The Genius of the AND

Recently in Washington, an important political figure asked me why I had the reputation of resisting change.

Since I've spent my life catalyzing change and embracing the latest technology, I found this a very strange statement.

I have no idea how history will record my life and work, but I think the answer is - it depends who you ask.

Wes Rishel wrote a great blog today that reduces the debate about standards and interoperability into two points of view - “the healthcare informatics crowd" and "the Internet crowd".

I've spent the past 4 years facilitating standards harmonization in HITSP, bringing together 800 organizations to discuss the parsimonious number of standards needed to facilitate the data exchanges which will support meaningful use.

From the point of view of the healthcare informatics crowd, the harmonization of disparate approaches into CDA/CCD with XDS.b, XDR, XCA and XDM represents significant simplification and convergence of the major stakeholders in healthcare IT.

From the point of view of the Internet crowd, it represents a set of complex content and security constructs that puts the SDOs in the HTTP business.

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.

Thus, my challenge as a leader is to bring together both the healthcare informatics crowd and the internet crowd, without having to take sides and choose either/or.

The answer to me is that we need to embrace both approaches - the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google's CCRg or PDF can do the job.

On the FACA blog today, Marc Overhage wrote about good enough standards for a particular purpose.

This blog posting is likely to generate debates from both the healthcare informatics crowd and the Internet crowd.

Certainly, I believe that a single standard with templates or subsets for a particular purpose would reduce costs and ease the vendor burden of having to support multiple standards, but the trick to accomplishing this is to ensure that the standard be simple enough to be easily implementable for "the little guy", the iPhone, and the use cases of EHR to PHR exchange where the goal is to provide basic summaries to patients. As I said in my blog last week, I'm convinced that the SDOs will continue to refine their content standards such as CDA and CCD to clean up the XML (get rid of moodCode) and provide templates to support a range of applications, both complex and simple (hide the OIDs so that most implementers do not need to deal with them).

Until then, we need a glide path that embraces the healthcare informatics crowd and the internet crowd, respecting the hard work and best thinking of both.

My proposal, as a private citizen and not in any of my committee roles is that we take the advice of Jim Collins in Built to Last in which he describes the "the tyranny of the OR verses the genius of the AND"

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, we use the CDA/CCD.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs such as would be used by Microsoft, Google or Keas, the CCR or PDF is good enough.

We separate content and transport, recognizing that some organizations will use XDS.b and XDR for SOAP-based transport, while others will use RESTful approaches, enforcing privacy policy with security features at the application level.

As standards evolve we can revisit this with the aim of convergence as long as further parsimony does not impede innovation.

It is my hope, that by embracing the right tool for the right purpose, we can balance standardization, ease of implementation, and innovation.

The genius of the AND - I hope that both the healthcare informatics crowd and the Internet crowd can embrace this path forward.