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!

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!

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.

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!

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.

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!

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!