Insight into the choices to be made in standards for the electronic exchange of health record information

Technical (archive)
1

For those of you interested: here (http://www.vivici.nl/
insight_into_choices_to_be_made/ ) you can download the translated
version of the document we've created within the Dutch mirror group
on information models & messages.
This document will be presented at the joint ISO/TC 215 Health
Informatics and CEN/TC 251 Health Informatics meeting in Instanbul
later this month. Hopefully it contributes to an even better
discussion about choices to be made in the various CEN/ISO member
countries.

Cheers,

Stef

2

Stef Verlinden wrote:

For those of you interested: here ([http://www.vivici.nl/](http://www.vivici.nl/)
insight_into_choices_to_be_made/ ) you can download the translated
version of the document we've created within the Dutch mirror group
on information models & messages.
This document will be presented at the joint ISO/TC 215 Health
Informatics and CEN/TC 251 Health Informatics meeting in Instanbul
later this month.  Hopefully it contributes to an even better
discussion about choices to be made in the various CEN/ISO member
countries.

This report contains the following statement:

3

Thomas.

Governments need to understand these realities, or they will continue to find it difficult to see how to apply any of the competing standards available today. I have to say that I don’t find this report particularly helpful, because it gives very little in the way of really solid advice on how governments should move forward.

Although I agree with you, you also know where we’re coming from: a situation where two camps dug in deep, proclaimed that their solution was the best and didn’t want to look over the fence. This is a consensus document generated by all parties involved and as such a big step ahead.

Another thing is that this document is about the interational EHRCOM standard 13606 and not about all the fantastic things we could do once openEHR derived commercial solutions finally become widely available. Since openEHR isn’t an international standard, nor widely implemented as a commercially product, so that people can see it’s beneifits, your remarks seem academic. Furthermore it’s intended audience is the people at CEN and ISO, not governments. For that purpose we’ll try to create a less technical document.

I completely agree with your remark that Governments need to understand these realities. Again I’ll invite everbody to come up with clear examples, proof and/or bussiness models, which are understandable for decission makers (technical lay-man) so they can get a good understanding of these realities and the consequences of their choices. So far the discussion is only accesible for the happy few who have the time, enthousiams and (some degree of:-)) technical understanding to dug in deep. To convince an average decission maker you have a couple of minutes. If we (as the openEHR community) aren’t capable of selling ‘our’ product to these decission makers in an understandable and concise manner, we still have the best product in the world but nobody will use it. So far I haven’t seen any document/ example/ bussiness case that can convince a decission maker/ goverment why they should consider using openEHR.

As you might know this is what we call the Dutch or Philips syndrome over here: Back in the eighties Philips created an brillant new and innovative product: a videoplayer called Video 2000. Since everybody was convinced that such an superior system would sell itself not much attention was paid to marketing.
At the same time a videoplayer which was on all fronts inferior to the Philips player was developped: the VHS player. Since it’s producers knew that marketing was key, they promoted the product as aggresively as they could and with great succes. Since for the end user the VHS already was a big step forward (untill then there was no way to record and play video at home) and all they heard about was VHS they bought into that system and took over the market. Any simllarities here?

Cheers,

Stef

4

Stef Verlinden wrote:

Thomas.

Governments need to understand these realities, or they will continue
to find it difficult to see how to apply any of the competing
standards available today. I have to say that I don't find this
report particularly helpful, because it gives very little in the way
of really solid advice on how governments should move forward.

Although I agree with you, you also know where we're coming from: a
situation where two camps dug in deep, proclaimed that their solution
was the best and didn't want to look over the fence. This is a
consensus document generated by all parties involved and as such a big
step ahead.

Another thing is that this document is about the interational EHRCOM
standard 13606 and not about all the fantastic things we could do once
openEHR derived commercial solutions finally become widely available.
Since openEHR isn't an international standard, nor widely implemented
as a commercially product, so that people can see it's beneifits,
your remarks seem academic. Furthermore it's intended audience is the
people at CEN and ISO, not governments. For that purpose we'll try to
create a less technical document.

well none of the standards mentioned are widely implemented. I would be
interested to know of any commercial offerings in fact.

I completely agree with your remark that Governments need to
understand these realities. Again I'll invite everbody to come up with
clear examples, proof and/or bussiness models, which are
understandable for decission makers (technical lay-man) so they can
get a good understanding of these realities and the consequences of
their choices. So far the discussion is only accesible for the happy
few who have the time, enthousiams and (some degree of:-)) technical
understanding to dug in deep. To convince an average decission maker
you have a couple of minutes. If we (as the openEHR community) aren't
capable of selling 'our' product to these decission makers in an
understandable and concise manner, we still have the best product in
the world but nobody will use it. So far I haven't seen any document/
example/ bussiness case that can convince a decission maker/ goverment
why they should consider using openEHR.

did you have a look at the PPT at the top of this page -
http://www.openehr.org/shared-resources/getting_started/government_orgs.html

As you might know this is what we call the Dutch or Philips syndrome
over here: Back in the eighties Philips created an brillant new and
innovative product: a videoplayer called Video 2000. Since everybody
was convinced that such an superior system would sell itself not much
attention was paid to marketing.
At the same time a videoplayer which was on all fronts inferior to the
Philips player was developped: the VHS player. Since it's producers
knew that marketing was key, they promoted the product as aggresively
as they could and with great succes. Since for the end user the VHS
already was a big step forward (untill then there was no way to record
and play video at home) and all they heard about was VHS they bought
into that system and took over the market. Any simllarities here?

I guess that's why some 'standards' bodies need a dedicated marketing
budget and personnel. I didn't know about Video 2000, but people always
talk about Sony Beta losing the race. In fact they did not; betamax has
been used in every TV studio in the world (probably not Russia I guess)
for years - the part of the market that needed quality. There are many
myths like this about the marketplace.

The key technical failing of many of the standards is that they are just
not integrated; they are competing and overlapping. And yet what is most
needed is a coherent framework, not a mish-mash of disparate standards
each designed to solve one problem in isolation. The very existence of
IHE is an indication that this is the case.

Decision-makers need to study evidence, not words.

- thomas beale

5

Stef,

I don't question your intentions, but I definitely question the value
of such a document in helping the discussions at CEN and ISO level. I
can only see it confusing the already muddied waters. You simply
cannot advance the cause of harmonisation of standards, or choosing
between standards, by dumbing down the issues to such an extent!

I'm sorry, Stef, if my response seems brutally rude, but I'm sure that
the level of debate at CEN and ISO must be more sophisticated than the
simplistic suggestions embodied in your document. If not then we are
centuries away from the sort of IT-enabled healthcare systems that
many of us can imagine.

And as for your analogy regarding the "Dutch Syndrome", we are not
talking about marketing a product, we are talking about standards and
specifications for e-health interoperability, decision support and
much more, that affect our own health and the health of others.

Please reconsider taking your document to those meetings.

regards,
eric browne

6

Thomas,

Strange you should malign the Russians so.

In 1994 I was on a joint British-Russian expedition to investigate the
mid-Atlantic ocean ridge, over 4km deep.
The only submersibles to get to those depths as a pair, and photograph
the "black smokers" and attendant sea creatures were Russian.

The Russian video footage (along with the British Channel 4 crew), was
all shot with Betamax. Quality, as you say, is paramount for this sort
of work. VHS was never, considered. I'm sure the same would be true of
the Russian TV studios.

So too, is quality of paramount importance in health care. Let us
_never_ lose sight of this requirement in the pursuit of interoperable
healthcare information systems and the evaluation of the solutions
that are marketed at us.

eric

7

Dear All

This discussion has been quite interesting. I do think it is important to keep the focus on the ball. Which leads me to asking what is the ball?

To me Health IT standards tend to be highly factional and closed. Though some are touted to be open in intent (not practically).

What will eventually work must be highly pragmatic- market-determined and driven. It is unlikely that we can predict what the market will choose.

However it is important to keep the openEHR as open as possible. That will mean the opportunity for all kinds of integration and implementations.

The sure thing is to supply a framework and tools to make it work.

In the end as an implementer I may go for a cocktail approach as long as it works for my corner of the world.

It is also important to have an AND mindset“Dd instead of an EITHER/OR one.

What the frontend will look like as we roll out would be a mashup or coarse-grained view of several fine-grained backend systems and standards.

The wisdom from IT trend in the last 20years is that openness wins and that includes allowing the different standards to do what they do best.

For my corner of the world Snomed CT etc don't even apply yet. It does not mean we are not watching though.

OpenEHR is great for what it intends to do but only the discipline of the market will determine and ensure its uptake.

Thanks.

Olusegun 0dujebe
Lagos,NIGERIA

  the electronic exchange of health record information

Stef Verlinden wrote:

Thomas.

Governments need to understand these realities, or they will continue
to find it difficult to see how to apply any of the competing
standards available today. I have to say that I don't find this
report particularly helpful, because it gives very little in the way
of really solid advice on how governments should move forward.

Although I agree with you, you also know where we're coming from: a
situation where two camps dug in deep, proclaimed that their solution
was the best and didn't want to look over the fence. This is a
consensus document generated by all parties involved and as such a big
step ahead.

Another thing is that this document is about the interational EHRCOM
standard 13606 and not about all the fantastic things we could do once
openEHR derived commercial solutions finally become widely available.
Since openEHR isn't an international standard, nor widely implemented
as a commercially product, so that people can see it's beneifits,
your remarks seem academic. Furthermore it's intended audience is the
people at CEN and ISO, not governments. For that purpose we'll try to
create a less technical document.

well none of the standards mentioned are widely implemented. I would be
interested to know of any commercial offerings in fact.

I completely agree with your remark that Governments need to
understand these realities. Again I'll invite everbody to come up with
clear examples, proof and/or bussiness models, which are
understandable for decission makers (technical lay-man) so they can
get a good understanding of these realities and the consequences of
their choices. So far the discussion is only accesible for the happy
few who have the time, enthousiams and (some degree of:-)) technical
understanding to dug in deep. To convince an average decission maker
you have a couple of minutes. If we (as the openEHR community) aren't
capable of selling 'our' product to these decission makers in an
understandable and concise manner, we still have the best product in
the world but nobody will use it. So far I haven't seen any document/
example/ bussiness case that can convince a decission maker/ goverment
why they should consider using openEHR.

did you have a look at the PPT at the top of this page -
http://www.openehr.org/shared-resources/getting_started/government_orgs.html

As you might know this is what we call the Dutch or Philips syndrome
over here: Back in the eighties Philips created an brillant new and
innovative product: a videoplayer called Video 2000. Since everybody
was convinced that such an superior system would sell itself not much
attention was paid to marketing.
At the same time a videoplayer which was on all fronts inferior to the
Philips player was developped: the VHS player. Since it's producers
knew that marketing was key, they promoted the product as aggresively
as they could and with great succes. Since for the end user the VHS
already was a big step forward (untill then there was no way to record
and play video at home) and all they heard about was VHS they bought
into that system and took over the market. Any simllarities here?

I guess that's why some 'standards' bodies need a dedicated marketing
budget and personnel. I didn't know about Video 2000, but people always
talk about Sony Beta losing the race. In fact they did not; betamax has
been used in every TV studio in the world (probably not Russia I guess)
for years - the part of the market that needed quality. There are many
myths like this about the marketplace.

The key technical failing of many of the standards is that they are just
not integrated; they are competing and overlapping. And yet what is most
needed is a coherent framework, not a mish-mash of disparate standards
each designed to solve one problem in isolation. The very existence of
IHE is an indication that this is the case.

Decision-makers need to study evidence, not words.

- thomas beale

8

Eric,

To be clear, it is not my document. It is the document created by the
members of the Dutch mirror group on, to which I've contributed. Like
I stated it's a consensus document which is great but also created
many boundaries to the extend we could extend the discussion. So
don't shoot the messenger.

Stef,

I don't question your intentions, but I definitely question the value
of such a document in helping the discussions at CEN and ISO level. I
can only see it confusing the already muddied waters. You simply
cannot advance the cause of harmonisation of standards, or choosing
between standards, by dumbing down the issues to such an extent!

I'm sorry, Stef, if my response seems brutally rude, but I'm sure that
the level of debate at CEN and ISO must be more sophisticated than the
simplistic suggestions embodied in your document. If not then we are
centuries away from the sort of IT-enabled healthcare systems that
many of us can imagine.

I'm sorry to disturb your sweet dreams, but this is the level of
debate that takes place at least at NEN. I'm not aware of more
sophisticated discussions at the level of CEN of ISO.

Please feel free to post your brilliant contribution to this debate
so we can educate the less sophisticated among us.

And as for your analogy regarding the "Dutch Syndrome", we are not
talking about marketing a product, we are talking about standards and
specifications for e-health interoperability, decision support and
much more, that affect our own health and the health of others.

Please reconsider taking your document to those meetings.

Again it's not my document and not my decission and if you had taken
the time to read my mail properly you could have known that.
Luckely the Istanbul meeting is in 2 weeks so there is plenty of time
to come up with an alternative document in which al of your brilliant
analyses are put togehter. I really encourage you to do so.

Cheers,

Stef

9

Luckely Wiki functions quite well as an independent referee is this kind of discussions:

“Video 2000 offered several innovative features unmatched by the competing standards, VHS and Betamax” (http://en.wikipedia.org/wiki/Video_2000)

Maybe we should open a Wiki topic on the subject of comparing and choosing EHR standards and see where the ‘wisdom of the crowds’ brings us.

Cheers,

Stef

10

Again it's not my document and not my decission and if you had taken
the time to read my mail properly you could have known that.
Luckely the Istanbul meeting is in 2 weeks so there is plenty of time
to come up with an alternative document in which al of your brilliant
analyses are put togehter. I really encourage you to do so.

Which Istanbul meeting? The combined ISO/CEN meeting that starts
on Sunday?

Grahame

11

hi Tom

I wasn't going to enter this thread, but:

Decision-makers need to study evidence, not words.

Evidence is just more words. And the key
issue is how to discern them.

Standards are necessarily competing - that allows
market forces to work.

Grahame

12

Grahame Grieve wrote:

13

Grahame Grieve wrote:

Decision-makers need to study evidence, not words.

Evidence is just more words. And the key
issue is how to discern them.

Standards are necessarily competing - that allows
market forces to work.

I expect Graham was grinning and pulling Tom's leg a bit when he wrote
this about
evidence and market forces, so don't take my further thought, here, too
seriously.

- as one of my heroes, Richard Feynmann, once said, you can prove
anything by analogy...

But, in a week when world financial systems are being placed on hugely
costly life support,
on the edge of market collapse, Graham's thought about market forces
made me think a bit, too,
about an analogy of information standards as currencies and the wider
collapse of confidence in information systems which we seem to be
heading towards.

It's important to sustain some focus on learning, practically and
experimentally (evidentially), about making information systems that
work. The hundred page documents on interoperability, doing the rounds,
are derivative products of a kind, adducing rather little direct
evidence of what is needed and what will work, in everyday health care
contexts.

Sadly, too much money ploughed into derivative markets has tended to
undermine practical governance of underlying, more practical, markets
which were, once upon a time, more the real deal.

The good thing is, in the case of money, it's only money! In the case of
health, it's health and well-being, which matter or will matter, a bit
more, to all of us.

David I

14

David, I agreed with yours thoughts on the matters. Your contributions are appreciated. Thanks.