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Posts Tagged ‘standards’

Sean Nolan, the chief software architect for Microsoft’s HealthVault has written an excellent post on the philosophy/approach that Microsoft is taking with regards to HIT standards (basically supporting whatever is in use).

What I found particularly interesting in the post (at least for this neophyte to the HIT sector) is that in healthcare it is not so much about getting the most accurate data, it is about getting the most complete data. This runs completely counter to what one will find in other industries, such as finance or manufacturing, where getting accurate, precise data is absolutely critical for running a business where the only time you run on fuzzy data is in the marketing department.

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It was only a matter of time as rumors have been swirling around for sometime now but CCHIT has announced the formation of an Advisory Task Force (ATF) to provide guidance to CCHIT on what should and should not be included as part of a PHR certification process.

While the announcement was extremely thin on details, I did some digging and came up with the following.

PHR attributes that may be considered for certification include:

  • Privacy: Of course, and we definitely need it as HON is inadequate,
  • Security: Why not and logical follow-on to privacy,
  • Interoperability: A CCHIT favorite – to be expected but unlikely to be necessary – market will rule on this one,
  • Functionality: No, they don’t need to go here, let the market decide what functionality is desired.

Proposed timetable:

  • May 2009: Publish criteria and test scripts
  • July 2009: Launch certification program
  • October 2009: First certified products announced

Odd, but somewhat predictable cast of characters on the ATF. You have the 3 platform play representatives in Dossia (Rick Benoit), Google (Missy Krasner) and Microsoft (Michael Stokes), several from non-profits (academia, government and others) and a couple of health plans.

Who’s missing?

A tried and true PHR vendor that is actually out there with a product and has been doing it for a few years. This panel is currently burdened with either big company representatives or what appears to be those who have never worked in a small company needing to take a product to market. There are unique challenges for such an entity that this ATF will have a difficult time empathizing with.

Hopefully there is still time to add another to the group.

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While doing some research on healthcare IT (HIT) standards for our upcoming report on the PHR market I stumbled upon 3 different organizations who all seem to be doing pretty much the same thing, defining a functional model for PHRs. Functional Models are basically just that, a model that defines what functions should be contained within a given software package or even a hosted Internet service. Logical functions for a PHR would include such items as medications list, allergies, current provider, maybe insurer, next of kin, home address and some basic biometric data – you get the idea.

First we have the payer-driven initiative launched by AHIP and Blue Cross Blue Shield to create a set of guidelines for health record transfer among insurers. This is a great effort on their part as among the multiple challenges health insurers face in promoting adoption of PHRs has been the lack of portability.  The average retention life of an individual with one insurer is on the order of 3-5 years, thus this portability issue is a big deal.  In June 2007, they released the technical specifications (warning PDF, all 156pgs!), that among other issues, states what types of data that will be contained within a PHR and need to be accounted for in such a transfer between insurers.  Those data types directly relate to specific functions within a PHR and must be mapped via an XML schema (insurers plan to use a combination of ICD-9 and CCD standards) for successful transfer.

I also knew of the efforts by the standards group HL7, who have developed a functional model for PHRs titled, PHR-S FM. Found a presentation, not from their website (trust me, their website is nearly impossible to navigate and found this via a search), but you’ll find it hl7-overview.ppt. Presentation gives a thin overview of the intentions for PHR-S FM (you’ll find the actual draft here, it’s ninth down in the table). Again, nice effort and looks like many of the stakeholders in the PHR space have commented upon the first draft, back in November 2007 (so it is inclusive). The revised version is currently being balloted upon, which will end April 28, 2008. Thus, we should see the final version hit the streets by summer.

Then today, I find that Project Health Design (PHD), a Robert Wood Johnson Foundation funded project looking at PHRs has created their own functional model for PHRs, which was released for comment in December 2007.

OK, we now have three, verifiable PHR functional models and that doesn’t account for what designs Google, Microsoft or Dossia, may have of their own. Hopefully they’ll adopt one of the above rather than create their own.

There is also the Markle Foundation, who has supported a number of efforts along these lines over the years. Markle, through sponsorship of various committees and work groups, has focused more on policy than prescriptive functional models. Yet, within those policies there is a significant amount of functions outlined. So we really cannot ignore them either.

And let us not forget our friends in Washington DC. While there has been no direct confirmation that CCHIT will take on the task of defining a functional model and/or some sort of certification process for PHRs (they currently have their hands full with EHR certifications), that has not stopped people from talking about it. My view is that it is only a matter of time before CCHIT jumps in as well.

While I applaud the efforts of the above organizations, their hearts and minds are in the right places, I do wish that they would start talking to one another and where possible avoid duplication and bring some clarity and consistency.   Instead, I see a significant amount of overlap, which is ultimately of little service to anyone.  Thankfully, it appears AHIP is thinking the same thing for upon release of their technical guidelines, they did state that they will work with HL7 to reconcile each organizations respective efforts. Hopefully, others listed here will do likewise.

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Civic Duty?

If you get bored of walking the aisles of HIMSS and can’t bear to hear another vendor pitch, well you could always wander over to a session where people will gather to discuss and reach consensus on what are arguably the 5 most used acronyms in the industry. You can contribute to the discussion as part of your civic duty as there are some in the federal government that believe lack of clarity on these terms is holding back the adoption of healthcare IT (HIT).

But really, does anyone in the right mind truly believe this is the problem with HIT adoption? There are a myriad of issues that are stunting the adoption of HIT that range from poor software to poor implementation of good software, to lack of training and the list goes on and on. Consensus on the definitions of five acronyms (EHR, EMR, HIE, PHR, RHIO) will solve NOTHING as it pertains to actual adoption of IT in the healthcare sector!

Maybe its just sour grapes on my part for I did not win the contract. One of the Beltway Bandits did and for a princely sum of $500,000. Hey HHS, I would have done it for you for a tenth of that amount and you would have the report by now. Better yet, maybe HHS can get its money back and instead go out and buy a box-car load of Diffusion of Innovations by Everett Rogers, the undisputed Bible of how technology is adopted and diffused. Distribute the book to all HHS employees involve in HIT promotion efforts, study it closely and apply the concepts. Guarantee the results will be more productive than this definition effort which you are currently funding. (Note: Moore basically plagiarized Rogers’ work for his own Crossing the Chasm. Diffusion of Innovations is more academic and far more thorough than Chasing the Chasm).

But I digress.

This is one glaring example and quite possibly the most egregious of what is wrong with government efforts to date to drive adoption of HIT (actually gave it a “Golden Fleece Award” when I first heard about it). I have nothing against the many dedicated federal employees that are really trying to do the right thing, in fact, I have enormous respect for them for they really are taking on a herculean task. I just wish some of them would think more and do less.

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John Halamka, the CIO of Boston based Beth Israel Deaconess Hospital and Chairperson of standards organization HITSP is a daring soul, having had an RFID implanted into his upper arm to validate the technology and most recently provides an interesting example of two formats for displaying his medical records.

Why is he doing this?

As a healthcare CIO, Halamka is intimately familiar with the challenges of data exchange, primarily within the confines of a hospital or IDN.  But Halamka also foresees a future where the patient will become the custodian of their health records.  In this future, patient-controlled health record paradigm data exchange will be infinitely more challenging.  In providing these two examples, Halamka attempts to show a future model that will alleviate the data exchange conundrum.

In the first, he uses PDF and ends up with a huge, 77 page file that would be daunting for even the most conscientious doctor to wade through. In the second example, he uses the CCD standard, which provides a concise overview of his medical record in a common Web-based document format with embedded hyper-links.

While Halamka uses this demonstration as an example of why standards such as CCD need to be adopted making the argument in his post. But when I look at the two examples, I find the CCD easily readable but sorely lacking in information. The PDF on the other hand, while lrage is quite comprehensive and one can easily search on terms in the PDF to find relevant information, e.g., what actually happened when Halamka contracted Lyme’s disease.

Now I am certainly no physician and have never claimed such but if I were a physician and I did have a choice, I’d take the PDF over the CCD as my propensity is to err on the side of safety. The CCD, at least in this example, simply does not provide sufficient information to provide quality care.

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This week, the standards group, HL7 announced the release of the personal health record system functional model (PHR-S FM) as a draft standard for trial use.  They expect the finalized standard to hit the streets in early 2008.

You’ll find the PDF press release for this announcement here.  This link will take you to HL7’s resource library search.  Just enter PHR in the “Title” field and you’ll pull up a link to the actual draft PHR-S FM.

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Last week, the HIMSS Electronic Health Record Vendors Association EHRVA announced the availability of a “Quickstart Guide for CCD Standard.”  The guide is structured to assist the multitude of electronic medical record (EMR) vendors, both large and small, in how to adopt the recently released (January 2007) Continuity of Care Document (CCD) standard in their current and future products.  By adopting this standard the EHRVA hopes that the industry will move closer to that elusive goal of interoperability across the various EMR solutions in use today.

Of course, this is not completely altruistic (is any vendor sponsored initiative altruistic?) as EHRVA would like to have some control over the situation rather than have some federal entity like the Certification Commission for Health Information Technology (CCHIT) force it upon them.

One question does arise when looking at such developments, especially those promoted by one distinct, albeit important group like the EHRVA and that is how will these standards be adopted and used by the multitude of other healthcare IT vendors such as those creating personal health records, enabling telehealth and the like.  The industry as a whole is moving towards greater involvement of the consumer in managing their health and wellness and I do not see the involvement of such stakeholders in this effort, which is unfortunate and seemingly myopic.

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