This post is my own expression, not an official view of the Society for Participatory Medicine.

Vince Kuraitis and David Kibbe are running an excellent series, “Is HITECH Working?”* In last week’s entry they linked to this slide deck by Wes Rishel and David McCallie of IT consulting firm Gartner. See discussion before watching.

Simple Interop for Healthcare (Wes Rishel)

“Interop” (interoperation, interoperability) is about how your health data will move from one doctor to another. It’s a big deal, because it affects how well doctors can coordinate our care, and in an emergency whether everyone can see what they need to know … to save your life.

Or your mother’s life. Or your child’s.

This is getting increasingly personal to me, because people have started coming to me and talking about the unnecessary death of a family member. I’m starting to see the pain in people’s faces from a premature death, and it’s starting to hurt. But keep ’em coming, because this is real and it needs to be out in the open.

At a policy meeting last winter I heard a tale – perhaps apocryphal, perhaps not:

A man’s having a great time in Las Vegas. He runs out of cash so he goes to the casino’s credit window. They pull up everything about his finances: his income, his credit card balances, which bank has his second mortgage, when he signed on it, everything. They find out what they need to know, make their decision, and give him the cash.

He goes back to the table, hits it big, and falls over with a heart attack. He’s rushed to the emergency room, where they know… nothing about him.

That story corresponds to the “use case” (the scenario) at the bottom of slide 15: “E.D. gets medical records for exceptional case.” When you’re thinking out how a standard will work, you need to think through a bunch of scenarios: who’ll need what information, and how it will get to where it’s needed.

And that gets complicated, which is why so much work is going on in Washington. It’s hard to get this work right, and you usually find strong differences of opinion. For one thing, the people who are already selling systems usually want the new standard to match what they’re doing, and the people who think they can do better want a wide open door to innovation. Understandably, just about everyone wants to maximize their own revenue.

That’s fine in ordinary commerce, such as the print industry where I used to work, where skull-knocking is just plain business. But I assert that in healthcare lives are at stake, and provincial concerns must be subordinated to human survival. Save lives first – then compete.

I think it reprehensible if a vendor wants to withhold medical information from another care provider in an emergency. Reprehensible. And “withhold” includes not actively finding ways to share the information.

Added 10:43am ET My sentiment here applies to providers, as well, who simply don’t want to adopt methods that keep patients safer. Paul Levy, CEO of Beth Israel Deaconess, drove this home persuasively in his speech this month to the hospitalist association, talking about the paradox of these smart people who went into this work to help patients, and who (paradoxically) are the fourth largest public health hazard. (That’s from Brent James of Intermountain Health: death by medical error is the fourth leading public health hazard.)

Why? Resistance to change. This must stop. And we, we all, must stop empowering the excuses. End of addition.

I say, if your top priority isn’t finding more ways to save lives, you ought not to participate in the billions of taxpayer-funded incentives – whose entire purpose is better care.

Lives first – then compete.

And that’s where this slide deck comes in. Its 45 slides reflect a lot of thinking, a lot of work; in the parent blog post author Rishel says he harvested many earlier posts about specific items, bringing it all together in this deck.

This is the first thing I’ve seen that, more or less, makes the issues clear to a lay audience. Here are a few definitions you may need if you’re new to such things:

  • Structured data is the computer equivalent of filling out a form: you write “Dave” in the First Name box,  “deBronkart” in the Last Name box, “21” for age, 03063 for zip code. Computers can track, summarize, and analyze structured data.
    • The opposite is free text: the kind of box in a form where you can write anything you want, and the computer won’t know or care whether it’s your age or your zip code.
      • The ultimate unstructured data is a fax. It conveys information, but only when a (falliable) human reads it. The same is true for all unstructured data.
      • BUT, unstructured data is better than no data – like the guy who went from casino to E.D.
    • The ultimate, the goal, is when the sending computer uses structured data and the receiving one does too.
      • Imagine if airlines had to work with unstructured data, with fax-like blobs of text. Structured data is information; unstructured blobs convey information only when read.
    • The trick, the difficult part, is that today everyone’s system stores the structured data differently, so it won’t transmit same-to-same.
    • And THAT is where we get into hairy details that can take forever to resolve.
    • Plus, the more complicated the details are, the harder everyone has to work, to write software that complies. That slows things down and raises costs for developers. And that raises costs for the physicians who pay for the systems.
  • MIME is the data format tht systems use today to send email. It can be used to send anything, not just email; its great advantage is that it’s as simple and common (already in use today!) as sending and receiving email. These slides propose using MIME as the way for one system to send your record to another one.
    • Simple! “Simple interoperation,” as the title says.
    • Requires little or no software development or testing.
    • Free text can be sent as the body of an email.
    • Structured data, including PDFs or images, can be  sent as attachments.

Particular slides to note:

  • Slide 7: What simple interop can do (handoffs of care to another provider, lab data (already in fields)
  • Slides 9 mentions PHRs, noting “patient uses PHR to collect their own data from multiple sources and disburse it as they see fit. (Yes!)
  • Slide 13: The use case of a primary doc referring you to a specialist – how does  your information travel? Considers cases where either doctor does not have a structured data system yet.
  • Slide 17 gives several more use cases for patient engagement.
  • 28: Minimum functions for PHRs (Personal Health Records): receive information from mulitple providers; attach it to the right person; deliver info to others as directed by the patient.

Don’t worry if some of these slides are unclear; you’ll still get the picture: even for a lay reader they explain the  pragmatic issues we’re facing, and they describe a clear and pragmatic pathway to encourage users  to adopt, i.e. to start using these systems.

There are people, with good intent, who don’t like simple subsets; who want to figure out a complete specification and then implement it all at once. But that’s old-school, it takes forever, and it creates a very long “time to value” outcome. (i.e., it takes forever before anyone earns back what they invested.) We don’t have time for that. People are being harmed unnecessarily. (Plus, as I said, it’s technically risky to try that approach.)

I reject the argument that any vendor has a right to put higher priority on its commercial interests than on saving more lives by transporting vital information between clinicians who need it to do healthcare.

Save lives first – then compete. I believe simple interop is a good, practical, expedient step forward. Thanks to Gartner for the slides and thanks to David Kibbe and Vince Kuraitis including them in their excellent series. (More on that seies shortly.)

* HITECH: Health Information Technology for Economic and Clinical Health act. HITECH is part of the 2009 ARRA economic stimulus bill

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