BB&T Executive Editor

ORLANDO — The annual conference of the Healthcare Information and Management Systems Society (HIMSS; Chicago) isn't your Uncle Bob's traditional healthcare conference.

But how to describe it? Let's try quantity.

More than 28,400 attendees, and quite a few more than the 26,000 initially projected, including 1,600 "senior" chief information officers, this number about 20% more than the previous year; more than 900 exhibitors on several soccer field-sized exhibit floors at the Orange County Convention Center, representing two dozen categories of products; everywhere you looked, laptops, laptops, laptops; and an array of star-caliber keynote speakers, from Michael Leavitt, head of the U.S. Department of Health and Human Services to some Internet heavy hitters, Steve Case, founder of AOL, and Eric Schmidt, CEO of Google.

But perhaps HIMSS 2008 should be characterized by the quality of its energy. For instance:

A pre-conference Oscar-themed party with band and dancing; an introductory session that can only be characterized as a "geek squad" pep rally — featuring rock music, young women twirling flags and very, very big video graphics • and a slogan: "This is our time!"

Those attending HIMSS do believe it is their time, as the Internet and computer systems continue to penetrate the healthcare arena, and the demands for speeding up that process in the U.S. healthcare system become louder and stronger.

That was the call for action made by John Wade, chair of HIMSS and CIO at St. Lukes Hospital (Kansas City, Missouri), who defined the major goals of the organization, and HIT in general, as improving patient quality and safety, and then asked the key strategic question: "How do we get the others to pick up the pace?"

The key: a national EMR

Key to this large goal, Wade said, was the establishment of a national electronic medical record (EMR) or, alternatively, electronic health record (EHR). While acknowledging the slow progress by the U.S. in reaching this goal, he declared: "No challenge is insurmountable!"

He went on to identify the broadly referenced report of 98,000 deaths yearly due to medical errors, by the Institute of Medicine (Washington), as an important turning point for HIT, because it "quantified for the first time" those errors and the need to reduce them, with HIT now "impacting the whole issue of patient safety and quality." And he said the broad achievement of seamless electronic interoperability in U.S. healthcare would "help your organization, help your patients and, in the end, help your country."

Underlining this message was the first keynoter, Bill Frist, MD, former Republican Senator, who said that the primary goal should be to make "the affordable resources available to every American out there today."

True to what his audience obviously wanted to hear, Frist emphasized the use of HIT to enable the broad dissemination of information required to improve healthcare value. Frist told attendees that what they do to bring about the seamless integration and dissemination of healthcare information could play a large part in solving these problems, and, echoing Wade, said, "Now is the time"

A military template for civilian care

While the show provided various virtual views of integrated e-health systems — via product showcases, demonstrations and, by presenters, descriptions of ongoing efforts in this direction — perhaps the best look at such a system was provided by the U.S. military through its presence in various conference presentations and on the exhibit floor.

The military's effort could serve as a template for future civil interoperable and portable e-health systems, ranging from hand-held systems used by Medecs on the battlefield point of care, these systems then feeding information concerning injuries and sickness into the military's EMR/database system, branded as AHLTA (not an acronym for anything).

One could easily transpose this to a civilian setting, with first-responders at the site of a car crash, for instance, or coming to the aid of a stroke victim, sending information to hospital facilities to ready emergency care, all of this and more data concerning the person's health history and contraindications kept in an easily accessible database.

Col. David Parramore, an information management officer, told Biomedical Business & Technology that the Iraq War has greatly speeded the military's efforts in developing its integration systems (so far primarily for out-patient care and not yet developed for in-patient care because of the long-time legacy electronic systems in its hospitals).

He said this acceleration in e-health was fueled by the special circumstances in Iraq and Afghanistan as never before, not even in the Gulf War. "The Gulf War was a 100-hour war — we got in and then we were out," he told BB&T during a tour of the Department of Defense installation. By contrast, the long-term fighting in Iraq and Afghanistan, several thousand miles away from the department's hospital facilities, has forced the military to totally revamp its medical care for long-term, long-distance warfighters.

He said, now, "the theater [of battle] is just the beginning of a long chain of events" far beyond the "golden hour" after injury or the various other traumas that war produces.

Military doing what others aren't

The military's AHLTA system gathers data, not just for healthcare, but for interfacing with the array of business and social issues facing connected to a soldier's health, their families and veterans. And military doctors unveiled and described new modules being added to the system — very much looking like a complex e-mail system, including such things as information about drug interactions and practice guidelines and even enabling physicians to create their own patient outcome registries.

Parramore candidly waved a hand at the 900-plus other exhibitors on the sprawling exhibit floor, saying that this tsunami of e-health offerings is exactly what's wrong with the current system.

"We're doing things that no one else is doing," Parramore said. "There are hundreds of systems. Everyone's trying to sell you a system to answer a fraction of the question," meaning that they provide only one part of the e-health answer, with the assumed hope of integration of all these pieces at some point downstream.

E-health in the theater of battle begins with a type of hand-held PDA carried by medics — the military's version of a first responder, or a medically trained soldier — with a series of screens and inputs, comparable to a paper medical chart.

Col. Tom Beach, a practicing physician with the Air Force assigned to AHLTA management, told BB&T that the AHLTA system is importantly entirely "patient-centric" and so different than its electronic legacy systems. The DoD's legacy systems have tended to be "adjuncts" to its paper records and "hospital-centric," he said, and that "AHLTA is now the record," following the patient throughout his or her healthcare history.

At the conference, BB&T asked more than once how many physicians are not just using AHLTA but using it well. One answer: "If they know how to use it, they like it."

Another from Beach: "95% to 98% of encounters are in AHLTA," though he candidly acknowledged that some military doctors have not completely weaned themselves from paper notes and records.

Beach said that the necessary changes in the e-health system were being developed about eight years ago and that these systems are now coming to fruition. And according to Parramore, "This war has taught us a lot of things we never knew before — at a rate that we have never seen before in history." The key change: "process improvement — we're employing techniques that we're still just learning about."

From governmental EHR to patient-centrism ...

While the military appears to be doing what the civilian world is pointing toward, the HIMSS conference indicated that the ultimate EHR system will not be in the hands of government but will be established largely by private enterprise and its contents controlled by patients — thus more of a very broad-based personal health record (PHR).

The federal government has been serving as the leader in developing standards for creating a universal, interoperable and portable EMR, often linked to the development of universal healthcare coverage, paralleling the government's hold on Medicare and Social Security information.

"Patient-centric" was the most common term heard in the meeting rooms and on the exhibit floor, emphasizing patient control and privacy. HIMSS Chair Wade said, "Patients, not providers, should be in charge of their healthcare information," with a system offering "a better patient-educated process, easy to use and organize, according to what is relevant to that particular individual."

That was the paradigm emphasized by Schmidt, CEO and chairman of Google (Mountain View, California), in his speech emphasizing the Internet's current huge role in offering healthcare information to general public, thus lifting the current that has protected the medical "holy of holies" that has been presided over by physicians for centuries.

Schmidt's main message at the conference was to promote the broad use of Google Health, the Internet Giant's new system which he described as an array of partnerships between Google and organizations with health data that can be used to create PHRs controlled by their users, completely portable and privacy-protected.

... and 'cloud computing'

Currently in pilot development, Google Health will utilize what Schmidt termed "cloud computing," the "cloud" being a huge server storing data that can be accessed instantaneously by users and those that only they, or their proxies, give the authority to access.

"We're in the midst of this enormous shift to cloud computing, rather than having all the information stuck on my personal computer," Schmidt said. "With this new, emergent model of server-based information, the computer connects to the Internet and a program comes down in less than a 10th of a second, with the data managed by professionals to make sure you never lose it."

He said that Google Health won't be "tethered to a particular health system." And he called Google Health "an opportunity to get [current disparate] systems tied together and get the best of breed in all of them." The data sets this system could provide would include "useful dashboards" concerning key health issues, such as children's immunizations and "customized news targeted" to a particular condition.

Thus, he said, one day a user could get this message: "The disease you have has been cured — call here," as one example.

He also promised that Google Health would not be "monetized," the short form for saying it won't contain advertising — at least not initially.

Completely private? — no, not completely

Following the presentation at HIMSS, in a meeting with reporters in a Q&A session, Schmidt mostly knocked back a variety of queries of the "Is this really possible?" variety from the skeptical herd. His answer was to focus on the positives and the benefits it would bring to patients.

But what about that privacy thing?

BB&T's question in the Q&A was: Is there an "absolute guarantee" that government would not tap into this highly personal information?

Schmidt said that if served by a court subpoena seeking information from the system, Google would determine if that request was "rational" and act accordingly. "We are subject to U.S. law," he said.

So, obviously no guarantee against government intrusion.

The Google Health partnerships so far range from Wal-Mart (Bentonville, Arkansas) to the prestigious Cleveland Clinic, the latter partnership reported in late February, and others continuing to sign on, most recently the Cleveland Clinic and Quest Diagnostics (Madison, New Jersey).

Through these relationships, Google intends to pull large amounts of the data that these partners have into the "cloud" server, with users having control of their own personal data as well as broad access to information concerning diseases and medical resources.

During his keynote presentation, Schmidt specifically selected the Cleveland Clinic for praise, calling it "a really neat group."

"They have a lot of different sites that were willing to work with us to help define the standards," Schmidt said. "We'll see how well this goes over the next month," with the expectation of then broadening it "to everyone possible in the U.S."

He emphasized that Google does not see itself as the owner of Google Health, but rather as providing a platform that many others have the ability to use. "Our message to you," Schmidt said, "is that if you have an opportunity to build an application on top of this platform ... [W]e want you to build it on top of this platform."

Social 'trust' the key to privacy

Throughout HIMSS 2008, the issue of privacy kept surfacing, and Michael Leavitt, secretary of the U.S. Department of Health and Human Services, another presenter in the robust lineup of biggies, said that the key to getting Americans to trust in the privacy of their health records was to build this trust via "sociological change." But this appeared to be very much a circular argument: that American would trust the privacy of EHR after they used it for awhile and learned to trust it — if it turned out to be trustworthy.

He assured the HIMSS attendees that the technology is available to guarantee privacy of health records, and offered his father as a case study, a parent who studied every one of his online bank statement deposits and withdrawals for months before he was absolutely certain that online this new system was exact and absolutely safe.

Thus, he said, "The story isn't about technology — the story isn't about technology change," with technology the "enabler of change" and that this change must be "sociological."

"People worry a lot about the personal information they have. They should," Leavitt said. "Real harm can come when you have personal information that's exposed. Real harm can come from a lack of access to important information."

The "underpinning" of a universal health information system, Leavitt said, is "robust protection," and he assured the HIMSS 2008 attendees that we now have available the "technical capacity to balance privacy concerns with information sharing." And the necessary trust will be "achieved one heart and one mind at a time," he said.

"People intuitively don't trust distant bureaucracy, but they do trust locally," he said, "things they know, people they know," he added, emphasizing the local nature of building the required trust.

Thus, he said he would be meeting with groups in the Orlando area, "to explore with them the ways for them to build a trusted network that can exchange information that will benefit consumers. We need to remove the barriers to connected systems, and incite action at the local level and then get out of the way so that we can accomplish it."

Government the 'organizer'

As an umbrella statement, Leavitt (the Leavitt of HHS) said that government's role is to "organize the market to go forward and let market forces guide and innovate."

He also emphasized his endorsement of the American Health Information Community (AHIC), a public/private partnership recognized as the official consultant to HHS on HIT.

He reported that AHIC has officially recognized 50 different standards to lay the foundation for interoperability and has received another 60 standards that it is considering.

He said that AHIC is important because "insulated from the political winds that blow," and he said AHIC 2.0 is now gearing up and will be important for avoiding "the inevitable pause that happens any time there's a change in administrations. We've got to launch it, get it going, outside those political winds to accelerate the progress that we've made."

Certification of EMRs using these standards is critical for helping consumers select the best products by serving as a "seal of approval."