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What Information an HIE Should Pass?

Posted on March 23, 2012 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I had a post by Dirk Stanley, MD recently pointed out to me where Dirk discusses the challenge of deciding which information an HIE should pass. Dirk is the CMIO at a hospital and also a genuinely nice guy. He frames the answer to the HIE data passing question really well:

And after a rousing discussion, the answer I heard was this :Everyone has a different opinion.

I guess it’s entirely understandable… ICU docs, PCPs, surgeons, specialists, hospitalists, and everyone else has a common goal – making the patient healthier – but they have different training and thus they all have different needs. This is why when I hear docs say “I just need the important information!“, I smile because ultimately, all of the information in a chart is important – It just depends on your context and clinical needs.

So I’m left with the ultimate Informatics challenge – How can we get the right information to the right person in the right place in the right time in the right way? Especially when everyone has a different opinion on what the right information is?

He then offers this zinger which describes the real core of the problem: “Looking at the current buffet table of documentation, it’s no wonder that every doctor has a differrent opinion of what they need. There aren’t really any hard standards for clinical documentation.”

Dirk then goes on to describe his solution to the problem which essentially revolves around the idea of a new type of note that can be transferred. You can read all the details in his post.

Reading through Dirk’s thoughts on the subject I’m reminded of the conversations that surrounded the creation of CCR back in the day. They seem to have taken a very similar approach to what Dirk describes. I wonder what Dirk thinks of the CCR (now basically merged with CCD) standards that are already out there. Do they not cover what he has in mind? Are their gaps in the CCD standard that don’t cover his “new note?” Could we just improve the CCD standard to cover those gaps? I’ll ping Dirk and hopefully he’ll join the conversation.

The real challenge when looking at what data should an HIE pass is that computers aren’t very good at understanding context. I’d be interested to hear people’s thoughts about this and how we’ll solve this problem going forward. My gut feeling is that we need to start with something that will solve a lot of problems for a lot of people. We don’t need something that will solve all things for everyone from day one. We can incrementally improve the exchange of data as we go forward.

Guest Post: The Long Term Fate of CCD

Posted on November 10, 2011 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

Comparison of CCR and CCD

Posted on November 5, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

CCD vs. CCR and Part of MU

Posted on October 30, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

Defining Implementation of an EHR

Posted on February 9, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

EHR Data Sharing Example

Posted on January 6, 2009 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In my recent post about hosted EHR versus client server EHR Dr. Rowley commented on the various scenarios that could occur for sharing a patient record. The comment was so worthwhile that I wanted to make it it’s own blog post and add a few comments of my own. Here’s Dr. Rowley’s comments on data sharing scenarios with various EHR:

Whether you are an enthusiast of free, hosted, web-based EMRs, or an enthusiast of local client/server installations (or a wait-and-see skeptic), the question of data sharing is one that is important to us all.

Maybe the discussion can be best moved forward by considering a real-life scenario and examining how data sharing can occur in different situations. Let’s say that I am the Family Practitioner taking care of Mr. Chest-Hurts, who just was released from the hospital after a heart attack, and you are the cardiologist who saw him there. Mr. Chest-Hurts is in my office for post-hospital follow up, wants a referral to see you as an outpatient, had numerous tests done (which I don’t have in my records when I see him), states that you changed several of his medications on discharge and is confused as to which ones to take (and did not bring them with him for his visit). I just did some lab test and found his cholesterol to be not-quite-at-target. Let us assume that the referral is a simple administrative matter that happens anyway. What is important for patient care here is for us to share our records with each other – we need to reconcile his meds lists, you need the labs I just got, I need the cath report from the hospitalization, etc. Now let’s explore how we share data, given different scenarios:

1. Neither of us have EMRs; we both use paper charts. In this case (the traditional one in medicine), we copy and fax information to each other from our charts. We take each other’s faxes and make them permanent parts of our own separate charts.
2. I have a client/server EMR and you use paper charts. I generate a fax to you from my EMR, which you place in your paper record. You fax records to me, which I scan and import into my EMR.
3. I have Practice Fusion, and you use paper charts. Several options exist here: (a) I can generate a fax to you, like scenario #2 above; or (b) you sign in to Practice Fusion (after all, it’s free, and with “Live in Five” provisioning, you will be able to have access almost immediately). You can then print out what you might need, for inclusion into your own paper chart.
4. We each have client/server EMRs (maybe the same one, or maybe different). Like with paper, we each have separate chart records, and there is no unified patient identifier. A few options exist here: (a) we each have our systems fax out the desired records to each other, and import the data as scanned documents into our separate charts; (b) we each output a Continuity of Care Record (CCR), and somehow push it to each other. There are some efforts (like Relay Health, for example) who are trying to build an infrastructure to be an intermediary for CCRs – I push out a CCR and post it to Relay Health, and you look there and import the CCR directly into your EMR. This need to build a connection between local installs is a challenge (weakness, in my view) of local client/server systems, and will take effort and money to build. There is a lot of activity here.
5. I have Practice Fusion and you have a local client/server EMR. Several options can take place: (a) we each fax our information to each other; (b) we exchange CCRs (like #4 above); (c) I give you access to Mr. Chest-Hurts’ chart (like #3 above), so that you can see the record, and copy-and-paste between the systems if desired.
6. We each have Practice Fusion. We can share the same record on the same patient, and with the right permissions, can see each other’s notes, shared lab values, meds lists, etc. No uploading or downloading of CCRs required. No faxing needed. This is the most compelling scenario.

Pardon my long-windedness here, but my belief is that the discussion of data sharing is very important, and vital to unlocking the true potential of e-tools in improving health care in this country.

I’ll be posting my comments on these scenarios in my next entry.

Google Health Beta Live – What does this mean for EHR?

Posted on May 19, 2008 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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.

Google Health Beta Page is Up

Posted on January 23, 2008 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

UPDATE: Google Health Beta is now LIVE!

Today I saw an article on TechCrunch that talked about how Google Blogscoped found a Google Health login page (UPDATE: The Google Health Beta Landing Page has been taken down) for the hopefully soon to be released Google Health. Of course, there isn’t really anything all that special about the login page. It looks just like almost all the other Google login pages. However, the Google Health page did include the following information:

With Google Health, you can:

* Build online health profiles that belong to you
* Download medical records from doctors and pharmacies
* Get personalized health guidance and relevant news
* Find qualified doctors and connect to time-saving services
* Share selected information with family or caregivers

Too bad none of the other links work, but it does give some interesting information about what Google Health will be like. The part that is most concerning to me is downloading medical records from doctors and pharmacies. How are they going to do that? The answer is that they aren’t really going to do it. There are going to be a handful of the thousands and thousands of doctors and pharmacies that will be able to work with Google Health.

I hope that Google Health does the right thing and integrates with something like CCR since it is already beginning to be established in many Electronic Medical Record software programs. That would be a huge boon to CCR, but it would also open up an entire set of doctors that could support upload to Google Health. This could definitely be a nice differentiator from Microsoft Health Vault which can’t do this either (unless it’s been added since I looked).

If Google Health decides to create their own standard for a clinic to be able to upload to Google Health they are crazy. Doctors have almost no motivation to support Google’s standard for uploading medical records. I’m not sure many EMR companies will support it either. I can see a few of them do it as a PR move, but I’d be very surprised if many of them bit on this. Doctors don’t buy EMR software because their patients can get their record out easier. It just doesn’t make business sense for EMRs or doctors to really do any sort of uploading like this to Google Health.

Of course the good thing for this all is that having another big player like Google interested in helping the healthcare system with some Health 2.0 solutions is great by me.

You can see my previous coverage of Google Health and also the Google Health Co-op.

Update: Here’s a screen shot of what Google Health could look like.
Google Health Screen shots

Update 2: What CEO of Google Eric Schmidt said about Google Health at HIMSS08.