Preadopting FHIR Release Content

There are many times when you aren't quite ready to adopt a new release, either because it isn't fully baked yet (as for FHIR STU3), or you just aren't ready to suck up a whole release in a development cycle to get the ONE feature you would really like to have.

The FHIR Extension mechanism is a way that you can add new stuff to an existing FHIR release. But how should you use it for problems like those described above?

I'm going to be playing with this in the near future because I have some STU2 stuff going on right now, but I really need some of the fixes to Coverage in STU3.  Right now, STU2 talks about subscriber*, but doesn't actually link the coverage to the member (the actual patient being treated)! STU3 fixes that, and I want to preadopt the fix.

So, how am I going to handle my extensions?  Well, first of all, for every field I add, what I want to do is to name it using the STU3 (Draft) URL (and later to the STU3 URL).  So my extension URL becomes something like http://hl7.org/fhir/2016Sep/coverage-definitions.html#Coverage.beneficiary_x_, and bang, I have a referenceable URL that pretty clearly defines the extension.

What does FHIR say about that?

The url SHALL be a URL, not a URN (e.g. not an OID or a UUID), and it SHALL be the canonical URL of a StructureDefinition that defines the extension.

Apparently what I've done isn't quite right because it doesn't follow the FHIR rules (even though it follows the spirit) of FHIR requirements for extensions. Right? So, NOW what?  Somehow we need to give each extension a name.

Actually, let's see what happens when I plug StructureDefinition into this equation.  I now get:
http://hl7.org/fhir/2016Sep/StructureDefinition/Coverage#Coverage.beneficiary_x_.  Click the link to open where that goes in a new window.  Dang!  Pretty fricken close. StructureDefinition/Coverage produces a redirect that goes to fhir/coverage.html instead of fhir/2016Sep/coverage.html.  So close.

In fact, that's nearly close enough for me.  It seems that if we were to fix the redirect problem on the HL7 Server, this would do exactly what I need.  Note: It's NOT a structure definition that defines an extension, its a structure definition that defines a resource.  But really?  Do I have to point you to a structure definition that defines it AS an extension?  Or can I just do the nearly right thing and get away with it.

I may want to adopt a resource that doesn't even exist yet.  Say I want to use some clinical decision support, but I've invested a bit already in Argonaut stuff based on STU2.  How do I handle that? Fortunately, FHIR has the Basic resource, but I'm going to need to extend the heck out of it.  No problem, I just use the same technique, with gusto, and even better, I could put some automation behind it to populate my stuff.  And so could anyone else.

I wonder what Grahame will think about this?

    Keith

P.S. *  Also broken as defined in STU2, and not yet fixed in STU3 because I am not a patient at my wife's OB/Gyn practice, nor am I a patient at my children's Pediatric practice, but they clearly have me on file as some sort of RelatedPerson.  There's already a tracker for this.

FHIR to EHR Data Mappings

I've looked at a lot of EHR database schema over my career.  One of the things that I've found about FHIR is that it captures the essential model of an EHR system (just about ANY EHR system).  There really shouldn't be any surprises here.  It's based on six years of work that led to CCD, C32 and CCDA as well as a lot of other good information sources.  You can also find a good bit of that model already present in in CIMI via some of Intermountain's detailed clinical modeling efforts from the past.  What FHIR does differently is expose the right grain size I think, from what prior efforts in HL7 have attempted.

As both Graham and John have pointed out, yesterday's diagramming work still leaves a lot to be desired.  However, I will continue on to see where it goes.  I think there's an important piece of information there we should all be looking at very carefully.  I was already quite pleased to see that the patient and physician show up right in the center of it all.  Clustering algorithms like those used in GraphViz tend to surface interesting relationships like that.

I'm wondering if there are some better clustering algorithms to play with that might help identify interesting groupings and see how we did with resource classification.  Clearly the grouping of Individuals nailed it in Identification (under Administration).  Something like these might be worth digging into.

   -- Keith

Towards a FHIR UML Resource Relationship Diagram

One of the things that I feel is missing from FHIR documentation is a UML-like diagram of the Resources and their relationships to each other.  With over 100 resources, this is rather challenging to produce.  Fortunately, due to the data driven nature of FHIR development, the production can be automated using layout tools like GraphViz (Grahame had a love-hate relationship with GraphViz during early FHIR development, which resulted in him using something else).

What I did was create an XSLT which produced a graphviz input file after processing all of the FHIR StructureDefinition inputs.  To create a single XML file, I cheated a bit, and simply ran:

c:\build\publish> for /r %f in (*.profile.xml) type %f >>all.fhir.xml

After that, I edited all.fhir.xml and stripped all the extra XML declarations, and wrapped it in an element named FHIR (in the FHIR namespace).  There are other ways to do that to automate that, but this was simple and easy.  Note: The output will include some things that may have been part of the FHIR Build, but not part of the specification (e.g., Account in STU2).  I dealt with that in a later step.

After that, I used a number of different layouts supported by GraphViz to see which worked.  Just using the basic options produces a drawing about 30" x 150".  That's not really easy to use.  The best layout I could find was sfdp, which produces a clustered layout based on edge weights, using a force dependent spring model.  The layout stilled looked dramatically ugly because the lines overlap the nodes, so I set the edges up to use orthogonal connectors.

That looked close enough to be useful, so the next thing I did was to color code the nodes based on the Resource categorization used on the Resources page.  Clinical resources took on a range of purple colors (by subcategory), identification resources were red, workflow became cyan, infrastructure blue, conformance various shades of gray, and finance was green.  The colors helped me to understand how things were clustering in the diagram, so that I could possibly hand tune it.

I plan on doing hand tuning with a graphics editing tool.  Right now I'm checking out GraphVizio, a Visio plugin that lets me import GraphViz drawings.  Running the compute on the graph through Visio is something that is worthy of a long coffee break (actually, the same is true for the various layout methods).  I'm hoping Visio gets out of my way long enough to make this a worthwhile exercise, otherwise, I may have to revert to some other drawing tools.  I still don't like all the stuff Visio added for connecting stuff.  As soon as I move something a bit, it auto-reroutes stuff I've carefully positioned, screwing things up again.  I haven't played around with it long enough to figure out how to turn that off.

While I'm messing around with the diagram, I thought I'd show my initial progress:


As you can see, there's still a ways to go.  The diagram is still way too big, and you cannot even zoom it large enough to read.  What is interesting is that in fact, the FHIR Resources do tend to cluster, and Patient, Practitioner, and RelatedPerson find themselves at the center of care, just like you might expect.

A long journey ends...

OK.  So I've been at this Master's degree thing for the majority of the time I've been with my current employer.  It took me three+ years to find the program that would take me (the Online MBI Program at Oregon Health & Science University), and almost three more, but I'm FINALLY FINISHED!  And the funny thing was, that I finished in the first place I first looked some six or more years ago.

Wow.  What a journey.  I think my favorite three classes are in order:

1. Human Computer Interaction (the most recently completed)
2. The Practice of Healthcare (the one I thought for sure was going to kill me)
3. Introduction to Informatics (one that had me on the floor laughing in the first week)

But quite frankly, I enjoyed every single one, and aced them all (save one, in which I only got an A, and it wasn't in any of the ones above). I'm about 2/100ths of a point from perfect, which quite honestly does NOT reflect my own perception of my ability at all.

I think the biggest thing that I learned over the last three years was the dramatic gulf that still existing between the "practical", technical, software engineering disciplines, and the academic, but also highly intuitive medical disciplines.  The latter are both more and less science than the former, or perhaps I have that reversed.  At the population level, the math and science in healthcare is all there.  Across the software engineering disciplines, not so much.  In the aggregate, software is still high art.  And yet at finer grains, healthcare is so much more art than the day-to-day of writing code and implementing algorithms, which is almost all logic (math).

One of the things that I have very clearly decided is that I will focus much more attention on teaching in the future.  I've always loved teaching.  The most enriching experiences I had was being a TA for the Standards and Interoperability class.  In most of the teaching I do, I see students for a day or two. I never really get to know them or see them grow over the course of a term.  Even though my time teaching was very short, working with others over a period of seven weeks, the last of which covered almost a week together in the same space, was truly different.  I got to see people learn and grow and even change the way that they think in ways I would not have expected, and yet pleasing none-the-less.

Again, I have to profusely thank my advisor, Dr. William Hersh.  Without his support I would never have entered the program, let alone finished it.  I have to say he made it interesting for me in many ways I didn't expect, one of which I hope you'll be seeing in a journal sometime in the next year.

Today, I sign off differently, tomorrow I'll be back to the same-old, same-old.  

   Keith W. Boone, MBI

P.S.  In a couple of weeks I'll be able to share the content of my capstone report with you.  Hopefully I'll be able to put all that writing energy that's been going elsewhere for the last three years back into this blog.

Other People's Stuff

Everyone likes to use their own toothbrush.  We know where it has been, and it fits our hand perfectly.  Someone else's toothbrush is just, well, ick!

The problem with standards is that they often have that "other person's toothbrush" feel to them.  It's not the way I'd do it, or I don't understand why they did X when clearly Y is so much better.  It takes a while sometimes to overcome that icky sensation of putting that thing in our mouth.

Eventually, if we keep at it, it becomes ours, to the point that we might actually find ourself facing the very same challenge trying to convince others to use what has now become "our standard."

It is certainly a true statement that trying to learn something new, or use something different that we are accustomed to is hard.  "I don't have time for this, why can't I just do what I've been doing?" I hear.  In fact, you might actually not have time.  But you may also be missing an opportunity to learn from what others have done.  Only you can decide which is more important.

Standards is all about using other people's stuff.  Few people are in a position to craft standards, many more are in a position to use them.  If, though, after asking yourself the question of "Is this the stuff I need to be worrying about, or is something else more important?"  you come to the conclusion that there is something more important to be worrying about, consider whether using other people's stuff might benefit you, so that you can move on to that more important thing.

It's always easier to understand what you did on your own, rather than to comprehend someone else's work and logic.  But that logic and rationale is present.  If you learn the knack of it, you can do awesome things.

   Keith

Changes

Ch-ch-ch-ch-Changes (Turn and face the strange)Turn and face the strainCh-ch-ChangesDon't have to be a richer manCh-ch-ch-ch-ChangesCh-ch-Changes (Turn and face the strange)Don't want to be a better manTime may change meBut I can't trace time -- David Bowie

I'm more than six months into my new position, and there have been a lot of changes over the past few months.

I dropped my eldest daughter off at college last week.  I still haven't adjusted to that.  I found myself wondering at 4:00 today why she wasn't home from school yet.  Oh yeah, I reminded myself.  November for Thanksgiving.

Next week I finish my last class in my Masters in Bioinformatics.  That and turning in my final capstone paper are all that stands between me an my degree.  I've learned a lot over the last three years in that program, and I cannot recommend it highly enough.  Bill Hersh has put together a great program at OHSU.  Whether you go for the certificate, the masters, or even just the 10x10 program, it's all good stuff.

My standards work is slacking off as my implementation work is picking up.  I'm principle architect for three teams working on Interoperability stuff.  I wear three hats. Some days I'm an architect, others a product manager, and others, an engineering manager.  Some days I do all three, sometimes at the same time.

My schedule is split between three time zones, the usual left-coast right-coast for the US that has been the norm for most of my life, but now also about 4 hours in the middle of the night (12am -4am) Bengaluru time.  I sleep when I'm tired, which is not as you would expect to be "most of the time".

I still struggle with what I want to be when I grow up, forgetting that since I managed to reach 50 without doing so a couple of years back, I don't actually have to grow up, and I have a certificate from my family to prove it.

I suppose that some day when I retire, I will want to teach full time, rather than spending about a third to half of my time doing that.  What I think that really means is that my projects will become my students, rather than having students because of my projects.

Now if I could just figure out how to get the next six things done that I need to before the day is over, without moving to somewhere like Mars, or worse yet, Mercury or Venus.

   Keith

FHIR in India

In case you missed me, I've just gotten back from a fifteen-day long trip, where I spent the last eleven days of it in India.  While there I conducted three training sessions on FHIR, one internally at GE offices in Whitefield, Bangalore, one for HL7 India, and a final one for a partner organization in Mumbai.  While in India I gave an overview of FHIR to nearly 200 software developers working in Healthcare.

Image via @msharmas

There's a great desire to learn more about FHIR in India, and I was privileged to be there to spark the fires as it were.  I am grateful to HL7 India who was able to pull together a half-day plus session in Bangalore on short notice.  I expect we'll be doing more together to follow up, as I expect I'll be back later to conduct some advanced sessions.  I'm also trying to get a FHIR Connectathon started in India as well, more on that later as plans come together.

   Keith

The Dog Whistles of Health Care

Discrimination in health care was institutionalized in Independence, Missouri on July 30, 1965 when President Johnson signed the Social Security Amendments of 1965 into law, creating “two moral frameworks for public financing of healthcare”. Medicare was supposedly an “earned” right for the elderly, while Medicaid was framed as a “welfare” program for the poor. It was a necessary political compromise. It was just a first step and bigger and better things would certainly be accomplished in due course. It was better than nothing. But fifty years later, and after taking yet another “first step” with Obamacare, the wasteful, divisive, discriminatory, and ultimately self-defeating direction we chose back in 1965, and again in 2010, has not changed one bit.

After 45 years of tinkering with Medicare and Medicaid, Obamacare in a bold stroke expanded the welfare model of medical care upwards into the heart of what used to be known as the American middle class, the former engine of progress and prosperity.  First, Obamacare expanded the Medicaid program itself to include people who are less poor than current Medicaid recipients. When Medicaid opened its doors in 1966, it provided charity health care to approximately 2% of Americans. Today, over 22% of Americans (72.6 million) and almost half of our children (35.3 million) are receiving their medical care via this welfare program and the numbers are trending sharply upwards.

Gift Horses

But the greatest innovation of Obamacare is undoubtedly the Health Insurance Marketplace, which is a brand new welfare program for the middle class. People who are not deemed poor enough to receive Medicaid charity can obtain Federal medical assistance on a means-tested sliding-scale. Largely unbeknownst to them, another 10.5 million working Americans were placed on welfare while “shopping” for health insurance in 2016.  These people are reportedly rejoicing their good fortune, because Obamacare is better than anything these people ever had, or could ever hope for.

In recent days, Aetna announced that it will drastically reduce its participation in the Obamacare marketplaces, joining a long string of other health insurers, including giants like United Healthcare and Humana, and small local outfits like Scott & White in Texas, all of which cited massive financial losses in this market. It looks like next year the many “choices” available to these people in the Obamacare marketplace will be severely curtailed, particularly in areas where poor, uneducated, low-information voters reside. The “choices” were not great to start with, seeing how most Obamacare plans rely on managed care provided by narrow networks of doctors and hospitals, and the level of charitable support is fixed, regardless of your “choice”. The optics of many choices was there to create an illusion of consumers “shopping”, as opposed to just having people apply for welfare.

The price for sparing these people the social stigma of being on welfare turned out to be not only too high, but also too low (think Escher paintings here). People who qualify for Medicaid are prohibited from “shopping” on the Obamacare marketplace, unless they are willing to forgo handouts and pay full price, because a “Marketplace insurance plan would cost more than Medicaid and usually wouldn’t offer more coverage or benefits”, and a government website proudly declares that Medicaid “generally provides a more comprehensive benefit package than private insurance”. If this is true, the Obamacare architects decided to pay private insurers on the marketplace more for less, which is not preventing insurers from bleeding cash. On the other hand, some of the same insurers, and many others, seem to be making money hand over fist in the Medicaid market which pays less for more.

How is that for a brain twister? Yes, yes, I know, if you are a physician and you accept Medicaid, you know precisely how to untwist this nasty little knot, but this narrative was not created for you. The first thing, or person (loosely speaking) to remember here is Jonathan Gruber. A while back Mr. Gruber shared with us that the guiding principles in the rooms where Obamacare was designed were that American voters are stupid and that lack of transparency is a good thing. It should be obvious by now that the introduction of Obamacare to the public was false and its initial incarnation, chockfull of choices, “subsidies”, marketplace “shopping” and all, was (designed to be?) temporary. But hey, it was just a first step and it was better than nothing. So what’s next?

The Morning After

As is the custom in our great nation, now that Obamacare marketplaces have been exposed as the hoax they really are, the cheerleading section is transitioning to its Monday morning role of funeral criers. Every ‘splaining media outlet is diving into lengthy treatises about risk pools, moral hazard, actuarial values, complete with charts and “I told you so” interviews on how to salvage the situation. The government, as usual, is doubling down on the “everything is (still) awesome” anthem of planned stagnation. Insurers leaving the marketplace are a sign of normal competitive business. Sky rocketing premiums are a result of initial underpricing of products. Things will eventually even out. And besides, why worry your little head about premiums going up or down, if the government is paying for the ride?

See, the more the premiums go up in 2017, the more people would be able to pay less for marketplace plans. This is because very poor people are disproportionately more likely to use the Obamacare marketplace, and these people seem to have a predilection for cheap health insurance plans. Theoretically, all Americans except the 20% or so at the top (the fifth highest income quintile), are eligible for welfare in the marketplace if their stars fall slightly out of alignment. Right now, the self-appointed elites are piloting this marketplace solution for people who have few if any choices in life in general, but make no mistake, the forthcoming rollout to the rest of us will be fast and furious.

After you read a dozen or so articles on the subject, several options surface as the popular wisdom of the unpopular elite minority who won’t be caught dead anywhere near an Obamacare marketplace:

• On autoplay since 2012 – Repeal and replace the whole darn thing with something really good.
• Whistling past the graveyard – Stay on target. Ignore the noise. Keep pushing the happy narrative. Nothing to see here. Next year will be better.
• Pedal to the metal – Add some serious fangs to the individual mandate. Force insurers to eat their marketplace veggies if they want public cash desserts.
• Resurrection – Remind me, why did we drop that “public option”? What was it again?

Plebeian logic says that at least for the immediate future we will be whistling past the graveyard of health care in America. After that, as strange as it may sound (go ahead and bookmark this), they will be rolling all four option into one grand solution.

The Pauper Option

If you are eligible for Medicaid in the state of Louisiana for example, you have five choices, which is more than some Obamacare marketplace “shoppers” have. On the Healthy Louisiana website, you can enroll, select a plan, compare plans, compare networks of providers, and compare plan benefits, including co-pays, cash rewards for healthy behavior, free cell phones and even free diapers and school supplies. Is this a marketplace? I think Healthy Louisiana is as much a marketplace as the Obamacare Venezuelan shopping mall. It provides infinitely more information. It includes plans from Obamacare quitters, such as Aetna and United Healthcare. The state pays less, beneficiaries get more, and insurers make very nice profits.

In Baton Rouge, there is one (1) oncologist in the United Healthcare network and zero (0) plastic surgeons in the Aetna network. Sometimes, you just have to travel to New Orleans, Shreveport or Lafayette. It’s only a few hours by car. Most people don’t need oncologists and plastic surgeons. Most people are perfectly fine just having 100 family practitioners, almost half of which are doctors.  In Louisiana, Medicaid pays $41.53 for a typical office visit (99213), which is a bit more than half the Medicare rate, and usually less than half of what private insurers pay. With a full time schedule, and average overhead, a primary care doctor seeing nothing but Medicaid patients in Louisiana, will end up with $100,000 to $130,000 a year before tax.

This is the secret sauce. This is what’s missing from the Obamacare marketplaces. There may be room for additional tinkering with networks, but it won’t be enough. The only way to bring costs down is to attack the supply chain. Like Walmart. Like Medicaid. But you can’t do it if you have to compete in earnest, because you will lose all your suppliers. Everybody has to do it together, and that would be collusion. So you either merge & acquire until you are the sole insurance provider in a market, or you make the government do it for you. Either way, we end up with a marketplace of Medicaid plans. Like Healthy Louisiana.

Before you argue that physicians will just stop accepting Obamacare marketplace plans, remember that many, many doctors do take Medicaid and adding 12.5 million people from the marketplace to the 72.6 million already on Medicaid is not a big deal at all. This is why insurers that specialize in Medicaid do better on the Obamacare exchanges. It’s not that they know how to manage these people. They know where to find and how to manage these doctors.

They probably won’t call it Medicaid. Maybe Medimart will be acceptable. It will most likely cost a little more to maintain the appearance of respectability, at least for a while, but this is a generous program for these people. The line is drawn at 400% Federal Poverty Level (FPL), and as the global sharing economy grows, and as employers begin to see the light, those who can’t quite reach six figures incomes, eighty percent of people in America, will be “shopping” at Medimart, because that’s what these people do.

Eliminating the Hurdles of Clinical Quality Measures for the 2016 Reporting Year

Dynamic Health IT is proud to announce we have successfully pilot-tested with ICSA Labs for 2015 Edition CQM-related measures (c)(2) and (c)(3).

That's a bit of a mouthful, but it means that our software, CQMsolution, remains at the forefront in providing meaningful, submission-ready clinical quality measure output. CQMsolution supports 93 CMS eCQMs and the 64 aligned PQRS measures.

Under 2015 Edition, Clinical Quality Measure reporting has been made more comprehensive. The three existing measures (c)(1), (c)(2) and (c)(3) have been revised:

• Cypress 3.0 validation software, which includes more robust testing relative to 2.6.1, must be supported
• The latest set of measure versions for the 2016 reporting year, validated by Cypress, must be supported
• Required data export capability is expanded
• Data import should be more accessible (“without developer assistance”)
• Exported data file must meet R2 implementation guide for QRDA

The three CQM measures are also joined by a new measure: measure(c)(4) - filtering. In meeting (c)(4), EHRs must be able to filter quality measure results at the patient and aggregate levels by a list of variables. The filtered results must be made available in a human-readable format and data file.

Not reinventing the wheel, replacing tires

Our developers put in rigorous work over the last quarter, incorporating feedback from clients, to dramatically enhance the software, making it easier-to-use, more robust and, of course, certification-ready for ONC 2015 Edition and Cypress 3.0.

We saw this development cycle as a great opportunity to take everything we have learned over the past few years - in the form of our feature enhancements and performance improvements - and integrate it fully with new development.

This meant taking the principles behind engine and UI that worked and preserving them, while using the regulatory changes in measure logic and output as a chance for a coordinated re-design. The CQMsolution calculation engine uses the eMeasure HQMF files, which are based on the Quality Data Model (QDM), as the basis for evaluation. We use these files to create the data structures through which we process patient data. 

In contrast to feature-specific roll-outs, this was a bottom-up version. It is not often you get a chance to re-write core parts of your application. This can be a perilous process, but there were two factors that made it successful:

• The ability to create a completely new calculation engine for 2016 reporting year without altering previous reporting year calculation engines meant we were not required to maintain backwards compatibility in the new code
• After identifying our time parameters and client needs, our development team realized complete development focus would be needed. The project was afforded development time in a distraction-free environment.

CQM data intake and calculation were worked all at once, allowing for a holistic approach. Combined with extensive testing, relying in part on a more exhaustive Cypress data set, the result was a robust upgrade, built on clean code.

-         Key changes

-        

The changes from the 2014 release measure to the 2015/2016 release measures were dramatic, requiring a rewrite of major portions of CQMsolution. Example of these changes can be seen in the text of the measures. New subset operators were added and new temporal operators that make the measures more clear. 

The changes in QRDA format also called for a rewrite to the parsing and generating pieces that enable our clients' certification and submission of CQMs.

On top of the CQM engine, we integrated user experience changes to make both certification testing and day-to-day use of the application easier and reflective of technical changes. These changes range from easier report tracking in the UI, to one-click certification testing through single-upload "compound" report and API to Cypress.

Improvements ahead

-         

CQMsolution 3.0 is now in beta testing with clients, pending final ONC certification. The development cycle is perpetual and we intend to stay at the forefront of CQM development. By year's end, 2017 reporting year support should be complete and a number of features are in the pipeline for the near term, including API-based data collection from client EMRs. 

We look forward to rolling those out and, of course, to our full certification on all four CQM measures. Stay tuned!

Well, Shit.

My twitter feed is all abuzz this morning on the death of @jess_jacobs. Jess is a woman with a challenging illness who documented some of the complete failures of our health system to provide her with even barely adequate care  I've met her briefly about four times in my life. Her death saddens me this morning, not because I knew her well, but because she did great things with her life, and because we share at least one thing in common, our jackets. But in some ways I feel the way that others do when their favorite celebrity dies.

Among many of my friends Jess IS a celebrity.  But outside our world, she is not known well enough, nor is her story told often enough.  So I will walk today in honor of Jess, and instead of telling my story, I will tell hers.

   Keith

Offering an Informal FHIR Chat, Whitfield area, Bengaluru, India

I'll be in Bangalore for about 10 days later this month, to work with several of my teams during the week of the 22nd, and to deliver some standards training internally the following week.  One of my architects suggested that we set up an informal FHIR chat on the weekend I'll be staying through, either Saturday, August 27th, or Sunday August 28th for folks in India who want to learn more about FHIR.

Timing is too tight for me to arrange a venue through any sort of official channels, however, others in the region might be able to put something together.

So, here is the offer.  I'm free for the entire day either Saturday or Sunday, and can deliver an overview of HL7 FHIR for developers in India.  If you are interested in helping to pull this together, please either leave a comment for me here, or e-mail me at keith.boone@ge.com.

   Keith

FHIR Applications Roundtable at Harvard Medical School

The DHIT Team has been an active participant in FHIRConnectathons during the past two years. Among the benefits of these events is the unique glimpse they provide into what the industry is delivering with FHIR and how the standard continues to evolve through active development.

Our team is also eager to find connections between out interoperability expertise and real-world healthcare problems. With those (and other) goals in mind, our President Jeff Robbins attended the 1^stannual FHIR Applications Roundtable at Harvard  Medical School in Boston to learn more.  

Although FHIR is a relatively new standard, it has great potential and forward-thinking healthcare IT organizations are already deploying FHIR solutions. 

Harvard Medical School

The Roundtable consisted of a series of 15 minute presentations by academics, software developers and consultants highlighting FHIR-related projects.

The projects on display included patient and provider-facing apps, Clinical Decision Support, clinical collaboration platforms, patient education, all the way up to a complete, native FHIR-based EHR. The expansiveness of the applications and implementations discussed demonstrates just how far the standard has come from its days in draft status.

On the policy front, Steve Posnack, Director of the Office of Standards and Technology at the Office of the National Coordinator for Health Information Technology spoke about efforts to encourage interoperability through FHIR developement and the  HL7 FHIR App Ecosystem. ONC is encouraging market-ready FHIR support through its "challenges."

DHIT plans to offer a CCDA-to-FHIR converter in the near future.  Stay tuned!

Matthew Dugal celebrates five years with Dynamic Health IT

Dynamic Health IT congratulates Matthew Dugal on five years with the company!

Matthew has blazed new trails with our development team. He is a dedicated, caring employee, offering a wealth of expertise on any project to which he lends his talents. 

Matthew, congratulations on your 5 year anniversary with DHIT.  I feel very fortunate to have you on our team and have really come to appreciate your huge talent for software development through seeing the success of the products you’ve developed here, particularly CQMsolution.  You are also an amazing resource and trove of information for all things related to computer software and hardware, from setting up servers to finding the right piece of software to get a task done, to security and network troubleshooting.  Finally, you are reliable, dependable and ethical --- all great qualities for an employee.  Thanks for all you do!

-- Jeff Robbins

A big 5 year Congratulations to you Matthew! You are an integral part of Dynamic Health IT’s team. Your engagement in the ‘Magic’ that occurs here at DHIT encourages our clients to count on us. Your patience and perseverance on some of the most difficult projects has contributed to our products' success. Your honesty and dedication is admired. Thank you for all you do.
-- Raychelle Fernandez

Matthew is a great resource when it comes to programming. Not only does he know how to get the job done, but he can clearly explain and teach you how it was done so you feel confident to do it again in the future. Over the past 5 years he has taught me several valuable tricks of the trade that I’ve applied here at DHIT and at school. THANKS MATTHEW!!!
-- Maria Ruiz

Congratulations on your 5 years with Dynamic Health IT, Matthew. It is a pleasure working with you. Your programming and problem-solving skills are enormous and appreciated. Your knowledge of technology is very broad and invaluable. Beyond that, you are a very kind person to work with. We are so lucky to know you as a person and have you as a team member!
-- Ozlem Kurt

Matthew is a pleasure to work with - very knowledgeable and always willing to help. He’s not only very committed to the company, he also invests time and energy to his coworkers. DHIT would not be what it is without Matthew’s support and dedication. 

-- Maureen Bell

Matthew is a great coworker and a complete professional. He always shows good results in his projects and I always learn from him when we work together.
-- Erick Lanford

Matthew is a wizard coder whose technical expertise touches everything DHIT does - from our product line to our network infrastructure. Each time we attend a conference or interact with colleagues and clients in the industry, you can see the fruits of his labor. His hard work and deep dive into quality measures is evident when you realize the kinds of unparalleled things CQMsolution can do. I'm grateful for his guidance anytime I seek information across our projects. Matthew is thoughtful and thorough in everything he does. It's fun to hear his insights, whether work-related or not.
-- Joshua Shreve

CCDA Implementation-a-Thon II: Chicago

HL7 International, the standard bearer for healthcare information exchange, has kept up its hands-on approach with implementers and developers. One of their newest offerings is a series of Implementation-a-thons for C-CDA. As we did in Orlando, our team traveled to take part in the C-CDA Implementation-a-Thon this month in Chicago.

HL7.org

After the Orlando meetup, we were looking to take a deeper dive into the standard and share what we had been working on since January.

One of HL7's stated goals for the event was to "identify issues and potential trouble spots" in the CCDA. While some of us in the room are nominally competitors, we are all united around the common goal of making CCDA use and implementation as easy as possible, resolving ambiguities in the standard and working toward greater interoperability. EHR firms such as Epic and NextGen and a range of other developers, users and experts were all in the room, working toward this shared goal.

The collaborative spirit was encouraging, though some of the major industry players have been missing. This can make it difficult to coalesce around a decision on how to overcome major roadblocks to interoperability.

As is often the case at Connect-a-thons and other healthcare IT meetups, there were plenty of new faces, an indication of the growth in interest and a reminder that the standard requires ongoing outreach and education.

Here's a quick and dirty rundown of some key topics covered, followed by a few of our observations on specific discussion areas:

• Implantable devices
• Gender identity: administrative gender and birth gender
• "Assessment and Plan" vs. "Assessment" and "Plan of Care" 
• Approaches to "no known" value (allergies, medications, problems, etc.)
• Discharge Medications (v1.1 vs. v2.1)
• Care Plan: when to send, defining sections
• ONC C-CDA test data review and import
• Human readable vs. machine readable format and its effect on interoperability
• Medications: approaches to recording a "tapered dose"

Implantable devices

PHOTO: Boston Scientific

A key question around implantable devices - a class of equipment that includes artificial joints and pacemakers - is where the implant should be recorded in a C-CDA.

Does it go into "Procedures,""Medical Equipment" or some combination of the two?

For ONC Certification, it is expected to be in "Procedures" section, unless there is no implantable info, then it lives in the"Medical Equipment" section. At the Implementation-a-thon, HL7 further clarified that the implantable device information should always appear in the Medical Equipment section. When the specific procedure for the implant is known, it should also go into Procedures.



Gender identity

There is not yet an agreed-upon standard in healthcare data for distinguishing the sex of the patient as determined at birth from other notions of gender identification.

HL7 currently uses the concept of administrative gender, defined as "the gender of a person used for administrative purposes." FHIR, which built upon RIM, can incorporate XML resources to capture gender identity, but the best practice has not been decided.

In the case of a transgender male - whose birth sex was assigned female and whose current gender identification is male - SNOMED codes are capable of capturing this distinction. Common practice in C-CDA would most likely record the Administrative gender for this patient as female.

As HL7 explains in its current detailed descriptions:

(G)ender may not match the biological sex as determined by genetics, or the individual's preferred identification... Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosonal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. 

That last sentence gets at the fact that even the underlying process for recording gender identity and sex assignment is in need of clarity. There is no single approach, for instance, to mapping gender as recorded on an intake form with relevant C-CDA sections.

The Implementation-a-thon also explored the example of administrative gender as represented in 'UNK' nullFlavor, paired with an observation recorded in Social History. The general guidance from HL7 is that gender identity concepts should appear in"Social History,"while the "pending guidance" on birth sex is as follows:

C-CDA recordtarget/Administrative Gender is the field used to record the Birth Sex and must be coded as follows: M (male), F (female) or a nullFlavor of 'UNK'.

However, there will be further clarification coming from ONC and report back to the group.

Future considerations on this subject:

• Some Clinical Quality Measures require a reliable location for patient birth sex.
• Similarly, certain genetic predispositions and Clinical Decision Support in general also require birth sex, but not at the expense of multiple conceptions of gender identity.
• Which concept of sex or gender identity should be used in patient matching across data sets?

The discussion centering around this issue further underscored the need for all major players to take part in the shaping of the standard in order to avoid confusion and incoherence.

Lessons Learned

HL7 events never fail to be highly educational. Among the takeaways for us:

• As the C-CDA standard becomes increasingly flexible and interoperable, wide participation in dialogue and educational outreach are esssential
• Recording of gender identity and sex will likely be unresolved until an industry-wide consensus can be achieved across major providers, EHR developers, payers and policymakers
• As the standard and certification testing evolve, development practices must follow suit. The new testing tool is a great help in this process.
• Translation codes for alternate value sets should be used whenever possible, rather than rejecting a C-CDA outright.
• More focus is needed on reconciling discrete values in machine readable with the text description in the human readable portion.

Vegetarian food beneficial but balanced diet crucial

While most doctors agree vegetables, fruits and cereals are beneficial for health, some also argue that complete absence of non-vegetarian items, mainly fish and egg, may deprive vegetarians of certain essential diet components such as omega-3 fatty acids and vitamin B12, that are not adequately available in vegetarian foods. Omega-3 fatty acids and vitamin B12 are essential to strengthen muscles and brain nerves.

Several studies in India and abroad comparing vegetarians with non-vegetarians have found incidence of heart diseases, cancers and obesity are lower in those following a vegetarian diet.

According to Dr S C Manchanda, head of preventive cardiology, Ganga Ram hospital, the rate of heart diseases and cancer is around 20% less among those eating a completely vegetarian diet than those eating meat. "Vegetables and fruits contain fibre which lowers cholesterol and helps in weight management. This in turn is good for the heart," says Dr Manchanda.

However, there is also a contrarian view existing among the medical fraternity itself. Though there is no denial of the benefits of a vegetarian diet, there are serious concerns about the "distorted vegetarianism" dominating the Indian palate.

Dr Anoop Misra, chairman of Fortis CDOC hospital for diabetes and allied specialties, points vegetarian diets are often high in carbohydrates, trans fat and are low in proteins, omega -3 fatty acids and vitamin B12. "Around 90% of Indians have vitamin B12 deficiency and traditionally weaker muscles," he adds.

While red meat and processed meat are considered particularly harmful for health, most doctors still advise measured portions of fish, egg and even chicken as part of a balanced diet.

"Diet prescriptions like drugs or medicines can never be generalized. Anything in excess can be harmful for the body - be it meat or oil or carbohydrate. The diet of an individual also depends on his body mass index, his blood and family history," says Dr Misra.

Source-The Times of India           Read more..

Peanuts may prevent childhood obesity

Children who eat a snack of peanuts regularly have a lower risk of being overweight or obese a new study has claimed.

Hispanic middle school children, at high risk for being overweight or obese, reduced their Body Mass Index (BMI) when they adhered to a nutrition intervention that included a snack of peanuts, compared to those children who did not. 

The 12-week study was conducted by researchers at the University of Houston Department of Health and Human Performance (HHP), Baylor College of Medicine and Texas Woman's University. Their findings are published in the Journal of Applied Research on Children. 

"Obesity is the most pressing health issue facing us today," said Craig Johnston, HHP assistant professor. "We'd like to think it's preventable, but from where I sit right now, there hasn't been a lot shown to be very effective on a large scale." 

The study acknowledged that snacking is more common during the adolescent years and that the unhealthy eating habit can lead to an unhealthy weight. This is especially true if a student doesn't have access to other meals during the school day. 

"We have a lot of kids skipping meals for a whole bunch of reasons," he said. "What we found is that kids get home from school around 4 p.m. There's less supervision by parents and less structure. Kids are sitting down at the TV and eating, eating, eating because they really didn't eat at school." 

Instructors guided 257 Latino adolescents from three Houston-area charter schools through a program of physical activity and nutrition education. About half the students received a snack of peanuts or peanut butter three to four times a week, while the rest received the snack fewer than once a week. The snack was administered after school as students were boarding the school bus to go home. Peanuts were chosen because nuts are nutrient-dense snacks that promote a feeling of being full. 

Following the 12-week intervention, students spent 12 more weeks maintaining the healthy snacking habit. At the end of the period, those students who received the snack more regularly experienced a decrease in their overall BMI (-.7kg/m2) compared to those who did not receive the regular peanut snack (-.3kg/m2). The researchers conclude that afterschool programs and schools can replace energy dense, unhealthy snacks with peanuts to provide a healthier alternative for children (researchers in the study ensured students did not suffer from nut allergies). 

Johnston says the fight against obesity needs creative solutions that help people manage their weight, appetite and hunger by offering socially acceptable food choices.

The findings were published in the journal of applied research on children. 

Nutritional needs of youth

Balanced diet is an elusive proposition for children today. Among host of reasons, the lack of financial resources is impeding several families to provide a nutritional-rich diet to their children. But, sadly unless one becomes physically fit and mentally agile which is a direct result of balanced diet- he can not make any contribution to his field. Particularly this is very true of our younger generation, who are endowed with great potential. 

FHIR Orlando: Getting up to code

FHIR Connectathon 11 took place in January 9 and 10 in Orlando, FL. As with every stop on the FHIR circuit, evidence of steady growth in the standard was in abundance. Look no further than the furious coding that took place in a crowded hotel conference room.

Credit: Bill Dickinson

At Dynamic Health IT, the focus of our FHIR development has been on clinical quality measures and patient-accessible data. We continue to refine our approach in these areas to match changes both in the standard and how it is understood and implemented in practice. Seeing the diversity of application using the standard– owing largely to potential for resources to be self-defined – reminds us why FHIR has become an increasingly essential building block in our product development.

Appropriately enough, the Connectathon has now expanded to eleven tracks – ranging from basic patient management to financial services to genomics. As a form of introductory track, implementers perform the following tasks in the "Patient" track (Track 1), against their own or an available FHIR test server:

• Register a Patient
• Update a Patient
• Retrieve Patient History
• Search for a Patient (using name)

HL7 International also offers four tutorials earlier in the week for those looking for a primer on the standard.

There were plenty of new coders in attendance in Orlando, which speaks to current developmental climate for FHIR. Roughly half of the attendees raised their hand when asked if this was their first Connectathon, It's worth noting that while FHIR is growing up, it is still a relatively young standard. Let’s not forget that HTML, often used as an exemplar for FHIR, was proposed in 1989 and is still undergoing major adaptations reflecting the evolution of the Web.

As Grahaem Grieve announced in Amsterdam, FHIR will now be a "working standard," reflecting the fact that it is being implemented in production environments, but still has many core elements subject to change. The move from a draft standard toward a "balloted" standard is due to take place officially sometime this spring.

This new-found maturity was evidenced in the shift toward implementing servers. There is now a major emphasis being placed on rigorous testing against servers. Vendors are presenting production-level products for testing FHIR servers and robust patient test decks are being rolled out to meet the demand.

It was great to again see a capacity crowd for this event (hopefully not a "FHIR hazard"). The ability of FHIR to realize all of its potential has much to do with the strong community it has built.