Surfing on the Labor Day Weekend

The long labor day weekend is upon us all. I plan to spend mine with my feet up, and with a cold drink sightseeing on the hot sands of the Southern California beach.  I even invested in a cell card, so I can now find the internet whether I am floating on my raft, in a dark hole, in a green swamp, or whatever. I realize I am surrounded by   the "can you hear me now" guy and the helicopter flying overhead (Verizon).

As far as health information exchange goes, this weekend, my network is down....

The Caboose

I suppose the health train express should not have a caboose because that implies the end of the train. However I missed an important addendum from Mike Leavitt's blog which he writes as he travels through Africa, attempting to analyze Africa's challenges, clinical overload, a far cry from the paperwork overload providers face in our country. Mike makes some comments about HIE and RHIOs, the subject of which motivate my original blog. The post which follows here is an important link for you to understand what has been done and what will take place over the next five years. Don't miss the TRAIN !!!

http://www.hhs.gov/healthit/community/background/

from Mike Leavitt's blog:

"Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website: http://www.hhs.gov/healthit/community/background/
People have been talking about interoperable systems for years but the standards to make them work haven’t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.
This is an extraordinarily complex problem but the biggest challenges aren’t technological; they’re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.
Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.
The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.
Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.
The last several years I have become rather interested in collaboration as a large scale problem solving tool. I’m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.
Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.
The development of AHIC 2.0 is a significant venture. I’m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.
If readers have a chance to look through the AHIC website, I’d be interested to hear your thoughts."

Hot Weather and HotTopics

Stop, don't click away just because you think you have arrived at the wrong site. As I promised there were going to be some fresh changes at Health Train Express. Not only has Elvis left the building, but so too has Health Train Express.

Every summer at this time of August I mention how fast the summer has gone by. Well, just when I think it's over...it's not. The forecast for the next week is 100-107 degrees. As Yogi Berra has said "It ain't over until it's over".



So too is my forecast about P4P, RHIOs, and EMRs. No one can easily predict the outcomes in this arena. However it certainly fuels entrepeneurial minded providers, third party administrators and a variety of industry vendors into a fury of Category 5 storms.



One of my favorite blogs is that of Phillipa Kenneally, The Entrepeneurial MD. She regularly hosts podcast interviews at her site, which can be found at http://trusted.md/ Her guests are often "out of the box" innovators with examples of where many physicians go when they are not seeing patients.



Richard Reece's blog, medinnovation now has a link on my site . This retired pathologist living along the banks of Long Island Sound will give you much food for thought from his experiences and knowledge base of 30 years of clinical pathology experience, much of which has nothing to do with looking through a microscope.



We will be taking a two week break until after Labor Day, when we will return to continue our new "look" to our blog.

Transitions

Fellow bloggers:

When I first began “blogging” about three years ago I intended it to be a newsletter for a RHIO that I was heading up in my area of the country. About a year ago I chose to rename it “Healthtrain Express”. The term recently coined by others came to my mind in 1989 (that definitely dates me) It was in the pre-DRG, pre RVU, pre managed care (ie, the “golden days”) that my residents often wistfully mention..
I often tell them that no “age in medicine” is trouble free. It’s the nature of the “beast”.

Healthtrain express conjures up the rapid changes that constantly occur in medicine. For those of you who have read “Future Shock “ by Alvin Tofler , this has always applied to medicine. I highly recommend this reading.

It also denotes a vehicle with a tremendous amount of inertia, barreling down a “track” . If you are on the track you had better be moving fast enough to stay ahead of the train. If you are stationery, then you must either move aside or be “smashed”.

Returning to more specifics of our “age in medicine” we see the predictions and evolution of pay for performance and reporting, health information technology, the methodology of reimbursement change, including CMS intention to not reimburse for “poor outcomes” or those due to “poor care”. Medicine will continue to be increasingly directed by third parties, consumers, and political and social planners. Most of whom have never treated a patient. This one issue frustrates most physicians, although it has become a fait acompli, I know it continues to “gall” most doctors.

Physician-hospital relations continue to be in a state of flux. Gone forever in most areas is the leadership of the medical staff as it pertains to the board of directors, or trustees of the hospitals. In some rural areas this may remain intact, unless the hospital is part of a larger financial “holding company”. Creative financing has allowed many hospitals to continue operations with “leaseback arrangements” for management, and other issues.

Looming on the horizon is radical change in hospital accreditation organizations.
The JCAH authority is about to be undermined by pending legislation and some hospitals chose to use alternative accreditation sources This may or may not be a good thing, given that operating requirements have radically changed for hospitals.

For those of my readers you may notice on the sidebar the expansion of medically related blogs. Over the next month this list will be expanded. This is going to involve a significant amount of my time selecting and moderating my personal favorites.

I am also extending a personal invitation for co-authors to contribute to “healthtrain express”. Please email me if you wish to do so. email gmlevinmd@gmail.com

GML

Change in Direction

For the past three years I have been beating the drum about the development of HIE and RHIOs. I have not come to any final conclusions about the destiny of this "visionary" prospect. There are a great deal of positives and negatives regarding HIE and EMRs.
I will deal with some of the negatives first.

1. Most providers complain about the complexity and bureaucracy of practicing medicine, in regard to regulatory requirements, the hurdles of reimbursement, and exponential increases in business overhead.
2. The burden of Health IT may outweigh the benefits.
3. HIT is very expensive
4. Automation and the impersonal nature of IT does not really fit in to the paradigm of medical care. Despite patient enthusiasm for all things technical most providers are reluctant to introduce an infrastructure that will make them dependent on third parties.
5. Most physician providers operate on the basis of accountability, reliability, and a one on one relationship with each patient. IT is not going to improve the patient relationship.
6. Medical care has always been a unique portion of our economy, and recently outside forces have forced change, some good, and some very detrimental to patient care.

Positive:
1. The introduction of web 2.0 has greatly expanded patient education, and allows patients to ask more relevant questions.
2. Web 2,0 also introduces transparency and allow for "error checking" on the part of patients
3. Web 2.0 also increases the providers outreach for reliable information instantly at the point of care.
4. Most providers who have installed EMR speak positively about having it, and "would not go back to the old system" (my comments are that they could not even if they wanted to, because of their heavy investment in the system.

That's my meager summary after three years, it is not all inclusive.

Beginning next week Health Train Express will change direction. Look for a change in content first, then a change in the front end. I hope to maintain the title "Health Train Express" however our domain name may change.

Mike Leavitt Sec HHS joins blogger world

HHS Secretary Leavitt Launches Blog To Boost Health Care Discussion
HHS Secretary Mike Leavitt this week launched a blog to foster public discussion and exchange ideas on health care issues, The Hill reports."If I can do it justice, we will continue," Leavitt said, adding, "If not -- we won't." Leavitt, who plans to write all his blog entries himself and read "as many of the comments as time allows," said he will "wade in a little deeper into blogdom" this month.Unlike some blogs, all comments will be screened prior to being posted, The Hill reports.One day after his first blog posting, Leavitt already had received more than a dozen comments, including one that had to be removed because it was inappropriate or offensive, according to a spokesperson (Retter, The Hill, 8/15).

News from Rhode Island

Providence, RI —July 30, 2007—Rhode Island is now one step closer to implementing a health information system that will allow physicians, with their patient’s permission, to access important patient health data from a variety of sources when and where it is needed. The State has chosen Electronic Data Systems Corporation (EDS), and its subcontractor InterSystems Corporation, to build and integrate the necessary technology and software.
National and local efforts have been underway for the last several years to computerize medical records and develop secure methods to share records electronically. Governor Carcieri has prioritized making health information electronic for the majority of Rhode Islanders by 2010. “Anywhere, Anytime Health Care Information” is one of five elements that make up the Governor’s health care agenda.
“We can now begin the important work of building a secure Health Information Exchange, which will result in a more cost-effective health care system by reducing unnecessary tests and potential medical errors,” said Governor Carcieri.
The Rhode Island Department of Health (HEALTH), working closely with community partners, providers, and other key stakeholders, will oversee the development of this interconnected, interoperable system. HEALTH has engaged a wide range of consumer advocacy groups, health care attorneys, and others to ensure the system protects patients’ privacy and addresses the needs of both health care consumers and clinicians.
“With the creation of a statewide Health Information Exchange, doctors will be able to look up their patient’s critical health information, giving them a more complete understanding of their patients and allowing them to provide higher quality, safer, more coordinated care,” said Director of Health, David R.Gifford, MD, MPH.
Following an RFP process, HEALTH selected EDS as the technical vendor to build the system’s technology. EDS will subcontract with InterSystems Corporation for its HealthShare software. Through a three year, federally funded, $1.71 million dollar contract, EDS and InterSystems will build the core components of the system, including giving authorized health care providers access to comprehensive lab results and medication history for their patients. Initially these data will come from Lifespan, East Side Clinical Labs, the Department of Health State Laboratories, and SureScripts (a national company that administers the network connecting physician offices and pharmacies for e-prescribing). During the course of the contract, the system may be enhanced to include additional data sources and types.
EDS is a leading global technology services company, with a local office in Warwick. The company has extensive experience working for the State of Rhode Island, such as serving as Medicaid’s fiscal agent. For more information about EDS, visit www.eds.com
InterSystems Corporation, a software company headquartered in Cambridge, Massachusetts, provides software for connecting healthcare information. For more information about InterSystems Corporation, visit www.Intersystems.com.
Editorial Contact:

One Step Forward Two steps Back

Report: Health IT Bills Will Not Affect U.S. Health Care
Congressional measures to boost health IT adoption would not go far enough to make a significant difference in U.S. health care, according to a Commonwealth Fund report released Thursday, Government Health IT reports.The report, which analyzed major health IT and other health-related bills introduced between 2005 and 2007, found that none of the bills "would commit the funds and central leadership required to realize the potential benefits of a health information system.""There's just not enough funding to get us to a paperless health system in five to 10 years, in my judgment," Commonwealth Fund President Karen Davis said, adding, "If the U.S. is to close the health information technology gap with other leading countries, it will need a strategy and commitment of requisite funds to achieve its promise."Davis said the federal government should subsidize health IT adoption for safety-net providers and the development of regional health information organizations. "The basic problem (with the legislation) is that giving small amounts of money -- compared to the $3 trillion in U.S. health care spending -- and setting standards is not going to be enough to accelerate the adoption of health IT," she said.Davis said the report's findings are applicable to the Wired for Health Quality Act of 2007.The bipartisan Wired for Health Care Quality Act of 2007 has won committee approval and is awaiting action from the full Senate. There is not yet a companion House bill, but Rep. Patrick Kennedy (D-R.I.) is planning to introduce a comprehensive health IT bill after Labor Day, according to his policy aide, Michael Zamore (Ferris, Government Health IT, 7/26).

Despite this bleak appraisal of federal mandates and lack of follow through we see progress in private entrepenurial ventures to fund HIE. Local initiatives and buy in by stakeholders remains the elemental ingredient for success. One has only to look at the success of Healthbridge in Ohio, which has been operational for almost a decade. The key ingredient is focus and dedication by those involved over the long term.

Curing Healthcare: Knowledge, Standards and the Healthcare Crisis: Part 10

Curing Healthcare: Knowledge, Standards and the Healthcare Crisis: Part 10

The Train Coming Down the Track

Is your information technology structure from the ‘90s? 1890??

In the next five years we will see a catalytic innovation take hold, and I don’t just mean electronic medical records, personal health records, or web 2.0 applications.
In the past several months we have seen several states release morbidity and mortality statistics from hospitals performing certain procedures. Most of these were selected based upon their high per capita cost. The figures are prominently announced and displayed on easily found web sites. This of course is quite controversial and is resulting in angst of both hospital administrators and physicians alike. Payers want the most “bang” for their “bucks”, that is to say the best possible outcomes for beneficiaries. (i.e., they are not going to pay for “bad results”.
Providers and hospitals have seen this coming for quite some time, but the impact of seeing this data displayed publicly is immeasurable. For those providers and hospitals on the top tier, this gives them a significant advantage when contract talks begin.
Internal quality assurance, outcome measurements and daily updates will be necessary to stay even with
Change management is one key for successful transition to healthcare 2.0. The significance of the paradigm shift in the early 1990s is not lost on health care institutions or the establishment of the RVU for determining reimbursements for services by providers. The lag in understanding the “strategic” shifts which occurred then caused thousands of practice business failures and also hospital shut downs. Even the sea-change of practice management firms could not stave off bankruptcy and/or operational demise. The drive toward multiple levels of management, i.e., IPA, MSO, and HMO with all it’s subsets of responsibility between patient, provider and hospital serves as a rationing method. The new system will not allow for this paradigm.

Consumer advocacy groups have arisen, and are and will be playing significant roles in “health change”.

Perhaps California was the “poster child” for bad things, the emigration of thousands of providers to other states, the cacophony of IPA closures, health plan demise, and the changing nameplates of groups, hospitals and others in the health industry.
It is a fairly simple analysis. (The have’s and the have not’s) The have not’s will not be providing health care in five years.

Not only will having EMR be critical but also additional systems that will enable chronic disease management by “remote control’ and telemedicine. Leveraging the capability of the medical staff to care for SNF patients, and at home chronic patients will enable providers. Payers must come to terms with reimbursements for these modalities, since the ultimate outcome will be to reduce hospital in patient and readmissions as well as needless office calls. Remote telemedicine is here with devices that can provide audio visual contact using dial up technology. Remote sensing of BP, Pulse, and Glucometers is already available, and many more are in development. Other peripheral include the Prothrombin time Micro coagulation System, telephonic stethoscope, digital scale, and pulse oximeter.

Payers have been reluctant to share in the development costs of these systems. Change management must analyze the short term ROI, rather than long term ROIs. Most businesses want to see results in three months ( a business quarter).Successful transition therefore will require carefully focused change implementation in limited areas and progress as each gains ROI. (Randy Moore, American Telehealthcare)

Reality Check

I recently navigated over to the "TOP 100 HEALTHCARE BLOGS" ranking, and found that my blog was down in the 300s. The top 3 were "Random Acts of Reality" "Medgadget" and "Bad Science"
I also noted that technorati seemed to play a significant role in popularity of the "winners"

In the past I have written a great deal about health information exchange and RHIOs. From what I learned in the past three years I have altered my course and given up on the idea of "warp speed" and will depend upon "Impulse engines".

There certainly appears to be no impuslivity as it pertains to EMRs nor HIEs.

I sent out letters this past week regarding the "NEW PLAN" to bring EMR and HIE to our region of Southern California. Today is a clear day and I can look out over most of it and see all the way from Mt Wilson to Mt San Gorgonio and San Jacinto. As an aviator I can say
"CAVU". A properly paced mirror or antenna on anyone of these peaks would serve as a "beacon" for the hub of a health information exchange. If TV and Radio stations can do that then why not health information? Would this be a "disruptive technology" or a "catalytic innovation"

Funding seems to be a barrier to implementation of EMR and HIE. Why not an excise tax like the 911 excise tax on phone bills to provide emergency services? Certainly health care is important enough to our society that there lies a real basis for this to fund EMR and health IT. It spreads out the fiancial support to almost everyone evenly.

For those of you in our local region who read this I hope you will respond to my letter and email regarding the HHS grant for HIE. Hopefully your administrative assistant did not file it in the round file. Personally I tire of the voicemail trees and the voicemail...

On another note. one of my colleagues wanted to test the capacity of his servers. He posted a comment about "Daniel Radcliffe Naked". Within one day Google had picked up this post and his site hits went up by 10000 hits/day.

The name of my new post shall be "Daniel Radcliffe Naked" in the Health Information Age.
BTW for those of you over age 40 Daniel is the actor who plays Harry Potter.

From the desert to the sea

Your willing sevant.

Google me

Google Health (GH) could be the event of the decade in advancing health care reform — not just healthcare information technology (HIT) reform,
The "ultimate" PHR????
Google Health (GH) could be the event of the decade in advancing health care reform — not just healthcare information technology (HIT) reform, but health care system reform. GH promises simultaneously to create AND dominate the market for next generation personal health records (PHRs). There is nothing else in our solar system or in the entire universe like it.
II. GH’s Anticipated Technology Model
We’ve been provided a number of clues about the technology model that GH is likely to develop:
Patient centric
A personal health URL
Automated data mechanisms to gather and store PHI
Interoperable technical standards: XML and the Continuity of Care Record (CCR) standard
A user interface
Appropriate security and confidentiality measures
Value added functionality (over time)
What do you think???

THE GLOSSARY

My apologies for the delay in getting this posted. It is a rather long one, but contains a lof of information for "newbies" I suggest you copy and paste it into a word document.....then if you have google desktop you can search for "glossary".


GLOSSARY


Access:
The process of obtaining data from, or placing into a computer system or storage device. It refers to such actions by any individual or entity who has the appropriate authorization for such actions.
American National Standards Institute (ANSI):
ANSI is a broad based agency charged with overseeing voluntary standards development for everything from computers to household products. ANSI accredits standards development organizations (SDO) based on their consensus process, then reviews and officially approves the SDO recommendations.

American Society for Testing and Materials (ASTM):
American Society for Testing and Materials develops standards on characteristics and performance of materials, products, systems, and services. There are numerous standards-writing technical committees. E31 is the Committee on Computerized Systems and E31.28 is the subcommittee on Healthcare Informatics responsible for the Continuity of Care (CCR) standard.
Annual Support & Maintenance:
Costs that are typically 15-20% of the software license costs. Where the actual license is normally a one- time fee, the support and maintenance costs are renewed on a yearly basis. This yearly fee basically covers two areas: 1) any upgrades or new releases; and 2) customer service and support. It should be noted that both vendor EHR software and third party software will need support, so it is important to determine which components the support costs cover. Also, some vendors might have more than one service level agreement representing different support options at different costs.
Architecture:
The orderly arrangement of parts; structure.

ASTM:
See American Society for Testing and Materials.
Asymmetric Key System:
A system that uses different keys for encryption and decryption. Within such a system, it is computationally infeasible to determine the decryption key (which is kept private) from the encryption key (which is made publicly available).
Attribute:

A characteristic or property.

Audit trail:
Chronological record of system activity which enables the reconstruction of information regarding the creation, distribution, modification, and deletion of data.

Authentication:
Verification of the identity of a person or process.
Authorization: The role or set of permissions for information system activity assigned to an individual.

Biometric Authentication Technology:
Technology that uses some human biological feature (e.g. fingerprint, voice pattern, retina scan, or signature dynamics) to uniquely identify an individual.

CA (certification authority):
The entity providing third party trust within PKI.
Certification/Conformance Testing: Testing a product for the existence of specific features, functions, or characteristics required by a standard in order to determine the extent to which that product satisfies the standard requirements.

Chief Complaint Mapper: A software product that maps chief complaints, captured as text, and transforms them into useful digital data that can be used in functions such as public health outbreak surveillance.
Clinical Classification:
A method of grouping clinical concepts in order to represent classes that support the generation of indicators of health status and health statistics.
Clinical Data Repository: The data warehouse that contains clinical data (HL7 messages) centrally.
Clinical Messaging:
The communication among providers involved in the care process that can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room), to asynchronous communication (for example, consult reports between physicians). Reference: Health Level Seven, Inc.
"HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp)
Clinical Messaging #1:
Continuity of Care Data Exchanges
(Inter-Provider Communication):
Communication among providers involved in the care process can range from real time communication (for example, fulfillment of an injection while the patient is in the exam room), to asynchronous communication (for example, consult reports between physicians). Some forms of inter-practitioner communication will be paper based and the EHRS must be able to produce appropriate documents. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp)
Clinical Messaging #2:
Secure Patient/Physician e-mail (Provider and Patient or Family Communication): Trigger or respond to electronic communication (inbound and outbound) between providers and patients or patient representatives with pertinent actions in the care process. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004.
Clinical Reminders (Clinical Guideline Prompts):
The ability to remind clinicians to consider certain actions at a particular point in time, such as prompts to ask the patient appropriate preventive medicine questions, notifications that ordered tests have not produced results when expected, and suggestions for certain therapeutic actions, such as giving a tetanus shot if one has not been given for 10 years. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative Foundation, 2005.
Clinical User Authentication:
The process used by the HIE to determine the identity of the person accessing the system with adequate certainty to maintain security and confidentiality of personal health information and to administer with certainty of identity a regulated process such as e-prescribing and chart signing.
Computerized Provider Order Entry (CPOE): A computer application that allows a physician's orders for diagnostic and treatment services (such as medications, laboratory, and other tests) to be entered electronically instead of being recorded on order sheets or prescription pads. The computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems. Reference: United States Department of Health and Human Services. Office of the National Coordinator for Health Information Technology (ONC) Glossary: http://www.hhs.gov/healthit/glossary.html.
Confidentiality:
A 3rd party's obligation to protect the personal information with which it has been entrusted.
Controlled Clinical Vocabulary: A system of standardizing the terms used in describing client-centered health and health service-related concepts.
Conversion Services:
Consulting services offered by the vendor. These services will take your original data, either in paper or electronic form, and transfer the data into the EHR system database.
Data Center:
The physical space and hardware used by the HIE to house its operations if these assets are kept within the HIE.
Data Integrity:
The accuracy and completeness of data, to be maintained by appropriate security measures and controls. Preservation of the original quality and accuracy of data, in written or in electronic form.
Data Recovery Services:

A mechanism and process to safely store duplicate databases and recreate the data should a disaster occur.
Decision Support:
Computerized functions that assist users in making decisions in their job functions. In the practice of medicine, these functions include providing electronic access to medical literature, alerting the user to potential adverse drug interactions, and suggesting alternative treatment plans for a certain diagnosis.
Decryption:
The technique of using mathematical procedures to "unscramble" data so that an unintelligible (encrypted) message becomes intelligible.
Demographics: Information about name, address, age, gender, and role used to link patient records from multiple sources in the absence of a unique patient identifier.
DICOM (Digital Imaging Communications in Medicine): A standard which defines protocols for the exchange of medical images and associated information (such as patient identification details and technique information) between instruments, information systems, and health care providers. It establishes a common language that enables medical images produced on one system to be processed and displayed on another.
Digital Signature:
A string of binary digits which is computed using an encryption algorithm. Digital signatures enable signatory authentication, confirmation of data integrity, and non-repudiation of messages.
Doctor Matching:
The process of cross-linking the multiple provider identifiers in a community from a variety of provider identifier sources and creating a master doctor identifier with a key for cross-referencing the various community identifiers.
Document Review, Edit, Sign:
A software process that allows for the secure review, editing, and signature through electronic, distributed technology of electronic health record components, such as operative reports, discharge summaries, and consultations.
eLaboratory:
The electronic delivery of laboratory results to practices so that such data may be integrated into electronic patient records in a full EHR system, or used by a dedicated application to view structured, context-rich, and/or longitudinal laboratory results on a patient. eLaboratory includes closing the orders loop, documenting the review of results by clinicians, and documenting that the results have been communicated to the patient. The full benefits of eLaboratory are not achieved until the results are used as input into clinical decision support systems (CDSS).
Electronic Billing (Claims, Eligibility, Remittance):
The ability to contact the payer before the patient is seen and get a response that indicates whether or not the services to be rendered will be covered by the payer. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative, 2005.
Electronic Billing Support:
The ability to contact the payer before the patient is seen and get a response that indicates whether or not the services to be rendered will be covered by the payer. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based HIE Initiatives and Organizations." Washington: eHealth Initiative Foundation, 2005.
Electronic Health Record: Electronically maintained information about an individual's lifetime health status and health care.
Electronic Imaging Results Delivery:
The ability to accept messages from radiology sources and integrate the data for presentation to a clinician. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations. " Washington: eHealth Initiative Foundation, 2005.
Electronic Prescribing (Pharmacy Communication):
Provides features to enable secure bidirectional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp
Electronic Quality Data Submission (Performance and Accountability Measures): Support the capture and reporting of quality, performance, and accountability measures to which providers/facilities/delivery.
Electronic Referral Management:
The ability to generate and/or receive summaries of relevant clinical information on a patient that are typically transferred between healthcare providers when a patient is referred to a specialist or admitted or discharged from a hospital. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative Foundation, 2005.
Electronic Referrals and Authorizations:
The ability to generate and/or receive summaries of relevant clinical information on a patient that are typically transferred between healthcare providers when a patient is referred to a specialist or admitted or discharged from a hospital. Reference: eHI Foundation. "Second Annual Survey of State, Regional and Community-based HIE Initiatives and Organizations. " Washington: eHealth Initiative Foundation, 2005.
Electronic Signature:

A digital signature, which serves as a unique identifier for an individual. Reference:
Encryption: The process of enciphering or encoding a message so as to render it unintelligible without a key to decrypt (unscramble) the message.
E-Prescribing: Provides features to enable secure bidirectional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp
Health Information Exchange (HIE): The mobilization of healthcare information electronically across organizations within a region or community.
HIE provides the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.
Formal organizations are now emerging to provide both form and function for health information exchange efforts. These organizations (often called Regional Health Information Organizations, or RHIOs) are ordinarily geographically-defined entities which develop and manage a set of contractual conventions and terms, arrange for the means of electronic exchange of information, and develop and maintain HIE standards.
Although HIE initiatives differ in many ways, survey results and eHI experiences with states, regions and communities indicate that those who are experiencing the most success share the following characteristics. They are:
Governed by a diverse and broad set of community stakeholders;
Develop and assure adherence to a common set of principles and standards for the technical and policy aspects of information sharing, addressing the needs of every stakeholder;
Develop and implement a technical infrastructure based on national standards to facilitate interoperability;
Develop and maintain a model for sustainability that aligns the costs with the benefits related to HIE; and
Use metrics to measure performance from the perspective of: patient care, public health, provider value, and economic value.
Reference: eHealth Initiative. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative, 2005.
Health Care Interoperability:
Assures the clear and reliable communication of meaning by providing the correct context and exact meaning of the shared information as approved by designated communities of practice. This adds value by allowing the information to be accurately linked to related information, further developed and applied by computer systems and by care providers for the real-time delivery of optimal patient care.

Health Level Seven (HL7): An ANSI approved American National Standard for electronic data exchange in health care. It enables disparate computer applications to exchange key sets of clinical and administrative information.
ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision): The 1992 revision of the international disease classification system developed by the World Health Organization.
ICD-10-CM (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification): The American modification of the ICD-10 classification system, for field review release in 1998.
ICD-10-PCS (International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Procedural Classification System): A classification system for reporting clinical procedures, to accompany ICD-10-CM, developed in the US, for 1998 field review release.
ICD-9 (International Classification of Disease, 9th Revision): The 1972 revision of the international disease classification system developed by the World Health Organization.
ICD-9-CM (International Classification of Disease, 9th Revision, Clinical Modification): The American modification of the ICD-9 classification system for both diagnoses and procedures.
Implementation Services: Consulting services offered by the vendor. These services will provide planning and actual implementation of an EHR system. It is important when comparing quoted implementation costs that physicians understand which detailed cost line items a particular vendor will be supplying. Also, make sure and take a look at their project plans.
Informatics: The application of computer science and information science to the management and processing of data, information, and knowledge.
Interface: Shared boundary between two functional units defined by various characteristics pertaining to the functions, physical interconnections, signal changes, and other characteristics as appropriate.

Interface to ADT System: The interface between an HIE and the systems that are sources for admission, discharge and transfer (ADT) of patients in the care delivery setting and that are resident within care delivery institution.

Interface to ASP EHR System: The interface between an HIE and Electronic Health Records (EHRs) that are maintained on ASP platforms (i.e. NexGen, AllScripts).
Interface to Claims System: The interface between an HIE and the systems that are sources for or routing pathways for claims data that are resident within health plans and claims clearinghouses.

Interface to EKG System: The interface between an HIE and the systems that are sources for EKG results that are resident within dispensing physician offices and hospitals.
Interface to Eligibility System: The interface between an HIE and the source data of which people have eligibility for which type of benefits that are resident within health plans and are not infrequently web-enabled.

Interface to Formulary System: The interface between an HIE and the systems that are sources for formulary status of specific drugs for specific health benefit designs and that are resident within pharmacy benefit management companies and hospitals.

Interface to Laboratory System: The interface between an HIE and systems that are sources of laboratory data.

Interface to Pharmacy System: The interface between an HIE and the systems that are sources for prescription data or that are resident within dispensing pharmacies, pharmacy benefit management companies and hospitals.

Interface to Practice Management System: The interface between an HIE and the systems that are sources for the financial management systems of physician practices.
Interface to Provider List System: The interface between an HIE and the systems that track the multiple providers and their identifying data that are resident within health plans, dispensing pharmacies, pharmacy benefit management companies laboratories, physician practices, and hospitals.

Interface to Provider Office EHR System: The interface between an HIE and EHRs that are maintained in practice-specific systems (e.g. EPIC).

Interface to Radiology System: The interface between an HIE and systems that are sources for radiological data.

Interface to Transcribed Reports System: The interface between an HIE and the systems that are sources for transcribed reports. Typically these systems are based at a transcription service or at a hospital and contain admission and discharge notes and consultations, operative reports, and pathology and radiology results.
Interoperability:
The ability of two or more systems or components to exchange information and to use the information that has been exchanged accurately, securely, and verifiably, when and where needed.

The International Organization for Standardization (ISO): It is a worldwide federation of national standards bodies from some 130 countries, one from each country. ISO's work results in international agreements which are published as International Standards.
Key Certificate: A data record that authenticates the owner of a public key for an asymmetric algorithm. It is issued by a certification authority and is protected by a digital signature allowing the certificate to be verified widely. The certificate may also contain other fields beside the value to the key and the name of the owner, for example an expiration date.
Keys: A sequence of symbols that controls the operations of encryption and decryption.
LOINC (Logical Observation Identifiers, Names, and Codes): The LOINC databases provide sets of universal names and ID codes for identifying laboratory and clinical test results. The purpose is to facilitate the exchange and pooling of results, such as blood hemoglobin, serum potassium, or vital signs, for clinical care, outcomes management, and research.

Medication Matching: The process of cross-linking the multiple possible medication identifiers naming conventions in a community from a variety of systems housing medication information and creating a master medication identifier with a key for cross-referencing the various community identifiers. For example there are hundreds of NDC codes for identical drugs as well as HCPCS codes that identify the same drug as NDC codes.
Medication Reconciliation: Alerts providers in real-time to potential administration errors such as wrong patient, wrong drug, wrong dose, wrong route and wrong time in support of medication administration or pharmacy dispense/supply management and workflow. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp

Message Integrity: Protecting a message against its unauthorized modification, often by the originator of the message generating a digital signature.

Messaging to Pharmacies: The process of communicating electronically with pharmacies. This typically includes the cost of communication lines and processes between the HIE and pharmacies. This is necessary to support the e-prescribing function when that function includes the process of electronically sending a digital prescription to the pharmacy.

Messaging to Providers: The process of communicating electronically with providers. This typically includes the cost of communication lines and processes between the HIE and provider terminals.

National Health Information Network: An interoperable, standards-based network across the nation for the secure exchange of heath care information. Reference: HHS Awards Contracts to Develop Nationwide Health Information Network. 2005.

Network Connectivity: The process used for maintaining connection for communication between the HIE and a data source (laboratory, radiology practice, physician practice, or hospital) and data user (physician practice or hospital).

Network: A set of connected elements. For computers, any collection of computers connected together so that they are able to communicate, permitting the sharing of data or programs.
Order Entry: The process of communicating health care provider orders through electronic, computerized processes.

OSI (Open Systems Interconnection): An international standard for networking adopted by the ISO (International Organization for Standardization). This 7-layer model offers the widest range of capabilities for networking.

Outbreak Surveillance: Support clinical health state monitoring of aggregate patient data for use in identifying health risks from the environment and/or population. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp

Parallel Pathways for Quality Healthcare: eHI has developed a set of principles and framework for alignment of incentives with both quality and efficiency goals as well as HIT capabilities within the physician practice and health information exchange capabilities across markets. This Framework—entitled “Parallel Pathways for Quality Healthcare” offers significant guidance to states, regions and communities who are exploring health information exchange as a foundation to address quality, safety and efficiency challenges.

Participant Roles: Examples of roles that may be recognized by the health system that participate in events affecting the health of people:
Provider
Governor
Manager
Recipient
Researcher
Educator
Worker
Family Member
Roles may be used to authorize an individual's access to information system functionality.
Patient Matching: The process of cross-linking the multiple patient identifiers in a community from a variety of patient identifier sources and creating a master patient identifier with a key for cross-referencing the various community identifiers. This is also referred to as a record locator service.

Pay-for-Performance/Quality Data Reporting: Supports the capture and reporting of quality, performance, and accountability measures to which providers/ facilities/ delivery systems/communities are held accountable including measures related to process, outcomes, and/or costs of care, may be used in 'pay for performance' monitoring and adherence to best practice guidelines. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp

Record (PHR): An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment. Reference: United States Department of Health and Human Services. Office of the National Coordinator for Health Information Technology (ONC) Glossary: http://www.hhs.gov/healthit/glossary.html. 2005

Public Key Infrastructure (PKI): A conceptual framework that enables the encryption, decryption and electronic "signing" of data transmissions in a secure fashion within an open network environment.

Privacy: Right of an individual to control the circulation of information about him-/herself within social relationships; freedom from unreasonable interference in an individual's private life; an individual's right to protection of data regarding him/her against misuse or unjustified publication.

Private Key: In asymmetric cryptography, the key which is held only by the user for signing and decrypting messages.

Public Health Outbreak Surveillance: Supports clinical health state monitoring of aggregate patient data for use in identifying health risks from the environment and/or population.

Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp
Public Health Processor: A software product that processes extracted data from health care provider systems for the purpose of tracking, trending, and reporting for public health reasons.

Public Key Certificate: A data record that authenticates the owner of a public key for an asymmetrical key system. It is issued by a CA and is protected by a digital signature, allowing the certificate to be verified widely.

Public Key: In asymmetric cryptography, the key which is published by the user to encrypt messages and so that others may verify his/her signature.
Recommend Treatment and Monitoring: The basis of cost, local formularies or therapeutic guidelines and protocols. Reference: Health Level Seven, Inc. "HL7 EHR-S Functional Model and Standard." July 2004. http://www.hl7.org/ehr/downloads/index.asp

Registration Authority: An entity (group or agency) that has been delegated by a CA to perform a specific set of ‘trusted authority’ functions within PKI.

Results Answer Matching: The process of cross-linking the multiple possible answers to asking for a given result. For instance, asking for the results of a chest x-ray could yield a dictated report or a digital image of an x-ray. In any case, the case received must be matched across the type of result to a term identifying a common result.

Results Name Matching: The process of cross-linking the multiple possible names of data results that can contain the same information. For instance a blood glucose reading can be called up by a blood glucose test, an SMA panel, or a glucometer result.

Results Review (Alerts to Providers): The ability to interpret the clinical data that is entered about a patient using a set of rules or algorithms which will generate warnings or alerts at various levels of severity to a clinician. These are intended to make the clinician aware of potentially harmful events, such as drug interactions, patient allergies, and abnormal results that may affect how a patient is treated, with the intention of speeding the clinical decision process while reducing medical errors. Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative Foundation, 2005.

Results Review: The ability to interpret the clinical data that is entered about a patient using a set of rules or algorithms which will generate warnings or alerts at various levels of severity to a clinician. These are intended to make the clinician aware of potentially harmful events, such as drug interactions, patient allergies, and abnormal results, which may affect how a patient is treated, with the intention of speeding the clinical decision process while reducing medical errors.

Risk Assessment: An evaluation of the chance of vulnerabilities being exploited based on the effectiveness of existing or proposed safeguards or countermeasures.

Risk: The chance of a vulnerability being exploited.

Rules Engine: A set of rules defined within a software process that converts clinical and administrative data streams into a meaningful representation of clinical quality markers to be used in functions such as pay for performance/quality data reporting.
Security: In information systems, the degree to which data, databases, or other assets are protected from exposure to accidental or malicious disclosure, interruption, unauthorized access, modification, removal or destruction.

Service Level Agreement-Compliance: A documented track record of how well the vendor is meeting it’s customer support commitments.

Service Level Agreement-Customer Responsibilities and Duties: The steps that the customer needs to take in order to ensure that the vendor has all the information they need to resolve an issue.

Service Level Agreement-Hours of Support: Methods that will be used for communicating and resolving issues. Typical methods are email, phone, and online chat. Ask whether remote diagnostics and/or on site visits by support analysts are available.

Service Level Agreement-Methods of Support: Will be used for communicating and resolving issues. Typical methods are email, phone, and online chat. Remote diagnostics can be available and, in some instances, it might be necessary to have a support analyst come on site.
Service Level Agreement-Problem Escalation & Triage: The mechanism that defines how a problem migrates through the support system and the different resources that get involved along the way. If a problem can’t be resolved in a certain amount of time, then it escalates until it is resolved.

Service Level Agreement-Response Times: Different functions of the system might warrant different response times based on severity level. There should be a schedule of response times for different types of problems, and the service level agreement should define this accountability.

Service Level Agreement-Severity/Priority Classification: Different types of problems have different levels of urgency and importance. The severity level of a problem is usually noted when a support ticket is opened up. Resolution guarantees are based on severity levels. For example, CPOE down would be a high severity level while a patient education database not working might be a lower level of severity.
SNOMED International: A nomenclature for use by all health services professionals developed in the US and updated at least semi-annually.

Stages of Health Information Exchange Development:

Stage One:
Recognition of the need for HIE among multiple stakeholders in your state, region, or community
Stage Two:

Getting organized by defining shared vision, goals, & objectives, identifying funding sources, and setting up legal & governance structures

Stage Three:
Transferring vision, goals, & objectives to tactics and business plan, defining needs and requirements and securing funding

Stage Four:
Well under-way with implementation – technical, financial, and legal
Stage Five:

Fully operational health information organization. Transmitting data that is being used by healthcare stakeholders Sustainable business model.

Stage Six:
Demonstration of expansion of organization to encompass a broader coalition of stakeholders than present in the initial operational model
Reference: eHealth Initiative Foundation. "Second Annual Survey of State, Regional and Community-based Health Information Exchange Initiatives and Organizations." Washington: eHealth Initiative Foundation, 2005.


Standard:

Documented agreements containing technical specifications or other precise criteria to be used consistently as rules, guidelines, or definitions of characteristics to ensure that materials, products, processes, and services are fit for their purpose. A standard* specifies a well defined approach that supports a business process and:
Has been agreed upon by a group of experts
Has been publicly vetted
Provides rules, guidelines, or characteristics
Helps to ensure that materials, products, processes and services are fit for their intended purpose
Available in an accessible format
Subject to ongoing review and revision process
*This differs from the healthcare industry's traditional definition of "standard of care."

Statistical Deviation Detector:

Identifies variances from patient-specific and standard care plans, guidelines, and protocols.
The International Organization for Standardization (ISO): It is a worldwide federation of national standards bodies from some 130 countries, one from each country. ISO's work results in international agreements which are published as International Standards.

Third Party-EHR Specific:

Applications that are essential to the basic infrastructure of the system. They are the building blocks, such as the technical platform upon which the EHR system is built (e.g.,Windows, Linux, or MacIntosh, etc.) Also what kind of database structure controls the system (e.g, SQL, Oracle, etc.). When comparing license costs, note if there are separate general system license costs or if these are rolled into the main cost. Also, ask whether there will be additional costs when the vendor upgrades their software and it becomes necessary to install a new version of the database or operating system. Make sure your infrastructure software will support any features you wish to add later on.
Third Party-General System: Applications that are essential to the basic infrastructure of the system. They are the building blocks such as the technical platform the EHR system is built on such as, Windows, Linux, or MacIntosh, etc. Also what kind of database structure controls the system – SQL, Oracle, etc. When comparing license costs note if there are separate general system license costs or if these are rolled into the main cost. Also, will there be additional costs when the vendor upgrades their software and it is necessary to install a new version of the database or operating system. Make sure your infrastructure software will support any features you wish to add later on.
Training Services:

Consulting services offered by the vendor. They provide hands on training for all aspects of the system.
UMLS (Unified Medical Language System):

A long-term research project developed by the US National Library of Medicine to assist health professionals and researchers to retrieve and integrate clinical vocabularies from a wide variety of information sources. The goal is to link information from scientific literature, patient records, factual databases, knowledge-based expert systems, and directories of institutions and individuals in health and health services.
Vendor Software Licenses: License cost of various modules. Typically, modules will be licensed on a concurrent or named user basis. For example, with a concurrent license, if there are 4 providers and 8 employees, a minimum of 12 concurrent licenses would be needed. However, if the providers were halftime [meaning, they only used the system half time] (and all 4 never used the system at any one time, only 10 licenses would be needed). If using a named user license under the same circumstances, 12 licenses would always be needed – as licenses are not shared among different people. There can be a provision though for “active” and “inactive” providers (which means they could look at information, but not enter it in the system). Under an ASP (monthly rental agreement), software licenses are not being purchased, but rented However, the same issues exist for determining number of ASP licenses as with a license purchase.
X12:

A committee chartered by the American National Standards Institute (ANSI) to develop uniform standards for inter-industry electronic interchange of business transactions—electronic data interchange (EDI).
X12N:

The principle responsibilities of ASC X12N Insurance Subcommittee are development and maintenance of X12 standards, standards interpretations, and guidelines for the insurance industry, including health insurance. Most electronic transactions regarding health insurance claims are conducted using these standards, many of which are mandated by HIPAA.
The website development and some of the content in the Toolkit have been made possible by grant number 1D1BTM00095-01 and 02, through the Health Resources and Services Administration HRSA Office of the Advancement of Telehealth (HRSA/OAT). The contents are solely the responsibility of the authors and do not necessarily represent the official view of HRSA/OAT.