We are pleased that Aneesh Chopra, blogging from the White House, recognized the early contribution of my blog in setting the direction that became the basis for The Direct Project. The Direct Project set a new speed record, going from a basic idea to actual production use for exchanging healthcare information in 11 months. Some of the reasons it was successful were:
- there was a huge pent-up need, greatly amplified by the need to achieve “meaningful use” in interoperable EHRs
- the problem statement was simple, avoiding the complexity of intermediating patient consent
- the solution approach was simple, building as much as possible on protocols in widespread operation
- the cost of participating was being committed to implementing
- It was decoupled from the regulatory cycle.
It was successful precisely because it was so simple that it could be done in a year. Efforts that take longer suffer from scope creep, exponentially expanding complexity, waning interest and membership turnover.
So, what does “simple” have to do with grand concepts like ultra large systems (ULS) and the PCAST report?
A friend recently shared Design Beyond Human Abilities by Richard Gabriel, an evocative and witty essay on ULS. It is well worth the half-hour it takes to read. I promise you will enjoy it. Gabriel identifies ULSs as having a gazillion lines of code, millions of computers/sensors, real-time requirements, and life-critical applications. A ULS operates against adversaries, those out to hurt the system or establish unauthorized access or changes to change its data.
Gabriel further characterizes a ULS as having ephemeral pieces but longevity as system. Some parts will be 25+ years old. A ULS will be subject to continual change, continual failure in hardware and software components. It will be hard to operate and have no fixed boundaries. Arguably, ULSs aren’t built in a planned series of stages; they evolve through the survival of the fittest. Those portions of the system that enable their users to survive in the jungle of their industry will grow and those portions of the ULS that don’t provide such tangible benefit will wither.
What do we know that sounds like a ULS? I can think of two things, the Internet and the network we need for healthcare interoperability across a broad spectrum of uses including applications that are solely patient-centered engage patients with care, support the complex interactions of an accountable care organization and enable the leveraging of data for research.
Neither Gabriel nor Carnegie-Mellon’s Ultra-Large-Scale Systems The Software Challenge of the Future does much more than characterize the problem and give a few hints on approaches. They describe an important research agenda. However, it is clear that the Internet is a good model. After an initial kick-start based on reliability of distributed environment it has grown primarily by survival of the fittest. Many more protocols have been proposed than have become widely used.
One of the principles that served the Internet well was to focus first on the narrow part of the hourglass, identifiers and some simple and versatile formats and protocols (see illustration). Ideally, economics and innovation will build on these simple interfaces to solve problems known and as yet unrecognized.
Previous healthcare IT standardization efforts bit off much bigger challenges. For example, they comingled the specifications for data and the protocols to solve operational problems. They comingled solutions to patient consent problems in a manner that made the cost of entry having systems and programming that dealt with rather complex data formats and promulgating patient consent. That has proven to be too big a bite. Because of their specific focus on identified transactions they have constrained innovative approaches to solving healthcare problems across a broad application space..
The Direct Project protocols build directly on simple IFaPs and leave the door open for innovative new ways to use its secure platform. Ironically, simplicity is a key to success and survival within the hodge-podge of systems and protocols that comprise a ULS.
And What’s All This Got Do With the PCAST Report?
I’m glad you asked. The term ULS never comes up in the report and it is focused on standards farther from the narrow portion of the hourglass than The Direct Project. However the scope it addresses is national and the national networking it anticipates will still be going when virtually every healthcare consumer will have a smart device and many will have multiple sensors. The report is direct towards creating an “infostructure” that enabled disruptive innovation. It seems impossible to look at the PCAST vision and not see an ultra large system in its future.
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Category: healthcare-providers interoperability
Tags: direct-project health-information-exchange health-internet healthcare-interoperability meaningful-use nhin-direct pcast-report simple-interop uls ultra-large-systems
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