Saturday, March 28, 2009


In an article in the New England Journal of Medicine [1], Kenneth Mandl and Isaac Kohane argue that spending billions of dollars of federal funds to stimulate the adoption of existing forms of health record software would be a costly policy mistake -- because current health record suppliers are offering pre-Internet era software, which are costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements. (We note that exactly this mistake was made in the United Kingdom with its Connecting for Health program.)

Mandl and Kohane propose instead that the government should be a rule-setting referee whose role would be to encourage the development of an open software platform on which innovators could write electronic health record applications in a way which would open the door to competition, flexibility and lower costs. They point to an analogy with Apple's IPhone platform, that anyone can use or write applications for.

This is, of course, a good idea, since it would bring in its wake the opportunity for thorough testing of particular applications before they are extended to larger communities of users. The potential flaw, of course, is that it leaves open the question of what the government-imposed framework of rules should be. The HL7 organization (founded in 1987) continues to be mightily influential in government circles. Consider, to take one simple example, the case of XML. Will it be XML itself that is government imposed? Or will it be HL7-XML, a peculiarly complicated non-standard version of XML resting on an idiosyncratic approach to development that is at odds with the approaches taken by developers with XML expertise?

[1] Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D. "No Small Change for the Health Information Economy", New England Journal of Medicine, Volume 360:1278-1281, March 26, 2009. See also New York Times, "Doctors Raise Doubts on Digital Health Data", March 25, 2009.


Fox said...

Having worked on Connecting for Health's National Programme in the UK and developed applications for Apple's iPhone I have some insight on matters:

"encourage the development of an open software platform... an analogy with Apple's IPhone platform, that anyone can use or write applications for"

The "IPhone" (sic) platform is not open, or free. You have to pay to become a certified Apple iPhone developer, and sign a very restrictive agreement with Apple, hence is not a particularly good analogy for the authors to make, and makes me think that perhaps they ought to limit their writings to matters in which they have expertise. A better example might be Google's Android, which *is* Open Source.

Organisations such as HL7 and OpenEHR are trying (with qualified success) to define information models for the communication of data between applications. I personally am unaware of HL7 v3's implementation as being either idiosyncratic, or non-standard. The RIM is most certainly complex, but the complexity arises from the underlying complexity of the information model, not the implementation in XML.

CfH's $20bn+ HCIT programme in the UK has/is failing. Our equivalent of the NAO has already declared that unless it delivers against it's objectives in the next 6 months it will be canned. Fujitsu, one of the prime contractors is already trying to sue CfH for approx. $1.2bn - certainly not a sign of a healthy programme.

The failings that the US can learn from here are:

* Do not bill something as an IT programme when it is actually a change management programme. Dressing change as IT in order to get your foot in the door to changing the way healthcare professionals do their job just irritates people when they find out the truth, then they just dig their heels in. Secondary care institutions in the UK have a great deal of autonomy, and trying to take that away from them was a battle that never needed to be engaged in.

* Adopting a 'one size fits all' mentality in order to try and leverage economies of scale betrays a deep lack of understanding of providers and the huge differentiation between them. In secondary care alone within the London area the requirements for a medium-sized District General hospital like QMS are hugely different from a cutting-edge teaching and research hospital like UCLH. Trying to sell them the same product was 'one size fits nobody' madness.

* Trying to impose a national repository of sensitive, private health records, owned by central government, without adequate security or privacy, with unlimited access for 'secondary uses' (research, clinical trials, policy etc.) and without either opt-in or opt-out choices for the subjects of said records, in a country which has already overturned several central government attempts to introduce ID cards, was doomed to failure before it started.

Many of us HCIT professionals in the UK have been saying the same thing, some of them for more than 20 years:

1) Agree on open standards for information interchange. Start small, layer the standards in complexity, have only the simpler layers be mandatory for compliance at first, and let the market move at it's own pace.

2) Let the Primary, Secondary and Tertiary care institutions pick the solution that is best for them. Employ a certification scheme whereby the solution providers can, for no (or nominal) cost, certify that their solution is 'standards compliant' and can therefore talk reliably to other solutions.

3) Employ financial incentives, rather than straight-jackets, for institutions to upgrade to 'standards compliant' solutions, at a pace of change that suits their organisational timetables, rather than try and have all institutions in the country proceed to upgrade in lock-step.

Hopefully the Obama administration can learn from and avoid the costly errors that the UK government have made.

KevinCoonanMD said...

HL7 XML is standard. It follows published W3C standards, which as far as most are concerned are the standards about XML which matter.

HL7 itself is a ANSI SDO, and anything that HL7 publishes as normative BY DEFINITION is a standard.

Finally, HL7 contributes, collaborates and uses the same ISO standard (21090) for data types, which is by-and-large the XML which makes up "HL7 XML."

Please, when you make statements such as that, you should constrain yourself to the facts, and not make such invalid and irresponsible statements.