I have been involved with interoperability standards in banking, media advertising, and healthcare in three countries for over 30 years. During that time I have consulted with industry committees and associations to design standard transaction formats and implementation guidelines, always working with our customers to make the standards work. From my experience, I can safely say this:
Standards are camels.
The old adage: “A camel is a horse designed by committee,” is never so true as it is when committees design standards for an industry, especially when it’s run—or at least influenced—by government. While living in Iran, I learned that white camels were highly prized; of all the proverbial camels I’ve ridden, healthcare is the biggest one – a glorious, white, 2 hump one.
So why don’t standards and checklists make it easy, or at least straightforward, to implement interoperability?
Standards are not standard.
Typically, standards come with many options that can be interpreted in different ways. In a sense, a “standard” can have many dialects, and those dialects are not compatible. Rather than having American, British, and Indian English, it’s more like you have Latin and the dialects are English, French, and Italian. The more the dialects, the higher the cost to implement and the greater risk of it not working. Then, by the time a standard starts to catch on, the language changes (e.g. HL7 uses 2 different language bases- X12 and XML). It’s like switching from Latin to Chinese. Now, try to ride that camel!
Ironically, in every industry I’ve worked in, standards were already in place long before a committee designed them. But, that’s another story.
Checklists are not implementation strategies.
Checklists are great for compliance and getting money from the government.
- Buy an EMR
- Use DIRECT
- Create an HIE
- Find the portal
- Send a CCD
- Get encryption
Great, now why isn’t it all just working? Why is my office less efficiently run than before all this? Why do I have a new cost center where none existed before? I can’t even read the stuff. Let’s just use the fax.
You wanted a horse and you got a camel.
Standards and checklists are created with the expectation that everyone has the same agenda and priority.
It’s like a marching band: everyone marching orderly down the same street, playing the same tune at the same time with the same beat, all together in a row. It will take a long time for this to happen, if ever.
I’ve heard many times in various conferences that the enemy of interoperability is flexibility.
But that’s not true. No industry works like that, especially healthcare.
The enemy of interoperability is rigidity. That’s why many HIE’s are sick or dying.
We have a camel. How do we ride it? Going back to my days near the Persian Gulf, I recommend riding the proverbial camels the same way I rode live camels: with flexibility. The more flexibility, the more participants and the smaller the impact on the community to move forward. The fewer impositions upon a healthcare community, the greater the interoperability.
One of the first steps is not to spend so much time defining standard containers of data. It’s of some help, but it is not the answer. The key is to gain agreement for the meaning or understanding of the data itself, and how it’s used. This seems like a no-brainer—and it is—as most companies get this done quickly, but don’t realize the power of it. For instance, in building your EMR interface for the data independently of formats and delivery (e.g., HL7, csv, XML, PDF, X12, fax, email, etc.) you may have a more flexible operation.
Only then can everyone in the community play in the same sandbox, in the way that works best for them, at the same time. Now that’s a viable caravan.
Additional Recommended Reading – AMA: HER Interoperability Part of Today’s Digital Snake Oil.
Published Jun 22, 2016