This week I was reading the monthly newsletter published by the Arizona Medical Association. This month's issue is devoted to health information technology projects being carried out in the state. I was particularly interested in the article written by Perry Yastrov concerning health information exchange in Arizona. Mr. Yastrov was the project director for Arizona Medical Information Exchange (AMIE), a proof of concept program to develop state-wide information exchange for the state Medicaid program. The project was funded by a federal Medicaid transformation grant. The three year effort came to an end late last year when funding ran out.
My understanding is that AMIE started from scratch. Policies and standards were agreed upon, procedures were developed, the technical infrastructure was built, a trust framework was adopted, and limited information exchange was piloted. Many stakeholders contributed to the effort. Several million patients were registered in the system. Now the participants don't have much to show for their work. The funding came from a federal grant program that did not include plans for sustainability. There have been numerous initiatives concerning health information exchange around the country that have met a similar fate. This leaves me wondering if we are spending our tax dollars wisely.
Earlier this year the Office of the National Coordinator for Health IT announced recipients of state grants to develop health information exchange (see State HIE grants.) Over $547 million in federal funding has been awarded to 56 entities to work on the same problem, state- or territory-wide health information exchange. To some extent, the awardees are expected to try to coordinate their efforts. The stated goal of this grants program is: "… building on existing efforts to advance regional and state-level health information exchange while moving toward nationwide interoperability." The outcome could be exactly the opposite.
One of the problems with health information exchange is that it does not scale well. A relatively simple approach can be taken to "pushing" data electronically from one provider to another. Tremendous complexity is required for fully enabled health information exchange that needs to occur seamlessly across various software platforms through jurisdictions that are governed by laws that often conflict. Just take a look at the particularly thorny issue of patient/consumer consent for an example of what I am talking about.
Since the days of the Constitutional Convention in the 1700's we have confronted the dilemma of how to balance federal influence and state's rights. That battle is still going on. I think the state HIE grants reflect the power and influence of state's rights advocates. Maybe this is a good way to distribute ARRA funds to stimulate the economic recovery. It may not be the best approach to stimulate the wide-spread development of interoperable HIEs needed for all stages of Meaningful Use. In my view, the federal government, as it spends money to promote health IT, should be taking a more aggressive role in harmonizing the various conflicting state laws and state initiatives to help us arrive at a place where health information exchange is facilitated, especially where information crosses jurisdictional boundaries. We should expand on best practices of the most successful HIEs, some of which have been working on the problem for over 20 years. Support infrastructure development and build out. We do not stand to gain much be reinventing the wheel 56 times. If we had had 50+ space programs, we would probably still be trying to land a person on the moon. Spend some of the money instead to discover truly sustainable solutions that can stand on their own without the continuous infusion of public funding and promote those to the state designated entities.
Friday, June 18, 2010
Wednesday, June 16, 2010
Messages vs. Documents
I have wanted to write about this topic for a while. Keep in mind that I am a clinician and not an engineer so what follows is my interpretation of how systems work.
The standards used to collect and manage the data most important to clinicians seem to come in two flavors, either messaging or documents. The newer standards and profiles that are being developed that deal with clinical workflow issues, clinical decision support, and reporting (quality and public health, for example) will not be the primary focus here. They are important to keep in mind however because of they will grow in significance over the next few years. The transition from Stage 1 through Stage 3 of Meaningful Use will drive future developments.
Documents have traditionally formed the bulk of the medical records clinicians keep on their patients. They provide a sense of permanence; they are not something to be used once and then discarded. Examples are history and physicals, discharge summaries, consultations, procedure reports, consents, and even laboratory reports. Documents, in the paper world, are so useful that their incorporation into electronic medical records should come as no surprise.
ASTM developed CCR, a sentinel standard for a clinical summary document. HL7, in an example of parallel innovation, developed CCD. Both are in common use today in EMRs. Superficially they seem very similar-section headers are similar and both are based on the XML programming language that offers the advantages of being both human readable and machine computable. At the core level though, they are different. CCR is strictly defined and modifications are therefore difficult. CCD, on the other hand is just one incidence of use of a standard developed by HL7, CDA or clinical document architecture. In simple terms, CDA is like an envelope and the letter it contains. On the outside there is certain routing information (like postage, address, and return address) and on the inside is the actual letter itself. There are potentially endless possibilities for CDA documents. HL7, IHE, and HITSP (when it still existed) have been leaders in development and amplification of this standard with implementation specifications/profiles. There are plans to develop a CDA template library/repository (see recent blog article by Keith Boone.) If vendors incorporate these templates into their systems, it will be a major step forward for interoperability. John Halamka recently wrote a blog article about how clinical summaries are used at his institution.
Vendors have voluntarily subjected their systems to interoperability testing at the annual IHE Connectathon, Many have then demonstrated their achievements at the HIMSS Interoperability Showcase that is featured at the HIMSS annual convention and trade show. One of the requirements for Stage 1 of Meaningful use is the ability of the EMR to create CCR or CCD documents. NIST (the National Institute for Standards and Technology) has developed tools that will be used to validate recognized CDA documents. These tools will be used by the yet to be determined certification agencies and testing labs during the required certification testing of EMRs.
Messaging standards are used for EMR tasks that tend to be more transient and process oriented. HL7 has developed complex standards for laboratory orders and lab results. X12 has developed standards to handle many of the administrative processes utilized in medical insurance related transactions such as eligibility checking, verification of insurance, claims processing, and prior authorization. There are a number of standards used to coordinate scheduling tasks.
I will reveal my bias and say that many of these purposes could be readily served by a document centric rather than a message-centered approach. For example, I would like to have a prior authorization document in my chart before I proceed with surgical care of a patient. Also, lab orders have traditionally been initiated by a document in the inpatient chart. Similarly, although lab results can be useful in message form, a lab result document is usually what clinicians use when they treat patients. HITSP recognized this dichotomy and worked last summer to harmonize standards for both lab result messages and lab result documents.
In the future, clinical decision support systems are likely to play an increasingly important role the EMR. Likewise, EMRs will be required to have the ability to collect and process data to provide a wide variety of quality reports and to forward data to public health entities. It would be idea if the clinical data to drive the necessary systems were collected at the point of care as a seamless function of providing care. Primarily, documents will be the source of the data that will facilitate this goal. The challenge will be to map the data elements so they can be easily accessed to be processed to complete the new tasks being developed.
The standards used to collect and manage the data most important to clinicians seem to come in two flavors, either messaging or documents. The newer standards and profiles that are being developed that deal with clinical workflow issues, clinical decision support, and reporting (quality and public health, for example) will not be the primary focus here. They are important to keep in mind however because of they will grow in significance over the next few years. The transition from Stage 1 through Stage 3 of Meaningful Use will drive future developments.
Documents have traditionally formed the bulk of the medical records clinicians keep on their patients. They provide a sense of permanence; they are not something to be used once and then discarded. Examples are history and physicals, discharge summaries, consultations, procedure reports, consents, and even laboratory reports. Documents, in the paper world, are so useful that their incorporation into electronic medical records should come as no surprise.
ASTM developed CCR, a sentinel standard for a clinical summary document. HL7, in an example of parallel innovation, developed CCD. Both are in common use today in EMRs. Superficially they seem very similar-section headers are similar and both are based on the XML programming language that offers the advantages of being both human readable and machine computable. At the core level though, they are different. CCR is strictly defined and modifications are therefore difficult. CCD, on the other hand is just one incidence of use of a standard developed by HL7, CDA or clinical document architecture. In simple terms, CDA is like an envelope and the letter it contains. On the outside there is certain routing information (like postage, address, and return address) and on the inside is the actual letter itself. There are potentially endless possibilities for CDA documents. HL7, IHE, and HITSP (when it still existed) have been leaders in development and amplification of this standard with implementation specifications/profiles. There are plans to develop a CDA template library/repository (see recent blog article by Keith Boone.) If vendors incorporate these templates into their systems, it will be a major step forward for interoperability. John Halamka recently wrote a blog article about how clinical summaries are used at his institution.
Vendors have voluntarily subjected their systems to interoperability testing at the annual IHE Connectathon, Many have then demonstrated their achievements at the HIMSS Interoperability Showcase that is featured at the HIMSS annual convention and trade show. One of the requirements for Stage 1 of Meaningful use is the ability of the EMR to create CCR or CCD documents. NIST (the National Institute for Standards and Technology) has developed tools that will be used to validate recognized CDA documents. These tools will be used by the yet to be determined certification agencies and testing labs during the required certification testing of EMRs.
Messaging standards are used for EMR tasks that tend to be more transient and process oriented. HL7 has developed complex standards for laboratory orders and lab results. X12 has developed standards to handle many of the administrative processes utilized in medical insurance related transactions such as eligibility checking, verification of insurance, claims processing, and prior authorization. There are a number of standards used to coordinate scheduling tasks.
I will reveal my bias and say that many of these purposes could be readily served by a document centric rather than a message-centered approach. For example, I would like to have a prior authorization document in my chart before I proceed with surgical care of a patient. Also, lab orders have traditionally been initiated by a document in the inpatient chart. Similarly, although lab results can be useful in message form, a lab result document is usually what clinicians use when they treat patients. HITSP recognized this dichotomy and worked last summer to harmonize standards for both lab result messages and lab result documents.
In the future, clinical decision support systems are likely to play an increasingly important role the EMR. Likewise, EMRs will be required to have the ability to collect and process data to provide a wide variety of quality reports and to forward data to public health entities. It would be idea if the clinical data to drive the necessary systems were collected at the point of care as a seamless function of providing care. Primarily, documents will be the source of the data that will facilitate this goal. The challenge will be to map the data elements so they can be easily accessed to be processed to complete the new tasks being developed.
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