As some of you will know, blue button started with the VA as a way to give veterans access to their medical records in a textual format. It was later expanded into blue button plus, a completely new approach to providing patient access to data.

Blue button plus is comprised of a push and a pull model.  The push model is dated, but still in existence. It’s based on the direct protocol which is essentially a form of secure email pushed from an EMR to another system. As I’ve noted in prior blogs, when you call providers and ask them to do the pushing they usually have no idea what you’re talking about.

If you can get your provider to do a push then you might not like what you get. There really is no way for the person who wants the data to influence what is sent other than to ask for specific records.  If you just want part of that data then you are out of luck.

In practice it is often more useful to do a pull so that you can select the data that you want.  The blue button plus program realized this and introduced a modern web protocol-based approach that has subsequently been revised to incorporate the FHIR (fast healthcare interoperability resources) protocol.  Its common these days to hear this referred to as the blue button rest API.

So, where are we now?

The technology is quite well built out.  There is a well-defined specification using Oauth2, restful services, and well-defined resources from the FHIR. If you are a JavaScript or a node.js developer then things are really well put together and Herculean efforts to arrive at libraries like bluebutton.js pave the way for you.

Unfortunately, Industry adoption is not coming along at a great rate. While meaningful use stage III had an opportunity to change this, the requirement for VDT (view, download, transmit) is still non-specific about the technology to be used.  Making blue button plus a stake in the ground would have been a good start towards getting vendor is on the train. maintains a website called the blue button connector that allows you to query for hospitals, health insurers, providers, pharmacies, labs, or immunization registries that support blue button (plus) services.  When I looked at the list of providers supporting blue button in the state of New York I got a little depressed.   There are about 10 major hospitals who support some blue button, and of these only six allow you to download records.

Interestingly, most do not display the blue button logo on their website.  Neither do they allow you to securely send your records to your preferred application, or receive automatic updates to your personal health record.

This is a pretty low level of adoption for hospitals within my home state.  Of course, everything could change in the blink of an eye if the vendor’s chose to support the program fully, and the government provided incentives that gave hospitals a reason to allow records out of their ivory garden.

So that’s hospitals.  What about providers?

Today blue button connector says that there are 1038 providers registered.  This is really trick accounting, because what they are showing here is the number of providers that have attested meaningful use stage to who may offer digital access through the VDT requirement.  It is by no means guaranteed that they are offering it using blue button.

Only one of my providers has any idea what blue button is, and since he is the head of the Informatics program at a local hospital, we can hardly consider him to be representative.

When we look at labs and health insurers blue button has had some decent traction and I had a sparkling conversation about the potential to use the protocol to exchange information with an analyst from one of the blues while I was at the HL-7 working group earlier this year.

Let’s summarize.  In my humble opinion, blue button plus is just a little ahead of its time. There is no doubt that the technology stack is well thought out and capable of doing the job. The wetware has to come along, and in healthcare that’s a slow process.  Given a little meaningful use leveraging to set the bar a little higher and some incentive to jump that bar, this could be the preferred way to exchange patient records.

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