Learning from Catastrophe

The Importance of Standards and how it relates to Healthcare Interoperability

In 1904, Baltimore suffered what became known as the third largest fire disaster in an American city, surpassed only by the Great Chicago Fire of 1871, and the San Francisco Earthquake and Fire of 1906[1]. On February 7th a small fire started on the south side of German Street. The fire spread so quickly that it forced local fire departments to ask for help from neighboring cities and counties. Soon fire departments from Altoona, Annapolis, Chester, Harrisburg, New York, Philadelphia, Wilmington, and York reached Baltimore to provide their support in extinguishing the flames. “Despite the 1,231 firefighters, 57 engines, nine trucks, two hose companies, one fireboat, and one police boat that was used” within 30 hours, the great fire of Baltimore claimed 1,545 buildings spanning 70 city blocks and amounting to over 140 acres. 35,000 people were left unemployed and over $3.84 billion (2014 dollars[2] worth) of damage had been suffered.

It was determined that though no one factor alone contributed to such devastation, the biggest reason for the duration, and therefore vast fire damage, was the lack of a national standard for fire-fighting equipment. Many of the fire crews that traveled to help quickly realized that their hoses would not connect to Baltimore’s water hydrants as the gauge sizes were different which rendered them useless for combating the flames.   The problem of differing gauge sizes was not unique to Baltimore rather it was true throughout most American cites.  In 1904 there were 600 sizes and variations of fire hose couplings in the U.S. This proliferation of variants was mostly driven by fire hose manufacturers and their patented designs.In 1905, following this catastrophe, the National Fire Protection Association (NFPA) committee established a standard diameter and number of threads per inch for hose couplings and fire hydrants. Sadly, the effort to establish this same standard received little interest just one year prior to the Baltimore fire.

Today’s complex healthcare IT ecosystem suffers from a similar need for standards. Health information is shared electronically among thousands of healthcare participants such as providers, payers, researchers, and beneficiaries. Healthcare participants use different Electronic Health Record (EHR) system providers. Much like fire hose manufactures, EHR system providers offer services and systems often based on proprietary technology, vocabularies, and data structures that are difficult to “couple” with other systems and networks.  Additionally, healthcare information is shared using health exchange networks which use different standards, security rules, and protocols making the exchange of information more difficult and costly.

There are several organizations dedicated to the creation of healthcare related standards such as Health Level Seven International (HL7), American National Standards Institute (ANSI), the International Health Terminology Standards Development Organization, the Office of the National Coordinator for Health Information Technology (ONC), etc.   The adoption of standards is as important as their creation and this adoption can take many years.

In fact, after the 1905 decision for firefighting equipment standardization “by 1914, only 287 of the 8,000 cities and towns in the U.S. had fire-hose couplings and hydrant outlets conforming to the standard. By 1917, 897 cities agreed to adopt the standards, but only 390 were using them. Every year the number of cities with standard hydrants and fire-hoses was increasing. By 1924, the number was 700 cities. Some of the cities made the change only after they experienced their own major fire”.[3] Standards only succeed if both the public and the private sector collaborate and are committed to adopting and using healthcare standards.

As demonstrated by the fire hose example, the healthcare ecosystem will reach semantic interoperability to enable the sharing of health information more consistently, timely and at a lower cost to patients by establishing, adopting, and measuring consistent rules and guidelines (standards).


[1] https://en.wikipedia.org/wiki/Great_Baltimore_Fire

[2] The Architecture of Baltimore: An Illustrated History, by Mary Ellen Hayward, Frank R. Shivers, Richard Hubbard Howland; Published 2004, JHU Press, Baltimore (Md.), ISBN 0-8018-7806-3, p. 237.

[3] NISTIR 7158 https://ws680.nist.gov/publication/get_pdf.cfm?pub_id=101300

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