In the spirit of David Letterman’s top 10 lists here are our takeaways from the San Francisco iHT2 event this past week. ihealthtran.com/
Our customers need resilient, secure and easy-to-deploy application messaging solutions that meet their changing demands. As more and more buzz around the cloud, application migration, security and compliance percolate to the surface, Cloak Labs has peaked the interest of more and more CIOs and Infrastructure Managers.
Transform: Cloak Labs enables enterprises of all sizes and industries to transform how they connect applications. Our cloud-based infrastructure provides scalability, embedded security, resliency and economies of scale. Because of the Cloud, our customers can rely on a service based messaging infrastructure, allowing managers to focus on mission critical tasks instead of deploying and managing costly VPNs and hardware.
Manage and Serve: As a service, Cloak Labs provides a robust network that guarantees the delivery of every message as well as providing “military grade” security and encryption.
Build: With Cloak Labs you can build application interfaces in minutes regardless of the application or transport protocol.
Consume: Cloak Labs’ application messaging services are easy to consume and do not require any hardware installation or IT training.
Mr. Lohr, great article and thank you for covering this topic.
Any story about hospitals taking steps towards connectivity is great, but I fear that most think that connectivity is a little easier than it really is, that it’s just a matter of getting everyone together. Integrating hospital systems is challenging enough, but it’s “everyone else” that will pose the greatest challenges and thus making connectivity a fragile vision if it cannot be streamlined for smaller practices, independent physicians, clinical labs, etc.
Mr. Lohr points out that only 25% of physician practices today are computerized, and that should improve given incentive payments and consequences for non-compliance. However, the real issue is that we are putting the carriage before the horse; physicians will adopt patient management systems, EHRs, and EMRs, but the connectivity piece will still be unanswered. Furthermore, smaller practices and physician groups most likely will not understand why it is that further steps for compliance need to be taken as most of them are being educated (by the very software vendors selling them their wares) that if they merely install software that allows them to manage patient data digitally, they are going to get compensated.
Recently on a call with a hospital CIO, we discussed how they had to put a connectivity project on hold because of the 200 physician practices outside of her hospital she had to bring onto the network, only 120 had EMRs and none of them wanted to deal with having to deploy and manage a VPN. Seems trivial, but the reality is that doctors are doctors 1st and anything not related to treating patients is a distraction and is perceived to decrease their bottom line (In the Docs’ defense, VPNs are a blunt instrument and I don’t blame them).
Healthcare connectivity is a long, windy road that needs better planning, better ideas, and better solutions. The Direct Project sponsored by NHIN is a great foundation for simplifying and standardizing connectivity, but this battle also needs to be won with hearts and minds.
Fortunately NHIN will not even tell you that the Direct Project is the end-all solution to making the ubiquitous exchange of health information a reality.
That being said, many interpret it as a simple evolutionary step to secure health information exchange and compliance. Let’s take a look at what the Direct Project is and specifies:
There are many other requirements that outline what is needed to adhere to the Direct Project specification, but above are the high-level concepts. In itself, it is a great and elegant approach to solving the problem of interoperability and health data exchange, but there are some items of concern that need to be addressed when determining how to gain widespread adoption:
At Cloak Labs we are very excited about the Direct Project and believe it does provide a solid foundation for improving health information exchange. Our concern, however, is that it will require that healthcare providers to allocate over-stretched resources to meet the requirements of Direct and get their health IT systems to integrate with the network even if their EMR/EHR supports Direct.
We believe that as an added goal of the Direct Project, implementation and integration should not be difficult and that health IT folks need a solution that will minimize the impact to their workflows and current workload.
Cloak Labs is defining a better way for health IT professionals to take advantage of everything the Direct Project has to offer while minimizing the impact to their IT infrastructure and workflows.
In the last blog we discussed 4 major file types/documents that are used in healthcare data exchange: HL7, DICOM, CCD and CCR. In order to exchange these data types, application interfaces need to be deployed to allow for the integration of disparate healthcare systems.
Today, we will cover how applications communicate or interface with each other.
Interfaces typically use what is called a transport protocol, which “provides end-to-end communication services for applications within a layered architecture of network components and protocols.”
The most common transport protocol in use is TCP or Transmission Control Protocol. Sometimes referred to as TCP/IP, it allows for applications to stream data to each other. For example, if you have a Patient Management System that generates HL7 SIU messages (scheduling messages) and that application interfaces to an HL7 routing engine, it is likely that the two interfaces would communicate via TCP.
In healthcare, there is a subset of TCP known as MLLP which adds specific delimeters to messages to denote the beginning and end of a message. The receiving application needs to know where one message ends and another begins in order to deliver the correct information to the system. In TCP, you would do this by specifying a length header, or more simply put, the details about where messages start and end. With MLLP, specifiying length headers is not necessary as the transport protocol inserts the delimiters for applications to know where the messages begin and end. Confusing, I know!
Sometimes, it may not be necessary or preferred to use TCP/MLLP for streaming data, and applications will use Simple File Transfer or file drop. This is accomlished by outputing the messages and storing them in a directory on the computer or server. Another application or interface checks the folder for new messages and consumes them when they are written to the directory.
Interfaces need transport protocols to exchange information and it is common for systems to need to communicate over various connectivity services, making integration somewhat challenging. Talking with your health information service provider and/or your integration specialist can help you understand the best method for interfacing healthcare applications together.
Yesterday we briefly covered what healthcare integration and interoperability is and what it means to the healthcare industry. In today’s segment, we will be discussing some of the file protocols that are used in conjunction with continuity of care and interoperability.
Much like the blood cell in the human system, HL7 messages are the lifeblood of healthcare data exchange. Established in 1987, Health Level 7 (HL7) is a non-profit organization who’s mission is to “[provide] standards for interoperability that improve care delivery, optimize work flow, reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including healthcare providers, government agencies, the vendor community, fellow SDOs and patients.”
In more simple terms, HL7 is a file protocol through which care providers leverage a standard for sharing patient data. HL7 messages are broken into specific types that relate to a specific event within a patient record, also known as a trigger event:
Each on of these trigger events is created by a hospital system and will need to be shared not just across internal systems, but also with hospitals, HIEs, physician groups, clinical labs, etc. that may reside outside of a healthcare providers network. Not each message type is relevant to all applications and many hospitals that maintain dozens of systems will leverage HL7 routing engines to deliver messages to the appropriate destination.
While the HL7 message protocol is a standard widely adopted healthcare providers, it is sometimes seen as Stephane Vigot of Caristix puts it, as a “non-standard standard”. What Mr. Vigot is saying is that even though the protocol specifies syntax and message headers for identifying pertinent information, different systems may use different templates. Take patient “sex” for example: one hospital may register a patient as either male or female and another may have up to 6 attributes relating to the patient’s sex. As a result, when systems are integrated, HL7 messages need to be normalized so that the systems know where to look for the information.
Probably the most important thing to know about HL7 version 2.x vs. version 3 is that the latter has not been embraced by the healthcare industry yet. Version 2.x is a textual, non-XML based file format that uses delimiters to separate information. Version 3 on the other hand is an XML based file format.
DICOM stands for Digital Imaging and Communications in Medicine. Like HL7, DICOM is a file format for exchanging patient data, but is used in conjunction with systems that exchange medical images. DICOM messages are the file protocol of choice for PACS (Picture Archiving and Communication Systems). Value Representations (VR) of a DICOM message.
These two documents perform very similar functions, and are considered summary documents. Both CCD and CCR are XML based documents and provide a summary of a patients healthcare history. Included in a CCD or CCR document is a human readable section that covers the patients care history as well as pertinent patient information such as demographics, insurance information, and administrative data.
The major difference between the two revolves around how closely one is tied to HL7 standards than the other and how much easier one fits into the current workflow of a particular health IT system. While some see CCD and CCR as competing standards, Vince Kuraitus of e-CareManagement argues that “the CCD and CCR standards are more complementary than competitive.” The basis of his opinion revolves around the “the right tool for the job” metaphor and HIEs adoption of CCD doesn’t say much.
Integration and interoperability need file protocol standards and as the healthcare IT industry keeps evolving, many of the ambiguities of the current standards will eventually (hopefully) be normalized and conformity will prevail. In the meantime, HL7 2.x, DICOM, CCD/CCR are here to stay and will continue to be the lifeblood of integration and connectivity.
Completely inspired from my trip to HIMSS last week, I thought it made sense to talk about healthcare interoperability, connectivity and the component pieces to making this happen. This mini series is broken up into several parts that will cover:
According to HIMSS, healthcare integration “is the arrangement of an organization’s information systems in way that allows them to communicate efficiently and effectively and brings together related parts into a single system.” †
The 2006 White House executive order defines Interoperability as (section 2 paragraph c):
”Interoperability” means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered.
These are great standard definitions and allow you to understand the difference between the two. Integration relates to how systems can work or collaborate for a common purpose, e.g. a patient management system working with a scheduling system. Interoperability speaks to how these systems are connected, in order to provide a continuous flow of information that improves care for the patient.
In order to achieve Interoperability, systems must be connected in a secure way, authenticating all users and allowing one healthcare application to share data with another anywhere in the country, without compromising a patient’s privacy.
From a real world scenario, what this means is that all systems must be integrated in order to achieve interoperability, i.e. a physicians patient management system must be able to authenticate and securely connect to a hospitals EMR; Ambulatory centers to pharmacies; hosted EMRs to wound treatment centers. Patient information can no longer live in just one place.
Connecting all of these systems is no small task and is as much of an organizational challenge as it is a technological one. People and healthcare systems no longer exist within a vacuum and teams need to collaborate to make integration projects happen. These same people will need to agree on the best way to solve the connectivity problem and rely on the guidance of Health Information Service Providers to come up with solutions that meet the needs of all while adhering to the mission of improving patient care. As we continue to move forward in achieving interoperability, the scope and magnitude and of what needs to happen cannot be underestimated and careful planning must take place.
Throughout the mini-series, we will discuss the component pieces that are involved in achieving interoperability including application interfaces, file protocols, transport protocols, security & authentication, and compliance.
Integration and Interoperability are significant pieces of the Meaningful Use objectives and the mission is to improve the care of individuals while providing them with secure, ubiquitous access to their health information. While there is no one way that can solve the challenge of interoperability, understanding the mission and the various parts of the goal can help make achieving connectivity as prescribed by the ONC and Meaningful Use.
I think Ascendian’s CEO Shawn McKenzie’s interview is a great summary of HIMSS 11 and what is happening in Healthcare IT:
If you don’t have time for watching videos at work, then I will try to sum it up the best I can:
Widgets, lot’s of them. Mostly unimportant.
Shawn makes a great point that there is no real plan for Healthcare IT and interoperability. Instead (as we have commented before) there is a focus on EHRs and building “widgets” for healthcare professionals, which is essentially creating healthcare “silos”. While there is a ton of innovation being made at the practice side, very little is going into interoperability and the traditional medi-evil VPN solution for connectivity still reigns.
After walking the floor of HIMSS for days, we learned on our own how true this was. Most EMRs and EHRs didn’t care about interoperability and were content to tell us it was the customer’s problem. This seemed odd to us in 2 ways: 1. The idea is to solve customer problems, not ignore them, and 2. As a business, they are leaving opportunity on the table.
The Direct Project also had a showcase that demonstrated interoperability, but it was not clear who should be interested and why.
Once people realize that connectivity and interoperability are a big issue, they will also realize that the old way of doing things will not be sufficient. Real investment in new technologies that utilize the Cloud and provide real solutions to the connectivity and interoperability problem are needed. To borrow from Mr. McKenzie again, what we have now is the coal but not the train or the tracks.
With new regulation comes new opportunity. New healthcare requirements around the digitization of health information has caused a wide variety of start-ups and services to surface. Innovation is great, but there are very few standards being adhered to, causing a lot of headaches for ISV’s who are working with new customers to implement their systems.
If a hospital, physician, or clinical lab would like to start using a new product or service, that application needs to be able to communicate with older systems that may not be ready for retirement. Who will be responsible for ensuring that the two systems can interface to each other? How much will this cost and what impact will it have on deployment schedules? This typically falls on the vendor and a solutions specialist needs to be brought in.
Take for example a PMS system at a physician practice that now needs to communicate with a scheduling system that resides in a data-center off-site. The physician PMS will need to exchanges HL7 SIU messages with the scheduling system securely, meeting HIPAA requirements for health information exchange.
In order for this to happen, a secure connection between the two endpoints needs to be established, application interfaces need to be built, ports to the firewall need to be opened, and eventually a mechanism for ensuring each endpoint is authenticated must be implemented (See Wikipedia Article under Security Rule). What seemed to be a simple roll-out of a new system now requires professional services, network changes, and protocol conversion if there is a different transport protocol in use.
These integrations and road blocks can increase sales cycles and implementation times, making it harder to sell while decreasing margins for the ISV. Not to mention, the burden this may place on the customer.
Once an integration occurs, it is also necessary to monitor and maintain the network, which requires IT resources that may not have previously existed or may not have the bandwidth to support an increasing number of integration points.
As part of your integration strategy, it is important to evaluate a build vs. buy strategy:
– What will be the cost impact of rolling a VPN and application interface for each endpoint?
– What will be the cost of managing and maintaining that network?
– Who will bear the cost?
– What impact will this have on implementation times and sales cycles?
– As compliance regulations change, how will this impact your solution and margins?
Healthcare interoperability is an extremely important part of HIPAA regulations and a lot of health IT professionals will be focused on it, but as an ISV, connectivity may not be a part of your core offering, making it a distraction instead of an opportunity. If the numbers do not add up, it may make sense to use an application integration service as part of your value proposition to the customer, making implementation smoother, and decreasing network costs.
You have a new application, vendor or hospital that you need to interface to. Everyone in meeting grumbles about how the application interface will be built, where the resources will come from, and who’s budget will take the hit for adding the new partner.
To get started, you start thinking about everything that will need to happen:
1. A new VPN connection will need to be created to bring the new trading partner onto the network… paperwork with the hosting company or telco, network configuration changes, firewall ports opened, etc.
2. Depending on the application or partner you are working with, you need to understand what interfaces you will need support/build, e.g. does the application have a specific transport protocol you are not familiar with, is there a specific message protocol that you will need to convert
3. Specialist that have worked with these types of interfaces will need to be selected and contracted
4. Depending on how many connections you are creating, you may need to bring on additional staff to manage and support these connections
5. If any value added services such as guaranteed delivery or file tracking need to be implemented, this will increase the scope of contract work
6. Each connection will need to be tested thoroughly
VPNs provide the basic necessity of secure connectivity, but they are a unwieldy solution for IT organizations that are faced with deploying many connections and are limited on technical resources, time, and money.
When working with new trading partners, healthcare application interfaces, or vendors, VPNs may not make the most sense for your needs. Think about some of the problems you may face when adding new VPNs and how you can mitigate those pain points:
1. Are there other secure, application connectivity solutions available? If so, do they offer the most basic needs for interoperability?
2. Does the VPN solution offer file-level tracking, encryption, guaranteed delivery and web portals to view message and data traffic?
3. Are there solutions available that do not require changes to the firewall and/or network
4. Is there a solution that will require minimal IT support, reducing the total cost of ownership for maintaining secure outbound connections?
5. Will these connections continue to meet changing government standards for connectivity or will additional work need to be done to keep them compliant?
6. Is there a solution available that does not take weeks or months to implement?
There are many more questions to be answered, but the basic question is “can you find a better way?”. As technology advances and the Cloud becomes a more trusted platform for offering services, it may be time to start seriously evaluating alternatives to VPNs.