When Every Problem is a Nail

When you build a better mouse-trap, the world will beat a path to your door.  But what if there isn't really a need to catch mice, but you've got something that can do that better than anything else?

The Direct Project was originally designed to be an on-ramp to the NwHIN.  But as a result of its success in development of the specification (not necessarily the implementation), it's been billed by some as the solution to all important (in 2011) exchange problems.  We've known for a long time that point-to-point isn't enough (look at the original design of Direct again), and the design of the NwHIN goes beyond that already in a suite of protocols that support both point-to-point and query/response type exchanges.  The HIMSS EHR Association even wrote a white paper (pdf) about how you go from simple, to more fully featured exchange capabilities.

Unfortunately for NwHIN, some of the work that was planned for the last year was held up for several months in 2011 due to a bidding protest (as I mentioned here).  So, what happens when all you have to sell is a mouse-trap?  You pitch the mouse-trap for all you are worth.

State HIE organizations that have been planning for something better than a mouse-trap are told that they must also use mouse-traps, even though a better solution is being developed by them.  I know at least two former interim HIE directors that were asked set aside long-standing plans to use Exchange-compatible technology to first support the Direct Protocol.  Fortunately, both were astute enough to understand the progression from Direct to Exchange and were able to modify their plans to ensure that they had a transition strategy.  That has been the exception rather than the rule, and even that distraction has still been problematic for the informed folks.  Other HIEs that were not as aware disposed of their previous implementation plans in favor of a Direct only solution.

Has Direct been an HIE killer?  I don't know of any HIE's that have gone under as a result of third party implementation of Direct.  I would imagine that some HIE's would welcome support from third party vendors, and others might have challenges as they still struggle with business models.  The reality here is that no matter what happens, if your HIE business model would be threatened by something as simple as Direct, then you probably need to think more about your approach.

In the last six weeks, some things have settled down quite a bit.  That appears to have been as a result of some well-informed and influential people asking tough questions and making their views known. The new message most recently from ONC has been about Exchange with some references to Direct.  This presentation, presented by Doug Fridsma to the HITSC at their last meeting talks quite a bit about Exchange (see slides 13 to the end), and barely references Direct for example.

Capping it all off, we have this January JAMIA article from Dr. Les Lenert (former CDC Director at the now disbanded NCPHI) and others hammering the ONC for their shift in focus in 2011.  Two months ago, I would have welcomed the article more enthusiastically.  Now, it already seems a bit dated (always a danger in journal publication).  Some of its critiques I have also made myself.  Others are a good deal more political, and I wouldn't touch with a 10-foot-pole (although this might work).

I found a few points to be a bit misleading.  For example, of the billions in funding for EHR and HIE by the article, ONC only got $2B to support grants for HIE, Regional Extension Centers, Workforce and Education, et cetera.  About $500M of HITECH funds went to HIE in any way, with the other large chunk going to expansion of broadband access.  While HITECH didn't say where the ONC $2B went, the writing was pretty much on the wall as to how that was to be divvy'd up. The $20B that CMS has to spend is really about EHR adoption. It COULD do more to support HIE, but not at all directly, only through mandating standards and criteria for use of exchanges and attestations for meaningful use.

The whole mess around the PCAST report hasn't helped, and has been a rather large distraction throughout for just about everyone involved.  There's some good in that report too, (e.g., the Query Health efforts), but frankly, there's also a quite a bit of axe-grinding going on in PCAST.  I even tried my hand on that whetstone.

What I find most disruptive in all of this is how the people making the decisions are disconnected from the people working on the exchanges or the standards.  It's better with the ONC FACA's than it is with other advisory bodies, but I still wish more of the communication was better connected.  Even in the S&I Framework projects, the people doing the work don't get to choose what projects are to be developed, and there are few FACA members involved in the ONC S&I projects that moving forward on the FACA indicated priorities.

Where I'm at with this chatter is done.  It's time to move forward on real Health Information Exchange, let's do it, and stop talking about it.