Ramblings: Health IT Standards – What went wrong where?

I had an interesting conversation with some individuals on Health IT  Standards recently, in a setting where we were discussing a few  selected standards.

Firstly, it’s on XDS (Cross Enterprise Document Sharing) from IHE and the topic was why it was not suitable for handling non-DICOM images.

The first red flag that went off the top of my head was ‘perversion of the XDS standard’.

XDS is not mean for ‘handling of non-DICOM images’, it is meant to “register and shares electronic health record documents between healthcare enterprises, ranging from physician offices to clinics to acute care inpatient facilities it is meant for cross whereas the conversation was about using it“.

In other words, its meant to be used in an EMR/EHR environment for sharing of documents (I came to realised that the same individual  didn’t really understand what the XDS was meant for because he was trying to explain XDS to someone else  the next day and he stumbled for quite a while before I stepped).

Now this guy can go on and complain about the how “XDS has failed for him” and he will be ‘correct’ because it has indeed ‘failed’, since XDS has been made to serve a wrong purpose (no surprises here).

Its like complaining that planes has failed because they are terrible when one try to drive it like a car, thinking both are transportation devices hence it should serve the same purposes – a case of plain cognitive failure.

As an advocate of Standards (I am the Vice-Chair of HL7 Singapore and a strong supporter of relevant standards in the right context), I tried to first highlight that if they are looking at imaging, then it is XDS-I (Cross-enterprise Document Sharing for Imaging).

(This part will take abit of explaining to illustrate the context, they were talking about ‘DICOMising’ non-DICOM images, hence they should look at XDS-I since everything would be in DICOM but this will be another story for another day, I think it’s a great example on not looking into the context before adopting a particular standard).

Before I could take arrive to my point, I was shot down (well, its 3 versus 1, I’m not going to waste too much time on a lost cause) by a comment saying there is one report off the internet citing how a physician was trying to access a patient’s medical records and he had trouble locating what he needed because he had to open every single document to find out what it was.

Now I was half amused and half worried at this stage.

Half amused because there he was describing a half-attempt adoption of XDS in order to support his point that XDS failed to support a workflow that it was never meant to (see the irony here).

Half-worried because there will be people in the audience who will be walking out spewing the same misguided information.

To describe the concept of XDS in a very simplistic manner, XDS  manages a federated document repositories and a document registry to create a longitudinal record of information pertaining to a patient (in a given ‘clinical affinity domain’). These are distinct entities with separate responsibilities.

  • Document Repository is responsible for storing documents in a transparent, secure, reliable and persistent manner and responding to document retrieval requests
  • Document Registry is responsible for storing information about those documents so that the documents of interest for the care of a patient may be easily found, selected and retrieved irrespective of the repository where they are actually stored

The example he quote verbally has obviously the Document Registry part missing and the implementation was not adopted in compliance of the XDS specification but somehow, XDS got blamed for it. (Its like saying ‘work is going to kill you’ because there are incidents of Karōshi in Japan).

Further attempts to set the context right were met by rebuttals claiming that;

  • Standards looks nice on paper but fail in real world implementation
  • He is from the industry and he ‘knows’ better

Well, I pointed out that Standards bodies like HL7 and IHE are made up of volunteers from the industry (myself included, I am practitioner  first,  academian second ) and Standards ‘failed in the real world’ due to  implementers (like himself) not understanding the standards being implemented, thus implementing it half-right or just plain-wrong.

To put his ‘argument’ into another context, its akin to saying that;

  • The traffic light system of Red = Stop, Amber = Caution and Green = Go has failed because motorist are ignoring them or that in some places the colour has been changed
  • Because he has been driving in a such a massively chaotic environment such as above, he is convinced that his opinion is the only one that matters. Well the world is a very big place and even traffic rules differs from places to places (speeding rules, left hand drive versus high hand drive), let alone healthcare systems

It is important to understand that the Standards has not failed, the implementation and enforcement has, there is a huge difference. If one cannot see the different then one cannot fix the problem. It is that simple.

Now don’t get me wrong, Healthcare IT are by no means perfect (and nothing is), hence there are people volunteering their time on Standards Development (there is a huge difference between Standards Development and Standards consumption) and it doesn’t help that healthcare itself is not a standardised / ‘procedurised’ industry.

However, spreading misguided information (such as the above) in a loud confident manner while cutting off attempts to clarify (and an opportunity to actually learn the real stuff) is not doing anyone any favour.

There were also a comment from the same individual about HL7 v2.x is all the same plus it’s not backward compatible etc. I tried to educate him but before I can explain the concepts of HL7 v2.x and why it is in such a chaotic state (due to the lack of lack of semantic interoperability), he became really defensive. Well, I just didn’t have the mood and energy any more but I hope he reads this so he can sound more intelligent the next time he tries to talk about HL7 v2.x).

I guess I need to spend more time advocating on standards (I also ‘have the solution’ on enforcement and governance of Standards but that is another story for another day).

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