'Content Neutrality' and Why It Is Important for EHR

Content neutrality is a concept that appears in many contexts. In law, free-speech cases hinge on whether an ordinance restricting speech was content-based, depending on what was said, or if it was content-neutral, limited only in the time, place, and manner of speaking. Similar distinctions apply to aspects of the EHR, especially data exchange. In this discussion, content-based will refer to data formats that require specific content to be expressed in specific ways and placed at specific locations. Content-neutral will refer to formats that define the time, place, and manner in which information is to be demarcated within a packet of data, but which impose few or no restrictions on the content itself.

Most of the things we do with computers correspond to things we have been doing for years with paper, pencils, cameras, voice recorders, etc.

The computer provides new and perhaps better ways to do the old things, but they are essentially the same old things. Electronic exchange of clinical data is a hot topic these days but has been slow in coming.

Perhaps the old way of exchanging clinical data, by sending paper through the mail, can provide some clues as to how best to accomplish exchange data using the computer.

In a typical scenario from yesteryear, a consultant, having concluded his/her examination and testing would write a report. That report would undoubtedly be divided into sections such as reason for referral, history, exam, testing, and results, impression and recommendations, or something similar. These divisions would be readily apparent to any other physician due to their visual attributes and would establish the context within which the content should be interpreted. The completed report would then be assembled with other material such as copies of test reports, EKGs, photos, X-rays and perhaps a cover letter. The package would be placed in an envelope, addressed, and mailed.

Reducing this process to the bare essentials, we discover a container (the envelope) and its content (the reports, etc.) In order for the envelope to do its job, it must convey specific information formatted to conform to postal service rules that specify required data elements (addressee, sender, and postage) and placement on the envelope. These are content-based specifications - if the addressee and the postage are missing or in the wrong place the envelope won't be delivered. On the other hand, the inside of the envelope is content-neutral. It doesn't care what you put in there as long as it fits. That's not to say that no one cares, just that the envelope doesn't care. It's worth noting that in this scenario, the items in envelope are physically separated (delimited) so the recipient can't end up with an EKG accidentally fused to a lab report except by an accident of glue or tape.

Thus, some goals are best achieved with content-based specifications while others benefit from a content-neutral approach. Any workable solution to clinical data exchange will inevitably employ a mixed-strategy. There is agreement that a delivery mechanism must be established (the envelope) as well as a scheme for arranging the content. Beyond that there is neither agreement on what mix is best nor even on an optimal approach to formulating content-based specifications.

The devil is in the details.

Most individuals understand that restrictions are the enemy of flexibility but they also understand that some restrictions are necessary if substantive data exchange is to occur. So committees are formed to reach agreement, i.e., to "standardize" data exchange. While giving every indication of being reasonable and appropriate, the standardization process works best when it assumes that the requirements are static, i.e., that daily events have a certain predictability. This is at odds with the world of medicine.

Although much of what happens in the medical setting is predictable in general terms, the details present almost infinite variety. Furthermore, as our knowledge and experience expand, the aspects of each case that are deemed worthy of documentation and exchange with other practitioners evolve continuously. For a data exchange scheme to retain viability it must accommodate this constant change. Rigid, content-based specifications will not be meaningful if the items specified are not longer available or of interest. Only a content-neutral approach offers the potential flexibility to exchange information via the EHR in an unpredictable future.

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