I might be a 21st Century Healthcare Leader

I'm catching up on my reading this afternoon while I wait for anaethesia to wear off and remaining disomfort to pass. Oh the joys of getting old. I ran across this post from @HealthIsSocial via @HL7Standards. My answers to the questions are below..

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Do you care? Yes
Do you learn something new everyday? No, but I try to.
Are you confused about our time? Yes.
Do you have a sense of humor? Yes,
Do you believe health care is a right or an earned asset? A right.
Have you ever imagined what it’s like to die in pain? Yes.
Do you prefer to be right or wrong? Right.
When was the last time you started a community centerred around health care? About 3 months ago.
If I Googled your name, would I find you in the top three results? Yes.
If I found you on Google – anywhere – what would I learn about you? Healthcare Standards geek with a background in XML.
If I can’t find you on Google, where are you? You can find me via Google.
Is Twitter trivial or relevant in health care? Relevant.
What about Facebook? Good for health care? Bad? OK, just not my cup of tea,
What have you written publicly about the nuances involved in healthcare and social media? See here. Mostly little.
What are you thoughts on the Quantified Self? I know some things about myself that I've measured. Measurement is key to improvement.
If you could build the Healthcare industry from scratch, what would be your first priority? Your second? Your third? Your last? Priority one: Change the payment system. Two: Change the education system. Three use Information Technology. Last: Get rid of drug ads.
What are your thoughts on paper versus electronic medical records? Electronic of course.
What’s your philosophy on how social and other digital technologies shape health care? Social is good for getting information out. Other digital tech for managing and maintaining it.
If you don’t have a philosophy about technology, what are your plans for navigating through the Century of Technology? I do have a philosophy about technology.
Do you think it’s acceptable for nursing homes to smell like garbage? Or is that par-for-the course in Healthcare? No and I don't knw.
Do you feel stupid about health care reform? Yes. Actuarial stuff is confusing.
Do you thirst after knowledge like water in a desert? Yes.
What does health mean to you? See Websters.
Have you ever commented on a blog, forum or anywhere else on anything related to health care? DUH.
What does “blogging” mean to you? Waste of time? Or a sign of 21st Century excellence in communication? It's a way to write down my thoughts and share them with others. Not a waste of time at all, and definately a sign of 21st century excellence.
How do you feel about curse words? Give me a damn break.
Following up to the previous question: if you never ever curse in public, how do I know you’re passionate about health care? Or anything for that matter? There are other ways, like how often I write here.
If someone is terminally dying (hours, days from death) and asks for more morphine, how fast or slow would you run it in? I'm not a doctor, I don't know the answer. Fast enough that they'd shortly feel no pain, but not so fast as to kill them by accident.
Would I ask you to help in a code, or kick you out of the room? You'd probably kick me out, but I'd want to help -- just not trained for it.
Do you have a mechanical view of the world, or an organic one? A bit of both.
What do health care leaders do, in your view?
What does “health care transformation” mean? Useless buzz-phrase, or something to work on? Most of the time its been a useless buzz-phrase, but I think its always been worth working on and right now we have a golden opportunity.
What matters to you most in health care? Making it better for me, my family, my tribe ...
Following up on the previous question: what are you doing about it right now, this moment? Answering your questions. In a little bit, looking into some ways to make healthcare IT systems work better together.

IHE ITI and PCC Technical Framework Supplements Published for Public Comment and IHE PCD White Paper Published

IHE Community,

IHE IT Infrastructure Technical Framework Supplements Published for Public Comment

The IHE IT Infrastructure Technical Committee has published the following supplements to the IHE IT Infrastructure Technical Framework for Public Comment on June 3, 2011:

• Cross-Community Fetch (XCF)
• Cross-Enterprise Document Workflow (XDW)
• Document Encryption (DEN)
• Support for Metadata-Limited Document Sources
• XAD-PID Change Management (XPID)

The documents are available for download at http://www.ihe.net/Technical_Framework/public_comment.cfm. Comments submitted by July 3, 2011 will be considered by the IT Infrastructure Technical Committee in developing the trial implementation versions of the supplements.  Comments should be submitted at http://www.ihe.net/iti/iticomments.cfm 

IHE Patient Care Coordination Technical Framework Supplements Published for Public Comment

The IHE Patient Care Coordination Technical Committee has published the following supplements to the IHE Patient Care Coordination Technical Framework for Public Comment on June 3, 2011:

·        CDA Content Modules

• Reconciliation of Diagnoses, Allergies and Medications (RECON)
• Transport Summary Profiles (includes the following profiles):
• EMS Transport Summary Profile (ETS)
• Interfacility Transport Summary Profile (ITS)

The documents are available for download at http://www.ihe.net/Technical_Framework/public_comment.cfm. Comments submitted by July 3, 2011 will be considered by the Patient Care Coordination Technical Committee in developing the trial implementation versions of the supplements.  Comments should be submitted at http://www.ihe.net/pcc/pcccomments.cfm

IHE Patient Care Device White Paper Published

The IHE Patient Care Device Technical Committee published the following White Paper on May 27, 2011:

• Medical Equipment Management (MEM): Cyber Security

 The document is available for download at http://www.ihe.net/Technical_Framework/index.cfm.

Constraining CDA

I'm looking at constraint patterns for CDA as part of the template meta-model work for the siframework project.  These can be applied to any UML-based model of information.

I explored this in a number of different ways to see how constraints could be modeled.  What I wound up doing was breaking a conformance statement down into three separate parts:

1. The basic conformance statement, mostly embodying the conformance level.
2. Constraints that can be applied to it, cardinality, existence, and all match.
3. Match patterns that can be used with it.

1. Conformance Statement

The basic object is a conformance statement.  Each conformance statement has a conformance level:  

• SHALL
• SHOULD
• MAY
• SHOULD NOT
• SHALL NOT

This corresponds to the error level reported by a conformance test, and follows the usual meanings in RFC-2119.

2. Constraints

2.1 Cardinality Constraint
There conformanceLevel exist some number of X items

The basic constraint is on the cardinality of the item, and is expressed in a min/max form, where 0 <= min <= max <= ∞ and min < ∞.

2.2 Existence Constraint
There conformanceLevel exists some number of X items that match pattern P.

This is the existence constraint that I talked about yesterday.

2.3 All Match Constraint

There conformanceLevel are some number of X items and all match pattern P.

This could also be expressed as two existence constraints:

There conformanceLevel exist some number of X items that match pattern P

There conformanceLevel exist 0 X items that match pattern !P

3. Patterns

Patterns are used to express different constraints and test conditions.

3.1. Range Pattern

A range pattern is an abstract pattern that places a limit on particular values that a data element can have.

3.1.1 Value Pattern

X.V = Y

The value pattern is an abstract extension of the Range Pattern, restricting a data element to contain a single value.

3.1.1.1 Specific Identifier Pattern

X.root = Y.root

X.extension = Y.extension

This is an extension to the Value Pattern where the data element being constrained is of the II data type. It is commonly used to require a class to assert conformance to a specific template, and in the typeId constraint found in CDA.

3.1.1.2 Specific Code Pattern

X.code = Y.code

X.codeSystem = Y.codeSystem

Similar to the Specific Identifier pattern, this requires the use of a specific code instead of an identifier.  It can be applied to any data element of the CD or derived data types.  It is commonly used in CDA fixed attributes (classCode and moodCode), and in section templates.

3.1.2 Identifier Namespace Pattern

X.root = Y.root

This is also an extension to the range  pattern where the data element being constrained by come from a specific namespace or assigning authority.  It can be used to require provider identifiers from a given assigning authority (e.g., NPI or DEA).

3.1.2.1 Vocabulary/Value Set Pattern

X.V is an element of Y

This is an extension of the Range pattern used to require use of a specific vocabulary or value set.  This is also applied to data elements of the CD or derived data types.  It is commonly used to restrict the value of the code element  in CDA documents, but can also be applied to the value element.

3.1.2.2 Data Type Pattern

X is of Type Y

This extends the range pattern and fixes the data type or data type flavor (a restriction on a data type) of an element to one of a specific list of possible types.  It is used most commonly on elements using the GTS data type, but can also be applied to other elements (e.g., the value element in CDA which is of unspecified type).  Restrictions on name and addr elements are data type patterns (not templates), as they specify a data type flavor to be applied to the name and addr elements.

3.1.2.3 Contains Text Pattern

X.text contains "Allergies"

This extends the range patter and requires the content of a text element to contain a specific value.  This type of constraint was used in CCD to restrict the titles in sections.

3.2 Contains Template Pattern

X.association.templateId = Y

This template is used to specify the inclusion of an association (participant, act relationship, role or entity) in a higher level class that conforms to a given template.

3.3 Logical Operator Pattern

Patterns can be combined using logical operators (AND/OR/XOR).  This pattern allows any number of other patterns (including the Logical Operator Pattern) to be combined using the AND, OR and XOR.  When combined with AND, all patterns must match, with OR, at least one must match, and with XOR, only one of the patterns is allowed to match.

Subtleties in Constraint Language

We were discussing this topic on an SIFramework call the other day, as related to the CDA Consolidation guide.  I'm putting together a rogues gallery of different types of implementation guide constraints (of which this is one input).

One of the subtleties of constraint in a guide has to do with how different constraints interact.  Consider the following two scenarios:

Scenario 1 (Cardinality AND Value Constraint):

1. There shall be exactly one [1..1] typeId element beneath the ClinicalDocument element.
1. The typeId/@root shall be "2.16.840.1.113883.1.3"
2. The typeId/@extension shall be "POCD_HD00004"

In XPath these three assertions could be individually represented as:

1. count(/ClinicalDocument/typeId) = 1 
1. /ClinicalDocument/typeId/@root="2.16.840.1.113883.1.3"
2. /ClinicalDocument/typeId/@extension="POCD_HD00004"

NOT: These could be combined into a single expression using and, but there is little value of that to end users because the test would no longer be able to tell them WHICH of the three requirements was not met.

Scenario 2 (Cardinality WITH Value Constraint):

1. There shall be exactly one [1..1] templateId element where @root = "2.16.840.1.113883.10.20.22.1.1"

In XPath, this could be represented as:

1. count(/ClinicalDocument/templateId[@root="2.16.840.1.113883.10.20.22.1.1"]) = 1

The first set of constraints indicate that there shall be only typeId element, and that it must have a particular value (using the II datatype).  It prohibits the appearance of a typeId element containing any other value.

The second constraint indicates that there is only one templateId element that has a particular value.  It does not prohibit the appearance of other templateId elements containing other values.

In other words, there is a difference between "there shall be only 1, and it shall have this value" and "there shall be only 1 with this value".

This is the root cause of one of the confusions with respect to using other medication vocabulary in the HITSP C32 to record the coded brand names.  The intent in that case was to following scenario 2, not scenario 1, as I explained here.

I think the rogue's gallery will help.

10 Mistakes Doctors Make with their Patients

The patient - doctor relationship is one that is so important for optimal health outcomes.  It is meant to be a "partnership", but in many cases, a Doctor's behavior can get in the way of optimal care:

If this sounds vaguely familiar, you may have read 10 mistakes Patients Make with their Doctors by Don Ammon the other day, either on the Action for Better Healthcare Site, or on Healthcare Finance News' Blog pages.

So, here is my set of the top 10 mistakes Doctors make with their patients.

1.  Paying attention to my chart, your computer or anything else but me for the first five minutes of our visit.
2.  Leaving out information in my treatment options.
3.  Expecting patients to have the answers you want just because you want them.
4.  Assuming you understand the reason for my visit.
5.  Not stating up front what your expectations are with respect to our relationship.
6.  You don't know what medications I'm taking.
7.  You don't answer my questions or concerns in a meaningful and understandable way.
8.  You don't have my medical records or images.
9.  You are too scared to have me disagree with you.
10. You rely on polls to tell you what patients do wrong, instead of figuring out that it really is about working together.

Let's try this one again, shall we.  As patients and healthcare providers, here are my top 5 ways we can work together as a team:

1.  We will work together and trust each other.

2.  We will communicate our expectations to each other.

3.  We will pay attention to each other.
4.  We will provide each other with the necessary information to support optimum care.  That includes keeping each other up to date on any changes in care, and making sure that information needed makes it to where it is needed in as easy a way as possible.
5.  We will realize that sometimes another viewpoint is necessary.

SDO Leaders Wanted: No experience required

There are plenty of opportunities for leadership in Standards Development Organizations. Both IHE and HL7 will be looking for leaders this fall.

What makes a good leader?

Most would assume that subject matter expertise is an important qualification.  Sometimes this is true but not always.  In fact, some of the most knowledgeable subject matter experts I know of would make for lousy leaders (I'm probably a prime example).  An SME will often focus one one topic and one way of doing things, and will have strong opinions to the exclusion of hearing alternatives.  But a good leader needs enable the work-group to explorer alternatives, will ensure that all sides are heard, and also drive consensus.

From my perspective, the best leaders are those who are skilled at facilitation and delegation, rather than those who can do the actual work.  You might need to understand the subject matter well enough to drive the agenda, but certainly not so well as to be needed to weigh in every decision.  In fact, being a little bit apart from the topic can enable a leader to help the work-group gain needed clarity. Project management skills count for a lot in work-group leadership.  A good PM with no subject matter expertise can be much more successful than an SME with no project management skills.

So, the next time there is an opportunity to provide leadership in an SDO or workgroup, ask yourself these questions:

• Are you a good facilitator and listener?  
• Do you have project management experience?  

If so, apply.  There will be plenty of opportunities for on-the-job subject matter training.

LOINC Mapper's Guide to the Top 2000+ Lab Observations

This crossed my desk this morning. This is a useful value set of laboratory observation codes developed from millions of lab reports. While they don't say who the organizations are, I can guess that its the same set of organizations that contributed data to the Common Lab Order value set (found on the same page at the link below). I know that includes information from both hospital and ambulatory providers from across the US.

These are good value sets. They should be looked at by the HIT Standards Committee for meaningful use stage 2. I would hope that the ONC SIframework Lab Results Interface Initiative project also considers them.

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The LOINC Development Team is proud to announce the release of a new
resource, the "LOINC Mapper's Guide to the Top 2000+ Lab Observations",
that is available at: http://loinc.org/usage

We've created an empirically-based list of the most common LOINC result
codes and written up a Mapper's Guide that contains a wealth of advice
and guidance about which codes to choose for which purpose. The Top
2000+ list contains result codes that cover about 98% of the test volume
carried by 3 big organizations who've mapped to LOINC. We think it will
be a great starter set for beginning your mapping. We've written up a
detailed Introduction document that explains how this guide was
developed, which you can download along with the Mapper's Guide (in pdf
and xlsx format) and/or a simple list of the Top 2000+ terms (in csv
format). All of these are available at no cost from the LOINC website.
As always, we welcome feedback...just send your comments to:
loinc@regenstrief.org

Happing LOINCing!
Kind Regards from the LOINC Development Team