Search Results for 'interoperability'

Page 3 of 4

A Medical Device Gateway Data Standard?

The Wipro OEM medical device gateway press release makes it all seem so easy (my highlight):

The device, consisting of interfaces that can feed-in data such as blood pressure, pulse rate, ECG reading and weight from the respective devices, is connected to the gateway that would format it into standard patient information and transmit it to either public health data platform such as Google Health or to private platforms like Microsoft Health Vault.

What exactly is “standard patient information”?  Maybe they’ve finally developed the magic interoperability bullet.  Yeah, right!  I’m sure companies like Capsule see these kind of claims all the time.  Statements like these are unfortunate because they give the impression that health data interoperability is a given. Of course we know that is not the case.

Also, since when is Google Health a public health data platform?

Hat tip: Avantrasara

UPDATE (11/19/09):  Wipro ties up with Intel for rural medical solutions

The Desperate Need for Simplicity

Ted Neward’s article “Agile is treating the symptoms, not the disease” touches on several important points about the software industry.

  • Modern software development tools and technologies require a significant learning curve.
  • Development methodologies (like Agile) exist for managing complexity, but do not reduce the load of these technologies.
  • In the last decade there has been no “Next Big Thing”, like Access was in the 90s.

What’s most interesting to me is:

We are in desperate need of simplicity in this industry. Whoever gets that, and gets it right, defines the “Next Big Thing”.

What’s true in the broader software world is also generally true in Healthcare IT.  In HIT there has never been an Access equivalent, just a lot of pieces and parts trying unsuccessfully to work together.

The need was touched on in Liberate the Data!.  Simplicity is desperately needed in order to create the “First Big Thing” for HIT interoperability.

UPDATE (10/14/09):  More commentary:

Access to Medical Data: Are PC Standards and PHRs (You) the Answer?

Dana Blankenhorn’s article Give medicine access to PC standards makes some good points about the medical device industry but (IMHO) misses the mark when trying to use PC standards and PHRs as models for working towards a solution.

I’ll get back to his central points in a minute. One thing I find fascinating is the knee-jerk reaction in the comments to even a hint of government control.  How on earth can someone jump from “industry standard” to a “march towards socialism”? We saw the same thing at this summer’s town hall meetings and in Washington a couple of weeks ago.  The whole health care debate is just mind boggling!

Anyway, let’s focus on the major points of the article. First:

Every industry, as its use of computing matures, eventually moves toward industry standards. It happened in law, it happened in manufacturing, it happened in publishing.

It has not happened, yet, in medicine.

Very true.  In the medical device world, connectivity and interoperability are hot topics. A couple of recent posts — Plug-and-Play Medicine and Medical Device Software on Shared Computers — point out the significant challenges in this area.  In particular, the development and adoption of standards is a very intensive and political process. But where’s the incentive for the industry to go through this? Dana’s comment addresses this (my emphasis):

The role I like best for government is in directing market incentives toward solutions, and not just to monopolies or bigger problems.

The reason health care costs jump every year is because market incentives cause them to. Those incentives must be changed, but the market won’t by itself because the market profits from them.

Only government can transform incentives.

Like it or not, this may to the only way to push the medical industry to do the right thing.  But those other industries didn’t need government intervention in order to create their standards.  Using PC (or other industry) standards as a model for facilitating medical data access just doesn’t work.  The health industry will have to dragged to the table kicking and screaming, and the carrot (or stick) will have to be large in order for them to come to a consensus.

Second, I don’t see the relationship between the use of PHRs and the promotion of standards.

By supporting PHRs, you support your right to your own data. You support liberating data from proprietary systems and placing it under industry standards.  You support integrating your health with the world of the Web, and the benefits such industry standards can deliver to you.

Taking responsibility for your own health data is great, but both Microsoft HealthVault and Google Health are proprietary systems.  Just because your data is on the Web doesn’t make it any more accessible.  And even if one of these PHRs did became an industry standard, it would have very little impact on how EMRs communicate with each other or medical devices in general.

There are no easy answers.

Inaugural Medical Device Connectivity Conference and Exhibition


Tim Gee has put together an impressive conference. It’s happening Sept. 10-11, 2009 in Boston. Unfortunately, I will not be able to attend. Hopefully Tim and others will be able to provide highlights from the many interesting topics.

Here’s a condensed list of the agenda:

Day 1:

MEDICAL DEVICE  CONNECTIVITY IN HEALTH CARE: WHERE ARE  WE, WHERE ARE WE GOING, AND HOW DO WE  GET THERE?  Tim Gee, Connectologist & Principal, Medical  Connectivity Consulting

CONNECTING  OPERATIONAL AND STRATEGIC PERSPECTIVES  Julian M. Goldman, MD, Medical Director of Biomedical Engineering, Partners HealthCare System, Director,  CIMIT Program on Interoperability and Medical Device Plug-and-Play Interoperability Program, Massachusetts General Hospital

INDUSTRY STANDARDS  (FORMAL AND DE FACTO) IN CONNECTIVITY Charles (Chuck) Parker, Executive Director, Continua Health Alliance


IMPACT OF PROPOSED FDA RULE ON MEDICAL DEVICE DATA SYSTEMS William A. Hyman, ScD, PE, Professor, Department of Biomedical Engineering, Texas A&M University & President, ACCE Healthcare Technology Foundation

President, Technology in Medicine, Inc. & Immediate Past President, American College of Clinical Engineering (ACCE)



THE BASIC COSTS OF CONNECTIVITY Bridget Moorman, CCE, President, BMoorman Consulting, LLC

Day 2:


















UPDATE (9/10/09): Tim is posting conference updates here: The Connectologist

UPDATE (9/16/09):

Review #1: Wireless connectivity and medical devices

Integrating wireless technology into medical devices presents the industry with both a carrot and a stick: Stimulus cash (carrot) versus increasing demand for connective devices from hospitals (stick).

Review #2:  Analyst: Healthcare’s wireless sensor opportunity

Gee broke down some of the drivers for the recent interest in medical sensors, outlined use cases and dissected the market for the more than 200 attendees at last week’s event.

Liberate the Data!

Peter Neupert’s post Tear Down the Walls and Liberate the Data is worth reading. There are some Microsoft-centric comments, but a number of the linked articles are good and the overall message is correct (IMO anyway).

I might have tried to find a better analogy than ‘tear down this wall’, but that’s because I was never a Ronald Reagan fan.  Nevertheless, this gets across the primary point:

What’s of paramount importance is liberating the data and making it available for re-use in different contexts.

Two major ‘walls’ stand in the way of this:

  1. “it’s-my-data”
  2. “waiting-for-the-right-standards-set-by-government”

Both exist because of the perceived competitive advantages they provide to organizations and vendors.

Interoperability of data, or enabling data to become “liquid” would allow it to flow easily from system to system. These challenges are the same ones addressed by Adam Bosworth that I discussed in Dreaming of Flexible, Simple, Sloppy, Tolerant in Healthcare IT.

The technical issues are complicated, but I also believe that they not the primary reason that prevent  health IT systems from inter operating.  As Peter suggests, it would be good for HiTech dollars to be used to break down some of the more difficult barriers that prevent data liquidity.

The “proven model[s] for extracting and transforming data” do exist and there is no excuse not to use them.

After thinking about it some more, a more cautionary analogy may be The Exodus — Mosses leading the Israelites out of the Land of Egypt (“let my data go!”).  1) It took an act of God to part the Red Sea, and 2) after their dramatic escape they roamed the desert for 40 years. Let’s hope that health IT interoperability does not need devine intervention or suffer the same fate.

Contradictory Observations and Electronic Medical Records

Martin Fowler has an interesting discussion in his ContradictoryObservations post.  This little slice of medically related software design insight is particularly relevant because it highlights (at least for me) the complexity of the use of electronic medical records and their interoperability.

In a broader sense I suppose it also shows some of the underlying difficulties that face the Obama administration’s new EMR adoption push.  But I’m not going there.

The concepts of observationsrejection, and evidence are good, but they’re just the tip of the iceberg:

rejected and evidence

Even after you’ve modeled the data interactions, how do you effectively communicate these concepts to the user?  Or to another EMR that doesn’t know about your model or how it’s used?

Martin’s view is that:

Most of the time, of course, we don’t use complicated schemes like this. We mostly program in a world that we assume is consistent.

Unfortunately, many of the issues facing electronic medical records do require complex solutions. And even when the world is consistent, how you implement a solution may be (actually, will probably be) very different than how I implement it.  Either way, interoperability will always be a challenge.

We’re going to need lots of good software design tools to solve these problems.

Dreaming of Flexible, Simple, Sloppy, Tolerant in Healthcare IT

I was recently browsing in the computer (nerd) section of the bookstore and ran across an old Joel Spolsky edited book: The Best Software Writing I.  Even though it’s been about four years, good writing is good writing, and there is still a lot of insightful material there.

One of the pieces that struck a cord for me was Adam Bosworth’s ISCOC04 Talk (fortunately posted on his Weblog).  He was promoting the use of simple user and programmer models (KISS — simple and sloppy for him) over complex ones for Internet development.  I think his jeremiad is just as relevant to the current state of  EMR and interoperability.  Please read the whole thing, but for me the statement that get’s to the point is this:

That software which is flexible, simple, sloppy, tolerant, and altogether forgiving of human foibles and weaknesses turns out to be actually the most steel cored, able to survive and grow while that software which is demanding, abstract, rich but systematized, turns out to collapse in on itself in a slow and grim implosion.

Why is it that when I read “demanding, abstract, rich but systematized” the first thing that comes to mind is HL7?  I’m not suggesting that some sort of open ad hoc system is the solution to The EMR-Medical Devices Mess.  But it’s painfully obvious that what has been built so far closely resemble “great creaking rotten oak trees”.

The challenge for the future of Healthcare interoperability is really no different than that of the Internet as a whole (emphasis mine):

It is in the content and the software’s ability to find and filter content and in the software’s ability to enable people to collaborate and communicate about content (and each other).

I would contend that the same is true for medical device interoperability. Rigid (and often times proprietary) systems are what keep devices from being able to communicate with one another.  IHE has created a process to try to bridge this gap, but the complexity of becoming a member, creating an IHE profile, and having it certified is a also a significant barrier.

Understanding how and why some software systems have grown and succeeded while others have failed may give us some insights. Flexible, Simple, Sloppy, Tolerant may be a dream, but it also might not be a bad place to start looking for future innovations.

Adam also had this vision while he was at Google: Thoughts on health care, continued (see the speech pdf):

… we have heard people say that it is too hard to build consistent standards and to define interoperable ways to move the information. It is not! … When we all make this vision real for health care, suddenly everyone will figure out how to deliver the information about medicines and prescriptions, about labs, about EKGs and CAT scans, and about diagnoses in ways that are standard enough to work.

Also see the Bosworth AMIA May07 Speech (pdf) for how this vision evolved, at least for Google’s PHR.

UPDATE (2/9/09): Here’s a  related article: The Truth About Health IT Standards – There’s No Good Reason to Delay Data Liquidity and Information Sharing that furthers this vision:

We don’t have to wait for new standards to make data accessible—we can do a ton now without standards.  What we need more than anything else is for people to demand that their personal health data are separated from the software applications that are used to collect and store the data.

UPDATE (4/17/09): John Zaleski’s Medical Device Open Source Frameworks post is also related.

Use of an open-source framework approach is probably as good as any. As a management model, I don’t see it as being that much different from the way traditional standards have been developed. Open-source just provides a more ad-hoc method for building consensus. Less bureaucracy is a good thing though. It may also allow for the introduction and sharing of more innovative solutions. In any case, I like visions.

USB plug-n-play (plug-n-pray to some) may be a reasonable connectivity goal, but it does not deal at all with system interoperability. Sure, you can connect a device to one or more monolithic (and stable) operating systems, but what about the plethora of applications software and other devices?  This just emphasizes the need to get out of the “data port” (and even “device driver”) mind-set when envisioning communication requirements and solutions.

CCHIT, The 800-Pound Gorilla

There’s a lively discussion on HIStalk (Readers Write 8/27/08) regarding the merits of CCHIT.  The Jim Tate piece isn’t long, or even that informative. It simply touts CCHIT as an

.. organization that is helping level the playing field and make it safer for clinicians to take the plunge into electronic records.

This seems innocuous enough.  Judging by the negative responses though, some people have real problems with CCHIT. In particular, the Al Borges, MD Response to “CCHIT: the 800-Pound Gorilla” is a detailed point-by-point rebuttal (“CCHIT is simply not necessary.”).

I guess it’s not surprising that the biggest issue seems to revolve around money. The cost of obtaining CCHIT certification has stratified EMR companies (big vs. small) and makes it even more difficult for practices to see a ROI.

Also, the discussion of interoperability standards (or lack thereof) is one of my hot buttons. As Mahoghany Rush (comment #9) says:

Anyone here who talks about being HL7 compliant – and thinks it really solves a problem – has never personally written an interface.

So true.

In this regard Inga asks (in News 8/29/08):

Are lab standards an issue one of the various work groups is addressing? Are the labs on board?

When you say “lab” what you’re really talking about are the large number of medical devices commonly found in both hospitals and private practice offices. As you note, the need for interfaces to these devices is so the data they generate can be associated with the proper patient record in the EMR. This not only allows a physician to have a more complete picture of the patients’ status, but the efficiency of the entire clinical staff is vastly improved when they don’t have to gather all of this information from multiple sources.

The answer to your second question is yes, many “labs” — medical device companies, are actively in involved in the development of interoperability standards.  The EMR companies are also major participants.

There are two fundamental problems with “standards” though:

  1. A standard is always a compromise.
  2. A standard is always evolving.

By their very design, the use of a standard will require the implementer to jump though at least a few hoops (some of which may be on fire).  Also, a device-to-EMR interface you complete today will probably not work for the same device and EMR in a year from now — one or both will be implementing the next generation standard by then.

Nobody dislikes standards. Interoperability is usually good for business. There are two primary reasons why a company might not embrace communications standards:

  1. The compromise may be too costly, either from a performance or resources point of view, so a company will just do it their own way.
  2. You build a proprietary system in order to explicitly lock out other players. This is a tactic used by large companies that provide end-to-end systems.

The “standards” problem is not just a Healthcare interoperability issue. The IT within every industry struggles with this.  The complexity of Healthcare IT and its multi-faceted evolutionary path has just exacerbated the situation.

So, the answer is that everyone is working very hard to resolve these tough interoperability issues. Unfortunately, the nature of beast is such that it’s going to take a long time for the solutions to become satisfactory.

UPDATE (9/3/08): The response to Inga was published here: Readers Write 9/3/08. Thanks Inga!

EHR System Modeling

I’m a regular Slashdot reader and it’s rare to come across a health care related post. So Arguing For Open Electronic Health Records of course caught my eye. I’m sure it was the open standards aspect that attracted them, but I also wanted to point out why the use of software modeling is so important to the development of EHRs.

The Tim Cook post is interesting in several respects.

The first is the reiteration of the importance of the “lack of true interoperability standards” and its affect on adoption of EMR. I’ve talked about this numerous times.

Another important point is that even though open source licensing may be free, the real costs of implementing any EHR system (i.e. going paperless) are significant.

The importance of understanding and communicating the “semantic context” of patient data is also a key concept.

The goal of the openEHR open-source project is to provide a model and specifications that capture patient data without loss of semantic context. A “two-level modeling” approach is used (from here):

Two-Level Software Engineering
(click on the image to see it at full resolution)

Within this process, IT developers concentrate on generic components such as data management and interoperability, while groups of domain experts work outside the software development process, generating definitions that are used by systems at runtime.

If you’ve done any work with Microsoft’s WPF, this model should look familiar. Separation of responsibilities (designer vs. developer) is one of the fundamental shifts in GUI development that XAML provides. Separating the domain experts from the developers when building a health care IT system is also clearly beneficial.

No matter how good the openEHR model is, it unfortunately has the same adoption problems as many other health care interoperability systems: competing “standards”. For example, HL7 V3 Reference Information Model (RIM) and CEN 13606 have the same goals as openEHR.

Developing software systems based on conceptual models of the real world is not new. For example, the OMG Model-driven Architecture (MDA, also see here):

These platform-independent models document the business functionality and behavior of an application separate from the technology-specific code that implements it, insulating the core of the application from technology and its relentless churn cycle while enabling interoperability both within and across platform boundaries.

These types of systems not only provide separation of responsibilities but are also designed to provide cross-platform interoperability and to minimize the cost of technology changes.

The future of inter-operable EHR systems will depend on choosing a common information/behavior model so that the benefits of these development technologies can be realized. The challenge is to make the use of a framework that implements that model something that all stakeholders find advantageous.

Personal Health Record Challenges

The Journal of the American Medical Informatics Association has an article entitled The Early Experiences with Personal Health Records [Volume 15, Issue 1, January-February 2008, Pages 1-7] (found via Constructive Medicine 2.0).

I’ve discussed PHR a number of times in the past. This article details three PHR implementations and discusses past and future challenges. Many of these are access policy issues — privacy, security, data stewardship, and personal control. There are also many technical challenges. For example:

Thus, we will need to modify our existing PHR systems to support a service oriented architecture that permits multiple applications to retrieve our institutional data with patient control and consent. Providing such an architecture will require the nation to create and adopt national standards for clinical data content transmission, terminology and security to ensure interoperability.

I’ve also previously discussed interoperability in some detail. A SOA is a great idea, but with so many standards and proprietary implementations out there, it seems like the only way a national standard will ever be adopted is if the federal government steps in. This would require not only the definition of what the standards are, but what types of PHR/EMR systems are affected, along with a time-line for mandatory implementation.

All of that seems like a tall order. The technical aspects alone would be tough, but getting it done would also require a political process that would likely drag on for years. You really have to wonder if a national standard for interoperability is even possible?

Their conclusion regarding the importance of the P in PHR is a good one:

By placing the patient at the center of healthcare data exchange and empowering the patient to become the steward of their own data, protecting patient confidentiality becomes the personal responsibility of every participating patient.

On a semi-related note (i.e. isn’t worth a separate post, so I’ll park it here), I finally saw Michael Moore’s movie SiCKO the other day. It achieved a certain level of shock value regarding how people in the US are treated by insurance companies and HMOs, but it was a disappointment overall. It made no effort to further the understanding of why the health care system in this country is so messed up in the first place or to try to suggest ways to improve it. Instead it just showed the US problems and quickly turned to how great the UK, France, and Cuba socialized systems are (gosh, you mean you don’t have to pay any money at all!). Oh well, that’s Hollywood for you.



Twitter Updates