“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?