C-CDAs — What are they good for?


David Kreda, SMART Translation Advisor
Joshua Mandel, SMART Lead Architect

Some readers of our JAMIA paper “Are Meaningful Use Stage 2 certified EHRs ready for Interoperability?” have wondered if we were insinuating that C-CDAs are all but useless because of their heterogeneity and other defects.

We did not say that.
Read more

Certification/MU tweaks to support patient subscriptions


This is a quick description of the minimum requirements to turn patient-mediated “transmit” into a usable system for feeding clinical data to a patient’s preferred endpoints. In my blog post last month, I described a small, incremental “trust tweak” asking ONC and CMS to converge on the Blue Button Patient Trust Bundle, so that any patient anywhere has the capability to send data to any app in the bundle.

This proposal builds on that initial tweak. I should be clear that the ideas here aren’t novel: they borrow very clearly from the Blue Button+ Direct implementation guide (which is not part of certification or MU — but aspects of it ought to be).

Problem: patients can’t establish a persistent data feed to apps

MU 2014 certification criteria allow patients to (attempt to) trigger the transmission of a Direct message message to a patient-selected endpoint. Even if the trust issues are worked out, there is a substantial usability problem: patients can only send one document at a time. There’s no way to transfer a historical backlog of encounter summaries, and no way to prospectively create a “feed” or “subscription” of future data.

The solution: enable patients to define “subscriptions” to their data

This proposal ensures that patients can establish a subscription to their data, rather than having to sign in to a portal (as is typical today) and manually select and send one document at a time. Here’s what it would take.

For ONC’s side

ONC should define new “VDT” certification criteria requiring EHRs to implement the following functionality:

  • The EHR associates a set of “subscription endpoints” with each patient record. These endpoints are just Direct email addresses listening for patient-specfic data.

  • The EHR supports an operation called “add subscription endpoint to a patient record”. This operation has two inputs, at minimum: the Direct address of the endpoint, and a boolean flag called “transmit all historical data now”. When the “now” flag is set, an initial message is automatically sent to the new subscription endpoint including all historical documents as attachments.

  • The EHR provides an operation called “remove a subscription endpoint from a patient record”. This operation just removes a Direct address from the set of endpoints associated with a patient’s record.

  • The EHR exposes a provider-facing UI for clinical staff to manually perform the “add” and “remove” operations upon a patient-authorized request (e.g. in-person or fax request). This allows third-parties to ask patients for limited-purpose permissions (for example, by signing a paper release form) and then “just take care of things” — all without asking patients to share a username and password.

  • The EHR provides a patient-facing UI to perform the “add” and “remove” operations, so patients can choose to manage their subscriptions themselves.

  • Any time a new document becomes available for patient “view and download”, a copy of that document is automatically transmitted to each subscription endpoint associated with the patient’s record. This functionality builds naturally on existing “view, download” capabilities by tying into today’s workflows. It exposes encounter summaries, discharge summaries, and referral summaries (at a minimum).

For CMS’s side

  • CMS should ask all Eligible Hospitals and Providers to attest that they are making the updated “VDT” functionality available to all patients, including the “add” and “remove” subscription operations.

Call to action!

This proposal builds incrementally on existing 2014 EHR Certification and MU2 attestation criteria. It involves a bit of software engineering, of course — but it’s exactly the kind of rules-based message routing behavior that EHRs and interface engines are already very good at.

As a community, we can make these changes and demonstrate success long before ONC and CMS action. Please contact me (joshua.mandel at childrens dot harvard dot edu, or @JoshCMandel on Twitter) if you would like to participate in our “coalition of the willing”!

Health App Privacy Policies Still Wild Frontier


Apple may have just tightened privacy requirements for developers who build apps on its HealthKit platform. But a broad assessment of the industry, published online last week in JAMIA, found that the iTunes and Google Play stores have a long way to go before such policies are readily discoverable and digestible to app users.

Improving patient access: small steps and patch-ups


In a blog post earlier this month, I advocated for ONC and CMS to adopt a grand scheme to improve patient data access through the SMART on FHIR API. Here, I’ll advocate for a very small scheme that ignores some of the big issues, but aims to patch up one of the most broken aspects of today’s system.

The problem: patient-facing “transmit” is broken

Not to mince words: ONC’s certification program and CMS’s attestation program are out of sync on patient access. As a result, patient portals don’t offer reliable “transmit” capabilities.

2014-certified EHR systems must demonstrate support for portal-based Direct message transmission, but providers don’t need to make these capabilities available for patients in real life. Today, two loopholes prevent patient access:
Read more

SMART Advice on JASON (and PCAST)


As architect for SMART Platforms and community lead for the Blue Button REST API, I’m defining open APIs for health data that spark innovation in patient care, consumer empowerment, clinical research. So I was very pleased last month at an invitation to join a newly-formed Federal Advisory Committee called the JASON Task Force, helping ONC respond to the JASON Report (“A Robust Health Data Infrastructure”).

We’re charged with making recommendations to ONC about how to proceed toward building practical, broad-reaching interoperability in Meaningful Use Stage 3 and beyond. Our committee is still meeting and forming recommendations throughout the summer and into the fall, but I wanted to share my initial thoughts on the scope of the problem; where we are today; and how we can make real progress as we move forward.

Read more

It’s About Time: Open APIs Finally Burst onto Healthcare’s Sluggish Scene


Nuviun Blog, June 9, 2014 — Sue Montgomery
In the midst of the struggles that we face with interoperability, efforts that support open API use may well hold the keys to the HIT Kingdom…

Advisory Committee Kickoff a Success


The SMART Advisory Committee had a high-energy kickoff meeting on May 15. Below are some scenes from the day, which featured presentations by Joshua Mandel and Clayton Christensen as well as demonstrations of apps to be deployed in the near future.
Read more

Forbes Adds to Advisory Committee News Coverage


Today Forbes published Who’s Who Of Health Care Join Forces For SMART Technology, the latest in recent news coverage of the SMART Advisory Committee launch.


Other pieces include:
Read more

Aneesh Chopra’s New Book Points to Launch of SMART Project


Aneesh Chopra, America’s first Chief Technology Officer and member of the SMART Platforms Advisory Committee, has published a new book called Innovative State: How New Technologies Can Transform Government. The SMART Project’s kickoff ITdotHealth meeting in 2009 is among the formative events he describes in Chapter 4, “Opening the Playbook.” Here he is seen with Ken Mandl at the Harvard Book Store, where he discussed the book on May 21. A video of the talk is provided by WGBH.


Introducing the SMART Advisory Committee


Our new advisory committee, made up of member organizations with strategic interest in transforming how the healthcare enterprise uses data, will play a critical role in guiding the SMART Platform toward broad adoption and use.

Learn more

SMART Advisory Committee