A forum to discuss ideas, approaches, standards, and architecture to establish and support open interoperability among healthcare IT systems.

Monday, July 24, 2006

To What Extent Computable?

As organizations strive to create semantically-meaningful, interoperable systems, the push is always toward establishing "computable data." In informatics speak, computable data is a representation of data values in a form that can be machine processesed and reasoned upon. It is usually depicted in a code value from some formal terminology where semantic links are meaningful and support activities such as decision support.

Present systems suffer in part because they lack this computable data. Free text information is helpful and valuable to a caregiver, but does not allow for the computer to provide the assistance that would be possible if a more structured representation were available. For instance, support functions such as drug-order checking, drug-drug interactions, allergy checking, and so on each require computable data to perform.

I have a big concern, however, that the pendulum has "swung" too far to the other side, where organizations are seeking solutions involving almost exclusively computable data. Computable data comes at a cost, and the "garbage-in, garbage-out" scenario applies here in spades. Without measures in place to validate data content, verify accuracy, and assure compliace to the valid codesets and terminologies in use within an organization, computable data is of no value.

Computable data comes at a cost. In addition to keeping up on data entry and assuring quality, the terminologies themselves must be maintained and kept current. Without quick response terminology maintenance, staff "in the trenches" will quickly become disenchanted and force-fit incorrect coded values for purposes other than what they are intended.

So what is the 'middle ground"? I am very supportive of computable data. It is essential in achieving the potential of EHR systems. That said, we must be judicious and not try to codify everything. Computable data comes at a cost. When that investment is made in capturing and maintaining data that has impacts on maintaining or improving patient health, it is a wise investment. If there is limited or no payback as a result of the effort, it is not a wise investment.

I recommend the following as a start to identify and manage computable data. It is only a start, but hopefully can get some dialogue going within the industry:

> Determine the behaviours you hope to influence, and codify data with direct/indirect impacts
> Identify the information that are the indicators of the health status you wish to monitor
> Identify the information that is the predominant basis for care or care consistency
> Focus on the "20%" which has the "80%" impact
> Relate the terminology work to business purpose. If you can't identify a purpose, question the effort
> Consider secondary uses of data in these decisions (for instance, epidemiology)
> Consider phased deployments of this. Not everything needs to be computable on day-one (but there are interdependencies that must be considered with this approach)
> Recognize that using computable data is not a wholesale replacement for free text

Monday, July 10, 2006

Standards Participation II: Returning Your Investment

Last time I made a case for getting involved in Standards, but I fell short of describing how to do so in a way that resulted in a productive engagement and ROI to your organization. Standards participation is an investment. Many companies, even those that do participate regularly in standards, neglect to remember this. I've found that there are a few principles to keep in mind when engaging within the standards community.

1) You get out what you put in. One of the most common gripes I hear about standards is that it is a "black hole", where organizations feel like they spend months or years and get little for their participation. These are often the same companies that send their second-tier players to meetings--the ones that sit at the back of the room and take notes but make no impact.

The standards community is a very dynamic, challenging, and political environment. Standards are about compromise, finding a tractable middle ground between different views that is acceptable to all (but likely optimal to none). If you send an inexperienced staff member or a "B"-player, don't expect results. You can expect a good set of meeting minutes, perhaps, but forwarding an important organizational agenda won't just happen. Besides, if 'the other guy' is sending their "A"-team, that's what your staff is up against.

2) Results will not come overnight. As a community, Standards folks have seen people come and go. There are many organizations who believe that they can "game" the system, showing up in force to a meeting or two and trying to push an agenda.

It doesn't work.

Why not? Think you're the first who has tried? Think again. Almost every meeting, almost every organization, it has been tried. The standards community tends to be durable, with people being involved in Stanards for years or decades. Fly-by-night interests come and go. It is a long-term commitment to achieving an objective that will produce success. Standards are about collaboration and compromise, hopefully en route to solving a shared problem.

A sustained involvement from an organization trying to achieve a set of objectives creates credibility, and will result in success. That success may take time--something that can be difficult to justify in a "quarter-to-quarter" basis, especially when you're getting started. Set realistic expectations and performance measures for your involvement, but do set measures to ensure that you are achieving return on investment.

3) You need consistent representation. One mistake many organizations make is in "rotating" around their standards participants among their staff, so everyone gets a chance to participate. Notionally, this makes sense, as a broader exposure within an organization broadens perspectives and is inherently valuable.

Whether this is a sound strategy depends upon the organization's objectives. If you are trying to educate staff this is a valid approach. Organizations trying to influence and change standards find little success in this method. Why? Because Standards groups are political, and interpersonal relationships are every bit as important here as in the rest of the business world. A more prudent approach is to have consistent company representation attend all meetings, and then to supplement that representation with "newbies" who are there to learn.

Remember, if someone is taking a tutorial or bouncing between committees, they are not going to be able to track the nuances of your business agenda and the potential implications of changing standards upon it.

4) Standards do not have to be altruistic. Many standards-goers will flame me for this statement, but I firmly believe that a well grounded business objective is critical to standards success. While it would be nice to think that Standards are all altruistically-based, ultimately some company is footing the bill to participate. Few organizations can afford to do that without a business benefit.

The key is to align the business objectives with the standards work. If you can find standards activities that are day-job relevant, there is a much clearer return on investment. Equally important, that means that the input to the standards process is that much more valuable, because it is based on actual need.

5) Welcome to the club. I hope I haven't scared you off of Standards. Standards involvement is a rich, rewarding, intellectually stimulating, and business-valuable endeavour. The professionals whom I have met in this venue are among the best and brightest in their respective fields, and have contributed countless benefits to me personally and the organiztions that I have represented. Many of this community will change employers several times, with a continual stipulation that they remain involved as they move from one job to the next.

Ultimately, standards particiation is an investment. That investment requires some nurturing, but the rewards are ultimately worth it.