Thoughts on my Daughter's Graduation

Last Friday, my daughter graduated from Wellesley High School.

Just as it was a milestone for her, it was a pivotal life event for her parents.

Lara was born 18 years ago.   We had no idea who she would be or what she would become.

During her early years, I was an Emergency Medicine resident.   The nature of shift work meant that I could spent at least 12 hours of every 24 hour cycle with her - reading, walking on the beach, going to the park, strolling the Los Angeles zoo, and playing her favorite computer games - Pajama Sam, Freddie Fish, and Spy Fox.

We moved to Massachusetts when she was 3, exactly 15 years ago this week.    My Emergency Medicine faculty and Informatics Fellow schedule enabled us to explore nature, hunt geocaches, and camp on the Boston Harbor Islands.

As I became a CIO, life became a bit more complicated, but every weekend we went to Drumlin Farm, Broadmoor, and other Audubon sites.

By the time she was an adolescent the time spent together evolved to time spent with her friends, extracurricular activities, and schoolwork.   I served as her transportation, advisor, and editor.

As she blossomed into an adult, we became peers, having honest and open dialog about relationships, world events, and the challenges ahead.

All along the path, we tried to give her the latitude to celebrate her own successes, learn from her own mistakes, and experience the many facets of the 21st century world - within limits that kept her from going seriously off track.

She begins college in just 2 short months, making decisions about when to sleep, what to eat, and how to study, all on her own.    Her house will be here whenever she wants to visit and her parents will be available whenever she wants to call.   We'll not have the pitter-patter of her feet on the stairs, the ebb and flow of her friends, or the vibrant but sometimes unpredictable schedules she added to our lives.

Her parents will garden, travel, rekindle their 30 years of romance together, plan for the future, and write checks for college.

Based on all my conversations with other parents, I know that this transition is truly not saying goodbye and declaring the end of parenthood.   It's the beginning of another chapter filled with new demands, more complex issues, and expanded possibilities.

As she graduates, the most important thing I can offer is my love and support, including a clear expectation of what I believe will constitute success in her next phase of life.   This poem by Ralph Waldo Emerson says it better than I can:

Success

To laugh often and much;
To win the respect of intelligent;
people and the affection of children;
To earn the appreciation of honest
critics and endure the betrayal of false friends;
To appreciate beauty, to find the best in others;
To leave the world a bit better,
whether by a healthy child, a garden patch,
or a redeemed social condition;
To know even one life has breathed
easier because you have lived.
This is to have succeeded

So Lara, congratulations on an extraordinary high school career.   Now, go define your own success.   We'll be here to beam with pride.

Harmonizing Provider Directory Standards

Two weeks ago, I wrote about a strawman for embracing internet-based standards to support the provider directory services needed by health information exchanges.

Wes Rishel wrote a blog post about a related approach to creating provider directories and exchange certificates using microformats embedded in web pages that are protected by Extended Validation Certificates to provide assurance that the information is trustworthy.  

Microformats are a simple idea - using standard tags embedded in simple web pages to create semantic interoperability, empower search, and enable standard visualization of data.  Microformats are already in use for calendaring and have been proposed for other standard information sources such as recipes and resumes.  Extended Validation Certificates are standard X.509 digital certificates issued using strict identity-verification criteria.  

As we prepare for the next HIT standards committee meeting, many people are thinking about the best approach for building an industry-wide provider-directory capability using simple web standards.   A guiding principle of the HIT Standards Committee is to “Keep it simple; think big, but start small; recommend standards as minimal as possible to support the business goal and then build as you go” . This eliminates most complex implementation guides based on assembling esoteric, seldomly implemented, non-internet friendly standards.

The committee will find use of generalized internet standards such as DNS and simple XML tagging structures such as microformats very appealing.

Is there a combination of the approach I suggested on my blog and the approach suggested by Wes that works?

I think so.

As Wes notes in his blog, exchanging health information using Direct requires a “Direct Address.”  Nationwide Health Information Network (NwHIN) enterprises other than those using Direct have no common addressing scheme.   Creating a .HEALTH Top Level Domain with an entry for each entity participating in health information exchange would create an easily recognizable addressing scheme for the industry.   These addresses could point to highly trusted microformatted web pages containing directory information and certificate data, creating a directory solution without changing existing business models or processes.   This could be a winning approach.

Direct has chosen DNS for certificate distribution and although the DNS standard supports this function, no one other than Direct has used this approach for certificate management.  Indeed, not all Direct participants use this approach.

The NwHIN, including but not limited to Direct participants,  requires routing information to exchange information between entities.

Would it be much cleaner to have a top level domain that encompasses all  entities which exchange health information, including but not limited to NwHIN Exchange and Direct participants, and that provides an index of secure microformatted web pages containing certificates and other directory information for all participants in health information exchange?

We'll have several calls and meetings on this subject over the next few weeks.    Expect a convergence and recommendations soon.

ICD10 Kickoff meeting

Although BIDMC has finished its 5010 work in anticipation of the January 1, 2012 deadline, we're just beginning our ICD10 project for an October 1, 2013 go live.

As I've written about previously, I believe that ICD10 implementation should be delayed until after Meaningful Use Stage 3 (2016) to enable widespread adoption of structured clinical documentation including vocabularies like SNOMED-CT which will provide the necessary detail for coders using ICD10.   Moving forward with ICD10 in the absence of enhanced electronic clinical documentation makes no sense.

That being said, we need to follow the October 2013 timeline, as that is the current requirement.

Our ICD10 Steering Committee includes a multi-stakeholder group from inpatient, ambulatory, finance, HIM, our physician's organization,  and IS.   ICD10 is not an IS project, but is an enterprise project involving all operational areas.

To ensure a common understanding about the scope of work ahead, I've prepared this presentation.

I've also circulated a sample project plan from the American Medical Association.

At our first meeting, we'll need to select a project manager and allocate the resources for the detailed work ahead including

*completing an inventory systems where ICD info is housed.
*checking with each of the software vendors so impacted to see if the current version of their software can support the extended characters and transitional issues
*determining the state of our software installs and plans for upgrades to compliant versions
*checking payer contracts for use of ICD10 codes
*creating test plans for pre-production cutover
*conducting training sessions for our coding staff on ICD10
*contacting payers on their timeframe for being compliant and arranging pre-production test plans
*checking web reporting systems such as State, Federal, or others on use of ICD10 codes

If ICD10 was delayed until 2016, our approach would be different.    We'd focus on getting widespread provider adoption of SNOMED-CT on the front end, then limit ICD10 implementation to back office functions, mapping clinically focused SNOMED-CT codes to administrative ICD10 codes for billing.  Let's hope wise folks at CMS realize the benefits of such an approach.

Until then, our project will march ahead.

The Accounting of Disclosures NPRM

On May 31, HHS Published a notice of proposed rulemaking (NPRM) on the HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act (HITECH).

Here's Robin Raiford's bookmarked version of it.

The purpose of the NPRM is to implement the statutory requirement under HITECH to require covered entities and business associates to account for disclosures of protected health information to carry out treatment, payment, and health care operations if such disclosures are through an electronic health record.

Remember that HIPAA did not require disclosure logging for treatment, payment and operations.  This revision does, when such data is disclosed/accessed via an EHR.

In the certification process, demonstrating accounting of disclosures is optional, so it's likely many certified EHRs lack accounting of disclosure functionality.

Wes Rishel wisely warns us that this may be very challenging to implement for hospitals with complex built and bought systems.

Here's Rebecca Herold's blog summarizing the major points of the NPRM.

She also describes the definition of a designated record set.

Under the current provisions of the HIPAA Privacy Rule, covered entities are required to maintain records on disclosures of protected health information for a period of six years, and to furnish an accounting of disclosures to individuals who request them. The HIPAA Privacy Rule included an exemption for disclosures for the purposes of treatment, payment, health care operations, and a variety of other special circumstances, including disclosures to the individual of their own PHI. Collectively, the excepted purposes constituted the vast majority of  disclosure.  HIPAA also covered all PHI, whether in paper or electronic form. HITECH shortened the accounting period to three years, but removed the exemptions for treatment, payment, and health care operations when the disclosure of information is from an EHR.  The NPRM explicitly lists the types of disclosures that are subject to the accounting of disclosure requirement, rather than the prior approach of generally requiring inclusion but enumerating specific exceptions.

The NPRM does exempt disclosures made through a health information exchange, noting that the technology to track such disclosures is still evolving.   The authors state

"as electronic health information exchange expands and standards for such exchange are adopted, we intend to work with ONC to assess whether such standards should include information about the purpose of each exchange transaction. Adoption of such standards may significantly reduce the burden on covered entities to account for treatment, payment, and health care operations disclosures through electronic health information exchange. We then intend to revisit this issue and determine whether the accounting requirements should be revised to encompass such disclosures, in light of the interests of individuals and the reduced burden on covered entities."

The burden of implementing this regulation, especially in complex organizations with many departmental systems, could be very high.

I'll watch the comment period very closely.

Cool Technology of the Week

As BIDMC creates automated workflows, moving from a hybrid paper-electronic record to a completely electronic record, we are supporting multiple approaches to capture the data.   We use electronic forms, web-based structured documentation, voice recognition, PDF files with metadata that inserts them into the correct record, and scanning.

Today, Ricoh introduced the eWriter Solution, a combination digital clipboard and cloud based solution for capturing structured data such as consents, patient intake information, and home care data.   It uses an e-Ink display with WiFi/3G/GPS built in and a 20 hour battery life.

The idea is simple - when forms are created, they have an appearance just like paper using the same display as the Kindle.   A stylus is used to check boxes, add free text, sign forms etc.   Data is sent to cloud servers as PDFs, XML-encoded structured data, and pen pressure/velocity metadata to provide reliable assurance that a signature is real, should forensics ever be needed.

This approach works very well for those workflows that are highly distributed in sites without significant IT support, for workers who have an affinity for paper and find the use of iPads/iPods/iPhones a challenging learning curve, and for those tasks that easily automated through the use of pre-populated forms with largely structured responses.

Gathering signatures on pre-op consents is most often done in the community setting.  Capturing consents electronically in small provider offices via a cloud-based service makes great sense.

A wireless clipboard based on the e-ink display with cloud based services to gather structured data.

That's cool!

Choosing a Great Single Malt

During my trip to Scotland I had the opportunity to learn more about single malts from my Scottish hosts.  If you really want to choose a great whisky, ask a Scotsman!

Andrew Morris, a Professor at the University of Dundee, and the person who invited me to Scotland, is a member of the Royal and Ancient Golf Club in St. Andrews.  For golfers, this is a sacred place, the home of golf.   Andrew is a member,  a remarkable honor since only 300 people in all of Scotland are members.   As we entered the club, I walked by the British Open trophy which sits next to the lockers of club members.   I looked at the name plate closest to me - "A. Palmer".

We retired to the "Great Room" under a painting of the Queen and asked about the single malts served by the club.   They serve two which are produced exclusively for the Royal and Ancient - an Islay (pronounced eye-lay) bottling from Western Scotland and a Speyside bottling from Eastern Scotland.    Western single malts are often more Peaty/Smokey/Earthy in character while Eastern single malts are more subtle with flavors of sherry and vanilla imparted from the casks they are aged in.   I ordered the Speyside and added just a drop of water to release the aroma.   Over 30 minutes I cradled the glass, sipping slowly to savor the amazing nose and palate.

As we left the Royal and Ancient at 10pm, people were still golfing on the 18th hole of the Old Course.

Here are the favorites suggested by the folks in Scotland I asked:

Lagavulin (Islay) - a smokey, peaty, complex  whisky  that is considered by many to be the finest single malt made in Scotland.   On most restaurant menus it commands a higher price because of its reputation and quality.

Highland Park (Orkney Islands) - a peaty whisky with a sweet/sour finish and subtle vanilla flavors.  The northernmost distillery in Scotland.

Talisker (Skye) - a peaty whisky, from the only distillery on Skye.  Robert Louis Stevenson regarded Talisker as 'the king of drinks' and who would argue with him?

There are many myths about Scotland - that kilt wearing, bag pipe playing,  freedom loving men (per Braveheart), are thrifty with their money and enjoy a wee dram in the pub on a daily basis.    I saw no kilts, heard no bag pipes, and although we did rehydrate at pubs after our hikes with fine Scottish ales, the only whisky I consumed was at the Royal and Ancient.   The Scottish are warm, gregarious, and selfless hosts.

Thank you Andrew for a remarkable experience and an amazing education about Scotland and its people.   I'll raise a toast with a freshly opened bottle of Lagavulin.

HIT Lessons Learned from Scotland

My trip to Scotland provided a remarkable opportunity to exchange ideas and experiences.

Scotland has nearly 100% adoption of electronic health records among general practioners and is making good progress in hospitals with innovative built/bought inpatient systems.   As in most countries, health information exchange is still evolving, but novel databases supporting disease management at the community level and an emergency care summary exchange are already live.

Here's what I learned while in Scotland

1.  Scotland has 5 million people - about the same size as Massachusetts.    There's a real "can do" attitude that makes significant change at the national and regional level possible.

2.  General Practictioners are passionate about IT.   There are 2 major electronic health records (Vision and EMIS) used in ambulatory settings in Scotland.  I was able to test them with demonstration patients and they seem to be a bit more focused on creating a journal of patient health events as compared to EHRs in the US which follow the Meaningful Use paradigm of structured problem lists,  e-prescribed medications, allergies, notes/reports, and coded diagnostic results.

3.  Healthcare information exchange between EHRs and hospitals is document centric.   My limited experience suggests that clinical encounter summaries in Scotland are shared via episode of care documents rather than structured data element exchange.

4.  There is a national healthcare identifier which enables records to be coordinated and aggregated in a national emergency care database, registries, and for continuity among caregivers.

5.  The National Health Service provides comprehensive care across all settings and therefore can drive innovation and adoption across the country.

Scotland has many of the same healthcare challenges as the US - increasing obesity, earlier onset and increased numbers of diabetics, and the worldwide issues of tobacco and alcohol use.  

Through the use of careplans/guidelines, registries, electronic health records, and care coordination across the community, Scotland is hard at work improving public health and population health.   I think of Scotland as an extraordinary testbed for healthcare IT implementation.  With its high adoption of EHRs among community clinicians, its bottom up approach to creating automation to meet the need of hospital stakeholders at a local level, and its population size that makes implementation doable, I highly recommend that vendors partner with Scottish healthcare provider organizations to test innovative solutions which can then be spread throughout the world after successful pilots.

Thanks for Andrew Morris and the University of Dundee for hosting me.  I look forward to our further work together.