phoenix Project”. I listened to the Audiobook with my wife, and we both loved it. She would beg me to turn it on in the car – “We have 15 minutes, can’t we listen to the book?” She had been the office manager of my medical practices and had been through all this with me. We both realized we had been doing DevOps all along, and we knew what it could do – but we could not see a way to help with something as big as healthcare in America, which costs us nearly 18% of GNP and is clearly underperforming.

My idea is to be a Project Manager, and not to try to do everything myself. I visualize a three-part structure modelled on what Kaiser Foundation uses. They enroll their patients through a non-profit organization, which in turn negotiates for healthcare from their two for-profit corporations, one for the doctors and one for the hospitals.

My first corporation would be a nonprofit “Foundation for Healthcare Transparency”. Founders of this foundation would be owners of a human body, preferably eligible to vote. We claim to have government of the people, by the people, for the people, but we have outsourced healthcare to our representatives because it seems so complicated. Turns out it is the other way around. American healthcare is made complicated so that voters will turn their rights and duties over to elected officials who will in turn sell themselves to healthcare lobbyists. My motto is “We must be anger-free. We will not win this debate. Instead, we the people will show them how it can be done.”

The second corporation will be the DevOps team. Their corporation will be employee-owned so that they share in their own success. And the third will be the small primary care doctors’ offices, who will be subsidized to own and use VistA, and will be required to maintain one or more IT employees on site.

I plan to start with a citizens’ meeting at my local YMCA, a focus group to assess interest in the process of planning, organizing and monetizing a Foundation for Healthcare Transparency. I will bring those results to the DevOps Enterprise Summit in Las Vegas where I expect attendees to recognize American healthcare as a typical picture of a low-performing business model. I want to assess suggestions for starting an initial DevOps team to install and maintain VistA in one or two small primary care doctors’ offices.

Chapter 2*

As night fell the intensive care unit called me to see a patient in trouble. I was a newly minted Family Practice doc in my 30’s, moonlighting the emergency room in a sleepy little Southern California hospital while serving a brief obligation to the Navy. I was proud of my education and confident of my skills, and I assumed the nurses on duty were caught in a dilemma and thought they might trust me to know what to do.

The patient was poorly responsive, sweating profusely, skin pale, cold, and clammy. Pulse was rapid and thready, blood pressure low, blood sugar over 300. Other than rapid heart rate, the EKG was essentially normal. Diagnosis seemed immediately obvious: diabetic ketoacidosis with life-threatening shock.

Treatment demanded two things: IV fluids to bring the blood pressure back up as quickly as possible and restore circulation to the brain and kidneys while reducing the strain on the heart. Plus administering IV insulin so the body can slowly begin to metabolize sugar again, instead of having to get its energy from fat, which creates toxic ketones and acidic wastes that lead to shock.

The ICU nurses, as usual, seemed already to know all this. They just needed a doctor to make the official diagnosis and write the orders. But I did not know them well, and they seemed somehow hesitant. The admitting doctor was a well-respected staff cardiologist, and his admitting diagnosis was rapid heartbeat with some chest pain, rule out heart attack.

I told them the diagnosis was not entirely correct; it might involve a heart attack but the man was clearly in diabetic shock and would die within hours if that aspect were not treated aggressively. I would call and speak with the admitting physician.

They got him on the phone. I introduced myself and described the situation, my assessment and plan, and assured him I would remain available through the night to monitor the patient’s progress. He thanked me and hung up. It was a very briefphone call.

The night wore on; the emergency room was seeing the usual minor emergencies. About midnight, the intercom came on with “Code Blue, ICU — Code Blue, ICU”. Somebody was in cardiac arrest, but I felt sure it had to be another patient — the last I had heard, my man was stable.

It was him, though. He was in full cardiac arrest, flat line. Now, I am good at CPR. I’ve brought more people back from the dead than Jesus ever did, not too difficult for an ER doctor. The nurses were already pumping his chest and breathing him with a mask and bag. I intubated him, thus getting control of the airway and preventing aspiration in case he should vomit. Then I began chest compressions while we administered defibrillator shocks. But there was no response at all.

I can circulate enough blood for the patient to wake up if the brain is functional, but he was still in a metabolic coma. He did not wake up. If a heart attack had produced electrical fibrillation, it would show on the monitor as a pulseless quivering line, and the heart would be reduced to an ineffective quivering muscle. An electric shock to the chest can convert fibrillation to normal rhythm and restore a steady heartbeat. He had no fibrillation pattern to defibrillate – just flat line.

The nurses explained that they had called the admitting doctor to report the patient’s status. His vital signs seemed stable but he continued unresponsive and still had a rapid heart rate. The doctor said to stop the rapid IV fluid drip, and ordered a sizable dose of IV Inderal (propranolol). The patient’s heart stopped.

Inderal is a beta blocker, a new class of drugs in the 70’s. They block adrenaline beta-receptors. To oversimplify, during fight-or-flight, adrenaline stimulates alpha-receptors to constrict blood vessels in the skin, while beta-receptors speed up the heart and send blood to the muscles. Taken in pill form beta-blockers lower blood pressure, and IV they dramatically slow the heart. They were a powerful addition to the cardiologist’s formulary, and we were all still learning how to use them. But I knew Inderal well enough to know the game was over. It would not wear off for at least a couple of hours, and we could not keep him alive that long. A few more minutes of CPR, a couple more shocks, and we called it enough.

I pronounced the death and wrote a note in the chart. I was furious. The nurses still seemed very quiet. I let them notify the doctor. I finished my shift.

I sincerely hoped that he was at home, drunk. That would explain his pitiful, incomprehensible behavior. I remember learning how to drink and practice medicine – I had an upperclass mentor in medical school who explained it to me. He said to always go to the bedside, no matter how late the hour, and never just give orders over the phone. You might get by with it, but if anything goes wrong, only the doctor at the bedside can fully understand the situation. He also explained how many times the police had given him a ride home in the squad car after they pulled him over. Those were the days.

After a day or two I wrote a letter to the hospital staff. I probably shouldn’t have accused the doctor of murder, but to me it wasn’t just malpractice. Any doctor can miss a diagnosis. But this was more like drunken driving leading to a fatal accident and a charge of manslaughter. I thought they’d want to know.

After a few days I got a call from my boss, the medical director of the emergency room. In a sad, quiet voice, he offered me the opportunity to resign. I objected that I was right, and he said perhaps so, but this doctor was a highly respected member of the staff and I was an unknown. I resigned, and fell into a deep and prolonged depression.

That was forty years ago, and yes, it seems like yesterday. And I still don’t have an answer. Certainly that was sickcare. The cardiologist was bringing in big money for the hospital – testing,  medicating, catheterizing, referring. My role was to see enough patients to keep the ER open, but mainly to admit a portion of them to the hospital for more services, where fees were more profitable. And my special role as family doc was to sign off on the medical necessity of it all.

But anger and blaming are not the answer. We have plenty of that already in this country. Who wants to live in a world of such violence? Our major health problems – obesity, smoking, drug addiction, suicide – all are ways to avoid pain. So maybe poor healthcare is what we subconsciously seek and deserve. Let’s all die soon!  Have a nice day!

I think there may be another way. It might involve conflict management and resolution. Instead of proving who’s right and who’s wrong, maybe we could look for ways to get along and work together. This would require honesty – deep and rigorous honesty. I want to propose a Foundation for Healthcare Transparency. I need founders for this foundation. Citizens who own one human body. No choice of sex, skin color, or family – but who would like to choose healthcare. Who are willing to research what that really means, and work toward making it happen.

You may have guessed that I believe there is one electronic medical record system that can help us, and it is old, not new. It is the VA system known internally as VistA, and it has already been shown to save patient lives without driving doctors to commit suicide.

More on this later, but for now, thanks for reading this. And I do need your encouragement

–Steve W

*One of my favorite writers, Lawrence Block, said to put your second chapter first. Don’t begin at the beginning

 

We are tyrants, We delegate, They died in vain

“It is rather for us to be here dedicated to the great task remaining before us—that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion—that we here highly resolve that these dead shall not have died in vain—that this nation, under God, shall have a new birth of freedom—and that government of the people, by the people, for the people, shall not perish from the earth.” Lincoln, Gettysburg, November 19, 1863.

But we, the people, have delegated governance to the money-politics-politics-money cycle. We have abdicated our duty of oversight.

And like tyrants, we don’t spend time caring about the pain and suffering that causes.

I’m 70 years old and in excellent health, take no meds, have no active diagnoses, and avoid doctors as much as possible. I think about how I’d like to die, and it’s the same as how I live: one day at a time. My wife is several years younger, and I don’t want to burden her as my caregiver. If I get cancer, I’d prefer to take one shot at treatment, and if unsuccessful, join hospice and die one day at a time. We only die once, so might as well enjoy it! But hospice is mainly for cancer patients, so what if I have dementia or Parkinson’s?

Our fee-for-medically-necessary-service paradigm has had unintended consequences. A 2001 study showed that a fourth of Medicare spending is for care in the last year of life, and that had not changed in 20 years (and probably hasn’t changed since then). What’s wrong with that?  For one thing, the most likely reason for the spending is that they are sick: heart disease, cancer, stroke, COPD, pneumonia/flu, dementia. Sick people don’t feel well; it’s money spent prolonging a poor quality of life.

“Death squads,” you’re thinking.  In this country, our “health care system offers little support for end-of-life care other than through traditional acute care providers.” Meaning expensive specialists using  expensive diagnostic tools, expensive hospitals, and expensive pharmaceuticals. So many wealthy corporations making so much money off sick Americans. So many treatments that are painful, stressful, or plain miserable, with long-term cure unlikely. Who will stand up and say, “Stop”? Not the corporations, and not our heavily lobbied delegates. Yes, I can understand you might hear “death squads”.

But we are using expensive sick-care tools to fight a battle that was lost long ago. I remember being taught that all diseases are pediatric: look again at the list. All are self-inflicted from early in life. They are strongly correlated with overeating (obesity), smoking, and lack of exercise. Contrast France, the healthiest nation in the world, where most people are still skinny (also written in 2001, when only 20% of us were obese), and are taught to live that way from birth. Who will teach Americans to give up fast food?

American primary care doctors are dispirited, quitting the practice of medicine as soon as possible, and advising their children and friends not to enter the profession. They are powerless to halt the pitiful effects of the American sickcare system on their fellow Americans.

To me, healthcare is a spiritual matter, and the first step of the 12-step spiritual programs is to admit defeat: “We admitted we were powerless over [something], that our lives had become unmanageable.” It’s paradoxical: we must surrender to win.

Honesty with ourselves is essential. In a sense, as of today,  they died in vain. We still have a chance, but we need to get honest.  It’s our fault.

I asked a good friend today whether he would rather die at home or in a hospital. He has morbid obesity and diabetes. He said, “Well, I don’t know. Home would be nice, but hospital might be where I should be to get the care I need.”

“So you have abdicated,” I said. He didn’t answer my question, leaving someone in authority to decide what he wants. Of course he probably thinks he has the right of consent, but it usually doesn’t work that way. Doctors feel a duty to explain so the patient will comply, and he is a compliant person.

Ask yourself, in that scenario, whether our medical system will address his fears of unnecessary misery, pain, or death, even if he denies he has them.  Will it provide counseling to help resolve his feelings about losing his life, and his wife’s feelings about losing him? What about his stuffed anger at the food industry; can we be honest here?

Is our medical system tyrannical? Will it focus instead on evidence-based standard-of-care diagnosis and treatment, while ignoring possible spiritual harm to him and his family?

Are we responsible?