EHR Visualization: “Google-Earth for the Body”

Posted on January 10, 2008 by Bob

Check out the IEEE Spectrum article Visualizing Electronic Health Records With "Google-Earth for the Body".

Image: IBM

The 3-D coordinates in the model are mapped to anatomical concepts, which serve as an index onto the electronic health record. This means that you can retrieve the information by just clicking on the relevant anatomical part. It’s both 3-D navigation and a 3-D indexed map.

Interesting stuff. Especially the general discussion about physician and patient acceptance of EHR systems in the clinic.

Many doctors complain that eHRs have turned them into clerks, while patients say that doctors using these automated systems seem more interested in typing on their computer keyboard than in listening to their health problems.

Also, I wonder how applicable the European experience with exposing patients to this 3D mapping technology would be to US doctors?

Posted in EMR | Leave a comment

Bill Gates CES2008 Keynote

Posted on January 7, 2008 by Bob

Bill is leaving his full time position at Microsoft this coming July. Even though it's vainglorious, the video clip from the presentation is pretty funny -- the cameo appearances show what money can buy (actually, it makes you wonder...): Bill Gates Last Day CES Clip

The entire keynote is here. The audio is out of sync and intermittent, which seems odd for what's supposed to be a show-case for next generation consumer products. CES should have consulted YouTube on how to put video on-line.

Posted in Microsoft | 1 Comment

HIPAA and EMR Design

Posted on January 3, 2008 by Bob

My last post prompted a comment from Mary Hawking which asked this question:

How does the legal framework in the USA influence the design of US EMRs?

My answer:

The only legal requirements for protecting patient health information in the US is the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA became effective in 2001, with mandatory compliance in 2003-2004. These rules only specify who (“covered entities”) must protect health information and the security standards for electronic transactions. All covered health care institutions in the US must now comply.

How does HIPAA influence EMR design? IMHO: Not a whole lot. Most of the functionality of an EMR system is incorporated in the data presentation and work-flow management within the EMR itself. HIPAA only dictates privacy rules and data protection when health information is being transmitted from one institution to another. Privacy and security measures must certainly be implemented within an EMR, but it is usually a relatively minor component.

I'm talking specifically about the affect HIPAA has on EMR software design though. HIPAA has had a large influence on the behavior of covered health care institutions. Here are some related resources:

Posted in EMR, HIPAA | 5 Comments

EHR System Modeling

Posted on January 1, 2008 by Bob

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.

Posted in EMR, HL7, Interoperability, Open Source | Tagged , , , | 4 Comments

BCI: Brain Computer Interface

Posted on December 21, 2007 by Bob

I ran across Commercial brain computer systems are coming today (original article is here). This is a cool graphic:

BCI

I've talked previously about Human-Computer interface (HCI) work.

Invasive BCI technologies have incredible potential. In addition to the unique device-human interface challenges (primarily sensors), it will also require significant advancements in the basic understanding of the underlying electrophysiology (cortical and motor). As reported, EEG-based processing will continue to be a corner-stone for this work, just as it is for non-invasive systems.

This slide from the report (pp. 170) summarizes the uses and importance of this type of work:

Figure C.9. Possible applications of BCIs.

Here's a shorter overview of BMI: Mind Controlled Bionic Limbs

Posted in EEG, HCI, Medical Devices | 9 Comments

Randall Munroe at Google

Posted on December 20, 2007 by Bob

Randall Munroe is the creator of xkcd, a webcomic of romance, sarcasm, math, and language. Munroe on Munroe: "I'm just this guy, you know? I'm a CNU graduate with a degree in physics. Before starting xkcd, I worked on robots at NASA's Langley Research Center in Virginia. As of June 2007 I live in Massachusetts. In my spare time I climb things, open strange doors, and go to goth clubs dressed as a frat guy so I can stand around and look terribly uncomfortable. At frat parties I do the same thing, but the other way around."

This Authors@Google event took place December 7, 2007 at Google Headquarters in Mountain View, CA.

Authors@Google: Randall Munroe

This guy is a true nerd.

Note: The embedded tag from YouTube does not behave well in WP.

Posted in General | Leave a comment

HL7 Interfacing: The last mile is the longest.

Posted on December 15, 2007 by Bob

Tim Gee mentions the Mirth Project as a cost effective solution for RHIOs (regional health information organizations). In particular, he notes that the WebReach appliance is "ready to go" hardware and software.

I've recently started looking at HL7 interface engines for providing our ICG electronic records to customer EMR systems. I've mainly been evaluating Mirth and NeoIntegrate from Neotool.

One of the Neotool bullet points about HL7 V2 states:

Not “Plug and Play” - it provides 80 percent of the interface and a framework to negotiate the remaining 20 percent on an interface-by-interface basis

Since HL7 V2 is the most widely adopted interface in the US, that last 20% can be a significant challenge. This is one of the primary purposes for HL7 integration tools like Mirth and NeoIntegrate -- to make it as easy as possible to complete that last mile.

If you look closely at the Mirth appliance literature you'll see this in the Support section:

For customers requiring assistance with channel development, WebReach consulting and engineering services are available, and any custom work performed by WebReach can be added to your annual support agreement.

They're providing a turn-key hardware and integration engine system, but you either have to create the custom interfaces yourself or hire them (or someone else) to do it for you.

<AnalogyAlert>
This means that you have bought the hammer and identified the nail(s) to pound in. All you need to do now is find and hire a carpenter to complete the job.
</AnalogyAlert>

This really shouldn't be that surprising though. Custom engineering and support is the business model for the WebReach Mirth project and I'm sure a large revenue generator for Neotool.

There is certainly great value in being able to purchase a preconfigured and supported HL7 interface appliance. Just be aware that it's not quite ready to go.

Update 17-Dec-07:

If anyone has experience using HL7 integration engines that they'd like to share, I'd love to here for you (preferably through the comments so they're shared, but private mail is also fine). In particular, I know there are a number of competing offerings to the ones mentioned in this post, and it would be good to know if they are worth evaluating. Thanks!

Posted in EMR, HL7, Interoperability, Networking | 3 Comments

Nerds and managing them

Posted on December 13, 2007 by Bob

If you consider yourself a nerd (or even if you're not sure) then you and your significant other will want to study this:

The Nerd Handbook

Funny stuff because it hits so close to home. It's a great read for both of you.

In addition to a lot of other interesting and humorous content on his site Michael Lopp (Rands) also wrote a book. The introductory web site Managing Humans is very clever.

Posted in General | 1 Comment

Personal Health Record Challenges

Posted on December 11, 2007 by Bob

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.

Posted in Interoperability, PHR | 1 Comment

Stereotyping Programmers

Posted on December 1, 2007 by Bob

Let's start with a definition of Stereotype:

Stereotypes are generalizations about groups and their individual members, based primarily on membership in that group. They may be positive or negative, they may be accurate or inaccurate regarding average characteristics of a group, and may be used to justify certain discriminatory behaviors. Some people consider all stereotypes to be negative because they are unjust to individuals who vary from group characteristics.

Over the last week Jeff Atwood had a couple of posts on this subject: The Two Types of Programmers and Mort, Elvis, Einstein, and You.

If you dig into some of the links from these posts you'll find that the Microsoft persona classifications have been the source of heated debate for a long time. There is no fine line here, in this context personas and stereotyping are the same thing.

The first time I heard the terms 'Mort' and 'Elvis' was when I read ALT.NET Recap: Front and center, let's talk constructively about Mort. As you can tell from my comment to that post, I was greatly offended. I probably over-reacted. I just reread the post though, and I still feel the same way. Here's an example of why:

Back to the question about whether or not Mort can get the stuff we're talking about like separation of concerns and TDD. The typical Mort has managed to acquire a working knowledge of...

And the "Mort related quotes" didn't help either.

Even though Jeremy's intent was to explore how to improve the ALT.NET community, the use of stereotypes in this manner seriously distracts from that purpose. As I commented, if I came away feeling that way, I'm sure that others will too.

I don't mean to single out Jeremy in this regard (even though I did) -- his blog is consistently high quality, and inoffensive. The use of Mort-Elvis-Einstein is ubiquitous in the Microsoft blogosphere.

On the other hand, when I read the posts by Jeff and others that debate this issue I take no offense at all. I can even thoughtfully try to place myself into the different personas like many of the commenter's did. This just shows how important context and intent are. As Jeff found out, this is a touchy issue -- nobody likes to be pigeonholed.

Grouping based on stereotypes is inherently non-inclusive (there's always someone not in a group, or in the wrong group). Even after you've figured out how to reach the unreachable, make sure that your message is made in an inclusive way.

UPDATE: (5-Dec-07)

This is sort of related: Call to Action : People Are Not Resources (via D'Arcy). Related in that calling people resources is also stereotyping, at least by the strictest definition. The more common form of stereotyping in exclusive, whereas being a pork-belly is all-inclusive. For some reason, I'm not as offended by being considered a resource as I am being called a Mort. But that's just me.

What I don't get is that if calling individual humans "resources" is bad, how come "Human Resources", as a department name, is fine? If you want to get rid of labels, you really need to start at the top. How about "Human Assets" or the "Recruitment, Retainment, and Severance" department?

UPDATE: (12-Dec-07)

Jay Kimble has another take on this issue in his Is it 80% and 20% or is 20% too high... post.

...it seems to me that there are 2 kinds of people.

Those that think hard on an issue and those that don't.

I would further generalize and say that laziness is one of the root causes of stereotyping. Stereotyping is the easy way out ("buzz words") and is done by people that don't want to take the time to understand another persons point-of-view or the complexity of an issue.

Posted in Microsoft, Programming | Leave a comment