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
Categories: Uncategorized
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.
Buying EMR or EHR directly for the software manufacturers is frought with fault. You need an IT partner on your side. We at Informed Inc. are here to help. With our healthcare and IT specialists, we can help you navigate the EMR landscape to identify the right solution at the right price for you.
We know how important is your practice for you and we ensure we keep that trust through the entire implementation process.
We are your EMR implementation partner. Please visit us at http://www.informed-inc.net
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
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)
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
“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.
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?!
How objective are the commentators of this post?
I have my doubts!
Dr. Seven Levels
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
With all the evidence found, I rest my case. Where is the objectivity of this post?
The HL7 Guy
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.
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.
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.
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.
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,
*** 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.
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.
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!)
Claudio:
¿Podrías decirnos que fruto da el olmo?
The HL7 Guy (a.k.a. El Catalán) is from Spain too! 🙂
Alan:
By the way, I have a life, but my boat had to go to the shop and of course they couldn’t get it ready for the Memorial day weekend!
So I decided to finish about 6 blogs that are partially done and you guys have distracted me from my purpose! 🙂
On another note:
I have extracted a few paragraphs from the HL7 website that explain HL7’s involvement with other open standards:
********************************************************
“XML
Health Level Seven has been actively working with XML technology since the formation of the SGML/XML Special Interest Group in September of 1996. Since that time, the SGML/XML group has evolved into two separate groups:
the XML Special Interest Group – which supports the HL7 mission through recommendations on use of Extensible Markup Language (XML) standards for all of HL7’s platform- and vendor-independent healthcare specifications.
the Structured Documents Technical Committee – which support the HL7 mission through development of structured document standards for healthcare.
Both of these groups have produced work items that have been ratified by the HL7 membership. In 1999, HL7 endorsed a recommendation for using XML as an alternative syntax for HL7 V2.3.1 messages. This recommendation was informative in nature (not required for compliance) and was thus not submitted to ANSI for approval. However, an XML encoding for Version 2.4 was balloted and submitted for approval to ANSI in early 2001.
In September 2000, the HL7 membership ratified Version 1 of the Clinical Document Architecture, which defines an XML architecture for exchange of clinical documents. The encoding is based on XML DTDs included in the specification and its semantics are defined using the HL7 RIM (Reference Information Model) and HL7 registered coded vocabularies. In January 2005, the HL7 Membership ratified Release 2 of CDA.
The initial release of Version 3 will use only XML encoding.
HL7 actively participates in and supports the W3C, the organization responsible for the development of XML.”
*******************************************************
This other one explains its usage as indicated in its ByLaws:
*******************************************************
02.03 Approach
02.03.01 Methodology
HL7 shall develop and publish protocol specifications based upon the knowledge of existing and
evolving methods and systems, but shall not establish protocol specifications that intentionally
favor the proprietary characteristics or interests of specific systems or entities.
02.03.02 Ownership
The information content of HL7 protocol specifications shall be in the public domain and be
actively promoted for use by any interested party. The protocol specification documents and
other productions thereof shall be the intellectual property of HL7. HL7 expressly reserves sole
right to publish and sell the documentation of its protocol specifications, and shall exercise all
applicable copyrights to said materials.
02.03.03 Operations
HL7 shall operate primarily with funds derived from membership dues, meeting registration fees,
and publication fees. HL7 is a not-for-profit enterprise and no part of the HL7 revenues shall
accrue to the benefit of any officer, participant, or contributor.
*******************************************************
Any questions?
The HL7 Guy (a.k.a. El Catalán)
Great debate, guys, but… So much of this conversation is taking a tastes-great-less-filling sort of absurdity, though. We can all agree that the HC system is broken and that we’d all love to have a hand at fixing it. Arguing “this is the problem, — no THIS is the problem” is pointless, because everyone’s right.
The biggest issue with open source is not that it’s the solution to everything, but that it’s *a* solution — and an important one at that. In an ecosystem of EHR/PHR/interoperability technologies, open source is an important choice necessary to bring down the costs of small-scale implementations, particularly for small practices and PHR start ups. What gives me HUGE cause for concern is that it’s been completely left out of healthcare reform. If memory serves me well, there hasn’t one mention of open source by Dave Blumenthal, or in all of John Halamka or David Kibbe’s great posts on THCB. For the time being, open source has been shut out and we’re going down a road that’s more expensive, less innovative and in the end less effective than it could be.
More important than software, it’s critical that standards be free, open and easily available to developers. Every restriction on cost or access is a brick wall in the path of innovation.
Open standards and open source are also reciprocal: as you take from the community you’re expected to give back. Corporations using open source are expected to fund initiatives, and individual developers are enticed to contribute their code back to the community. In fact, any organization that takes from the OS community and does not give back is quickly seen as a pariah.
Cost of maintaining standards is an issue, there’s no argument. However, the very business model of how the standards bodies work is flawed to the core. For example, IHTSDO spends millions of euros to keep expensive full-time medical experts on its payroll. It could be allowing qualified medical experts in the field to make contributions, and then maintain a much smaller staff to review these contributions and add them to SNOMED as it sees fit. (In fact, it would probably be a badge of honor to be a SNOMED contributor, and give you more letters you could tack on after your name. ) IHTSDO’s closed-door approach is out of date, and will have to change towards a more open model. It’s inevitable.
Open source and interoperability are part of a larger, more difficult problem: healthcare has set itself apart on an island where skills, norms, and standards from other industries don’t apply. You can be a world-class developer, designer, information architect, or illustrator but your skills wouldn’t translate to healthcare, often because your expertise is viewed as worthless without a medical degree.
As a result, Healthcare can’t learn from other industries, nor can it benefit from the innovations that have been made elsewhere. EMR systems shouldn’t run on MUMPS, not because the technology’s old, but because it completely out of the mainstream everywhere else. A sensible approach would run on common standards that are ubiquitous.
Personally, I believe that EMRs and PHRs have everything in common with content management systems (CMS’s) and e-commerce solutions that have been around for years. For example, 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.
To me, it’s absurd to go through the costly process of reinventing the wheel for healthcare IT, when 6th and 7th generation solutions are everywhere. It’s equally absurd to define reform in terms of pay-for-standards monopolies held by a clubby minority that’s offered very little innovation in the past.
‘No hay que pedirle peras al olmo.’
– Spanish proverb: you can’t ask for pears from an elm tree
Example of where sensitive personal information is exchanged via an open standard and there is a good bit of interoperability: Criminal Justice.
The FBI and the DOD’s Electronic Biometrics Transmission Specification along with its underlying specification from NIST are public domain and they do a great job exchanging information.
State, Federal, and international groups are readily able to exchange criminal information as a result. Under this system, vendors, government (global), and other stakeholders still participate in the development of the standard. It costs a little money to attend the meetings etc, but the result is a free download which can be accessed by anyone. It wasn’t always that way, until the FBI decided to put their foot down in the 1990s so they wouldn’t end up with a proprietary system or only one vendor. In their case, an open architecture is a matter of national security. I know the FBI and many others in the identity/biometrics space emphatically agree that their decision to open things up dramatically sped up interoperability. In this case, the general public can get the format..in XML or otherwise. You are right most people aren’t going to do anything with it, but its nice to know that it is in the public domain. Regardless of your opinion on the FBI, DOD, or the criminal justice world, they are light years ahead of the health care industry in terms of open formats and interoperability.
I still can’t see where HL7 is open or free. Look at the licensing. I do applaud your personal open source efforts. HL7 is just not open source like the spec for TCP/IP, HTTP, etc. (Those are also “messaging” formats. I think all health related formats should follow the same model.
The government needs to fundamentally reconsider the role of standards development organizations in regard to health informatics formats.
In general I think we need a BSD-style open source licensing (over GPL) because it preserves the right to package the code in commercial applications. I may not be a huge fan of Microsoft, but I sort of agree with the fact that GPL can be dangerous to businesses. BSD on the other hand is a different. A perfect example is Mac OSX, which is based on BSD Unix. Its also generally compatible with other Unix/Linux OSs.
Microsoft HealthVault is format agnostic, but has support for CCR and CCD. Google Health is CCR. These are PHR applications, not EMRs but PHRs. Personally I think Microsoft would make a pretty good EMR and for a lot less money…and this is coming from a Linux geek. These issues barriers I raise are so big they even help keep Microsoft (and small start ups) from penetrating the EMR market. Eventually though I think outside companies will chip away and help modernize the health IT industry.
Sure there are incremental success stories all over, but the overall interoperability picture is still pretty bleak. Just because a horse can carry supplies over a mountain, doesn’t mean a truck can’t do it faster and better.
Cindy: I’ll have to take a look at DDI. Looks interesting.
The weather outside is too nice on this holiday weekend. Are we w/o a life, geeks, or just passionate in our beliefs? Not sure, but its family time. I’m also hungry, but I won’t eat at McDonnalds.
I love you all…nothing personal.
-Alan
Frankly one of the better running commentaries on here ever. I frequent other sites where article might be interesting but the commentary is real what drives the value of the site.
Few points:
– Disco died in Comiskey Park in 1979 yet MUMPS is alive and well in most U.S. hospitals and a ton of other healthcare providers. We essentially are going to pay billions of dollars over the next 7 years for state of the art technology circa 1975. Alright.
– Consumer Empowerment is a nice and warm fuzzy term that has been getting bantered about alot the past year or two. Problem is that that is so vague for most of the time and has so much attached to it that it essentially has become meaningless. It needs much better granularity particularly in terms of what processes it is trying to address and what healthcare IT applications this covers. While I agree with some of the principles and that there are some applications that may have wider applicability to the population as a whole, the reality is that it will be a slow and grinding process and that there will still a large number of individuals and the population as a whole that just won’t be engaged until they become very sick/ill.
– “Open source” is another term that gets bantered about endlessly and seems to somehow manage to stay free of any type of negative association. Markets certainly do need some level of healthy competition in them to push innovation (FTC has fallen asleep at the wheel during the last decade on this issue in just about every American industry) but there are several real drawbacks to “open source” too. There isn’t some mythical domain on the Internet where is code is magically maintained by an army of magical programming gnomes. It is alot more subtle than that and messy too. Need somebody or something to provide some rational structure and boundaries to any Open Source project.
Unless someone can come up with a better example, it looks like the Data Documentation Initiative (DDI) http://www.ddialliance.org/ might provide some clues about how to make data interoperable and usable to those interested (a.k.a. transparency).
I know this is a social science-based initiative. And I know the data isn’t extremely sensitive in terms of life-and-death. But I think it’s interesting how far this initiative has come without breaking tax-payer bank accounts. It’s been in use for years.
If you want to conduct publicly-funded social science or behavioral research, chances are you will be required to meet these standards (and demonstrate how you plan to meet the standards) before you collect a penny of government money, let alone a single piece of data.
From my perspective, the conversation is coming full circle. The earlier comparison Michael made between the banking industry and the health care industry makes sense on one level, except the problem is that the health care industry is *supposed* to be, as a whole, a functional system.
It is not surprising or unethical that banks choose not to share data with each other. This is the norm for a capitalist system. A capitalist approach to health care, as has been demonstrated, is simply not sustainable. Regulations, standards, checks and balances, or whatever you want to call them need to be in place to strike a balance between capitalism, pragmatism, profit, and concern for the common good.
Clay Christenson’s book is a must-read.
Alan,
By the way, if you visit my blog site you can see for yourself that it is an OPEN and FREE service to the healthcare interoperability community.
You can also see how I clearly support projects, both open source and proprietary, that lead to the common goals we are all seeking for.
I also make a clear distinction of open source and proprietary endeavors that are only relevant to OPEN interoperability.
Thanks,
The HL7 Guy
Alan,
You have been twisting the blog around and for reasons I have no idea of.
Cindy mentioned several points that I gave my opinion on several of them.
The first one has to do with consumer involvment and I answered that this an end goal for the healthcare interoperability domain. Efforts from Google, Microsoft, Dossia, and many others are in this direction. HIMSS for many years has been promoting the PHR. HL7 an SDO organization has also been working on specific standards for this purpose.
Folks in healthcare interoperability have been tough critics of monolithic technology companies taking over hospital organizations and keeping the hospitals silo-locked.
Second she mentions the privacy issue. The privacy issue has been a big factor in keeping interoperability between hospitals difficult. This is a hurdle that has to be dealt with. We have the laws and technology but we still have a long way to go to get it right. Even banks and other industries can’t deal with privacy issues very well. What about theft identity? What domain are you comparing health IT with? Financial? Seems like this is a bad example, huh?
Third, what industry should we learn from? The financial? I just mentioned in the above paragraph how good example they are, good for nothing. The insurance industry? They are part to blame for the big mess healthcare is in. Oh, the fast food industry, oh yeah! Healthcare should follow McDonald’s and Wendy’s model. Ludicrous! No, you mean WalMart! Let’s wait and see.
Fourth, with regard to open source, healthcare interoperability has nothing to do whether the software is open source or not. The only cost that open source saves on is the entry cost. After implementation, open source is more costly or totally fails.
I am a strong supporter of 2 serious open source projects in the healthcare IT domain, one is Mirth Project and the other ClearCanvas.
You are saying that HL7 is responsible for the interoperability mess. HL7 came about to give the healthcare industry a common language because it used to be a “Tower of Babel”.
You have been questioning whether HL7 is open or not. *YES, HL7 IS OPEN AND FREE!* HL7 can be freely used by anyone. There is no licensing to use it. If you want to become a member of the HL7 organization then you have to pay membership fees. This is the only source that the HL7 has in order to finance itself. This organization is formed by thousands of industry experts and many who are from the open source world. Take a look at the list of members for yourself.
Fifth, I think Microsoft is taking the long term vision of this whole issue. They could be accused of being proprietary, but sorry, they are opening their interoperability capabilities to the community. Now what?
And responding your question of the patient having access to the data exchange formats: What the heck are they going to do with it? Do bank consumers have access to XML for a logical purpose? No.
What industry should we copy?
And yes, I do make a living at making healthcare interoperable and I have accomplished succesful outcomes of some of the biggest interoperability challenges in the country.
The HL7 Guy
On your link I read, “Note: Many documents and presentations referred to in this section are available to HL7 members only or for sale through the HL7 Bookstore. To get more information about HL7 Membership, click here.”
I would emphatically disagree that the standards and technology are not are part of the problem. I, and many others, contend that while it may not be the whole problem, it is a component.
Agreed there are external disincentives for information exchange and transparency. What incentive does any EMR vendor have to be interoperable? Interoperability exposes the vendor to competition and can decrease revenue. Competition and free markets is the American way! There is nothing wrong w/ commercial, proprietary software, but the formats should be open. I don’t want to single out HL7 either. Good people have spent many years on those formats. This is a systemic problem in health care.
Memberships are fine too. Charge me (the developer/corporation) for a seat at the table, but the work product (the formats) should be open…all versions.
Kudos to the Indivo Document Model,used by Dossia and others, for getting this right. In answer to, “Where is the public XSD and documentation?”, the answer is right here:
http://bit.ly/2lJ3NG
I have no relationship whatsoever with this group..as an open source and patient advocate I appreciate their licensing model.
The standards will only reach harmonization/interoperability when they are in the light of day.
Agreed sometimes complexity is introduced and sometimes for complexity’s sake. Many large companies have discovered that adding complexity is a great revenue model, because it means lots of developers, lots of services, etc. This is especially true for SOA/SOAP style systems. A good resource on the topic is “Big Web Services” in the book “REST-ful Web Services”.
Some people might think a person who goes by “The HL7 Guy” and makes a living at this might be a little biased?
C’mon America, lets push the reset button on Health IT.
HL7 Guy: Do you think patients should have access to these formats?
Bev MD: I hear you, and I agree…trying to help. This is just one angle.
-Alan
Last comment on this, but federal government sponsorship of a FOSS or several FOSS projects is not even worth debating.
The reason for sponsorship by the government (which theoretically at least is supposed to represent the collective will of the people) is to facilitate the development of a public good at low cost that potentially offers great benefit to the public.
Any investment of public funds would and could be minimal, vanishingly so with respect to normal disbursement of funds now for sundry projects, not to mention the $30 billion allocation in the ARRA. If there is little “uptake”, i.e. usage, there is little “waste” of public funds. The upside is enormous however.
In the case of a FOSS EMR, there would certainly be an out-of-pocket cost to a “user”, e.g. physicians’ practice, for software installation (potentially minimal), for training on software use, probably for some equipment installation, primarily for setting up a network and for the inevitable, occasional trouble-shooting. That cost could be significant, but does not have to be. The big cost – to repeat – is the implicit time and effort that users of all types have to commit to learn how to best use any application’s features.
Commercial vendors would continue to exist and presumably thrive as commercial products thrive alongside FOSS product in all existing applications.
An immediate benefit to the public as a whole is that a well-supported FOSS product would greatly increase price competition among commercial vendors, a characteristic almost completely lacking now, as it is in most aspects of medical services in general. It might increase interest on the part of physicians, many of whom seem to refuse to consider EMR system adoption on the basis of price – a more or less legitimate concern in my opinion. In regard to pricing I note a comment made by one of the founders of eClinicalWorks a few years back that the economics of its business were such that the product could be offered at something like $35 (as opposed to $10,000 for an initial provider and $5,000 per additional provider) and the company would still make money.
There is of course nothing about a FOSS product that necessarily requires any particular software engineering expertise.
The comment by bev M.D. is the overriding issue in any case. Whether electronic messages use HL7 as the standard or use XML is immaterial. They both can be used effectively. The important thing is to routinely, accurately and universally digitize data so clinical records are available at a moment’s notice anywhere, so the situation she cites is the exception, not the norm.
bev M.D. – You’ve cut through to one of the really critical points here. There is a huge disconnect between “interoperability” and “meaningful use.”
This is one of the things that should be figured out *before* the money has entered the Health Care Bermuda Triangle.
Alan,
You can download all versions, except the latest, of the HL7 standard here: http://www.hl7.org/Library/standards.cfm
Anyways, I don’t think people care too much about the latest. It hasn’t been significantly adopted and many experts are hessitant to implement it since it is overly complex. It was bornt while technology was changing at a rapid pace. 12 years ago it followed the XML format but it couldn’t evolve as fast since it was very specific. Plain vanilla XML was given much more opportunity since it had a broader audience that helped tailor it much more.
There are many sources for HL7 in the world and on