Phishing in the Stream: Unlimited Bandwidth, Driverless Cars, and the Future of Health Data | Dave Levin, M.D. | Healthcare Blogs Skip to content Skip to navigation

Phishing in the Stream: Unlimited Bandwidth, Driverless Cars, and the Future of Health Data

September 20, 2017
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Data must flow freely in order to be valuable. That’s what well designed APIs do: they can create huge increases in bandwidth.
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Most Labor Day weekends, I head to Denver with a group of family and friends for an extended weekend of hiking, great food, great beer, and 3 nights of Phish (a most awesome jam band if you are into that kind of thing). It is always a good time and a chance for two generations to connect and share.

Driving to breakfast one morning, my brother Steve observed, “The next generation doesn’t own music the way we did. They don’t own CD’s or even download and store much anymore. They just stream what they want in real time.”  This echoed a similar thought that had crossed my mind the previous night while hanging out with one of my nephews.  Steve and I decided we would explore this further over breakfast with his boys, Matt and Dan, and Dan’s girlfriend Alex. They are all college grads in their mid-to-late twenties. After agreeing to buy them a great creole breakfast in exchange for tolerating our questions, we launched into an interesting and wide-ranging discussion.

The entire conversation was essentially about the commodification of bandwidth in different forms. It turns out that as the cost of bandwidth drops, it can dramatically change how we think and behave.

What we learned in our discussion is that while these young adults all have a strong interest in music, their attachment is to the music experience not the media. Growing up in a different age, my brother and I collected albums, studied the covers and “liner” notes and later graduated to collecting (or burning) CDs. To be attached to the music you also had to be attached to the media.

No more. These young people stream what they want in real time. As long as they can get what they want, when and where they want it, they will stream. When do they download? “When I am going to be on a plane,” said Alex, “or when I am going for a hike in the mountains and I know the cell coverage will be spotty or absent.”

In short, when the bandwidth is adequate and reliable, they see no need to possess a copy of the music.

The conversation then flowed from talking about music to a discussion about driverless cars and cars-on-demand (COD) like Uber or ZipCar.  Because it’s a great place to live and people have flocked to the region, Denver has developed a serious traffic problem, and it’s getting worse as the streets were designed for an earlier age.  Now, I’m no urban planner, but I’ve read some interesting things about how COD could have a significant positive impact on city traffic, parking and the like. You call for the car. It comes to pick you up, takes you to your destination, and either parks somewhere or goes to fetch the next rider. The concept is essentially the same whether it’s Uber or driverless.

I asked, “Well what about cars?”  There was a bit of back and forth on this topic, but eventually we learned that these millennials viewed cars the same way they viewed music.  Assuming they can get the car they want, when they want it and at a fair price, they would be fine with COD. There’s no great attachment to the object – the car. The attachment is to reliable transportation. As Matt pointed out, “Owning a car in the city is expensive and a pain.” ZipCar’s tag line, “Own the trip, not the car” captures this nicely. Much to my surprise, I am beginning to think American’s long-term love affair with cars will fade as the bandwidth of COD increases.

This is fascinating from an emotional and philosophical perspective. The relationship, value and emotional attachment is to the experience not the ownership or the object. In an effort to test this further my brother and I pushed for examples where physical ownership – having your own “copy” matters as much as the experience. It wasn’t a surprise when this group of active young people chose camping gear as an example. In this case it was not just about having the gear they want when they want it. There was an emotional attachment to the object as well. It was more personal. It held memories and experiences beyond the mere utility of the tent or sleeping bag. It turns out there are limits to unlimited bandwidth. There will always be gearheads, steam punks, and record album collectors.

Being an API evangelist, I couldn’t help but see a connection between our breakfast conversation and how we manage data in healthcare today. There is a widespread belief, misguided in my judgement, that owning your own copy of the data has intrinsic value and gives organizations competitive advantages. Even worse, traditional integration methods, like those based on HL7, inherently drive developers towards duplicate databases and all the problems this leads to when it comes to synchronization, security and portability.

In contrast, APIs promote a single source of truth approach by making the data available on-demand. I don’t need to have a copy of the data if I can get what I want, when I want it and the way I want it. Sound familiar?

Carried to its logical conclusion, this means Continuity of Care Documents (CCDs) and Health Information Exchanges (HIEs) and the like are “old school,” like owning a record album. Why do we need to consolidate copies of data in an HIE or exchange half-baked CCDs if we can exchange that data from point-to-point in real time? Maybe HIEs should evolve to be the keepers of the master pointers that help us locate and route the data rather than the repository of the data itself. CCDs are really “retro” and just need to go away entirely, and the sooner the better.

Making copies and hording data may confer advantage in the short-term – but only in the short term. The real and lasting value comes from competing on analytics by turning data into actionable information. This implies the ability to deliver on velocity, volume and variety when it comes to moving data, in other words, bandwidth. This theme of getting the data to flow also runs through this recent pair of essays in The New England Journal of Medicine on the state of healthcare IT and the impact of the HITECH Act.

Data must flow freely in order to be valuable. That’s what well designed APIs do: they can create huge increases in bandwidth. That’s one reason why the rest of the digital economy adopted them long ago. And as these young adults are showing us, that’s the way of the future.


Special thanks to Dr. Stephen Levin, Dan, Matt and Alex for their contributions to this post.

Dr. Dave Levin has been a physician executive and entrepreneur for more than 30 years. He is a former Chief Medical Information Officer for the Cleveland Clinic and serves in a variety of leadership and advisory roles for healthcare IT companies, health systems and investors. You can follow him @DaveLevinMD or email



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HL7 Model Identifies Clinical Genomics Workflows, Use Cases

January 16, 2019
by David Raths, Contributing Editor
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Domain Analysis Model covers pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics

HL7’s Clinical Genomics Work Group has published an HL7 Domain Analysis Model (DAM) to identify common workflows and use cases to facilitate scalable and interoperable data standards for the breadth of clinical genomics scenarios.

The Domain Analysis Model (DAM), which has underdone a rigorous ISO/ANSI-compatible balloting process, covers a myriad of use cases, including emerging ones such as pre-implantation genetic diagnosis, whole-exome sequencing, RNA sequencing and proteomics.

The effort “builds on the DAM Clinical Sequencing work that is already being used to design precision medicine workflows at hospitals across the country,” said Gil Alterovitz, Ph.D., an HL7 Clinical Genomics Work Group co-chair, in a prepared statement. He also serves as a Harvard professor with the Computational Health Informatics Program/Boston Children’s Hospital.

The Clinical Sequencing DAM fueled the design of FHIR Genomics, the subset of HL7’s FHIR standard designed to communicate clinical genomic information. “By extending to broader domains, it can serve as a standard going forward to aid in the design of workflows, exchange formats as well as other areas,” Alterovitz added,

The document presents narrative context and workflow diagrams to guide readers through the stages of each use case and details steps involving the various stakeholders such as patients, health care providers, laboratories and geneticists. This contextual knowledge aids in the development and implementation of software designed to interpret and communicate the relevant results in a clinical computer system, especially a patient's electronic health record.

The HL7 Clinical Genomics Work Group developed several new applications and refinements in the Domain Analysis Model beyond its original scope of clinical sequencing. One notable addition is the analysis of the common workflows for pre-implantation genetic diagnosis (PGD). For those undergoing in-vitro fertilization, advanced pre-implantation genetic screening has become increasingly popular as it avoids the implantation of embryos carrying chromosomal aneuploidies, a common cause of birth defects. Implementers can follow the workflow diagram and see the context for each transfer of information, including the types of tests performed such as blastocyst biopsy and embryo vitrification.

As the clinical utility of proteomics (detecting, quantifying and characterizing proteins) and RNA-sequencing increases, the DAM also outlines clinical and laboratory workflows to capitalize on these emerging technologies.

HL7 notes that future challenges arise from uncertainty about the specific storage location of genomic data, such as a Genomics Archive and Computer/Communication System (GACS), as well as the structure of a patient’s genomic and other omics data for access on demand, both by clinicians and laboratories. Best practices in handling such considerations are being formulated within HL7 and include international input from across the spectrum of stakeholders. In parallel, the HL7 Clinical Genomics Work Group has been preparing an implementation guide for clinical genomics around many of these use cases, to be leveraged alongside the newly published HL7 FHIR Release 4 standard.


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ONC Releases Interoperability Standards Advisory Reference 2019

January 15, 2019
by Heather Landi, Associate Editor
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The Office of the National Coordinator for Health IT (ONC) has released the 2019 Interoperability Standards Advisory (ISA) Reference Edition, which serves as a “snapshot” view of the ISA.

The 2019 Interoperability Standards Advisory represents ONC’s current assessment of the heath IT standards landscape. According to ONC, this static version of the ISA won’t change throughout the year, while the web version is updated on a regular basis. The ISA contains numerous standards and implementation specifications to meet interoperability needs in healthcare and serves as an open and transparent resource for the industry.

The Interoperability Standards Advisory (ISA) process represents the model by which ONC coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications that can be used by the healthcare industry to address specific interoperability needs including, but not limited to, interoperability for clinical, public health, research and administrative purposes. ONC encourages all stakeholders to implement and use the standards and implementation specifications identified in the ISA as applicable to the specific interoperability needs they seek to address. Furthermore, ONC encourages further pilot testing and industry experience to be sought with respect to standards and implementation specifications identified as “emerging” in the ISA.

The newest ISA reference edition includes improvements made based on comments provided by industry stakeholder during the public comment period, which ended Oct. 1, according to a blog post written by Steven Posnack, executive director of ONC’s Office of Technology, Chris Muir, standards division director, Office of Technology, and Brett Andriesen, ONC project officer. ONC received 74 comments on the ISA this year, resulting in nearly 400 individual recommendations for revisions.

According to the blog post, the ISA contains “a variety of standards and implementation specifications curated by developers, standards gurus, and other stakeholders to meet interoperability needs (a term we use in the ISA to represent the purpose for use of standards or implementation specifications – similar to a use case) in healthcare.”

“The ISA itself is a dynamic document and is updated throughout the year, reflecting a number of substantive and structural updates based on ongoing dialogue, discussion, and feedback,” Posnack, Muir and Andriesen wrote.

The latest changes to the reference manual include RSS feed functionality to enable users to track ISA revisions in real-time; shifting structure from lettered sub-sections to a simple alphabetized list; and revising many of the interoperability need titles to better reflect their uses and align with overall ISA bets practices. According to the ONC blog post, the updates also include several new interoperability needs, including representing relationship between patient and another person; several electronic prescribing-related interoperability needs, such as prescribing weight-based dosing and request for refills; and operating rules for claims, enrollment and premium payments.

The latest changes also include more granular updates such as added standards, updated characteristics and additional information about interoperability needs.

The ONC officials wrote that the ISA should be considered as an open and transparent resource for industry and reflects the latest thinking around standards development with an eye toward nationwide interoperability.

The ISA traditionally has reflected recommendations from the Health IT Advisory Committee and its predecessors the HIT Policy Committee and HIT Standards Committee and includes an educational section that helps decode key interoperability terminology.


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ONC Report: Health IT Progress Stifled by Technical, Financial Barriers

January 15, 2019
by Heather Landi, Associate Editor
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While progress has been made in the adoption of health IT across the U.S. healthcare industry, significant interoperability hurdles remain, including technical, financial and trust barriers, according to a report from the Office of the National Coordinator for Health Information Technology (ONC).

Currently, the potential value of health information captured in certified health IT is often limited by a lack of accessibility across systems and across different end users, the ONC report stated.

The annual report from the U.S. Department of Health and Human Services (HHS) and ONC to Congress highlights nationwide health IT infrastructure progress and the use of health data to improve healthcare delivery throughout the U.S.

The report, “2018 Report to Congress: Annual Update on the Adoption of a Nationwide System for the Electronic Use and Exchange of Health Information,” also reflects progress on the implementaions of the Federal Health IT Strategic Plan 2015-202 and the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.

In the report, ONC notes that most hospitals and health care providers have a digital footprint. As of 2015, 96 percent of non-federal acute care hospitals and 78 percent of office-based physicians adopted certified health IT. The increase in health IT adoption means most Americans receiving health care services now have their health data recorded electronically.

However, hurdles to progress still remain. For example, ONC notes that many certified health IT products lack capabilities that allow for greater innovation in how health information can be securely accessed and easily shared with appropriate members of the care team. “Such innovation is more common in other industries. Also, lack of transparent expectations for data sharing and burdensome experiences for health care providers limit the return on investment for health care providers and the value patients are able to gain from using certified health IT,” the report authors wrote.

While health information is increasingly recorded in a digital format, rather than paper, this information is not always accessible across systems and by all end users—such as patients, health care providers and payers, the report authors note. Patients often lack access to their own health information, healthcare providers often lack access to patient data at the point of care, particularly when multiple healthcare providers maintain different pieces of data, own different systems or use health IT solutions purchased form different developers, and payers often lack access to clinical data on groups of covered individuals to assess the value of services provided by their customers.

Currently, patients electronically access their health information through patient portals that prevent them from easily pulling from multiple sources or health care providers. Patient access to their electronic health information also requires repeated use of logins and manual data updates, according to the report. For healthcare providers and payers, interoperable access and exchange of health records is focused on accessing one record at a time. “Without the capability to access multiple records across a population of patients, healthcare providers and payers will not benefit from the value of using modern computing solutions—such as machine learning and artificial intelligence—to inform care decisions and identify trends,” the report authors wrote.

Looking at the future state, the report authors contend that certified health IT includes important upgrades to support interoperability and improve user experience. Noting ONC’s most recent 2015 edition of certification criteria and standards, these upgraded capabilities will show as hospitals and healthcare provider practices upgrade their technology to the 2015 edition, the report authors state.

“As HHS implements the provisions in the Cures Act, we look forward to continued engagement between government and industry on health IT matters and on the role health IT can play to increase competition in healthcare markets,” the report authors wrote, noting that one particular focus will be open APIs (application programming interfaces). The use of open APIs will support patients’ ability to have more access to information electronically through, for example, smartphones and mobile applications, and will allow payers to receive necessary and appropriate information on a group of members without having to access one record at a time.

Healthcare industry stakeholders have indicated that many barriers to interoperable access to health information remain, including technical, financial, trust and business practice barriers. “In addition, burden arising from quality reporting, documentation, administrative, and billing requirements that prescribe how health IT systems are designed also hamper the innovative usability of health IT,” the report authors wrote.

The report also outlines actions that HHS is taking to address these issues. Federal agencies, states, and industry have taken steps to address technical, trust, and financial challenges to interoperable health information access, exchange, and use for patients, health care providers, and payers (including insurers). HHS aims to build on these successes through the ONC Health IT Certification Program, HHS rulemaking, health IT innovation projects, and health IT coordination, the report authors wrote.

In accordance with the Cures Act, HHS is actively leading and coordinating a number of key programs and projects, including “continued work to deter and penalize poor business practices that lead to information blocking,” for example.

The report also calls out HHS’ efforts to develop a Trusted Exchange Framework and a Common Agreement (TEFCA) to support enabling trusted health information exchange. “Additional actions to meet statutory requirements within the Cures Act including supporting patient access to personal health information, reducing clinician burden, and engaging health and health IT stakeholders to promote market-based solutions,” the report authors wrote.

Moving forward, collaboration and innovation are critical to the continued progress on the nationwide health IT infrastructure. To that end, the HHS report authors recommend that the agency, and the health IT community overall, focus on a number of key steps to accelerate progress. Namely, health IT stakeholders should focus on improving interoperability and upgrading technical capabilities of health IT, so patients can securely access, aggregate and move their health information using their smartphones, or other devices, and healthcare providers can easily send, receive and analyze patient data.

The health IT community also should focus on increasing transparency in data sharing practices and strengthen technical capabilities of health IT, so payers can access population-level clinical data to promote economic transparency and operational efficiency, which helps to lower the cost of care and administrative costs, the report authors note.

Health IT developers and industry stakeholders also needs to prioritize improving health IT and reducing documentation burden, time inefficiencies and hassle for healthcare providers so clinicians and physicians can focus on their patients rather than their computers.


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