Saturday, June 09, 2007

Knowledge, Standards and the Healthcare Crisis: Part 6

In the previous posts [click here for first in series], I described many of the problems facing the healthcare industry as it attempts to deal with data and technology standards. These daunting problems include high cost, complexity, difficulty accommodating changes, loss of meaning and nuance, trouble defining quality, inadequate measures, political influence, etc. I now discuss how an innovative approach to the use of health information technology would help solve these problems.

Solving the Problems with Healthcare Standards

From a technological perspective, what's needed to solve the problem with standards is a simple, low-cost, reliable, secure, hassle-free way to exchange and view structured & unstructured health information, anywhere and anytime, in a way that:
  • Maintains the full meaning and nuance of the information being exchanged in order to maximize understanding and the information's usefulness, regardless of the data standards being used.

  • Supports fluid connectivity between all IT systems, regardless of their technology standards.

  • Gives all authorized consumers/patients, providers, suppliers, payers (insurers), and purchasers (employers and self-insured) the information they need, in the way they need it, to support decisions and guide actions.

  • Supplies researchers with the information they need to evaluate clinical outcomes and care processes, so they can create, continually evolve, and widely disseminate evidence-based guidelines.
I contend that the best way to do this is through a secure node-to-node network architecture using template-driven software applications having "publisher-subscriber," data translation, and personalized reporting capabilities. Let me explain.

Why a Node-to-Node Architecture

In a node-to-node architecture, each node is a software application in a computer that sends and receives information from other nodes. This architecture supports "peer-to-peer" (P2P) networks in which each node stores its data files locally and shares them with other nodes without being controlled by a centralized server.[1] The telephone system and e-mail are good examples of node-to-node. Every phone and every computer are nodes. By picking up the phone and dial a number, or by typing in an e-mail address, you can communicate with whomever you want, and do it anytime and anywhere. Your call or e-mail is routed automatically to where you want it to go through a series of simple switches. This open network is quite different than a centralized system in which you must first sign on to a central server that determines who you are authorized to contact before sending them your message, i.e., all information must pass through a central authority that controls all communications. In addition, such centralized systems typically require the costly development and ongoing maintenance of a centralized patient record locator to know where to find patient data.

The following make the case for a node-to-node/peer-to-peer architecture for exchanging healthcare data:

  • "The United States' National Health Information Network, or NHIN, will differ from the UK's project in a number of ways. Rather than having a single, closed network with a central database overseen by one government agency, the U.S. system will be decentralized, operating more like a peer-to-peer network, with records distributed across the system. Think Napster on steroids. …the NHIN will allow a doctor to quickly call up a patient's digital records from whatever databases they may reside in-at a hospital, at the family doctor's or dentist's office, at a clinical lab, wherever."[2]

  • "After initial testing using a centralized patient index, [Massachusetts' MA-Share HIE determined that] the maintenance for that looked like it would be more than users would want to pay. So the exchange uses distributed peer-to-peer networking. The MA-Share exchange provides an appliance to let members push financial transactions, e-prescriptions, and clinical summaries-so a doctor can send a file to another doctor or provide prescription data to a pharmacy." [3]

  • "To make significant gains in patient safety through the adoption of health IT, providers will need to adopt IT systems that can 'speak the same language' to each other. In computer terms, they should be 'interoperable.' But interoperability isn't enough. To communicate, different health IT systems must also be linked in some way. This is 'connectivity.' One model of connectivity, in a national health IT context, would be a non-proprietary 'network of networks.' …Several issues must be addressed if different health information systems are to communicate. …Some suggest that there should be one uniform national system with one central repository. This approach presents challenges: the sheer volume of data that would need to be handled, significant concerns about privacy and security threats, and likely disputes about governing and paying for a centralized system. Another option is a series of regional networks, as advocated by ONC [the Office of the National Coordinator of Health Information Technology, formally ONCHIT]. ONC's strategic frame- work suggests that a national network should be structured around regional health information organizations (RHIOs). RHIOs would store, organize and exchange patient health information within a defined geographic region, under local rather than national governance. These regional organizations would form a "network of networks" across the nation." [4]

Publisher-Scriber Communications Model

The nodes in these P2P networks employ a publisher-subscriber communications model in which a publisher node uses its communications software application to publish (send) information to one or more authorized subscriber (receiver) nodes. Once transmitted, the subscriber nodes use their subscriber applications to retrieve that information and present it as reports. In other words, the publisher-subscriber model uses an "application to application" transfer process in which each participating node uses a particular software application for exchanging (sending and receiving) information.

The publisher and subscriber applications support a particular operating system OS) and Internet connection using broadband or dial-up service. A node that uses an e-mail client (such as Microsoft Outlook on Windows OS) is one such example.

At one end of the connection, the publisher node must authorize the information transfer by authenticating that the subscriber node is allowed to receive the information. At the other end of the connection, each subscriber node must allow the publisher to deposit the information into a directory (i.e., a folder in computer's drive) as a file with a specific format (such as an MS Word, Excel, or "comma separated value" file).

Universal Translation

A node-to node architecture incorporating "universal translation" provides a means for modifying (transforming, translating) information as it passes between nodes, so that each subscriber node receives from a publisher node the right information, in the right format (structure), and with the right terminologies (semantics).

This is where data and technology standards are handled. That is, the universal translator makes the necessary transformations to the information sent by a publisher node, so different subscriber nodes can use that information to generate their particular reports and, if desired, to store the information received in the subscriber nodes' databases. It can accommodate any data standards and operate with systems using any technology standards.

Advantages & Benefits of the Node-to-Node Architecture

The advantages and benefits of this asynchronous, publisher-subscriber, node-to-node architecture are many, including the following:
  • Is exceptionally flexible:
    • Accommodates any data and technology standards, so everyone gets the information they need in the way they need it
    • Allows anyone to communicate with anyone else in any way
    • Can use multiple connectivity options, i.e., radio transmission, satellite transmission, wire transmission, wireless transmission.

  • Has maximum reliability since it leverages the most reliable network in the world, i.e., the switched network (like the telephone system).

  • Is inexpensive to deploy and operate because it doesn't require changes to existing I.T. infrastructures and keeps implementation costs low by eschewing additional equipment and system purchases.
  • Is robust and resilient since there is no single point of failure; so, unlike centralized networks that are disrupted if a central server goes down, the node-to-node network is survivable in a disaster since it keeps going even if individual nodes are disabled.

  • Makes scalability a non-issue, which means there's no need to purchase new equipment or redesign software as the network grows; this is unlike a centralized system in which there tends to be significant costs in time and money to meet the needs of a growing network.
  • Is highly secure since there are no external database queries; firewalls are not crossed.
In my next post, I discuss other parts of the solution: Composite Reporting and Application Integration.

References:

[1] Wikipedia - Peer to Peer and WellnessWiki - Network Architectures (see Node Mesh Network)

[2] Charett, R.N. (2006). Dying for Data: A comprehensive system of electronic medical records promises to save lives and cut health care costs-but how do you build one? IEEE Spectrum Online (Oct 2006)

[3] Kolbasuk McGee, M. (May 28, 2007). Urgent Care. Informationweek.com

[4] Linking Providers Via Health Information Networks. Alliance for Health Reform. (Dec 2006).



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