Earlier this week, 51 healthcare groups wrote to the Centers for Medicare and Medicaid Services asking for the current federal EHR adoption goals to be done "in a manner that will remove barriers to and promote the widespread adoption of health information technology.” This letter, sent on May 3, is an interesting backdrop for Wil Yu and Joshua Seidman's participation in the Health 2.0 Show's webinar on meaningful use today. It appears from the letter to CMS that the concern is not simply the adoption rules for EHRs but how these groups' advanced HIT systems might or might not meet those requirements by 2011 and most importantly whether hospitals are eligible for the associated incentives.  (The debate over 'pushing' adoption through institutions, as opposed to 'pulling' adoption through patient-centered approaches will be taken up in another post.)

Dr. Seidman started his Health 2.0 Show webinar with a similar comment to his other addresses to eHealth groups, "it is not about technology but about transforming healthcare."  He is right, and this is the heart of the meaningful use discussion.  It is also a perspective that should inform our reaction to the letter to CMS from earlier this week.  Slowing things down until 2017 or speeding them up will not matter unless we are approaching the problem in the right way.  With over $200M in beacon grants announced this week, we must ask ourselves:

Are EHRs a data-source or a presentation layer? If we are simply replicating paper-based medical documents in electronic form, are we really advancing the state of the art?  What parts of these data challenges should be handled in federal rules and which parts should be tackled by new open standards to re-architect the very plumbing of the Internet?

CLOUD is a non-profit technology standards consortia advocating, promoting and developing a language for people on the Internet.  This language, like HTML, is not focused on any particular domain, health or otherwise.  As a result, we are not advocating a specific approach to EHRs or final rules from ONC at HHS.  A thorough background on CLOUD's impact and perspective can be found in Gary Thompson's comment at the FACA blog on "Creating a Vision for Engaging Patients and Families Through the Meaningful Use of Health IT." Since there is some concern that CLOUD's post to the FACA blog is "advocating a product," it is also posted here in the CLOUD Health section of our site.  As I mentioned to Dr. Seidman via an email exchange, CLOUD is not advocating a product but instead pushing forward a paradigm change and one that is vital.  We are not seeking permission for this new approach but actively engaging appropriate communities from health to finance to education and beyond to ensure that this new approach meets the needs of individuals and in the case of health, this individual could be a patient, physician or other healthcare provider.

The bottomline is that by 2014 it is highly likely that CLOUD's contextual markup language (CTML) will be in either active use or aggressive adoption and as a result, it will have significant implications for the way in which our information is used and how that information is made both more private and more secure throughout the Internet.  CLOUD will be posting 4 web vignettes shortly to the What is CLOUD? section of its site that walks through CLOUD's view of the Internet, the idea of ME 1.0 as opposed to Web 2.0, the power of Who I Am, and the impact of separating Who I Am from What I Am to make privacy and security a part of the architecture of the Internet.

As I listen to today's discussion, I can't help be struck by a key assumption in the discussion of an EHR.  This assumption is that an electronic health record is simply a digital version of the previously created paper versions of the same record.  This discussion is not dissimilar to the debate several years ago at the Securities and Exchange Commission as they moved to mandate XBRL (eXtensible Business Reporting Language) for the reporting of financial data by public companies in the United States.  XBRL represents a move towards a data-centric model from a document-centric one in financial reporting, and this type of thinking is a vital one in our ongoing health debate.  The EHR in many ways is simply a "container" by which to view health information.  If a clinical trial investigator were looking at the same information, their "container" for viewing the information might be entirely different.  Architecting around the data, rather than the document, is a vital step.  Ensuring that data is also architected around the individual is equally vital.