AHLTA CITRIX Roaming Sessions

AHLTA, DoD’s Electronic Health Record, has been getting some bad press lately due to user interface and performance and reliabilty issues, but instead of complaining, some saavy military CIOs, like Captain William E. Sorrells, MSC, USAF, FACHE, CPHIMS, are doing something to improve the situation now.   Volume 12, Issue 6, September 2008 of Military Medical Technology reports that 3rd Medical Group had great success in deploying a roaming session environment for several applications.  The CITRIX roaming sessions keep a single session open all day for a provider. The provider can access this session all day as he/she moves from room to room.  This simple innovation saved 2880 hours per year for the 18 providers at Elmendorf.  Many MTFs have  yet to implement this option for AHLTA.

NHIN CONNECT Enterprise Service Component (ESC) Code and SDK Released!

As previously reported at http://www.ehealthdesigns.com, the HHS ONC for healthcare IT announced the release of open source NHIN CONNECT Code and SDK at the 2009 annual HIMSS conference. The code may be used under a government BSD, non viral license.  LCDR Steve Steffensen, MC, USN, and Captain (Sel) Emory Fry, MC, USN, were instrumental in working with the FHA to develop the adapter layer and common access layer, which will allow the NHIN gateway and enterprise service components to connect to back end federal and commercial EHRs.

The NHIN 2.0 gateway download site is http://www.connectopensource.org/display/NHINR2/Release+2.0+Home;jsessionid=C2640BB1D07CF4D900963717596B3BE2.  This is a significant advance towards the national goal of exchanging interoperable healthcare data, in that the code and SDK will allow software developers to connect federal agency back-end government and commercial healthcare systems to the NHIN.

Per the CONNECT website:

“If the Nationwide Health Information Network (NHIN) is the information highway for health data exchange, CONNECT is the universal on-ramp for federal agencies. CONNECT is a software solution that lets federal agencies securely link their existing systems to the NHIN. More than 20 federal agencies collaborated to build CONNECT through the Federal Health Architecture (FHA), and as a result, agencies are heading down the road toward interoperability.

The Office of the National Coordinator for Health Information Technology (ONC) has been facilitating development of the NHIN, which will tie together health information exchanges, integrated delivery networks, pharmacies, government, labs, providers, payors and other stakeholders into a “network of networks.” The NHIN provides a mechanism for previously disconnected systems and exchanges to connect to each other and share data using nationally recognized interoperability standards, specifications, participation agreements and policies. The ability to share data electronically among organizations will provide a wide range of benefits to citizens, among them: having up-to-date records available at the point of care; enhancing population health screening; and being able to collect case research faster to facilitate disability claims.

The CONNECT software is the outcome of a 2008 decision by federal agencies to begin work on connecting their health IT systems into the NHIN. Rather than individually build the software required to make this possible, the federal agencies collaborated through the Federal Health Architecture program to create a single solution that can be reused by each agency within its own environment. The agencies built CONNECT in open source in order to keep costs low when it is deployed in each organization. An additional benefit of developing the offering in open source is that CONNECT has now been made available to the healthcare industry at large. CONNECT will act as an accelerant to promote NHIN adoption and additional innovation in the industry.

The CONNECT Gateway is built on open source technologies and will be made available to the public in March of 2009. Three primary elements make up the CONNECT Gateway:

• The NHIN Gateway implements the core NHIN services enabling such functions as locating patients at other health organizations within the NHIN, requesting and receiving documents associated with the patient, and recording these transactions for subsequent auditing by patients and others. Other features include authenticating network participants, formulating and evaluating authorizations for the release of medical information, and honoring consumer preferences for sharing their information.

• The Enterprise Service Component (ESC) provides default implementations of many critical enterprise components required to support electronic health information exchange, including a Master Patient Index (MPI), Document Registry and Repository, Authorization Policy Engine, Consumer Preferences Manager, HIPAA-compliant Audit Log and others. Agencies are free to adopt the default enterprise component implementations packaged in the CONNECT ESC or to plug in existing agency implementations of these service components. This component also includes a software development kit (SDK) for developing adapters to plug in existing systems such as electronic health record solutions to turn on information flows to support the secure exchange of health information across the NHIN. This makes CONNECT a platform for participation in health information exchanges.

• The Universal Client Framework enables agencies to develop end-user applications using the enterprise service components in the ESC. This makes CONNECT a platform for innovation.”

As of 8:00 AM on 7 April 2009, there was very high demand for the software, and HHS put a limit on the number of downloads.  If you cannot get into the download site, keep trying!  E-Health Designs, LLC has subsequently learned that in order to get the code, one must register first with a user name, password, and valid e-mail address.  Upon registration, an e-mail is sent back to the user and he/she must validate that address prior to moving to the next step and being able to actually download the software.  As of 9 April 2009, I was still waiting on the e-mail to arrive so I could validate it.  I presumed that this was an automated process similar to other web sites, however, an FHA representative confirmed to me this afternoon that there is a human involved in the process to send the e-mail, and he/she is back-logged.  FHA is looking to an alternative solution so as to make the downloads more available.

Veterans Health Information Systems and Technology Architecture (VistA)

VistA is the Veteran’s Health Administration’s venerable healthcare architecture for more than 100 applications which comprise a veteran’s electronic health record.

VistA is not the same as DoD’s AHLTA system, but AHLTA and VistA share data through the DoD/VHA Bi-Directional Health Information Exchange (BHIE).

VistA documentation may be found at:

http://www.virec.research.va.gov/DataSourcesName/VISTA/VISTAdocumentation.htm

VistA code is open source and has been released into the public domain.

This does not mean that VistA is free.

There are substantial costs to host, deploy, train, and sustain VISTA.

Resources to implement VistA may be found at:

http://www.vistasoftware.org/resources/index.html

VistA has a very good front end acceptable to clinicians, but it relies heavily on free text.

Free text has display value at the point-of-care, but is not computable and cannot support semantic interoperability unless first converted to codes or facts through the use of Natural Language Processing.

According to a 2006 cite at http://govhealthit.com/articles/2006/06/vha-eyes-opensource-replacement-for-vista.asp, Dr. Rob Kolodner said that “the VA needs to replace VistA because VHA needs a system that users can easily search instead of sifting through VistA’s free text.  VistA consists of more than 100 applications running at 187 hospitals and more than 800 ambulatory care and community health facilities. VHA also wants to incorporate personal health records for the more than 5 million veterans who use VHA hospitals and clinics.”  However, E-Health Designs, LLC has recently learned that the VHA has hired Dr. Quing Zeng to lead VHA’s efforts in Natural Language Processing, which turn free text into codes.

Dr. Stanley Saiki, director of Honolulu-based Pacific Telehealth and Technology Hui, a partnership between the VA and the Army’s Telemedicine and Advanced Technology Research Center, said basing the next-generation system on open-source code would benefit VHA and other health care organizations.”

VHA has efforts underway to create a Health Data Repository (HDR), with highly structured reference terminologies, similar to DOD AHLTA’s Clinical Data Repository (CDR) and Health Data Dictionary (HDD).  The AHLTA CDR and HDD products are licensed from 3M.

A DoD/VHA project known as CHDR will connect the VHA HDR with the DoD CDR to provide for fully computable data.

NHIN 2.0 Adapter/Enterprise Service Bus Code and SDK To Be Released

During HIMSS next week, the ONC for Healthcare IT will make a major announcement regarding the release of open source NHIN code and a System Development Kit (SDK).  

The code and SDK will be released under an open-source government BSD license, that will allow government and civilian back-end healthcare databases to connect to the NHIN gateway. 

This code provides for an adapter/enterprise service bus which provides patient identity management services, discovery services, orchestration services, and HITSP C.32 document management services. 

It was developed in Java Glassfish and uses GELLO. 

It is probable that new services will be added to the bus over time, such as terminology mediation services, semantic search, clinical decision support, the ability to connect patient education content to a document, and perhaps natural language processing (text to facts). 

U.S. Army TATRC may be instrumental in shaping the services that go into the NHIN adapter/bus, through the use existing and future Congressional Special Interest dollars, and will continue to work with the FHA

Conficker Worm Updates

http://www.us-cert.gov/cas/alerts/SA09-088A.html

http://news.cnet.com/8301-1009_3-10208722-83.html?tag=newsEditorsPicksArea.0

Per Symantec:

“What does the Conficker worm do?

The Conficker worm has created secure infrastructure for cybercrime. The worm allows its creators to remotely install software on infected machines.

What will that software do?

We don’t know. Most likely the worm will be used to create a botnet that will be rented out to criminals who want to send SPAM, steal IDs and direct users to online scams and phishing sites.

The Conficker worm mostly spreads across networks. If it finds a vulnerable computer, it turns off the automatic backup service, deletes previous restore points, disables many security services, blocks access to a number of security web sites and opens infected machines to receive additional programs from the malware’s creator. The worm then tries to spread itself to other computers on the same network.

How does the worm infect a computer?

The worm tries to take advantage of a problem with Windows (a vulnerability) called MS08-067 to quietly install itself. Users who automatically receive updates from Microsoft are already protected from this. The worm also tries to spread by copying itself into shared folders on networks and by infecting USB devices such as memory sticks.

Who is at risk?

Users whose computers are not configured to receive patches and updates from Microsoft and who are not running an up to date antivirus product are most at risk. Users who do not have a genuine version of Windows from Microsoft are most at risk since pirated system usually cannot get Microsoft updates and patches.”

Single Life-Long EHR for DOD and VHA?

Government Health Executive reports on 27 March 2009 that The Defense and Veterans Affairs departments have formed a working group to pursue a joint lifetime electronic heath and benefits record for service members, veterans, and their families.

http://govhealthit.com/articles/2009/03/27/joint-lifetime-health-record.aspx?s=GHIT_310309

It only makes sense for DoD and VHA to use the same electronic health record, particularly in those cases where VHA and DOD operate joint facilities, such as in Great Lakes.

It is still not clear, however, if there will be a single hosted EHR system using the same code for both DoD and VHA,  or whether the agencies will use Service Oriented Architecture to merge the best elements of the VHA VISTA and DoD AHLTA systems to create a single view and a life-long longtitudinal EHR.

Past efforts to create a Government Computerized Patient Record (GCPR) in the 90s resulted only in the establishment of the DoD/VHA Bi-Directional Health Information Exchange (BHIE), and not a single unified, computable DoD/VHA record.

See http://www.usmedicine.com/article.cfm?articleID=66&issueID=16

It seems likely that the leadership should pull the GCPR plans off the shelf?

Although oversimplified, DoD AHLTA probably has a better back-end with its use of the 3M CDR and HDD to provide for highly structured reference data to support computability and interoperability.

VHA’s VISTA may have the better front-end, but it also relies heavily on free text, which is not computable unless converted to codes using NLP.

To this end, VHA recently hired Dr. Quing Zeng from Harvard to lead VHA’s initiative in Natural Language Processing (NLP).