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.

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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?

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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	Click Here!	1-888-998-2663 P: 4123232	John Donnelly, Ed Larsen
10:00am-12:00pm	UC Care Planning WG	Click Here!	1-888-998-2663 P: 2101200	Greg Smith, Amy Berk, Ed Larsen
1:30-3:00pm	CIM/Vocab WG	Click Here!	1-888-998-2663 P: 4123232	Holly Miller, Russell Leftwich, Meredith Lewis
1:30-3:00pm	Standards Analysis WG	Click Here!	1-888-998-2663 P: 2101200	John Donnelly, Rich Kernan
3:00-5:00pm	Architecture/IR & RI WGs	Click Here!	1-888-998-2663 P: 4123232	Mayuri Patel, Mark Bamberg, Joan Duhaime
3:00-5:00pm	UC Simplification WG	Click Here!	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	Click Here!	1-888-998-2663 P: 4123232	Mayuri Patel, Mark Bamberg, Joan Duhaime
10:00am-12:00pm	Standards Analysis & Data Element WGs	Click Here!	1-888-998-2663 P: 2101200	John Donnelly, Rich Kernan
1:30-3:00pm	Architecture/IR & RI WGs	Click Here!	1-888-998-2663 P: 4123232	Mayuri Patel, Mark Bamberg, Joan Duhaime
1:30-3:00pm	CIM/Vocab WG	Click Here!	1-888-998-2663 P: 2101200	Holly Miller, Russell Leftwich, Meredith Lewis
3:00-5:00pm	CIM/Vocab WG	Click Here!	1-888-998-2663 P: 2101200	Holly Miller, Russell Leftwich, Meredith Lewis
3:00-5:00pm	CDA Consolidation (Documentation WG)	Click Here!	1-888-998-2663 P: 4123232	Keith Boone

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.

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.

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	Announcement of ONC-Approved Accreditor (ONC-AA) The Office of the National Coordinator for Health Information Technology (ONC) is pleased to announce that the American National Standards Institute (ANSI) has been approved as the ONC-AA for the Permanent Certification Program for Health Information Technology (Permanent Certification Program). The ONC-AA will accredit organizations to certify electronic health record technology and perform other responsibilities under the Permanent Certification Program. Approval of the ONC-AA is one of the initial steps in the implementation of the Permanent Certification Program, which is anticipated to replace the Temporary Certification Program for Health Information Technology in 2012.

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.

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.

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.