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The NHIN Direct Addressing Specification

Every Tuesday, the NHIN Direct Implementation Group holds a teleconference to update the entire team on the progress of the technical workgroups. This week, we discussed the completed addressing specification.

As I've said many times in my blog, the most important standards implementation problem to solve right now is transport, not only the basics of transmitting data securely but also transaction orchestration and the constellation of supporting functions such as addressing the messages.

In previous blogs, I've described one way to solve the addressing problem - give every patient a voluntary opt in "Health URL" that they could use to receive all healthcare data from hospitals, offices, labs, and pharmacies.

For use cases such as sending data from provider to provider, hospital to provider or provider to public health we need some similar approach to ensure data is delivered to the right place.

The NHIN Direct Addressing specification proposes five ways to do this - secure email addressing (SMTP plus TLS), REST, SOAP, and the HL7 routing schemes XCN and XON.

First, two definitions. A "Healthcare Internet Address" is made up of a Health Domain name and a Health Endpoint Name

Health Domain Name

A Health Domain Name is a string conforming to the requirements of RFC 1034.

A Health Domain Name identifies the organizations that assign the Health Endpoint Names and assures that they correspond to the real-world person, organization, machine or other endpoint that they purport to be. For example, my organizations (BIDMC and Harvard Medical School) could control nhin.bidmc.org or nhin.hms.harvard.edu

A Health Domain Name MUST be a fully qualified domain name, and SHOULD be dedicated solely to the purposes of health information exchange.

Organizations that manage Health Domain Names MUST maintain NHIN Direct Health Information Service Provider (HISP) Address Directory entries for the Health Domain Name, as specified by the Abstract Model, and corresponding to rules established for concrete implementations of the Abstract Model. Organizations that manage Health Domain Names MUST ensure that transactions are available for Health Endpoint Names, either through proprietary means or following the Destination role transactions of the Abstract Model. Organizations may take on the HISP role or assign this function to another organization playing the HISP role (such as GoDaddy does for hosting regular email on behalf of other organizations).

Health Endpoint Name

A Health Endpoint Name is a string conforming to the local-part requirements of RFC 5322

Health Endpoint Names express real-world origination points and endpoints of health information exchange, as vouched for by the organization managing the Health Domain Name. For me, that could be a person such as Dr. John Halamka, an organization such as BIDMC Emergency Department or an aggregation point such as BIDPO Quality Data Center. Here are examples of each address type

Email

Jhalamka@nhin.bidmc.org for health information exchange (not regular email) directed to me at BIDMC

REST (example of a possible format)

https://nhin.bidmc.org/nhin/1_0/nhin.bidmc.org/jhalamka/

1_0 refers to the REST API version.

SOAP (example of a possible format)

https://nhin.bidmc.org/nhin/1_0/wsdls/messages

the person or organizational endpoint would be specified in the SOAP message itself.

1_0 refers to the SOAP API version.

HL7 XCN (extended composite ID number and name for persons)

urn:nhin:nhin.bidmc.org:jhalamka^Halamka^John^D^DR^MD^^&NHIN OID&OID

The XCN representation could be used in multiple contexts, including the intendedRecipient in an XDS/XDR web service call or in an HL7 2.x message to refer to the sender or receiver of a message (e.g., in a PV1 segment)

HL7 XON (extended composite name and identification number for organizations)

Beth Israel Deaconess Medical Center^^^^^&NHIN OID&OID^^^^urn:nhin:nhin.bidmc.org:emergency_department

Note that XCN and XON are included for compatibility with the IHE XDR spec, NHIN Document Submission, and HITSP T31.

Imagine if every EHR could send data to every other EHR using a simple addressing mechanism like Email, a consistent REST implementation or a well described SOAP WSDL. Interoperability would follow rapidly because novel packages of data will be sent to support real business needs without any barriers of how to get the data from endpoint to endpoint.

The NHIN Direct process is working well and builds upon the work of the past. It does not compete with, diminish, or in any way represent a replacement of the hard work done by so many people over the past years in HITSP, IHE, and the SDOs.

I'll continue to provide NHIN Direct updates as reference implementations with running code are deployed. Massachusetts, through NEHEN and the Massachusetts eHealth Collaborative has volunteered to test these techniques with other surrounding states. Let the testing begin this Summer!

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Pecha Kucha Presentation

1. Nadia Comaneci
Since I was seven years old my dream has been to be a World Champion Athlete.
My hero at the time was Nadia Comaneci who I watched on TV score the first perfect ten in women�s gymnastics. I wanted to be her. Today my dream is still alive�what is it that makes a hero and can my dream come true?



2. Wilma Rudolf
The following year when I was eight I saw a made for TV movie about the life of Wilma Rudolf, who at a young age contracted infantile paralysis from polio and was told she would never walk without corrective braces. Not only did she go on to walk normally but win 3 Olympic gold medals in track and Field.
Now I had two heroes.



3. Kayaking
For ten years I chased my childhood dream. I was a professional whitewater kayaker and lived a nomadic life following summer and the rivers of the world hoping to win the Freestyle Kayaking World Championships. The closest I ever came was 5th in the World and 5 years ago my fire burnt out and I walked away from my dream.

5. Vietnam
In the middle of my kayaking career I got invited on a National Geographic Sea Kayaking Expedition in Vietnam. My main role was to look after the non-swimming non-kayaking interpreter, and to assist the film crew. I mentioned an idea I had to make a film about nomadic women kayakers to the National Geographic filmmaker and he was encouraging.

6. Nomads
So being basically na�ve and having no filmmaking experience I bought a video camera with my Visa card and set out to make my first movie. Needless to say..it took awhile and 6 Years later I finished Nomads which I funded myself through teaching kayaking.
Nomads went on to be the official selection in over 30 international film festivals and won half a dozen awards.

7. Nomads/ Jessie
Nomads tells the story of three women I knew from kayaking who were paddling on the White Nile River In Uganda and decide they can give back to the village they are staying in. DR Jessie Stone is the primary character who through her own fundraising built a rural clinic, does malaria education and prevention, and family planning education.

8. Soft Power Health
I returned to Uganda last year to make a follow up film on DR Jessie Stone�s humanitarian work. To date she has sold over 100,000 mosquito nets and educated over 30,000 Ugandans about malaria, and her clinic is thriving. Jessie is a huge inspiration in that not only did she realize she could make a difference. She also is combining it with her passion for kayaking and having a good time doing it.

9. Blue Planet Run
The success of Nomads lead to my first big video job. I got asked to be the primary videographer for the Blue Planet Run. The first ever 24 hour a day around the world relay, raising awareness and funds for safe drinking water in third world countries. The run went non- stop for 95 days and nights covering over 15,000 miles overland thru 16 countries.

10. Balance
Thoroughly exhausted from the Blue Planet Run and needing a home base after years of constant travel I moved to Gisborne. I needed balance, and wanted to see what the rest of life had to offer. I started my production company Flair Films, learned how to surf, rekindled oil painting again, began a regular yoga practice, cycled, and started selling my kayaking gear.

11. Arnd and the seed- Kelly Surf shot
Over this past New Years an old friend of mine from kayaking came to visit me and go surfing. He started talking about kayaking and the last World Championships, and offhandedly said �Polly you know if you started training again I think you could be in the top ten in the world�, and I said If I start training again I don�t want to be top ten I want to win.

12. Vipassana meditation photo-
Shortly after my friends visit, I went on a ten -day vipassana meditation course. That course was the hardest and best thing I have ever done. Sitting in silent meditation for 11 hours a day gave me a lot of time to reflect on my life, and what I want to do with it. My childhood dream came back and call it divine inspiration but I knew I had to go for it one last time.

13. A fire within
I committed to start training again. Setting my sights on winning the 2011 World Freestyle Kayaking Championships. Going within on the meditation course relit my inner fire, and I decided if I was going to achieve my childhood dream it was now or never. This time around it�s not just about winning a gold medal but about being the best person can be at the same time.

14. Movie
I have also decided to make a documentary about my journey. In the hopes that what I discover along the way will help other people on their paths. Making the film and going for my dream feel like something I have to do. I really can�t explain why, I have felt the fear of failure, which isn�t going to stop me, and am facing it head on, and I also know I can�t do it alone.

15. Ego
The last time around going for my dream I think I was coming from a place of needing to prove something. It felt very ego driven and external. This time I want it to be different. It isn�t about proving to the world that I can win, but about fulfilling this deep-seated childhood dream, and doing it in a way that is balanced, with the intention of inspiring others to go for their dreams.

15. Your own backyard

The reason behind making my new documentary, which is called, A Fire Within, stemmed from audiences reactions to my other films. People who want to make a difference but don�t know how. What I realized meditating is that true change can only come from within, and making a difference can happen in our own backyard. So I am trying to be that change.

16. Sunflowers
Some examples of positive change that I am consciously incorporating in my life are living with integrity and forgiveness, giving someone a smile, being nice to my grocery clerk, and pursuing what brings me joy. I notice when I am happy and positive it rubs off. And that�s the person I want to be in the world.

17. Flair Films
The whole reason I started my production company was to tell stories about inspiring people doing positive things in the world. Our world is full of modern day heroes and I want to tell their stories. The impact seeing Nadia cominice score the first perfect ten and seeing Wilma Rudolf�s story on TV when I was 8 years old, changed my life, and I am hoping maybe my films can do that for someone else.

18. My Hero Project
I have also become a mentor for the My Hero Project. A non profit organization who�s mission is to use media and technology to celebrate the best of humanity and to empower young people to realize their own potential to effect positive change in the world. I attended the My Hero Film festival in LA, and came away so inspired. I knew this was a project I wanted to be involved in.


19. Gratitude
I feel extremely lucky to have had all of the experiences I have had. And I also value the true grit and inspiring determination of my heroes, Wilma Rudolf and Nadia Comaneci who paved the way before me.
Living the life I have chosen isn�t always easy, but I know I am following my passion and want to die knowing I gave it my best shot.

20. Own Drummer
I have chosen to live my life beating to my own drummer�. and will end with a quote from Abraham hicks who says�
"Do I have a responsibility to make the whole world beat to my drum?" No, nor could
you. You beat your drum, and the Universe will respond to the drum that you are
beating�

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Failed Leaders of Citigroup as Leaders of Health Care

When we began this blog, I never dreamed I would do so much writing about finance and the financial services sector of the economy, but,... 

The Governance of Citigroup

The discussions and revelations generated by the global financial collapse/ great recession continue to provide insights into the ongoing health care crisis.  Let me start with a small item from the Dow Jones Newswire this week:

The California Public Employees' Retirement System said it opposes the re-election of two Citigroup Inc. (C) directors, in part because of their roles in the recent financial crisis.

The nation's largest public pension fund, which owns about 61.2 million Citigroup shares, plans to cast 'withhold' votes for board nominees Andrew Liveris, chairman and chief executive of Dow Chemical Co. (DOW), and Judith Rodin, Rockefeller Foundation president, at the annual shareowners meeting Tuesday.

Both served on the company's audit and risk committee before the financial crisis. During the crisis, the banking giant accepted a total federal government infusion of $45 billion, which it has repaid.

'It's time for new blood in the boardroom,' said Anne Simpson, the senior portfolio manager who heads the Calpers corporate governance program....

Let me back up a bit.

The near-failure of global banking giant Citigroup, prevented only by a massive US government bail-out, was one of the central components of the global financial collapse. We noted recently how Mr Robert Rubin, one of the key leaders of Citigroup was accused of "being asleep at the switch," "irresponsibility and misjudgment," and being a "very well paid boob" after his testimony at hearings by the committee investigating the collapse. We also noted his link to health care. As senior member of the Harvard Corporation, Rubin is one of six top stewards of the US' oldest and arguably most presigious university, containing one the country's most prestigious medical schools and teaching hospitals.

Although all those who were members of the Citigroup at the time it collapsed have not been hauled in front of the committee, there has been considerable discussion of their responsibility for the company's failures. For example, in 2008, soon after the government rescue of Citigroup began, the Wall Street Journal published an editorial:

"Citi never sleeps," says the bank's advertising slogan. But its directors apparently do. While CEO Vikram Pandit can argue that many of Citi's problems were created before he arrived in 2007, most board members have no such excuse. Former Treasury Secretary Robert Rubin has served on the Citi board for a decade. For much of that time he was chairman of the executive committee, collecting tens of millions to massage the Beltway crowd, though apparently not for asking tough questions about risk management.

Chairman Sir Win Bischoff has held senior positions at Citi since 2000. Six other directors have served for more than 10 years -- including former CIA Director John Deutch, Time Warner Chairman Richard Parsons, foundation executive Franklin Thomas, former AT&T CEO C. Michael Armstrong, Alcoa Chairman Alain Belda, and former Chevron Chairman Kenneth Derr.

When taxpayers are being asked to provide the equivalent of $1,000 each in guarantees on Citi's dubious investments, how can these men possibly say they deserve to remain on the board?

While other banks can claim to be victims of the current panic, Citi is at least a three-time loser. The same directors were at the helm in 2005 when the Fed suspended Citi's ability to make acquisitions because of the bank's failure to adhere to regulatory and ethical standards. Citi also needed resuscitation after the sovereign debt disaster of the 1980s, and it required an orchestrated private rescue in the 1990s.

Last year, as reported by Bloomberg,

Citigroup Inc. investors should vote against re-electing four of 14 board members, including John Deutch and Michael Armstrong, to improve management of the company�s risks, a shareholder advisory group said.

Deutch, former U.S. Central Intelligence Agency director, Armstrong, former AT& T Inc. chief executive officer, and Alain Belda, chairman of Alcoa Inc., should be opposed 'for poor risk oversight,' RiskMetrics Group Inc.�s ISS Governance Services said today. Xerox Corp. CEO Anne Mulcahy shouldn�t be re-elected because she sits on more than three boards, which may limit her effectiveness, the group said.

'The pattern of chronic oversight failure at Citi and the magnitude of the corresponding shareholder losses warrant removal from the board of directors most responsible for risk oversight,' RiskMetrics said in the statement.

Furthermore,

'Despite the fact that the board has many incumbent directors that have been successful in their respective fields and have been on the board for some time, their track record taken as a whole is dismal given that the company is currently surviving on federal assistance,' RiskMetrics said.

Rick Conrad, of the Seeking Alpha blog, thus berated the CEO of Citigroup at its 2009 shareholders meeting,

Mr. Armstrong, who has been a director since 1989 is no longer part of the Audit Committee, as of this year, continues his 'service' to our Company on the Nomination as well as the Compensation Committee. Much as this company has suffered under an illusion of prosperity, it appears to continue to suffer under an illusion of competence.

John [Deutch] has served on the Audit Committee of our Company since 1997 and hence, likely drank the Kool-Aid as to the Illusion of Prosperity.

I note that the audit and risk management committee has many members who, like Mr Deutch and MrArmstrong presided over this seemingly out of control disaster.

Andrew Liveris since 2005 on Audit

Ann Mulcahy since 2007 on Audit

Dr Judith Rodin since 2004 on both Executive and Audit Committees.

Overlaps Among Citigroup's Board and Health Care Organizations' Leadership
So there seems to be good reason to believe that the board of Citigroup at the time the firm collapsed were a collective example of inattentive goverance and poor stewardship. We have previously documented overlaps among poor governance and leadership of finance, and the governance and leadership of health care, suggesting that the poor leadership and governance of the latter may be in part a result of infection from the former. So I looked for overlaps among the Citigroup board and health care organizational leadership.

A list of the membership of the failed board comes from the 2008 Citigroup proxy statement.  The biographies provided therein, supplemented with some Google searching, produced the following overlaps:

- C Michael Armstrong - is also Chairman, Johns Hopkins Medicine, Health Systems and Hospital

- Alain J P Belda - was a Trustee and member of the Corporation of Brown University (including the Warren Alpert Medical School) (see link).  (He stepped down prior to 2009 at an unknown time.)

- Sir Winfried Bischoff, Chairman of the Board - is a director of Eli Lilly and Co.

- Kenneth T Derr - is a director of the University of California San Francisco Foundation.

- John M Deutch - no overlap found

- Roberto Hernandez Ramirez - no overlap found

- Andrew N Liveris - is a Trustee of Tufts University (including the School of Medicine and Tufts- New England Medical Center)

- Anne M Mulcahy - in 2009, was appointed to the Board of Directors of Johnson and Johnson (see link)

- Vikran S Pandit, CEO - is a Trustee of Columbia University (including the College of Physicians and Surgeons and Columbia University Medical Center)

- Richard D Parsons - is a Trustee of Howard University (including the College of Medicine and Howard University Hospital)

- Judith Rodin - is President of the Rockefeller Foundation

- Robert E Rubin - is a member of the Harvard Corporation (including Harvard Medical School and multiple Harvard teaching hospitals), and a Trustee of Mount Sinai Medical Center

- Robert L Ryan - was a director of UnitedHealth Group, is a Trustee of Cornell University (including Weill Cornell Medical College, and Weill Cornell Medical Center), and was a Senior Vice President and CFO of Medtronic

- Franklin A Thomas - no overlaps found

Summary

So in summary, of 14 board members, 2 are trustees of major medical centers (Johns Hopkins and Mount Sinai), 6 were or are trustees or equivalent of universities that include medical schools and medical centers (Brown, Tufts, Columbia, Howard, Harvard and Cornell), one is a trustee of such a university's foundation (University of California San Francisco Foundation), 2 are or would be board members of pharmaceutical corporations (Eli Lilly and Johnson and Johnson), one was a board member of a commercial managed care organization/ health insurance company (UnitedHealth), one was a former top executive of a medical device company (Medtronic), and one is the President of a large charitable foundation which historically has supported multiple medical and public health initiatives (Rockefeller Foundation).  Only 3 of 14 did not have a major leadership role of a health care organization.  

Most of these health care organizations have been involved with cases we have discussed on Health Care Renewal (see links above).

Given the seriousness of the failure of Citigroup, one has to wonder why so many of the directors who presided over it still have such influential positions in health care organizations?

As we have pointed out, as the world economy was driven to near ruin by "masters of the universe," some of the same also became leaders of academia and academic medicine in their spare time. Maybe this made sense 10 or 20 years ago, but why does it still make sense? On the other hand, now that we understand how bad the leadership of finance really was, it is a little easier to understand why the leadership of health care has become so bad. Iit seems reasonable to hypothesize that some of the problems of academia, and particularly the problems of medical academia, may have been at least enabled by leadership more used to working in an increasingly amoral marketplace than to upholding the academic mission.  The failures of the leadership and governance of finance thus suggest we need to re-examine the leadership of health care.

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A Short, Pithy, Open Letter to the National Coordinator for Health IT Dr. David Blumenthal

Sent: Wednesday, April 21, 2010 7:17 AM
To: David.Blumenthal@hhs.gov
Cc: fschulte@huffpostfund.org; 'Ross Koppel'; 'Justin Starren'
Subject: Re: "As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge"

Dear Dr. Blumenthal,

In the Apr. 20, 2010 article "As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge" at http://huffpostfund.org/stories/2010/04/doctors-shift-electronic-health-systems-signs-harm-emerge#ixzz0ljMzNOzD you are quoted as saying that:

"... CPOE alert and decision support features make doctors better ... CPOE is critical to the success of the electronic health records initiative. We need to support it and make sure it happens. How fast and in what form remains to be seen."

I have written that our approaches to IT in medicine lack the scientific approach we use in medicine itself. The foundation of that approach is the use of evidence.

Yet the evidence base is increasingly shedding doubt on statements such as yours, including studies and articles I've been compiling at http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=2009 . This growing corpus of literature suggests these statements may be premature regarding the health IT experiment.

I also share a belief that HIT potentially holds great promise towards improving healthcare quality, safety and costs. However, my beliefs are based on my experiences developing such technology for highly specialized clinical settings, but specifically not based on my experiences with commercial HIT upon which your office is leading a multi-billion dollar spending frenzy. My experiences with that sector have been disappointing as I have repeatedly documented at the Healthcare Renewal blog of the Foundation for Integrity and Responsibility in Medicine.

As we enter the second decade of the 21st century this potential has been largely unrealized. Significant factors impeding HIT achievement have been false assumptions concerning the challenges presented by this still-experimental technology, underestimations of the expertise essential to achieve the potential benefits of HIT, and the current orthodoxies around leadership for this grand social reengineering experiment.

The enabler and driver of these factors has been a lack of critical thinking about the technology, about social informatics and its implications, and a marketing and HIMSS driven 'irrational exuberance.'

We really need to return to critical thinking and to a scientific approach to our evaluations and prognostications about HIT.

With that in mind, please show us the hard evidence, now, that would support such statements, or please stop making statements to an unwitting medical audience and public that "CPOE is critical to the success of the electronic health records initiative."

Such statements sound more and more like marketing, not the measured statements on experimental technology I would expect to hear from a Harvard physician-scientist.

-- SS

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College Touring Advice

I've just finished 700 miles of driving with my wife and daughter touring Dartmouth, University of Vermont, Middlebury, University of Massachusetts Amherst, Smith, Mt. Holyoke and Connecticut College. Locally we've already toured Tufts, Brandeis, and Harvard.

It's been a great experience for all, filled with observations about the students (they look really tired or they look like they have a reasonable amount of free time), comparison of the admission officer standard presentations, and a first impression of the culture of each school.

My lesson learned - applying to college in 2010 is nothing like applying to college in 1980. It's much more complicated with many more online resources and an iterative process to find the right fit.

However, the best advice is from the Middlebury Office of Admissions, which published this quick guide for Parents.

10. Remember - the process is not about you.

9. Support and encouragement are more appropriate than pressure and unsolicited advice.

8. Do not use the words "we" or "our" when referring to your child's application process.

7. Help them prepare but let them perform.

6. Encourage your children to make their own college appointments, phone calls and emails.

5. Allow your children to ask the questions.

4. Prepare your children for disappointment.

3. Never complete any portion of the college application for your child.

2. Do not let stereotypes or outdated information steer your child away from schools in which they would otherwise have an interest.

1 . Never, ever, buy a college t-shirt or sweater from the bookstore in your size.

Words to live by.

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Participating in Food Allergy Studies

With so many food allergy studies going on, researchers are actively recruiting individuals to participate. Those interested in being a part of a clinical study can look at lists of ongoing studies at Clinical Trials.gov. This organization is a service of the U.S. National Institutes of Health. Read Understanding Clinical Trials to get a full appreciation of the commitment involved in a study.

FAAN (Food Allergy and Anaphylaxis Network) also maintains a list of current study needs.

It's a big decision to participate in a study. It's even bigger when deciding if you should allow your child to do so. Give it careful consideration and make the best decision for your family.

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