An illusion in the minds of many is that Center for Certification of Health Information Technology (CCHIT) certified EHR systems are interoperable. To many, this would be one of the major if not sole reasons for CCHIT to exist. The surprising reality is that this is something that CCHIT certification does not currently include. Another reality is that ‘interoperability’ is a loaded term that is very difficult to define among proprietary EHR’s. This CCHIT announcement is interesting in that CCHIT will “…begin building a testing resource to evaluate compliance of electronic health records (EHR) and networks with certification criteria for interoperability. This new initiative will make it easier for health information technology companies to add standards-based information exchange capabilities to their products and prepare those products for certification. The testing software will be developed under an open source license so that it is free and publicly available, and the Certification Commission will use the software running on a secure platform during its inspection of a product’s compliance…”
This announcement is confusing in many ways. In a nutshell, in order to be CCHIT certified you will have to prove interoperability against what is essentially an open-source software middle-ware that CCHIT and MITRE are developing. Aside from the nearly impossible task of defining interoperability satisfactorily, it appears to be doing or giving teeth to what many understand to be the reason for the HL7 organization. It also appears to be partially re-inventing much of Webreach’s Mirth project or OpenHRE Toolkit and possibly other Free and Open Source Software (FOSS) licensed efforts.
While the open-source aspect of this is noteworthy, and the goal of this is to “…make faster progress toward interoperability,” CCHIT’s fatal flaw is that it still returns to the knee-jerk response of preserving the proprietary EHR business model status quo at all costs.
Aside from this open-source interoperability testing software announcement, the logical conclusion of the CCHIT certification process is essentially a cartel similar to the current United States cell phone industry. This is in contrast to what it could be which is a thriving ecosystem in which novel applications are commonplace and free to rapidly evolve like the Internet and Web 2.0. What do CCHIT’s announced interoperability software, Internet/Web 2.0, Mirth, OpenHRE toolkit have in common? They largely use FOSS licensed software that safeguard important rights from proprietary vendor lock down.
Yet again it seems that the FOSS in medicine world is far ahead of most of medicine in that it already has solutions to what the proprietary EHR world unsuccessfully lurches towards in a unsatisfactory, time-consuming, and expensive manner. It seems that Webreach’s Mirth project and OpenHRE toolkit and possibly other FOSS projects have already done much of what CCHIT/MITRE is attempting to do except for the certification process. It is unclear by the announcement if CCHIT/MITRE are working with these organizations or projects. What is not remarkable is if Mirth, OpenHRE toolkit are ignored or excluded by CCHIT given the default ‘preserve the proprietary EHR business model sacred cow even if it hasn’t worked for decades’ orientation. Still, that CCHIT’s testing software is ostensibly being released as open source (under which license?) is a step in the right direction, albeit a superficial one.
Why does such a certification organization not exist in the FOSS EHR world? Quite simply because it is much less necessary. True interoperability at virtually any level in the FOSS EHR world can be achieved when a sufficiently skilled software engineer downloads (copies) the target software, runs it with an originating system, studies how it works, improves it by modifying either the original software or the target to the desired level of interoperability and then distributes (if they wish, they can keep their private changes private) the improved version. These basic and important software rights: to run, copy, distribute, study, change and improve the software are inherently granted by FOSS licenses. Yet, CCHIT, medicine in general, and the proprietary EHR industry in particular largely have little comment on, actively or passively deny these rights while continuing to try harder to make proprietary EHR’s work when they have repeatedly not worked in the past. They continue to deny these rights because they have difficulty conceptualizing the transition to something that will probably work, but threatens broken proprietary business models. Meanwhile, medicine continues to be under-computerized, quality cannot be meaningfully improved, and medicine continues to be expensive and error-prone.
While the announcement that CCHIT/MITRE’s testing software will be open-source is significant, it is far too little an acknowledgment of the importance of FOSS in medicine and what has already been achieved. When medicine in general and CCHIT in particular abandons protection of proprietary EHR business models and acknowledges that FOSS licensed EHR’s are superior to proprietary ones in many ways, particularly with interoperability, then Health IT will truly be poised for the rapid progress desired by all. Until then, the tepid pace of Health IT change and adoption will continue and the unsatisfactory proprietary status quo will continue to be preserved.