I think people have enjoyed a collection of my best tweets from the healthcare IT and EMR conferences I’ve been attending. If you don’t like them, let me know in the comments. I think they’re interesting since they’re nuggets of interesting topics. The following tweets come from the Digital Health Conference in New York. It’s been a really well attended event and includes a lot of the real health IT movers and shakers in the New York healthcare scene. Plus, they’ve had some really great content as well.

Here goes (with my comments after the tweet):

I’ll be interested to see http://t.co/EnvXwoJ5 evolve and start sharing clinical provider quality information. #dhc11

December 1, 2011 6:24 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Healthcare.gov is an interesting site. Still too new to decide its impact though.

Todd Park highlighting all of the healthcare data that the government makes available in APIs. #dhc11

December 1, 2011 6:34 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Todd Park did make a pretty compelling case for the healthcare data they’re going to make available from the government and it seems like they’re just getting started. I could see a lot of startups leverage that data in their companies. I wonder what assurance an entrepreneur will get that the data won’t get yanked.

Great example by Todd Park of how mobile health can change healthcare using the asthma example. #dhc11

December 1, 2011 6:53 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Simple examples like this is why mobile health is so fascinating.

Standing O for Todd Park’s keynote at #dhc11

December 1, 2011 7:06 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Todd Park really did do a great job. Attendees were commenting on how good he’d done all day. As Matthew Browning said, Practice Makes Perfect!

Standing room only for #dhc11 session on HIE event detection and provider notification. http://t.co/aE6rwRMW

December 1, 2011 8:27 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Obviously a lot of interest in the HIE stuff and in the notifications that they can do.

Did I hear right that NYC metro area has 4 RHIOs? #dhc11 RHIO is HIE for those not familiar with RHIO

December 1, 2011 8:43 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

I know that NYC is large and has a lot of people, but I’m having a hard time understanding how it has 4 RHIO. Are there 4 regions in NYC? I’m sure there’s a long political story behind it.

Dr. Calman hits the nail on the head-tech. is an enabler, doesn’t provide context. #DHC11

December 1, 2011 8:25 am via LinkedInReplyRetweetFavorite

@PeachBytes5

Babette Peach

This is why we’ll always need doctors. It’s just how they do what they do that will change.

I love that people are talking about concern over being flooded with information when right now were not sending any info. #dhc11

December 1, 2011 8:51 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Such a good point. If they were actually getting all that information then they’d have reason to complain. Although, we can’t make the systems filter the flood properly when there’s no flood.

I’d never heard @MatthewBrowning tell his @yournurseison story. Fun to hear. #dhc11 #HITStartups

December 1, 2011 11:27 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Great funding story. I bet there’s even more to it than he shared. I’ll have to get him to share the rest some time.

We bring a little Rock n Roll rhythm to the slow dancing healthcare industry. -@matthewbrowning #dhc11

December 1, 2011 11:30 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

Great quote from Matthew. I don’t mind a little slow dancing, but the dance floor usually empties for the slow songs and is hopping with the rock songs. This is a pretty systemic problem in healthcare. I met one healthcare salesperson who said he was just contacted about a deal he’d worked on 3 years ago with a hospital. They contacted him to say that they’d finally closed the deal. Too bad this sales person is no longer at the company.

Time again for our weekend EHR Twitter round up. Let the fun begin.

@ahier – Brian Ahier
#EHR’s need encryption says @HealthPrivacy to Senate panel bitly.com/rTnx6s

Is there an EHR software that doesn’t use encryption? Is there a doctor’s office that’s paying for an EHR that doesn’t use encryption? Certainly not all EHR encryption implementations are created equal. In fact, I wish that things like encrypting data were part of an EHR certification. Why? Cause that’s something you can actually certify in a meaningful manner.

@drmikesevilla – Mike Sevilla, MD
RT @SeattleMamaDoc Computers all down in the exam rooms today. One major limitation of an EMR/EHR (dependence on a computer)

Definitely is one challenge with an EMR/EHR. I wonder how many patients were seen without the chart, because it couldn’t be found quickly. There are always pros and cons to IT. It does highlight the need to have a well thought out plan for how you’re going to care for patients when your EHR is down.

@iWatch – iWatch News
State health exchanges might not be sustainable after $548M in stimulus money runs out: bit.ly/t9QfSl #HIE #EHR

Wait, so changing the name of them from RHIO to HIE didn’t solve any of the problems with these exchanges? Oh yes, I forgot to mention the extra $548 million to help solve the problems. I think this best illustrates that money isn’t the issue or at least there are more issues with HIE than just the money.

I live in Chicago, a highly competitive healthcare market with some world-class medical schools (Northwestern, University of Chicago, Loyola, Rush) and a pretty decent record of EMR adoption. At least four major institutions/health systems run similar Epic EMRs: University of Chicago Medical Center, Northwestern Memorial Hospital, Rush University Medical Center and, in the northern suburbs, NorthShore University HealthSystem (formerly Evanston-Northwestern Healthcare).

Three NorthShore hospitals–Evanston Hospital, Glenbrook Hospital and Highland Park Hospital–were among the first in the country to reach Stage 7 on the HIMSS Analytics EMR Adoption Model.(NorthShore’s Skokie Hospital since has reached Stage 7). Several others, notably Rush, Advocate Lutheran General Hospital in northwest suburban Park Ridge, Mercy Hospital & Medical Center and  Swedish Covenant Hospital, have gotten to Stage 6.

But there’s been very little effort to interconnect these institutions and affiliated physician practices. Even during the RHIO heyday of 2004-07, I don’t recall much interoperability talk in the Chicago area. (In fact, one family physician, Dr. Stasia Kahn, in far west suburban St. Charles, got so frustrated that she formed her own group to promote EMR adoption and health information exchange, Northern Illinois Physicians for Connectivity. I had heard talk for a while of some south suburban hospitals joining in an HIE with counterparts across the state line in Northwest Indiana since Illinois was moving too slowly.)

All of that non-action at the state and regional levels happened under the not-so-watchful eye of one Gov. Rod Blagojevich, who apparently was more preoccupied with his own vanity and “giving healthcare to kids” (while also allegedly trying to blackmail the CEO of Children’s Memorial Hospital into donating to his campaign fund and also slowing Medicaid payments to pay for his All Kids program) than in, you know, actually improving healthcare for everyone by promoting HIE.

In February 2009, shortly after Blagojevich was removed from office and a couple weeks before the federal American Recovery and Reinvestment Act became law, new Gov. Pat Quinn signed a law allocating $3 million to the state’s Department of Healthcare and Family Services for HIE planning. That laid the groundwork for this week’s widely publicized announcement that the not-for-profit Metropolitan Chicago Healthcare Council had chosen technology from Microsoft, Computer Sciences Corp. and HealthUnity to build what could be the largest big-city HIE in the country, potentially serving 9.4 million people in nine Illinois counties and small parts of Indiana and Wisconsin.

I bring all of this up because I met yesterday with executives from the Metropolitan Chicago Healthcare Council, a 76-year-old coalition of healthcare organizations in and around the city. It just so happened that the 2011 Microsoft Connected Health Conference was in town this week, so it was the perfect time and location for Microsoft to drop the news. According to MCHC Vice President Mary Ann Kelly, more than 70 percent of the council’s 150-some members have made a commitment to participate, and they seem to have a plan to make the HIE effort sustainable.

The exchange will operate on a subscription model, with the vendors taking on some of the risk, Kelly said. “The subscription fee will be based on the benefit each member derives,” Kelly explained.

Initially, the exchange will involve 22 hospitals in nine organizations, said Teresa Jacobsen, the council’s HIE director. “We want to get one or two use cases running first,” she said. They will start by linking emergency departments to exchange clinical summaries and for syndromic surveillance, according to Jacobsen. Once that’s going, the HIE plans on adding medication and allergy lists, diagnostic testing results and Continuity of Care Document reports, as well as additional elements for public health, including immunization records.

It all sounds great, and it’s a good idea for them to start slowly, but I wonder when and if smaller physician practices will get involved. My own physician has had an EMR for a while, but not every doctor in the practice uses it. (The four-physician practice recently upgraded to the Meaningful Use Edition of Sage Intergy and has started the 90-day clock for qualifying for Stage 1 Medicare incentives this year, but there’s essentially zero interoperability with other healthcare entities, unless you consider faxing records to others straight from a computer interoperability. I sure don’t.)

My guess is that scenarios like this are playing out all over the country. I wish them luck, but I’m not counting on nationwide interoperability for many years. For one thing, the federally funded, state-chartered Illinois HIE Authority held its very first organizational meeting Wednesday afternoon. “That’s the biggest wild card we don’t know,” MCHC CFO Dan Yunker said.

It’s key to getting payers—particularly Illinois Medicaid—on board with HIE and linking metropolitan exchange networks across the state and beyond. “Our hospitals in Chicago are responsible for the snowbirds who are in Naples (Florida),” Yunker noted. They’re also responsible for patients who come from places like Rockford, Springfield, Champaign, Carbondale and the Quad Cities for certain specialized services only available in the big city.

Yeah, this interoperability thing isn’t so easy.

Everyone seems to love talking about RHIO, HIE and all of the other various initiatives happening around sharing patient health information amongst doctors. This weekend, I want to open it up to you the readers to get an idea of what type of participation you’ve had in an RHIO, HIE or other clinical data exchange.

Are you participating in one now? Do you like it? Do you hate it? In fact, what do you like and what do you hate? Do you use an EMR to interface with the exchange? What’s the interface like? How much work is it to manage the interface?

I’d also be interested in hearing about people who are working through the process now. Where are you at in the process? What’s holding you up from making this happen?

Let’s help educate each other on what’s happening with something that I think we can all universally agree is important and INCREDIBLY challenging.

I recently read a Healthcare IT article that talks about some of the challenges with the EMR stimulus money. Here’s a couple of the challenges discussed with my commentary.

Albert L. Strunk, MD, representing the American College of Obstetricians and Gynecologists, said ACOG is concerned that the measures, while clinical in nature, are not related to adoption of electronic medical records. “The meaningful use measures for ARRA should determine whether a physician has met the objectives shown in the meaningful use matrix, not whether the EMR is being used to report clinical quality measures that rarely apply to that physician’s patients,” he said.

I think this is an interesting analysis. Clinical quality measures are one of the main goals of having an EMR. However, very few doctors look at it that way. I think they will get the incentives wrong if they focus on the clinical quality measures and not on the features of an EMR that benefit the doctor. I’m still sticking with my original analysis that the government really wants doctors to have an EMR so they can improve the Medicare reimbursement rates (in their favor of course).

Another section about interoperable EMR software:

Experts at the hearing testified that providers are willing to wait to purchase a HIT system until they know it will be interoperable. They said physicians from small practices often interact with more than five community hospitals and several labs, each with a different system. Doctors need to know that whatever electronic health record they buy will work with the systems the labs and hospitals have.

I don’t personally get the feeling that most doctors care about interoperability when making their EMR selection. Ok, let me clarify. They want it to connect with their lab and hospital. However, most don’t worry about it interacting with other doctors offices in a true interoperable fashion. The problem is that interoperability between a doctors office and hospitals/labs is not the same as what most people consider an interoperable EMR. I’m talking about EMR software talking to other EMR software (or an RHIO or HIE). Most doctors don’t care about this. At least not more than all the other financial issues related to EMR.

I’ll admit to not being the most expert person on HIE, RHIO, NHIN, and all of the other acronyms associated what really is just creating systems and structures for sharing healthcare data between various doctors and systems. However, I do have some knowledge in the area since I believe all of these things will be important for those using an EMR. So, I was surprised when I’d never heard of HHS’ health connect software.

Here’s a short bit from Government Health IT of the government’s connect software’s latest update:

The Health & Human Services Department (HHS) has updated the government’s Connect software to improve information security and enterprise services for organizations that want to use it to exchange health data, said its senior architect.

Connect is federally developed software that lets agencies and healthcare organizations share health data by using the protocols, agreements and core services that make up the nationwide health information network (NHIN).

HHS is trying to develop improvements in the Connect gateway quickly so it can serve as an early model of the NHIN, executives said yesterday.

“The intent of the plan is that Connect will be a reference implementation of NHIN and provide a mechanism for organizations that are building gateways to have the ability to test against it and to provide for feedback to the NHIN specification group,” said Les Westberg, Connect technical lead in the Federal Health Architecture program and an executive with Agilex.

Is there anyone that knows more about this program that can give us a review of what’s going on. I’d love to hear about how far it’s come, the challenges its overcome and the challenges it still faces.

In fact, if you are someone working on one of the acronyms listed at the top that are trying to provide the all to elusive healthcare data interoperability I’d love to learn more about what’s going on in the comments or through a guest post if you have a lot to say.

I’m not sure how many of my readers have heard about the Virginia Prescription Monitoring Program being hacked yesterday. The Prescription Monitoring Program is used by pharmacists and others to discover prescription drug abuse. The story gets really interesting since it looks like the hackers encrypted over 8 million patient records and over 35 million prescriptions. Then, the hackers posted the following note on the Virginia Prescription Monitoring Program website (according to wikileaks):

“I have your [expletive] In *my* possession, right now, are 8,257,378 patient records and a total of 35,548,087 prescriptions. Also, I made an encrypted backup and deleted the original. Unfortunately for Virginia, their backups seem to have gone missing, too. Uhoh :(For $10 million, I will gladly send along the password.”

The website has now been entirely disabled and just times out if you try to visit the site.

The Washington Post blog has reported the following:

Sandra Whitley Ryals, director of Virginia’s Department of Health Professions, declined to discuss details of the hacker’s claims, and referred inquires to the FBI.

“There is a criminal investigation under way by federal and state authorities, and we take the information security very serious,” she said.

A spokesman for the FBI declined to confirm or deny that the agency may be investigating.

Whitley Ryals said the state discovered the intrusion on April 30, after which time it shut down Web site site access to dozens of pages serving the Department of Health Professions. The state also has temporarily discontinued e-mail to and from the department pending the outcome of a security audit, Whitley Ryals said.

“We do have some of systems restored, but we’re being very careful in working with experts and authorities to take essential steps as we proceed forward,” she said. “Only when the experts tell us that these systems are safe and secure for being live and interactive will that restoration be complete.”

Seems interesting that 5 days after they discovered the intrusion the website is still not back online. Must have been a pretty serious hack job.

The Washington Post also explained that this is the second such extortion attack using patient health care data.

In October 2008, Express Scripts, one of the nation’s largest processors of pharmacy prescriptions, disclosed that extortionists were threatening to disclose personal and medical information on millions of Americans if the company failed to meet payment demands. Express Scripts is currently offering a $1 million reward for information leading to the arrest and conviction of the individual(s) responsible for trying to extort money from the company.

Stories like this will set back any sort of RHIO or national HIE movement. Sure makes you think about the security of it all. What is interesting is that the patient data doesn’t seem to have much value outside of extortion. Otherwise, I’d think those who breached the system would have used it in some other way.

If you’ve been reading my blog, then you know that I’ve started a pretty interesting and complicated discussion about EHR and EMR sharing of patient data. I first posted an example of sharing data with an EHR and then followed it up with some challenges associated with sharing of EHR data.

In my interoperability challenges post, Bjorn from Health Xcel posted a lengthy comment discussing some challenges of data sharing and made the case for RHIO (Regional Health Information Organizations) and HIE (Health Information Exchanges) as a means for sharing patient data between hospitals and doctors offices.

His comment was so well done that I’m copying it below for more people to see and read it. I don’t personally agree with everything that was said. I also think he didn’t address the funding challenges of RHIO and the policy problems. Maybe Bjorn will return with some comments on how those might work. Enjoy Bjorn’s take on RHIO and HIE (emphasis added):

I think Google Health and MS HealthVault will be good awareness catalysts for the quiet e-health revolution that is taking place. However, I do not think the defining change we need lies with their business model. A patient-centric model sounds good but we’d be assuming that everyone has an account with one of these systems and that they know how to use them. How will the data about a patient that is stored in a hospital be reconciled with Google Health? Which of course leads to interoperability concerns.

Web 2.0 does not lend itself to creating a reliable e-health solution either as service A is dependent on service B and if service B is down, service A won’t function and has no power to fix it by their own volition.

I think so far the industry, aka hospitals, has been trying to solve the problem by adding a patient interface to large hospital systems so patients can see their records. It’s also a step in the right direction but again it is not the golden calf we are looking for.

So what is the ideal system of the future?
A patient should be able to enter any hospital in the world, conscious or unconscious, and the hospital should have all the information they need about the patient to administer correct treatment and to notify the right people.

How do we do this?
I am a believer in the HIE / RHIO model. In the [not too distant] future, hospitals should concern themselves with healing people and not how to spend their IT budget. Hospitals, insurance agencies, smaller providers and patients will all be connected to an RHIO (Region Health Information Organization) where they will have a wealth of services; either to enter sensitive data or to discover data about one patient or the entire population. RHIOs will be connected to a larger e-health backbone consisting of HIEs that are the great data aggregators of the world. RHIOs would be responsible for conforming to regional regulations. This model is similar to how we connect to the Internet today. We don’t jack directly into one of the main Internet hubs of the world but go through an ISP that can provide us with an email address, a web page AND connect us to the rest of the world.

HIEs and RHIOs run on a software platform where health IT vendors can deploy their software applications. Some required components:

- User discovery
o Any one node on the system should be able to query the other nodes to find a user and her data
- Portable user
o This goes with the first bullet point in that a user should be able to log in to the system anywhere in the world and even though the user does not have an account with the RHIO she is directly interfacing with, RHIO should know how to authenticate her correctly
- Interoperability / Standards / Data aggregation and discovery
o The key to any successful e-health venture. Services need to be able to talk to each other. It shouldn’t matter whether the services reside within the same application or in different parts of the world. I believe the semantic web (web 3.0) will be a key facilitator of making this possible.
- Federated security
o If we take the previous examples of Google Health and MS HealthVault, they would all have to have their own security scheme and user authentication and access control. Multiply that by a dozen and suddenly a lot of money is being spent on recreating the wheel over and over. We need a unified system for this.
- Updates
o All applications should reside server side and users should have thin-client access only. When the applications are being updated, it should happen across the board overnight. If something goes wrong, there should be a way to undo the upgrade without hospitals or anyone else having to do anything.
- Data sharing
o The patient-centric network will definitely happen as users become more educated. But hospitals still need to be able to have access to patient data even though they have not been granted access, in case of emergency.

Ok, this suddenly got really long ;-) There is a lot of work to do for everyone in order to get true e-health solutions to work. The biggest obstacles aren’t technical but political and also the willingness to adopt a new way of interfacing with your health.

Cheers
bjorn