Of the nearly 100 people I interviewed for my upcoming book, John Halmaka was one of the most fascinating. Halamka is CIO of Beth Israel Deaconess Medical Center and a national leader in health IT policy. He also runs a family farm, on which he raises ducks, alpacas and llamas. His penchant for black mock turtlenecks, along with his brilliance and quirkiness, raise inevitable comparisons to Steve Jobs. I interviewed him in Boston on August 12, 2014.
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Our conversation was very wide ranging, but I was particularly struck by what Halamka had to say about federal privacy regulations and HIPAA and their impact on his job as CIO. Let’s start with that.
Halamka: Not long ago, one of our physicians went into an Apple store and bought a laptop. He returned to his office, plugged it in, and synched his email. He then left for a meeting. When he came back, the laptop was gone. We looked at the video footage and saw that a known felon had entered the building, grabbed the laptop, and fled. We found him, and he was arrested.
Now, what is the likelihood that this drug fiend stole the device because he had identity theft in mind? That would be zero. But the case has now exceeded $500,000 in legal fees, forensic work, and investigations. We are close to signing a settlement agreement where we basically say, “It wasn’t our fault but here’s a set of actions Beth Israel will put in place so that no doctor is ever allowed again to bring a device into our environment and download patient data to it.”
RW: Is this the number one crazy-making issue for CIOs?
JH: Absolutely. Basically, my medical center board, the attorney general, and federal regulators are saying, “You are personally accountable for every byte of data on every thumb drive, every mobile device, and every network in your system.” So I came up with a 3-year plan where I explained to the board that it’s going to cost 5 million dollars a year and I’ll need 14 new staff. They said, “OK.”
RW: I see how expensive and impossible that is. But how does it harm patient care?
JH: What ends up happening is that, to protect the 3 percent of patients who deeply care, I have to compromise the liquidity of 97 percent of the patients’ data. My medical record is public. My wife’s record is public. My father-in-law’s record is public. We don’t care. My daughter is 21, and she puts her relationship status on Facebook. Does she care about her flu shot? No. It’s just fascinating. We create this culture of culpability and fear to address a very small percentage of the population that is convinced that their allergy to whatever is going to cause them loss of standing in their community.
RW: Between meaningful use requirements and HIPAA, there’s no doubt that the world of health IT has become far more bureaucratic and restrictive. Would you say that that’s getting in the way of nimbleness and innovation?
JH: Basically, I spend 50 percent of my time — five-oh — on this stuff. Not on building innovative, mobile devices for our doctors. Not on building highly usable applications for the inpatient ward. It’s on, “How do I prevent your iPhone from downloading a piece of patient information should you lose your phone?”
I became the CIO of Beth Israel Deaconess in 1997. Since that time, 300,000 pages of new health care regulations have been published. Back in ’97, I actually spent my day writing applications. We thought, “Let’s see how we can engage patients and families? Let’s create the first personal health record in the country.” We had daily meetings about features and functions we would add to the PHR.
Today it’s like, “Oh God. ICD-10. I need to come up with a new interface to allow you to code guinea fowl injury.”
RW: If a young person came to you and asked, “Should I go into clinical informatics?” what would you say?
JH: I’m in this field not for fame and fortune but to make a difference. It’s possible to make a difference, but you may want to do it in a different context than being in a health care delivery organization.
Can you create an app that will revolutionize patient care? Yes. But can you — in the context of working in a hospital, which is trying to meet the requirements of ICD-10, meaningful use, and the ACA — spend vast amounts of time on innovation? You can’t, really.
With HITECH and meaningful use, this is a time of great change in health IT. I asked Halamka to sketch out his vision for health IT after the dust settles.
JH: Today’s EHRs — they’re a horribly flawed construct. It’s just digital paper. What we really need is a combination of Wikipedia and Facebook. The Wikipedia part is the narrative of your life, and it’s written by a team and updated frequently. Facebook-like walls contain the events that are happening now. They say, “Oh, I had a TIA today. And I went to the ED. Oh, and I had a head CT …”
RW: What does the future doctor-patient visit look like?
JH: We use scribes in our emergency department, and that has vastly improved physician productivity and the quality of the record. Why should a doctor have to document the vital signs? It’s crazy. So shared team documentation with a single accountable person who just edits the note inside the EMR — that’s the future.
I do envision a day where the medical record could simply be an audio or video record of the encounter. We’ll say to patients, “We’re going to put that in a shared medical record where you and I can see and hear what we’ve talked about today.” But unfortunately, it’s very hard to do quality measures on that.
I asked Halamka to share a bit of his personal story.
JH: When I was 12 years old, I lived in Southern California. My parents went to law school. I was a latchkey child in the early 70s, when defense contractors were very, very big in Southern California. It was the heyday of that industry.
Integrated circuits were very expensive and rare, but when a TRW or a Hughes Aircraft would build a satellite, and things didn’t meet military spec, they would sell their integrated circuits by the pound.
As a 12-year-old, I rode my bike to surplus stores picking up integrated circuits. Then I got the manuals for the circuits, and I taught myself analog and digital logic, then early programming. In 1979, when Altair came out with the 8800 and the specs were published in Popular Electronics, I built an Altair 8800.
When I arrived at Stanford in 1980, I was the first student there to have a computer. While I was there, both the PC and the Apple were introduced. I was in the middle of that environment as this whole revolution was taking place.
RW: That’s pretty incredible. You could have gone on to work in Silicon Valley. What made you want to go to med school?
JH: From about the age of eight, I wanted to be a doctor and a scientist. Biological systems really fascinated me. The Six Million Dollar Man and the idea of machine-human integration really fascinated me.
My dual interests — in life sciences plus technology — led me to enroll in the MSTP [MD/PhD] program at UCSF. My advisors were [future Nobel prize winners] Harold Varmus and J. Michael Bishop. They said, “You want to do engineering? Why?” While working at Lawrence Livermore Laboratory, I founded a technology start-up. But one of my med school advisors said, “You cannot be a medical student and run a company. We’re either going to kick you out of medical school, or you have to give up your company,” so I gave up the company.
During my emergency medicine residency at Harbor UCLA, I helped computerize the ED — the ED became mobile and paperless. The county of Los Angeles gave me its Employee of the Year award in 1996.
RW: Did people think you were a complete oddball?
JH: Yes. But when I came out to Boston, I was finishing up a fellowship at MIT while attending in emergency medicine. Tom Delbanco [then chief of general medicine at Beth Israel Hospital], said, “You know what we need? We need somebody who understands technology and medicine. You’ll be responsible for all quality measurements and business intelligence within our delivery system.”
So here I was, a month out of fellowship, now running a staff and a budget. Jim Reinertsen, the new CEO of the medical center, said, “I’ve got a problem. The doctors hate IT and hate the IT leader here. I hear there’s this young guy who has created things on the Web.” In an act of administrative malpractice, he made me the CIO in one bold stroke. No interview. Just “You’re the CIO, OK.” And I’ve been on this ride since ‘97.
I ended by asking Halamka whether computers will ever replace physicians.
JH: Of course, I embrace technology and innovation, but remember that IBM’s Watson thinks Toronto is a U.S. city [a famous misstep in its otherwise astounding 2011 Jeopardy victory]. As an emergency physician, what do I believe is the difference between a novice and an expert? Two things: I know what data to ignore, and intuition.
RW: What does intuition mean in the IT world?
John: You walk into a patient’s room and see objective data. But then you look at the patient and can say in 30 seconds whether this person needs to be admitted or not.
RW: But won’t computers figure out how to do that?
JH: Computers can be excellent filters. Then a human can look at that filtered result and say, “Ah, I think this is a patient who has X.” Yes, absolutely. They can turn unstructured data into structured data. They can highlight, they can emphasize, they can alert, and they can remind. But the decision-making — I think that is still ultimately human.
RW: Why?
JH: Because of nuance. Take my wife and her cancer treatment. She had totally protocol-driven cancer treatment. But she’s a visual artist. Taxol has this interesting problem of causing neuropathy, which if you’re a jackhammer operator, who cares? But if you’re a visual artist and there’s this subtle loss of feeling in your fingers, what should the computers say? Stop the Taxol. Change the protocol. This is a judgment based on subtlety. I just worry that computers will never quite get there.
RW: Never, as opposed to, say, in the next 20 years?
JH: Without question they can simplify, they can make our lives and our workflow more efficient. But they can’t replace us.
Bob Wachter is a professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition and the upcoming The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Digital Age. He blogs at Wachter’s World, where this article originally appeared.
