Mobile Device Strategy Project

As a service to the healthcare IT community and as part of the BIDMC's strategic planning process, we're studying the best practice implementation of mobile devices in clinical settings.

Mobile devices can take many forms

*Handheld barcode scanner/printer such as used by rent-a-car agencies

*iPhones and iPads

*laptops and tablets

*computers on wheels

*various bluetooth devices that separate bar code reading, data entry, and printing

*voice recognition systems such as Vocera

Mobile devices can have many purposes

*Positive patient id at the bedside - scanning a barcoded wristband to verify patient identity as part of medication and lab workflow

*Lab label printing at the bedside

*Result viewing

*Test ordering

*Vital sign entry

*Dictation

*Reference/knowledgebase access

*New and innovative applications - just scan the Apple App Store for health related software. At Harvard we use mobile devices for students to capture information about their clinical experiences such as the diagnoses of patients they have treated.

*Web access

*Part of a geolocation system using triangulation of wifi signals

For the next 4 weeks, Ankur Seth, a Duke MBA Candidate will be speaking with

*CIOs throughout the country to understand their current and planned mobile device deployments

*IT staff at BIDMC and Harvard

*Clinicians at BIDMC

*Selected vendors

He would welcome the opportunity to speak with you or your designate about innovative products you have deployed or are considering, especially those which support laboratory and medication workflow. Everything we learn will be posted on my blog and in articles we'll share openly.

If you would like to share your mobile strategy to inform this effort, please email Ankur Seth at ankur.seth@fuqua.duke.edu. Thanks for any input you can offer

The Stresses of Modern Life

In recent articles, I've reflected on the way humans treat each other in our modern era, competing for resources, attention and priority.

I turn 48 this month and even in my lifetime, I've seen major changes in the nature and quality of life. A few observations:

*When I was in college, faxes, FedEx, and email did not exist. Fast communication meant a land line phone call.

*The pace of each day was limited by the number of in person encounters you could have.

*Real estate was relatively inexpensive and houses in places like Marin County and Palo Alto could be found for $150,000.

*Debt was something to avoid.

*When I was growing up, a McDonald's meal cost a dollar and consisted of a small hamburger, 4 oz of fries, and 8 ounces of Coke with sugar, not high fructose corn syrup. It was under 500 calories.

*Doctors were respected members of the community. Lawsuits were rare.

*There was no expectation that you'd have a car, a VCR, a flat screen TV and an iPod. You spent what you could afford and accepted the fact that you lived within your means.

*No one had peanut allergies

*People took responsibility and accountability for their actions. If you chose to bathe with a toaster and died, your family would not sue for the toaster manufacturer for making an unsafe product.

*Government was a safety net for truly critical emergencies, not day to day life.

I realize that the items above are filtered through the haze of imperfect 40 year old memories.

However, I really do believe that something has happened in modern society that makes each day distinctly different from my childhood experience in the 1960's.

*Instant communication means that anyone can email the CEO and demand immediate action for their personal projects.

*Someone else is always to blame to everything that goes wrong.

*A baseline quality of life includes much more than in the past and if you cannot afford it, credit cards can provide it for you.

*Stress is a badge of courage.

*Information overload is the accepted norm.

When I was an undergraduate at Stanford, Herb Caen wrote many columns about the changes that took place in the 20th century that reduced the quality of life from his perspective... food, culture, and human interaction.

I hope that at some point, modern society stops and reflects about the nature of our day to day lives and realizes that we need to rethink our priorities i.e.

*Replace reality TV with a good book

*Treat your fellow humans with humility and respect

*Stop the real time communication with everyone you know

*Treat meals as an experience not as refueling

*Understand that this is the only life we have and we should savor it, not be stressed by it

After a recent particularly difficult day, I asked my wife if Ted Kaczynski's Montana Cabin was still available. Of course, as I age access to medical care will be important and cabin life would be a bit challenging, but the concept of wilderness life without an internet connection is intriguing!

No matter how challenging the stresses of modern life, as long as I remember that for everything there is a process, there will always be a path forward.

Cool Technology of the Week

Massachusetts Data Protection regulations require us to encrypt mobile devices. Red Flag rules require us to implement processes to protect against identify theft. ARRA requires notification of prominent media for any inappropriate data disclosures.

This all sounds great, but what if you drop your wallet containing credit cards, identification cards, and maybe even your personal health information?

The answer - a Kevlar and Carbon Fiber wallet with biometric identification.

Tungsten W created such a wallet. Its features include:

*Fingerprint access only

*Bluetooth enabled for notification alerts - automated notification via bluetooth if your wallet strays more than 10 feet from your body

*Protected against RFID electronic theft - the case shields all contents from RFID scanners

A portable, monitored, personal safe you can keep in your back pocket and open via biometrics. That's cool.

A Functional View of my Brain

As part of the Personal Genome Project, the PGP 10 participate in a variety of projects and diagnostic tests. We've done genome sequencing, published our medical records, and made our stem cells available to the research community worldwide.

Last week, I joined a Functional MRI/Genome study run by Randy Buckner at Harvard. The project is a collaboration among investigators across Harvard and its affiliated hospitals to construct the largest available reference database of brain function for both normal individuals and for individuals with psychiatric illness. Over the past year and a half, they have collected brain imaging data from 1500 volunteers with the help of 20 laboratories spread across Harvard, Massachusetts General Hospital, and McLean Hospital. The goal is to use the database as an openly available reference to understand psychiatric disorders including autism, depression, and schizophrenia with a particular focus on how genetic risk factors for illness alter the brain’s function.

What you are seeing above is what Randy refers to as the “Default Network” of my brain. These are the brain areas that are active when I think to myself. According to Randy, my images are particularly sharp - not because my brain is special but because I moved less than a half millimeter during the study. A dime is about one millimeter thick. Randy's team has speculated that the default network is involved in internal modes of cognition such as when a person is remembering or planning for the future.

Since I'm always planning for the future, you now have a picture of how my brain works. The good news is - I have a brain!

Wisdom from Xena: Warrior Princess

My family is a "nerd herd", a "gaggle of geeks", a "den of dorks". We do not watch television, but we do occasionally watch DVDs of cult series such as Babylon 5, The Prisoner, Doctor Who, The Secret Adventures of Jules Verne, and Xena: Warrior Princess.

Last night, we watched an episode in which Xena (Lucy Lawless) described her secret to winning competitions/battles/confrontations - "Act, do not react".

Today, while speaking to my staff about a few challenging projects, I realized the wisdom of this statement.

When I think about challenging projects with difficult to please customers, negative emotions may start to flow. You know what I mean - the emails with subject lines or From addresses that you dread reading. The meetings you do not want to attend. The politics that are impossible to successfully navigate.

Reacting to any situation when you've already biased yourself with negative emotions leads to less than perfect thinking and communication. All that stimulation of the sympathetic nervous system (fight or flight response) leads to a dry mouth, a racing heart, and scattered thoughts.

Instead, if you think about the endpoint you want to reach - a successful project, a better technology, a completed implementation - and take the actions needed to achieve this result, you'll be thoughtful, calm, and reasoned.

Here's an example. Rolling out EHRs to 1700 clinicians including all the capabilities and workflow redesign to achieve meaningful use is a change management challenge. Along the way, there will be naysayers, raised voices, and criticism. There may even be mean-spirited personal verbal jousting.

We know what actions we need to take - implement a practice every week between now and the end of the year. Follow our proven model office configuration. Build the interfaces and interoperability needed for care coordination, patient engagement, and quality measurement. By keeping our focus on the "act" and not the "react" to the few naysayers, we get closer to our goal every day, without emotion or negativity.

So next time you have a difficult project, difficult people, or difficult politics, think about the wisdom of Xena - Act, do not react.

You'll feel better and achieve your goals.

Administrative Simplification and Healthcare Reform

In addition to enrollment transactions and demonstration projects, there are two sections in the Healthcare Reform Bill that require significant IT efforts in support of Administrative Simplification:

*Sec. 1104 – Administrative Simplification

*Sec. 10109 – Development of Standards for Financial and Administrative Transactions

Here's a summary:

Operating Rules General Provisions (1104(b)(1)–(3))

Establishes that the standards and associated operating rules adopted by HHS shall, among other things, require minimal augmentation by paper or other communication, describe all data elements (including reason and remark codes) in unambiguous terms, and prohibit additional conditions except where necessary to implement state or federal law or protect against fraud and abuse.

Defines Operating Rules as necessary business rules and guidelines for electronic exchange of information not defined by a standard or its implementation specifications.

Requires HHS to adopt a single set of consensus-based operating rules for each transaction for which standard has been adopted.

Defines criteria for qualified nonprofit entities to provide recommendations on operating rules (entities such as CAQH).

Assigns NCVHS to advise HHS on whether nonprofit entity meets criteria, and whether the recommended operating rules shall be adopted.

Operating Rules Implementation (1104(b)(4))

Requires HHS to adopt operating rules by regulation following recommendations from developer of operating rules, NCVHS and consultation with providers.

Establishes July 1, 2011 as deadline to adopt operating rules for eligibility and claim status transactions, so that they are effective no later than January 1, 2013 (may allow the use of a machine readable identification card).

Establishes July 1, 2012 as deadline to adopt operating rules for Electronic Fund Transfer (EFT) and claim payment/remittance advice transactions, so that they are effective no later than January 1, 2014. Operating rules for EFT and claim payment must allow for automated reconciliation of the electronic payment with the remittance advice.

Establishes July 1, 2014 as deadline to adopt operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payment, referral certification and authorization transactions, so that they are effective no later than January 1, 2016.

Requires HHS to use expedite rulemaking (interim final rule with 60 days public comment) in applying any standard or operating rule recommended by NCVHS for the transactions noted above.

Health Plan Certification Requirements (1104(b)(5)(h))

Requires health plans to file a certification statement with HHS no later than December 31, 2013 certifying that the data and information systems for such plan are in compliance with the standards and operating rules for EFT, eligibility, claim status and health care payment/remittance advice transactions.

Requires health plans to file a certification statement with HHS no later than December 31, 2015 certifying that the data and information systems for such plan are in compliance with the standards and operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payment, referral certification and authorization transactions AND health claims attachments.

Requires that documentation provided to support certification statement demonstrates that plans conduct the electronic transactions in a manner that fully complies with the regulations and that plans has completed end-to-end testing with their partners.

Requires health plans to extend requirements to business associates through Business Associate Agreements.

Requires health plans to file a certification statement with HHS certifying that the data and information systems are in compliance with any applicable revised standards and associated operating rule adopted under interim final rule promulgated by HHS.

Requires HHS to conduct periodic audits to ensure that health plans are in compliance with standards and operating rules.

HHS Review Committee Provisions (1104(b)(5)(i))

Requires HHS to establish a Review Committee no later than January 1, 2014 to advise HHS on evaluation and review of the adopted standards and operating rules. Review Committee can be NCVHS.

Requires HHS, acting through the Review Committee, to conduct hearings to evaluate and review the adopted standards and operating rules, starting no later than April 1, 2014 and not less than biennially thereafter.

Requires the Review Committee to deliver a report no later than July 1, 2014 (and not less than biennially thereafter) providing recommendations for updating and improving such standards and operating rules; a single set of operating rules per transactions must be provided, maintaining the goal of maximum uniformity in the implementation of electronic standards.

Any amendment of adopted standards and operating rules that has been approved by the Review Committee must be adopted via interim final rulemaking no later than 90 days after receipt of Committee’s report.

Effective date of amendment adopted through interim final rule shall be 25 months following the close of 60-day public comment period.

Requires HHS to adopt a single set of operating rules for any transaction for which a standard has been adopted.

Provisions on Penalty Fees (1104(b)(5)(j))

Requires HHS to assess a penalty fee against a health plan that failed to meet requirements; the fee amount equals $1 per covered life until certification is complete. Covered life for which the plan’s data systems are not in compliance and shall be imposed for each day the plan is not in compliance.

Penalty fee for deliberate misrepresentation is twice the amount imposed for failure to comply.

Penalty fee increases annually by the annual percentage increase in total national health care expenditures.

Penalty cannot exceed on an annual basis an amount equal to $20 per covered life or $40 per covered life for deliberate misrepresentation.

Unique Health Plan Identifier Provisions (1104(c)(1))

Requires HHS to promulgate final rule to establish a unique health plan identifier based on input from NCVHS in a manner that the rule is effective no later than October 1, 2012.

Electronic Fund Transfer Transaction Provisions (1104(c)(2))

Requires HHS to promulgate final rule to establish a standard for EFT no later than January 1, 2012, so that the rule is effective no later than January 1, 2014.

Claim Attachments Provisions (1104(c)(3))

Require HHS to promulgate final rule to establish a standard and a single set of operating rules for health claim attachments that is consistent with X12 version 5010 no later than January 1, 2014, so that the rule is effective no later than January 1, 2016.

Consultation with NCVHS, HIT Policy Committee, HIT Standards Committee, SDOs (10109(a)-(b))

Requires HHS to solicit no later than January 1, 2012, and not less than every 3 years thereafter, input from NCVHS, HIT Policy Committee, HIT Standards Committee and SDOs on whether there could be greater uniformity in financial and administrative activities and items; whether such activities should be considered financial and administrative transactions for which adoption of standards and operating rules would improve the operation of the health care system.

Requires HHS to solicit input no later than January 1, 2012 on the following:

Whether application process, including use of uniform application form for enrollment of health care providers by health plans can be made electronic and standardized.

Whether standards and operating rules shall apply to health care transactions of auto insurance, workers’ compensation and other programs or persons not currently covered.

Whether standardized forms could apply to financial audits required by health plans, federal and state agencies, and others.

Whether there could be greater transparency and consistency of methodologies and processes used to establish claim edits used by health plans.

Whether health plans should be required to publish their timeliness of payment rules.

ICD-9 - ICD-10 Crosswalks Provisions (10109(c))

Require HHS to task the ICD-9-CM Coordination and Maintenance Committee to convene a meeting no later than January 1, 2011 to receive input on the crosswalk between ICD-9 and ICD-10 posted on CMS website and make recommendations on appropriate revisions to the crosswalk. Any revised crosswalks shall be treated as a code set for which a standard has been adopted.

Here's a implementation timeline in a simple to read table. Thanks to Walter Suarez at Kaiser Permanente for putting this together!

Using a Cold Frame for Spring Vegetables

Since I missed my personal blog on Thursday due to the Governor's Healthcare IT Conference, I'm posting one now.

As I've discussed in numerous previous blogs, I grow a significant proportion of my vegetables l between March 1 and October 1. The problem with New England is that the weather is very unpredictable.

How do I deal with a Spring that can be 80 degrees one day and snowing the next?

The answer is that I use Cold Frames for my Spring vegetables, especially lettuces. This year I planed Arugula, Oak Leaf, Red Salad Bowl, Red Verona Chicory, Batavian Endive and Garden Cress in March.

The Cold Frame traps the sun's heat, protects young buds from ice/snow/wind, and keeps the chipmunks from munching the tender leaves.

However, this is one caveat - you need to automatically vent the cold frame in direct proportion to temperatures above 60F, otherwise the Cold Frame becomes and oven that roasts your vegetables.

I modified my Cold Frame with an automated vent/lid opener. As the pneumatic cylinder heats, air expands and automatically opens the lid. In my case, the lid starts to open at 60F and opens fully by 80F.

For the past 3 weeks, all the greens for our family meals have come from the Cold Frame. I use scissors to harvest fresh greens minutes before they're served. In our household, we use just a touch of balsamic vinegar and no oil on our greens. They're great!

Cold Frames are definitely a gardener's friend in New England.