It’s something you can see all around the world: governments sponsoring large national healthcare projects of one form or another (EHRs, prescription systems, HIEs, etc), and the bodies running these projects getting very involved with international healthcare standards bodies (HL7, IHTSDO, IHE, etc) (yes, I know IHE isn’t a standards body. but everyone knows what I mean). I’m referring to ONC, Infoway, Connecting for Health, NEHTA, etc (btw, declaration: I’ve worked for nearly all of these – or still do – in their standards programs).
There’s a difference between the goals of the national project, and the value proposition of using standards, and this difference can create considerable tension.
These national programs are generally constituted by elected politicians who commit large sums of money to big goals that are difficult to achieve, and quite risky politically. In fact, these projects only happen because there’s such a huge pressure on the national programs in terms of getting more for less, and these projects appear to offer the prospect of delivering that – and they *will*, if they succeed. But these projects are difficult at every level – hard to make change, technically demanding, and at the limit of our knowledge of informatics, and how to deliver computing support in really well integrated ways to a wetware (very wet) dominated process.
So there’s real risks, and because of election cycles, short time lines run by risk averse sponsors.These projects have to succeed, and have to stick to their timelines. (Which does make me wonder, where do they make these timelines up from?)
The Standards process, on the other hand, doesn’t work like that. It’s a slow, consensus based process which emphasizes getting agreement to a common position, and voluntary participation from the community with gradual buy in. That’s it’s greatest strength. It’s not going to run out and transform a community prospectively. But gradually, incrementally, and surely, the presence of the standards transforms the community and empowers it. However you can’t rush the process – putting a timeline on it, or throwing money at the volunteers – that is a high risk option. The real workers, the ones who can make a difference, because they know how to write a standard that people can make work – they’re busy, making the standards work. If you put a timeline on it, quality goes straight out the window. If you throw money at the process, the ones who are better at winning contracts rather than writing standards will take over. It’s not that timelines or money can’t accelerate the process – but both are high risk options that need careful management and strong community buy in before they can be successful.
Note, I’m not arguing that the standards process should be strictly linear, but resetting the direction and the community is also a high risk option.
Why then, would you mix these two? Put like that, using standards for a national project sounds like a sure recipe for a disaster. So why do national project offices even try to use standards? Why not just be XML Cowboys, and do everything in a bespoke way?
- using international standards means that international vendors won’t charge an arm and a leg to play ball (probably just an arm…)
- using standards means that the local community can rely on some change control over the process, protecting them from the whims of the sponsors, and electoral change etc. This breaks down to $$$ too
- using standards means that the national program can leverage the existing skill base of the community without destroying the community while doing so
- using standards means that the project is constrained to behaving more along the lines of international consensus
But these goals are mostly long term outcomes. You can only really achieve them if the sponsors are prepared to give something up – their own custom requirements and most of all, tight timelines. Because standards means giving something up in one place to gain in another. If they aren’t prepared to trade these things away (somewhat, anyway) for these other goals, they won’t achieve these outcomes from the standards process. They won’t get the meaningful and deep community engagement they need, and they won’t produce specifications that align with other countries – and they will often wonder why the cost-benefit of standards is so low. And their engagement with standards will be… fraught with confusion and misunderstandings.
But it can work (well, even) – if the projects and their sponsors can live within their limitations.