Monday, January 28, 2013

Why Direct makes sense for Data Delivery to an EHR Hub

Who precisely are you sending that message to?


There is a little recognized problem in using legacy HL7 over VPNs to deliver data (lab results, image studies, reports, etc). The orderer is in the message regardless of whether you are trying to send to them or not. The CC list is in the message regardless as well. The attending, the primary, etc. all there but maybe not who you are routing to. Who are you routing it to?

How is this a problem?


In today's modern world of Software as a Service (SaaS), many of the EHRs get data delivery through a common gateway for many practices. If you route a message to a single practice with a locally installed EHR, then when the data source (e.g. hospital or an HIE as its proxy) sends a message to the practice, the practice endpoint and the EHR endpoint are one in the same. There is no confusion about who the message is for. When the EHR serves multiple practices is where we get the confusion. The endpoint of the practice is a spoke off of the EHR vendor hub.

Which of those spokes is the message intended to go to?


The message identifies many providers who could potentially be routed the message (ordered by, CC, attending, primary, etc.). But those may not be who this message is intended for at this endpoint. This is because some of those may be getting this message a different endpoint (they have a different EHR). Some may be getting it at this endpoint but they are still getting fax and are not ready for the structured data message.

Why is this a problem?


First off, the EHR Hub may wonder who you are routing to and may come back to ask about the additional providers that they cannot identify. That isn't a real big issue. The bigger issue is that if an HIE or HISP is in use, some providers may be getting this message by an older point to point feed and could wind up with the message twice. Some providers simply are not whom the sending facility was trying to send to (e.g. the attending has their copy in the hospital system and they are not trying to send it to their ambulatory practice connection). Lastly, there may be a business relationship and BAA chain issue if the EHR Hub sends a message to a practice that does not have a service agreement with the HIE or HISP that sent the message to them.

How do you solve the problem with Direct as it becomes the standard?


The good thing about direct is that it is a routing protocol, an email message. The content of the message may be an HL7 message, as it is with the lab results initiative (LRI). This way the concept of routing is added outside of the clinical content of the message. So Direct will eventually solve the problem across the board as we move from VPNs to Direct over the next several years. That problem being, we only want the message to go to those we intended and not send it to others even if they are in the clinical data for some other reason.

How do you solve the problem with Legacy HL7 over VPN today?


The bad thing about HL7 over VPN is that it uses content based routing within an EHR Hub. The best solution we have found is to add a specific new segment and field for routing and not rely on trying to interpret routing from the clinical message content. This can be accomplished by adding a Z-segment with a provider XCN field to the outbound message to be used by the EHR Hub. This new field is then used exclusively by the EHR Hub for content based routing and the other fields in the clinical content are not used. This resolves any issue with hub and spoke (HIE and/or EHR Hub) based routing until Direct can be introduced as the wrapper to handle the same.

How does it work?


We implement this as either the concept of a "receiving system" for some EHR hubs or as a Z-Segment approach for other EHR hubs in the HIE that I am associated with and it is yet another benefit of the SOA based abstraction that we implement as the foundation of our HIE and it serves as a stepping stone to Direct via the HIE as we are routing based on addressing for user accounts that are specified in the subscriptions (for publish-subscribe SOA pattern) rather than purely on content, even if that subscription is triggered by IDs in the content.

Thursday, January 17, 2013

eRegister and Get Rid of the Clipboard

The Real Use Case for Personal Health Records (PHR)


I have been at this, HIE game, for a few years or so now. And when I go out and meet new people, I get the typical, "so, what do you do" question. Once I tell them and give a little explanation of what it means, about half of them have a follow-up question. There is only ever one follow-up question and it is always the same question "so, are you going to get rid of that clipboard of paperwork that I have to do over and over again every time I go to see a doctor".

The fact that I only get one question from general consumers and it is always the same question tells me one thing. This is what matters to them. This is how they see their information making it from them to their provider today. This is what they want to eliminate by using HIE or a PHR.

In essence, I see the HIE and PHR as one in the same. The HIE, in a fixed repository model, is a collection of "views" of the patient. We have a primary care view from one doctor. We have a couple specialist views from some other doctors. We have a couple hospitals views from some inpatient and emergency encounters. The PHR is either the same as the HIE consolidated view of these, or in an improved form, it is the consumers view of themselves as a patient. In essence, it is what the patient would put on the registration/intake forms when presented with them.

For a few years now, I have been putting forth what I call the eRegistration use case. eRegistration is the elimination of paperwork and pre-population of the providers system. It populates the Contact Information, Health History, Family History, Social History, Other Providers, Employment, Insurance, Payment, Disclosures, Consents and any other necessary information.

Main Case:

  1. Patient Enters Provider’s Waiting Room
  2. Patient uses smartphone to scan a barcode on the wall with the provider's Direct address
  3. Smartphone collects any relevant data from the patient (who is the request for – if multiple PHRs are registered on the same device, why are you here today, what payment do you want to use – if multiple are recorded)
  4. Smartphone sends request to PHR/HIE cloud to share data
  5. PHR/HIE cloud sends standardized message with XML Registration package containing:
    1. Patient Direct Address
    2. Health, Social, and Family History
    3. Care Team info (including Direct addresses) and desire to share visit information with care team.
    4. Insurance Info
    5. Payment Info
    6. Legal disclosures and consents
  6. Provider PMS/EHR prepopulates the PMS/EHR system with the data.
  7. Patient is seen by provider without having to fill-out the clipboard full of documents
  8. Patient is discharged without having to stop and do any paperwork
  9. Patient receives discharge instructions back via their contact address (PHR or HIE portal account)
  10. Patients care team receives appropriate encounter data
The main issue is that eRegistration cannot be achieved in vacuum by the HIE or PHR system vendor or RHIO. We need to make a few, not many, decisions on what XML documents to put into the registration package. Every provider and their system vendors needs to work together to implement such a change. That said, my real use case contains some alternate paths so that providers can all participate regardless of their technical limitations. This is done by having the HIE fill in for the EHR where the provider may not have an EHR or the EHR may not support this use case yet. This way, we continue to not let the perfect get in the way of the good and adoption of new technology move faster.

The ability to scan a barcode on the wall of my provider's office and my paperwork is done is tangible to patients. It is self-enabling. The physical action delivers feelings of trust and ownership in the act of sharing private information. Since the data is in the HIE cloud and not on the smartphone the information is safe. I believe this to be an enabler of HIE that empowers and binds the consumer to the cost and sustainability of HIE. The consumer will now feel their self-interest in HIE in a tangible way if we create this system of empowerment.