Recasting e-health in the USA

On December the 8th, 2010 the US President’s Council of Advisors on Science and Technology (PCAST) published an extraordinary “Report to the President realizing the full potential of health information technology to improve healthcare for Americans: the path forward“. This report is extraordinary for a number of reasons.

Firstly,  PCAST is not comprised of government bureaucrats with little technical understanding, but by some of “the nation’s leading scientists and engineers”.

Secondly, PCAST concludes that “achievement of the President’s goals requires significantly accelerated progress toward the robust exchange of health information“. The report specifically denies a requirement for any national health record; it specifically denies any need for a national patient healthcare identifier; and specifically shuns the current shift towards exchanging documents in favour of exchanging structured atomic data tagged with context and privacy metadata.

Thirdly, the report seems to lack a deep technical understanding  of e-health information exchange requirements. It postulates a need for a “Data Element Access Service” based on a new, yet to be specified “exchange language”, but provides no analysis of what might constitute a Data Element, other than the repeated example of a mammogram. Nor does it provide any analysis of the breadth and depth of such a service and seems oblivious of the complexity and diversity of clinical information and of current information systems. It suggests that most of the required services can be added to existing systems via middleware, but provides no justification for this belief. There is no proper analysis of the role that terminologies can and should play in this new “exchange language”. There is no recognition of the existence of the International Health Terminology Standards Development Organisation, for example.

Fourthly, the report provides no analysis of the existing approaches being pursued to address the chronic lack of atomic level computable information exchange in healthcare. The work in Sweden, the UK, Singapore and even Australia, based on openEHR or ISO 13606 archetypes (i.e. implementable renditions of Detailed Clinical Models) is far more advanced and promising than that offered by the PCAST approach.

The report has been published at a time when the President’s economic stimulus package around “Meaningful Use” is showing a likely poorer than anticipated take-up. In a  survey of members of the College for Health Information Management Executives released this month,  only 15 percent of respondents were confident of making the April 2011 timetable, compared to 28 percent 3 months earlier. This is a salutary lesson for Australia’s PCEHR, especially considering that the US government has offered $US28billion, compared with some $US50million by the Australian government.

I concur with the report insofar as their vague identification of the major problem – the need for a better way to represent and exchange structured clinical information. But if the President wishes to pursue such a radical approach, then he needs a far more sophisticated analysis of both the problem and the potential options to address the problem.