Editor’s note: This article was originally published April 16 on Keith Boone’s Healthcare Standards blog. Special thanks to Keith for allowing us to republish the article in its entirety on HL7Standards.com. Six GOP Senators call for overview of Meaningful Use EHR incentive program was the tweet.  It referenced this link. Which then referred to this report by Senators Thune, [...]
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Part 2 in a series. Read Part 1: Brick Walls Are No Match For Regina Holliday’s Medical Advocacy “Courage does not always roar. Sometimes courage is the quiet voice at the end of the day saying, ‘I will try again tomorrow.’” ― Mary Anne Radmacher Think about the last time you saw, heard or experienced something [...]
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I recently had the pleasure of attending a presentation by Grahame Grieve, the originator of FHIR, on the details behind this evolving health IT standard. I have written a couple of blogs previously to introduce FHIR, including 5 Things to Know About HL7 FHIR and Review of The HL7 FHIR Session at HIMSS13. This standard [...]
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This is in response to Dave Shaver’s (President of Corepoint Health) comment on my blog.

Hi David,

Thanks for weighing in.  Your comment reminds me of one of the earliest conversations we had where you made much the same point: That it’s not the best technology that wins, but the best marketed one.  It was an argument that made a lot of sense at the time – Microsoft seemed almighty and it looked like Windows was going to be dominant forever.

Back in the early 2000′s the winners in the technology space were the guys that accepted less than perfection in their products and sold the heck out of them.  Unfortunately, in healthcare IT this model continues to be executed all too often. The end is result is a lot of enterprise health IT systems that just don’t deliver the value that they ought to.

I think that an inordinate amount of interoperability problems originate from the lack of high quality products used throughout the healthcare industry.

As leaders of technology organizations in North America, we need to set the bar much higher. If we don’t show that type of leadership, and we create weak organizations that do not have first class products, we open our collective economic eco-system to weakness and fragility. Those weakness lead directly to the misery and distress that ordinary people face in cities like Detroit, Michigan.

We need to show greater social responsibility by being uncompromising in the pursuit of excellence.

Fortunately, we live in a time when we do have role models for leaders that have shown that if you focus on excellence and the customer experience that you can be very successful. One of the role models I aspire to is Steve Jobs. He was a very divisive figure – but no one can deny that he had a profound impact how we see computing today.

Steve Jobs was way ahead of curve in understanding just what a pile of technical debt Adobe Flash was.  His competitors made a big noise about it and how much better their platforms were for supporting Flash. But at the end of day Steve Jobs showed he got it.  He wasn’t someone that was afraid to put his stake in the ground and say what he believed in. He wasn’t a ‘me too’ leader.

At the end of day – he was right.

Steve Jobs killed Flash on the mobile platform.

We need more leaders like Steve Jobs.

I am comfortable with having a different focus.  I do not feel the need to wrap myself in the flag of standards. Nor do I need to wax lyrical about consensus. I want to do what is right for healthcare and do my part to deliver value and help fix the big problems we see.  I will do what I feel needs to done and am not afraid to take unconventional paths to get there.

Having said all that – thanks for the beer on Tuesday night – it was great (although I did feel it the next morning – ugh!)

I’m off to Europe tomorrow for two and half weeks holiday so don’t expect to hear much from me – enjoy the summer, it looks like it’s going to be a great one.

Au revoir!

iNTERFACEWARE

Big Day in Genomics Angelina Jolie’s very open revelation, “My Medical Choice” in the The New York Times, was brave, and a “big day for genomics”, according to Leslie Ziegler of Rock Health. Jolie, in a powerful and personal narrative, explains why she chose a preventative double mastectomy after genetic testing found the BRCA1 gene. She was estimated to have [...]
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Last week in a bold and historic move (and a bitter pill indeed for many healthcare executives finding themselves explaining the obscure financial inner workings of a hospital) the HHS/CMS released the national charge master data. The release seems to be a response to Steven Brill’s epic TIME magazine article on medical billing: Bitter Pill: [...]
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There are lots of places where FHIR shows underlying problems in it’s conception.

One of the areas is in how to handle database transactions. It’s a big topic of discussion within the FHIR team of how to handle this. I tried to think of a few constructive ways to solve the problem – maybe flattening out resources and allowing composite updates to be made in a single envelope.

Nope.

Didn’t smell right.

Real world RESTful interfaces don’t have this problem. Real world RESTful interfaces closely mirror the underlying data model of the application they are exposing and so decisions about how transactions are implemented is something which is very specific to the application.

You don’t see 37Signals explaining how their RESTful API handles database transactions because they have grouped the data in their API calls that makes sense for transactions in their application.  This simply isn’t a problem that you have to think when you use real world RESTful APIs.

The problem shows up because FHIR is trying to do something which is a flawed idea to begin with. No one has ever tried to make a general purpose vertical RESTful API which covers as wide a range of disparate data as FHIR.

Why?

Because it’s a bad idea!

What bites FHIR in the butt is the whole principle of leaky abstraction. FHIR has negative value because it confuses the integrator with as to the nature of how the underlying application actually works.

Look at the patient resource:

http://www.hl7.org/implement/standards/fhir/patient.htm

and imagine putting this on top of real EMR system.  Some EMRs are really flexible – they have the concept of a person table.  Others represent a patient using a flat record with say HomePhone, BusinessPhone and OtherPhone implemented as columns in a single table.

How the application stores data inevitably leaks through into it’s interface.  Having a generalized interface like FHIR makes each integration harder work. It will take more time per interface because as an integrator you have to figure out the underlying limitations of each system. This is same problem as Version 2.0 HL7 – HL7 interfaces – HL7 interfaces are invariably a thin wrapper around the underlying data-structure of the application.

Why?  Because there is no other way.  

This is what makes HL7 integration hard. It’s easy enough to consume HL7 data. But it’s hard work figuring out what parts of the HL7 standard that a vendor has implemented and what data fields to populate because invariably you have to figure out the right ones to populate to get the data in the right spot to display in the right part of the GUI that the user needs in their work flow.

A native RESTful API that is fits like a glove on to a real application is going to be a lot easier to use than HL7, and a lot less costly to integrate with than FHIR.

Welcome to the real world.  Deal with it.

iNTERFACEWARE

In my post about FHIR + Iguana = Profit I made a passing mention of an important event in Amazon’s history from back in 2002 – give or take a year or so.

Jeff Bezos issued a mandate:

• All teams will henceforth expose their data and functionality through service interfaces.
• Teams must communicate with each other through these interfaces.
• There will be no other form of inter-process communication allowed: no direct linking, no direct reads of another team’s data store, no shared-memory model, no back-doors whatsoever. The only communication allowed is via service interface calls over the network.
• It doesn’t matter what technology they use.
• All service interfaces, without exception, must be designed from the ground up to be externalizable. That is to say, the team must plan and design to be able to expose the interface to developers in the outside world. No exceptions.

He finished his mandate with:

Anyone who doesn’t do this will be fired. Thank you; have a nice day!

It was an extremely smart business decision. With this mandate Jeff Bezos set the foundation for transforming Amazon from a bookseller into a multi billion-dollar cloud-computing powerhouse. This is where is it all started.

It’s an exquisite business lesson in teaching us what every fortune five hundred company in healthcare needs to do. We do with business with just about all of you. And you all have exactly the same business problem.

You grew your businesses by acquisition.  Your products have different data models, are built on different technologies, at different times by different teams. You have too many products and not enough engineers. You are all spinning your wheels with your internal integration pain.

I have talked to generations of inter-operability teams at practically all the big vendors in healthcare. It’s funny how much faith seems to be placed in standards and centralizing inter-operability. The first hope was that somehow Version 3.0 and the RIM was going to solve the pain. That was never going to be the case.  There was no way that any of you would have the resources required to rewrite all your products to be compliant with any single data model; even if it was a great model.

The new faith is that somehow that the IHE profiles will sort things out.  Sorry, that’s not going to work either.

Somewhere, somehow, someone important in one of these companies is going to read this blog.  Synapses will spark and one of these giants will awaken. The right edict will go out. And for all the competitors? Watch out. You are about to be out evolved.  It will take a couple of years but the first large healthcare IT player to get their internal API-house together will have an overwhelming competitive advantage.

(and with a bit of luck your competitors won’t read this blog and will try and implement FHIR)

(Oh and to talk to all those legacy systems using HL7 from your competitors that you will be replacing: Use Iguana!)

iNTERFACEWARE

So back in Toronto for the week – I’m headed off for a holiday in Europe with my family next week so expect it to be quiet from me over the next few weeks.

While I was at the HL7 WGM in Atlanta a lot of new furniture arrived and including the stools for our corner lounge area in the new office. It’s one feature I was really looking forward to – there’s a really a nice bench which you can park yourself at with your laptop and enjoy the view – it’s gorgeous – you can see right over the Toronto skyline including the CN tower.  It’s a nice way to start the day with going through emails and having a coffee (doing that right now!).

I’m not a great photographer but I took a quick snap – it’s the view you can look forward to if you come to our first user conference for Iguana in September the 19th and 20th. After spending a lot of time last week in the windowless basement of the Sheraton for the HL7 WGM I think it will give quite a different feel both in content and in feeling. I’m excited about it.

My team will get some more photos up when the last of the furniture arrives. I firmly believe that if you want to build a team that is going to change the world (and make no mistake – we are changing the world and intend to continue doing so) then you don’t want to put that team in a basement.  The new office is huge, airy and has large open spaces to make it easy to share ideas and collaborate.

The HL7 WGM was really interesting – it’s been about eight years since I have been to a WGM. I’m older, uglier and (somewhat) wiser. Given all my experience since then I think I had a far better grasp on what the issues are for HL7. HL7 has an information problem. It’s like any large corporation – there is a huge difficulty in information traveling from one part to another. In the 1990′s HL7 was the disruptor – they broke new ground in terms of getting grass-roots support from hospitals and smaller vendors to make data flow in healthcare. The processes that HL7 had then aren’t scaling well to deal with the size and complexity of modern healthcare IT that exist today.

Some of the international affiliates like the UK often feel like outsiders in the process – the standards are generated within the core and consumed by the colonies – although Grahame Grieve is breaking new ground since he comes from Australia and I guess Ewout Kramer is from Holland and Lloyd McKenzie is from Canada. I think it’s quite a subtle dance as to who get’s to influence the standards. The world isn’t black and white – there are many shades of grey.

I was blogging a lot during the event – there was a lot of material. There was a fascinating thread which opened up on my last blog post.  Barry Smith of HL7 Watch took some of the more salient points.  There was enough material that I could have easily filled up another 10 entries. HL7 definitely does have some issues to sort through. There was too much good stuff happening last week – Toni and Jeff got to go hang out with the cool kids over at Rockhealth - can’t help but think I got the short straw on that one! Toni next WGM you come to it and I’ll go somewhere really fun. It’s one of the many things that HL7 needs to work on, embracing start ups and entrepreneurs more – the organization has never really felt like it welcomed that type of energy as much as it should do. I think it’s a really big problem for HL7 because you need to cultivate that grass roots support.

Bit of fun trivia – I found out that Grahame and I went to the same schools in New Zealand – Raroa Intermediate and Wellington Boys college – holy cow, it’s a small world.

Ah – my coffee is done, time to start some real work.

Notice the trees of Toronto have conveniently decided to produce our corporate green

iNTERFACEWARE

In my last post, I talked about the concept of slacktivism in the era of social media. Slacktivism is sort of a pseudo-activism , where participants takes part in gestures – like changing their Facebook profiles photos to that of a cause – that make them feel good, but are meaningless in making any real social change. [...]
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