Graham Grieve is a data architect who thinks like a mountain climber.
“You build a mountain, you stand on top of it and see a bigger mountain that you can go and stand on top of,” Grieve said in an interview with HIStalk. “The urgent need to build bigger mountains never goes away. We’ll just keep climbing up the stack towards a useful system.”
Setting aside the idea of “building” mountains, Grieve is describing something very familiar to seasoned hikers and climbers—a false summit. When you are so close to the mountain, and we are all so very close to health IT and the constant interoperability updates, it’s impossible to see the higher peaks in the distance.
Which begs the question: When will we summit this range?
“Each mountain is about a 10 to 15 year building process,” Grieve says. “That’s how it has gone historically.”
In other words, we probably can’t even see the next peak from where we’re standing, the initial false summit still looming above us.
In his conversation with Mr. HIStalk, Grieve makes a compelling argument for modifying expectations, working diligently and putting all the pieces in place to ensure future success.
For example, Grieve is working on HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification enabling EHRs to exchange information. If you’re one of the many that hope FHIR becomes healthcare’s silver bullet, Grieve would like you to rethink that expectation.
“There’s people out there who think that with FHIR we’ve solved all the problems,” he says. “We haven’t, because we’re not authorized to solve lots of the problems.”
Primary among these other problems is the lack of a single patient identifier via a Master Patient Index (MPI) for use across the American healthcare system. Quite simply, FHIR alone is not a fix.
“Yup. MPI is unavoidable,” Grieve told Forbes blogger and author Dan Munro, whose analysis of interoperability and MPI is highly valuable and relevant (see, for example, automobile industry reference and link below).
And why don’t we have MPI in place already? Because in 1998, long before interoperability approached Kardashian-like frequency on the Internet, Congress passed and President Clinton signed a law forbidding federal funding of any effort to create national patient identifiers. This was two years after Congress mandated the creation of a patient identifier when they passed HIPAA.
(Staying with the mountain metaphor, one might believe the two years between legislative acts were the peak of health IT lobbying and campaign contributions.)
As we all know, incentives for EHR adoption have expanded the use of health IT platforms to somewhere in the neighborhood of 75 percent. But with few standards for exchanging patient data, we’ve created silos of patient information and a system that still benefits just about everyone in it more than the patient. Health IT vendors have enriched themselves with tax dollars. Hospitals are using EHRs to keep patients from going elsewhere and gobbling up small physician practices. Status quo incentives remain for influential segments of the overall health IT marketplace.
As former hospital CEO and THCB blogger Paul Levy wrote, “We’ve been swindled.”
And it’s not like this kind of situation is completely new. People are not cars, to be sure, but a similar scenario endured until 1981 in the automobile industry. Chaos convinced the National Transportation Safety Administration (NTSA) to implement the national Vehicle Identification Number (VIN) system to more effectively track thefts, accidents, damages and recalls. The use of VIN numbers also makes businesses like CARFAX possible.
It’s clear that VIN numbers enabled the NTSA to more actively and accurately track the sale and registration of autos. It’s also clear that automakers had no financial incentive to resist the national standard other than to avoid accurate tracking of defects that could put driver safety at risk, making VIN implementation as much a moral issue as anything else.
National schemes? A moral component? Congressional discretion? That scenario should sound familiar to you.
Indeed, as quoted in Bob Wachter’s book The Digital Doctor, UCSF Medical Center CIO Michael Blum called Congress’s failure to establish a universal patient ID “the biggest single failure in the history of health IT legislation.”
“Our national interest does not coincide with those corporate strategic interests,” says Levy.
In other words, what patients lack is an organized lobby, which is unfortunate since it seems that all roads on the health IT progress roadmap eventually lead back to Congress.
“There’s a number of industries where they have data sharing arrangements of one kind or another,” says Grieve. “Those things are possible and they work to some degree. They need some kind of governmental interference or mandate to make them happen. Very often, most of those industries wouldn’t go back to the chaos they had before.”
This is disconcerting. On the one hand, the current Congress is passing legislation like the 21st Century Cures Act that mandates interoperability without mandating a certain standard. On the other, a previous Congress avoided the responsibility of creating the prerequisite for interoperability in a national patient identifier.
“Standards arise in a broken market,” Grieve told HIStalk. “We’re trying to move the market to a better, stable place.”
We have one prerequisite—a broken market. We need Congress to implement the other—a national identifier. Yes, an adoptable data exchange standard like FHIR is necessary, but without a national patient identifier it is not sufficient. Until then, every goal we achieve in the foreseeable future will be a false summit.