National Institute for Health Innovation (NIHI)

It’s the world’s largest health software exhibit; and it looks it, too. More than once I was simply lost in the acres of vendor booths, and equally felt a surge of vertigo when looking out over the forest of vendor banners – Siemens, Perot Systems, Allscripts, etc., etc., etc. Somehow the vertigo seems to increase after they start giving away drinks around 4.30pm.

Nonetheless, the opportunity for hours of back-to-back demos, all in one spot, is just wonder and so informative. Before talking about personal highlights from the demos, I might mention a couple of the keynote presentations.

If you want technical presentations that take you to the leading edge of methods of information in medicine, go to the AMIA Annual Symposium, not HIMSS. For glitz and big names in the plenaries, however, HIMSS has AMIA beat to the nth degree.

The opening keynote was from Denis Quaid. I didn’t get at first why on Earth we’d want to listen to an actor, but he recounted the story of his twins that received (twice in 12 hours!) a 1000-times overdose of anticoagulant. He told the story very effectively, of the long wait to see if they’d survive, of the time they spent giving literally off the chart readings. And furthermore of the remarkable efforts he’s made since to reduce the rate at which such things happen in the future. His call for interoperability and standards is a little simplistic, but I have to admit it was a great way to personalize health safety and get the crowd polarized to launch into the conference with some sober dedication to the reality of our business. (I already mentioned the free drinks, right; so a little sobriety is a useful counterpoint.)

On the last day of the conference, the morning keynote was Alan Greenspan. After so many years at the literal helm of our economic apparatus, it was the first time I had heard the man speak at length. And I can only dream that at 83 I might be so aware, incisive and up-to-date. What a stunning intellect! I suppose there’s a bit of a charged atmosphere around the question of whether our current economic woes are ‘his fault.’ I don’t know. Undoubtedly, with omniscience he might’ve called for greater banking regulation. I’m not judging things on that scale here. What I saw was somebody who had a stunning perspective on what’s happening, where we’ve come from and where we’re going. His main message for us was that “the arithmetic is inexorable” (scary word, ‘inexorable’) with respect to the aging of the Baby Boomer generation and long-term slowed economic growth, and how all that will mean that the further growth of healthcare expenditure will require real sacrifices to maintain into the future (i.e., healthcare will have to compete with other pressing priorities for funding in a way that it has never done before, at least in the US). It puts the onus back on us health IT types to find efficiencies and, better still, truly innovative new ways of doing things. The demographic message is one that’s been very clear in my mind pretty much always, and with respect to chronic disease management for at least a decade, but, for me, Greenspan gave it a new force and clarity.

Back to the vendor booths… the IHE Interoperability showcase is supposed to be a main feature. For me, however, there are now so many participants (73, I think) that it’s pretty much a given that every worthwhile vendor can manage at least some input and/or output to a modern HL7 message or document that can somehow be shoehorned into an IHE profile. But I think we already knew that, given the will (e.g., the will to be included in a high profile Showcase), vendors can manage to interface with other vendors. What I really appreciated was the opportunity to compare the user interfaces, functions, and a few engineers’ insights, regarding the working of some of the vendor solutions out there today. Most notable for me…

VA CPRS and openVista. One of the elders of comprehensive EMRs, and the one with the biggest footprint through all the Veterans hospitals, and now available to the world via the Freedom of Information Act as openVista, I thought the VA booth was worth a good long visit. One has to realize that the success of the CPRS is as much about ‘systems’ in the broader sense – about integration, governance and clinical user compliance – as about ‘systems’ in the narrow ‘software’ sense. That said, the VA system is a nicely extensible framework onto which they can add new data templates, new decision support alerts and, mainly, can see all the data for a chronic complex patient over time. In fact, while the main contents are pointedly old-fashioned looking courier font notes, I also saw a pretty flashy timeline viewer for panning and zooming on observations trends. The only real drawback is that, as a result of its long legacy, I felt it was always a keystroke of two more roundabout, at any step, than some of the more modern competitors. I don’t know if the companies pushing business models around openVista, e.g., Perot Systems and Medsphere, will be able to overcome this.

A system that struck me with the quality of its user interface for physicians’ offices was eClinicalWorks, which has a large install base in the US for a variety of physician specialties (since Americans seem to barely know what a ‘GP’ is – I’m pretty sure that’s true, since one vendor said, “I barely knew what you meant, when you said ‘GP’” [he later swaggered off, spurs jingling and hands on his six guns]). It just had a very smooth feel for entering data, including an impressive demo of voice data entry (based on Dragon) integrating with the package, and also the ability to insert sketches into the notes. But it wasn’t just about text and doodles; it had a strong capability around custom templates and clinical audit reporting. Here was a package that was polished by the double competition of (a) a large direct competitor base (200 in the US market, so they said); and (b) the fact that most US physicians still don’t care to be bothered to be electronic at all. I suspect these guys will do very well indeed once Obama’s incentives for physicians to become electronic take hold.

Given the interest in the achievements of Kaiser Permanente, a stop at the Epic booth was a must. This was my second time getting a walkthough of their HyperSpace clinical user interface. On both occasions I’ve been impressed with its two-layered tailorability. First, a clinician (or, in a bigger organization, probably some internal clinical IT function) can define templates to be used in different kinds of encounters. Second, one can define macros (short-cut autotext) that the physician-user can exploit to bang in a suit of clinical values and/or, for instance, advice to the patient. I had seen this demoed at Kaiser and the physician could really make it fly. Also, I quizzed around on their interoperability options and was fairly impressed. One can access the Oracle DBMS directly via ODBC or (better for most decision support applications) access a shadow database via an API. They can produce CCD and one can input events (e.g., clinical alerts) based on an external quality assessment algorithm. I got the impression they were a smaller shop than, say, McKesson, or alternatively that they were sending their actual technical people rather than a slick sales force. Of course, also neat about Epic is the now well-tested role of their patient portal. The way the demo ran it was as if the only way to start an appointment was for the patient to log in and schedule one – I know that’s not the only way, but it was interesting that they gave the impression that it was the most natural one.

It was also nice to visit our local (i.e., Auckland based) favourites, Orion Systems, although I was a little disappointed to only find US based staff, who (although they had literature about Orion’s work in NSW on their stand) I don’t think knew much about Australasia (like where it was, what an NSW might be, or the like). Probably no detraction in that for the majority of the HIMSS attendees. I was also interested to see an application with, evidently a huge US installbase, called PatientKeeper that seemed to be in very much the same space as Orion’s Concerto, but who (at least the guy I spoke to) had never heard of Orion.

All in all, it was great fun and informative. Probably even worth the shocking cost (in light of the current exchange rate on the NZ dollar and the relentless pricing around the Chicago downtown area).

Monday was quite a full day. I found the keynote about EHRs by Halvorson was interesting because of the emphasis he placed on chronic conditions and how, if we focus clinical attention on these conditions, the healthcare system could make huge savings. The EHR concept could play a significant role in this. He also emphasised how the Economic Stimulus Package could contribute to better healthcare, based on scientific evidence.

There are so many presentations that I’d like to attend but just can’t. Too many parallel sessions that are interesting and so I decided to pick the ones that got my imagination going. In the programme there was a session named “No more passive patients: Enhancing the patient experience through interactive care” and I thought it would be interesting to see what is considered a non-passive patient. It turns out that patient focus and the idea of active patients isn’t about clinical participation in a person’s healthcare interventions but having a customer face to hospital care. This presentation was more about remote monitoring of ICU patients and having a computer at the general ward bedside so that patients can provide online feedback on their care, ask for help with non-nursing activities, and watch health education movies on demand.

I took this theme further when I wandered around the exhibits – so much of the language used here is about the patient being in the centre and how EMRs can be safely shared or that the e-health record is secure. When I drilled down to the concept of patient centric care, it turns out taht the talk is mostly from the provider perspective. It’s not clear what people think is ‘citizen centric care’ or ‘patient centric care’.

So I went to a session on games and the internet in healthcare. This was quite futuristic but it added a fun element to what can be a serious topic. What caught my imagination was the idea of a nurse avatar helping people to navigate the plethora of health information that is readily available to anyone who looks for it.

The next session was about the role of Web 2.0 in healthcare. What got me thinking at this session was the idea that people are used to trawling the web for their own knowledge gathering purposes and these people could be anyone in the collection of people involved in healthcare, including those of us who become patients. Web 2.0 technology is chaotic at the moment – who knows what might emerge? Such an exciting period of transition from what we know to what we cannot imagine.

Another walk through the exhibition hall left me breathless with the possibilities in eHealth. So many companies offering variations of the EMR/EHR, so few with real contributions to the patient’s ‘window’ into healthcare. It was interesting talking to some people – one person outlined a project she’s working on regarding the idea of using metadata to draw trends and patterns from an EMR database to support clinical decisions, and support predictive modelling. Another was eager to show me their clinical information system from a nurse perpsective – this demonstration raised the question of how the physician would map his/her information needs into an existing nursing-focussed system.

Suddenly it was the end of the day.