Complex HIT issues lack absolute answers

HalamkaListening to Obama and McCain you realize that some issues have no absolute right
answer. Pro-Life v. Pro-Choice, Pro-Gun v. Anti-Gun, Less Government v. More Government etc. Everyone has an opinion and often the emotions run high.

The same thing is true about health care data standards and interoperability, although the stakes are a bit lower than life and death issues.

Recently folks have asked me to comment about Carol Diamond and Clay Shirky’s article in Health Affairs which contains potentially controversial statements such as:

Yet after three years of standards documentation and the resolution of several standards ‘disputes,’ we remain a long way from seeing these standards used and implemented to enable health information sharing. As Sam Karp of the California HealthCare Foundation stated in his testimony to the Institute of Medicine Board on Health Care Services and National Research Council Computer Science and Telecommunications Board, ‘Not a single data element has been exchanged in real world health care systems using standards this process has developed or deployed.’

I did not find Carol and Clay’s article controversial. Both are good friends of mine and I agree with their thesis that technology is not enough to ensure successful interoperability. We need to agree on appropriate policies to protect privacy, incentives for implementation, and justifications for continued use of technologies to ensure widespread adoption.

What about Sam’s comments? Sam Karp and Walter Sujansky, who works
closely with California Healthcare Foundation on their standards projects are also good friends.

Per Sam’s comments, should we approach health care data standards by
making incremental improvements to the status quo or create a blueprint
for the ideal and then implement that in a phased way?

Although far less controversial from a philosophical and religious
standpoint than the Obama/Mcain issues I’ve mentioned above, there is
no obvious right answer to this question, just opinion.

Sam’s point is that incremental additions to the status quo move us forward without the controversy of major change.

I’ve used Sam’s approach for some projects and it’s worked. However,
the risk of stepwise improvement on the status quo is analogous to a
house remodel. Sometimes you end up with a less than perfect floor plan
by adding a room here, a staircase there, and a door in anticipation of
a future need.

What HITSP has done, which is a reasonable approach in my opinion,
is to articulate a vision for a very good endpoint, then work with HHS,
AHIC and ONC to implement that endpoint in phases. It’s like creating
the blueprint for a whole house and then building at the pace your
budget allows. The end result will be a logical floorplan, but it will
take a bit of time to implement it all.

For example, CCHIT has created functional criteria for
e-Prescribing, lab, and read-only clinical summary exchange for this
year. Next year, functional criteria will include additional lab
details and import of clinical summaries based on HITSP
interoperability specifications. The year after, even more will be

Implementation of HITSP interoperability specifications for
health care is similar to BluRay for home entertainment. The
stakeholders have decided that BluRay is the preferred format, yet few
households actually have BluRay. In the next few years, it will be more
common. BluRay is not an incremental improvement, it’s a new endpoint
that requires replacement of existing DVD players over time.

When Sam Karp made his comments in September of 2007, few HITSP
interoperability specifications were in production, because they were
not finalized and recognized by Secretary Leavitt until January 2008.

At this point in September 2008, thousands of transactions occur
every day using HITSP interoperability specifications. The
Massachusetts RHIO uses HITSP’s C32 for exchange of clinical summaries
among hospitals, BIDMC uses C32 to exchange clinical summaries with the
social security administration, and Kaiser is implementing all the
HITSP lab specifications in support of its 9 million patients etc.

I want to thank Carol, Clay, and Sam. They’re moving us forward.

Every day, health care IT and interoperability gets a bit better.
There are no absolute right answers, but step by step, all stakeholders
are narrowing the optionality in standards, enhancing policy, and
implementing pilots.

My tenure as chair of HITSP lasts another year. In the next year, I
look forward to working with all our national stakeholders as we change
administrations in Washington, continue to implement new
interoperability specifications, and assist
payers/providers/vendors/patients with implementation of the work HITSP
has done thus far through our education and outreach efforts. It will
be a great journey for us all.

John D. Halamka, MD, MS, is Chief Information Officer of the
CareGroup Health System, Chief Information Officer and Dean for
Technology at Harvard Medical School, Chairman of the New England
Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE
(the Regional Health Information Organization), Chair of the US
Healthcare Information Technology Standards Panel (HITSP), and a
practicing emergency physician.

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2 replies »

  1. “It’s like creating the blueprint for a whole house and then building at the pace your budget allows. The end result will be a logical floorplan, but it will take a bit of time to implement it all.”
    The key constraining factor of this approach – and reason that a lot of people are impatient at the pace – is funding! More funding, faster pace (to a point).
    Little funding + volunteers doing the work = slow pace.

  2. Having gone through an electronic medical record implementation within my medical group, I can tell you that the best technology is not the answer if the underlying processes and standards are not first cleaned up. The best technology in the world will also not resolve issues between players in the system (physicians, insurers, etc.) who are not able to see exactly how those standards benefit them. At some point, the question has to be: How will the standards improve the system as a whole? That’s the socially responsible thinking that ultimately benefits everyone.