Technology

Could the Apple iTunes App Store be the paradigm that cures what ails the nation’s health care information technology malaise?  According to Drs. Kenneth D. Mandl and Issac S. Kohane, writing in the March 26 issue of the New England Journal of Medicine, the answer may be a resounding yes.

The stimulus package signed into law by President Barack Obama this February earmarked $19 billion for investing in the nation’s health information technology system, and it’s arguable that this money will do little good absent any systemic backbone, if you will, that allows the various assets that make up such a diverse and expansive system—the applications that perform specific health care-related tasks, the hardware and software that does all the talking between node points, and the health care data itself—to get along together nicely.  Absent such a backbone, we could get bogged down in lengthy technology duels a la Betamax/VHS.  This would be disastrous; as a nation, we can’t afford to wait out such a stretch, and $19 billion is a lot of money to spend without much to show for it.

Dr. Mandl’s and Dr. Kohane’s proposal makes a good deal of common sense.  The reason the Apple iTunes App Store was so successful, they argue, was because Apple presented developers with an open platform—the iPhone OS—and let them run with it as they saw fit.  Further, Apple provided them with a forum—a marketplace—where they could profit from their innovations.  By decoupling the platform from the functionality provided by the applications, argue Dr. Mandl and Dr. Kohane, Apple created an environment where the consumer could be committed to the platform, but not the applications, which compete with each other based on value and cost.  Don’t like your calendar app?  Scrap it and download another one—you don’t have to scrap your iPhone.

The same sort of paradigm could be used to create and grow a sustainable, highly active marketplace for health care information technology.  If developers were provided an open platform, they could develop the type of applications that health care providers need:  medication management, documentation, panel management, quality improvement, administrative tools, communication tools, public health reporting, research, decision support, and data acquisition.  What’s more, it’s not as if these applications don’t have parallels outside of health care information technology.  This will enable developers to leverage designs, technology, and implementation methods they’ve used for other verticals for the health care vertical, saving them time and money, and allowing them to iterate and innovate more quickly in order to meet the specific needs of the health care industry.

Mandl and Kohane argue that aside from interoperability and security—which should be included as givens—any health care information technology system should feature the liquidity of data and the substitutability of applications.  Liquidity of data would allow for the unimpeded transfer, in some sort of previously agreed-upon form, of information from one application to another.  The banking industry follows a similar model with automatic teller machines (ATMs), say Mandl and Kohane:  consumers can withdraw money from virtually any bank that has an ATM machine, even though they can only perform some functions via their own bank’s ATM network.

Substitutability of applications goes beyond merely the ability to swap one application out for another easily.  According to Mandl and Kohane, physicians should have the ability to use an application from one vendor to perform one function, another application from another vendor to perform another function, and yet another app from another vendor to do something else, and all apps should get along with each other seamlessly.  Call it the ability to build a modular system, ad hoc, almost, of the applications that best suit your needs.  The beauty of this is that developers could build these applications in a cloud, host them there, and provide them to physician-consumers as utilities, charging physician-customers for computing services on an as-used basis, keeping costs, including start-up costs, low.

Of course, all this is predicated on the notion that an environment—a platform—for a national health care information technology system can be established, open source and all, in the first place.  To tackle this daunting task, Drs. Mandl and Kohane call out the US Department of Health and Human Services (DHHS).  They believe that DHHS should promote the creation of such a health care system via a program of regulation, the creation of financial incentives, and the establishment of a transparent process for evaluating the platform as it begins to take shape.

For the federal government, the regulation of such a system might be the easy part.  These days, the word regulation itself conjures up unsavory things—especially for free-market capitalists.  But let’s not forget that regulation also means “to make regular,” as in to make sure everything’s the same and predictable across the board, as in a “well regulated militia.”  And without a well-regulated system in place, how could developers write code and build apps?  Do we really expect developers to be able to hit a constantly moving target?  Regulation, in all probability, would not come in the form of mandates from on high, but rather, trickle up from developers—those in the trenches—and codified as best practices.

A standardized, open source platform providing a robust marketplace for application developers to innovate and make money.  A Darwinian ecosphere in which the best applications survive and get better because they serve their customers the best.  What’s not to like about such a set-up?  Apparently something, for the Wall Street Journal took a shot at Dr. Mandl’s and Dr. Kohane’s prescription for the nation’s health care information technology system in its editorial suggestion.  The Journal, it seems, fears that the federal government’s $19 billion investment might give the Obama administration too big of a seat at the table:  it hands them, in the words of the Journal, “the power to define and approve ‘certified’ records, therefore the power to create a health-tech monopoly.  With stimulus money being shoveled out as quickly as possible, doctors and hospitals may end up prematurely investing in the costly systems that happen to have the government seal of approval—and in the process freezing out an innovative marketplace.”

The Journal, however, has it wrong in this instance.  The government wouldn’t be granting a seal of approval to anything except for the standards for a platform itself.  Presumably, that platform, and the applications for it, would be built by private enterprise—and private enterprise with a financial stake in the outcome.  Rather than stifle an innovative marketplace, Dr. Mandl’s and Dr. Kohane’s proposal might be just the thing to foster it in the first place.

By Robert Pothier