Cool Technology of the Week

My Cool Technology of the Week is very simple.

A solution to urban parking problems.

Check out this video of an automated parking system in Budapest.

Parking 400 cars underground in a limited space using a robotic control system for rapid car placement and retrieval. That's cool!

My Outdoor Footwear

I choose my outdoor gear the same way I run IT projects - first I define requirements, then I write specifications, then I choose the right solution for the task to be done.

My 5 Summer activities are

*Walking with my wife in the mornings

*Kayaking the Charles in the late afternoons/evenings

*Cycling Dover/Sherborn/South Natick on weekends

*Hiking the Franconia/Kinsman/Presidential ranges in the White Mountains in Friday mornings. Instead of taking my customary last week of July vacation this year, I'm taking off Friday mornings in July to hike. Given all the Stimulus-related Healthcare IT activity in Washington and Massachusetts, it's easier for me to be available at least a portion of each day to ensure that I'm not a rate limiting step.

*Climbing in New Hampshire and Yosemite

I try to own and carry the most minimal gear possible for each activity. I want to be safe, capable of self-rescue, and reasonably comfortable, but I always want to be light and fast. In many activities, an agile response to changes in weather is safer than carrying a heavy load of equipment.

Each of my activities requires specialized footwear and I have selected shoes that meet my requirements, providing optimal function without a lot of complexity.

For Cycling, I use Pearl Izumi X-Alp Seek, a lightweight riding and running shoe that enables me ride on or off road, hike to my final destination, and portage my bike through mud/water.

For Hiking, I use the Five Ten Savant, an amphibious shoe what enables me to hike through rain, mud, river crossings, swamps, and canyons without worrying about getting my feet wet. The Savant drains so well that I arrive at my destination with dry and comfortable feet.

For Climbing, I use the Five Ten Prism that are optimally shaped for edging on small footholds and crack climbing.

For light treking/walking, I've used the Chaco Unaweep Z1 but their heavy sole is really more than I need for flat trails. For Kayaking, I've used NRS Kickers neoprene booties but they are really too hot for summer and neoprene really smells bad in warm, humid weather.

So, I needed a lightweight protective shoe that meets my light hiking and warm weather kayaking needs. My search led me to Vibram KSO Five Fingers. My daughter describes them as the strangest looking shoes she's every seen. Although they are indeed different than other footwear, they are light, durable, comfortable, and ideally suited for light trails and kayaking. Wearing Five Fingers feels like walking barefoot but without damaging your skin on rocks and roots. They dry rapidly, and their low volume means they are easy to fit into tight kayak hulls or narrow surfski footbraces. I would not have predicted that Five Fingers would work so well, but they are my favorite outdoor shoe at this point. Of course, I'm not likely to win any fashion awards, but I'm an engineer, so judge me for my efficiency, not my sense of style.

Since my feet are ultrawide (9EEE), I usually buy a half size larger shoe (9.5). However, the standard sizes of Five Fingers work perfectly for a wide foot. Check out the Vibram Five Fingers - together we'll make it a trend.

A Do it Yourself Presentation on the Standards Rule

Just as I did with the Meaningful Use Rule, I've prepared a presentation that you can use for your Board and stakeholders to review the Standards Final Rule. Feel free to use it without attribution to me.

This should save thousands of hours since everyone will be preparing the same material. Download it here.

Here's how I've organized it:

I've listed the Content, Vocabulary and Privacy/Security Standards and Implementation Guidance.

Please let me know if I can clarify or add to this presentation to make it more useful for you.

A Do it Yourself Presentation on the Meaningful Use Final Rule

Just as I did in January with the Meaningful Use NPRM, I've prepared a presentation that you can use for your Board and stakeholders to review the requirements the final Meaningful Use Rule. Feel free to use it without attribution to me.

This should save thousands of hours since everyone will be preparing the same material. Download it here.

Here's how I've organized it:

I've listed the Core Set 15 projects and their metrics for achieving stimulus funding followed by the 10 Menu Set projects, of which 5 must be chosen by eligible providers and hospitals.

Please let me know if I can clarify or add to this presentation to make it more useful for you.

An Analysis of the Final Standards Rule

At 10am today, the final Standards Rule was released as described on my previous blog. Here are additional details for stakeholders who want a technical analysis.

ONC received many comments on the balance between specificity (which can make certification and implementation easier) and generality (which can enable more rapid innovation). The Final Standards Rule achieves an optimal balance by providing very specific implementation guidance for mature standards and leaving flexibility for those still in evolution or without significant industry deployment

Content Standards

Patient Summary Record

Standard - HL7 Clinical Document Architecture (CDA) Release 2, Continuity of Care Document (CCD)

Implementation specifications - The Healthcare Information Technology Standards Panel (HITSP) Summary Documents Using HL7 CCD Component HITSP/C32

OR

Standard - ASTM E2369 Standard Specification for Continuity of Care Record and Adjunct to ASTM E2369

Electronic Prescribing

Standard - The National Council for the Prescription Drug

Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT standard, Implementation Guide Version 8, Release 1 (Version 8.1) October 2005

OR

Standard - NCPDP SCRIPT Standard, Implementation Guide, Version 10.6

Electronic Submission of Lab Results to Public Agencies

Standard - HL7 2.5.1

Implementation specifications - HL7 Version 2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1

Electronic submission to public health agencies for surveillance or reporting

Standard - HL7 2.3.1

OR

Standard - HL7 2.5.1

Implementation specifications - Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification

Electronic submission to immunization registries

Standard - HL7 2.3.1

Implementation specifications - Implementation Guide for Immunization Data Transactions using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol Implementation Guide Version 2.2

OR

Standard - HL7 2.5.1

Implementation specifications - HL7 2.5.1 Implementation Guide for Immunization Messaging Release 1.0

Quality Reporting

Standard - The CMS Physician Quality Reporting Initiative (PQRI) 2009 Registry XML Specification

Implementation specifications - Physician Quality Reporting Initiative Measure Specifications Manual for Claims and Registry

Vocabulary Standards

Problem List

Standard - The code set specified at 45 CFR 162.1002(a)(1) for the indicated conditions (i.e. ICD9-CM)

OR

Standard - International Health Terminology Standards Development Organization (IHTSDO) Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) July 2009 version

Procedures

Standard - The code set specified at 45 CFR 162.1002(a)(2). (2) Standard. The code set specified at 45 CFR 162.1002(a)(5) (i.e. CPT-4)

Laboratory test results

Standard - Logical Observation Identifiers Names and Codes (LOINC®) version 2.27

Medications

Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine.

Immunizations

Standard - HL7 Standard Code Set CVX - Vaccines Administered, July 30, 2009 version

Race and Ethnicity

Standard - The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directory No. 15, October 30, 1997

Privacy and Security (includes transport standards)

Encryption and decryption of electronic health information

In general - Any encryption algorithm identified by the National Institute of Standards and Technology (NIST) as an approved security function in Annex A of the Federal Information Processing Standards (FIPS) Publication 140-2

For data exchange - Any encrypted and integrity protected link

Record actions related to electronic health information

The date, time, patient identification, and user identification must be recorded when electronic health information is created, modified, accessed, or deleted; and an indication of which action(s) occurred and by whom must also be recorded

Verification that electronic health information has not been altered in transit

Standard - A hashing algorithm with a security strength equal to or greater than SHA-1 (Secure Hash Algorithm (SHA-1) as specified by the National Institute of Standards and Technology (NIST) in FIPS PUB 180-3 (October, 2008)) must be used to verify that electronic health information has not been altered.

Record treatment, payment, and health care operations disclosures

The date, time, patient identification, user identification, and a description of the disclosure must be recorded for disclosures for treatment, payment, and health care operations, as these terms are defined at 45 CFR 164.501

Of note, REST and SOAP were removed as specified transport standards, enabling flexibility for secure transmission as long as data are encrypted and integrity assured. This will enable innovation such as we've seen with the NHIN Direct Project and several State HIE Efforts.

I'm quite pleased with the balance achieved by ONC. The major recommendations of the Federal Advisory Committees have all been incorporated, enabling the industry to move forward with enhanced interoperability in a way that is technologically achievable today.

Meaningful Use and the Standards are Finalized

Today at 10am, CMS and ONC released the final rules that will guide electronic health record rollouts for the next 5 years. Key resources include

New England Journal of Medicine overview. The table provides a detailed list of final meaningful use requirements.

Federal Register publication of the Meaningful Use regulation

Federal Register publication of the Standards regulation

Here's my analysis of the key changes in the Final Rule.

1. HHS has adopted the HIT Policy Committee recommendation to frame Meaningful Use as core requirements and discretionary requirements. In so doing, they have reduced the total number of requirements and introduced choice.

In the NPRM there were 25 requirements for Eligible Professionals and 23 for hospitals.

In the Final Rule there are 15 core requirements for Eligible Professionals and 14 for hospitals.

There are 10 discretionary requirements from which 5 must be chosen.

2. Thresholds have been reduced in many cases. For example, CPOE had a threshold of 80% of orders for Eligible Professionals and 10% of orders for hospitals. The language in the final rule focuses on order entry of medications and requires that 30% of patients with medication orders to have at least 1 medication order entered electronically. This requirement applies to both Eligible Professionals and Hospitals.

3. Administrative Simplification has been postponed to Stage 2.

4. Decision Support rules changed from 5 to 1

5. Required Clinical quality measures have been reduced to 6 for professionals and 15 for hospitals. For professionals, there are 3 core measures required, 3 alternative core measures, and a choice of 3 from a pool of discretionary measures. Reporting by attestation is required in 2011, electronic reporting is required in 2012. Clinical quality measurements for specialists have been eliminated for stage 1. There has been great effort to align meaningful use with PQRI measures.

6. The NPRM did not include the recording of advanced directives or a provision for providing patients with educational materials. The final rule includes these as discretionary meaningful use requirements.

Overall this final rule maintains a balance between the policy objectives sought and the technology changes possible that are achievable now. There will still be 3 stages of meaningful use and later stages will be more demanding. All the original stage 1 requirements will still be part of meaningful use by stage 2.

In January of 2011, the clinicians may begin the 90 day process of using a certified record per meaningful use requirements. Attestation of this use begins in April 2011. CMS payments will begin May 2011.

ONC also released the final rule on Standards and Certification today. They have done a remarkable job adding detailed implementation guidance specificity for patient care summaries, public health laboratory reporting, syndromic surveillance, and immunizations. It's a tricky balance to ensure there is enough specificity to test and certify EHRs and modules for interoperability while at the same time encouraging innovation. The final rule issued today achieves that balance perfectly, ensuring that only mature implementation guides are specified, leaving room for innovation in such as areas as how to transport data from point to point via NHIN Direct and other demonstration projects.

Overall, a very good day for ONC, HHS and stakeholders. The final rule means Meaningful Use will be achievable by many. The Standards and the process to certify their use are sufficiently specific. I'm impressed.

Dawn, Sunrise, Twilight, Sunset and Dusk

In last Thursday's blog, I described early morning walks with my wife after we rise at dawn. I promised to describe what "dawn" means.

Dawn is the time that marks the beginning of the twilight before sunrise. Per the definitions below, there is astronomical dawn, nautical dawn, and civil dawn.

Sunrise is the instant at which the upper edge of the Sun appears above the horizon in the east.

Twilight is the time between dawn and sunrise, and between sunset and dusk. Per the definitions below, there is astronomical twilight, nautical twilight, and civil twilight.

Sunset is the daily disappearance of the sun below the horizon as a result of the Earth's rotation.

Dusk is the beginning of darkness in the evening. Per the definitions below, there is astronomical dawn, nautical dawn and civil dusk.

Morning civil twilight begins when the geometric center of the sun is 6° below the horizon (the point of civil dawn), and ends at sunrise. Evening civil twilight begins at sunset and ends when the center of the sun reaches 6° below the horizon (the point of civil dusk). In general, civil twilight is the point where artificial illumination is required to read outside.

Nautical twilight is the time when the center of the sun is between 6° and 12° below the horizon. In general, nautical twilight ends when navigation via the horizon at sea is no longer possible.

Astronomical twilight is the time when the center of the Sun is between 12° and 18° below the horizon. In general, the end of astronomical twilight is the point where the sky is no longer illuminated by the sun and is dark enough for all astronomical observations.

All of this is summarized in the graphic above.

So when I say that I walk with my wife at dawn, I mean that we rise at civil dawn and begin our walk in civil twilight, ending it after sunrise.

Never again will you confuse dawn with sunrise or sunset with dusk!