Beware an impending e-records train wreck
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Outdated technologies and inadequate transparency are hampering HHS's electronic health records effort, but the experience could provide lessons other agencies can use to avoid similar pitfalls, says columnist Michael Daconta.
I have some experience in health care information technology systems, having built an early stage telehealth system called Teleprovider in 1996. That system managed patient records, enabled videoconferencing for tele-consultations, facilitated collaborative whiteboarding and handled images compliant with the Digital Imaging and Communications in Medicine standard.
I learned a lot from that experience and enjoyed working with the doctors at Stanford University and Samsung Medical Center. Seeing the doctors use my nascent Java whiteboarding application — remember this was 1996 — for a tele-consultation between the university and a Korean hospital was especially rewarding.
Thus, given my interest, I recently joined the Healthcare Information and Management Systems Society and have been trying to untangle the convoluted web of health care data standards. My attempt to understand this mess has been unsuccessful so far. And if someone like me — someone with years of experience in IT and a small amount of experience in health care — can’t figure it out, where does that leave the average person?
For now, even from my limited vantage point, I see two trends that concern me: use of outdated technologies and limited transparency.
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First, let’s examine the issues around outdated technology. On July 28, the Health and Human Services Department posted its final rule on the initial set of standards for electronic health records (EHRs). Two points in the rule stood out: First, in response to comments, they removed the adoption of Simple Object Access Protocol (SOAP) and Representational State Transfer (REST). So, whereas the majority of industry and government is moving as fast as possible to adopt those Web-based technologies, our so-called modernized health care system will need to stick with its hodgepodge of protocols.
Second, there was the selection of many Health Level 7 standards, including some based on Electronic Data Interchange. EDI is binary-formatted — newer versions are text-based — pre-Internet, pre-XML, 1970s technology. Given that Extensible Markup Language has been a standard since 1998, this is outdated technology.
Before you say, “But it works,” remember that “working” from a user perspective does not mean there are not serious negative ramifications for continued use of an outdated technology. For example, I can still send messages using paper and postal mail, but it is much more efficient to use e-mail. And as the years pass and improvements in technology continue to pile up, the performance gap between old and new technology grows exponentially. Welcome to Moore’s law.
An even more egregious example is the Veterans Affairs Department’s Veterans Health Information System and Technology Architecture for EHR. VA is pushing this as the future of EHRs, but it is built upon a prerelational database, pre-object-oriented, 1960s-era programming language called the Massachusetts General Hospital Utility Multi-Programming System. If you examine the Wikipedia page on MUMPS, you will see a sample program that is in violation of almost every modern best practice for programming. I am flabbergasted — a 1960s programming language as the future of health care. Wow.
And let’s briefly examine the issues around transparency. Why are HHS datasets on the department’s own website instead of Data.gov? That defeats the purpose of having Data.gov. And HHS has selected a set of standards that the public does not have access to because HL7 charges to view its standards. Why not select a standard such as openEHR that is free to the public? HL7 also has been criticized by Barry Smith, whom I have worked with and respect. Data standards for something that will affect every recipient of medical care should be available for public review.
Frankly, I think an EHR train wreck is possible unless HHS gets serious about tackling these issues. I readily admit that I am still a novice in this domain and am happy to be proven wrong on these issues. Of course, there is really only one way to find out — let’s see the road map to replace outdated technologies — and, more important, show us the data standards.