Making Patient Engagement Useful

Stage 2 of Meaningful Use is likely to include numerous patient engagement features.

BIDMC has been offering Personal Health Records since 1999 and we've learned that patient information must be organized appropriately and wrapped in patient education materials so that the data is transformed into knowledge, and is actionable.

I recently visited my PCP for an annual physical.  Ok, to be honest it was my first visit in 4 years since as a physician I am uniquely poor at seeking regular preventative/wellness care.   My PCP ordered a Urinalysis, a metabolic panel, lipids, and a CBC from Quest.   Quest has a very cool feature that enables patients to upload their lab results into Microsoft Healthvault and Google Health.

Google does a technically elegant but less than useful thing - a list of test names and values in alphabetical order that mixes my urine, chemistry, microbiology, and hematology tests together randomly.    You cannot even tell what is a blood result and what is a urine result.   There are no educational materials.

Microsoft organizes the results by panel, which is great.    Although at times, healthcare data should be organized into attribute-value pairs for mining and analysis, presentation to patients requires persistence of the original format of the lab panels as they were ordered.  Microsoft wisely recognizes this.   The only improvement would be to include educational materials for each test.

BIDMC's Patientsite includes tests clustered in panels as they were ordered, trends them over time, and provides educational materials.

My advice to the industry - please do not consider labs to be discrete data elements, instead treat them as collections of data that are clustered according to body fluid, date, and panel.   The user interface needs to include patient educational materials/self management tools so the patient understands what is being tested and why the result is relevant.

Ideally, after viewing labs, patients should be able to ask their clinicians questions, schedule an appointment, or seek a referral online.   Since most stand-alone Personal Health Records do not include integration into clinician office workflows, patients tend to prefer Personal Health Records that are directly linked to the EHR of their providers, such as those offered by Epic (MyChart), eClinicalWorks (Patient Portal), and self-built provider systems (BIDMC's Patientsite, Partners' Patient Gateway).

If we're going to change the culture so that patients demand personal health records and stewardship of their own data, we need to make the tools usable!

Cool Technology of the Week

CIOs are expected to deliver stability, reliability and security.   Change and unpredictability make this is a very challenging proposition.

The exponential adoption of mobile devices is one of the greatest challenges for CIOs as consumer devices are connected to corporate networks and users expect to run enterprise applications in environments like iPads, iPhones, and Android devices.

At BIDMC, our web applications, distributed via the Imperva web application firewall, work just fine on these mobile devices.

However, we have little control other than policies as to how devices are configured and secured.

Good Technologies provides a suite of products that builds a secure containing for business applications while enabling personal data and applications to co-exist on consumer oriented devices.

Here's an overview of how it works.

Many fellow CIOs across industries have told me that Good provides the controls and security that enables a CIO to keep business applications secure, while allowing customers the freedom of buying and supporting their own personal devices.

A technology that offers consumers choice, while also supporting the CIO's need to protect enterprise applications.

That's cool!

How Does Your Garden Grow?

Thursday blog posts are an opportunity for personal reflection.

This Spring, my wife and I planted flowers and vegetables in the Wellesley Brookside Community Garden (we're plot 13 at the corner of Oakland and Brookside)

Here's a glimpse of the garden as we approach the first day of summer.

Our 5 raised beds include tomatoes, peas, lettuce, eggplant  and basil:

Cutting flowers and climbing vines for the hummingbirds:

Beans, squash, borage, spinach, and thyme

Onions, cucumbers, kale,  parsley, and beets

A hand-built grape trellis, with morning glories, and runner beans.

I also built 2 bird houses (wren/bluebird, and nuthatch/chickadee) and 2 birdfeeders (hummingbird nectar and sunflower seed).

We're already harvesting more lettuce than we can eat.

As we weed, compost, and tend to the garden on nights and weekends,  I leave my Blackberry in the car because unlike this recent article in the Boston Globe, a mental recharge is more about being disconnected than connected.

During quiet times of reflection, I'd rather focus on sunflowers than servers, eggplant than email, nasturtiums rather than networks, mushrooms rather than malware, and gardening rather than Gantt charts.

Society today is so stressed that community volunteer work is considered is distraction, the shortest measurable time is not the nanosecond but the time from the light changing green until the BMW behind you honks, and aggressiveness is confused with leadership.

My garden grows with the family's love and attention to the process of transforming a seed into a delectable shared meal, knowing that our labor created food for the soul as well as the body.

The Massachusetts HIT-HIE Advisory Committee

Today, the Massachusetts HIT-HIE Advisory Committee  begins its work.  The Advisory Committee will serve as a multi-stakeholder advisory body to the Health Information Technology Council,  the Massachusetts HIT governance body chaired by Executive Office of Health and Human Services (EOHHS) Secretary JudyAnn Bigby. The Advisory Committee’s primary focus will be to make recommendations on  the design and implementation of healthcare information exchange (HIE), as well as on other health information technology policies for the Commonwealth.

We'll be reviewing this presentation which includes a review of the HIE work done to date, the proposed State Medicaid Health Plan, and the national standards work ahead.

The key initiatives of the State Medicaid Health Plan (SMHP) include:

EHR Program – Administer the Incentive Payment program enabling payments through the state’s MMIS (Medicaid) system

Direct Project  - Promote the adoption of the Point-to-Point Push capability by providing increased level of documentation, training and a common HIE interface. Extend use case to include some EOHHS Department of Public Health services

Record Locator Service – Enabling a citizen record locator service.  Infrastructure could be leveraged for statewide use.

Provider Directory Interface –  Create/establish a statewide Provider Directory

Public Key Infrastructure (PKI)/Certificate Management  - To support HIE and Medicaid security infrastructure.

Health Information Service Provider – To make HIE services available to providers that meet certain economic and technical qualifications. This is especially targeted to HIE actors not affiliated with larger organizations and networks. Including in this consideration is consumer education and involvement.

Massachusetts Virtual Gateway (VG) upgrade – VG is the front door for many of the Health and Human state services  Enhance this critical service by further increasing support for standards-based interfaces including Direct.

Clinical Database – Enabling a data-marts in support of Meaningful Use measures.

Connection to Quality Data Center – Establish Medicaid performance measure infrastructure leveraging standards-based Quality Data Center service providers.

Formulary/Medication Management - Reducing errors in drug identification by enabling global access to accurate medication data for improving prescription practices and patient compliance using NCPDP 8.1 for Medication History and HL7 for Medication Reconciliation. Electronic Prior Authorization is another area of opportunity.

Re-architecting and Enabling Payment Methodologies – With the advent of payment reform, flexible IT claim processing systems shall be needed to quickly adapt to the evolving ACO (and other) programs and reforms.

Claims Relay Service Analysis and Design Project – Similar to the HL7 and HIPAA Hub concept, this project shall provide a single gateway for the submission of claims for MassHealth (regardless of medical, pharmacy, Dental or Health Safety Net Claims)

Public Health Interfaces (labs, immunizations, syndromic surveillance) – Targeting an EOHHS MA Single End Point (XML Gateway) for a variety of “services” including both HL7 transactions and HIPAA transactions. This includes bi-directional sync and async support.

Statewide HIE Solution Integration Services – Systems Integrator services supporting above project and aggressively advancing the adoption of  statewide HIE services.

Our first task will be reconcile health information exchange planning done to date with the state medicaid health plan and evolving meaningful use stage 2 requirements.

I look forward to the discussion!

Standards Summer Camp

At the April HIT Standards Committee meeting, Doug Fridsma kicked off the Summer of standards - an accelerated effort to support the regulation requirements of Meaningful Use Stage 2.

We've been hard at work with meetings and phone calls since then.   The schedule for standards deliverables has crystalized and here's what we've done and we're doing:

April
Certificate Recommendations

May
Metadata preliminary recommendations
Provider preliminary recommendations
Vocabulary preliminary recommendations

June
Metadata recommendations
Provider Directory recommendations
Patient Matching preliminary recommendations
Vocabulary recommendations

July
Patient Matching recommendations
ePrescribing of discharged medications recommendations
Syndromic Surveillance recommendations
Quality Measurement recommendations

August
Simple Lab Results recommendations
Transitions of Care recommendations
CDA Cleanup recommendations
NwHIN preliminary recommendations

September
NwHIN recommendations
Summary of all recommendations from Summer Camp

The June HIT Standards Committee will include reports from
a.  the metadata workgroup on patient identifiers, data provenance, and privacy flags
b.  evaluation of competing provider directory approaches - LDAP, DNS, and microformats
c.  an early look at strategies for patient matching

We'll also have to consider the implications of recent Policy Committee debate on Meaningful Use Stage 2.    As you'll see in their presentation, there are many requests for new standards.

We'll have an exciting few months ahead.   When our handoff is complete in September, ONC will turn our recommendations into a Notice of Proposed Rulemaking by December/January and the country will have a complete set of Meaningful Use, Standards and Certification regulations finalized in mid-2012.

Given that Meaningful Use Stage 2 will likely be deferred a year (organizations who attest in 2011, can begin the measurement period for stage 2 on October 1, 2013 with attestation on October 1,2014, receiving three years of payment based on stage 1 requirements), this timing should give the industry 18 months to rollout the software changes needed.

Assessing US National Healthcare IT Efforts

As I travel the world speaking about the Health Information Technology for Economic and Clinical Health (HITECH) Act, I'm often asked to present objective evidence that it is making a difference.

Here's the progress thus far:

1.  The HITECH program has elevated our national consciousness about Electronic Health Records (EHR) and moved the market considerably forward.   Every hospital CEO knows the term Meaningful Use and believes it is an important 2011 goal.   On my plane back from Scotland two weeks ago, the person sitting next to me (a scanning software engineer), asked about the impact on Meaningful Use on the scanning software market.    With every strategic affiliation BIDMC proposes, the first question asked is how Health Information Exchange (HIE) will support care coordination and the analytics which support the evolving payment models of healthcare reform.    It's clear that EHR and HIE have become commonplace topics of conversation.

2.  State HIE plans require a focus on e-prescribing, electronic lab result messaging, and clinical summary exchange.    State will have to report metrics.   With publicly reported metrics, you can be sure states will be motivated to accelerate adoption.

3.  Every recipient of federal HIE funds had to create a strategic and operational plan, which is a great step forward.  Those plans are publicly available.   As Beacon community and HIE success stories become widely known, it's likely these HIE plans will be revised so that a network of networks connecting state HIEs together will evolve.

4.  Kaiser recently podcast an interview with Farzad Mostashari, National Coordinator, highlighting the progress thus far.

5.   According to the National Health Information Technology Research Center (HITRC), the HIT Regional Extension Centers nationwide have enrolled more than 50,000 Priority Primary Care Providers (PPCPs) to begin the process of achieving Meaningful Use.

6.  Doug Fridsma notes that Direct Project for health information exchange has support from vendors which constitute 90% of the US IT market share.

7.  For the first time in history, patients are telling me they will not go to a doctor without an EHR, since they view it as essential for quality, safety, and efficiency.

Yes, we'll need to wait a few more months before concrete numbers on Meaningful Use attestation are available.   However, I believe the cultural transformation, leading to widespread support for EHRs in the US, has already happened as a result of the US national healthcare IT efforts.

Cool Technology of the Week

Stolen laptops can have a cost that far exceeds the repurchase or hardware or software.

There is lost work, lost important personal media (such as photographs of family), and possibly confidential data.   Hopefully any mobile device hosting patient data is encrypted.

Hidden App makes software that is analogous to a nanny cam.   Pictures and screen prints of your mobile device are secretly sent to a cloud-based server to assist in recovery of the device.  The cost is $15.00/year.

Here's a great USA Today case study that describes a successful laptop recovery.

A nanny cam for your mobile devices.  That's cool!