is the best for the system-as-a-whole and
not one particular interest group, perspective, or part of the ecosystem. This is a very
big challenge in an environment where
money drives much of the decision-making
and conflicts of interest are hard to avoid.
We tend to ignore the rest of the
world. In the United States, we tend to
think completely from a US-centric point of
view, while most other countries consider
internationally-developed standards and
efforts, like ISO T215, critical to their planning. Do we really think that the need for
interoperability stops at national borders
any more than we think it stops at state
We tend to reinvent the wheel.
Whether you consider them a success, a
failure, or something in between, our past
efforts at organizing interoperability planning in the United States (AHIC, 3 HITSP,
HISPC, NeHC, IHE, S&I Framework, and
others) yielded high-quality artifacts that
often go largely ignored when the next
initiative begins. Some become building
blocks of other efforts but more often than
not, they just languish and collect dust.
Shame on us all for failing to leverage this
solid earlier work.
Our timelines are too aggressive. Or
are they too lax? I read editorials that
decry our rush to implementation given
the complexity of it all. But there are those,
including Congress, who just think we
ought to “get on with it” and stop wasting
time. Most organizations can only plan on
a three-year horizon, and want only general direction beyond that. We need to craft
strategy that strikes this balance well.
Different paces for different partici-
pants. The pace of implementation will dif-
fer for different types of participants based
on the use cases selected, the perceived
benefits, and the investments made. Intra-
organizational interoperability often is a
precursor to inter-organizational interop-
erability and also affects this pace. We need
to speak clearly – and often differently – to
early adopters, mainstream implementers,
and laggards (see comments on audience
The tension between being too broad
versus too granular. “Action plans” can
be very practical and helpful, but when
they are out of context – or simply have a
voluminous number of steps and activities
– they make us apoplectic. We need a better
balance between clear and broad strategy
and a limited, concise set of action steps we
can all get behind.
Standards change too often. We have
certainly seen just how long it takes to
implement standards broadly, as well as
how aggressively many of the SDOs work
to improve and correct what they develop.
Without backward compatibility this is
a real structural problem. Introduce the
notion of a paradigm shift in standards (like
IHE Profiles/C-CDA to FHIR) and it feels
paralyzing. Annual updates to standards
are just too frequent. We should consider
declaring standards and giving them a
“freshness date;” so, for instance, a par-
ticular standard would be selected for 2016
with an explicit expected retirement in, say,
2020. We should also continue to insist on
a separation of data format from transport
in our standards articulation. FHIR, in an
attempt to “simplify,” seems to have vio-
lated this rule. Finally, we should identify
bundles of standards that fulfill specific use
cases and promote them together.
A “common data set” has limited
usefulness. It is more important to define
The pace of implementation will differ for
different types of participants based on
the use cases selected, the perceived
benefits, and the investments made.
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