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.
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 e-mail. 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, “Okay.”
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% of patients who deeply care, I have to compromise the liquidity of 97% 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% 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 healthcare 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 healthcare 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 analogue 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, okay.” 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.
* * *
Edited for length and clarity. I’ll post additional interviews over the next few months. My book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Digital Age, will be published by McGraw-Hill in early April; it’s available for advance purchase now.
Happy New Year to you and yours.
Recently I learned that the average MD spends $87,000 per year on billing costs to bill insurance.
And a doc joined our group because in his smaller group he was being assessed $17,000 a month to maintain and pay for his EHR. I tried to devise an algorithm to accurately code
hospital physician charges but was told this was a mistake because it was too rational
and looked like we were trying to upcode rather than merely record the thinking behind
the charges in case we were ever questioned. Now this guy is hiring 14 new people to
assist with information security. Medicine in dying by a thousand cuts. .
I found this interview excerpt profoundly depressing. Here are some of the reasons:
1. HIPAA and other ill-considered government mandates are apparently consuming human and intellectual resources we desperately need for solving other problems. This almost makes my remaining concerns irrelevant in the current environment. On this score—the disproportionate and stultifying emphasis on privacy—I’m very much in agreement with Halamka.
2. JH: “I do envision a day where the medical record could simply be an audio or video record of the encounter.” That would also be, to use Halamka’s phrase, “a horribly flawed construct”. I’m not sure why he would suggest such a thing, other than as a fond imagining of a fantasy world in which “record”-keeping just happens in the background.
3. From Halamka’s explanation of what he means by nuance: “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.” No, it’s a judgment based on the fact that patient is a visual artist, and needs and values that feeling in her fingers. There is no reason why external guidance in decision-making can’t account for that. The fact just has to be considered relevant. The question of whether computers will replace clinicians is really beside the point, and is asked way too often. I don’t expect that, but I do expect that our notion of what it means to be a clinician must change in major ways, and specific kinds of external support for decision-making need to be a major part of that. The simple fact is that the combinatorial complexity of modern medicine overwhelms the capacities of the limited human mind. Specialization is an ultimately self-defeating response to that, with its ill effects exacerbated by economic and psychological factors.
I appreciate the sentiment about 3% of the patients not wanting for their data to be easily shared and it gumming up the system, but it’s a little cavalier to use an allergy to a cream as the example. I think the 3% who don’t want their data easily shared have just cause, there are so many conditions that are stigmatized and are simply embarrassing. Unlike financial information, health data says something about who a person is and what they’ve done, not only what they’ve done.
Regardless of whether or not someone’s cause for not wanting to share data is reasonable, the rules in place are inadequate and not designed for the time we live. Great post!
For some perspective on how long we’ve been struggling with the privacy problem, see this article from the September 1998 ACP-ASIM Observer.
I was Chief Fellow in GI at UCSF at the same time Bob was the Medicine Chief Resident. About a year ago, I retired from medicine, due to a chronic medical condition. On the day of my retirement, I felt an incredible sense of relaxation and contentment. The misuse of EMR’s, the inability to share patient data, and the annexation of medicine and physicians by sociopathic bean counters would all have made me sicker, just as it has medical care. In my small town, 33 patients were infected with Hepatitis C at the local hospital. I believe in my heart of hearts that one of the most egregious episodes of medical negligence might have never occurred had someone cared. It sickened me. Perhaps I am incorrect, and I say this with no malice, but a fish rots from the top down.
I am currently in grad school, in American History. As I write this, I am about to start my book on this episode. It will be historical fiction. Why? 32 of the 33 lawsuits have been settled, with nary a deposition taken. Confidentiality agreements line the walls of the institution.
Not to sound old and backwards, but I gave better medical care in 1998 than 2013. We need thought leaders like Bob to dismember the bureaucracy.
“You cannot be a medical student and run a company.”
As if. I mean whats an anatomy exam following a meeting with a rapacious band of VC types. Just a mere flesh wound of course.
Thats going on my refrigerator.
[…] in medical education happened last summer when the Institute of Medicine (IOM) released a new report, “Graduate Medical Education That Meets the Nation’s Health Needs.” The report was requested […]
Failure here just as in the UK NHS. Costly in dollars and lives.
[…] This Article […]
I’m surprised a scientist would throw out a figure of 3% without any evidence to support it. Every single person who has a chronic illness or a past history of any serious disease or problem, any mention of a mental disorder would be subject to hiring discrimination. How many employers would hire someone with a past history of cancer if they knew it? I doubt his daughter would like the whole world to see her social history notes when she gets older nor the notes on her method of birth control. Of course if you are a male with no significant past history , then privacy is not an issue. Very closed minded for a scientist.
Regrettably, Dr. Halamka has not supported the need for oversight of the devices he extols.