The Guide to Health Informatics 3rd Edition

A common strategy for structuring complex human systems is to demand that everything be standards-based. The standards movement has taken hold in education and healthcare, and technical standards are seen as a prerequisite for information technology.

In healthcare, standards are visible in three critical areas, typical of many sectors: 1/ Evidence-based practice, where synthesis of the latest research generates best-practice recommendations; 2/ Safety, where performance indicators flag when processes are sub-optimal; and 3/ Technical standards, especially in information systems, which are designed to ensure different technical systems can interoperate with each other, or comply with minimum standards required for safe operation. There is a belief that ‘standardisation’ will be a forcing function, with compliance ensuring the “system” moves to the desired goal – whether that be safe care, appropriate adoption of recommended practices, or technology that actually works once implemented.

In the world of healthcare information systems, the mantra of standards and intra-operability is near a religion. Standards bodies proclaim them, governments mandate them, and as much as they can without being noticed, industry pays lip service to them, satisficing wherever they can. For such a pervasive technology, and we should see technical standards as exactly that – another technical artifact – it is surprising that there appears to be no evidence base that supports the case for their use. There seem to be no scientific trials to show that working with standards is better than not. Commonsense, communities of practice, vested interests and sunk costs, all along with the weight of belief, sustain the standards enterprise.

For those who advocate standards as a solution to system change, I believe the growing challenge of systems inertia has one a disturbing consequence. The inevitable result of an ever-growing supply of standards meeting scarce human attention and resource should from first principles reasoning lead to a new ‘Malthus’ law of standards – that the fraction of standards produced that are actually complied with, will with time asymptote toward zero[1]. To paraphrase Nobelist Herb Simon’s famous quip on information and attention, a wealth of standards leads to a poverty of their implementation[1].

It should come as no surprise then that standardisation is widely resisted, except perhaps by standards makers. Even then they tend to aggregate in competing tribes pushing one version of a standard over another. Unsurprisingly, safety goals remain elusive and evidence-based practice to many clinicians seems an academic fantasy. Given that clinical standards are often not evidence-based, such resistance may not be inappropriate[2 3].

In IT, standards committees sit for years arguing over what the ‘right’ standard is, only to find that once published, there are competing standards in the marketplace, and that technology vendors resist because of the cost of upgrading their systems to meet the new standard. Pragmatic experience in healthcare indicates standards can stifle local innovation and expertise[4]. In resource-constrained settings, trying to become standards compliant simply moves crucial resources away from front-line service provision.

There is a growing recognition that standards are a worthy and critical research topic[5]. Most standards research is empirical and case based. An important but small literature examines the ‘standardisation problem’[6] – the decision to choose amongst a set of standards. Economists have used agent-based modelling in a limited way to study the rate and extent of standards adoption[7]. Crucially, standards adoption is seen as an end in itself with current research, and there seems little work examining the effect of standardisation on system behaviour. Are standards always a good thing? There seems to be no work on the core questions of when to standardise, what to standardise, and how much of any standard one should comply with.

Clearly, some standardisation may be needed to allow the different elements of a complex human system to work together, but it is not clear how much ‘standard’ is enough, or what goes into such a standard. My theoretical work on the continuum between information and communication system design provides some guidance on when formalisation of information processes makes sense, and when things are best left fluid[8]. That framework showed that in dynamic settings where there is task uncertainty, standardisation is not a great idea. Further information system design can be shaped by understanding the dynamics of the ‘conversation’ between IT system and user, and by the task specific costs and benefits associated with technology choice[9 10].

It is remarkable that these questions are not being asked more widely. What is now needed is a rigorous analysis of how system behaviour is shaped and constrained by the act of standardisation, and whether we can develop more adaptive, dynamic approaches to standardisation that avoid system inertia and deliver flexible and sustainable human systems.

This blog is excerpted from my paper “Stasis and Adaptation“, which I gave in Copenhagen earlier this year, to open the Context-Sensitive Healthcare Conference. For an even more polemic paper from the same conference, check out Lars Botin’s paper How Standards will Degrade the Concepts of the Art of Medicine.

1. Coiera E. Why system inertia makes health reform so hard. British Medical Journal 2011;343:27-29 doi: doi:10.1136/bmj.d3693[published Online First: Epub Date]|.

2. Lee DH, Vielemeyer O. Analysis of Overall Level of Evidence Behind Infectious Diseases Society of America Practice Guidelines. Arch Intern Med 2011;171:18-22

3. Tricoci P, Allen JM, Kramer JM, et al. (2009) Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines. JAMA 301: 831-841. JAMA 2009;301:831-41

4. Coiera E. Building a National Health IT System from the Middle Out. J Am Med Inform Assoc 2009;16(3):271-73 doi: 10.1197/jamia.M3183[published Online First: Epub Date]|.

5. Lyytinen K, King JL. Standard making:  A critical research frontier for information systems research. MIS Quarterly 2006;30:405-11

6. The Standardisation problem – an economic analysis of standards in information systems. Proceedings of the 1st IEEE Conference on standardization and innovation in information technology SIIT ´99 1999.

7. Weitzel T, Beimborn D, Konig W. A unified economic model of standard diffusion: the impact of standardisation cost, network effects and network topology. MIS Quarterly 2006;30:489-514

8. Coiera E. When conversation is better than computation. Journal of the American Medical Informatics Association 2000;7(3):277-86

9. Coiera E. Mediated agent interaction. In: Quaglini BaA, ed. 8th Conference on Artificial Intelligence in Medicine. Berlin: Springer Lecture Notes in Artificial Intelligence No. 2101, 2001:1-15.

10. Coiera E. Interaction design theory. International Journal of Medical Informatics 2003;69:205-22