I want to take a moment to make sure we are all on the same page here with the business of health care reform. This is inanely simple. When it comes to health care, keep doing things the same way. It’s a proven business model. Here are a few specific pointers.1) Don’t Involve ConsumersThis is really critical. Do *not* ask consumers what they want. Whatever you do, don’t ask consumers to define “meaningful use.” These kinds of rhetorical debates are best left to academics and bureaucrats inside the beltway. Every time a consumer mentions anything resembling meaningful use or a “personal” health record, change the subject immediately.2) Act Like Privacy Issues are InsurmountableThe possibilities here are endless. The more you can distract consumers with potential privacy issues, the less they will pay attention to the ways in which they would benefit from having true ownership of their health care data.
3) Don’t Learn from Other IndustriesDon’t bother reading that book by Clay Christenson. He has spent a decade studying the inefficiencies of the health care system. Inefficient by whose standards? Let the academics put their two cents in when it comes to meaningful use, but don’t listen to any of that Harvard B-school innovation nonsense.4) Act Like Open Source Doesn’t ExistFortunately, most people have long forgotten that once upon a time, software was free and/or inexpensive. They continue to blindly support proprietary software, even during a prolonged recession. They even purchase new computers to run this bulky, expensive software!This ties into the next point. 5) Think Short TermThe time to think through any major conceptual problems is not now. Come up with brilliant, yet strangely expensive health care solutions (remember, they must be proprietary). Don’t worry about long term sustainability or stupid things like sharing your source code. Having proprietary solutions is exactly the leverage you need to maintain your involvement in perpetuating, I mean solving, the problem. This is advice you can (both literally and figuratively) take to the bank.Oh, yeah, speaking of the bank, by the time tax payers realize what you’ve done, you will have already deposited your bonus check and had a fabulous spa treatment.
Cindy Throop is a University of Michigan-trained social science researcher specializing in social policy and evaluation. She is one of the few social workers who can program in SAS, SPSS, SQL, VBA, and Perl. She provides research, data, and project management expertise to projects on various topics, including social welfare, education, and health. www.cindythroop.com
And to clarify my position I believe the following:
HL7 should publish all the standards freely from their website. There are ways to obtain the standard freely since HL7 allows its organizational members to distribute the standard in its entirety.
I don’t mind that HL7 sells products through a bookstore since I have noticed that many open source projects do the same. They have special discounts for their members. Are they trying to promote membership? Definitely.
I have developed significant applications without ever buying anything from their store. I just relied on the standard documentation which I have always obtained freely or through a member organization.
I do believe HL7 should modernize its website. I am a frequent visitor and I do have difficulties finding things many times.
And remember HL7 is an international organization and many of its current directors are from other countries other than the US. Therefore they have a global scope and aren’t related to the American healthcare crisis.
HL7 is widely accepted and is the reason for the 10% of hospitals in the US healthcare domain to have been able to create meaningful interoperable solutions.
We should be concerned of the 90% of hospitals that have not! These hospitals have no excuse. And yes, answering “bev M.D.”, physician apathy is one of the major reasons hospitals don’t succesfully implement interoperable solutions since they never even use the early adoptions.
While implementing a very powerful EHR that was almost flawless in every sense I have had physicians say that they are not secretaries and that their nurses should do the computer “stuff”. I have sat down with physicians telling me that they will not go through the bother with a system using credentials to log in. I have worked with thousands of physicians and only a handful are technically inclined. I have been in hospitals where once obtaining success certain groups started sabotaging the efforts to avoid an overall implementation. I have seen legal battles occur over the dispute between the groups favoring technology and the groups acting against it. And yes, most likely the hospitals where your elder family member went are of the same type as the ones I am explaining here.
Thanks,
The HL7 Guy (Stranded at home this weekend!)
Cindy, the discussion you have engendered would be amusing were the issues and subject matter not so serious.
The variety of perspectives represented is a perfect metaphor for what ails healthcare and healthcare IT. We start out with a simple question and the discussion rapidly degenerates into tech-speak that obfuscates the issues, eg., open source vs proprietary software, harmonize vs. what — fight? interoperability vs EMR systems that can’t/won’t share data, government control vs capitalism, bank silos vs care provider silos, etc., etc., etc. It’s like the old story of the blind men and the elephant!
I share your appreciation of Clay Christensen’s analysis and solutions for healthcare. Clay identifies and addresses the systemic problems that plague our healthcare system and account for its inordinately high cost, less than satisfactory quality, and failure to involve patients in their own care. Unless we deal with these underlying systemic problems all we will be doing is moving the proverbial deck chairs on the Titanic — and whether we do so using HL7, HML, open source or some other form of witches’ brew won’t make a bit of difference!
In his analyses, the increasing concentration of power and the consolidation of players at all levels — whether they be non-profits, for-profits or government — increase the rigidity in our healthcare system, and sorely limit our ability to innovate and change the system as our needs change. His solution, with which I wholeheartedly agree, is to restructure and fragment our healthcare delivery system into smaller economically viable units that provide the different levels of care patients require — at costs and prices appropriate for each level, to align care provider compensation with keeping patients well, to actively put patients in control of their care and give them an economic stake in their care choices, and to create an IT system that allows for the exchange of patient medical records to support a fragmented delivery system.
In my opinion, unless we recognize these broad, strategic issues and frame our solutions to fit the world of tomorrow rather than merely fight to perpetuate the worlds of today and yesterday, we’re doomed to living with an increasingly inadequate and expensive system.
hi all,
*** Hope this isn’t a double post. Please delete if is. Something strange going on ***
i’m coming to this late, but is great debate. Maybe I can add something, maybe not, but let’s see.
i’ve just spent 3 years working on the UK NHS national EHR. It has been hard and very difficult. Is it a success? At the moment, not really, but at least a basic level of functionality has been put in place and there is potential for it to grow. This assumes that the significant non-technical challenges can be overcome. I won’t repeat these because they chime with everything said above. In terms of standards, the UK NHS EHR builds on HL7 and SNOMED-CT. So, I do think I have some experience which is valid.
My concern with HIT at the moment are related to the quality of HL7 and the scope of SNOMED.
HL7 V2 is relatively old now and is complex to use, and leaves a lot undefined which makes data exchange difficult. As far as I can tell, IHE is doing some good work to tighten up the constraints and get everyone on the same page. (Btw, should we be talking more about the interesting work that the IHE is doing, XDS, etc?) Still the HL7 V2 standard is pretty old and needs to be replaced. HL7 V3 (mostly used on the UK NHS project) is the new version, but is really a bit of a dog’s dinner (excuse the technical term – and for more info see below) and shouldn’t really go anywhere, but probably will because there isn’t anything else.
SNOMED appears to be a good piece of work, especially given its scope. My concern here is particularly that scope. SNOMED essentially tries to be the framework for pretty much the entire vocabulary of healthcare (correct me if I’m wrong here!). This is a massive scope. Does this worry anyone else? The IHTSDO seems like a pretty smart organisation, which is good, but given how much they are trying to control, I don’t feel comfortable.
So, my questions in this area are related to moving forward.
Ultimately, do we know if HL7 is fit for purpose? HL7 V3 really wasn’t/isn’t great for the UK NHS. Just too complex given that the same could be achieved using new technologies with much less. It might get us through, but it does feel like a worrying standard to build new healthcare system on top of. If HL7 does need replacing, who is going to do it? What frameworks are future standards going to developed with? Should we continue with the current HL7 org? No answers to these questions, but surely they are valid questions to ask?
In terms of SNOMED and its very broad scope, is this really in our interest? It might be, and I’m open here, but I do worry about how the HIT industry ensures it isn’t overly coupled to IHTSDO and that the single approach doesn’t slow progress/adaption/evolution down in a way that isn’t helpful. I must admit that I think I’d like to see an approach which provides greater de-coupling. I’ve yet to be convinced that a single org needs to control it all. Maybe we should be considering separating some of the concerns so not a single org for everything? Btw, has anyone successfully implemented SNOMED post-coordination yet, so again, while parts of the standard may work well, there are significant issues with other parts. Will we have to wait for IHTSDO to fix these, or would completely new approaches be valuable? Not sure what the right approach should be here, but feels like a lot of eggs in one basket.
All of the above, make me wonder whether we need a new approach to healthcare standards in some areas. Should the new generation of Health 2.0 applications (for example) be getting together to agree interop approaches that build on the examples of Web 2.0 (I think @modulist is pointing in this direction), etc. I know there are issues here, for example, the WS-* standards are hardly a super success. Still, I think there is something in the modern open internet approach/standards/design paradigms that could really benefit HIT.
Btw, CCR is an interesting standard that I quite like. It limits its scope and doesn’t try to do too much. Should we be considering more “micro” standards like CCR and the narrower separation of concerns that such an approach implies? Might be nice not to go through ASTM though. If not, which standards orgs would make more sense and what “micro” standards would be of really high priority?
Regards,
Robin.
Huh?
Kidding! This is all so interesting. The complexity of IT systems plus the dysfunction of health care makes for a challenging mix.
I think we have the foundation for a book here: HIT for Dummies/Idiots Guide to HIT.
hi all,
I’m coming to this late, but is great debate. Maybe I can add something, maybe not, but let’s see.
I’ve just spent 3 years working on the UK NHS national EHR. It has been hard and very difficult. Is it a success? At the moment, not really, but at least a basic level of functionality has been put in place and there is potential for it to grow. This assumes that the significant non-technical challenges can be overcome. I won’t repeat these because they chime with everything said above. In terms of standards, the UK NHS EHR builds on HL7 and SNOMED-CT. So, I do think I have some experience which is valid.
My concern with HIT at the moment are related to the quality of HL7 and the scope of SNOMED.
HL7 V2 is relatively old now and is complex to use, and leaves a lot undefined which makes data exchange difficult. As far as I can tell, IHE is doing some good work to tighten up the constraints and get everyone on the same page (Btw, should we be talking more about the interesting work the IHE is doing, e.g. XDS, etc.) Still the HL7 V2 standard is pretty old and needs to be replaced. HL7 V3 (mostly used on the UK NHS project) is the new version, but is really a bit of a dog’s dinner (excuse the technical term – and for more info see below) and shouldn’t really go anywhere, but probably will because there isn’t anything else.
SNOMED appears to be a good piece of work, especially given its scope. My concern here is particularly that scope. SNOMED essentially tries to be the framework for pretty much the entire vocabulary of healthcare (correct me if I’m wrong here!). This is a massive scope. Does this worry anyone else? The IHTSDO seems like a pretty smart organisation, which is good, but given how much they are trying to control, I don’t feel comfortable.
So, my questions in this area are related to moving forward.
Ultimately, do we know if HL7 is fit for purpose? HL7 V3 really wasn’t/isn’t great for the UK NHS. Just too complex given that the same could be achieved using new technologies with much less. It might get us through, but it does feel like a worrying standard to build new healthcare system on top of. If HL7 does need replacing, who is going to do it? What frameworks are future standards going to developed with? Should we continue with the current HL7 org? No answers to these questions, but surely they are valid questions to ask?
In terms of SNOMED and its very broad scope, is this really in our interest? It might be, and I’m open here, but I do worry about how the HIT industry ensures it isn’t overly coupled to IHTSDO and that the single approach doesn’t slow progress/adaption/evolution down in a way that isn’t helpful. I must admit that I think I’d like to see an approach which provides greater de-coupling. I’ve yet to be convinced that a single org needs to control it all. Maybe we should be considering separating some of the concerns so not a single org for everything? Btw, has anyone successfully implemented SNOMED post-coordination yet, so again, while parts of the standard may work well, there are significant issues with other parts. Will we have to wait for IHTSDO to fix these, or would completely new approaches be valuable? Not sure what the right approach should be here, but feels like a lot of eggs in one basket.
All of the above, make me wonder whether we need a new approach to healthcare standards in some areas. Should the new generation of Health 2.0 applications (for example) be getting together to agree interop approaches that build on the examples of Web 2.0, etc (I believe this is what @modulist is pointing too). I know there are issues here, for example, the WS-* standards are hardly a super success. Still, I think there is something in the modern open internet approach/standards/design paradigms that could really benefit HIT.
Btw, CCR is an interesting standard that I quite like. It limits its scope and doesn’t try to do too much. Should we be considering more “micro” standards like CCR and the narrower separation of concerns that such an approach implies? Might be nice not to go through ASTM though. If not, which standards orgs would make more sense and what “micro” standards would be really high priority?
Regards,
Robin.
Today, the average cost for a simple HL7 interface using v2.x is $14,000 to small practices. This has proven to be the key obstacle to the interoperability that is already possible. Can anyone offer any evidence this obstacle of affordability is not about to become far worse if we continue to follow the road maps proposed by those currently controlling the industry? Perhaps PHR interfaces will finally bypass the silos and bring affordable interoperability to the masses?
hi all,
i’m coming to this late, but is great debate. Maybe I can add something, maybe not, but let’s see.
i’ve just spent 3 years working on the UK NHS national EHR. It has been hard and very difficult. Is it a success? At the moment, not really, but at least a basic level of functionality has been put in place and there is potential for it to grow. This assumes that the significant non-technical challenges can be overcome. I won’t repeat these because they chime with everything said above. In terms of standards, the UK NHS EHR builds on HL7 and SNOMED-CT. So, I do think I have some experience which is valid.
My concern with HIT at the moment are related to the quality of HL7 and the scope of SNOMED.
HL7 V2 is relatively old now and is complex to use, and leaves a lot undefined which makes data exchange difficult. As far as I can tell, IHE is doing some good work to tighten up the constraints and get everyone on the same page (Btw, should we be talking more about the interesting work the IHE is doing, e.g. XDS, etc.) Still the HL7 V2 standard is pretty old and needs to be replaced. HL7 V3 (mostly used on the UK NHS project) is the new version, but is really a bit of a dog’s dinner (excuse the technical term – and for more info see below) and shouldn’t really go anywhere, but probably will because there isn’t anything else.
SNOMED appears to be a good piece of work, especially given its scope. My concern here is particularly that scope. SNOMED essentially tries to be the framework for pretty much the entire vocabulary of healthcare (correct me if I’m wrong here!). This is a massive scope. Does this worry anyone else? The IHTSDO seems like a pretty smart organisation, which is good, but given how much they are trying to control, I don’t feel comfortable.
So, my questions in this area are related to moving forward.
Ultimately, do we know if HL7 is fit for purpose? HL7 V3 really wasn’t/isn’t great for the UK NHS. Just too complex given that the same could be achieved using new technologies with much less. It might get us through, but it does feel like a worrying standard to build new healthcare system on top of. If HL7 does need replacing, who is going to do it? What frameworks are future standards going to developed with? Should we continue with the current HL7 org? No answers to these questions, but surely they are valid questions to ask?
In terms of SNOMED and its very broad scope, is this really in our interest? It might be, and I’m open here, but I do worry about how the HIT industry ensures it isn’t overly coupled to IHTSDO and that the single approach doesn’t slow progress/adaption/evolution down in a way that isn’t helpful. I must admit that I think I’d like to see an approach which provides greater de-coupling. I’ve yet to be convinced that a single org needs to control it all. Maybe we should be considering separating some of the concerns so not a single org for everything? Btw, has anyone successfully implemented SNOMED post-coordination yet, so again, while parts of the standard may work well, there are significant issues with other parts. Will we have to wait for IHTSDO to fix these, or would completely new approaches be valuable? Not sure what the right approach should be here, but feels like a lot of eggs in one basket.
All of the above, make me wonder whether we need a new approach to healthcare standards in some areas. Should the new generation of Health 2.0 applications (for example) be getting together to agree interop approaches that build on the examples of Web 2.0, etc (I believe this is what @modulist is pointing too). I know there are issues here, for example, the WS-* standards are hardly a super success. Still, I think there is something in the modern open internet approach/standards/design paradigms that could really benefit HIT.
Btw, CCR is an interesting standard that I quite like. It limits its scope and doesn’t try to do too much. Should we be considering more “micro” standards like CCR and the narrower separation of concerns that such an approach implies? Might be nice not to go through ASTM though. If not, which standards orgs would make more sense and what “micro” standards would be really high priority?
Regards,
Robin.
Cindy, the discussion you launched would be amusing were the issues and subject matter not so serious.
The variety of perspectives represented is a perfect metaphor for what ails healthcare and healthcare IT. We start out with a simple question and the discussion rapidly degenerates into tech-speak that obfuscates the issues, eg., open source vs proprietary software, harmonize vs. what — fight? interoperability vs EMR systems that can’t/won’t share data, government control vs capitalism, bank silos vs care provider silos, etc., etc., etc. It’s like the old story of the blind men and the elephant!
I share your appreciation of Clay Christensen’s analysis and solutions for healthcare. Clay identifies and addresses the systemic problems that plague our healthcare system and account for its inordinately high cost, less than satisfactory quality, and failure to involve patients in their own care. Unless we deal with these underlying systemic problems all we will be doing is moving the proverbial deck chairs on the Titanic!
In his analyses, the increasing concentration of power and the consolidation of players at all levels — whether they be non-profits, for-profits or government — increase the rigidity in our healthcare system, and sorely limit our ability to innovate and change the system as our needs change. His solution, with which I wholeheartedly agree, is to restructure and fragment our healthcare delivery system into smaller economically viable units that provide the different levels of care patients require — at costs and prices appropriate for each level, to align care provider compensation with keeping patients well, to actively put patients in control of their care and give them an economic stake in their care choices, and to create an IT system that allows for the exchange of patient medical records to support a fragmented delivery system.
In my opinion, unless we recognize these broad, strategic issues and frame our solutions to fit the world of tomorrow rather than merely fight to perpetuate the worlds of today and yesterday, we’re doomed to living with an increasingly inadequate and expensive system.
Huh?
Just kidding.
I think the information above is more than enough to write a book or two on HIT for Dummies, HIT for Wonks, etc.
I look forward to learning more.
Have at it, folks. Too technical for me and most patients. Don’t forget that most patients are healthy and are never going to care. Most doctors view the computer as a resource but not a patient care tool.
With all the evidence found, I rest my case. Where is the objectivity of this post?
The HL7 Guy
With all the evidence discovered that most of the commentators of this post have strong ties to the author, I rest my case.
Where is the objectivity of this post?
Please reply!
The HL7 Guy
How objective are the commentators of this post?
I have my doubts!
Dr. Seven Levels
Well, here’s one big vendor’s take on ARRA money(hint; the title is, ARRA could boost Cerner take 33%):
http://kansascity.bizjournals.com/kansascity/stories/2009/04/27/daily29.html?surround=lfn
Talk about brazen salivation in public….is that legal?!
“I’m convinced that an inexpensive EMR could be built on a Linux-Apache-MySQL-PHP platform (a LAMP stack) using a combination of an existing CMS with an ecomm solution like Ubercart.”
Already exists as openEMR. PatientOS is Java-based and has significant potential in my opinion.
“‘Open source’ is another term that gets bantered about endlessly and seems to somehow manage to stay free of any type of negative association.”
It is free of negative associations because there are no negative associations!
I read recently an excellent article by a developer who developed a commercial application that competes with several open-source projects that perform the exact same functions. He does a good job of highlighting the deficiencies of open-source projects to indicate how commercial software can compete effectively with open-source. His own product is proof of that. Also read any of Eric Raymond’s essays on open-source. He is a practitioner and “theoretician” of the open-source process. His essays are outstanding.
Read Claudio Luis Vera’s comment.
The “HL7 is Free or UnFree” debate is amusing. Yes, it is free, there are no license fees. No it is not free, it costs $600/year to have the latest specification.
I was very fortunate a few years ago, while preparing to teach a course on information technology in healthcare, to have lunch and a little “interview” with Samuel Schutz, one of the inventors of HL7. He was for awhile at the University of Missori’s Informatics program, and is now with Cardinal Consulting. (http://ccigroup.org/index_files/Page354.htm)
He told me the group’s original intent was for HL7 to be run in the style of the “Internet Standards” as entirely open and free in every respect. But their early successes led people to ask “how they could join”. Well, there was some need for funding. He does not like the way it has gone since then.
From my point of view, the $600 individual membership fee is not a serious hinderance even for a hobbyist but the point is taken — HL7 is free-to-use but is not-quite-entirely open. Should it be? Gee, I don’t know.
t
Interoperability will only be achieved when we have the network and the yellow pages to go with it available to all. How can Hospital A connect with Hospital B or C or D in a cost effective manner without knowing the connection? BUILD IT LIKE THE BANKS – it’s been way to long (CHIN, RHIO, HIE….yada yada yada)
Sorry to say this, but if you don’t work for a member organization or are an individual/student member of the HL7 organization then you don’t have free access to the current versions of HL7.
John
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Cindy,
Some very good points. Good points on the maturity of open source software as well. We are no longer talking about Apache 10 years ago. If not purely open source, there are defnitely cheaper solutions being built that are easily integateable with other technologies.
Again, good points on getting customers involved from the get go.