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Friday, February 20, 2015

If you were in Washington in 2008 and somebody gave you $30 billion to spend on health IT...


A beaut of an interview with Dr. Mark Smith over at THCB:
Bob Wachter, MD: If you were in Washington in 2008 and somebody gave you $30 billion to spend on health IT, would you have spent it the way the government did?

Mark Smith, MD: My sense is that they missed an opportunity to impose or to bring about standards, which would have let the IT people compete on the interface. In other words, if the backbone of the data were standardized, then you could have IT companies not competing on standards, but competing on the beauty of their interface, the intuitiveness of their interaction with providers. What we have instead is competition all up and down the vertical, and that I think is the tragedy.

That’s the magic of HTML, right? Most people have Windows, some people have Macs, some people have Linux – you can choose whatever interface you like. Companies compete on the intuitiveness, the attractiveness, and the beauty of the interface.  Whoever does that well will win.
 Standards.
"[I]f the backbone of the data were standardized, then you could have IT companies not competing on standards, but competing on the beauty of their interface, the intuitiveness of their interaction with providers."
What have I been harping on repeatedly?
One.Single.Core.Comphrehensive.
Data.Dictionary.Standard
One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images. All things above that are mere “representations” of the basic data (e.g., text lengths, datetime formats, Boolean/logical, .pngs, bmps, .tiffs, .jpegs etc)... 


Again, from my February 2014 post We should not prescribe specific functionality for the EHR other than interoperability and security.
- John Halamka
But, hey, what do I know? (And, to be fair, my rant is principally about interop, not UX per se.) Anyway, we're now all in the thrall of HL7® FHIR®, right? Gonna be salvation.

I eagerly await the release of Dr. Wachter's new book "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age."

"While modern medicine produces miracles, it also delivers care that is too often unsafe, unreliable, unsatisfying, and impossibly expensive. For the past few decades, technology has been touted as the cure for all of healthcare’s ills.

But medicine stubbornly resisted computerization – until now. Over the past five years, thanks largely to billions of dollars in federal incentives, healthcare has finally gone digital.

Yet once clinicians started using computers to actually deliver care, it dawned on them that something was deeply wrong. Why were doctors no longer making eye contact with their patients? How could one of America’s leading hospitals give a teenager a 39-fold overdose of a common antibiotic, despite a state-of-the-art computerized prescribing system? How could a recruiting ad for physicians tout the absence of an electronic medical record as a major selling point?

Logically enough, we’ve pinned the problems on clunky software, flawed implementations, absurd regulations, and bad karma. It was all of those things, but it was also something far more complicated. And far more interesting . . .

Written with a rare combination of compelling stories and hard-hitting analysis by one of the nation’s most thoughtful physicians, The Digital Doctor examines healthcare at the dawn of its computer age. It tackles the hard questions, from how technology is changing care at the bedside to whether government intervention has been useful or destructive. And it does so with clarity, insight, humor, and compassion. Ultimately, it is a hopeful story.

"We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12," writes the author Dr. Robert Wachter. "Instead, they transform the work, the people who do it, and their relationships with each other and with patients. . . . Sure, we should have thought of this sooner. But it’s not too late to get it right."

This riveting book offers the prescription for getting it right, making it essential reading for everyone – patient and provider alike – who cares about our healthcare system."
___

More to come...

3 comments:

  1. Let me first say that I am not from this industry...

    You say:
    > There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, those within other normative vocabulary code sets, and unstructured, e.g., open-ended free-form SOAP note narratives), numbers (integer and floating-point decimal), and images.

    You point to a post, with an exemplary screen shot of an OpenEMR data-dictionary (schema) subset:
    http://regionalextensioncenter.blogspot.com/2014/02/we-should-not-prescribe-specific.html

    And you imply (again, after implying it elsewhere often) that FHIR ain't going to save us.

    Looking at FHIR's data structures, it certainly seems to contain all the scaffolding to incorporate everything that you are talking about in that exerpted quote above. The extension mechanism seem raw/rough/immature, but my question is this: Is there any reason not to use FHIR as an encoding and interchange vehicle for transferring files based on said standard data dictionary? If so, can you suggest another better place to start?

    Best Regards,
    W. Archibald
    =

    ReplyDelete
  2. Thanks for your thoughtful comment. Don't have time to fully respond at the moment. My Mother in Law died Saturday night. We're scrambling. All I can say right now is that, absent a std data dictionary, you will be essentially left with point-to-point interfacing. "API" MEANS "Interface," after all. Someone will have to do all of this cross-data mapping if data are to be assimilated into a recipient's EHR RDBMS -- rather than residing separately in some xml document-level inbox items. Recall the IEEE definition of "interoperability." -- usage without additional steps.

    All I'm implying is some skepticism toward FHIR. Maybe it'll suffice as a partial fix. We'll see. And I'm fully aware that my std data dictionary proffer, whatever its theoretical architectural merits, is unlikely to happen.

    ReplyDelete
  3. I am so sorry that this has happened to your family -- and I am shocked that you answered at all.

    Thank you.

    I suspect we are maybe looking at FHIR from different angles, and I would love to talk more when you have dealt with life. Just reply to this when you become more free/open and we can pick up from there?

    ReplyDelete