From The Editor | July 2, 2012

The Curious Case Of Blue Button

Ken Congdon, Editor In Chief of Health IT Outcomes

By Ken Congdon, editor in chief, Health IT Outcomes
Follow Me On Twitter @KenOnHIT

Until recently, I took only a passing interest in Blue Button, the Department of Veterans Affairs’ (VA’s) app that allows veterans to download their health records to a computer, mobile device, or jump drive. I realize this probably reflects poorly on me given the fact that I’m a health IT journalist, but I guess I viewed Blue Button more as a nifty feature on the VA’s online patient portal, My HealtheVet, than a game-changer in the world of HIE (health information exchange) and patient engagement. Quite frankly, in the wake of Google Health’s demise, I didn’t think many veterans would even be inclined to use Blue Button. However, my interest in this initiative was renewed during a HIMSS Tweet Chat with former Chief Technology Officer of the United States Aneesh Chopra held in May. During the chat, Chopra was asked to reveal the most inspiring health IT story he’d heard in the past 3 months. In fewer than 140 characters, Chopra vaguely spoke of an injured disabled vet that successfully used Blue Button to aid in his own recovery. For some reason, I became obsessed with learning as much as I could about this use case.

Blue Button To The Rescue

A few strategically placed emails and phone calls was all it took to get me in touch with the disabled vet referenced in Chopra’s tweet. His name is Craig Luigart, and he’s not only a Blue Button user, but he’s also the CIO for Health with the Veterans Health Administration. At first, I thought Craig’s affiliation with the VA would cheapen his account of Blue Button in action. “Of course he uses it, he works for the government outfit that developed it,” I said to myself. However, my tune quickly changed once Craig described his ordeal.

Craig is a former Naval commander that acquired a service-connected disability that confines him to a wheelchair. On top of that, Craig has a rare (only 500 to 1,000 cases known worldwide) neuromuscular disease called PLS (primary lateral sclerosis). PLS is characterized by progressive muscle weakness in voluntary muscles. There is no cure for PLS, but its symptoms are treated using a ‘cocktail’ or more than a dozen ‘off-label’ prescription medications.

One evening, Craig suffered a deep laceration to his scalp when he accidentally hit his head on his truck’s bumper while attempting to transfer from his wheelchair to the vehicle. His wife rushed him to the Emergency Room at Walter Reed Military Medical Center for treatment.

“When we arrived at Walter Reed, their system was down and the doctors were unable to access my health record,” says Luigart. “I told them I had PLS, and the physicians really wanted to have a full understanding of the medication cocktail I was on prior to treating me for my head injury. I whipped out my iPhone, logged onto MyHealtheVet, and downloaded my health data — complete with prescription dose and frequency. Without Blue Button, I would have either been forced to wait for Walter Reed’s system to come back online before I received treatment, or been subject to a potential adverse drug event if the physicians decided to treat me without full knowledge of the prescriptions I was already taking.”

Interoperability Questions Loom Around Blue Button

Craig’s story is truly inspiring, and it helped open my eyes to the benefit of providing patients with access to and control of their own health data. However, many still question whether the Blue Button model is the prototype that will bring patient engagement, HIE, and PHRs (personal health records) to the masses.

First, there’s the question of interoperability. Blue Button outputs health data as either plain text (ASCII) or in a PDF. While easy for the patient to read and understand, these formats aren’t easily uploaded into provider EHR systems. In accordance with Meaningful Use, EHR vendors have adopted the CCD (Continuity of Care Document) as the accepted standard for health information transfer among providers and with patients. The CCD contains structured data, but can also be read by humans using a standard style sheet. Many argue that if Blue Button health data is taken to a provider, it will have to be manually entered into the EHR by the staff, creating a duplication of effort. This is an assertion Luigart adamantly contests.

“While it is true that structured data has certain advantages, it is also true that the technology industry has known how to manipulate unstructured data for years,” says Luigart. “Plus, we’re now seeing groups like HL7 and others creating tags, labels, and codes around Blue Button to further enable interoperability.”

Plus, does the notion that Blue Button isn’t based on the CCD standard make Craig’s story any less impactful? Nope. In fact, in Craig’s scenario, the EHR system that stored his medical record was unavailable. It was the fact that Craig was able to access and provide physicians with his health record when the EHR system couldn’t that made his account so compelling, and ultimately may have saved his life. CCD compatibility is definitely one way Blue Button can be enhanced to add a greater convenience to providers and patients, but it doesn’t dictate its value.

Is Blue Button What Patients Really Want?

To me, the bigger question surrounding Blue Button is whether or not patients truly want to be the keeper of their own health records. Rather than carrying your health records on your person, many (including myself) believe patients would rather submit a query (either personally or via a health provider) to have their health records transferred to the appropriate system electronically. In a recent interview, Michael Mistretta, CIO of MedCentral Health System provided a good analogy to describe this position.

“I believe patients want to interact with their health records much like they interact with their finances in an electronic world,” says Mistretta. “Think about it: You don’t go to an ATM, take out $100, and then walk down the street to another financial institution to deposit it. You authorize an electronic transfer of the funds. I believe patients want to authorize transfers of their health records in a similar fashion, rather than carrying them around with them.”

Luigart doesn’t discount Mistretta’s opinion. In fact, he states that those with this opinion may be right.

“The point of Blue Button was to make health data available to the patients,” says Luigart. “It has been successful in this regard — so much so that it has smashed through the noise about health IT standards, and actually has gotten patients involved in managing their own health records and their own care. As for ongoing models for how this data is accessed and transferred? That’s something the market will decide.”

Indeed, the market will decide. While it may not be the answer to all HIE and patient engagement challenges, Blue Button does prove one thing — there is a large contingent of patients out there that want control and access to their health records. To date, more than 376,000 unique registered users have downloaded more than 900,000 health data files through Blue Button. Rather than dwell on its perceived weaknesses, the health IT industry would be wise to consider the progress Blue Button has made and improve upon the concept.