The savvy tech strategy behind Obamacare

The ONC's Doug Fridsma explains why the health IT for EHRs and Obamacare should be like the Internet, and not like ERP or traditional IT systems

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Why health IT can't be like ERP or AOL: Avoiding the path of least regret

Fridsma: I like to remind people that five years ago we didn't realize that we had to summarize our entire life in 140 characters, because we didn't know about Twitter or tweets. I think it's humbling to realize that was just a few years ago. In my lifetime I remember using links from Web pages. I'm dating myself when I say that. But who would envision that we would order most of our Christmas gifts using the protocols that were developed in a physics lab to support researchers exchanging information?

InfoWorld: I used to work at the IEEE in the mid-'80s when we had access to ARPAnet before it became the Internet. We had email, and a few dozen other organizations in the world had email. We were early users and had no clue how this would go.

Fridsma: I remember the difference between Bitnet and ARPAnet, and there was different syntax. We in health care are at that point where there is this new technology, or maybe there's this new functionality that we're trying to enable with various standards. And it's not entirely standardized yet. We have the equivalents of Bitnet and ARPAnet and there's different syntax,; we have all the different early players in the space.

InfoWorld: What's interesting, though, is this issue of standardization, when you were talking about Project Direct and how it was part of a portfolio of approaches. I've been telling people that the health care industry is going through something like what many businesses went through at ERP a decade or 15 years ago, except ERP was about standardizing processes and creating a set of standards that people had to adapt to.

What you're describing is much more complicated. You're not trying to do an ERP for health care, which says this is the way the process should work, how things should work. You're trying to support multiple approaches that are valid and contextual and situational. Yes, there are standards around them, but it's not saying here's the way to do it, which is what ERP did, and why a lot of ERP efforts actually failed in the early days because they were too restrictive. It's a much harder problem, I think, that you're trying to address at the ONC.

Fridsma: Yeah, I think what we're trying to do is the equivalent of what you've got in the Internet, which is horizontal integration rather than vertical integration. You create the ability to take a common transport mechanism -- TCP/IP, whatever -- and you create the mechanism that I can take my computer, and I can plug it into a wired network and I can unplug it and it will connect to the wireless network, and my application or email doesn't miss a beat, because there're layers of abstraction between those systems.

I hope that the Direct and Web Services protocols, and other things like that become that horizontal integration, that allow you to say, "What's the appropriate mechanism to exchange the information? And what's the appropriate format to use so that the user just says -- I need to make sure this consult goes from my office to their office and it needs to happen in an expeditious way. I want to know that it's been received and it's an urgent request." Just by outlining that, the systems will understand how to route that information using the correct protocol.

We've done a lot of work looking at what other countries have done, and we've tried to learn from those experiences. Rather than trying to build this top down and create restrictions, we're really trying to ask, "What's the path of least regret in what we need to do?"

Because technology is going to go far faster than our ability to change and modify health care delivery, how can we make sure that there are fundamental building blocks? We know we're going to need vocabularies to help us in critical decision support and identify drug interactions. We know we're going to have to have syntax that computers can parse and understand. We know that we're going to have to have ways of exchanging information, and to solve a problem that says, "I want my patient to have a copy of her lab test at the same time that I have it" might require a vocabulary, a content standard, and an exchange specification that can be bundled according to whether it's urgent or not urgent or the like. We'd like to get to the point where whether it's on a mobile platform like an iPad or whether it's on your computer, the underlying infrastructure all works to provide that.

We've taken inspiration from the World Wide Web and the way in which it's approached a lot of the standards and tried to create the health care equivalences and do it in a way that's incremental. I don't think that we will ever have success if we try to get all the requirements ahead of time and institute a system that addresses them. Because as soon as you've completed the requirements, the world has changed -- and you have to start over.

InfoWorld: It's true. And your analogy of the Internet is an apt one, because it also has evolved. There were standards early on but they've all evolved and new ones have come into play and some have been discarded because people don't use certain things anymore, so they still exist technically but no one cares. It has adapted and we have adapted to it.

Fridsma: Yeah. You remember the early days when some Web pages would load in Internet Explorer and others would load in Mozilla, but not all of them would work in Safari?

InfoWorld: We're barely out of those days.

Fridsma: We're up to HTML5 now, which has a lot more functionality and the like, so the gap has closed considerably.

There is a sense of urgency and there's a sense of impatience, because I think people look at what is happening in the rest of their life and the way in which they can do their online banking -- you don't even have to deposit your checks anymore; you just take a picture of it, for God's sake, with your smartphone and they deposit the money in your account. Who would have thought that when the first ATM came out that might be the evolution that we would see?

InfoWorld: Fifteen years ago those banking systems were horrible to use. They did not work very well. What we experience today didn't just come out of nothing, and I think that's maybe one of the frustrations people have is they've seen other technologies move to this being a sort of "normal" part of their lives and health care is behind that. But these things never started that way.

Fridsma: Yeah, I remember Quicken. I was an early adopter of Quicken, and I entered all my checks in individually to balance my checkbook. Then I started to get these QIF files that I could download and import, but if you imported it twice it created duplicates. Then you started getting data feeds you could download directly, then you started to be able to have a two-way, where you could actually write checks as well as download transactions. Then we moved to online banking and now we've got

Part of what we're trying to do is build in the ability to move from one way of doing things to a different way of doing things. If you build one big system and one-size-fits-all, you have to do rip-and-replace, you have to start over.

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