Monday, June 9, 2014

MeaningfulUse VDT, BlueButton Plus Push, Pull, Direct and FHIR, untangling it all

VDT, or View, Download and Transmit, is a set of requirements for 2014 Certified Electronic Health records under Meaningful Use for the EHR to enable the patient to View, Download or Transmit their data.  In addition to VDT requirements, the EHR must also use the Consolidated CDA (CCDA) under those regulations, and must support The Direct Protocol, and may support other protocols.

Providers who want to get incentive $$$ for Meaningful Use must use the standard format (CCDA) when enabling patients to Download or Transmit data.  They may, but are not required to use the standard protocols the EHR must support for transmission of CCDA documents for referral.  This is a rare exception to the general rule that to obtain the incentive, you must use the certified capability.  In making this exception CMS understood that some very functional referral networks already had document transmission capabilities and did NOT want to have to replace them with The Direct Protocol just to support the same feature.

Blue Button Plus is an extension of Blue Button that uses the CCD and CCDA formats specified under the 2011 and 2014 Certification and Standards rules to exchange patient data.  When the document is transmitted using The Direct Protocol, effectively you have the BB+ Push capability.  When it can be downloaded using a pre-draft subset of the HL7 FHIR standard, you have the BB+ Pull capability.

Neither the 2011, 2014, or proposed 2015 certification criteria require Blue Button or Blue Button Plus. Blue Button Plus has been proposed for 2017 certification criteria.

Oh, and finally, Blue Button, Blue Button Plus and Open Notes are very similar.  When you can get your Open Notes using the CCD or CCDA format, effectively you are using the same content standards supported by BB+, and then it is all a matter of how you would download or transmit it.

That is the challenge when setting the low bar in VDT.  More functional bars like BB+ Push or BB+ Pull aren't required by Meaningful Use, but are perfectly capable of meeting the requirements for it.


  1. Keith,

    I think another source of related confusion is that the Blue Button Connector site ( which contains a directory of health record sources that (you would think) support Blue Button, includes (in fact, these are the majority) data sources that provide view-only access via a portal and don't support any kind of download/transmit (only view).

    Similarly, the fact that a provider has attested to MU2 doesn't mean that when you ask them for an electronic copy you will get it in C-CDA format. And then there is a question of what hoops you will have to jump through to get that electronic copy (which you are legally entitled to) - regardless of format. Simply having a DIRECT-compatible address doesn't mean a given provider (even of an MU2-certified EHR) will send it to you.

    So, formal standards aside - what is the likelihood today that a typical patient can really get a C-CDA over DIRECT from their provider with their results/summary? What will it be in two years? In five years?

    Wish we were putting more energy into improving the answer to those questions instead of introducing new formats and transmission protocols (CDA R2.1/3, C-CDA R2.0, FHIR, etc.), new certification criteria/tools/process (2015 Edition, 2017 Edition, etc.), and similar.

  2. As you know, I favor MU adopting standards that measurably improve care quality and access. Those results matter far more than network transports. Arguably, though, a common format like CCDA can help measurably improve care. As a Medicare recipient, I prioritize care over technical nits. I hope to see better care, at stable cost, before I no longer could benefit from it. Current health IT progress is discouraging.

  3. "...They may, but are not required to use the standard protocols the EHR must support for transmission of CCDA documents for referral. This is a rare exception to the general rule that to obtain the incentive, you must use the certified capability. ..."

    Coming from a standards guy, I'd expect you to comment about how this particular exception defeats the purpose of defining a standard and is causing confusion in the field.

  4. ONC wasted years of effort under the consumer office trying to turn VDT into a "Blue Button" (or Blue Button+ - but other staffers and the REC's didn't understand it.. It was really just a marketing campaign but it was pushed back multiple times (where are the public service announcements they announced last fall) and eventually was nothing more than a web site (as noted above) .

    Numerous senior people at ONC didn't support it thankfully and they just axed the very sweet director of the consumer office and eliminated the position. ONC really doesn't seem to grasp the technology or EHR's for that matter.. Do they have a single EHR developer or even any computer science people on staff or are they policy wonks?