Friday, April 30, 2010

My Thanks to HITSP

Today I wrote this email to all HITSP members thanking them for all their service from October 2005 to the present.

Today is a milestone day. The HITSP Contract extension expires but our work will live on as a foundation to meaningful use, standards and certification.

It is my hope that all of us will continue to be part of the ONC processes, providing input to the Federal Advisory Committees, staffing workgroups, and implementing interoperability solutions in our communities.

The HITSP website, containing all the HITSP documents, will continue to be available. ANSI has graciously offered to maintain the website for the next few months until contracts are awarded and other arrangements are made.

The new RFPs have not yet been awarded and we'll continue to watch for those announcements.
What's new in the heatlhcare standards world this month?

The April HIT Standards Committee focused on vocabulary standards, consumer engagement and healthcare reform transactions.

NHIN Direct continued its work to define simple transport implementation guides and addressing specifications.

We'll see the revised Interim Final Rule on Standards and the Notice of Proposed Rulemaking on Meaningful Use before Summer.

A busy time for all as we implement all the standards and interoperability we've all worked so hard to define.

Thank you for all you do and I look forward to seeing you in Washington as we continue our work in a new ONC framework that leverages everything HITSP has accomplished.


CEO Summit at the Governor's HIT Conference

On most Thursdays, I write about something personal. However, this week is filled with special HIT events convened by Massachusetts Governor Deval Patrick.

Today, the Governor's Healthcare IT Conference began with a panel of CEOs from Humedica, Patientkeeper, Vecna, eCW, Microsoft, Intersystems, Concordant, Biscom, Bessemer Ventures, Life Image, EMC, NaviNet, Navigator Ventures, Meditech, and T2Bio.

Here's a summary of their comments

*The uncertainty in meaningful use and standards caused a delay in sales for 6 months, followed by record sales once hospitals and eligible professionals felt confident about their purchases

*Qualified staff is getting harder to find. Over the next few years, there is likely to be a competition for trained healthcare IT professional, similar to the Dot Com era. The states can really help by adding additional resources to community colleges for staff development as we prepare for 50,000 new HIT jobs.

*Medicaid programs and private insurers can accelerate adoption of HIT by aligning incentives. For example, if states and private insurers adopted meaningful use criteria, we could reduce healthcare costs by eliminating redundant testing.

*Massachusetts CEOs emphasized the need for affordable housing and transportation investments so that staff living in lower cost areas can commute to corporate locations.

*Standards, especially a consistent way to transmit clinical data from place to place are enablers.

*Loan programs for clinicians will aid investment today to achieve meaningful use stimulus payments in the future

*Health Information Exchange is a Greatest Good for the Greatest Number activity. State Governments need to provide leadership to ensure the stakeholders in each region are aligned with a single project plan, a single set of transaction priorities, and all the enablers such as regional infrastructure to accelerate adoption of data exchange.

*Regulatory barriers such as variation in privacy laws need state and federal government action to enable data liquidity. For example, revisions in the clinical laboratory improvement act (CLIA) and e-prescribing for controlled substances are already in process.

The afternoon of the conference included a great keynote by David Blumenthal outlining everything ONC has done thus far.

All that remains in the current grant program is the announcement of Beacon Communities, which he said will occur very soon.

Wednesday, April 28, 2010

The April HIT Standards Committee Meeting

The April HIT Standards Committee today had a rich agenda and very active discussion.

We began with an update from the Implementation Workgroup and their desire to make toolkits, accelerators, and best practices available via the web. They'll align their efforts with the Tools and Standards Repository RFP described in my earlier blog.

We next discussed healthcare reform and its requirements for comprehensive insurance plan enrollment standards support as written in SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND PROTOCOLS.

"Not later than 180 days after the date of enactment of this title, the Secretary, in consultation with the HIT Policy Committee and the HIT Standards Committee, shall develop interoperable and secure standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs, as determined by the Secretary."

As David Blumenthal described it, the intent of this provision is to make signing up for insurance as easy as using an ATM card. All the supportive transactions including identity documentation, eligibility checking, and matching identity among diverse databases needs to be specified over the next 6 months. To do this, it is clear that the Policy and Standards Committees will need to work together. Doug Fridsma and ONC was charged with recommending a process, a structure, and a framework for us to do this work.

Dixie Baker and Steve Findlay updated us on consent standards and the suite of consumer focused domain standards. The industry is asking for more specificity in the patient engagement portions of meaningful use - when producing an electronic copy of a health record, what should be included? What fields are required for an outpatient summary? The HIT Standards Committee working with ONC has more work to do in this area.

Janet Corrigan and Floyd Eisenberg described the ongoing efforts by the Quality workgroup to retool existing metrics to be EHR friendly and their project to catalog existing electronic quality measures already in use.

After lunch, Jamie Ferguson outlined two recommendations of the Vocabulary Task Force. The need for a single government office or agency to coordinate vocabulary subsets/codesets and the need to make them available via "one stop shopping" in a single repository. The committee endorsed these recommendations and they were forwarded to ONC.

Arien Malec and Doug Fridsma presented an update on the NHIN Direct effort and its short timeline to produce reference implementation. NEHEN will work to connect Massachusetts with other states as a demonstration of the NHIN Direct protocols. The HIT Standards Committee agreed that we need to coordinate all the privacy/security efforts of the HIT Policy Committee, HIT Standards Committee, NHIN Connect, and NHIN Direct efforts to ensure consistency.

Finally, Jodi Daniel from ONC and Michelle Ferritto from the Drug Enforcement Administration/Office of Diversion Control presented all the requirements for e-Prescribing controlled substances. Identity proofing is key to reducing fraud, so two factor authentication is required. Audit trails are required. Certification of software is required. e-Prescribing of controlled substances is not required as part of meaningful use at this point, but it is likely clinicians will want to do it so that they have the same workflows for prescribing Lipitor (a non-controlled substance) as Valium (a controlled substance).

The work ahead for the next few months will include

Content standards - administrative transactions such as enrollment and claims attachments in support of healthcare reform

Vocabulary standards - all the subsets/codesets required for meaningful use

Transmission standards - supporting the NHIN Direct effort

Privacy/Security - continuing our work on consent standards and the specificity needed for patient engagement

All of this will be done in the context of evolving harmonization frameworks which are supported by new RFPs.

I look forward to the work ahead!

Tuesday, April 27, 2010

The Genomes, Environments and Traits Conference

This morning, I'll be on stage with all the humans who have had their genomes sequenced - James Watson (pictured above), Henry Louis Gates, Misha Angrist, John West, Jay Flatley, Greg Lucier, Seong-Jim Kim, Rosalynn Gill, George Church, and James Lupski.

The GET Conference 2010 marks the last chance in history to collect everyone with a personal genome sequence on the same stage to share their experiences and discuss the important ways in which personal genomes will affect all of our lives in the coming years.

From 9a-12p, we'll discuss our personal experiences with sequencing and its impact on our lives, families, medical care, and policy thinking.

At noon we'll gather for a photograph of all the sequenced humans. By 2011 the number of individuals with personal genome sequences will rise dramatically, from a dozen today to hundreds, and possibly thousands. This makes tomorrow's photograph the last opportunity to have us all together.

I'll publish the photo on my blog as soon as it is available.

A few interesting items from the conference

In April 1953, Watson and Crick published their article characterizing DNA
In April 2003 the first Human Genome sequence was completed
In April 2008 the genetic non-discrimination act (GINA) was published

The cost of a complete human sequence in 2000 was $3 billion

The cost of a sequence 2004-2007 was $70 million

The cost of sequence in 2008 was $50,000

The cost of a sequence in 2010 is $1500

This is Moore's law on steroids. No one in the industry can believe the amazing drop in sequencing costs over the past decade.
My sequence is in the public domain and my stem cells are available online for $85.00.

I'm Coriell subject 21070.

The next addition to my online public data is a functional MRI map of my brain. I completed the scans over the weekend and I'll post an overview soon.

Monday, April 26, 2010

The Governor's Healthcare IT Conference

Although healthcare reform has its supporters and detractors, healthcare IT reform - the use of technology to improve the quality, safety and efficiency of healthcare throughout the country - has broad support from all stakeholders.

The passage of last year’s $787 billion economic stimulus bill brought with it a healthcare IT modernization program that could inject about $30 billion into the economy. Since Massachusetts is a leader both in the use and the manufacturing of healthcare IT systems, this could translate into over a $1 billion for the Commonwealth of Massachusetts.

This isn’t a “cash for computers” program though – it’s much more than that. The stimulus bill was crafted very wisely. It’s not a field day either for the doctors and hospitals who would receive these funds, or for the vendors selling this hardware and software. That’s because in order to get these dollars, physicians and hospitals have to not only buy the new systems, they have to prove that they’re using them to improve care before they’ll qualify to get any money back from the government. What does it mean to improve care? The requirements are actually quite specific and include: improving care coordination, reducing healthcare disparities, engaging patients and their families, improving population and public health, and ensuring adequate privacy and security protections.

The health IT modernization program promotes the use of advanced tools which could significantly improve the quality and efficiency of healthcare in the country today. Massachusetts is well positioned to lead this charge.

The genius of the program is that it is carefully tailored to fit our uniquely American economy and culture. We are a society that prizes individual initiative and rejects “top-down” solutions, and no other part of the economy is more reflective of that than health care delivery. We also believe in the power of markets to allocate resources where they’ll create the most value and to drive innovation that improves peoples’ lives. So unlike other countries where the government is creating its own infrastructure and dictating which systems the medical community must use, the Obama Administration’s health IT program uses federal dollars to give an adrenaline boost to the market.

It does this in three ways: incentives to providers who use IT to achieve higher quality, lower cost care; non-proprietary strict standards to create a level playing field for users and sellers of software and hardware systems; unbiased certification of software to provider assurance that it meets basic quality, safety, and efficiency standards.

Incentives. Medicare and Medicaid have defined 25 basic projects that each hospital and clinician office must complete to demonstrate that they have embraced technology to improve care. For example, medications must be electronically ordered, checked for safety, and routed to pharmacies - going from the clinician's brain to the patient's vein without paper or error-prone handwriting. Massachusetts is already the #1 electronic prescriber in the country and has been for the past 3 years. Even so, less than one-third of all prescriptions in the Commonwealth are transmitted electronically today. Fortunately, all of our regional health plans have been champions of e-prescribing, as have all of our major provider groups. Multi-stakeholder partnerships such as the New England Healthcare Institute, Massachusetts Health Data Consortium, and Massachusetts eHealth Collaborative have focused on medication safety. So even though we’re ahead of the pack, we still have a long way to go. The federal health IT program will provide a valuable boost to all of these efforts.

Standards. Well-defined precise electronic formats are needed to share data in our communities with patient consent. For more than a decade, Massachusetts has been a leading state in the secure exchange of patient data via the New England Healthcare Exchange Network (NEHEN), SafeHealth, Community Hospitals and Physician Practice Systems (CHAPS) and the Northern Berkshire eHealth Collaborative sponsored by the Massachusetts eHealth Collaborative. Massachusetts is also a national leader in providing patient access to their medical records through such programs as PatientSite, PatientGateway, myHealth Online, and Indivo Health and providers and health plans making their data available to GoogleHealth and Microsoft HealthVault.

Certification. Medical software, like any other technology that directly impacts public safety, must conform to basic testing and certification to ensure it has the capabilities needed to improve quality, safety and efficiency in hospitals and offices.

Incentives to physicians and hospitals adds fuel to the health care delivery sector, which is one of the engines of the Massachusetts economy. Furthermore, incentives to purchase software and hardware will draw dollars from other parts of the country because Massachusetts is home to several leading vendors of electronic record products such as eClinicalWorks in Westborough, AthenaHealth in Watertown, and Meditech in Westwood.

In addition to direct stimulus payments to hospitals and providers, our state has already garnered millions of dollars in grants to establish core infrastructure to spur the market. The Massachusetts eHealth Institute, a subsidiary of the quasi-governmental Massachusetts Technology Collaborative, has received almost $25 million to accelerate healthcare information exchange and facilitate electronic health record rollout. Harvard Medical School received $15 million for advanced research in electronic health records. Our academic, government, and industry experts will continue to compete successfully for additional grants as they become available.

On April 29 and 30, Governor Deval Patrick will host the Health Information Technology: Creating Jobs, Reducing Costs and Improving Quality Conference. HHS Secretary Sebelius, National Healthcare IT Coordinator David Blumenthal, and many governors will attend. It will offer us a remarkable opportunity to showcase the strength of our healthcare technology accomplishments in Massachusetts, and to learn from leaders from other parts of the country.

For all we've accomplished, there is much to do.

We still have silos of information locked away in hospitals, offices, pharmacies, and labs. We still have redundant and unnecessary testing because our care is uncoordinated. We're still using a huge amount of paper in our healthcare facilities. Paper kills.


My grandmother's life was cut short by medical error. She was prescribed a combination of medications that should never be given to an older person. She developed stomach bleeding, a sudden drop in blood pressure, a stroke, and ultimately died as a result of it.

With electronic health records, data sharing, and decision support rules that inform clinicians about best practices for personalized medical care, she would have avoided harm.

Massachusetts has been an intellectual, economic, and political leader for healthcare IT for decades. We're now at the tipping point with the funding, momentum, and opportunity to ensure every patient has an electronic health record. The work ahead to complete the transformation of our manual workflows and data silos into a coordinated electronic healthcare system will be hard. Politicians, payers, providers, and patients must work together to make it happen over the next 5 years.

The lives of our grandmothers depend on it.

Friday, April 23, 2010

Cool Technology of the Week

While touring colleges this week, I was impressed by the focus on green technologies at many institutions. Many have LEED certified buildings, extensive recycling programs and innovative alternative energy sources.

I was most intrigued by Middlebury's commitment to be carbon neutral by 2016. A major component of that effort is their Biomass gasification facility pictured above, my cool technology of the week.

The idea is simple. Biomass is fuel derived from plants, such as trees, grass, soybeans and corn. Middlebury's plant uses a highly efficient gasification process in which wood chips are super-heated in an oxygen deprived environment, where they smolder creating gasses that are ignited to heat the boiler, which produces steam. The filters in the biomass facility are rated to remove 99.7 % of the particulates from the exhaust. Overall the emissions produced by the biomass plant are not greater than those that result from Number 6 fuel oil. Burning wood produce ssignificantly less emission of sulfur compounds, which contribute to acid rain.

Benefits include
*40% reduction in net emissions of carbon (12,500 metric tons)
*eliminates 1 million gallons of Number 6 fuel oil
*utilizes a local, renewable resource
*education of students and the public about energy use
*research into new fuel sources, such as willows that local farmers can grow on marginal lands
*support for locally manufactured green technology
*stimulation of the local and state economy
*less dependence on foreign oil

Additionally, the biomass plant uses the excess pressure from the steam to co-generate approximately 3-5 million kilowatt-hours of electricity per year. Also, the heat from the exhaust is used to preheat water going into the boiler.

A renewal, carbon neutral, co-generation plant - that's cool!

Thursday, April 22, 2010

The NHIN Direct Addressing Specification

Every Tuesday, the NHIN Direct Implementation Group holds a teleconference to update the entire team on the progress of the technical workgroups. This week, we discussed the completed addressing specification.

As I've said many times in my blog, the most important standards implementation problem to solve right now is transport, not only the basics of transmitting data securely but also transaction orchestration and the constellation of supporting functions such as addressing the messages.

In previous blogs, I've described one way to solve the addressing problem - give every patient a voluntary opt in "Health URL" that they could use to receive all healthcare data from hospitals, offices, labs, and pharmacies.

For use cases such as sending data from provider to provider, hospital to provider or provider to public health we need some similar approach to ensure data is delivered to the right place.

The NHIN Direct Addressing specification proposes five ways to do this - secure email addressing (SMTP plus TLS), REST, SOAP, and the HL7 routing schemes XCN and XON.

First, two definitions. A "Healthcare Internet Address" is made up of a Health Domain name and a Health Endpoint Name

Health Domain Name
A Health Domain Name is a string conforming to the requirements of RFC 1034.

A Health Domain Name identifies the organizations that assign the Health Endpoint Names and assures that they correspond to the real-world person, organization, machine or other endpoint that they purport to be. For example, my organizations (BIDMC and Harvard Medical School) could control or

A Health Domain Name MUST be a fully qualified domain name, and SHOULD be dedicated solely to the purposes of health information exchange.

Organizations that manage Health Domain Names MUST maintain NHIN Direct Health Information Service Provider (HISP) Address Directory entries for the Health Domain Name, as specified by the Abstract Model, and corresponding to rules established for concrete implementations of the Abstract Model. Organizations that manage Health Domain Names MUST ensure that transactions are available for Health Endpoint Names, either through proprietary means or following the Destination role transactions of the Abstract Model. Organizations may take on the HISP role or assign this function to another organization playing the HISP role (such as GoDaddy does for hosting regular email on behalf of other organizations).

Health Endpoint Name
A Health Endpoint Name is a string conforming to the local-part requirements of RFC 5322

Health Endpoint Names express real-world origination points and endpoints of health information exchange, as vouched for by the organization managing the Health Domain Name. For me, that could be a person such as Dr. John Halamka, an organization such as BIDMC Emergency Department or an aggregation point such as BIDPO Quality Data Center. Here are examples of each address type

Email for health information exchange (not regular email) directed to me at BIDMC

REST (example of a possible format)

1_0 refers to the REST API version.

SOAP (example of a possible format)

the person or organizational endpoint would be specified in the SOAP message itself.
1_0 refers to the SOAP API version.

HL7 XCN (extended composite ID number and name for persons)^Halamka^John^D^DR^MD^^&NHIN OID&OID

The XCN representation could be used in multiple contexts, including the intendedRecipient in an XDS/XDR web service call or in an HL7 2.x message to refer to the sender or receiver of a message (e.g., in a PV1 segment)

HL7 XON (extended composite name and identification number for organizations)
Beth Israel Deaconess Medical Center^^^^^&NHIN OID&OID^^^^

Note that XCN and XON are included for compatibility with the IHE XDR spec, NHIN Document Submission, and HITSP T31.

Imagine if every EHR could send data to every other EHR using a simple addressing mechanism like Email, a consistent REST implementation or a well described SOAP WSDL. Interoperability would follow rapidly because novel packages of data will be sent to support real business needs without any barriers of how to get the data from endpoint to endpoint.

The NHIN Direct process is working well and builds upon the work of the past. It does not compete with, diminish, or in any way represent a replacement of the hard work done by so many people over the past years in HITSP, IHE, and the SDOs.

I'll continue to provide NHIN Direct updates as reference implementations with running code are deployed. Massachusetts, through NEHEN and the Massachusetts eHealth Collaborative has volunteered to test these techniques with other surrounding states. Let the testing begin this Summer!

Wednesday, April 21, 2010

College Touring Advice

I've just finished 700 miles of driving with my wife and daughter touring Dartmouth, University of Vermont, Middlebury, University of Massachusetts Amherst, Smith, Mt. Holyoke and Connecticut College. Locally we've already toured Tufts, Brandeis, and Harvard.

It's been a great experience for all, filled with observations about the students (they look really tired or they look like they have a reasonable amount of free time), comparison of the admission officer standard presentations, and a first impression of the culture of each school.

My lesson learned - applying to college in 2010 is nothing like applying to college in 1980. It's much more complicated with many more online resources and an iterative process to find the right fit.

However, the best advice is from the Middlebury Office of Admissions, which published this quick guide for Parents.

10. Remember - the process is not about you.

9. Support and encouragement are more appropriate than pressure and unsolicited advice.

8. Do not use the words "we" or "our" when referring to your child's application process.

7. Help them prepare but let them perform.

6. Encourage your children to make their own college appointments, phone calls and emails.

5. Allow your children to ask the questions.

4. Prepare your children for disappointment.

3. Never complete any portion of the college application for your child.

2. Do not let stereotypes or outdated information steer your child away from schools in which they would otherwise have an interest.

1 . Never, ever, buy a college t-shirt or sweater from the bookstore in your size.

Words to live by.

Tuesday, April 20, 2010

The Stimulus and Skilled Nursing/Long Term Care

I'm often asked questions about HITECH and its implications for specific organizations and groups. Last week, I was asked specifically about Skilled Nursing Facilities.

John Derr of Golden Living, LLC is a member of the HIT Standards Committee. I asked him for his view. Below is his answer, which I hope you find helpful.

"This email is in response to your email to Dr. Halamka and the HITECH program including Skilled Nursing Facilities (SNF). Even though SNFs and other long term & post acute care (LTPAC) providers were not yet included in the ARRA stimulus funds we have many programs underway to participate in the electronic health record (EHR) initiative. There are representatives of LTPAC providers on the HHS Federal Advisory Committee for both Policy and Standards. I am on the Standards Committee as well as the Quality and Implementation Committee Workgroups. I am also a Commissioner on the Commission for Certification of Health Information Technology (CCHIT) as we have a workgroup underway developing EHR Certification Standards for the SNF and other LTPAC provider applications. I also am on National Quality Forum (NQF) Committees working on the electronic quality measures. I mention this to let you know that after many years where SNF (LTPAC) was not at the table, we now have representation at the committee levels but have not yet received much attention from Congress that is why we are not in the ARRA.

In 2004 at the meeting where Secretary Thompson announced the Presidents Executive Order to develop the EHR the Secretary asked me to coordinate LTC HIT. I formed a collaborative called the LTPAC HIT Collaborative which is made up of all the LTPAC provider and vendor stakeholders. I assume Bethany Home Society of San Joaquin County is a member of AAHSA and CAST. they are both members of the Collaborative. I have attached a copy of the comments the Collaborative made on the ARRA Meaningful Use which provides the names of the organizations.

With that said, we are working very hard to have SNFs and Home Care be part of the incentive programs because many of the eligible hospital and physician "Meaningful Use" electronic quality measures will require interconnectivity and interoperability with SNFs and Home Care Agencies. At this point the HITECH program does require that providers with a large number of Medicaid patients be included in the HITECH program. In fact the states will have to write their plans to include all high census Medicaid providers in order to have their plans approved by CMS and ONC. The Collaborative is working with the states to develop a kit to help them include SNFs in their plans. We are also working with NQF on the "Meaningful Use" electronic quality measures so that a patient will have the same quality measures as they move from a hospital or physician practice to a SNF.

On June 7th and 8th there is an LTPAC HIT Summit in Baltimore where you can receive all the HIT activities concerning LTPAC. I would encourage you to attend this summit and to become involved at the state level. Much of the decisions will be at the state level and the more SNF informed CIOs that work with the state the better our chances of receiving incentive assistance.

Dr. Halamka's work and leadership is so very helpful to us all. Even though SNFs were left out of the ARRA legislation we are all working together to ensure that SNFs have not been left out of the future planning. If you attend the LTPAC HIT Summit you will receive the 2010 - 2012 updated LTPAC HIT Roadmap which can help you in the planning of your HIT system. Plus there is an interoperability showcase where there will be demonstrations of what others are doing to implement the EHR. I have attached a copy of the current draft program and a flyer.

Thank you for asking Dr. Halamka your question and for following his Blog. If you have any further questions please do not hesitate to ask.

John F. Derr, R.Ph.
Strategic Technology Consultant
Golden Living, LLC"

Monday, April 19, 2010

For Everything There is a Process

I've written a number of related blog posts on the theme of respecting your colleagues, neighbors, and family - the Greatest Good for the Greatest Number, Your Karma Balance, and a Plea for Civility.

A related topic is the way we should react when issues are escalated to us. No matter what the issue, always remember that there is process for every situation, no matter how emotional or urgent. Here's what I do:

1. Escalated issues are usually complex and difficult to resolve by email. This means that either you pick up the phone or schedule a quick meeting with stakeholders. It's generally best to schedule such meetings rapidly to prevent further misunderstandings and angst. At the meeting, the role of the leader is to listen and accept responsibility, even if the situation is not directly caused by you or your staff. When I've had challenging conversations with vendors, I'm always impressed by CEOs who take an active role in problem resolution even when responsibility for the root cause is not always clear.

2. Build a reasonable path forward. The challenging with being a leader is that demand for resources - staff time and budgets - always exceeds supply. I have to be careful not to overpromise and underdeliver. Thus, I'll work with the stakeholders to develop reasonable next steps which include short term wins, governance committee discussions, and phased delivery of solutions in the long term.

3. Instead of saying "No", say "Not now". Sometimes its tempting to just say "no" to a request that sounds unreasonable, untimely, or unstrategic. A better approach is gather the scope of the request, submit it to a governance committee, and then let the prioritization take place by a group representing many institutional interests. The answer back may be a "not now, but in the queue of other institutional priorities" which is more satisfying than "no".

4. You can catch more flies with honey than with vinegar - it is easier to persuade people if you use polite arguments and flattery than if you are confrontational. As a CIO I have complete accountability for all IT related issues but lack blanket authority. It would be great to be a benign dictator and just say "make it so", but that's not the case. Instead I have to use informal authority, build trust, create consensus and build a guiding coalition. I do that with humor, optimism and enthusiasm. Doing it by yelling, intimidating, or formal authority may work in the short term but it destroys trust and loyalty in the long term. I've been a CIO for nearly 15 years using the "honey" rather than "vinegar" approach.

5. Do not throw people under the bus, especially your own staff. I've experienced so leaders who are quick to place the blame on someone else as a way of deflecting responsibility. It's always awkward to be in a meeting when someone, often without warning, is identified as the root cause of a problem. To me, people are rarely the root cause - it's the project management and the governance that were flawed and enabled people to do the wrong thing. Thus, I never shoot the messenger or point fingers at a person. Instead I ask how we can all do better by changing the way we work.

Today, I'll have several challenging meetings. I know that there will be confrontations, tough questions, and even misunderstandings based on incomplete information. However, going into every meeting, I know there is a process to resolve every issue without requiring me to counter emotion with more emotion.

Friday, April 16, 2010

Cool Technology of the Week

I recently wrote about the floods in Massachusetts and eliminating single points of failure in my home sump pump system. Here's the home "disaster recovery" infrastructure I built.

I have a 18"x18" sump pit 24 inches deep in my basement. It has a gravel bottom and collects water during the Spring thaw and heavy Spring rains.

The primary pump is 1/3 Horsepower Wayne Cast Iron Pedestal Pump connected via a Wayne 1-1/2" check valve to a Wayne 1-1/2" discharge hose. This is a very simple and elegant system - just 3 parts and no connections that can break/leak outside the sump pit.

The backup pump is a high flow battery operated Wayne ESP25 Submersible Pump connected to check valve and discharge hose. It too has just 3 parts and no connections to leak outside the sump pit.

The backup pump is connected to a Wayne 75 Amp Hour Deep Cycle Battery on a continuous charging system with alarm notification if the power fails or the battery ceases to charge.

The end result - 2 pumps, 2 power sources, 2 check valves, 2 discharge hoses (securely mounted with 2 supports per hose) eliminating any single points of failure.

I can now rest assured that my basement is as reliable as my data center!

Thursday, April 15, 2010

Maryland Wines

When you ponder the great wines of America, you think of Napa, Sonoma, and Oregon. You rarely think of Baltimore.

I recently had the opportunity to try some remarkable wines from this evolving region.

My hosts at Loyola University arranged a dinner at the Woodberry Kitchen which specializes in locavore cuisine include a few vegetarian and vegan dishes. The chef was very accommodating and served me a vegan flatbread, a salad of "adolescent greens" and a Mushroom-Leek Mosaic made from Anson Mills farro, Twin Oaks tofu, sweet potato, and kale. It's the kind of dish that pairs perfectly with a fine Syrah. Keeping with the local theme, we ordered a Black Ankle Syrah, grown in nearby vineyards.

Black Ankle is named for the road that runs past the vineyard - notable for its rich dark mud that gave travelers black ankles. Of course it also symbolizes the darkened feet of traditional winemakers who stomped their grapes.

I also had the opportunity to sample a collection of Boordy wines in a pre-dinner wine tasting at my hotel. These wines are lighter and simpler in style, but well made and very pleasant.

So next time you're in the Chesapeake region, take the wine tour. Here's a guide to the local growers and winemakers.

A hidden gem!

Wednesday, April 14, 2010

Meaningful Use as an Interoperability Accelerator

I was recently interviewed about the incredible growth of e-prescribing transactions over the past year. Here's the data:

Electronic requests for prescription benefit information grew from 79 million in 2008 to 303 million in 2009.

Prescription histories delivered to prescribers grew from over 16 million in 2008 to 81 million in 2009.

Prescriptions routed electronically grew from 68 million in 2008 to 191 million in 2009.

The number of prescribers routing prescriptions electronically grew from 74,000 at the end of 2008 to 156,000 by the end of 2009 – representing about 25 percent of all office-based prescribers.

At the end of 2009, Surescripts provided access to prescription benefit and history information for more than 65 percent of patients in the U.S. on behalf of payers and pharmacies.

At the end of 2009, approximately 85 percent of community pharmacies in the U.S. were connected for prescription routing and six of the largest mail order pharmacies were able to receive prescriptions electronically.

What were the drivers?

*Alignment of incentives i.e. meaningful use requires it, private payers are offering pay for performance incentives, and it reduces labor costs in the office.
*Availability of EHR software with the capabilities needed to e-prescribe
*Increased adoption by large clinics and health systems
*Education and awareness programs.
*State and regional level initiatives

Based on this eRx experience, I believe that meaningful use will accelerate all 6 interoperability transactions required for 2011. These exchanges include:

1. ePrescribing (includes eligibility, formulary, history, routing, refill).
2. Patient engagement - sending reminders to patients, providing patients with an electronic copy and access to their records
3. Checking insurance eligibility and submitting claims
4. Capability to exchange key clinical information among care providers and patient authorized entities
5. Capability to submit data to immunization registries, provide syndromic surveillance and lab data to public health agencies
6. Quality measurement and reporting

Although vocabulary and content standards for all these transactions are well specified in the Interim Final Rule, the details of transmission are missing. The NHIN Direct project was established to prototype transmission approaches for several use cases including

*Primary care provider refers patient to specialist including summary care record
*Primary care provider refers patient to hospital including summary care record
*Specialist sends summary care information back to referring provider
*Hospital sends discharge information to referring provider
*Laboratory sends lab results to ordering provider
*Message sender receives delivery receipt
*Provider sends and receives data with minimal HIT technology
*Provider sends patient health information to the patient
*Hospital sends patient health information to the patient
*Provider sends a clinical summary of an office visit to the patient
*Hospital sends a clinical summary at discharge to the patient
*Provider sends reminder for preventive or follow-up care to the patient
*Primary care provider sends patient immunization data to public health
*Provider or hospital reports quality measures to CMS
*Provider or hospital reports quality measures to State
*Laboratory reports test results for some specific conditions to public health
*State public health agency reports public health data to Centers for Disease Control
*Pharmacist sends medication therapy management consult to primary care provider
*A patient-designated caregiver monitors and coordinates care among 3 domains
*A Provider EHR orders a test
*A patient sends a message to the provider

Once data generators - eligible professionals and hospitals - can export their data in standard formats via uniform transmission approaches, many next steps will follow:

Public Health organizations can aggregate de-identified laboratory data to follow H1N1 outbreaks.

Quality Measurement organizations can aggregate data for Physician Quality Reporting Initiative (PQRI) reporting.

Clinicians can send summaries to other providers and to patients via secure messaging approaches. Disease registries can be built as summaries are exchanged.

Once data is recorded in repositories using controlled vocabularies and standards-based metadata, novel architectures are possible.

At Harvard, the Clinical and Translation Science Awards (CTSA) funded a federated data atomic query mechanism called SHRINE.

Here's how it works.

Using a web-based graphical user interface, a clinical researcher can design an arbitrary query such as

"How many patients taking Vioxx have a diagnosis of myocardial infarction"

SHRINE first queries the metadata mapping at the border of each organization i.e. is medication name and diagnosis data available?

Once the metadata indicates a search is possible, a distributed query is launched to each site. De-identified counts of patients matching the search criteria are returned to the user. Here's an example.

The journey toward interoperability starts with electronic capture of data in standards based formats. Transmission standards for getting the information from place to place are the next step. Finally, novel aggregation and query systems will evolve as standards-based repositories are built. Many architectures will be developed to support many use cases with varied requirements.

It is all part of an evolution empowered by regulations issued by ONC and supported by the HITECH stimulus. Meaningful use will be a real driver of interoperability over the next 5 years.

Tuesday, April 13, 2010

Healthcare Reform and HIT

I recently planned a speaking engagement and was warned to avoid healthcare reform commentary - too controversial and too emotionally charged.

Regardless of your politics, some aspects of healthcare reform are not controversial. Here's a list of health information technology tactics included in healthcare reform.

Accountable Care Organizations (ACO)- No later than January 1, 2012, the Secretary is required to establish a shared savings program that would reward ACOs that take reasonability for the costs and quality of care received by their patient panel over time. The bill requires ACOs to “define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies.” (Sec. 3022)

Independence at Home Demonstration Project- The bill creates a new demonstration program to begin not later than January 1, 2012, for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home-based primary care teams aimed at reducing expenditures and improving health outcomes. It also defines an “independence at home medical practice” as one that “uses electronic health information systems, remote monitoring, and mobile diagnostic technology.” (Sec. 3024)

Community Health Teams to Support the Medical Home- The bill directs the Secretary to establish a program to provide grants to or enter into contracts with eligible entities that can establish community-based interdisciplinary, inter-professional teams to support primary care practices, including obstetrics and gynecology practices, within the hospital services areas served by the entities. It also requires the health teams to “support patient-centered medical homes” defined as a “mode of care that includes. . .safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements.” (Sec. 3502)

State Option to Provide Health Homes for Individuals with Chronic Conditions in Medicaid- The bill creates a new Medicaid state plan option under which enrollees with at least two chronic conditions, or with one chronic condition and at risk of developing another, or with at least one serious and persistent mental health condition, could designate a provider, a team of health care professionals, or a health team as their health home. States will also include in their state plan amendments “a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).” (Sec. 2703)

Here's a great summary of healthcare reform and its IT implications by Bill Bernstein at Manatt, Phelps & Phillips, LLP.

It's time to put aside the emotion and begin the work of planning IT as funded and supported by healthcare reform. Reform is built on a foundation of meaningful use, so I see this effort as part of single plan incorporating Healthcare Reform and Healthcare IT Reform!

Monday, April 12, 2010

The Harvard SHARP Grant

Last week, ONC awarded $60 million to four institutions - Mayo Clinic, Harvard University, University of Texas Health Science Center at Houston and University of Illinois at Urbana-Champaign - through the Strategic Health IT Advanced Research Projects (SHARP) program.

Each institution's research projects will identify short-term and long-term solutions to address key challenges, including ensuring the security of health IT (University of Illinois at Urbana-Champaign), enabling patient-centered cognitive support for clinicians (The University of Texas Health Science Center at Houston), making progress toward new health care application and network-platform architectures (Harvard University), and promoting the secondary use of EHR data while maintaining privacy and security (Mayo Clinic of Medicine).

Many of my readers have asked for details about the Harvard grant.

It's led by Zak Kohane and Ken Mandl of the Children’s Hospital Informatics Program (CHIP) and Harvard Medical School, and includes many collaborators such as Griffin Weber MD/Phd in my HMS IT group.

They will investigate, evaluate, and prototype approaches to achieving an “iPhone-like” health information technology platform model, as was first described by Mandl and Kohane in a March 2009 Perspectives article in The New England Journal of Medicine.

The platform architecture, described as a “SMArt” (Substitutable Medical Applications, reusable technologies) architecture, will provide core services and support extensively networked data from across the health system, as well as facilitate substitutable applications – enabling the equivalent of the iTunes App Store for health.

This new approach to a health information infrastructure was the focus of a June 2009 working group meeting at the Harvard Medical School Center for Biomedical Informatics and an October HIT meeting which brought together more than 100 key stakeholders across academia, government and industry in an exploration of innovative ways to transform the national health IT system.

The SMArt platform will provide a common interface to the “App Store” for the Indivo open source personally controlled health record platform developed by the CHIP team more than a decade ago, as well as open source platforms created by other subcontractors on the ONC grant: Partners HealthCare System’s i2b2 analytic platform and the Regenstrief Institute’s CareWeb EHR.

Over the past year, much has been said about modular approaches to EHRs. Now the Certification NPRM includes that concept. One problem with the modular approach is lack of data exchange and workflow integration between modules. Zak, Ken and team will work hard, via the SHARP grant, to solve that problem.

Friday, April 9, 2010

Cool Technology of the Week

Continuing my theme of cool green technologies, HYmini is a handheld, universal charger/adapter device that harnesses renewable wind power / solar power to support most 5V digital devices.

Features include:
*Built-in wind powered generator to capture small scale wind power from 9mph to 40mph windspeeds. The prevailing windspeed in Boston is 12mph, but you can also attached it to your bicycle to charge while you ride.

*Optional HYmini portable miniSOLAR panels

*miniHANDCRANK generator

*Bicycle dynamo hub generator

An interesting way to harness wind/solar/bicycle motion for your cell phone, iPod, or digital camera.

The company also produces SolarBulb, a solar powered LED lamp that fastens onto conventional beverage containers and lights up automatically in the dark controlled by a built-in light sensor. It charges with 4 hours of sunlight and then provides 6 hours of continuous LED lighting.

Features include:
*Fits onto most plastic water, and soft drink bottles.

*Captures solar power efficiently with unique adjustable head design that allows you to point the solar module directly toward the sun

Innovative, consumer green technologies. That's cool!

Thursday, April 8, 2010

The Halamka Family History

When I visited the Czech Republic in 2007, I found 2 pages of Halamka's in the Prague phone book. There are also a few in the Helsinki, Finland phone book.

In the United States, there are 115. How do I know? I used the How Many of Me website to get the results pictured above. The 2 John Halamka's are my father and me.

Halamka is a very uncommon name with roots in Kladno, Czech Republic.

For other Halamka's in the world, here are 3 PDFs containing all I know about my family history - gleaned from the last 6 generations.

The history on my father's (Halamka) side based on his father and his mother.

The history on my mother's side (Vanags)

A few of the dates in these documents are wrong i.e. I have a great grandfather who died before he was born, my parents wedding date is wrong etc.

Halamka's have been tinkers, tailors, soldiers, and engineers. (no spies that I know of)

To add to these histories, I met my wife Kathy A. Greene at Stanford in 1980 and we were married in 1984. The details about her are on this blog. Our daughter, Lara, was born in 1993. You can read about her on this blog

I welcome any additional info from Halamka's and Vanags' around the world!

Wednesday, April 7, 2010

Telemonitoring for the Home

As Accountable Care Organizations and medical homes start thinking about alternative quality contracts that reimburse for keeping patients healthly and not for delivering more care, it's likely that wellness care will include home telemonitoring between clinician visits.

Devices will include electronic scales for measuring fluid retention in CHF patients, blood pressure measurement for refractory hypertension, glucometers for diabetics, and home spirometry for patients with COPD or asthma.

I recently tested a home monitoring product that illustrates the future of consumer healthcare devices, emerging approaches to interoperability, and the need for consistent transport standards.

The Withings Internet Connected Body Scale incorporates several mainstream technologies to achieve a highly functional result. Here's how it works:

After taking the scale out of the box, you connect it to your USB port (only used during setup) and launch the scale configuration website. You specify the wireless access point and security settings to use and link the scale to a web-based account. You set up users in your account and provide basic height/age/preferred method for body mass index calculation. Technologies used - WiFi with WEP or WPA security, HTTPS, and USB.

Once the scale is associated with your account, using it is simple. When you stand on the scale, it wirelessly uses a RESTful protocol to compare your weight with the list of known scale users on your account, probabilistically choosing the right user by matching weights. It retrieves demographic information, calculates body mass index, and % body fat, then sends the data to the user account.

Once posted, there are multiple data options - graphing over time, PDF of measured weights, automated posting to Google Health, automated posting to Microsoft Healthvault, and even posting in realtime to Twitter (I'm not sure who would want to do this). Technologies used include PDF rendering, calling the Google API, and calling the Microsoft Health API.

I had my Withings scale updating my Google Health account (shown above) in real time via WiFi in about 5 minutes after opening the box. No programming or technical knowledge was required. This illustrates the power of standardized APIs.

Here's the technical detail of how the scale's API works.

A few observations on interoperability.

Although Withings did something remarkable by incorporating WiFi, WEP, WPA, HTTPS, REST, Google Health, Microsoft Health, and PDF in one product, it does require that the device posts to the Withings website and that this website manages interoperability with other website APIs.

Per the discussion by the NHIN Direct Implementation Group, imagine a world in which all vendors have agreed on a consistent RESTful or SMTP-based transport protocol using a well defined addressing mechanism, such as described in my Health URL blog. Imagine that the payload adhered to a consistent, vocabulary controlled format such as the work being done by the Continua Alliance. The scale could directly interact with Google, Microsoft or other vendor sites. The only scale configuration needed is to specify the Health URL of each user.

As Beacon Communities focus on advanced interoperability that engages patients and families for disease management, I'm confident that devices such as the Withings scale will be widely deployed in homes.

Over the next few years, I'm hopeful that devices will evolve from interoperability that works by embracing multiple proprietary APIs to a single simple interop that begins with common transport and addressing standards and progresses to demand for rapid adoption of common content standards.

Kudos to the Withings engineering team for great steps on the journey to bring interoperability to the home.

Tuesday, April 6, 2010

The iPad goes live at BIDMC

The following is a guest post from Dr. Larry Nathanson MD, who leads BIDMC's Emergency Medicine Informatics efforts. (Note that the photo contains only fictitious patient names):

I had been anxiously awaiting the arrival of my iPad --This is the form factor I have been asking (begging) of all the vendors for years. I'm very happy to say that it appears to be living up to my high expectations.

The screen is gorgeous. It's very clear and bright, I had no trouble seeing the screen in bright outdoor light. The machine seems extremely responsive -- it reacts immediately to user input and the browser renders pages as fast as my laptop. In landscape mode, its surprisingly easy to type on the on screen keyboard. I wouldn't call it "touch typing" but the autocorrection fixes almost all of the typos that are introduced when I just let my fingers fly. It turns out to be much easier to enter data than I expected, and in fact this entire review was typed completely on my iPad.

I tested it today during my shift in the ER. Initial tests with our clinical applications went amazingly well. The ED dashboard, WebOMR and Provider Order Entry all appear to function well without modification. The popup blocker does try to get in the way of new windows, but it's a only a minor annoyance. The EKGs look better onscreen than on paper. It was great having all of the clinical information right at the bedside to discuss with the patient. The only problem was that the increase in efficiency was offset by the patients and family who wanted to gawk at it.

The battery life is one of the most astounding features. I don't know how they did it but the claimed 10 hour run time might actually be more accurate than the usual inflated claims that I'm used to for mobile devices. The device arrived at full charge and after testing all day and leaving it playing several full length movies the battery still had 40% left. This could easily make it through an entire ER shift on one charge, eliminating the need for hot swappable batteries.

I am a little concerned about how well it will hold up in a clinical environment, particularly the abuse it will get in the ER. The case is very smooth and the rounded bottom makes it easy for it to slide out of a hand or off a table. I don't get the feeling it will be as forgiving of drops as some better padded (albeit heavier) devices. I'm hoping someone will create a case that has a hand strap on the back (like the Panasonic MCA has).

One problem that plagues all tablets that I've used clinically is the difficulty entering strong passwords. The onscreen keyboards of mobile devices makes it much harder to quickly enter numbers, symbols and mixed case and is, in my opinion, one of the biggest barriers to medical tablet adoption. A biometric, or other creative way of addressing this will likely be needed.

From a consumer electronics point of view I'm also impressed. When just web surfing or watching video I do like that I can just lean back and hold the iPad as I would a book or magazine. My wife found that she preferred the iPad Kindle program to the actual Kindle device. (That bodes poorly for my plans to develop software on it!)

In summary, I'm very excited -- the form factor is close to perfect and it's robust enough to keep up with a busy ER. I think this is one of the most promising developments in medical mobile computing in a long time.

There is one major drawback however: Now my iPhone seems slow and inadequate!

Sent from my iPad

Monday, April 5, 2010

Rethinking Clinical Documentation

Over the past 5 years, I worked with HITSP and the HIT Standards Committee to select standards for exchanging clinical summaries. But what exactly is a clinical summary?

There is common agreement about the need to exchange codified, structured data for problem lists, medications, allergies, and labs.

However, what is the role of unstructured clinical documentation text?

Some have suggested that unstructured text is hard to navigate, at times repetitious, and challenging for computers to interpret.

I believe the exchange of free text notes such as operative reports, history&physicals, ED charts, consult notes, and discharge summaries is very important.

Consider this example.

A 40 year male with no family history of heart disease presents to the ED at 3am with a chief complaint of chest pain and left arm numbness. The EKG is normal, a stress test is normal, labs are normal, and a cardiology consult is completed. The patient is discharged on H2 blockers with a diagnosis of gastritis.

A summary which only includes a problem and med list may state a Problem List of Gastritis and a Medication List of Prilosec OTC.

When the patient next visits an Emergency Department, no one will know about the cardiology consult, the differential diagnosis considered, and the thought process that led to the diagnosis of gastritis to explain the chest pain.

An entire workup will be started from scratch.

There is a great article in the March 25, 2010 of the New England Journal of Medicine "Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?" by Gordon D. Schiff, M.D., and David W. Bates, M.D. in which the authors note:

"Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties."

I agree.

Notes should be included as part of clinical summaries.

However, we should do all we can to improve the quality of notes.

Over the next year, we hope to try a radically different approach to clinical documentation at BIDMC which we think will leverage all the strengths of the full text note as described by Drs. Schiff and Bates without the repetition and navigation issues.

Today's inpatient charges are a collection of SOAP notes written by the medical student, intern, resident, fellow, attending, and consultants largely for billing and medico-legal purposes.

What if the chart was recast as a communication vehicle for the entire team that summarized the day's events and collective wisdom on next steps?

Our answer - a daily Wiki entry for each patient authored by the entire team and signed/locked by the attending at the end of each day.

How will this work?

Think of it as a private wikipedia build inside our clinical systems and hosted in our data center.

Each member of the care team will use our Team Census application to view the list of patients for whom the team is responsible.

Clicking on any patient name will bring up the daily Wiki. Each member can add documentation, revise existing text, and leverage the work of others on the team until the attending makes the final edits and signs/locks the day's documentation. Just like a wiki, a complete journal shows all all edits/changes/deletes, so no information is lost. Importantly the day's wiki entry has one physical exam, one assessment, and one plan - not 17 repetitive entries saying the same thing that often appears in today's paper charts.

The idea of a daily wiki entry for each patient creates highly readable succinct documentation authored by the entire team with a medical legal record of the process that was used to generate it. It's a perfect single document to share with the referring clinician and the patient/patient's family.

After our initial pilot work, I'm guessing we'll also engage the patient and families to add to the Wiki, reflecting the shared decision making between the team, the patient, and the patient's family.

We're in the design stage now, but I'll report back on how it goes.

A daily patient Wiki as unified clinical documentation, exchanged with the team, other providers, and the patient. I bet even the free-text naysayers will agree that this should be part of the clinical summary!

Friday, April 2, 2010

Cool Technology of the Week

I've written about my Strida folding bike for commuting between meetings in Boston. It's worked very well for my use case - pedaling a few miles on flat ground on city streets.

What if your commute is longer, the terrain is more hilly, and you need to go a bit faster?

The Yike Bike from New Zealand is a masterpiece of engineering. It's a fully electric foldable bike weighing about 20 pounds with a top speed of 15mph.

It's not yet in production and will be pricy - about $4500, but it's definitely an intriguing technology as we consider greener ways to commute and strategies to avoid traffic delays.

The Segway seemed like a good idea at the time but its competition with pedestrians for sidewalk space has been problematic. The YikeBike should be no different than an urban bicycle, using city streets and existing bike laws. It will be interesting to see how cities react to it.

Of course, a helmet should always be worn, despite the lack of them in the demonstration video. Definitely a cool technology design!

Thursday, April 1, 2010

The Greatest Good for the Greatest Number

In my career I've had many roles. I've been a consensus builder and a disruptive innovator. Sometimes I'm a leader and sometimes I'm a follower.

No matter what I've done in academia, industry, or government, I've been guided by a few basic principles:

*The Boston Globe test (customize to the locale of your choice) - if your actions were published as a front page article, would they seem fair and reasonable to the average reader?

*The Sister Mary Noel test (my second grade teacher at St. James Catholic School) - if you had to explain your actions to Sister Noel, would you pass her sense of right and wrong or be rapped on the knuckles with a ruler?

*The Sunday night phone call with parents test - when you describe your week to your mom, will your actions seem noble?

*The Senate testimony test - when describing your actions to a Senate panel, is there any reason to say "I have no recollection of those events Senator"

*The Greatest Good for the Greatest Number test - will your actions have a lasting impact on your organization, your state, or your country without direct personal benefit. Although it's true that actions on behalf of others can indirectly bring notoriety to you, fame is not the primary motivation for what you do.

Unfortunately, in our modern society many people I encounter seem more interested in their fame, their fortune, and their reputation.

It could be the economy. It could be competition for resources. It could be a biased sample selection.

How many people have you encountered today who put their co-workers, neighbors, and society first?

When the topic of healthcare reform is discussed, the first question is - what will it mean to my benefits, my costs, and my retirement rather than what will it mean for the 32 million uninsured, future generations, and our nation's competitiveness.

We're only on this planet for 80 years. We cannot take anything with us. If happiness can be measured by making a difference during our short tenure, I hope that more people will ask big picture questions focused on the world around us rather than the size of their house, the speed of the car, or the stylishness of their bling.

I'm not suggesting that we have blind faith in authority or that we all embrace socialism as the solution to every policy problem.

I am suggesting that we move beyond a narrow self focus in all that we do. We should evaluate policy with the lens of the greatest good for the greatest number in our communities, states, and country. We need to move past special interest thinking, including our own.

Change is hard and fear of the unknown can be unsettling. As I've written previously in my blog about your Karma account balance , the good guy (or gal) can lead a life where accounts received exceeds the balance due (borrowed from a Janis Ian song)

If we guide our behavior each day based on choices that look good to the Boston Globe, Sister Noel, our Moms, public scrutiny, and our fellow humans, the world will be a better place.