Friday, May 28, 2010

Cool Technology of the Week

Every Memorial Day, I plant my summer vegetable garden with those species that do not tolerate cold - eggplant, cucumbers, corn, and peppers. I clear out the spring planting beds that were filled with numerous kinds of lettuce, turn my compost pile, and use fresh compost to amend the soil before planting.

In the Spring, I start making compost by using greens (cut grass, weeds, trimmings) and a few browns (leaves, twigs, kitchen trimmings). I add a bit of baking soda to reduce the acid content of the mix, add compost starter and moisten the mixture to the consistency of a wet sponge - not too wet, not too dry. Everything goes into my rotating compost bin.

Thus, as Memorial Day approaches I have compost on my mind, which leads to the Cool Technology of the Week - Composting Toilets.

I'm a big fan of green technologies and living off grid, which I hope to do someday. Here's how composting toilets work.

Composting is a natural process through which organic material is decomposed and used to produce a valuable soil conditioner. In a composting toilet, water is not used at all, and human waste and other organic materials are deposited into a chamber where aerobic bacteria decompose solid portions. The liquid portion (the water content of urine, feces and added organic matter) is left to evaporate through a specially designed ventilation system.

The digestion chambers fill up over time. Once full, the chamber is left to compost over a period of weeks. During this time a second chamber is used. Finished compost is rendered sterile by the heat of the composting process and can be safely removed.

Here's detailed overview from the EPA.

Waterless, green, natural composting toilets - that's cool.

Thursday, May 27, 2010

The Leiter Lecture

Yesterday after the HIT Standards Committee meeting, I had the honor of delivering the 2010 Leiter Lecture at the National Library of Medicine.

My topic was the grand challenges and proposed solutions as we implement healthcare information technology in support of meaningful use with a special focus on the role of Medical Librarians and Informaticians that provide knowledge services.

Here are my slides.

My grand challenges included

1. Managing Consent for data exchange
2. Engaging Patients and resolving the National Healthcare Identifier issue
3. Accelerating use of Standards, especially vocabularies
4. Aggregating Data for population health, registries, and research
5. Providing Decision Support

Here's the streaming video.

Wednesday, May 26, 2010

The May HIT Standards Committee Meeting

Today, the HIT Standards Committee held their May meeting via teleconference and discussed several important topics.

1. The National Information Exchange Model Standards and Interoperability Framework continues to make progress. 11 RFPs have been issued (I will post updates next week) and 8 will be funded shortly. Coordinating 11 different contracts which support standards harmonization, specification writing, testing etc. requires masterful orchestration. A Concept of Operations (ConOps) document will detail the processes by which all these efforts will intertwine. At the June Standards Committee meeting, we will review the ConOps document, ensuring alignment between the NIEM effort and the HIT Standards Committee work.

2. NHIN Direct continues to make substantial progress. There is much confusion in the industry about NHIN Direct. It's a project, not a product. It's a pilot, not a regulation. There is no guarantee that NHIN Direct implementation guides will be formally incorporated into the NHIN project. NHIN Direct is an agile development project with 4 development teams creating software that demonstrates SMTP/TLS, REST, SOAP, and XMPP (Jabber) protocols for transmitting data and metadata between two points. To ensure oversight, review, and comment by the HIT Standards Committee, NHIN Direct has asked for a working group to evaluate the 4 workstreams and comment on which is best to be the focus of early pilots. The HIT Standards Committee agreed to take on this task, delivering an evaluation by June 10.

3. Privacy and Security work has many threads at ONC - the HIT Standards Committee P&S Workgroup, the HIT Policy Committee P&S Workgroup, the NHIN Coordinating Committee etc. To align all the efforts, Joy Pritts, the new ONC Chief Privacy Officer, will create a Privacy and Security Tiger Team, staffed by experts from all the other workgroups. They'll work hard for 6 months to accelerate policy and technology work to support privacy and security efforts in such areas as NHIN Direct, Consent and segmentation of various parts of the healthcare record.

4, The Patient Protection and Affordable Care Act (Healthcare Reform) contains a section (1561) on healthcare IT standards for enrollment. A new multi-stakeholder workgroup will be chaired by US CTO Aneesh Chopra and California Healthcare Foundation's Sam Karp. Its initial work products are due in 120 days, covering the secure standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs.

5. The Implementation Workgroup will provide online resources to accelerate interoperability using some of the tools to be provided by the NIEM RFP contracts.

While the above work is going on, the HIT Standards Committee will continue its efforts on Vocabulary and Quality.

A great discussion. The many simultaneous ONC standards efforts have been aligned to ensure the involvement HIT Standards Committee every step of the way.

Tuesday, May 25, 2010

Gas Fueled Power Systems

This Spring, many houses in Massachusetts suffered flooding due to failed sump pumps. This motivated me to replace our existing sump pump and install a back system.

When I think about home disaster recovery in general, an electrical power is a single point of failure. When does power fail - during a storm, when you need heat, water pumping, and humidity control.

The likelihood that gas (natural gas/liquid propane) will fail at the same time as electrical is very remote, so natural gas powered electrical generators seem like a reasonable choice for creating home electrical redundancy.

Home Depot sells the kind of unit that is needed.

Yes, it must be professionally installed, but if you live in an area with frequent storms and power outages, natural gas fueled standby and backup power systems make sense.

Speaking of "natural" gas, the New York Times recently published an article about using methane from cow manure to power data centers. Since many new data centers are being built near inexpensive hydroelectric power in rural areas where manure is prevalent, this may be a reasonable alternative energy source.

Here's the opinion of our power experts on using manure to power infrastructure:

*Similar in some ways to a co-generation plant but using farm waste instead of natural gas.

*Natural gas in the streets only has a small amount of methane, because methane is a low pressure gas.

*High pressure gases need to be used to generate significant amounts of power via gas turbines & steam.

*Methane being a low pressure gas does not burn as hot and cannot handle sudden increases in loads.

*Typically farmers burn the cow patties directly to produce heating for their homes.

*The NY Times article did not describe the step needed to store methane in a high pressure form that can support power generation.

* Bird manure has a higher energy content and has been used more successfully.

A few thoughts specific to data centers:

*Natural gas back-up generators typically do not have on-site storage since stored natural gas can be highly explosive

*Storage of liquified gas is allowed on ground level floors, but it is stored at 0-degrees Kelvin and a large containment area needs to be established because if a leak were to occur, everything it comes in contact with would be frozen instantly and become brittle.

*The diesel generators at datacenters typically have 48-72hrs. of fuel available on site to run stand alone.

*Natural gas turbines are twice as expensive as diesel engines.

*Reliability and redundancy are always important, therefore the methane power plant would need a utility back-up line to supplement the methane plant during sudden increases of electrical load and back-up the plant in the event of failure or maintenance downtime. The utility line would have to be sized to feed the entire datacenter.

*When a gas leak is detected in the street the utility provider will shutdown the entire line affecting all users until the leak is found and repaired. Therefore, redundant pipes from different sources would be needed to maintain uptime of the gas feed.

Thus, manure is not an easy solution to the problem of growing data center power needs. However, as energy costs rise and carbon footprint becomes more important, it's worth keeping in mind.

The best quote from the article - “Information technology and manure have a symbiotic relationship.”

Monday, May 24, 2010

Digital Signatures with SAFE-BioPharma

In the recent TISH meeting I attended, one of the discussants emphasized authentication/securing the endpoints/identity management as one of the great enablers of healthcare information exchange.

SAFE-BioPharma is a multi-stakeholder effort that uses digital certificates with private keys held on a smartcard or a USB device to provide electronic signatures which the FDA has determined meet 21 CFR Part 11 requirements, and also to authenticate securely among the stakeholders and Federal government agencies. The effort uses public key infrastructure and enables all of the stakeholders to have a common trust relationship with Federal agencies using the Federal government’s own federated security mechanisms.

As we think about strong authentication methods - biometrics, hard tokens, and smart cards, the SAFE-BioPharma approach is another option to consider.

How does it work?

SAFE-BioPharma member companies are using the SAFE-BioPharma standard in ways that achieve numerous goals including streamlining processes, protecting intellectual property and reducing costs. The standard is a convenient way to apply legally binding (and regulatory compliant) digital signatures to electronic documents. The identity of the signer is clearly verified and the integrity of each digitally signed document is cryptographically guaranteed. SAFE-BioPharma digital signatures are being used to sign electronic laboratory notebooks, electronic regulatory submissions, contracts and a wide variety of forms. Member companies also use the SAFE-BioPharma standard for a variety of identity management functions including employee access, external partner authentication, etc.

For details on the companies involved, the actual systems in production and the business processes used to implement SAFE-BioPharma in production, see this summary.

SAFE is achieving federated identity management using digital certificates on inexpensive smartcards or USB devices. Definitely worth adding to our strong authentication armamentarium.

Friday, May 21, 2010

Cool Technology of the Week

As readers of my blog know, I'm a big fan of flexible work arrangements , virtual presentations, and telepresence.

One limitation of all these approaches is that you lose the "over the cubicle effect" - the ability to wander around the office and chat with your colleagues.

The Texai robot is an attempt to merge teleconferencing with mobility and it's under development at Willow Garage . I encourage you to watch this video demonstration.

The project began as a solution to a problem. Two Willow Garage engineers, Dallas Goecker and Curt Meyers, working 2000 miles apart, needed a more efficient method of interacting and collaborating throughout the day. Skype and conference calls hindered the casual conversations more representative of day-to-day, in-person interactions around the office. Seeking a better solution, Dallas and Curt applied their knowledge of building battle bots and the PR2 to create Texai.

A teleconferencing solution that enables you to wander from meeting to meeting and cubicle to cubicle without having to worry about Skype, Webex, or ISDN lines. That's cool!

Thursday, May 20, 2010

My Parents

I've written about being a parent, a husband, and a son.

It's time to write a blog about my parents and their impact on my development, my day to day thinking, and my future.

I was born in Des Moines, Iowa to Dagmar Vanags and John E. Halamka, who were both 20 at the time (typical parenting age for Iowa in the 1950's and early 60's). They are approaching their 50th wedding anniversary. I've blogged about our family history going back to the 1800's. When I was 0-2 years old, we lived with my father's parents as my father finished college. He joined the Air Force and we moved to Colorado Springs, Levittown (Willingboro) New Jersey, and finally Southern California in the mid 1960's. He worked for Aerospace contractors such as CSC, Aerojet General, and TRW.

His engineering work meant that our apartment was filled with tools, various electronic/mechanical surplus, and a culture of inventiveness. On weekends, we went to surplus stores and we built things together including a working wooden model of Da Vinci's catapult, a minibike, and a metal detector.

My father arranged access to the TRW timesharing system via a 110 baud acoustic modem and we worked on FORTRAN, COBOL and BASIC programming. Thus, by 14 I had already spent hundreds of hours developing software (in 1976). As Malcolm Gladwell describes in Outliers, having this much computer science and engineering experience in the mid to late 1970's prepared me for success when the personal computer revolution occurred in the early 1980's.

My father became a patent attorney and when I wrote software, he patented the work itself and the business processes, such as my 1984 patent of the electronic greeting card.

In my adult life, he's provided legal advice, financial advice, and feedback on the various career threads I've pursued. His perspective from the eyes of an engineer/attorney is always welcome.

My mother has been a life long teacher/professor and attorney. She arranged for me to attend a community college physics course when I was in elementary school. She ensured there were books in the house and I learned to read at a very early age. There was no significant family time spent around the television (except watching the original airing of Star Trek from 1966-69). I went to Broadway plays by the time I was 4. I visited major national parks and monuments throughout the country by car by the time I was 6.

If my father brought me love of science/technology/engineering/math, then my mother brought me love of learning, writing and public speaking.

Throughout high school I entered every essay contest I could find and spoke at every speaking competition offered. The ability to think fast on my feet in front of an audience is my mother's skill.

In my adult life, she's provided legal advice, academic career advice, and parenting advice. Her perspective as a teacher, public speaker, and gregarious social person is always welcome.

Today, my parents are retired and have recently moved to a great one story house. They continue to stay in touch with friends, former students and colleagues. Over the next few years, I'm sure they will do volunteer work, cultural events, gardening, reading, and travel. We talk every week and they continue to stay involved with everything going on in our extended family.

I look forward to many more years of sharing our journeys together!

Wednesday, May 19, 2010

Trustworthy Information Systems for Healthcare

I'm an advisor to the Dartmouth Trustworthy Information Systems for Healthcare (TISH) project, a National Science Foundation funded effort to address emerging areas of information security in healthcare. Specifically, TISH will examine novel approaches to the protection of clinical information while ensuring clinicians can access the information they need when and where they need it. The work also focuses on the collection of sensor data through personal sensor devices including both physiological and activity data to enable monitoring of patient outcomes while giving patients control over their privacy.

We heard 4 presentations today that framed the scope of research ahead:

mHealth - how can we use wireless sensor networks on the body or in the home to gather telemetry that can be used to monitor or improve health? How do we maintain integrity of that data? What patient controls over data uses should be included? How can we guarantee the authenticity of the data, ensuring it came from the right person?

Economics and Risks - how can we reduce fraud including falsified billing, stolen pharmaceuticals/supplies/equipment schemes, or medical identity theft? How do we mitigate the risks of security failures such as stolen laptops, deceptions, and inadvertent disclosure that might occur through accidental search engine exposure or through the use of peer to peer file sharing? Will HITECH help?

Access Control - What is the current state of access control practices among various industries? How often are complex access rules used in practice? How often do users circumvent control mechanisms to get their work done? Can we express security policies by specifying who is using what and why (user/action/resources) with allow/deny settings?

Social Informatics - What is the patient perception of uses of their healthcare data? How does this compare to actual IT practices? What is the pattern of data flow for the average patient. For example, in 1997, an Institute of Medicine study For the Record identified that patient data is sent to 27 different groups in the course of treatment.

I look forward to participating in this effort, since answers to these questions will empower the policy and technology work we're doing nationally, regionally and locally.

Tuesday, May 18, 2010

Paper Kills

BIDMC implemented Computerized Provider Order Entry in 2001. As we approach the ten year anniversary of our implementation, it's great to see the recent press on the Stanford study demonstrating a 20% decrease in mortality after implementing CPOE at Lucile Packard Children’s Hospital.

I've written about our experience and my top 10 approaches to make CPOE successful.

Our CEO has blogged about it.

Medscape has a great summary of the effort.

The bottom line - of course bad software implemented poorly can cause new errors. Of course change in workflow can cause unintended consequences.

However, now that the industry has broad experience with electronic ordering (it's a meaningful use requirement for 2011), I think we can conclude that questioning the wisdom of implementing CPOE is like asking if a parachute works against gravity - I do not want to be in the control group of that clinical trial!

We need to be careful to design clinician friendly user interfaces, embrace web-based systems that require little training, and incorporate enough decision support to keep patients safe but careful to avoid crying wolf too often, creating alert fatigue.

As I wrote in a recent blog, paper-based medication ordering killed my grandmother. Unreadable orders, drug-drug interactions, and prescribing errors in the elderly cause harm.

The Stanford study now gives us the objective evidence we've been waiting for. We can use CPOE with confidence and finish the implementation in those community hospitals which do not yet have it.

CPOE is the medication version of a parachute. I would not want to write medications without CPOE any more than I would want to jump from a plane without a parachute.

Monday, May 17, 2010

Allergies and Workflow

I was recently asked about the best way to record allergies in healthcare environments.


At what point should allergy verification be occurring for a planned hospital admission? Should it be prior to admission or at the time of admission?

Is there any data yet to support decreased adverse drug reactions when the patient is asked to complete their own history initially through a patient portal?

Should data entry of allergies into smaller best of breed procedural area systems be permitted or should allergies only have one official “source of truth” location and be entered there?

Here's the answers I received from our workflow experts.

For outpatients:

For existing patients, allergies are printed on the patient's medication list which is given to him/her at the time of check in to support the medication reconciliation process. The patient can update both their medications and allergies at that time. This is given to the clinician or practice assistant to enter in the system at the time of their visit.
If medication lists are not distributed to patients prior to their appointment (such as for new patients), clinicians will enter allergies during the course of their visit with the patient.

For inpatients:

Whether entered in a PHR prior to admission or entered by clinicians at the time of admission, as long as it is done accurately, the timing does not matter. Certainly there is evidence that accurate recording of allergies (a meaningful use criterion) reduces errors, but I am unaware of specific evidence that recording them in a PHR verses an EHR makes a significant difference.
Whenever possible, one source of truth for allergies is the way to go. Otherwise the medical record will contain silos of conflicting information.

At BIDMC we have a single unified inpatient and outpatient record. Medications and allergies are shared between all inpatient (CPOE) and outpatient (EHR) systems. Medication reconciliation, e-prescribing, and transitions of care between inpatient and outpatient visits are integrated rather than interfaced. The last bit of implementation we need to do is bedside medication verification with an electronic medication administration record.

Friday, May 14, 2010

A Day at the Brookings Institution

Although I usually publish a Cool Technology blog on Fridays, today I'm at a Brookings Institution Conference - Making Enhanced Use of Health Information.

The first panel was a dialog between Mark McClellan (Brookings) and Farzad Mostashari (ONC) with reaction/commentary by Amanda Parsons (New York City Primary Care Information Project) and me. The most important take home point was Farzad's commentary that health IT work be guided by several principles

1. Keep data as close to the source as possible, minimizing the need for complex centralized databases.
2. Minimize burden. Data should be collected through routine delivery of care
3. Collect once, use many
4. Be humble about what government can do
5. Watch out for the little guy
6. Foster innovation
7. Observe and adapt
8. Don’t build cathedrals
9. Don’t rip and replace
10. Standards, shared services, and policies can help

The second panel was a comparative description of models to use health information in novel ways. Speakers included James Walker (Geisinger), Robert Steffel (Heathbridge), David Patterson (South Carolina HIE), John Steiner (Kaiser), and Mike Raymer (Microsoft). My take home from listening to these folks was that each has created a live functional health information exchange, coordinating care and supporting population health. There was real optimism among the speakers.

The third panel was a discussion of policy implications. Speakers included Andrew McLaughlin (Whitehouse Office of Science and Technology), Carol Diamond (Markle) Landen Bain (CDISC), and Andrew Webber (National Business Coalition on Health). It's clear that there are accelerators that can support data exchanges. Andrew McLaughlin highlighted mechanisms to authenticate providers and patients, Carol highlighted mechanisms for measuring quality, Landen Bain highlighted guidance from the FDA and Andrew Weber highlighted the need for healthcare reform to align incentives.

A very worthwhile morning!

Thursday, May 13, 2010

Spring in New England

I grew up in California and moved to New England when I was 34. At this point, my family is committed to spending the rest of our lives here. Why?

Seasonal expectations - the renewal of Spring, the outdoor joys of Summer, the colors and harvest of Fall, and walks in the silent forests of a snowy Winter.

I've written about Fall in New England, now it's time for an ode to New England Spring. My backyard today is pictured above.

In March, the snow melts and I plant my first vegetables in Cold Frames. Trees begin to bud, spring flowers poke their heads up and snow drops appear.

In swamps and bogs, Skunk Cabbage is thermogenic and melts surrounding snow to emerge from frozen mud.

In April, cherry trees, dogwoods, pears, and wisteria (picture is an old wisteria in my backyard) explode with blossoms.

Birds nests appear, young rabbits scurry through the yard and the lengthening days enhance everyone's mood. Every Spring, I build a small pond/rock to serve as a local water source for local animals and their new offspring.

My Spring outdoor activities include mountain biking in places like Noanet Woodlands when the mud firms up, kayaking the Charles when water temperature exceeds 50F, and walking with my family around Wellesley College's Lake Waban.

Temperatures vary between the high 30's and the low 80's. It's a time of renewal. Houses get cleaned, windows get opened, and neighbors see each other for the first time in months. Porches get swept and we all prepare for the outdoor living of Summer.

Spring in New England. It's a time to celebrate.

Wednesday, May 12, 2010

Geeks, Dorks, and Nerds

My daughter and I were recently discussing the precise definitions of Geeks, Dorks, and Nerds.

When I first started this blog, I could have called it NerdDoctor or DorkDoc, but luckily I chose Geekdoctor, since it aligns well with the definition of a Geek.

Here's the key vocabulary:

Geek – someone who is passionate about some particular area or subject, often an obscure or difficult one, such as healthcare IT.

Dork – someone who has difficulty with common social expectations and interactions.

Nerd – someone who loves learning and academics.

My daughter and I agree that we're an admixture of all these qualities.

In high school, I was part of small cohort of computer geeks who used MITS Altair 8800 , Wang word processors, and 110 baud dial up teletypes with thermal paper instead of video displays. We were obsessed with the potential of early microcomputers, an esoteric subject that meets the definition of geeky behavior.

In elementary and high school, I wore shirts buttoned to the top and had no sense of fashion or rhythm. I was definitely socially awkward, a dork.

I spent 30 years in academics as a student, so I guess that makes me nerdy.

Of course, I've long exhibited other characteristics that are badges of courage for geeks, dorks and nerds.

*Watched every Star Trek episode multiple times and can recite most dialog from memory

*Played Dungeons and Dragons and Magic: The Gathering

*Favorite books include Lord of the Rings and just about any science fiction

*Favorite TV series include Twilight Zone, Outer Limits, and Dr. Who.

*Favorite movies include Star Wars, Blade Runner, and bad Japanese monster films

Here's a great video that embodies my Geek, Dork and Nerd values. Highly recommended!

Tuesday, May 11, 2010

Mobile Device Strategy Project

As a service to the healthcare IT community and as part of the BIDMC's strategic planning process, we're studying the best practice implementation of mobile devices in clinical settings.

Mobile devices can take many forms
*Handheld barcode scanner/printer such as used by rent-a-car agencies
*iPhones and iPads
*laptops and tablets
*computers on wheels
*various bluetooth devices that separate bar code reading, data entry, and printing
*voice recognition systems such as Vocera

Mobile devices can have many purposes
*Positive patient id at the bedside - scanning a barcoded wristband to verify patient identity as part of medication and lab workflow
*Lab label printing at the bedside
*Result viewing
*Test ordering
*Vital sign entry
*Reference/knowledgebase access
*New and innovative applications - just scan the Apple App Store for health related software. At Harvard we use mobile devices for students to capture information about their clinical experiences such as the diagnoses of patients they have treated.
*Web access
*Part of a geolocation system using triangulation of wifi signals

For the next 4 weeks, Ankur Seth, a Duke MBA Candidate will be speaking with

*CIOs throughout the country to understand their current and planned mobile device deployments
*IT staff at BIDMC and Harvard
*Clinicians at BIDMC
*Selected vendors

He would welcome the opportunity to speak with you or your designate about innovative products you have deployed or are considering, especially those which support laboratory and medication workflow. Everything we learn will be posted on my blog and in articles we'll share openly.

If you would like to share your mobile strategy to inform this effort, please email Ankur Seth at Thanks for any input you can offer

Monday, May 10, 2010

The Stresses of Modern Life

In recent articles, I've reflected on the way humans treat each other in our modern era, competing for resources, attention and priority.

I turn 48 this month and even in my lifetime, I've seen major changes in the nature and quality of life. A few observations:

*When I was in college, faxes, FedEx, and email did not exist. Fast communication meant a land line phone call.

*The pace of each day was limited by the number of in person encounters you could have.

*Real estate was relatively inexpensive and houses in places like Marin County and Palo Alto could be found for $150,000.

*Debt was something to avoid.

*When I was growing up, a McDonald's meal cost a dollar and consisted of a small hamburger, 4 oz of fries, and 8 ounces of Coke with sugar, not high fructose corn syrup. It was under 500 calories.

*Doctors were respected members of the community. Lawsuits were rare.

*There was no expectation that you'd have a car, a VCR, a flat screen TV and an iPod. You spent what you could afford and accepted the fact that you lived within your means.

*No one had peanut allergies

*People took responsibility and accountability for their actions. If you chose to bathe with a toaster and died, your family would not sue for the toaster manufacturer for making an unsafe product.

*Government was a safety net for truly critical emergencies, not day to day life.

I realize that the items above are filtered through the haze of imperfect 40 year old memories.

However, I really do believe that something has happened in modern society that makes each day distinctly different from my childhood experience in the 1960's.

*Instant communication means that anyone can email the CEO and demand immediate action for their personal projects.

*Someone else is always to blame to everything that goes wrong.

*A baseline quality of life includes much more than in the past and if you cannot afford it, credit cards can provide it for you.

*Stress is a badge of courage.

*Information overload is the accepted norm.

When I was an undergraduate at Stanford, Herb Caen wrote many columns about the changes that took place in the 20th century that reduced the quality of life from his perspective... food, culture, and human interaction.

I hope that at some point, modern society stops and reflects about the nature of our day to day lives and realizes that we need to rethink our priorities i.e.

*Replace reality TV with a good book

*Treat your fellow humans with humility and respect

*Stop the real time communication with everyone you know

*Treat meals as an experience not as refueling

*Understand that this is the only life we have and we should savor it, not be stressed by it

After a recent particularly difficult day, I asked my wife if Ted Kaczynski's Montana Cabin was still available. Of course, as I age access to medical care will be important and cabin life would be a bit challenging, but the concept of wilderness life without an internet connection is intriguing!

No matter how challenging the stresses of modern life, as long as I remember that for everything there is a process, there will always be a path forward.

Friday, May 7, 2010

Cool Technology of the Week

Massachusetts Data Protection regulations require us to encrypt mobile devices. Red Flag rules require us to implement processes to protect against identify theft. ARRA requires notification of prominent media for any inappropriate data disclosures.

This all sounds great, but what if you drop your wallet containing credit cards, identification cards, and maybe even your personal health information?

The answer - a Kevlar and Carbon Fiber wallet with biometric identification.

Tungsten W created such a wallet. Its features include:

*Fingerprint access only

*Bluetooth enabled for notification alerts - automated notification via bluetooth if your wallet strays more than 10 feet from your body

*Protected against RFID electronic theft - the case shields all contents from RFID scanners

A portable, monitored, personal safe you can keep in your back pocket and open via biometrics. That's cool.

Thursday, May 6, 2010

A Functional View of my Brain

As part of the Personal Genome Project, the PGP 10 participate in a variety of projects and diagnostic tests. We've done genome sequencing, published our medical records, and made our stem cells available to the research community worldwide.

Last week, I joined a Functional MRI/Genome study run by Randy Buckner at Harvard. The project is a collaboration among investigators across Harvard and its affiliated hospitals to construct the largest available reference database of brain function for both normal individuals and for individuals with psychiatric illness. Over the past year and a half, they have collected brain imaging data from 1500 volunteers with the help of 20 laboratories spread across Harvard, Massachusetts General Hospital, and McLean Hospital. The goal is to use the database as an openly available reference to understand psychiatric disorders including autism, depression, and schizophrenia with a particular focus on how genetic risk factors for illness alter the brain’s function.

What you are seeing above is what Randy refers to as the “Default Network” of my brain. These are the brain areas that are active when I think to myself. According to Randy, my images are particularly sharp - not because my brain is special but because I moved less than a half millimeter during the study. A dime is about one millimeter thick. Randy's team has speculated that the default network is involved in internal modes of cognition such as when a person is remembering or planning for the future.

Since I'm always planning for the future, you now have a picture of how my brain works. The good news is - I have a brain!

Wednesday, May 5, 2010

Wisdom from Xena: Warrior Princess

My family is a "nerd herd", a "gaggle of geeks", a "den of dorks". We do not watch television, but we do occasionally watch DVDs of cult series such as Babylon 5, The Prisoner, Doctor Who, The Secret Adventures of Jules Verne, and Xena: Warrior Princess.

Last night, we watched an episode in which Xena (Lucy Lawless) described her secret to winning competitions/battles/confrontations - "Act, do not react".

Today, while speaking to my staff about a few challenging projects, I realized the wisdom of this statement.

When I think about challenging projects with difficult to please customers, negative emotions may start to flow. You know what I mean - the emails with subject lines or From addresses that you dread reading. The meetings you do not want to attend. The politics that are impossible to successfully navigate.

Reacting to any situation when you've already biased yourself with negative emotions leads to less than perfect thinking and communication. All that stimulation of the sympathetic nervous system (fight or flight response) leads to a dry mouth, a racing heart, and scattered thoughts.

Instead, if you think about the endpoint you want to reach - a successful project, a better technology, a completed implementation - and take the actions needed to achieve this result, you'll be thoughtful, calm, and reasoned.

Here's an example. Rolling out EHRs to 1700 clinicians including all the capabilities and workflow redesign to achieve meaningful use is a change management challenge. Along the way, there will be naysayers, raised voices, and criticism. There may even be mean-spirited personal verbal jousting.

We know what actions we need to take - implement a practice every week between now and the end of the year. Follow our proven model office configuration. Build the interfaces and interoperability needed for care coordination, patient engagement, and quality measurement. By keeping our focus on the "act" and not the "react" to the few naysayers, we get closer to our goal every day, without emotion or negativity.

So next time you have a difficult project, difficult people, or difficult politics, think about the wisdom of Xena - Act, do not react.

You'll feel better and achieve your goals.

Tuesday, May 4, 2010

Administrative Simplification and Healthcare Reform

In addition to enrollment transactions and demonstration projects, there are two sections in the Healthcare Reform Bill that require significant IT efforts in support of Administrative Simplification:

*Sec. 1104 – Administrative Simplification
*Sec. 10109 – Development of Standards for Financial and Administrative Transactions

Here's a summary:

Operating Rules General Provisions (1104(b)(1)–(3))

Establishes that the standards and associated operating rules adopted by HHS shall, among other things, require minimal augmentation by paper or other communication, describe all data elements (including reason and remark codes) in unambiguous terms, and prohibit additional conditions except where necessary to implement state or federal law or protect against fraud and abuse.

Defines Operating Rules as necessary business rules and guidelines for electronic exchange of information not defined by a standard or its implementation specifications.

Requires HHS to adopt a single set of consensus-based operating rules for each transaction for which standard has been adopted.

Defines criteria for qualified nonprofit entities to provide recommendations on operating rules (entities such as CAQH).

Assigns NCVHS to advise HHS on whether nonprofit entity meets criteria, and whether the recommended operating rules shall be adopted.

Operating Rules Implementation (1104(b)(4))

Requires HHS to adopt operating rules by regulation following recommendations from developer of operating rules, NCVHS and consultation with providers.

Establishes July 1, 2011 as deadline to adopt operating rules for eligibility and claim status transactions, so that they are effective no later than January 1, 2013 (may allow the use of a machine readable identification card).

Establishes July 1, 2012 as deadline to adopt operating rules for Electronic Fund Transfer (EFT) and claim payment/remittance advice transactions, so that they are effective no later than January 1, 2014. Operating rules for EFT and claim payment must allow for automated reconciliation of the electronic payment with the remittance advice.

Establishes July 1, 2014 as deadline to adopt operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payment, referral certification and authorization transactions, so that they are effective no later than January 1, 2016.

Requires HHS to use expedite rulemaking (interim final rule with 60 days public comment) in applying any standard or operating rule recommended by NCVHS for the transactions noted above.

Health Plan Certification Requirements (1104(b)(5)(h))

Requires health plans to file a certification statement with HHS no later than December 31, 2013 certifying that the data and information systems for such plan are in compliance with the standards and operating rules for EFT, eligibility, claim status and health care payment/remittance advice transactions.

Requires health plans to file a certification statement with HHS no later than December 31, 2015 certifying that the data and information systems for such plan are in compliance with the standards and operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payment, referral certification and authorization transactions AND health claims attachments.

Requires that documentation provided to support certification statement demonstrates that plans conduct the electronic transactions in a manner that fully complies with the regulations and that plans has completed end-to-end testing with their partners.

Requires health plans to extend requirements to business associates through Business Associate Agreements.

Requires health plans to file a certification statement with HHS certifying that the data and information systems are in compliance with any applicable revised standards and associated operating rule adopted under interim final rule promulgated by HHS.

Requires HHS to conduct periodic audits to ensure that health plans are in compliance with standards and operating rules.

HHS Review Committee Provisions (1104(b)(5)(i))

Requires HHS to establish a Review Committee no later than January 1, 2014 to advise HHS on evaluation and review of the adopted standards and operating rules. Review Committee can be NCVHS.

Requires HHS, acting through the Review Committee, to conduct hearings to evaluate and review the adopted standards and operating rules, starting no later than April 1, 2014 and not less than biennially thereafter.

Requires the Review Committee to deliver a report no later than July 1, 2014 (and not less than biennially thereafter) providing recommendations for updating and improving such standards and operating rules; a single set of operating rules per transactions must be provided, maintaining the goal of maximum uniformity in the implementation of electronic standards.

Any amendment of adopted standards and operating rules that has been approved by the Review Committee must be adopted via interim final rulemaking no later than 90 days after receipt of Committee’s report.

Effective date of amendment adopted through interim final rule shall be 25 months following the close of 60-day public comment period.

Requires HHS to adopt a single set of operating rules for any transaction for which a standard has been adopted.

Provisions on Penalty Fees (1104(b)(5)(j))

Requires HHS to assess a penalty fee against a health plan that failed to meet requirements; the fee amount equals $1 per covered life until certification is complete. Covered life for which the plan’s data systems are not in compliance and shall be imposed for each day the plan is not in compliance.

Penalty fee for deliberate misrepresentation is twice the amount imposed for failure to comply.

Penalty fee increases annually by the annual percentage increase in total national health care expenditures.

Penalty cannot exceed on an annual basis an amount equal to $20 per covered life or $40 per covered life for deliberate misrepresentation.

Unique Health Plan Identifier Provisions (1104(c)(1))

Requires HHS to promulgate final rule to establish a unique health plan identifier based on input from NCVHS in a manner that the rule is effective no later than October 1, 2012.

Electronic Fund Transfer Transaction Provisions (1104(c)(2))

Requires HHS to promulgate final rule to establish a standard for EFT no later than January 1, 2012, so that the rule is effective no later than January 1, 2014.

Claim Attachments Provisions (1104(c)(3))

Require HHS to promulgate final rule to establish a standard and a single set of operating rules for health claim attachments that is consistent with X12 version 5010 no later than January 1, 2014, so that the rule is effective no later than January 1, 2016.

Consultation with NCVHS, HIT Policy Committee, HIT Standards Committee, SDOs (10109(a)-(b))

Requires HHS to solicit no later than January 1, 2012, and not less than every 3 years thereafter, input from NCVHS, HIT Policy Committee, HIT Standards Committee and SDOs on whether there could be greater uniformity in financial and administrative activities and items; whether such activities should be considered financial and administrative transactions for which adoption of standards and operating rules would improve the operation of the health care system.

Requires HHS to solicit input no later than January 1, 2012 on the following:

Whether application process, including use of uniform application form for enrollment of health care providers by health plans can be made electronic and standardized.
Whether standards and operating rules shall apply to health care transactions of auto insurance, workers’ compensation and other programs or persons not currently covered.
Whether standardized forms could apply to financial audits required by health plans, federal and state agencies, and others.
Whether there could be greater transparency and consistency of methodologies and processes used to establish claim edits used by health plans.
Whether health plans should be required to publish their timeliness of payment rules.

ICD-9 - ICD-10 Crosswalks Provisions (10109(c))

Require HHS to task the ICD-9-CM Coordination and Maintenance Committee to convene a meeting no later than January 1, 2011 to receive input on the crosswalk between ICD-9 and ICD-10 posted on CMS website and make recommendations on appropriate revisions to the crosswalk. Any revised crosswalks shall be treated as a code set for which a standard has been adopted.

Here's a implementation timeline in a simple to read table. Thanks to Walter Suarez at Kaiser Permanente for putting this together!

Monday, May 3, 2010

Using a Cold Frame for Spring Vegetables

Since I missed my personal blog on Thursday due to the Governor's Healthcare IT Conference, I'm posting one now.

As I've discussed in numerous previous blogs, I grow a significant proportion of my vegetables l between March 1 and October 1. The problem with New England is that the weather is very unpredictable.

How do I deal with a Spring that can be 80 degrees one day and snowing the next?

The answer is that I use Cold Frames for my Spring vegetables, especially lettuces. This year I planed Arugula, Oak Leaf, Red Salad Bowl, Red Verona Chicory, Batavian Endive and Garden Cress in March.

The Cold Frame traps the sun's heat, protects young buds from ice/snow/wind, and keeps the chipmunks from munching the tender leaves.

However, this is one caveat - you need to automatically vent the cold frame in direct proportion to temperatures above 60F, otherwise the Cold Frame becomes and oven that roasts your vegetables.

I modified my Cold Frame with an automated vent/lid opener. As the pneumatic cylinder heats, air expands and automatically opens the lid. In my case, the lid starts to open at 60F and opens fully by 80F.

For the past 3 weeks, all the greens for our family meals have come from the Cold Frame. I use scissors to harvest fresh greens minutes before they're served. In our household, we use just a touch of balsamic vinegar and no oil on our greens. They're great!

Cold Frames are definitely a gardener's friend in New England.