The following is part of an email interaction I had with an EHR vendor about the future of CCD. Of course, I can never let strong opinions go unpublished. So I asked if I could put this on my site. I have a feeling there will be many people who have a different view of CCD and how these standards will play out. I’d certainly be happy to publish an opposing view as well. My contact page is here. I’m interested to hear other view points on the subject.

Stage 1 MU allowed either CCR or CCD. Stage 2, and the short term efforts will require CCD. The jury is still out on what Stage 3 of MU will focus upon. Many at the ONC can see that the CCD will never have the flexibility to deliver. These are largely the same people that facilitated the Direct Project initiatives.

I still predict that it is inevitable that the data will become uncoupled from unwieldy, anachronistic document structures. That will be the only means to get to true information portability that can deliver patient-centric use of the information. The CCD will still be around for a while to come, just as CD’s are still around for music sharing. For now, we have to have the CCD to preserve legacy, industry-centric control of the information.

John Halamka has a couple of recent posts that do a good job of explaining what is evolving…. http://geekdoctor.blogspot.com/2011/09/september-hit-standards-committee.html and http://geekdoctor.blogspot.com/2011/10/cool-technology-of-week.html . Both of these contain links to some very interesting information. When the ONC proceeded to issue an advanced notice of rulemaking, the industry power elites became enraged. http://www.ihealthbeat.org/articles/2011/9/22/groups-urge-onc-not-to-include-metadata-standards-in-stage-2.aspx

Technology delivering to patients will eventually win out just as the open-platform WWW won out over proprietary CompuServe. http://www.healthdatamanagement.com/news/onc-metadata-ehr-meaningful-use-43021-1.html Once we have a means to truly exchange the content without the overhead associated with the CCD/RIM crap, we will see a revolution in healthcare similar to the social networking phenomenon.

Again, the whole CCD/CDA will stick around to support legacy information needs, but it will eventually be largely eclipsed by more straight-forward solutions that don’t require a team of consultants and IT engineers to implement.

In one of my many discussions with people at HIMSS 10 we started talking about EHR interoperability standards. The person I was talking to worked as an engineer for a vendor that’s entire work is interoperability of EHR data. As we talked, I made the comment that it seems like CCD has won the battle for EMR interoperability. He gave me a kind of blank stare and said, yeah. Basically his response was like yeah everyone knows that. Almost as if there weren’t any other real EMR interoperability options out there. Well, I guess someone better let Google Health know too.

As I went through the HIMSS showroom floor, I got the same feeling.

The good thing is that I think the people behind CCR are satisfied with this result since CCD is a derivative of sorts from CCR.

In response to my previous post about CCR and CCD, I’ve learned a whole bunch about the two different standards for healthcare data exchange. Although, I must admit that it’s all a bit messy right now.

Since I know that many of you don’t read all the comments on the site, nor do you get to read the emails I receive, I think you’ll find some of the following links about CCR and CCD quite interesting.

First is a description of the difference between CCR and CCD. This is written by David Kibbe who helped create the CCR specifications. So, keep that in perspective, but it’s a really interesting write up comparing the two standards.

Dr. Jeff also put together this interesting “summary” of CCR and CCD. It’s a little scattered, but has some good nuggets in it that expanded my knowledge of the various standards.

The other good thing that came out of my previous post is an interview with Dr. David Kibbe which I’ll be posting next week. He ducks some of the politically charged questions, but I think you’ll really enjoy the interview. If you don’t, I’m sure you’ll be willing to let me know that too.

I’ve been a fan of the concept of CCR since it first started many years ago. However, I’ll be honest that I haven’t followed the progression of CCR much since then.

I know that Google Health was using a modified version of CCR. I also know a number of EMR vendors that have integrated CCR with their EMR. So, I’m looking to my readers to give me an update on what’s been happening with CCR.

Also, I’ve been hearing some people refer to it as CCD instead of CCR. I think that CCD stands for continuity of care document. I assume it’s basically the document that CCR uses to share healthcare information?

At one of the conferences I attended, they suggested that CCR was the standard that was going to be used to show “meaningful use.” I haven’t ever seen the standard formalized. Did I miss this somewhere?

Ok, here’s looking to you. Leave some comments on what you know about CCR.

One of the key facets of any EHR investment by the government will look at ways to award money for usage of an EHR. The hard question they’ll try to answer is how do you define an EHR that’s implemented.

This discussion is not new. Every study you can find on EHR implementation has struggled with the idea of defining when an EHR is actually implemented. I think that most surveys I’ve seen usually allow the user to define whether they’re EHR is fully implemented or partially implemented. The problem with this is that each person is likely to define a fully implemented EHR in different ways.

If a researcher has a problem defining an implemented EHR can you imagine how much fun the government will have defining this same thing. Not to mention when you start to attach money to the definition it gets really hairy.

Let me propose a simple definition of a fully implemented EHR using 2 main factors.

1. Paper Charts are no longer created or passed around the office.
2. Patient data can be transferred amongst EHR using a standard such as CCR.

The first factor is easy to measure. Take a look at the paper charts and see how many were created during the past year. Also, look at how a practice handles a patient who already has a paper chart. As long as a practice is relying on a paper chart, they are not full EHR. I should clarify that paper charts can exist in the practice, but they just should only be used for sending out records for past patients.

The second factor is easy to measure, but I’m just a little afraid that the CCR standard is just not quite fully defined. I hope that having Google Health and Microsoft HealthVault will help to establish this standard in an effective way across the industry. Some sort of medium for sharing important information is needed. Even if it’s simply allergies and medications for now would be fine with me. It can always be expanded later.

Should be simple enough. The problem is that it’s probably too simple for government work.

Today I came across the HHS Secretary Mike Leavitt’s blog. To be honest, I saw Mike Leavitt’s picture on the blog and I felt like I was meeting an old friend. No, I don’t really know Mike Leavitt from the next person on the street. We have never met before and the closest I’ve been to him is probably when I watched him pass by in numerous 24th of July parades in Utah. However, he was the governor of Utah for many of the years I lived in Utah and so I feel like I kind of know the man.

Reminiscing aside, I find Mike Leavitt’s blog completely captivating. He currently has been writing about his trip to China. For some reason I’ve always had an inner itch whenever I heard about China. I don’t know what it is, but I find the place completely fascinating. So, you can imagine my fascination with the HHS secretary’s interaction with the Chinese government. Plus, these posts about HHS and China give Mike a real personal quality that I find real and interesting.

Of course, I couldn’t begin to read the HHS Secretary’s blog without making sure to find some post about EHR or EMR. I quickly found a post entitled Value-Driven Health Care Interoperability which I think could more aptly be entitled “Electronic Health Records (EHR) Progress Report.” Of course, he is in government so that explains the title.

I’m grateful that the HHS Secretary is willing to engage the public in a discussion about EHR and EHR adoption, but unfortunately the post I found is so filled with political rhetoric. It sounds really good, but really has very little substance.

First, I’ll start with the good.

Three years ago, there were 200 vendors selling electronic health record systems but there was no assurance that the systems would ever be able to share privacy protected data in interoperable formats.

I think the concept of a certification for interoperability is good. It just makes sense that every EMR software vendor should be able to interact with another. Establishing a quality standard for this interoperability is valuable and even worth certifying.

Unfortunately, I think the HHS Secretary has been getting bad information when he says the following:

Since then, we have made remarkable progress.

An EHR standards process is now in place, and we are marching steadily towards interoperability. We created the CCHIT process to certify products using the national standards and it is functioning well. More than 75% of the products being sold today carry the certification.

Where to begin? First, Mike has suggested that there were 200 vendors selling EHR systems 3 years ago (It’s probably a few more than 200 EHR, but we’ll let this one slide). Mike asserts that “75% of the products being sold today carry the certification.” If that’s the case, then simple math tells us that there should be 150 certified EHR software, no?

If you look at the 2006 CCHIT Certified Ambulatory EHR list I count 92 EHR software products. Let’s see, that’s only 46% of EHR products that are certified. Plus, my count of 92 EHR counts some of the software multiple times since a number of the EHR software vendors certified multiple versions of their product. That sounds like less than 75% of EHR products sold to me.

Of course, Mike Leavitt certainly could say that 75% represents a percentage of actual products sold. Certainly the certified eMD’s has a lot more installs than any of the free open source EMR products out there. However, I think it’s a bit deceptive to say 200 EHR and then 75% of products sold if they aren’t the same thing.

I also love how it says 75% of products sold. I think we’re all aware of the outrageous failure rates of so many of the EHR products out there. It’s unfortunate that we don’t have a percentage of products installed. Then, you’d have a much better idea of how many doctor’s offices really have the possibility of interoperability.

Wait a minute! I was being extra generous above when I said that there were 92 Ambulatory EHR CCHIT certified. Why? Because it was 92 EHR certified with the 2006 CCHIT Certification. Correct me if I’m wrong, but I think that interoperability was taken out of the 2006 CCHIT Certification (along with the joke of the pediatric requirements). I’m pretty confident about this, because I work on one of the 2006 CCHIT Certified EHR and I have no way of sending a chart to another clinic other than manually going through the product and printing out the chart.

What does all this mean? That means that instead of 92 interoperable CCHIT certified EHR, there are only 31 EHR CCHIT certified in 2007. That represents 15.5% (not 75%) of the 200 EHR products on the market today are interoperable according to number of certified EHR.

I’m not really blaming Mike Leavitt for this. I’m sure him or his office was given a nice executive report with a bunch of data and they made it look as nice as possible. Reminds me a lot of what I call EMR sales miscommunications. Sometimes the data just gets lost in translation. Let’s just hope my trackback to Mike Leavitt’s blog gets read.

You thought I was done. Nope. Still plenty more to say and I’m just hitting the major points.

In addition, a National Health Information Network will start testing data exchange by the end of the year and go into production with real data transmission the year after.

This concept I really find intriguing. I look forward to seeing this go public and I’m glad it’s on the agenda. However, I fear that this isn’t more than political hyperbole. I’d love to see how they plan to address any of the following: unique identifier, the ultimate hacker’s health information paradise, economic model, motivational model and that’s just the list off the top of my head.

The primary reasons for low adoption rates among small practices are predictable: economics and the burden of change.

I’m glad you pointed out the obvious. If this was so obvious, then why did you support the implementation of a certification that costs so much money that EHR will inevitably raise the cost a small practice pays for an EHR? That doesn’t make much economic sense. Not to mention you missed what I think is the biggest factor in lack of implementation: fear. Not fear of change. Not fear of the expense. Certainly those are two major factors, but I believe that adoption rates by small practices are so low because most doctors have seen too many of their colleagues fail at implementing an EHR.

Let’s start waving the CCHIT certification flag again. Many will be willing to make the case that CCHIT certification helps supplant a doctor’s fear that their EHR implementation will fail. It may even supplant some fear, but what it doesn’t do is decrease the number of failed EHR implementations. It’s a problem I’ve discussed many times on this blog. Certifications don’t certify usability. They never have and never will.

I actually have a thought about what should have been done instead of CCHIT, but I think I’ll save that for a future post.

Thanks Mike for opening up the lines of communication with your blog. Now it will be interesting to see if Mike Leavitt and HHS have really embraced new social media and participate in the discussion they started. I’m certain that Mike’s blog is going to become one of my favorite reads.

I’ve been following the Google Health announcements for quite a while now and today Google Health finally went live.

It’s been a long time coming and so it will be interesting to finally take a look under the hood. I haven’t personally had enough time to do a full analysis of Google Health myself, but techcrunch posted the announcement live and an initial review.

I think that techcrunch summed up a major part of Google Health and its meaning for EHR software in the following:

Google is planning to open up APIs to Google health to make it easy for other partners to tap into its health platform. And make no mistake about it. That is what this is: a platform. Health apps anyone?

Sure does make for some interesting thinking about how an EMR or EHR could integrate with Google Health. Depending on how my next couple days go, I may see if Google Health has given any sort of specifications for importing a patient record into Google Health from an EMR or EHR software program. In my previous posts it was said to use some form of CCR to integrate Google Health with EMR and EHR software. I hope this is the case. If it is, I think I’ll try to be the first to integrate Google Health with my EMR. I don’t think most of it would be that difficult.

Well, my prediction that Eric Schmidt would announce Google Health at the HIMSS08 conference were pretty close. From what I’ve read so far, that’s all he really talked about. I’m still waiting to see my contact that was able to attend HIMSS to see his thoughts on what was said. Sounds like he mostly reiterated what we already knew. A few interesting points:

-Google Health will not contain ads (although I bet that won’t stop them from using the information to target the ads it shows you other places)
-Eric Schmidt repeatedly said no data would be shared without the consumer’s consent (unless of course some hacker finds a way around Google’s security measures)
-1,370 volunteers at the Cleveland Clinic are beta testing the application
-Portability is the key (we heard that this was a form of CCR, but if it requires consent are people going to go to the effort to make it portable?)

Despite certain privacy questions and fears around Google Health I think that Eric Schmidt made a very good point about the way Google will protect your information from legal cases when he said:

“In the Google implementation, your personal health information will not be given to anyone without their explicit permission, which is not true completely for HIPAA-compliant systems. If we get a subpoena, we always check our judgment as to whether the subpoena is narrow enough. If we think it’s a fishing expedition, we will fight it in court. That has worked well for us so far.”

The battle of PHRs by Google Health and Microsoft HealthVault have begun. While I love to see the big players participating in healthcare, I’m not sure they’ve figured out the right motivational drivers that will make this a smashing success. It wouldn’t surprise me if in a few years we hear stories about a life being saved because of proper information and how even one saved life is worth it.

The biggest disappointment: No announcement about when we can get in and try it out ourselves.

UPDATE: Techcrunch think that whoever cracks the healthcare nut will have a huge new market. I don’t see it ever cracking. Marissa Mayer talks about Google Health on the Official Google Blog.

Today I’ve been reading about the news that Microsoft has entered the health care space with a major offering that will certainly make Google and Google Health take a hard look at their electronic medical record plans. Microsoft’s Lifelong Electronic Health Record is called HealthVault.

I’ve been reading this Microsoft Health Blog for a while and as expected, there was a nice blog post about HealthVault. Read it with the knowledge that he works at Microsoft and you’ll get some good information and figure out where it is good old PR spin. Here’s just one example of where I think you need to read between the lines:

* The Microsoft HealthVault record you create is controlled by you.
* You decide what goes into your HealthVault record.
* You decide who can see and use your information on a case by case basis.
* Microsoft does not use your health information for commercial purposes unless you are asked and you clearly tell Microsoft they may.

This is a good list of information. However, the last one concerns me. I’m afraid that Microsoft “asking” to use your information will be something akin to a really long privacy policy that no one reads and everyone clicks through. We all know about these and it’s very common. However, is that really Microsoft “clearly” telling you what they’re going to do? Of course this is my speculation, but it’s a pretty common practice and I wouldn’t be surprised if Microsoft employs it in HealthVault.

I’ll have to save a full review of Microsoft HealthVault until I have more time to really dig my teeth into it. However, a few parting thoughts.

-I think that many people will use this, because most people aren’t afraid of sharing their medical history. Essentially the ones that have “nothing to hide.” More on this in the future.
-I hate that Microsoft uses the Net passport as the login. Give me a special login and don’t make me log in and out of my email passport and my health record passport.
-Microsoft needs to look at getting the info into their system using something like CCR. Otherwise, people just aren’t going to update it which basically renders it useless.

Why would an EMR company not want to use these databases (or at least ones like them)?

I’ve recenly come accross SnoMed and RxNorm. I honestly don’t know too much about them, but my impression is that at a minimum these 2 databases list all the ICD9 codes and standardize the listing of Rx’s using the NDC number. Lists like these would have made my life so much easier. When I first implemented an EMR I really didn’t know what I was doing at all. I was learning the medical side as quickly as I could so I would know how to configure the software. I guess I could have sat back and said I’d be happy to just install the server, install the software and let the doctors deal with the medical side of it. However, if I did that I think that we wouldn’t be anywhere near an EMR implementation. So, I jumped in head first and tried to learn what needed to be uploaded to our new EMR system. I found myself having to upload all the ICD9 codes and find a way to add all the medications we wanted to prescribe into the EMR system. Anyone that has looked at these lists knows how much fun this was. Having access to some databases like SnoMed and RxNorm would have made my life so much easier. Even more important is that an EMR vendor should have this standard.

Ok, don’t start flaming this thread(although maybe I should encourage comments since this is a subject I don’t know that well), but there are some challenges for EMR companies wanting to implement it. I’m sure if you list every drug every created then I’m going to start complaining about that too. Not to mention every ICD9 code. At least you have to plan a way for me to sort through the lengthy list. Also, I don’t think it’s just a flip that is switched to turn this type of integration on or off. I also will give those older EMR companies a little slack since it’s going to be a definite challenge integrating these databases if you haven’t been using them in the past. However, it’s not impossible.

I think the biggest reason to implement some type of database like SnoMed and RxNorm is because of the potential integrations that can be done in the future. RHIO is a hot topic, but if we don’t all speak the same language as far as ICD9 codes and drug names then it will be difficult to integrate. The whole CCR initiative will be so much better if we have a standard language that we all use.

Ok, so I apologize for my primitive understanding on the topic, but I figured I had to start somewhere. More information to come.