On Codes

Recently, a request came in to change some of the codes for an HL7 Vocabulary (specifically the < and > codes in ObservationInterpretation). The complaint was that these characters must be escaped in XML.  

This spawned the usual deluge of e-mails about proper ways to generate identifiers for codes.  The best practice according to the erudite vocabularists is to use meaningless (semantically void) code values.  This, everyone agrees, is the best practice for managing code systems.  Well sure it is, when you have thousands of codes and nobody is ever expected to have to interface with the code system directly through code values.  But when you have a small code set, or one like ICD where people are expected to interface with these identifiers directly, mnemonic, or at least easy to remember code identifiers make sense, at least for the people who have to use them.

The only absolute I ever learned that hasn't failed me yet is that there are no absolutes.

   Keith

P.S.  I've never had to escape those codes when creating XML, or any other special character for that matter.  If you have to worry about XML syntax in your code, you are doing it wrong.  Use a tool, don't write it manually.

Not necessarily an ePatient

There are days when I feel like an outsider to the ePatient movement.  An alien looking in.  I may show up in a list of e-Patients somewhere, but I'm not really a patient, because I get paid to work in healthcare (or so the theory goes). But I feel like a patient, and I act like one. In my day to day work, I think first like one. At the same time, I've been told in no uncertain terms that I can't be, because I work for "The Man", and am a cog in the wheel of the healthcare industry. Others, even more supportive of patients are thrown in the same boat, because they too are part of the system.  And God forbid you should be an MD, except with some very good supporters in the wings.

I've seen the healthcare industry be dumped on because it doesn't properly engage with patients.  Over the past year I've seen numerous conferences and industry events picked on because the don't respect patients enough in some way. They don't offer patients scholarships, or make the prices affordable for patients, or have patients on the organizing committee, or as speakers. Provider organizations, ACO's, HIE's, et cetera, are all at fault because patients aren't present.

At the same time, I know how to do things on a budget. I know of many organizations that I can join for free, and some for as little as $30 a year that provide me with a great deal of inside track information. Geeks like me don't get to go to every conference then want to.  I'd love to go to AHIMA, AMIA or MedX, but they are unlikely to be on a list of conferences I'm approved to travel to (maybe when I become Chief Geek). Yet, I know many ways to get into a conference that don't require me (or my employer) to foot  the bill. You want to get into a conference for free, the way the pros do?  Offer to speak, and not at the last minute (a couple of weeks beforehand), but 6-11 months before when the call for speakers or papers goes out, and have a good message. Or get someone to fund you to go. If you represent a stakeholder group and they cannot fund you, are you really representing them without any of their skin in the game? Or are you just pretending to?  If you have a message to send, and you aren't getting on the right agendas at the right time, whose fault is that? The organizers?  Or yours? If you aren't at a conference to provide a message, then you are there to take one back. If the take-away is something you cannot share, should you be expected to pay less for it than anyone else?  I'm not so sure about that.

Equipped, enabled, empowered and engaged is the motto. Be it. Don't ask for a free ride, or complain when it isn't given. Find a way; learn the landscape, and engage back. Figure out who to talk to and when to talk to them to be effective. Stop whining, and start doing.

In some ways, I think as an insider, my job is a lot harder.  I have to weigh every decision against what it means to take home a paycheck, and still figure out how to do the right thing, in a way that works for everyone.  A simple "patient" can argue that they should be supported, and everyone will clap, and nobody above them exists to care about the business impacts of that message.

But insiders like me, we've got to sell that to an audience that doesn't want to hear it, and make it march, and sound like a good idea for them, and the upper-ups.  Let's see, what was that message?  Oh yeah, "Spend less money on healthcare, and provide it better and cheaper". Back in the day when I sold computers out of a retail storefront, we had an expression that explained how that worked.  You see, we sold below cost, but we made it up on volume.

Now, I'm not saying the healthcare industry is right, or that things don't need to change.  But what I am saying is that it isn't whether you are an insider or not, or a patient or not, but rather what you do and the message that you send that matters.  And if you want to be tagged as a "Patient", go for it, but at the same time, work it like a pro would, you'll be far more effective.

Thank you

I get thanked an awful lot for my work on CDA, and it feels good to be thanked.   But my work wouldn't nearly be so meaningful (no pun intended THIS time) if weren't for all the people who are implementing the standards that I work on.  So, to all those implementers, thanks for doing what you do, and keep up the good work.  

Oh, and Happy Holidays to everyone!  And may you all have peace, at least for a week.  I promise that ONC won't release anything tomorrow [not that I have any control over what ONC does, I just know the FR will be closed].

BREAKING: Dr. Karen DeSalvo announced as new National Coordinator

This showed up in my inbox this afternoon.  You can read a recent interview with Dr. DeSalvo here.

---

From: Sebelius, Kathleen (HHS/OS)
Sent: Thursday, December 19, 2013 11:19 AM
To: OS - Political Staff; OS - ONC Feds (HHS/OS)
Subject: Important Staff Announcement

Colleagues,

I would like to announce that Dr. Karen DeSalvo, who currently serves as the City of New Orleans Health Commissioner and Senior Health Policy Advisor to Mayor Mitch Landrieu, will be the next National Coordinator for Health Information Technology here at the Department.

During her tenure, Dr. DeSalvo has been at the forefront of efforts to modernize the New Orleans health care system. Following Hurricane Katrina, for example, she led projects to increase access to care by augmenting the city's neighborhood-based medical homes for low income, uninsured and other vulnerable populations in the New Orleans area.

Throughout her career, Dr. DeSalvo has advocated increasing the use of health information technology (HIT) to improve access to care, the quality of care, and overall population health outcomes –including efforts post-Katrina to redesign of the health system with HIT as a foundational element. She served as President of the Louisiana Health Care Quality Forum, the Louisiana lead for their health information exchange and regional extension center grants. She has also served as a member of the Steering Committee for the Crescent City Beacon Community grant.

As the New Orleans Health Commissioner she has made the increased utilization of HIT a cornerstone of the city's primary care efforts and a key part of the city's policy development, public health initiatives and emergency preparedness. Further, she has led the planning and construction of the city's newest public hospital, which will have a fully-integrated HIT network. Her work as commissioner has led to positive changes to the way healthcare providers deliver care to their patients, improved accessibility and outcomes for patients, and improved the health of all New Orleanians. Dr. DeSalvo is a graduate of Suffolk University, Tulane Schools of Medicine and Public Health, Harvard School of Public Health.

Dr. DeSalvo's hands-on experience with health delivery system reform and HIT and its potential to improve health care and public health will be invaluable assets to the Office of the National Coordinator and the Department. I would also like to take this opportunity to thank Dr. Jacob Reider, the Acting National Coordinator for his leadership of ONC during this time of transition. I am pleased she is joining our committed team, and ask you to join me in welcoming her to HHS when she starts on Monday, January 13th.

Sincerely,

Kathleen Sebelius

A Catalog of Meetings

We all participate in far too many meetings.  I thought if maybe we could catalog and number the different kinds of meetings we participate in, it might help us prepare better for them.

1. About the Recent Crisis:  This meeting includes every possible stakeholder, and is called by leadership to yell about the current crisis, and scramble to try to solve it.  If you are busy solving this crisis, skip the meeting, because what you are doing is far more productive.  However, it is considered good form to send a nice e-mail to all involved letting them know why you won't be present.  To avoid a command performance, it helps if you misspell the meeting leaders e-mail address in your response.
2. The Weekly Status Meeting: Judy and Tom will spend half the meeting time having a conversation they should have had in the hallway before the meeting started, while the other six of you check your e-mail, read your RSS feeds and respond to urgent requests.  Tim's presentation which is planned to occur at the end of the meeting will have to be delayed until next week because we ran out of time. Everyone else, please be sure to respond to your manager's latest e-mail on being sure to complete whatever it was before the close of the quarter.
3. The Kickoff Meeting:  That new project that everyone has been preparing for over the last three weeks is now going to be officially kicked-off by management.  That means all time is now billable. We will have 45 people packed in a room (or on a webex) while the leaders present slides that those of us who have been around a while have all seen at least seven variations on.  This meeting is mandatory for everyone.  This is a good day to take some personal time off for that Doctor's appointment you've been meaning to have.
4. The 15-Minute Stand-up Meeting: Delayed due to technical difficulties, and for some reason, Mary didn't get the e-mail, so could someone go track her down?  Oh, and we need Jim today too, can you see if he is on Skype and let him know to dial in?  Oh yeah, the meeting number, isn't it in the e-mail?  Sure, let me read it off to you.
5. The Quarterly Report: Things are going OK (or getting better), we did about as well as could be expected in this market, and for the most part, senior leadership thinks they will earn their bonuses for the year.  Thanks to George and Liz who worked really hard closing that last really big deal we should have had at the beginning of the quarter, for saving all our butts.
6. Replanning: The sky is falling, the project is late, how are we going to deliver on the original schedule?  We need to double down our efforts and improve our efficiency to make this better and reassure management that we know what we are doing and that we won't be late.

If you should need to schedule any of these meetings with me, please simply order it by number, and I will respond appropriately.

WEBINAR: Learn More about ONC's Proposed Certification Timeline Join ONC on Wednesday, December 18 for a webinar discussion regarding the proposed regulatory timeline for EHR certification criteria for 2015. Web Conference Information Conference Line: 888-469-1748 Meeting Number: 243-89 ONC subject matter experts will provide information about the new timeline and then will be available for a question-and-answer session following the presentation. Agenda ·         Certification of EHR Technology: Proposed Certification Regulatory Timeline Steve Posnack, Director, Federal Policy Division, Office of the National Coordinator for Health Information Technology   ·         Q & A Steve Posnack and Nora Super Register Now! Sincerely, Nora Super Director, Public Affairs Office of the National Coordinator of Health Information Technology

Predictions on the MeaningfulUse 2015 Certification Criteria

You've all probably heard by now that there's going to be a change to the Meaningful Use Stage 3 roll-out. This new strategy allows ONC to advance on Stage 3 in a step-wise fashion, without the all-or-nothing commitment to new standards present in prior years.  So, what is in store?  I don't have any real inside track knowledge, just the same awareness that everyone else could have if they participate in standards development activities.  These are my guesses.

1. Blue Button Plus: Let's face it, with all the discussion going on around patient access, and the really close proximity of V/D/T to Blue Button Plus already, this one is just a no-brainer.  I'd be surprised if it wasn't included.
2. Laboratory Orders: The S&I Framework Laboratory Orders initiative has resulted in the HL7 Publication of a new implementation guide on Laboratory Orders.  It's a good bet they'll want to try this out before making it a requirement of stage 3.  I'd say this is a pretty solid bet.
3. HeD and VMR for Clinical Decision Support: Why kill yourself trying to get something done quickly if not to use it?  Thus I predict that HeD and VMR will be included in the 2015 criteria.  I'm fairly certain these two will make an appearance.
4. HQMF Release 2 for Quality Measures:  Quality Measures released by CMS have been structured using HQMF Release 1 since the start of the Meaningful Use program.  Release 2.0 of that DSTU makes them computable from within the EHR.  Another pretty solid bet, but tempered by the fact that I've got a lot personally invested in this project, and may be more hopeful than reality might otherwise suggest.
5. What is CCDA Release 2.0 for $357 Alex.  I'm somewhat dubious here.  Yes, I think ONC wants it, but I'd be very challenged to understand how it works alongside the currently selected work, especially as an optional certification.  You'd have to support the 1.1 version as well, because some systems will only work with that.  Yes, the structure is mainly the same, but the way that it is identified that makes it challenging. I'm hoping ONC treads carefully here, but I'd give this one even odds of being in the proposed rule, and some small chance it could drop out in the final rule.

My bets are placed.  How about yours?

On Influence

Recently, I was asked to explain my role in terms of the processes I use.  The idea seems almost as oxymoronic as the phrases "creative process", or "innovation process".

For example, what is the process for being influentual?

Looked at properly, as a process that takes some time to execute, it can be explained in part:

• Associate your self with activities that will be influentual (so that some of that rubs off).  figuring out what activities will be influential includes:
• guessing (in an informed manner)
• being lucky,
• and influencing others to think that it is important by your own behaviors (e.g. implementig, promoting).
• Take on influential leadership positions, and then do the work associated with them.  Note that many working groups are looking for cochairs and facilitators, and that those positions are basically there for the asking (and doing the work).
• Try something innovative and succeed (that may involve failing a few times first, try to minimize that, but don't avoid it)
• Repeat what works and refine it, even if it was unintentional or unplanned (like this blog),
• Don't expect immediate results, but always strive for them.

Does the process work?  Yes, it does, but following it does not guarantee success.  Sometimes there is just too much working against you to succeed.  In that case, just as in poker, you need to know when to fold 'em, and save your bets (and effort) for where they will be more beneficial.

Old Friends and New

This is the fourth time this year I've been to Riyadh.  Briefly, I'm working with the Ministry of Health on their National e-Health Strategy.  It's a huge initiative in this country, with a very long term vision and lofty goals. As part of this project, I've be doing workshops on standards, and how to use them to meet some of those goals with various physicians, nurses and other healthcare and IT professionals.  If you look at the first picture on the link above, and find the Enterprise Standards and Profiles component, I'm working right in the middle of that part of it.  It is extremely interesting and demanding work, especially as you see all of the the various timelines shown in the image below. Imagine having to herd all of those cats.

If I had one think to say about the team who is working with us, its like "Dude, we're getting the band back together."  I get to work again on a national program with many of my friends from HITSP and who have also been working on regional and national and international programs elsewhere.  But in addition to old friends, I've also made some new ones:

Me with the Saudi Healthcare Standards Team

Yes, that's me in a thobe in the middle wearing traditional Saudi garb, next to the Chief Architect also in the middle, with two of the Standards Specialists (a new role in the Ministry I imagine) on either side.  

You may wonder, especially those of you who work in standards where the Middle East and Africa are in Healthcare standards.  Well, they are coming, and these gentlemen are leading the way.  I hope to introduce you to them someday at an IHE or HL7 meeting.

Fhew!

This morning (at 3:00am), I finished my last class in my first term as an Informatics student at OHSU.  I have mixed feelings about it, although I would have to say that mostly, I am quite happy about it.  I'll miss poking fun at Bill at getting hammered by Paul (with homework and readings), and chatting in the forums with other students.

What did I learn?  Wow.

How to be a student again, and what a difference at a personal level wanting to succeed and do well does for learning.  How technology can help or hamper your efforts, and what it means to have to think about dealing with it when you aren't in control of your location.  For example, I was greatly challenged accessing video during the day here (limited hotel bandwidth), but fortunately for me, that didn't interfere with tonight's presentation. It's one of the reasons I didn't object to the time, trying to do a virtual meeting with three or four video feeds is tough on bandwidth.  Also, being prepared with the materials on my iPad helped, and I'd like to thank Bill for getting those Zipped up to make downloading them from home easier.  But those are not the things you probably care about, so let me get to them.

Dr. Paul Gorman's class on the Practice of Medicine was an awesome experience for me in many ways.  I got to look at situations from a different perspective (which is the intent of the class).  Interestingly enough, I was in a very small group of people who didn't have a clinical background.  Most of my classmates probably felt that this material was much easier for them, given that they already had it.  It made me push all the harder to keep up.  Here's a quote from the Syllabus (I would have pointed you to it online, but they are apparently updating it).

Course Description

This course introduces the medical informatics student to the clinical practice of healthcare including

• The underlying biology and manifestations of selected disease states;

• The information gathering and reasoning processes used to detect, understand, and treat diseases;

• The health professionals who provide and support care;

• The clinical settings in which care takes place.

The objective is to enable non-clinicians to understand the context, the vocabulary, and some of
the challenges for supporting clinical work in real settings with informatics tools.

Each week we look a new case.  Over the term, what you have to do for each case builds from the previous week's material.  We also here from other clinicians, including a PA, a pharmacist, and a nurse.  Be thankful you have the web for this class, I cannot imagine any other way to access information more readily.  The OHSU Library also makes some great online resources accessible to you as a student (I might just have to become a lifelong learner for that alone).

My brain is still trying to process all I learned from that class.  When it emerges and I start to synthesize that into my work, I know I'll be looking at things just a little bit differently.  Fortunately for me, I can also remember how things were before I learned something (although it takes a mental gear shift), so I don't expect that I'll go completely "Academic" on you.

Dr. Bill Hersh's Introduction to Informatics class is required material, but I would have taken it anyway.  It's pretty much the same content he uses in the AMIA 10X10 program.  I expect he'll be updating some slides after having me in class ;-), but even so, the material is very good, and valuable even for the Venerated Ancient (see the link under Academic above).  Some weeks I could just breeze through the material and the tests, and other weeks I really had to work at it.  Even so, I spent as more time on the unit on standards than I did on others (for reasons you might guess).  The last week, on Clinical Genomics was the toughest for me, even though I've had some exposure to the field, and work with experts in it in my standards work.  My main challenge was managing time for that last week, but the informatics challenges in that field are also immense.

I'm hoping to be in Riyadh when he teaches the last class of an i10x10 session being run here in person. Already I've run into at least three people who have graduated from the OHSU program, or are connected to it in some way. The first person I ran into (in Riyadh) had assumed that I had graduated from it already, about the same time as he did (14 years ago).  I laughed an explained my background to him.  He laughed as well.

I'm looking forward to next semester (to everything except the bill).  The only thing left inn the term at this point for me is to get my grades.  All my quizzes are complete, paper's finished, and finals are turned in, well in advance of the deadline.

Now I have to get back to work for my next deadline.

Timey-Wimey

I said it earlier, I'll say it again: Only ONC could figure out how to extend timelines and move them up at the same time.  This is in reference to the late breaking news article on changes to Meaningful Use deadlines.  Brian Ahier is of course on top of things, but so is Tom Sullivan over at Government Health IT.  The news that Meaningful Use stages are going to be extended to allow for adaptation to feedback is quite welcome in this quarter.  We've heard over and over again that what you cannot measure, you cannot improve.  It seems as if ONC and CMS have figured that out (actually, I'm quite sure they already had, it was Congress who really set the deadlines).

I don't know how this is going to affect reimbursement under the program, but I suspect there will be no change.  After all, the stick is coming, and that's an incentive too.  Also, it would likely take an act of Congress to change the HITECH act, and that doesn't seem any more likely this session than last.

At the same time, now we have the "optional" 2015 criteria to worry about.  Now I understand the rush to press on HQMF, HeD, and CCDA Release 2.0.  Really, though, I somehow wish there could be more transparency around regulatory planning. I'm sure this has been on the inside track for some time.  And that's the worrysome part for me, because instead of having to deal with regulations that would go final in 2016, I now have to deal with regs that are targeted for 2015.

Christmas anyone?  Not at the Office of No Christmas would be my guess.  Ah well.  I guess I have to take the bad with the good.

What is the purpose of XDS formatCode

There's a big discussion on the FHIR list serve about formatCode, and how to model it in the DocumentReference resource.  I thought I would take a few moments to explain its purpose.

There are a lot of different ways to classify clinical documents.  The first of these is to describe the MIME type.  This allows you to say that the document is in plain text (text/plain), RTF (text/rtf), HTML (text/html), XML (text/xml), PDF (application/pdf) and various other formats.  Back when XDS was written, many of the XML based formats hadn't yet started using or registering the various +xml MIME types following the new conventions.  So we had text/xml which wasn't distinct enough (and still today we have this problem with XML formats).

Document type (using LOINC), and document Class classifies documents in fine and coarse grained ways, the former for detailed classification, the latter for selection among pick lists.  A discharge summary could be in any number of MIME types, and still have the same document type code.

The purpose of formatCode was to distinguish between the cases where type code and MIME type still didn't give you enough distinction.  The problem back in 2004/2005 was very real, as a CDA and a CCR were using text/xml for MIME type, but the Schemas  were very different.  There are other cases where the Schema (big S) could be the same, but the schema (little s) is different, even when using CDA.  Today we have CCD, and two versions of it, the one in CCD Release 1.0, and the other in CCD 1.1 found in the CCDA specification.

One of the challenges with format code is that while we understood the need for it in IHE, it took us a while to figure out the correct use.  The correct use of formatCode is to present enough information to distinguish between two formats, but no more.  In CCDA, there are nine different document types, eight of which are CDA Level 1/2/3 and one of which (the unstructured document) is CDA level 1 only.

For format code, we'd want to be able to distinguish that the document complied with one of the eight document types, and might also conform to the ninth (yes, formatCode could be many -- we restricted it to one in XDS because at the time it was the right thing to do, the concept was new enough that people would have understood it even less if we allowed for many).  CCDA doesn't have a formatCode yet, and that's yet another discussion.  CCDA is an HL7 document, and so HL7 should specify the format code for it.

My recommendation on what that should look like will likely come up on an HL7 SDWG call or on the list serve. The idea is that somewhere within it, it will distinguish two flavors of CCDA, that with structured content, and that with unstructured content.  MIME type will already be the same, but typeCode is enough to distinguish between the nine varieties if we have format code, MIME type, and type code.

The best acts of coordination are invisible

Have you ever been in a room when someone talked about a project they were working on and you pointed them to someone they should talk to, or introduced them, or told them about some other activity they should connect with?

Did someone ever ask you a question that you didn't know the answer to, but went and found it for them?

Have you ever told someone about a project that they might (or should) be interested in?

After making the connection, did you walk away and let nature take its course?

I cannot tell you how many times I've been on either end of that transaction, and how valuable it has been. Often these are small investments of time, and sometimes they pay off big.  My career wouldn't be where it is today for the countless acts like these from many individuals I sometimes find difficult to remember, and sometimes I do recall how deeply I am indebted to that person.

These are invisible acts of coordination, and for those, I thank you.

I know I'm whining...

One of the unwritten rules of the Ad Hoc Harley awards is that I try to award them to people who would otherwise go unrecognized (which reminds me that I have one to do shortly).  It's an unwritten rule like many of them, because I do break it when I feel like it.

Today I saw this post over on Health IT News, and I thought to myself, not again.  Here's yet another case where the media really fails to recognize the real contributors to the advancement of Health IT.  I wasn't at all disappointed to see Regina and Dave on those lists.  However, I was disappointed to find that I couldn't just vote for them.  They represent the real men and women of health IT, undercompensated, overachievers, who've taken their passion to the trenches.  As for the others, they may have done some really cool things, but they are also in a position to do that, and to some degree, when you have C*O after your name, I expect greatness from you.

Maybe someday I'll be an executive and feel differently, but the real work in Health IT doesn't happen on the executive side.  Sure, they have have the vision, but they are also given the power and resources to achieve it.  The people I like to see rewarded are those with vision, and somehow find the resources to make it happen despite the lack of influence they might wield by their position.

It may sound like sour grapes, and in all fairness, I'm sure there is some of that sentiment involved.  But surely somewhere there could be a place where these folks get recognized in a way that is significant, and not just on this blog.  If anyone is interested in taking me up on the idea, I'll even be on the nominating committee.

Paying for Telehealth

This question came up in one of my classes last week:

What do you believe is/are the most likely and important applications of telemedicine/telehealth in the future?

I liked my answer so much, I thought I'd share it.  It's the sort of upside-down thinking that appeals to me.

I see a lot of attention for telehealth being focused on big ticket items, or on issues where distance is a real challenge. While I think these are areas that have a lot of value, I wonder about the smaller things.

I would have loved to be able to care for my daugher's ear infections using telemedicine, using something like this.

I really want to be able to remote home monitoring with an iHealth BP cuff, a Withings scale, or a smart-phone enabled glucose monitor for my wife and be able to communicate that information readily to my healthcare provider so that he can incorporate it into his EHR record.

I'd love to be able to remotely request prescription refills and schedule appointments. I'd love to be able to fill out forms online instead of spending an extra 10 minutes for that at the doctors office. I'd love to be able to pick referrals like I pick flights, with information about both time and cost readily available and comparable.

Yes, I think e-visits would be extremely valuable. A 30 minute consultation with a dietician over webex is something I'd do, whereas it requires a two hour time committment to get the dietician in my physician's practice. And a lot of the stuff I'd spend time as "pre-work" before we actually talked I could do via the internet.

I put a $ value on my personal time, for something I'm disinclined to like, it's more, and for stuff I like to do, less. I'd be willing to spend a bit more money to be able to have access to those services. The other value for these services is to employers. If insurance companies were willing to reimburse primary care providers for these fairly straight-forward telehealth implementations on an annual basis per patient, employers could likely see savings resulting from less use of personal time for healthcare related visits.

For some quick back of the napkin calculations, business receive from $50,000 to $1,000,000 of revenue per employee per year. That's a value of $25 to $500 an hour. Let's say a physician in general practice sees 700 patients a year whose insurers will pay him an annual "bonus" for providing simple telehealth services (half of the low end panel size from this article). Let's say that average revenue per employee is on the low side, but not at the bottom, call it $50 / hour. If telehealth can save two hours of a consumer's time, then the value to the employer is $100. Give up half that to the payers ($50/patient), and give a large chunk of that to the providers ($45). That results in a payment of $31,500 a year to providers. Employers save $100 of revenue a year that would be otherwise lost, pay out $50 of that to payers, and providers get a chunk of money that can go into the telehealth technology, and they'll save time and money too.

Adult Consumer Health Internet Access Trends 2000-2012

I was working on my term paper on Consumer Health Informatics for Bill Hersh's Introduction to Informatics class (it's overlong by about five pages, so I have to make some judicious cuts tomorrow night).  While I was perusing some of the data over a the Pew Internet and American Life Project that Susannah Fox is always promoting (and rightly so).  I wondered about year over year trends on this data set, and so I asked.

@SusannahFox Any data on year-over-year trends for health information access?
— Keith W. Boone (@motorcycle_guy) December 1, 2013

And shortly after, Arien Malec pointed me to the spreadsheet.  While I didn't absolutely have to have the data for my paper, it was just too intriguing to ignore.  I had to know what the trends were.  Now you do to.

Connecting Standards with Academia

I've been outside of academia for most of my career (although that changed recently).  One of my complaints about "academics" is that they are disconnected to some degree from the implementation work that goes on in the real world.  In my own classwork, I find that some of the value I bring to the classroom is that implementation work (with standards for me), and that is also true of many of the students who have been in the field (on other topics) that I'm studying with (be they healthcare professionals or Health IT geeks like me).

In retrospect, I've probably been a bit to hard on "academics" in general (but probably not in specific).

The challenges are interesting.  Academics are interested in developing knowledge.  Standards geeks are interested in taking existing knowledge and producing standard ways of doing things with it.  It's the innovation vs. standards juxtaposition all over again.  Good software developers are trained to reuse or build on existing work.  Academics are too.  However, what is missing here is the intersection of knowledge spaces so that Academics can discover what is going on in Health IT standards development (but not so much in the reverse, as there are enough academics involved in standards development that we get that input).  I think the challenge is that there aren't enough standards geeks in academia for the necessary cross-fertilization of information.

This has been a perennial challenge for standards organizations like HL7 and IHE for quite some time.  ISO seems to be a bit less challenged here, but then, I also find ISO standards to be somewhat less influential in the implementation space, more so in the process space.

Where do academics go for information? Academic journals. Yet, when I search PUBMED for recent articles related to standards implementation, I have a hard time finding them if I don't already know the name of the standard.  They don't naturally float to the top even when you include the term "standard" in the search and use appropriate terms to find them.  In looking through the various ways I could search, I don't find an easy way for these articles (few as they are) to show up where they might be relevant.  Compare this search targeted to find CDA or like standards, with this one that does much better.  You basically have to know who creates Health IT standards to find them.  Otherwise, those books simply aren't in their library.

The literature on standards is certainly lacking (see these searches related to CDA, QRDA and HQMF), but there is also no way to even give it some prominence in the search should someone even have interest in the topic of health IT standards.  It's like going to the automotive parts store and being told that you need the part number in order to get the part, but all you have is a description of it.  It might actually be helpful to add the standards to PUBMED, and to classify them and articles about them in MeSH in a way that makes them more accessible to people who might benefit from that knowledge.

Thanks to Bill Hersh for making me think about this a bit differently, and to Aaron for making me do some work that got me to analyze the issue.

Stupid or Cagey?

When I was in college a few decades ago studying computer science, one of my instructors ran a small software company that made telecommunications (modem) software that ran on the IBM PC.  It was patterned after a rather expensive software package, and nearly cloned the user interface.  The product as I remember it was appropriately called Mirror, or something like it.  The bigger and more expensive guy did what you would expect, which was sue to have the software changed.  My instructor took this battle to the courts, and as a result got a lot of publicity.  When the final judgement was made and went against him, he implemented the required UI changes overnight (which had already been under development since the battle started).  Stupid?  Hell no.  He was cagey like a fox.  The publicity covering the court battle also took into account the price (great) and product capability differential (none).  So he wound up with a lot of free publicity, which meant a lot of increased product sales, which more than made of for his costs in the battle.

Was his (larger) competitor stupid?  Not really.  Their moves were quite predictable, because the choreography of that dance was already laid down in business law centuries ago.  It simply had to play out, and my instructor took advantage of how it had to play out.

Why is this relevant today?  Well, I see another battle going on today where many of the moves are completely scripted in law and regulation set forth decades ago.  We could argue about whether those regulations are the right ones, but that's not really the point.  They exist, and so does the FDA, and it has to enforce them.  Whether or not they make sense.

I'm not certain what the goal is from the perspective of 23andMe, and have no insight as to what their strategy is.  However, it's pretty clear to me that all the FDA's moves are fairly predictable.  And so whatever game 23andMe is playing, it can pretty accurately predict the moves of its opponent, and is doing very little to discuss its next moves.  There are plenty of reasons why 23andMe could be playing the game it's playing that make sense, including publicity and getting policy changes made.  The former may not have as big a payoff as the latter (because the publicity available to them by "winning" a battle with the FDA would be huge), but either could be a rational business strategy worked out by 23andMe and its backers, or they could be looking at something completely different.  I have NO clue.  I do know enough to look just a bit deeper under the covers and see that this isn't a normal game.

I'm going to be quite interested in how this one turns out.  I gave my sample several years ago to 23andMe and I find the service to be pretty useful, and would certainly want continued access to my data.  But I'm not going to make any predictions.  I can only guess at the next move by 23andMe, even though all of FDA's options to that response are fairly transparent.

Empowering Us

One of the real challenges for the e-Patient movement is in the self-sufficiency (or perceived lack thereof) of patients.  Among all the P's in the healthcare environment:

• Payers 
• Physicians
• Providers 
• Politicians
• Policy makers
• Paycheck writers
• Pharma
• Product makers (vendors)
• Professional advisors (consultants)

All of these are considered to be sufficient to protect their own interests.  However, none of them view patients as being sufficient enough to project their own interests, and all of them feel that it is their role to speak for patients.  At the same time, patients (myself included) reject each of them as being adequate representatives of what we truly need and care about (see this list as an example).

As a general rule, patient's don't lobby, testify before congress, negotiate prices, aggregate themselves into societies or groups of like minded people (there are some exceptions for each).

So, how can we (as patients) get what we need?  I have some thoughts on this topic, but would love to hear yours.

My HITThanks

0. Thanks to Jon Mertz for HIT Thanks.
1. Thanks HL7 board and members for making HL7 standards freely accessible to everyone.
2. Thanks IHE staff for the last eight years of supporting me in a cochair role in Patient Care Coordination.
3. Thanks OCR for the memo to patients about OUR rights.
4. Thanks to Bill Hersh for getting me into his Informatics program.
5. Thank you ONC for allowing us to have an uninterrupted Christmas this year.

That last one may be a bit to hopeful, but perhaps if I get it onto the table, it might stick.

When SDOs Collide

The other day, a message like this showed up in my inbox.  You may have seen it also.  Now, the other part of the story is that SDO2 has been doing this kind of thing for years, and is already a leader in that space, to the point that the standard is being adopted by governmental agencies.

So, why would I spend my money this way? Whom does this benefit?  Certainly not my industry.  It might have been helpful if the problem being solved was a) one that didn't already have a solution, and b) needed one.

   Keith

P.S.  What's nice about this one is that I get to sit it out... I'm familiar with both SDOs but not deeply involved in either, and the purpose-of-use isn't my baliwick.  I'm just hoping they can learn from the prior SDO wars we've all seen.

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The SDO1 invites Your Employer to be part of a new initiative to develop a machine-readable content classification standard that will enable the interoperable exchange of Content via System.

The Name of our Proposed Standard Technical Committee will define a Geek-speak-gobbelty-gook comprised of a standards-based vocabulary and content classification ontology.
The group will also collaborate on an eStudly-Capped-Acronym data model and format for exchanging content via the cloud or physical media. eStudly-Capped-Acronym will be designed to support government agency requirements as well as long-term electronic archiving of content.

All purpose-of-use stakeholders are invited to participate in this standard. The work will build on some other Reference Model produced by the yet another Community and on the CamelCasedNameWeCanTrademark eStudly-Capped-Acronym Specification; additional input contributions will be welcome.

As a member of the SDO1 eStudly-Capped-Acronym Committee, Your Employer has the opportunity to influence the development of eStudly-Capped-Acronym as an international standard. You ensure your requirements and use cases are taken into account and promote demand for compliant products.

You are welcome to join the eStudly-Capped-Acronym TC at any time, but in order to secure voting rights at the first meeting on 16 Dec (where a chair or two co-chairs will be elected) you must join by 9 Dec.

SDO1 membership is the only requirement for participation. You may choose between several dues/benefits levels (see link below).

Please let me know if you have questions about the eStudly-Capped-Acronym TC technical agenda or about getting involved in this work. We would welcome your participation.

Hug a Public Health Nurse

I spent half a day today with our town's public health nurse.  After that exercise, I can tell you that's a truly awesome and under-appreciated position.  I learned quite a bit about what a small-town public health nurse does, and their influence on the community.  The job is a cross between direct care, social service, junior filing clerk, senior filing clerk, master statistician, school gate-keeper, public health enforcer, and shoulder to cry on.  There's not a lot of supervision, resources, or space.  At the same time, there's a lot of discretion, and ability to make a difference within a community.

My respect for public health nurses, especially in small towns like mine has increased greatly today.

What's the ROI on that?

I teach IHE profile developers to have a one page attention grabbing slide that shows some numbers that provides the value behind a profile proposal.  It's the "Money Slide", the one that gets people to understand the value proposition.  And it's backed up with someone else's assessment of the value or cost of a problem.

Recently the S&I Framework initiative started a program to improve interoperability between EHR systems and Prescription Drug Monitoring Programs.  Now, this, like just about every other S&I Framework Initiative seems like a good idea. But there's some missing data here, and I'd love to see it.  This is the kind of thing that we should be assessing when we invest in a project.

First of all, let's look at the Charter, where it claims: "Prescription drug misuse and overdose is one of the fastest growing health epidemics in the United States."[1].  The footnote is mine, because the charter didn't include this link to the CDC Report (but perhaps should have).  The next statement: "One of the most promising clinical tools to address prescription drug abuse are prescription drug monitoring programs (PDMPs)" [2],[3] (again my footnotes).  I cannot judge based on the Charter any realistic evaluation of the utility of these programs are, because I don't know how much they cost [4] (see page 7 for estimates), nor how much they save. [5] (see page 4)

Come on guys, this was a five minute post.  You can do better than this.  Show me why an initiative is valuable without making me go Google it myself.  It would boost your credibility when you announce new initiatives.

Try these Google Searches:

• PDMP Effectiveness
• PDMP ROI
• PDMP Cost

Just that little bit might go a long way towards boosting the perceived value of what you are trying to achieve. If you could take it to the next level, and show the current integration and workflow costs that you are trying to eliminate, that would also help.

FHIR Oriented RESTful Services

I'm starting to look at how I'd create RESTfully oriented FHIR services.  I'm looking at using the current FHIR DSTU as a collection of Entity Services.  What I want to focus on next are the Task oriented services which use those entities to supply business logic to perform a particular function.

From a service perspective, the key thing about task services is that rather than focusing on what entities exist, they focus on the logic needed to manipulate them to work on a particular function.  An example of this in Healthcare would be the case of Patient Admission.  In this context, you need to gather a number of entities carrying data about the patient, such as their demographics and insurance information, current problems (e.g., chief complaint and/or reason for visit), and create a new encounter associated with that patient entity (which has to be created in a system if it doesn't already exist, or which has to update existing records for the patient if there are any changes), and then associate the chief complaint, reason for visit or admission diagnosis with the encounter.

A task oriented service could call on other task oriented services as well. Admission has a smaller step of patient registration, and so I'd have the admission service call on the registration service first, and if that succeeded, then call on the remainder of the logic to finish the job.

Defining this simply could be a challenge.  I want to be able to support the same level of ease of definition in creating a task service as FHIR already has for its current set of resources.  From the perspective of how this looks over the wire, what I see is that each service has an end-point, from which one or more capabilities are provided (another part of the endpoint).  So, for the Admission Service, I might have an Admit capability and a Register Capability.

http://server.com/service/admission/admit
http://server.com/service/admission/register

Each of these endpoints would have an "API" as it were, a defined set of required and optional inputs, specified similarly to how search parameters are specified in FHIR for the various resources.

Some inputs might be simple types, such as codes, endpoint URLs, and strings.  Others would be resource references, or resources, or compositions, messages, documents or resource feeds.

Simple types and resource references might be specified as URL parameters in making the call.  Full resources might be specified in the request body.  I'm thinking the request would be a POST (or maybe a PUT).  The response would follow usual HTTP patterns, just a 200 OK if everything did what it needed to, but might also include a FHIR Resource or collection (atom) in response to the resource request.

Anyway, that's what I'm thinking about.

Segmenting Mobile Health

One of the challenges with mHealth as John Moehrke points out, is the variety of solutions which can be described as "mobile health".  And every industry that wants to be buzzword compliant is of course, demanding that its own sector be included in the definition of mHealth.

I see five different market segments in the mHealth space, and various mHealth solutions can fit into each of these segments:

• Mobile Sensing
• Mobile Access
• Mobile Computing
• Mobile Technology (e.g., Diagnostics/Therapeutic tech)
• Mobile Communication

Mobile sensing involves the ability of a disconnected sensor to gather and report on information about a patient, and periodically transfer it to another device. Transfers could be as complex as WiFi and ZigBee, or as simple as a USB Stick or SD Memory card (e.g., C-PAP or Glucose Monitor).

Mobile access is the flip-side of sensing.  It allows the component through which data is displayed, played back or otherwise provided to be mobile.  Chromecast is one example of this kind of technology.

Mobile computing is simply the application of computing power we used to require a room to fill to something that now fits into your pocket or a briefcase.

That same application of technology improvement applied to provide mobile computing can also be applied to diagnostic or therapeutic or other equipment, so that now an ultra-sound device can fit into your hand, or that tests require complex laboratory equipment can now be done on a piece of paper and be made highly portable (at least in comparison to traditional methods), or that other therapeutic treatment can be made more accessible.

Finally, mobile communications is really the elimination of wires, and can involve personal, local, or wide-area networking that is accessed by mobile equipment.  Interestingly enough, most mobile communications involves a great deal of infrastructure that is NOT mobile at all.  It just lets other equipment be mobile.

Google glass is an example of a device that can be used in the mHealth space to support mobile sensing, display/playback (access), computing and communication.  A 2G cell-phone realistically supports mobile access and communication.  A smart-phone (even one using 2G technology) can also support mobile computing.

So, the next time someone tells you that they are a leader in mobile health, ask them to explain what they really mean.  I guarantee that they don't have the entire space covered.

Principles of Standards Selection for use by the HITSC Clinical Quality Workgroup

One of the work items that I was asked to develop for the Clinical Quality Workgroup was to consolidate the principles I presented a couple of weeks ago into a short list of generally applicable principles.

• Fits into the existing/planned architecture
• Meets program goals and requirements
• Is well-suited and/or designed for the purpose
• Widely recognized, well-established, mature
• Has, or is expected to have implementation, adoption and use
• Testable and tested
• Has SDO support
• Readily available w/o encumbrances
• Low Complexity
• Extensible

Building from that are a list of questions that we could use to help with that assessment.

• What is our Architecture?
• The $64,000 question
• What are we trying to do?
• Does our architecture need to change to support that?
• Is this standard designed to do that?
• If not, why is it still a good fit?
• What risks are we willing to take?
• How mature is it?
• If new, does it build on previous knowledge?
• Has it ever been used in real world environment?
• Has it been tested?
• Can I get it today?
• Who maintains it?
• Is it easily and inexpensively implemented?
• Is it future-proof and adaptable to change?

My recommendation is that we present this to the HIT Standards Committee as something that could be considered as a process that is generally applicable.  Also, that a work stream be started to understand the architecture that we have.  I'd love to see a short slide deck presenting a block diagram that shows at a very high level what we currently have, and how the pieces already fit together.  I think the NwHIN Power Team and the Security/Privacy Work group already have the necessary expertise to address these issues relatively quickly.

On the what we are trying to do question, I was asked to explain what I meant by that.  From my perspective the question our workgroup was tasked with amounts to this:
What are the standards that support prospective assessment of what we need to do to provide quality care, and what we need to do to assess whether or not quality care was provided.  We typically call the former Clinical Decision Support, and the latter Clinical Quality Measures.

As I mentioned a couple weeks ago, there is ongoing work to harmonize the CDS and CQM standards within HL7, and we will see some of those outputs in the coming months.  I believe these efforts are better placed to support where we should be headed in the future, and they are a progression of existing standards HeD and HQMF Release 2 that we could start getting experience with in the next round.

   Keith

P.S.  I'm know I'm behind on posting, but I think I've finally caught up with myself.

IHE World Summit 2014

Join IHE International for a conference bringing together stakeholders in health IT with thought leaders on standards, interoperability and electronic health records from around the world. Representatives of health IT and EHR initiatives, administrators of health delivery networks and developers of health IT systems will join leaders of IHE national deployment initiatives to address issues including interoperability, standards, privacy and security, testing and conformity assessment, efficient implementation and sustainability. The Summit will take place at the Rosen Center, attached to the Orlando Convention Center, and will immediately precede the HIMSS14 Annual Conference and Exhibition. Return here for details on speakers and the schedule of events. Registration opens November 25!

Who am I today?

In the standards world, it is quite common for someone to play the roles of subject matter expert, technical writer, or facilitator.  In fact, some of the best SME's I know are also tech writers or facilitators or all of the above.  The best are always very clear about what hat they are wearing and when.  When I write as an SME, my writing style varies from when I'm acting as tech writer.

It's important to understand what role you are playing, and when you are playing it, especially in engagements where you have to wear multiple hats.

When I facilitate, I try very hard not to get into the SME role.  You can shut down discussion in that mode of discussion if you aren't careful, especially when the group you are facilitating isn't as up on the topic as you are.  Sometimes it is unavoidable, and in those cases, I find it helpful to move into a different space, both mentally and physically.

When I read what I've written as an SME with my technical writer/editor's hat on, I can be pretty harsh on myself, but only if I can get the right distance.  Again, I have to change mindsets to do that, and not just physical distance, but time is also an essential part of being able to do that.  After I've finished writing something with my SME hat on, I have let it rest a day or three before reading it again with a reviewer's/implementer's mindset.  And I review in a place different from where I write.

Ideally, I like to work with a team, so that I'm not playing (or even trying to play) multiple roles at the same time.  And, so that I can play the role I'm best suited to, and they can play theirs.  And when I get to pick that team, look out.

Important Announcement Regarding HL7 Ballot Pool Sign Up Date Changes

Below is an important announcement regarding HL7 Ballot Pool sign up dates. Due to changes made in response to the recent ANSI audit, HL7 now needs to close ballot pool sign up prior to the opening of balloting.  This could impact your ability to vote on selected ballots, so be sure to sign up early this time, and get into the habit.

     Keith

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Important Announcement Regarding Ballot Pool Sign Up Date Changes

We want to make you aware of an important change to the ballot signup period for HL7 standards balloting. A recent ANSI audit has prompted a significant change in our ballot pool signup procedure. This change was required to address shortcomings in the way HL7 addresses balance of interest in our pools.

In the past, ballot pool signup for any pool remained open until a week before that pool was scheduled to close; however, starting with the upcoming January 2014 ballot, the ballot pool signup period for any pool will close when that pool opens for voting. This means that for this cycle, with pools scheduled to open on Friday, December 13, 2013, ballot pool signup will close at end-of-day Thursday, December 12, 2013.

What I'm getting out of being an Informatics student (so far)

• A ton of homework.
• An appreciation for what my daughter is going through in school.
• Another 1000 words of writing to do each day.
• A better understanding of what those involved in the healthcare system are thinking when they are doing their jobs.

Priceless.

I think what I love the most is hearing material that I might elsewhere be teaching, or which I've learned through the school of hard knocks being taught in a way that helps me relate to clinicians.  Now I can point to so-and-so's paper which classifies quality measures in three ways, instead of just knowing what the ways are.  Going back to some recent reading on rhetoric, this helps me to establish ethos with my audience.  I enjoy too seeing how others learn the material, and make use of it, and integrate it.  And I am beginning to see ways in my own work that I can change what I'm doing subtly to make what I'm trying to communicate easier to understand, as I struggle with understanding unfamiliar material yet again.

Learning about the practice of medicine, and studying pathophysiology to some degree also gives me a much greater appreciation of what physicians are trying to do, and how information systems that they are using can do the job better.  I'm beginning, just beginning mind you, to get a picture in my mind of what an EHR might look like that is radically different from current models.  It's a start.

    Keith

P.S.  And just for fun, today I got to teach a unit in a class I haven't had yet to some bright software engineers.

I don't get paid for that

Ding!  Someone just pushed the wrong button for me, when I'm tired and cranky and low on sleep and still jet-lagged.  The question is in the handling of a bi-directional PHR, where the physician communicates with the patient, but the patient also has an opportunity to communicate with the physician:

<rant>
Physicians don't get paid for that is a tired argument.

Physicians are in more control of what they get paid for than I as a patient am.  Physicians negotiate the rates that they get paid with various payers.  I'm not included in that loop, and unfortunately for me, other parties looking out for my best interests are in more control than I am in that negotiation.  I have a few choices about which insurers I can use, and I'm one of the lucky ones.  Some folks have precious little choice at all.

I'm not sympathetic to the complaint that physicians don't get paid for that. I pay for most non-preventative services out of my own pocket, based on prices physicians negotiate with someone else.

If you consider the cost to the physician of the three calls necessary to get a prescription refill in terms of office time, vs. the cost of an online patient update, and subsequent approval of the prescription in the office, that should be a no-brainer. And that's just the calls we made, there were two or three others from our pharmacy. There's no payment for that, but the change to the physicians bottom line should be obvious.

What about the repeated entering of all that history? WIth a bidirectional PHR, I could (and would) enter all that for them, every visit. Otherwise, they or someone else has to do it. They get paid for that, but it costs them more if they do than if I do it.

It is a matter of providing better service at lower cost, or providing the same level of service that we've been getting for the past decade with our costs continuing to rise. And, if it continues, other funding will dry up, because I'll leave the practice to find someone else who can provide better service.

The standard of care is changing. I tell my children to expect more than what I'm willing to put up with. When they need a doctor, they'll have greater expectations than I did when I moved in to my current neighborhood 16 years ago. And when I move again (soon), I'll be looking at what I desire in a physician (and their EHR system) in a whole new light. I likely won't change my primary care provider until then, but when I do, it will be a clean sweep with not just my primary, but the whole lot of physicians I interact with, on the basis of what services are provided, and what I want today.
</rant>

If the attitude is I don't get paid for that, eventually, you won't get paid at all.  At least by me.

Clinical Quality Workgroup discusses Standards Selection Criteria for CDS and CQM

Today I got to present to the HIT Standards Clinical Quality Workgroup on principles for standards selection.  I had raised the point at our last meeting that it would be good if, before we started selecting standards, we actually understood the principles behind which such a selection was made.

A lot of work has already been done in this area, as I reminded the workgroup.  I started from first principles as to why consensus standards are desirable, moving to a derivation from NIST's Guiding Principles for Identifying Standards for Implementation as found in the Framework and Roadmap for Smart Grid Interoperability, and then on to principles found in HITSP's Tier 2 standards evaluation criteria, and the unwritten principles (now written down) for IHE standards selection, and the written principles for taking a profile to final text.

Then I gave an overview of the feedback I had received from many interested parties who responded to this post, or whom I found it interesting to talk to about the issue, including the guy who labels himself as "a dumb family doc" but is now sitting in the National Coordinator's seat (he wasn't at the time I asked). Next time around I get to summarize this into a strawman proposal for the workgroup (the reward for a job well-done is another job).

There was a really great question from the caller from AHRQ, which was related to the point I raised about what is our standards architecture for Meaningful Use. After all, if you don't plan one, it just sort of happens. I'm hoping we can discuss that on a future call. I have some idea about what sort of architecture could be extracted from that program.

The transcript will be posted later, and you can find the materials and a subsequent transcript of what was discussed on the HIT FACA Web Site. Here are my slides: