Who Is To Blame? - Briana

Perhaps we can agree that the general state of healthcare documentation is a mess. In fact, it's worse than a mess - it's what my dad would refer to as "a pig's breakfast", and he grew up on a farm so he knew a pig's breakfast when he saw it, whether before or after the pig in question had breakfasted.

It's been more than 15 years since HIPAA was passed, and many years before that we had a little thing called HL-7 that was supposed to unify the way information was to be structured in the electronic document.  In an effort to seize relevance from the scrap heap of yawning indifference, the HL-7 folks are trying now to make the case that HL-7 will enable the implementation of the "meaningful use" requirements for EHR certification, but it certainly won't if they keep on doing things the way they've done them up until now - meaning, by committees that wrangle incessantly over minutiae until they finally, with a loud shriek and a grunt, proudly produce a bouncing baby crocabuzzard.  Eureka!  "The field for the medical record identifier shall be not more than 21 characters in length (unless it is 30, or perhaps 57), and may contain only alphanumeric characters (unless special characters, runic symbols, hieroglyphics or Morse code are required)." 

Well, give 'em a break.  How would you like to go through a 12-year gestation?

And da widdle baby is sweet, isn't he?  Er - you take him, honey.  I think he just made a poo-poo.

No sooner had the crocabuzzard been born than those fun-lovers on The Hill had a blessed event of their own.  This alleged Immaculate Contraption (no one got screwed, we promise!), otherwise known as HIPAA, was supposed to do 2 things from the standpoint of documentation: 

1.  Enable the exchange of information among healthcare providers and relevant third parties (arguably, we should call those bill-payers FIRST parties, shouldn't we?) to facilitate insurance coverage "portability", and...

2.  Secure that information (because the exchange of highly sensitive information demands security).

Now, the Congress in passing HIPAA cleverly took note of the crocabuzzard, and decided not to roll around in bed with any of those HL-7 people.  Congress wasn't going to say exactly how HIPAA was going to work.  Instead, Congress would be content with issuing two divine edicts:

1.  Thou SHALT be exchanging information, amen and hallelujiah, let us turn to hymn number 63.

2.  Thou SHALT be keeping medical information under your hats, hallelujiah and amen, Brother Williams will you please pass the offering plate thank you.

Of course there were some followup shalts:  This shalt be done by 1999, no wait, this shalt be done by 2000, no wait, this shalt be done by 2001, we meant to say this shalt be done by...well, you get the idea.

And on the eleventeen-hundredth day, Congress looked at what it had wrought and said, "It is good.  In fact, it's downright holy".  (What did you think the "H" stood for?)

This, in a nutshell, is HIPAA along with a bunch of other guff that doesn't concern us.  I'm not sure funding for a much-needed seaside resort in Kansas isn't in there somewhere but who cares?

Well, Congress did something else, too.  Having skated on a few little details, they passed off implementation of the new law to the Department of Health and Human Services - and also the Justice Department, the State Department, the Department of Nuclear Bombs and the Department of Redundancy Department.

Let us pass quickly by the early years of the little wunderkind, mainly because he doesn't do anything very interesting except kick the can down the road and shirk his homework.  We come to his teens with exactly the same horrified fascination, fear and bewilderment that all teenagers bring into our lives, and with good reason because up to this point he's given us precious little reason to be hopeful about his future.  We long ago gave up the dream that he might become a doctor or a Pope.  Now we just hope that he won't find prison too unbearable and that he might learn to read while he's there.  Not much was accomplished along those lines while he sat at the feet of his teachers at DHHS, that's for sure.  They were too busy with the usual academic pursuits of promulgating incomprehensible rules and taking the names of those who violated them. (You can see the list online, by the way.)

We come now to my question:  Who Is To Blame?  When the prison warden wants to talk to those who are responsible for this walking disaster carving pistols out of soap and banging his tin cup, whose number should he call?

Everyone, that's who.  Congress, DHHS, the Center for Medicare Mismanagement, the boards and directors of hospitals, AHIMA, AHDI, the health insurers, the pharmaceutical companies, the clearing houses, the medical transcription companies, the unions, the political parties, and perhaps even patients themselves, or at least their "advocacy" groups.  Every single one of them and more has been shoving this kid this way and that until it's no wonder he's such a mess.

He's got until 2014 to learn how to read.  Unless, of course, it's 2015, or 2038.  We've got him just about to the middle of the alphabet. 

Anyone care to bet?