Wednesday, February 25, 2015

EHR Interoperability, Part 2

The following comment was posted on the Mr HISTalk web site, in response to my earlier blog about interoperability:

"Dale, why hasn’t Health Catalyst published its data model and algorithms to the world? You want all the EHR vendors to bow down and provide their Intellectual Property to you for free so that you can make money building on it?

Where are your APIs Dale? Where is your data model published Dale? Get it published and make it available to all your competitors, other startups and innovators in general and then feel free to throw stones.

You’re just one more self interested wanna be in the healthcare start up game talking tough while holding yourself to a different standard."

This is my response:

Your comment is a little snarky, but the underlying theme has merit—I cannot expect from others what I do not expect of myself.

My blog was written as a practicing CIO, motivated by the best interests of our country, our patients, our physicians, and… get ready… EHR vendors. As evidenced by Epic’s recent decision to create an app store, I’m by no means the only person in the industry who believes that open APIs are the right thing to do for interoperability and innovation, as does the DoD. The DoD has been the historical leader of open systems in the world—ASN.1, SGML, DCE, CORBA, Ada, POSIX, TCP/IP and many others. Epic’s app store decision in light of the DoD procurement is a great recognition of that DoD legacy. The Epic app store will benefit the entire industry.

You can try to discredit my comments about interoperability by firing back at Health Catalyst, but the criticism just won’t hold up. Health Catalyst is a tiny little startup, fighting it out in the best interests of our clients, in the trenches of American capitalism. We are economic and market influence gnats on the rump of today’s EHR vendors—the same EHR vendors that have benefitted from billions of tax dollar subsidies. And when you benefit from that sort of tax money, along with that benefit comes a new level of scrutiny and accountability back to those tax payers to do the right thing. When and if the healthcare analytics market benefits from $25B in tax subsidies, the bar of national accountability will raise for Health Catalyst, too.

You would be surprised at how little influence I have on the way that Health Catalyst operates. I cannot and do not speak officially for the company. My contract with Health Catalyst stipulates that I can continue to speak, publish and blog on matters that reflect my personal opinion about the healthcare industry, which is the case in this discussion. In that context, I sit on the Canada Health InfoWay External Advisory Panel for Interoperability and that panel is in the midst of developing Canada’s roadmap for healthcare interoperability. We are hoping to help Canada avoid the ills that have plagued the US.

I will go out on a limb and offer speculation—I bet Health Catalyst leadership would love nothing more than to publish all sorts of open APIs around their platform and products. As soon as any other vendor, including EHR vendors, asked or wanted to build products around the edges of the Health Catalyst platform, Health Catalyst would open the API doors– and not out of na├»ve altruism, but out of common business sense. The bigger the ecosystem of products that can interact with Health Catalyst, the better for Health Catalyst and the better for Health Catalyst clients and the industry. The Health Catalyst web site is an open cookbook for analytic success in healthcare. Take a look at any other healthcare IT vendors’ web sites and compare it to Health Catalyst. We don’t even offer a login-protected portion of that web site for clients. Everything we do is in the open because that type of openess raises everyone’s game, including ours.

The only thing that Health Catalyst wants from EHR vendors is EHR data and data tags so that Health Catalyst clients can analyze their own data. It’s interoperability at the data warehousing level. I don’t see how EHR data can be considered IP that belongs to the EHR vendors. That data belongs to EHR clients and their patients, and I bet patients would like to know that their data is easy to access for analysis that benefits them clinically and financially.

I will close by asking: Is there anyone out there who genuinely believes in their heart that our national healthcare IT interoperability and innovation strategy is working? Is there anyone out there who believes that anything in my blog is asking or expecting too much of EHR vendors? I guess one person does, but would guess that most do not.

As usual, my thanks to Mr. HISTalk for providing this unique forum.


Monday, February 23, 2015

Barriers to EHR Interoperability Are Contractual and Cost

The barriers to EHR interoperability are not just technical. They are contractual and cost, as well.  I’m speaking as a first-hand source of knowledge about this, as a healthcare CIO.

EHR vendors who enjoy the benefit of our tax dollars under the HITECH act are preventing interoperability-- and innovation around the edges of their EHR products by third party developers-- by placing limitations and restrictions in their contracts with clients. The vendors who are engaged in this type of exclusive behavior can point to their technology and say, "See? We can share data. We follow data sharing technical standards. Quit criticizing us." But when you look into these vendors’ contracts, the license fees associated with interoperability are cost prohibitive, and the interoperability clauses are surrounded by onerous contractual obstacles that are veiled to protect the vendors' intellectual property, yet are actually ensuring the vendors' continued stranglehold on data and preventing innovation around their products.

This behavior on the part of some EHR vendors is strikingly ironic, given the enormous success of open source, easily accessible APIs that benefit interoperability.  The more open your products are, from a software architecture perspective, the more value you accrete to your products’ intellectual property.  Open, transparent APIs create a greater dependence and ecosystem around your products, not less.

Several years ago, I sponsored a meeting with senior executives from four large EHR vendors, lobbying them to open their APIs and migrate their software engineering architecture from tightly coupled, difficult-to-modify-and-upgrade, message oriented architectures; to loosely coupled, flexible, services oriented architectures (SOA) with open, published APIs, so that my engineering teams could write innovative products around the edges of these EHR products.  We even sketched the architecture of an SOA-based EHR, along with about 20 core services-- it was easy; it is not rocket science. Within 18 months after those meetings, three of the four vendors launched formal initiatives in their companies to create more open, friendly APIs, both technically and contractually, and they’ve stayed the course.

I will never forget the response from the fourth of those EHR senior executives.  That person said, “We see ourselves as more than a database vendor.”  Meaning, of course, “Our closed APIs are a market and proprietary advantage.”  Bill Gates and Microsoft used to think the same thing about Windows, Office, and Internet Explorer.  You can see how that worked out for them when you compare what’s happened with the openness of Android, iOS, the browser market, and office suite products; and you can also see Microsoft’s amazing pivot towards open architectures and interoperability in the last few years. is the supreme example of business success based upon an open API and open culture.

One of my current colleagues, who has been deeply involved in the interoperability environment for many years, described his thoughts in an email to me, summarized below:

Current “Interoperability” standards, selected by the ONC and required by MU-S2 do not contain an adequate amount of data/data types to support the quality measurement requirements of the same MU-S2 program. This gap in data is what enables the EHR suppliers to continue the veil of “interoperability” while still protecting their proprietary intellectual property, serving the interests of the owners of these companies with little regard to what may be best for care, providers, patients or consumers.

Several EHR vendors are banning together around a new magic bullet technical standard called HL7-FHIR based on JASON technology.  While this new standard is great from a technical perspective (XML, REST, etc.), in its current form, based largely on existing HL7 v2, v3 and CDA concepts, it does NOT improve the accessibility of proprietary EHR data types, and those data types are needed for quality and cost performance improvement in healthcare.  While FHIR could be expanded to include this type of data, it appears the first efforts are focused on reinventing the technology for currently defined interoperability data types.

I’m not sure what, if anything, Congress can do at this point to fix the ills of Meaningful Use Stage 1, which, in effect, rewarded existing vendors with billions of dollars in tax money to maintain those vendors’ closed and proprietary APIs.  Decertification by ONC will become a bureaucratic mess, but I appreciate the symbolic stance taken by Congress around decertification, nonetheless. One thing that must happen—and maybe our legal courts are the only option for this—the contractual threats and cost barriers in EHR vendor contracts that stand in the way of interoperability and innovation must be removed.

Interoperability and innovation in healthcare IT are suffering, both technically and contractually, by old-fashioned, old-school thinking on the part of some EHR vendors.

And, as an outcome, our healthcare system and patient care are suffering, too. We can do better as a country, and the EHR vendors can actually profit from being more open, not suffer.

Monday, February 16, 2015

The Personal and Professional Downside to Gratitude

Gratitude has become a very mainstream trend in the last few years. That's generally a good thing, but I've come to realize that too much gratitude has had a downside in my life, both personally and professionally.  This is a giant and new insight for me, given my upbringing and philosophies of life.

I was born and raised in a family that exuded gratitude. My dear Mom and Dad lost two of their children, very early in life, to tragic accidents, but they remained strong, positive and grateful, and it carried over to their four remaining children, and innumerable grandkids, friends, and neighbors.

Every night, I go to sleep saying my 'gratefuls' not prayers. I spend the moments before drifting off, replaying the day, reviewing all the wonderful and fascinating things that occurred in my life that day. Inevitably, no matter what bad things the day held, there are always a larger number of things for which I can sincerely step back and give thanks. I love this practice and have no plans of changing it.


Now reflecting back, at 55-years into life, I can see a number of situations, both personally and professionally, in which too much gratitude actually played a negative role in my life, not positive.

In abusive, unhealthy relationships, I kept expressing gratitude-- finding all the good things in those relationships-- to the detriment of my self-esteem, life potential, and happiness.  That happened twice, in significant ways.  I was simply grateful that someone loved me, even if that "love" came wrapped in psychological abuse and relationships that were clearly unhealthy. My gratitude kept me engaged in those relationships, much longer than was healthy.

In a number of business negotiations, usually involving employment compensation, sometimes also job titles and new responsibilities, I've been too grateful-- taking a very passive, trusting, selfless, and soft approach to those negotiations, but underplaying my value, skills, and contributions. In these cases, I was a combination of too grateful for the compensation or job offer, and to have any job at all, and also too humble. I failed to recognize and acknowledge the value of my own work.

It took many years for me to become aware of this tendency towards too much gratitude, and it's especially unusual that this awareness should arrive at a time when practicing gratitude is a cultural phenomenon. The popularity of gratitude in today's society is probably one of the reasons that my awareness of its downside became highlighted.

Be grateful, but be careful.  In any situation, personal or professional, if you are endlessly grateful, odds are, you are going to be a lot less likely to say, "I (or we) can do better." Don't let too much gratitude keep you in an unhealthy relationship or keep you from negotiating firmly and truthfully about your own professional value, or from improving a situation to achieve greater potential. And be prepared-- it takes courage to pull back on the reins of gratitude and declare, "Wait a second, I don't have to be grateful about this situation. There's nothing wrong with expecting a little more."

I can't believe I'm going to say this-- don't let gratitude hold you back.

When I Googled, "is it possible to be too grateful" I found a good, 11-minute video from Amie Gordon, a PhD researcher who has given this topic some very formal, academic thought:

Nuclear and Healthcare Decision Making

Nuclear warfare operations was my data-driven decision making environment before the healthcare phase of my career. It was all about recogni...