Ignacio,
Thanks for taking the time to put this comment together. I most
certainly agree that the utility of commercial monolithic/integrated EHRs
is
yet to be published. You likely would agree that most of the documentation
user interfaces are kludges that slows physicians down, CPOE systems are
poorly thought out and over all design does not reflect the cognitive model
of the provider or the workflow of the clinical environment. I am sure
that
if we had a standard "back end" or workbench (think Eclipse) then the
functionality we need could be accomplished by small applications that do a
few things very well, and could be swapped with another if the first wasn't
what the user liked (sounds like 'nix...hmmmm....maybe onto something).
Informatics is a maturing field. Given the complexity of the domain
(how many banks have data dictionaries like the UMLS?) and the substantial
underfunding industry wide the early (1960s even) promises of a panacea
seem
naïve. Hype from vendors is, well, hype from vendors. Consider the
source.
Press releases from a hospitals (or other) PR firms are obviously not a
very
realistic portrayal of reality. If you believe those, I have a new ACEi
(or
'statin or SSRI) I would like to sell you. Good things come to those who
wait!
However, I believe you have made a few comments that are quite in
error. First, HL7 isn't an "interoperability protocol"--it is an all
volunteer organization of people (of which anyone is free to join). HL7
develops standards (just like W3C does) for messaging between disparate
systems at the application (not user) level. The messaging standard
(version 2.x) is possibly what you are referring to, is widely used (for
example so and EHR can communicate w/ a laboratory system) and provides a
syntactic framework, but is far from ideal. The emerging, newer, version
of
the messaging standard (version 3) is much more specific, much more
detailed. In addition to the specification, there will be conformance
criteria to assure adherence. While the interoperability protocol is not
specified by HL7, most use conventional approaches (e.g. HTTP, SSL, etc.)
In addition, version 3 is designed to provide semantic
interoperability. Local variations and options are not permitted (although
some variation between countries is permitted). The degree of
specification
and standardization is tremendously different between the two versions.
Beyond the messaging standard, HL7 provides a standard for exchange of
documents (CDA), single log-in to multiple applications (CCOW), and
creation
of medical logic modules (Arden syntax). In addition, HL7 is creating
functional models for various systems, again with conformance criteria.
The comment about users needing to learn new interfaces between
systems is complete nonsense. The HL7 specifications are all at the
application level, and users would have no knowledge or awareness of which
(if any) messaging protocols they are using. This is like suggestion that
visitors to a web site would need to adapt to a new XML Schema each time
they went to a different web site. The browser needs to grok the underlying
representation, but if users who see XML (or HTML) code show up on their
screen there is an error somewhere. Users may have to learn the
applications they use, but this is hardly a novel observation, nor
restricted to the medical domain. Given the complexity of what we do, it
is
much acutely felt.
As for the RHIOs, if they are making up standards they are doing it
wrong. HHS (via the NCVHS) has specified the standards that should be
used.
If there are needs for specialized regional messages, that is fine, but it
would make no sense to create, validate and test a new wheel. If they have
a health care system interoperability need that isn't met by the available
standards they need to tell someone so that it can be addressed properly.
I
doubt, however, this is a significant occurrence. Calling RHIOs a failure
is premature, given that most exist only in MOUs at this time and those who
have been functioning (some up to two years!) seem to be doing some good.
I
would be interested if you can provide some examples of the problems you
cite.
I would encourage you to visit HL7's web site and take a look at the
RIM and version 3 specifications. Similarly, if you can provide some
constructive critique of CDA R2, I am sure it would be most welcome.
I believe if you look into VistA you will find that in spite of it's
warts, it was a transforming technology. Similarly, other large system
(mostly home built at places like Columbia, MGH, Brigham and Women's, LDS
Hospital) have shown considerable benefits. There is a dearth of similar
publications about commercial systems, so extrapolating these results to
the
vendor supplied applications would be unwise. The concept of a single
source, all-in-one system that you can just adapt to your institution is
probably part of the current problem. This is one area in particular that
the readers of these lists can help inform others. 'nix success is largely
due to the lack of such a design (unlike some other OS) where various
components can be selected, combined, experimented with and discarded if
useless. The EMR community needs to move towards the notion of a
distribution of components, many of which may be shared between vendors.
If
everyone speaks the same language (such as HL7 v3) on the back end, there
will be much less risk in adopting EMRs, and a much higher chance of
individual success.
Thanks for you continued efforts in this community.
Kevin
Disclaimer of possible conflict of interest: I belong to HL7 and use SuSE
as well as that "other OS." Sorry, some of us need a 12-step program or
something. I am also a former user of CHCS, which is a derivative of VistA
the DoD uses (which, 10 years ago, was still better than what my commercial
system can do today).
___________________________________________________________
Kevin M. Coonan, MD Adjunct Assistant Professor, Division of Emergency
Medicine
NLM Fellow, Department of Medical Informatics
University of Utah School of Medicine
[EMAIL PROTECTED]
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED]
On Behalf Of Ignacio Valdes
Sent: Monday, December 12, 2005 11:25 AM
To: [email protected]; [email protected];
[EMAIL PROTECTED]; [email protected];
[email protected]; 'Tia Abner'
Subject: [os-wg] Editorial: RHIO's and the Illusion of Health IT Success
"Does it bother anyone that for years, Health Information Technology
(IT) successes implied by the news and even in casual conversation may
largely be an illusion? Does it bother anyone that Regional Health
Information Organization (RHIO)'s might be failing at a very high rate? It
is important to ask the question given the United States rich history of
failure and two notable successes with large scale Health IT."
Read the full article at
http://www.linuxmednews.com/1134404398/index_html
-- Ignacio Valdes, MD, MS
-- Editor: Linux Medical News
-- http://www.linuxmednews.com
P.S.: Please link the article and the website to your page if you find it
useful.
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