The July meeting of the HIT Standards Committee

The July meeting of the HIT Standards Committee included important discussions of certification for post acute care and behavior health applications, review of data segmentation for privacy,  analysis of provider directory standards, an update on the standards/interoperability framework projects, and a first look at the new subcommittee co-chairs of the Standards Committee.

We started the meeting with a review of attestation data by Jennifer King. Jacob Reider reminded us not to judge the trajectory of the project based on the those who attested early.    The data indicates that the bulk of attestations were completed using just a few vendor products, implying that 2014 certified products from multiple vendors are not yet widely implemented.   I asked if any updates were available about the NPRM to offer more flexibility for stage 2 attestation.   HHS is still reviewing the comments, so there is no specific new information that the NPRM will be finalized and we all should continue our work on existing stage 2 criteria during this last federal quarter of 2014.

We next heard from Larry Wolf about the multi-stakeholder effort to specify certification criteria for long term post acute care and behavioral health .  The motivation for this work is to create interoperability and standardization, bringing LTPAC/BH stakeholders into the same ecosystem as those providers participating in the meaningful use program.   Thus far LTPAC/BH vendors have been very interested in the reputational benefits and possible market share gains available from having certified software.   The workgroup did an amazing job specifying high value certification criteria.

Next we heard from Deven McGraw about advances in standards work for Data Segmentation that enables more granular patient control over healthcare information exchange.   An important motivator for this effort is 42 CFR Part 2 which protects the privacy of substance abuse treatment records.   The workgroup was very practical and presented a multi-phased approach that incrementally improves EHR technology.   The first step would be to add a “lockbox” that receives content that cannot be redistributed without additional consent.   If a patient consents to disclose substance abuse treatment from institution A for transmission to institution B, then institution B cannot share that information with institution C unless the patient is re-consented.   The Standards Committee will review the recommendations and standards for for their implementability.   I hope there are early industry pilots that help us learn how best to implement novel consent and privacy controls.

Next, Dixie Baker presented a Provider Directory standards update.   The committee adopted their recommendations which were - no mature standards for provider directory query exist, ONC should organize pilots of simple RESTful/FHIR approaches,  and the National Provider Identifier database should be considered as a potential infrastructure to host provider Direct addresses.

Next, Steve Posnack presented an update on S&I Framework projects.    He also announced that ONC would be encouraging industry and provider stakeholder groups to develop test procedures so that we do not repeat the experience of Stage 2 - test procedures and scripts that are burdensome and not aligned with real world workflow.

Finally, Jacob Reider reviewed the new subcommittee structure of the HIT Standards Committee including co-chairs.   The co-chair of the steering committee is still a work in process.

A very productive meeting.   I look forward to the work ahead as we focus our attention on standards needed to support Stage 3 of meaningful use focusing on fewer use cases in greater depth.

A New Arrival at Unity Farm

Today at 5pm,  our first baby alpaca was born at Unity Farm.   She's 17 pounds and her name is Sunny.    She's eating well and running around the paddock.   The herd is caring for her attentively.

My only role was caring for mom and ensuring the placenta was delivered intact.  Here's a photo of her first steps.

Unity Farm Journal - Second Week of July 2014

I returned from Japan to find that 9 baby guineas (keets) raised by ducks had hatched.   We have one adult white guinea and its genetics seem recessive - of the 100+ keets we’ve hatched there have been no whites.   In this batch, we finally got a white.   Since our one adult white is sitting on a batch of 40 eggs, it’s possible that more whites are on the way.   During the Summer, our guineas build nests and spend the night outside the coop.    At the moment we have 21 guineas roosting in the coop, six sitting on nests, four babies in the mini-coop, and nine in the brooder (pictured below)

Luckily no baby alpaca (cria) arrived during my travels.   I really want to be present to attend their births.   I have just a few days of travel left this Summer.  Let’s hope the alpaca do not pick a travel day!

The hoop house continues to produce an immense amounts of vegetables.    This week we harvested cucumbers which we’ll making in our sweet Unity pickles.

Many flowers are blossoming in the heat of summer, attracting hummingbirds and butterflies, like this painted lady.

The bee hives are continuing to grow during the peak of nectar flow.   We've spun 18 frames of honey and this weekend we hope to spin 9 more.

The animals are thriving, the apples are beginning to fruit, and the meadows are exploding with color.  Even the tree frogs are dropping by for a visit.

Crafting a Next Generation IT strategy

During my 16 years as CIO, I’ve witnessed the transition from client server to web, from desktops to
mobile, and from locally hosted to cloud.  

As Beth Israel Deaconess merges and acquires more hospitals, more practices and more care management capabilities, what are its strategic IT choices?

I will not even mention “best of breed”, because I think the industry has abandoned such a strategy as unworkable in an era when everyone needs access to everything for care coordination, population health, and patient/family engagement.

The choices are basically two

a.  Single monolithic vendor application for everyone everywhere
b.  Best of Suite - the smallest number of applications/modules that meet the need for business integration (defined in the graphic above)

It’s extremely popular among academic medical centers, ACOs, and healthcare systems to choose “A”, often at great cost.

BIDMC has a 30 year tradition of building and buying systems balancing costs, agility, and functionality.

As I plan for the next generation of IT systems, I favor “B” and believe I can achieve our business goals in shorter time, at lower cost, with less risk.

Here’s the thinking.  

1.  At BIDMC, we need a web-based, mobile friendly, cloud hosted solution that has the agility to support rapidly evolving research, education, and clinical requirements.   The culture at BIDMC is not top down, command/control, willing to compromise but bottom up, collaborative, and impatient for innovation.    We will continue to build the core clinical systems at BIDMC until there is a vendor application that meets the cultural requirements and is affordable.

2.  At all other sites, we will use cloud hosted inpatient and ambulatory vendor-based systems that are aligned with the business requirements and culture of the institutions.

3.  Our budgets are very limited to serve 22,000 users and 3000 doctors.  Operating budgets for IT are 1.9% of the total spend.   Capital is about $10 million a year.   One time capital for major IT initiatives is unlikely to ever exceed $20 million.    When I hear about expenditures of hundreds of millions for IT systems, I really wonder how the economics are sustainable.

4.  Interoperability for care coordination across a small number of applications is possible via bidirectional viewing, pushing summaries, and pulling records via the state healthcare information highway.

5.  Business intelligence/analytics across the network is supported by financial and clinical registries, populated via well described interfaces.

Over the next 90 days stakeholders from throughout the organization will complete the next generation IT plan as follows:

July - strategy complete, draft budgets submitted
August - organizational structure for unified enterprise IT proposed, budgets finalized
September - staffing plan finalized and timelines aligned for execution beginning October 1

As with any plan, change management will be the most challenging aspect, balancing time, resources, and scope.

Over the coming months, I’ll share the decisions we’ve made for a cloud of community hospital functionality and a cloud of ambulatory EHR functionality that unifies all our practices.

On Top of Mt. Fuji

July 4 began with a breakfast meeting to discuss cloud computing with Japanese industry leaders.   Japanese industry is ready to provide cloud solutions, but there are policy and adoption barriers including privacy protection, service level guarantees, and general distrust of the internet as a transport mechanism for healthcare data.     To explore these barriers, I visited the Japanese Medical Association for lunch and had a remarkable discussion while walking in the Rikugien Gardens.   I spent the afternoon with policymakers at the Japanese Ministry of Health, Welfare and Labor.    We reviewed the Beth Israel Deaconess clinical systems, Massachusetts eHealth Collaborative Quality Data Center and  the Massachusetts Health Information Highway as examples of private/public collaboration for public health, population health, and care management cloud-based applications.

The meeting ended at 3:30pm I took a taxi to the Shinjuku West Bus Terminal where my Japanese hiking partner (Dr. Nagata) and I exchanged our business suits for hiking gear.   After stashing our computers and luggage in a locker we boarded the Fuji bus carrying water, food (onigiri rice balls), and the appropriate clothing we'd need to climb the 12,376 foot Mt. Fuji in rain, light snow, and freezing temperatures.   I travel internationally with carry on baggage, so I had to be very minimalistic in choosing the hiking gear to bring.

Our plan was to do a "bullet climb" - from the trailhead of the Yoshida trail to the summit of Fuji without stopping to rest/sleep at the mountain huts along the way.    The trail was uncrowded given the bad weather and cold summit of early July.      The trailhead weather was in the high 40's F and raining.    Hiking in warm wet weather in total body Gore-tex is always a clammy experience.    In a few hours, we climbed to 10, 170 feet, the 8th station, without feeling any altitude effects.    As an experiment, we carried a small pulse oximeter and found that at 10,000 feet our oxygen saturation was about 95 with a pulse rate in the 80's.

The trail from the 8th station to the summit becomes much steeper, with loose, wet, volcanic rock.  At this point those hikers who brought running shoes have difficulty traversing the trail.   It's also the point at which the temperature drops and altitude effects become noticeable.    Our goal was a steady pace and we climbed to the 8.5th station, the 9th station, and finally the summit arriving at 2:30am to light snow, 10 mph winds and freezing temperatures.     Since twilight and sunrise viewing would be best 3:30am-4:30am, we decided to sleep a bit on the platforms near the shrine at the summit.    Hiking at freezing temperatures in a base layer and gore-tex is easy, but sleeping is challenging.  We did have mid layers for warmth which we added as our bodies cooled down.    While at rest our oxygen saturation varied from 88 to 92 with a pulse of about 100.  

We were the first hikers on the summit that morning and we watched the line of headlamps snaking up the mountain from our summit perch.

Between 4am-4:30am, the clouds parted and we saw the sunrise - the rising sun from the highest point in the land of the rising sun.

After sunrise we explored the crater of Mt. Fuji and then began our descent through the large Torii gate at the summit.   We walked through thick cloud cover and pouring rain, arriving back at the trailhead by 8am.     In retrospect, I had a 24 hour day that began and ended with a discussion of "clouds" in Japan.

Unity Farm Journal - First week of July 2014

While I’m in Japan, Kathy has her hands full at Unity Farm.   I did my best to prepare the farm for my 5 days away including building bee hive supplies, ensuring the health of all the animals, and completing all the monthly maintenance tasks.

As I’ve posted before, Guinea fowl are horrible parents.  They lay eggs in a communal pile then assign a designated layer to incubate them.  When the eggs hatch the young have to find their way to the coop, often through tall wet grass and through predator laden terrain.   Most don’t make it.   This year, we’re helping them a bit.

The ducks hatched 4 guineas and kept the babies (keets) warm and safe in a brooder for 2 weeks before moving them into the coop.   It’s likely the adults would attack them if they ran free in the barnyard, so we had to build a protected enclosure - a coop within a coop.  I call it the mini-cooper (sounds like a catchy name).   Here’s a photo of the keets enjoying their new coop space, safe from the adults.

The ducks have been sitting on another 17 eggs and we moved them from the duck house to the incubator before I left to prevent Kathy’s having to keep newly hatched birds from drowning in the duck pond (Guineas can’t swim).

At the moment, we have two large nests on the farm - one to the north near the hoop house with about 40 eggs and another to the south with about 30 eggs.   Two designed female guineas keep the eggs warm all night and thus far have not been attacked by nighttime predators.   The keets should hatch July 18, so we’ll be on the lookout and rescue them if needed.    We have 30 guineas today (and could accommodate 50),  Every summer we lose some to predators, so the new additions are likely to keep the population stable.

Over the weekend we weighed, immunized, and examined every animal in the farm.  Two of the alpaca are pregnant (Mint and Persia).   Their abdomens are round and their breasts are filling with milk.   We believe they will deliver in the next 30 days after an 11 1/2 month gestation.   Baby alpaca are called cria and these will be the first new alpaca born on the farm.   Every day is a cria watch.  I really hope they do not deliver while I’m in Japan.

Belle, the duck with the injured eye is healing fast and after 3 weeks of antibiotics, she has returned to her daily duck activities - swimming in the pond, hunting for insects, and nest building with her comrades.

We inspected the bee hives and added queens to two of them, given that lack of eggs in the brood boxes that implies the old queens have died.   Normally, the bees would have made “emergency queens” by feeding royal jelly to a developing bee, but in this case, there were no queen cells in the hives, implying that the queen’s death must have been rapid and unexpected.

Shiro, our 125 pound male Great Pyrenees, turned 2 years old this week.     When he was born, a blue ribbon was placed around his neck.    Today he wears a blue collar.   Here are “before” and “after” pictures.

Next weekend I'll be hauling logs and cleaning up any debris for the hurricane that is on track to hit the East Cost on Friday.

Dispatch from Tokyo

I’m in Japan today lecturing at the TOPOS Conference. per the request of several colleagues.  Think of it as TED in Tokyo.    I’ve been asked to discuss the Meaning of Life in an Aging Society without referencing Healthcare IT, which is a real challenge for a CIO.

The approach I’ve taken is to explore life through the eyes of those in my family - my father who passed away last March, my mother, my wife and my daughter.   I’m reviewing our experiences together and the impact they’ve had on my life, while recounting what is meaningful to them.   Here’s the powerpoint I’m using.

Tomorrow will be a day of meetings with government, academic, and industry leaders to discuss the use of cloud computing in Japanese healthcare.   Although there have been examples of cloud computing used after 3/11 (the great Tohoku earthquake, tsunami, and Fukushima nuclear plant destruction) there is still great distrust of the cloud.    The internet in Japan is considered a swamp of malware and bad actors, which it is.  However, there are technologies and policies that can ensure the data integrity and privacy of patient identified data.

Japan does not need more locally installed large servers, it needs a cloud of low cost commodity servers distributed geographically such that any natural event will not cause data loss or disruption.

After my meetings, I will climb Mt. Fuji over night, with the hope of watching the sunrise from 12,500 feet - the rising sun in the land of the rising sun.   The mountain opens for hiking on July 1, so early July is generally the time less traveled.   There will be subfreezing temperatures and light snow at the top, but 70F temperatures at the bottom.   I’ve already told my hiking partner, a professor from Kyushu University, that summiting is optional.   Returning to Tokyo is mandatory.

Wish me luck.