Wednesday, June 15, 2011

Go ahead. I dare you.

Call yourself a dog or a cat.  I don't care.  AHIMA, AMIA, ANSI, Connecting For Health, eHI, EHRA, HIMSS, HL7, IHE, IHE USA, Internet2, Liberty Alliance; ONC; Continua, CCHIT, Health Story, NeHC; X12N, NCPDP, CAQH/CORE, PHSDC, the SCO, ASTM, OASIS, OMG; OHT.  Anyone else I've missed (I'm sure there are some)?

Let's have a meeting of the minds ... a come to Jesus meeting.

You,  represent (and I quote) "an extraordinary diversity of stakeholders who share a commitment to improving the health care system through more effective use of health information."

Come together again, but this time, let's put some skin into the game.  Every single one of you has something you are doing that is focused on Healthcare Interoperability and Standards.  Many of you are US focused, some exclusively, others have a strong US presence.  Many of you derive revenue from these activities.

We need to break down more silos, but these are all your own silos.  I'm tired of silos.  I want you all to go into a room, we'll feed you coffee, tea, pizza and mountain dew and all the water you can drink, but there will be no bathroom breaks until you've emerged with a solution about how we can develop standards, implementation guides, reference implementations, and open source, under a common governance framework, with shared benefits to all, to meet the needs of the US healthcare system, and to support our goals internationally as well.  Call it the US Standards Collaborative.  Call it SI Framework 2.0.  Call it what you want.  Make it happen.

Oh, and ONC, you need to put some skin into this game too.  You, as I recall, wanted a public-private partnership to come out of the SI framework process.  What will you put forth to make that happen?  You know the money for SI Framework runs out in what, two years or so?  How will you keep that going.

Nah, it'll never happen.  There's just too much competition for leadership in this space for people to work together on a common goal like this.

But it could.  If just a few someones were willing to take the dare.

Thoughts after a Standards Meeting

It's not a Healthcare standards meeting unless sushi has been eaten.  Tonight several (6) of us went to my favorite DC Sushi Restaurant: Sushi Taro.  We all ordered the Sushi Tasting, and it is definitely an experience to be savored.  We spent nearly three hours on these 11 courses.  Dinner tonight was on my own dime because there is no way this would fly on my T&E budget, but it was worth every penny.

The SI framework meeting that I'm attending has been equally valuable on many different fronts.  Being present face to face is the first opportunity many of us have had to meet new faces.  It's also a good opportunity to meet many old friends from HITSP, and continue ongoing relationships in HL7 and IHE.

What's up at SI Framework?  I'm pretty much focused on the Transfers of Care work, so I don't have much to say about the LRI work.  But here are some high points:

Clinical Information Modeling:  This workgroup is closing in on content needed for 4 different transfers of care use cases (Discharge, referral to consult, consult report and patient discharge instructions).  There are three tiers of information.  In Tier A is the data that is needed for every transfer:  Active Problems, Meds, Allergies, et cetera.  In Tier B is the stuff that should be available to be sent because it may be pertinent and relevant for a transfer.  I'm not sure about Tier C, but I think it falls into the category of nice to have but not necessary.  So, we should soon have the CIMs.  What's a CIM?  Well, these are ONC SI Framework CIMs not HL7 constrained infomation models (isn't it lovely that we can reuse the same acronym for a similar thing).  And not to be confused with Intermountain's Clinical Element Models (that is clearly a CEM).  I'm not sure why there's all this reinvention, but because we don't have a metamodel for CIMs yet (I hope to be working on that with the MDHT team), it's something that can be fixed by retrofitting what we already know about clinical models from around the world.  The workgroup lead is someone I hadn't previously met, Dr. Holly Miller.  I got to listen to her explain the importance of pertinent and relevant to the CIM team while I was in the back of the room.  This evening I upgraded her ribbon from Rock Star to Goddess.  I don't know how many times I've tried to explain that to people.  She joined the group who headed to Sushi for dinner.

Data Elements:  This workgroup has nearly completed mapping data elements required for the use case back to the HITSP C154 work that was done in 2010.  John Donnelly led these efforts (he was another member of the dinner team tonight).  It's almost all there, which is what I would expect.  There's some confusion because there's a different between a set of data elements to describe something like a condition, and the clinical context in which it appears.  For example, you use the same set of fields to describe a condition regardless of whether its part of the active problem list or is part of the history of past illness.  It's that classification of the set of data elements which is dynamic (and depends upon clinical judgement about relevance), and the data elements themselves, which are static.  I got to spend some overdue time with this workgroup.

Standards Analysis is proceeding well, but depends on the output of the CIM workgroup.  It appears as if the strategy might be C83 for today, moving towards the CDA Consolidation work when it is ready (e.g., when we have some deployment experience and a reference implementation).  The CCR doesn't seem to be up to the job from the reports of several people (not just me).  I described it to one person thus:  You can have a fast motorcycle and a fast car.  In a short race, the fast motorcyle will win every time.  But in the longer races, the car will beat it every time.  The motorcycle has more accelleration, and will get you to top speed faster (e.g., the CCR and transfers of care), but the Camaro will beat it out in any long race because it has a higher top speed (CDA and CCD).  That is going to be an interesting discussion because most of the CCR proponents aren't at this face to face meeting.  I miss seeing Steve Waldren, he was a force for good in HITSP, and we haven't connected back up since those days.

The Reference Implementation and Architecture workgroup came under quite a bit of fire when we reviewed their scope and purpose. Even when  we ripped that to shreds and reworked it, much of the architecture remained, but our focus appears to be changed.  That group seems to want to adopt me and I'm not adverse to the idea.  There's quite a bit of overlap between what they want to do and work that already exists in MDHT and the Template Meta-model work.

There's a ton of data that we need to gather.  Some of that will likely be in a template exchange format based on the template meta-model.  My own work in this space is leading me down the path of rebuilding the model from an XML Schema designed from the model.  While EMF is capable of generating a schema from a model, I'm not well versed in how it does it yet to get the XML Schema that I think should be generated.  So I generated and XML schema that I'll hand-edit, and then reverse engineer that back into an EMF model.  I some work I've done this week I've already identified a gap, which is a business name associated with the class attribute being constrained.  That might actually enable us to tie the clinical information models, data elements and template models together in MDHT.  Then we can build a transformational architecture based on the model data using something like MDMI (which we may shortly have access to an open-source implementation of).  Once I get that working the way I like it I'll have to explain it to the templates workgroup at HL7 who is working on updating the Templates DSTU.  I wish all these projects weren't trying to be pertinent and relevant at the same time.

From there, I think there is a step of building an interface to support storing CIMs in an exchange instance and loading an exchange instance into a model so we can extract the data elements from CIMs.  That's a place where something like MOF2TEXT could help.  Any .Net coders out there that want to write code generation for the .Net interfaces?

There's some thought that the interface for the reference implementation should be a service.  I think the first step is to build an API and then to refactor a service interface out of it.  The former will be more fine-grained than the latter.  Since the API is model driven, it shouldn't be too difficult to get several implementations if we can get the right people engaged.

There's clearly signs of growing pains in SI framework.  The late venue change (we are now in the Hilton Hotel down the street instead of in another office buidling) is due to 170 people registering for the meeting.  This would have been pretty normal turnout for a HITSP meeting, probably five times what they had for Direct, and predictable given the size and number of workgroups.  Both ToC and LRI workgroups were stuck with two large conference spaces that we had to share for our breakout sessions.  Communication has been a bit of a challenge, but late breaking news has made it to people via e-mail instead of just being on the wiki.  This is a welcome change because I do read my e-mail every day, several times a day, but I don't go to the SI Framework wiki all that often.  Wiki's are great collaboration and documentation tools, but lousy ways to deal with conversations.  I wish we'd just get a list server and figure out how to integrate it into the wiki.

There were some other "up-level" conversations that we also had about the SI Framework process.  One of my challenges is having yet-another-standards-activity to follow.  ToC alone has umpteen hours of calls a week, at least twice as much as what I try to follow in HL7.  The RI workgroup was new to me because I cannot keep up.  They are spawning (in ToC and LRI) about two workgroups a month -- with more to come on at least two other projects (Provider Directories is one of those, and the other you'll hear about later).

One of the things Doug asked, first to the workgroup leaders, and second to the entire group was "what is it that this organization does that the SDOs do not."  There are a lot of different answers to this question.  One of them is "Support from ONC".  For some reason, neither IHE nor HL7 (nor the former HITSP) seem to get the respect from certain people at ONC or the FACA's that they'd like.  And yet when I look in the room for the SI framework project, more than half of it is made up of HL7, IHE and former HITSPites.  There seems to still be a belief in some quarters that these organizations haven't served the industry.  While they all have their blemishes, I think that they have done so.  One of the comments made about the need for SI framework was that "we aren't there yet", but the same person also said "Interoperability is a journey, not a destination."  Clearly there are some waypoints on this journey that people would like us to hit.  I want to know what they are, and how they are being established (something not apparent in how SI framework projects get chosen today).  This is not any one organization's problem.  It belongs to all of us, just like my jacket tells not just my story, but those of many other volunteers in many different organizations working to bring about change.

Members of IHE and HL7 will continue to participate in these efforts, but I really wish that someday there could be a come-to-Jesus meeting with all parties where everyone could air their griefs and get over some of these impasses, so we could be more focused across the board.  There's still too much back-room-snyping going on in way too many places.  Maybe it's all just "Politics" and I should just ignore it, but I'd really like to make it go away so we can focus on the real work.  This shouldn't be so dog-eat-dog competitive.  There should be a way for all of these organizations to work more closely together (maybe something like the Canadian model -- I think I'll propose something later in a blog post).

The Documentation workgroup meets in the afternoon to talk about the "transition strategy document".  This was deemed out of scope in the HL7 efforts, but really needs to exist if the ToC project is to succeed.  There needs to be a map drawn from the way we do it today (C32 Version 2.5 and CCR) to the way being proposed for the next stages of meaningful use.  I'm wondering if trying to bring in a publisher might help with this.

All-in-all, it's been a very productive standards meeting thus far.

Monday, June 13, 2011

The Debut

I promise to have better pictures tomorrow, I made the mistake of leaving the SD card at home so my best shots are still in my camera. My new walking jacket debuted at the SI Framework leadership meeting tonight in advance of the face to face tomorrow.


Here it is hanging in the hotel room. The most prominent feature is the rising Phoenix, an image that I've had on the back of my vest for about 5 years. My (then four-year-old) youngest daughter picked it out for me at a county fair. It arrived about the same time as I did on the Health IT scene, and became an emblem for me of the rebirth of my career.

In this image, the Phoenix's wings list many healthcare standards activities and specifications that I've played a part in: The HITSP C32, IHE XPHR, The CCD, HL7, CDA, HIE, ICD-9 (which I sunk my teeth automated coding as my first healthcare IT application), and ONC whose SI Framework activities I'm spending time on this week.


Below is a shot of me wearing it at the SI Framework TOC Leadership meeting tonight.



It goes on a more public display tomorrow at the SI Framework face to face meeting, where at least 170 people have registered.

Speaking of that meeting, if you are unable to attend in person, here are the dial in details. I understand the CDA Harmonization workgroup will still be meeting at their regular time tomorrow. The wheels keep
tchurning...


-- Keith

P.S.  I'm thinking about leading a Metro ride over to 73 cents at 5001 Connecticut Ave tomorrow evening.  Any takers?


ToC Initiative Members:

The SI Framework's June Face-to-Face (F2F) meeting kicks-off tomorrow morning in Washington, D.C. We welcome all who are attending in-person!

However, if you are unable to attend the F2F in-person, web-conferencing information is available on the ToC F2F Wiki page.

For your convenience, you will also find it below this message.

Regards,
SI Framework Admin Support

Tuesday, June 14
Time (EST)
Agenda Items
Webinar
for Breakout
Dial-in
for Breakout
Facilitators
10:00am-12:00pm
Data Elements WG
1-888-998-2663
P: 4123232
John Donnelly, Ed Larsen
10:00am-12:00pm
UC Care Planning WG
1-888-998-2663
P: 2101200
Greg Smith, Amy Berk, Ed Larsen
1:30-3:00pm
CIM/Vocab WG
1-888-998-2663
P: 4123232
Holly Miller, Russell Leftwich, Meredith Lewis
1:30-3:00pm
Standards Analysis WG
1-888-998-2663
P: 2101200
John Donnelly, Rich Kernan
3:00-5:00pm
Architecture/IR & RI WGs
1-888-998-2663
P: 4123232
Mayuri Patel, Mark Bamberg, Joan Duhaime
3:00-5:00pm
UC Simplification WG
1-888-998-2663
P: 2101200
Gary Dickinson, Amy Berk, Ed Larsen

Wednesday, June 15

Time (EST)
Agenda Item
Webinar
for Breakout
Dial-in
for Breakout
Facilitators
10:00am-12:00pm
Architecture/IR & RI WGs
1-888-998-2663
P: 4123232
Mayuri Patel, Mark Bamberg, Joan Duhaime
10:00am-12:00pm
Standards Analysis &
Data Element WGs
1-888-998-2663
P: 2101200
John Donnelly, Rich Kernan
1:30-3:00pm
Architecture/IR & RI WGs
1-888-998-2663
P: 4123232
Mayuri Patel, Mark Bamberg, Joan Duhaime
1:30-3:00pm
CIM/Vocab WG
1-888-998-2663
P: 2101200
Holly Miller, Russell Leftwich, Meredith Lewis
3:00-5:00pm
CIM/Vocab WG
1-888-998-2663
P: 2101200
Holly Miller, Russell Leftwich, Meredith Lewis
3:00-5:00pm
CDA Consolidation
(Documentation WG)
1-888-998-2663
P: 4123232
Keith Boone



Friday, June 10, 2011

Thoughts on Implementing Usability

Over last week there has been an amazing flurry of activity with regard to health, health data, electronic health records, et cetera.  Most of it took place in Washington DC, during DC Health Innovation Week.

One of the workshops held last week was about EHR usability, hosted by NIST.  I wasn't able to attend, but I will be reading through the presentations as I am able.

One of the blog posts I retweeted this week on usability mentions Tufte's sparklines.  If you don't know who Tufte is, you probably haven't been working in design, and if you are working in design and don't know him, you need to go find out.

Sparklines are very cool.  They are small information graphics about the size of a a long word in text.  A few examples appear in the picture below.

Let's say that you decided to implement this in an EHR.  There are a couple of places that you can get open source implementations of sparklines, and there are graphic libraries that you can use to generate the images as well.  Seems pretty simple in concept, with some really great value to offer providers.  Let us dig into some of the issues that we'll need to address in an implementation:

Outliers:  Some results can be out of range, unmeasurable, et cetera.  How should these handled?  This is actually one of the questions raised on the Tufte post.  The response, to use log scales in some cases is not really a satisfactory answer.

Time Scale:  How is the time scale determined?  Is it the last year, last month, last week, or patient life?  Time scale is often a question of relevance, in which case it means that clinical judgement needs to be applied.  Whose judgement?  The customer's?  The developer's?  

Units: The same result can be reported using different units.  Which one do you normalize to?  The example above doesn't show units at all [probably not a good idea for reasons described later].  How do you chose?  Temperature above is in degrees Fahrenheit.  OK, that might be fine in the US, but if I have to ship the same product to Europe, they better be in degrees Celsius, and some US institutions prefer degrees Celsius anyway.  Another configuration option.  That means I better report the normalized units being used.  Oh, and just for fun, some results can use units of volume while others use units of weight.  For example, kilogram of water takes up 1 liter of volume.  I'm not sure if this is an issue for common tests, but it certainly is for some uncommon ones.


Configurability: Is Time scale, units or normal range a configurable option or not?  If it is a configurable option, how do you deal with the case that clinicians at one site will have one set of expectations, and those at another have a different set, and you could have one provider having to deal with both, with the potential for misinterpreting a result because of the different system configurations?  Oh, and what happens when a new system is installed with a different configuration, or some poor physician has to transition to a new system with a different configuration.  If everyone uses sparklines in their EHR, what are the standards for displaying them that avoid this sort of problem (see this example for ECG graphs)?

Normal Ranges: The gray bars represent the normal range of values.  This gets complicated a number of ways.  Whose normals?  The lab's?  The healthcare provider's?  The developer's?  Is this configurable?  Two labs may report the same lab result with different normal ranges that depend on patient age, height, weight, and other factors (including the test method).  The normal range changes as the patient changes (age, height, and weight are variable over the patient life).  See for example some normals for respiration rate.  How do we deal with that?

Units again:  Many lab systems report results using different vocabularies for units (with variations on ANSI and ISO units).  Without a standard vocabulary for units (like UCUM), we need to deal with transformations to a normalized set of units.

Graphics: You are going to need a lot of these, and they need to be generated quickly.  You may want to add some cool features like mouse overs or hovers.  What tools should you use.  How do you validate these?  Do it your-selfer's be warned:  Generating small images accurately and quickly takes skills with numerical algorithms and processing.  A small error on a small graphic can represent a big difference in interpretation.  Look at respiration again, or WBC in the image above.  Are these values inside of, or outside of the normal range?  How important is that? How far inside or outside is it?

Good data: Key to getting sparklines right is having good data.  After all, GIGO out is one of the first things we learn in computer science.  Good data means that you have good interfaces.  You need to be able to ensure that WBC, glucose, et cetera all come across the lab interface in a way that they are mapped into the right place (e.g., using a vocabulary like LOINC), that normal values are present (if using the lab's normal range), that exceptional values are reported consistently, that units are mapped consistently.

So, simple idea, but a lot to think about in the implementation, and some definite prerequisites on the interoperability side before it can be executed upon. 

What is the moral of this story?  Nothing is ever as easy as it looks.


Thursday, June 9, 2011

ANSI Announced as ONC Approved Accreditor

This just crossed my desk. It was quite predictable given the role of the AA and ANSI's experience in that space, but nice to know this has been finalized.





The Office of the National Coordinator for Health Information Technology























Wednesday, June 8, 2011

Over Capacity

I went to The Walking Gallery tonight. The jacket representing the stories of my community wasn't done yet. Instead, like many others, it carried this picture (from the back of Lisa Shah's jacket). It is the perfect representation of where our health system is today.


Over capacity. And no matter how many 3 AMs anyone sees, it will take more than we ever anticipated to make up the difference. Am I disappointed to leave without a jacket? Of course I am, but I got what I really came for, which was more stories about patients that are served by the standards I and others in the Standards Community develop. And there still will be a jacket, one of high quality -- and which will last, even if it didn't meet an arbitrary deadline.

There is one story, one jacket, and one person which struck me vividly tonight. If I were judging best of show, this jacket would be it.


It tells the story of patients at the cross-roads. I wore that gown Monday (nothing serious). On my way to DC, I worked on HIT, HIE, EHR and EMR, and will continue to do so. The young lady (Leah) wearing the jacket has, according to one ONC staffer, 1 class left to finish medical school. Leah herself told me that she took a year off from medical school to work at ONC and that she's on the "Meaningful Use" team. I told her that this is an opportunity that comes along once in a lifetime. I don't think she really understands the impact she, or so many others in the room today will have on our healthcare system. We cannot understand how large an opportunity this is right now. It is so immense that at the same time it is broken, and fixing things; Bass-akwards and foward thinking. insane and exciting, crazy and creative, full of awful deadlines and awsome achievements.

We all stand at that same juncture, tearing out our hair at the insanity of the deadlines, the crazyness of the regulations, the impossible deadlines to define, create, update, develop, sell, implement and deploy meaningful applications. We've got less than four yesars. Most nations give themselves a decade or more to try what we are in half that time. Insane? Yes. Inane? No. We will do amazing things. Things to be proud of. That will mean more times being awake on the wrong side of 3, 4, 5 or even 6AM. It will be worth it. We will only understand it after we are through it; when we can tell the stories of these times to our children or grand-children. "In my day, kiddo, the doctor never even gave you your records..."

I think about that young lady, and I'm jealous. I wish I'd had the opportunity she has at that same age. At the same time, I'm also happy to be where I am. As my wife always tells me, you had to be where you were to get where you are. And I think we have to be here, to get where we need to be.

-- Keith

P.S. Here are some more pictures of The Walking Gallery that I took tonight. Ted Eytan also took some great shots.  More details about some of these jackets can be found on Regina's blog.

P.P.S. My jacket will hopefully be makeing its debut next week at the SIFramework meetings in DC.

Tuesday, June 7, 2011

IHE's Free Educational Webinar Series & N.A. Connectathon 2012 Announced!

IHE Community,

IHE Launches their Annual Free Educational Webinar Series on June 28,
2011

IHE is announcing its annual Free Educational Webinar Series
 this year to provide
education about IHE and to learn how your organization can participate
in IHE's year-round development and deployment activities. "The IHE
Webinar Series provides insights from thought leaders who can explain
the value of standards-based interoperability as well as the clinical
and administrative benefits for end-users who implement IHE-based
solutions and for vendors who develop and offer IHE-based products,"
stated Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSS, FAAN, President, IHE
USA.

IHE's Webinar series begins with an Introduction to IHE session on
Tuesday, June 28, 2011 at 9:00am CT and continues weekly on Tuesdays and Thursdays until
September 1, 2011. Webinar sessions will present new profiles in each of
the IHE clinical and operational domains and highlight how to
participate in IHE's Domain Committees, National Deployment Committees,
Connectathons and demonstrations. Register online today to participate
on IHE's free webinar series! 
The full schedule of
presentations and speakers is available on IHE International's website or interested parties can 
sign up for the listserv to receive updated information.

IHE N.A. Connectathon 2012 Dates, Policy and Guidelines Published for
Review on IHE USA website- January 9-14, 2012

IHE USA is sponsoring the IHE N.A. Connectathon 2012 this year on
January 9-14, 2012. The 2012 Participant Resources and  Policy and
Guidelines
 have been posted on IHE USA's website to prepare vendors for the
opening of registration on August 22 through September 30, 2011.
Participants can also attend the IHE N.A. Connectathon 2012 Registration
Kick-Off Webinar
 on August 18, 2011 or attend any of the IHE's Free Educational
Webinar Series
 hosted 
June-September 2011 to learn more!

Please note there is an important change in the N.A. Connectathon
schedule this year. The N.A. Connectathon 2012 will begin Monday
afternoon at 2:00pm, January 9, 2012 with badge registration and system
set-up. Connectathon test participants must be in attendance through
5:00pm CT on Friday, January 13, 2012. HIMSS12 Interoperability Showcase
connected demonstration testing will take place on Saturday, January 14,
2012 until 12:00pm CT. Please review the list of important dates on IHE
USA's website or access the detailed Connectathon and Showcase time
lines online here
.

New to IHE- Learn more about the role of IHE Connectathons in advancing
healthcare IT online
or
attend an educational presentation during the IHE Webinar Series on July 14, 2011 at
10:30am CT. Click here to register in advance.