Emergency Medical Informatics Section Newsletter - August 2007, Vol 12, #3
Vernon D. Smith, MD
Angela Franklin, Esq.
Annual EM Informatics Section Meeting
Please plan to join us for our annual section meeting which will be held at the ACEP Scientific Assembly in Seattle WA. The date will be Wednesday, October 10th from 12:00 PM to 2:00 PM, PDT. The meeting will be located in Room 618-19 of the Washington State Convention and Trade Center.
The meeting will consist of a business portion, including the election of Section Officers. This year Vernon D. Smith, MD, will become Chair, Al Villarin, MD, FACEP, will take the position of Secretary/Newsletter Editor, and Dr. Randall Case, MD, MBA, MSE, FACEP is our Councillor. Therefore, the Chair-Elect, Secretary/Newsletter Editor-Elect, and Alternate Councillor offices are open for nominations by the Nominating Committee. Nominations from the floor will also be accepted at the meeting. Officers will be elected by a majority vote of the Section members present and voting at the meeting. For more information on the responsibilities of each office, please review the Operational Guidelines on the Section website. Please contact our staff liaison Angela Franklin, c/o email@example.com with questions, or to indicate your interest in seeking office.
The meeting will also feature a special presentation by Microsoft. The Section would like to thank Microsoft for its generous support of the Section Meeting. In keeping with its vision of improving health, around the world, Microsoft’s Health Solutions Group develops applications and solutions for the clinical and business requirements of healthcare professionals in the enterprise, and for improved personal health management by consumers. Azyxxi, the group’s enterprise product, is a unified health enterprise platform that unlocks the value in a hospital’s vast store of critical patient information. By aggregating data from across an organization’s existing systems to enable instant, customizable reports and analysis, Azyxxi assists clinicians and administrators in making informed decisions.
Register now at: www.acep.org/sa!
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Developments in Health IT
CCHIT Includes Emergency Medicine in New Workgroups
On June 14, the Certification Commission for Healthcare IT (CCHIT) announced new workgroups and expert panels to help carry out the expanded work of the Commission. One of the new workgroups is the Emergency Department EHR Workgroup, which is co-chaired by Donald Kamens, MD, FACEP, and includes Drs. Steven Davidson, MD, MBA, FACEP, Timothy Johnson, DO, MMM, Todd Rothenhaus, MD, FACEP, and James McClay, MS, MD. The workgroup is tasked with refining and finalizing the criteria surrounding core ED EHR functionality. The first meeting of the Workgroup took place on July 10 in Chicago. A complete listing of work groups, expert panels, and their members is available at: http://www.cchit.org/about/organization/. A visual summary of work completed to date, and future work may also be found on the website. See related article in this issue, HITSP’s Progress on the Emergency Responder Electronic Health Record.
Robert Wears, MD, FACEP Appointed to EHR Workgroup. In July, Dr. Robert Wears was appointed to the Electronic Health Records Workgroup of the American Health Information Community (AHIC) to represent ACEP. The EHR Workgroup was instrumental in prioritizing the need for an Emergency Responder EHR Use case at the AHIC, and is charged with making recommendations to the Community on ways to achieve widespread adoption of certified EHRs, and minimizing gaps in adoption among providers.
AHIC Seeks Comments on Transition Plan. At the July 31st meeting of the AHIC, HHS Secretary Michael Leavitt continued to lay out plans for the AHIC transition to a public-private entity, and announced that HHS will seek "conveners" of the successor organization via a grant process. ACEP members have been key participants in the AHIC, with Dr. Brian Keaton serving on the Population Health Workgroup (formerly Biosurveillance) and Dr. Robert Wears’ recent appointment to the Electronic Health Records Workgroup. ACEP has also provided significant input and comments on the Biosurveillance Utilization, Emergency Response-EHR, and the Medication Management use cases (inset). ACEP expects to continue to be involved in the successor organization.
AHIC Successor. The successor is expected be open to all comers, with staggered dues based on an organization’s size. Secretary Leavitt emphasized that current work will continue apace until the "baton" is passed to the successor, expressed the belief that the successor organization would be able to establish consensus technical standards more quickly, and noted that HHS would likely be its largest and most influential member. He also plans to reach out to organizations he considers "logical conveners" and urged would-be conveners to organize themselves in a multi-stakeholder fashion to increase their chances of success in the process.
- HHS has released key elements of the successor in the "American Health Information Community Successor White Paper" for public comment. Comments are expected to "inform the plans for transitioning the locus of activity from a Federal advisory committee to an independent public-private partnership while maintaining momentum." The white paper will be made available for public review and comment from August 6 through September 10 on the AHIC website at www.hhs.gov/healthit/community/background/AHICsuccessor.html
- August 2007 - HHS will host a public meeting for potential grant applicants (conveners) on August 17, and possibly another in September
- October 2007 - HHS plans to choose a convener by October 1, which will be charged with establishing a plan for transitioning the AHIC by March of 2008
- March 2008 - If HHS accepts the convener’s plan, a transition period will begin and the AHIC could be fully privatized before the November 2008 elections
- November 2008 - HHS will award a grant to the successor organization to support its start-up.
The AHIC was created by Secretary Leavitt in 2005 to advise him on healthcare information technology policy. The Secretary serves as the Chairman, and its members are a mix of private sector, federal agency and state representatives. The Office of the National Coordinator for Health IT (ONC) also advises the Secretary and the AHIC and manages several contracts to achieve AHIC objectives, including contracts let to NHIN consortia, CCHIT, HITSP and other groups.
Call for Volunteers
Section members are urged to become involved in the work in all these areas, particularly the EC-SIG and EDIS functional profile work, as well as involvement in significant, longer term work, which is being led by Drs. Kamens, Rothenhaus and several other Section members on revising the Data Elements for Emergency Department Systems (DEEDS). Please contact Drs. Kamens and Rothenhaus directly, or Angela Franklin at ACEP (c/o firstname.lastname@example.org); (202) 728-0610 x3014) to find out how to participate.
Dr. Michael Gillam MD, FACEP would like to alert Section members that the National Institute for Medical Informatics (NIMI) is providing several grant opportunities. NIMI would provide $1,000 to grantees for interesting projects, and $3,000 for more complex projects. Those interested must submit a single page description to Dr. Gillam for consideration.
In addition, Microsoft will sponsor one-year fellowships, with compensation in-line with a resident’s salary and located in Washington DC. Opportunities for a single month, or "as many months as desired" electives are also available. Participants would work in emergency medicine informatics in Washington, DC. Those interested must submit a letter of intent and curriculum vitae. Please contact Dr. Gillam directly, or Angela Franklin at ACEP (c/o email@example.com); (202) 728-0610 x3014) for additional information.
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Welcome New Informatics Section Members
Owen T Traynor, MD, Pittsburgh, PA
Kabir Yadav, MD, Bronx, NY
Dana L Emery, MD, Newark, NJ
Eliezer A Mordan, MD, Perth Amboy, NJ
Stanley E Koontz, MD, New Berrn, NC
Michel G Moreau, Secaucus, NJ
Eric M Kardon, MD, FACEP, Athens, GA
Mitchell J Heller, MD, Princeton, NJ
Christopher M McCarthy, MD, Morristown, NJ
Lisa M Roazen, MD, New York, NY
David Wei, MD, Ann Arbor, MI
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Linking Emergency Departments Together
Edward Barthell, MD, FACEP
Many emergency physicians across the country have been involved with efforts to establish regional health information exchanges. Emergency medicine provides an appealing use case for demonstrating value from these exchanges, as emergency clinicians frequently are faced with patients that cannot otherwise provide details of their past medical history.
Southeast Wisconsin has experienced some success in moving forward with plans and funding for a regional health information exchange, with a recent formal announcement of an ED Linking project at a kick off meeting June 20th. Through the collaborative efforts of the Wisconsin Health Information Exchange (WHIE), the Milwaukee Health Care Partnership, the State of Wisconsin Department of Health and Family Services, and Microsoft Corporation, a unique system is being established to secure and share medical information and to facilitate care coordination protocols that will assist in caring for patients, providing for better continuity of care, and improving patient safety.
The goal is straightforward: at the time of every emergency encounter in the region, a query for past medical history information is automatically made through the regional health information exchange system, and a rapid response to that query occurs in a way that is useful for clinicians. Note the emphasis on automatic and rapid, to ensure the system is used, and useful, so that the system has a positive impact on the care process. The regional query will be triggered by an HL7 based ADT registration message, without the ED staff having to separately log on and enter information. Various departments are designing their workflows to maximize the probability that key information derived from the regional query is in front of the clinicians at the time they first see the patients.
The WHIE system is designed to be useful for all patients, with an initial focus on
safety net providers and emergency departments. WHIE has obtained commitments for $5 million in funding to implement the ED Linking system in Milwaukee, including funding from the Wisconsin Department of Health and Family Services. Patients enrolled in Medicaid will be among the first group of patients with data available through the system.
Now WHIE will be working with Microsoft Corporation, which will provide its unique Azyxxi software platform to implement the local information exchange system. Azyxxi, which (as already known by many informatics section members) was designed by emergency physicians, aggregates and enables analysis of all relevant data across disparate systems, for a single integrated emergency department view of patient information. The software allows health care workers to maximize the value of information and make the most informed decisions. The WHIE system will be the first application of the Azyxxi software in this type of health information exchange.
The WHIE ED Linking system is expected to roll out this summer with initial hospitals connected before year end and 10 hospitals in total connected to the network over the next two years. An evaluation of the ED Linking health information exchange will be performed by academic researchers from the University of Wisconsin and the Medical College of Wisconsin. A variety of information on the project and the regional exchange are available at www.whie.org.
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HITSP’s Progress on the Emergency Responder Electronic Health Record
Jeffrey Nielson, MD, MS
ER-EHR Use Case
In December 2006, the American Health Information Community (AHIC), supported by a grant from the Office of the National Coordinator for Health Information Technology (ONC), a division of the U.S. Department of Health and Human Services, released several use cases designed to stimulate and guide the development of health information technology solutions. These use cases have been created to guide the development and selection of IT standards. The Health Information Technology Standards Panel (HITSP) is the organization now charged with bringing this plan to fruition.
One of the use cases is the Emergency Responder Electronic Health Record (ER-EHR). It describes what health information needs would arise in a small or large scale disaster. This use case was, in part, a response to deficiencies identified during the Katrina response. The bulk of the use case concerns situational awareness, incident management, and the flow of data from prehospital care, through the emergency department, to hospitalization, and ultimately, discharge. While huge in scope, the case is constrained to support information flow and not the sum total of information collected and recorded by providers along the continuum of care, although by direct extension some requirements materialize. ACEP and some ACEP members had input into its creation. This work is of particular interest to emergency physicians as the implementation will likely affect our daily practice.
ANSI and HITSP
The American National Standards Institute (ANSI) received funding to transform the use case into a real working recommendation. In 2005, ANSI created ("sponsored") the Healthcare Information Technology Standards Panel (HITSP) as the body designated to perform the work. HITSP is headed by John D. Halamka, MD, MS, an emergency physician at Harvard Medical School. The process of transforming the use cases into specific recommendations (and possibly requirements) is meticulous and time consuming.
From the HITSP web site:
The mission of the Healthcare Information Technology Standards Panel is to serve as a cooperative partnership between the public and private sectors for the purpose of achieving a widely accepted and useful set of standards specifically to enable and support widespread interoperability among healthcare software applications, as they will interact in a local, regional and national health information network for the United States.
Comprised of a wide range of stakeholders, the Panel will assist in the development of the U.S. Nationwide Health Information Network (NHIN) by addressing issues such as privacy and security within a shared healthcare information system.
HITSP’s goal is to identify, recommend, and constrain existing messaging standards that meet the use case requirements. It identifies gaps and overlaps in the standards. Their final product will be documentation on how health information communication should take place. It will not specify how or what information is obtained or stored. HITSP may identify issues or oversights within the use case and comment on them, but it will not change the use case. The HITSP ER-EHR work is being performed within the Care Delivery Technical Committee (CD-TC).
HITSP Work Progress
HITSP's work product for each use case begins with a Requirements, Design and Standards Selection (RDSS). This document 1) restates and organizes the data communication requirements of the use case, names the actors and gives some insight into the data communicated and 2) provides a preliminary list of some of the standards that might be considered. Their scope in this document, and in all their recommendations, is focused on data communications between systems. The RDSS goes through several comment periods before being finalized.
The next step is the Interoperability Summary (IS) in which the real decisions are outlined for which standards are to be recommended for each communication. The ER-EHR Interoperability Summary is currently in a very short inspection and testing period.
ACEP and HL7 EC-SIG: ER-EHR RDSS Involvement
The initial comment period for the ER-EHR ended in June 2007, and the comments are still being processed. The document was reviewed by the HL7 EC-SIG, and nearly 40 comments were submitted. A few of the comments, with the CD-TC responses are summarized below:
The document doesn't represent a substantial collection of new information or represent the physician's needs. It doesn't recognize DEEDS, NEMSIS (though only a specification), or have any plans for ED visit summary. Physician information needs are not addressed.
Response: The RDSS is an information gathering stage, the IS will be more specific. DEEDS and NEMSIS will be considered as candidate standards. The IHE Emergency Care Documentation Summary will also be considered.
Response: Data security issues were deferred to the Security and Privacy subcommittee, newly formed since the RDSS was first drafted. Discussions with this committee revealed that this will be a local policy decision as the security rules are just a framework.
The use case describes small scale incident in a way that sounds like a common evening ED shift. Emergency Medicine needs solutions now, not more requirements and a new system in case it gets really busy.
Response: EMS shared these same sentiments. The introduction to the RDSS will now include a paragraph making the strong suggestion that these recommendations be included in the daily activities of care providers so that we have a system that scales well, rather than dual systems.
The RDSS makes technology suggestions that do not recognize the workflow of healthcare providers. Documentation and attestation is not always done at the time of care both pre-hospital and in the ED.
Response: This will be included in the introduction as an obstacle. No specific recommendations are made.
Many of our suggestions ultimately were a reflection on the use case, its practicality, informatics implementation strategies, and perceived oversights. Every comment was specifically addressed with HL7 EC-SIG representation at their committee meetings but the changes were not included in any draft as this article went to press. HITSP has a lot of work to do, a tremendous scope, and many hurdles to overcome before the ER-EHR IS is implementable.
The Inspection Testing phase began on July 23, 2007, and goes through August 13, 2007. This phase is a formalized review of the Interoperability Specification. The HL7 EC-SIG will review the IS and make comments as well. HITSP has a very aggressive timetable.
Although the ER-EHR IS is under heavy development, and the committee is still only exploring candidate standards, the HHS Office of the National Coordinator for Health Information Technology (ONC) released a request for proposal (due July 2007) for a trial of the National Health Information Network (NHIN). It specifically named the ER-EHR as a requirement. More on the NHIN testing can be found at the NHIN HIT implementation website. Many members of the HL7 EC-SIG have expressed concern that the aggressive timetable will not allow HITSP and NHIN to reach an appropriate endpoint.
For more information, contact the author firstname.lastname@example.org or visit:
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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.