The November HIT Standards Committee meeting focused on existing implementations of point to point transport standards as a foundation for its evaluation of the Direct project.
We began the meeting with a report from the Implementation Workgroup, which will gather testimony on January 10-11, 2011 about the experience of implementing standards in certified systems and achieving meaningful use goals.
We discussed the work of the other HIT Standards Committee workgroups including the upcoming effort by the Vocabulary Task Force to take testimony on device content and vocabulary standards. Given the evolving importance of home care devices, implantable devices, and mHealth, ensuring robust standards in this area is important.
We started the day's testimony noting that we will be discussing just point to point "push" use cases this month. Typical components of such an approach are a routing method, a provider directory, certificate management, auditing, and acknowledgement of delivery. Use cases covered by the "push" approach include PCP to specialist referrals, routing to registries, e-prescribing data exchanges between providers/pharmacies, and sending summaries to patients.
Here are links to the testimony:
Peter Tippett, Verizon
John Feikema, Visionshare
Joseph Carlson, Covisint
Anand Shroff, Axolotl
Cris Ross, Surescripts
Eric Dishman & Gary Binder, Intel
After the testimony we summarized the major themes.
Directories - Proposed directory options ranged from a nationally centralized yellow pages of organizations to a federated white pages of persons/departments/machines to undiscoverable local directories. Email is an example of a directory which is generally undiscoverable outside an organization. Once you know the email address of a person, email gateways route from organization to organization. Once email arrives at the organization, it is routed to the recipient using a local directory. Whatever directory and addressing scheme is chosen, it is very important that all vendors support it to achieve a network of networks that enables any provider to connect to any other provider.
Identity/Trust - Each of the vendors is using X.509 certificate-based approaches to secure organization to organization transport plus a formal certificate management approach (based on policy) to verifying identity and achieving a trust fabric. Creating a chain of trust among vendors is very important to supporting network to network transport.
Transport - SMTP/SMIME, REST, and SOAP have all been used successfully in the real world as transport standards for health information exchange. Achieving common directories and a trust fabric are more important than settling on a single transport protocol. However, in the interest of keeping the architecture simple, there should be few, not many standards options for transport. Having at least one common transport approach to enable universal addressing is desirable.
The internet itself is based on a small number of standards specifying directories such as the Domain Naming System (DNS) system, which is implemented in a federated architecture. The internet has a small set of standards enabling certificate authorities to act as "electronic notaries", establishing identity and trust. On top of this foundation of directories and trust, there are multiple transport protocols that used to support specific use cases such as HTTPS, FTP, SMTP, etc. Push-based healthcare information exchange should use an analogous approach - get the directory/addressing and identify/trust right, then use the transport standards that best support workflow and are easy to implement.
Our next steps are to get policy guidance from the HIT Policy Committee Provider Directory Workgroup, review the Implementation guides from the testifying vendors who have successfully implemented a trust fabric, and assemble a multi-stakeholder team of interested participants from the HIT Standards Committee to evaluate NHIN Direct. We'll use objective criteria, informed by today's testimony to consider NHIN Direct on its own merits, evaluating its implementation specifications against the project goals to be simple, direct, scalable, and secure transport for the little guy.
Tuesday, November 30, 2010
Monday, November 29, 2010
A Milestone for the Direct Project
Nine months ago, I wrote about the NHIN Direct project and its effort to enable health information exchange for the little guy.
Since then, I've written many times about the need to transport standard specifications to accelerate interoperability. It's even one of my FY11 keep me awake at night topics.
Today, the Direct Project team issued this press release.
As Arien Malec, Coordinator of the Direct Project, noted in his Thanksgiving message to the project participants:
"We have two specifications that are content complete (needing editorial review and revision); two reference implementations that are at a 1.0 state and can "out of the box, just add trust" enable exchange with a simple install and configuration; some amazing documentation, from the elegant generalist overview, to the most geeked out installation and programming guides; a compelling presentation; solid best practices and security reviews to protect privacy, security and trust; and some incredible implementation geographies integrating directed exchange into physician workflow to enable meaningful use and improved quality."
This effort is terrific and I look forward to the thorough analysis of the implementation specifications that the HIT Standards Committee will do over the next month to ensure the work meets the design requirements for simple, direct, scalable, and secure transport.
Tomorrow, the HIT Standards Committee begins that process by taking public testimony from six leading HIE vendors. It will be interesting to see who commits to implementing Direct and how they compare its specifications to other implementations of SOAP, REST, and SMTP for point to point data exchange.
There is no question that having alignment and energy behind a data transport solution is a critical need for the industry. You don’t need to go any further than a hospital referral department, awash in paper and fax machines, to know that this is really important.
Since then, I've written many times about the need to transport standard specifications to accelerate interoperability. It's even one of my FY11 keep me awake at night topics.
Today, the Direct Project team issued this press release.
As Arien Malec, Coordinator of the Direct Project, noted in his Thanksgiving message to the project participants:
"We have two specifications that are content complete (needing editorial review and revision); two reference implementations that are at a 1.0 state and can "out of the box, just add trust" enable exchange with a simple install and configuration; some amazing documentation, from the elegant generalist overview, to the most geeked out installation and programming guides; a compelling presentation; solid best practices and security reviews to protect privacy, security and trust; and some incredible implementation geographies integrating directed exchange into physician workflow to enable meaningful use and improved quality."
This effort is terrific and I look forward to the thorough analysis of the implementation specifications that the HIT Standards Committee will do over the next month to ensure the work meets the design requirements for simple, direct, scalable, and secure transport.
Tomorrow, the HIT Standards Committee begins that process by taking public testimony from six leading HIE vendors. It will be interesting to see who commits to implementing Direct and how they compare its specifications to other implementations of SOAP, REST, and SMTP for point to point data exchange.
There is no question that having alignment and energy behind a data transport solution is a critical need for the industry. You don’t need to go any further than a hospital referral department, awash in paper and fax machines, to know that this is really important.
Friday, November 26, 2010
Cool Technology of the Week
I've written about my goal to be as low impact as I can be over the rest of my life, eventually retiring to a small, green engineered cabin in the woods and taking inspiration from early architectural innovators.
To support that goal, I'm always learning about new technologies that support green living.
In February I wrote about innovative lighting using LEDs. Since then, I've learned a great deal about building codes, efficiency measures, and physics. Here's how to be an intelligent consumer of emerging LED lighting technology.
You'll find that LED bulbs from Sylvania, Philips, and EcoSmart are sold based on wattage i.e. it's a replacement for a 40W bulb.
That really does not mean anything.
The amount of light produced for the wattage consumed is the measure of interest.
The "40W" LED bulbs produced by Sylvania in February produced 350 lumens of light using 8 watts of power. The current Sylvania bulbs produce 450 lumens of light using 8 watts of power. How does that compare to an incandescent? A typical incandescent 40 watt bulb produces 500 lumens of light. How about compact fluorescents? A typical compact fluorescent equivalent to a 40W incandescent bulb produces 450 lumens of light using 9 watts of power.
How do we evaluate the lighting efficiency of these bulbs? The right measure is lumens/watt (lm/w)
Incandescent - 500lm/40w = 12.5 lm/w
Compact Fluorescent - 450lm/9w = 50 lm/w
First generation LED 350lm/8w = 43.75 lm/w
Second generation LED 450lm/8w = 56.25 lm/w
Just announced LED products include a downlight with 1439 lumens at 82 lm/w and a new LED "60W" bulb with 810 lumens at 67.5 lm/w.
With LEDs producing more light and less heat for less energy than compact fluorescents without mercury or other toxic concerns, they are clearly the future. Also, the bulb life of LEDs is 25,000 hours. Compact fluorescents typically have a rated lifespan of between 6,000 and 15,000 hours, whereas incandescent lamps have a lifespan of 750 hours or 1,000 hours.
The only issue is acquisition cost of LEDs, since total cost of ownership based on energy savings and bulb life has a reasonable return on investment. Current industry predictions are that LEDs will match the cost of compact fluorescents within 2 years.
All of this is good news for compliance with the 2009 International Energy Conservation Code (which I'll follow for my cabin in the woods). It requires:
60 lm/w for bulbs over 40W
50 lm/w for bulbs 16W to 40W
40 lm/w for bulbs 15W and under
The LEDs coming into the marketplace now accomplish this nicely. Lighting an entire house with 100 watts of power- that's cool!
Thursday, November 25, 2010
A Time to Give Thanks
Last week I was on a flight to Dallas and forgot my airplane reading, so I purchased a copy of The Economist 2011 Forecast Issue.
While perusing articles about war, population growth, economic struggle, environmental challenges, and the growing divide between the haves and have nots, I had the sobering realization that the things keeping me up at night are truly minor in comparison.
Reflecting on the past year, I do not even remember the projects, problems, and conflicts that seemed so urgent 12 months ago. I do not remember the meetings I felt guilty about missing because I triaged other things first. I do not remember the times I was late and felt too rushed to let in that driver trying to merge.
Our jobs are important and can define much of our self worth. But jobs are transient. Bosses come and go, organizational priorities change, and your personal star can rise and fall. No one has a gravestone the reads "my only regret is that I did not attend more meetings". I do remember those times I brought stress home, missed a family event, or stared at email while my family waited to start dinner.
So put away your Blackberry, stop the tweeting, change your Facebook status to 'focusing on my family' and embrace your loved ones. Today is a day for giving thanks to the people around us, the relationships we've made, and the effort we need to put into sustaining them.
We're carving the roasted vegetables, ladling the squash soup and filing the rice bowls. Everyone is healthy and our trajectory is good.
It's time to give thanks.
While perusing articles about war, population growth, economic struggle, environmental challenges, and the growing divide between the haves and have nots, I had the sobering realization that the things keeping me up at night are truly minor in comparison.
Reflecting on the past year, I do not even remember the projects, problems, and conflicts that seemed so urgent 12 months ago. I do not remember the meetings I felt guilty about missing because I triaged other things first. I do not remember the times I was late and felt too rushed to let in that driver trying to merge.
Our jobs are important and can define much of our self worth. But jobs are transient. Bosses come and go, organizational priorities change, and your personal star can rise and fall. No one has a gravestone the reads "my only regret is that I did not attend more meetings". I do remember those times I brought stress home, missed a family event, or stared at email while my family waited to start dinner.
So put away your Blackberry, stop the tweeting, change your Facebook status to 'focusing on my family' and embrace your loved ones. Today is a day for giving thanks to the people around us, the relationships we've made, and the effort we need to put into sustaining them.
We're carving the roasted vegetables, ladling the squash soup and filing the rice bowls. Everyone is healthy and our trajectory is good.
It's time to give thanks.
Wednesday, November 24, 2010
What Keeps Me Up at Night - FY11 edition
Every year, I reflect on those projects that are risky or so fraught with change management peril that they keep me up at night (it's a metaphor, since I sleep soundly for 4 hours a night). Here's the FY11 edition of my concerns in each of my 5 lives:
Federal
*Transport Standards - the Standards and Certification Final Rule provided detailed implementation guides for Content, Vocabulary, and Security standards but nothing for Transport standards. NHIN Direct and numerous private sector approaches are piloting REST, SOAP, and SMTP approaches to send data from point A to point B. We need to converge on a single approach for Transport by 2011 to accelerate interoperability and avoid the chaos of 50 different state HIE implementations.
*Mobile and Homecare Devices - As Ray Ozzie described in his farewell memo to Microsoft staff, mobile devices such as phones, iPads, smart appliances, and wearable sensors are likely to serve as the human-application interface in the future. We need content, vocabulary, security, and transmission standards to support interoperability of all the devices we'll use.
*Vocabulary Resources - We need a one stop shop for all the vocabularies and code sets required to support Meaningful Use Stages 1, 2, and 3. This resource needs to be easy to use and free (see Intellectual Property issues below)
*Intellectual property issues - Today, most standards implementation guides are incomplete because they cannot include the intellectual property from Standards Development Organizations (SDOs) without disrupting the business models of those organizations. We need a new model - government funding, a simple annual assessment paid to a government agency/administrative organization to enable download of complete implementation specifications, or some combination of public/private funding. Otherwise we'll suffer the problem of indirection - incomplete implementation guides which refer to proprietary information which refer to proprietary information etc. Here's an example of a perfect implementation guide from the Social Security Administration - everything you need to create seamless interoperability without indirection.
*Adoption and Implementation - Standards are not imposed, they are adopted. The measure of success for all Federal standards efforts will be the number of transactions flowing in 2011, 2013 and 2015 using the harmonized standards selected to support meaningful use.
State
*Governance - The Commonwealth of Massachusetts is exploring several HIE Governance models and needs to implement open, transparent, public/private governance to ensure trust and investment from the private sector.
*Procurement - The Commonwealth needs to procure directory services, certificate management services, and routing services to support all unconnected stakeholders.
*Sustainability - The Commonwealth needs to consider subscription, transaction, assessment, government subsidy, and bond offerings to provide a sustainability model for the HIE which connects all stakeholders
*Connecting the little guy - A public good HISP (healthcare information services provider) needs to provide healthcare information exchange at low cost to small practices that may not be served by the private sector because of the expense of implementing connectivity to a small, isolated site.
*Moving at meaningful use speed - The Commonwealth needs to have these solutions in place by 2011. Hospital meaningful use attestation needs to be done by November 2011, so we need to act now on Governance, Procurement, and Sustainability.
Harvard Medical School
*Research liaison - The research community at Harvard needs a scientist and a team of experts who can translate challenging scientific problems into creative IT solutions. Our traditional method of providing storage services, high performance computing, and software licensing is no longer sufficient. We need to merge science and IT in novel ways.
*Extranet migration to a content management system - Like many organizations, Harvard's web presence is a collection of sites created by departments, labs, and administrators. It needs to be completely transformed into a content management system with a common look and feel, Google search, and federated authoring/editing.
*Sustainability model for staff and infrastructure - In challenging economic times, getting additional FTEs/operating budget is problematic. However, ARRA funds have brought new demands, new infrastructure, and new services to Harvard, all of which require additional staff. There needs to be an NIH compliant direct and indirect cost chargeback model which enables IT to grow organically as new grants are received.
*Compliance and Security - In all my organizations, 2011 is going to be a year of increased compliance. Harvard has new data security rules. Internal audit is focusing on applications which manipulate person identified data. Conflict of Interest tracking requires new reporting capabilities. The reaccreditation of Harvard Medical School in 2011 will bring increased scrutiny to business processes. Labs require new training and certifications for safety, administered electronically.
*Matching IT supply and demand through Governance - In all my organizations, 2011 is the year of Governance. As we emerge from the economic doldrums of 2009-2010 we have the potential to increase FTEs. Governance committees for research, administration, and education can balance supply and demand as well as advocate for new resources.
BIDMC
*Certification/Behavioral Change for Meaningful Use - During the week of December 6, I'll work with CCHIT to certify all the hospital and ambulatory systems of BIDMC, both built and bought, as part of their Site Certification program. I'll document the experience so that other hospitals with heterogeneous systems will be successful in achieving certification. The real risk is that private clinicians in the community will not find incentives compelling and will not use EHRs in a meaningful way over the next several years, making quality measurement, global payments, and accountable care organization implementation difficult.
*Preparing for healthcare reform and accountable care organizations - Is it better to create a strategic plan to become an Accountable Care Organization or be an opportunist, creating affiliations and IT integration on the path of healthcare reform over the next few years, given the continuously changing policy landscape? We're creating the foundation by ensuring BIDMC can send and receive healthcare data with patient consent to any provider organization, public health entity, or registry which measures outcomes on our behalf.
*Clinical Documentation (including ICD-10 and Medication Management) - 2013 is right around the corner and we need full compliance with 5010 and ICD-10 standards in our clinical and financial systems. More importantly, we need robust clinical documentation in all areas of care to be able to justify the ICD-10 codes that our HIM professionals select. We also need robust medication management including bedside medication verification and electronic medication administration records to support Stage 2 and Stage 3 of meaningful use in 2013 and 2015. This will require a substantial effort by business owners to define new workflows and automation requirements.
*Ever Increasing Demands for Compliance and Security - Just as with HMS, there will be numerous compliance efforts in the next year - FLSA compliance with advanced time keeping systems, followup to our Joint Commission and CMS visits to ensure we meet all their criteria, and increasingly sophisticated monitors/audits to address new Massachusetts Data Protection requirements.
*Matching IT supply and demand through Governance - The BIDMC IS Governance Committees help match supply and demand, set priorities/timing, and support the need for additional resources. Increased resources for project management, allocation of appropriate resources for ongoing support/maintenance of technology, and reduction of mid-year unplanned projects are essential to our success.
Personal
*Parents - After their recent hospitalizations, I need to support them in any way I can to keep them healthy and happy.
*Daughter - As my daughter approaches adulthood (she'll be 18 in 2011), I need to provide a balance of guidance and independence. We'll hear about her college application (early decision to Tufts) in 3 weeks.
*Wife - My wife and I have been together for 30 years. In 2011, we'll transition to empty nesters, entering a new stage of our lives. We'll continue our morning walks, our moonlight conversations, and our enjoyment of the world around us.
*Self - In 2011, I'll continue allocating time for mental and physical health. My outdoor activities - hiking, biking, kayaking, climbing, and skiing ensure I keep a clear mind and fit body.
*The world around me - In the interesting of leaving my daughter with a world she can thrive in, I'm reducing my carbon footprint by eliminating travel whenever possible, focusing on Green energy, and maximizing sustainability in my lifestyle choices.
That's what keeping me up at night this year. The great joy about life is that I never know what next year will bring!
Federal
*Transport Standards - the Standards and Certification Final Rule provided detailed implementation guides for Content, Vocabulary, and Security standards but nothing for Transport standards. NHIN Direct and numerous private sector approaches are piloting REST, SOAP, and SMTP approaches to send data from point A to point B. We need to converge on a single approach for Transport by 2011 to accelerate interoperability and avoid the chaos of 50 different state HIE implementations.
*Mobile and Homecare Devices - As Ray Ozzie described in his farewell memo to Microsoft staff, mobile devices such as phones, iPads, smart appliances, and wearable sensors are likely to serve as the human-application interface in the future. We need content, vocabulary, security, and transmission standards to support interoperability of all the devices we'll use.
*Vocabulary Resources - We need a one stop shop for all the vocabularies and code sets required to support Meaningful Use Stages 1, 2, and 3. This resource needs to be easy to use and free (see Intellectual Property issues below)
*Intellectual property issues - Today, most standards implementation guides are incomplete because they cannot include the intellectual property from Standards Development Organizations (SDOs) without disrupting the business models of those organizations. We need a new model - government funding, a simple annual assessment paid to a government agency/administrative organization to enable download of complete implementation specifications, or some combination of public/private funding. Otherwise we'll suffer the problem of indirection - incomplete implementation guides which refer to proprietary information which refer to proprietary information etc. Here's an example of a perfect implementation guide from the Social Security Administration - everything you need to create seamless interoperability without indirection.
*Adoption and Implementation - Standards are not imposed, they are adopted. The measure of success for all Federal standards efforts will be the number of transactions flowing in 2011, 2013 and 2015 using the harmonized standards selected to support meaningful use.
State
*Governance - The Commonwealth of Massachusetts is exploring several HIE Governance models and needs to implement open, transparent, public/private governance to ensure trust and investment from the private sector.
*Procurement - The Commonwealth needs to procure directory services, certificate management services, and routing services to support all unconnected stakeholders.
*Sustainability - The Commonwealth needs to consider subscription, transaction, assessment, government subsidy, and bond offerings to provide a sustainability model for the HIE which connects all stakeholders
*Connecting the little guy - A public good HISP (healthcare information services provider) needs to provide healthcare information exchange at low cost to small practices that may not be served by the private sector because of the expense of implementing connectivity to a small, isolated site.
*Moving at meaningful use speed - The Commonwealth needs to have these solutions in place by 2011. Hospital meaningful use attestation needs to be done by November 2011, so we need to act now on Governance, Procurement, and Sustainability.
Harvard Medical School
*Research liaison - The research community at Harvard needs a scientist and a team of experts who can translate challenging scientific problems into creative IT solutions. Our traditional method of providing storage services, high performance computing, and software licensing is no longer sufficient. We need to merge science and IT in novel ways.
*Extranet migration to a content management system - Like many organizations, Harvard's web presence is a collection of sites created by departments, labs, and administrators. It needs to be completely transformed into a content management system with a common look and feel, Google search, and federated authoring/editing.
*Sustainability model for staff and infrastructure - In challenging economic times, getting additional FTEs/operating budget is problematic. However, ARRA funds have brought new demands, new infrastructure, and new services to Harvard, all of which require additional staff. There needs to be an NIH compliant direct and indirect cost chargeback model which enables IT to grow organically as new grants are received.
*Compliance and Security - In all my organizations, 2011 is going to be a year of increased compliance. Harvard has new data security rules. Internal audit is focusing on applications which manipulate person identified data. Conflict of Interest tracking requires new reporting capabilities. The reaccreditation of Harvard Medical School in 2011 will bring increased scrutiny to business processes. Labs require new training and certifications for safety, administered electronically.
*Matching IT supply and demand through Governance - In all my organizations, 2011 is the year of Governance. As we emerge from the economic doldrums of 2009-2010 we have the potential to increase FTEs. Governance committees for research, administration, and education can balance supply and demand as well as advocate for new resources.
BIDMC
*Certification/Behavioral Change for Meaningful Use - During the week of December 6, I'll work with CCHIT to certify all the hospital and ambulatory systems of BIDMC, both built and bought, as part of their Site Certification program. I'll document the experience so that other hospitals with heterogeneous systems will be successful in achieving certification. The real risk is that private clinicians in the community will not find incentives compelling and will not use EHRs in a meaningful way over the next several years, making quality measurement, global payments, and accountable care organization implementation difficult.
*Preparing for healthcare reform and accountable care organizations - Is it better to create a strategic plan to become an Accountable Care Organization or be an opportunist, creating affiliations and IT integration on the path of healthcare reform over the next few years, given the continuously changing policy landscape? We're creating the foundation by ensuring BIDMC can send and receive healthcare data with patient consent to any provider organization, public health entity, or registry which measures outcomes on our behalf.
*Clinical Documentation (including ICD-10 and Medication Management) - 2013 is right around the corner and we need full compliance with 5010 and ICD-10 standards in our clinical and financial systems. More importantly, we need robust clinical documentation in all areas of care to be able to justify the ICD-10 codes that our HIM professionals select. We also need robust medication management including bedside medication verification and electronic medication administration records to support Stage 2 and Stage 3 of meaningful use in 2013 and 2015. This will require a substantial effort by business owners to define new workflows and automation requirements.
*Ever Increasing Demands for Compliance and Security - Just as with HMS, there will be numerous compliance efforts in the next year - FLSA compliance with advanced time keeping systems, followup to our Joint Commission and CMS visits to ensure we meet all their criteria, and increasingly sophisticated monitors/audits to address new Massachusetts Data Protection requirements.
*Matching IT supply and demand through Governance - The BIDMC IS Governance Committees help match supply and demand, set priorities/timing, and support the need for additional resources. Increased resources for project management, allocation of appropriate resources for ongoing support/maintenance of technology, and reduction of mid-year unplanned projects are essential to our success.
Personal
*Parents - After their recent hospitalizations, I need to support them in any way I can to keep them healthy and happy.
*Daughter - As my daughter approaches adulthood (she'll be 18 in 2011), I need to provide a balance of guidance and independence. We'll hear about her college application (early decision to Tufts) in 3 weeks.
*Wife - My wife and I have been together for 30 years. In 2011, we'll transition to empty nesters, entering a new stage of our lives. We'll continue our morning walks, our moonlight conversations, and our enjoyment of the world around us.
*Self - In 2011, I'll continue allocating time for mental and physical health. My outdoor activities - hiking, biking, kayaking, climbing, and skiing ensure I keep a clear mind and fit body.
*The world around me - In the interesting of leaving my daughter with a world she can thrive in, I'm reducing my carbon footprint by eliminating travel whenever possible, focusing on Green energy, and maximizing sustainability in my lifestyle choices.
That's what keeping me up at night this year. The great joy about life is that I never know what next year will bring!
Tuesday, November 23, 2010
Clinical Systems Goals for FY11
Every year, the IS governance committees of BIDMC translate the organization's short term and long term strategy into IS priorities and projects. Clinical Systems is a particularly challenging area because so many of the workflow innovations require inventing automation that is not commonplace in US hospitals and clinics.
Here's our complete Clinical Systems strategy and staffing for FY11. We have a very lean team given that we support 6000 clinicians and staff at BIDMC plus over 10,000 affiliated users.
For FY11, major areas of innovation include
*Elimination of the last handwritten orders in the organization, which requires innovative CPOE approaches in the NICU and ED
*Innovative surveillance and analytic approaches to support infection control and anti-microbial management
*Closing the loop between PCPs and specialists to ensure referrals are completed and documented including alerting PCPs if patients do not schedule a specialist appointment
*Ensure all diagnostic test results are delivered to the person who ordered them and signed off, with followup arranged for abnormal results.
*Enhanced Healthcare Information Exchange in support of meaningful use
*Creative approaches to clinical documentation in the acute care setting including templates, macros, wikis, and social networking approaches to collaboration
*Move us closer to a completely electronic inpatient ("paperless charts") workflow by automating paper forms
*Scanning paper from outside organizations so that even non-electronic referrals are added to our electronic documentation
*Enterprise image management that archives all modalities (radiology, cardiology, pulmonology, ob/gyn etc.) in one repository for viewing anywhere, anytime, using a common viewer
*Business Intelligence that turns data into information, knowledge, and wisdom using advanced reporting and analysis tools in MS SQLServer and related technologies.
*Intranet and Extranet enhancements that move us from a reliance on shared files and email to blogs, wikis, tag clouds, and crowdsourcing
For 2011, we'll be adding three programmers, one analyst, an enterprise PMO director, and 2 infrastructure support staff, so resources are coming after the economic doldrums of 2009.
Our next step is to achieve certification of all inpatient and outpatient built and bought systems, which will complete by the end of the year. Our Meaningful Use reporting period will be January-March followed by attestation in April. Our complete replacement of all laboratory information systems goes live in June and we'll be done with all our community EHR rollouts, supporting 1700 clinicians by Summer.
2011 will be a banner year for Clinical Systems.
Here's our complete Clinical Systems strategy and staffing for FY11. We have a very lean team given that we support 6000 clinicians and staff at BIDMC plus over 10,000 affiliated users.
For FY11, major areas of innovation include
*Elimination of the last handwritten orders in the organization, which requires innovative CPOE approaches in the NICU and ED
*Innovative surveillance and analytic approaches to support infection control and anti-microbial management
*Closing the loop between PCPs and specialists to ensure referrals are completed and documented including alerting PCPs if patients do not schedule a specialist appointment
*Ensure all diagnostic test results are delivered to the person who ordered them and signed off, with followup arranged for abnormal results.
*Enhanced Healthcare Information Exchange in support of meaningful use
*Creative approaches to clinical documentation in the acute care setting including templates, macros, wikis, and social networking approaches to collaboration
*Move us closer to a completely electronic inpatient ("paperless charts") workflow by automating paper forms
*Scanning paper from outside organizations so that even non-electronic referrals are added to our electronic documentation
*Enterprise image management that archives all modalities (radiology, cardiology, pulmonology, ob/gyn etc.) in one repository for viewing anywhere, anytime, using a common viewer
*Business Intelligence that turns data into information, knowledge, and wisdom using advanced reporting and analysis tools in MS SQLServer and related technologies.
*Intranet and Extranet enhancements that move us from a reliance on shared files and email to blogs, wikis, tag clouds, and crowdsourcing
For 2011, we'll be adding three programmers, one analyst, an enterprise PMO director, and 2 infrastructure support staff, so resources are coming after the economic doldrums of 2009.
Our next step is to achieve certification of all inpatient and outpatient built and bought systems, which will complete by the end of the year. Our Meaningful Use reporting period will be January-March followed by attestation in April. Our complete replacement of all laboratory information systems goes live in June and we'll be done with all our community EHR rollouts, supporting 1700 clinicians by Summer.
2011 will be a banner year for Clinical Systems.
Monday, November 22, 2010
Smart Medication Reconciliation and Problem Lists
Last week, I spent a few days in California when both my parents ended up in the hospital with different issues. They're home, settled and doing well at this point.
Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.
As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.
Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family. What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.
My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.
Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.
The result is that my parents received unnecessary medications as well as did not receive necessary ones.
The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.
How do we solve this?
1. Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.
2. Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes. Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.
3. At its very simplest, carry a wallet card with an active medication list and problem list.
While in California, I isolated every medication in the house, current and historical. I documented active medications, active problems and the relationship between the medications and the problems. I reviewed the resulting lists will all family members (with their consent). My parents will ensure all their clinicians update their records to reflect this accurate information. They will carry with them to any future hospitalizations. I disposed of historical medications (safely) to prevent any future confusion. I isolated medications for each person so there would be no accidental taking of medications intended for other people.
Admittedly as a clinician, I have the training that enables me to do this.
For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.
As we build electronic systems, the outpatient to inpatient transition will become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.
Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.
As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.
Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family. What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.
My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.
Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.
The result is that my parents received unnecessary medications as well as did not receive necessary ones.
The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.
How do we solve this?
1. Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.
2. Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes. Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.
3. At its very simplest, carry a wallet card with an active medication list and problem list.
While in California, I isolated every medication in the house, current and historical. I documented active medications, active problems and the relationship between the medications and the problems. I reviewed the resulting lists will all family members (with their consent). My parents will ensure all their clinicians update their records to reflect this accurate information. They will carry with them to any future hospitalizations. I disposed of historical medications (safely) to prevent any future confusion. I isolated medications for each person so there would be no accidental taking of medications intended for other people.
Admittedly as a clinician, I have the training that enables me to do this.
For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.
As we build electronic systems, the outpatient to inpatient transition will become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.
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