Some electronic health record (EHR) vendors are offering solutions as a cloud-based offering. This offers an approach intended to help providers better manage the IT investments that need to be made to support EHR implementations. And just as we’ve seen in other industries, there is an ongoing debate within healthcare as to the viability of cloud-based solutions given the care needed for patient privacy and sensitive personal information.

Providers’ trust in the public cloud is still relatively weak, but increasing numbers are considering using private clouds. However, EHR applications hosted in the cloud do seem to be gaining traction.

One example of a cloud-based EHR offering is CareCloud. My fellow Radar blogger Andy Oram wrote about them two years ago at HIMSS, and they have made significant progress since then. CareCloud creates apps that help medical professionals run their businesses. Those apps include a community collaboration and communication platform to securely share patient information, a medical practice management system for billing and scheduling, and a revenue cycle management service. CareCloud also provides electronic health records. It’s built with Ruby on Rails, a highly abstracted programming language quite well suited for rapid development of web applications. CareCloud was a co-winner of the IBM Global Entrepreneur Silicon Valley SmartCamp competition in 2010 (see video below).

I ran into the folks at CareCloud at the HIMSS 2012 conference and was impressed with both their use of open source and their strategy on leveraging the cloud in healthcare. Mike Cuesta, CareCloud’s director of marketing and user experience, defined CareCloud’s strategy as one of future survival.

“Being able to deliver the product across platforms is crucial,” Cuesta said. “In healthcare there is a glaring lack of modern web apps. What we wanted to do was create an elegant and user-friendly application that is accessible anywhere. Companies have to be able to deliver a desktop-class experience that works across platforms.”

CareCloud relies on open source. “I had my eyes opened to open source about eight years ago when I was looking for a project management system,” said CareCloud CTO Tom Packert. “I discovered I could use something like dotproject, which is a GPL-licensed PHP-MySQL web-based project management application. It only took us a day to put it up on SUSE Linux and we didn’t need SQL seat licenses. Open source allows you to scale horizontally. It’s not as scary as a lot of people think it is.”

Another EHR in the cloud is athenahealth. Athenahealth’s co-founders Todd Park, the new U.S. chief technology officer (CTO), and Jonathan Bush, purchased a birthing practice in 1997. Soon, like most medical practices, they were buried in paper and spent most of their resources trying to get paid. Searching for innovative solutions led them to create their own software. Enlisting the help of Todd’s younger brother Ed, a software developer, they created an EHR and financial revenue cycle system with a rules engine of dynamic billing rules data. I met Ed Park at HIMSS when I remarked that he looked a lot like Todd Park, and Jonathan introduced him to me as Todd’s “younger, smarter, and much better looking brother.” Apparently his programming skills are paying off …

This year, athenahealth was named to the TR50, Technology Review’s third annual list of the world’s most innovative technology companies. At this year’s HIMSS conference, athenahealth showed the company’s plans for an iPhone app that will gives its EHR users access to certain features of its athenaClinicals cloud-based platform. An iPad version of the web-based athenahealth EHR app is also currently under development and set to launch in 2013.

Being based on cloud technology makes athenahealth much more nimble in launching mobile products in services. In the video below, I discuss with Jonathan Bush how athenahealth is using the cloud in their EHR.

(Thanks to Nate DeNiro and Open Affairs Television for their assistance with this video.)

Related:

• AI will eventually drive healthcare, but not anytime soon
• Medical imaging in the cloud: a conversation about eMix
• Health gets personal in the cloud

Moderator Dan Briody started the event with a question about things we had seen at HIMSS that had changed our thinking about health IT. Never being shy, I jumped right in and spoke about the issues of payment reform and how the private market is beginning to show signs of disruptive innovation. After a great deal of back and forth among the panelists it seemed we slipped into listing many of the barriers — technological, political and cultural — that health IT faces. I was hoping we would get back to sharing possible solutions, so I made the proposal that big data is the next big thing in health IT (see video below).

When I talk about “big data” I am referring to a dataset that is too large for a typical database software tool to store, manage, and analyze. Obviously, as technology changes and improves, the size of a dataset that would be qualify as “big data” will change as well. There is also a big data difference between healthcare and other industry sectors, since there are different tools available and the required datasets have varying sizes. Since health data is very personal and sensitive, it also has special security and privacy protections. This makes sharing, aggregating, sorting and analyzing the data sometimes challenging.

Another difficulty in making the most of big data in healthcare is those who control different pools of data have different financial incentives. There is a lack of transparency in performance, cost and quality; it is currently structured so that payers who would gain from decreasing revenue to providers, but the providers control the clinical data that is necessary to analyze in order to pay for value. The payers control another pool, which includes claims data. This is not very useful for advanced analysis that will provide real insight. But enabling transparency of the data will help to identify and analyze sources of variability as well as find waste and inefficiencies. Publishing quality and performance data will also help patients make informed health decisions.

The proliferation of digital health information, including both clinical and claims information, is creating some very large datasets. This also creates some significant opportunity. For instance, analyzing and synthesizing clinical records and claims data can help identify patients appropriate for inclusion in a particular clinical trial. These new datasets can also help to provide insight into improved clinical decision making. One great example of this is when an analysis of a database of 1.4 million Kaiser Permanente members helped determine that Vioxx, a popular pain reliever that was widely used by arthritis patients, was dangerous. Vioxx was a big moneymaker for Merck, generating about $2.5 billion in yearly sales, and there was quite a battle to get the drug off the market. Only by having the huge dataset available from years of electronic health records, and tools to properly analyze the data, was this possible.

The big data portion of the Dell think tank discussion is embedded below. You can find video from the full session here.

Related:

• What is big data?
• Building the health information infrastructure for the modern epatient
• Report from HIMSS: health care tries to leap the chasm from the average to the superb

I will be moderating panel presentations at the HIMSS Social Media Center on Tuesday and Wednesday. This year I expect social media to play a much larger presence in the conference, and the new location for the pavilion will put it front and center. Since the keynote this year is from one of the founders of Twitter, Biz Stone, I’m sure there will be a social media flavor throughout the event.

I will also be participating in the brand new eCollaboration Forum at HIMSS on Thursday. The Collaborative Health Consortium has partnered with HIMSS to sponsor a new, exclusive event focused on the shift to collaborative care platforms to take place at the conference. The event will focus on collaborative platforms as foundations for transformation to accountable care. Attendees will be able to learn what a collaborative healthcare platform is and why the healthcare industry needs it, discover paths to take to effectively implement collaborative technologies, and get further resources to help evaluate the solutions available in the shift toward an accountable care health model.

I am honored to be moderating a panel with David C. Kibbe, MD MBA, senior advisor at the American Academy of Family Physicians; Jonathan Hare, chairman of Resilient Network Systems; and Scott Rea, vice president GOV/EDU Relations and senior PKI Architect at DigiCert.

Our session, “Developing Trust in the Health Internet as a Platform,” will focus on the tools, technologies and rules we must decide upon to establish trust in the Internet as the platform for healthcare. Effective health information exchange of any resource requires deep trust, following from the right architecture and the right rules. We will discuss efforts like DirectTrust.org and the EHR/HIE Interoperability Workgroup as conveners that are creating a community to move us forward.

My fellow Radar blogger Andy Oram will also be on hand to provide context and his own unique perspective (as well as keep me focused on what matters).

Related:

• Previous HIMSS coverage
• See more of Radar’s health IT coverage

This year David Riley gave an update on Aurion (developed from the CONNECT codebase), which is a major project of the Alembic Foundation. Alembic was founded by David, formerly the CONNECT initiative lead for the Federal Health Architecture (FHA), and Brian Behlendorf, the chief technology officer for theWorld Economic Forum. David’s presentation focused on the Aurion Project’s relationship to CONNECT, and it gave us a sense of where the Project is heading in the future. I spoke with Brian and David during OSCON, and in this first clip they discuss the mission and goals of the Alembic Foundation:

In this next clip they speak about how their efforts are related to the broader work on health information exchange, and specifically how Aurion will support the Direct Project:

In this final clip, brought on by an earlier question from Fred Trotter, they explore possibilities for Alembic to work on open source electronic health records like the Veterans Health Information Systems and Technology Architecture (VistA):

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Related:

• See more of Radar’s health IT coverage

There was an excellent panel discussion Sunday at HIMSS that looked at innovation in health care with Aneesh Chopra, CTO of the United States, Peter Levin, CTO at the Department of Veterans Affairs, and Farzad Mostashari, Deputy National Coordinator at the ONC. They discussed a three-pronged approach to health care innovation:

1. Invest in the building blocks of innovation, such as R&D and human capital
2. Set the right policy conditions to foster market-based innovations
3. Foster an all-hands-on-deck approach to R&D and standards

There was a great deal of focus on the government in its role as a convener and collaborator and using government as a platform for innovation. Using the examples of the Direct Project and the Blue Button initiative as templates for how government can solve not only problems we face in health care in this country, but other sectors such as energy and education as well.

I spoke with Chopra after the panel. He touched on general topics ranging from the Direct Project, to open government, to ways government can act as a platform for innovation. He also discussed:

• The work of the the Smart Grid Interoperability Standards Project at the National Institute of Standards and Technology (NIST).
• How we can use the open and transparent process that led to the Direct Project as a template for other efforts to solve our country’s problems.

The full interview is available in the following video:

Thanks to Open Affairs Television for providing the video for this conversation. They will also be posting video from the entire panel discussion on their site.

Related:

• Data and simplicity can build the government platform
• 2010 is the year of participatory platforms

Arien Malec, Brian Behlendorf and a host of volunteers have guided the project to this point. It’s not complete, but below you’ll see we have achieved some major milestones.

There’s still a need for coders and developers — especially those with open source skills and experience — to help in the healthcare arena. Check out the different workgroups and see where you might fit in. The free NHIN University is also worth attending.

Three volunteers from the project’s Communications Workgroup collaborated on the following post. Read on for a glimpse of what’s been accomplished and where we’re heading. — Brian Ahier

This post was co-authored by Brian Ahier, Rich Elmore and David C. Kibbe.

The Direct Project announced today the completion of its open-source connectivity-enabling software and the start of a series of pilots that will be demonstrating directed secure messaging for healthcare stakeholders over the Internet.

The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send encrypted health information directly to trusted recipients over the Internet.

Also announced:

• A new name: the Direct Project was previously known as NHIN Direct.
• An NHIN University course, “The Direct Project – Where We Are Today,” to be presented by Arien Malec, Nov. 29 at 1 PM ET, sponsored by the National eHealth Collaborative.
• More than 20 health IT (HIT) vendors have announced plans to use the Direct Project for message transport in connection with their solutions and services.
• Presentations at the HIT Standards Committee on Tuesday, Nov. 30, where three or more vendors will be announcing their support for the Direct Project.
• A thorough documentation library, including a Direct Project Overview.
• Best practice guidance for directed messaging based on the policy work of the Privacy and Security Tiger team.
• A new website at DirectProject.org.
• A new hashtag, #directproject, for following the Direct Project on Twitter.

The Direct Project is the collaborative and voluntary work of a group of healthcare stakeholders representing more than 50 provider, state, health information exchange (HIE) and HIT vendor organizations. More than 200 participants have contributed to the project. Its rapid progress, transparency, and community consensus approach have established it as a model of how to drive innovation at a national level.

What is the Direct Project?

Today, communication of health information among providers and patients is most often achieved by sending paper through the mail or via fax. The Direct Project seeks to benefit patients and providers by improving the transport of health information: making it faster, more secure, and less expensive. The Direct Project will facilitate “direct” communication patterns with an eye toward approaching more advanced levels of interoperability than simple paper can provide.

The Direct Project provides for universal boundary-free addressing to other Direct Project participants using a health Internet “email-like” address.

The project focuses on the technical standards and services necessary to securely transport content from point A to point B, and does not specify the actual content exchanged. When the Direct Project is used by providers to transport and share qualifying clinical content, the combination of content and Direct Project-specified transport standards may satisfy some Stage 1 Meaningful Use requirements. For example, a primary care physician who is referring a patient to a specialist can use the Direct Project to send a clinical summary of that patient to the specialist and to receive a summary of the consultation.

How might the Direct Project be used?

The 2009-10 Congress and agencies of the federal government have created regulations that require physicians and hospitals participating in the ARRA/HITECH incentives awarded for meaningful use of electronic health record (EHR) technology to:

• Send messages and data to each other for referral and care coordination purposes.
• Send alerts and reminders for preventive care to their patients.
• Send patients clinical summaries of their visit and of their health information.
• Receive lab results from labs.
• Send immunization and syndromic surveillance data to public health agencies.
• Integrate with HIT vendor systems

Each capability can be enabled with point-to-point secure e-mail or in a more integrated manner as HIT vendors and public health agencies enable communication with the Direct Project.

How will the Direct Project affect states and Health Information Exchanges?

States that are receiving federal funding to enable message exchange are being asked by the ONC to facilitate Stage 1 Meaningful Use information exchange. The Direct Project may serve as a key enabler of directed messaging for all states and Health Information Exchanges. Even states that have some level of health information exchange capability need to address areas that are currently uncovered by a regional or local Health Information Organization (HIO).

As state plans seek to address a means to fill the gaps in exchange capability coverage, the Direct Project may provide a bridge to enabling the basic exchange requirements for Stage 1 Meaningful Use. The Direct Project does not obviate the need for state planning for HIE, neither does it undercut the business case for HIOs. More robust services can be layered over simple directed messaging that will provide value to exchange participants.

There are already organizations that have announced the establishment of national clinical exchange networks, including integration with the Direct Project. States and HIOs will need to decide how best to provide Direct Project services to their constituents, whether by partnering with existing exchange networks or incorporating direct messaging into the services they provide.

The Direct Project implementation

The Direct Project is organizing real-world pilots to demonstrate health information exchange using The Direct Project standards and services. Six pilots are ramping up including:

Rhode Island Quality Institute, Redwood MedNet and MedAllies will be sending Continuity of Care Documents to other providers for referrals and transitions of care. Visionshare will be linking to immunization registries. Carespark (Tennessee) will be linking the Department of Veterans Affairs with private clinics providing health services to veterans. And Connecticut’s Medical Professional Services, an independent practice association (IPA), will be linking Middlesex Hospital with primary care providers.

The reference implementation

To help the Direct Project implementers, an open source reference implementation of the Direct Project standards and services has been developed under the guidance of the Direct Project. To ensure the broadest possible participation, the reference implementation has been implemented in two flavors: Java and .NET.

Health Information Service Providers

Connectivity among providers is facilitated by Health Information Service Providers (HISP). HISP describes both a function (the management of security and transport for directed exchange) and an organizational model (an organization that performs HISP functions on behalf of the sending or receiving organization or individual).

Best practices

The Direct Project is bound by a set of policies that have been recommended to ONC by the HIT Policy Committee (HITPC) or are being examined by the HITPC’s Privacy and Security Tiger Team for directed messaging. Within this context, the Direct Project has developed best practice guidance for secure communication of health data among health care participants who already know and trust each other.

The Direct Project assumes that the Sender is responsible for several minimum requirements before sending data, including the collection of patient consent. These requirements may or may not be handled in an electronic health record, but they are handled nonetheless, even when sharing information today via paper or fax. For example, a sender may call to ask whether a fax was sent to the correct fax number and was received by the intended provider.

The following best practices provide context for the Direct Project standards and services:

• The Sender has obtained the patient’s consent to send the information to the Receiver.
• The Sender and Receiver ensure that the patient’s privacy preferences are being honored.
• The Sender of a Direct Project transmission has determined that it is clinically and legally appropriate to send the information to the Receiver.
• The Sender has determined that the Receiver’s address is correct.
• The Sender has communicated to the receiver, perhaps out-of-band, the purpose for exchanging the information.
• The Sender and Receiver do not require common or pre-negotiated patient identifiers. Similar to the exchange of fax or paper documents, there is no expectation that a received message will be automatically matched to a patient or automatically filed in an EHR.

The communication will be performed in a secure, encrypted, and reliable way, as described in the detailed Direct Project technical specifications. When the HISP is a separate entity from the sending or receiving organization, best practice guidance for the HISP has been developed for privacy, security and transparency.

What the Direct Project isn’t

The Direct Project is not targeted at complex scenarios, such as an unconscious patient who is brought by ambulance to an emergency department (ED). In the unconscious-patient scenario, a provider in the ED must “search and discover” whether this patient has records available from any accessible clinical source. This type of broad query is not simple and direct, and therefore requires a more robust set of health information exchange tools and services that the Direct Project does not provide.

The Direct Project in context of the Nationwide Health Information Network

The Direct Project is an integral component in a broader national strategy to have an interconnected health system through a Nationwide Health Information Network (NHIN). The NHIN is:

“… a set of standards, services and policies that enable secure health information exchange over the Internet. The NHIN will provide a foundation for the exchange of health IT across diverse entities, within communities and across the country, helping to achieve the goals of the HITECH Act.”

The authors

Brian Ahier is chairman of the State of Oregon’s Health Information Technology Oversight Council Technology Workgroup.

Rich Elmore is Vice President, Strategic Initiatives at Allscripts.

David C. Kibbe is a family physician, senior adviser to American Academy of Family Physicians and co-founder of the Clinical Groupware Collaborative.

The panel discussed how technologies are working together to improve patient care, enhance clinical and payor efficiencies, and lower costs. There were presentations on personal health records (PHRs), healthcare in the home, and current work on the Health 2.0 Developer Challenge.

Here’s a rundown of the panelists and the points they made during the session:

William Hersh, M.D., Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology in the School of Medicine at Oregon Health & Science University (OHSU)

OHSU has received millions in funding for its biomedical informatics graduate program and development of health IT curricula. Hersh said OHSU will help educate the estimated 50,000 professionals needed to convert the country to electronic health records by the year 2014. There is already a growing need in the healthcare community for trained health IT workers, and this need will begin to stress the system as increased adoption of electronic health records takes place.

Eric Dishman, Director of Health Innovation for Intel’s Digital Health Group (PCMH)

Dishman focused on moving healthcare into the home. That means not only having a patient-centered medical home, but actually having healthy homes. He discussed “10,000 households or bust” — an effort to create a living lab for older adults in a wide range of economic and geographical conditions. This would form a robust cohort of older people to test health technologies on a large scale. Dishman also compared health 2.0 to the e-mail revolution of the 1990s, noting that new health technology is not meant to replace the doctor-patient relationship but to enhance it through new tools.

Susan Woods, Associate National Director, eHealth Veterans Health Administration

Woods spoke about the importance of personal health records (PHR) and engaging patients in their healthcare. A key takeaway from her talk was the need to achieve “meaningful use for patients.” She gave an introduction into the VA’s electronic health record system (based on VistA) and the new MyHealth eVet. She also spoke about the patient-centered medical home and how making this coordinated and efficient really requires new models of care. She summed it up with a great formula: Patients + Information + Experts + Each Other. This will truly equal better care!

Lizzie Dunklee, Executive Producer at Health 2.0

Dunklee presented on the Health 2.0 Developer Challenge and brought a national perspective to the new local chapter. The Developer Challenge is partly a continuation of the great work done within the Community Health Data Initiative, and partly an expansion of the code-a-thon/developer camp effort that’s a hallmark of the Health 2.0 community.

Jeffrey Brandt, CTO of CSI graduate OHSU Biomedical Informatics program (Mobility)

Brandt and CSI, Inc. are working on a Health 2.0 Developer Challenge where their PHR will be integrated with the Practice Fusion electronic health record system. Brandt also spoke about the importance of including mobile in the PHR framework. “Smartphones will one day be the remote control for our healthcare,” he said.

Frank Ille, Co-founder of HealthSaaS (PHRs)

Ille and HealthSaaS are also working on a Developer Challenge and he is the manager of the new Health 2.0 Northwest Chapter.

Each of the panelists gives their take on the event in the following video:

Related:

• First impression: Health reform and Health IT
• Analysis: A defining moment for “meaningful use”
• How open source can improve healthcare
• The software behind the VA healthcare transformation

Our full interview is available in the associated podcast. Topics and questions we covered included:

• What happens when you actually solve a health care problem?
• How the foundation’s Project HealthDesign aims to capture observations of daily living (ODLs) like sleep patterns and eating habits.
• Current trends in computing and health care. Specifically, how capturing, tracking, and understanding health data can help manage chronic disease

Disclosure: The Robert Wood Johnson Foundation was a sponsor of the health track at last week’s OSCON convention.

David Riley, head of the CONNECT initiative for the Federal Health Architecture (FHA) Program. Riley is responsible for creating the product direction and overseeing product development for CONNECT.

Brian Behlendorf is a collaboration advisor for the CONNECT project, and he co-founded the Apache Web Server Project.

Arien Malec is the coordinator for NHIN Direct, where he manages the activities of a public-private group that’s developing specifications for data transport in support of the meaningful use rules.

With the health information technology industry ramping up to help physicians and hospitals meet meaningful use, there is opportunity to bring open source solutions to bear. At the intersection of health care, government and open source, these three have a unique perspective on how to address the pressing needs within health care. Watch below as they give an overview of their efforts and explain how open source solutions can help improve our health care system.

Related:

• Day one of the health care IT track at O’Reilly’s Open Source convention
• Giving patient data meaningful use: Interview with Arien Malec
• From Apache to Health and Human Services: Interview with Brian Behlendorf

I spoke with the event organizer Jono Bacon, who works at Canonical as the Ubuntu community manager, and is author of the book “The Art of Community: Building the New Age of Participation.” Watch below as he describes how the basic principles of his book led to the creation of this event:

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