Tennessee statewide HIE vendor chosen!

I am back to blogging after a hiatus of a few months.  So, what has been going on? 


During this time I have participated in the HIP-TN Technical Workgroup writing the technical requirements for the state-wide HIE RFP (see http://www.hiptn.org/hip-tn-rfp/)  and evaluating the various HIE solution vendors.


We evaluated thirteen vendors based on their experience and response to our RFP (clinical, financial, technical).


A number of the respondents were eliminated in the first round because they could not meet the "mandatory requirements.  In the second round we split in little groups each evaluating a specific vendor.  The vendors that emerged out of the this round  participated in a "face-to-face" meeting in Nashville, where we all descended upon the "Tennessee Health Association" headquarters. 


Even after that we had two vendors that were very closely scored.  After further evaluation of their offering one vendor come out victorious:  Axolotl.  You can view the press release here.


I feel the vendors were evaluated in a fair manner with input from various workgroups which represented a wide range of organizations from the Tennessee healthcare spectrum.  


So who were the software vendors that participated?  Sorry, I cannot tell you.  The general consensus was that we would not divulge the names of those who responded to the RFP in order to avoid negative publicity for those companies.


The HIP-TN Technical Workgroup will continue to meet and provide feedback in the process of state wide HIE implementation.  Stay tuned!

NHIN Direct - introduction

At HIMSS 2010 Dr. Blumenthal launched the new ONC's initiative - NHIN Direct.  This created quite of bit of confusion ... myself included.  Why now? What is new? What's wrong with existing NHIN?  Why are HIEs still needed?  Is this a "skinny NHIN"?  
Wes Reshel outlines the differences very well in his blog.  I have included the article below for convenience:


NHIN Direct v. HIEs: Competitors or Collaborators
"Recently a person organizing a state’s HIE effort reported a hospital CIO saying, “why do I need your complex HIE when can have NHIN Direct?”

This question gets to the heart of the confusion that some states or stated designated entities are experiencing with the introduction of NHIN Direct into the mix. I wrote this fellow back, outlining the relative value propositions of HIEs and NHIN Direct. It is clear that the two notions are complimentary even if there is still some need to work out the rough edges. Here is what I wrote.

The hospital that is evaluating its need to participate in a state HIE needs to answer the following questions.

How long will the hospital and community physicians be satisfied with the following assumptions that will probably be baked into NHIN Direct:

• We will be sending information but not offering clinicians the opportunity to look up a patient and retrieve their information.
• We will be sending the information to a practice without sending the practice’s patient ID number
• We will send out structured lab information from our lab using standard LOINC codes
• We will independently determine whether it is appropriate to send each transmission to a specific provider.
• We will send all information with only a very general usage agreement in place.
• We will accept inbound information without our patient ID so each such input will have to be matched by the receiver.
• We will accept information without assurance as to whether coded information is standard.

Most of the hospital CIOs that I talk to say, “I’d be happy to live with those restrictions in order to get started reaching out to physicians in my community sooner. I know that practices that I send info to would be willing to live with them as well.”

This is a fair trade-off. However, it provides clear limits in supporting care transitions in that the sender has to know to whom the patient is transitioning – or the receiver has to make a special request for information that must be manually approved by the sender.

Furthermore, it is unlikely that community physicians will remain satisfied with this approach if an HIE is available that supports both the hospital and the practice or if HIEs are linked in a way to provide the connection.

The value that HIEs typically add include

• Maintaining a common patient index
• Providing the trust mechanism, software interfaces. access control and consent mechanism that enables lookup up information
• Developing a common trust agreement that all parties can accept.
• An interface to consumer advocates that will assert their role protecting the interests of the patients.
• A common software channel and active support to enable multiple data sources (e.g., labs and hospitals) to send results to multiple recipients and provide both senders and receivers a single point of contact for troubleshooting.
• Mapping imprecise recipients data (e.g., taking a physician name as the recipient of the lab result and determining whether to deliver the result by fax, on-line lookup or structured transmission to the EMR).
• Aggregating data at a community or state level for measuring quality, epidemiology, and other programs.

The only thing that an HIE has to do to compete with NHIN Direct-based communications is exist.

How, then should an HIE deal with the fact that by the time it comes to an operational state a great deal of communication may be going on under NHIN Direct? Easy: join it instead of fighting it. Be prepared to bring practices that are already using NHIN Direct into the fold without having to immediately change what they do. Add immediate value by forwarding patient results and notes with the practice’s patient ID. Provide shims for labs that cannot get to standard approaches. Allow them to begin to look up patients (using new interfaces) as soon as their EHR is ready. Allow them to use a portal to look up patients and have the results sent to them through NHIN Direct.

To really seize the initiative the HIE should become a provider of NHIN Direct services to physicians that don’t yet have an EHR or have an EHR that is not yet capable of dealing with NHIN direct. Operators of such a portal are in an ideal state to gradually introduce services that add value as soon as they can make the software and business agreement arrangements."

HIMSS 2010

HIMSS was huge this year.  It took me close to 3 hours to walk the two main exhibit floors ... without stopping.  


I spent a significant time at the Interoperability Showcase Booth.  I also got to meet (face to face) an NHIN team mate from Kaiser Permanente ... after having spent almost a year together in weekly telephone conferences.  He was demonstrating the NHIN connection between Kaiser and Veteran Administration. 


Here is a picture of a gentlemen that gave the orientation tour at the Interop Showcase:

Here is a picture of the Showcase booth itself with lots of companies demonstrating how they could "play nicely" on the health IT playground:

Here is another picture capturing the vendors participating in the showcase:

Top Electronic Health Records (EHR) software

There is ehr software and then there is EHR software.  When asked which company is the best my answer is ... you guessed: "it depends".  Here are some factors to keep in mind:
- size of the practice
- specialization
- certification (CCHIT for now)
- features
- quality of support
- number of sites
- location of data (local or cloud)
- sales rep likeability factor ( ... oops, scratch this one :-))


It is rather hard to compare EHR packages.  Klas is an organization that attempts to do that.   Here is their 2009 top 20 best of Klas awards for EHR.  Please use this information as a starting point.  As I mentioned there are other factors to keep in mind.  


2009 Top 20 Best in KLAS Awards: Professional Services Awards


Over 100 Physicians
1. Epic EpicCare Ambulatory EMR
2. NextGen EMR
3. Allscripts Enterprise EHR


26-100 Physicians
1. eClinicalWorks EMR
2. NextGen EMR
3. Allscripts Enterprise EHR


6-25 Physicians
1. Greenway Medical PrimeSuite Chart
2. e-MDs Chart
3. Optimed CHARTCARE EMR (CLINICARE)
4. Sage Intergy EHR
5. eClinicalWorks EMR
6. NextGen EMR
7. McKesson Practice Partner EMR
8. Allscripts Professional EHR


2-5 Physicians
1. Greenway Medical PrimeSuite Chart
2. Amazing Charts EMR
3. Allscripts Professional EHR
4. e-MDs Chart
5. eClinicalWorks EMR
6. McKesson Practice Partner EMR
7. Aprima AprimaEHR (iMedica)
8. NextGen EMR
9. Sage Intergy EHR


1 Physician
1. e-MDs Chart
2. eClinicalWorks EMR
3. Aprima AprimaEHR (iMedica)


* Rankings were calculated in December 2009


Here is a quick description of KLAS is and how they come up with this classification.


Who is KLAS Enterprises?
KLAS Enterprises helps healthcare providers make informed technology decisions by offering accurate, honest, and impartial vendor performance information. KLAS independently monitors vendor performance through the active participation of thousands of healthcare organizations. KLAS uses a stringent methodology to ensure all data and ratings are accurate, honest and impartial. Research results are offered to healthcare providers through, a free directory of vendor and product information, free online access to vendor ratings for participating providers and in-depth published reports.


What is the purpose of KLAS research? 
Their mission is to improve healthcare technology delivery by honestly, accurately, and impartially measuring vendor performance.


Where does the data come from? 
KLAS speaks with hospital and clinic executives, administrators, physicians, nurses, and other directors and managers with business responsibilities regarding the experiences they are having with their vendors and products. Routinely, KLAS speaks with approximately 5,000 hospitals and nearly 3,000 ambulatory organizations annually in order to gather direct client feedback on vendor performance.


How does KLAS obtain and verify data? 
Evaluations are received online from the KLASresearch.com website, via fax, by email, or directly from one-on-one interviews with professionals from provider organizations. Each research participant responds to a standard set of questions. These answers, once they are aggregated and averaged, determine a vendor’s overall score and rank as reflected in KLAS reports and online databases. All completed evaluations are followed up with a confidential interview by a KLAS research analyst. Each phone call includes a candid conversation regarding the experience with the participant’s vendor(s). Appropriate comments from that conversation are included anonymously in the research. KLAS confirms the role and responsibility of the participant and assesses any conflict of interest. If an evaluation cannot be confirmed or corroborated as valid, it is discarded. Where the providers participate at the invitation of the vendor, KLAS more heavily scrutinizes the data for evidences of bias. The results are posted to the KLAS Database and subsequent.

Chattanooga within the national context

Let's travel together :-).  It is 2012 and the health information exchange (HIE) in Chattanooga is operational.  Deep in the belly of the HIE there are  documents capturing the episodes of care of various people in TN, AL or GA.   John D., is among the patients with such documents.  He lives in Chattanooga but regularly goes out of town for business trips.  In this particular trip to Denver, CO he feels lousy and necessitates a trip to the emergency room.  How does the ER doctor get the access to the health records John has in Chattanooga?  The answer is Nationwide Health Information Network (NHIN).  The ER doctor contacts Denver's HIE, which in turn contacts Chattanooga's HIE and retrieves John's electronic health record.  All at the wire speed, all through NHIN.

On the map below,  Chattanooga and Denver HIE are green hexagons.  There are some other entities also represented on the map:  Google Health (PHR), hospitals, labs, pharmacies, federal agencies, etc.

This is how the health information is going to flow in US.  I have been involved with NHIN team since the beginning of 2009 and I can testify that this vision (started in 2004 by president Bush's administration) is moving forward.

"Standards" for an HIE

When talking about sharing clinical data, we technical people have the tendency to point to the lack of standards and headaches associated with the secure transmission of such sensitive information. The good news is that over the years IHE (see below) has been faithfully working at creating frameworks for sharing medical data.

Last year, while at Connect 2009 in Washington DC, I had a chance to meet Karen Witting - the co-chair of IHE's IT Infrastructure technical committee. Karen, a senior software engineer with IBM, has done a lot of work for IHE and NHIN since 2006 and together with other very dedicated people has been working tirelessly at providing standards for sharing medical info.

Why is this relevant? Because no HIE should buy software from a vendor that does not implement the IHE frameworks. By the way, these are not "standards" but rather a theoretical abstraction of the interaction between various health entities. They are definitely the starting point.

Here is a short description of what IHE does:

"Integrating the Healthcare Enterprise (IHE) is an organization whose aim is to improve how electronic patient information is shared among healthcare systems and, by doing so, to make sure that current and accurate data is readily available to both patients and healthcare professionals. IHE has developed technical frameworks that define how to process healthcare events, how data is shared, how security is handled, how audit records are generated, and how components interact with one another. The frameworks are made up of integration profiles that provide specifications of how each type of event is processed and how the audit message should be generated for each type of event. The profiles also define standards for security, communication, and time synchronization. These profiles are designed to ensure that data is transmitted securely and accurately among systems, and that data handling is coordinated according to communication and security standards. Having this common framework gives the various participants in a healthcare system a common base for integrating disperse systems."

Counties served by Chattanooga's medical institutions

Chattanooga serves the medical needs of a population spread across several states. I have attached the map with the patients coming from the adjacent counties in TN, GA and AL.

Wouldn't be great if:

- the clinical information would be shared in a seamless and secure way among all the providers in this area?

- the patients would be able to obtain their medical records in a few minutes even when they visit relatives in California?

- the quality of care would be increased as a result of the faster exchange of medical information?

In the next few months, drawing from the experience gained while working with various national HIEs, I will share my thoughts on how I think we can make this happen. Stay tuned.