Friday, August 6, 2010

Top 'O the Week

A lot of professional blogs that I know have some features that can be automated. One of the "features" that I'm working on is something that reports the top post of the week, top 3 for the month, and top posts of the year or all time. It's really very simple. You need to monitor you blog using a tool like Google Analytics. Then you need another tool runs a simple process over the analytics output to generate the Top N page. I tried hosting the tool in the cloud, but for some reason, Google App Engine doesn't like the way I use stylesheets to process things. It has something to do with how they've plugged some security vulnerabilities in the Java XSLT implementation. I'll figure it out eventually, but I might just give up an go to my own hosted box, since that will be quite a bit easier to deal with. I can just FTP to that to deploy new code, and have much more control over what can be done.

In any case, the real trick to it is to use the Google Analytics API to get a feed for the metrics I want. In my case, I'm looking for top hits in the last week, month, year and all time. I then run that feed through an XSLT transform to generate a simplifed XHTML result. That result just contains the blog post title and a link to it.

So enough jabber, here's the data:

Top post of the week:

Meaningful Use Posters

Top 3 for the last month:

Top 10 for the last year:

The web knows I need a degree...

I was just doing some personal griping about glass ceilings for people like me without a formal education, when I noticed that the top of the next page had a University of Phoenix ad on it. I've done enough natural language processing, analytics, and machine learning to understand how little was really needed to target me for that ad. For the algorithm to work, it needs to do the following:

1. Identify me as a good candidate for the ad based on a few key words,
2. Offer it to me (and others like me a few thousand times), in a way that is attractive but not offensive,
3. Deal with the fact that it helps maybe 1 in 100,000 people who see it.

One of the "problems" of CDS is identifying which clinical decision support algorithms are applicable, and when to use them.

The same set of techniques could also be used in an EHR, so long as they are equally unobtrusive.

Thursday, August 5, 2010

...don't do that!

The classic response to "Doc, it hurts when I do this", which is an excellent example to use in exploring the various kinds of observations that can be recorded on a problem list using the HL7 Continutity of Care Document Problem Observation Template as profiled in Problem Entry in the IHE PCC Technical Framework and used in the HITSP C32 Specification.

The code element of the problem observation in the IHE template supports on of 7 values reflecting different degrees of clinical judgement.

Code	Description	Degree of clinical judgement
409586006	Complaint	When the patient comes into the office and says "Doc, it hurts when I do this", that's a complaint.
418799008	Symptom	When the doctor asks "Does it hurt when you do this, and the paitent responds affirmatively", that's a symptom. Usually occuring during review of symptoms, although also found during history taking.
404684003	Finding	When the doctor says "Does it hurt when I do this," flexes your ankle, and he/she observes you wince, that's a clinical finding. Usually occuring during a physical examination.
282291009	Diagnosis	When the doctor says, "OK, you have sprained your ankle", that's a diagnosis.
64572001	Condition	Other things could also be causing your problem, some of them are not "problems" in and of themselves, but they are medical conditions. If your ankle pain is due to swollen ankles, brought on by hormonal changes due to pregnancy, hopefully, the condition of pregnancy is not really a "problem". It is a normal biological process after all.
55607006	Problem	But, that "ankle sprain" certainly is a problem, and the patient could report it as such.
248536006	Functional Limitation	As a result of the ankle sprain, the patient may have difficulty walking or climbing steps. This is also a problem, but a more specific type of problem, describing a physical limitation for the patient.

The level of clinical judgement is important in understanding what's happening with a problem. If "ankle pain" is simply listed as a complaint, then more examination is needed. If it's listed as a diagnosis, then your doctor might want to see what has been done to identify the cause of this otherwise unexplained pain. In order to reach that stage of clinical decision making, some investigation should have occured to get there.

Usually, "ankle pain" won't appear as a diagnosis, but if that was the reason for the visit, and no other explanation appears to the provider, the final "diagnosis" code appearing on the bill for the visit to your insurer (another reason to avoid use of billing codes) will often be for "ankle pain".

Having identified the level of clinical judgement, the question of where to put the code for ankle pain has probably occured to you. It codes in the value element of the observation. This follows the question/answer pattern that is supported by the TERMINFO guide, where the code is the question (what is the complaint/problem/condition/diagnosis et cetera), and the value is the answer. The HL7 TERMINFO would prefer that the code value be "ASSERTION", but allows for these other codes to be used, because they are "supertypes" of assertion.

Quite honestly, ASSERTION is a rather weak statement of a fact, because as we've seen above, there are different degrees of confidence and decision making involved in making assertions about patient care.

That's why IHE chose this represention among the many possible different representations that could have been used for the Problem Entry.

Wednesday, August 4, 2010

Standards Activity around Clinical Decision Support

The next week for me is about, in large part, clinical decision support, and I hope to figure out just a bit more about where it is going. I've had to spend a couple of hours each of the last couple of days thinking about it. There is quite a bit and yet not quite enough is going on with CDS these days. The holy grail of CDS is to build a repository of CDS algorithms that can be identified and applied to the appropriate patients, but we still aren't there yet. Except for Meaningful Use, Clinical Decision Support is the most often searched for topic hitting this space.

Here's just a brief summary of some things that are going on:

AHRQ is working with Thomson Reuters to develop a way to describe a CDS algorithm. This particular project is a bit cart before the horse because the real problem is NOT how to describe logic (for that we have programming languages), but how to describe the data needed to solve the problem.

HL7 start work on a respecification of GELLO, as a "profile" of the OMG Object Constrain Language (OCL), instead of a derivation from it a bit more than a year ago. GELLO is a side-effect free declarative language for Clinical Decision Support that has quite a number of very useful properties for clinical decision support applications. This work may help. There are only a few commercialized implementations of GELLO that extend from the original OCL base. But there could be a lot more implementations of OCL that could be used without extension once the new specification is completed. The increased availability of GELLO (using the 2.0 specification) should make implementation of clinical decision support logic more widely available. Even so, we don't have any lack of programming languages to express logic in, declarative or procedural.

Another project going on is the development a repository of CDS algorithms (at the behest of ONC and through RAND), and demonstration of their use. Once again, a repository is good, but until we know how to index the data that we need, we probably don't know what metadata is needed in the repository. It should be interesting to see where this work is headed though.

HL7 is working on a Domain Analysis Model for the Virtual Medical Record. This is critical work but is still very much in development. The VMR is to the electronic health records as the W3C DOM is to XML. These models will be critical in any eventual expression of clinical decision support logic.

IHE has developed at least three different profiles (QED, CM, and RFD), all of which should help us to integrate clinical decision support services into healthcare applications. These IHE profiles provide implementations of a functional CDS service, and are also congruent with recent HL7/OMG work on Clinical Decision Support Services.

And at the same time, NQF is developing data models for quality measures. These same data models need to be coordinated with other work in CDS to be baked in clinical processes described in guidelines at the very beginning.

Another area of interest is the finalization of the order sets standard in HL7. Order sets are prepackaged collections of activites to perform for patients meeting a particular criteria.

There's a lot going on, and everyone seems to be headed in a slightly different direction. But what we are seeing is a natural divergence in an important new phase in healthcare. If the same development cycles follow here as everywhere else in IT, there will be an eventual convergence, but it is clearly a little way away.

The divergence is just a little bit frustrating for anyone trying to follow everything that is going in. In fact, if you think you are succeeding in this area, drop me a line and I'll give you a few more threads to follow. There are a few gaps left, but introducing more work before some of it is completed just isn't an effective way to keep everything moving forwards.
And of course, in all of this, we are still really talking about just the tip of the iceberg. Clinical decision support is more than just the black box that answers questions. See my first post on the topic for a summary of what is included in CDS.

Tuesday, August 3, 2010

What is this Gunge in my Head

As a standards geek, I spend a surprising amount of time (at least to me): digging through, commenting on, and refering others to applicable laws and regulation for my region. My region happens to be the United States, and here are some of the laws and regulations that I have to read through. Those with a

next to them have been bookmarked by the second recipient of the Ad Hoc Harley Award. If I could ever go back in time, I think the last thing I would ever do is tell myself that I've had to read the Senate Bill, the House bill, and the conference committee consolidation all in the same week, or that I'd plowed through more than the equivalent of two reams of regulations in a single day. I'd laugh myself out of the room.

Never-the-less, being aware of local policy (law and regulation) that impacts standards and interoperability is a pretty important part of my job. I hadn't realized how much gunge was in my head until I spent an hour and a half with a new regulatory analyst yesterday. This isn't a complete list of applicable laws and regulations, but if you do what I do (or what she does), it's probably a good start.

Laws

Health Insurance Portability and Accountability Act (HIPAA)
American Rehabilitation and Reinvestment Act (ARRA)
Title XIII of Division A and Title IV of Division B of ARRA are known as the Health Information Technology for Economic and Clinical Health Act (HITECH)
Clinical Laboratory Improvement Amendments (CLIA)
Medicare Modernization Act (MMA)

Regulations

ARRA/HITECH

45 CFR Part 170 Meaningful Use Standards Final Rule

42 CFR Parts 412, 413, 422, and 495 Meaningful Use Incentives Final Rule

45 CFR Part 170.400 Meaningful Use Temporary Certification Final Rule

45 CFR Part 170.400 and 170.500 Meaningful Use Certification Notice of Proposed Rulemaking

45 CFR Parts 160 and 164: Breach Notification Interim Final Rule

HIPAA

Combined text of all HIPAA Regulations including:

45 CFR Parts 160 and 162 Code Sets and Transaction Final Rule
45 CFR Parts 160, 162 and 164 Privacy Final Rule, Security Final Rule
45 CFR Parts 160 and 164 Privacy Final Rule

Claim Attachments Notice of Proposed Rulemaking (Withdrawn)
ICD-10 Final Rule
X12N 5010 Final Rule

CLIA

42 CFR Part 493 Clinical Laboratory Improvement Regulations

MMA

Medicare Part D Regulations

Other

45 CDF Part 411 Stark Relaxation and Anti-Kickback Safe Harbors for EHR and e-Prescribing

DEA ePrescribing Interim Final Rule

Monday, August 2, 2010

About that preliminary CCHIT Certification

Under the changes to the rules finalized for Meaningful Use recently, were some clarifications about certification and testing processes. Did you previously certify your EHR product through CCHIT? Even if it passed, you will probably have retest the features again. Why? Because under the final rule, only certification testing methods approved by the National Coordinator for Healthcare IT will be acceptable for meaningful use certification.

Right now, so far as I know, only NIST is developing testing scripts and methods that ONC is expected to approve. CCHIT will either have to recertify using the NIST scripts and methods, or get the testing methods it used in its preliminary certification approved by the National Coordinator. I would NOT place any bets on that being terribly successful, given the desire for a level playing field for ATCBs (but I've been wrong before).

I'm planning on having to retest everything, and so should you. As to whether that was a useful expenditure, I'm not sure I care to comment.

As always: The opinions represented in this blog are my own, and not that of my employer or the respective standards organizations that I work with.

IHE PCC Call for Proposals

Dear PCC Colleagues,

It is with great pleasure that we announce the IHE annual planning cycle kick off beginning in August 2010, and continuing through October 2010. This e-mail describes the planning cycle process, including the face-to-face meeting in October and the PCC Planning Webinars that lead up to that meeting.

IHE PCC Call for Proposals: Interested parties are invited to submit proposals for new Profiles for the Patient Care Coordination (PCC) Domain to be considered for development in the 2011-2012 cycle of the IHE PCC Domain. Additionally, all IHE members are invited to forward this announcement to their committee mailing lists and other interested persons.

The deadline for submission of a proposal for new Profiles is September 17^th, 2010 at 11:59 pm CST.

Proposals must follow the structure and format of the Brief Proposal Template attached, specifically addressing the following:

What is the problem you propose to solve by this proposal, and how is that problem expressed in practice? (eg. a use case)
How would fixing this problem improve health care in practice?
What specific components of standards could be used to solve this problem?
Include some indication of the business case surrounding the situation if possible. For example, is there an economic motivation for addressing this problem immediately?
Identify one or more potential editor(s) in the event that the proposal is selected for further evaluation and possible development.

Please use the Brief Profile Template to submit your proposal. Email Completed Proposal documents to both PCC Planning Co-Chairs and HIMSS secretariat:

§ Michael J. McCoy, MD: MMcCoy@che.org

§ Keith Boone: keith.boone@ge.com

§ HIMSS Secretariat: IHE@himss.org

Invitation to attend IHE PCC Planning Committee meeting: Tuesday & Wednesday, October 19-20, 2010

The meeting RSVP survey link, hotel accommodations, and agenda will be sent out the week of August 9, 2010. Please save these dates on your calendar by opening the ICS calendar invite that is attached to this email.

Dates: October 19 – 20, 2010

Location: Radiological Society of North America

820 Jorie Boulevard , Oak Brook, IL 60523 Phone: (630) 571-2670

The PCC Planning Committee will hold its 2010 planning meeting on October 19-20, 2010 at the RSNA headquarters in Oakbrook, IL. A preliminary agenda of our activities will be sent out after the September 17^th deadline, however, history has indicated that our time during the days is flexible and depends on the nature and number of profile proposals. The PCC Planning Committee will vote on the final selection of short-listed proposals at this meeting to move forward for submission to the PCC Technical Committee.

We urge those who propose profiles to attend the Planning Committee meeting either in person or by phone. In-person advocacy has proven to be especially effective in getting profile proposals understood and accepted. We have a relatively short window for turn-around of the detailed proposals for the items selected for this year's cycle so acceptance of proposals depends heavily on the Planning Committee's consensus about the market needs, relative priorities, and level-of-difficulty of all profile proposals at this face-to-face meeting.

IHE membership is required to attend or participate in the PCC Planning face-to-face meeting, and to submit votes on October 19-20, 2010. If you are unsure your organization is an IHE member, please check the membership list. If you would like to apply for membership, please visit this webpage.

In order to participate in meetings, you must first be a delegate of an approved IHE member organization. Membership is granted only to “organizations,” and each member organization names delegates to participate in various domain committees. Please check the membership list to ensure your organization is a bona fide member of IHE. If not, then you can apply for membership (it’s free) using this webpage.

PCC October face-to-face Planning Meeting participation: Any member is entitled to send a delegate to attend a meeting. However in order to vote, the member (organization) must have earned (and maintained) voting privileges prior to the designated meeting. The rules around voting privileges are articulated on the IHE website.

PCC Planning Webinars (Prior to the face-to-face): PCC will schedule four Planning Webinars prior to the October meeting to allow authors to present their proposals to the PCC Planning Committee in advance of the face-to-face. This procedure also allows all Planning Committee members to re-establish their voting rights. We have established specific procedures for the Planning Webinars, so please make sure you understand and follow the instructions below to ensure you will have the right to vote at the meeting.

1. PCC Planning Webinars have been tentatively set for the dates listed below. The exact dates and times will be sent out as soon as possible. We will populate the schedule of presentations immediately following the September 17^th submission deadline.

§ The PCC Planning Webinars will run during the following weeks:

September 27 – October 1, 2010

October 4 – October 8, 2010

Webinars will be two hours long with 6- 15 minute profile presentations

2. These webinars will be considered decision meetings. We will attempt to reach consensus (rather than hold a formal vote) at each webinar as to the validity of each individual proposal, including whether it makes sense to request proposal authors to combine initiatives where overlaps exist. No proposals will be rejected at this stage, only aligned with one another, and only where appropriate.

In order to ensure voting privileges at the face-to-face meeting, we will require each member (organization) to attend a minimum of 2 (out of the 4) webinars that precede the meeting. We will be taking careful attendance at each webinar to ensure proper execution of this process. Please ensure you clearly understand this requirement.

Committee rosters can be viewed on the IHE FTP site at: PCC Rosters

PCC Planning Webinar Procedures: Each webinar will be organized as follows (this will vary slightly depending upon how many proposals we will be reviewing):

1. The two hour time allocation will be divided into six, 15 minute time-slots, with 30 minutes for introductory remarks and follow-up discussion.

2. Each 15 minute timeslot will be allocated to a profile proposal… the first 10 minutes will be taken up by a presentation by the proposal author, with the remaining 5 minutes reserved for discussion and any disposition (if required). In order to maintain equity across all presenters, we will constrain each presenter to this requirement!

3. Each 10 minute presentation will be constrained to a maximum of five (5) PowerPoint slides, presenting your proposal concisely and completely. We have taken the liberty of supplying a presentation template that you may choose to use, and this can be found in the following folder on the IHE ftp site at: ftp://ftp.ihe.net/Document_templates/Planning%20Documents_2009/

4. A sample webinar agenda is shown below (note that we will assign presenters/topics to each timeslot after the September 17^thsubmission deadline):

*Sample* - IHE PCC Planning Committee Webinar #1 (of 4) October 4, 2010 • from 1 pm- 3pm Central Time WebEx: https://ihe.webex.com/ihe/j.php?J=922746120 Call-in toll-free number (US/Canada): 866-469-3239 Access code:922 746 120
Item	Description	Time (min)
1	Introduction	10
2	Presentation #1 (topic, presenter) Discussion	10 5
7	Presentation #6 (topic, presenter) Discussion	10 5
8	Wrap-up discussion, disposition	20

5. The final webinar will be reserved for presentation/discussion on any proposals that have been combined or otherwise re-worked as a result of discussion during the first three sessions. We will ensure that the agenda for this session is published with as much advance notice as possible.

6. Each of the four webinars will be recorded with links published, so members can view (or review) the profile proposals prior to the October face-to-face meeting. We will also publish an agenda, together with procedures, for our face-to-face meeting.

IHE PCC Planning Webinar Dates:

Webinar #1 & 2: September 27 – October 1, 2010 – Dates and times TBD.
Webinar #3 & 4: October 4 – October 8, 2010 – Dates and time TBD.

The agenda’s for these Webinars will be sent out after the September 17^th, 2010 deadline.

If you have any additional questions please contact the PCC Planning Co-Chairs.

Thank you for your participation and support of IHE.

Sincerely,

Keith Boone and Michael McCoy

IHE PCC Planning Co-Chairs

Healthcare Standards

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