Resolving Conflicts

I just finished a week in a class focusing on leadership skills. I found one of the presentations especially valuable to my current work, and with the permission of the instructor, am sharing some of that content with you.

The session I'm referring to was on Conflict Management, and referred to five different approaches to managing conflicts.  One of the conflicts that I'm presently trying to "manage", has to do with disconnects between ONC's S&I Framework, HIT Standards Committee, HL7 and IHE.  Now, for me to say that I'm managing this conflict would seem rather arrogant.  The point is not that its my responsibility to "manage" it, so much as it is my goal to do what I can to ensure that the current situation improves.

Before I explain my main point, I want to give you a little bit of background that I got from the class.  As I mentioned, there are five different approaches to conflict resolution that were addressed in the class.  These are shown in the diagram below (which is my depiction of what the instructor showed us):

Each of the five techniques has two different properties that help you determine when they are effective.  One has to do with the stakes or risk inherent in the situation.  The other has to do with the importance of the relationship.  This shows up on the two axes of the image.  High cooperation is important when when the relationship is important, lower when there is less importance in the relationship.  High competition is present when the stakes or risk are high, lower when the risks or stakes aren't as important.  I've tried to shade the graph to show that there is a continuum, and that the different techniques really identify different places in this continuum.

Technique	Stakes/Risk	Relationship
Avoidance	Not High	Not Important
Accommodation	Not High	Important
Compromise	Moderate	Somewhat Important
Compete	High	Not Important
Collaborate	High	Important

Looking at these three techniques, and evaluating national HIT Standards needs along with the important of the relationship between these national groups (ONC and HIT Standards FACA), and HL7 and IHE, it's pretty easy to assert:

1. The stakes are very high for everybody.
2. From the HL7 and IHE perspective, it's very clear that the relationship between ONC and the HIT Standards committee is very important.
3. I would hope that the national groups (ONC and the HIT Standards Committee) would feel the same way about the importance of the relationship.

If we are all agreed on that, then it becomes very clear what ONC, IHE, and HL7 must do, and that is collaborate.  I believe that these collaborations are beginning to take place.  If you look for example at the work done by IHE for updating XDS Metadata to support Direct, and from HL7, where they are continuing with the CDA Consolidation effort, I see some effective efforts at collaboration.  But, I still want to see more. 

There's another way to look at the five techniques.  We can, for each party, look at "What's In It for Me" (WIIFM).  If we look at each of these conflicts as a game, there are different kinds of games being played, with different outcomes.

Avoid is I don't care and you lose.  Accommodate is I don't care and you win.  Compromise is we both care, and both win some and lose some.  Compete is we both care, and I win and you lose.  None of these are ideal outcomes when the risk is high and the relationship matters.  Collaboration is the only technique that allows both parties to win.

Let's all win.

   -- Keith

P.S.  I speak about IHE and HL7 and ONC and HIT FACA, but I realize that those aren't the only parties in this game, they are simply the parties that I usually interact with.  I'll reiterate, we all need to win, and we all need to collaborate. 

Time for "The Talk"

I was twittering a bit with @SusannahFox of Pew Internet fame, about data on teen use of "Dr. Internet". They don't have any data yet (but who knows, maybe they will soon). After thinking about it, I decided that it was time for another one my children's dreaded (not really) "Daddy Lectures." This one will about how they use the Internet with respect to health information. Key points will be, how to use it safely, what to do if it freaks you out, and who to talk to if you don't want to talk to mom or dad. I really don't think this will be a problem for my kids. They know quite a bit already about how to use the Internet safely, and to check out what they learn for veracity. My daughter rarely if ever spams me with the junk her buddies send about the latest virus scare or Internet scam. My eldest has even learned my innoculation trick (harvest e-mails from spam, and send back the facts). The key point for her, is as she reaches the age where her body is changing, she may become more curious about health issues related to that. So, we'll have a deeper chat about "Dr. Internet" and its limitations, and her need to use adults and doctors to help her filter the information. Oh boy, just what I needed this week, another pitch to prepare ;-). [I'm in training all week, learning to give pitches, and at the same time, just booked three new ones for the next three weeks]. Well, back to my homework, two pitches to give tomorrow.

Finding Related Documents

This question showed up on the ihe-xds-implementors Google group (that group is an excellent resource by the way, for those implementing IHE XDS and related profiles).

While I responded to the question on the group, I've also come across a different interpretation of the graph, and I also think the answer deserves a bit wider audience.  Assume that you have the following documents registered in an XDS Registry:

Here is one interpretation of the graph:  

The original document was addended 3 times (by AppendDocument1, 2 and 3).  Two of the Addenda were replaced by subsequent versions (AppendDocument11 replacing AppendDocument1, and AppendDocument31 replacing AppendDocument31).  Without arguing the potential for this occuring, the querant asks:

Is there a way, given any of these documents, to query for all of the relevant documents associated with it.

Fortunately, under this interpretation there is.  Each addenda is to the original document, and would maintain an APND relationship back to the original document, and so could be obtained by calling the GetRelatedDocuments query on the Original Document.

There is another interpretation of this graph:

This is one where AppendDocument11 and AppendDocument31 append to AppendDocument1 and AppendDocument3 respectively.  In this case, there is no query, because what you are asking for is the "closure" of the APND relationship to be queried for.  There's no simple solution for computing the closure, and so, there is no query to support it.  

Does it make sense in this case, to addend an addenda?  I don't think so, and XDS remains quiet on this idea.  

Now, if instead, AppendDocument3 and AppendDocument31 had instead been ReplaceDocument11 and ReplaceDocument111, the next question would be:  Could you get to the entire document chain.  Again, because you are looking for closure over the RPLC association, the answer again is no, there is no single query to support it.

So, my rewording of the question to IT Infrastructure is this:  Should there be a query created, say "GetDocumentHistory" that gets all documents in an APND, RPLC, XFRM or XFRM_RPLC relationship and the closure over all those relationships to discover the complete history of a document (that could be executed from any document in the tree).  It remains to be seen whether a Change Proposal will be submitted on this topic.  

I wouldn't be hugely in favor of it for one main reason:  The functionality exists in XDS today to get the history WHEN you need it through one or more queries in a deterministic fashion.  In a well implemented systems with what I think are good policies (e.g., don't allow people to addend and addenda), the need to use those calls should be infrequent.  The use case; as I see it for the main functions supported by an XDS registry for HIE is very limited for "GetDocumentHistory".  I see no reason to add that complexity until there is a better use case for it.  

Note:  I can imagine a better use case, which is to compute metrics over documentation tree complexity in an HIE (an operational measure that might be useful).  But for that case, I would see this not as a CP, but as a profile proposal for an additional query (or queries) to support computing this and other operational HIE metrics efficiently.  And if I wanted the debate to really get interesting, I'd ask someone to show me the operational quality measures that they want, and what evidence base is for their use. 

The pause that refreshes

Where am I this week? In training -- on the receiving end for a week.

 This morning we spent half the day on communication styles. I apparently have an action oriented, emotive style -- they call it expressive.  Though on the survey I score somewhere between action oriented, and querying. That's actually a matter of training rather than proclivity. This morning's session was a review for me. I had similar training back in 1994, and I recall at the end of that, we each tacked at 2-blocker with a dot in one corner showing our "quadrant" up in each cube, as a reminder to other team members as to what their style was.

It was quite a fun session, and I might even have to turn my colleagues onto it. I'd forgotten about half of what I learned the first go-round.  After that team finished it's project, we were sent off to other projects, and the skills just didn't stick without the reinforcements we had set up for ourselves.  I'll need to try that again differently.

Yesterday was almost a whole day on communicating to leadership, with half the day spent on one communication tool, and the other half split over several others. I gave myself an extra homework assignment and applied several of those tools to my CDA R3 = HTML5 + Microdata idea. I've got to redo some things on my next presentation sets for them.   I realized that A) my first approach followed the pattern very well, but B) there were some gaps with respect to obstacles, and so now C) I simply need to readdress the gaps, reapplying what I just learned, rather than re-communicate the whole idea over again.

Today our class got to see how steam turbine generators are made.  It was like being live on the set of How It's Made, only for really BIG stuff.  Very cool.

In other news, I prepared a paper for a W3C workshop that Compares CDA Release 2.0 with HTML5 and Microdata (NOTE: If you are thinking about attending, sorry, the price of attendance was submitting a paper, and that deadline already passed). My paper was not only selected (which means I get to attend), but was also chosen for presentation. So now I get to tell some W3C geeks about what CDA has that HTML5 and Microdata are missing.  I've definitely missed my early XML days with some of those folks, even though I was much more on the periphery of XML standards than I am in Healthcare standards today.  After the workshop, I'll share more details.   Thanks, BTW to Gerald Buechelt at MITRE who alerted me to the workshop in the first place.  It was truly timely.

One example for missing pieces in HTML5+Microdata is a schema spec. I've been perusing JSON Schema lately, and I think that it simply needs to be reversed engineered back into HTML5 + Microdata as a format for Microdata schemas. That's just so sickly recursive I want to kick myself.

So, I've been off twitter mostly, and barely writing here.  The last two posts were "pre-recorded" on Sunday when I arrived.  The rest of the time I've just been a sponge.  It's been interesting thus far.  One person I sat next too yesterday was legally able to fly by himself before he could drive, and now designs and (flight) tests jet engines.  That's the kind of crowd I'm sitting with this week.  It really isn't all that more intense than the usual gang of people that I hang out with, because they are all super-smart and capable, too.  But very few of these folk do anything at all with Healthcare.  For a week, that can be really refreshing.

Table of Example UCUM Codes for Electronic Messaging Now Available

Good stuff from Regenstrief (as always)!

---

The LOINC Development Team is very pleased to announce the availability of a new table of example UCUM codes for use in HL7 and other electronic messages: http://loinc.org/usage/units

This is a draft enumeration of The Unified Code for Units of Measure (UCUM), designed to make it clear what the UCUM syntax would produce for specific unit patterns in electronic communication. This table was compiled by the National Library of Medicine, National Institutes of Health, U.S. Department of Health and Human Services with content contributions from Intermountain Healthcare and the Regenstrief Institute. You can read more about how this table was developed in the Preface that is also available from the LOINC website.

---

We hope you find this new resource helpful. As always, we welcome feedback...just send your comments to: loinc@regenstrief.org
Happing LOINCing!

Daniel J. Vreeman, PT, DPT, MSc
Assistant Research Professor, Indiana University School of Medicine
Research Scientist, Regenstrief Institute, Inc

Security, Masking, and Legal Signatures in CDA

A while back I made a statement about how "Masking" interferes with the wholeness and legal authenticity of a document that has been signed in CDA.  Someone recently asked for clarification on the point that I made:

The main problem with "MASKING" as it were are that in implementing such an infrastructure you are interfering with the wholeness and legal authenticity of the content being viewed. 

So, to clarify:

1. In CDA, the legal signature attests that the provider has legally signed (and is thereby taking responsibility) for the content in the whole document.
2. That signature does not necessarily apply to the provider taking responsibility for a "MASKED" version of the document, as masking could eliminate critical information.

What the signature means in this case depends on how one interprets the applicable policies. 

Two other questions were also asked:

1. What is the legal authenticity of a CCD?
   
   CDA documents need not be signed, but can be.  A CCD does not require a legal signature, that is up to organizational policies.  A couple of other points: The signature of a CDA document (and thus a CCD) is not a "digital signature".  Instead, it is an "electronic signature".  The latter is merely a mark indicating that a signature has been obtained.  The former is a strong mathematical proof that it was obtained.  For more information on using digital signatures with CDA documents, see two excellent posts from John Moehrke:
1. IHE Privacy and Security Profiles (a detailed Bloginar on several security related topics)
2. Signing CDA Documents
2. Does a CCD have to be diplayed in its entirety?
   
   How the CCD is used depends upon also upon organizational policy.  The advice I give is that if the use case is to "summarize the encounter" to a human, to display the whole content, but there are plenty of other uses that may not have that same requirement, such as medication reconciliation.

In all cases, the actually resolution of these questions would need to be addressed by local policy.  Local policy is a phrase you will frequently hear security geeks use to mean:  Governing laws, regulation and the procedures instituted by organizations to implement them.  Essentially that means that the CDA and CCD specifications do not set forth what is the "legal authenticity".  Those decisions are made in courts.  They do however, support procedures that enable others to establish the "legal authenticity".

Comments on CLIA/HIPAA Harmonization (Patient Access to Labs) NPRM

Monday a week ago, HHS announced the publication of a new proposed rule titled: CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports.  John Halamka wrote about it this Monday, and you can find a copy of the Federal Register publication.  Because of the HL7 Working group meeting, I'm a bit behind on writing my review of this rule, so here it is:

Quoting from the summary:

This proposed rule would amend the Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations to specify that, upon a patient’s request, the laboratory may provide access to completed test reports that, using the laboratory’s authentication process, can be identified as belonging to that patient.

The summary goes on for a couple more sentences, but when I read this I nearly cheered out loud at the HL7 Plenary session.  The CLIA regulations and state laws have prevented many HIEs from providing patients with access to their lab results because of either real or perceived regulatory requirements under CLIA and HIPAA laws and regulations. In many cases, HIEs that have been the desire to share results so have implemented complex workflows to "work through" the requirements of these and local regulations.

Again quoting the NPRM:

Under the current regulations at § 493.1291(f), CLIA limits a laboratory’s disclosure of laboratory test results to three categories of individuals: the ‘‘authorized person,’’ the person responsible for using the test results in the treatment context, and, in the case of reference laboratories, the referring lab. Authorized person is defined in § 493.2 as the individual authorized under State law to order or receive test results, or both. In States that do not provide for individual access to the individual’s test results, the individual must receive his or her results through the ordering provider.  

Table 3 in the NPRM shows how this would impact labs (and patients) in the various regions of the country, and table 6 shows which state laws would be overridden (see *'d columns below) by this new regulation.

TABLE 3—IMPACT OF PROPOSED RULE CHANGE ON LABORATORIES
Impacts laboratories		Does not impact laboratories
No State law	Allows test reports  only to provider*	Allows test reports  to patient	Allows test reports to patient with provider approval*
Alabama	Arkansas	Delaware	California
Alaska	Georgia	District of Columbia	Connecticut
Arizona	Hawaii	Maryland	Florida
Colorado	Illinois	New Hampshire	Massachusetts
Guam	Kansas	New Jersey	Michigan
Idaho	Maine	Nevada	New York
Indiana	Missouri	Oregon	Virginia
Iowa	Pennsylvania	Puerto Rico
Kentucky	Rhode Island	West Virginia
Louisiana	Tennessee
Minnesota	Washington
Mississippi	Wisconsin
Montana	Wyoming
Nebraska
New Mexico
North Carolina
North Dakota
N. Mariana Islands
Ohio
Oklahoma
South Carolina
South Dakota
Texas
Utah
Vermont
Virgin Islands

While I can get mine (with provider approval), my mother cannot get hers at all direct from her lab.  The new regulation would change that for both of us.  I would no longer need my provider to approve, and she can get them where she couldn't previously.

What follows is the text of the rule with markup (underlines = insertions, strikethrough = deletions):

---

Title 42—Public Health 
PART 493—LABORATORY REQUIREMENTS
1. The authority citation for part 493 continues to read as follows:
Authority: Section 353 of the Public Health Service Act, secs. 1102, 1861(e), the sentence following sections 1861(s)(11) through 1861(16) of the Social Security Act (42 U.S.C. 263a, 1302, 1395x(e), the sentence following 1395x(s)(11) through 1395x(s)(16)).
Subpart K—Quality System for Nonwaived Testing
2. Section 493.1291 is amended by—
A. Revising paragraph (f).
B. Adding a new paragraph (l).
The revision and addition read as follows:
§ 493.1291 Standard: Test report.
* * * * *
(f) Except as provided in paragraph (l) of this section, test results must be released only to authorized persons and, if applicable, the individuals (or their personal representative) responsible for using the test results and the laboratory that initially requested the test.
* * * * *
(l) Upon a patient’s request, the laboratory may provide access to completed test reports that, using the
laboratory’s authentication process, can be identified as belonging to that patient.

Title 45—Public Welfare
PART 164—SECURITY AND PRIVACY
3. The authority citation for part 164 continues to read as follows: Authority: 42 U.S.C. 1320d–1320d–8; sec. 264, Pub. Law 104–191, 110 Stat. 2033–2034 (42 U.S.C. 1320d–2 (note)); secs. 13400–
13402, Pub. Law 111–5, 123 Stat. 258–263.
4. Section 164.524 is amended by revising paragraphs (a)(1)(i) and (ii) and removing paragraph (a)(1)(iii) to read as follows:
§ 164.524 Access of individuals to protected health information.
(a) (1) * * *
(i) Psychotherapy notes; and
(ii) Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative
action or proceeding. and;
(iii) Protected health information maintained by a covered entity that is:
(A) Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. 263a, to the extent the provision of access to the individual would be prohibited by law; or
(B) Exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR 493.3(a)(2).
* * * * *

---

For all the preamble and commentary, it's really a very small, but hugely impactful set of changes.  There's been some notable reaction to this rule in the industry, and it was even discussed on today's HITsm chat.  There seems to be two reactions:

1. Patients should not have access to the information before their doctor does.
2. Patients should have access to their data in the same form that the doctor does.

These are sometimes presented as being conflicting statements, but I can see where both can be met under the new rule.  The provisions of the HIPAA access rules allow for up to 30 days for a provider to respond with the information.  A lab can easily insert a small administrative delay to ensure that providers have had time to review results and contact patients without any problems under HIPAA.  Some have suggested a 3-day delay.  I believe that physicians also have a responsibility to provide patients with not just their interpretations of the results, but also the data that they have.

Like John, I see this as being a terrific change that will open up more access to patient data.

IHE XDS for mHealth access to HIE

I submitted (late) a proposal to the IHE IT Infrastructure workgroup a proposal for an IHE Profile titled XDS for mHealth.  I was graciously given time by the planning co-chair to present it even though it was submitted late, to allow the committee to understand it, and determine whether or not to accept it as a late submission.

The committee did agree to accept the proposal through the process, and so now I'll explain it a bit using the same presentation materials I used this morning, just reformatted for this blog.  The next step is to see if it makes the prioritization cut at the October 11-12 IHE ITI Face to Face meeting.  There are 3 other profile submissions and documentation maintenance work to consider.  Ensuring that the committee has identified resources who are willing to work on it is very important in this next step.  After that, it has to make the technical committee cut with respect to "do-ability".  I'll shortly be working on a prototype to show that it is in fact feasible.

If you aren't an IHE member, but want to support this project, join now (it's free).  If you are a member, please show up to the face to face meeting I mentioned above.  I expect there will be T-con access for members who cannot be present at the face to face (there usually is).

  -- Keith

---

Support for XDS in mHealth Evironment

The Problem

•  mHealth platforms are resource constrained
•  SOAP Stack missing or buggy (e.g., WSDL support for Objective C)
• Bandwidth constrained (10Kbps to 10Mbps)
• Limited resources (e.g., memory), often no “back-end” server
• Increasing proliferation of unconnected apps
•  ~9,000 consumer health apps¹ in Apple’s App store
•  ~13,000 by 2012
• mHealth is an emerging market, failure to support this space could reduce relevance of IHE
• Difficult to use XMLHttpRequest for browser-based, multi-platform mHealth apps.

¹Source: MobiHealthNews http://shar.es/HMlff

Use Case

1. Patient sees a specialist for a particular condition.
2. The specialist asks for detailed information from the patient.
3. The patient, not remembering their list of medications, pulls out their mobile device and activates an application.
4. The application queries the HIE and retrieves a list of clinical summaries in date order, from most to least recent (or on-demand medication list document).
5. They select the most relevant document, and it is downloaded to the device.  The application extracts and displays their medication list.

Proposed Standards & Systems

Standards

• XML
• XDS Metadata
• ebXML
• XSLT
• JSON, JSON Schema
• XMLHttpRequest
• OHT APIs (not really a standard, but a place to start from)

Systems

• EHR
• PHR
• Patient Portal
• HIE
• Mobile Device (iPhone/iPad/iPod, Tablet, Android, Smart Phone, Windows Phone, etc.)

Discussion

• There has been substantial work already in simplifying the XML in OHT, that could be used as one basis for the effort.
• Metadata could be transformed from a simplified representation to ebXML representation using XSLT.
• Transactions could be optimized to use W3C standard XMLHttpRequest object.
• Below is one example of how the actors and transactions could be organized:

IHE News: Demonstrate Leadership in HealthIT

Normally, I'd save this release for tomorrow, but the deadline for the HIMSS showcase registration is this Friday!

---

Dear IHE Community,

IHE N.A. Connectathon Registration Closes September 30, 2011

The IHE North America Connectathon 2012 will take place January 9-14, 2012, in Chicago. Fast-track your organization’s EHR system, medical devices or drive down the product life cycle and implementation cost and register for the 2012 Connectathon. This year profiles from nine IHE Domains will be tested at the Connectathon: Anatomic Pathology, Cardiology, IT Infrastructure, Laboratory, Patient Care Coordination, Patient Care Devices, Quality, Research and Public Health, and Radiology. Learn how to participate in the IHE N.A. Connectathon 2012 by visiting IHE USA’s Participant Resources or review the Policies and Guidelines document. Connectathon System Registration is closing soon- Register before Friday, September 30, 2011.

HIMSS12 Interoperability Showcase Contracts are due by September 23, 2011

For healthcare providers today, the need to purchase and meaningfully use standards-based interoperable health IT solutions tops their list of mission critical challenges. And the HIMSS12 Interoperability Showcase™ will top their list as the number one place where they can find practical solutions to their unique needs—offering real world case studies  from EHRs and PHRs, Radiology PACS and RIS systems, to public health registries and health IT infrastructure services. Space in the HIMSS12 Interoperability Showcase is Limited! Contracts are due by September 23, 2011. To learn more visit the HIMSS Interoperability Showcase website or contact the HIMSS sales staff.

IHE Patient Care Coordination Technical Framework Volumes and Supplements Published

This apparently got stuck in my inbox. I should have published it a couple weeks ago.  Document links are to the PDFs that were published:

---

IHE Community,

IHE Patient Care Coordination Technical Framework Volumes and Trial Implementation Supplements published

The IHE Patient Care Coordination Technical Committee has published the following Final Text Technical Framework Volumes as of September 9, 2011:

·       Volume 1 (PCC TF-1): Integration Profiles

·       Volume 2 (PCC TF-2): Transactions and Content Modules

The committee has also published the following supplements to the Technical Framework for Trial Implementation as of September 9, 2011:

·       Antepartum Profiles (includes APE, APHP, APL, and APS)

·       CDA Content Modules Supplement (was published on 2011-09-02)

·       Emergency Department Encounter Summary (includes CTNN, EDPN, NN, and TN)

·       EMS Transfer of Care (ETC) – has been deprecated

·       Immunization Content (IC)

·       Labor and Delivery Profiles (includes LDHP, LDS, and MDS)

·       Newborn Discharge Summary (NDS)

·       Patient Plan of Care (PPOC)

·       Postpartum Visit Summary (PPVS)

·       Reconciliation of Diagnoses, Allergies and Medications (RECON)

·       Transport Record Summary Profiles (includes ETS and ITS and replaces ETC)

These profiles will be available for testing at subsequent IHE Connectathons.  The documents are available for download at http://www.ihe.net/Technical_Framework.

Comments on all documents can be submitted at http://www.ihe.net/pcc/pcccomments.cfm.

Virtualization vs. Fair-Share Scheduling

I was cc'd on a very kind e-mail the other day that was sent up my management chain.  I won't duplicate it all, but the essential points are below:

You may know he was virtually EVERYWHERE at our recent ... conference, which is turning out to have been a crucial meeting in elucidating future roadmaps  ...  I strongly suspect he was in multiple sessions speaking AT THE SAME TIME.

He goes on to ask about sharing our standards expert cloning or virtualization technology.  I wish such a thing did exist because I often want to be two places at once.

This keeps cropping up in my life.  I got my boss yesterday to agree to send me to a conference on HTML5 that I want to go to.  It's not the usual line of activity for me, so that was a big win.  I forgot to check my calendar, because I have other commitments to IHE that week that I must attend.  IHE has to win because I already have that as a prior commitment.

This summer, the Query Health Summer concert series ended in a big bang the SAME week that the CDC Public Health Informatics conference was going on in Atlanta.  Not one presentation at that conference addressed Query Health (which has Public Health as the first of its stakeholders).  Does holding "concerts" the same week that a key audience is going to be out of town make a lot of sense?  I didn't think so.

National Health IT week was last week in Washington, DC.  So was "International Health IT Week", otherwise known as the HL7 Working Group Meeting, in San Diego, CA.  We might as well have been worlds apart.  And it's not like the timing of the HL7 meeting was a well hidden secret, these meetings are scheduled a YEAR in advance.

Yesterday I had to chose between attending the second of two Query Health calls, or being on an HL7 EHR call to promote a project for developing a functional definition for metadata used in Health Information Exchange.  It was an unfortunate choice to have to make, because both calls were of great interest to me.  If I had virtualization technology, I would have been in both places at once.

Today, I have to chose again between a Query Health call, and a CDA Documentation Workgroup call because they were knowingly double-booked.  Fortunately, there is another cochair to run the latter, and I'm going to attend the former.  I truly hate it when the same organization forces me to chose between two of its own activities.  It really demonstrates a failure to effectively use valuable volunteer time.

This isn't a standards problem, or a problem due to lack of available, standards based solutions that are freely available to the public.  What we really need is a public calendar of activities affecting HealthIT that is managed and curated.  I've mentioned this idea to a few folks at ONC.  I hope they can do something to help.

We all have day jobs and pre-existing commitments.  It would be great if we could coordinate schedules better to enable folks to honor them and participate in S&I Framework activities at the same time.  Perhaps ONC has some virtualization technology for standards geeks that they are willing to share...  Until then, we'll have to go back to the age-old, time honored tradition of scheduling jobs in a fair-share scheduling system.  After all, it's one thing to be an impatient conveigner with a perhaps slightly higher priority, but another altogether to hog all of the CPU.  After all, the S&I Framework is simply a source of Health IT solutions, but not the only one.

Adventures in Plumbing

One of the disadvantages of working from home is that after a long day, you are right there to address challenges around the house.  Today's after hours challenge was the upstairs toilet.  Besides the fact that the flusher has been finicky lately (it sometimes needed two or even three tugs on the handle), the fill valve would no longer shut off.  So I was constantly running water.  This is a major distraction downstairs where I can hear it running.  So, I went off to the hardware store.

Now, as every do-it-yourselfer knows, every project requires three trips.  First to collect the parts that you think you need.  Second to collect the part or tool you didn't know you were going to need.  Finally, to get the part you should have known you needed but decided you could do without, or to get the part that you broke putting it all back together.  I joked about this with the hardware store clerk.  He said in parting, "See you later!" with a grin.  I was bound and determined to avoid three trips.  So after disassembly, when I couldn't get the big nut off the bottom with my hands, and couldn't find my wrench (yes, there is a tool for that), I improvised a big wrench with a C-clamp and a block of wood.  No way was I going back 3 times. So I won, and got it off.

Getting the fill valve off was a lot harder.  The problem was that it was still attached to the tube that went down to the shut-off valve.  That tube connects to the shut-off valve with a compression fitting.  It was much easier to disconnect that then the ancient and corroded metal pipes that came from the bottom of the fill valve.  Try as I might, even with all the right tools (how many people have 50-year-old plumbers wrenches in their basement), I could not budge the corroded pipe.  Hacksaw I thought, but that meant I was going to need another connector from the shut-off value to the fill valve.  Still, it's only two trips I though.  So off I went.  The clerk and I had another discussion about the number of trips as I purchased a universal connector.  This is the last piece I need I declared.  I thought about getting new washers for the tank bolts, but I had plenty of washers in my tool kit at home.  We joked about breaking hacksaw blades when I explained to him what I was up to next.  I told him I had three hacksaws and plenty of spare blades.

So, I started hacking off the fitting on the fill valve.  After a few minutes of hacking, I got nowhere, sure enough, that blade was very dull.  So I replaced it with another blade.  Off it came easy.  I put everything back together and then began to test fit the new connecting pipe to the shut-off valve.  It didn't fit.  The connector was WAY too big.  Dang it, I thought.  This is supposed to be a universal connector.  But this piece doesn't work.  I remembered some adapters that I still had left over from my dishwasher installation.  I went down to find them only to discover they were the wrong gender.  They were male-to-male or female-to-male,. but I needed a female-to-female size reducer.  I came back upstairs.  I looked at the tube.  This packaging I was about to throw away but saved in case I needed to return it was sitting right there.  "I swore this said universal" I declared, holding it up.  Out fell a bag of three female-to-female adapters.  One of them was the right size and I managed to nearly finish the job.

I reassembled everything, did a test fill, and everything seemed to work.   Then I flushed.  Clean water went everywhere.  I'd forgotten to put back an important rubber washer at the base of the new flapper.  So I disassembled again, put that back on, and reassembled.  It worked, but I had a drip.  And I couldn't find washers of the right size.  The clerk laughed at me when he saw me return.  This is the last trip I said.  Don't worry he said as I departed, we close in another half hour.  You still have time if you need us.

So, I put on the new washers, tightened everything down, and ruminated on the adapters.  Of course I saved the extra parts, I always do.  You never know when you might need one of those things again, and it could save me from that third trip to the hardware store.  Having the right adapter in place for the right purpose is a really good idea.

I'll be proposing a new profile proposal for IHE IT Infrastructure next week.  It's essentially like that  plumbing adapter.  It supports connecting mHealth devices to an XDS Registry/Repository.  It accounts for the fact that on those devices, you don't often have access to a SOAP stack, and that simpler XML would be easier to work with as well, as the best you are likely to have is an XMLHttpRequest object.  That is after all, a standard fitting. Perhaps IHE should have an adapter for that in its toolbox.  We'll see how it goes.

     Keith

P.S.  My wife is calling me.  I need to go re-tighten those bolts.  She hears leaking.  I hope I get it right because the hardware store is closed now.

FY 2012 ICD-9-CM Vocabulary Now Available from CDC

Greetings,

CDC Vocabulary server (PHIN VADS) has been updated with the latest version of ICD-9 CM (FY 2012). This version will be effective from Oct 1st 2011.

CDC PHIN VADS Download Files / Links:

(a) ICD-9 CM Diagnosis - Vol 1 & 2

       - Download File (Excel Spreadsheet)

       - PHIN VADS hyperlink provides metadata needed for HL7 messaging such as OID's.

(b) ICD-9 CM Procedure - Vol 3 

         - Download File (Excel Spreadsheet) 

         - PHIN VADS hyperlink provides metadata needed for messaging such as OID's,

Source file for ICD-9 CM codes have been taken from Centers for Medicare & Medicaid Services (CMS). CMS publishes the ICD-9 Codes with short description, long description and ICD-9 codes without decimals. For electronic data exchange, it is recommended to use the ICD-9 codes without decimals. CMS also publishes the updates (New, Revised and Deleted codes) which may be useful for implementers of ICD-9 CM (link).

CDC Vocabulary team have published the ICD-9 CM FY2012 which includes the ICD-9 codes with and without decimals. We have also created a preferred name that includes long description and ICD-9 CM code with decimals.

Leading and trailing zeroes are important which could be truncated by Microsoft Excel, if the columns are not formatted as "Text". We have imported the ICD-9 CM codes in a spreadsheet for your convenience with the following fields:

Example:

(A)  ICD-9 CM Code without Decimal: 24900

     -concept code to be used in electronic data exchange including HL7 messages.

(B) Short description: Sec DM wo cmp nt st uncn

(C) ICD-9 CM code with Decimals: 249.00

 (D) Long Description with ICD-9 CM Decimal Codes: Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified [249.00]

Thanks

CDC Vocabulary Team

PHINVS@CDC.GOV

Quality is not only in the domain of the EHR

One of the challenges with quality measures that I've mentioned previously on this blog is fitting it into the provider workflow.  The example used in the illustration previously has to do with aspirin and heart attack.  Other challenges have to do with quality measures around Venous Thromboembolism (VTE) and Stroke.

The problem that EHRs run into is that in order to measure quality, you need to know about certain condition specific data. Yet this data is often very hard to codify in an EHR.  I delve into some discussion on contraindications and exclusions in Quality Improvement Never Ends that I wrote last week.  And I also tweeted a statement someone made at the CDC Public Health conference.  Farzad Mostashari asked for some details in a response to that tweet, so here they are.

I'll first go back to some of the work that HITSP did on VTE and Stroke.  There are some key data elements used in exclusions for these measures:

• Comfort Measures Only
• Elective Carotid Intervention
• VTE Prophylaxis
• Reasons for No VTE Prophylaxis

Where would you find these data elements in an EHR?  We were challenged to find a code for comfort measures in SNOMED CT.  You might find a procedure code for Carotid Intervention, but would you find whether that was elective or medically required?  Whose definition of elective would you be using?  An insurers?  Someone's guideline?  If so, from where? Next up: VTE Prophylaxis:  There are three types, medication based, device based, or compression stockings (arguably a device as well).  OK, how is this routinely coded in the EHR?  Medications certainly are coded using RxNORM, but looking through ICD-9-CM (Procedure codes used in a hospital setting), I have trouble identifying codes for application/use of VTE prophylactic devices.

On reasons for no VTE prophylaxis, think about how the data would get there.  A provider very well versed in treatment of patients who are at risk for VTE but aware that prophylactic measures are contraindicated would have to take an extra step to indicate why the weren't indicated for a patient.  I'm not saying it shouldn't be done, but often workflow questions like these about "what didn't you do and why" don't get raised during the implementation of an EHR, and so the data doesn't get captured.  And it wouldn't necessarily be built in because in some settings, it might not even be needed.

Looking at the specific question of HAI, one of the components in the HAI report is the location of care.  This is documented as using the NHSNHealthcareServiceLocationCode code system.  This is a very detailed code system.  More detailed in fact, than is often used in patient registration systems.  Patient Registration systems, I also note, are not necessarily the same as the EHR, and while they may be connected, might contain information such as patient location type that isn't accessible through EHR capabilities.

Another example is in the "Infection Condition Observation".  In this case, the type of infection being reported also has detailed coding.  Some of the condition codes include superficial/deep primary/secondary surgical site infections.  Note that there are not even SNOMED codes at this level of detail, and it often wouldn't be captured in the EHR.  Instead, this information would be captured by the infection control officer in a separate Health IT system devoted to the capture of detailed information for HAI reporting.

So, there may be a system that is able to capture data at this level, but it is a system that is used by one or two specialists within the entire facility, and I would be hard pressed to call this an EHR system.  Thus, I quoted the speakers statement:  Data needed for HAI reporting are not typically captured in an EHR.

Personally, I might amend that statement if I weren't quoting someone else to clarify that "Some data" needed for HAI reporting ..., but for the most part, it is a true statement.  The EHR doesn't solve every healthcare problem.  The EHR is but one component of an ultra-large-scale system.  We need to be aware that there are other components in this system beyond the EHR, and that the EHR will not solve every single Healthcare IT problem by itself.  In fact, the HAI specifications produced by HL7 were specifically created for systems used by infection control officers.

Google-

I'm still not a big fan of Google+.  When I need to engage, I need to engage in as many places as possible.  G+ makes that extremely difficult for me.  I have to take extra steps to engage there.  Sure, I could hook up a set of tools and write all of my posts in G+, but then I'd need to switch away to access the other social networks where I have existing engagements to keep up with them.  I can't access them through G+.

Instead of making it easy for me to remain engaged with my already established social communities, they've decided that they want to own them.  But they, like me, aren't leaving the services that their own constituencies have already adopted.  Basically, it's like changing your phone number because you just changed phone companies.  Google Dudes/Dudettes ... how 20th century of you.

The other challenge I have with G+ is that because each plusser gets one and only one channel that I can see, I don't get to pick and choose which channel I want.  It's like being forced to watch Fox news because I also like to watch Bones.  That's a pretty steep price to pay.

On Twitter I have two channels.  One is very personal.  About 10 people see it.  The other is where I engage in my own advocacy for Health IT and change in the Healthcare system.  Some of my friends subscribe to both channels, and have chosen to.  But with Google Plus, I don't have the option of letting my readers pick which "Keith" channels they want to listen to.

I made a similar switch on Facebook not long ago.  Originally, I was on Facebook to connect with online friends and family from time to time.  Soon, my standards colleagues from around the world found me there.  I let one in, then another, then another ... and so on until I couldn't find the content that was the reason I was there in the first place.  So I "unfollowed" anyone not in my circle of friends, and created a new Facebook account for that other persona.  I then requested friendship with all the people I just "defriended" from the new account.  Having made that separation, I expanded my twitter tweets into that other Facebook space.

When I want to share something on G+, I feel like I'm back in high school.  It's not circles, but cliques.  I have reading cliques, and writing cliques.  What I read comes from one, what I write goes to another.  Something that is posted on G+ is stuck there.  Like Wes, I know the feedback I make is limited to the group that it is shared with, and sometimes I want to broaden the discussion.  I can reshare, but that's another click, and doesn't let those not on G+ get access to the discussion.

I'm glad that G+ released their API, and disappointed that it's still read-only.  I can only hope that Tweetdeck won't be too far behind with an update to support it even if it is just read-only right now.  At least then I can get back to one tool for monitoring all my social networks, instead of simply ignoring G+ most of the time.

My last complaint about G+ is being able to find good content.  It seems that people haven't yet figured out cliques well enough to enable meaningful sharing, and for some reason, G+ is unable to let me set good search Filters.  That just doesn't make any sense at all.  I like Twitter, I can see what I'm subscribing to before I subscribe.  For some folks, I'm willing to deal with a noisy channel because the occasional gold-nuggets are truly valuable.  For others, I'd rather not listen.  I want the ability to share widely and listen cautiously.  G+ just doesn't give me what I want.

Making Connections

My brother died because of a medical error: he was effectively anesthesized to death.  There error was in the construction of the new ED that he was admitted to, and the oxygen and anesthesia lines became mixed.  I like to believe that this sort of error could not possibly happen today.  I haven't thought of him in more than a decade.  He died more than three decades ago.  I thought about him today because I was on a round table discussion for the Kaiser Permanente Total Health Blog this morning.  When asked what topics the blog should speak to, one commenter talked about gag orders in settlements for medical errors, and a petition to stop the practice.

There was no gag order in my brother's case; As the news already had it, no gag order could have been imposed.  .  My parents found out because of a front page news article published in the local paper.  I found out because a friend told me about the story (my family had tried to hide it from us, I was 12 and my younger brother 9 when it happened). My brother probably would have died anyway without the mixup.  My parent's anger at the situation was more about how they found out, and the new grief imposed upon their children because of it.  If the hospital had contacted them, and told them about the mistake, they might very well have been forgiving.  My father would have no part of the money.  It was, as he called it "blood money". That settlement paid for my brother's education, and mine.  I like to think that the real justice in that was that my education  (such as it was) led me to the place that I am today, and that what I do in Health IT standards to prevent similar mix-ups in communication between providers that could equally as harmful.

One of the discussion topics that went on during the round table was the idea of connecting diverse communities into and around total health.  As @ReginaHolliday put it, you really cannot tell if a person driving a trash truck wouldn't have an interest in #HealthIT.  From my perspective, I never would have expected an artist to have an interest in the topic either.  But so she does, as I well know.

What I do know is the importance of these social connections that I make across diverse backgrounds.  I'm not a doctor, but every now and then I jump onto #MDchat just to see what Docs are saying.  I've become myself a member of the Society for Participatory Medicine because of my connections with other engaged patients.  Listening to what they are saying is vitally important to what I do.

The value of creating a connected, diverse community around the topic of total health is a terrific one.  After all, it is through community that we can make a better world.  The connection I made this morning is one that might not have happened had it not been for the round table discussion this morning.  It renews my spirit to rediscover part of my past that I had forgotten, and to see after thirty years a resolution that my father, also departed, might be proud of.  And damn it, yes, I am crying.

Rambling from the HL7WGM

Lots of new irons in the fire this week.  Like Grahame's Resources for Healthcare proposal, the HTML5 + Microdata proposal is gaining traction.  Not overwhelming support like Grahame's work, but significant forward momentum.  I'm working on updating a Project Scope statement for ITS to review in a subsequent meeting.  I now need to reach out to my former standards community (HTML and XML geeks), and start really coming up to speed on what is going on in that space.  I just finished writing a position paper I hope to present next month at a W3C Workshop in the Boston area comparing HTML5 + Microdata with CDA Release 2.0, noting the gaps and opportunities.

I will also be presenting an EHR Functional Profile proposal to the EHR TC next week to rapidly develop a functional profile supporting metadata expression requirements for exchange with HIEs.  This is an action item that the HL7 Policy Advisory Committee (PAC) will put into their response to the ONC Metadata ANPRM that I've written about several times over the last few weeks.  Many committees have provided input to the PAC's proposed response to that ANPRM, some were working on it even before the committee requested feedback.

One very quick and easy win this week from the PAC perspective was the recent HL7 announcement that it has taken ONC's Pledge for Non-Data Holders, and its encouragement for members to do the same. There will be an HL7 newsletter article going out on that soon as well.  This happened relatively quickly, the time between ONC announcement of the pledge, my presentation of the proposal to the board, their response and announcement through a press release was under 48 hours.

On other notes, I will never live down the time we spent talking about a real problem implementers have raised, and which I commented on in the CDA Consolidation ballot, about how to deal with people with only one name (now dubbed the "Rock Star" problem).  I don't mind, we now have sufficient guidance I can point to.  One time might be an oddity, but this was a question I have seen from three different sources in as many weeks.  The answer is pretty straightforward.  Put the single name where your organization requires it to go, and use a nullFlavor for the other components.  Doug Fridsma even had HL7 staff print up a badge with name and organizational details all saying "Not Applicable".  I can deal with it.  In fact, I have a "Rock Star" ribbon for him to place under that badge.  I don't need them any more as I will probably never wear one on my own badge again (at least at an HL7 meeting) ;-)

I taught the CCD class again this meeting.  I've used pretty much the same material for the last 4 years.  I'll need to update it for January, and again for May to address changes in CCD 1.1.  Yes, CCD 1.1 is part of the CDA Consolidation Guide activity.

There are yet more irons in the fire.  I have a mobile-health profile proposal to present in a couple weeks to a very hard audience, the IHE IT Infrastructure workgroup.  It addresses a use case for software stack constrained platforms often used for mHealth applications that want to access information from a Health Information exchange.  I expect lively discussion.

Having just finished teaching CCD to a group of students, I have to prepare for my next teaching event.  IHE will be offering a day of CDA training (limited seating) to members after the November Face-to-Face.  This will be a new class because my goal will be to teach members how to create CDA-based IHE profiles.  That should prove to be an interesting combination.  By offering members this opportunity to enhance their skills, I'm hoping to scale up.

BIN Counts in X12 and Canonicalization

Someone complained to me the other day about a problem transmitting claims attachments between systems.  While I don't usually get into X12 transactions, this is one that I'm pretty familiar with because it was a topic of great concern to the Claims Attachments SIG in 2007.

You see, attachments use EDI formats to exchange information.  Many of these systems still use "big iron", and translation between ASCII on one end and EBCDIC on the other, and visa versa are common.  This was a challenge because carraige return/newline pairs in one environment get translated to single characters in another, and so forth.

The X12 BIN Segment has two parts, the binary data, and a count of the length of that data.  The challenge is that the whitespace is being changed from 2 characters to 1 or visa versa.  And then when the system outputs the record in the new encoding, the length is off.  This problem is clearly stated in the 275 transaction that contains a BIN segment:

It has been noted that line constraints, transfer protocols ... may insert additional control characters ... If this occurs in BIN02, the senders stated count in BIN01 may no longer be equal to the received content of the data in BIN02.

This is a truly big challenge, because if BIN02 count doesn't match BIN01, business logic set up to detect errors could wind up rejecting the response to the request for an attachment.

There is an even more sinister problem in XML.  There are three different valid ways to represent the character A, each with a different length.  Once as the letter A, another using a decimal character entity, and the final as a hexadecimal character entity.  As far as an XML processor is concerned, all three are the same.  And then there are different character sets that an XML processor must support.

This would seem to provide a challenge for creating digital signatures, but XMLDSIG addresses that with the Canonicalization Algorithm.  The algorithm ensures that the digital signature is computed over the same content by ensuring a consistent octet stream is used for the computation.

In X12, the BIN01 serves a similar purpose as a digital signature.  It is a "check" that the data has not been modified (but it doesn't support non-repudiation or any other cool features of XMLDSIG.  Canonicalizing Base-64 is simple.  Ignore any whitespace.

Given that the specification notes the disparity, I would presume that receivers are expected to deal with it.  So, give an innaccurate count to start with.  Don't count the whitespace because it doesn't matter.  Better yet, use the octet length of the original CDA document.  The challenge here is that senders and receivers would have to change the counting algorithm for the BIN segment to make it ignore whitespace.  That might be hard, but the only other solution I can think of is to upgrade the operating systems and hardware.  I haven't run into an EBCDIC to ASCII issue in years.

The next Ad Hoc Award will never be repeated ...

Long time readers of this blog probably understand the rules.  For new readers, it's very simple.  I am the sole arbiter and judge.  There is no nominating committee, but nominations are certainly welcome.  I won't award more than one a year for the same kind of service (and since this nominee is unique, I'm certain that won't be an issue).  I try to keep the number of awardees to five per year (no reason, as I said, the rules are arbitrary).  In general I try to give awards to folks who would not otherwise be recognized for their contributions.  One tradition is that I have given out an award on the same day that the HL7 Ed Hammond awards are announced.  Not so much to compete, but more to build on a trend.

I don't see how the current award possibly could be duplicated; ever.  As I mentioned previously, I just finished reading Ten Faces of Innovation.  This next recipient is a collaborator extra-ordinaire, but even more importantly a story teller of unsurpassed skill in both word and deed.  I first learned about this individual when I watched the HHS announcement of the Meaningful Use regulation.  This awardee has done a great deal to raise the awareness of Health IT to patients across this country, and even Internationally.  Their work has seen HL7 appear in circles that nobody would ever expect.

Without further ado, I proudly welcome the next recipient:

This certifies that 

Regina Holliday, Patient Advocate and Artist

Has hereby been recognized for outstanding contributions to the forwarding of Healthcare Standardization through Art.

Regina, welcome to "The Riding Gallery".

For those of you who don't know Regina, see her blog for some truly amazing story telling in both art and print.  I'm a very proud member of The Walking Gallery which she created to raise awareness of patient needs.  Her work was recently featured on the cover of The Illustrator's Journal.  If you look closely at the upper right hand corner, you can see a reference to HL7.  If you happen to be at HL7 this week, and want to see an example of her art, I'll be wearing it.

Quality Improvement never Ends

I had an interesting discussion over dinner with an expert on quality measures earlier this week.  They spoke about how in quality measures, there appears to be a tendency to complicate the measure with exclusions.  There are many reasons to add exclusions to a measure.  I'll take an easy to understand example:

In treating patients with heart attacks, research has shown that amount of time between the event and being given aspirin is related to survival and future re-occurrences.  So, a quality measure could be developed to ensure that patients are given aspirin as early as possible in these cases when it is appropriate.

Now, there are a number of reasons why getting aspirin might not be a good idea for all patients in this case.  For some, they may have an adverse reaction;  for others, there may be other contraindications, such as concurrent use of other medications.  One could ask for exclusions for this reason or that reason because giving the patient aspirin might not be possible, or aspirin may not be in supply, et cetera.  So the measure can continue to be refined with more and more exclusions.

But what is the point?  The point of the measure is to improve the quality of care, not to enable organizations to get a perfect score.  Why do I say that?  Where do you go after you've reached 100%?  Surely those patients who are excluded from the measure are impacted by the issue.  Is it OK that we are able to provide quality care only to those patients for whom we have treatment for?  Surely not.  Quality improvement never ends, but the 100% score seems to indicate that there is the notion of "perfect quality".

As we get into the details, and start drilling into the last percentage points, do these additional exclusions really improve the measure?  I'm certain that there are other details about how care is provided in the institution that have a greater influence on the care that a patient receives than these small adjustments.  As you look at these measures and begin to compare them against those of other institutions, does a half a percentage point really matter, or are we into the statistical noise?

What about the complexity and cost?  Adding refinements to the measure requires capturing additional data that could make it even more costly to implement.  Which measure has more bang for the buck?  The one you can implement today, or the one you can implement next year?  That is another important consideration.

After all, perhaps the most important thing to think about in measuring quality is whether your quality is headed in the right direction.