Comments to ONC: PCAST HIT Report Becomes a Political Piñata

The PCAST Report on Health IT has become a political piñata. 

Early Feedback on PCAST 

Like many of my colleagues, I was taken aback by the release of the Report in early December 2010 — I didn’t know quite what to make of it. Response in the first week of release was: 
  • Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report. 
  • Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
  • Focused on technical and/or clinical perspectives around two broad themes.
    • The vision is on target:  “extraordinary”, “breathtakingly innovative”.
    • These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Today’s POV on PCAST 

What  a difference a six weeks makes. 

Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards

We concluded our last post in this series with a blunt prediction that “key physicians will sit on the sidelines” and that clinician non-adoption of EHR technology is a potential “deal-breaker for the success of HITECH”.

While this might sound like a criticism of the way HITECH has been implemented, it’s not intended that way — it’s a commentary on 1) the complexity and scope of change that will be required to make HITECH successful, and 2) the level of protective entrenchment existing American health care today.

Rather, we believe that the Office of the National Coordinator (ONC) for Health IT – Dr. David Blumenthal and his staff — have done a superb job in interpreting and defining key aspects of HITECH legislation. We’re big fans.

For those of you who have been following our writings over the past 18 months, think of this post as a summary and status report on the extensive incumbent (cat) vs. innovator (dog) dialogue:

  1. A Recap  — The Stagnant Electronic Medical Record (EMR) Market Before 2009
  2. ONC Gets It Right In Three Major Interpretations and Definitions of HITECH

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

Chilmark Needs to Chill Out on CCR/CCD Findings

John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.

However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” in The Health Care Blog. He writes:

In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future.  The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.

I have four beefs with John’s essay:

  1. It’s no news that HIEs prefer CCD.
  2. HIEs are not representative of the broader health IT market.
  3. The narrow findings don’t justify the broad conclusion.
  4. The CCD and CCR standards are more complementary than competitive

Let’s look at these one at a time.

John Halamka’s Stunning 180: “Dogs and Cats Should Live in Harmony”

The King of the Cats has just acknowledged that indeed cats and dogs should co-exist peacefully.

Dr. John Halamka — Vice Chair of the HIT Standards Committee of the ONC and one of the most vocal and influential figures in health IT — writes a blog post this morning entitled “The Genius of AND”. Halamka reasonably summarizes the essence of the debate about standards and interoperability as being between “the healthcare informatics crowd” (cats) and the “Internet crowd” (dogs):

He notes that the debate shouldn’t be about one or the other POV prevailing (“either/or”), but about integrating both points of view (“and”):

..we need to embrace both approaches – the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google’s CCRg or PDF can do the job.

I’m absolutely stunned…and speechless.

The Third Rail in HITECH Implementation: “Please Don’t Make Us All Speak Latin”

By Vince Kuraitis and Steven Waldren MD, MS.  Dr Waldren is Director of the Center for Health Information Technology at the American Academy of Family Practice (AAFP).

Two issues have rightfully surfaced front and center in the public’s understanding of HITECH Act implementation:

  • ” definition of “Meaningful Use” of EHRs, and
  • ” definition of “certification” process for EHRs

…and we applaud the progress of the workgroups and the HIT Policy Committee in addressing these issues constructively.

However…a THIRD issue lurks – “Data harmonization at the expense of data liquidity“, or put another way – “misplaced pursuit of one (and only one) language at the expense of practical communication.”

On August 20, the HIT Standards Committee approved recommendations to bring forward to the HIT Policy Committee meeting later this September. 

In this post, we will:

  1. Summarize aspects of the HIT Standards Committee’s recommendations that are problematic
  2. Develop an analogy to illustrate how the recommendations will limit innovation and increase barriers to communication.  Our analogy:

The Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013.


Dr. Blumenthal has wisely anticipated that there could be a situation where in his role as national coordinator that he should not follow a Committee’s advice:

“This committee does provide advice to the national coordinator, but it does not make policy,” Blumenthal said, with a noticeable emphasis on “not.” [iHealth Beat; August 18, 2009]

Dr. Blumenthal, this is exactly the situation you have anticipated.

CCHIT Should Support BOTH the HL7 CCD and the ASTM CCR for PHRs.

The federal government sponsored Certification Commission for Healthcare Information Technology (CCHIT ) is undertaking a certification process for personal health records (PHRs) . The CCHIT PHR Work Group has invited public comment on the First Draft of the PHR Certification Criteria .

The current draft of the PHR Certification Criteria specifies use of the HL7 Continuity of Care Document (CCD) as the only endorsed standard for interoperable exchange of information to and from PHRs.  This is extremely short-sighted.

I wrote a comment to the PHR Work Group explaining why it’s important to adopt BOTH the HL7 CCD and the ASTM Continuity of Care Record (CCR) .  I suspect most professionals commenting on these criteria will be looking through the lenses of health information technology, so I thought it would be important to share a different view — one through the lenses of business strategy and public policy.  Here’s my commentary:

Untangling the Electronic Health Data Exchange

by David C. Kibbe MD, MBA

The purpose of this post is to help a non-technical audience untangle some of the confusion regarding health data exchange standards, and particularly come to a better understanding of the similarities and  differences between the Continuity of Care Record (CCR) standard and the CDA Continuity of Care Document (CCD). But what I’m most interested in is getting beyond the technical, political, or economic positions and interests of the proponents of any particular standard to arrive at some principles that demonstrate in plain language what we are trying to achieve by using such standards in the first place.

Frankly, I don’t give a hoot about what standardized XML format for capturing clinical data and information about a person becomes the norm in the health care industry over the next several years. I do care that the decision is made by the people, institutions, and companies who use the standards, and not made by a quasi-governmental panel or a group of “industry experts” whose economic or political interests are served by the outcome, and dominated by a particular standards development organization with whom they are very cozy. 

In other words, I do want free and open market forces to be able to operate freely and openly as health information exchange evolves, in part because I believe market forces will work in the direction of continuously improving health IT, whereas in my experience top-down efforts are often protective of established interests and discouraging to innovation.

Herein lies the problem, in my opinion, with the standards adoption process that the Office of the National Coordinator of HIT (ONC) and HITSP have overseen during the past four years.

Healthcare Informatics Webinar: Google, Microsoft, & Dossia Create the Personal Health Information Network

  • What are companies like Google, Microsoft, and Dossia (sponsored by Intel, Wal-Mart, AT&T and others) hoping to accomplish in health care?
  • What is the emerging Personal Health Information Network (PHIN) and why should you care?
  • What’s the Continuity of Care Record (CCR) Standard, and how is it destined to become an initial focal point of data exchange initiatives?
  • Why is the PHIN potentially disruptive to many business models? What types of companies or organizations could be affected the most?
  • What are opportunities and threats to major health care players — hospitals, physicians, health plans, enterprise HIT vendors, ambulatory HIT vendors, and others?
  • What specific actions can you take to be a leader in advancing the PHIN and positioning your company for success?

In a recent blog posting, David C. Kibbe, MD, MBA and I wrote an overview of our vision for the PHIN

Now, for the first time, we look forward to discussing our vision for the PHIN. This Healthcare Informatics webinar will be held:

Thursday, April 17, 1 PM Eastern, 10 AM Pacific.

Click here for details….read “Event Info” to see a more specific description of the webinar.  Get a 15% discount by using Promo Code VK15.

Here’s a diagram of the PHIN as we see it today:


(click on the picture for a larger version)

The Speakers

Birth Announcement: the Personal Health Information Network (PHIN)

Vince Kuraitis and David C. Kibbe, MD MBA 

The Internet and digital technologies have transformed many aspects of our lives over the past twenty years.  We can get cash at ATMs all over the world; we can book our own airline reservations; we can shop and get best prices over the Internet.

Why hasn’t this happened in health care?  Something is missing.

Recently, major global information and communication companies have announced their intention to bring their technologies and business models to health care.  While the creation of Google Health (GH), Microsoft HealthVault (HV), and Dossia (sponsors include Intel, Wal-Mart, AT&T) are important news items by themselves, what’s more important is what they represent collectively — a new Personal Health Information Network (PHIN). The PHIN and applications developed around the PHIN will fill in many missing pieces and bring health care into the Information Age.

For example, suppose you just found out you have high blood pressure – that’s not uncommon.  Suppose you could easily submit information about your condition using the Google Health platform to receive a service that does the following:

  • informs you whether there are clues in your medical history that point to a cause for your high blood pressure
  • explains why being overweight can be a contributing factor
  • tells you in easy-to understand language what the top number and the bottom number mean (“140 over 90”)
  • explains which laboratory tests are necessary
  • alerts you to the possibility that one of your prescription or over the counter  drugs could be making your high blood pressure worse
  • advises you about the usefulness of using non-drug approaches to treatment
  • tells you which treatment drugs have the greatest efficacy and safety for your specific circumstances
  • tells you if any of those generics high blood pressure drugs are available at Walgreens for $4 a month
  • offers to provide you a map with several Walgreens stores in your city that carry those $4 a month medications

…and many more possibilities we have not yet begun to imagine!

This essay:

  • Is the first in a series of articles we’ll be writing to describe the PHIN and why it’s important — expect about a dozen follow-up posts.
  • Is an overview of the basic idea — think executive summary or long abstract
  • Introduces some new concepts, which we’ll try to simplify and define.  We understand that some of this is not easy reading. ….so we suggest you refill your cup of coffee and settle in.

A First Comparison of Google Health and MS HealthVault

While details are thin, here’s a first pass at comparing and contrasting Google Health (GH) and Microsoft HealthVault (HV).  Overall, there are many common features, some differences, and many common challenges between these two platforms. 

A High Level Comparison

Google Health and Microsoft HealthVault Personal Health Information (PHI) Platforms

There’s still not much information available about the specifics of GH, although they did release sketchy information on the Official Google Blog.  I’ll comment on a few of the particulars.