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Tuesday, June 24, 2008

Health Information Exchange – Some Really Sound Thoughts and Why NEHTA might be Off Course.

The following post appeared on the e-CareManagement blog a day or two ago.

Untangling the Electronic Health Data Exchange

Posted by Vince Kuraitis on

by David C. Kibbe MD, MBA

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and differences between the Continuity of Care Recordt (CCR) standard and the CDA Continuity of Care Document t(CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy.

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinatort of HIT (ONC) and HITSPt have overseen during the past four years.

It is the epitome of a top-down, large established player-controlled, and anti-competitive juggernaut in which a “one size fits all” paradigm has been promoted and lobbied for. In this case, HITSP has “selected” the CCD and not the CCR standard, despite the market forces that seem to be continuing the use of the CCR standard. This is simply stupid and likely will turn out to be futile.

I am one of the many volunteer co-developers of the Continuity of Care Record tstandard, which has been developed under the auspices of ASTM Internationalt, a not-for-profit organization that develops standards for many industries, including avionics, petroleum, and air and water quality. The CCR is sponsored by the American Academy of Family Physicians and numerous other physician groups. I am also the 2008-2010 chair of the E31 Technical Committee on Healthcare Informatics, the leadership group within ASTM that is working with Google Health and many other individuals and organizations on the implementation and use of the CCR standard in this country and abroad.

Much more here:


It needs to be said that while there is a risk of some sort of partisanship in all this David Kibbe is a man who knows what he is talking about. Some of the points he makes I find really compelling – especially in the light of some of the choices NEHTA is making in the same domain at present.

Of special importance is the last paragraph of the blog.

“Which brings me to the finale of this post, namely, to state in plain language that interoperability can only be approached in incremental stages when so much health data and information exists in non-structured formats. The principle to uphold is the encouragement of any and all efforts to innovate in the direction of computability and interoperability, even if some of these appear less than perfect or even piece-meal. One size will not fit all uses or use-cases, and what is good for consumers’ PHRs may not be the same thing that works in a very large medical enterprises. Control over standards by large enterprises and/or their vendors is spurious, anti-competitive, and probably won’t be effective. The standards are supposed to make our lives simpler, not more complicated.”

What Dr Kibbe is saying you is you have to start simple and grow – not do a NEHTA and come up with untested – and probably unusable – 100+ page documents defining how to do a discharge summary or referral.

He also clearly recognises the inapplicability of the top down ‘we will instruct and you will comply’ approach, so beloved of NEHTA, in the e-Health domain.

A great read. Certainly a blog to subscribe to notifications of updates!



Anonymous said...

As a programmer (you know, those irrelevant guys who have to actually make all this happen), I'm sceptical about Dr Kibbe's statement.

Firstly, he is advancing an agenda. He claims not to care which standard is used, and then talks about his membership of the CCR committtee. Could it be that he's unhappy because NEHTA decided on HL7, despite his claim that he doesn't care which standard is used?

Secondly, I genuinely don't care which standard is used. I want someone to pick a damned standard, everyone else to fall in line behind that standard, and then I might actually be able to build something that actually connects with something else. Top-down is fine, the problem is that people keep on shifting the goalposts, which makes it very hard to score goals.

Anonymous said...

Have to agree with previous anonymous. From a narrow pathology result perspective every path lab is busy customising the hell out of their messages to keep the customers happy.

The receiving desktop apps used by GPs have no incentive to improve their message handling and result layout functions since each lab has developed their messages to overcome the inherent problems of these apps.

The waste of time and money must be astronomical, particularly in a public institution like mine where the money could certainly be better spent.

There is something to be said for enforcing a standard even if its not yet ideal. No standard will ever be instantly perfect, so evolution is to be expected. At least simple exchange of messages will be possible.

Aus HIT Man said...

I think that is what I (and Dr Kibbe) are saying - choose something simple and practical, implement it and run for a few years - learn the lessons and then update.


Anonymous said...

That's what Dr Kibbe is claiming to say, but the substance of his post is "I don't care where the goalposts are, but I'd prefer it if the goalposts were somewhere else."

This is the problem with the way things are being run - changes that seem irrelevant to you result in months of rework for us.