NOSH ChartingSystem

A new open source health charting system for doctors.

Shut out, shut up, and shut down

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I’ve been tracking the troubled launch of Healthcare.gov and I was surprised to find some disturbing themes as we learn more about what led to the disaster.  Aside from all the political rhetoric (which I won’t go into here, as I find it irrelevant) and the vague and shallow analysis that is predominant in the mainstream media, I came upon several blog articles that went into some meaningful discussion about why this happened and what can be done to prevent it in the future.

Shut out

One interesting post comes from Clay Johnson, who spent 6 months as a White House Presidential Innovation Fellow, who talks about the procurement process and how federal and state governments complete aversion to risk produces a bidding process that all but nixes out the best and the brightest minds and technological companies at a major cost to the citizens of the country.  A shocking statistic is that more than 90% of projects that cost more than $10 million ends up failing.  In his post, Clay Johnson states that the process is riddled with practices such as these: pre-approved vendor lists,  6,500 pages of regulation, cumbersome business registration processes, and hostile bidding environments.  All of these practices practically ensure that vendors that cater to the government and know how to cut through the red tape (because it’s their specialty, not because they know how to make innovative products) are chosen for new projects, even if the older projects have spectacularly failed.  In my world in clinical medicine, I’ve heard from several government-related officials about IT infrastructure  and implementation disasters (health and human services documentation systems, immunization registries, and even electronic health record systems for county-funded clinics).  I never knew exactly why these disasters kept affecting government-related projects, but now it seems much more plausible that it’s not just pure dumb luck (or the lack thereof).  It’s about the inadvertent shutting out of the best and brightest in an antiquated and mis-guided procurement process.

Shut up

Robert McMillan’s article in Wired, talks about how the open-source code for the front end (the part that people see when they visit Healthcare.gov) was removed from GitHub (where the large majority of open source code, including NOSH, is stored) was one of the few aspects of the website that actually did work as intended.  The GitHub site was also where many people sought answers to why Healthcare.gov was not working as expected.  It became clear through those discussions that it was the backend, which was closed and proprietary, that was at fault but there was no one that could answer for these issues.  So the Centers for Medicare & Medicaid Services simply just shut down the GitHub site.  I personally don’t think this was the right thing to do, especially in the spirit of open source.  Even if one concluded that the problem was found to be a part of the backend, wouldn’t it be helpful for those that are implementing and managing Healthcare.gov to know what other’s think of the problem?   I don’t think anyone really knows what CMS was thinking when they decided to pull their GitHub site, but thankfully, in the spirit of open source, someone forked the code and there is now a new GitHub site with the front end code.  The one thing about open source code is that nothing every dies, even if you want to shove it back in the closet never to be seen again.

Shut down

And where it all seems to fail is this concept that we’re building a contraption that has so many parts that even though only one part of it is open source and the rest is not, it’s just not an open source project.  Period.  Kin Lane writes about how the lack of transparency is the overwhelming flaw  in this project.  A term that describes this is called openwashing

Openwashing in government is spin that deceptively promotes IT projects and policies as “transparent” and “innovative” when actual practices and spending are not.

Open source code is just one aspect of an open process.  And that also includes the procurement process and its lack of open-ness that starts it all.  Imagine an alternate reality where all the synergy of collaboration and energies are spent in a transparent, open process along with open source code.  It’s process as if people mattered, both in the developmental process and in the delivery of services to help people.  Perhaps that is why I’m passionate about open source computing, and in fact, even open source health care, if there is such a thing.  The more we exclude, the more we hurt ourselves.  I feel that the Healthcare.gov is a perfect case study in what happens when you have a process that is non-transparent, exclusionary, and closed-minded.  In effect, shutting out, shutting up, and ultimately leading to a shut down.

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Author: shihjay

I am a family physician and previous medical director for a child abuse assessment center. I am now promoting my new electronic health record system (NOSH ChartingSystem) that I have developed and used for myself in my private practice since 2010 and now I want to share it to the rest of the doctoring world.

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