This post originally appeared in Wired magazine’s Cloudline blog.

In 1990, when I got my first health care job driving ambulances, not a soul in the New Orleans EMS department had a cellphone. Not even the head of the service. The mayor, his chief of staff and the police chief each had one. That was about it. These phones weighed like 15 pounds and were hardwired to a car battery. And we ambulance drivers documented our care on “run sheets” found on metal clipboards but, since so few people bothered to read them, we also wrote key vital signs and other metrics on a three-inch-wide piece of white tape smacked across the patient’s abdomen.

Today, everyone in New Orleans — and everywhere else — has a cellphone. These cellphones have the computing power to find, and add to, and direct everything that anyone would need to know about a patient anywhere in the world… but they don’t do it! Today’s “do-everything” cellphones are the size of your wallet, yet most ambulance crew run sheets are still paper, found on metal clipboards. And most good patient data is still found on those three-inch-wide pieces of tape.

Why? I’ll give you one good reason and one bad one.

A countless number of companies and technologies and ideas were harmed — and, in fact, blown up completely — between the days of the brick Motorola cellphone and the iPhone of today. Remember “DSL” companies that connected houses to the internet over copper wire? Remember “booster antennae”? Remember when we all thought the “flip phone” was the shizzle?

There are many corpses scattered in the wake of the Internet and cellphone renaissance that has occurred over the past 20 years and we are all fine with that. The young engineers and designers that were part of exploding companies simply took their backpacks and mini-fridges and went to the next cool company. When the company worked out, the options for these young engineers and designers were worth millions. When it didn’t work out, they moved on.

But there’s a big difference when it comes to health care. If each of these companies had been dealing in critical patient information in an EMR and lives were at stake, this would have been a dangerous game. The innovation would have been faster but the collateral damage would probably have been too much for our social values.

OK, now here is the bad reason:

The market for exchanging information in health care, specifically for sending referrals, is, in many cases, not legal. I’m not kidding. A few years after we nationalized health care coverage for seniors (Medicare) and for those in need (Medicaid) in 1965, we also made it illegal for the sender of a patient to be given anything of value by the receiver of that patient.

There was a good reason for it as we were afraid of kickbacks driving up federally funded care. Well, federally funded care has gone up quite a lot since it was originally funded, but no supply chain emerged.

Cellphone carriers can pay retailers who hook up folks to their network, but specialists can’t pay primary care doctors for the effort required to send clean electronic clinical info over to them that would improve care and reduce duplication.

If they could, there would be a lot more than, like, six Wired readers using their engineering talents in health care. (Hi! Please come work at athenahealth.) Instead, the only information systems that people pay for are those that work within their own controlled environments. There are legacy, non-cloud software systems that are only useful for exchanging information within the institution that owns that particular IT system. Weird, right?

As a result, in the last three years, we have hospitals that bought an EMR under the HITECH Act (and Meaningful Use) that have also bought the practices of the doctors that use them! We have gone from some 22 percent of docs employed by hospitals in 2008 to about 44 percent employed by them today. Making people work for you in order to exchange information with them is not exactly New Age. And most of those doctor acquisitions will fall apart in the next three years. You heard it here first.

The good news is that, even despite these obstacles, the obvious benefits of cloud computing, especially through electronic medical records, are driving health care into the 21st century. We at athenahealth are growing like crazy and we serve all our clients on one single instance of our web-native application. We are also being asked by our clients to move information in and out of legacy systems that don’t communicate well. We have even gotten the federal government — the Office of the Inspector General in the Department of Health and Human Services, to be exact — to bless a small ($1) interchange fee as “NOT a kickback” in order to attract more entrepreneurial energy into the efficient exchange of clean health information.

All of this makes me feel like heady times are ahead in health care. Even though we are watched by a nervous, panicky government that doesn’t quite get the deets, enough good seems to be getting done for Uncle Sam to continue letting us move about the cabin. And the government is getting behind the cloud — or, at the very least, not getting in the way of it.

So, people of Wired, come to health care! The water is, well, a little chilly, but it’s getting warmer all the time. In fact, I’d say spring really is here!

Delays and more delays

Originally, the 10th revision of the International Statistical Classification of Disease and Related Health Problems–aka ICD-10–was slated for adoption here in the United States on October 1, 2011 by all “covered entities” under HIPAA.

As early as January 2009, the deadline was pushed out to October 1, 2013 and with it, migration to ANSI 5010 moved to January 1, 2012 in order to support ICD-10 codification. If, like me, you have become so immersed in the politics of such timing, just remember that the ANSI 5010 standard and ICD-10 code set updates are intended to be helpful, streamlining and improving transactions and improving diagnosis reporting and analysis.

Anyway, the “best-laid schemes of mice and men oft go awry”… unless you’re living in France, or one of the Nordic countries…circa 1997.

The industry transition to ANSI 5010 has been less than smooth and the Centers for Medicare and Medicaid Services (CMS) recently extended the enforcement start date to July 1, 2012. In response to feedback from organizations like the American Medical Association (AMA) regarding the administrative burden and cost of the ICD-10 transition, CMS announced in February that the agency would also consider postponement of ICD-10 implementation.

No lack of points of view

Finally, on April 17, the Department of Health and Human Services (HHS) published a Notice of Proposed Rulemaking (NPRM) in the Federal Register to propose a one-year delay to the implementation of ICD-10 until October 1, 2014. Prior to the release of the NPRM, policymakers and thought leaders weighed in with a wide range of opinions as varied as: “Don’t delay!”, “Make it a 2 or 3 year delay”, “Let’s just move on to ICD-11”, “Do we even need ICD-10 or can SNOMED suffice?” (While this last idea may seem a bit radical and unlikely, we tend to agree with its potential to simplify—removing the administrative burden on providers and avoiding redundancy.)

But at this point, the length of a delay doesn’t really matter. What does matter is that delays continue for everything—ANSI 5010, Meaningful Use, ICD-10, the Sustainable Growth Rate resolution. And with each delay, the innovative doctors, vendors, patients, health systems and payers aren’t rewarded for their speed and efficiency.

I understand the thoughtful arguments of advocates on all sides and I know we’re collectively tackling monstrous issues. But, the culture of delay is really beginning to keep our industry stuck in a rut. The discussion seems to be increasingly focused on “When will we?” rather than “How can we?”

As always, we’d love to hear your thoughts and, more importantly, encourage you to share them with the feds, who take the comment process very seriously.

You can review the NPRM at the Federal Register. The rule also includes proposals for the adoption of a standard for a unique health plan identifier (HPID), a data element that would serve as an “other entity” identifier (OEID) and a National Provider Identifier (NPI) requirement. Comments are due no later than 5 p.m. on May 17, 2012 and instructions regarding submission can be found on page 22950 of the rule.

To say Florida Woman Care has been an expanding medical practice across the Sunshine State would be an understatement. At the end of 2009, its first year in business, Florida Woman Care had 38 physicians. After its second year, that number grew to 158. The practice now has some 260 physicians and almost 400 total clinical providers on staff, at locations across the state from Pensacola to Miami.

When Florida Woman Care was looking for physician billing services and an EMR that would support its growth goals, the leadership wanted a solution that allowed them to drill down into data, get paid efficiently and avoid running the practice like a patient conveyor belt.

Find out how Florida Woman Care has made the most of athenahealth’s cloud-based services to satisfy these needs.

At the HIMSS 2012 conference in Las Vegas this past February, Dr. Farzad Mostashari, National Coordinator of Health Information Technology, observed that while there is still a lot of work to do on the adoption and use of electronic medical records (EMR), the majority of physicians in the US will be using an EMR within the next two years.

And we like that. It shows progress.

It also means we are experiencing an acceleration of the paradigm shift from the “Old World” of paper-based health records to the “New World” of EMRs.

None of it feels like a small adjustment; more like a tectonic paradigm shift for the health care industry. Even as the Old World recedes around us and the New World emerges, Old World concepts of health records and record ownership do persist. They manifest themselves in some unusual ways, too, and with surprising staying power, persisting in laws, regulations, the way we think about records, the way we do business and, often, even in EMR offerings themselves.

EMR systems that have not fully transitioned to the new paradigm represent a “Middle Path” that slows down change and innovation. To move forward successfully from the Middle Path to the New World, we will ultimately need to resolve the conflicts between the paradigms.

Ownership vs. Use

So, what about these conflicts? In the Old World, records are regarded principally as physical items–paper files that contain information. Therefore, the Old World focuses on custodianship of the record, which then translates into the question of who “owns” the record and, therefore, the items (information/data) contained within the record. This is a property-based approach to health information. In the New World, the interest is the data itself and, more important, aggregated data across multiple records that:

• provides meaningful insight about what care protocols work
• enables caregivers to communicate better with patients
• enables researchers to more expediently identify patients to participate in studies
• achieves better public health reporting and analysis, among other uses…

Therefore, in the New World, how the data can be used and how it can be leveraged is more relevant than who owns it.

Are you still living in the Old World? Did you make the leap to the New World? Tell us about it.

Next week, we will explore static records vs. real-time records and ways that software-based EMR systems often represent the inertia of the Old World paradigm.

Do you feel like you’re working harder for less pay? When you were young, did you have dreams of being a noble caregiver, only to spend your days worrying about reimbursements or getting sued or the next cumbersome government regulation? Are your collections late? Did life NOT improve after the local health system acquired your practice?

Okay, forget being in the health care business—we are all patients sometimes, too. Do you feel like an actual human in the exam room or a numbered paper gown with dollars signs attached to it? Has trying to get well ever nearly bankrupted you?

Well, you’re not alone.

This is a tough time to run a medical practice—or be a patient—and we all know that is why, in fact, athenahealth exists. We are here to make it suck less.

For a light-hearted look at your plight—and ours—we have a little video. It’s a parody of a song from the Tony Award-winning musical “Avenue Q.”

Hang on. Things get really great at the 3:29 mark….