At TEDMED, Eric Dishman makes a bold argument: The US healthcare system is like computing circa 1959, tethered to big, unwieldy central systems: hospitals, doctors, nursing homes. As our aging population booms, it is imperative, he says, to create personal, networked, home-based healthcare for all.
Nobody who really cares about the health and welfare of the general population would ever disagree with the statement that “it’s imperative … to create personal, networked, home-based health care for all.” I have a lot of respect for Eric Dishman and his passion for improvements in healthcare—have a look at his 2013 talk on “Health care should be a team sport.” However, I had issue with one of the themes in his 2010 talk, “Take health care off the mainframe.” I feel that to blame technology, or rather a specific type of technology, as being the main impediment holding the world back from a lofty healthcare goal was ludicrous.
Eric Dishman’s 2010 talk is very interesting for the most part, as he talks about how computing and communications can play important roles in early recognition of behavioral markers for the elderly. Certainly as many of us get older we are more concerned about falls, and the idea of using technology to not only monitor the elderly, but also to help in early diagnoses is compelling. But he then segues into some unnecessary and biased technical finger pointing using terms like “mainframe poisoning” and “mainframe mentality,” and insists that we can no longer afford mainframe healthcare. I hesitate to point out that this sounds a little like something his employer, Intel, might say rather than Eric Dishman himself. Now to be fair, after the segue, he does go on to talk more about the state of healthcare and to offer excellent advice.
It needs to be said here that the mainframe has been a stalwart player in healthcare IT for decades. Far from being old, outdated, too expensive, and a technology that imposes its weighty dogma on the healthcare system, it is updated constantly, is in fact cutting edge, and is ideal for the types of processing that is needed now and in the future to promote the best possible IT performance for healthcare.
Criticisms like the concern about a mainframe mentality may have meant something a decade ago or more, but that line of thinking is obsolete. It does not honestly reflect the advances that have been made by IBM on the mainframe and other platforms, and the continued advances that are taking place even now. Today, IBM’s Watson is on the forefront of IT in medicine, with its Watson Health cognitive systems, and is actually run on a platform of distributed servers: Power7 systems, that are similar to Intel x86 systems. IBM for some time now has been aware of the concept and benefits of the mixed platform environment—using the platform that makes the most sense for the task at hand—whether mainframe, distributed servers, or mobile devices. This contrasts sharply with other platform vendors / chip makers who are solely interested in replacing other platforms with their platforms.
Eric Dishman’s statement that we cannot afford the mainframe in healthcare has been pretty much discredited in other industries. By that I mean if you replace a mainframe system with another technology, and build into that technology all of the throughput capacity, the processing performance, the reliability, the security and the ongoing IT support costs, (not to mention all the application re-engineering that would be required) you will end up paying a lot more for that technology than you did for your mainframe technology. Often the cost comparison between platforms focuses on only one or two factors in the total cost—typically the purchase cost of the hardware—and does not include many other factors, which are just as impactful on the bottom line.
Eric Dishman seems to blame the general inertia in healthcare IT on the mainframe. Getting away from “business as usual” in healthcare IT is a legitimate goal as healthcare IT still has a long way to go. However, it is not and never was an IT platform technological issue, it has always been a top-down approach to medicine that, as Eric Dishman points out, has been a characteristic of healthcare in general, long before there ever was such a thing as “healthcare IT.”
His statement that the healthcare IT challenge of getting “… doctors using electronic medical records in the mainframe” is more than a bit misleading. It is likely that most doctors and other healthcare practitioners do not have an opinion on which platform electronic medical records reside; the paradigm shift was always about getting them from a paper records filing system and into a digital records filing system—the actual platform technology was never really an issue.
The needed shift of getting healthcare IT from the mainframe to the home is not about the mainframe at all: it is about getting from centralized healthcare to a home-focused healthcare paradigm, which is an important goal and is independent of whatever hardware platform is used where. The home-based patient interface will be smartphones, tablets and IoT (Internet of Things) devices—not mainframe or x86 systems.
However, the data collected will ultimately wind up in back-end databases that can easily be accessed by healthcare professionals using their own smartphones and tablets. And BTW, those back-end databases, will be either mainframe, x86 or PowerPC based systems. Which one? It does not really matter as that will be decided by IT experts who will decide which platform is best suited to the specific business environment.
In most cases, the back-end platform(s) used will probably not change, even in cases where mainframe systems are in place now because that is where the most IT intellectual property is invested. Let us ask whether or not it would be better to invest money in new treatment equipment or services instead of advocating a wholesale replacement of existing technology. Reinventing the wheel is rarely if ever a good idea, and besides, there have been many advancements in mainframe IT in other business sectors for which healthcare IT could take a lesson.
Take banking for example: If you have a quick look at the balance on your checking account right now using your phone, you are going to be accessing a back-end mainframe system. In fact, you are initiating a transaction involving not just your phone, but also a mainframe online application that was written more than 10 years ago. Actually, depending upon which bank, that application might be much older than that. The new technology is in the interfaces between the user and the legacy systems—rather than reinventing the wheel, new applications leverage the legacy applications. And that is actually the most efficient and cost-effective way to harness the power of home-based smartphone / tablet /IoT devices. The point is that the platform that you use in the back end is irrelevant to the ultimate end users: the patients and healthcare professionals.
Aside from his attack on the mainframe, I agree with what Eric Dishman said in his 2010 talk. The disruptive technologies that we are looking for in healthcare IT can be created today. Now. We can leverage what we have now, and build what we need quicker and more cost effectively than if we burned everything to the ground. It has been done in other industries already, it just needs to be applied to healthcare IT. That is how we drive a compliant and customized healthcare system that uses the latest technology to change our behavior, and to improve personal healthcare. And that is how we can create a personal healthcare movement, something that will be increasingly important to us all.