Reflecting on Our IT Progress

In a time of EHR naysayers, mean-spirited election year politics, and press misinterpretation (ONC and CMS do not intend to relax patient engagement provisions), it's important that we all send a unified message about our progress on the national priorities we've developed by consensus.

1.   Query-based exchange - every country in the world that I've advised (Japan, China, New Zealand, Scotland/UK, Norway, Sweden, Canada,  and Singapore)  has started with push-based exchange,replacing paper and fax machines with standards-based technology and policy.   Once "push" is done and builds confidence with stakeholders, "pull" or query-response exchange is the obvious next step.  Although there are gaps to be filled, we can and should make progress on this next phase of exchange.   The naysayers need to realize that there is a process for advancing interoperability and we'll all working as fast as we can.   Query-based exchange will be built on top of the foundation created by Meaningful Use Stage 1 and 2.

2.  Billing - although several reports have linked EHRs to billing fraud/abuse and the recent OIG survey seeks to explore the connection between EHR implementation and increased reimbursement, the real issue is that EHRs, when implemented properly, can enhance clinical documentation.  The work of the next two years as we prepare for ICD-10 is to embrace emerging natural language processing technologies and structured data entry to create highly reproducible/auditable clinical documentation that supports the billing process.  Meaningful Use Stage 1 and 2 have added content and vocabulary standards that will ensure future documentation is much more codified.

3.  Safety - some have argued that electronic health records introduce new errors and safety concerns.  Although it is true that bad software implemented badly can cause harm, the vast majority of certified EHR technology enhances workflow and reduces error.  Meaningful Use Stage 1 and 2 enhance medication accuracy and create a foundation for improved decision support.  The HealtheDecisions initiative will bring us guidelines/protocols that add substantial safety to today's EHRs.

4.  Privacy and Security - some have argued that EHRs reduce security by making records available in electronic form, possibly over internet connections.   Efforts to enhance certification of the security of EHRs, encrypt data at rest, and create guidance for EHR modules that interoperate with built in security will further protect the data that needs to be shared for care coordination and population health.

5. Innovation - some have argued that meaningful use led to the growth of a small number of vendors and dependency/lock in with those vendors.    Meaningful Use Stage 2 requires interoperability between vendors, export of data from EHRs to reduce lock in, and standards that will enable a new generation of modular "plug ins".   I'm confident that SHARP grant funded work, like the SMART initiative will lead to an ecosystem of applications from small vendors - an app store for health.

Thus, our mantra should be that Meaningful Use Stage 1 and 2 have created a foundation for query-based exchange, accurate billing, safety, security, and innovation.

Stage 3 work is already in progress and from the early thinking that I've seen (will post a blog about that in a few weeks), the trajectory of Meaningful Use will address all the naysayers concerns.

The Next Phase of State HIE Planning

With the Golden Spike on October 16, Massachusetts began a new era of healthcare information exchange.   Now that we have momentum and the perfect storm for innovation with alignment of government, industry, academia, stakeholders, and funding,  we want to rapidly advance to the next phase.

Last week, while I was in China, a group from Massachusetts visited CMS in Baltimore to present the Phase 2 plans.   Here is the powerpoint they used.

A few key points

1.  After summarizing the accomplishments of our Phase 1 go live, they presented the sustainability model in detail (see slide 15-16).   The tiered pricing was developed based on several key principles (see slide 13-14) such as the need for large organizations which derive high value from the HIE to subsidize small practices which have limited resources and bandwidth for new projects.   The end result is that comprehensive HIE services cost a solo practitioner just $5/month.

2.  We know that "push" transactions are easiest from a policy and technology perspective, so Phase 1 was limited to use cases like PCP to Specialist, Provider to Public Health, and Hospital to PCP exchange.    We also know that "pull" transactions have a great deal of value by providing just in time delivery of community wide longitudinal health records (slide 21).   Pull models require significantly more complex technology and policy.    Pull models require a master patient index/record locator service and some means of recording consent to disclose records.   Rather than declare that the standards are not ready, the informatics challenges are too great, and the consent models are too complex, we're just moving forward with an aggressive timeline to get it done in 12-18 months.  (timeline is on slide 31)

3.  With Phase 1, we built a guiding coalition of providers, payers, patients, government, and employers to break down barriers and create community wide demand for the service.  Where there were standards gaps we filled them with simple SOAP-based XML exchanges (provider directory query/response).   In this next phase, we're going to do the same thing as outlined in slides 23-30.   Is there a simple set of standards for managing consent that is widely deployed in the industry?  No - we'll create one and refine it in actual production across thousands of users and millions of transactions.   Is there a simple set of RESTful interfaces for query/response retrieval of records across a complex community of non-affiliated organizations?  No - we'll create one and show that it works really well.   To date, our implementation guides for SOAP/REST XML exchanges are less than 10 pages each and do the job well.   Of course we'll use existing mature standards where they exist but we will not select implementation guides that fail the standards readiness criteria simply because the right standards have not yet been invented yet.

Over the next few months our push HIE will grow to scale as more providers and vendor products are connected to it.   Currently NEHEN, our administrative transaction HIE in Massachusetts, does over 100 million exchanges per year, so we're confident we can achieve and support clinical healthcare information exchange at large volumes.    We'll dive headlong into the pull HIE work very soon as the funding is finalized.   We'll broadly share our lessons learned, our policies, and our technology.

It's a great time for HIE in Massachusetts and I hope we can be a catalyst for wider push and pull HIE adoption in the country.

On the Road in China

Last week I spent 5 days in Shanghai and Hangzhou as part of an American delegation advising Chinese government and private sector leaders about healthcare reform.

We met with the Mayor of Shanghai, the Health Minister of Shanghai, many hospital presidents, and several public health officials.

The themes we highlighted included:

*Quality must be measured, not assumed, and this should be enabled by the universal adoption of electronic health records

*Data should be shared among caregivers with a focus on longitudinal coordination of wellness rather than episodic treatment of illness

*A primary care model coordinating patient treatment via a team that knows patient care plans and preferences will be more efficient than the current model in China in which the patient can go anywhere without a referral.   A simple headache might be first evaluated by a neurosurgeon at a tertiary care facility.

*The measures of success should be healthcare value (quality/cost), safety, and patient satisfaction

My role was to spread the gospel of Meaningful Use.   I highlighted the multi-phased journey in the US and our focus on policy outcomes rather than hardware/software implementation.

I toured several facilities and had the opportunity to study the IT infrastructure and applications used in different settings.

A few observations:

*Shanghai community hospitals have deployed a standardized EHR that is good enough - it enables enough clinical documentation to provide continuity of care.

*Tertiary facilities have not widely adopted advanced clinical IT systems.  They have focused on  administrative transactions (registration/scheduling) and ancillary automation (lab/rad/pharmacy) but not provider order entry, decision support, or clinical documentation.   The systems are optimized for episodic and not continuous care.

*This is my third visit to Shanghai and I've advised their health information exchange efforts by suggesting content, vocabulary and transport standards.    Shanghai is piloting health information exchange that involves transport of XML-based summary records over VPN.  The Chinese have a national identifier they use for healthcare and have privacy policy that makes data sharing a public good in society.    Culturally, there seem to be few expectations of healthcare data privacy.    Limited regulatory/compliance oversight enables the Chinese to move quickly but also providers fewer controls.   There is very little assertion of malpractice.

My conclusion from these Chinese visits is that healthcare IT challenges are similar worldwide.   I enjoy sharing our US experiences with other countries and look forward to the day when continuous lifetime coordinated care based on interoperability of data is a worldwide possibility.

In Shanghai this Week

This week I'm in Shanghai and surrounding cities working on EHR implementation and health information exchange issues.

There will be a few days without blog posts this week due to my travels, but I will detail all the lessons learned when I return.

Aligning quality, safety, and efficiency with technology and politics pose the same challenges all over the world but the scale of China makes implementation particularly interesting.  

And now off to spread the gospel of Meaningful Use.

Cool Technology of the Week

Not exactly a cool technology, but a cool product of nature.   I was walking in the apple orchard at dawn this morning and found a Giant Puffball mushroom - Calvatia Gigantea

As a mycologist, I generally get calls about humans eating mushrooms.   With this one, I'm more concerned about mushrooms eating humans!

Fungi that's bigger than a car tire.   That's cool!

Building Unity Farm - the Barn

To me, the barn is the centerpiece of any farm.    The tools, the hay/food, animal stalls, season specific items, and heavy equipment are all protected from the elements in the barn.

In New England, barns are a classic barn red or white, having sliding access doors, and ventilation such as a cupola.    Ours is red with black accents.

At Unity Farm, our barn is about 40x40 feet in size, has two post and beam stories, and three access doors.    The front of the barn holds our grains and seeds in water proof metal cans held closed by spring loaded metal chains and hooks of my own design - call them unchewable bungie cords.    Our tools are racked in a Rubbermaid tool caddy.   The chainsaw and brush cutter are stacked against the east wall.   Our red dragon flamethrower (for weeding), and our commercial sprayer are hung on hooks.    A Craftsman workbench and pegboard provides storage for hammers, screw drivers and saws.

We store our portable animal pens (great for veterinary visits, isolating animals during their introduction to the herd, and for containing animals when they need to be haltered) and llama/alpaca scale against the west wall.

Our freeze proof water source - a yard hydrant - is also on the first floor inside a five foot deep french drain.

Fly management is via hanging fly tapes strategically placed in areas that flies gather.

Ventilation fans on the first floor keep the air moving.  

The animal stalls have heavy sliding wood doors that keep the animals separated from the tool and storage area.  Sliding weatherproof doors give them easy access to the paddocks.    Lighting inside the barn is all LED, consuming less than 100 watts for the entire structure.   Lighting outside the barn includes 4 classic gooseneck barn lights with halogen bulbs on a photo sensor circuit that turns them on during night time hours.

The stalls are outfitted with wall mounted buckets and hay feeders.  Floors are lined with one inch thick rubber mats that are easy to clean.  

The second floor hayloft can store up to 10 tons of hay.  Hay doors give us easy loading access using a hay elevator.   A heat activated ventilator fan keeps the hay cool and dry.

Kathy designed the Unity Farm signage that is mounted on rails attached to the clapboard.

The barn is so functional that all our animal chores are simple.  We can move animals in and out of stalls, retrieve hay, and fill water buckets seamlessly.

We clean the stalls twice a day - once in the early morning and once in the early evening, managing manure in our compost area.

Our Great Pyrenees Mountain dogs sleep with the alpacas and llamas, which is especially comforting for us when we hear a pack of coyotes calling from the apple orchard late at night.    Thus far, the security of the barn with its nighttime lighting and livestock guardian animals has kept the citizens of Unity Farm healthy and happy.

The scent of hay, sounds of humming camelids, and crunch of straw underfoot is so appealing, that I often sit in the barn with the animals at night before bed.  

If I'm ever asked about my manners, I can always claim that I feel at home in a barn!

The October HIT Standards Committee meeting

The October HIT Standards Committee reviewed the FDA Universal Device Identifer NPRM, the transition of the NwHIN to a public/private partnership, and an update from ONC on S&I Framework/related programs.

Jamie Ferguson presented a very thoughtful list of recommendations to the FDA, including the notion that all healthcare devices, including consumer devices, should have a universal device identifier that can be used as metadata when exchanging information.  A UDI will help us understand the nature of the data, the accuracy of the data, and the range of possible data from each healthcare device.

Mariann Yeager, Interim Executive Director of Healtheway, presented an overview of the public/private partnership successor to the NwHIN program.  As ARRA/HITECH funds diminish, it is important to move ongoing ONC operational components such as NwHIN to self- sustaining partnerships.   Healtheway will ensure continuity of the NwHIN Exchange efforts, regardless of the outcome of the election or fluctuations in Federal budgets.

Continuing the theme of public/private partnership, Doug Frisdma presented an overview of ONC project transitions to a combination of public, public/private, and private efforts.

I look forward to the next meeting in which we'll likely begin discussion of the testing and certification scripts as we move forward to the implementation of Stage 2 programs.

The Golden Spike Part 2

Today we made history in the Commonwealth of Massachusetts.   At 11:35am Governor Deval and his physician sent the Governor's healthcare record from Massachusetts General Hospital to Baystate Medical Center.   It arrived and was integrated into Baystate's Cerner medical record.

The Massachusetts HIE is now open for business.

Immediately following the Governor's record, institutions throughout the Commonwealth sent their own transactions.

The record I exchanged had special significance to my family.

When Kathy was diagnosed with breast cancer (a highly suspicious mammogram) at Newton Wellesley (a Partners hospital), she was told that Massachusetts had no healthcare information highway and she would have to drive her records and images to Beth Israel Deaconess where she chose to seek the care of oncologists,surgeons, and radiation oncologists.

Two months after she began treatment, her health plan called and told her "we think you have cancer because you have incurred $25,000 in chemotherapy costs since December";.

Her out of network caregivers had no visibility into her cancer care.

Her care at multiple institutions was not aggregated for quality measurement.

All of that ended today.   In front of the press and leaders of Massachusetts, I accessed her BIDMC records, with her consent, and sent them electronically to Partners Healthcare, a payer (Network Health), a private primary care provider (Dr. Ayobami Ojutalayo, MD at Ruhke Medical Center), and the Massachusetts eHealth Collaborative (a quality measurement and analytics service provider).    Within seconds, we broke down silos, demonstrating that care coordination, population health, and quality analytics based on healthcare information exchange is now possible in Massachusetts.   EHRs included Partners' LMR, eClincialWorks, a custom payer system, and self built analytic applications.

Other transactions followed.

Tufts New England Medical Center sent summaries to and received summaries from Vanguard Health Systems New England illustrating primary care physician to specialist closed loop workflow.   EHRs included Siemens Soarian and Meditech.

Boston Children's sent pediatric patient summaries to Atrius Healthcare, a multi-specialty group, illustrating tertiary hospital to primary care giver coordination.

All were successful and were documented in real time on the Twitter stream.  

The Governor distributed golden spikes (photo above) made from actual railroad spikes salvaged from rail near  Promontory Point.

Just as the original golden spike in 1869 issued in a new era of connectness, so does today's HIT golden spike change business as usual in Massachusetts.  Over the next year, we'll be building new "bridges", ensuring that every payer, provider, and payer can join the ecosystem.

Here's to innovation!

The Golden Spike Part 1

Tomorrow at 11am, Massachusetts Governor Deval Patrick will drive the Golden Spike into the Statewide Healthcare Information Exchange, the MassHIway, by sending a record between an Eastern Massachusetts hospital and a Western Massachusetts hospital.

We'll then commence transactions that demonstrate:

ACO to ACO transmission - two large healthcare systems breaking down silos and exchanging lifetime summary records for care coordination

Provider to Registry transmission  - EHR data sent to a third party for computation of quality and performance metrics

Provider to Plan transmission - EHR encounter data sent from a provider organizations to a payer for care management

Pediatric Care Coordination - EHR transmission between a community provider and a tertiary referral hospital

Suburban to Urban Specialist referral - A PCP at a community site sends referral data to an urban specialist, electronically closing the loop between the two

These transactions will flow over the production state HIE and the production EHRs of

Partners Healthcare
Baystate Health
Beth Israel Deaconess Medical Center
Mass eHealth Collaborative
Tufts Medical Center
Network Health
Childrens Hospital Boston
Atrius Health
Vanguard Health Systems New England

Vendors involved include Orion, Cerner, Siemens, Epic, Meditech and eClinicalWorks as well as the home built systems Partners' LMR and BIDMC's webOMR.

Tomorrow I'll let you know how it went.

If all goes well, no patient will again be told that the only information highway in Massachusetts is the turnpike!

Cool Technology of the Week

Last week I joined several industry experts to discuss the future of Big Data, Analytics, and Healthcare IT in general with a moderator from Intel.

Here's a preview clip on You Tube.

If you'd like to register to view the entire discussion, which will be broadcast on October 23, just click here.

What else is cool this week?
.
As many of my readers know, I cycle between meetings on a foldable bike.

The only challenge is that it's pricy and prone to theft.

What if you could buy an ecofriendly "disposable" bicycle for under $10?

Sound impossible?

This cardboard bicycle is an engineering miracle.   Now that functional prototypes have demonstrated the possibilities, I look forward to seeing such low cost, recyclable, and robust vehicles on the road.   At $10, it's unlikely they'll be stolen.   Maybe cities could make racks of them available for generalized use at no charge?

That's cool!

Building Unity Farm - the Economics

My wife Kathy and I ran a winery from 1986-1993 while I was in medical school and graduate school.   We grew, harvested, and crushed all Rhone varietals.   At the time Kathy raised Chow Chows and we named them after grape varietals, explaining that their purple tongues came from sampling the products of the vineyard.   After 7 years in the wine business, we discovered that you can make a small fortune running a vineyard, as long as you start with a large fortune.

The economics of agriculture are challenging.

At Unity Farm, what can we expect to earn for our efforts?

Alpaca - Alpaca fiber is the softest animal fiber available.  It's in high demand by fiber artists and weavers.   A spring alpaca shearing may bring $200 for the fiber from each animal.   I've calculated our cost of feeding and healthcare for the animals.  It's about $200 per year - breakeven at best.   Alpaca cost anywhere from $500 to $50,000 per animal, although most are in the $1000-$2000 range.   Breeding alpaca might be more profitable that fiber harvesting, but we are not planning an alpaca breeding program at this time.   There have been various tax deduction schemes associated with alpaca farms, but we have no interest in those.   About the most we'll do is investigate options for property tax reduction given that we now have a working agricultural property.

Chickens - Chickens raised for meat live 14 weeks.   Chickens raised for eggs live 2 to 3 years before they are "retired".   As vegans (my wife is a vegetarian and eats eggs), we do not plan to slaughter our chickens.   Each has a name, a personality, and unique place in the ecosystem of our barnyard family.   Our chickens will live 10-14 YEARS, not weeks.  During the peak of egg laying, we'll get an egg from each chicken every 25 hours (such as the brightly colored eggs pictured above laid by our Ameraucanas).   We can sell a dozen eggs for $3.50 and given the 8 month egg laying season (chickens do not lay during the dark of winter or when they are molting), we can earn about $70 per chicken per year.   The cost of raising a chicken for us is about $50/year.     The economics might work if the chickens lived 2-3 years, but with a 10 year lifespan and 5-6 egg laying years, they are likely a loss.

Dogs - Great Pyrenees are wonderful livestock guardian dogs.   They cost between $500-$2000 with a mean of about $800.    However, we do not plan to run a dog breeding program.

Thus, for the animals of Unity Farm, raised in a free range/long life environment, the likely income is related to tax credits or property tax reduction.

Fruits, vegetables, and flowers are another potential income source.  This fall we're planting an apple orchard and 400 high bush blueberry plants.  

Apples will not be ready for 5-10 years and although we could charge up to $25 per peck, profitability is very dependent on weather conditions and competition since there are many apple sellers in Massachusetts

Blueberries can fetch $2.50 a pound at a U-pick.  We might be able to generate $10,000 per year for 400 plants after 10 years, but that will require significant up front capital investment and labor.

We're also creating a 30x72 foot hoophouse - hoophouses, high tunnels and cold frames will be featured in another post about extending the growing season for our vegetables.    What kind of prices can you realize for such crops (per Growing for Market by Lynn Byczynski)?

Arugula $1.31 per square foot
Cilantro $.95
Cucumbers $1.34
Tomatoes $3.55
Leeks $1.10

Given the labor and initial capital for the raised beds/hoophouse, you can see that growing 2000 square feet of vegetables will not generate much.

So, what are the economics of running a small farm?

Since I began my morning and evening tasks on the farm in April 2012, I've lost 10 pounds, but gained upper body strength.   My gray hair has disappeared.   My optimism and equanimity are peaking higher than every before.    I'm guessing the benefits from healthcare cost avoidance (mental and physical) could be substantial over a decade.

The seasonal expectations of pressing your own cider, picking crisp vegetables for every meal (lettuces and kale grow in the hoophouse in winter), and waking up every morning knowing that 50 animals depend on you for their survival - priceless.

Farming at small scale is truly a labor of love. If you believe in losing a dollar on every tomato, but making it up with joy, you'll understand why we created Unity Farm.

Why Meaningful Use Stage 2 is So Important

Last week my mother fell and broke her hip.

She was taken to a very good local hospital and received excellent orthopedic care.

The hospital used certified EHR technology and did their best to reconcile her medications.

They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).

Although are her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard).  There was no way to seamlessly exchange and synthesize all her data from various sites of care.

Meaningful Use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation.   OpenNotes is not yet universally adopted across the country.

When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.

After receiving medication, she was not able to accurately reconcile her own medications.

My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list.   The best he could do in addition to his notes was to bring in every medication bottle he could find at home.

By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.

Her mental status on 22 medications was such that she was not oriented to person, place, or situation.

To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because  "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status.  Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans.

My role as her son and her healthcare advocate was to assemble the care team and explain that she was TWO medications at home, not TWENTY-TWO.   How did this happen?  In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications.    In an effort to be complete, the hospital placed her on all of them in standing doses.   Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking.   She ceased to be able to participate in physical therapy because of difficulty understanding the training.

Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.

The next morning, my mother asked why she felt so foggy.   She had no recollection of the previous two days or any of the visitors who spoke with her.   She regained her involvement with the rehabilitation process and became a partner in her care planning.

Under stage 2 of Meaningful Use, patient and family view/access/download/transmit to her various data sources will be required.     Data exchange at transitions of care will be required.   Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.

As I wrote yesterday, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory.   We need to walk before we can run.   Clinicians throughout the country are rapidly adopting more advanced EHRs which support the workflow needed to prevent the problems my mother experienced.    Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support.   These changes are occurring at fast pace but an appropriate pace.   The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe Meaningful Use can or should be done faster than the current timelines.

To those who say that the industry should have solved all these issues years ago, I respond that 9 women cannot grow a baby in a month.   It takes the focused energy of 1 woman for 9 months.

I look forward to Meaningful Use Stage 2 and 3.   My own family experiences illustrates why the path we're on is so appropriate and so essential.

A Time for Boundless Energy and Optimism

2012 has been a challenging year for me.

On the personal side, my wife had cancer.   Together we moved two households, relocated her studio, and closed her gallery.    This week my mother broke her hip in Los Angeles and I'm writing from her hospital room as we finalize her discharge and home care plan before I fly back to Boston.

On the business side, the IT community around me has worked hard on Meaningful Use Stage 2, the Massachusetts State Health Information Exchange, improvements in data security, groundbreaking new  applications, and complex projects like ICD10 with enormous scope.

We did all this with boundless energy and optimism, knowing that every day we're creating a foundation that will improve the future for our country, communities, and families.

My personal life has never been better - Kathy's cancer is in remission, our farm is thriving, and our daughter is maturing into a fine young woman at Tufts University.

My business life has never been better - Meaningful Use Stage 2 provides new rigorous standards for content/vocabulary/transport at a time when EHR use has doubled since 2008,  the State HIE goes live in one week, and BIDMC was voted the number #1 IT organization the country.

It's clear that many have discounted the amazing accomplishments that we've all made, overcoming technology and political barriers with questions such as "how can we?" and "why not?" rather than "why is it taking so long?" They would rather pursue their own goals - be they election year politics, academic recognition, or readership traffic on a website.

As many have seen, this letter from the Ways and Means Committee makes comments about standards  that clearly have no other purpose than election year politics.   These House members are very smart people and I have great respect for their staff.    I'm happy to walk them through the Standards and Certification Regulations (MU stage 1 and stage 2) so they understand that the majority of their letter is simply not true  - it ignores the work of hundreds of people over thousands of hours to close the standards gaps via open, transparent, and bipartisan harmonization in both the Bush and Obama administrations.

I spoke with the authors of the Wall Street Journal article "A Major Glitch for Digitized Health-Care Records" and discovered that their issue was not interoperability standards but a lack of usability in non-standard EHR user interface design.  When a clinician goes from Epic to Cerner to Meditech and tries to perform the same task (e-prescribing, managing a problem list, or looking up a lab), the learning curve can be steep.   The authors and I reviewed the Consolidated CDA specification that is required by Meaningful Use Stage 2 and they are completely satisfied that interoperability standards gaps are no longer a rate limiting step.

Many reporters have asked me about the New York Times article "Medicare Bills Rise as Records Turn Electronic"

I've said three things:

1.  In the past, paper documentation lacked details to accurately document acuity.  As we make the multi-year journey from simple EHRs that support electronic billing to complex EHRs that include decision support, interoperability, and patient/family engagement, there will be an interim period when increasing detail in documentation results in higher acuity, which results in increased reimbursement.  

2.  These trends long pre-date the health IT incentive program.  Meaningful Use re-orients the healthcare IT industry away EHRs supporting billing to EHRs which focus on prevention, care coordination, population health management.  It is these functionalities that will both enable, and be incentivized by the shift in payment policies towards value, and away from volume.   In a healthcare reform world, clinicians will be paid for wellness not sickness and the EHR will help them increase efficiency, safety, and quality, which will be required for reimbursement.

3.  As quoted in the Center for Public Integrity's Cracking the Code series, Donald Berwick said he believes that only a small portion of the upswing in coding is the result of fraud. In most cases, he said, the hospitals have learned “how to play the game,” and are targeting the vulnerabilities of the Medicare payment system.  “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get”.

As the cartoon above illustrates, our current society tries to find fault in everyone and everything. Social media and our increased connectedness has turned criticism into a spectator sport.

If everyone could align their efforts into an agenda of optimism, we'd all be better for it.

I may be asking too much to expect positive energy and optimism from Congress, the Wall Street Journal, and the New York Times, but as 2012 has proven to me, anything is possible if you try hard enough.

Cool Technology of the Week

As readers of my blog know, my wife was diagnosed with Breast Cancer in December 2011 and is now in full remission.

She picked up the presence of the tumor (a very fast growing aggressive type) by self examination.

Recently, I heard about an electronic tool called SureTouch which records breast examination via an array of pressure transducers, producing a digital signal as the sensor is pressed and moved over the tissue.  The data is then presented in a useful visualization.

The result is objective, repeatable, and painless.

Although this does not replace standard mammography screening exams, it is a very interesting electronic approach to performing and documenting the clinical breast exam.

Objective digital data gathered as part of the physical exam.  That's cool!

Building Unity Farm - Hay and Other Foods

When we brought our 8 alpacas and our llama to Unity Farm, we were hay novices.   We had no idea how to choose good hay, differentiate first cut from second cut, or understand the difference between grasses and legumes.

Over the past few months, we've become experts, purchasing five tons of fine, grassy, second cut hay from Western New York and a ton of legume rich hay.    It's stacked neatly in the hayloft of our barn, pictured above.

Our first experience with hay was buying a small amount of first cut, harvested in June, which tended to have less green and more stems than our alpaca would eat.   We had a lot of waste and our manure management pile filled fast because our barn sweepings included so much uneaten hay.

In August we found green, sweet, tender second cut hay - a mixture of timothy and orchard grass.   The alpaca eat it out of our hands.   It's high in protein and very low in waste.   At this point, the alpaca eat their feeders clean.   We saved a dozen bales of first cut hay to use as bedding material and donated the left over first cut to horse rescue.

We also purchased second cut orchard grass hay mixed with legumes  (clover and alfalfa) for use in winter when the alpacas need a bit more fattening food.

Here's a great guide to evaluating hay quality

Now that we've experienced the difference between course, stem filled hay and fine, grassy hay, we'll never make the mistake of buying poor quality hay again.

We place the hay in feeders that minimize waste and protect it from the rain

Also, we planted half an acre of our own orchard grass hay.   We alternate feeding the males and females in this pasture, reducing the amount of purchased hay we have to use.   The alpaca pronk (jump for joy), roll around, and relish their days eating fresh tall orchard grass.

As a special treat, we feed our alpacas and llama a small serving of grain pellets - Poulin Grain Milk and Cria.   They have such an affinity for this food that we need to lock our storage bins.

We use Poulin and Blue Seal grain products to feed our chickens and guinea fowl.   The guineas receive a high protein game bird mix as a supplement to their daily foraging for ticks and other insects.

We store all these food products in cool, dry, dark places.   Our hayloft has a ventilator fan to minimize overheating and mold formation.   Our grains are stored in waterproof metal trash cans, sealed with metal bungee cords to prevent our livestock and forest creatures from feeding on them.

After a few months, we've figured out what to feed, how much to feed, and how to feed.

The winter will be a great learning experience for us, since we've not had the opportunity to keep our animals fed and warm in blustery New England weather.

When you're running a farm, the learning never stops.   And whoever thought rolling in the hay was a good idea has never had to do laundry after hauling 5 tons of hay into the loft!

Open Notes

An important article was published in the Annals of Internal Medicine yesterday about the OpenNotes study, Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead

There are also two accompanying editorials:

A Patient's View of OpenNotes 

Pushing the Envelope of Electronic Patient Portals to Engage Patients in Their Care 

Here's a BIDMC video about it.  

We're all enthusiastic about expanding this access to all BIDMC patients.  Here's the press release:

BOSTON – Patients with access to notes written by their doctors feel more in control of their care and report a better understanding of their medical issues, improved recall of their care plan and being more likely to take their medications as prescribed, a Beth Israel Deaconess Medical Center-led study has found.

Doctors participating in the OpenNotes trial at BIDMC, Geisinger Health System in Danville, PA and Harborview Medical Center in Seattle reported that most of their fears about an additional time burden and offending or worrying patients did not materialize, and many reported enhanced trust, transparency, and communication with their patients.

The findings were published in the Oct. 2 issue of the Annals of Internal Medicine.

“Patients are enthusiastic about open access to their primary care doctors’ notes. More than 85 percent read them, and 99 percent of those completing surveys recommended that this transparency continue,” says Tom Delbanco, MD, co-first author, a primary care doctor at BIDMC and the Koplow-Tullis Professor of General Medicine and Primary Care at Harvard Medical School. “Open notes may both engage patients far more actively in their care and enhance safety when the patient reviews their records with a second set of eyes.”

“Perhaps most important clinically, a remarkable number of patients reported becoming more likely to take medications as prescribed,” adds Jan Walker, RN, MBA, co-first author and a Principal Associate in Medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. “And in contrast to the fears of many doctors, few patients reported being confused, worried or offended by what they read.”

The findings reflect the views of 105 primary care physicians and 13,564 of their patients who had at least one note available during a year-long voluntary program that provided patients at an urban academic medical center, a predominantly rural network of physicians, and an urban safety net hospital with electronic links to their doctors’ notes.

Of 5,391 patients who opened at least one note and returned surveys, between 77 and 87 percent reported open notes made them feel more in control of their care, with 60 to 78 percent reporting increased adherence to medications. Only 1 to 8 percent of patients reported worry, confusion or offense, three out of five felt they should be able to add comments to their doctors’ notes, and 86 percent agreed that availability of notes would influence their choice of providers in the future.

Among doctors, a maximum of 5 percent reported longer visits, and no more than 8 percent said they spent extra time addressing patients’ questions outside of visits. A maximum of 21 percent reported taking more time to write notes, while between 3 and 36 percent reported changing documentation content.

No doctor elected to stop providing access to notes after the experimental period ended.

“The benefits were achieved with far less impact on the work life of doctors and their staffs than anticipated,” says Delbanco. “While a sizeable minority reported changing the way their notes addressed substance abuse, mental health issues, malignancies and obesity, a smaller minority spent more time preparing their notes, and some commented that they were improved.”

“As one doctor noted: ‘My fears? Longer notes, more questions and messages from patients … In reality, it was not a big deal.’”

Walker suggests that so few patients were worried, confused or offended by the note because “fear or uncertainty of what’s in a doctor’s ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select to not read them.”

“We anticipate that some patients may be disturbed in the short term by reading their notes and doctors will need to work with patients to prevent such harms, ideally by talking frankly with them or agreeing proactively that some things are at times best left unread.”

“When this study began, it was a fascinating idea in theory,” says Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, the primary funder of the study. “Now it’s tested and proven. The evidence is in: Patients support, use, and benefit from open medical notes. These results are exciting – and hold tremendous promise for transforming patient care.”

Security Assessment Kickoff

Meaningful Use Stage 2 requires a security audit.

"Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data at rest in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process."

Yesterday, we kicked off the enterprise security audit at BIDMC.

Every audit requires a framework.   For security, framework choices include NIST, ISO 27002, HITRUST, PCI and COBIT.    We've elected to use a NIST approach.

NIST is the National Institute of Standards and Technology, a component of the Department of Commerce (formerly National Bureau of Standards).  One of the NIST subject areas is Information Technology - the "800" series.

NIST publishes hundreds of Bulletins, Standards and Guidelines related to Information Technology.   Topics range from "What about Cloud Security" to "Smart Grid Interoperability".  Relevant to security audits is the NIST 800-30 "Guide for Conducting Risk Assessments".

Why did we choose NIST?

NIST is mandated within the Federal Government.   It is gradually being extended to contractors, including Medicare providers.    Recently, several NIH grants I've reviewed have included the need for a NIST-based risk assessment.    The Center for Medicare and Medicaid Services (CMS) increasingly refers to NIST assessments in their compliance efforts.

All security frameworks, including NIST 800, share common themes.   For example, risk is defined in terms of threat, vulnerability, likelihood of occurrence, and impact.

"Threat" could be malware, a natural disaster, disgruntled employee or a myriad of other things
"Vulnerability" is a weakness that makes a system susceptible to the threat
"Likelihood" is the probability the threat and vulnerability will come together
"Impact" is the consequence to the organization of an occurrence

For example,
        -  Threat = thief
        -  Vulnerability = laptop visible on front seat of a car parked in a public lot
        -  Likelihood of Occurrence = high,
        -  Impact = significant if the laptop contains ePHI

NIST 800 also provides recommended controls for mitigating risk.   NIST 800-53 describes 194 security controls that roll up into 18 families.    (see the above graphic)

I'll report back on the results of our audit and lessons learned when it is completed in November.

Solving the Provider Directory Standards Gap

In 2012, the HIT Standards Committee evaluated the provider directory standards suggested for the Nationwide Health Information Network and concluded that none of the current implementation guides was sufficiently mature and adopted to mandate as a certification criteria for Meaningful Use Stage 2.

This means that vendors and HIEs will continue to pilot various approaches to provider directories until Stage 3.

In Massachusetts, we chose a simple web-friendly implementation that goes live across the Commonwealth in two weeks.

We created a SOAP 1.2-based API that enables any trusted partner to query the state-wide provider directory via HTTPS per this specification.

The provider search web service provides following parameters to search a provider.
First Name
Last Name
Middle Name
Specialty
Type
Gender
Street
City
State
Zip
Phone
Email
Language
Id

but requires one of the elements in the list below in order to perform a successful search.

First Name
Last Name
ZIP
Specialty
Id
Street
Phone

With a simple SOAP query response approach and a WSDL, we have everything we need - no complicated implementation guide or non-standard use of LDAP/DNS required.

If this works well in production, it could be a model for the country.

How will we load the provider directory?

Each organization will be registered via an identity proofing process that ensures we have a fabric of trusted entities which have signed participant agreements.

As part of the registration process, the organizations will pre-load their provider data into the state directory using this spreadsheet.

Ongoing updates (adds/deletes/changes) can be sent via the same template.

Once in production, I'm sure we will refine our approach, but creating a simple SOAP-based query/response and a template for loading/updating data in batch seems to solve the Provider Directory standards gap nicely.