Complex Issues Rarely Have Absolute Right Answers

Listening 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 healthcare 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:

"The Office of the National Coordinator for Health Information Technology established the Health Information Technology Standards Panel (HITSP) to harmonize and designate health information standards and the Certification Commission for Health Information Technology (CCHIT) to certify vendor products three years ago. These efforts deserve praise for increasing public and industry interest in health IT and for encouraging adoption of technical standards. 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.' He went on to state that 'greater emphasis is placed on ideal standards and less on what can be feasibly implemented in the short-term—hence three years of work, millions of dollars spent and little real progress toward interoperability.' " (Sam Karp, California HealthCare Foundation, Review of the Adoption and Implementation of Health IT
Standards by the Office of National Coordinator for Health Information Technology, Testimony before the Institute of Medicine Board on Health Care Services and the National Research Council Computer Science and Telecommunications Board, 17 September 2007, http://www.chcf.org/documents/healthit/KarpITAdoptionIOM.pdf )

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 CHCF on their standards projects are also good friends.

Per Sam's comments, should we approach healthcare 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 religous 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 required.

Implementation of HITSP interoperability specifications for healthcare 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, healthcare 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.