For a while, we will all be trying to estimate how the American Recovery and Reinvestment Act of 2009 (ARRA) will impact our bailiwicks. On list servers some writers read the tea leaves to see a much broader and more systematic look at healthcare informatics and interoperability than has been pursued by the ONCHIT. They argue with some justification that the true “electronic health record” is more about information and the way individual health IT systems are interconnected than it is another term for the EMR with some unspecified interoperability thrown in.
Soothsayers, however, should say a different sooth. Congress is clearly not looking to go back to the drawing boards. The ARRA encodes in law the approach adopted by the Bush administration through executive orders and administrative actions.
Some believe that the current approach is doomed to failure because of the lack of the aforementioned systematic framework for current interoperability efforts. Others, including me, believe that applications integration is always messy, if for no other reason than that the goal will always be to integrate systems that are in different points in their life cycle and have different information models. Successful application integration depends entirely on identifying specific scenarios that are in easy reach for a majority of systems in usage or have such a clear and measurable value to the owners of the system (not the vendors) that they will pay for the re-engineering.
In other words, national interoperability in the U.S. can not rise above rough-cut precision in the short term (say, ten years).
One can only hope that the US gets that far. Interoperability under HIPAA has been successful in a few cooperating communities but generally a disaster. HIPAA absolutely proved that the full Federal regulatory process is too lugubrious for promulgating IT standards.
The current U.S. approach is faster than HIPAA, but it suffers from one of HIPAA’s main problems, that the entity responsible for producing the specifications is not responsible for their being implemented. For some time, I have been speaking about the notion of a profiler-enforcer organization (PEOs). (Gartner clients can read a more detailed piece on this topic here.) Organizations such as Connecting for Health in England and Infoway in Canada take multiple standards, develop harmonized profiles and see the process through contracting with HIT vendors to implement them. Their charter is to get HIT implemented and standards are a part of the process. IHE is similar in that it at least takes responsibility for a full cycle through Connectathons.
The fundamental point is that interoperability is not achieved by a waterfall process, but by recycling. Early deliverable specifications are rough drafts to be tuned by implementation experience. Unless the entity responsible for creating the specs is responsible for them being used well, the feedback loop will remain open and confusion will prevail.
In the U.S., the work is split between HITSP, CCHIT, the NHIN Trial Implementation project and perhaps other implementation projects. The feedback loop is broken.
The ARRA allow a hopeful person some justification for short-term and long-term optimism for healthcare interoperability. In the short term, the language includes support for rejiggering the U.S. process so that the goal of creating actual interoperation might be under a tighter span of control.
Long term hope arises from language directing NIST to award academic grants for multidisciplinary “centers for health care information enterprise integration.” We can hope that NIST develops the grants in a way to support a more systematic look the challenges of healthcare interoperability. One also hopes potential applicants for such grants will work immediately to bone up on the excellent if incomplete work done by HL7, the Object Management Group and the National Cancer Institute in establishing a more rigorous basis for interoperability. Principles developed there can find their way into the architecture of HIT systems over time and can get us from rough-cut to a smooth finish, if not to finely honed cabinetry.
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