This week’s New England Journal of Medicine provides something of a real-world mini-primer for everyone’s radar on electronic health records and the HITECH funding included in ARRA, the economic stimulus bill.

The cautionary paragraph, offered by Mandl and Kohane in their essay, No small change for the health information economy, is: “We take it as a given that health care software must be interoperable and secure and must protect patient privacy. But these qualities are not sufficient to produce an optimal system, which must evolve on a health care platform that extends beyond PCHRs to include other critical infrastructural components, such as…EHRs and applications that support the complex communication required in health care.”

The point here is that, “it’s about the data and knowledge-sharing, stupid,” which is a sentence that the peer-reviewed NEJM would probably not allow in its learned pages. However, this is essentially the point.

There is an “ecosystem of applications” used by health care clinicians; it’s not about a strict, closed, set menu. Consider the importance of flexibility and substitutability when looking at this list of applications used, in different ways, by clinicians:

  • Medication management, via prescribing, order entry, or drug safety alerts
  • Documentation, whether by structured text or dictation
  • Panel management, for results notification, appointment reminders, care instructions
  • Administrative tools, such as billing, collection and revenue cycle management, and referrals
  • Communication, whether doctor-patient communication, patient support for disease management, or clinician social networking
  • Public health reporting and research, for disease surveillance or clinical trial data
  • Decision support, whether for lab test analysis, genomics, etc.

Mandl’s and Kohane’s perspective complements an ongoing discussion initiated by Dr. David Kibbe and Dr. Brian Klepper on The Health Care Blog concerning the EHR “machine” versus open-source, flexible approaches to data liquidity. First in An Open Letter to the Obama Team, and then in Let’s Reboot America’s Health IT Conversation (Part I and Part II), K2 argue for open-ness, flexibility, and data liquidity that supports participatory medicine and patient collaboration.

Health Populi’s Hot Points: “The applications enabling these functions should be as substitutable as different stethoscopes in a doctor’s office,” Mandl and Kohane conclude.

The analog here is the standards-based, banking ATM, which provided a consistent platform upon which various applications can be selected and personalized for use based on clinicians’ and consumers’ preferences.

Mandle, Kohand and K2 are spot-on in their rationale. As we approach the silly season that is the annual meeting of HIMSS (beginning April 5th) and the market-mania surrounding ARRA funding for EHRs, we should all keep the themes of data liquidity, flexibility, and substitutability front-of-mind.