The KHIT Blog: Interoperability solution? HL7® FHIR® -- We ® Family

Monday, October 20, 2014

Interoperability solution? HL7® FHIR® -- We ® Family

FHIR® – Fast Healthcare Interoperability Resources (hl7.org/fhir) – is a next generation standards framework created by HL7. FHIR combines the best features of HL7’s Version 2, Version 3 and CDA® product lines while leveraging the latest web standards and applying a tight focus on implementability.

FHIR solutions are built from a set of modular components called “Resources”. These resources can easily be assembled into working systems that solve real world clinical and administrative problems at a fraction of the price of existing alternatives. FHIR is suitable for use in a wide variety of contexts – mobile phone apps, cloud communications, EHR-based data sharing, server communication in large institutional healthcare providers, and much more...

A central challenge for healthcare standards is how to handle variability caused by diverse healthcare processes. Over time, more fields and optionality are added to the specification, gradually adding cost and complexity to the resulting implementations. The alternative is relying on custom extensions, but these create many implementation problems too.

FHIR solves this challenge by defining a simple framework for extending and adapting the existing resources. All systems, no matter how they are developed, can easily read these extensions and extension definitions can be retrieved using the same framework as retrieving other resources.

Example Resource: Patient
This simple example shows the important parts of a resource: a local extension, the human readable HTML presentation, and the standard defined data content...

I hope no one's thinking this will be an example of "UX-friendly." OK, let's just focus in on the patient name coding for a moment.

"Family?" Well (ignoring for the moment the lack of reference to a "middle name"), how many ways might we see some of these data expressed in the myriad ONC Certified EHR RDBMS dictionaries (and all manner of databases more broadly)?

Last

Lastname

Last_name

LName

First

Firstname

First_name

FName

Etc. Assuming case insensitivity here. e.g., from the Open EMR tables:

I'd love to get a look at the data dictionaries for the major commercial EHRs, but they are all closely held "proprietary" structures. ONC should be able to examine them, though.

Now, were HL7 FHIR -- 'scuse me, HL7® FHIR® -- to be adopted by ONC as the comprehensive uniform data dictionary standard I have long advocated, perhaps this aspect of the Health IT problem would be largely solved.

Given that that's supremely unlikely, though, we inevitably remain faced with a huge point-to-point or hub/spoke data mapping "interoperability interface" task.

Do some combinatorial math. Recall from the dreaded undergrad stats or finite math class?

Assume, for outset simplicity, six mainstream EHRs whose names come readily to mind.

What are the maximum possible bidirectional data map interop interfaces via which to enable comprehensive data exchange? Going clockwise around the ring, starting with eCW:

eCW -- e-MDs
eCW -- Epic
eCW -- Practice Fusion
eCW -- Cerner
eCW -- athenahealth
e-MDs -- Epic
e-MDs -- Practice Fusion
e-MDs -- Cerner
e-MDs -- athenahealth
Epic -- Practice Fusion
Epic -- Cerner
Epic -- athenahealth
Practice Fusion -- Cerner
Practice Fusion -- athenahealth
Cerner -- athenahealth

See the recursively diminishing (n-1) pattern? Combinatorics 101. In this example, n = the 6 EHRs, m = 2, the requisite bidirectional interfaces (we assume here bidirectionality of data exchange capability). Consequently, 6! ("factorial") = 6 x 5 x 4 x 3 x 2 x 1 = 720, (n - m)! = 4 x 3 x 2 x 1 = 24, times m! (2 x 1) = 48, and 720/48 = 15.

Easier to simply count the 15 connecting lines.

OK, let's scale up a bit, taking just today's ONC CHPL Certified EHR data, and using only the subset of "complete ambulatory and inpatient EHRs," 482 of them.

Combinatorally, we're talking 115,921 bidirectional data exchange interfaces. Were we to compute all 1,963 certified products, the number would be 1,925,703.

Several necessary observations:

The ONC CHPL list surely overcounts the EHRs, given that the list is not "de-duped" for actual named products. It includes all versions for which a vendor's product has passed Cert. Nonetheless, to the extent a newer version of EHR "x" has data dictionary modifications, it's appropriate to count it. Suffice it to say with confidence that the problem is a huge one.
My observations here are simply about the nominal aggregate 2-way interface numbers. Deeper down will be the myriad metadata "data typing" issues within each interface, going beyond simply the spelling of each variable name. Data types matter when it comes iterative health data exchange. Information corruption resulting from data dictionary definition variability propagates.
Relatedly -- to use the Open EMR example (the only one I've seen readily available, given that it's open source): The Open EMR RDBMS is today comprised of 169 tables encompassing 3,731 variables. "N" number of certed EHRs, times "M" number of data cross-maps, times "V" number of vars, well, need I elaborate?
Q: Would a hub/spoke architecture be simpler and more manageable (in particular once we expand the discussion beyond traditional EHRs and out to mobile, etc)? -- where the "hub" would be the central translation and routing service.

Maybe ONC simply does not have the regulatory authority to require that CHPL applicants submit their data dictionaries for confidential study and assessment in order to size the scope of the data cross-mapping task required for seamless "interoperability" / data exchange. But, absent someone analyzing the issue, my concern is that we'll simply face more years of a fervent yet Quixotic Standards® Promulgation® Industry® in lieu of a sorely needed actual, single interop standard.

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NEW FROM EHR SCIENCE

Dr. Carter never disappoints.

Tables verses Documents: A Reason for Using NoSQL?

Dr. Carter responds to my heads-up:

He and I agree totally on standardizing data elements.

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CODA: AND, "HOW®"

A Bestselling Author Claims To Own The Word 'How' And He's Launched A Lawsuit Over It

A best-selling author is suing Greek yogurt company Chobani for using the word "how."

Dov Seidman, who wrote a business management book called "How: Why How We Do Anything Means Everything," says that Chobani's new marketing campaign infringes on his trademark of the word...

Lordy. We have far too many lawyers.
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P.S.

Indeed.
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More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
___

"'Solutions' exist only in mathematics."

- Karen Martin
___

"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
___

"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Monday, October 20, 2014

Interoperability solution? HL7® FHIR® -- We ® Family

Tables verses Documents: A Reason for Using NoSQL?

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