Thursday, September 30, 2010

The Definition of My Daughter's Success

As I read articles about talented college graduates unable to find work because the US job growth rate is not keeping pace with the college graduation rate, I speculate about the best way to define success for my 17 year old daughter.

Is it a high paying job as doctor, lawyer, or stockbroker?

Is it fame resulting from some remarkable talent?

Is it her pursuit of one of my dreams  - being a naturalist, an environmental engineer, or outdoor educator?

Is it successfully competing with some local, regional, or national peers to be the best at something?

Should I compare her to the athletes, musicians, performers, artists, and academicians in her school and ask her to be as good or better than they are?

All such measures of success are perilous.

How many doctors, lawyers, or hedge fund traders have you met that are satisfied with their lives and look forward to the challenges of their career every day?

How well does fame really serve anyone?  Just ask Paris Hilton, Lindsey Lohan, or Michael Jackson's family.

Imprinting unfilled parental dreams on children is likely not sustainable.  Children need to find and pursue their own passions.

Competitive spirit is a great thing to have, except when it leads to a winning at all costs mentality, sacrificing ethics along the way.   Just ask the steroid using baseball players.

Comparing your children to others is an insult to the individuality of your children.   When I think back on my own childhood, my peers who could have been held up as ideal comparisons did not end up with happy or fulfilling lives.   Some peaked in High School.    A journey of continuous optimism and life improvement, striving to be the best you can be on your own terms, seems like a better course than making comparisons to other people along the way.

The bottom line - asking my daughter to fulfill my expectations, follow in my footsteps. or live up to standards I set does not respect her ability to  choose and pursue her own dreams.

Thus, my definition of success for my daughter is simple.  It's not related  to grades, talent, dollars, or fame.  

If she can develop a sense of self-worth, pursing a path designed by her that fuels her self-esteem, then she will be successful.

The world of the 21st century is a complex place.   Traditional measures of success - a job, a house, a family - are not necessarily the obvious goals that should be pursued by the next generation.  

As she enters the college of her choice (it's up to her), and pursues the educational path of her choice, following her passions and crafting her own life path, I only ask one thing.

If 5 years from now she can say "I feel good about me", then she (and I as a parent) have been successful.

Wednesday, September 29, 2010

A Milestone for Vocabulary Resources

The Vocabulary Task Force of the HIT Standards Committee is hard at work specifying the vocabularies and codesets that should be publicly available to accelerate certification and meaningful use efforts.

Today, Kaiser Permanente announced the donation of its Convergent Medical Terminology (CMT) to the International Healthcare Terminology Standards Development Organisation (IHTSDO©) for U.S. distribution through the U.S. Department of Health and Human Services (HHS) so that all health care providers—large and small—can benefit from the translation-enabling technology.

This donation makes the results of years of work at Kaiser Permanente available to help U.S. health professionals and hospitals achieve key meaningful use standards set forth by the Office of the National Coordinator of Health IT and the Center for Medicare and Medicaid Services.

The donation includes:

1.  Over 75,000 extensions to existing vocabularies (new concepts, natural language descriptions for clinicians and patient friendly terms)

2.  Derivative works (crossmaps of vocabularies to each other)

3.  Toolkits for collaborative editing

In addition to the Kaiser donation, below is a guide to other freely available resources, such as crossmaps from SNOMED CT to ICD-9-CM and ICD-10-CM.

The CM versions used in the US (produced by the National Center for Health Statistics, CDC)  are different from the basic ICD-9 and ICD-10 as released by the World Health Organization.  There is a project to map SNOMED CT to the basic ICD-10 that is being undertaken by the International Health Terminology Standards Development Organisation (IHTSDO), which is the owner of SNOMED CT.

SNOMED CT to ICD-9-CM  - There are two free mappings from SNOMED CT to ICD-10-CM, a basic "conceptual" mapping which is released with SNOMED CT (free to all US users under the UMLS license) and a draft rule-based mapping for the reimbursement use case.  The rule-based map includes IF-THEN rules for selecting the appropriate ICD-9-CM code for a condition in those cases when a SNOMED CT concept could map to more than one ICD-9-CM entry.  For example, in order to select the appropriate ICD-9-CM code for infertility, you must look elsewhere in the patient's record to determine whether the patient is male or female.  Having received modest feedback on the draft mapping, the next step is to produce a current rule-based map that covers all entries in the SNOMED CT CORE problem list subset, which we hope to complete by early 2011.

SNOMED CT to ICD-10-CM - NLM is currently inserting ICD-10-CM into the UMLS Metathesaurus, which will create the synonymous mappings between SNOMED CT and ICD-10-CM.  When this step has been completed (by November 2010), we will work on a rule-based mapping between the SNOMED CT CORE Problem list subset and ICD-10-CM.  This should become available in later in 2011.

All of the above information refers to mappings of diagnoses and conditions - not procedures.

For completeness, access to DRG and Medicare/Medicaid data resources is described below.

The “GROUPER” program, used by Medicare associates ICD-9-CM codes with specific “diagnosis-related” codes.  These codes, previously called “DRGs” (“diagnosis-related groups”) are now properly called Medicare Severity Diagnosis Related Groups (MS-DRGs).   The GROUPER logic, which was developed and is maintained by 3M/Health Information Systems, is updated annually as part of the regulatory update process required for Medicare Inpatient Prospective Payment System.

The software for the GROUPER is distributed for a fee from NTIS.  The complete documentation of the GROUPER logic/Definitions Manual is distributed for a fee from 3M.

Medicare or Medicaid data is available for research from CMS’s Research Data Assistance Center (“ResDAC”), which is a CMS contractor that provides free assistance to academic, government and non-profit researchers interested in using Medicare and/or Medicaid data for their research. ResDAC is staffed by a consortium of epidemiologists, public health specialists, health services researchers, biostatisticians, and health informatics specialists from the University of Minnesota.  Please see the ResDAC website for more information.

Tuesday, September 28, 2010

Clarifying the Meaningful Use Quality Measures

As the country prepares for meaningful use stage 1, many are studying the functionality of their EHRs, hospital information systems, and data warehouses to ensure they can produce the ambulatory and hospital quality measures.

This has led to many implementation questions.

The ambulatory measures and guidance are detailed on a previous blog.

The hospital quality measures for 2011-2012 are found in pages 303-305 of the Final Rule, available here.

Additional guidance from CMS is available here.

The detailed HITSP documentation detailing the standards for computing numerators and denominators is available here.

The most useful, focused, and streamlined materials are the definitions of the quality measures. These measures are encoded according to the HL7 Health Quality Measures Format. To view them

1. Download the file.
2. Create a new folder on your hard drive.
3. Extract the entire contents of the file into the new folder.
4. Open the new folder.
5. Double click on a file to open and read the individual .xml files using your internet browser

For the two Emergency Department (ED) Throughput measures, ED-1/NQF 0495 and ED-2/NQF 0497, the information on the numerators/denominators/exclusions is available here.  To fall into the admitted to the emergency department denominator a patient must do two things:

1)      Initially present at the ED

Then either 2) be subsequently admitted to the inpatient side or 2) receive observation services.

A patient seen in the ED who is neither admitted or receives observation services would not be in the denominator.

Hospitals have varying rules about where they provide what type of observation services and patients could receive observation services without ever going through the ED just like they could be admitted to the hospital without ever going through the ED. It is not CMS' intent to expand into Place of Service (POS) Code 22 (Outpatient Hospital - A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.). This is why CMS had to include the first criteria.

I hope these resources are helpful to you.

Monday, September 27, 2010

Unconscious in the Emergency Department

As State Health Information Exchanges and Federal efforts (NHIN Connect/NHIN Direct) implement the data sharing technology that will enable all providers in the country to achieve Meaningful Use Stage 1, I'm often asked  "but when will this healthcare information exchange technology be able to retrieve all my records from everywhere when I'm lying unconscious in the Emergency Department and cannot give a history?"

Here are my thoughts about the trajectory we're on and how it will lead us to supporting the "Unconscious in the ED" use case.

Meaningful Use Stage 1 is about capturing data electronically in EHRs.  Getting healthcare data in electronic form is foundational to any data exchanges.   By 2011 we should have medication lists, problem lists, allergies, and summaries available from EHRs.

The data exchanges in Stage 1 are simple pushes of data from point A to point B - from provider to public health, from provider to provider, and from provider to pharmacy.   There is no master patient index, no record locator service, and no centralized database containing everyone's lifetime health record.

The Stage 1 data exchanges are the right first step.   Serving as chair for a health information exchange for 12 years, I can tell you that pushing data from point A to point B builds trust and breaks down political barriers to data sharing.   The policy needed to guide  push technology is straightforward, since the parties involved in the exchange are limited - the sender and the receiver.  Consent can be simple.  For a referral, this might be "do you permit me to send your data to a specialist so that your care can be coordinated?"

But how are we going to get to a model that supports the pulling of data by emergency rooms?

There are several engineering approaches.

One is to create a master patient index for a state or region so that the identity of patients seeking care is known.   Once we have a master patient index, we can build a record locator service to keep track of every site the patient visits.   Then, we can build a consent repository so that the patient can control what is shared.  During an emergency department encounter, summaries can be pulled from those sites listed in the record locator service which the patient has agreed to share.

I know that this approach works, because it is what I implemented at the hospitals of CareGroup in 1997 as the focus of my MIT thesis.

However, it does have scalability problems.   Given that there are 500,000 doctors and 5000 acute care hospitals, the engineering complexity to pull data from multiple, disparate sites is significant and it requires that all sites support real time queries 24x7x365, maintaining the necessary security and robustness to enable such interchange.   That's a tall order.

An alternative, that is simpler from an engineering perspective and achievable with the Stage 1 push technologies looks like this.

What if payers, providers, and private vendors offered something called "the electronic medical home"?  The patient needs to pick some hosting option they trust.  Just as Stage 1 of meaningful use supports push transactions from provider to provider, the same transactions could be pushed to the electronic medical home designated by the patient.    This has the added advantage of providing a means to  support the patient engagement provisions of Stage 1 (deliver summaries of ambulatory encounters within 3 business days, deliver inpatient summaries upon request, deliver lifetime health summaries upon request).   If every producer of data (lab, pharmacy, hospital, eligible professional etc) pushed a copy of the data they generated to the electronic medical home chosen by the patient, then the patient could become steward of their lifetime medical record hosted by the trusted agent of their choice.  Medical home data would be complete and constantly updated by data producers.

Patients could store their electronic medical home designation on a card in their wallet or on a medical alert bracelet.   If patients visited the emergency room of a hospital they had registered at previously, the hospital would have a record of the patient's electronic medical home selection since the hospital would be one of the medical home data sources.

Ok, but what if the patient arrives in the Emergency Department, naked and unconscious so there is no electronic medical home designation on their body?   I can tell you that in all my years of practicing emergency medicine, I have never treated a naked and unconscious patient, but let's think about the scenario.

There could be a national or a federated regional database which keeps a record of the designated electronic medical home - an "electronic medical home locator service" that is easy to implement because it only has to point to one place, not to every location which has records about the patient.

When the patient arrives naked and unconscious in the emergency department, assuming someone knows the name/date of birth of the patient, the electronic medical home locator service is queried and once the selection of medical home is known, that one location could be queried to retrieve all of the records.

Finally, just to play out the complete use case to its most absurd, if no one knows the patient identity, then we could suggest the electronic medical home locator service should contain a hash of a fingerprint, so that  a biometric - a scan of the patient's finger - could be used to identify the electronic medical home designation and then retrieve the  lifetime record summary.


1.  In Meaningful Use Phase 1, we implement push transactions by 2011.   Google Health, Microsoft Healthvault, Hospitals, and Payers should create electronic medical home repositories capable of receiving push transactions so that copies of inpatient, outpatient and lifetime summaries can be sent there.   The transport mechanism used to push data to the medical home could be REST, SOAP, or SMTP, just as the NHIN Direct project has suggested.   Ideally electronic medical home providers will issue each patient a Health URL, making it easy for EHRs and  health information exchanges to route data to the correct location.

2.  When an electronic medical home designation is elected, a copy of the designation and a hash of the patient's fingerprint is sent to a regional or national electronic medical home locator service.

3.  When the patient arrives unconscious, the name and date of birth  of the patient is used to query the electronic medical home locator service, retrieve the electronic medical home designation and then retrieve the lifetime record summary.

4.  If the patient is naked and unconscious, a fingerprint scan could be used to retrieve the electronic medical home designation and their records.

5.  All of this is empowered by Stage 1 of Meaningful Use as currently written.   All that needs to happen is that providers, payers and vendors need to offer a place to push transactions on behalf of the patient.  

Some have suggested that we should abandon the NHIN Connect, NHIN Direct, and Stage 1 push exchanges in favor of an engineering optimal solution of creating one large database of all electronic health records in the cloud.

Sometimes the engineering optimal solution is not the social/policy optimal solution.

The idea of creating a voluntary, opt-in electronic medical home supported by many hosts - payers, providers, vendors etc.  is achievable and appealing.

In the US, we are wary of any top down, government mandate.   We  are suspicious of centralizing anything.  Maintaining patient control of healthcare data and letting the market provide multiple hosting options seems like an achievable architecture that builds upon what we have already implemented and the meaningful use regulations already in place.

Friday, September 24, 2010

Cool Technology of the Week

Over the last few weeks, I've been writing about green energy sources and products.

One alternative I've never considered is harnessing the chattiness of teenagers.   It's not yet ready for use in general consumer devices, but the research is fascinating.

Another alternative I've never considered is using the power of dog poop to provide lighting in dog parks.   Here it is in action.

Capturing alternative energy sources  through innovation and creativity - that's cool.

Thursday, September 23, 2010

The Olympic Kayak Experience

During the Summer, I kayak the Charles River each evening using performance and fitness kayaks. Depending on wind and weather conditions I'll chose the Epic 18X (a fast, stable sea kayak optimized for ocean racing), the Epic V10 Sport (a faster, moderately stable surfski) or the Epic V12 (the fastest, less stable surfski).

However, I've not ever tried a K1 racing kayak, considered the boat of elite, highly advanced paddlers that is so unstable, you must keep paddling to keep it upright.

One of our BIDMC IT managers, Tyrone Dell, trained for the 1992 Olympic kayak team and he still paddles his Cleaver K1 from that era. Of interest, the boat was made for John Long, one of the legendary rock climbers of our era and the first person to free climb El Capitan in a day. Ty and John kayaked together in Marina Del Rey during the same years I lived in Southern California. Small world.

Ty generously offered to teach me to paddle his K1.

Last weekend, we drove to Hingham, Massachusetts and launched our boats in the calm seas of the inner harbor.

How'd it go? Here's a YouTube video that illustrates the challenge.

Over the course of two hours, I progressed from 10 feet to a full quarter mile before flipping the kayak into the harbor.

The water was 62 degrees and the winds were calm, so my Hydroskin pants and Kokotat paddle jacket kept me warm during my frequent swimming experiences.

When a K1 flips, you cannot get back into it. You need to swim to shore, kayak in tow, empty it out, then reenter. Ty did a marvelous job of keeping me stable until I could balance on my own and begin paddling.

At this point, I fully understand the challenge of using a K1 - it's remarkably fast, but so tippy that rotation of the hips, shoulders or neck results in a swim. I now know how to balance, how to make slow/smooth strokes, and how to achieve the focus needed to keep the boat afloat.

Next Summer, I'll plan on taking a K1 such as the Volcan from Simon River Sports (available for rental at Charles River Canoe and Kayak) to Walden Pond where the sandy beach, clear water, and lack of vegetation will give me a great training ground. The advantage of mastering a K1 is that any style of kayak feels like a barge by comparison!

Wednesday, September 22, 2010

The SafeRx Awards

Yesterday at the Senate Hart Building in Washington DC, Surescripts announced the E-prescribing leaders in the US. Massachusetts was named #1 in the country. Steve Fox from Blue Cross Blue Shield of Massachusetts and I represented the Commonwealth. The 10 states with the highest rates of E-Prescribing are:

1. Massachusetts
2. Michigan
3. Rhode Island
4. Delaware
5. North Carolina
6. Connecticut
7. Pennsylvania
8. Hawaii*
9. Indiana*
10. Florida*
*New to the top 10

Our next challenge in Massachusetts is to implement E-prescribing of controlled substances. We'll pilot the use of biometrics and hard tokens to determine the best approach for two factor authentication in different use cases.

Our secret to maintaining the #1 spot in E-prescribing in the country for 4 years? Payer/provider collaboration and region-wide adoption of tools including educational materials, an E-prescribing gateway, common implementation guides, and broad collaboration with Surescripts.

Tuesday, September 21, 2010

The September HIT Standards Committee

The September HIT Standards Committee included three major topics, all of which are important for "living the dream" of achieving meaningful use in the real world.

First, Jamie Ferguson and Betsy Humphreys briefed the committee on the recent Vocabulary Task Force Hearings which focused on reducing barriers and creating enablers to accelerate interoperability. One such enabler is creating a "one stop shopping" resource for downloading the vocabularies and codesets required by the Standards Final Rule. Major themes from the hearings were:

*Clarity about what is required, of whom, for what intended purpose and future vision is more important than simplicity

*A comprehensive plan does not mean it should be done all it once. Phased implementation of prioritized content sets and maps will ease adoption burdens

*A major issue reported by testifiers was intellectual property barriers to making code sets and value sets widely available. For examples, there are mappings that are only available to licensed users of proprietary vocabularies (i.e. RxNorm to First Data Bank mapping) and some code sets are embedded in HL7 and NCPDP standards which are only available via yearly membership in those organizations.

Vocabularies are increasingly important and Betsy Humphreys reported that licensure of UMLS for access to SNOMED-CT and RxNorm has grown tremendously. The final rule has accelerated adoption of controlled terminology. Thus, it is important that resources which facilitate the implementation and maintenance of meaningful use vocabularies are made widely available.

Several ideas for addressing intellectual property issues were discussed including government licensure of vocabularies for general use and centralized procurement/license management for vocabularies needed for meaningful use that reduces the burden on hospitals and eligible professionals.

Judy Murphy and Liz Johnson presented the Implementation Workgroup's key priorities for the next year which include information sharing and communication to reduce the burden of achieving meaningful use. Hospitals and eligible professionals have similar questions, frustrations, and change management challenges. By leveraging the wisdom of the crowd via novel social networking approaches and education, we can accelerate the process for all.

Doug Fridsma presented the Standards and Interoperability Framework, the RFPs that have been awarded, and processes that will be defined to ensure that clear, easy to use implementation guides are available in the future.

Next month we'll hear from the HIT Policy Committee so that we can begin the standards selection effort in support of Meaningful Use Stage 2 and 3. The industry needs a phased implementation plan and thus my preference would be to declare what is needed for stage 3 and then define stage 2 as the incremental steps to get us on the right trajectory.

Monday, September 20, 2010

Milestones in Interoperability

On September 20, there were two important events that laid the foundation for future interoperability efforts.

The first event - ONC kicked off the Standards and Interoperability Framework, which is the successor to the HITSP's (October 2004- April 2010) activities. The new framework is described in detail with slides on Keith Boone's blog.

The new design incorporates a coordinated, parallel process of use case writing, standards development, standards harmonization, reference implementation, and testing, including all the tools and technologies needed to ensure that everyone participates and takes accountability for the deliverables.

Although the National Information Exchange Model (NIEM) process will be used and Information Exchange Package Documentation (IEPD) will be produced, existing NIEM XML/Data types will not be used, enabling existing healthcare content, vocabulary, and transport standards to be incorporated.

The second event - CCHIT hosted a town hall on certification, rolling out their entire process and describing the tools that will be used to educate stakeholders about certification, the attestation that will be used, and the testing processes for EHRs, EHR modules, and Sites. You'll find an overview on the CCHIT website.

Later this week, I'll begin my review of the CCHIT Site certification materials that I'll use for BIDMC. As I've promised previously, I will share my experiences, costs, and timelines for Site certification on my blog.

Friday, September 17, 2010

Cool Technology of the Week

During a recent bike ride, I took a brief rest break at the South Natick Dam and noticed that all the recycling and trash bins in the park were solar powered. The Big Belly Solar Compactor charges during the day and compacts waste at 5 times normal density, reducing the number of pickups. Fewer pickups mean lower labor costs and less carbon emissions from Diesel trash trucks. The ROI is rapid - 3 to 4 years.

For 100 trash cans in a typical small town collected 5-7 times per week
Collection frequency reduction from 5-7x a week to approximately 2x a week
10 year cost savings of $1,250,000 - $1,500,000
151 Tons of C02 emissions saved annually
13,750 gallons of fuel saved annually

Solar powered compactors that reduce cost and greenhouse gases. That's cool!

Thursday, September 16, 2010

Fall Expectations

Every year, like clockwork, the weather in New England changes from sweltering heat and humidity to the crisp mornings and long shadowed afternoons of Fall.

We put away our kayaks, plant mums, and harvest squash.

It's a great time of year.

The blackflies and mosquitos are gone, the buzz of air conditioners goes silent, and in September and October we have warmth with heat/cool without cold.

I grew up in Southern California where it's 72 year round. June and December are about the same, except that June can actually be more gray and gloomy.

I've been in New England for 15 years and look forward to my seasonal expectations.

Fall brings hikes in the White Mountains and the color changes of Autumn. It brings bike rides through backroads in Dover and Sherborn where farms are harvesting their Summer crops and putting away silage for the Winter. It brings festivals and gatherings. We all have one last opportunity to get together outside before cloistering ourselves for Winter.

On Columbus Day, my family will climb Mt. Monadnock and view the foliage in 3 states.

My wife and her NKG Gallery in Boston's South End are busy in the Fall with shows and openings. Here's a Boston Globe review of her Fall show (I know, a shameless plug, but that's a side effect of marriage!)

So get out, put on a sweater, and take in the sights, sounds, and smells of Fall. It's my favorite season.

Wednesday, September 15, 2010

Filling Gaps in HIE Services

Just as the NEHEN Board did a gap analysis of the capabilities needed to support meaningful use, the Massachusetts eHealth Institute Ad Hoc HIE Working group discussed the services that need to be procured to meet ONC's HIE goals. Here's what they discussed.

a. Aggregation, Analysis and Reporting - No procurement is needed but a contract/service level agreement between the service providers and the state HIE would be helpful.

Immunization, Syndromic Surveillance, Reportable Lab Registry
-EOHHS (Department of Public Health) will provide virtual gateway / HL7 gateway access to immunization registry for ambulatory users

-EOHHS (Department of Public Health) will provide virtual gateway / HL7 gateway access to immunization, syndromic surveillance, and reportable lab registries for hospitals

-Boston Public Health Commission will provide access to immunization, syndromic surveillance, and reportable lab registries for all users.

Quality Data Center - EHRs are required to provide this functionality,
although some organizations may choose an outsourced vendor at their own
expense to aggregate data from multiple EHRs. Hospitals already have internal and external processes in place to aggregate and report quality data to CMS.

b. Directory Services - Procurement is needed
-The Commonwealth should procure directory services (providers, payers, public health entities) to meet local needs and should adopt regional/national standards for these directories when they become available.

c. Routing - Procurement is needed
-NEHEN connects 10,000 providers today, about half the providers in the
Commonwealth and 90% in Eastern Massachusetts. This would not need to be
"re-procured" because it is already paid for by the private sector. However, NEHEN and other existing networks should conform to the standards and service levels agreed to by the state HIE governance body.

-The Commonwealth should procure routing services for the 50% of providers without current routing capability.

d. Consent - Procurement will be needed to prepare for 2013
-A consent repository will likely be needed for 2013/Meaningful Use Stage 2 to record facility specific opt in consent for disclosure of healthcare information. However, the requirements for Stage 2 data exchanges are not yet known and the policy is a work in process by the Privacy and Security Tiger Team and the Massachusetts eHealth Institute Ad Hoc Privacy and Security Work Group. Procurement should be done in 2011 when the technology needs and policy guidance becomes clearer.

e. Public Key Infrastructure Services - Procurement is needed
-The public and private sectors in the Commonwealth should align their existing PKI projects to create a single identity management service to support secure routing among providers, payers and public health.

f. Vocabulary Services - No procurement is needed
-The HIT Standards Committee Vocabulary Task Force, the HIT Standards Implementation Workgroup, and the ONC Standards and Interoperability Framework contractors are working on a national repository of vocabularies and codesets to support all HIE needs. The Commonwealth should leverage this Federal effort.

Now that we have defined Governance characteristics and completed the above gap analysis, we'll have a discussion with the Commonwealth's HIT Council which should lead us to creating a governance body, finalizing a sustainable business/operating model, and procuring the services needed to have a Statewide HIE in 2011.

Tuesday, September 14, 2010

The Characteristics of HIE Governance

Today, the Massachusetts eHealth Institute Ad Hoc Health Information Exchange Workgroup discussed the desirable characteristics of HIE governance. Here's what we outlined:

Guiding Principle - To provide oversight and governance for an effective rollout of HIE across Massachusetts that accelerates and enables a network-of-network approach by tying existing assets to procured services in a unified, transparent and standards driven manner while embracing and enhancing the principle of public private partnership.

Specific Principles for Governance
* Principle #1 - Enhance trust and credibility by establishing a Multi-Stakeholder, open and transparent body
* Note - Need to draw distinction between this governing body and the existing ones and perhaps consolidate to a fewer number.

* Principle #2 - Reflect Public/Private partnership in a way that balances the priorities of regulation, transparency and common good with the imperatives of value generation, sustainability and market economics.

* Principle #3 - Enhance credibility and trust by adopting best practices that eliminate any conflicts of interest.
* Manage procurement by groups not having an interest in bidding for services
* Govern operational delivery utilizing groups and individuals separate from the community that provides these services.

* Principle #4 - Provide a comprehensive platform that merges the tactical task of oversight of HIE rollout with the strategic need for innovation driven vision setting. Provide the following functions
* Priority setting for HIE procurement
* Provide oversight of an HIE project/program management office
* Holding service providers accountable for meeting goals
* Provide oversight for resource allocation
* Provide a forum for fostering innovation, and
* Be an enabler and accelerator for the adoption of HIE by anticipating and removing roadblocks

A great discussion and a very sound set of governance characteristics. Our next step is to present these ideas to the Massachusetts HIT Council for their feedback and then think about various structures to operationalize HIE governance - i.e. state department, new 501c(3), private sector etc.

Monday, September 13, 2010

A Health Information Exchange Gap Analysis

At last week's New England Healthcare Exchange Network (NEHEN) Board meeting, its multi-stakeholder non-profit Board discussed the healthcare information exchange capabilities required to support meaningful use stage 1 for all stakeholders in the Commonwealth.

NEHEN based the gap analysis on the work of the Massachusetts eHealth Institute (MeHI) Ad Hoc HIE Workgroup which has made functional recommendations as part of the ONC State HIE process. The vision that the Ad Hoc Workgroup outlined over the Summer was:

Our 2011 vision is to provide the routing, directories, security, public key infrastructure, quality registries, and public health repositories necessary for every provider in the Commonwealth to achieve meaningful use stage 1, improving healthcare quality, safety and efficiency.

Our 2013 vision is to provide the master patient index, record locator, all payer database, event notification, and data exchange tools necessary to achieve meaningful use stage 2, improving care coordination and population health in the Commonwealth.

Our 2015 vision is To provide the surveillance, decision support, clinical research, and privacy protection tools necessary to achieve meaningful use stage 3, creating the foundation for accountable care organizations and supporting healthcare reform in the Commonwealth.

To achieve the goal of connecting every provider to meaningful use transactions, new HIE capabilities will be procured to fill gaps in functionality and coverage.

The attached presentation illustrates how NEHEN's current capabilities would be expand to fill the gaps in order to achieve the HIE vision for the Commonwealth. It's likely many vendors and existing local HIE activities will all collaborate to form a network of networks in the Commonwealth. The NEHEN analysis illustrates the kind of in the trenches work that will need to be done to achieve statewide meaningful use.

Friday, September 10, 2010

Cool Technology of the Week

I often write about green technologies and my goal to live on the planet earth with minimal impact on the environment.

Probably the most important aspect of life on our planet is access to clean, fresh water. Yet, millions die every year because of contaminated water supplies.

What can we do, especially in economies without the resources to build infrastructure?

Here's a simple idea - using clays to create filters. Potters for Peace teaches local artisans how to make clay filters and use them to purify water for millions of people.

Here's a simple "tea bag" that employs activated carbon to filter water directly from the bottle.

Inexpensive, sustainable, reliable ways to filter contaminated water.

That's cool.

Thursday, September 9, 2010

The Year of Living Anxiously

I've written many blog posts about the lack of civility in modern society, the uncertainty in the economy, and the mismatch among scope, resources and time in organizations facing profitability pressures.

The next year will be a year of living anxiously (a reference to a 1982 Peter Wier film)

As I think about the increased conflict, tension, and uncertainty we face every day, what are the causes?

*Increasing competition from a global economy at time when the US is losing is leadership role in math/science/engineering
*Increasing mismatch between the cost of living and wages earned
*Increasing costs of healthcare as a percentage of Gross Domestic Product
*Increasing costs of compliance/regulation/legal fees - we are a very legalistic society and we've created substantial increases in overhead over the past few decades to cover lawsuits/risk mitigation/legal consultation
*Structural issues with our economy. Robert B. Reich, secretary of labor in the Clinton administration, wrote a fascinating article in the NY Times on September 2, in which he notes "In the late 1970s, the richest 1 percent of American families took in about 9 percent of the nation’s total income; by 2007, the top 1 percent took in 23.5 percent of total income."

Instead of creating dozens of entry level jobs, we're paying hedge fund traders to put hot tubs in the Lear Jets. There is something very wrong about this.

Believe me, I'm not nostalgic for the simpler times of the 1970's - I'm realistic about the challenges and realities of the 21st century. However, there is a point when cannot continue the pace of work, the rate of consumption, and the lifestyle we've come to expect.

While the next year is filled with Stimulus fund projects causing people to work harder and faster, while the efforts to accelerate HIT in the US create more change management anxiety, and while people feel increasing tension to compete with each other for budgets, I will endeavor to stay true to my own beliefs.

*The nice guy can finish first.
*Treating people fairly is the right thing to do
*You can lose the battle and still win the war.
*Expressing negative emotion in leadership or business context diminishes you
*Joy comes from relationships and experiences, not from owning more stuff

I never know what tomorrow will bring or how my business and personal life will evolve. By staying calm, honest, and altruistic, I'm convinced good things will happen.

In the next year, try to reduce the anxiety level in your workplace. Let's hope it's contagious!

Wednesday, September 8, 2010

Preparing for Certification

Some have said that certification will be costly and time consuming.

In the Standards Final Rule Cost analysis, HHS estimates that a previously certified EHR will cost at least $500,000 and likely $1 million or more to prepare for the new certification. A system for eligible professionals that has never been certified will cost at least $1.2 million and likely close to $2.4 million to achieve certification. Hospital systems will cost perhaps $1 million more. Achieving standards compliance nationwide could cost developers and users more than $136 million.

In my conversations with folks applying to be Authorized Testing and Certification Bodies, I believe these estimates should be substantially reduced. For example, if vendors already have a CCHIT certified ambulatory product, the only new items to add are CCR/CCD display, the smoking status options, the quality measure calculations, and Syndromic surveillance (an optional menu set criteria).

Today, I kicked off the BIDMC Site Certification activities. Since Site Certification is a new concept, I will keep you informed what we do, how we do it and what it costs.

BIDMC has chosen to work with CCHIT when their program for site certification becomes available. My first step is working with CCHIT in a pilot program to test their attestation website and other supporting tools, then prepare for a web-ex demonstration of each certification criterion.

Note: BIDMC is one of a number of participants in a pilot program designed to validate the supporting tools and processes for CCHIT's EHR Alternative Certification for Hospitals (EACH™), an ONC-ATCB EHR certification program for customized or self-developed hospital EHR technology slated for launch by CCHIT late this year. The program relies solely on HHS criteria and standards, and NIST test procedures. None of the testing results observed during this pilot and reported here should be interpreted as final.

Tuesday, September 7, 2010

The Vocabulary Task Force Hearings

On September 1 and 2, the Vocabulary Task Force of the HIT Standards Committee held a public hearing to get input on requirements for the infrastructure to make vocabulary content (including taxonomies, value sets, subsets and crossmaps) available to support the Meaningful Use program.

Our previous hearing on vocabulary governance resulted in a set of recommendations, particularly centering on a theme of establishing “one-stop shopping” for Meaningful Use vocabulary content. This new hearing encompassed four panels. First we heard from developers and publishers of vocabulary value sets and subsets; the second panel was made up of hospital, clinical and academic EHR implementers and end users of the vocabularies; the third panel included large and small vendors of EHRs sold to care delivery organizations and small office physician practices, and Canada Health Infoway; finally the fourth panel covered the full range of public and private sector terminology services providers and vendors.

The task force engaged in many hours of rich and far-ranging discussion such as different models of one-stop shopping including “Nordstrom” vs. “Costco” vs. “Boutique.” There were a few major themes woven throughout all the panels from different perspectives.

What started out as a plea for simplicity and harmony turned into broad cross-stakeholder agreement that clarity is more important and more urgent than simplicity. It was agreed that the government must provide clarity, stability and predictability for Meaningful Use vocabularies in terms of what is required, of and by whom, and for what intended purpose.

Other areas where clarity is needed are the responsibilities for ownership, stewardship, validation, review, and support of vocabulary content.

The absolute criticality of versioning for all vocabulary content, and version controls including expiration dates on content sets, was heard loud and clear.

Providing enumerated lists of codes that comprise value sets is not enough for value set implementation. Panels discussed different context mechanisms to establish unique suitability for purpose for the intended use of content sets, and the task force also explored issues surrounding the “off-label use” of value sets.

Infrastructure has to provide good performance, scalability, security, uptime, etc. and the panels mentioned different approaches to achieve these goals.

Not to be left off any summary are the issues around intellectual property as a barrier to adoption and use of vocabulary content - which were part of every panel discussion. A variety of views and possible solutions were considered including legal prohibitions against monopolies, national licensing alternatives, and rights management schemes.

Although the hearing was focused on vocabulary issues, some of the comments regarding intellectual property were clearly focused on message standards - which despite their relative low cost can still be more expensive than some local public health authorities (for example) can afford. Here's a few examples of the kinds of freely available resources that help accelerate interoperability.

SNOMED CT to ICD-9-CM - There are two free mappings from SNOMED CT to ICD-10-CM, a basic "conceptual" mapping which is released with SNOMED CT (free to all US users under the UMLS license) and a draft rule-based mapping for the reimbursement use case. The rule-based map includes IF-THEN rules for selecting the appropriate ICD-9-CM code for a condition in those cases when a SNOMED CT concept could map to more than one ICD-9-CM entry. For example, in order to select the appropriate ICD-9-CM code for infertility, you must look elsewhere in the patient's record to determine whether the patient is male or female. Having received modest feedback on the draft mapping, the next step is to produce a current rule-based map that covers all entries in the SNOMED CT CORE problem list subset, which we hope to complete by early 2011.

SNOMED CT to ICD-10-CM - NLM is currently inserting ICD-10-CM into the UMLS Metathesaurus, which will create the synonymous mappings between SNOMED CT and ICD-10-CM. When this step has been completed (by November 2010), we will work on a rule-based mapping between the SNOMED CT CORE Problem list subset and ICD-10-CM. This should become available in later in 2011.

Next, the Task force will review what we heard and consider making recommendations to the HIT Standards Committee.

Friday, September 3, 2010

The AMIA Policy Meeting

On Wednesday, I joined the Annual AMIA Policy meeting and participated in a debate of the question

"Recent increases in HIT funding, public awareness, and Federal policy, if sustained, are sufficient to enable vibrant informatics research and development efforts that will assure innovation and progress in clinical informatics for the future of health and health care."

Don Rucker and I were asked to argue on behalf of the question

Here were my arguments.

What do we need to ensure innovation and progress in clinical informatics?

1. Policy drivers that create a business value case. Implementation and adoption of informatics will be sustained if there is a business case to do so. ARRA/HITECH and ACA have created the necessary policy drivers. Meaningful use provides 3 stages of functionality with increasing amounts of data exchange, decision support, and innovative informatics from 2011-2015. Healthcare reform brings new kinds of data aggregation, quality analysis, administrative simplification., and decision support to increase the efficiency of healthcare - all of these drive informatics demand. Finally the work of the Privacy and Security Tiger Team has given us a framework for consent that is an enabler to innovative uses of data.

2. A well defined technology stack
The Standards and Certification final rule provides content, vocabulary and security standards needed for healthcare information exchange. NHIN Direct and NHIN Connect provide transport standards. The new Standards and Interoperability Framework using the NIEM process provides a means to add new standards as needed to meet the demands of use cases.

3. Funding
SHARP grants, HIE/REC Grants, Comparative Effectiveness funding, Center for Innovation in Medicare and Medicaid Services funding, and direct payments to providers/hospitals provide more than $30 billion in resources.

4. Governance and Processes to support innovation - the HIT Standards Committee, the HIT Policy Committee, and NCVHS provide Federal Advisory Committees that are open, transparent, public forums for prioritization of projects and resolution of controversies.

5. People - there are many types of professionals needed to ensure progress in clinical informatics - fellowship trained MDs and PhDs, AMIA 10x10 trained informaticians, certificate program trained implementers/practice consultants. The National Library of Medicine funds 400 fellows at 20 locations to ensure the country has a pipeline of fellowship trainees. AMIA's online resources have trained countless informaticians. ARRA funds include $118 million for certificate programs.

Thus, we have policy, technology, and funding initiatives which are sufficient to ensure innovation and progress in clinical informatics. Governance and a pipeline of trained professionals will ensure the foundation built today evolves to meet future needs. It's a great time for clinical IT. Never before in history have so many factors been aligned for success.

Thursday, September 2, 2010

Simplifying Your Life

My iGoogle portal page displays a different WikiHow every day and I was recently impressed by the advice offered in Simplify Your Life.

Here's my own version using their outline.

1.1 Starting out
In my 20's I believed success was measured by the the amount of stuff you owned, the size of your house, the style of your car etc. Luckily by the age of 25 I realized these were all superficial and began a life long process of living simply - owning the minimum of clothing, electronics, real estate etc.

My daughter has embraced these values and at 17 she does not own any designer clothing or trendy "must have" consumer goods. By her own design, her bedroom is a minimalist tatami room with a futon, kotatsu (a low wooden table), and clothes storage.

1.2 Home and family life
When I was in my 20's and had a larger home, I spent all weekend maintaining the home and garden. My belongings owned me, I did not own them. Complexity and quantity bring maintenance burdens, so I did not have free time to just enjoy the world around me and live an examined life.

Today, my only maintenance tasks are keeping indoor plants watered, supporting our seasonal traditions of planting fruits and vegetables, and the basics of keeping a house in good condition.

Our family life is simple. I married the first woman I dated. We've been together for 30 years. We have one child. We gather for dinner together every night (wife, daughter, father in law, me). We visit the Sierra in August. We spend Columbus Day weekend near Mt. Monadnock. On occasion we travel to Japan together. We do not have nor want a vacation home, a boat, an RV, or yearly events that require a significant planning burden.

My business clothing is all black. My outdoor clothing is red and black. Everything I wear is made by just a few manufacturers - Arcteryx, Vegetarian Shoes, and Injinji. On average, my clothes last 5 years.

Our foods are all simple vegetables - no meat, no eggs, no dairy. We rarely eat out.

1.3 Finances
We live in small home without a mortgage. We avoid consumer debt. We save as much as we can.

1.4 Work
In each of my jobs, I have strong direct reports with very little turnover. We all work hard to put governance processes in place that minimize conflict and simplify resource allocation.

I try to minimize travel. 2009-2010 required a day or two per month in Washington to support ARRA/HITECH efforts, but in general I try to avoid airports.

My workday routine is a morning walk with my wife, followed by a BIDMC/Harvard time from 8am-6p, followed by a family dinner, followed by writing in the evening - it's generally very predictable.

1.5 Technology and Communications
I own a Blackberry Bold 9700 and a MacBook Air - no other technologies or gadgets to maintain and support.

1.6 Personal health and well being
As a vegan for 10 years, I've been able to keep my body mass index at 20. My seasonal activities - hiking, biking, kayaking, skiing, and climbing keep me exercising outdoors. Avoiding caffeine keeps my mood even.

1.7 Time spent with others
Morning walks with my wife, winter hiking with my friends, and multiple visits to my parents in California ensure I'm always sharing my thoughts, feelings, and fears with others.

Having lived many lifestyles as an adult - from Silicon valley entrepreneur to winemaker to doctor, I can say that the journey is truly more important than the destination. Living simply along the journey enables you to savor the details of existence along the way.

Of course, I would never criticize anyone for wanting to try a complex, high burn rate lifestyle. However, once you've experienced all the options, I suspect that you too will decide that less is more.

Wednesday, September 1, 2010

Assessing My Own Risk

Leaders often think about succession plans for their direct reports, but what about themselves?

What if I had a serious health problem or accident that impaired my ability to lead my IT organizations? Here's my brief analysis.


My role at BIDMC is to document the strategies prioritized by our governance groups, ensure our organizational chart structure is optimized for executing the strategies, and to find/retain the best people. I also work on the processes that support our strategy including governance, budgeting, and communication.

In the 1990's, I wrote the code that powered our clinical web-based applications and intranet. At this point, we've retired all the code I've written or transitioned its development/support to full time programmers. I am no longer a single point of failure for any application or infrastructure. At BIDMC, about 30% of applications are built and 70% are purchased. Occasionally some stakeholders wonder if building a few applications is a risk. It's actually a risk mitigator. We create the "glue" that links together vendor applications via portals and web-based service-oriented architecture approaches. Since we control the front end that clinicians see for electronic health records and provider order entry we can rapidly add features needed for meaningful use, healthcare reform and Joint Commission requirements. We've implemented novel solutions for medication reconciliation, decision support, and health information exchange. Building what is not available in the marketplace and buying products that are mature is the best way to reduce risk.

Some projects depend upon my strength of will - implementing EHRs for the community, embracing interoperability/standards, and keeping us focused on the large projects that move us forward. If I were to disappear, it is true that efforts to achieve meaningful use would slow significantly. As I've discussed in my blog several times, it takes all the energy and reputation I have to ensure all our clinicians - those in academic health centers and those in small community practices - have all the tools they need and training/education they require to achieve meaningful use.

In any large complex organization, satisfaction with IT goes up and down. As resources are pulled into large projects, smaller projects suffer and stakeholders may feel underserved. As compliance requirements, new regulations, Joint Commission mandates, and senior management signature initiatives appear, existing initiatives may be slowed or cancelled. My role is to foster communication, ensure that governance includes all stakeholders, and to provide a buffer for my staff from the ups and downs of opinion and changing priorities. If I disappeared, the "tyranny of the urgent" may triumph, preventing IT from staying focused on the functionality needed to achieve meaningful use.


At Harvard Medical School, my role in governance, strategy, structure, staffing and process is similar to BIDMC. I work with research, education, and administrative stakeholders to define their priorities and allocate resources. My major projects include building one of the top 100 supercomputers in the world, providing a petabyte of storage to support translational research, and supporting all the interactive media for over 1000 courses. My role is a balance of managing day to day issues while also engaging all stakeholders in long term planning activities. If I were to disappear, the communication/education of stakeholders and the delicate balance of services among the research/education/administrative communities would suffer.

Overall in my roles as CIO of two institutions, my greatest utility is to provide a common link between the academic/education/research activities of the medical school and the clinical/financial/research activities of the hospital while also leveraging my state and federal activities to ensure BIDMC and HMS are early adopters of federal requirements and participants in pilots. My multi-organizational role provides economies of scale, knowledge sharing, and community-wide visibility for IT activities. My absence would diminish these cross-organizational collaborations, slowing down our work.

My role has evolved substantially over the past decade and I've moved from programmer to convener, from a focus on operations to a focus on innovation, and from technologist to policymaker. Senior leaders owe it to their organizations to periodically reflect on their role and how their organization would carry on without them.