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New ONC Scorecard Tool Grades C-CDA Documents

Posted on August 2, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The ONC has released a new scorecard tool which helps providers and developers find and resolve interoperability problems with C-CDA documents. According to HealthDataManagement, C-CDA docs that score well are coded with appropriate structure and semantics under HL7, and so have a better chance of being parseable by different systems.

The scorecard tool, which can be found here, actually offers two different types of scores for C-CDA documents, which must be uploaded to the site to be analyzed. One score diagnoses whether the document meets the requirements of the 2015 Edition Health IT Certification for Transitions of Care, granting a pass/fail grade. The other score, which is awarded as a letter grade ranging from A+ to D, is based on a set of enhanced interoperability rules developed by HL7.

The C-CDA scorecard takes advantage of the work done to develop SMART (Substitutable Medical Apps Resusable Technologies). SMART leverages FHIR, which is intended to make it simpler for app developers to access data and for EMR vendors to develop an API for this purpose. The scorecard, which leverages open-source technology, focuses on C-CDA 2.1 documents.

The SMART C-CDA scorecard was designed to promote best practices in C-CDA implementation by helping creators figure out how well and how often they follow best practices. The idea is also to highlight improvements that can be made right away (a welcome approach in a world where improvement can be elusive and even hard to define).

As SMART backers note, existing C-CDA validation tools like the Transport Testing Tool provided by NIST and Mode-Driven Health Tools, offer a comprehensive analysis of syntactic conformance to C-CDA specs, but don’t promote higher-level best practices. The new scorecard is intended to close this gap.

In case developers and providers have HIPAA concerns, the ONC makes a point of letting users know that the scorecard tool doesn’t retain submitted C-CDA files, and actually deletes them from the server after the files have been processed. That being said, ONC leaders still suggest that submitters not include any PHI or personally-identifiable information in the scorecards they have analyzed.

Checking up on C-CDA validity is becoming increasingly important, as this format is being used far more often than one might expect. For example, according to a story appearing last year in Modern Healthcare:

  • Epic customers shared 10.2 million C-CDA documents in March 2015, including 1.3 million outside the Epic ecosystem (non-Epic EMRs, HIEs and the health systems for the Defense and Veterans Affairs Departments)
  • Cerner customers sent 7.3 million C-CDA docs that month, more than half of which were consumed by non-Cerner systems.
  • Athenahealth customers sent about 117,000 C-CDA documents directly to other doctors during the first quarter of 2015.

Critics note that it’s still not clear how useful C-CDA information is to care, nor how often these documents are shared relative to the absolute number of patient visits. Still, even if the jury is still out on their benefits, it certainly makes sense to get C-CDA docs right if they’re going to be transmitted this often.

Annual Evaluation of Health IT: Are We Stuck in a Holding Pattern? (Part 2 of 3)

Posted on April 14, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous installment of this article was devoted to the various controversies whirling around Meaningful Use. But there are lots of other areas of technology and regulation affecting the progress (or stasis) of health IT.

FHIR: Great Promise, But So Far Just a Promise

After a decade or so of trying to make incompatible formats based on obsolete technology serve modern needs such as seamless data exchange, the health IT industry made a sudden turn to a standard invented by a few entrepreneurial developers. With FHIR they pulled on a thread that will unravel the whole garment of current practices and standards, while forming the basis for a beautiful new tapestry. FHIR will support modern data exchange (through a RESTful API), modern security, modern health practices such as using patient-generated data, and common standards that can be extended in a structured manner by different disciplines and communities.

When it’s done, that is. FHIR is still at version 0.82. Any version number less than 1, in the computer field, signals that all sorts of unanticipated changes may still be made and that anyone coding around the standard risks having to rip out their work and starting over. Furthermore, FHIR is a garment deliberately designed with big holes to be filled by others:

  • Many fields are defined precisely, but elements of the contents are left open, such as the units in which medicine is measured. This is obviously a pretty important detail to tie down.

  • Security relies on standards in the OpenID/OAuth area, which are dependable and well known by developers through their popularity on the Web. Still, somebody has to build this security in to health IT products.

  • Because countries and medical disciplines vary so greatly, the final word on FHIR data is left to “profiles” to be worked out by those communities.

One health data expert I talked to expressed the hope that market forces would compel the vendors to cooperate and make sure these various patches are interoperable as they are pieced into the garment. I would rather design a standard with firm support for these things.

Some of the missing pieces can be supplied relatively painlessly through SMART, an open API that predates FHIR but has been ported to it. An impressive set of major vendors and provider organizations have formed the Argonaut project to carry out some tasks with quick pay-offs, like making security work and implementing some high-value profiles. Let’s hope that FHIR and its accompanying projects start to have an impact soon.

The ONC has repeatedly expressed enthusiasm for FHIR, and CMS has alerted vendors that they need to start working on implementations. Interestingly, the Meaningful Use Stage 3 recommendation from CMS announces the opinion that health care providers shouldn’t charge their patients for access to their data through an API. An end to this scandalous exploitation of patients by both vendors and health care providers might have an impact on providers’ income.

Accountable Care Organizations: Walls Still Up

CMS created ACOs as a regulatory package delivering the gifts of coordinated care and pay-for-value. This was risky. ACOs require data exchange to effect smooth transfers of care, but data exchange was a rare occurrence as late as 2013, and the technical conditions have not changed since then so I can’t imagine it’s much better.

Pay-for-value also calls for analytics so providers can stratify populations and make rational choices. Finally, the degree of risk that CMS has asked ACOs to take on is pretty low, so they are not being pushed too hard to make the necessary culture changes to benefit from pay-for-value.

All that said, ACOs aren’t doing too badly. New ones are coming on board, albeit slowly, and cost savings have been demonstrated. An article titled “Poor interoperability, exchange hinders ACOs” actually reports much more positive results than the title suggests. There may be good grounds for ONC’s pronouncement that they will push more providers to form ACOs.

Still, ACOs are making a slow tack toward interoperability and coordinated care. The walls between health care settings are gradually lowering, but providers still huddle behind the larger walls of incompatible software that has trouble handling analytics.

I’ll wrap up this look at progress and its adversaries in the next installment of this article.

Communities Help Open Source Electronic Health Records Thrive (Part 3 of 3: Project Round-up)

Posted on December 16, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

This series examines the importance of community and what steps are being taken by open source projects in health IT to create communities around their projects. My previous posting covered VistA and its custodial organization, OSEHRA. The last article in this series covers some important projects in open source with very different approaches to building community.

In addition to VistA, the electronic health record with the most success in building community is OpenMRS, using a unique approach. The project has an unusual genesis. They didn’t come out of a technology center such as Silicon Valley, or a center of health research such as my own Boston. Instead, they were inspired by the Regenstrief Institute at Indiana University.

Getting only a small amount of attention in the United States, OpenMRS proved quite valuable in the developing regions of Africa, especially Rwanda. The U.S. developers realized right away that, for their software to be useful in cultures so far from Indiana, it would have to be understood and fully embraced by local experts.

Indeed, a number of accomplished software developers can be found in Rwanda and surrounding countries. The challenge to OpenMRS was to attract them to the goal of improving health care and to make work on OpenMRS easy.

OpenMRS not only trained developers in African countries to understand and adapt their software to local conditions, but mentored them into becoming trainers for other developers. The initial project to train Rwandan developers thus evolved, the local developers becoming competent to train others in neighboring countries.

In this way, the OpenMRS developers back in the U.S. opened up the project in a unique way to people on other continents. To be sure, the developers had a practical end: they knew they could not provide support to every site that wanted to install OpenMRS, or adapt it to local needs. But they ultimately created a new, intensely committed, international community around OpenMRS. Regular conferences bring together OpenMRS developers from far-flung regions.

The SMART platform is not an EHR itself, but an application programming interface (API) that its developers are asking EHR vendors to adopt. The pay-off for adoption will be that all compliant EHRs can interoperate, and a software developer can write a single app that runs on all of them. SMART was developed at Harvard Medical School with support from ONC. It now runs on top of FHIR, an HL7 project to provide a modern API giving access to all EHR data.

EHRs are not by any means the only community-building efforts in open source health IT. Another significant player is Open Health Tools, which came into being in recognition of the creative work being done by research firms, university professors, and others in various health IT areas.

OHT brings together a wide range of developers to build software for research, clinical work, and other health-related projects. It’s remarkably diverse, providing a meeting place for all projects interested in making health care technology work better. Although they have had problems finding financial support, they now solicit dues from interested projects and seem poised to grow.

For a while, OHT had grand visions of recruiting their members to contribute to a unified “framework” on which other software developers could build applications. This proved to be a bit too big a bite to chew, given the wide range of activities that go on in health IT. But OHT still encourages members to find common ground and make use of each other’s advances.

Aaron Seib, CEO of Open Health Tools, listed the main goals OHT has for its member developers: making communities discoverable, making their licensing intelligible, and addressing the intellectual property barriers that can constrain a project’s adoption. OHT also helps establish trust and connect the dots among the community members to multiply effects across member communities. Roger Maduro of Open Health News writes that OHT has played a critical role in building the open health ecosystem, including the VistA community.

Many other institutions also sense a need for community. A few years ago I spoke with John Speakman, who was working for the National Cancer Institute at the time. They had developed some software that was very popular among developers, but no one made any contributions back to the common software base, and the NCI wanted the users of the software to start taking responsibility for the tools on which they depended. He took on the task of building community, but left when he realized it was not going to take hold.

Among the problems was the well-known dependence of government agencies such as the NCI on contractors. Speakman points to an organizational and cultural gap between “the big Beltway Bandit companies (who will never use the code themselves to do biomedical science) over academic groups engaged in biomedicine.” He also thinks the NCI intervened too much in community activities, instead of letting community members work out disagreements on their own. “If the government is going to invest in the seeding of open source communities,” he says, “it has to (a) focus on releasing the data and see what folks do with it, and (b) use as light a hold as possible on how the communities run themselves.”

Athenahealth stands out among EHR vendors with its More Disruption Please program. There it is building an ecoystem of third-party tools that its customers can use as part of its cloud-based service. This goal is similar to that of the open source SMART platform, which is trying to get EHR vendors and other data stores to adopt a common API and thus make themselves more open to software developers.

Openness and community go together. Although the health IT field is slow to adopt both practices, some projects could be entering into a virtuous cycle where open source developers learn to appreciate the value of their communities, which in turn reward the most open projects with greater success.

Open Standards Advance in Health Care Through the Appeal of FHIR and SMART

Posted on October 13, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The poor state of interoperability between EHRs–target of fulminations and curses from health care activists over the years–is starting to grind its way forward. Dr. Kenneth Mandl, a leader of the SMART Platform and professor at the Boston Children’s Hospital Informatics Program, found that out when his team, including lead architect Josh Mandel, went to HIMSS this year to support Cerner’s implementation of his standard, and discovered three other vendors running it.

That’s the beauty of open source and standards. Put them out there and anyone can use them without a by-your-leave. Standards can diffuse in ways the original developers never anticipated.

A bit of background. The SMART platform, which I covered a few years ago, was developed by Mandl’s team at Harvard Medical School and Children’s Hospital to solve the festering problem of inaccessibility in EHRs and other health care software. SMART fulfilled the long-time vision of open source advocates to provide a common platform for every vendor that chose to support it, and that would allow third-party developers to create useful applications.

Without a standard, third-party developers were in limbo. They had to write special code to support each EHR they want to run on. Worse still, they may have to ask the EHR vendor for permission to connect. This has been stunting the market for apps expanding the use of patient data by clinicians as well as the patients themselves.

SMART’s prospects have been energized by the creation of a modern interoperability resource called FHIR. It breaks with the traditional health care standards by being lean, extendible in controllable ways, and in tune with modern development standards such as REST and JSON.

It helps that SMART was supported by funds from the ONC, and that FHIR was adopted by the leading health care standards group, HL7. HL7’s backing of FHIR in particular lent these standards authority among the vendor and health care provider community. Now the chocolate and peanut butter favored by health IT advocates have come together in the SMART on FHIR project, which I wrote about earlier this year.

Mandl explains that SMART allows innovators to get access to the point of care. As more organizations and products adopt the SMART on FHIR, API, a SMART app written once will run anywhere.

Vendors have been coming to FHIR meetings and expressing approval in the abstract for these standards. But it was still a pleasant surprise for Mandl to hear of SMART implementations demo’d at HIMSS by Intermountain, Hewlett-Packard, and Harris as well as Cerner.

The SMART project has just released guidlines for health care providers who want to issue RFPs soliciting vendors for SMART implementations. This will help ensure that providers get what they ask and pay for: an API that reliably runs any app written for SMART.

It’s wise to be cautious and very specific when soliciting products based on standards. The notion of “openness” is often misunderstood and taken to places it wasn’t meant to go. In health care, one major vendor can trumpet its “openness” while picking and choosing which vendors to allow use of its API, and charging money for every document transferred.

The slipperiness of the “open” concept is not limited to health IT. For years, Microsoft promulgated an “open source” initiative while keeping to the old proprietary practices of exerting patent rights and restricting who had access to code. Currently they have made great progress and are a major contributor to Linux and other projects, including tools used with their HealthVault PHR.

Google, too, although a major supporter of open source projects, plays games with its Android platform. The code is nominally under an open license–and is being exploited by numerous embedded systems developers that way–but is developed in anything but an open manner at Google, and is hedged by so many requirements that it’s hard to release a product with the Android moniker unless one partners closely with Google.

After talking to Mandl, I had a phone interview with Stan Huff, Chief Informatics Officer for Intermountain. Huff is an expert in interoperability and active in HL7. About a year ago he led an effort at Intermountain to improve interoperability. The motivation was not some ethereal vision of openness but the realization that Intermountain couldn’t do everything it needed to be competitive on its own–it would have to seek out the contributions of outsiders.

When Intermountain partnered with Cerner, senior management had by that time received a good education in the value of a standard API. Cerner was also committed to it, luckily, and the two companies collaborated on FHIR and SMART. Cerner’s task was to wrap their services in a FHIR-compliant API and to make sure to use standard technology, such as in codes for lab data.

Intermountain also participated in launching a not-for-profit corporation, the Healthcare Services Platform Consortium, that promotes SMART-on-FHIR and other standards. A lot of vendors have joined up, and Huff encourages other vendors to give up their fears that standardization is a catheter siphoning away business and to try the consortium out.

Intermountain currently is offering several applications that run in web browsers (and therefore should be widely usable on different platforms). Although currently in the prototype stage, the applications should be available later this year. Besides an application developed by Intermountain to monitor hemolytic disease among neonates and suggest paths for doctors to take, they support several demonstration apps produced by the SMART project, including a growth chart app, a blood pressure management app, and a cardiovascular app.

Huff reports that apps are easy to build on SMART. In at least one case, it took just two weeks for the coding.

Attendees at HIMSS were very excited about Intermountain’s support for SMART. The health care providers want more flexible and innovative software with good user interfaces, and see SMART providing that. Many vendors look to replicate what Intermountain has done (although some hold back). Understanding that progress is possible can empower doctors and advocates to call for more.

Do We Really Like the JASON Recommendations for Interoperable Health Data?

Posted on August 28, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The health IT community has been abuzz over the past few months about a report released by the Agency for Healthcare Research and Quality. Although the report mostly confirmed thoughts that reformers in the health IT space have been discussing for some time, seeing it aired in an official government capacity was galvanizing. The Office of the National Coordinator has held several forums about the report, known by the acronym JASON, and seems favorably inclined toward its recommendations.

Even though only four months have passed since its publication, we can already get some inkling of how it will fare at the ONC, which is going through major realignment of its own. And to tell the truth, I don’t see much happening with the JASON recommendations. In this article I’ll look at what I see to be its specific goals, and what I’ve heard regarding their implementation:
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