Ranking Interoperability

I always appreciate it when important ideas can be communicated in easy to understand ways.  One of my colleagues recently did that in a way that impressed me over dinner at the HL7 Working Group Meeting last week.  Scott Bolte describes, using the lens of "Healthcare Economics," a method to evaluate interoperability opportunities rather concisely.  

My own post on Scope and Focus was written shortly after our conversation, and I had asked Scott for help putting together a more detailed post on his topic for this blog.  I think after you read what he has to say, you will see how the two pieces are tied together. 

Scott sent me his bullet points on the conversation via e-mail, and it was so simply written, yet easily understood that I post it below without change.  Here are his words:

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How to compare interoperability opportunities...

1. high disease penetration in a population.
2. high societal cost burden.
3. highly motivated patients.
4. there is a meaningful intervention.
5. opportunity to improve situation with improved interoperability.

#1 makes sure healthcare providers will see the condition often enough to invest their time and money adopting any improved capabilities.

#2 improves the odds that payors will reimburse.

#3 is critical to healthcare provider engagement.

#4 means there is a chance to move the dial.

#5 is actually a fill-in-the-blank. The first four can be used to assess any opportunity, but in this case it's to determine if improved interoperability is worth pursuing.

People who are worried that going after only the big hitting diseases does a disservice to rare conditions should be reassured that once the improved interoperability is working, it will benefit all similar scenarios.

What the C32 says about translation for Medications

A number of people have asked questions about how to represent medications using coding systems other than the recommended RxNORM values.  The problem stems from interpretation of the C83 specification.  The table below comes from page 51 of C83 Version 2.0.

cda:consumable/  cda:manufacturedProduct	Medication Information	R/Y	2.2.2.8.10
cda:manufacturedMaterial/    cda:code/@code	8.13 - Coded Product Name	R2/Y	2.2.2.8.11
cda:translation/@code	8.14 - Coded Brand Name	R2/Y	2.2.2.8.12
cda:originalText	8.15 - Free Text Product Name	R/N	2.2.2.8.13
cda:manufacturedMaterial/      cda:name	8.16 - Free Text Brand Name	R2/N	2.2.2.8.14

What the highlighted line says is that the coded brand name is found in the translation element, and is required if known.  We (HITSP Care Management and Health Records) put the medication brand name in translation because for clinical purposes, the concept that would seem to be most important are the active ingredients in the medication (the product), rather than any specific brand name medication.

What is interesting here is the HITSP mapping process.  The concepts (found in C154) were givens (even when C32 was original constructed), and the harmonization task was mapping them onto CDA Release 2.0 and the CCD specification.  That means that our process established where this information belongs in the CDA specification.  But this mapping may not be one-to-one and onto.  That is to say that similar concepts may map into the same location.  An example of where this occurs is in the identification of allergens.  There are several different ways to identify substances to which a patient may have an adverse reaction.  These may be medications, classes of medications, or specific substances that may not even be a medication.  All of these wind up mapping to the same place in the CDA document, and it is the vocabulary that is used that identifies the purpose for which the content is mapped.

So, as it turns out, we have a similar situation with medications.  The interoperable concept we want to exchange is a value set for products from RxNROM, and other codes that may get you to that concept should appear in the translation element.  That means that you can include translations to a brand name code from a separate value set in RxNORM (the value set identifying brand name medications), or you could include translations from other coding systems,  such as First Data Bank, MediSpan or NDC.

When we get to clarify the C83 specification, we should modify it to indicate that translation/@code is to be interpreted as brand name when the value set used is from the RxNORM.

This illustrates the challenge with mappings.  It is only when a mapping is one to one and onto that you can assume that a data element in one place always means what has been mapped to it from another.

ONC Relaxes 2011 requirements on Guides for Public Health Reporting

It took them about 7 weeks to write and publish the 18 or so pages needed to fix the problem, but fix it they did, and in the right way given deadlines under Meaningful Use.  ONC has removed the use of the HL7 2.5.1 implementation guide specified for public health reporting in a recent interim final rule.  The rule is now "on display" and is expecte to be published in the Federal Register on or soon after Wednesday of this week.

You can view the rule (now published in the Federal Register) below:


I still owe you a review of the work being done by ISDS. That is, in my opinion, presently being implemented through an unbalanced process that is dominated by one side of the transaction (the one not having  "receiving" requirements under the Incentives rule).

Having said that, at least the current rule allows implementations to proceed using the 2011 criteria, and we can all breathe a bit easier right now. You will soon be able to just simply use the HITSP C39 Specification for public health reporting without hacking it to support 2.3.1 as I had previously suggested.

I'm not sure how much of that seven weeks delay could have been saved without eradicating the root cause of the mistake in the first place.  While we presently have Government 2.0 initiatives, I'm not sure that we are quite ready for "Agile Government" or the potential backlash it could cause.  But, maybe something could be done about more nimble communcations...

Scope and Focus

One of the places I've been paying attention to in HL7 and in our national program is how to make the best use of resources.  I've had some very interesting discussions on this topic over the last three weeks on both fronts.  One of my concerns about our national program is that we seem to be getting distracted by every good idea.  The same thing is true in HL7.  For example, here are a list of projects in HL7 that are in some ways trying to facilitate use of HL7 standards:

1. Green CDA
2. Micro-ITS
3. New ITS
4. RIM ITS
5. Mapping Tools
6. Templating Tools
7. Template Registry Pilot 
8. Virtual Medical Record
9. Netrual Mapping Notation
10. CDA Release 3
11. Common Document Types
12. hData ITS
13. Template Design Pilot
14. ... (I think you get the point)

The good thing about these is that they are aligned to some degree to a strategic initiative.  The bad thing is that there really is no overall architecture that explains how all of these things work together, and how they are tied into that strategic initiative.

On top of that are all of the other projects that are coming in that are not related to a strategic initiative.

Each project has a cost in time and effort, not only in members that are active in development of the project, but other members who observe, participate and vote to approve the project and its outputs (standards and implementation guides).

There are limited resources in any organization, and I know in most businesses, that for every project suggested and approved, there are probably 2 to 10 that didn't make the cut because they don't offer sufficient return on investment.  Since these standards are our products in HL7, we should be making some business decisions about the projects to produce them that affects what we deliver to our customers (and as I've noted before, our customers and our members are two different audiences).  That means that occasionally we need to say no, and that we need to better align and coordinate those projects that are part of strategic programs.

The same thing is true in our national program.  We are about to see use cases coming out of the woodwork.  We need to develop a framework of governance that ensures these uses cases are

1. Aligned with National Strategic Initiatives
2. Will have a reasonable impact, based on an assessment of the increases in effectiveness, outcomes or access, and the efforts involved.

I'll be trying to figure out how we accomplish this over the next couple of years, both in HL7 and in the US

Wherein Stumping around becomes Stomping Around

The HL7 Board Election results were announced this morning to the membership, and last night to the board.

Don Mon is the incoming Chair.  Catherine Chronaki has been relected as an Affiliate director, and Jill Kaufman was reelected as Secretary.  Ed Hammond steps down from his role as outgoing chair and has been elected as a board member.  Stan Huff will be stepping down from the board after honorable service.

I too was elected to the HL7 Board, and I must thank all of you who supported me in reaching this position.

What I said in Stumping Around still applies, but now I need to start doing it.  I will need your input and your help.  Thank you for your continued support.

     Keith

The next Ad Hoc Motorcycle Guy Harley Award ...

About the award

Wednesday morning at HL7 is the day that we recognize contributions from the HL7 community through the Ed Hammond Awards.  If Ed can do it, I figured that I could to.  It might have started as a lark, but I really mean it.  The rules of who gets the Ad Hoc Motorcycle Guy Harley award are completely arbitrary. There is no nominating committee, although nominees are always welcome. The bar to recognition is fairly high if the first, second, third and now the fourth recipients are any evidence.  I hope to maintain the quality of recipients in subsequent awards. I won't award more than one a year for the same type of industry service, and I expect to award no more than five a year.

Given activities at HL7 this week, I too am giving out an award this morning.  This next awardee is has built a tool that I've been seeing more and more of lately in HL7 meetings.  It first came to my attention a little over a year ago when one of my colleagues pointed me to it as a good place to find documentation about CCD, IHE, and HITSP specifications ALL IN ONE PLACE.  Since then the tool has gone on to be used to develop an HL7 CDA based Implementation guide.  You heard about this tool in yesterday's post.

This certifies that

Dave Carlson of the VA

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

Dave, congratulations and thank you for leading the efforts on development of CDA Tools and the Model Driven Health Tools.  One of the things that I think you will soon learn if you haven't already is that the reward for a job well done is another job.  For the work that you have done on this project, you deserve at least a much bigger computer display and a lot more help.

IHE North American Connectathon and Showcase Registration Deadline this Friday, October 8

Crossed my desk today while at the HL7 Working Group Meeting...

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IHE Community,

IHE North American Connectathon Applications Due October 8
The registration deadline is this Friday for testing participants in the North American Connectathon 2011. The Application is available online at www.ihe.net/north_america/connectathon2011.cfm.

The IHE North America Connectathon will take place January 17-21, 2011 in Chicago and is the healthcare IT industry's largest face-to-face interoperability testing event. IHE profiles enable effective interoperability in a wide range of clinical settings, including health information exchanges. They also support many of the objectives for "meaningful use of electronic health records" advanced by the Health IT Standards Committee of the US Office of the National Coordinator for Health IT.

HIMSS11 Interoperability Showcase Registration Also Closes October 8
Friday is also the last day to register to participate in the Interoperability Showcase, taking place February 21 – 24 at HIMSS11 in Orlando, FL. Demonstrate your leadership in interoperability and connect with thousands of healthcare IT buyers and end-users in one major venue.

At HIMSS10 nearly 5,000 visitors tours the HIMSS Interoperability Showcase- 16% of conference attendees! View the results from HIMSS10.

Interested organizations can view all registration information online or contact the HIMSS Sales staff directly for more information.