Wednesday, December 20, 2017

EMR/EHR Interoperability: The Missing Link

There has been much wailing and gnashing of teeth about the lack of interoperability of our electronic medical and health records (EMRs and EHRs). Some of this frustration can be directed toward a fundamental flaw of the American Healthcare System; lack of a national patient identifier. There is, however, another culprit whose head struggles to rise above the noise, hype and politics of interoperability: lack of a payload for interoperability.
            As a radiologist and imaging informaticist versed in imaging interoperability based primarily on the Health Level 7 (HL7) and Digital Imaging and Communication in Medicine (DICOM) standards and the Integrating the Healthcare Enterprise (IHE) integration profile choreography of those two standards, I am flummoxed that the rest of health care does not have the interoperability that we enjoy in Imaging. We have a patient centered “export all” button and the rest of healthcare does not.
This functionality has three important repercussions for health care. You can go to any digital medical imaging department in the world, and with patient consent ask for all the imaging studies of that patient. In the worst case scenario, you will be given a set of CDs; in the best case, you will be directed to an on-line service provider. Not only will those CDs contain, most often, an end user image viewer with a standardized user interface but after appropriate cross-institution, patient identity management, you can import these studies into a subsequent picture archive and communication system (PACS) for use as comparison studies in the clinical setting.
Of interest is the fact that radiology reports fall somewhere in between medical images and EMR results. Radiology reports are, in fact, often included, on CDs when image studies are exported. They are, however, less well formally defined, there is some variability in both their presence and the ability to import them into electronic medical record systems in a computable fashion.
The second repercussion of having all this data available in a standard format is that it is available for image processing and machine learning. All of the major image processing environments, proprietary or open, are able to process these medical images in any number of ways.
The third repercussion of this function of DICOM and IHE is that you can migrate imaging data, in bulk, from one PACS to another and this happens routinely. PACS systems are still evolving functionality and after 7 or 10 years of service (since PACS have been in service now for almost 25 years!) it is not uncommon for an institution to choose a new PACS and migrate all of the image data from the previous system to the new one. It is not a perfect or painless process due, typically, to a bit of data uncleanliness that builds up over the years, but it is insightful, straight forward, vendor supported and achievable. It happens, without much fuss every day.
None of this is the case for EMR data. The unit of exchange in what we call EMR interoperability (or the lack thereof) is not patient data but rather abstraction of patient data into Clinical Document Architecture (CDA) documents. The name, itself, positions it as nothing more than paving the cow path of the old three ring patient information binder and its paper documents. The aggregation of all of a patient’s CDA documents from all of a patient’s providers by no means represents all of the medical information about the patient.
CDAs are designed, from the get go, to be ‘human readable’ yet they are, for the most part, illegible. HL7 and the Office of the National Coordinator for Health Information Technology (ONCHIT) had to sponsor a challenge last year, to improve rendering of these documents. From a technology perspective, HL7 erred in blending the human readable and machine computable in one document. Much of modern computing is based on the model, view, controller (MVC) paradigm wherein data, delivery and display are separate not the least of why is so that each may be optimized.
Note that HL7’s Fast Healthcare Interoperability Resources (FHIR) specification does not solve this problem. FHIR defines modular resources that represent components of the patient’s record. There is a mechanism for bundling resources and for getting all available resources from a single system. Modular resources have not yet, however, been defined to cover the complete breadth of patient data. They will continue to be developed and released for years to come (as will CDAs). Moreover, vendors are not required to implement any given set of modular resources and, so, availability is and will be haphazard.So, neither the patient’s complete collection of CDAs nor all their FHIR modular resources can be used to develop a complete clinical picture of the patient. Nor can they be used to develop a complete computable data structure of the patient. This hampers the development of new computer applications in health care at a time when the technology for doing so is burgeoning.
Equally important, these collections also cannot be used to migrate patient data from one EMR to the next. This lack of migration stifles innovation and competition amongst EMR vendors. We want vendors to compete on novel ways of capturing, creating and making use of patient data not on the basis of possession of patient data. The lack of a clear, vendor neutral, affordable migration pathway traps the customer steward of patient data in an untenable, expensive situation. We, in Imaging, learned this important lesson decades ago; can you imagine, today, having to purchase a proprietary interface from each imaging modality vendor?!
So, how do we fix this interoperability problem once and for all? I suggest that HL7 International pause and take a breath. They are perfectly suited to develop a single, new extensible markup language (XML) artifact, perhaps based on the Reference Information Model (RIM), which can be used to instantiate all of a patient’s EMR content at a given point of time. Let’s call this the XMR for ‘exportable medical record’. This XMR artifact, though geek readable, does not have to be human readable (and I say that in the nicest way possible). Let the systems that receive, aggregate and process these new artifacts compete on how best to do so.

The problem of the lack of interoperability in health care information systems can be solved as has been done for decades in subdomains like Imaging. This new XMR payload artifact could be transported by any number of proprietary, IHE or FHIR transport mechanisms for any number of purposes. At any point in time, a patient could go to their provider and ask for their XMR (perhaps delivered on a thumb drive). More importantly, using existing exchange and patient record locator services EMRs could query their peers for a patient’s XMRs and these could be aggregated and incorporated, as structured data, into the local EMR. The collection of XMRs could be used to present more complete clinical information, drive the development of novel computer processing of patient data and liberate patient data from proprietary silos where it is now trapped. The ONCHIT could then live up to its name and mandate the use of this XMR artifact and the ‘export all’ button.

Friday, August 25, 2017

Photos From The Great Eclipse Ride (TGER) 2017, Elkton, Kentucky, August 21, 2017

OK, here are the pictures from the eclipse. We rode down from Indiana into Kentucky trying to get as far into the zone of totality as possible before the Eclipse started. I used the app to see where we were with respect to totality. We stopped in Elkton, KY which was not to far from the center line. The town looked quite prepared. The town square had a festive look to it with a small crowd congregating about the Town Hall. Everyone was very friendly and having a great time. (And it was a sincere good time since they are a dry county!) There was music piped in for the occasion.

 Note: All photos of the sun/eclipse were taken with my Google Nexus 6 phone! (I fried my GoPro, but that is another story for another day). I used the Manual Camera App from Geeky Devs Studio (a great app). This app lets you adjust all of the functions you would find on a 35mm camera (ISO, F-stop, shutter speed, focus, etc.). I used an ISO/CE certified Silver-Black Polymer Sheet solar filter from Thousand Oaks Optical over the lens. I cut a square from the sheet and placed it inside my phone case wedging it over the lens so it was held in place. The morning of the eclipse, I did a test shot of the sun rising over our breakfast spot.
For the actual eclipse, before totality, I set the ISO very low, to about 50, otherwise the glare/flare from the remaining sun 'blossomed" on the image. I tried to keep the shutter speed around 1/250 so as to avoid motion.  So the early eclipse looked like this:

As the sliver of sun got progressively smaller, I progressively adjusted the ISO up.
 I was only disappointed that I didn't get the 'diamond ring' shot either coming or going.
 I used the 4X optical zoom for all the photos.
For this next shot, I zoomed out to get the eclipse and, I believe, Venus, just as a point of light in the lower right.

My friend Aaron, had taken a few pictures of the surrounds during totality:

And I managed to remove my filter and grab one as well.

Then, I reversed the progress as the moon withdrew:

Then we went to the local post office to get our envelopes and first day covers canceled:

Overall, a great ride and a great eclipse experience. Planning is under way for 2024 though we won't have to travel far in upstate NY for totality!

TGER2017 Homeward Bound (II)

"Home where my thought's escaping, 
Home where my music's playing,
Home where my love lies waiting
Silently for me."
It is another beautiful day. I have Skyline Drive to myself. Very little traffic. The way is silent; the views spectacular. I am meandering at a pace of 35-40 miles per hour. I come around a corner and there is a fawn by the side of the road; undisturbed by my presence. It is cool at over 3000 ft elevation; I am wearing a heavy shirt and my light jacket. But it is an enjoyable chill that accompanies the one running down my spine from the beauty of the moment. This is one of the East Coast's old ladies of roads. I am left with a desire to return and explore on foot.
The rest of trip is anti-climactic. I slab up 81, one of my least favorite highways. Always an accident or construction to cram traffic into a miles long, single lane delay. Tonight, old 81 did not disappoint; we had both, several times over the course of 200 miles across the state of PA. But, in the end, all road lead home, in this case, not just to my "love lying waiting" but to a steak dinner with all the trimmings. What better way to end the TGER2017.

TGER2017 - Homeward bound (I)

As Mr. Burns (no, not that one), said, “The best laid schemes o' mice an' men / Gang aft a-gley.” It looks like the road to Charleston is paved with stormy weather. So, I turn the wheels northeasterly and begin the journey home. Last night we noted the tail of a bank of storms passing through the mid-Atlantic all the way up the coast. I will slip just west of them. The line of the front accompanies me on the right the majority of the day, but I am dry. I have dodged the weather once more. I take 11W north. Another enjoyable country road. The national forests are to my right. Then I join 219 for a bit. This is the same 219 that I took down on Day 1 next to the Allegheny National Forest. Interestingly, as I was riding the 11, I noticed some debris on the road. A sheriff that I had just passed lit up his lights. I was not going that fast. I pull over at the next driveway. He is slow to get to me. When he does, he apologizes.  "I only turned on my lights so as to safely remove the debris. I didn't mean to pull you over." It turns out he is a biker, too. We had quite a good chat about riding, the Cherohela, Dragon's Tail and, surprisingly, he had high recommendations for 219. This is a road that needs exploring!
But the highlight of the day were the roads through the Monongahela National Forest and the Washington and Jefferson National Forest. From the look of the trees on the map, they look like the same forest but they span the WV and VA border. On the WV side, the road to beat is the 92, "The Pocahontas Trail". Spectacular riding. I then took the 250 across to the VA side and it, too, is great. Several challenging, pronounced, "harrowing", turns. Great fun. I should have continued 250 to 64 and the base of Skyline Drive. Instead, I followed Google Maps on a  meander to Harrisonburg, VA and the upper segment of the Drive, for tomorrow. Don't get me wrong, it was a great meander.

Monday, August 21, 2017

TGER2017 Elkton, Kentucky - Success

We rose, early, to a clear sky just lightening to the east. The cool and the dew gave us just the right frisson of anticipation. We rode south from the Brown County In heading for Kentucky and the zone of totality. 46 was a lovely,winding road through the woods the enjoyment of which was just slightly reduced by an unexpected amount of traffic. An omen of things to come? Fortunately not. We continued on 37 South an enjoyable road, in its own right, that led through the Hoosier National Forest. By now, the heat was building as was the anticipation. We knew we were approaching the zone. We crossed the Ohio River into Owensboro, Kentucky past the Glenmore Distillery. We meandered south going further into the zone passing occasional small gatherings waiting for the eclipse.
We settled on the town of Elkton very close to the centerline of totality. It seemed like the entire town was gathered around the square. There was music piped in from somewhere (a lot of "Here Comes the Sun", etc.). Everyone in town was wearing Eclipse t-shirts,many promoting local businesses. After sandwiches and several bottles of water (ironically, in the heart of burbon country Elkton is is Todd County which is dry!), we found a corner in the shade to watch and wait. We took a bunch of photos that will be added when I have a better connection. The moment of totality came quite suddenly with a great cheer and oohing and aahing from the small crowd. The feel of the situation was wierd. It is twilight with this unusual ring hanging in the sky. The light is a strange color not quite black and white. Both Jupiter and Venus

were easily visible. More photos. Calm. And then, boom, another shriek from the crowd as the retreating diamond ring appears and totality is over. We watch through the filters as the moon retreats. We then sauntered to the post office to have them cancel our first day covers. They were happy to do so with a special cancel they had ordered. We finished another 20 minute ride to our hotel just over the line in Tennessee. Met many friendly people along the way each sharing their eclipse story. I am sure there are many more to come.

Sunday, August 20, 2017

TGER2017 Day 2: Cold to Hot

I see that the theme of this ride will be morning fog. I slept like a log right after dinner. That meant I was up to ride at 5 AM. It was clear and cool as I set out guided this time by solar photons reflected off Venus. The thermometer, at 5AM, said 63 but the riding felt like 53. I had my undershirt, my riding shirt, my heavy shirt ,my light jacket and the safety vest and was just comfortable. Every 100 miles I took a layer off until I rode into Indiana naked at 92° (I am exaggerating only slightly). But the morning ride through the fog laden mountains of West Virginia was quite refreshing especially as the sun rose (verb and color) behind me. This was not light tendrils of upstate NY fog, this was the real deal, a heavy blanket. I stayed at 35-40 mph for the first hour or so. I took mostly 50 West and then 32 West both labeled the Appalachian Highway. Nice enough roads through what is the heartland of America. Farms and small towns. Interestingly, this highway has intersections so you do about 60 then stop for a light every once in a while. Crossed the Ohio River into Ohio and continued straight West. I was mostly alone until I hit (and got lost in) Cinncinati. From there westward, fellow bikers everywhere. Another 400 miles under the belt. Tomorrow into Kentucky for the eclipse! Stay tuned.

Saturday, August 19, 2017

TGER2017 - Day 1 in the bag.

"Fog's rollin' in off the East River bank...." But it's not. Our fog is tendrils of cotton strewn amongst the hills that accompany the Susquehanna. With the sun rising behind me, the fog slowly lifts revealing the tree clad peaks of those hills. The road is empty and quiet. I make good time to my exit from the highway. From hone, the first leg is nearly due West. I join a new secondary road that neither I nor my bike has seen. It parallels the NY/PA border dancing from hill to farm and back again. I turn south at Bradford PA for a beautiful ride through the Allegheny National Forest. The urge to stop and explore is nearly insurmountable but my timeline does not permit. The forest is dark, cool and inviting, Clouds have come in and the radar hints at a pop-up storm so I put on the rain gear. False alarm as within a couple hours the clouds are much more friendly. In fact, its getting quite warm and I finish, sweating,in the high 80s here in WV. Tomorrow, it's, "Westward Ho!" to Indiana to meet Aaron.

The Great Eclipse Ride of 2017 (1)

As I wake, the sky is a crystal clear, deep, Rich azure the likes of which one rarely sees. I am chasing the sun for its eclipse but this morning, the rising sun is chasing me westward. Down through western PA to West Virginia. The XRAY2 photon is accelerated by those that follow me from the East.

Tuesday, June 20, 2017

AI/DL/ML win or fail?!

So, I recently received the following recommendations from Quora of topics / people to follow:
This merits some work to figure out what is going on here. Note the first recommendation to follow "Jewish Theology and Philosophy." Expected recommendation: I am Jewish and I 'follow' several other Jewish topics on Quora. The Ariel Sharon recommendation is, however, thought provoking. It is true that Ariel Sharon, deceased in 2014, was Jewish and was a leader of the State of Israel. Might be reasonable to suggest this recommendation based on my Judaism. Maybe Quora has access to some of my personal data (unlikely?) that shows I've been in Israel several times (I got married there). Quora says it is making the recommendation, "Because you follow Sharon, MA." At first glance, you might think this is an AI/DL/ML fail confusing the name of the person with the name of the town. I follow Sharon, MA because that is where I grew up. If you know a little more about Sharon, you know that it has (or had) a large Jewish population. It also has had a number of youth make various trips to Israel and a Jewish, Sharon teen was killed in Israel not too long ago. So, now, it's looking like the AI/DL/ML algorithm is really smart and has examined far more data that we would think. Or not. As we start to develop AI/DL/ML in medical and medical imaging contexts, we're going to run into similar situations where we are not quite sure if the AI/DL/ML is brilliant or a moron. Of course, we're all used to dealing with the 'idiot savant' resident who occasionally blurts out a brilliant answer. Interesting times ahead.

Friday, June 16, 2017

A Prayer for the Motorcyclist

Just got back from 2017 Ride 2 Remember. I thought that for next time, we might need a Mi Sheberach. I propose the following for general use...
מי שברך אבותינו, אברהם יצחק ויעקב, ואמותינו שרה, רבקה, רחל ולאה, הוא יברך את כל רוכבי סוס ברזל, את משפחתם, ואת מכונאיתם ואת כל  אשר להם.
הקדוש ברוך הוא ישמר ויציל אנשי שני או שלוש גלגלים מכל צרה וסכנה, מצמיגים שטוחים עד בורח מגז.
והוא יגו אותם ממָכָּ'ם וגשם, מגנבים ונהגי מיטה.
אנו מפצירים בו להעניק את רצונם לטיולים ארוכים ובטוחים, דרך אור שמש ומתפתלות המוליכים הביתה אל משפחותיהם האהובות.
ונאמר אמן.

May he who blessed our forefathers Abraham, Isaac and Jacob, and our foremothers Sarah, Rivka, Rachel and Leah bless all who ride the iron horse, their families and mechanics and all that is theirs.
May the Holy One, blessed be He watch over and save the people of two or three wheels from every trouble and danger from flat tires to running out of gas.
May he shield them from radar and rain, thieves and bad drivers.
We implore him to grant their wishes for long safe trips through sunshine and winding roads leading home to their beloved families.

And so, let us say, amen.

All feedback and grammatical corrections welcome. Keep the shiny side up.


Sunday, June 4, 2017

A one-line, state legislative fix for at risk, state Obamacare exchanges

First, let us not shed a tear for the health insurers threatening to leave (or having recently left) unprofitable state health insurance exchanges. None of the top 5 (10?) health insurers in the United States (outside the federal government) failed to make a profit (or revenues in excess of expenses, for those not-for-profits) in their most recent fiscal year. Many (most?) have large reserves or endowments that would put many to shame. Admittedly, some are losing money on their exchange plans, but that is how the health insurance game is meant to be played whether in private or in public. The wealthy must subsidize the poor and the healthy the ill (and the young, the old). They could and should amortize any ACA losses across their other plans. So, I propose the following language to be put on the books of any state where ACA exchanges are at risk:
"Any entity underwriting health insurance of any kind in the great State of XX shall also offer at least one set of conforming medal (bronze, silver and gold) plans in the State of XX's health insurance exchange." In the unlikely event that all health insurance carriers leave the state, that's a great vote for a state-wide single payer plan which is where we should be anyway.