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EMR/EHR’s and HL7: Part One – General Overview

Posted on May 21, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

How do you make health databases talk?  Use the ‘Health Level Seven’  (HL7) protocol.  

How do you make them say something other than four letter words?  A lot of study, smarts, and intuitive understanding, and nifty tools I outline here will be your best allies in that sense. 

HL7 essentially describes a transfer protocol that is used between health care databases.  Why would you care if you were implementing an EHR?  Simple.  I assure you your EHR does not run the radiology equipment, or the radiation oncology equipment, or the lab system, or the drug dispensing system, or the supplies system . . . In other words, I know that a majority of places have multiple systems in play out of operational necessity.  HL7 attempts to give us a way to get around that, by creating a data standard that describes messaging ‘events,” and the body of that message.  An HL7 (2.x)  Message looks something like this

MSH|^~\&|LABSYSTEM|HAPPILANDLAB|OUREHR|HAPPILANDHEALTH|200905210930||ORU^R01^ORU_R01|CTRL-9876|P|2.4 CR
PID|||010-11-1111||Marion^Maid^E^^^^L|Wench|19720520|F|||256 Sherwood Forest Dr.^^Baton
Rouge^LA^70809||(555)555-1212|(555)555-1234||||AC010111111||76-B4335^LA^20070520 CR
OBR|1|948642^LABSYSTEM|917363^HAPPILANDLAB|1554-5^GLUCOSE|||200502150730|||||||||020-22-2222^
Hood^Robin^^^^MD^^Sherwood Health Associates|||||||||F|||||||030-33-3333&
Hood&Friar&&&&MD CR
OBX|1|SN|1554-5^GLUCOSE^^^POST 12H CFST:MCNC:PT:SER/PLAS:QN||^175|mg/dl|70_105|H|||F CR

I know.  That looks like a bunch of gibberish, doesn’t it?  But really, it’s not.   I want to try and demistify a little about this message over the next few posts, and hopefully help you to understand what HL7 does, how it transmits data, and how you can make it work for you.

Often, people ask me the differences about HL7 standards.  The standards have undergone enormous changes over the years, and you can always keep up with them at www.hl7.org.  There are so many resources over at that site, and my main purpose is to give you an overview of what I find to be the most useful, and a general guide on how to use it.

First I want to explain a few things about HL7.  Think of it like DICOM, only not really . . . you know, standard.  Because, like almost everything in healthcare, a standard is just what you make of it.  Think of HL7 more of being guidelines for where to put data in a message.  While it seems rigid at first, the more you are exposed to the different vendors and their different capabilities as it relates to HL7, the more you will understand what I mean (instead of thinking I’m launching into an explanation of what the word ‘is’ is).   HL7 itself has undergone several different versions, but most vendors I have seen are using version 2.x (that’s 2.anything), but version 3 has some pretty slick features, and utilizes XML to make it much more accessible.   The first thing you want to do is make sure that the two systems you want to have a conversation will be using the same language.

If they can’t, don’t despair, because often people use an engine to sit between the source and the destination, and you can do all sorts of nifty transformations in those things.  There are variety of platforms for this intermediary server, and an incomplete list can be found here on HL7’s site.  The type of environment, be it eBiz, Ensemble, Interfaceware, Corepoint — that selection is going to be made based on how you are going to use your engine.  Do you plan to use it for multiple interfaces?  How many, really?  What kind of functionality do you want it to have?  Generally, I stay tool agnostic, because these choice are best left to organizations. 

Just know that the engine will do one vital thing — it will change your interface process from one step to two.  You will have one interface from source to engine (and thus one specification and one set of code) and another interface from engine to destination (thus a second specification for a second set of code).  Often times, HL7 will also involve configuration of the source and destination systems on HL7 message handling.

The next part of this series will discuss HL7 event types in overview.

EHR, EMR, and Meaningful Use

Posted on May 20, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

John over at EMR, EHR, and HIPAA wrote a great blog on meaningful use, and some of the definitions that are being kicked around in the healthcare IT world.  It is interesting to me that HIMSS includes in its definition of meaningful use ‘decision support.’

For a long time, my work revolved around decision support.  It’s truly an interesting area, and can include such suave topics as BI and decision support.  My biggest issue with it being a deciding factor in meaningful use is that it simply isn’t an option yet, especially for folks early in their adoption of the EHR.  

I’ve blogged about reporting off of an EHR before, and I will reiterate my point — it is vital that the reporting needs of an organization are explored during the EHR RFP process.   If the reporting needs aren’t understood when the EHR is adopted, chances are they won’t be met.   This also extends to decision support — just think of it as reporting needs on steroids.  Now, not only are you supporting one or two data points, you are supporting several, and attempting to allow the system to enact the 80/20 rule — that with 20% effort it could support 80% of the decisions.  

In order to support decision support (wow), it is necessary to have key data indicators in place, preferably in a discrete format (and not a bunch of free text) so that a few queries could be run, or a dashboard report created that will take care of it all.  If this doesn’t happen, I’ve seen quite a few clients turn to solutions that include SAS and SPSS for text mining to attempt to get at the same information.  Both SAS and SPSS are excellent tools for such work, and a little less unwieldy than attempting to write a query that includes a bunch of junk in the where clause because . . . Oh wait.  Let me go a bit slower.

If you end up having a lot of free text data that you have to report off of, you have to remember this little accidental thing called a typo.  One of the first text mining projects that I worked on involved data that came from an insurance call center, and “Payment” was spelled in over 75 different ways (including typos). Don’t believe me?

PAYMENT

PMT

PAYMT

PYAMT

PYAMENT

PAY

PMNT

MPT

 

To write a SQL query that would be able to SORT OF predict if a person meant payment would have a query that would be very, very slow to run.  Add on the volume that your clinic has, and in a few years it could be quite a mess.  All of this can be taken care of if you simply address the needs from the beginning, and start to watch regulations and motions in congress to understand what upcoming data needs for things like HEDIS, PQRI, and Pay for Performance would be.   To make matters worse, there are still often ‘fixes’ you have to put in the data in order to make it fit into some reporting needs, and ultimately decision support.

My problem with ‘meaningful use’ including decision support is the fact that it will sting early adopters.  So, if you had adopted an EHR in, say, 2002, you might not have seen all of these issues coming — and your EHR may not include robust decision support, or have strong data structures to support it.  I would hope that if you adopted your EHR in 2002 that much care has gone into it, but I have also seen EHR’s implemented as late as 2006 that contain unruly data.  I tend to find that in the larger the clinic and the more the users, the more of a problem this becomes.

Yes, there are ways to retroactively fit an EHR to support decision support, but it involves a lot of groundwork.  You have to establish how far you will want to go back, you’ll have to understand the amount and quality of data at every single step, and you will have to somehow code around that data.  You have to decide if you want to retroactively fit that data back into the medical record, or if you want to introduce a data warehouse to hold it (a project that is both expensive and very likely to have issues along the way, depending on what systems are included).

I do believe that decision support is a vital function of the modern EHR.  I’ve seen some that really assist a physician in performing their tasks, yet were rejected in an RFP phase because they would not support reporting requirements such as HEDIS or OSHPD, or even the operational and financial statistics of the department.  What I’m not sure about it is how they expect to legislate this.  Are they going to come into clinics and run our data to see?  As a big privacy advocate, I can’t say I like that decision.  But I’m also not keen on ‘self reporting.’

I worry about organizations that will try to short cut their decision support by just ‘using the billing data.’  Billing data needs to be created in tandem with clinical data, but it functions under different rules, and has different requirements.  The skew that using billing data with no clinical context will not be true decision support — it will be merely meeting the letter and not the spirit of the law.  How will legislation address this?

I am wondering how they are going to legislate this, given that at quite a few of the clients I have worked with, their only recourse is running reports, and getting back to the department that is acting like an “EHR Rogue.”  How will Congress decide who is meaningfully using systems?  How can this possibly be regulated at a federal level, when we all have problems regulating it ourselves?

Food for thought, for sure.

Teletrauma, A Precursor to Video EMR?

Posted on May 19, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Neil Versel wrote an interesting piece over on Fierce Mobile healthcare which talks about EMTs and hospitals using technology to facilitate better care for patients. Neil however argues (rightly so) that not many emergency physicians are going to make a diagnosis based on a grainy photo. Then, he goes on to talk about video. Here’s a small section of his article:

Now, imagine if doctors and nurses could provide real medical advice to help EMTs treat patients in transit based on high-quality, two-way live video. That’s exactly what they have been doing in Tucson, AZ, for nearly two years, thanks to a 227-square-mile Wi-Fi grid that covers most of the city. East Baton Rouge Parish, LA, which includes the city of Baton Rouge, recently launched a similar system that eventually will link to seven hospitals across the parish.

Tucson’s University Medical Center saves $5,000 each time it can prevent an unnecessary activation of a Level 1 trauma team and, more importantly, can save lives by providing remote diagnoses and triage and making sure the trauma team is ready while the patient is still in transit. I wrote about this technology in the May issue of Hospitals and Health Networks, but that short piece only tells part of the story.

I just love the fact that hospitals are looking at this. However, I couldn’t help but have my mind drift off into an EMR. I wonder if this same video technology won’t one day be introduced into an EMR. Only makes sense to me. Hard drives are getting bigger. Video technology is getting smaller. One day a doctor won’t need to chart at all. They’ll just have the full video.

Now we just have to ask ourselves if that’s a good or a bad thing for doctors.

UPDATE: I started thinking and seemed to remember having a similar idea before. I thought it was with recorded audio. I did some digging and sure enough back in March of 2006 I wrote about what could be a video EMR. Interesting to think how some things go full circle.

HIMSS, CCHIT and Meaningful Use

Posted on May 15, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I found this post about HIMSS, Meaningful Use and CCHIT to be really interesting. Here’s some highlights that I think are worth the read:

Will CCHIT certification be required?

CCHIT, a creature of the HIMSS vendor group, currently controls certification of Electronic Medical Record systems, and wants its certification to control meaningful use. It has lined up its allies (including consumer groups) to retain that power.

Conservatives are constantly harping on the idea that, if regulation is to exist, it must be simple, straightforward, and light. Focus on results, and let the market direct the rest.

In this case they are absolutely right. The question is whether the industry groups which supported the last conservative Administration are going to now step up to the plate and walk their talk, or use their influence to undermine what they claim is their cause.

So far self-interest is winning.

I think it’s hilarious they referred to CCHIT as a creature of HIMSS. Pretty much is the case. However, to the bigger point, I think HIMSS is winning their fight to protect their interests. Unfortunately, that’s at the loss to many doctors out there.

Mayo Clinic Launches PHR Available to Anyone

Posted on May 14, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Here’s the story from the American Medical News:

The Mayo Clinic announced the launch of a new personal health record system that will be available to anyone, including those who are not Mayo patients. Those involved with the project say the system, powered by Microsoft HealthVault, could also carry benefits for non-Mayo physicians.

Is it just me, or is my headline (which is theirs also) really misleading? When I saw the headline I was really interested to see the type of PHR that Mayo Clinic had created. Instead, all they’re doing is adopting Microsoft HealthVault. That’s a big win for Microsoft HealthVault, but that’s been publicly available for a while. I’m not sure why Mayo Clinic joining HealthVault makes it any more available to those outside of Mayo.

The more interesting part of the article is when they talk about Mayo Clinic moving forward despite Beth Israel Deaconess Medical Center in Boston stopping claims data from being sent to Google Health:

The launch of Mayo’s system came days after Beth Israel Deaconess Medical Center in Boston announced it would stop sending claims data to patients’ Google Health accounts due to the possibility that the data contain errors. The move reignited the debate over whether PHRs can contain too much data that is not useful to physicians, or dangerous for them to rely on.

Mayo’s system will allow the import of claims data through Health Vault, but Mayo’s physicians will likely not use it, the organization said. Other patients and their physicians can choose whether the information is relevant enough to be kept.

I’d still like to see better support for PHR in various EMR and EHR products. However, until there’s a good standard I don’t expect that to happen anytime soon.

EMR Adoption Higher When Fewer Privacy Laws Exist

Posted on May 9, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Everyone knows that HIPAA rules the privacy world of healthcare.  However, each state actually has their own laws governing the privacy of patient data and in particular data stored in an EMR.  I recently came across an interesting study talking about how those states which have fewer privacy laws for patient data actually have higher EMR adoption rates.  Here’s a short section from the article:

State laws in place to protect patients’ confidentiality may be causing some hospitals to be more skittish about adopting electronic medical records systems, a factor that could impede the push for the industry to go paperless, a study says.

Researchers from the Massachusetts Institute of Technology and the University of Virginia recently concluded that state privacy regulations reduce aggregate EMR adoption by between 20% and 30%. States that got rid of some of their regulations experienced a 21% gain in hospital EMR adoption rates around the years the laws changed compared with just an 11% gain in states that kept them intact, said the study.

This is really interesting, because I would have initially just called privacy laws an excuse. However, if this study holds true, then it’s more than just an excuse for why EMR adoption is low. Granted, it’s just one of many that people are using. I also think it’s worth noting that this is talking about EMR adoption in hospitals. I’m not sure most small doctors’ offices really pay enough attention to HIPAA and privacy rules for it to affect their adoption of EMR.

The Advantages of EMR Systems

Posted on May 5, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re always happy to welcome people interested in doing quality guest posts on this blog.  So, when I got this in my email, I thought it was an important subject to cover on this blog.  The following guest post looks at some of the advantages of an EMR system.  This is a good start for those looking at an EMR system.  I think there are a number of other advantages that aren’t listed below.  I’d love to hear about other advantages of an EMR system in the comments.

The Advantages of EMR Systems

There’s talk of every public hospital in the USA being equipped with electronic medical record systems in a year or two; that’s how popular and necessary these information technology systems have become. And why not, considering the various advantages they hold. EMR systems:

  • Lower costs in the long term: While the initial cost may be high, over a period of time, the average cost of the system becomes much less than a similar manual system. When records are maintained electronically, there is less room for error. Security is also enhanced leading to patient confidentiality and privacy.
  • Eliminate repetitive and unnecessary testing: EMR systems help prevent repetitive testing and thus save both patients and hospitals a lot of money. They can be transferred via email to any hospital or medical practitioner in an instant thus avoiding the need for tests that have already been performed.
  • Provide accurate medical information: Information that’s stored in the electronic format is not prone to human error and can be retrieved easily at the touch of a button or the click of a mouse. Search and retrieval times are a fraction of what they would be in manual systems.
  • Allow information to be available anytime, anywhere: Doctors and other medical personnel can access medical records from anywhere using handheld devices like the iPhone and related software. This allows them to continue treatment no matter where they are and also to pass on information so that other physicians can also provide emergency care when needed.
  • Allow for streamlined information: The information is stored in such a way so that retrieval of select data based on certain criteria and filters can be accessed. Besides this, physicians can also use the system to prescribe medicines for their patients from pharmacies that are part of the program. This allows patients to get refills directly without having to go to the doctor or the pharmacist. EMR systems also allow physicians to order diagnostic tests and view the results online.

This article is written by Kat Sanders, who regularly blogs on the topic of phlebotomist school at her blog Health Zone Blog. She welcomes your comments and questions at her email address:katsanders25@gmail.com.

That Pesky Denominator

Posted on May 3, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As a consultant, I’ve had the pleasure to work with several large clients, and almost every single one has made the same request of me —

“How can we get a report telling us patient volume by (insert ‘data cut’ here) in a timely manner?”

And boy, is that a doozy.  I’ve filled out lots and lots of joint commission reports, and one of the main data points they want is ‘how many,’ yet many of my clients find that number frustrating, if not impossible, to get to.  So many times, I’ve heard CEO’s, CFO’s and the like complaining that two reports from two different people on the same number come out with different results.

Considering that many of them had EHR’s in place – why is this number so hard, when it seems it would be the simplest?

The answer I’ve come to (and always seem to come to) is that it depends on who the client is.

The definition of a ‘patient’ in a capitated sense is different from a ‘patient’ in a clinical setting, yet both of these are reasonable numbers.

Consider — I worked for network oncology operations (so, the operation of all clinics)  in one place.  They considered a patient to be someone who had started a course of treatment.  However, the clinical operations  considered a patient to be someone who walked through the door.

Both of these are valid numbers, but when finance asked for ‘how many patients did you see,’ the two came up with wildly different numbers.

It’s easy to see why, isn’t it?

In this situation, we held a five hour meeting during which we attempted to come to a resolution between all involved on what these key performance indicators were, and how we would define and derive them.  Five hours later, we barely had defined what a patient was, and it seemed on the surface to many involved that the old fashioned method of having people keep count and report to us with a phone call still seemed rather sweet.  After all, the biggest concern for everyone was that we didn’t present the CFO with different numbers, but we couldn’t make the clinic and overall operations agree on which was the more accurate statistic.  But, I pushed back, and pushed back hard that we should not be spending four to five analyst hours per day on gathering the number when we could do it from the system with just a little more effort.

We called another meeting — and I took over and suggested a compromise.  We ended up implementing my plan, which was a simple one — we would define the statistics more carefully, and report all of them to the CFO — so he could pick which numbers he wanted to use after having a full understanding of what they mean.  We ended up with Patient Starts, Patient Consults, and Patients.

Was it a pain?  Not as painful as the meetings where we were all upbraided because we couldn’t report a seemingly simple number.  Yes, two five hour meetings discussing the definition of patient was painful.  No way around that.  But it was necessary.  From these three definitions we were able to leverage the information in our EHR and create reports that were meaningful — they just reported three numbers, and the analyst FTE was changed instead to a database script.

While examining the output of these reports, we found several instances in which the system was not being correctly used, and used our ‘data goal’ to come up with new internal policies and training guides to ensure our clinics were entering what we needed — and if they needed more staff to support, we were able to comply — we now had an analyst FTE’s that could assist the clinic in proper EHR utilization, instead of just calling people and asking for a number.  She was much more challenged in this role, and a happier employee, and it stopped the angry calls from admin to the clinics for numbers.

So, if you are thinking of implementing an EHR, I would strenuously suggest that reporting be a key factor in selection, configuration, and implementation.  It’s far less painful (and expensive) to have reporting requirements out of the gate than to try and rig a system around poor configuration ex post facto, or to completley change front desk and clinical worfklows far after initial implementation.  EHR may be a clinical concept, but it touches all areas of healthcare operations, and COO’s, CFO’s, and CEO’s are stakeholders in these systems in addition to CMO’s, CTO’s, and CIO’s.