Working around the ONC Certified Health IT Product List bug for those Attesting to MeaningfulUse today

One of the EHRA members discovered that organizations using the ONC Certified Health IT Product List website may not be able to find products by name due to a bug in the web site.  The problem occurs when using the search by Product Name or search by Vendor Name.

The problem can be demonstrated by entering a Vendor Name or Product Name and then displaying the results for some Vendors and Products with more than one record.  Thanks to Laura Nasipak of eClinicalWorks who discovered this problem.  She has been in contact with ONC and they are working on a fix.  I have verified that this impacts multiple Vendors (including GE Healthcare) and Products (including Centricity EMR 9.5).

If you are unable to find your vendor or product, the workaround is to change the number of records to display from 25 (the default) to 200.  If you still cannot find your vendor, try browsing the entire list.

The two screenshots below illustrate the problem and work-around  (click on the images to see them full-size).

The problem:

The workaround:

 

Some thoughts for ONC Head Dr. Mostashari on IHE XDS for HIE

For most of you, this post qualifies as "preaching to the choir".  In this particular case, I hope I'm preaching to the Bishop.

The other day the new ONC Coordinator, Dr. Farzad Mostashari, spoke briefly with members of the HIMSS EHRA at the all-member call.  One of the things he said struck me:

One thing will not change [at ONC], and that is Listening.

The reason is struck me was that we had been discussing that very same topic the night before on the #HITsm tweetchat.  I do know that Dr. Mostashari is listening to some of us.  My evidence is his recognition of me at HIMSS by my twitter handle.  I'm pretty certain that Dr. Mostashari is lurking on twitter (I have that from a very good source that works with him).  I even DM'ed my source to tell Farzad to check the twitter/chat stream.  That particular statement appears to have been stated in a number of other places as well.

Another interesting comment he made was on ONC's emphasis.  They will be emphasizing patient engagement.  If you read further into the stream, you'll see that I made a similar suggestion.  Was I prescient and great minds simply think alike or was he listening and responding?  Either way, I'm happy to hear it.

We do have one point of disagreement, which on on how standards should be developed.  It's pretty clear from the way he answered my question about existing standards and innovation that he feels that if a standard is not gaining traction it is because it isn't ready.  Readiness of a standard requires three things:  A good standard, customer demand for what it provides, and the technology to implement it.  "If we build it they will come" is not a good reason to implement.  There must be demand for it.  For most organizations looking at adopting new features and standards, the demand needs to be apparent or the vision something that can be promoted.  Sometimes promotion of that vision, especially if the technology is novel needs time.  If you've been tracking healthcare technologies, you are probably familiar with the Gartner Hype Cycle.  Many items on the hype cycle spend at least a year in each phase -- at least when I look at Healthcare IT.

When we worked on what would become Cross Enterprise Document Sharing (XDS) for the joint IHE/HL7 demonstration, we saw a great deal of customer excitement about the possibilities, but the market barely even existed!  We knew it would take time.  Over the following years we've seen the explosion of eHealth and HIEs as a market, one that I heard being sized at over $12 billion annually (see previous link).  There have been a number of different technologies put into play, and large number of vendors across all different sizes with a wide variety of products.  Much of the technology is proprietary and doesn't work with other solutions.

The XDS family of standards does stand above the rest:

• It demonstrates world-wide penetration in a way that nothing else has.  
• More and more I've seen a large number of these solutions adopt support for the XDS family of profiles for exchange.  
• You can also get it for free from a number of open source solutions (I have 9 listed).

XDS is just exiting the first half the the Hype Cycle (now climbing the slope). Not every solution takes off virally like Direct.  In fact, in healthcare IT,  time frames have been quite different   Technology like the iPads (proprietary) and Direct (standards based) are exceptions rather than the rule.  I appreciate Dr. Mostashari's desire to change the adoption curve, and I too would like to see that change.  Where I remain concerned with is the assessment of readiness.  If we are nearly ready, but go back to reinvent the wheel, we could find ourselves back where we started.  We will also have lost a great deal of momentum and investment that the industry has built up around this particular solution.

So, if you are still listening Dr. Mostashari, I have a couple of follow-up question to ask: What would readiness look like?  How would you assess existing HIE standards against it?  What are the gaps?  Let's have a dialogue.

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

Industry Survey on Potential CORE Rule Opportunity Areas for EFT and ERA Transactions

This is the second of two announcements for today. While I don't usually focus on payment issues, this one is relevant for HITECH and PPACA programs, and CORE is looking for participating in this survey. Give them a few moments of your time if you can.

Keith

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Dear Stakeholder,

Survey Background
On March 23, 2011, the National Committee on Vital and Health Statistics (NCVHS) submitted a recommendation to the Secretary of the Department of Health and Human Services (HHS) recommending CAQH CORE in collaboration with NACHA as operating rule authoring entity for EFT and ERA transactions. The NCVHS letter also recommends that the Secretary require CAQH CORE, in collaboration with NACHA, to submit to NCVHS fully vetted EFT and ERA operating rules for consideration by the Committee by August 1, 2011.

CAQH CORE convened EFT and ERA Subgroups to develop operating rules for these transactions using the established CORE rules approval process. To assist the CORE participants and the industry in its decision making on EFT and ERA operating rules, CAQH CORE staff has outlined a list of potential rule opportunity areas based on:

• Scope of operating rules as defined by ACA Section 1104
• Current industry initiatives including state and regional efforts (e.g., Minnesota State Administrative Uniformity Committee, Washington State Healthcare Forum), work done by ASC X12 and/or WEDI, CAQH CORE and NACHA research, existing draft CORE Operating Rules

Both CORE participating and non-participating entities are asked to provide feedback on the CAQH CORE list of potential rule opportunity areas to focus the Subgroups’ rule development efforts, which will be shared with the CORE Rules Work Group (see evaluation criteria at bottom of this email).

Survey Instructions
All industry stakeholders are invited to follow the link to complete the Industry Survey on Potential CORE Rule Opportunity Areas for EFT and ERA Transactions and affirm your organization’s priorities on potential EFT and ERA operating rule areas. CAQH CORE has included a section for soliciting additional rule opportunity areas; should you add items, be sure to consider scope of operating rules and other criteria such as timing. The survey should take about 30 minutes to complete. Please coordinate survey response with EFT and ERA experts within your organization as appropriate.

NOTE: This survey is informative only and does not constitute an official CAQH CORE vote.

Survey responses are due by Monday, April 18th, 2011. Results of the survey will be shared on the EFT & ERA Subgroup calls and on the next CORE Town Hall call, which will be open to both CORE participating and non-participating entities. A PDF of the survey document is available via request; however survey responses must be submitted via the online survey tool. One submission per organization is required.

If you need clarification or have any questions please contact Erin Richter, CORE Senior Manager, at erichter@caqh.org. This information is also available online at www.caqh.org/EFT_ERASurvey.php

Thank you for your time.

The CORE Team

Evaluation Criteria
Given the scope for potential EFT and ERA operating rules as previously outlined, the following evaluation criteria can be applied to potential rule opportunity areas to identify key areas of focus for the Subgroups’ efforts.

IHE News: New Window opens on European eHealth- Read more at www.ihe-europe.net.

This is a day for announcements. This is the first of two, this one from IHE...

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IHE Community,

New Window opens on European eHealth

IHE-Europe launches a newly re-designed website, www.ihe-europe.net, in perfect timing with the 11^th Annual IHE-Europe Connectathon taking place this week in Pisa, Italy. The European Connectathon is also host to daily round-tables and educational seminars on specific health-care topics. The recent activities from IHE-Europe open a new window on the accelerating movement to electronic records across Europe.

Visit the new IHE Europe Website

The IHE-Europe website features links to five pan-European initiatives, nine national programs, and highlights success stories from regional implementations. Plus, a new feature of the IHE-Europe website are the EU Projects, a section devoted to the growing number of programs for coordinating and harmonizing electronic health practices. According to Harm-Jan Wessels, Chair of IHE-Europe's Marketing Communications Committee, "the website is the result of a collaborative effort of eHealth experts from the various IHE national initiatives across Europe. This cooperation towards the common goal of eHealth interoperability is the foundation for IHE's international impact and success." Read the full Press Release online.

IHE-Europe's 11^th Annual Connectathon in Pisa, Italy- April 11-15, 2011

The IHE Connectathon is a 5-day event which main purpose is testing the interoperability and connectivity of health-care IT systems. For five days in a vast hall that is hard-wired for high speed internet, more than 300 IT engineers come together in a casual but intensely concentrated setting to interconnect more than 100 systems and collaboratively solve problems. Participants state, the cost of identifying and fixing a system bug during an IHE Connectathon is ten times less expensive and difficult than de-bugging a system once it is installed at a hospital of clinic.

Official Connectathon 2011 results and a press release will be sent out at the close of testing this week. For more information please visit the IHE-Europe website.

Comments on Goal V of the ONC HealthIT Strategic Plan

This is the last post of the series on the ONC Health IT Strategic plan.

I posted Comments on Goal IV of the ONC HealthIT Strategic Plan a few days ago. John Moehrke covered Goal III quite well in his post at the end of March.  My thoughts on Goal IIappeared the same day, just before the ACO rule was announced, just in case you missed them.  And my comments on Goal I appeared the day before that.

Goal V: Achieve Rapid Learning and Technological Advancement
Overall, this goal is probably the furthest off and the weakest written.  There's too much focus on the Federal sphere and not enough outside of it.
A. Lead the creation of a learning health system to support quality, research, and public and population health
Strategy V.A.1: Establish an initial group of learning health system participants.
Two items jump out: "The learning health system’s success will depend in part on the participation of a select number of institutions that collect and use large amounts of health care data." and "Several federal organizations are already fostering learning systems scaled to their own agencies, and some of these agencies will be key initial members of this group."
While the Federal sector is clearly important, many other organizations should be able to contribute to this effort.  The qualification of "a select number of institutions that collect and use large amounts of health data" ignores smaller providers.  There are a number of initiatives that include these providers in efforts to collect and use large amounts of health data.  State HIE initiatives should be included so to see how HIE technologies can support the learning health system.  The FDA, CDC and ASPE efforts, while important, are rather narrowly focused efforts that ignore the potential of other, non-federal contributors to this effort.

Strategy V.A.2: Develop standards, policies, and technologies to connect individual participants within the learning health system.
Another quote in this section stands out: "In order to make the learning health system a reality on a national scale, standards, policies, and mutually reinforcing technologies must be put in place to ensure that data collected at the point of care can be accurately de-identified, aggregated, analyzed, and queried for population health studies and quality improvement."
I don't see the rationale.  The Learning Health System needs to be national in scope, but specific learning efforts could be regional in scale and more quickly executed upon.  There should be mechanisms to support both, and to foster communications between regional efforts.


Strategy V.A.3: Engage patients, providers, researchers, and institutions to exchange information through the learning health system.
I can see obvious benefits for researchers and institutions in participation.  But, what's in it for me as a patient?  When will I get lower cost or better care as a result in the near term?  What would a physician get from participation beyond a nebulous future beneficial result for their patients?  The Learning health system needs to look at innovation in the arenas of both patient and provider engagement.  One quick thought that occurs to me on provider engagement:  Healthcare providers all have continuing education requirements.  Would there be a way to report results produced by the learning health system to providers, or to encourage providers to engage patients that the learning health system is seeking that would include an educational component fulfilling some of these education requirements.  This is the kind of innovation that a learning health system needs to think about first.

B. Broaden the capacity of health IT through innovation and research

Strategy V.B.1: Liberate health data to enable health IT innovation.
This is a pretty good section.  Data liberation is just at the beginning stages as part of Meaningful Use stage 1, and will improve through subsequent stages.  Open government initiatives to consolidate data silos and make aggregated data accessible will certainly be valuable here.

Strategy V.B.2: Make targeted investments in health IT research.
Many of the investments discussed in this section have already been made.  There are certainly a few generously funded activities.  I'd be interested in seeing a broader approach to some of the research.  Which will produce better results?  Four $15M grants, or 120 $500,000 grants?  Innovation occurs in many ways, and a bigger net may gather more fish.

Strategy V.B.3: Employ government programs and services as test beds for innovative health IT.
Eating your own dog-food is a well established principle used by many innovative IT organizations.

Strategy V.B.4: Monitor and promote industry innovation.
Another quote "The government facilitates and monitors the health IT industry and stays abreast of innovation’s impact on federal policies and programs in order to further promote innovation within the industry. Such activity is conducted primarily through panels, conferences, white papers, and similar outreach efforts."
Monitoring includes attending health IT industry activities, not just hosting them.  There is quite a bit of activity going on in Health IT in standards organizations like HL7 and IHE that could use more input and feedback from ONC. Just as ONC needs to engage patients where they are, they should also be engaging providers and the health IT industry where they are.  Even though I'm pretty close to DC, attending ONC sponsored activities is not something I can always fit into my travel budget.  But I do attend quite a few other industry events.  I think one of the challenges here is that ONC doesn't want to show favoritism to any one organization -- fine, spread the wealth like CDC and VHA do.  Everyone will benefit.

Strategy V.B.5: Provide clear direction to the health IT industry regarding government roles and policies for protecting individuals while not stifling innovation.
I'm curious about IOM rather than FDA leadership in this area, especially with respect to patient safety.  I'm not sure why IOM was chosen to lead this activity, rather than the FDA; who has been addressing these issues for quite some time.

Affects of Efficient XML on HL7 Version 3

Diego Kaminker (cochair of the HL7 Education workgroup) reminded me this morning that I'm overdue on a post about Efficient XML, a new standard recently recognized by the W3C.  The creation of this standard is pretty significant for several reasons.  As designed, XML (and its predecessor SGML) were created to be text markup languages suitable for expert human users to use to annotate electronic text.  Because of this design, XML has become very easy for software engineers to use for a variety of different tasks.  XML users (and SGML users) have become quite familiar with editing raw markup directly in text files.  But the most common use for XML and its predecessor was software processing of the text and associated markup.

Uses for this markup abound and include display and formatting of text, book production (where I first encountered it), communication of software commands and responses to them (e.g., Web Services), structuring of tabular and hierarchical data, electronic commerce, et cetera.  One of the major complaints from the EDI world was that XML was notoriously costly for messaging in several ways:

1. Data Size
   Converting data elements from a binary format to text-based formats increases the size of the data, often by an order of magnitude.  The use of XML tags to delimit data elements instead of position in a data field, or simpler delimiters creates quite a bit of additional bytes to transmit.  End tags in XML are quite redundant -- useful for humans, but not all that useful for computers at a certain point in the production cycle.  These additions can add yet another order of magnitude to storage requirements.
   Impacts on Data Size affect:
1. Storage Capacity
2. Transmission Bandwidth
3. Memory Utilization
2. Processing/Marshalling
   Converting from binary data types for numbers, dates, times and similar data types to text requires computing time.  Dealing with all those start and end tags, and parsing decisions on the text also requires computing time.  The compute time spent on these tasks could be better spent on OTHER things, especially given that parsed XML has similar representations on many different platforms.

These problems make it difficult for devices with limited resources to efficiently use XML for computation or communication, even though the format has numerous other advantages for software development.  What are some of these benefits?

1. Ready access to tools which make content visible and editable.  Because XML is fundamentally text, any text editor can be used to open it up and edit it.  You may not recall a time when this was a problem for other data, but I do.  
2. Standards AND tools for describing the content allowed to be in an XML document.
3. Standards AND tools  to translate the content from one format to another.
4. Engineer (which is not necessarily the same as human) readability.
5. Implementability ... one of the guiding principals of the XML work was that it had a particular complexity goal in mind.  An XML parser should be implementable as a semester long college Senior project.

These benefits, and Moore's law trends in storage, network speed, memory sizes and processor speed have meant that the processing and data size issues have not significantly interfered with XML dominance as a data syntax.  But, small devices, or large bandwidth applications have still had some problems.  In the UK, one of the reported problems in adopting HL7 Version 3 was the verbosity of the V3 XML syntax.  In this particular case, the volume is on the order of hundreds of millions of messages per day.  The computation resources to parse the XML were significant, as was the bandwidth.

The HL7 Implementation Technology Specification workgroup  began development of an ITS that would simplify (flatten) the XML in 2008.  Those efforts began before I had even started this blog, so I don't even have a post on how I felt about that particular effort.  I can tell you I was quite negative on that ballot and it didn't go forward.  I ran a little test and what I found was that several existing models were only marginally improved (<10%) by the new algorithm.  I believe I argued successfully at that time that the right way to approach the problem was lower in the stack, rather than at the XML ITS layer.  

This argument applies not just to HL7 XML messaging, but to any form of XML processing.  What the application deals with is the XML Infoset, typically stored using the XML Document Object Model .  What is communicated to the application is an XML document.  Between communication and processing is a layer which translates the XML document from the XML syntax into the the XML Infoset.  That's where EXI has a huge impact.  By changing the format from text-based content to one better able to address the EXI requirements, an EXI implementation is better able to perform the translation back and forth between these layers.  It does so using a much reduced footprint from both a storage and a processing perspective.  Diego reports to me that in his brief experiment, a 60KB CDA document is compressed at a ratio of 20:1, which nearly makes up for the 1-2 orders of magnitude size increase.   Diego plans on performing other tests to evaluate performance.

What I have been able to determine from the W3C bake-off comparing the various technologies that they considered, and from the vendor's website for the technology that "won" is that you can also expect somewhere between 1-2 orders of magnitude improvement on processing (parsing) speed.

What happens next?  Having reached the point of becoming a standard, people are going to want to start implementing this in their products.  There are already 2 open source and one commercial implementation of the standard available. I think you can count on EXI being incorporated into your favorite XML parser pretty quickly.  Java implementations will probably be available sooner than C++/.Net.  Once web servers and browsers start supporting this technology, it will be interesting to see what it does to the browsing experience on sites that support it and which exchange XML or XHTML.   

One of the nice features about the EXI standard is that you can enable others who communicate with you to take advantage of it quite readily.  It plugs into the communications stack at the content encoder/decoder. At least one of the commercial products out there EXI enables your protocol stack.  You won't get all of the benefits of using EXI, but at least your communication partners could.  For XML based Web Services, this is a no-brainer feature to support.  Just make sure your client and server technologies support EXI on the stack and support use of x-efi as an encoding in Content-Encoding and Accept-Encoding headers.

When I was Your Age

My youngest daughter (8-years old, soon to be 9) was asked by her teacher (at E.G. Lyons School in Randolph, MA) to write two paragraphs about what was different in her parents lives.  Since I was working she interviewed my wife, but I thought it would be interesting for this community to hear and think about our own responses.  Sort of a reverse Beloit College Mindset List.

1. We had just got our first color TV, and we got 6 channels on it.  We didn't have to worry about hooking it up to a VCR or DVD player, Satellite Dish, or Cable because those things hadn't been invented yet.
2. Telephone handsets had wires that connected them to the phone, and that was wired to the wall.  There were only two styles and a limited selection of colors.  We didn't have cell-phones.  Some families still shared phones with their neighbors.
3. Maps were always on paper.  There was no such thing as a GPS.  In fact, the satellites used for TV stations (not home TVs) had barely been in use for more than a couple of years. The global positioning satellites wouldn't exist for another 20 years.
4. Kids didn't have e-mail addresses.  In fact, even adults didn't have e-mail addresses.  The whole Internet thing, with e-mail, web-pages, Twitter, Facebook, Google and all that other stuff was at least 20 years away. People did not have computers, but some companies did.  I had to wait until I was twice your age to get one.  Mine had 16K of RAM and cost 3 times as much as your netbook.
5. Candy was pretty cheap.  A candy bar cost a quarter and there was penny-candy that really cost a penny.
6. Almost all recyclables went into the trash with all the other garbage (garbage disposals weren't popular, even though they had been around for decades).  Most recycling focused on aluminum cans and news-papers (which I collected from people on the last Saturday of the month as a way to raise money for boy-scouts).
7. Oh yeah, we got the newspaper daily and the Sunday edition had color comics.  Most news came either from the paper, the TV or the radio: Not Twitter, the web, Google and Facebook, or Fox, CNN and Cable
8. The Walkman (you'd think it was an old-fashioned iPod) hadn't even been invented yet.  We had portable radios for our music (if we were lucky), and we had to go to record stores (you know, those old-fashioned CDs) to buy recordings of music.  Cassette tapes were also available.
9. My mother paid 0.55 for a gallon of gas.  That was during the first OIL crisis.  Before that she paid less than 0.40 for it. 
10. My job didn't exist.  In fact, while the whole idea of the Computerized Health Record had been "invented" by a guy named Larry Weed before I was born, they still aren't used in many Doctor's offices (although they are in yours and mine).

Some of the things you still have:

1. Instant Hot Cocoa, Frosted Lucky Charms, Captain Crunch, Pop Tarts, Peanut-Butter and Jelly and Wonder Bread, Marshmallow Peeps and snickers bars all existed when I was little.
2. Milk still gets delivered by the milk man and comes from local cows.
3. Skateboards.
4. Motorcross bicycles.
5. Libraries and Museums.

Looking back on this, what will you be able to tell your children a few decades from now.

1. Displays used to be heavy and expensive, instead of thin, lightweight, and roll-away.  Every thing used to have its own display instead of working with any display in the house.  People had lots of computers because everything needed a dedicated computer instead of using the cloud.  My dad had at one point in time a computer for work, one for home, one for fun, a tablet, a cell-phone and a GPS, and a garage full of old stuff.  It was really hard to make computers understand people.  And we had to have PRINTERS!?!  Can you imagine all the paper they wasted?
2. Light used to come from bulbs that had to be replaced every few months instead of being permanently installed and having to be replaced only when something went wrong.  And it took 100 times as much power to generate the same amount of light.
3. I couldn't get my own inbox (e-mail address) because I was too little.
4. A phone call overseas was expensive, and a video call not something most people did. 
5. They used to have to pick up the trash once a week because we threw away so much stuff!
6. Houses had to be connected to electricity by wires instead of mostly making their own.
7. You used to have to go to a special office to get shots and stuff to keep you healthy.  The people that worked there saw you a few times a year and a lot of them still kept track of everything they knew about you on paper instead of just beaming it to you or getting you to beam it to them.  Can you imagine having to go to an office for the doctor to look at you?  Didn't they even know about telepresence?
8. We had these things called cars that could hold 4 and sometimes even 8 people that we drove around in to get places -- and it used GASOLINE!
9. They used to have these placed called libraries that stored tons and tons of books on PAPER!
10. Most people never left their own country to travel.  It was too expensive and difficult and there were all these rules about places you could go and wars and stuff.

And for your kids:

1. Instant Cocoa, lucky charms, pop-tarts, PBJ and all that stuff will still exist.
2. Their milk will still come from the milk-man and local cows.
3. Skateboards will still exist.
4. Bicycles will still be around, but about half the weight and cost.
5. The library will be a museum.