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.

Wednesday, July 16, 2014

The July meeting of the HIT Standards Committee

The July meeting of the HIT Standards Committee included important discussions of certification for post acute care and behavior health applications, review of data segmentation for privacy,  analysis of provider directory standards, an update on the standards/interoperability framework projects, and a first look at the new subcommittee co-chairs of the Standards Committee.

We started the meeting with a review of attestation data by Jennifer King. Jacob Reider reminded us not to judge the trajectory of the project based on the those who attested early.    The data indicates that the bulk of attestations were completed using just a few vendor products, implying that 2014 certified products from multiple vendors are not yet widely implemented.   I asked if any updates were available about the NPRM to offer more flexibility for stage 2 attestation.   HHS is still reviewing the comments, so there is no specific new information that the NPRM will be finalized and we all should continue our work on existing stage 2 criteria during this last federal quarter of 2014.

We next heard from Larry Wolf about the multi-stakeholder effort to specify certification criteria for long term post acute care and behavioral health .  The motivation for this work is to create interoperability and standardization, bringing LTPAC/BH stakeholders into the same ecosystem as those providers participating in the meaningful use program.   Thus far LTPAC/BH vendors have been very interested in the reputational benefits and possible market share gains available from having certified software.   The workgroup did an amazing job specifying high value certification criteria.

Next we heard from Deven McGraw about advances in standards work for Data Segmentation that enables more granular patient control over healthcare information exchange.   An important motivator for this effort is 42 CFR Part 2 which protects the privacy of substance abuse treatment records.   The workgroup was very practical and presented a multi-phased approach that incrementally improves EHR technology.   The first step would be to add a “lockbox” that receives content that cannot be redistributed without additional consent.   If a patient consents to disclose substance abuse treatment from institution A for transmission to institution B, then institution B cannot share that information with institution C unless the patient is re-consented.   The Standards Committee will review the recommendations and standards for for their implementability.   I hope there are early industry pilots that help us learn how best to implement novel consent and privacy controls.

Next, Dixie Baker presented a Provider Directory standards update.   The committee adopted their recommendations which were - no mature standards for provider directory query exist, ONC should organize pilots of simple RESTful/FHIR approaches,  and the National Provider Identifier database should be considered as a potential infrastructure to host provider Direct addresses.

Next, Steve Posnack presented an update on S&I Framework projects.    He also announced that ONC would be encouraging industry and provider stakeholder groups to develop test procedures so that we do not repeat the experience of Stage 2 - test procedures and scripts that are burdensome and not aligned with real world workflow.

Finally, Jacob Reider reviewed the new subcommittee structure of the HIT Standards Committee including co-chairs.   The co-chair of the steering committee is still a work in process.

A very productive meeting.   I look forward to the work ahead as we focus our attention on standards needed to support Stage 3 of meaningful use focusing on fewer use cases in greater depth.

Tuesday, July 15, 2014

A New Arrival at Unity Farm

Today at 5pm,  our first baby alpaca was born at Unity Farm.   She's 17 pounds and her name is Sunny.    She's eating well and running around the paddock.   The herd is caring for her attentively.

My only role was caring for mom and ensuring the placenta was delivered intact.  Here's a photo of her first steps.

Thursday, July 10, 2014

Unity Farm Journal - Second Week of July 2014

I returned from Japan to find that 9 baby guineas (keets) raised by ducks had hatched.   We have one adult white guinea and its genetics seem recessive - of the 100+ keets we’ve hatched there have been no whites.   In this batch, we finally got a white.   Since our one adult white is sitting on a batch of 40 eggs, it’s possible that more whites are on the way.   During the Summer, our guineas build nests and spend the night outside the coop.    At the moment we have 21 guineas roosting in the coop, six sitting on nests, four babies in the mini-coop, and nine in the brooder (pictured below)

Luckily no baby alpaca (cria) arrived during my travels.   I really want to be present to attend their births.   I have just a few days of travel left this Summer.  Let’s hope the alpaca do not pick a travel day!

The hoop house continues to produce an immense amounts of vegetables.    This week we harvested cucumbers which we’ll making in our sweet Unity pickles.

Many flowers are blossoming in the heat of summer, attracting hummingbirds and butterflies, like this painted lady.

The bee hives are continuing to grow during the peak of nectar flow.   We've spun 18 frames of honey and this weekend we hope to spin 9 more.

The animals are thriving, the apples are beginning to fruit, and the meadows are exploding with color.  Even the tree frogs are dropping by for a visit.

Wednesday, July 9, 2014

Crafting a Next Generation IT strategy

During my 16 years as CIO, I’ve witnessed the transition from client server to web, from desktops to
mobile, and from locally hosted to cloud.  

As Beth Israel Deaconess merges and acquires more hospitals, more practices and more care management capabilities, what are its strategic IT choices?

I will not even mention “best of breed”, because I think the industry has abandoned such a strategy as unworkable in an era when everyone needs access to everything for care coordination, population health, and patient/family engagement.

The choices are basically two

a.  Single monolithic vendor application for everyone everywhere
b.  Best of Suite - the smallest number of applications/modules that meet the need for business integration (defined in the graphic above)

It’s extremely popular among academic medical centers, ACOs, and healthcare systems to choose “A”, often at great cost.

BIDMC has a 30 year tradition of building and buying systems balancing costs, agility, and functionality.

As I plan for the next generation of IT systems, I favor “B” and believe I can achieve our business goals in shorter time, at lower cost, with less risk.

Here’s the thinking.  

1.  At BIDMC, we need a web-based, mobile friendly, cloud hosted solution that has the agility to support rapidly evolving research, education, and clinical requirements.   The culture at BIDMC is not top down, command/control, willing to compromise but bottom up, collaborative, and impatient for innovation.    We will continue to build the core clinical systems at BIDMC until there is a vendor application that meets the cultural requirements and is affordable.

2.  At all other sites, we will use cloud hosted inpatient and ambulatory vendor-based systems that are aligned with the business requirements and culture of the institutions.

3.  Our budgets are very limited to serve 22,000 users and 3000 doctors.  Operating budgets for IT are 1.9% of the total spend.   Capital is about $10 million a year.   One time capital for major IT initiatives is unlikely to ever exceed $20 million.    When I hear about expenditures of hundreds of millions for IT systems, I really wonder how the economics are sustainable.

4.  Interoperability for care coordination across a small number of applications is possible via bidirectional viewing, pushing summaries, and pulling records via the state healthcare information highway.

5.  Business intelligence/analytics across the network is supported by financial and clinical registries, populated via well described interfaces.

Over the next 90 days stakeholders from throughout the organization will complete the next generation IT plan as follows:

July - strategy complete, draft budgets submitted
August - organizational structure for unified enterprise IT proposed, budgets finalized
September - staffing plan finalized and timelines aligned for execution beginning October 1

As with any plan, change management will be the most challenging aspect, balancing time, resources, and scope.

Over the coming months, I’ll share the decisions we’ve made for a cloud of community hospital functionality and a cloud of ambulatory EHR functionality that unifies all our practices.