WorldVista Meaningful Use Certified

Not sure why this was not formally annouced, but I was just doing some last minute fact-checking on my new health IT book, and I discovered that WorldVista EHR is a meaningful use certified product.

This is quite an accomplishment, and I am somewhat surprised that WorldVistA has not had an announcement about this. This is really important news and have broad implications. WorldVistA, unlike ClearHealth and Medsphere, is a non-profit organization.

Medsphere and ClearHealth provide only “pro” customers with the benifit of certification. How will WorldVistA handle this?

It is not clear to me if this could be the first completely available (sans proprietary ontologies of course) meaningful use certified Open Source EHR that you do not have to pay for support for. To make an analogy its like the difference between Fedora getting a certification vs RedHat Enterprise Linux getting a certification. Both are Open Source, but the latter is expensive

The other Open Source options as I understand them:

Tolven is partially certified as is OpenEMR.

ClearHealth was the first to be fully certified, and Medsphere also has a fully certified product.

Meaningful Use book

The first chapters of Getting to Meaningful Use are available online for public comment.

I am often surprised to meet people at conferences who say “I read your blog”. I mean, I know you read… because I have server logs to prove it…. but actually meeting someone kind of blows my mind.

So if you read my blog, and you enjoy it, please take a moment to read the first chapters of my book and give me some feedback on it.

I would especially like feedback on the Introduction. I was the primary author on that part (although that chapter especially had help from both co-author David Uhlman and my editor Andy Oram). Getting that chapter right is really important to me, because it is really sets the tone for the whole book. It details how Health IT is really different from normal IT.

If you are a regular reader, please, take a look.

-FT

Announcing Open Glaze

Hi,

I am here at the first ever Quantified Self Conference and I am announcing a new Open Source Game Layer project called Open Glaze.

Here are the basics of my Game Layer philosophy that are influencing my work on Open Glaze.

  • This is not one monolithic system. Its a Unix software development philosophy. It is a series of tools that do one thing really really well, and you can chain them together to do interesting stuff.
  • This is not intended to be a platform play. Platforms are intended to be profit sources which is why they are so popular in start-ups, but I am not convinced that this model works in this area.
  • I suppose you could make a platform play out of Open Glaze if that is what interested you.
  • I am substantially non-committal on the Open Glaze software sub-projects. I will probably be open sourcing almost everything (unless there is a very good reason not to) and if the projects are not popular or useful, and cannot attract other maintainers, I intended to abandon them.
  • Everything here, is part of the huge experiment that I call Programmable Self experiments that do not work will be taken out back and shot.

What -is- Open Glaze? It is a series of tools:

  • TokenGeo. This is a website that lets you create reverse geo tokens. Take a look at the reverse geo caching box, for a reference. The basic workflow is, create token stickers that use QR code-based URLs that  to lead you to a place using your GPS enabled smart phone, and then, once you get to that spot, open up some new spot on the Internet (open a secret URL).
  • 1 to 11. (because this one… goes to eleven) is a place to create your own Quantting web forms, that log the results to Twitter in the Graffiter syntax.
  • LinkedLast is a method for using your Twitter feed as a controller for the destination of a QR code.
  • StatusPresent is a method for using your Twitter feed as presentation software, and to crowd source tweets for Q/A sessions. (not sure how this relates to healthcare frankly… but it was an experiment)
  • WalkOrGive is a website that uses the fitbit API and the Twitter API to create “giving performance gambling”. If you meet your step goals for the week, walkorgive will tweet your success to your stream and ask your followers to make donations to your favorite charity (using a PayPal link) in your honor.
  • Of course, more to come

RPMS is certified

RPMS, the VistA cousin run by the Indian Health Services has received ambulatory and inpatient meaningful use certification.

RPMS is substantially available under FOIA, (there are some proprietary components required to emulate the certified stack, I believe) and is the first Open Source stack that I know of to be certified as both inpatient and ambulatory.

More as it develops.

-FT

Correcting Information Asymmetry for patients

Consumer reports is invaluable tool for the purchase of almost anything.

Anytime I am considering a major purchase like a car, or perhaps expensive electronics, I always by temporary access to consumerreports.org. While the Consumer Reports magazine can be interesting to browse, the website is even more valuable. You can access any recent product review done for the magazine in an instant.

The problem that consumer reports addresses is “information asymmetry“.

Consider going to the car lot to buy a car and then comparing two similar car models. Both of the new cars cost about the same amount of money. Both of the cars have the same essential features. Which brand of car should I buy?

The problem here is that there is an asymmetry of information. The car sales man knows much more about the performance of these brands of cars than I do. So there is a danger that he will recommend the worse of the two cars, which he will have over-priced. If I trust the car salesman, I might be doing what is best for him, not best for me. Even if the salesman is honest, he might be making his recommendation based on what the needs of the average car buyer. To the degree that I am different from the average car buyer, my needs might be different.

Consumer reports helps to reduce this asymmetry. I can learn about how the cars perform from an objective source. I might end up taking the car salesman’s recommendation… I might not. My decision will be based on -my priorities- which can be very divergent from both a typical customers and from the salesman’s interests.

This kind of information asymmetry is even more pronounced in healthcare. I could learn what a car salesman knows about cars in about a month of diligent study. But to understand what a doctor does I would have to study for years. If I am trying to make a decision like “Should I have this surgery” I am at the mercy of the doctors much-greater information position. The Surgeon might be recommending surgery because that would generate income. He also might be recommending surgery because he is assuming that my priorities are the same as the “typical patient”.

Rectifying this information deficient for as a patient is much more difficult, because the resources available to patients are often problematic.

The information on WebMD is probably accurate as far as it goes, but it is dumbed-down. You can always spot information that might not go deep enough on the web, because it always ends with “ask your doctor about…”. That is the least helpful thing to say here. It means “This is actually a much more complicated issue, but we are not going to give you any more information, instead go ask the car salesman (the doctor)!”. It is the doctor that I am trying to evaluate here!

Wikipedia has much more accurate information that goes much deeper, but its articles are of sporadic quality (usually very high, sometimes very low… which one are you reading now?) and it may not be updated with the latest information on its more esoteric articles. It was not never intended to be relied upon for medical information that changes very very rapidly.

My boss and collaborator at the Cautious Patient Foundation Dr. Cari Oliver has just written a detailed blog post where she details how patients can use at service called uptodate.com to get around this problem. This service is intended for doctors, but they have recently allowed temporary access rates so that patients can access a topic or two and not pay the expensive yearly access fee. Of course, this service is aimed at doctors. It might be a little over your head. But it is better to have access to accurate, recent information about the risks and benefits of different procedures, from a disinterested third party authority that is too complex than not to have it all!

This type of recommendation excites me as a technologist passionate about social change! This is a classic example of using information to make patients more powerful!!

-FT

Two other Open Source EHRs Meaningful Use certified (partially)

I just found out that at least two other Open Source projects have been meaningful use certified.

OpenEMR has been partially certified.

Medspheres OpenVistA CareVue has been certified.

I hope to get more information about exactly what the partial certification means and what the meaningful use strategies of these organizations mean, but this means that the ClearHealth is no longer alone in certification. (Although from what I can tell, ClearHealth remains the only fully certified Open Source EHR)

I will write more when I know more…

Glen Tullman presents the Chewbacca defense

I have been meaning to write about this for a while.

Glen Tullman and I have pretty different opinions about Health IT. Glen is the CEO of Allscripts, which is the largest proprietary EHR vendor in the country. When ONC called for testimony for the definition of meaningful use, Glen and I sat on the same panel. I testified after him, and I painted a much different picture of the state of Health IT than he did. The summary of his testimony: “The future of EHRs is already here, we are doing meaningful use today”. The summary of my testimony: “There is a market failure in Health IT, no other industry needed to be paid to computerize”. He holds his own software company out as an example of the “right way” where as I generally hold VA VistA, which was developed in a Open Source collaborative fashion as the way forward.

Of course we are both financially biased in this regard. I am an upper-middle income software developer, and Glen got paid $4,072,270 last year. Given the kind of money I make on this Open Source stuff you should probably take everything I say with a grain of salt, and take everything he says with about 45 grains of salt… you know… based on the relative bias involved…

But Glen Tullman got an opportunity to testify again (without me this time), regarding VA VistA. (text, video)

In this testimony, I want to focus on one specific statement, that is particularly galling to me.

While the private sector has been moving forward in light of these incentives, the Government has been investing in their own proprietary systems for many years.  Billions of dollars have been spent to build and implement the VistA/CPRS system within the Veteran Health Administration and the AHLTA system within the Military Health System.

So the VistA/CPRS is “proprietary”, while Glens own software is “private sector”. Wow. The Chewbacca defense at its best.

VistA/CPRS can be run for any purpose, the sourcecode is available for anyone to download without cost, you can redistribute those copies of VistA/CPRS without cost, and you can also redistribute modified versions of the software. That means VistA/CPRS meets the definition of freedom-respecting software, which is the soul of Open Source. Moreover, it was and is developed in a collaborative fashion that is at the heart of every successful Open Source project. If you want to know more, you should read What is VistA Really page that I edit for WorldVistA.

Then, Glen takes credit for accomplishments of Open Source technology:

For example, in Hartford, Connecticut, we have been partners in a project for almost two years that has not only led to widespread health IT adoption but successful implementation of open source health information exchange technologies.

What Glen meant by this is that there are some Allscripts node on an Open Source HIE created by MOSS, Misys Open Source Solutions. In short, Open Source -was- responsible for the exchange, and this had very very little to do with Allscripts software.

He goes on to say:

the fact remains that VistA’s basic platform, which relies on the 25-year old technology called Mumps, cannot support the open, flexible approach needed by those providing care to our nation’s wounded servicemen and women. Rather, the demands of today’s military and veteran healthcare environment necessitate the use of technologies – such as those based on Microsoft’s architecture – that can support an open, shared approach that will not just be desirable, but a fundamental requirement in the near future.

It should be noted that -every- instance of VA VistA inside the VA is capable of communicating with every other instance of VistA inside the VA. The VA was the first and probably still the only large scale organization to achieve this kind of internal data fluidity, which has been happening for more than a decade. Interestingly, the other “large” vendor in Health IT is Epic, a proprietary EHR company that relies heavily on MUMPS. I can think of nothing that Allscripts software can do that either Epic, or VistA is not capable of. Holding out Microsoft technology as a source for peer-to-peer leadership is also pretty ironic, but whatever…

Glen is pretty used to speaking out of both sides of his mouth regarding Open Source. And this testimony is far from the only instance. First there was this article in Forbes, which originally claimed that Allscripts had an Open Source platform, but was then quickly redacted to its current “clearer” status. This was not before it was completely flamed..

most recently, Glen was interviewed in the January 2011 Edition (Vol. 19, No. 1) of HealthData Management Magazine

And Tullman has spent those years (since 1997) being a relentless advocate of the use of open source architecture for health I.T. software and pushed his company to develop tool sets to connect its EHR software with virtually any device or software on the market.

This is was, of course, published in time with the edition of the magazine that would be available during the 2011 HIMSS conference.

This is a very disturbing case of a proprietary EHR CEO being completely intellectually dishonest regarding Open Source. I am on speaking terms with several of the top CEOs of proprietary EHR systems. People like Jonathan Bush of Athenahealth and David Winn (formerly CEO of) eMDs. I have advocated Open Source to these figures on a regular basis. But the remain proprietary companies because they believe that they will make more money as proprietary companies. I believe that Open Source has value that should be more important than profit, and have a friendly disagreement about this with most industry CEO’s. They think my ideas are intriguing and have potential, but see no reason to “bet the farm” on Open Source.

But they also -never- hold themselves out as the “Open” or “Open Source” option. Nor do they malign technologies merely because they are other than those chosen by their own developers. Glen Tullman regularly does both of these. Hell, he did in testimony to Congress.

Look I know that not everyone agrees that Open Source is the way to go, this is not what I am arguing here. I am arguing that we need to have honest and sincere disagreements about licensing and technology issues in Health IT rather than listening to Glen Tullman and his Chewbacca defense.

Direct and CONNECT governance too far from technology

Hi,

I have just submitted a comment to the HITPC governance working group regarding there process for making governance recommendations to ONC. I make the argument that for the most part, comments from HITPC regarding privacy and security architecture have been largely counter-productive because they fail to account for what the chosen NW-HIN (the artist formerly known as NHIN, shortly to be known as the Health Internet) protocols dictate regarding security and privacy architecture. Here is my comment:

Hi,
Thank you for your work on this project. As a minor note, I am pretty sure you mean “governance of the nationwide health information -network-” as opposed to just “nationwide health information”. Your link for “how to participate” does not actually have information about how to submit a comment. I must assume that comments to this post is what you mean, because there does not appear to be any other detectable process for commenting here.

I worked on the Security and Trust Working Group for the Direct Project, which forms one of the two approved protocols on the NHIN. I am somewhat informed regarding the other project CONNECT and the IHE protocols it implements.

In the Direct Project Security and Trust working group, we took -great- care to ensure that our work, would not trample the ability of HITPC or ONC to make reasonable (or for that matter unreasonable) decisions about how trust, security and privacy should be made. However, out of necessity, we did have to choose a technology stack and specific protocol configurations in order to get any kind of working system in place. Those decisions were not intended to limit your ability to make policy decisions, except in one important way; to quote the current version of the introduction to our Direct Project Security Overview: “In some cases, these protocols and technologies will come with specific configuration options that will have policy implications and may also present constraints that Direct Project will force on the trust policies of its users.”

In short, we asked that you implement your policy decisions in terms of the technology choices that we made. Most specifically we chose X.509 as a protocol for managing trust relationships. This is the same underlying trust architecture that is implemented in IHE and CONNECT. Rather than honor this basic request, to speak in relevant technological terms, HITPC has largely decided to recommend ‘in the abstract’. HITPC has ignored the fact that the fundamental designs of both Direct and IHE dictate that certain security and policy issues -must- be answered, and renders other issues irrelevant.

For instance, your document asks: ‘When is exchange not considered NW-HIN and, therefore, not subject to NW-HIN governance? ‘ While this may be a relevant question for those under the IHE protocol, the Direct protocol ‘Circle of Trust’ concept supersedes this questions basic premise. Its not the ‘answers’ the question… it just makes it irrelevant. With Circles of Trust participating in the ‘official NW-HIN’ is a fluid concept. Nodes will float freely in and out of any given definition of what ‘official NW-HIN’ means.

However, in your “what to do plans” you note that you expect to: “Establish technical requirements to assure policy and technical interoperability.” With all due respect, that work is largely done, and what little remains will be finished by participants in the Direct and CONNECT projects. Moreover, any ‘governance’ of these issues, that cannot influence the contents of reference implementations of the IHE and Direct protocols is mostly just blowing smoke. ‘policy and technical interoperability’ will be 100% dictated by what the Direct and CONNECT programmers put into those projects. Which means that for any governance body to get ‘policy and technical interoperability’, that body will need to be deeply linked in with the developers of those projects. So far there has been a substantial breakdown between what we the developers have asked for as far as policy guidance and what we have been given. Most of the advice from the Security and Privacy Tiger Team, while well-intentioned, made extremely poor technical assumptions and did not begin to approach the actual issues that we needed to address. For the most part, HITPC discussions of Security and Privacy have been a distraction to those of us actually deciding how things where going to be implemented.

Which brings me to what I think is the really only relevant issue here: Who should be on the governance board for the NW-HIN.

The answer to that question is pretty straight forward to me: You need to have at least one representatives from the Security and Trust developers from each of the two projects. Preferably the people who are actually involved with the implementation of the relevant portions of the code. (which rules me out sadly).

Moreover, -every- other member of the governance body should be well-versed in X-509. This means that it should be made up -entirely- of people who are both technology and policy fluent. If the members of a governance board are uncomfortable discussing revocation lists, and CA chain of trust or cross-certification intelligently, then they do not belong on the governance body for any portion of the NW-HIN. There are enough clinicians, who are capable of meeting those requirements that we have no reason not to expect this level of competence. Moreover, you should fully expect that the governance body will largely ignore your abstract questions and recommendations, and instead focus on those security and privacy issues that bubble up from our protocol choices, and start to ignore those that issues that are largely handled in-protocol.

Regards,

-FT

Please consider liking this comment if you have felt some of the same frustrations.

Regards,

-FT

The ethics of weight and body fat on Twitter

Update 12-16-2010:

I have just purchased a Withings scale. Indeed, as I discussed in my original article, it will only let me twitter my weight instead of my body fat. How frustrating. But, you can customize the static portion of each tweet. I will be tweeting my weight with a bit.ly link ( http://bit.ly/gS05Nz )to this article and @withings in each post.  Eventually, they will get tired of this and reply to my blog post or otherwise acknowledge this issue.

They also ask for my twitter password, which is no longer the right way to authenticate…

I originally blogged this while hanging out with Alan from videnitity.com ( originally met at health 2.0 ) at an mhealth conference. I should have mentioned videntity before.. they do cool work with Django and python for life streaming. In fact the discussion that I am about to go over prompted him to cover, in detail, some of the work he did using the Wii balance board to lifestream your weight. Hardware hacking for healthcare. Pretty cool stuff.

Almost immediately on seeing Alan again, our conversation turned to our mutual interest in quantified self. We are both interested wifi enabled scales.

But almost immediately I stumbled upon a mutual frustration. The most popular and well-known wifi scale in the space is the withings scale. The withings scale measures both weight and body fat percentage (impedance method). We were both frustrated with the default ability for the device to post to Twitter.

Take a look at the search for http://withings.com on twitter. Notice anything? Thats right folks… the withings scale posts weight. Just weight.

I do not need to bother to tell my readership ( clinicians and health interested IT folks) the problem with this. Our culture continues to have an obsession with weight at runs contrary to health. My own life is a great example. I weigh about 270 pounds. I am overweight, but my relatively high level of physical activity ensures that much of my weight is muscle. If I could manage to lose 10 pounds of fat and gain 10 pounds of muscle it would be better for me long term (as my muscle helped accelerate further weight lose) than just losing 10 pounds of fat. There is some debate about whether BMI or body composition is a better measure, but pretty much everyone agrees that thinking in terms of either BMI or body composition are vastly superior to simple weight measurements, because both take height into account (explicitly or implicitly).

So here we have the basic ethical quandary.

  1. Focusing on weight contributes to an unhealthy obsession with a single number that cripples our ability to compare two people effectively. This obsession can merely be inconvenient for people like me, who are capable of seeing past the number but are frustrated that I have to constantly do that work… Or it can be dangerous for those with certain eating disorders.
  2. The withings scale is capable of publishing both the body fat percentage/BMI and/or weight to Twitter providing social pressure for those who seek to manage their health.
  3. The withings scale chooses to publish only weight to Twitter.
  4. To add insult to injury, salt to the wound, spittle to the slap, and gratuitous cliches to the sentence: Withings knows that its users are requesting body fat percent in the tweet stream, they know they are requesting full templating of tweets, and they are taking a poll on what users want, but the poll does not have full templating (which would allow tweeting of body fat) or simple body fat tweeting as poll options.

Withings is playing “the users are too stupid” card on this one. From the comments of the blog post in question, in response to Paul who suggested a templating system:

Hi Paul, we first wanted to do so but as I said in the post above, we noticed that fully customizable tweets are too confusing for non computer-skilled users.

Moreover, a fully cuztomizable tweet can lead to unrelevant tweets.
Lets say youre trying to lose weight and your tweet is my current weight is %wc% and I only have %wo% to lose to reach my objective.
If ever you pass your objective on a specific weigh-in, the tweet will be unrelevant (it will say you still have -2 lbs to lose for instance) unless you think of changing the default tweet message just before weighing in…

Oh thank you pointy haired bosses at Withings. You have answered a tremendous consumer demand with a technology that further perpetuates fundamental healthcare mythologies. You have given us something at is 95% similar to what we need, but now serves a subtle destructive force instead of what you could have done which would be to apply social pressure to the right problem…and now as your user community suggests methods to allow us to fix your mistake… You tell us that we are not smart enough to do handle the tools we need to do that… Oh thank you from saving ourselves from ourselves!

This is the fundamental problem with Health IT today: we as health IT programmers are constantly making very subtle ethical decisions, and we regularly flub them up. More importantly, we ignore our users when they urge us to fix ourselves…

Withings made an ethical mistake in having the default tweetable data weight instead of body fat. Their UX justifications would be valid if they had made the right ethical decision to start. If I could only get body fat percent… That would be a frustration, but I could deal… As it stands they are just wrong.

But I understand why. Imagine the meeting:

Developer: we should integrate with Twitter
Pointy haired boss: cool do it.
Developer: we do not have time to do a complex integration. We can use weight, body fat percent or BMI…
Pointy haired boss: no one understands body fat percentage or BMI. This is a weight scale. People understand that… Lets go with that….
Developer: but body fat percentage….
Pointy haired boss: would not be as popular. This is a marketing and time question. We only have time for one of the two and most people will want weight…

The pointy haired boss is right. The fact is that people do understand weight better. Withings has probably sold more scales by choosing just to only tweet weight. This is not just a principle vs. profit issue. Assuming scales make a difference for people, more scales equals more difference. Frankly I do not blame Withings for starting with this decision. They were wrong, but their heart was in the right place.

But the arrogant position on templating systems and the fact that the poll they setup on the issues did not even give an option to chose body fat percent as an option is pretty unacceptable.

The other problem that Alan pointed out is that to get at the Withings scale data, you currently had to integrate with the Withings server rather than with the scale itself. So you have a device that records data about you, and then to get at that data, you need the by-your-leave of the device manufacturer… Not OK.

This device should be a “home health appliance”, and it should integrate with the Withings server -as a convenience- not as a requirement. I should be able to point this system anywhere I like. I should be able to easily point the data that the device generates anywhere I want to.

Withings need to take the following steps, and soon.

Support templating as a fundamental method of data export.
Support sending that templated data to any Internet location via simple POST, without going through Withings servers
Support full XML and JSON data export with those posts
Make body fat percentage the default measure sent to Twitter and give users the option to change it back to weight

If you support this idea… Please leave me a comment here, and retweet this article, with the @withings tag. I am pretty sure withings watches twitter.

-ft