Thursday, July 31, 2014

Unity Farm Journal - 5th Week of July 2014

The great thing about running a farm is that every day is filled with the unexpected.

Sunny, our new baby alpaca did not consume her first meal of mother’s milk in time to receive the antibodies that are necessary to keep her healthy.   She was not gaining weight.   We had only one choice - a transfusion of alpaca plasma containing IgG (about $150).     We drove to Tufts Veterinary School and picked up 500cc of plasma.   There are two ways to transfuse a baby alpaca - jugular vein IV or peritoneal infusion.   Inserting an IV in a baby alpaca is like wrestling an alligator.  We chose the peritoneal approach which required shaving her belly, a bit of anesthetic, and a quick puncture to insert a blunt tube for infusion.   After 10 minutes of infusion she was back to the paddock.   Since the infusion, she has gained weight, had boundless energy and is on her way to becoming a healthy adult alpaca.   Here are before and after pictures, illustrating the use of our kitchen as an operating room.



Over the weekend, I put on my bee suit to help my wife and daughter inspect the hives and move heavy honey filled frames.   As I walked past the cider house I noticed a grey guinea fowl that had disappeared in the forest about a month ago.  We were convinced that a coyote had taken her.   Behind her were 17 babies that she successfully raised in the forest and now was leading back to the coop.   Other guineas in the flock do not seem to recognize their own young species and tend to harass babies, sometimes to the point of killing them.  I ran to the hives and asked for my daughter’s help.   Together we wrangled all 17 babies into a large farming bucket and placed them in a 100 degree F brooder where they ate, drank, and warmed up after their travel through wet grass.    Today they are happy and healthy and we’ll move them to one of the mini-coops on August 16.   Mom is a little disturbed that we took her babies away, but she’s returned to the coop and settled in with the other guineas.    We still have two nests in the forest and if they are successful, we’ll have over 100 guineas on the farm.     We’ve already put up notices at local farm stands offering guinea chicks for sale.


All of this guinea mania required a bit of new construction.    I built another mini coop in the larger coop, so now we have 5 areas for poultry.

brooder - 3 levels, can hold 100 chicks
mini-coop #1 - can hold 5 “teenagers”
mini-coop #2 - can hold 10 “pre-teens”
coop side #1 - can hold 25 adults
coop side #2 - can hold 25 adults



Today we have 17 chicks, 3 teens, 9 pre-teens, and 27 adults.   We’re going to run out of space if they forest nests are successful.


The hoop house continues to produce massive quantities of cucumbers, tomatoes, chard, squash, and eggplant.   One of my favorite vegetables is Japanese pumpkin (Kabocha) and I’ll harvest 25 pounds of it this weekend.

All is well on the farm as Fall approaches.   The ducks are eating worms in the compost pile and the joyful chaos continues.



Wednesday, July 30, 2014

Real Time Big Data Analytics for Clinical Care

Over the summer, I’ve given many lectures about SMAC - social media, mobile, analytics and cloud computing.

The most popular analytics topics are business intelligence, big data, and novel data visualizations.

Recently, Dr. Chris Longhurst, chief medical information officer at Lucile Packard Children's Hospital, and colleagues wrote an article in the Big Data Issue of Health Affairs, that suggests a very practical approach for enabling real time analytics within an EHR.   They call it the Green Button.

The Blue Button is for patient view/download/transmit of medical records.

The Green Button is for instant access to outcomes, cost, and risk information for patients that match a given profile.

Here’s a personal example.

When my wife was diagnosed with Stage IIIA Breast Cancer in December of 2011, the biomarkers of the tumor were HER2 -, Estrogen +, Progesterone +.    Imagine that while in her record, a Green Button enabled access to the de-identified records of all 50 year old, Asian females with similar tumors and showed the treatment protocol used, the side effects, the cure rate, the cost, and the complications.

Although not completely scientific, such an approach does not identify causality, it does demonstrate experience and standard practices in the community.   The Green Button idea is foundational to the learning healthcare system we’re all trying to build.

We do need to be careful.   Here’s one example from our work with I2B2/Shrine.

Did you know that the average human white blood cell count is 5 at noon but 13 at 3am?

Scientifically we know that white count does not vary with circadian rhythm.   However, who has a white blood cell count drawn at 3am?  Sick people.

You cannot conclude that white count varies over the course of a day because the data has confounding complexities.

However, there is an interesting possible conclusion.   People who get white counts drawn at 3am, get blood cultures at 4am, and antibiotics at 5am.   We can suggest that if you order a white count at 3am then you want to order a blood culture and antibiotics at the same time, since you’ll end up doing it anyway.

The Green button idea is to present valuable historical observational data at the point of care.

I2B2 is a great tool for clinical research and clinical trial enrollment, but imperfect for point of care advice.

How might the Green button be developed?

Emerging companies like QPID are creating new tools that summarize structured and unstructured data into unique visualizations.

The BIDMC experience with care management using a third party registry populated via the state HIE also provides promise.

I look forward to experimenting with the Green Button concept - another item on my to do list for the next year.

Monday, July 28, 2014

There’s More to ePrescribing Standards Than You Think

In followup to my guest post from Dr. Marvin Harper about e-Prescribing gaps, John Klimek, R.Ph., Senior VP, Standards and Information Technology, NCPDP wrote the following helpful guest post:

The National Council for Prescription Drug Programs (NCPDP) leaders and members read with interest the guest post from Dr. Marvin Harper, CMIO at Boston Children's Hospital, entitled “Limitations of e-Prescribing Standards.” Dr. Harper’s thoughtful post brings a critical issue to light: the need for increased industry awareness and adoption of the full functionality that already exists in ePrescribing standards – going beyond the core requirements of Meaningful Use. ePrescribing is important in improving both the quality of patient care and patient safety. It provides a key point of communication between care providers, and can help improve patient compliance with treatment regimens.

ePrescribing Standards: What’s Covered

Three standards are used in ePrescribing – the NCPDP SCRIPT Standard and the NCPDP Formulary and Benefit Standard, and the ASC X12 Standards for Electronic Data Interchange Technical Report 3 - Health Care Eligibility Benefit Inquiry and Response - 270/271. The eligibility transaction is typically exchanged prior to the patient encounter and can supply the prescriber system with information about the patient’s pharmacy benefit, including the payer, member ID, formulary and coverage pointers, and other details. The Formulary and Benefit Standard provides a means for pharmacy benefit payers to communicate formulary and benefit information to prescribers via technology vendor systems at the point of prescribing. The file exchange includes information on formulary status, alternative drugs, co-pays and other information.

The healthcare industry is currently using SCRIPT Standard version 10.6 which contains thirteen different transactional exchanges for ePrescribing functions, including:
Sending a New Prescription;
Changes to a Prescription;
Renewals and Resupply Exchanges;
Cancellation of a Prescription;
Fill Status Notifications;
Medication History; and
Census Exchanges.

Most of these transactions have been named in the regulations associated with the Medicare Modernization Act. While the electronic exchange of new prescriptions, renewals and medication history have grown exponentially, implementation of other transactions has been very slow.

Other capabilities, including the specific issues raised by Dr. Harper, are also available in the existing standard, underscoring the urgent need to increase awareness and industry-wide adoption of the breadth of functionality afforded by the ePrescribing standards. Among them are:

Structured and codified sig - promotes greater consistency in specifying directions and for clinical review/analysis. The current version used by the industry contains a 140 byte free text field, along with fields to describe the route, indication, vehicle, site, timing, and duration. The structured and codified sig format present in SCRIPT version 10.6 was not intended to support 100% of sigs; however a pilot found that 95% of the fully parsed sig strings were accommodated by the format. Enhancements incorporated in SCRIPT version 2012+ include a more robust Structured Sig Segment which supports a text field size of 1000, as well as other enhancements, recommendations and clarifications from the pilot.
Support for patient observations - allows prescribers to supply Patient Height, Weight, Diastolic and Systolic Blood Pressure. Patient Weight is useful for validating proper pediatric dosing. Based on questions posed by a Council on Clinical Information Technology Executive Committee article, recommendations for pediatric prescriptions were included in the SCRIPT Implementation Recommendations document publicly available for implementers at http://www.ncpdp.org/Resources/ePrescribing under NCPDP Resources. A challenge is for the prescribing systems to send this information. Enhancements for more observation measurements were included in a more recent version.
Support for scheduled medications - provides fields necessary to enable ePrescribing of controlled substances.
Compound prescription support - approved in SCRIPT version 10.8 when industry champions came forward to analyze the needs and work through the requirements.
Adverse events/reactions - the NCPDP SCRIPT Standard supports the exchange of drug use review (DUR) fields. The industry is actively exploring adding the use of adverse events/reactions/etc., which is used in other transactions, for the use in the ePrescribing transactions via the NCPDP WG11 ePrescribing Best Practices Task Group.
Support for prior authorizations – provides the means to exchange information needed in prior authorization (PA) requirements, including access to information on covered medications at the point of care, information on PA approvals and denials. The ePA transactions were added in a more recent version that industry participants are actively implementing.

Moving the Needle on Adoption and Implementation of ePrescribing Standards
ePrescribing standards have been enhanced based on requests by the industry which has opted to build functionality in layers. For example, the SCRIPT Standard version 10.6 was published in 2008, with enhancements that are approved and published at least twice a year. But publication is one action; implementation is another. So the question is: How do we move the needle to increase adoption and implementation of the ePrescribing standards?

1. Technology/System Vendors Can Take the Lead or Wait for a Mandate - There are many demands on industry vendors for impact analysis, development, implementation, testing and distribution. Then there is coordination of both prescribing and pharmacy systems implementation, and all within regulatory requirements. In an effort to build a predictable, repeatable process, the industry will be examining if a cyclical implementation timeframe could be adopted to move versions in a more timely and expected manner. In the absence of a mandate, uptake on adoption and implementation depends on technology vendor priorities.

2. Share Lessons Learned to Improve Implementation Guidance – Implementation can be slow when you are blazing new trails. The data itself is complex. It may be pulled from data that is not discrete or doesn’t use the same nomenclature or requires the use of an unfamiliar vocabulary. The electronic exchange can be complicated. It forces analysis of manual workflows. Trading partners may be at different stages of implementation maturity. Benefits are seen from different perspectives. Industry experience in the use of the functionality available is needed, with lessons learned to improve future implementation. NCPDP has active task groups including ePrescribing Best Practices Task Group, Implementation of Structured and Codified Sig Task Group, and many others that are open to materially interested parties to come together in consensus to develop industry guidance, implementation guidance, and future enhancements to the standards.

The complex but vital enhancements to industry standards are developed by the dedicated volunteers across the healthcare industry who share questions, findings, and recommendations. NCPDP, the standards development organization, provides the forum for this important work. See http://www.ncpdp.org/Resources/ePrescribing for more information, including how to get involved.

Thursday, July 24, 2014

Unity Farm Journal - 4th week of July 2014

Just as running a winery isn’t all romance, art, and elegance, running a farm is not all romping with your animals, a joyful harvest, and making a profit from the fruits of your labor.

Farming is hard work year round, during the hot humid days of summer, the wet days of Spring/Fall and the chill of winter.  There’s always maintenance and always unexpected tasks.

Some of my farm related posts gloss over the details of day to day operations.  This week, I’ll give you a taste of the kinds of things that require attention.

Our 1.5 miles of trails, our mushroom operations, and manure management all depend on the Terex Front Loader, at PT-30.   Last week, it began leaking hydraulic fluid (basically 30W oil) so rapidly that the roadways are covered with oil stains and the hydraulic fluid tank level is in the red zone.   I crawled under the front loader and found that fluid was dripping from the lowest point of the protective under carriage pan - clearly a hose had come loose or an o-ring had flattened.  The Terex weights 3000 pounds and I have no way of lifting it to remove the protective plates and do an inspection.   Thus we needed to arrange a truck to take it to a service center.   I used a pressure washer to remove some of the driveway oil stains but it has not worked very well.   I'm trying a variety of detergents to loosen the oil from the asphalt, but no magic bullet thus far.

We have an eXMark Turf Tracer mower to manage our acres of pasture and fields.    Many of these areas have not been consistently trimmed in the past and under the 2 foot tall grasses were hidden rocks, logs, and other debris.    The very powerful mower uses a hydraulic power take off to turn the blades.   The debris was simply chopped up - yes the mower cut off the tops of rocks.    Although the end result of all my summer mowing has been beautiful trails and pastures, the mower blades were severely worn.   I had to lift the 550 pound mower, unbolt the blades, and sharpen them with a grinder - it’s all part of standard farm maintenance.   Now that everything is trimmed I’ve removed all rocks and debris so the blades should not be abused again.

Our new baby alpaca, Sunny, is growing up.   She’s learned how to take a dust bath, how to use the alpaca designated poop piles, and how to munch the romaine lettuce from our hoop house that we give the animals every night.    The vet called to say that her IgG measured low the day after her birth.   Like humans, Alpaca get their first antibodies from mother’s milk since they do not pass the placenta.   Sunny was a little slow to start eating, so she was delayed in getting these antibodies.  The vet recommended we monitor her temperature daily for early detection of any infection.    The normal body temperature of a baby alpaca is 101.5-102.5.   Anything greater than 103 is a fever.    Every night for the past week, Kathy and I have taken her rectal temperature.   It’s generally about 101.8, no fever.   Imagine the fun of corralling a 20 pound with the personality of a 2 year old for daily temperature taking!

Of the 3 guinea nests in the forest, one is now abandoned.   Raccoons ate the majority of the eggs and we candled the remainder to discover they were non-viable.   Mom now spends the night safely in the coop.   The other 2 nests were poorly managed - guineas are terrible parents.   I used straw to build warm, self contained incubation areas and now the guineas at least have a chance of hatching their young.    The ducks continue to incubate 9 guinea eggs that the guineas had abandoned.

One of the oyster mushroom areas finished its 3 month spawn run and my task last weekend was to remove 2000 pounds of poplar logs from the black plastic trash bags that served as incubators/humidfiers for the wood and spawn.   We now have about 10,000 pounds of poplar in production for oyster mushrooms and look forward to a major Fall harvest.

We continue to maintain the bee hives.   We spun 9 full frames of perfect summer honey (mostly clover) late one night last week by the light of a lantern.   We’ve used the hot summer days to melt bees wax in our solar melter and at this point we have 10 pounds of wax for votive candle making when then weather turns old and we focus on indoor tasks.

Although the weekend was filled with needed maintenance, there was a bit of joyful harvest.   We  picked over 100 pounds of cucumbers and are using our own cider vinegar to make sweet/hot pickles. We also picked 50 pounds of zucchini, japanese pumpkin, peas, beans, and tomatoes.   This weekend we’ll harvest the carrots, eggplant, and kale.

The next week will be more harvesting, more pickle making, more bee work, more animal care, and planning for our fall crops.    There is no rest for a farmer during the glorious weather of mid summer.

Wednesday, July 23, 2014

Patient Generated Data Goes Mainstream

Since 1999, Patientsite, the BIDMC  shared record between doctor and patient,  has enabled patients to track blood pressure, glucometer readings, activities of daily living, mood, pain etc. but few patients have used those features.

Why?  Because it requires time and energy to maintain that data.

What if data gathering was entirely passive?

Today, I own a Withings bathroom scale and Withings Pulse O2 wearable monitor.    When I get up each morning, my weight, body mass index, and fat percentage is measured by my scale and wirelessly sent to the Withings cloud where it is routed to my Microsoft HealthVault account and my iPhone Withings app.

As I go through each day, my Pulse O2 device tracks my sleep pattern, my activity level (distance and elevation), my heart rate, and my pulse ox measurement.    Using Bluetooth Low Energy (BTLE), all the data is instantly synched to my iPhone and viewable by hour, by day and by week.

There is nothing I have to do.   All of this just happens as part of my activities of daily living.

There are three factors that are combining to create a perfect storm for patient generated data to enter the mainstream

1.  The devices, standards (content, vocabulary, transport), and usability are good enough.  The total expense of acquiring/using them is cheap enough

2.  ACOs are beginning to accept the fact that home care devices such as pulse oximeters, blood pressure cuffs, electronic  scales, glucometers, and sleep monitors will be essential to care delivery between episodic visits with clinicians.

3.  It’s likely that Meaningful Use and other government programs will offer stimulus (or penalties for non-compliance) for incorporation of patient generated data into the electronic health record.

Every year I take on a personal project and do my best to roll it out in production.  In the past that has included administrative simplification, healthcare information exchange, patient/family engagement, Google Glass, mobile support for our consumer/clinician facing applications, shared care plan creation etc.

Patient generated healthcare data is the next key frontier in care coordination, population health, and clinical research.  Although Beth Israel Deaconess has invested significantly in home care, care management, and telemedicine, it has not yet made the commitment to be a leader in patient generated healthcare data.

I’ve used the pulse oximeter on Mt. Fuji to track my performance and I’ve learned that I walk an average of 20,000 steps per day during my life as a healthcare CIO and farmer.   I’ve learned that sleep pattern is instant deep sleep for an hour, punctuated by light sleep/deep sleep intervals for 30 minutes, followed by waking in 4 hours.    I’ve watched variation of my weight - weekends have more activity and less time eating, so by Sunday night I’m at the lowest point of the week.   During the weekday meetings and office time, I eat more and exercise less.    The good news is that over the course of each month, my weight peaks and troughs cancel each other.

For the next year I’ll be exploring patient generated data, both in devices I use myself, and in the creation of novel applications that enable such data to be incorporated in ACO and clinician workflow without creating data overload for any stakeholder.

I’ll document all my lessons learned along the journey.


Monday, July 21, 2014

Limitations of e-Prescribing Standards

The following is an important guest post from Dr. Marvin Harper, CMIO at Boston Children's Hospital, identifying a gap in e-prescribing standards:

Why am I guest writing a blog post here?   As a practicing pediatrician and CMIO at Boston Children’s Hospital I am particularly sensitive to specific limitations of current e-prescribing standards.

Being able to write and route prescriptions electronically provides many advantages over the handwritten paper prescription process that inherently uses families as couriers.  Nonetheless the current standards for e-prescribing have created a void that permits limitations in certified vendor software on both the prescribing and pharmacy receiving side. The result is that our patients are not yet benefiting from the full potential of eprescribing. Additional national standards for electronic prescription transmission are needed to provide the common ground needed by software vendors at each stage of the prescription life cycle.

The core elements to consider when writing a prescription are the name of the medication, the dose form (e.g., capsules, tablets, extended release tablets, liquids), the amount of medication the patient should take at each dose, the dose frequency (e.g., once, twice or three times per day) and the duration of time for the patient to take this medication.

Currently there are no standards for provision, transmission, receipt or display of weight within electronic prescriptions. To prescribe the correct quantity per dose of the desired medication the weight based dose is converted to a finite dose using a recent, appropriate, and reliable patient weight.  This is then converted to an appropriate drug volume dose (e.g., one tablet, five milliliters) based on the drug product selected (e.g. amoxicillin 500 mg capsule or amoxicillin 250 mg/5 mL suspension).  Considering all of these manipulations, it is then obvious that in order for a pharmacist to review and verify that the correct dose is being dispensed, in addition to the medication and finite dose, the pharmacist needs to have the prescriber’s target weight based dose and the patient weight available at the time of review.   Stated another way, providing the weight is not fully sufficient for the pharmacist to verify the intended target weight based dose. With today’s standard the pharmacist only gets a volumetric dose  (e.g., 5 mL) which is then inferred into a strength dose (e.g., mg/kg) from the prescribed formulation. It is therefore impossible for a pharmacist to fully verify that prescribed doses are appropriate for their pediatric patients.

The current limitation for the entire prescription sig line within a prescription to be transmitted electronically is 140 characters.  Basically a tweet.  Not close to enough for many prescriptions.  As a result we must continue to provide some prescriptions on paper to the patient.

Many commonly prescribed medications require slowly increasing or decreasing the finite dose. These are commonly referred to as medication titrations or tapers and are therapeutically very important to avoid secondary complications.  It can be complex to transfer this information satisfactorily to patients and the pharmacist in the best of circumstances.  It is impossible with a 140 character limit to the sig.  In my experience within pediatrics this is most problematic for prescribing anticonvulsants, steroids, and immunosuppressive medications.

Did I mention the current limitation for the sig line within a prescription to be transmitted electronically is 140 characters.  Basically a tweet.  Not close to enough.  It is not possible to provide a compounding recipe within 140 characters.  Why do we need to write prescriptions for compounded medications? Not all patients can take medications in the dose forms available domestically from pharmaceutical companies.  As a result some medications must be compounded (typically crushed and mixed with other ingredients).  In pediatrics, compounding is most often required to make the medication available in a liquid form for patients unable to swallow a pill. This may also apply to adults, especially those needing to receive medications via feeding tubes.  Occasionally medications must be compounded for other reasons such as palatability or patient allergies.

As uses of medications expand beyond traditional indications, in order for a pharmacist to truly review and verify a prescription order, in addition to mathematical checking, it is critical for a pharmacist to know what the medication is being used for to ensure that the prescribed dose is within the recommended range for any particular indication.  Different indications often require vastly different doses of a medication.

Access to known allergies the patient may have to medications and increasingly access to patient genetic information relating to drug metabolism or adverse reactions can help assure that patients receive the safest medications and doses.

In summary it is important that additional standards for expected eprescribe capabilities are defined for vendors providing prescription writing software, the transmission of prescriptions and the software utilized by pharmacists receiving prescriptions. Most importantly, in my mind, are capabilities to transmit the weight, target weight based dose and more space for the electronic sig to accommodate information needed for medication tapers and compounding.

Thursday, July 17, 2014

Unity Farm Journal - Third Week of July 2014

Although midsummer is a time of harvest, the focus of the past week has been on the birth of our new baby alpaca, Sunny.   Our philosophy at Unity Farm is “living things first” - maintenance, infrastructure, and new projects must wait until all our living things are cared for.

Sunny was born at 5pm on July 15 after an 11 1/2 month gestation.   She weighed 17 pounds at birth and walked in the first 30 minutes.   After an hour she was feeding vigorously and proudly displayed her milk mustache.   Her mother is very attentive and the two spend the day playing, resting, and eating.    Our traveling veterinarian visited the farm on July 16 and declared mom and baby in perfect health.    The placenta was perfectly intact, so we are confident that mom will not have any retained tissue.     In the next few weeks, we’ll have another alpaca birth and Sunny will have a playmate to grow up with.


The guineas continue to sit on their woodland nests.    They generally do a very poor job of keeping the eggs warm, so we’re not expecting many new birds from our four nesting moms.   We gathered 50 eggs from one nest and candled them, finding that 9 were developing and 41 were not.   We gave the 9 to the ducks, which are great parents, to hatch.    The ducks also have the advantage that their nests are inside a protected coop at night.   The guineas in the forest have to contend with raccoons, foxes, and fisher cats.

While maintaining one of our pond pumps, I found a garter snake nest.  She has an interesting choice of companion,  bonding with a power cord.   Clearly she prefers her men long, black, and generally quiet.



This week we harvested 25 pounds of Shitake mushrooms, 25 pounds of cucumbers, multiple types of squash, chinese long beans, and tomatoes.   Dinners have included homemade ramen noodles with fresh vegetables and mushrooms as well as mediterranean style tomato/cucumber salads.    It’s Summer and the living is easy!

The weekend will be filled with cleaning our animal areas,  harvesting vegetables, and spreading wood chips on trails.    I've been wearing a pedometer and the average Unity Farm day takes 10 miles of walking, but it's joyful work.