Today, the EHR/HIE Interoperability Workgroup, originally formed by the New York eHealth Collaborative (NYeC), will announce the collaborative work of seven states (California, Colorado, Maryland, Massachusetts, New Jersey, New York, and Oregon), eight EHR vendors (Allscripts, eClinicalWorks, e-MDs, Greenway, McKesson Physician Practice Solutions, NextGen Healthcare, Sage, and Siemens Healthcare), and three HIE vendors (Axolotl, InterSystems, and Medicity.)
The objective of the EHR/HIE Interoperability Workgroup has been to define a single set of standardized, easy-to-implement interoperability specifications that will increase the adoption of EHRs and Health Information Exchange services. The effort leverages existing published standards for interoperability from the Office of the National Coordinator (ONC).
The work includes refinements to mature, well tested standards including:
*A summary of care implementation guide that further constrains the CCD/C32
*An enhanced Direct specification including SMTP/SMINE, XDR for connection to HISPs, and PKI/Certificate distribution.
The work also includes enhanced guides for those standards that the HIT Standards Committee felt required additional testing and refinement including:
*A detailed guide for implementing HPD/LDAP provider directories
*An updated guide to the components of the NwHIN Exchange specifications for "pulling" data from multiple data sources.
I offered the following quote to describe their work:
"I applaud the work that the EHR/HIE Interoperability Workgroup is doing to move states from implementation guides to production. Their selection of Consolidated CDA and Direct is well aligned with HIT Standards Committee discussions. The EHR/HIE Interoperability Workgroup is also doing important work with NwHIN Exchange and Provider Directories that will provide the country with lessons learned, so that the HIT Standards Committee can recommend refinements to these emerging technologies. I expect that the flexibility and agility of the EHR/HIE Interoperability Workgroup will serve as an ideal laboratory for standards that are rapidly evolving."
Massachusetts is rapidly implementing Direct for exchange of clinical summaries. It's very likely that our implementation will be able to leverage the work of EHR/HIE Interoperability Workgroup for multi-state compatibility and reusability.
It's going to be a great year for HIE.
The Accountable Care Organization Final Rule
Robin Raiford has been hard at work annotating the Final ACO Rule. Here's a version that is fully bookmarked.
She's also recommended important new resources on the CMS website:
Eligible Professionals
*Updated CMS Specification Sheets
Eligible Hospitals
*Updated CMS Specification Sheets
Thanks Robin!
She's also recommended important new resources on the CMS website:
Eligible Professionals
*Updated CMS Specification Sheets
Eligible Hospitals
*Updated CMS Specification Sheets
Thanks Robin!
Cool Technology of the Week
Thus, the water cooler chatter is all about generators.
Although a Bloom box would be nice, the $700,000 price tag is a barrier. Alternatives such as solar do not really work in New England winters with limited sunlight.
The next best thing is a natural gas powered generator that automatically starts and provides backup power when street power fails. Generac is a popular model. It's highly unlikely that natural gas will stop flowing when electricity fails. In New England, our issue is that electricity is needed to circulate heated water, steam, or hot air, so a power failure results in a heating failure. A generator is a necessity in places like rural New Hampshire which can be without power for weeks every year.
Here's a handy calculator to help you size your generator.
Natural gas generators that keep you powered and warm when power lines fail. That cool! (or hot as the case may be)
The Benefits of RxNorm
I was recently asked about the benefits of RxNorm and asked my friends at the National Library of Medicine for the answers:
1. What are the benefits of RxNorm over NDC, or SNOMED?
RxNorm represents drugs in a way that corresponds directly to a prescriber's view of a drug, as an ingredient + strength + dose form. The dose form is the form as it is actually administered (e.g. 'Injectable suspension"), not necessarily the form as it is manufactured and delivered to a pharmacy (e.g. 'Powder for suspension). The NLM has taken government and commercial sources of data, creating normalized names to produce a complete list of the drugs used in the United States. We have a very slim policy-making process, allowing us to respond quickly and effectively to tweak our model if necessary, which we have done a number of times.
The benefit of this approach is that the drugs are named consistently, the names and codes are centrally published and maintained, improvements can be incorporated quickly, and the set of drugs is complete (for the U.S.).
NDC codes represent drugs from what might be called an 'inventory' perspective. NDCs characterize and differentiate drugs on the basis of manufacturer and package size, for example. Two different NDCs could correspond to a singe RxNorm identifier; a generic drug could be made by different manufacturers or provided in different package sizes. NDCs require the use of a 'representative NDC' in order to provide a single identifier for a single clinical drug. Schemes of representative NDCs has proven to be very clumsy to use here in the US. In addition, NDCs are not centrally assigned or maintained. Each manufacturer/packager issues its own NDCs and there is no 'official list' of all NDCs in the US.
SNOMED CT is an international terminology that has a relatively complex editorial process, and requires license fees and participation in its governing organization, the International Health Terminology Standards Development Organization (IHTSDO). The SNOMED CT International Release is meant to contain the 'common denominator' of drugs across the world; each country using SNOMED CT for drugs needs to develop a National Extension separate from the International Release.
2. What evidence is there for its use, that it has worked successfully and in which hospitals?
RxNorm has been tested by the US Centers for Medicare and Medicaid (CMS) in both a live and a 'lab' environment and found to be complete and usable. Some minor challenges noted in some details of implementation, but overall it was found extremely useful and work-able.
For a variety of reasons having to do with legacy workflows in the US, RxNorm is not currently used in e-prescribing (sending prescriptions from a prescriber to a pharmacy). However it is used in both research and in after-the-fact analysis of drug data in institutions like Stanford Hospital and University of Florida.
3. What is the current percentage of hospitals using RxNorm, and what has been the uptake over the last few years in the US, forecast for the next few years?
The standards environment in the US is quickly converging upon RxNorm as the designated drug vocabulary for sending electronic messages containing drug content, and I anticipate that RxNorm will be mandated for many of these uses within the US very shortly.
Thanks to the NLM for this and I look forward to continued implementation of RxNorm in my own institution.
1. What are the benefits of RxNorm over NDC, or SNOMED?
RxNorm represents drugs in a way that corresponds directly to a prescriber's view of a drug, as an ingredient + strength + dose form. The dose form is the form as it is actually administered (e.g. 'Injectable suspension"), not necessarily the form as it is manufactured and delivered to a pharmacy (e.g. 'Powder for suspension). The NLM has taken government and commercial sources of data, creating normalized names to produce a complete list of the drugs used in the United States. We have a very slim policy-making process, allowing us to respond quickly and effectively to tweak our model if necessary, which we have done a number of times.
The benefit of this approach is that the drugs are named consistently, the names and codes are centrally published and maintained, improvements can be incorporated quickly, and the set of drugs is complete (for the U.S.).
NDC codes represent drugs from what might be called an 'inventory' perspective. NDCs characterize and differentiate drugs on the basis of manufacturer and package size, for example. Two different NDCs could correspond to a singe RxNorm identifier; a generic drug could be made by different manufacturers or provided in different package sizes. NDCs require the use of a 'representative NDC' in order to provide a single identifier for a single clinical drug. Schemes of representative NDCs has proven to be very clumsy to use here in the US. In addition, NDCs are not centrally assigned or maintained. Each manufacturer/packager issues its own NDCs and there is no 'official list' of all NDCs in the US.
SNOMED CT is an international terminology that has a relatively complex editorial process, and requires license fees and participation in its governing organization, the International Health Terminology Standards Development Organization (IHTSDO). The SNOMED CT International Release is meant to contain the 'common denominator' of drugs across the world; each country using SNOMED CT for drugs needs to develop a National Extension separate from the International Release.
2. What evidence is there for its use, that it has worked successfully and in which hospitals?
RxNorm has been tested by the US Centers for Medicare and Medicaid (CMS) in both a live and a 'lab' environment and found to be complete and usable. Some minor challenges noted in some details of implementation, but overall it was found extremely useful and work-able.
For a variety of reasons having to do with legacy workflows in the US, RxNorm is not currently used in e-prescribing (sending prescriptions from a prescriber to a pharmacy). However it is used in both research and in after-the-fact analysis of drug data in institutions like Stanford Hospital and University of Florida.
3. What is the current percentage of hospitals using RxNorm, and what has been the uptake over the last few years in the US, forecast for the next few years?
The standards environment in the US is quickly converging upon RxNorm as the designated drug vocabulary for sending electronic messages containing drug content, and I anticipate that RxNorm will be mandated for many of these uses within the US very shortly.
Thanks to the NLM for this and I look forward to continued implementation of RxNorm in my own institution.
The New Metrics for CIO Success
When I begin my career as a CIO in 1997, success was function of the basics - email delivery, network connectivity, and application functionality. I personally wrote code, experimented with new operating systems, and created analytics using web servers, SQL, and ASP pages.
In 2011, CIO success is much more complex to measure.
Infrastructure success can be defined as 99.99% uptime of all systems and no loss/corruption/breach of data. The magical belief in the cloud sets expectations that IT infrastructure should be like heat, power, and light - just there as a utility whenever it is is needed in whatever amount is needed.
Application success could be defined as on time, on budget delivery of go lives according to project plans. Two important forces make this more complex
*Consumer software stores set expectations that enterprise software should be easy - we need to fix revenue cycle workflow, isn't there an app for that?
*As the economy forces downsizing and efficiency gains, there's an expectation that workflow automation is a pre-requisite to organizational change so there is more pressure on the IT department to deliver application solutions quickly.
This all sounds impossible - deliver massive infrastructure with constant change but keep it entirely reliable and secure. Deliver applications that support business processes in increasingly short timeframes with limited IT and business owner resources.
Thus, the modern CIO is no longer a technologist or evangelist for innovation. The modern CIO is a customer relationship manager, a strategic communicator, and a project manager, delicately balancing project portfolios, available resources, and governance.
Modern CIOs have little time to get infrastructure and applications right, so they must "skate where the puck will be", thinking more like CEOs about business needs and future strategies, so that critical information technology is deployed by the time it is needed.
What am I doing in FY12 to become a more effective modern CIO?
1. I've defined key business customers (BIDMC senior management and chiefs). I'm meeting with each one to ensure their priorities for the next year and beyond are reflected in the FY12 IT operating plan and the 5 year IT strategic plan. Planning much more than 5 years in IT is problematic given the pace of technology change. Working with the governance committees, I will trim this list into those projects that have the greatest impact on business strategy, quality/safety, and efficiency.
2. I'm standardizing communication so that key customers receive monthly updates about their priority projects.
3. I'm defining a process for managing IT projects across the enterprise that includes standardizing the IT Project Intake Process, the IT Project Life-cycle, and Project Management tools ( project documentation, project plans, and status reports).
It's my hope that by focusing on customer relationship management, communication and project management that I will create a positive working environment for the IT staff with a more limited set of well-defined projects and more engaged customers. Doing fewer projects with greater speed and depth which meet the most critical needs of the business is much harder than agreeing to do many niche projects and moving forward slowly on all. Given that the supply of IT resources is likely to be fixed since healthcare budgets are under increasing pressure from healthcare reform, the modern CIO should be judged on demand management and achieving reasonable levels of customer satisfaction despite having to focus on a narrower project portfolio delivered at a faster pace.
In 2011, CIO success is much more complex to measure.
Infrastructure success can be defined as 99.99% uptime of all systems and no loss/corruption/breach of data. The magical belief in the cloud sets expectations that IT infrastructure should be like heat, power, and light - just there as a utility whenever it is is needed in whatever amount is needed.
Application success could be defined as on time, on budget delivery of go lives according to project plans. Two important forces make this more complex
*Consumer software stores set expectations that enterprise software should be easy - we need to fix revenue cycle workflow, isn't there an app for that?
*As the economy forces downsizing and efficiency gains, there's an expectation that workflow automation is a pre-requisite to organizational change so there is more pressure on the IT department to deliver application solutions quickly.
This all sounds impossible - deliver massive infrastructure with constant change but keep it entirely reliable and secure. Deliver applications that support business processes in increasingly short timeframes with limited IT and business owner resources.
Thus, the modern CIO is no longer a technologist or evangelist for innovation. The modern CIO is a customer relationship manager, a strategic communicator, and a project manager, delicately balancing project portfolios, available resources, and governance.
Modern CIOs have little time to get infrastructure and applications right, so they must "skate where the puck will be", thinking more like CEOs about business needs and future strategies, so that critical information technology is deployed by the time it is needed.
What am I doing in FY12 to become a more effective modern CIO?
1. I've defined key business customers (BIDMC senior management and chiefs). I'm meeting with each one to ensure their priorities for the next year and beyond are reflected in the FY12 IT operating plan and the 5 year IT strategic plan. Planning much more than 5 years in IT is problematic given the pace of technology change. Working with the governance committees, I will trim this list into those projects that have the greatest impact on business strategy, quality/safety, and efficiency.
2. I'm standardizing communication so that key customers receive monthly updates about their priority projects.
3. I'm defining a process for managing IT projects across the enterprise that includes standardizing the IT Project Intake Process, the IT Project Life-cycle, and Project Management tools ( project documentation, project plans, and status reports).
It's my hope that by focusing on customer relationship management, communication and project management that I will create a positive working environment for the IT staff with a more limited set of well-defined projects and more engaged customers. Doing fewer projects with greater speed and depth which meet the most critical needs of the business is much harder than agreeing to do many niche projects and moving forward slowly on all. Given that the supply of IT resources is likely to be fixed since healthcare budgets are under increasing pressure from healthcare reform, the modern CIO should be judged on demand management and achieving reasonable levels of customer satisfaction despite having to focus on a narrower project portfolio delivered at a faster pace.
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