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February 29 2012

Report from HIMSS 12: wrap-up of the largest health IT conference

This is a time of great promise in health care, yet an oppressive atmosphere hung over much of href="http://www.himssconference.org/">HIMSS. All the speakers--not least the government representatives who announced rules for the adoption of electronic health records--stressed commendable practices such as data exchange, providing the patient with information, and engaging with the patient. Many berated hospitals, doctors, and vendors for neglecting the elements that maintain health. But the thrust of most sessions was on such details as how to convert patient records to the latest classification of diseases (ICD-10).

Intelligent Hospital pavilion shows off tempting technology
Intelligent Hospital pavilion shows off tempting technology.

I have nothing against ICD-10 and I'm sure adopting it is a big headache that deserves attention at the conference. The reason I call the atmosphere oppressive is that I felt stuck among health care providers unable to think long-term or to embrace the systems approach that we'll need to cure people and cut costs. While some health care institutions took the ICD-10 change-over seriously and put resources into meeting the deadline, others pressured the Dept. of Health and Human services to delay implementation, and apparently won a major reprieve. The health IT community, including HIMSS, criticized the delay. But resistance to progress usually does not break out so overtly, and remains ingrained in day-to-day habits.

But ICD-10 is a sideline to the major issue of Stage 2 meaningful use. Why, as I reported on Wednesday, were so many of the 35,000 HIMSS attendees wrapped up in the next step being forced on them by the federal government? The scandal is that these meaningful use concepts (using data to drive care, giving care-givers information that other care-givers have collected about the patient) have to be forced on them. Indeed, institutions like Kaiser Permanente that integrated their electronic records years ago and concentrated on the whole patient had relatively little work to do to conform to Stage 1, and probably have the building blocks for Stage 2 in place. And of course these things are part of the landscape of health care in other countries. (The proposed regulations were finally posted last Thursday.)

Recipients of Regina Holliday jackets record patient involvement stories
Recipients of Regina Holliday jackets record patient involvement stories.

Haven't our providers heard that an ounce of prevention is worth a pound of cure? Don't well-educated and well-paid executives invest in quality measures with the expectation that they'll pay off in the long run? And aren't we all in the field for the good of the patients? What is that snickering I hear?

Actually, I don't accept the premise that providers are all in it for the money. If so many are newly incentivized to join the government's program for a mere $15,000 per doctor (plus avoiding some cuts in Medicare payments), which is a small fraction of the money they'll have to spend implementing the program, they must know that it's time to do the right thing. Meaningful use can be a good framework to concretize the idealistic goals of health care reform, but I just wish the vendors and doctors would keep their eyes more on the final goal.

Redwood MedNet in Northern California is an example of a health information exchange that adopted standards (CONNECT, before the Direct project was in place) to simplify data exchange between health providers. Will Ross of Redwood MedNet told me that qualifying for Stage 2 would be simple for them, "but you won't hear that from many vendors in this exhibit hall."

Annual surveys by Family Practice Management journal about their readers' satisfaction with EHRs, reviewed in one HIMSS session, showed widespread dissatisfaction that doesn't change from year to year. For instance, 39% were dissatisfied with support and training, although a few vendors rated quite high. Still, considering that doctors tend to veer away from open source solutions and pay big bucks for proprietary ones out of a hope of receiving better support and training, they deserve better. It's worth noting that the longer a practice uses its system, the more they're likely to express satisfaction. But only 38% of respondents would purchase the same systems now if they weren't already locked in.

That's the big, frustrating contradiction at HIMSS. The vendors have standards (HL7 and others), they've been setting up health information exchanges (under various other names) for years, they have a big, popular interoperability lab at each conference--and yet most patients still have to carry paper records and CDs with images from one doctor to another. (A survey of HIMSS members showed that one-quarter allowed access by patients to their data, which is an advance but still just a start.) The industry as a whole has failed to make a dent in the 90,000 to 100,000 needless deaths that occur in treatment facilities each year. And (according to one speaker) 20% of patients hospitalized under Medicare have to return to the hospital shortly after discharge.

Omens of change

Suffice it say that by my fourth day at HIMSS I was not happy. Advances come, but slowly. Examples of developments I can give a thumbs-up to at HIMSS were data sharing among physicians who use Practice Fusion, a popular example of a growing move to web services for electronic records, and a CardioEngagement Challenge funded by Novartis to encourage at-risk patients to take more interest in their health. The winner was a Sensei mobile app that acts as an automated coach. Sensei CEO Robert Schwarzberg, a cardiologist, told me had put together phone-in coaching services for heart patients during the years before mobile apps, and was frustrated that these coaches were available less than once a week when what patients needed was round-the-clock motivation. Sensei Wellness is one of the many mobile apps that make both patients and doctors more connected, and HIMSS quite properly devoted a whole section of the exhibit floor to them.

Talking about Sensei Wellness with Dr. Robert Schwarzberg
Talking about Sensei Wellness with Dr. Robert Schwarzberg.

I dropped by the IBM booth for the obligatory demo of Watson's medical application, and some background from Dr. Josko Silobrcic. I also filled in some of this report from an earlier conversation with tech staff.

Medical diagnosis involves more structured data than solving Jeopardy riddles, structure that appears mostly in the form of links between data sets. For instance, medicines are linked to diagnoses, to lab results, and to other medicines (for instance, some drugs are counter-indicated when the patient is taking other drugs). Watson follows these relationships.

But because Watson is a natural language processing application--based on UIMA, which IBM donated to the Apache Foundation--it doesn't try to do much reasoning to pick out the best diagnosis or treatment, both of which are sometimes requested of it. Instead, it dumps huge indexes of medical articles into its data stores on one side, and takes in the text about the patient's complaint and doctor's evaluation on the other. Matching them up is not so different from a Jeopardy question, after all. Any possible match is considered and kept live until the final round of weighing answers, even if the chance of matching is near zero.

Dr. Josko Silobrcic before Watson demonstration
Dr. Josko Silobrcic before Watson demonstration.

Also because of the NLP basis for matching, there is rarely a need to harmonize disparate data taken in from different journals or medical sources.

I assumed that any processing that uses such a large data set and works so fast must run on a huge server farm, but the staff assured me it's not as big as one would think. For production use, of course, they'll need to take into account the need to scale. The medical informatics equivalent of a Christmas rush on sales would be an epidemic where everybody in the region is urgently hitting Watson for critical diagnoses.

Coming to peace

Healing came to me on my last day at HIMSS, at too related conferences off to the side of the main events: a meeting of Open Health Tools members and the eCollaboration forum, run by health activists who want to break down barriers to care. Both groups have partnerships with HIMSS.

Open Health Tools positions itself as an umbrella organization for projects making free software for a lot of different purposes in health care: recording, treatment, research and more. One illustrative project I got to hear about at their meeting was the Medical Imaging Network Transport (MINT), which Johns Hopkins is working on in coordination with other teams

MINT cuts down on the transfers of huge images by doing some processing in place and transferring only portions of the data. Switching to modern storage formats (XML and JSON) and better methods of data transfer also reduces waste. For instance, current DICOM vendors transmit images over TCP, which introduces more overhead than necessary when handling the packet losses engendered by transmitting files that are several gigabytes in size. MINT allows UDP and other protocols that are leaner than TCP.

Best of all, MINT DICOM images can be displayed through HTML5, which means any browser can view them in good resolution, there is no need to install a specialized viewer at each location where the doctor is checking the image, and dependence on proprietary software is reduced. (The same reliance on standard browsers is also claimed by eMix in a recent interview.

At the eCollaboration forum, E-patient Dave DeBronkart reported that being an engaged patient is still swimming upstream. It's hard to get one's records, hard to find out what treatments will cost, and hard to get taken seriously as an adult interested in monitoring one's own care. Meg McCabe of Aetna says that insurers need to offer more sophisticated guidance to patients trying to choose a health provider--simple lists of options are confusing and hard to choose from.

One speaker warned providers that if they try to open their data for collaborative care, they may find themselves hampered by contracts that maintain vendor ownership of EHR data. But speakers assured us vendors are not evil. The issue is what the providers ask for when they buy the EHR systems.

Here's the strange thing about the eCollaboration forum: they signed up enough people to fill the room ahead of time and left many potential attendees lamenting that they couldn't get in. Yet on the actual day of the event, there were about eight empty seats for every attendee. Maybe HIMSS attendees felt that had to devote all their time to the stage 2 regulations, previously mentioned. But I take the disappointing turn-out as a sign of the providers' and vendors' lack of commitment to change. Shown a dazzling roster of interesting talks about data exchange, open record sharing, and patient engagement, they're quick to sign up--but they don't show up when it counts.

As members of the general public, we can move the health care field forward by demanding more from our providers, at the point where we have some influence. Anyone looking for concrete guidance for increasing their influence as a patient can try e-Patients Live Longer: The Complete Guide to Managing Health Care Using Technology, by Nancy B. Finn.

Public attention and anger have been focused on insurers, who have certainly engaged in some unsavory practices to avoid paying for care--but nothing as destructive as the preventable errors and deaths caused by old-fashioned medical practices. And while economists complain about the 30 cents out of every dollar wasted in the American hodge-podge of payment systems, we know that unnecessary medical procedures or, conversely, preventative steps that were omitted, also suck up a lot of money. One speaker at the eCollaboration forum compared the sky-rocketing costs of health care and insurance to a financial bubble that can't last. Let's all take some responsibility for instituting better medical and reporting systems so the costs come down in a healthy manner.

Other articles about HIMSS were posted last Tuesday and Wednesday.

February 23 2012

Report from HIMSS 2012: toward interoperability and openness

I was wondering how it would feel to be in the midst of 35,000 people whose livelihoods are driven by the decisions of a large institution at the moment when that institution releases a major set of rules. I didn't really find out, though. The 35,000 people I speak of are the attendees of the HIMSS conference and the institution is the Department of Health and Human Services. But HHS just sort of half-released the rules (called Stage 2 of meaningful use), telling us that they would appear online tomorrow and meanwhile rushing over a few of the key points in a presentation that drew overflow crowds in two rooms.

The reaction, I sensed, was a mix of relief and frustration. Relief because Farzad Mostashari, National Coordinator for Health Information Technology, promised us the rules would be familiar and hewed closely to what advisors had requested. Frustration, however, at not seeing the details. The few snippets put up on the screen contained enough ambiguities and poorly worded phrases that I'm glad there's a 60-day comment period before the final rules are adopted.

There isn't much one can say about the Stage 2 rules until they are posted and the experts have a chance to parse them closely, and I'm a bit reluctant to throw onto the Internet one of potentially 35,000 reactions to the announcement, but a few points struck me enough to be worth writing about. Mostashari used his pulpit for several pronouncements about the rules:

  • HHS would push ahead on goals for interoperability and health information exchange. "We can't wait five years," said Mostashari. He emphasized the phrase "standard-based" in referring to HIE.

  • Patient engagement was another priority. To attest to Stage 2, institutions will have to allow at least half their patients to download and transfer their records.

  • They would strive for continuous quality improvement and clinical decision support, key goals enabled by the building blocks of meaningful use.

Two key pillars of the Stage 2 announcement are requirements to use the Direct project for data exchange and HL7's consolidated CDA for the format (the only data exchange I heard mentioned was a summary of care, which is all that most institutions exchange when a patient is referred).

The announcement demonstrates the confidence that HHS has in the Direct project, which it launched just a couple years ago and that exemplifies a successful joint government/private sector project. Direct will allow health care providers of any size and financial endowment to use email or the Web to share summaries of care. (I mentioned it in yesterday's article.) With Direct, we can hope to leave the cumbersome and costly days of health information exchange behind. The older and more complex CONNECT project will be an option as well.

The other half of that announcement, regarding adoption of the CDA (incarnated as a CCD for summaries of care), is a loss for the older CCR format, which was an option in Stage 1. The CCR was the Silicon Valley version of health data, a sleek and consistent XML format used by Google Health and Microsoft HealthVault. But health care experts criticized the CCR as not rich enough to convey the information institutions need, so it lost out to the more complex CCD.

The news on formats is good overall, though. The HL7 consortium, which has historically funded itself by requiring organizations to become members in order to use its standards, is opening some of them for free use. This is critical for the development of open source projects. And at an HL7 panel today, a spokesperson said they would like to head more in the direction of free licensing and have to determine whether they can survive financially while doing so.

So I'm feeling optimistic that U.S. health care is moving "toward interoperability and openness," the phrase I used in the title to his article and also used in a posting from HIMSS two years ago.

HHS allowed late-coming institutions (those who began the Stage 1 process in 2011) to continue at Stage 1 for another year. This is welcome because they have so much work to do, but means that providers who want to demonstrate Stage 2 information exchange may have trouble because they can't do it with other providers who are ready only for Stage 1.

HHS endorsed some other standards today as well, notably SNOMED for diseases and LRI for lab results. Another nice tidbit from the summit includes the requirement to use electronic medication administration (for instance, bar codes to check for errors in giving medicine) to foster patient safety.

February 22 2012

Report from HIMSS: health care tries to leap the chasm from the average to the superb

I couldn't attend the session today on StealthVest--and small surprise. Who wouldn't want to come see an Arduino-based garment that can hold numerous health-monitoring devices in a way that is supposed to feel like a completely normal piece of clothing? As with many events at the HIMSS conference, which has registered over 35,000 people (at least four thousand more than last year), the StealthVest presentation drew an overflow crowd.

StealthVest sounds incredibly cool (and I may have another chance to report on it Thursday), but when I gave up on getting into the talk I walked downstairs to a session that sounds kind of boring but may actually be more significant: Practical Application of Control Theory to Improve Capacity in a Clinical Setting.

The speakers on this session, from Banner Gateway Medical Center in Gilbert, Arizona, laid out a fairly standard use of analytics to predict when the hospital units are likely to exceed their capacity, and then to reschedule patients and provider schedules to smooth out the curve. The basic idea comes from chemical engineering, and requires them to monitor all the factors that lead patients to come in to the hospital and that determine how long they stay. Queuing theory can show when things are likely to get tight. Hospitals care a lot about these workflow issues, as Fred Trotter and David Uhlman discuss in the O'Reilly book Beyond Meaningful Use, and they have a real effect on patient care too.

The reason I find this topic interesting is that capacity planning leads fairly quickly to visible cost savings. So hospitals are likely to do it. Furthermore, once they go down the path of collecting long-term data and crunching it, they may extend the practice to clinical decision support, public health reporting, and other things that can make a big difference to patient care.

A few stats about data in U.S. health care

Do we need a big push to do such things? We sure do, and that's why meaningful use was introduced into HITECH sections of the American Recovery and Reinvestment Act. HHS released mounds of government health data on Health.data.gov hoping to serve a similar purpose. Let's just take a look at how far the United States is from using its health data effectively.

  • Last November, a CompTIA survey (reported by Health Care IT News) found that only 28% of providers have comprehensive EHRs in use, and another 17% have partial implementations. One has to remember that even a "comprehensive" EHR is unlikely to support the sophisticated data mining, information exchange, and process improvement that will eventually lead to lower costs and better care.

  • According to a recent Beacon Partners survey (PDF), half of the responding institutions have not yet set up an infrastructure for pursuing health information exchange, although 70% consider it a priority. The main problem, according to a HIMSS survey, is budget: HIEs are shockingly expensive. There's more to this story, which I reported on from a recent conference in Massachusetts.

Stats like these have to be considered when HIMSS board chair, Charlene S. Underwood, extolled the organization's achievements in the morning keynote. HIMSS has promoted good causes, but only recently has it addressed cost, interoperability, and open source issues that can allow health IT to break out of the elite of institutions large or sophisticated enough to adopt the right practices.

As signs of change, I am particularly happy to hear of HIMSS's new collaboration with Open Health Tools and their acquisition of the mHealth summit. These should guide the health care field toward more patient engagement and adaptable computer systems. HIEs are another area crying out for change.

An HIE optimist

With the flaccid figures for HIE adoption in mind, I met Charles Parisot, chair of Interoperability Standards and Testing Manager for EHRA, which is HIMSS's Electronic Health Records Association. The biggest EHR vendors and HIEs come together in this association, and Parisot was just stoked with positive stories about their advances.

His take on the cost of HIEs is that most of them just do it in a brute force manner that doesn't work. They actually copy the data from each institution into a central database, which is hard to manage from many standpoints. The HIEs that have done it right (notably in New York state and parts of Tennessee) are sleek and low-cost. The solution involves:

  • Keeping the data at the health care providers, and storing in the HIE only some glue data that associates the patient and the type of data to the provider.

  • Keeping all metadata about formats out to the HIE, so that new formats, new codes, and new types of data can easily be introduced into the system without recoding the HIE.

  • Breaking information exchange down into constituent parts--the data itself, the exchange protocols, identification, standards for encryption and integrity, etc.--and finding standard solutions for each of these.

So EHRA has developed profiles (also known by its ONC term, implementation specifications) that indicate which standard is used for each part of the data exchange. Metadata can be stored in the core HL7 document, the Clinical Document Architecture, and differences between implementations of HL7 documents by different vendors can also be documented.

A view of different architectures in their approach can be found in an EHRA white paper, Supporting a Robust Health Information Exchange Strategy with a Pragmatic Transport Framework. As testament to their success, Parisot claimed that the interoperability lab (a huge part of the exhibit hall floor space, and a popular destination for attendees) could set up the software connecting all the vendors' and HIEs' systems in one hour.

I asked him about the simple email solution promised by the government's Direct project, and whether that may be the path forward for small, cash-strapped providers. He accepted that Direct is part of the solution, but warned that it doesn't make things so simple. Unless two providers have a pre-existing relationship, they need to be part of a directory or even a set of federated directories, and assure their identities through digital signatures.

And what if a large hospital receives hundreds of email messages a day from various doctors who don't even know to whom their patients are being referred? Parisot says metadata must accompany any communications--and he's found that it's more effective for institutions to pull the data they want than for referring physicians to push it.

Intelligence for hospitals

Finally, Parisot told me EHRA has developed standards for submitting data to EHRs from 350 types of devices, and have 50 manufacturers working on devices with these standards. I visited a booth of iSirona as an example. They accept basic monitoring data such as pulses from different systems that use different formats, and translate over 50 items of information into a simple text format that they transmit to an EHR. They also add networking to devices that communicate only over cables. Outlying values can be rejected by a person monitoring the data. The vendor pointed out that format translation will be necessary for some time to come, because neither vendors nor hospitals will replace their devices simply to implement a new data transfer protocol.

For more about devices, I dropped by one of the most entertaining parts of the conference, the Intelligent Hospital Pavilion. Here, after a badge scan, you are somberly led through a series of locked doors into simulated hospital rooms where you get to watch actors in nursing outfits work with lifesize dolls and check innumerable monitors. I think the information overload is barely ameliorated and may be worsened by the arrays of constantly updated screens.

But the background presentation is persuasive: by using attaching RFIDs and all sorts of other devices to everything from people to equipment, and basically making the hospital more like a factory, providers can radically speed up responses in emergency situations and reduce errors. Some devices use the ISM "junk" band, whereas more critical ones use dedicated spectrum. Redundancy is built in throughout the background servers.

Waiting for the main event

The US health care field held their breaths most of last week, waiting for Stage 2 meaningful use guidelines from HHS. The announcement never came, nor did it come this morning as many people had hoped. Because meaningful use is the major theme of HIMSS, and many sessions were planned on helping providers move to Stage 2, the delay in the announcement put the conference in an awkward position.

HIMSS is also nonplussed over a delay in another initiative, the adoption of a new standard in the classification of disease and procedures. ICD-10 is actually pretty old, having been standardized in the 1980s, and the U.S. lags decades behind other countries in adopting it. Advantages touted for ICD-10 are:

  • It incorporates newer discoveries in medicine than the dominant standard in the U.S., ICD-9, and therefore permits better disease tracking and treatment.

  • Additionally, it's much more detailed than ICD-9 (with an order of magnitude more classifications). This allows the recording of more information but complicates the job of classifying a patient correctly.

ICD-10 is rather controversial. Some people would prefer to base clinical decisions on SNOMED, a standard described in the Beyond Meaningful Use book mentioned earlier. Ultimately, doctors lobbied hard against the HHS timeline for adopting ICD-10 because providers are so busy with meaningful use. (But of course, the goals of adopting meaningful use are closely tied to the goals of adopting ICD-10.) It was the pushback from these institutions that led HHS to accede and announce a delay. HIMSS and many of its members were disappointed by the delay.

In addition, there is an upcoming standard, ICD-11, whose sandal some say ICD-10 is not even worthy to lace. A strong suggestion that the industry just move to ICD-11 was aired in Government Health IT, and the possibility was raised in Health Care IT News as well. In addition reflecting the newest knowledge about disease, ICD-11 is praised for its interaction with SNOMED and its use of Semantic Web technology.

That last point makes me a bit worried. The Semantic Web has not been widely adopted, and if people in the health IT field think ICD-10 is complex, how are they going to deal with drawing up and following relationships through OWL? I plan to learn more about ICD-11 at the conference.

February 10 2012

Preview of HIMSS 2012

I am very happy to be attending the Healthcare Information and Management Systems Society (HIMSS) conference this year. We are at a pivotal moment in the history of healthcare in this country and health IT is playing a very prominent role. This will be one of the most important healthcare conferences of the year. If you can't make it to Las Vegas in person, there are opportunities to attend virtually. Just go to himssvirtual.org for more information.

I will be moderating panel presentations at the HIMSS Social Media Center on Tuesday and Wednesday. This year I expect social media to play a much larger presence in the conference, and the new location for the pavilion will put it front and center. Since the keynote this year is from one of the founders of Twitter, Biz Stone, I'm sure there will be a social media flavor throughout the event.

I will also be participating in the brand new eCollaboration Forum at HIMSS on Thursday. The Collaborative Health Consortium has partnered with HIMSS to sponsor a new, exclusive event focused on the shift to collaborative care platforms to take place at the conference. The event will focus on collaborative platforms as foundations for transformation to accountable care. Attendees will be able to learn what a collaborative healthcare platform is and why the healthcare industry needs it, discover paths to take to effectively implement collaborative technologies, and get further resources to help evaluate the solutions available in the shift toward an accountable care health model.

I am honored to be moderating a panel with David C. Kibbe, MD MBA, senior advisor at the American Academy of Family Physicians; Jonathan Hare, chairman of Resilient Network Systems; and Scott Rea, vice president GOV/EDU Relations and senior PKI Architect at DigiCert.

Our session, "Developing Trust in the Health Internet as a Platform," will focus on the tools, technologies and rules we must decide upon to establish trust in the Internet as the platform for healthcare. Effective health information exchange of any resource requires deep trust, following from the right architecture and the right rules. We will discuss efforts like DirectTrust.org and the EHR/HIE Interoperability Workgroup as conveners that are creating a community to move us forward.

My fellow Radar blogger Andy Oram will also be on hand to provide context and his own unique perspective (as well as keep me focused on what matters).

Related:

March 05 2010

Report from HIMMS Health IT conference: building or bypassing infrastructure

Today the Healthcare Information and
Management Systems Society (HIMSS)
conference wrapped up. In
previous blogs, I laid out the href="http://radar.oreilly.com/2010/03/report-from-himms-health-it-co.html">
benefits of risk-taking in health care IT followed by my main
theme, href="http://radar.oreilly.com/2010/03/report-from-himms-health-it-co-1.html">
interoperability and openness. This blog will cover a few topics
about a third important issue, infrastructure.

Why did I decide this topic was worth a blog? When physicians install
electronic systems, they find that they need all kinds of underlying
support. Backups and high availability, which might have been
optional or haphazard before, now have to be professional. Your
patient doesn't want to hear, "You need an antibiotic right away, but
we'll order it tomorrow when our IT guy comes in to reboot the
system." Your accounts manager would be almost as upset if you told
her that billing will be delayed for the same reason.

Network bandwidth

An old sales pitch in the computer field (which I first heard at
Apollo Computer in the 1980s) goes, "The network is the computer." In
the coming age of EHRs, the network is the clinic. My family
practitioner (in an office of five practitioners) had to install a T1
line when they installed an EHR. In eastern Massachusetts, whose soil
probably holds more T1 lines than maple tree roots, that was no big
deal. It's considerably more problematic in an isolated rural area
where the bandwidth is more comparable to what I got in my hotel room
during the conference (particularly after 10:30 at night, when I'm
guessing a kid in a nearby room joined an MMPG). One provider from the
mid-West told me that the incumbent changes $800 per month for a T1.
Luckily, he found a cheaper alternative.

So the FCC is href="http://www.fcc.gov/cgb/rural/rhcp.html">involved in health care
now. Bandwidth is perhaps their main focus at the moment, and
they're explicitly tasked with making sure rural providers are able to
get high-speed connections. This is not a totally new concern; the
landmark 1994 Telecom Act included rural health care providers in its
universal service provisions. I heard one economist deride the
provision, asking what was special about rural health care providers
that they should get government funding. Fifteen years later, I think
rising health care costs and deteriorating lifestyles have answered
that question.

Wireless hubs

The last meter is just as important as the rest of your network, and
hospitals with modern, technology-soaked staff are depending
increasingly on mobile devices. I chatted with the staff of a small
wireless company called Aerohive that aims its products at hospitals.
Its key features are:

Totally cable-free hubs

Not only do Aerohive's hubs communicate with your wireless endpoints,
they communicate with other hubs and switches wirelessly. They just
make the hub-to-endpoint traffic and hub-to-hub traffic share the
bandwidth in the available 2.4 and 5 GHz ranges. This allows you to
put them just about anywhere you want and move them easily.

Dynamic airtime scheduling

The normal 802.11 protocols share the bandwidth on a packet-by-packet
basis, so a slow device can cause all the faster devices to go slower
even when there is empty airtime. I was told that an 802.11n device
can go slower than a 802.11b device if it's remote and its signal has
to go around barriers. Aerohive just checks how fast packets are
coming in and allocates bandwidth on that ratio, like time-division
multiplexing. If your device is ten times faster than someone else's
and the bandwidth is available, you can use ten times as much
bandwidth.

Dynamic rerouting

Aerohive hubs use mesh networking and an algorithm somewhat like
Spanning Tree Protocol to reconfigure the network when a hub is added
or removed. Furthermore, when you authenticate with one hub, its
neighbors store your access information so they can pick up your
traffic without taking time to re-authenticate. This makes roaming
easy and allows you to continue a conversation without a hitch if a
hub goes down.

Security checking at the endpoint

Each hub has a built-in firewall so that no unauthorized device can
attach to the network. This should be of interest in an open, public
environment like a hospital where you have no idea who's coming in.

High bandwidth

The top-of-the-line hub has two MIMO radios, each with three
directional antennae.

Go virtual, part 1

VMware has href="http://www.vmware.com/solutions/industry/healthcare/case-studies.html">customers
in health care, as in other industries. In addition, they've
incorporated virtualization into several products from medical
equipment and service vendors,

Radiology

Hospitals consider these critical devices. Virtualization here
supports high availability.

Services

A transcription service could require ten servers. Virtualization can
consolidate them onto one or two pieces of hardware.

Roaming desktops

Nurses often move from station to station. Desktop virtualization
allows them to pull up the windows just as they were left on the
previous workstation.

Go virtual, squared

If all this talk of bandwidth and servers brings pain to your head as
well as to the bottom line, consider heading into the cloud. At one
talk I attended today on cost analysis, a hospital administrator
reported that about 20% of their costs went to server hosting. They
saved a lot of money by rigorously eliminating unneeded backups, and a
lot on air conditioning by arranging their servers more efficiently.
Although she didn't discuss Software as a Service, those are a couple
examples of costs that could go down if functions were outsourced.

Lots of traditional vendors are providing their services over the Web
so you don't have to install anything, and several companies at the
conference are entirely Software as a Service. I mentioned href="http://www.practicefusion.com/">Practice Fusion in my
previous blog. At the conference, I asked them three key questions
pertinent to Software as a Service.

Security

This is the biggest question clients ask when using all kinds of cloud
services (although I think it's easier to solve than many other
architectural issues). Practice Fusion runs on HIPAA-compliant
Salesforce.com servers.

Data portability

If you don't like your service, can you get your data out? Practice
Fusion hasn't had any customers ask for their data yet, but upon
request they will produce a DVD containing your data in CSV files, or
in other common formats, overnight.

Extendibility

As I explained in my previous blog, clients increasingly expect a
service to be open to enhancements and third-party programs. Practice
Fusion has an API in beta, and plans to offer a sandbox on their site
for people to develop and play with extensions--which I consider
really cool. One of the API's features is to enforce a notice to the
clinician before transferring sensitive data.

The big selling point that first attracts providers to Practice Fusion
is that it's cost-free. They support the service through ads, which
users tell them are unobtrusive and useful. But you can also pay to
turn off ads. The service now has 30,000 users and is adding about 100
each day.

Another SaaS company I mentioned in my previous blog is href="http://www.covisint.com/">Covisint. Their service is
broader than Practice Fusion, covering not only patient records but
billing, prescription ordering, etc. Operating also as an HIE, they
speed up access to data on patients by indexing all the data on each
patient in the extended network. The actual data, for security and
storage reasons, stays with the provider. But once you ask about a
patient, the system can instantly tell you what sorts of data are
available and hook you up with the providers for each data set.

Finally, I talked to the managers of a nimble new company called href="http://carecloud.com/">CareCloud, which will start serving
customers in early April. CareCloud, too, offers a range of services
in patient health records, practice management, and and revenue cycle
management. It was built entirely on open source software--Ruby on
Rails and a PostgreSQL database--while using Flex to build their
snazzy interface, which can run in any browser (including the iPhone,
thanks to Adobe's upcoming translation to native code).upcoming
translation to native code). Their strategy is based on improving
physicians' productivity and the overall patient experience through a
social networking platform. The interface has endearing Web 2.0 style
touches such as a news feed, SMS and email confirmations, and
integration with Google Maps.

And with that reference to Google Maps (which, in my first blog, I
complained about mislocating the address 285 International Blvd NW for
the Georgia World Congress Center--thanks to the Google Local staff
for getting in touch with me right after a tweet) I'll end my coverage
of this year's HIMSS.

March 04 2010

Report from HIMMS Health IT conference: toward interoperability and openness

Yesterday and today I spent once again at the href="http://www.himss.org/">Healthcare Information and Management
Systems Society (HIMSS) conference in Atlanta, rushing from panel
session to vendor booth to interoperability demo and back (or
forward--I'm not sure which direction I've been going). All these
peregrinations involve a quest to find progress in the areas of
interoperability and openness.

The U.S. has a mobile population, bringing their aches and pains to a
plethora of institutions and small providers. That's why health care
needs interoperability. Furthermore, despite superb medical research,
we desperately need to share more information and crunch it in
creative new ways. That's why health care needs openness.

My href="http://radar.oreilly.com/2010/03/report-from-himms-health-it-co.html">blog
yesterday covered risk-taking; today I'll explore the reasons it's
so hard to create change.

The health care information exchange architecture

Some of the vendors I talked to boasted of being in the field for 20
years. This give them time to refine and build on their offerings,
but it tends to reinforce approaches to building and selling software
that were prominent in the 1980s. These guys certainly know what the
rest of the computer field is doing, such as the Web, and they reflect
the concerns for interoperability and openness in their own ways. I
just feel that what I'm seeing is a kind of hybrid--more marsupial
than mammal.

Information exchange in the health care field has evolved the
following architecture:

Electronic medical systems and electronic record systems

These do all the heavy labor that make health care IT work (or fail).
They can be divided into many categories, ranging from the simple
capturing of clinical observations to incredibly detailed templates
listing patient symptoms and treatments. Billing and routine workflow
(practice management) are other categories of electronic records that
don't strictly speaking fall into the category of health records.
Although each provider traditionally has had to buy computer systems
to support the software and deal with all the issues of hosting it,
Software as a Service has come along in solutions such as href="http://www.practicefusion.com/">Practice Fusion.

Services and value-added applications

As with any complex software problem, nimble development firms partner
with the big vendors or offer add-on tools to do what health care
providers find too difficult to do on their own.

Health information exchanges (HIEs)

Eventually a patient has to see a specialist or transfer records to a
hospital in another city--perhaps urgently. Partly due to a lack of
planning, and partly due to privacy concerns and other particular
issues caught up in health care, transfer is not as simple as querying
Amazon.com or Google. So record transfer is a whole industry of its
own. Some institutions can transfer records directly, while others
have to use repositories--paper or electronic--maintained by states or
other organizations in their geographic regions.


HIE software and Regional Health Information Organizations
(RHIOs)

The demands of record exchange create a new information need that's
filled by still more companies. States and public agencies have also
weighed in with rules and standards through organizations called
Regional Health Information Organizations.

Let's see how various companies and agencies fit into this complicated
landscape. My first item covered a huge range of products that
vendors don't like to have lumped together. Some vendors, such as the
Vocera company I mentioned in yesterday's blog and href="http://solutions.3m.com/wps/portal/3M/en_US/3M_Health_Information_Systems/HIS/">3M,
offer products that capture clinicians' notes, which can be a job in
itself, particularly through speech recognition. href="http://emdeon.com/">Emdeon covers billing, and adds validity
checking to increase the provider's chances of getting reimbursed the
first time they submit a bill. There are many activities in a doctor's
office, and some vendors try to cover more than others.

Having captured huge amounts of data--symptoms, diagnoses, tests
ordered, results of those tests, procedures performed, medicines
ordered and administered--these systems face their first data exchange
challenge: retrieving information about conditions and medicines that
may make a critical difference to care. For instance, I saw a cool
demo at the booth of Epic, one of
the leading health record companies." A doctor ordered a diuretic that
has the side-effect of lowering potassium levels. So Epic's screen
automatically brought up the patient's history of potassium levels
along with information about the diuretic.

Since no physician can keep all the side-effects and interactions
between drugs in his head, most subscribe to databases that keep track
of such things; the most popular company that provides this data is href="http://firstdatabank.com/">First DataBank. Health record
systems simply integrate the information into their user interfaces.
As I've heard repeatedly at this conference, the timing and delivery
of information is just as important as having the information; the
data is not of much value if a clinician or patient has to think about
it and go searching for it. And such support is central to the HITECH
act's meaningful use criteria, mentioned in yesterday's blog.

So I asked the Epic rep how this information got into the system. When
the physicians sign up for the databases, the data is sent in simple
CSV files or other text formats. Although different databases are
formatted in different ways, the health record vendor can easily read
it in and set up a system to handle updates.

Variations on this theme turn up with other vendors. For instance, href="http://www.nextgen.com/">NextGen Healthcare contracts
directly with First DataBank so they can integrate the data intimately
with NextGen's screens and database.

So where does First DataBank get this data? They employ about 40
doctors to study available literature, including drug manufacturers'
information and medical journals. This leads to a constantly updated,
independent, reliable source for doses, side-effects,
counterindications, etc.

This leads to an interesting case of data validity. Like any
researchers--myself writing this blog, for instance--First DataBank
could theoretically make a mistake. Their printed publications include
disclaimers, and they require the companies who licence the data to
reprint the disclaimers in their own literature. But of course, the
disclaimer does not pop up on every dialog box the doctor views while
using the product. Caveat emptor...

Still, decision support as a data import problem is fairly well
solved. When health record systems communicate with each other,
however, things are not so simple.

The challenges in health information exchange: identification

When a patient visits another provider who wants to see her records,
the first issue the system must face is identifying the patient at the
other provider. Many countries have universal IDs, and therefore
unique identifiers that can be used to retrieve information on a
person wherever she goes, but the United States public finds such
forms of control anathema (remember the push-back over Read ID?).
There are costs to restraining the information state: in this case,
the hospital you visit during a health crisis may have trouble
figuring out which patient at your other providers is really you.

HIEs solve the problem by matching information such as name, birth
date, age, gender, and even cell phone number. One proponent of the
federal government's Nationwide
Health Information Network
told me it can look for up to 19 fields
of personal information to make a match. False positives are
effectively eliminated by strict matching rules, but legitimate
records may be missed.

Another issue HIEs face is obtaining authorization for health data,
which is the most sensitive data that usually concerns ordinary
people. When requesting data from another provider, the clinician has
to log in securely and then offer information not only about who he is
but why he needs the data. The sender, for many reasons, may say no:

  • Someone identified as a VIP, such as a movie star or high-ranking
    politician, is automatically protected from requests for information.

  • Some types of medical information, such as HIV status, are considered
    especially sensitive and treated with more care.

  • The state of California allows ordinary individuals to restrict the
    distribution of information at the granularity of a single institution
    or even a single clinician, and other states are likely to do the
    same.

Thus, each clinician needs to register with the HIE that transmits the
data, and accompany each request with a personal identifier as well as
the type of information requested and the purpose. One service I
talked to, Covisint, can query
the AMA if necessary to verify the unique number assigned to each
physician in the us, the Drug Enforcement Administration (DEA) number.
(This is not the intended use of a DEA number, of course; it was
created to control the spread of pharmaceuticals, not data.)

One of the positive impacts of all this identification is that some
systems can retrieve information about patients from a variety of
hospitals, labs, pharmacies, and clinics even if the requester doesn't
know where it is. It's still up to them to determine whether to send
the data to the requester. Currently, providers exchange a Data Use
and Reciprocal Support Agreement (DURSA) to promise that information
will be stored properly and used only for the agreed-on purpose.
Exchanging these documents is currently cumbersome, and I've been told
the government is looking for a way to standardize the agreement so
the providers don't need to directly communicate.

The challenges in health information exchange: format

Let's suppose we're at the point where the owner of the record has
decided to send it to the requester. Despite the reverence expressed
by vendors for HL7 and other
standards with which the health care field is rife, documents require
a good deal of translation before they can be incorporated into the
receiving system. Each vendor presents a slightly different challenge,
so to connect n different products a vendor has to implement
n2 different transformations.

Reasons for this interoperability lie at many levels:

Lack of adherence to standards

Many vendors created their initial offerings before applicable
standards existed, and haven't yet upgraded to the standards or still
offer new features not covered by standards. The meaningful use
criteria discussed in yesterday's blog will accelerate the move to
standards.

Fuzzy standards

Like many standards, the ones that are common in the medical field
leave details unspecified.

Problems that lie out of scope

The standards tend to cover the easiest aspect of data exchange, the
document's format. As an indication of the problem, the 7 in HL7
refers to the seventh (application) layer of the ISO model. Brian
Behlendorf of Apache fame, now consulting with the federal government
to implement the NHIN, offers the following analogy. "Suppose that we
created the Internet by standardizing HTML and CSS but saying nothing
about TCP/IP and DNS."

Complex standards

As in other fields, the standards that work best in health records are
simple ones. There is currently a debate, for instance, over whether
to use the CCR or CCD exchange format for patient data. The trade-off
seems to be that the newer CCD is richer and more flexible but a lot
harder to support.

Misuse

As one example, the University of Pittsburgh Medical Center tried to
harmonize its problem lists and found that a huge number of
patients--including many men--were coded as smoking during pregnancy.
They should have been coded with a general tobacco disorder. As Dr.
William Hogan said, "People have an amazing ability to make a standard
do what it's not meant to do, even when it's highly specified and
constrained."

So many to choose from

Dell/Perot manager Jack Wankowski told me that even though other
countries have digitized their health records far more than the U.S.
has, they have a lot fewer published standards. It might seem logical
to share standards--given that people are people everywhere--but in
fact, that's hard to do because diagnosis and treatment are a lot
different in different cultures. Wankowski says, "Unlike other
industries such as manufacturing and financial services, where a lot
can be replicated, health care is very individual on a country by
country basis at the moment. Because of this, change is a lot slower."

Encumbrances

The UPMC coded its problem lists in ICD-9-CM instead of SNOMED, even
through SNOMED was far superior in specificity and clarity. Along with
historical reasons, they avoided SNOMED because it was a licensed
product until 2003 whereas ICD-9-CM was free. As for ICD-9-CM, its
official standard is distributed as RTF documents, making correct
adoption difficult.

Here are a few examples of how vendors told me they handle
interoperability.

InterSystems is a major
player in health care. The basis of their offerings is Caché,
an object database written in the classic programming language for
medical information processing, MUMPS. (MUMPS was also standardized by
an ANSI committee under the name M.) Caché can be found in all
major hospitals. For data exchange, InterSystems provides an HIE
called HealthShare, which they claim can communicate with other
vendors' systems by supporting HL7 and other appropriate standards.
HealthShare is both communications software and an actual hub that can
create the connections for customers.

Medicity is another key
HIE vendor. Providers can set up their own hubs or contract with a
server set up by Medicity in their geographic area. Having a hub means
that a small practice can register just once with the hub and then
communicate with all other providers in that region.

Let's turn again to Epic. Two facilities that use it can exchange a
wide range of data, because some of its data is not covered by
standards. A facility that uses another product can exchange a
narrower set of data with an Epic system over href="http://www.epic.com/software-interoperability.php">Care
Everywhere, using the standards. The Epic rep said they will move
more and more fields into Care Everywhere as standards evolve.

What all this comes down to is an enormous redundant infrastructure
that adds no value to electronic records, but merely runs a Red
Queen's Race to provide the value that already exists in those
records. We've already seen that defining more standards has a
limited impact on the problem. But a lot of programmers at this point
will claim the solution lies in open source, so let's see what's
happening in that area.

The open source challengers

The previous sections, like acts of a play, laid out the character of
the vendors in the health care space as earnest, hard-working, and
sometimes brilliantly accomplished, but ultimately stumbling through a
plot whose bad turns overwhelm them. In the current act we turn to a
new character, one who is not so well known nor so well tested, one
who has shown promise on other stages but is still finding her footing
on our proscenium.

The best-known open source projects in health care are href="http://openmrs.org/">OpenMRS, the Veterans Administration's
VistA, and the href="http://www.connectopensource.org/">NHIN CONNECT Gateway. I
won't say anything more about OpenMRS because it has received high
praise but has made little inroads into American health care. I'll
devote a few paragraphs to the strengths and weaknesses of VistA and
CONNECT.

Buzz in the medical world is that VistA beats commercial offerings for
usability and a general fit to the clinicians' needs. But it's
tailored to the Veterans Administration and--as a rep for the href="http://www.vxvista.org/">vxVistA called it--has to be
deveteranized for general use. This is what vxVistA does, but they are
not open source. They make changes to the core and contribute it back,
but their own products are proprietary. A community project called href="http://www.worldvista.org/">WorldVistA also works on a
version of VistA for the non-government sector.

One of the hurdles of adapting VistA is that one has to learn its
underlying language, MUMPS. Most people who dive in license a MUMPS
compiler. The vxVistA rep knows of no significant users of the free
software MUMPS compiler GT.M. VistA also runs on the Caché
database, mentioned earlier in this article. If you don't want to
license Caché from InterSystems, you need to find some other
database solution.

So while VistA is a bona fide open source project with a community,
it's ecosystem does not fit neatly with the habits of most free
software developers.

CONNECT is championed by the same Office of the National Coordinator
for Health Information Technology that is implementing the HITECH
recovery plan and meaningful use. A means for authenticating requests
and sending patient data between providers, CONNECT may well be
emerging as the HIE solution for our age. But it has some maturing to
do as well. It uses a SOAP-based protocol that requires knowledge of
typical SOA-based technologies such as SAML.

Two free software companies that have entered the field to make
installing CONNECT easier are href="http://www.axialexchange.com/">Axial Exchange, which creates
open source libraries and tools to work with the system, and the href="http://www.mirthcorp.com/">Mirth Corporation. Jon Teichrow
of Mirth told me how a typical CONNECT setup at a rural hospital took
just a week to complete, and can run for the cost of just a couple
hours of support time per week. The complexities of handling CONNECT
that make so many people tremulous, he said, were actually much easier
for Mirth than the more typical problem of interpreting the hospital's
idiosyncratic data formats.

Just last week, href="http://www.healthcareitnews.com/news/nhin-direct-launched-simpler-data-exchange">the
government announced a simpler interface to the NHIN called NHIN
Direct. Hopefully, this will bring in a new level of providers
who couldn't afford the costs of negotiating with CONNECT.

CONNECT has certainly built up an active community. href="http://agilex.com/">Agilex employee Scott E. Borst, who is
responsible for a good deal of the testing of CONNECT, tells me that
participation in development, testing, and online discussion is
intense, and that two people were recently approved as committers
without being associated with any company or government agency
officially affiliated with CONNECT.

The community is willing to stand up for itself, too. Borst says that
when CONNECT was made open source last year, it came with a Sun-based
development environment including such components as NetBeans and
GlassFish. Many community members wanted to work on CONNECT using
other popular free software tools. Accommodating them was tough at
first, but the project leaders listened to them and ended up with a
much more flexible environment where contributors could use
essentially any tools that struck their fancy.

Buried in href="http://www.healthcareitnews.com/news/blumenthal-unveils-proposed-certification-rule-himss10">a
major announcement yesterday about certification for meaningful
use was an endorsement by the Office of the National Coordinator
for open source. My colleague and fellow blogger Brian Ahier href="http://ahier.blogspot.com/2010/03/meaningful-certification.html">points
out that rule 4 for certification programs explicitly mentions
open source as well self-developed solutions. This will not magically
lead to more open source electronic health record systems like
OpenMRS, but it offers an optimistic assessment that they will emerge
and will reach maturity.

As I mentioned earlier, traditional vendors are moving more toward
openness in the form of APIs that offer their products as platforms.
InterSystems does this with a SOAP-based interface called Ensemble,
for instance. Eclipsys,
offering its own SOAP-based interface called Helios, claims that they
want an app store on top of their product--and that they will not kick
off applications that compete with their own.

Web-based Practice Fusion has an API in beta, and is also planning an
innovation that makes me really excited: a sandbox provided by their
web site where developers can work on extensions without having to
download and install software.

But to a long-time observer such as Dr. Adrian Gropper, founder of the
MedCommons storage service,
true open source is the only way forward for health care records. He
says we need to replace all those SOAP and WS-* standards with RESTful
interfaces, perform authentication over OpenID and OAuth, and use the
simplest possible formats. And only an enlightenment among the major
users--the health care providers--will bring about the revolution.

But at this point in the play, having explored the characters of
electronic record vendors and the open source community, we need to
round out the drama by introducing yet a third character: the patient.
Gropper's MedCommons is a patient-centered service, and thus part of a
movement that may bring us openness sooner than OpenMRS, VistA, or
CONNECT.

Enter the patient

Most people are familiar with Microsoft's HealthVault and Google
Health. Both allow patients to enter data about their own health, and
provide APIs that individuals and companies alike are using to provide
services. A Journal of Participatory
Medicine
has just been launched, reflecting the growth of interest
in patient-centered or participatory medicine. I saw a book on the
subject by HIMSS itself in the conference bookstore.

The promise of personal health records goes far beyond keeping track
of data. Like electronic records in clinicians' hands, the data will
just be fodder for services with incredible potential to improve
health. In a lively session given today by Patricia Brennan of href="http://www.projecthealthdesign.org/">Project HealthDesign,
she used the metaphors of "intelligent medicines" and "smart
Band-Aids" that reduce errors and help patients follow directions.

Project HealthDesign's research has injected a dose of realism into
our understanding of the doctor-patient relationship. For instance,
they learned that we can't expect patients to share everything with
their doctors. They get embarrassed when they lapse in their behavior,
and don't want to admit they take extra medications or do other things
not recommended by doctors. So patient-centered health should focus on
delivering information so patients can independently evaluate what
they're doing.

As critical patient data becomes distributed among a hundred million
individual records, instead of being concentrated in the hands of
providers, simple formats and frictionless data exchange will emerge
to handle them. Electronic record vendors will adapt or die. And a
whole generation of products--as well as users--will grow up with no
experience of anything but completely open, interoperable systems.

March 02 2010

Report from HIMMS Health IT conference: from Silicon Valley technology to Silicon Valley risk-taking

I'm in Atlanta for the biggest US conference in health care IT, run by
the Healthcare Information and
Management Systems Society (HIMSS)
. This organization, along with
the branch of the federal government responsible for dispersing funds
for a medical records overhaul, has to do a huge job in an extremely
short time. I'll report what I hear (and how I interpret it) over the
next few days, aiming both at people who care in general about the
future of health care at particularly at readers who are wondering
whether their next career move may be into health care.

Although many people have been saying that the medical field would
benefit from a Silicon Valley approach to technology, it's coming to
seem that even more important would be a Silicon Valley approach to
risk-taking. I'll look at the events that created this imperative.

Where the pressure comes from

Why are most doctors in the U.S., some thirty years after IT became
ubiquitous in American offices, still working with paper records? The
main reason is that they work in small offices instead of large
institutions, as I describe in href="http://radar.oreilly.com/2009/11/converting-to-electronic-healt.html">an
earlier blog about electronic health records. Most economically
advanced nations have centralized, government-administered health care
systems, and therefore electronic records. Large institutions in the
U.S. also have them--the Veterans Administration's VistA is a famous
example--and more hospitals have made the move than small physicians'
offices.

A crisis in costs and achievements provides a nice impetus for change
( href="http://www.nytimes.com/2010/02/28/weekinreview/28abelson.html">an
article in last Sunday's New York Times lays out the stakes), but
cold cash does even better. Few things can make an industry perk up as
much as a sudden infusion of twenty billion dollars. Thus the impact
of a provision in the federal stimulus bill (properly known as the
American Recovery and Reinvestment Act of 2009 or ARRA) that mandates
the adoption of electronic medical records.

The framers and implementers of the stimulus bill were both ambitious
and idealistic, but they weren't naive. They know that the adoption of
electronic health records, like any computer system, can be botched
and can turn out to miss the benefits that it's supposed to bring. So
in this part of the act, called Health Information Technology for
Economic and Clinical Health (HITECH), they lay out a demanding list
of practices that clinics and hospitals must carry out to qualify for
government money. In other words, HITECH is really about behavior and
workflow, not technology.

What does HITECH call for? Some requirements seem fairly easy to meet,
such as tracking key clinical conditions on patients. Others get quite
complex, even at Stage 1 of the implementation. For instance, doctors
are supposed to use their electronic systems to help check their
treatment plans for errors and suggest best practices, a field called
clinical decision support. Stages 2 and 3 require complex data
exchanges with other organizations, which in turn requires
interoperation among different systems from different vendors. I'll
return to interoperability in a later blog. Other rules include
evidence-based order sets (which bring up suggested treatment regimes
based on research) and reporting treatments and results to registries
to foster the further development of best practices.

All these requirements are put forward under the buzzword
meaningful use, an ironic choice given that the requirements
aren't even completely defined yet. Still, whether it's meaningful or
not, the term has instantly leapt to the forefront of discussion among
vendors and providers, because of the financial rewards attached to
them.

In principle, the meaningful use criteria are good. The government bodies
creating the requirements got stakeholders involved early and often.
It's well understood that these things are needed to improve care and
reduce inefficiency. As in any major attempt at social change,
doom-sayers predict disaster. (I'm not necessarily saying they're
wrong; in this case they include href="http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&type=Blog&tier=7&id=B98FF5D2B2E34463A550B2407329FC6C">CIO
Anthony Guerra and href="http://blog.srssoft.com/2010/02/government-ehr-program-potentially-harmful-unintended-consequences/">IT
company CTO Evan Steele, both featured at the HIMSS conference.)
But for the most part, the health care industry is lined up behind
meaningful use--or at least behind the promise of the money that
health care providers will be paid to implement it. Grumbling among
vendors and practitioners focuses on the timetable for implementation,
not on the practices themselves.

If you've gotten the impression from this summary that Congress and
the Administration have bypassed all the political bickering around
health care reform bills and implemented it under the guise of a
financial recovery, I'd say you're right. HITECH doesn't directly
address the health care industry or other controversial issues such as
how to pay doctors. And those issues still need to be resolved. But
HITECH does try to reform the health care system around better
practices.

So the HIMSS conference is taking place at the height of a suspenseful
moment in U.S. health care history. The Administration has released
proposed final rules, but they're in the middle of a 60-day comment
period. Meanwhile, working from the drafts that have been released
all along, vendors are feverishly bringing their tools into
conformance and claiming (how could they not?) that the tools will be
ready soon for adoption.

The pressures extend to other players all throughout the health care
industry. A certification body called the Certification Commission
for Health Information Technology (CCHIT) is design certifications for
vendors' systems as well as the hospitals and individual providers who
adopt them, matching the meaningful use criteria "no more and no
less," as said today by the outgoing CCHIT chair, Dr. Mark Leavitt.
The pressure will then be on the providers--and here is where I'm
seeing the most resistance.

Suspicion and silos

Given that many clinicians never adopted electronic systems, and
others who did regretted doing so, we don't have to be surprised to
hear that some don't think it will work or don't believe that they can
make the change.

It would seem that heath care IT is hot right now. HIMSS is sprawled
across three buildings in the Georgia World Congress Center (whose
address completely confuses Google Local, by the way). Getting from
one place to another between sessions means forcing my way through
hundreds and hundreds of attendees. To walk from one corner of one
show floor to the other would take several minutes. I picked up half a
dozen magazines on health care IT.

But even here--among people who paid to attend a health care IT
conference--dissent can be felt. There's a lot of anger at electronic
systems and their vendors, complaints ranging from high costs and
inflexible templates to user interfaces that slow down busy staff and
problems with data exchange. A few observers claim that HIMSS and
CCHIT are just vendor-controlled consortia who want to milk providers
and walk away with government money. I must say, though, that debate
here ranges across many points of view. I was impressed to see an
HIMSS book on patient-centered records, which--if made the basis of
health care--would produce a bigger revolution than anything discussed
so far. (I'll explain why in another blog this week.)

Although attendees want to make the move to electronic records, many
talk about other people who won't. And a typical session on clinical
decision support was devoted, not to ways of using electronic medical
systems, but to persuading the attendees that electronic medical
systems would be worthwhile.

The timetable does seem like a forced march. Even though the systems
that meet the meaningful use criteria are still under development--and
so is the certification--providers will be rewarded as early as 2011
for installing them and using them heavily. (The records have to be
used for 80% of some practices in order to get the money.) And each
year that providers wait before meeting the meaningful use criteria,
they get less money. A stick also accompanies the carrot; providers
that accept Medicare and Medicaid will actually be penalized if they
don't demonstrate meaningful use.

Furthermore, implementing the rules will require the hiring of more IT
staff and telling clinical staff to take time to serve on committees.
These considerations contributed to a href="http://www.healthcareitnews.com/news/chime-airs-critical-concerns-about-ehr-incentive-program">declaration
by a consortium of Chief Medical Officers that the timetable was
too aggressive. Some Congressmen have recently href="http://www.himssconference.org/daily/tuesday.aspx#1">made the
same request, so you know someone has been talking to them.

But many others in the field--including the vendors, confident in
their ability to deliver, and some hospital managers in the forefront
of implementing electronic records--urge the government to stay the
course. Their attitude is that the need is great (because health care
costs are rising so precipitously), the schedule is demanding but
still feasible, and "if not now, when?"

I stated earlier that HITECH was more about behavior and workflow than
technology. The push to implement the meaningful use rules brings
this to the fore. Old silos between IT, doctors, and other staff won't
work; neither will silos between doctors, billing, labs, and other
departments.

Providers trying to achieve meaningful use must talk to their staff:
not just doctors, but also nurses, technicians, and anyone else who
touches a record. They have to examine their workflows and be willing
to admit when they don't conform to health care standards or are
inefficient. They have to make some of the same mistakes offices and
factories made when they computerized in the 1980s, and learn from
those mistakes. To some extent, implementing an electronic system is a
bottom-up activity.

That's why I say that a Silicon Valley approach to risk-taking is even
more important for this field than a Silicon Valley approach to
technology. I'm not so concerned with the famous Silicon Valley
tolerance for failure. Health care is not a social network, and
failure there has serious consequences. I'm more interested in a
Silicon Valley willingness to cross organizational boundaries and to
encourage people's opinions on things where other people are the
recognized experts.

Overall, I don't think the money offered by HITECH will really drive
the decision to change. I think providers will move as they hear of
others running awesome applications to make life easier--and save
lives. I've stopped using the phrase "killer app" in the health care
field for obvious reasons, but the standards, protocols, and storage
mechanisms won't have much impact until applications follow.

So I'll end with a nod toward a company for which I have a fond spot
because it happens to be the href="http://www.oreillynet.com/pub/wlg/3961">first health care
company I talked about in a blog, over six seven years ago. href="http://vocera.com/">Vocera is still going strong, providing
mobile devices with health care applications to over 600 sites.
Medical staff can issue orders, call for help, or scan medications
using these tiny clip-on devices.

Although Vocera doesn't work on the immensely popular iPhone, it does
have partnerships with the makers of several other handhelds,
including the Blackberry and one from Motorola. It collects scads of
statistics about things such as the number of contacts made and the
success of speech recognition software, to help sites judge its
effectiveness. I find it an example of the kind of product that will
drive electronic medical systems, because it will please not only a
Chief Medical Officer, regulator, or insurance claim processor, but
someone doing clinical work on the floor of the hospital.

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Don't be the product, buy the product!

Schweinderl