Welcome to EMR and EHR

Anyone that works in Healthcare IT knows who John Halamka is and so of course I was interested in his post of his top 10 impressions after HIMSS. It’s an interesting list and I think he does a pretty good job of looking at things from a very high level. Here they are as posted on his blog:

1. Meaningful Use is everywhere. Vendors are promising EHRs, modules, appliances, and services to help clinicians achieve it. I had dinner on Monday night in a small Indian vegetarian restaurant. Sitting next to me were 3 engineers from Bangalore who were arguing about the details of Meaningful Use in between bites of vegetable curry. I could not escape Meaningful Use anywhere!

2. Certification is everywhere. It’s particularly ironic that many vendors claimed their systems were certified, even though the certification NPRM was just released today, making compliance with the new certification process in time for HIMSS impossible.

3. Cloud computing, Software as a Service and ASP models are popular tactics to accelerate EHR rollouts. There are still lingering concerns about how to ensure privacy in a cloud environment.

4. Several firms such as Intersystems, Axolotol, and Medicity are offering HIE platforms that include many of the standards noted in the IFR. The marketplace for HIE products is just emerging and it’s hard to predict who will become the market leader.

5. The Continuity of Care Document is gaining traction. I found many vendors supporting CCD exports from their EHRs. A company called M*Modal , has developed natural language processing technology that captures dictated content in its original context (ontology-driven
rules) as a CDA document.

6. Consultants abound. It’s clear that Regional Extension Centers and Health Information Exchanges will require expertise and staffing from professional firms. They all had large booths at HIMSS.

7. 30,000 people attended, including 10,000 I did not recognize (just kidding). It’s clear to me that many IT professionals, even those with limited healthcare domain expertise, attended HIMSS to better understand how they could participate in the euphoria of HITECH stimulus dollars.

8. Self service kiosks for patient identification and self-registration are now mainstream. Just as we print our airline boarding passes, we can now use credit cards or biometrics to check into ambulatory care appointments and automatically settle all co-pay balances.

9. Image exchange in the cloud is being offered by several vendors. As I mentioned in Monday’s blog, Symantec announced an appliance for small clinician offices that cloud enables all imaging modalities using a facebook-like social networking invitation to share/view images.

10. PHRs and patient engagement are becoming more mainstream. Google and Microsoft continue to innovate in the non-tethered PHR marketplace.

I’ve been really interested in the various standards of interoperability in healthcare. I previously posted a bunch of random items related to CCR and CCD in healthcare. I remember when CCR first came out. It was a very exciting movement to try and make EMR software interoperable.

So, today I was really interested to read Chilmark essentially declaring CCD the winner in the EMR interoperability battle. Officially he says that CCD is gaining traction and CCR is fading, but if you read his post you’ll see that in his opinion (which I trust a lot) CCD will be the winner in the battle between CCR and CCD.

The cool part is that I don’t think those that helped develop CCR will mind at all. Partially because CCD is a derivative of CCR and CDA. Plus, from what I understand, the people behind CCR were mostly interested in facilitating the flow of healthcare information between EMR software. If that is achieved by CCD, then the goal was achieved.

I’ll be interested to hear what the chatter will be around CCD and CCR at HIMSS to see if Chilmark’s feelings are shared by others.

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.

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

We keep hearing about the Big National Data Bank for Healthcare Information. The thought is that you need a big data bank so everyone’s health information is available anywhere/anytime. This type of personal health information repository has many problems. First it is complex and expensive to set up and maintain. Second there are very significant and well-founded privacy concerns. And finally, this large, complex electronic structure may not be needed … it might even be counterproductive!

Is there another way to transport patient health data from one platform to another (so it can go from one EMR to another), so that healthcare providers, anywhere/anytime can provide fully informed care for individual patients which would be less expensive and higher in quality?

I think the answer is YES!

There are standard data exchange platforms currently being used which can help us all share “meaningful” personal health information. They are called the Continuity of Care Record (CCR), CCD and HL7. For more information on these platforms, I suggest you read Brian Klepper’s blog post. This blog gave me great insight into this connectivity issue.

In addition to obviating the need for a big data bank, these data exchange platforms make it possible for small, innovative EMR companies to compete and survive in the “EMR Jungle”. By allowing for diversity and encouraging innovation, we will end up with better EMR software. In addition, physicians will be able to pick EMRs that suit their practice style and can make them more efficient, productive and better doctors. I think we need a patchwork quilt of unique EMRs that are all well connected rather than a few big standard lemming EMRs that are totally connected by “big brother” or “big business”.

What are your thoughts on this topic?