More interesting material on Eliot Muir's Interfaceware blog, in a thread on the topic of FIHR integration. Here Eliot proposes a strategy to counteract the looming redifficultization of FIHR, by opening up and democratizing the standards process and thus lowering the transaction costs in collaborating:
V3 and CDA proponents [along with proponents of other standards] could
register resources and see who uses them. Over time natural selection will
occur – people will gravitate to the resources that are most common and useful.
… Some resources will be easier to do quality validation on. This will impact
on the value that people see in those resources – for instance very large CDA
documents are difficult to validate effectively so that may impact on the value
that people see in them.
FHIR as currently conceived, in
contrast, is to be, like other parts of HL7, centrally defined:
I’m just
sitting on a group that is looking at device integration with FHIR. It’s a
beautiful example of how problematic it is trying to make centrally defined
standards to handle device data. There are so many different types of devices
and the area is always changing. On the other side most of the EMRs don’t have
the capability to display the data.
On why healthcare information
standards need to be as simple as possible:
… the
complexity and problems of the healthcare business itself provide more than
enough craziness. Also crazy healthcare standards tend to help competing vendors
that are willing to hold their nose and make specialized tools to deal with the
niches they helped to create.
… Truth
is that there are lots of incentives for different economic actors in
healthcare to make interoperability and standards more complicated. The reality
is that some times these create barriers to entry for competitors. What happens
though is at some point a tipping point occurs when suddenly it becomes in
everyone’s interest to make inter-operability easier rather than harder.
You have
to look at the players realistically to try understand what their motivations
are. Follow the money. One area that people make money in is being a consultant
to government organizations in terms of helping them with developing
interoperability with all the various programs they want to do. There are
perverse incentives to make the standards a little complex and obtuse because
it creates barriers to entry for competitors to do the work you want to do.
Of
course you can have too much of a good thing. One beautiful example was
the NHS
Spine. I had the joy of reading the spec on that one time to see if we
could implement it. It was a nutty amalgam of LDAP, V3, ebXML combined into an
impenetrable mess.
There
were consulting companies associated with the development of that spec that had
then developed products to implement connection to it. They were a little too
effective; though in the sense I think in the end the NHS saw through it all
and realized that it was too complicated to succeed. It was
a classic example of ‘consultant capture’.
What would it take for FHIR to be successful:
... all participants have to able to only
use the tools they are already comfortable with. One of the numerous reasons
that V3 failed to get widespread market adoption was that it required a large
investment in time to learn all the tools that were developed internally by
HL7.
… An
engineer in Mumbai that is working on a glucometer for medical device start up
needs to be able to easily find or create a FHIR profile and be able to discuss
it online without finding the equivalent of 3 months salary to come to WGM in
order to find out they will need to come to six meetings and lobby like crazy
before they even get a shot at contributing to the standard.
One of
the things I noticed at the HL7 working group is how daunted a lot of the
people were with even the current full tool set get going with FHIR. You have
to install subversion and have the right version of Java. All of this stuff
comes with a whole learning curve associated with it. Right now I can’t even
really locate where the tools can be downloaded from the FHIR site.
