Tuesday, September 30, 2008

HITSP Public Comment Period Begins

Date: September 29, 2008

TO: Healthcare Information Technology Standards Panel (HITSP) and
Public Stakeholders - - FOR REVIEW AND ACTION

FROM: Michelle Maas Deane
HITSP Secretariat
American National Standards Institute

RE: Public Comment Period Begins for Personalized Healthcare, Consultations and Transfers of Care, Immunizations and Response Management, Public Health Case Reporting, Patient-Provider Secure Messaging and Remote Monitoring documents.

The Healthcare Information Technology Standards Panel (HITSP) announces the opening of a public comment period for the following HITSP documents:

The public comment period will be open from today, Monday September 29, 2008 until Close of Business, Friday, October 24, 2008. HITSP members and public stakeholders are encouraged to review these documents and provide comments through the HITSP comment tracking system. The documents and the HITSP comment tracking system are accessible through http://www.hitsp.org/

All Panel and public comments received on these documents will be reviewed and dispositioned by the HITSP Technical Committees (TCs) in preparation for Panel approval in December.
HITSP members and public stakeholders are encouraged to work with the Technical Committees as they continue the process of standards selection and construct development. If your organization is a HITSP member and you are not currently signed up as a Technical Committee member, but would like to participate in this process, please contact jkant@himss.org

Friday, September 19, 2008

In humor there is Truth

Eight something years ago, I got my start in healthcare, and quite a bit has happened since. I'd like to make a point here at the close of my third international HL7 working group meeting. Nothing has been made more apparent to me in the nearly six years I've been participating in HL7 activities than the fact that these are some of the funniest, serious, geekiest, and incredibly intelligent people to work with.

Members of HL7 have a pretty good sense of humor, most of it self deprecating, and I'd like to share some of that. About two years ago, HL7 held an international working group meeting in Cologne, Germany. Cologne is the home of the Dom Cathedral, an immense and inspiring piece of architecture.

This led to many comments on the similarity and differences between the DOM and the HL7 RIM, some of which I share below:

One is a relic from another century, the other is a church.
Both are built on firmly held religious beliefs.
One is stable.
One is built on solid architectural principals.
One of them actually gets used.
Both have been around for centuries.
Both are eternally under construction.
Both provide rites in a language that is nearly impossible to understand.
You can use either to look down on people.

These are hysterical, and in some ways, quite painfully true. HL7 is presently reengaging in trying to connect with its users, and has a new vision.
Its name is SOA-Aware Enterprise Application Framework (SAEAF -- pronounced safe). I'm not sure why we need a new name for principles that many organizations have been using for years, but that also seems to be geek behaviour.
SAEAF needs a bit of work (especially on the name), but what I've seen so far is very good stuff, developed by some really intelligent people. I won't try to explain SAEAF today, but as HL7 and I learn more, I will.
Feel free to add your own analogies between the DOM and the RIM, or see if you can draw new ones between some feature of Vancouver and HL7.

Tuesday, September 16, 2008

Presidential Politics and Healthcare IT

I never expected to attend an international standards meeting in a foreign country and then hear, in the plenary session, a political message from the US Presidential campaign. In an ideal world, standards and politics don't mix. The world I work in is far from ideal, and nothing brought that home more than the political messages of the US candidates compared to the messages presented by Canadian Health Infoway, British Columbia, The EU, Brazil and Singapore. We got to see the healthcare infrastructure that benefit the patients in those regions. The US "report", as it were, brought home how badly behind the US technical infrastructure is for providing healthcare.

Speaking as a volunteer for the McCain campaign was Stephen Parente, PhD, MPH and MSc. He presented the McCain plan for healthcare in four points.
  1. The first incentive is a $2,500 / person, $5,000 / family tax credit. The credit would be paid for by adjusting (removing?) the tax exemption provided on healthcare benefits. It wasn't clear to me whether that meant for individuals or corporations, but I'm sure you could read the McCain plan elsewhere on the web. Stephen asserted that this would be a break even prospect over 10 years. In part the reason it would break even is because the tax credit would be adjusted upwards on the rate of inflation in general, rather than the rate of healthcare cost inflation. In later discussion on this topic, the question of "single payer" came up, and Stephen responded that culturally the US was not ready for that step yet.
  2. Common to both plans was to guarantee access to healthcare for all. I was unable to determine from Stephen's presentation much more beyond that. He did indicate that this would be a fairly large investment, atypical of past Republican initiatives.
  3. Stephen spent some time making the point that the cost of the "same" health insurance plan in different states varies, by as much as 100% in cost. This is due to legislation passed in 1945, before the internet and the mobile populations that we have today. Large corporations have an ERISA exemption to this act. So, this incentive would make it possible for patients to purchase health insurance across state lines.
  4. The last incentive was unclear to me.

In discussions of the opportunities for Healthcare IT related to this plan, Stephen mentioned that the tax incentive could provide some opportunity. He did make the point that spending by consumers based on the tax credit would still be subject to consumer choices. He thought that one opportunity would be to develop a Health card that would enable the exchange of clinical information. He also discussed using and sharing of data available to payers through attachments, such as labs, with other providers, possibly enabled in some way through health cards and authentication technologies available in them.

When I asked a question about how the McCain plan would impact the ongoing work of ONC, including AHIC, HITSP, CCHIT, NHIN, and HISPC, Stephen responded by saying that this "is an open discussion that needs to happen."

Speaking as a volunteer for the Obama campaign was Blackford Middleton, MD, MPH, MSc. Blackford's presentation included highlighting of the three points of the Obama campaign. However, he stared first describing some of what the problems were. Many of us in the standards space have seen this data before, but using it seemed to show some awareness of the audience.

The three key points he touched on included:

  1. All access, and in presentation of data on patient satisfaction with the current system, made the point that US patients are ready for change.
  2. Modernization of the healthcare system. Included in this part of the presentation were some studies reporting where some of the costs are and where the benefits of EHR use go (most of it to others than providers). As part if this point, he discussed the investment of $10B in healthcare IT over 5 years, an investment on par with some of the topics presented by other countries in that session.
  3. Lastly, Blackford discussed connecting healthcare IT providers and public health, focusing on more wellness, instead of illness.

Blackford, when asked the same question about the role of ONC et. al., felt that the role of these organizations would be strengthened under the Obama plan. The opportunities for healthcare IT were discussed under point #2 above.

I found some interesting points in both presentations, but am far from an impartial observer, as I'm pretty well known as a liberal Democrat with regard to healthcare issues. I'll repeat the admonition that opinions mentioned in this blog are my own, and not those of my employer, or any of the organizations the I volunteer with. Some of my own observations follow:

Stephen needed to be introduced, as he's not necessarily well know in HL7 circles. His discussion of Healthcare IT, health cards as an opportunity for fixing the problems, and use of payer data, showed to me disconnect from the work of HL7. He did use the "Attachments" keyword, but that's only one part of a much bigger picture. When I asked the question about ONC and the alphabet soup, I felt his response was a little like a deer caught in the headlights. I found myself strongly questioning how a $2500 / adult tax credit could "trickle up" into investment in Healthcare IT. I also found myself further questioning how a tax credit that simply shifts money from an employer tax exemption to my pocket would change my overall healthcare costs. Those additional expenses need to be paid for in some way, and that will either come out of my benefits or salary increases, or will impact employment.

Blackford is already well known in Healthcare IT circles. He connected with the audience first by reporting on some of the reasons that we need to invest in Healthcare IT. His slides included geeky references to Star Trek and Dilbert. He had a much better story on the opportunities for Healthcare IT for this audience, and I personally think, for patients as well. Blackford is helping to create AHIC 2.0, and is well aware of the role and work of ONC, HITSP, HISPC and CCHIT in the US. Blackford did not discuss the details of the Obama plan, however, a complete document from the Obama campain describing those details was present in the program materials. I wish the McCain campaign had been smart enough to do the same.

Overall, I enjoyed the discussion of the US campaigns approaches to healthcare, but also have to question whether this was an appropriate use of HL7 member's time. If this had been a meeting of the HL7 US Affiliatiation (an imaginary body), I could see where this would fit. Given that this is the Plenary of HL7, I have to question the approach. Next time I'd actually like to see a presentation from what I still like to call the US National program, which would be much more comparable to what we saw from other HL7 member delegations.

Thursday, September 4, 2008


What do you do when two industry segments with overlapping constituencies decide to go in different directions with respect to standards?

It used to be the case that market forces would eventually work this out. This leads to a win/lose zero-sum game, as I've mentioned in the past. One standard (and vendors and providers who've adopted that standard) win, and others lose (as do the patients of those providers).

Who benefits from this competition? One can argue that we get better standards that way, just like we get better products from competition, but history shows this isn't always the case.
If we go back a decade or more, can we really say that VHS was technically any better than BetaMax? I've seen a number of technical arguments for the Beta format, but what really drove the success of VHS was that the suppliers of that technology had better marketing and penetration at the end.

Can anyone who purchased an Blu-Ray format DVD say that they've benefited from competition? Folks who purchased Blu-Ray format may have benefited, but actually, while the competition was going on, they really lost out on a wider selection. How about HD DVD player vendors and owners? They all lost out.

My current windmill tilt has to do with competing standards for medical device communication as used in the home. Two organizations that I work with are pushing different approaches. One organization is looking at an approach that would utilize standards already used elsewhere in healthcare for medical device communication to apply them to home health. Another organization is looking at applying some new technologies and existing standards in a way that hasn't been done before in a new market segment. There are benefits and disadvantages to either, few of which seem to be related to technical capabilities.

From a technical perspective, it appears that either solution communicates the information needed. My hope is that the two organizations will go work it out with each other for a while. They agreed today to do just that, after 2 hours of lengthy discussion today. We'll see what they come up with.