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May 21 2012

Health Information Technology: putting the patient back into health care


Government Accountability Office

441 G Street NW.

Washington, DC 20548

Dear Sirs and Madams:





Andrew Oram

Editor, O'Reilly Media

(This letter represents my personal view only)

February 29 2012


This is a time of great promise in health care, yet an oppressive atmosphere hung over much of href="">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 22 2012


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 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.

July 22 2010


open source advocate Fred Trotter, informally stepping in as session
the health care field were in the room, including two VistA

This meeting, which drew about 40 doctors, project leaders,
O'Reilly conference. The day's sessions unveiled the potential of open
source in health care and how dedicated implementors were making it a
attracted over 75 people and continuing through the next seven hours
until a dwindling hard core delayed drinks and hors d'oeuvres for half
Swan on DIYgenomics.

Nine talks representing the breadth of a vital programming area can't
open source advocates reaching out to solve pressing problems that
proprietary vendors will not or cannot address.

Tim O'Reilly's talk laid out key elements of the health care
revolution: electronic records, the quantified self (measuring one's
behavior such as whether a patient has taken his medicine.

Talk to me

We were honored to have key leaders from Health and Human Services
came from the Office of the National Coordinator along with lead
contractor href="">Arien
Administration's health care policy because they allow different
health care providers to exchange patient information securely.

I have href="">written
recently about "meaningful use" for health care records. Malec
provided a homespun and compelling vision of the problems with the
knew every patient personally, modern health care is delivered as
episodic interventions. As Fred Trotter said in his talk, we've
reached the limit of what we can achieve through clinical efforts.
health care systems need to remember us. That's what
electronic health records can do, combined with the data exchange
protocols provided by NHIN.

online--rapidly laid out the architecture of CONNECT and what's
planned for upcoming releases. Requests between agencies for health
care data have gone from months to minutes with CONNECT. Currently
over REST, XMPP, and SMTP.

agencies that produce or consume health care and how the same benefits
to formalize an architecture that would become the new CONNECT.

NHIN is an even more impressive case of open government and
collaborative development than CONNECT. The public was involved from
the earliest design stage. Some people complained that established
vendors bent the process to preserve their advantages, but they
probably had less success this way than if HHS followed normal
government procedures. NHIN already has reference implementations in
reference implementations in your language of choice.

In addition to supporting the NHIN Direct protocol, some of the
upcoming features in CONNECT include:

  • Identity management services. This will probably be based on a
    voluntary patient identifier.

  • Support for meaningful use criteria.

    enabled by this enhancement will be the ability to recognize sensitive

  • Moving to the Spring Framework.

Riley has done some pretty rigorous cost analysis and determines that
careful management--which includes holding costs down and bringing
multiple agencies together to work on CONNECT--has reduced development
costs from over 200 million dollars to about 13 million dollars.
Recent code sprints drew heavily from community volunteers: 4 or 5
volunteers along with 12 contractors.

In an href="">overview
talk, Deborah Bryant of OSU Open Source Lab raised the issue
continuity in relation to NHIN and CONNECT. Every open source project
that the project continues to evolve and adapt to changing
circumstances. Government-backed projects, she admitted, provide
need for community management.

who have to learn how to accept community input and communicate with
outsiders. Behlendorf said that simple things like putting all code
in Subversion and all documentation on a wiki helps. Consultants are
also encouraged to request feedback on designs and to talk about the
goals of sprints as far as possible in advance.

IntraHealth International manages the basic health care resource: people

The problems of the developing world were represented most directly by
presented by href="">
Carl Leitner. IntraHealth International helps many Sub-Saharan and
South Asian countries manage one of their most precious and dwindling
resources: health care professionals. The system, called iHRIS lets
individual hospitals as well as whole nations determine where their
most pressing staffing needs lie, break down staff by demographic
track their locations.

iHRIS records expenditures, what do countries often find? Some
administrator has splurged on sending himself to the same training
expose graft.

funds are scarce, but because localization is critical. Lots of
languages whose very existence is hidden from proprietary vendors need
to be supported. Each country also has different regulations and
conditions. IntraHealth International holds regular unconferences,
organization tries to spread the training over many people.

OpenEMR and Tolven

The overarching challenge for any electronic health record system, if
its developers hope it to be taken seriously over the next couple
certification to support meaningful use as well. But smaller providers
have been unable to afford these systems.

The need for an open source solution with meaningful use certification
they have implemented about 80% of the required functionality, but
more slowly than expected. Extraordinary measures were required on
many fronts:

  • Medical experts had to read thousands of pages of specifications as
    they came out, and follow comments and debates to determine which
    development time.

    spike in productivity created by the contractors attracted a huge
    project leaders had to upgrade some of their infrastructure to handle
    an increased number of commits. They also discovered that lack of
    maintaining a community required--well, maintenance.

  • Project leaders had to go to Washington and argue with government
    bureaucrats to change requirements that would have essentially made it
    impossible for open source projects to meet the meaningful use
    requirements. They succeeded in removing the offending clauses, and
    believe they were also responsible for winning such accomplishments as
    allowing sites to certify modules instead of entire stand-alone
    systems. Nevertheless, some aspects of certification require
    contracts with proprietary vendors, such as lab interface, which is
    drug-to-allergy interactions, which require interaction with expensive

Tony McCormick pointed out that the goal of meaningful use
certification provided a focus that most open source projects lack.
In addition, the government provided tests (called scripts) that
served as a QA plan.

Meaningful use, as much as it represents an advance over today's
health information silos, does not yet involve the patient. The
Jones on Tolven.

Swan summarized the first two generations of DNA sequencing (which
generation that could bring full genome sequencing down to a cost that
consumers could afford. A part of the open science movement,
DIYgenomics helps patients combine with others to do research, a
process that is certainly less rigorous than controlled experiments
but can provide preliminary data that suggests future research. For
many rare conditions, the crowdsourced approach can fill a gap that
professional researchers won't fill.

In addition to providing access to studies and some other useful
drugs--DIYgenomics conducts its own longitudinal studies. One current
properly, a condition to which up to half the population is
vulnerable. Another study, for which they are seeking 10,000
participants, covers aging.

broader issues of patient-centered medicine. Tolven simultaneously
the patient (personal health records).

In a system designed especially for the Netherlands--where privacy
laws are much stricter and better specified than in the United
States--Tolven stores medical records in large, centralized
repositories because it's easier to ensure security that way. However,
strict boundaries between doctors prevent them from viewing each
other's data. Even more significantly, data is encrypted during both
it. Audit trails add another layer of protection.

explicitly approves every data transfer. (Patients can designate
special repositories to which their relatives have access, in case of
emergencies when they're not competent to make the transfer.)

started our evening BOF with introductions, but more and more people
introductions ended up taking the entire hour allocated for the BOF.

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="">
benefits of risk-taking in health care IT followed by my main
theme, href="">
interoperability and openness. This blog will cover a few topics
about a third important issue, infrastructure.

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
her that billing will be delayed for the same reason.

Network bandwidth

Apollo Computer in the 1980s) goes, "The network is the computer." In
deal. It's considerably more problematic in an isolated rural area
during the conference (particularly after 10:30 at night, when I'm
Luckily, he found a cheaper alternative.

So the FCC is href="">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
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
rising health care costs and deteriorating lifestyles have answered
that question.

Wireless hubs

hospitals with modern, technology-soaked staff are depending
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
put them just about anywhere you want and move them easily.

Dynamic airtime scheduling

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
multiplexing. If your device is ten times faster than someone else's

Dynamic rerouting

Aerohive hubs use mesh networking and an algorithm somewhat like
Spanning Tree Protocol to reconfigure the network when a hub is added
neighbors store your access information so they can pick up your
traffic without taking time to re-authenticate. This makes roaming
hub goes down.

Security checking at the endpoint

environment like a hospital where you have no idea who's coming in.

High bandwidth

directional antennae.

Go virtual, part 1

VMware has href="">customers
in health care, as in other industries. In addition, they've
incorporated virtualization into several products from medical
equipment and service vendors,


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


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
previous workstation.

Go virtual, squared

talk I attended today on cost analysis, a hospital administrator
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="">Practice Fusion in my
pertinent to Software as a Service.


services (although I think it's easier to solve than many other
architectural issues). Practice Fusion runs on HIPAA-compliant 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
in other common formats, overnight.


As I explained in my previous blog, clients increasingly expect a
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
each day.

Another SaaS company I mentioned in my previous blog is href="">Covisint. Their service is
broader than Practice Fusion, covering not only patient records but

Finally, I talked to the managers of a nimble new company called href="">CareCloud, which will start serving
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
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
integration with Google Maps.

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

Systems Society (HIMSS) conference in Atlanta, rushing from panel
session to vendor booth to interoperability demo and back (or
peregrinations involve a quest to find progress in the areas of
interoperability and openness.

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="">blog
yesterday covered risk-taking; today I'll explore the reasons it's
so hard to create change.

The health care information exchange architecture

but it tends to reinforce approaches to building and selling software
the concerns for interoperability and openness in their own ways. I
than mammal.

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

Electronic medical systems and electronic record systems

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

Services and value-added applications

As with any complex software problem, nimble development firms partner
providers find too difficult to do on their own.

Health information exchanges (HIEs)

planning, and partly due to privacy concerns and other particular
own. Some institutions can transfer records directly, while others
other organizations in their geographic regions.

HIE software and Regional Health Information Organizations

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
checking to increase the provider's chances of getting reimbursed the
office, and some vendors try to cover more than others.

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
demo at the booth of Epic, one of
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
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
act's meaningful use criteria, mentioned in yesterday's blog.

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.

directly with First DataBank so they can integrate the data intimately
with NextGen's screens and database.

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
could theoretically make a mistake. Their printed publications include
disclaimers, and they require the companies who licence the data to
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

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
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
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

    politician, is automatically protected from requests for information.

    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

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
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
and Reciprocal Support Agreement (DURSA) to promise that information
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

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

Fuzzy standards

leave details unspecified.

Problems that lie out of scope

Behlendorf of Apache fame, now consulting with the federal government
created the Internet by standardizing HTML and CSS but saying nothing
about TCP/IP and DNS."

Complex standards

harder to support.


As one example, the University of Pittsburgh Medical Center tried to
harmonize its problem lists and found that a huge number of

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.
different in different cultures. Wankowski says, "Unlike other
industries such as manufacturing and financial services, where a lot


through SNOMED was far superior in specificity and clarity. Along with
historical reasons, they avoided SNOMED because it was a licensed
official standard is distributed as RTF documents, making correct
adoption difficult.

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

InterSystems is a major
an object database written in the classic programming language for
medical information processing, MUMPS. (MUMPS was also standardized by
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
communicate with all other providers in that region.

standards. A facility that uses another product can exchange a
more and more fields into Care Everywhere as standards evolve.

What all this comes down to is an enormous redundant infrastructure
Queen's Race to provide the value that already exists in those
records. We've already seen that defining more standards has a
happening in that area.

The open source challengers

sometimes brilliantly accomplished, but ultimately stumbling through a
on our proscenium.

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

Buzz in the medical world is that VistA beats commercial offerings for
version of VistA for the non-government sector.

software MUMPS compiler GT.M. VistA also runs on the Caché
license Caché from InterSystems, you need to find some other
database solution.

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
typical SOA-based technologies such as SAML.

Two free software companies that have entered the field to make
hours of support time per week. The complexities of handling CONNECT
for Mirth than the more typical problem of interpreting the hospital's
idiosyncratic data formats.

Just last week, href="">the
government announced a simpler interface to the NHIN called NHIN
who couldn't afford the costs of negotiating with CONNECT.

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.

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
much more flexible environment where contributors could use
essentially any tools that struck their fancy.

Buried in href="">a
major announcement yesterday about certification for meaningful
use was an endorsement by the Office of the National Coordinator
out that rule 4 for certification programs explicitly mentions
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
InterSystems does this with a SOAP-based interface called Ensemble,
for instance. Eclipsys,
off applications that compete with their own.

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.

MedCommons storage service,
interfaces, perform authentication over OpenID and OAuth, and use the
simplest possible formats. And only an enlightenment among the major

electronic record vendors and the open source community, we need to

Enter the patient

Most people are familiar with Microsoft's HealthVault and Google
provide APIs that individuals and companies alike are using to provide
services. A Journal of Participatory
has just been launched, reflecting the growth of interest
subject by HIMSS itself in the conference bookstore.

The promise of personal health records goes far beyond keeping track
just be fodder for services with incredible potential to improve
she used the metaphors of "intelligent medicines" and "smart

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
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
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="">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'

A crisis in costs and achievements provides a nice impetus for change
( href="">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

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="">CIO
Anthony Guerra and href="">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

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="">declaration
by a consortium of Chief Medical Officers that the timetable was
too aggressive. Some Congressmen have recently href="">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

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="">first health care
company I talked about in a blog, over six seven years ago. href="">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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