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Rant on Heath Information Technology Asynchrony

by Wes Rishel  |  January 2, 2010  |  8 Comments

Here is some pseudo XML.

<joke style=”jocular, but with a purpose”>There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?” (From David Foster Wallace, novelist, speaking at Kenyon College, 2005.)</joke>

The water in the healthcare IT pond is the slow and asynchronous adoption of new technology. We know that small healthcare organizations are slow to adopt new technologies and large organizations adopt new technologies slowly.

The ARRA money and a certification program for EHRs can make a bump in the adoption curve. However, we know that not all providers are eligible, not all hospitals are eligible and not all generators of important clinical data (such as labs) are rewarded by the incentive program. We know that not all those that are eligible will take advantage of the incentives.

We expect that the incentive-bump will create a ripple of adoption of interoperable HIT. We hope the ripple will be a good-sized wave. The wave will ultimately reach those not directly incented in the program, as they find it in their interest to interoperate with those that adopted because of the incentives. The same ripple wave will ultimately bring along those who chose not to pursue the incentives in the first two years.

So what’s the big deal? Slow adoption of technology is as obvious as, um, water.

The big deal is interoperability. Compound adoption curves apply. If 2/3 of the HCOs in the country have reached a certain level adoption the probability of intereopration for any given transfer of information is 4/9=44%.

Changes to standards are rolled out by vendors and self-developers in release cycles, and most release cycles take about three years to reach 90% roll-out. With those parameters after one year 11% of sites could interoperate on the new standards. The number is actually a lot lower because the vendors will release new versions of their product at different times.

These numbers could improve as more clients by remotely hosted EHRs and if vendors release interoperability changes at the same time for all clients for a fee included in the maintenance or subscription fees. These improvements could occur over time but that is a long-term consideration.

The big question is what happens to interoperability among EHR users that are on different versions of the standard? Many of the readers of this blog will remember a time when Internet email clients only supported plain text. Nowadays most email clients support HTML. This change did not happen by everyone switching over from plain-text to HTML mail clients. It happened through new readers being developed that sent both plain text and HTML. Old clients read the plain text continued to write plain text. A new client, when receiving a message from another new client was able to display the decorated text in its full glory. However it could still understand and display text from old clients. My recollection is that the period of transition from the point where < 10% of Internet email users had new clients until the point where > 90% did probably took more than 10 years. It might have taken longer except that the vast majority of current email users started during the transition period, thereby getting new email clients to start. Early users of hand-held email devices benefited from the “dual-mode” because the devices were made simpler by not having to support HTML.

It must be the same in healthcare as it was for email clients. New releases of software that embody new standards must not shut down interoperation with other older releases of software.

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Category: healthcare-providers  interoperability  vertical-industries  

Tags: arra  ehr  emr  healthcare-interoperability  healthcare-providers  meaningful-use  

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

Thoughts on Rant on Heath Information Technology Asynchrony

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  4. I think this is spot on and reflects a realistic view of how to grow new solutions. First and foremost, you support the previous standard as long as possible. Remember how long COBOL stayed alive?

  5. […] is no Moore’s Law of Training — and the fears of Gartner analyst Wes Rishel, who delivered a “rant on health information technology asynchrony” over the […]

  6. MedInformaticsMD says:

    I think operability must come before interoperability if adoption is to accelerate. See for example: and

    Excellent also is “Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method” by Greenhalgh and colleasgues at University College London. Available at:

  7. […] people and automatic computer processing programs. We have done so because of the issues raised in Rant on Heath Information Technology Asynchrony . This proposition entails solving some issues. For example, what […]

  8. […] “What the hell is water?” (From David Foster Wallace, novelist, speaking at Kenyon … Read More RECOMMENDED BOOKS REVIEWS AND OPINIONS A Powerful Lesson on How to do […]

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