This is a reply to Shane Taylor’s interesting comment on my Simple Healthcare Interop for Easy Applications post. I am using his comment as an opportunity to flog some important notions.
Notion 1: You Can’t Step on Someone’s Toes with a Thoughtful Blog Comment
Shane expressed a concern that his reply might be considered inappropriate. Nothing that adds to the discourse is inappropriate. Gartner has ‘bots to delete autoposting from other ‘bots that are simple product pitches. I might delete a comment that was totally irrelevant or grossly offensive, but vendors are welcome to post descriptions of their products that add to the subject at hand. I assume my readers will look at the quality of the ideas and consider the source when evaluating the evidence that supports the ideas.
Notion 2: The Fax is the Standard to Beat
Strengths: If we are going to ever get beyond the fax we have to first recognize the full value it adds.
- The fax can communicate complex information in human readable format. Text and diagrams, and handwritten notes are all handled well.
- It is a ubiquitous capability that can be added to an office for less than $25/mo. The technology is used for many purposes so the allocated cost for clinical information sharing is close to nothing.
- It involves only two parties the sender and the receiver.
- There are no complications associated with verifying the trust relationship between the sender and receiver. That happens off-line.
- The transmission itself is reasonably secure. HIPAA quite reasonably does not impose encryption requirements on information sent over a switchable network.
- There is no time-consuming and difficult to understand overhead to maintain security keys.
- Every fax machine in the world is directly addressable with a simple number containing fewer than 12 digits.
- Fax can easily be integrated into IT systems both for outgoing and incoming messages.
- It works well in mixed modes, where some providers have integrated IT systems and others have no integration or no clinical IT system.
Weaknesses. Since it will be at least a decade before we can match the ubiquity of the fax with any other technology, there must be things that can be fixed that add enough value to justify the complexity of dealing with the Internet. Fortunately there are several.
- Fax communications errors sometimes obscure the documents. The error-recover protocol (call back and have the document sent again) is so heavyweight it is often skipped.
- No-one uses features that would provide end-point authentication. Who hasn’t once or twice received a fax intended for someone else with confidential financial data therein? In any event it is trivially easy to fake the end-point credential of a fax machine.
- The solution for color is not ubiquitous.
- Resolution of photographs is too low for all but the most trivial uses.
- There is no ability to mix structured and human-readable data and pass the structured data directly to an IT system.
- There is no potential to automate patient identity mapping in IT systems. Even when the fax comes into an IT system a person still has to review the document, match it to a patient and determine what to do with it, but it is not necessary to take a piece of paper from the fax machine and run it through a scanner.
- There is no reliable directory service that will get you, say, to the fax machine associated with the gastroenterology clinic of the Lucile Packard Children’s Hospital on the Stanford University campus. The identifier (fax number) also must be established externally.
The approach we are working on depends on fixing enough of these problems to be worth investing in changing things. We aren’t trying to fix them all, because that would raise the cost and implementation time too much.
Notion 3: Direct Patient/Consumer Involvement Is Not the Solution
While I am a big fan of consumer/patient engagement through the Web I am not in favor of entangling that approach with provider-to-provider communications that occur in the routine course of giving care. Consumer involvement may be the only solution that supports ad hoc lookups of patient data. Communication between providers and consumers is also very important. But if patient facilitation is required for all IT-based communications among providers in the course of treating the patient, fax will continue to be the default technology 10 years from now.
Notion 4: The eBay Model of Trust is Inadequate for Healthcare
Comparisons to the Web megavendors must be made carefully. This is particularly true when you compare the business value and risks involved in sharing information with value and risks of conducting financial transactions. Shane’s characterization of eBay has merit although it could be misleading The primary value that eBay brings to the world is the auction-based marketplace. This is not a value you would expect to provide for healthcare information.
The analogy is good, though, in that the secondary value that eBay adds is trust, at least to the scale of large consumer transactions and the transactions of small businesses. However, the trust model is based on the ability to limit losses to the dollar value of the merchandise exchanged. I can’t imagine a manufacturer of baby food buying ingredients on eBay just using the level of trust that can be conveyed through eBay. They would have to have a separate trust relationship with the ingredient-seller, often-based on sending inspectors to the plant from time to time to review their QA procedures. We need to think carefully about the level of trust that a vendor would need to convey in order to be an eBay-like connector of healthcare organizations that do not have a separate means of establishing trust.
My current approach is different than RHIOs or HIEs in that it doesn’t assume that an intermediary or protocol is adding business trust, only authenticity.
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