Thursday, November 1, 2007

Hardening of the Categories

An October 22, 2007 posting on the web site of the National Alliance for Health Information Technology describes an important effort for the Office of the National Coordinator for Health Information Technology (ONC) to develop consensus-based definitions for key health information technology terms. The call for participation states that this effort is being managed by the consulting firm Bearing Point.
The posting states:

The first set of terms will focus on creating and securing industry endorsement of definitions for electronic health record (EHR), electronic medical record (EMR), personal health record (PHR), health information exchange (HIE) and regional health information organization (RHIO).

This need for clarification seems essential if an external entity is to certify a product and tie compensation for services to use of a certified product. I suppose we have - loosely and technically - definitions for terms like "automobile," "truck," and "train." These seem important; if we are all going to share the road with other hurtling vehicles capable of weaving through lanes or rushing through intersections, it is reassuring to note at least that such vehicles have certain predictable characteristics. (If only we could say the same for drivers; somehow this driver is not convinced that licensure confers absolute levels of safety.) Similarly, trains need to run on fixed tracks. I makes sense that one who purchases or rides on a train can be assured that efforts have been made to ensure that such trains both fit and stay on the tracks for which they were designed.

One wonders, however, how exactly one should define an emerging technology or even a functionality within a technology. One wonders what would have happened to the automobile industry if a definition of automobile was prematurely imposed. Initially, our vision of an automobile was constrained by our imagination; few could look past the notion of a "horseless carriage" and envision the wide array of evolving transportation products and services now included in the definition of "automobile."

Similarly, imagine creating economic constraints that would have restricted computer uses to CPM operating systems, cathode ray tubes, and ascii text. Imagine defining a "personal computer" as it could have been done before networking was ubiquitous and at a period when inexpensive email capability was restricted to those with accounts on mini-computers or mainframes. Imagine the competition among vendors if attributes within the definition determined whether or not products could compete for government contracts. Imagine certifying a "library" as a collection of books.

Now think about the term "health." What does it mean? How is "health" different from "medical." These are definitely important issues. As one joins a deliberative body and walks around a machine or set of services searching for an "essence" or set of characteristics that define the product or service, one will, no doubt, get a better sense of what one means by the underlying purposes or aims for which the device or services have been created. Perhaps this is a task best left to theologians, semioticians, and deconstructionist scholars.

One can imagine the process leading to a richer and deeper appreciation for the diversity of services and devices which - when combined - can help us understand more completely the untapped potential to improve health and deliver health care services. Done well - and defined through a set of objectives that are imagined to evolve over time - such definitions can help educate and foster the public debate. Done poorly, or addressed with the intent to gain a near-term advantage, such deliberations lead to anachronisms, obsolescence, and most likely an endless and time-consuming bureaucracy that through its efforts seeks vainly to keep up with the wide range of human creativity and perhaps indirectly constrains such creativity.

This writer is at this juncture skeptical. No doubt the terms "EHR," "PHR," "RHIO," and "HIE" are used in a wide variety of circumstances to address differing aims (a bit like societies use of many other terms including "peace," "tranquility," "war," and even "life"). At the top level, perhaps one needs an effort first to define the term "define" and then a large groups of bodies that define what we mean by "medical," "health," and "exchange." How this effort proceeds will very much dictate the extent to which the process follows the deliberative nature of good scholarship, strong science, or effective policy. Implicit in any definition is an understanding of things, a set of expectations about how others interpret words, and a belief that through more precise definitions, one can make sure that two parties who disagree are disagreeing over the same idea and not, in reality, "violently agreeing" with different uses of a term.

It is important to get this right. It is important to set expectations and to put forth the notion that virtually any definition outside of theological dogma may evolve rapidly. Some terms beg for at least an interim characterization - "EMR" comes to mind. Other terms ("RHIO") may help clarify thinking or may simply lead to an endless morass of irrelevant debate.

One hopes that our definitions are based on our aspirations about our health and that most technologies and systems are viewed merely as a means to an ever-evolving (and hopefully rising) set of expectations about what we as a society can accomplish and how we as citizens can more properly care for ourselves, our families, and each other.


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