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Fred Trotter Thinks CONNECT Will Unify Health Information Transfer

Posted on November 25, 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’ll admit beforehand that I’m a member of the Fred Trotter fan club. He’s a little bit psycho when it comes to open source licensing and the like, but that’s probably why I love him so much. When he truly believes in something he’s fully engaged in that cause.

So, of course I am completely interested in Fred Trotter’s blog post about CONNECT where he said the following:

The right conversation starts with this: we can assume that CONNECT -will- unify the health information transfer in the US. It will serve as the basis for the core NHIN and regional networks will have the option of implementing it. That means that CONNECT sets the bar for health exchange. Software must be as good as CONNECT to be considered for a local Health Information Exchange, otherwise, why not use CONNECT?

I think this is the second time that I’ve heard the name of the project CONNECT like this. I think that’s a sign that I better do some more looking into this project.

Interesting Updates on Free Vista EMR

Posted on November 24, 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 previously did a post about some of the problems with Vista-FM. I considered that it was different than Vista, but wasn’t sure completely. The beauty of blogging is that when you make mistakes smart people come and correct you in the comments. This is one of those times. Plus, along with helping me understand the difference between Vista and Vista-FM Chris Richardson, provides an update on some of the other things happening with the open source community around Vista. I don’t agree with everything he says, but it’s definitely interesting. The following is Chris’ comment:

You jumped at the wrong conclusion when you jumped on VistA as being the faulty item here. What has failed is the “-FM” portion of the GAO report, the Foundation Modernization. You see, VistA is NOT VistA-FM. VistA-FM is the effort to dismantel VistA. Just like all of the other Attempts in the past nearly 20 years, these efforts are under-functioned, over-priced, and way over their delivery schedule. A mere fraction of the cost of what has been expended to replace VistA would have made VistA able to totally out-class every other approach to EHRs. There is work currently going on in the Open Source community to extend VistA and it is working very well. Here are some of the projects that are currently on the way or already in production;

Lab, while the VA is outsourceing to Cerner (with interesting results), the rest of the community outside the VA is continuing on with enhancements and options that will make it easier to install and higher functioning as well as affordable to nearly everyone.

Continuity of Care Records and Data (CCR/CCD) while this standard is a bit anemic, it does promise that we might be able to project all of the VistA databases to other systems or accession data from others.

Holographic EHR – This is one of our concepts, basically you could think of it as “VistA for One” (or a small group of patients), a self consistent subset of the parent VistA environment which could be booted separately. The self-consistent “VistA for One” becomes a mechanism for complete transfer of patient data from one site to another with merge capability. It also becomes an in-hand user copy of his records which can be protected via a network keying system which registers the data set, and records the efforts to open the data set and by whom, and who is attempting to accession the data to what target VistA system.

CPRS
This is fun. I cannot tell you the number of times that I have heard, we need to keep CPRS, but get rid of VistA. The engine behind CPRS IS VistA. Without VistA, CPRS is a screen-saver. The Open Source Community is making enhancements for the CPRS/VistA environments. There is another group that is working on the webification of VistA with open source tools.

By the way, I worked on the proposal team for CHCS-I and we used MUMPS to build interfaces for various other vendors to communicate with each other. In fact, the MUMPS interfaces worked better than the Clover-leaf connection engines.

There is a reason that the Subject Matter Expert developed systems of the VA, DoD, and IHS have been so effective and difficult to replace. VistA is a whole enterprise solution that the vendors hope you never find out about. The vendors focus on dismantling VistA to provide a new niche to build “customer loyalty” (make it too painful and expensive to move to something else so the customer is essentually stuck with the vendor’s solution only. With the VistA model the SMEs are the folks at the point of care, and not a programmer who has never spent an hour in a hospital, yet is charged with the setting of policy for the hospital in his interpretation of the requirements (which may or may not reflect the intent of the SMEs).

By having VistA as Open Source, this means that the cost of doing development has dropped right into the basement. Success can be tried in a thousand places, but with Open Source, as soon as someone comes up with an enhancement or corrects a problem, the change can go out to the rest of the World. The best of breed solutions float to the top to be applied everywhere.

You know, VistA is still running the VA hosptials for over 30 years, don’t you think that if the vendors could have replaced it, they would have? They have tried and gotten paid well for the attempts. But this is part of the problem. There is no incentive to ever complete a task or attempt because then the paydays end. This is why they have confused the community with the use of VistA-FM, use their failures as justification to try to replace VistA yet again.

Let’s take a look at some of these magnificent failures. How about the replacement of IFCAP (the financial part of VistA) with Core-FLS. Now get this. The VA developed IFCAP (by the way, it was not vendors who did this work, it was the VA SMEs who did the daily work of inventory and supply and finance) and owned the code. The VA paid nothing for the code other than the VA programmers and SME’s time. Then they were going to replace it with a package which would only have to do 30% of what IFCAP did. Congress committed $470 million to replace something the VA already owned with something that had less functionality but was more glossy and the VA would have to pay big bucks to the vendor to support. The roll-out of the product was done at Bay Pines VA Medical Center and was so bad that they had to close elective surgery. The vendor spent over half the money just to install the first site and the project was mercifully stopped and IFCAP was re-installed. So much for modernization. This is not an isolated incident.

There was the Spanish Pharmacy labels. Peurto Rico and many of the boarder VA Medical Centers needed to be able to produce Spanish Labels for the Hispanic Patients. This was done by duplicating code rather than completing Internationalization that was started back in the early 1990’s, but stopped by the Clinger-Cohen Act. It would have taken less time and less money to complete internationalization for all of VistA than it took to do a one-up parallel code base for Spanish Pharmacy Labels. Adding another language would mean even more complexity (such as French or German), would be even more duplicate code for a single functionality. By myself, I built a tool to convert all of VistA into being ready for Internationalization and made it so there could be any number of languages that could be selected by the user and not necessarily locked to a single language. It takes about 50 minutes to parse all of VistA into the instrumented code and load the DIALOG file with the words and phrases, ~165,000 phrases in all on a 800 mhz laptop. It does not modify the distributed code but builds the instrumented code in a separate location. This code is available for free download from WorldVistA.

The community is alive an well, and vibrant with new ideas. We are starting to catch up from the “legacy era” and allowing the evolution of the tools to progress again. Want to join in?? It is a lot of fun and a set of real challenges that will bring the power of what needs to be done, back into the hands of the people who are at the point of care. Interesting thing about the word “Legacy”, people think of it as old or non-functional. It really isn’t. It also means that the code is doing the job and doing it just fine. Can it be improved, sure, VistA was made to be improved, to expand beyond what was known and what was learned. But, do remember, VistA-FM is NOT VistA, it is the attempt to break up the integrated hospital system into a series of stove-pipes. VistA-FM is the worst of all FUD (Fear, Uncertainty, and Distrust). VistA is still running the hospitals and it is running more community hospitals every year.

EMR US Adoption Rates

Posted on November 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.

People are always interested in learning what the adoption rates for EMR software are in the US. Chilmark recently posted about a Harvard School of Public Health study that was presented at the PHAT conference. This study focused on EMR adoption rates and the reasons that doctors and practice managers have chosen not to adopt an EMR, yet. Here’s a summary of the findings:

Hospital EMR

  • 90% of Hospitals have no functional comprehensive EHR
  • Mostly large hospitals and teaching hospitals do
  • Top Barriers to EMR Adoption: Inadequate capital (73%), maintenance costs (44%) and physician resistance (36%)

Ambulatory EMR

  • 83% do not have a functional EHR
  • 17% stated they have purchased an EHR, but not implemented
  • 26% plan to purchase an EMR in the next 2 years
  • Top Barriers to EMR Adoption: lack of capital (67%), finding a system that meets their needs (54%) and uncertainty of ROI (51%)

Chrome OS Electronic Medical Record Anyone?

Posted on November 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.

The tech world is buzzing about Google’s new Operating System (OS) called Chrome. You can read the full writeup from Google’s Chrome OS announcement on Techcrunch or the official announcement on the Official Google blog. Basically, Google has created an operating system for a netbook (or at least netbook like) computer that will be super fast. The reason it can work so fast is that it will basically only run web applications. Yes, this is hard to wrap your head around, but it is really interesting.

Let’s apply the Chrome OS to EMR and healthcare. Imagine you have an EMR software that’s completely web based (yes, there are a number of them already). Then, the Chrome OS would be perfect for that EMR. I should also mention that the Chrome OS computer is likely to be in the $300-$500 range. That’s a lot of savings.

Now let’s talk about speed. I’ve been using the Chrome web browser for months now and it’s just flat out faster than any other browser out there. In fact, every once in a while I open another browser and have to avoid slitting my throat as I wait for it to load. I expect the Chrome OS will be just as fast. Yes, every doctors office likes speed. Can the EMR integrate with Chrome at a level that they optimize the speed of the EMR? They could. Will be interesting to see if anyone will.

How about security? Well, there’s nothing being stored on the Chrome OS laptop. Yes, that means all of the data from this new laptop is being stored on the server. Even the data that’s temporarily stored on the laptop is encrypted. Now imagine you lose a laptop (nah, that’s never happened in healthcare, right?). Good news is that there’s no patient data on the laptop since it’s all stored in the cloud.

Of course, one downside with the Chrome OS is that you’re dependent on your internet connection to do much of anything. However, with an EMR that’s generally true anyway. So, I don’t see much difference there.

One challenge I do see is the document management piece of an EMR. Document management is file intensive and needs a real OS. I don’t see much getting around this. I don’t see Google adding in support for things like high end scanners (or even low end ones for that matter). However, you just purchase one or two computers for your office that can handle the scanning. Problem solved.

No doubt the Chrome OS isn’t the end all be all to computers. It likely won’t even takeover a HUGE percentage of market share. However, it is a really interesting development that could be interesting applied to an EMR and healthcare.

EMR Tire Kickers

Posted on November 18, 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.

The people over at Software advice ran a poll asking essentially whether the HITECH act had created EMR buyers or just brought out the EMR Tire Kickers. Sadly, only 74 people responded. I wish I would have known about it and I would have promoted the poll so we had a wider audience voting to get a more interesting set of data.

The poll did essentially say that right now it’s brought out the tire kickers. I’ve been talking for a while now about how the HITECH act would actually slow EMR adoption (at least in the short term for sure). This poll basically agrees with that prediction.

The question remains whether those EMR tire kickers will turn into EMR sales. I’d be really interested to see the results of the same poll in say February or March. I think we’re going to see a tremendous increase in EMR purchases at that point in time.

Practice Fusion Adds Free PHR

Posted on 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.

There’s no doubt that Practice Fusion has been making a big splash in the world of EMR. They were the first EMR company that I’d seen that was pioneering the “free” ad based EMR on the web. You can read more about my first impressions of their free EMR offering on EMR and HIPAA. This interview with the CEO of Practice Fusion is pretty interesting as well.

Now Practice Fusion has made the next logical step and added a PHR front end for patients to be able to access their clinical record. From the look of the screenshots (see below), I’m not seeing anything particularly special about the PHR. In fact, I’d likely say that this isn’t much more than an initial PHR offering. Since it is their initial offering, I guess that makes sense. Certainly they’ll be building it out over time.

What I find more interesting about this new PHR is that Practice Fusion built the PHR on top of Sales Force. SaleseForce.com recently made an investment in Practice Fusion and so this seems to be an extension of that partnership. I see this as a really interesting move for Practice Fusion to build a healthcare application on top of the Force.com cloud. It also will be interesting for SalesForce.com to enter the healthcare space.

Check out the following screenshots of the PHR application:


New EHR Certifying Body – Drummond Group CEO Interview Highlights

Posted on November 16, 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.

Healthcare Informatics has been doing a number of really interesting interviews lately. One of their most recent ones is an interview with RiK Drummond, CEO of The Drummond Group. You may have seen that the Drummond Group will be certifying EHR for ARRA funding. So the interview with Rik Drummond is pretty interesting. It is in 2 parts, but here are some highlights from the first part (since the second part isn’t up yet):

In regards to the cost of EHR certification (looks like Drummond Group EHR certification could still be pricey):

GUERRA: So you don’t have a better sense of whether they feel the current pricing is too high or if the certification process is too long? You’re not getting a more definite sense of what it is they’re coming to you for?

DRUMMOND: We’ve been kind of overwhelmed with a lot of this for the last three or four weeks, so we’re going back to interview some of them just to see what the actual problem is. I should know more in probably three or four weeks.

I expect that this is like normal testing where pricing is always an issue. Every test that anyone does, people think it’s too high because it’s one more cost to add in the end. The flipside is we find that once people understand what pricing gives them – it’s almost the last part of their software cycle – they see the cost is not nearly as high as they would anticipate, because it’s a cost of shifting from internal testing to external testing, and it also gives them a big marketing boon because someone is stamping their seal of approval on you, you’ve met these conditions. And that marketing boon is worth anything, you pay for that sort of thing.

In regards to establishing the EHR criteria and CCHIT certification (glad to see they like the separation of requirements making and requirements testing):

DRUMMOND: We think it’s very important to keep the stakeholder groups who define the requirement areas distinct from the testing parts, if at all possible. That doesn’t mean it can’t be the same organization, but it means you have to have some really clear boundaries. So CCHIT has both of those combined, and we always try to avoid having those two combined very closely.

Our focus would be very much on working with CCHIT, our working in parallel with them, but we all have to use exactly the same test criteria to make this whole thing work. So it has to be defined somehow so that happens. We need to focus on the technical aspects in making everything come together appropriately, so that when people go buy these products they can say, “Well, I’m one step into meaningful use. I have one key component in place. Now, I have to show how I use it to get the rest of it.”

Getting an EMR Job

Posted on November 12, 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.

It looks like Shahid gets a lot of the same emails I get. He recently posted some suggestions on how to break into the healthcare IT industry. Here’s some of his ideas:

  • If you’ve got experience running or working in a medical office or you’re an experienced project manager you can apply for an implementation specialist or assistant at almost any healthcare IT firm like an EMR or EHR vendor, consulting firm, or systems integrator. The thing to keep in mind is that every customer that buys an EMR needs to have it installed and deployed and that’s done by implementation folks. There is a shortage of people that can take complex products like EHRs and EMRs live.
  • If you have a little or a lot of general IT experience but no healthcare IT experience you can start by working in a technical support or training capacity. You would get the opportunity to learn new products and use your IT experience to provide customer service, support, and training talent.
  • If you’re interested in the software side you can think of being a tester of software; vendors need good quality assurance and configuration management personnel and that’s a great place to begin your healthcare IT career.
  • If you’re good at writing, consider joining the documentation team for creating training materials, videos, screencasts, or other related artifacts necessary to teach people how to use healthcare IT.
  • If you’re a developer interested in writing software but you’re not experienced in healthcare, join one of the many open source projects that are out there building open source EMRs, EHRs, PHRs, and related tools. Open source is a great way to join a community of people willing to help you if you’re willing to give back to them, too.
  • If you’re an integration specialist (you know EAI, EDI, EII, ETL, ESBs, or other integration techniques) start to learn HL7, CCR, and CCD and you can write your own ticket almost anywhere. The majority of healthcare problems in the IT arena are integration and deployment problems so if you know scripting and HL7 you’re good to go.

That’s a pretty good list for people searching for HIT jobs. I also like to point people to this list of EMR, EHR and HIT job websites. I’ve had really good reviews for that resource. I also liked Shahid’s suggestion of working on an open source EMR project in order to gain the experience in the healthcare field.

Issues with VA Vista EMR

Posted on November 10, 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.

So many people have propped up the VA’s EMR system (Vista) as the model for how EMR should be done.  This story about the GAO finding the EMR implementation over budget is really interesting.  Here’s just one short section about the budget that they have for the VA EMR:

VA officials cited resource availability and interdependencies among projects as key drivers of cost and schedule variances. The GAO has estimated that the program will overrun its current budget – worth approximately $1.897 billion – by $350.2 million.

WOW! That’s a lot of money. I would hope that if you’re spending close to $2 billion you’d have something good to show for it. Too bad it’s just not reasonable for most doctors offices to spend that kind of money.

Here’s another interesting quote from the article (emphasis added):

VistA-FM is designed to provide a framework as well as additional standardization and common services components. It’s also intended to eliminate redundancies in coding and support interoperability among applications. However, VA officials have told the GAO that VistA-FM is costly and difficult to maintain and doesn’t integrate well with newer software packages.

I’m sure the MUMPS fans will come out of the wood work and tell us how great it is. I’m sure it does some things very well. However, I agree with the quote from this article is that it doesn’t integrate well with newer software packages. This is a major problem if we’re talking about inter operable EMR software.

Vista is free for doctors offices. I think it’s the “difficult to maintain” issue that kills most people even with the free price tag. Of course, my focus is on ambulatory EMR. The hospital environment is a mess regardless of which EMR you choose.

Information on CCR, CCD and EMR

Posted on November 4, 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.

Dr. Jeff sent me the following summary of quotes he put together about CCR and CCD and how they relate to EMR. I don’t think he meant for it to be published, but the information was too good not to publish it. So, sorry that it’s missing references to where the quotes were made and is a little scattered. With that said, take the following quotes as information purposes and I’d be happy to update the source if someone knows where it’s from. I think Dr. Jeff is going to find some of the sources as well. Enjoy!

“The Continuity of Care Record (CCR) is a patient health summary standard.  It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one care giver to the next” – Wikipedia

XML(Extensible Markup Language) is an open standard for structuring information. – the standard data exchange interchange language used by the CCR

PDF and Office Open XML – other formats that the CCR uses

“Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application” – Brian Klepper

CDA(Clinical Document Architecture) stores or moves clinical documents between medical systems. Documents are things like discharge summaries, progress notes, history and physical reports, prior lab results, etc. The CDA uses XML for encoding of the documents and breaks down the document in generic, unnamed, and non-templated sections.

The CCR Standard was developed by a collaborative – the Massachusetts Medical Society (MMS), the HIMSS (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors – under the auspices of ASTM International, a not-for-profit organization that developes standards for many industries, including avionics, petroleum, and air and water quality” – Brian Klepper

“The CCR’s advance will allow patient health data to be easily transported from one platform to another, intact and with integrity, so that better decisions can positively impact care, health, and the costs of achieving them” – Brian Klepper

CCD(Continuity of Care Document) is the result of a collaborative effort between the Health Level Seven and ASTM organizations to “harmonize” the data format between ASTM’s Continuity of Care Record (CCR) and HL7’s Clinical Document Architecture (CDA) specifications. [CORRECTION: See these comments from David C. Kibbe, MD MBA]

HL7(Health Level Seven) is the registered trade mark of the HL7 consortium – an ANSI approved non-profit standards body set up to establish communications protocols for the health industry.

CCD is an attempt to meld  CCR with HL7 standards for data exchange” – jd

“There’s something of a religious war going on here.  BUT many of the more “open” vendors are using both CCR and CCD.  The more “closed” vendors seem to be waiting until CCD “wins” the war” – Matthew Holt

CCD and CCR are often seen as competing standards.  Google Health supports a subset of CCR, while Microsoft HealthVault claims to support a subset of both CCR and CCD” – Mehdi Akiki

IMHO, CCR and CCD are more complimentary than competitive” – Vince Kuraitis

CCD standard is likely to be used by organizations that already use HL7 (large delivery systems), to support existing business models, in non-disruptive applications that achieve cost savings and/or quality improvements by automating EXISTING processes that are INTERNAL TO THE ORGANIZATION (or with existing trading partners), e.g., hospitals sending test result information to doctors and where implementers have already incurred significant fixed costs to adapt HL7 as a broad enterprise standard” – Vince Kuraitis

CCR standard is likely to be used by organizations that have not yet adopted any standard (e.g., early stage companies), to support new business models, in disruptive applications that achieve cost savings and/or quality improvements by creating NEW PROCESSES, often involving parties that are not currently exchanging information, e.g., improving patient chronic care management with the goal of avoiding ER visits and hospitalizations and where the implementers are highly sensitive to incremental costs of IT resources and view the CCR as a “better, faster, cheaper” alternative” – Vince Kuraitis

“Most institutions and vendors that have large investments in HL7 are dealing with the “classic” HL7 versions, the 2.x standards” – Margalit Gur-Arie

“For many applications – especially ambulatory and small companies – the CCR is a complete solution.  Hospitals can also deploy CCR for specific applications.  However, hospitals will not view CCR as a complete data exchange solution for all applications.  Hospitals will need to adopt HL7.  The vast majority of hospitals today are on HL7 2.x.  While HL7 3.x is incompatible with 2.x, my assumption is that hospitals view “eventual” migration to 3.x as necessary, albeit dreaded because of the reasons you cite” – Vince Kuraitis

“Forcing vendors and institutions to adopt those standards (CDA and the RIM), if one can call them standards, will result in increased IT spending all over the board.  I don’t think this is something we need right now.  On the other hand, the CCR is almost “simple stupid” which is a compliment when it applies to a standard and could be implemented at very short notice.  I just think we have to start somewhere and CCR is just the easies and simplest way to start the process and achieve meaningful results” – Margalit Gur-Arie

LOINC , SNOMED , RxNORM – other data exchange standards

“The CCR authors recognize the need for our industry to “ease into” structure … the format does a great job of encouraging coding and normalization without creating an unrealistic bar – this is a tough tightrope to walk” – Sean Nolan

“Both formats (CCR and CCD) are important and help move the ball forward.  We come across situations every day where CCD is a better (or sometimes the only) option for some particular problem, so both HealthVault and Amalga are built to embrace them both.  Frankly this isn’t just a CCR/CCD issue – there are a zillion formats out there holding useful information, and the reality is we’re all just going to have to deal with that for some time to come.  The good news is that we do seem to have a little bit of bedrock in the form of XML and XSLT – these help a ton.  The key thing, I believe, is to stay focused on moving data so that it can be reused and shared – not getting dogmatic about how we move it.  Turns out that when we do that … the right things are happening, a little more quickly with every turn of the crank” – Sean Nolan

“Should there be evidence that any proposed approaches to interoperability will actually succeed in the real world before we declare such approaches as required?  Otherwise, who can determine what approaches to interoperability will prove acceptable to the majority of medical practices?” – Randal Oates, MD

CCR is simple and straightforward” – Margalit Gur-Arie

SureScripts is a certified network able to connect one EHR with another EHR.  Mainly used for connecting doctor’s offices to pharmacies.

“But consider that CVS MinuteClinic is already sending many thousands of CCR xml files from its EHR via SureScripts network, where they are either routed electronically to practices in thexml format (not many yet) or transformed into PDF and sent electronically or faxed.  There is no reason that existing national network operators (e.g. NaviMedix, Zix and Quest, just to name a few that easily come to mind) couldn’t do the same job.  It’s really simply an electronic post office.  There is growing real world experience.  It’s just not coming very often from incumbent health care organizations and vendors” – David C. Kibbe, MD MBA

“Consider this a model (SureScripts, Prescriptions, CVS MinuteClinic) for health network exchange of data like that which is in the CCR standard XML file format supported by Google Health, limited to demographics, insurance info, problem list/diagnoses, medications, allergy and alerts, vital signs, and lab results [I would add consultation reports, hospital discharge and operative reports and test results (ie.  stress test, cardiac catheterization].  Not a lot of data, but meaningful data much of the time.  Kept current and accurate by a person’s healthcare team (nurses, doctors and pharmacists) which includes the patient” – David Kibble, MD MPH

“My argument is that it is much more efficient, and in the long run much easier to implement, a system that pays for the data to be transmitted in CCR format among providers, and between care systems;  and to trust that the market will come up with innovative tools and technologies for helping doctors and patients do this; than it is for government, or anyone else, to pay for complicated “EHRs” that create new silos of data and which force physicians to click dozens or hundreds of times to document a “visit”, while not creating the data set that could be useful in so many ways outside the four walls of the practice to help managed care!  I don’t think this is as complicated as we’re made to think this is, and I know that the tools are available now to get it done.” – David C. Kibbe, MD MPH

“I do agree that the HITECH money would be better spent on facilitating simple data transfer, as opposed to complex data entry” – Margalit Gur-Arie

I have to agree with MD regarding the reality of office and hospital computer systems.  It seems there is a disconnect between the people talking abut all the wonderful things these systems do, and we physicians whose experience with the things in the real world is almost uniformly negative, to neutral at best.  Some of the people with big visions need to visit a hospital or large doctor’s office sometime and see how these things actually work (or don’t)” – Bev M.D.

This summary compiled by Jeffrey E. Epstein, MD