Semantic Interoperability for Electronic Health Records

Whenever I lecture about standards harmonization, I'm asked how far along we are on the journey toward interoperability. First a definition of interoperability:

Technical interoperability - the ability to send a human readable record from place to place. A fax machine, secure email, and sending of free text from EHR to a PHR are examples of technical interoperability. For example, at present, Microsoft Health Vault enables documents and photos to be sent from a hospital, clinic, lab or pharmacy to a secure personal health record. Once there, they are viewable by the patient. However, at present, Microsoft Health Vault cannot combine multiple documents together to create a single uniform medication list, problem list and allergy list for the patient. Health Vault supports technical interoperability but not semantic interoperability.

Semantic interoperability - the ability to send human readable and computable records from place to place. An electronic health record with vocabulary controlled, structured problem lists, medications, labs, and radiology studies sending this data into structured lists within a personal health record is an example of semantic interoperability. Semantic interoperability ensures that decision support software can interpret the transmitted data and perform quality and safety checks such as drug/drug or drug/allergy checking. Google Health supports semantic interoperability for problems, medications, allergies and laboratories. The Continuity of Care Document, the clinical summary which has been recognized by Secretary Leavitt and the American Health Information Community (AHIC) is semantically interoperable, as detailed below.

Process interoperability - Per my recent blog about Decision Support Service Providers, wouldn't it be great if the best practices for healthcare including protocols, guidelines, care plans, and rules were transferable from one organization to another? Sending a clinical summary from one organization to another would immediately result in event driven medicine based on all the new data provided. Unfortunately, we really have not achieved this degree of interoperability.

At this point in the standards harmonization work, based on the efforts of 500 organizations working in HITSP over the past 2 years, we have achieved semantic interoperability for Electronic Health Records and Personal Health Records using the Continuity of Care Document clinical summary Here's the state of the art of interoperability:

a. Problems - CCD contains human readable and semantically interoperable problem lists, using SNOMED CT as the problem list vocabulary.
b. Medications -CCD contains human readable and semantically interoperable medication lists, using RxNorm as the medication list vocabulary.
c. Allergies - CCD contains human readable and semantically interoperable allergy lists, using UNII as the vocabulary for Food and Substance allergies and RxNorm for Medications.
d. Notes - CCD contains human readable structured and unstructured clinical notes/reports. Additional HL7 ballots over the next few months will provide even more options for structured notes via the Clinical Document Architecture.
e. Labs - CCD contains human readable and semantically interoperable lab results using LOINC vocabularies to describe the lab test and UCUM to indicate the unit of measure of the result.
f. Radiology - CCD contains human readable reports, but does not yet include images. In 2008, the HITSP Consultation and Transfer of Care use case will require us to develop interoperability specifications to share images.
g. Vital signs - CCD contains human readable and semantically interoperable vital sign measurements, using LOINC as the vocabulary to describe the site and method of measurement for each vital sign.

Thus, in 2008, we have all the standards needed to send structured information from provider to provider, from provider to patient, and from provider to public health agency. Of course, this data must be sent with appropriate security to protect the privacy of the patient. My blog entry tomorrow will describe the national, regional and local efforts that ensure confidentiality is maintained per the wishes of the patient.

Women's Choice

I came across a blog that I want to share with the readers of EverythingHealth. This New York gynecologist wrote a compelling blog on why she chose her specialty. It's worth a read here at The Blog That Ate Manhattan.

McCain's Health Plan - seriously flawed

Candidate John McCain has proposed a health policy reform that will not work, and would worsen the uninsured problem in the United States. Let's take a look:Seventy-one percent of insured people are now covered (in some fashion) by their employers. McCain proposes eliminating employer sponsored health insurance and giving tax credits to people to buy their own insurance. A family would receive a

Cool Technology of the Week

As I write this on my MacBook Air connected to my home WPA-secured 802.11a wireless network traveling over the internet at 20 megabits/second via Verizon FIOS, with my Blackberry 8320 strapped to my belt, and my 4 Gig USB drive in my pocket, my vote for the Cool Technology of the Week is the all of them.

Let's consider how these technologies have evolved in my lifetime. The photo is a 1956 IBM 305 REMAC, the first computer with a hard disk drive. It weighed over a ton and stored 5 Megabytes of data.

In 1984, I bought my first IBM XT that weighed 32 pounds and stored 10 Megabytes of data.

In 1987, I bought a Unisys server to run my small company that included 128 Megabytes of RAM and half a Gigabyte of storage - a supercomputer for the time.

In 2008, Gigabyte USB drives are given away in junk mail and weigh 1 ounce.

Think about the impact of traveling back in time with the Macbook Air, Blackberry and USB drive.

Think about showing the Macbook Air to Alan Kay in 1972 at Xerox Parc, side by side with drawings of his fictional Dynabook.

Think about showing a functional 2008 Blackberry to Gene Roddenberry in 1965, side by side with his fictional Star Trek Communicator.

Think about explaining to an IBM engineer in 1956 that Gigabytes are free, Terabytes are cheap, and Pedabytes are the technology we're now installing. Exabytes (1000 Pedabytes or 1,000,000,000,000,000,000 bytes) will probably be included in my daughter's laptop in her lifetime.

Arthur C. Clarke formulated the three "laws" of prediction which apply well to the evolution of technology in my lifetime.

1. When a distinguished but elderly scientist states that something is possible, he is almost certainly right. When he states that something is impossible, he is very probably wrong.

2. The only way of discovering the limits of the possible is to venture a little way past them into the impossible.

3. Any sufficiently advanced technology is indistinguishable from magic.

The Macbook Air, the Blackberry, and the USB drive are magic for a guy born in the same era as the IBM 305 REMAC.

The greatest benefit of being a CIO is experiencing the daily march of innovation. I know that my job will never be done and life will never be boring.

Grand Rounds This Week

For a fun spin around the medical blogosphere check out this weeks Grand Rounds, hosted by Dr. Gurley. Lots of great and stimulating reading!

Breastfeeding New Infants

The benefits of breast feeding for at least the first six months of life have been proven over and over with scientific studies. Let's face it...nature hardly ever gets it wrong. Breast milk is a perfect nutrient, contains antibodies and is easy to digest. It is also free and readily available!A new study by the Center for Disease Control and Prevention shows that 77% of new mothers

The Way of Koh

You're probably familiar with the Japanese martial art Ju-do ("the gentle way"), the Japanese martial art of fencing Ken-do ("the way of the sword"), and you may have heard of the Samurai code of honor Bushi-do ("the way of the warrior"), but you probably have not heard about Japanese Koh-do ("the way of incense").

At the end of each day, I have a de-stressing ritual. I leave the anxiety, frustration, and emotion of each day at the office, so I'm always optimistic, energetic, and focused on my family when I arrive home. I chat with my wife and daughter about their day, change in my causal clothing, make a cup of Gyokuro Asahi green tea, and light a stick of incense in my 300 year old Buddhist incense burner. Then I "listen to" the fragrance. This is Koh-do, the Japanese Incense Ceremony.

During Japan’s Muromachi Period (1333-1576), Incense Ceremony became formalized as one of the one of the three leading traditional Japanese arts, along with Tea Ceremony (chanoyu) and Flower Arrangement (jkebana). In the incense ceremony, aromatic wood (koh) is burned and participants appreciate the aesthetic qualities of the aroma. Although the sense of smell plays a leading role, the appreciation of the mood/atmosphere created by entire experience of burning fragrant wood leads practitioners of the art say that they are “listening to” the aroma. Understanding the Japanese art of Koh-do is as fascinating as understanding the tea ceremony, the Japanese Flute or Sake.

Lafcadio Hearn, a 19th century American author famous for his books about Japan wrote about the experience of Koh in his book Ghostly Japan (1899)

"Wherever Buddhism lives there is incense. In every house containing a Buddhist shrine or Buddhist tablets, incense is burned at certain times; and in even the rudest country solitudes you will find incense smouldering before wayside images, -- little stone figures of Fudo, Jizo, or Kwannon. Many experiences of travel, -- strange impressions of sound as well as of sight, -- remain associated in my own memory with that fragrance: -- vast silent shadowed avenues leading to weird old shrines; -- mossed flights of worn steps ascending to temples that moulder above the clouds; -- joyous tumult of festival nights; -- sheeted funeral-trains gliding by in glimmer of lanterns; -- murmur of household prayer in fisherman's huts on far wild coasts; -- and visions of desolate little graves marked only by threads of blue smoke ascending, -- graves of pet animals or birds remembered by simplehearts in the hour of prayer to Amida, the Lord of Immeasurable Light."

There are five traditional incense materials described in early Buddhist texts. Aloeswood is associated with the Buddha Family, and symbolizes the transmutation of the "poison of ignorance." Sandalwood is associated with the Padma or Lotus Family and symbolizes the transmutation of the "poison of attachment." Clove is associated with the Vajra or Wisdom Family and symbolizes the transmutation of the "poison of aversion." Turmeric is associated with the Karma Family and symbolizes the transmutation of the "poison of jealousy". Borneol Camphor is associated with the Ratna family and symbolizes the transmutation of the "poison of pride".

If these particular incense materials were unavailable, Buddhist monks made substitutions including Patchouli, Benzoin, and Cinnamon.

My Koh-do ceremony uses a mixture of the Sandalwood, Clove, Turmeric, Camphor, Benzoin and Patchouli called Matsu-no-tomo (Friend of Pine)

The most extraordinary experience I've had with Koh-do is the burning of Aloeswood. Aloeswood is the resinous wood from the Aquilaria tree, an evergreen tree native to northern India, Laos, Cambodia, Malaysia, Indonesia, and Vietnam. The trees frequently become infected with the fungus Phialophora parasitica, and produce an aromatic resin as a defense mechanism. This resin is Aloeswood and it's often aged for many years before burning. The Aloeswood Koh-do experience is so memorable that the Japanese have a classification system to describe the 5 aromas you may sense as the wood burns

1. Sweet -- Resembles the smell of honey or sugar
2. Sour -- Resembles the smell of plums or other acidic foods.
3. Hot -- Resembles the smell of peppers on a fire.
4. Salty -- Resembles the smell of ocean water when seaweed is dried on a fire.
5. Bitter -- Resembles the smell of bitter herbal medicine when it is mixed or boiled.

High quality Aloeswood is so rare and expensive, that I've only experienced it in Koh-do ceremonies in Japan.

So, pour a cup of tea, light a stick of incense, listen to the aroma, and de-stress. You'll recharge and be ready for the challenges ahead.