Meaningful Use 2 mandates Electronic Health Records to support secure health transport to specifically fulfill the following measures:

• Measure #1: Providers should send a summary of care for more than 50% transitions of care and referrals.
• Measure #2: Providers should electronically transmit summary of care for than 10% transitions of care and referrals.
• Measure #3: At least one summary of care document sent electronically should be to a recipient with a different EHR vendor or to CMS test EHR.

Above construct very clearly mandates EHR vendors (AllScripts, EPIC, eClinicalWorks etc.) to support a standards based mechanism to allow transitions of care and referrals electronically.

The certification of Meaning Use 2, specifies the following technologies to fulfill above requirements:

1. Document Type: C-CDA document with requisite data specified for MU. The data elements are detailed by siframework here, and constitute things like patient demographics, allergies, vital signs, lab tests, referrals or transitions, care team, preferred language, smoking status, problems, encounter diagnoses, procedures, medications, inpatient-info if applicable etc. As you walk through this list, it turns out to be pretty thorough and useful!
2. Document Transport:
   1. Direct : Following are specified options for Direct
      • Option A: Direct (required) : This is Direct built in to the EHR.
      • Option B: Direct + XDR/ XDM (optional, but not alternative)
      • Option C: SOAP + XDR / XDM (optional, but not alternative)
   2. NwHIN Exchange: The documents can be transferred as part of Nationwide Health Information Network using the associated eHealth Exchange. The regulations for this are not established.

Under the transport guidance from ONC – Direct is required to be part of EHR application to be certified for meaningful use. There are really two options for EHR vendors and these were discussed at length in an EHRA (http://www.himssehra.org/) meeting I attended during the HIMSS conference. The options are detailed in a document released by the association, and following is my summary on what an EHR should do:

1. Provide a robust C-CDA and have ONC Direct as part of the application (this is equivalent to Option A). The downside of this is that the EHR has to implement all the technology like certificate management, SMTP gateways, direct address management as part of the offering. I’m not aware of many (except a couple of big ones) going this route.
2. Partner with a HISP to do meaningful use certification by implementing a XDR capability in the EHR (this is equivalent to Option B). EHR vendor would generate robust C-CDA or perhaps they can use services of some value added HISPs to generate these C-CDA. The downside of this approach is that the EHR vendor has to collaborate with the HISP on Direct user management however the upside its that with a standard interface (XDR/XDM) they are not tied to one HISP solution vendor. However, for certification EHR vendor do need to work with a HISP to show that they can satisfy meaningful use measures but during deployment, they can pick any HISP which provides the API capability.

There is even a third option (not discussed by EHRA) where the EHR vendors can have a custom interface with the HISP or perhaps just so a secure SMTP to the HISP and certify together with the HISP for meaningful use. This is a bit unfavorable for the EHR vendors as they locked in the HISP partnership but it also allows them time to build substantial technologies like XDR/XDM interfaces or being able to generate first-class C-CDA documents.

Thoughts or comments? As usual, use the space below.

Resources:

• EHR Vendors Association: http://www.himssehra.org/
• Guidance on Meaning Use 2 Secure Transport from EHRA: Link
• ONC EHR guidance: Link
• NwHIN Exchange specifications: http://exchange-specifications.wikispaces.com/

Having said above, among a plethora of sessions and events I’m looking forward to following events at the conference -

• Interoperability Showcase : A real-life standards play in action!
• Brian Ahier’s – Developing Trust in the Health Internet as a Platform
• ONC’s HIE Seminar
• Exhibit Show floor buzzed with words like – ICD-10, Meaningful Use, ACO, etc.

Editor of my book – Programmable Self with HealthVault, Andy Oram will be covering the conference along with others for O’Reilly. Brian Ahier has a good preview of the coverage.

If you are at the conference or are virtual (@ #HIMSS13) please drop me a note as I would love to connect!

Apologies I have been a bit on blogging hiatus! Among other things, I recently released my book on HealthVault, Enabling Programmable Self with HealthVault.

Quantified Self blog covered the book and the story behind it in its toolmaker talk series. Over next few weeks I’m hoping to post about a number of topics including Restful Health Exchange, NwHIN Governance, FHIR, HealthVault mobile applications and I’ll also be updating the compendium website for the book – www.enablingprogrammableself.com.

Please let me know in comments if you have suggestions for me to write about.

P.S. – I also moved on from Microsoft and I’m active in healthcare and technology community travelling frequently between Seattle, Bay Area and sometimes Minnesota.

Following is an example of method_missing in action :

class Roman
  def romanToInt(str)
    # ...
  end
  def method_missing(methId)
    str = methId.id2name
    romanToInt(str)
  end
end

Results:

r = Roman.new
r.iv
»
4
r.xxiii
»
23
r.mm

Following is a C# 4.0 equivalent using the dynamic keyword.

using System;
using System.Dynamic;
namespace Vitraag.MetaProgramming
{
    class Program
    {
        static void Main(string[] args)
        {
            dynamic Caesar = new Roman();
            Console.WriteLine(Caesar.IV);
            Console.ReadKey();
        }
    }

    class Roman: DynamicObject
    {
        int StringToRoman(string s)
        {
            // Simple logic needs a better function
            switch (s)
            {
                case "I" : return 1;
                case "IV": return 4;
                // Should add more cases
                default: return 0;
            }
        }

        public override bool TryGetMember(GetMemberBinder binder,
             out object result)
        {
            result = StringToRoman(binder.Name);
            // This logic could be improved
            if ((int)result != 0)
            {
                return true;
            }
            return false;
        }
    }
}

Running the above code gives us the result as: 4

I’ll be adding more thoughts in coming weeks around meta-programming and having an extensible type and formatting system. Please feel free to share your best reads or comments on the topic below!

For those new to the idea, Quantified Self is a forum for users and tool makers to interact and share knowledge, experiences, tips & tricks to enable better self discovery through tracking. The Seattle chapter of this forum is managed by great folks at Habitlabs (Buster & Amelia) and Limeade (David).

With over 20 people joining the conversation it was great to see energy in self-tracking and self-improvement. Most people seem to share the problem of not knowing what to do with the data they have. It was interesting to see Amelia to talk about positive effect of just tacking a 10-day running average of her weight. Robby gave a great presentation on his month long project to track transportation costs, and the conclusion to use a bicycle.

I’m looking forward to hear more this community. I have been trying to use HealthVault PowerShell and excel with power-pivot to track and visualize few properties of Health data.

I’ll try to keep this post short, give a general overview of International Statistical classification of Disease (ICD), talk a little about ICD-9 & ICD-10 and leave your folks will links to practical advise on converting from ICD-9 to ICD-10, and SNOMED-CT to ICD-10.

What is ICD?

Attempts to classify diseases started in 17th century. The prime driver of this classification was to gather statistics around cause of death could across countries. Over 19th century the list of international diseases rapidly versioned, the sixth version was published in 1946, ninth in 1975 and 10th in 1990! The revision 9th and 10th are most common and referred as ICD-9 and ICD-10 respectively.

Overtime many countries started using ICD codes for insurance re-imbursements with a slight modification (clinical modification – CM), and that is a prime reason why these code have become so prominent in the Health-IT industry.

The ICD code is an alpha-numeric code which tracks a diagnosis, symptoms and cause of death.

So what’s ICD-9-CM, ICD-10-CM?

ICD-9-CM stands for the 9th revision of ICD with clinical modifications. This is most prevalent code used in the US healthcare industry for insurance re-imbursements. Following are few examples of how this code looks -

Fig 1. ICD-9-CM codes

Note the format. AAA.BB. AAA stands for category and BB stands for etiology, anatomical site or manifestation.

ICD-10-CM is the 10th revision of ICD with clinical manifestation. All the US hospitals are mandated to use these code, starting 2013 only these codes will be re-imbursed by the payers / insurance providers. Following are few examples of how this code looks -

Fig 2. ICD-10-CM codes

Note ICD-10 is of the format – ZAA.BBBC

Z is supposed to Alphabetic. AA are numeric. Together ZAA make the category.
BBB is alpha-numeric and together they make etiology, anatomical site or manifestation
C is stands for code revision or extension

How do I convert from ICD-9 to ICD-10?

Shahid has a very good blog-post on practical advise for converting ICD-9 to ICD-10.

Following are interesting tools for the conversion -

1. ICD-9 data converter – http://www.icd10data.com/Convert
2. Who online training – http://apps.who.int/classifications/apps/icd/ICD10Training/

And what about mapping ICD-10 to SNOMED-CT?

As you have noticed ICD is more simplistic than SNOMED, rightfully since its original intent was to help with cause of death statistics. Overtime the ICD codes have been used in billing and increasing they have gotten specialized that they need to represent the diseases accurately. Naturally they have moving closer towards SNOMED-CT.

WHO has a preview release mapping some SNOMED-CT codes to ICD-10-CM.

Few notable incubators -

1. Healthbox – Chicago based incubator, powered by Sandbox industries.
2. Blueprint – NYC based incubator started by Brad Weinberg founder of Shapeup. Blueprint is focused more on enterprise startups
3. Rock health – A San Francisco based incubator. Most of the startups in the program are consumer focused.

Why are healthcare startups hard?
I’ll highlight few of very well known facts about the health industry that serve as a big barriers for the startups –

1. Regulations – There are a plethora of law’s regulating the industry – HIPAA, FDA etc.; and that in turn puts a lot of tax on a healthcare startup.
2. Long sale cycles – Enterprise sales in the industry have very long sales cycles.
3. Complicated economy – Someone has to give-up a dollar for startup to make one, its very hard to “generate” wealth in the Healthcare economy; it’s a very much a zero-sum economy. Additionally, the payer equation many times doesn’t align up well with other players in the system.

So what are the characteristics of the winners?
Lets take example of very of the well-established healthcare startups and see if there are themes for success.

1. Disruptors – Patients like me fundamentally challenges the current curing methodologies and introduces the social aspect to finding effective treatments using the power of social interaction.
2. Enablers – Zocdoc enables convenience for scheduling appointments and finding physicians. The service has seen a great uptake owing to fact that most folks like the ease of online scheduling.
3. Cost Savers – Given that the health care economy is zero-sum a lot of companies fit this bill. Most enterprise companies playing in the re-admission management, pre-registration, public health reporting, meaningful use etc. play in this realm.

Dear reader — anything else you as an obvious wining characteristics? Please comment below..

Most of the above incubators are still taking applications for their next set of companies, and if you have been pursuing a health care venture what better time to apply!! Act on your innovative ideas..

PS C:\Users\vaibhavb\Desktop> Import-Module HvPosh
PS C:\Users\vaibhavb\Desktop> Grant-HVaccess

Is auth done?
Is Auth done – (Y)?
[Y] Yes  [A] Yes to All  [N] No  [L] No to All  [S] Suspend  [?] Help
(default is “Y”):y

PS C:\Users\vaibhavb\Desktop> Get-Things weight | Format-Table

When        Value       Key         TypeId      TypeName    EffectiveDa       State       Flags  IsPersonal IsDownVersi
te                                                     oned
—-        —–       —         ——      ——–    ———–       —–       —–  ———- ———–
10/12/2011  175 pounds  f7931e43… 3d34d87e… Weight M… 10/12/20…      Active        None       False       False
10/12/2011  385         d4b2e3ab… 3d34d87e… Weight M… 10/12/20…      Active        None       False       False
8/5/2011… 160         382e9e1f… 3d34d87e… Weight M… 8/5/2011…      Active        None       False       False
7/7/2010… 250 pounds  1a76d859… 3d34d87e… Weight M… 7/7/2010…      Active        None       False       False
…

PS C:\Users\vaibhavb\Desktop> Add-Things weight 170
PS C:\Users\vaibhavb\Desktop> Get-Things weight | Format-Table

When        Value       Key         TypeId      TypeName    EffectiveDa       State       Flags  IsPersonal IsDownVersi
te                                                     oned
—-        —–       —         ——      ——–    ———–       —–       —–  ———- ———–
10/13/2011  170 pounds  45abc16d… 3d34d87e… Weight M… 10/13/20…      Active        None       False       False
10/12/2011  175 pounds  f7931e43… 3d34d87e… Weight M… 10/12/20…      Active        None       False       False
10/12/2011  385         d4b2e3ab… 3d34d87e… Weight M… 10/12/20…      Active        None       False       False
8/5/2011… 160         382e9e1f… 3d34d87e… Weight M… 8/5/2011…      Active        None       False       False

So what is the cool thing going on above? Well in five commands we are able to authenticate, get and put weight readings in to HealthVault!

This is all possible owing to the magic of powershell, and a powershell HealthVault module (HvPosh). This is just a start, there all kinds of nerd scenarios this HealthVault command line shell can do! Think about command line automation for getting in all that data in to HealthVault, working with test data, understanding the healthvault xml, and doing all sorts of quantization on your personal health data!! The possibilities are limit-less, well at least for the command line nerds .

So what is HvPosh?

HvPosh is a HealthVault powershell module currently running as a desktop client application. The source for this module is up on github and you are welcome to contribute more functions, cmdlets, test data or infact various analysis modules!

Take HvPosh for a spin, and yep! this is right out of oven so be gentle!

Fig 1. HvPosh On GitHub.

Last year I talked about Programming Healthcare Silos, the Direct project is an innovative way to bridge the silos in Healthcare and provide a secure provider to provider and provider to patient mode of data exchange.

If you are around stop by for the talk or come grab us of any relevant questions. We’ll post the slides online after the talk.

I’m looking forward to the conference, and particularly to the talk on personal data locker project and more. It has been a pet peeve of mine to build some akin to that, with the locker talk and more awesomeness hopefully I’ll get to hacking on it soon!