Wes Rishel

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Wes Rishel
VP Distinguished Analyst
12 years at Gartner
45 years IT industry

Wes Rishel is a vice president and distinguished analyst in Gartner's healthcare provider research practice. He covers electronic medical records, interoperability, health information exchanges and the underlying technologies of healthcare IT, including application integration and standards. Read Full Bio

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Further on the US Healthcare IT Standards Debate

by Wes Rishel  |  November 9, 2009  |  9 Comments

In A Singular Opportunity for Health Interoperability I summarized a metaphor based on the Web standards HTTP and HTML which was “get HL7 and other SDOs out of the HTTP business.”

Metaphors gain their power from poetic ambiguity. One of the great things about a metaphor is that it can rally so many folks to believe they agree. They each read the metaphor as supporting their favorite point. The follow-on to a metaphoric rally must be a drill-down to tease out where the metaphor singles out an important common cause and where it papers over differences.  Using a RESTful approach to interoperability is another metaphor. Some of the discussants take it quite literally as the single most important point to agree on; others see RESTful as an example of a broad approach to rapid innovation.

Over the last few days I have come to believe the following “big takes” on this discussion. In another simplification I break the discussants into two groups,  “the Internet crowd” and “the healthcare informatics crowd.” I mean no disrespect to either group and understand that many people have a foot in both camps or at least a foot in one and a toe in the other.

There are implicitly three levels of contention. I will arbitrarily assign them to a vertical stack.

Bottom: Connecting (in the broadest sense). So much has been accomplished with well-layered Internet protocols to create quite complex behaviors and progress has progressed so rapidly that “the Internet crowd” can’t understand why “the healthcare IT crowd” wants to stick to technologies for secure transport that are “so five years ago” but preclude participating in rapid evolution. “RESTful operations” are a token of the deeper conflict, not the actual point of contention. Some of the informatics crowd significantly confuses the issue by presenting discussions on security based on standardized roles and other as yet unproven constructs.

Top: Semantics of Data. Understanding data clearly is a never-ending task. As Bertrand Russell said “Everything is vague to a degree you do not realize till you have tried to make it precise.” The Internet crowd has done very well with a model where semantics evolve as rapidly with experience. They have productivity tools that rely on some unstated but “common sense” approaches such as using business names as XML element names. The health IT crowd has been through this learning curve on clinical data and wants to skip over many learning steps that uncover ambiguities on health data. However the health IT crowd (including HL7) has made it more difficult to propagate its knowledge about health data because they have chosen to package it in self-created modeling formalisms and XML that is obscure to the max and doesn’t work well with common XML tools. They further complicate the issue by not knowing how to package their sophisticated understanding in a way that it can be understood by programmers who know the data of their own application but don’t comprehend the abstract approach.

Middle: The Semantics of Exchange Sequences. To a certain extent saying something is “architecturally neutral” means “it isn’t interoperable in any architecture.”Any attempt to truly achieve interoperability involves a state machine that implies certain sequences of transactions needed to get the job done.

The Internet crowd is used to improvising the sequences of actions that are required to accomplish a task but not standardizing them. The health IT crowd has attempted to establish very loose architectures (i.e., no technology or system factoring constraints) that standardize the sequences enough that two products that are expected to be interoperable could interoperate without continually adjusting the code based on what is going on in the broader community. Thus the Healthcare IT has fought its way to largely agreeing on XDS over a five year period (and XDS has evolved in that period) and the Internet crowd sees XDS as not applicable to their use cases and restricting their ability to improvise.

The Internet crowd represents a culture that employs the power of the Internet protocols in an enterprising, high-energy, innovative and incremental approach that has revolutionized some industries. The informatics crowd really does have the ability to shortcut many learning cycles based on experience and understanding. How can we introduce combine the peanut butter with the chocolate? Oops! There goes anothe r metaphor.

9 Comments »

Category: Healthcare Providers Interoperability Vertical Industries     Tags: , , , , ,

9 responses so far ↓

  • 1 David McCallie   November 9, 2009 at 12:08 pm

    Good post Wes.

    I think it would be useful to further clarify the notion of “architecturally neutral.” The HIT Policy Committee used that term to define a core constraint for HIE. What did they mean?

    I suspect that what is most important are the following:

    * the architecture is based on open protocols and open standards
    * the architecture is not constrained by any proprietary hooks such as hidden patents, etc.
    * the architecture can run on any modern operating system
    * the architecture can be made accessible from any modern device
    * the architecture can be developed using standard tools that are readily available to all

    As a bonus:

    * the architecture is simple enough that massive training is not required.
    * the core components of the architecture are available as open source software

    The Internet fulfilled all of these, yet it there was clearly a well-defined and precise “architecture” present. It would be a mistake to assume that the NHIN or any other national system of HIE could exist without some kind of “architecture” — preferably one that met the above criteria.

  • 2 Brian Wells   November 9, 2009 at 3:15 pm

    Wes – Great post! Having spent years coding software solutions that had to succeed in both camps I am well aware of the limitations and powers that reside in each. It would be a huge help for me to assess the applicability of the Internet camp approach, to learn of a non-healthcare business application domain (that has as complicated a data model as healthcare) that is successfully interoperating between disparate entities using Internet protocols without predefined content standards. I just cannot see how that could work in a dependable way.

    Said another way, is there something more complicated than e-commerce type transactions going on over simply Internet protocols that we can all learn from and apply to healthcare?

    I am an admitted healthcare centric cynic that is open to a new way if someone can show me one that works.

    BPW

  • 3 Tweets that mention Further on the US Healthcare IT Standards Debate -- Topsy.com   November 10, 2009 at 6:10 pm

    [...] This post was mentioned on Twitter by Chris Winters, Elizabeth Leddy. Elizabeth Leddy said: My everyday battle: US healthcare [tech] sucks because "healthcare informatics" wanks are winning – http://bit.ly/7JvQS #ugh [...]

  • 4 Charles Parisot   November 13, 2009 at 12:56 pm

    I like very much your analysis, but I am wondering who may really be this \Healthcare IT crowd\.
    If we compare apples-to-apples, the discussion should be between REST versus SOAP based Web Services. This is a rather internal IT debate, one between the MIcrosoft, Oracle, Intel, IBM, Linux crowd that have been pushing SOAP based WS in WC3 for several years, and the Internet Crowd of these same companies.
    I am as much surprised as John Halamka, quoting his blog (the power of AND):
    \The work I’ve done for the past 4 years aimed at unifying the industry on a web services approach, embracing web-centric standards such as SOAP, XML, and HTTPS. In 2006-2007, this was considered very forward looking. In 2009, RESTful data exchange of simple payloads with TLS and application level security is considered cutting edge.\
    I too am puzzled that after having been encouraged to adopt SOAP and WS in healthcare, we may be faced with an attempt to turn healthcare in an IT battle field, where the real HealthCare IT crowd may simply be a sort of hostage.
    Should this real healthcare IT crowd not exert a liitle wisdom here and step back, let that debate be sorted within the IT/internet Industry and see where the puck falls ? SOAP-based WS have a wide acceptance basis, and feel to me like the safer side to be on for the time being.

  • 5 Charles Parisot   November 13, 2009 at 1:02 pm

    I like very much your analysis, but I am wondering who may really be this \Healthcare IT crowd\.
    If we compare apples-to-apples, the discussion should be between REST versus SOAP based Web Services. This is a rather internal IT debate, one between the MIcrosoft, Oracle, Intel, IBM, Linux crowd that have been pushing SOAP based WS in WC3 for several years, and the Internet Crowd of these same companies.
    I am as much surprised as John Halamka, quoting his blog (the power of AND):
    “The work I’ve done for the past 4 years aimed at unifying the industry on a web services approach, embracing web-centric standards such as SOAP, XML, and HTTPS. In 2006-2007, this was considered very forward looking. In 2009, RESTful data exchange of simple payloads with TLS and application level security is considered cutting edge.”
    I too am puzzled that after having been encouraged to adopt SOAP and WS in healthcare, we may be faced with an attempt to turn healthcare in an IT battle field, where the real HealthCare IT crowd may simply be a sort of hostage.
    Should this real healthcare IT crowd not exert a liitle wisdom here and step back, let that debate be sorted within the IT/internet Industry and see where the puck falls ? SOAP-based WS have a wide acceptance basis, and feel to me like the safer side to be on for the time being.

  • 6 Gerard Freriks   November 14, 2009 at 12:52 am

    Wess I think you presented the present situation aptly.

    There are two paradigms. Each with its strengths and problems:
    – Message paradigm: Exchange between proprietary databases using an intermediate message information model (e.g. HL7 RIM based) The implementation of messages is time and money consuming. This paradigm is an example of the case of the healthcare informatics crowd.
    -Two Level Model paradigm: Exchange (federation even) between standardised databases using a simple interface that Gets, Puts, Publishes, etc and self describing artefacts that get exchanged.
    The self describing artefacts (objects) are called Archetypes and Templates. Archetypes and templates are implemented instantaniously without (re-)programming. This paradigm corresponds to the RESTfull case and the Internet folks.

    At this moment there is an accepted CEN and ISO standard (EN13606) and an implementable specification that defines this Two-Level Model paradigm, because one model is implemented in the system and a second model is used to define archetypes and templates that define records and records fragments. The tools based on this second model allow healthcare providers to define what they need to store, retrieve, exchange and archive. And archetype/template is implemented in IT-systems on the fly.

    Using this approach it was possible to have two proprietary hospitals systems produce and use the same patient summary. It took only two weeks to develop it. Agile development was possible, since each improvement was only a change in the archetype using the archetype editor.

  • 7 uberVU - social comments   November 14, 2009 at 6:01 pm

    Social comments and analytics for this post…

    This post was mentioned on Twitter by eleddy: My everyday battle: US healthcare [tech] sucks because “healthcare informatics” wanks are winning – http://bit.ly/7JvQS #ugh…

  • 8 Martijn Linssen   November 15, 2009 at 8:09 am

    We EDI guys (yup!) were really happy with our X12 and EDIFACT over FTP 20-10 years ago

    The introduction of XML along with the formalisation of IT architecture as an actual profession have lowered the threshold on the one side, and obfuscated the debate on the other side. How come we allow architects to daze away in cloud metaphors?

    The self-describing aspect of XML makes it totally unfit for conducting B2B or any other machine-to-machine interaction.
    XML is fun for humans on one side of the line, but machines are not supposed to just suddenly change human agreements based on a single self-describing document that breaks the rules

    SOAP and WS are immature and already so complex and compromised that they’ll just never work. Take a look at SMTP: that works perfectly for everyone, why not adopt that mechanism?

    If we could just agree on the semantics and write that down in a legible, human, business-information form, then we can then let the techies loose on mess(ag)ing that up. The outcome is easy: the simplest (= cheapest) messages will win

    More on my blog (http://martijnlinssen.blogspot.com/) about all that…

  • 9 Simplified Interop: You Want it When?   December 3, 2009 at 12:10 am

    [...] there are a bunch of other use cases in David’s categories I and II. Beyond that, the lesson of the Internet crowd is that if we get something simple actually into operation we will find that enterprising [...]