Note to Sec. Sebelius

Secretary Sebelius,

I appreciate very much your stated position (according to Healthcare IT News) that technology adoption is in healthcare is not enough, that interoperability of technology is also necessary for healthcare reform. I wonder how much you know about interoperability of healthcare information systems. I wonder only because there is nothing in your published biographical information that leads me to believe that you have any background-in-depth in a technology discipline.

I don't mean for this to sound like criticism--it isn't--I think your position is a correct one and your advisers have done a good job. I wonder if you are aware, though, that there has been talk of interoperability for several years within the healthcare marketplace and there have even been claims of the achievement of interoperability. There has even been a "certification standard" published purporting to validate system interoperability.

All of this isn't worth the effort it took me to type the words. The reason for this "much ado about nothing" is simply that there is no incentive within the marketplace for the level of cooperation it would take. Technology of all kinds is the cash cow of healthcare and no one involved has any reason at all to kill that cow or even to bring it into the barn.

In the early 1980's, the Department of Defense had a very similar problem. Each branch (Navy, Army, Air Force, Marine Corps, Coast Guard) had its own procurement structure and its own pet contractors. There were no standards and all that was necessary for a contractor to be successful was to maintain some level of credibility with the procurement officer(s) involved. The result was that (for example) Army units in the field couldn't talk to units of other services because their communications equipment was incompatible. Logistics was a nightmare because of the variety of spare parts that had to be maintained and computer systems incorporated the "dialect" of the purchasing service and could not exchange information with the systems of the other services. This is the surface of the problem. The technological diversity went much deeper as well to the point where it was a major procurement effort to get two systems to cummunicate.

NASA was developing plans for an international space station and realized that they were going to have to fundamentally change the way that systems were specified, developed, and implemented if there was ever to be any hope of success.

The Defense Dept. took control of the situation through an initiative called Software Technology for Adaptable, Reliable Systems (STARS). DoD mandated that processes and methods (and their documentation byproducts) as well as tools and other technology used in the creation of systems be standardized for the purposes of reducing costs and delivering a level of interoperability.

Healthcare operations and all of their vendors--virtually everyone outside the walls of the DoD and the Software Engineering Institute at Carnegie-Mellon University remain blissfully unaware of any of this history, all the while enjoying its fruits.

I want you to know that I believe interoperablity can be obtained, but not without the institution of new paradigms and some major upheavals in the technology vendor community. I have dedicated 13 years of my life to laying some foundations where I can and I fervently hope that you have the commitment and the political will to see this through. Without that, government efforts are likely only to increase costs.