Friday, April 30, 2010

A VisiCalc Moment

This story is about a VisiCalc moment that happened to me in 2004. If you don’t get the reference, it’s about that moment after the early adopters of VisiCalc realized what could happen with this new invention.

This story starts in about March of 2003, when the company that I worked for back then decided that they needed to become leaders in healthcare standards. I had previously been involved with W3C standards at a previous employer, where I worked with three or four different co-chairs of various XML related standards, and I had been working with XML and SGML since about 1993. So, I joined HL7 and started participating in the weekly t-con's with Structured Documents, which was working on CDA Release 2.0 at that time.

In about June or July of that year, IHE and HL7 announced that they would be doing a Joint Connectathon and a Demonstration at HIMSS in February of 2004. The initial call describing this activity had about 50 people from 30 different vendors, and was led by Steve Moore and Liora Alschuler.

Steve works for the Mallinckrodt Institute of Radiology, and is an avid Cubs fan. His team creates many of the MESA testing tools used by IHE to test implementations of its profiles. The participants in the connectathon will sometimes refer to Steve as "Mother", because he tells you in no uncertain terms what to do, when, where and what the punishment will be if you don't do it. His job is worse than herding cats, it's more like rounding up all the animals in the zoo after someone left their cages open, and he does this job very well.

Liora figures prominently in this story, as she is the mother of two important developments that appear within it. She runs a consulting firm out of Vermont that focuses on implementation of HL7 standards, especially the Clinical Document Architecture or CDA. She is also one of the co-chairs of the HL7 Structured Documents Technical Committee that developed the CDA standard.

Being demonstrated that year were four new profile from the newly created IT Infrastructure Technical Committee. Leading up that domain are two of the more prominent faces of IHE, Glen Marshall and Charles Parisot, also two of my mentors.

Glen Marshall used to work in the Standards and Regulatory area within Siemens, and is now a consultant and occasional blogger. He is a science geek from way back. In his early high school years he won a prominent science fair with his expertise in chemistry. He got his start in healthcare IT very early as a night computer operator for a hospital. In addition to his IHE leadership responsibilities, Glen is one of the foremost experts in Healthcare Security Standards. There are about 20 people on the planet with his degree of experience. He also plays guitar, and can usually tell you where to find good Sushi. He makes a point of mentoring new talent within IHE. One of the more important lessons I learned from Glen is how to get Charles to stop talking for a minute.

Charles Parisot (a collegue at GE) also appears prominently in this story. He's one of those brilliant people who can keep track of 1000s of thinks at once, and does so all around the Globe. While he lives in France, he spends about half a year in the US, and a significant fraction of his life has been spent inside an airplane. Charles is not only "Mr. IHE" to some, but also considered to be one of the Father's of the DICOM standard. He keeps track of not only ITI activities (he is presently co-chair of the ITI Planning committee), but also is active in other IHE Domains, HL7 ISO, HITSP, EHRVA and just about anywhere else that will listen to him. He's been engaged in US and International projects all over the world.

So, back to the four profiles in the ITI Technical Framework:
Consistent Time (CT)
Enterprise User Authentication (EUA)
Patient Identifier Cross Referencing (PIX)
Request Information for Display (RID)

My employer at that time decided to implement RID to display lists of CDA documents, and individual CDA documents, as well as the Consistent Time Profile. While I was busy pre-testing my application before connectathon (an IHE requirement), Glen, Liora, Steve and Didi Davis were planning the Demonstration. Didi is a fellow biker and blogger, and also one been of the leaders behind the growth of IHE Interoperability showcases at HIMSS over the last five years.

During the process of planning the demonstration, we wanted to highlight the benefits of CDA for interoperability between EHR systems. Reenter Liora with a twinkle in her eye, and a novel idea. The National Institute of Standards and Testing (NIST) maintains a registry of HL7 modeling artifacts, under the direction of Lisa Carnahan. Working for her was Bill Majurski, and his small team of developers. The idea was to send a simple message to a registry, and let it maintain a list of documents available from a number of different systems.

Because of the lateness of this idea, we were scrambling to implement this idea in the weeks before the connectathon, and Steve Moore was tearing out his hair.

The connectathon was held in a hotel ballroom in San Diego. We spend 5 days inside that hotel ballroom when most of us would rather have been at the beach. We managed to get past the testing and make it all work, but mostly at the last minute.

Then comes the showcase. It was a disaster for those of us presenting products. We had done all of this work to demonstrate our products, and who was getting all of the attention? Bill Majurski and NIST, because they had a web page that would show all of the clinical content from 10 different EHRs. It was so bad that we had to move his booth, which took 10 engineers: 9 to move the table, and 1 to ensure we wouldn’t get caught by facilities staff. We barely avoided ripping out the network cable and the carpet. This was my “VisiCalc” moment for Healthcare IT.

The next year, IHE developed that demonstration into the Cross Enterprise Document Sharing profile. Charles led the drive within IT Infrastructure to make that happen. Bill and I and a few others spent a great deal of time editing that profile, and many others contributed to the content.

When we demonstrated the profile the next year at HIMSS, an industry analyst approached Bill Majurski and told him he’d invented a $2B dollar a year industry. I’ve been tracking the data ever since he told me that story. I was able to count $2B in the US alone for the HIE industry based on HIMSS Analytics data in 2008. Last number I heard was $12B, and I don’t know whether that’s US or international, but I suspect the former.

XDS is now used around the world.


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