What is the Optimal Future Role for ONC?

As Meaningful Use winds down and incentive dollars are fully spent, what is the optimal role for ONC going forward?

Some pundits have suggested that ONC step aside and return all aspects of HIT policy and technology to the private sector.   Others have suggested top down command and control of HIT including centralized governance to ensure interoperability.

Harmony is when all parties feel equally good about the path forward.  Compromise is when everyone leaves the table equally unhappy.   Here’s my view about the future of ONC that includes points from both sides.

The Argonaut initiative is a good exemplar of the private sector working to enhance interoperability in response to the market demands of accountable care organizations, which depend on data to succeed in a risk contracting world.    There is clearly a role for the private sector to lead innovation and standards adoption, and this role will continue to grow as demand for richer interoperability increases and technology matures.   However, even the best innovations require a regulatory and ecosystem context to enable the marketplace to blossom.   The health care sector is the most fragmented industry in our complicated economy, both on the demand side (patients, insurers, employers) and on the supply side (physician practices and hospitals).  ONC can be a focal point for the discussion of regulatory barriers to data liquidity, novel workflows, and alignment of incentives.

In Massachusetts, opioid abuse is a critical public health problem.   We believe that collecting all opioid prescriptions at a state government level and sharing that data with licensed caregivers is appropriate.   Yet, right across the border in New Hampshire, it’s illegal to share such data with government entities.  Similar prohibitions exist on sharing immunization data to prevent measles outbreaks or syndromic survellience data to detect Ebola.   Extrapolate this problem out to the various combinations of 56 states and territories and it's an interoperability nightmare for patients, providers, and vendors.  ONC can provide national frameworks that enable regional variation but can suggest guardrails so that a federated national network of interoperability and functionality is not impeded.

Canada has 35 million people.   Sweden has 10 million.   Healthcare IT policymaking that takes into account stakeholder opinions in these countries is easier than resolving the difference of 320 million US residents.   Someone needs to be a convener to give voice to the myriad stakeholder priorities of a country that glorifies individual freedom.   ONC can be such a convener.

The US government is a large player in the health care market, even aside from any oversight role it might play.  Medicare and Medicaid are the largest health insurers in the country.  The US government has over 20 million employees whose health benefits it covers.  The DoD, VA, and Indian Health Services are large providers of care.  The number of federal agencies and the many and varied ways that they affect health care delivery and health information technology is hard to quantify.   There is no single front door in the federal government for HIT related strategic planning across agencies.    ONC can serve as government agency harmonizer.

Although Accountable Care Organizations now have economic incentives to accelerate interoperability, they do not have specific incentives to focus on healthcare IT usability and the safety of IT tools.   We are now at a point where everything that happens in a hospital is somehow tied to information technology.  ONC can provide funding to study issues that lack a specific private sector market force, just as NHTSA and NTSB do with auto and airline safety.

Finally, although there are many federal and state laws that protect privacy and security, it is challenging to know how to measure the security of an EHR.   By working with other federal agencies to identify best practices, ONC can foster data integrity and promote respect for patient privacy preferences.

Thus, although the private sector can lead innovation and accelerate standards development, the combination of government, industry and academia is needed to optimize our journey.     I recently spoke with a cabinet secretary in the Massachusetts government and the person told me “the Baker Administration does not believe in less regulation or more regulation, it believes in right regulation.”    The same can be said of the balance between ONC and the private sector.   The list of tasks above seems like the “right regulation” to me.

Unity Farm Journal - 4th week of February 2015

With Spring arriving in 23 days, the farm is beginning the transition from surviving the bitter cold to nesting and reproduction - the Birds and the Bees.

First the Birds.    I sent my daughter the picture below and asked her if she could guess what happened?

Over the weekend,  I went into the coop to fill the feeders and found a dead guinea surrounded by a pile of feathers.   

 I looked up and a large red tail hawk was standing on the roost above my head.

I removed all the guineas/chickens and closed the coop door.    Not knowing how the bird would respond to my interventions I asked Kathy to supervise me in case I was attacked.

Wearing my kevlar work gloves I gently picked up the bird by its talons and placed it on my arm so I could walk it out of the coop.     The bird and I had a conversation for several minutes.   I explained that I respected its position at the top of the local food chain,  but that Unity Farm could not be a weekly smorgasbord during the lean times of winter.    As you can see in the picture, our discussion was intense - direct eye contact and uninterrupted focus.    The bird and I walked to the orchard and I encouraged it to fly by gently moving my arm up and down, exercising the raptor’s wings.    The bird then flew off, circled the barnyard once, and roosted in a tall old maple snag.   

Although I have no desire to take up falconry (it’s not very vegan), I did read about the history, training techniques, and bird personalities involved in the sport.   Red tail hawks are known for the equanimity - a very even temperament.    They never develop affection for their handlers, but they do develop trust.   Given the chickens,  ducks and guineas at Unity Farm, we do not want the hawk to visit often.   

Next, the Bees.

On Sunday, the temperature rose above freezing for the first time in a month.   The bees cannot fly below 40 degrees, and in general, we do not open the hives below 50 degrees.  Bees do not excrete in the hive, so they have had to “hold it” for the past 30 freezing days.    As soon as the temperature hit 45F, our 100,000 bees began their cleansing flights.   

We have not been able to open the hives since January, so we had now idea how the hives were overwintering through -10F temperatures and weekly snowstorms.   Every Sunday I have shoveled out the hives, but the snow between the barn and the hives requires walking 1/4 mile in 7 foot deep snow - challenging even with snowshoes.     A stethoscope can be used to listen for “buzzing”, a crude measure of hive survival.   My initial examination suggested that two of the twelve hives had not survived the unusually brutal winter.  Clearly we needed to do an emergency inspection and decided that the 45F temperatures would be sufficient for a very quick look.

I carved a path to the hives and Kathy brought 18 sheets of fondant (sugar icing).  One by one we opened each hive and added food.    As we feared, two hives did not survive, but we found no clear evidence of nosema, american foulbrood, or heavy varroa mite loads.   Once the weather warms we’ll look at all the hives, frame by frame.

One possibility is that the snow drifts were so high, the warmth of the sun from the south was blocked by the shadows of the enormous piles.    Next week, the snowblower attachment for the front loader arrives and I’ll be carving paths, reducing drifts, and making management of the entire farm infinitely easier.    I’ve worn out my alpine climbing gear by simply traversing the farm this winter.   Using a commercial snowblower is  a much better strategy than an ice ax, snow shoes, and total body vortex. 

As March begins, I’m hopeful the snow will stop and the sun will shine, warming the hoop house to the point we can begin planting.    Maybe next weekend I can finally get the peas in the ground.    The lettuces, spinach, chard, bok choi, and mache have overwintered well - we’ll have our first harvest in early March.

Making Time for Innovation

CIOs are at a challenging crossroads in their careers.   Regulatory burdens, security threats, and changing reimbursement models have led to a demand for change that seems overwhelming.   As workflow pressures increase, it’s easy to declare IT the rate limiting step.

Given that many CIOs are ready to raise the white flag of defeat in desperation, finding time for innovation amidst the swirl of must do projects can be a challenge.

My hope, and something I strive to do, is to take the long view, asking what innovations we’ll need in the next few years, which will enhance productivity, and possibly serve as generalizable tools, reducing the number of requests for niche systems.   As I think about 2016, here are a  few of the kinds of innovations I think we’ll want for healthcare organizations:

1.   In our home  lives, we use cloud hosted storage accessible  on our personal devices.     How can we give folks the same easy access to their files (in lieu of the SSLVPN web-based access) while still protecting patient privacy?

2.  In our home lives, we use social networking - Facebook, LinkedIn, and Google+ to provide collaboration spaces for sharing ideas, messages, and files among groups.   How do we offer these kind of applications to support our work lives?  Is Slack a good fit for healthcare organizations?

3.  In our home lives, we use texting for communication among teams.   How do we deploy secure, enterprise grade texting that is fault tolerant, supports delegation (if you are unreachable),  role-based messaging (the current administrator on call, whoever that is), and audibility.   Per Harvard rules, I must disclose that I serve on the Board of Directors for Imprivata which produces such a product.   I will recuse myself from any decision making processes about secure texting procurement.

4.  As I’ve blogged about previously, patient generated healthcare data will become increasingly important and we need to be able to incorporate objective data (home devices) from smartphone middleware like HealthKit and subjective data (electronic patient reported outcomes).

5.  Interoperability use cases will increasingly require closed loop transactions with tighter coupling among organizations.   The FHIR work accelerated by the Argonauts group is the best path forward to achieve this goal.

As usual, sometimes we buy innovation and sometimes we build innovation.   If practical, we should procure these services from cloud-based software as a service providers.

We need to work closely with our compliance and legal colleagues to balance risk and benefit, accepting that with all change and innovation there is a risk of the unknown.    We can mitigate risk in the face of ambiguity.

Often organizations focus on the short term - the tyranny of the urgent.   Carving out time for innovation with a long term view is necessary to create true breakthroughs.   A dozen short term sprints will not add up to the marathon of transformation that is only accomplished via a steady pace over time.

Unity Farm Journal - Third Week of February 2015

What happened to the term “polar vortex”?   Are we now beyond it into something more severe?  Unity Farm has not had a day above freezing or a night above the single digits (often negative single digits) in over a month.    The most simple acts - walking to the hoop house, stacking supplies, and shoveling manure - require full alpine climbing gear.

Despite my hours in the Terex front loader creating a grand canyon of snow, it’s difficult to keep every aspect of the farm running.    To understand the scale of our storms, imagine filling Patriots Stadium to the brim 90 times - and that is just the amount of snow removed from downtown Boston the past 30 days.     The entire public transportation system will be shutdown/on limited schedule for the next month.   And another storm is on the way for this weekend.

“Snow rage” abounds as commutes are measured in hours per mile, not miles per hour.

I can only hope that this winter does not become a standard experience.   If it does, then the farm’s next capital purchase will be the snowblower attachment for the Terex.

No more, Mr. Nice Guy.  A properly equipped Terex can blow 100 tons of snow per hour, 45 feet into the air.     The idea of cruising along the farm roads and trails in the warmth of a the Terex cab, listening to Japanese flute music while slicing through 7 foot snow drifts sounds very appealing.   I’ll keep it in mind for next season.

This year I split 8 cords of wood to keep the fireplaces toasty.   My morning routine now consists of caring for the animals then hauling a hundred pounds of wood indoors so that it can thaw before nightfall.   Who could have known that the neatly stacked wood would be 7 feet under non-melting snowbanks for the month of February?

I’m doing my best to offer grain/seeds to all the squirrels, turkeys and deer trying to survive the winter.   How does a squirrel navigate a 7 foot snow pack?  They must have talked to the moles, because we now have squirrel tunnels to the feeding areas.

This Sunday may include wintery mix - ice, snow and rain.    The snow on the roofs currently weighs 5 pounds per cubic foot, but wet snow will weigh 21 pounds per cubic foot.   I’m using a 20 foot snow rake to clear the sheds, barn and house before it comes icy concrete.

One advantage of this much snow is that it makes filling the bird feeders much easier.  The 8 foot feeders are now at ground level.

 Although the creatures are feeling claustrophobic, they are well fed and watered, which is key to their winter survival.    I've carved a "duck highway" and covered it with straw, so they have a yellow brick road between the warm of their house and the extra food/water we've put out for all the birds.

Despite the hardship, the alpaca and llamas are getting dedicated attention.   As one Alpaca farmer in New York posted

"I am head waiter at the Alpaca Fine Dining Restaurant located here in Western New York. For today's offering, we start with a fine appetizer of select grains served with a finely chopped, alfalfa chaffee hay salad. For our main course we offer delicious second cut orchard grass beautifully arrayed in our special "hay" feeders. To complement this, we offer slightly warmed fresh well water. I can expect a 20% tip of artfully arranged (and I might add frozen solid) alpaca beans. All's right with the world!!"

Mobile Applications Update

I have long believed that social networking concepts, mobile devices, analytics, and cloud are key tactics for the success of any IT organization.   We’re in an era as significant as the mainframe to PC revolution in which BYOD devices and apps are becoming the platform of choice.    Given the regulatory/compliance mandates for security, the need for auditability, and the need for provenance (can we trust the data?), implementing a mobile strategy in a healthcare environment can be tricky business.

Here’s an update on two projects we’re working on now that attempt to balance functionality with security.

We’ve written an iOS app that enables patients to connect their home devices with BIDMC clinical systems using HealthKit as middleware.

Below is a screen shots of the application in use.   My staff have been testing it with electronic scales that report weight to HealthKit.  

App users do a one time registration to give the BIDMC app permission to read values from Healthkit.  They also login to our Personal Health Record, Patientsite, one time to enable upload.  Then the App gets called by the iOS operating system whenever there is a new weight entry into Healthkit.  The new weight entries (since last successful upload) are automatically uploaded and the user gets a notification of success.

Here’s how the data appears in the BIDMC systems.   Each transaction is logged with a universal ID, date/time and provenance ensuring data integrity and traceability of each data element.

We’ll pilot the application and then enhance its usability based on lessons learned.   We’ll continue our work to determine what alerts/reminders are sent to clinicians, care managers, and family members based on variation in the data provided by home devices.    Weight changes can predict fluid retention leading to congestive heart failure exacerbations.    Blood pressure tracking can support personalized adjustment of medications.   Shared glucometer data can lead to better control of glucose over time.  Very exciting possibilities.

One of the downsides of BYOD is that smartphone photography can lead to privacy issues such as revealing clinical information inappropriately, should the photograph become available on a social network or publicly available website.   BIDMC is piloting a new camera created by Ricoh that uploads photos to the electronic health record and deletes them from the camera immediately, enabling photographs to be curated via the all the usual policy and technology controls surrounding the electronic health record.

If the pilot is successful, we can then change policy at BIDMC, requiring that purpose built, EHR connected, secure cameras be used for all clinical photography.   The combination of technology and policy should reduce risk.

We continue to explore options to make our workforce more mobile, procuring services that enhance productivity and usability while protecting security and safety.   More to come!

Snow Update from Unity Farm

In the past few hours, another 17 inches has fallen.   The temperature is 10F, but headed to -10F tonight.   We have 30 mph winds.

The creatures are warm and dry in the barn.   All the feeders and waterers are full.   I've picked fresh greens from the hoop house and given them to chickens, ducks, and guinea fowl.

How did I do this?

I put on my Mt. Washington climbing gear to exit the front door, where the snow level was higher than the door knob.      The snow in the paddocks is over 7 feet high.   The driveway piles are 10 feet high.   The bee hives and apple trees were completely submerged by snow drifts and I dug them out with my avalanche rescue gear.

Is this Unity Farm or the Ernest Shackleton expedition?

Unity Farm Journal - Second Week of February 2015

Every time I step outside at Unity Farm, I want to sing “Let It Go, Let It Go…” since the world around is clearly Frozen.  The icicles weigh more than 25 pounds.    The Prius "snowmobile" is only visible by looking for the side mirror.

We’ve had over  72 inches of snow in the past 3 weeks.   The top of the snow gauge is UNDER 3 feet of snow.    The weather has been in the single digits, so no melting has happened.   I’m 6 foot 2 and the snow drifts are now taller than me.

As an alpinist, I’ve climbed every peak in New England during winter.   I’ve taken an engineering approach to clothing, reducing heat loss caused by conduction, radiation, and convection.

My morning animal care and farm maintenance requires a polyester base layer, Polartec Power shield, vortex, my ice climbing boots, and thick nylon gloves/gaiters.

Walking a mile on the farm at the moment is harder than climbing Mt. Washington  in winter (the worst weather in the world).

The Terex front loader has been an essential tool since it enables me to create 8 foot high canyons of snow for the animals and to open up paths to buildings/supplies.   I’ve been using 10 gallons of diesel per week just to clear snow/ice.    We’re expecting another foot of snow today and there is no place left to put it, so I’m converting one of the pastures to a snow parking lot.

Llamas and alpacas live in the Andes, a dry/cold area.   They are comfortable with temps below zero, but really do not like navigating deep snow.   The Terex and the snow blower together have been enable to create paths and create areas for eating/sleeping outside the barn.    They spend storm days inside the barn, but have cabin fever, and want to run, which is difficult in 6 foot deep frozen quicksand.

Our chickens are bred for cold climates and do not mind chilly temperatures, but they find the wetness of winter unpleasant.   The ducks seem like stay outdoors in all conditions except blizzard conditions which they ride out in their duck house.   The guinea fowl, our flying dinosaurs, seem capable of handling any “fowl” weather.

The Great Pyrenees dig, role, and relish the snow.   They are in 6 feet of heaven.

I use my avalanche shovel to keep the bee hives clear of snow.  I’ve felt like a Sisyphus shoveling snow away from the hives every night, then waking to find them covered again.

As the next storm approaches, the sand barrels are filled will 100 pounds of dry, general purpose sand. Five hundred pounds of calcium chloride/magnesium chloride are stacked in the barn, ready for safe ice melting around vegetation.   The diesel and gas tanks/storage are full.   The shovels are placed near each key doorway.   I even removed a pasture gate so that the new “snow parking lot” will not be blocked by a snow covered barrier.

The next few days will see high temperatures below 10F and lows below -10F.   This week I replaced the heater base for our water fonts in the coop - they failed from overuse.

As my wife says “The Winter of 2015 - I’m ready to Let It Go!”

The February HIT Standards/HIT Policy Joint Meeting

The February HIT Standards Committee was a joint meeting with the HIT Policy Committee to align the policy and technology work ahead in 2015.

Erica Galvez began the discussion by reviewing the recently published Interoperability Roadmap.  She first highlighted supportive business, clinical, cultural and regulatory environments:

*On January 26, HHS and CMS announced that they are aiming to have 30 percent of Medicare fee-for-service payments tied to quality or value through alternative payment models by the end of 2016,and 50 percent of payments by the end of 2018.
*Requirements for participants in these new models can reinforce interoperability.
*Near term actions for the Federal government include linking policy and funding activities beyond Meaningful Use to adoption and use of certified health IT and electronic information sharing according to national standards.
*Near term actions for state government include a “call to action” to use available levers and Medicaid purchasing power to expand upon existing efforts to support interoperability and explore new options.
*Near term actions for non-government payers/purchasers include a  “call to action” to explore financial incentives and other ways to emphasize the interoperable exchange of health information among provider networks.

Erica continued with a discussion of governance, emphasizing the need for a framework than a new organization with “top down” authority.  

She then continued with an overview of privacy and security protections for health information including the need to address the variation in state rules which make it difficult to build software systems that accurately capture, maintain, and persist consent data.  ONC’s role is to help facilitate the alignment of policy among all stakeholders.

We then discussed the core technical standards/functions and certification/testing to support adoption and optimization of health IT products and services.    Near term actions include ONC’s effort to publish annual list of best available technical standards for core interoperability functions.   The private and public sectors must:

• Define a common clinical data set to achieve semantic
interoperability
• Constrain implementation of the C-CDA
• Advance standards for data provenance at the document and data element
level
• Advance standard, open RESTful APIs to support simple, scalable
interoperability

Erica concluded with a discussion of the next steps.   Workgroups were assigned sections of the roadmap to review to make the best use of resources and avoid overlap.

Steve Posnack continued with an overview of the recently published Standards Advisory document.  The goals of the Advisory are to be specific about the best standards available for each purpose.  It’s a non-regulatory approach with an interactive, predictable process.  Hopefully it will be a widely vetted resource that  will enable a “look first” philosophy for government programs, procurements, testing or certification programs, and standards development.

Steve then provided a Certification Program update including plans for quality improvement, greater transparency, increased collaboration, and improved customer service.

Finally, Dawn Heisey-Grove and Elisabeth Myers provided an update on Meaningful Use attestations.

A great meeting with many next steps.    It’s clear that interoperability will significantly increase when the right standards, supported by constrained implementation guides, are paired with consent/security policies widely accepted by all stakeholders.

Unity Farm Journal - First week of February 2015

We’ve had nearly 4 feet of snow this week, sub zero temperatures and high winds.    The barnyard looks like the grand canyon with piles of snow 7 feet high.    The Terex PT-30 Compact Track Loader can lift 1000 pounds of snow at a time and we’ve cleared 2 acres of snow for all the creatures that live on the farm.  

My years as an alpinist (pictured below) have prepared me well for shoveling manure in the dark at sub zero temperatures.   As a farmer, I cannot sleep in, wear my bunny slippers and sip tea by the fire.   Every morning, over 100 lives depend on me to feed them, provider water, and clean their living spaces.   At the moment, every creature is warm, dry, hydrated, well feed, and loved.

The driveway to Unity farm is a quarter mile long.   It’s just the same as shoveling your driveway, with a different scale.   When 4 feet of snow fall, the issue is not finding someone to plow.   The issue is finding somewhere to store all that snow.

The hoop house vegetables continue to grow under their row covers even in the subzero temps.   Spinach, Romaine, and Winter Density Lettuce are particularly successful.   I pick them every day for the humans and the creatures which all enjoy their greens in the depth of winter.

The bird feeders are filled with high calorie seeds and suet.   Dozens of species visit the farm every day for food, water, and warmth.    I find Carolina wrens, sparrows, and blue birds sleeping in the barn every morning.

The work of keeping a farm productive in the winter requires attention to detail - shoveling around the generator, keeping the bee hives well ventilated by clearing snow, using additives in gasoline and diesel to keep the machinery running, splitting wood every day, and heating all forms of water to keep the animals hydrated.

This winter is proving to be more difficult than the last, but thus far, everyone is healthy and happy.   My productivity given a 4 bar LTE connection to mobile devices, a high speed fiber network on the farm, and multiple teleconferencing modalities has worked seamlessly, so that every part of my work life has continued through the storms without missing a beat.

The next week will be marked by more snow and continuing subzero temperatures.   I look forward to the end of snow management and the beginning of early spring indoor seed germination in the weeks ahead.

The athenahealth/BIDMC Collaboration

BIDMC has self-developed its core clinical information systems for many years.  We certified all our applications for the 2011 and 2014 ONC criteria, attesting to Meaningful Use Stage 1 and 2 in every appropriate year.   BIDMC has hundreds of person-years invested in our web-based, cloud-hosted in-patient and out-patient applications.  The culture of BIDMC has always been to challenge to the status quo, to be willing to be a first mover, and to focus on value—establishing the highest quality at the lowest cost.

But the days of self-built systems cannot last forever.  While we want to continue to innovate, we know that commercial vendors will be able to leverage their knowledge and capabilities to build future platforms at larger scale.

We know those platforms will need to support evolving capabilities. I have long believed that the key to the future of healthcare involves maintaining wellness across the continuum of care, not optimizing the treatment of episodic sickness in silo-ed organizations.   Academic medical centers are important for research and education, but the majority of care can be delivered safely in community hospitals and practices near the home, at lower cost.  The HIT software of the future needs to leverage the experience of internet centric companies, offering cloud-hosted services with a zero client footprint, easily deployable in all sites of care.  There should be no special browser, desktop, or infrastructure requirements.   The services should be delivered via a subscription model that can be easily turned on and off as needed.   Products should include practice management, billing, a patient/clinician inpatient/outpatient shared medical record, care management, population health, and an app store of third party developed mobile products.

During my life in New England, I’ve had the opportunity to work with several professors specializing in negotiation theory.   I’ve learned about the importance of aligned interests.  

athenahealth is a cloud-hosted service provider with billing, ambulatory clinical, and population health products.    It has a culture of rapid cycle improvement and disruptive innovation.

For all of these reasons, BIDMC and athenahealth announced a new and unique collaboration. The collaboration between the two organizations provides athenahealth the chance to take BIDMC’s experience to a much larger audience, hopefully making a difference to providers, patients, and payers across the country.   athenahealth will also accelerate its ability to develop expanded functionality more rapidly than doing it alone.

I have always served as Geneva, a neutral convener.   I hope that the industry understands that I will not receive any compensation or personal benefit from the collaboration.   I do not and cannot own any athenahealth stock.  BIDMC will not write code for athenahealth’s new products nor receive royalties.   BIDMC’s community hospitals will continue to implement the cloud hosted, web-enabled Meditech version 6.1x for inpatient support.  Many BIDMC community practices use eClinicalWorks.

Over the next 5 years at BIDMC, we will select the best products and best services that meet the needs of our highly diverse network.   athenahealth products will be piloted in outpatient and inpatient locations.   We certainly hope that athenahealth produces excellent products but at BIDMC, we are a meritocracy and the best services at the lowest cost will win.

Just as Mayo chose Epic to reduce the number of different IT systems, BIDMC will pursue a parsimony solution - the fewest moving parts possible.  That might be one vendor, but hopefully it will not be more than two.

I look forward to seeing what happens  as webOMR moves from a 25 person development team to a 1500 person development team.

The future belongs to social, mobile, analytics, and cloud.   The transfer of our self-developed software to athenahealth will give the industry a unique opportunity to explore the cutting edge of the possible.