Jun 18 2012
The details for the Integrated Electronic Health Record (IEHR) are just now beginning to roll out. It’s pretty much a replay of the “Best of Breed” marketing approach that I’ve seen been pitched for decades. Basically, collect all the parts and the whole will fall together with “just a bit of integration.” They are issuing dozens of RFPs and RFIs describing all the pieces they seek; how it all fits together is a lot of hand-waving at the moment, with an inordinate faith in the role of an Enterprise Service Bus to magically make everything work together.
This is a little like someone selling you the world’s best car, based on “best of breed” components from all the best manufactures. An engine from a Corvette, seats from a Rolls Royce, transmission from a Ferrari, etc. To make it all fit together, they would say it is all “standardized” – every part would use metric nuts and bolts, 12 volts electricity, and a common electrical harness (equivalent of the Enterprise Service Bus), to make sure that all the parts could work together.
We took an opposite approach in VistA, starting with a conceptual model of a system driven by active metadata – a common roadmap to patient database. We were “integrated” by virtue of not “disintegrating” into pieces in the first place. We had an overarching Conceptual Integrity to the design that gave us a common foundation from which to grow, climbing up the ladder of abstraction rather than falling down it.
This turns out to have been a good decision. The President’s Council of Advisors for Science and Technology (PCAST) issued a report the report—Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward— that specifically pointed out VistA as one of the success stories for large scale EHR systems. It also advocated greater use of metadata: tagging data dynamically through meta rather than “pigeonholing” it into pre-defined, previously synchronized slots.
This argument can be very abstract to some people, particularly to bureaucrats whose entire life has been engulfed by hierarchies and “pigeonhole” systems thinking. The notion that systems can associate dynamically, spanning hierarchies (or not even being associated with a hierarchy) casts them into unfamiliar uncharted territory. To them, complex systems require complex organizations to manage and regulate them. They seek efficiency, rather than resilience, adaptability, or robustness.
In order to make this a bit more understandable, I am proposing a theme song for the IEHR architecture: Johnny Cash’s One Piece at a Time. Think of the IEHR vision as Johnny Cash’s Cadillac. I’ll let the viewer draw their own analogies. Of course, Johnny didn’t have billions of taxpayers dollars to spend, nor did he have a gaggle of consultants ready to reap huge contracts to do the “little bit of integration.”