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Thursday, September 19, 2013

How We Got Here is Almost as Important as Where We are Going

I met a man on Monday after the Consumer Health IT Summit who proceeded to explain to me what's wrong with Blue Button, CCDA and Meaningful Use. He was a physician, an anesthesiologist by trade.  And for ten minutes I was harangued about how badly broken smoking status and CCDA was in Meaningful Use stage 2.  How the value set was useless to him, didn't capture the data he needed, and how of course everyone knew that the right way to measure smoking history was pack-years.

I listened to his story patiently, and stopped to ask him some of the same questions I had asked 2, 3, 4, 5 and more years ago on the same topic.  The first question is what about non-cigarette equivalences (e.g., pipe, cigar or chew).  I never did  get to the next question about what is the unit of measure (because pack is as arbitrary as tablet) because we moved onto a different part of the topic.

I managed to explain that these questions had been asked (by me) as much as seven or eight years ago, when IHE was first developing some of its profiles, and again some 5 or 6 when HITSP was working on some other topics.  And that at the time, we never did get consensus among physicians as to what the correct way to represent the result was.  So his "everyone knows" didn't come out because what everyone knew was different (Ask the same question of five physicians and you can get six answers, the same is true of lawyers and engineers, the only difference is the question topic).

And then we talked about the fact that the original set of concepts found in Meaningful Use stage 1 came from a CDC Survey Instrument.  And that the main use of these was with quality measures about smoking cessation, not assessment of cancer risk.  And that while the CDC survey concepts may have been solid, what was recorded in EHRs using those same categories blurred the lines because of course EPs don't ask questions the way that CDC surveyed people.  And then how later in stage 2 physicians complained because these concepts didn't fit their workflow because they weren't fine grained enough (light and heavy smoker were subsequently added).  I'll note now that this points out that there are multiple uses for this datum.  And that implementers complained that a set of concepts without codes wasn't useful, and so the Smoking Status value set was born.  And that my friends, is how we come to a value set that it seems the only consensus is that everyone dislikes using it, but have little better to offer.

We also talked about (the new) Blue Button.  He complained that it was still stuck on documents, and that that was not useful (I seem to recall he used stronger language). Yes. For now. And had he been involved in the ABBI workgroup (too little).  Was he aware how it prepares the way (the route) for being about more than documents, supporting the data elements we want (No).  And how it's using the parts of FHIR that appear to be ready now (a bit).  Yes he was familiar with FHIR, he's on an HL7 workgroup looking at FHIR now.  And have you voted on FHIR (I never got a solid answer). I fear the answer is in the negative, and hope otherwise.

It was an interesting encounter.  I felt as if I had somehow managed to explain to one person what is happening and how we got here, and where we are going, and had some success.


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