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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Simple Interop: A PowerPoint Presentation

by Wes Rishel  |  January 24, 2010  |  19 Comments

Sir Blogsalot has written quite a bit about the idea of simple interoperation, each post developing some aspect of the idea.

Recently I combined all the ideas in a single PPT presentation. You can download it by clicking here to leave the Gartner Blogs web site and then clicking on the link to the presentation.

It will come from my personal web site for two reasons.

  • I offer it under a creative commons license that allows you to use it as you wish, including incorporating it in commercial material.
  • Gartner’s policy for blogging is not to post files in formats that might be dangerous. My laptop seems well protected by and my web site is maintained by a seemingly reliable ISP but I urge that you use the same precautions that you would or should when downloading any Office document — just in case.

There is some new material in the presentation that is not in any of the previous blogs on the topic. This includes:

  • An idea about structuring the roll-out into “quick” and “extensive” phases with the quick phase hopefully sufficient to meet the minimum interoperability measures for Stage 1 of the criteria for receiving the meaningful use incentive. The “extensive” phase is more scalable.
  • Discussion of the relationship to disease registries.
  • Expanded use cases cast in terms of the meaningful use requirements.
  • A discussion of business opportunities for open source and proprietary providers of technology, hardware and services.
  • Some open issues are cited.

After you have reviewed the presentation I would love to hear your comments added to this blot posting. You are free to re-use the presentation as you wish, but I would appreciate a comment here, an email or a tweet letting me know how you are using it.

19 Comments »

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

19 responses so far ↓

  • 1 Gerry Yantis   January 24, 2010 at 9:07 am

    Thank you Wes.

    I believe the concepts and ideas are interesting and pragmatic…the key being pragmatic. It appears that many HIE programs are seeking to do everything at one time (your “kerplunk” approach). When I worked with NHS Wales Informing Healthcare Programme, the model/approach we developed took a similarly simplistic/pragmatic approach because we needed to manage adoption, expectations, and costs. The central principle of interoperability we used was that sharing something/anything about the patient’s health (e.g., meds, current condition, last clinician of care), even in text form, would be be 100% better than what has been shared previously, especially in emergency and out of hour situations. As such I agree with the approach described as it is an essential step in an incremental approach. One only needs to examine the NHS England approach (kerpluk) to see starting with complexity (e.g., HL7 v3) is hardly a cost effective means to rolling out a HIE/EHR.

    In an attempt to divert some traffic to my blog (shameless promotion as Wes has stated in his email), I have articulated a couple of ideas that may help to extend Wes’ model. Your thoughts would be greatly appreciated…and I will share them back here on Wes’ blog for continuing the effort to dialog and refine Simplistic Interoperability.

    The ideas address:
    1. The need for a Health Internet Registrar.
    2. A use case for interoperability between patients.

    More on http://www.capgemini.com/health-blog. Thoughts would be appreciated.

  • 2 Arien Malec   January 24, 2010 at 3:02 pm

    Wes –

    First, many thanks for this presentation. It crystallizes very well the series of blog posts you and David have been engaged in, as well as some of the discussion we’ve been having at the NHIN Workgroup meetings. It also does a nice job of expressing the “what” in terms concrete enough to understand while making it generally clear that there are multiple ways of getting to the “how”.

    I have a few immediate comments, and some longer term things that I am stewing on.

    First, on the use cases. I think the use cases could be made even more basic than those you describe in the presentation. For instance, there isn’t a standard way for one physician to send information to another in the context of a referral or coordination of care. (There are a number of standard ways of packaging the information, as text, PDF, HL7 2.x, CDA in various templates, CCR, etc. but no basic way of getting it where it belongs). Those of us who operate HIEs have a substantial amount of work we put into “edge connectivity” — simple interop supported by most EHRs in a standard way would substantially speed utilization even in areas currently served by an HIE. I also believe that simple interop will create a business model for multiple kinds of intermediaries to give away basic connectivity to providers who are not currently served by an HIE. For example, electronic prescribing intermediaries (to drive the value of pharmacy networks), SaaS based electronic prescribing and EHR providers (to drive adoption of the value-add modules), eligibility and claims intermediaries (packaged with EDI services), etc.

    Second, on addressing. I think the minimally sufficient need is to have an address. Expressing that address as an email address has some strong positives: it’s familiar, and it helps non-EHR providers to exchange information in a secure way with technology they currently understand (i.e., their email client). There are some downsides, however. The first is that it sets an expectation that the transport is SMTP, rather than that being an option. The second is that an email address sets an expectation that the public email system can be used for transport. This is a minor point, however,and I think that when we get down to the details of APIs and such, we can get to an addressing scheme that allows for, but does not mandate an email address.

    More to come.

    Arien

  • 3 Wes Rishel   January 24, 2010 at 3:10 pm

    Arien, thanks for the thoughtful comments. I look forward to the “more to come.”

    You identified a really important omission, the common referral case. I have included a slide to cover this in a revised PPT; those who download the PPT from now one will see that slide.

  • 4 Dixie Baker   January 24, 2010 at 7:56 pm

    Wes,

    I really appreciate your efforts to distill the vast array of interoperability needs and expectations down into a “simple” starting point. I think we’re far more likely to reach our goal by starting with what is reasonably achievable in the near term — and by keeping “simplicity” as a design goal throughout the ensuing steps.

    I have only two comments/suggestions:
    1) Your goal slide (7) and many of the use cases (12-17) talk about “people” as end points, though the simplest interoperability (slide 17) is really an exchange between entity abstractions (e.g., domain names, X.509 certificates). I think once we need to consider things like “did my doctor actually read the message,” the problem takes on much more complexity. I think a solution to the “simple” problem of getting health information from point A to point B, with each end point authenticated, the transmission secured, the data integrity protected, and a reasonable level of assurance of delivery would be a significant achievement and is a worthy goal.
    2) The term “PHR” is used in different ways by different people. Some of the vendors whom I consider “PHR vendors” are denying that that’s what they are, and some EHR vendors are now offering “PHR” modules that provide patients access to and some level of control over a copy of the information maintained by the EHR product. A key attribute of what I consider a PHR, in addition to consumer control, is whether the record is subject to HIPAA rules. Having one end of the exchange outside HIPAA governance changes the game. I suggest you define “PHR” for the purpose of this exercise.

    -Dixie

  • 5 Steven E. Waldren, M.D.   January 24, 2010 at 8:14 pm

    Great slide deck Wes. This is what my colleagues and I have been advocating for the last five years, glad to see it is getting into the mainstream!

    Best,
    Steven

  • 6 Wes Rishel   January 24, 2010 at 8:31 pm

    Thanks, Dixie.
    You wrote “I think once we need to consider things like “did my doctor actually read the message,” the problem takes on much more complexity. I think a solution to the “simple” problem of getting health information from point A to point B, with each end point authenticated, the transmission secured, the data integrity protected, and a reasonable level of assurance of delivery would be a significant achievement and is a worthy goal.”

    The issue here is to define what is a quickly achievable step forward that supports Meaninful Use and use that is meaningful. In other words, is the level of assurance associated with using a fax machine acceptable in order to get off the dime and create a framework where interoperation grows staring in 2011 at a fast enough pace to do some real good for patients and allow EPs and hospitals to meet their interoperability measures. If you or other folks reading the blog think that we shouldn’t start at all unless we can achieve a higher level of assurance then we should discuss it. You or they can saying why a higher level of assured delivery is required, perhaps by painting a picture of the consequences of failing to reach that deliver. If they post that information somewhere I invite them to post a comment here pointing to it. If they have no other place to publish it they can send it to me and I will post it as a guest blog entry. It can oppose what I say as long as it is well-reasoned and written in an emotionally neutral style.

    You wrote “A key attribute of what I consider a PHR, in addition to consumer control, is whether the record is subject to HIPAA rules. Having one end of the exchange outside HIPAA governance changes the game. I suggest you define “PHR” for the purpose of this exercise.”

    I deliberately did not set out to define PHR for fear of drowning in the resulting controversy. I used this term “personal health records, patient-mediated health IT ecosystems or medical record banks” to emphasize my neutrality on the specifics. I think the HIPAA independence is less of an issue than some might think. Because the disclosure by all of them is patient-mediated I think it would all fly under HIPAA consent rules were they covered.

  • 7 ICMCC News Page » Simple Interop: A PowerPoint Presentation   January 25, 2010 at 3:09 am

    [...] Article Wes Rishel, Gartner, 24 January 2010 [...]

  • 8 Tweets that mention Simple Interop: A PowerPoint Presentation -- Topsy.com   January 25, 2010 at 6:57 am

    [...] This post was mentioned on Twitter by Wes Rishel, Steven Waldren MD and Richard Vaughn MD, Vince Kuraitis. Vince Kuraitis said: OUTSTANDING! RT @wrishel: Simple Health Interop is simmering, going to boil I. See PPT at http://bit.ly/8T6Ufx. #healthIT #EHR #PHR #hitpol [...]

  • 9 Dixie Baker   January 25, 2010 at 12:44 pm

    Wes,

    I apologize for my extremely difficult to parse sentence. I’m in violent agreement with your response. What I was attempting to point out is that this level of simple, short-term-achievable interoperability does not, and should not, reach up to the “person” level. What I MEANT to point out was that including the “send to person -> often” row in slide 7, and including the “person” use cases SUGGEST that this simple interoperability is intended to do more than it does — which is “simply” getting health information from point A to point B, with end points authenticated, transmission secured the integrity protected, with “reasonable” assurance of delivery.

    -Dixie

  • 10 Trevor Kerr   January 30, 2010 at 4:53 pm

    Sorely disappointed that you “Removed disease registry discussion to avoid complications about discussing consent for aggregation (other than the PHR).” :)
    As a rank outsider practising in a tiny niche of medicine, my opinion is that the concept of “registries” is a crucial sell to governments wishing to take the next step. In Australia, that next step is a raft of legislation designed to both homogenise “business” in the private and public spheres, and to underwrite the political will to uphold the virtues of privacy.
    My gut sense is that Health IT is about to split off a branch that is dedicated to sharing information and data between clients and service providers. When we consider that a large minority of the parents of fat children do not know their kids are obese, it may make more sense to start providing tools that bridge the gaps in knowledge. Like the graphics in your PPT.

  • 11 Wes Rishel   January 30, 2010 at 8:14 pm

    Trevor I feel a bit guilty that this whole series is unabashedly concentrated on the U.S. even though the Internet, the need and most of the drivers and inhibitors of interoperability are universal. My tunnel vision is entirely due to the U.S. being at a rare cusp where decisions are being made that will have long-term impact and I serve on one of the advisory committees.

    Furthermore, I feel that registries are, indeed, critical to achieving population health, You might check out “It Takes a Region:” Progress Without EHRs in this regard.

    My presentation is licensed to encourage its being leveraged anywhere. Perhaps you would like to create your own fork culling out what does not apply and adding more on registries. Here are the changes. Feel free to use the old words (or not).

    Simple Interop: Three Models for Sharing Identifiable Patient Data

    Routine Care

    Information sharing about a patient occurs following well-established patterns for the treatment of the patient
    Implicit consent
    Provider organizations know one another or have ways of establishing trust
    No central index of patients or data  no required automatic patient ID mapping

    PHR

    Patient controlled
    Patient uses PHR to aggregate their own data and disburse it as seen fit
    PHR matches inputs from multiple sources to the patient

    Disease Registry

    Hybrid between PHR and routine care
    Includes identity mapping
    Limited to specific content
    Patient consent interface to DR may be through provider

  • 12 David Szabo   February 6, 2010 at 4:18 pm

    Great slide deck. Where in the U.S. is simple interop being tried? Have you presented your ideas to any of the regional extension centers being formed under HITECH, or to state governments that are developing statewide HIT plans?

  • 13 Wes Rishel   February 6, 2010 at 11:29 pm

    David,

    Thanks for your questions. I have had a number of expressions of interest and I suspect that some pilots will develop. But so far none has come to the surface.

  • 14 Simple Interop Gets Respectable: More News at HIMSS   February 26, 2010 at 7:02 pm

    [...] people have contacted me about getting started with Simple Interop. I have been lining up some Web resources to host a series of “birds of a feather” [...]

  • 15 A Direct Explanation of NHIN Direct « Medicity   March 17, 2010 at 11:29 am

    [...] domain registrars – inspired by a collaboration between Wes Rishel and David McCallie called Simple Interop. Although a simple concept, NHIN Direct probably doesn’t go far enough yet because it still will [...]

  • 16 Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards | e-CareManagement   April 14, 2010 at 7:36 pm

    [...] and David McCallie have extended this point of view with their insightful perspectives on “simple interoperability”. Simple interoperability is defining the underlying thinking in the ongoing development of the [...]

  • 17 e-Patient Dave   April 22, 2010 at 3:56 am

    Excellent. Per your permission I uploaded it to Slideshare, and I’m writing a post about it on e-patients.net.

  • 18 Save lives first, *then* compete: Simple Interop for Healthcare | e-Patients.net   April 22, 2010 at 5:20 am

    [...] 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 [...]

  • 19 Save lives first, *then* compete: Simple Interop for Healthcare | Divine Heal   April 25, 2010 at 7:48 pm

    [...] 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 [...]