It's not time ...

As I write this, I am preparing to head off to Chicago to see my good friend and colleague, Charles Parisot, and also do something I very rarely get to do, which is sit in a room with him for several hours while he listens to other people speak.  I'm second or third up on the roster to roast him, and we will have hours yet after I speak for others to say more about Charles, who he is, what he has done, and so on.  In fact, we have about as long as a normal post meeting conversation with Charles to say it all, which in fact will barely be enough.

Rather than talk to you about what Charles is though I will get to that, I want to start with a few things that he isn't.  First of all, he is not a planetary body.  Yes, Charles does have a gravity well (it's pretty deep), and he does have an orbit.  In fact, he mostly fits all of the modern characteristics defining a planet:

1. He orbits the sun,
2. He is not a satellite ... for anyone or anything,
3. He has cleared his own orbit by repeatedly brushing aside all obstacles, and finally
4. He does have sufficient mass to be mostly round.

He even fits the definition for the old Greek term, which essentially means wanderer, and he certainly is a wanderer.  But, he is not a planet.  The reason I know that Charles is not a planet is because he fails under one very conspicuous criteria, which is that he has an event horizon, and should you get too close, you will never escape it.  Any the only things known to date which have an event horizon are black holes, former suns or larger bodies which cannot, by definition, be planets.

He's also not Carmen San Diego.  Yes, you can find him wandering all over the world, but that's the point.  You CAN find him.  All you need do is listen closely and head towards the action, or at least the action as it relates to Healthcare IT.  When I used to be in more regular touch with Charles, often the first question I would need to ask, is where are you today, even if I spoke to him yesterday.  Twice, without even knowing beforehand, I simply asked hum which ministry call he was on this morning and twice he met my expectations, although in all fairness, it was only one of those days that he was testifying to Parliment somewhere.

Charles does not sleep, except perhaps on long-distance flights.  I know this because I've gotten e-mails from him at all times of day, and so have you.

Charles doesn't do any real work.  That's what his gravity well is for.  Should you happen to get sucked into it, you will do the work.  Charles will just sit back and do what he likes to do, which is talk, and argue.  Charles will talk for so long, you will agree to do just about anything for him just in order to get some peace.  But if he doesn't do any work, how does he get so much done?  See, that's just the point.  Charles doesn't create projects, he co-opts them, often several at a time.  Then he puts them into a big bucket, stirs them up, and watches as things magically arise from the bizarre concoction of ideas.  Charles doesn’t have a say-do ratio, in fact he completely destroys the concept of say-do ratio, because no matter how much he speaks, what comes out of it is clearly more than what went into it.  It’s more like the ratio of aleph null to aleph one.

Charles is neither a noun, or a verb, although he has been used in both senses.  You can pull a Charles, or Charles someone.  Charles is also not an unstoppable force, he can be moved, but his reaction to outside influences is quite confusing, more like a centrifuge or gyroscope.  When you try to push Charles in a particular direction, be very wary, because his response will often be at right angles to the direction of the applied force.  Be very wary when he agrees with you (especially completely), because that often means you are about to be the recipient of a perpendicular reaction that is completely unexpected.  This is what it means to have been Charles'd.

The last thing I will say about what Charles is not is that Charles is almost certainly not retired.  We here all know that he will be continuing to pop up in our lives, perhaps in even new and more interesting ways, now that he will soon be removed from the restraints placed upon him by his current employer.  I'm certain we will all continue to see him, because fortunately or not, we are all inside his event horizon.

OK, I lied.  That was not the last not.  Charles is also not a recipient of the Ad Hoc Harley award.  But as to what he is, and I did say I'd get to that, is certainly overdue for induction into 2018 class of the Lords and Ladies of the Ad Hoc Harley.

Charles Parisot

Semper et semper ascendens deinceps

(ever and ever riding forward)

Mapping Data Types in FHIR

Community social mapping by
Community Eye Health, on Flickr

One of the cool things about FHIR is the sheer amount of data about the standard that is available in computable (or nearly so) form.  For example, all the HL7 Version 2, Version 3 and CDA mappings.  One of my day to day challenges is converting things to and from FHIR, and so I've been thinking about the problem of how to handle conversion in a generalized way.  FHIR has a Mapping Language, but it requires expression of a large amount of information that I find to be somewhat repetitive.  It's essential to have all of the information it requires to get the mapping to work, but there should be an easier way to do this.

In thinking through this problem, I recall a tracker item I created for the ConceptMap translation operation structure that was related to how one might select a concept mapping based not just on a code, but also on other values (dependencies) that might be present in an instance that needs to be mapped.  ConceptMap has both dependsOn and product, which reflect additional data in translation.  A given mapping that uses dependsOn and product well can be made reversible, which is a REALLY nice feature to have laying around.  NOTE: I said "can be made", not "is".  You have to work at it, because mappings that generalize in one direction, will wind up specializing in another direction, which can be a bad thing.  It might be OK to generalize up a level for some things, but specializing down can often lead to incorrect conclusions.

The devil is in the details, but that is where dependsOn and product fields in a concept can help, because they can provide details to produce mappings that have only equivalents, instead of other less precise mappings.  So, if we can create a reversible concept mapping table, would it also be possible to create a reversible structure mapping table?  NOTE: Reversibility isn't a requirement of what I'm trying to do, but it would be nice if the outcome was something that could allow me to express a mapping that could be reversed.

The basic process of mapping takes one or more components (or perhaps zero or more if mapping to a fixed value, but I digress) from the source structure, and maps it, possibly through some transformation, to one or more components of a target structure.

I think that there are two kinds of mappings that I need to worry about: Type mappings, and instance mappings.  In a type mapping, I can say "this source type" can be mapped to "that target type".  I would express those as MSH -> MessageHeader.  Read that as "MSH produces MessageHeader".
In an instance mapping, I want to say that "this source element" is mapped to "that target element", or more directly: Bundle.entry.resource <= MSH(0).  Read this as Bundle.entry.resource takes the values produced by mapping MSH.

Some things might generate two or more objects when going from source to target.  For example, the V2 XCN data type should generate both a HumanName data type, as well as an Identifier Data type.  The XCN data type in question could be generating a Patient, Practitioner, or RelatedPerson, but from a mapping perspective, the mapping should reflect the specific level of detail we know.  Other context, such as where the XCN data type is used would then tell us which one of those resources is actually being produced.  This might be expressed in the form: XCN -> HumanName, Identifier.

In the previous example, there's really only one edge case in most HL7 messages where an XCN might be other than Practitioner (In TXA, where the document originator might be the patient or an authorized representative), so it's not a huge problem here.  For most uses of XCN, we'd just probably want to say something like: source-field -> destination-field, for example: PV1-7 -> Practitioner, and also PV1-7 -> Encounter.participant.individual.  But in this odd-ball case, we'd probably need something else to tell us that what we are generating is Patient or RelatedPerson.

Type specific mapping rules can handle certain cases, in the above for example, to address the case of referencing the generated practitioner in the case of PV1-7.

One thing can map to two items, but in some cases, the one thing has to map to two parts of the same item.  For example, CWE-1 to CWE-3 map to a single coding.  I might say that the compound {CWE-1, CWE-2, CWE-3} -> Coding.  Figuring out where to put this is sometimes complicated.  It might go into a coding element, a CodeableConcept, or be (concept) mapped to a FHIR code in the resulting structure.

I'm leaving a lot of details out of my mapping on purpose, because what I want to be able to do  is INFER a lot of the detail with the data I have, either from context, from more general rules, or from configuration.  I ought to be able do some of that inference based on data types and potential data type conversions.  To explain: If I say that CWE -> CodeableConcept, the system that interprets my mapping structures should know fairly well how to down-convert a codeable concept to a coding or a code, and the mapping context should be able to help.  That way, any time CWE  The same thing might also be true for certain HL7 data types which in some versions are simply strings, but in later versions are more complex data types where the value found in the earlier version is stored in the first component of the data type (e.g., compare for example, XCN-1 in HL7 2.3.1 vs. 2.5.1 where FN replaces ST, and thus, one could "down-convert" FN to ST by taking the value of its first component).

Done right, one might be able to express a mapping from one structure to another fairly concisely with some default rules (e.g., to handle various type conversions), in a way that could enable definition of a one-to-one and onto mapping that might well be reversible.

I'm still struggling with various parts of this, but I think I'm somewhat close to having something working.

   Keith

P.S.  Don't worry, I'll get back to that other exercise I'm doing on Risk Analysis, I just haven't had the time to do some of the additional research I need.

Happy Thanksgiving All

For those of us in the US, happy thanksgiving.  For those of you outside the US, happy day without having to deal with the rest of us here who will be off for the rest of the week.

As has been my tradition over many years, I'm posting the Engage with Grace slide again.  Consider having this discussion after dinner tomorrow.

-- Keith

A Risk Assessment Excercise in multiple parts: Threats

Continuing my risk assessment from last post, I'd like first to report a missing item or three from the previous list of assets being protected:

• The USB device itself (duh).
• Other data on that device (personal or otherwise).
• Anything that device could connect to

Having identified what needs protection, now we need to look at what we are protecting it from:

• Theft
• Damage (e.g., electrical hardware damage)
• Data Corruption
• Loss of sensitive information
• Exposure of sensitive information
• Infection by malware (virus, trojan, ransomware, other)
• Denial of Service

There are a number of downstream consequences that might result from these core threats, but these threats get at most of the root causes.  I'll look at various potential mitigations for these issues next week.

A Risk Assessment Excercise in Several Parts

Guidelines of impact relevance for IHE profiles
from the IHE Security Cookbook

One of the challenges for anyone involved in activities in Healthcare IT standards development is being able to share documents, presentations, training and other materials used in the development of the standards.  Like many in this field, I have access to not just those materials which I need to be able to share, but also access to a lot of other things that shouldn't be shared and which needs to be protected.

I've been in settings where I'm creating or revising a document or presentation, where the fastest way to get it to somebody somewhere is via a USB memory device.  But if access to external storage is locked out, then I cannot share information, or accept information from devices that may be shared with me.  In some cases, it's been nearly the only way (ever try to get to wireless or WIFI at a very busy, yet under-provisioned conference setting ... sometimes it's just not possible).  I've been in presentation settings where the presenter system is owned by the organization, and for related reasons, is the only thing that can be used for presenting, so the only way to get content may well be a USB stick.  These are infrequent, yet USB is still the fastest way often.

Yet, USB sticks (and other devices) are a two way infection vector, and also a way to enable transfers of huge amounts of information that sometimes shouldn't be shared. Even in cases where it should be, may need its own set of protections (e.g., encryption and authentication for use) to prevent it from falling into the wrong hands.

So, I need a risk assessment and mitigation strategy if I'm to justify any sort of exception to a complete lock-down.  This post represents the first of several posts that walk through a risk assessment process.  We'll start first in this post with assets to protect, move on next to threats, then assessment and mitigation.

Here's a partial list of assets that need protection.

• My Company Issued Laptop
• My Data
  I have pictures on my laptop that are mine, which I might want to save, my company laptop has access to many web sites I use for both personal and professional reasons.  I may have personal data related to my work (e.g., Payroll, taxes, benefits, health insurance). I want to protect that content.
• Infrastructure
  Anything my laptop (where the USB device would be used) can access, can subsequently be attacked by my laptop were it to be infected.
• Corporate Infrastructure
• Customer Infrastructure
• Intellectual Property
  Anything I have access to via that laptop could potentially be a target, including:
• Company IP
• Partner IP
• Customer IP
• SDO IP
  Examples include presentations, training material, and draft content of specifications that I may be working on.  This is material I often need to share with others.
• Individually Identifiable Data
  Various regulation requires additional safety around certain classes of data that might be available via my laptop, including:
• Patient Data (PHI)
• Data about other Individuals (PII)

Consequential to the threats to any of these assets, are threats to my reputation, and those of my employer, its partners and customers, and to the financial status of those organizations.  One simply need look at what happened last year with the NotPetya attacks to see how much damage can be done.

I invite your comments and feedback below!

Reassessing HealthIT Standards

After spending umpteen years having a pretty good handle on what's important and where to spend my time, I'm now back at (mostly) square one, having to reassess the standards in flight in HL7, IHE and various other organizations after being out of many loops over the past few years on the implementation side.  For each of about 17 standards organizations, I have to assess what they are doing, and how important it is to me (and to my employer), and then to work out what my strategy should be.  All at the same time sucking from a tremendous fire hose.

Below are links to where you can find out more information for your own assessments, and my thoughts from my current investigations.  While I track many general IT standards; W3C, IETF, Oasis, et cetera, generally require too much in the way of resources [both time and money], and others working in these are generally more qualified than I to handle that work, so those aren't listed. 

HL7: There's a lot of activity around FHIR (of course), and still some activity around CDA (new guides building on C-CDA).  Other things of note: SMART on FHIR, CQL and QUICK. Also, Argonaut and Da Vinci projects can be expected to ballot or contribute some materials back through the HL7 processes.  Attachments is undergoing a shift in focus, and given what's going on with Da Vinci, this should be an interesting time for that work group.  This is an important place to be engaged if you are interested in Health Information Exchange.

IHE: ITI and PCC don't have a lot new to speak of, there's some maintenance work that needs to happen, as well perhaps as some revival.  ITI is considering whether to go to a continuous (quarterly) work cycle, something I tried unsuccessfully to do in PCC for years.  This is a good thing, I think, because it allows for adoption of things in a more timely fashion.  QRPH on the other hand has a few things that seem to be quite attractive, including new work on Aggregate Date Exchange (ADX) [FHIR-based this time, though why they didn't start there is a mystery to me], CQL (an exotic but interestingly useful language for quality measurement and clinical decision support), and PDMP's (that we've seen popping up all over the place in the US).

ISO TC215: There's some interesting things going on here, but not much for my needs.  Much of it is either medical device, or process oriented.

ASTM: Haven't heard a peep in a few years here. Drill down to the sublinks and you'll see few if any new work items. 

OpenID: Something to watch, especially as it relates to SMART on FHIR.

NCPDP: A place to keep my eye on, especially as it relates to PDMP and APIs.

CARIN: Some interesting work on patient facing APIs, a new entre into the space that bears paying attention to.

Carequality: Some new workgroups are forming, FHIR is coming.

CommonWell: Biggest news from CommonWell over the past 12 months has been the connection to Carequality.  I'm not seeing much else, but also not digging too deeply either.

X12: Not really doing it for me.  Everything interesting happening in standards for the Payer sector seems to be discussed in either HL7 Attachments or the Da Vinci Project right now, at least as far as I'm concerned.  If you work for a payer, your mileage could certainly vary.

What's Changing?

With a new employer will come changes.  For the most part, little enough that I barely had to make only a few small edits to the policies for this blog.  My new employer is Audacious Inquiry, and to the extent that I'm adhering to my own policies, that is about all I'll say here, other than I've known about 1/2 of the senior members of the team for quite some time and highly respect them.  There will be other venues where you can read about what I'll be doing for them in the future.

I'm looking forward to spending more time on standards work, and more time here in this, my own space, where I will talk about the standards work that I'm doing.


   Keith