Why should HIEs be scrapped, and what else might work

“Just because Jimmy’s mom lets him do it does not mean I am going to let you do it.  Would you jump off a cliff if he did?”

This argument is the best one I can make extolling the merits of the Healthcare Information Exchanges (HIEs) and the National Health Information Network (N-HIN).  The strategy behind the HIEs and the N-HIN are somewhere between killing a mosquito with a tank.  As the camel is a horse designed by a committee, so may be the goal of having HIEs serve as the cog of the N-HIN.

Why?  Because I think the architecture needed to make this happen exists in a far simpler form.

For example, let us look at iTunes.  To be transparent, I do not have the knowledge to describe or explain the technical underpinnings.  But what if we look at the business strategy around what makes iTunes work for Apple and its customers, perhaps there is something relevant worth borrowing.

Like physics for librarians, permit me to oversimplify the idea to see if a similar set of underpinnings could work in healthcare.

For purposes of explaining the analogy as a business network, what if we equate the major components thusly?

  • Apple (iTunes)                                  Government

o   HIEs

  • The tunes                                            Patient records
  • The Internet                                      N-HIN
  • Customers                                          Patients

While it is never as simple as it seems, especially given Apple’s success with iTunes, here is the simplified version.

There a millions and millions of songs (patient records).  For Apple, the songs exist digitally—ones and zeroes—and are stored digitally.  No LPs, no tapes, no CD (no paper charts).

Apple never physically touches a single song.  What does Apple do if it doesn’t sell CDs?

  • Apple brokers the entire transaction to its customers
  • The tunes move securely and unaltered from one entity, Apple, to one customer, millions of times
  • Apple secures all parts of the business

o   Nobody has hacked into Apple to steal tunes

o   Nobody has stolen customer information

o   Nobody who does not own the songs has been able to alter their content wheter they are in transit or with their owner

  • In the iTunes business model the iPod is no more important than a toothbrush has to do with Crest’s business model
  • The business model’s success is based upon a new delivery system for music
  • Apple’s business model did not necessitate creating hundreds of disparate and separate distribution systems to link tunes from Apple to its customers.
  • Apple did not create a new way of moving ones and zeroes from virtual point A to millions of virtual Point B’s.
  • Apple was successful using and existing, and inexpensive transportation network, thereby keeping overhead much lower than it would have been

So, if we equate the two paradigms, and buy into the fact that a model such as iTunes—if you prefer you can substitute aspects of financial services, airline ticketing, GPS (On-Star), EBay, and Amazon—in its most basic form, is nothing more than the secure transport of billions of ones and zeros, it is not a big stretch to see how one can argue that the transport of millions of electronic health records may not require a solution as complex as the HIE—N-HIN model.

And if that is true, can a business argument be made to justify building hundreds of HIEs?  I do not believe it can.  The HIEs are designed to act as middlemen.  Their purpose is to hand ones and zeros from one network node to the other, and they way they will do this is by building more nodes.  They will not so much as add a one or a zero to a patient record.

Rule One of engineering a business process is that if a process does not add value to the whole, the process adds cost and complexity without adding any value.  Under the current national EHR rollout, I think HIEs are such a process.

Before discounting this notion, what would be required to make an iTunes’ model work for electronic health records?

7 thoughts on “Why should HIEs be scrapped, and what else might work

  1. Paul,
    You have been sitting in front of you iPad to long. LOL. Many like to use Apple as a enology for simplistic and from the users perspective this is true very simple. The backend processing of Apple iTune store is very complicated and far from simplistic, hence all of the unhappy developers. Don’t get me started :’) A secure digital data network with multiple permission levels, areas of control/jurisdiction (state boundaries) is a different beast all together. I have had many years of date Integration and data transport experience and this is no iThing User Interface. You have hit some very good point about the way we are going about this and that maybe this is not the most efficient. Unlike Apple that is a monarch/dictatorship, good or bad, NHIN is not. There are a lot of politics involved!! I was asked twice this year to speak to the OR Democratic Caucus on Healthcare about the state of the HIE. Very Interesting to see government working up close. States have to be given the ability to setup their own HIE or they will not play ball. STATES RIGHTS! OH NO, the Fed is coming.

    I have read many of the NHIN docs and they seem to know what they are doing. Not that I away agree. Top down monolithic network design is difficult and very expensive to implement and difficult to get buy in, unless you are a dictator. The HIE actually make more sense from a network design, a bottom-up, federated system. Easier to get buy in, build and implement. You can get smaller pieces talking to each other in smaller groups and build on top of the groups (HIE), linking them together.

    The NHIN direct project now named Direct project is an interesting system, A bottom up approach for outlying providers that the state HIE must connect to, or from what I have overheard, figure out how to utilize. The Direct Project was Crowdsource designed, put together in 3 months by hardworking engineers from all over the country. The public was asked to join in on the discussion. The good thing about this project is that it is Open Source and it opens the design to non-HIT engineers. It is alway good to get outside input from people that spend their lives building data networks.

    Yes, I agree that we have been moving like data for many years with other systems. Our phone system went from analog to digital in the 80’s without anyone missing a call. The difference with HIE/NHIN system is this has become a political sword that both parties are using on each other. Much fear has been interjected into the mix which complicates the issue. There are also talking heads that are using hot issues to get notoriety for themselves, adding complexity to the system Is there a better way to do this, are there systems in place today that could make this easier, I think the answer is yes. The Direct Project utilized one of the oldest Internet protocols out there to move patient data, SMTP or secure email. That is how they got it designed so quickly. Off the shelf instead of building it.

    I await your reply, What fun!



    • I always learn from your well-written responses. I have the luxury of not knowing what I do not know. Not knowing why something won’t work allows me to believe they are possible.

      Nobody who knows me has ever accused me of being technical—I am still trying to plug in my 8-track player. So, while I do not understand the technical underpinnings of the existing plan to build a national, interconnected electronic health records network from the bottom up using Health Information Exchanges to send and receive records to and from the N-HIN, I believe one can argue that strategically the plan is a sandwich or two short of a picnic.

      With the hundreds of millions, potentially billions be spent on a plan that may not work, and the announcement of an interoperability agreement between the EU and the US, I think there is justification in looking at how an iTunes type of platform could be made to work to move the health records. I am hard pressed to believe that it would be as difficult or expensive as the present plan, and am equally hard pressed to believe it cannot be done.

      There is a wheel out there that does not need to be reinvented.

      I think many people object to new ideas because they do not know how to make the idea real. Not knowing how something might work does not mean it won’t work. I really think the current HIE—N-HIN plan is so complex that it will take years before we learn it won’t bear fruit; that dog won’t hunt. If that is true, it will take even longer to make interoperability real.

      All I am asking is for the conversation to begin around the notion of how could an existing business architecture, like iTunes, be adapted to moving health records.


  2. Paul, I didn’t get you to bite on the iPad comment. I do agree with you, other industries have been doing sort of data exchange for a long time. Reinventing the wheel makes no sense. But that is how government and many businesses works. In engineering we call it “must be invented here” syndrome. The NHIN Direct project is trying to change that way of doing thing. I seen healthcare facilities toss out working EHR systems so they can start over and place their name on the cornerstone. I have also read that multiple State DMV across the country that have spend million on solutions then had to scrap them because they didn’t work.

    We need to get more networking domain experts to the table. I am not saying that we don’t need docs and HIT, because we do. You alway need domain experts One of the reasons that there is a shortage of HIT people is because the Health industry will not let other industries in to assist. Same is true with the HIE, the boards and committees are full of doctors, lawyer, administrators, educators… These are smart people but in their domain. We need to get the best of breed from all domain to solve this problem.

    I still believe that it is better to do something than nothing at all. Getting the ball rolling is the hardest part of the task. There are a lot of people working hard on this solution and it will not be 100% correct when released, but it is a start the we desperately need



  3. I agree fully with you, but in this case I think they are pushing the ball uphill. It sort of reminds me of the scene in the movie “City Slickers” when one character states, “We don’t know where we are going, but we are making really good time.”

    I sense a lot of people believe at best HIEs are not needed, and at worse will crater the N-HIN. Reversing this direction would be like trying to turn around the Queen Mary in the middle of the Potomac. The only way to achieve that is to cut off the front and the back.


  4. Paul, I have taken a brief look at some of the later documents that the NHIN had published and I was presently surprised. I do wonder why people believe that the HIE are not needed. Sneaker net of moving data went out in the early 80’s. We tried with the RHIO and soon found out that no one wanted then but it wasn’t for the good of the patient. Healthcare facilities didn’t want to share customer information, what business does??

    How wide is the Potomac? I live on a river and I watch tugs turn around very large ships everyday. it is cool to watch. (no reference to NHIN)



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