Super Glue Eyelid

This little girl accidentally got Super Glue onto her eyelid. She came to the doctor without pain and she was able to move the eyeball under the lid but could not open it.Her doctor in Decatur, Ala gently irrigated the eye area with normal saline and applied antibiotic ointment and a gauze patch over the eye area but the lid remained stuck together. The next day he was able to gently pull the

The Health Information Technology Platform Meeting

Today at Harvard Medical School, Zak Kohane and Ken Mandl assembled 100 folks to discuss "Substitutability" - the notion that EHRs of the future will be more modular and more iPhone app-like, possibly with common Application Programming Interfaces.

Some of the speakers at the conference were Mitch Kapor (Lotus founder), Sean Nolan (Microsoft), David McCallie (Cerner), Alfred Spector (Google), Rob Kolodner (formerly of ONC), David Liss (New York Presbyterian), Charles Friedman (currently at ONC), Mark Frisse (Vanderbilt), Clay Christensen (HBS), David Kibbe (Senior Advisor to AAFP), Aneesh Chopra (US CTO), Todd Park (HHS CTO), and Regina Herzlinger (HBS)

I served on the opening panel called Open or Closed Platforms? One or More Platforms.

Here are a few of the key points.

I suggested that standards can be required at different levels of specificity depending on the transaction. e-Prescribing transactions should be highly specified to ensure the right drug, right dose, right form, right patient are transmitted securely with data integrity from provider to pharmacy. Sharing an office note might be done with less specificity - a secure transport layer plus a human readable payload that might be XML such as a CCD document, PDF, or a scanned TIF image. Quality measures are very precise and require a high degree of specificity to ensure comparability among clinicians and institutions. Even though these examples have different levels of specificity required for interoperability, the architecture is left open to innovation - these transactions could be done in comprehensive EHRs, iPhone apps, or PHRs with point to point data exchange or via a healthcare information exchange.

Several of the panelists thought a common API in front of various EHR vendor products was unlikely. Exchange at the data layer was viewed by all as very possible and most thought the meaningful use plan for 2011,2013, and 2015 data exchanges made sense.

All agreed that common data transport with appropriate security is important.

The general theme of the panel was openness. Microsoft offers a standards-based way to enter and retrieve data from healthvault. Cerner is supporting XDR, XDM and XDS as well as Cerner proprietary APIs which enable custom plugin applications to work with their products. OpenMRS is an open source platform for electronic health record development, embraced widely in developing countries.

The move toward more openness - regardless of architecture, platform, or open source/proprietary product type - was refreshing. To me, being able to extract data out of an EHR (even via a proprietary API) combined with common data transport standards and translation into structured vocabularies gives us a path forward for health information exchange in the near term.

The industry is changing, motivated by meaningful use, a business case for data sharing, and patients expecting coordination of care. Add to that healthcare reform which requires quality measures and H1N1 surveillance which requires public health data exchange, and the pace will accelerate.

It's clear the we'll have many product choices in the future - some integrated, some interfaced, some modular, and some platform-based. My take home message from the conference is that innovation and data standardization can co-exist.

In the Patient's Interest

I spent the entire day in meetings today. One would think that is a boring or unproductive way for a physician to spend time, however these meetings made me proud to be a doctor and proud of my colleagues in medicine.The morning was spent with nurses, respiratory therapists and quality experts who came together to celebrate success with patient safety and quality initiatives that have saved at

Preparing for ICD-10

In 2013, CMS will require the use of ICD-10 for coding of diagnoses in billing/administrative transactions. The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion of the 17,000 codes available in ICD-9. How can we best prepare for this transition?

1. Improve electronic clinical documentation

The granularity of ICD-10 requires precise clinical documentation. Unstructured paper-based notes are unlikely to enable coding beyond the most general code for each diagnosis. ARRA incentives require ambulatory EHR implementation with structured problem lists, medication management, and clinical documentation as well as hospital CPOE use. These electronic systems will provide the foundation for the detail needed by billers/coders to accurately select the most specific diagnoses.

Here's an example - in ICD-10-CM, the code L89.133 is for a pressure ulcer of right lower back, stage 111. This single code in ICD 10 is specific to the right lower back and stage. Detailed electronic clinical documentation is needed to select the right code.

2. Train HIM professionals

The American Health Information Management Association (AHIMA) is the leading advocate for ICD-10 and training HIM professionals.

You'll find their training materials and courses online

Here's an example illustrating the training needed:

The ICD 10 code for Pathological fracture, right radius, initial encounter is M84.433A. This code is specific as to the location of the fracture, including laterality. The seventh character extension identifies the episode of care. Separate code categories are available for pathologic fractures specified due to a neoplasm or osteoporosis.

3. Embrace SNOMED-CT

Meaningful Use specifies ICD9 or SNOMED-CT for problem list management in 2011, ICD10 or SNOMED-CT for problem list management in 2013, and SNOMED-CT for problem list management in 2015. SNOMED-CT enables a clinician to document signs/symptoms, rule-out diagnoses, and problems, not just diagnoses. The structured clinical observations embodied in SNOMED-CT encoded clinical document will facilitate the accurate coding of ICD-10 diagnoses. The NLM's SNOMED-CT Core Set will include an ICD-10 crosswalk in the future.

4. Ensure we have the right vocabulary tools

Just as with the NLM SNOMED-CT Core set, it's important that the country has easy access to ICD9-ICD10-SNOMED-LOINC mappings that enable fluid translation of one codeset to another for various purposes. Many companies are working on such resources such as

Intelligent Medical Objects, which provides such services inside the EPIC EHR

AnvitaHealth (disclosure: I serve on the Board) which provides such services to Google Health

Apelon which has provided terminology services to Intersystems, Intel and the New Zealand Ministry of Health.

SNOMED Terminology Solutions not only maintains SNOMED CT on behalf of the IHTSDO but also provides mapping and consulting services to help provider organizations, vendors, various agencies of HHS, and other HIT-related companies with the successful implementation of terminology standards.

Over the next year, the HIT Standards Committee Clinical Operations Workgroup will discuss the vocabulary tools needed to support meaningful use.

5. Work with vendors to ensure EHRs and Hospital Information Systems are capable of supporting ICD-10 and X12 5010.

Existing EHRs and HISs will need to be upgraded to support ICD-10 coding and the transmission of transactions to payers via X12 5010 (replacing 4010). Vendors will provide one piece of the puzzle - software that is capable of supporting the new standards. Vendor efforts need to be supplemented with all the other strategies mentioned above to ensure successful ICD-10 implementation/meaningful use.

I realize that the dual transition of ICD-10 and SNOMED-CT over the next 5 years seems daunting. In my view, embracing SNOMED-CT for clinical observation encoding as part of electronic documentation provides the foundation for ICD-10 implementation by providing the clinical detail needed by billers/coders to accurately select the proper ICD-10 code. If we think of SNOMED-CT as the clinician facing vocabulary and ICD-10 as the administrative billing vocabulary for HIM professionals, adopting both codes is part of a single project plan to enhance the quality of healthcare data for all stakeholders.

Building the Nationwide Healthcare Information Network

I describe interoperability as a set of business partners with aligned incentives who exchange data to enhance efficiency, reduce costs, and improve coordination of care. Generally healthcare information exchange is local - hospitals, labs, pharmacies, clinician offices, and public health in a region exchange data for a specific purpose. Privacy and data use concerns are resolved locally. I do not believe that an architecture that requires a monolithic central database in the basement of the Whitehouse is going to be acceptable to stakeholders.

So what is the Nationwide Healthcare Information Network (NHIN) likely to be?

It will be a federated network of networks based on a common set of policies and data standards, enabling local, regional and domain specific (VA, DOD, Children's Hospitals) networks to connect with each other. Think of HIE's as similar to local phone exchanges and the NHIN as long distance service. What is required for a successful implementation of a "long distance carrier" for healthcare data?

1. Governance - A national framework for setting policy and technology for the NHIN. The HIT Policy and HIT Standards Committee could serve this purpose.

2. Education/Promotion - We need to ensure all state HIEs think of the NHIN as a connector between regional activities and understand how to use it. ONC could do this or partner with an organization such as the National eHealth Collaborative (NaeHC) or the e-Health Initiative (eHI).

3. Incentives - Meaningful use provides a powerful set of incentives to foster healthcare information exchange. Ideally, communications with Federal stakeholders such as CDC, SSA, FDA, and CMS would be done via the NHIN. This will incentivize all stakeholders to purchase EHRs and build HIEs which are compliant with NHIN policies and data standards.

4. Common transport, content and vocabulary standards - When EHR and HIE data exchanges are built, implementers have a choice of architectures and standards to implement. The work of HITSP and the HIT Standards Committee is architecture neutral, but provides enough constraints in the standards to reduce the number of choices, enhancing interoperability. Ideally, EHRs, HIEs, and the NHIN should should the same data transport (SOAP or REST over TLS), the same content (HL7 2.51, CCD, NCPDP Script 10.x, X12 4010 or 5010), and the same vocabularies (LOINC, SNOMED-CT, RxNorm, UNII) ensuring easy integration of regional and national efforts.

5. An agreed-upon set of security and privacy rules, including data use and reciprocal support agreements to which everyone who links to the NHIN must conform. Entities that link into the NHIN, and consumers who allow their information to be sent over the network, should be able to safely assume that some well defined, basic protection rules are enforced throughout, and that some well defined rules for representing, exchanging, and enforcing authorizations and consents are in place throughout the network.

Over the next year, the HIT Policy and Standards Committees are likely to work on NHIN related issues. I look forward to a secure nationwide network of networks with common policies and data standards that supports healthcare reform, public health, and the needs of patients, providers and payers. This is something we will create - we do not need to wait for our children to build it!

Shameless Corporation of the Week Award

Each week EverythingHealth will bestow its "Shameless Corporation of the Week Award" to a deserving health insurance company. Somehow I do not think it will be hard to find a recipient each week.Today's award goes to: Blue Shield of California HMO.When Rosalinda Miran-Ramirez awoke with bleeding from her left breast nipple she awakened her husband and had him drive her to the local emergency

Fertility Clinic Mistake Ends Up Good

It made me feel good to read that a mistake by a fertility clinic in Michigan ended with a happy ending. The biologic parents created an in-vitro embryo that was accidentally implanted into another woman at the clinic. A few days later the clinic notified Carolyn Savage that she was carrying Paul and Shannon Morell's embryo. She never considered terminating the pregnancy or trying to fight for