As readers of my blog may know, I'm a consulting mycologist, treating over 600 patients who ingest toxic mushrooms every year.
Now there's a novel way to use mushrooms to create custom packing materials.
Imagine choosing your packaging based on its absorptive, cushioning, and strength criteria, then just growing the package you need.
It seems like science fiction but a New York company is doing this.
Ecovative Design "grows" packaging components for Dell Inc. servers and Crate and Barrel furniture, among others.
Mushroom-based packaging you can custom grow for each customer. That's cool!
Friday, March 9, 2012
Thursday, March 8, 2012
Our Cancer Journey Week 12
Last week Kathy started Taxol. She's tolerated it well and did not have any of the fatigue, appetite changes, or anemia that came with Adriamycin/Cytoxan.
The short term challenge with Taxol is not the medication, but the solvent (called Cremophor) used to create an injectable solution. Solvent-related hypersensitivity reactions are relatively common, so Kathy's pre-chemotherapy medications included:
*Dexamethasone 20 mg IV 30 minutes prior to chemotherapy.
*Diphenhydramine (Benadryl) 25-50 mg IV 30 - 60 minutes prior to chemotherapy. 50 mg for first dose. May reduce dose to 25 mg on subsequent doses if tolerated
*Famotidine (Pepcid) 20 mg IV infuse over 15 minutes. 30 minutes prior to chemotherapy.
She had no reaction of any kind, so tomorrow's Taxol dose will include 25mg of Diphenhydramine, yielding less Benadryl-induced sleepiness.
Her usual pattern of chemotherapy, one good day, one moderate day, two bad days, then back to good days has been replaced with chemotherapy followed by good, good, and good days. Since we're preparing our Wellesley house for sale (goes on the market April 1) as part of our move to a farm property in Sherborn, Massachusetts, she needs all the energy she can get. Our nights and weekends are filled with painting, cleaning, and boxing.
Her mood is good, our hope for cure is strong, and our optimism for an American Gothic future keeps us going every day.
The short term challenge with Taxol is not the medication, but the solvent (called Cremophor) used to create an injectable solution. Solvent-related hypersensitivity reactions are relatively common, so Kathy's pre-chemotherapy medications included:
*Dexamethasone 20 mg IV 30 minutes prior to chemotherapy.
*Diphenhydramine (Benadryl) 25-50 mg IV 30 - 60 minutes prior to chemotherapy. 50 mg for first dose. May reduce dose to 25 mg on subsequent doses if tolerated
*Famotidine (Pepcid) 20 mg IV infuse over 15 minutes. 30 minutes prior to chemotherapy.
She had no reaction of any kind, so tomorrow's Taxol dose will include 25mg of Diphenhydramine, yielding less Benadryl-induced sleepiness.
Her usual pattern of chemotherapy, one good day, one moderate day, two bad days, then back to good days has been replaced with chemotherapy followed by good, good, and good days. Since we're preparing our Wellesley house for sale (goes on the market April 1) as part of our move to a farm property in Sherborn, Massachusetts, she needs all the energy she can get. Our nights and weekends are filled with painting, cleaning, and boxing.
Her mood is good, our hope for cure is strong, and our optimism for an American Gothic future keeps us going every day.
Wednesday, March 7, 2012
Early NPRM Questions
As HIT stakeholders review the Meaningful Use Stage 2 NPRMs in detail, questions about the intent of the language are circulating throughout the industry.
The two most common questions I've heard are related to image display (is it viewing via an EHR, through an EHR, DICOM required etc.) and Healthcare Information Exchange transport standards.
Here's a very thoughtful blog post from David Clunie that summarizes the issues of image viewing in the Stage 2 NPRMs.
Healthcare Information Exchange transport is now required per this provision in the CMS NPRM:
"The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using certified EHR technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals."
Many are asking what standards and what architecture will be required, since the Standards and Certification NPRM offers a few options.
The HITSC NwHIN Power Team will continue to make recommendations to ONC, but here's my suggestion:
1. For Push transactions, use SMTP/SMIME between Health Information Services Providers (HISPs) with the option of SOAP for "on ramps" and "off ramps" to EHRs (and PHRs). For point to point transport between EHRs without a HISP use SOAP.
2. For Pull transactions, use SOAP per a rewritten NwHIN Exchange implementation guide (eliminate the layering of specifications that refer to standards within standards within standards). For point to point Pull, consider the kind of simplified Exchange-like SOAP transaction we've implemented between BIDMC and Atrius that does not require a master patient index, record locator service, or document registry.
3. If a RESTful implementation guide becomes available for Push or Pull, consider it.
Over the next 60 days, HITPC and HITSC experts will examine all the ambiguities in both NPRMs. I'm confident that with public comment and expert review, CMS and ONC will polish the NPRMs into Final Rules that are pure poetry.
The two most common questions I've heard are related to image display (is it viewing via an EHR, through an EHR, DICOM required etc.) and Healthcare Information Exchange transport standards.
Here's a very thoughtful blog post from David Clunie that summarizes the issues of image viewing in the Stage 2 NPRMs.
Healthcare Information Exchange transport is now required per this provision in the CMS NPRM:
"The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using certified EHR technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals."
Many are asking what standards and what architecture will be required, since the Standards and Certification NPRM offers a few options.
The HITSC NwHIN Power Team will continue to make recommendations to ONC, but here's my suggestion:
1. For Push transactions, use SMTP/SMIME between Health Information Services Providers (HISPs) with the option of SOAP for "on ramps" and "off ramps" to EHRs (and PHRs). For point to point transport between EHRs without a HISP use SOAP.
2. For Pull transactions, use SOAP per a rewritten NwHIN Exchange implementation guide (eliminate the layering of specifications that refer to standards within standards within standards). For point to point Pull, consider the kind of simplified Exchange-like SOAP transaction we've implemented between BIDMC and Atrius that does not require a master patient index, record locator service, or document registry.
3. If a RESTful implementation guide becomes available for Push or Pull, consider it.
Over the next 60 days, HITPC and HITSC experts will examine all the ambiguities in both NPRMs. I'm confident that with public comment and expert review, CMS and ONC will polish the NPRMs into Final Rules that are pure poetry.
Tuesday, March 6, 2012
The Bookmarked CMS and ONC rules
Thanks for Robin Raiford of the Advisory Board for these resources
She's created a poster comparing Meaningful Use Stage 1 to Stage 2 as currently proposed. This is a 48” x 66” wall poster if you want to render it at a commercial printing service, or zoom to 75% to see it on your screen.
Here's the bookmarked CMS Notice of Proposed Rule Making Stage 2 EHR Incentive Program
Here's the bookmarked ONC Notice of Proposed Rule Making Standards and Certification Criteria
I hope you find these useful.
She's created a poster comparing Meaningful Use Stage 1 to Stage 2 as currently proposed. This is a 48” x 66” wall poster if you want to render it at a commercial printing service, or zoom to 75% to see it on your screen.
Here's the bookmarked CMS Notice of Proposed Rule Making Stage 2 EHR Incentive Program
Here's the bookmarked ONC Notice of Proposed Rule Making Standards and Certification Criteria
I hope you find these useful.
Monday, March 5, 2012
Data Segmentation
In my recent post about consent policy for HIEs, I reflected that opt in consent to disclose at each institution generating data is patient centric and implementable. One challenge with trying to implement a special "consent to view data at each encounter" workflow for HIV is the difficulty of segmenting the medical record to isolate HIV data. Here's a sample record that illustrates the problem:
Medications
1. Tylenol
2. Sudafed
3. AZT
4. Bactrim
Problem List
1. Headache
2. Sinus Infection
3. HIV positive
4. UTI
Letter
I hope you and your partner had a great weekend in Provincetown and that the thrush has improved with the mouthwash sample I gave you
We can create filters for medications that are related to HIV treatment such as AZT. However, some medications are ambiguous. Is the Bactrim being used as prophylaxis against an HIV-related respiratory illness or something else? We see from the problem list that the patient has a UTI, so likely the Bactrim is not HIV related and should be listed as a non-HIV medication. The Letter does not include the words HIV, AIDS, or any medication name. However, it lists Provincetown, which has the highest concentration of same-sex couple households of any zip code in the United States. It mentions thrush which occurs in immunocompromised patients. The Letter could imply HIV positivity.
ONC has launched the data segmentation initiative with the goal of tagging portions of the medical record with enough metadata to separate data into categories that better allow control of information exchange in accordance with patient privacy preferences.
For example, a sample medical record might contain
*Standard care information - problem list, medications, allergies, labs, notes, and immunizations that are not specific to the categories listed below
*Mental Health
*Sexually transmitted diseases
*Substance abuse
*Domestic Violence history
*HIV status
A person's preference may be to share Standard care information with any care provider, but only share STDs and HIV status with a primary care provider, and only share mental health, substance abuse, and domestic violence history with a mental health provider.
The current state of EHRs and HIEs is that data segmentation is very hard because of ambiguity in categorizing data elements, per the example I gave above. With the ONC data segmentation initiative, implementers will receive guidance so that providers and automated decision support tools can tag data as it is entered, enabling segmentation.
Once data is segmented, we can then record patient privacy preferences for each segment. How do we do that?
Mitre has created an open source patient consent policy management tool called Kairon Consents that is available for use now.
It enables the patient to designate who they want to share data with (e.g., by name, institution, referral relationship to PCP, etc.) and what data they wish to share (e.g. allergies) and for what purposes (treatment, research, etc.).
When a request for data is received, there is a policy reasoner that examines the request and presents the record holder with the relevant patient policies for that request (e.g., "The request is from an allowed physician but only allergy data is allowed to be communicated".
Clearly this is just the beginning of national-scale consent management tool development, but it is a reasonable platform for initial capabilities and can be scaled for institutional use.
In 2008, I proposed a "Consent Assertion Markup Language" (CAML). With the Data Segmentation initiative and Kairon Consents, a mechanism for gathering and enforcing more granular patient privacy preferences will soon become a reality.
Medications
1. Tylenol
2. Sudafed
3. AZT
4. Bactrim
Problem List
1. Headache
2. Sinus Infection
3. HIV positive
4. UTI
Letter
I hope you and your partner had a great weekend in Provincetown and that the thrush has improved with the mouthwash sample I gave you
We can create filters for medications that are related to HIV treatment such as AZT. However, some medications are ambiguous. Is the Bactrim being used as prophylaxis against an HIV-related respiratory illness or something else? We see from the problem list that the patient has a UTI, so likely the Bactrim is not HIV related and should be listed as a non-HIV medication. The Letter does not include the words HIV, AIDS, or any medication name. However, it lists Provincetown, which has the highest concentration of same-sex couple households of any zip code in the United States. It mentions thrush which occurs in immunocompromised patients. The Letter could imply HIV positivity.
ONC has launched the data segmentation initiative with the goal of tagging portions of the medical record with enough metadata to separate data into categories that better allow control of information exchange in accordance with patient privacy preferences.
For example, a sample medical record might contain
*Standard care information - problem list, medications, allergies, labs, notes, and immunizations that are not specific to the categories listed below
*Mental Health
*Sexually transmitted diseases
*Substance abuse
*Domestic Violence history
*HIV status
A person's preference may be to share Standard care information with any care provider, but only share STDs and HIV status with a primary care provider, and only share mental health, substance abuse, and domestic violence history with a mental health provider.
The current state of EHRs and HIEs is that data segmentation is very hard because of ambiguity in categorizing data elements, per the example I gave above. With the ONC data segmentation initiative, implementers will receive guidance so that providers and automated decision support tools can tag data as it is entered, enabling segmentation.
Once data is segmented, we can then record patient privacy preferences for each segment. How do we do that?
Mitre has created an open source patient consent policy management tool called Kairon Consents that is available for use now.
It enables the patient to designate who they want to share data with (e.g., by name, institution, referral relationship to PCP, etc.) and what data they wish to share (e.g. allergies) and for what purposes (treatment, research, etc.).
When a request for data is received, there is a policy reasoner that examines the request and presents the record holder with the relevant patient policies for that request (e.g., "The request is from an allowed physician but only allergy data is allowed to be communicated".
Clearly this is just the beginning of national-scale consent management tool development, but it is a reasonable platform for initial capabilities and can be scaled for institutional use.
In 2008, I proposed a "Consent Assertion Markup Language" (CAML). With the Data Segmentation initiative and Kairon Consents, a mechanism for gathering and enforcing more granular patient privacy preferences will soon become a reality.
Friday, March 2, 2012
Cool Technology of the Week
Although I did not attend HIMSS this year because of my wife's chemotherapy timing, I did send several of my staff. I asked them to summarize the cool technologies, most frequently heard buzzwords, and the overall conference trends.
Just as "Plastics" was the catchword from The Graduate, this year's HIMSS Conference theme was a combination "Cloud-based EHRs" and "HIE".
Cloud-based EHRs which follow the model pioneered by AthenaHeath for minimal hardware and minimal configuration in the office now include a number of new entrants including CareCloud and iPatientCare. It will be interesting to see how these companies address the issue of integration with hardware in the office, the desire for customization, and the need for unique interfacing/integration with third party products.
HIE companies are appearing on the landscape faster than ever before. Companies such as Orion, Intersystems, RelayHealth, United/OptumInsight, Aenta/Medicity, DBmotion, Axway, and Certify are increasingly visible in the industry.
With the Stage 2 NPRMs and increased HIMSS emphasis on interoperability, the industry is fast moving toward the Learning Healthcare System we've all envisioned. That's cool!
Just as "Plastics" was the catchword from The Graduate, this year's HIMSS Conference theme was a combination "Cloud-based EHRs" and "HIE".
Cloud-based EHRs which follow the model pioneered by AthenaHeath for minimal hardware and minimal configuration in the office now include a number of new entrants including CareCloud and iPatientCare. It will be interesting to see how these companies address the issue of integration with hardware in the office, the desire for customization, and the need for unique interfacing/integration with third party products.
HIE companies are appearing on the landscape faster than ever before. Companies such as Orion, Intersystems, RelayHealth, United/OptumInsight, Aenta/Medicity, DBmotion, Axway, and Certify are increasingly visible in the industry.
With the Stage 2 NPRMs and increased HIMSS emphasis on interoperability, the industry is fast moving toward the Learning Healthcare System we've all envisioned. That's cool!
Thursday, March 1, 2012
Our Cancer Journey - Week 11
Tomorrow, Kathy starts her next round of chemotherapy - 12 weeks of Taxol administered every Friday at noon.
As with Adriamycin/Cytoxan (AC), we fear the unknown - what symptoms will it bring, how will it affect day to day and long term physical well being (since Taxol causes numbness that can be permanent). Kathy reacted very well to AC so we're hopeful that she'll tolerate Taxol.
The process of treating breast cancer - 20 weeks of chemotherapy followed by surgery and radiation, can be wearing. Of course, we are focused on optimizing the therapy, but at the same time we've needed a long term goal that brings joy and passion for the future, minimizing the day to day challenges of treatment.
Together we've been looking for a farm property, discussing the plans/projects ahead, and preparing for our next stage of life. We moved to Massachusetts 16 years ago and raised our daughter in a family neighborhood, nearby to great public schools and a local library. We believe that we have at least 2 more phases in our lives. Phase 1 - 15 years as empty nesters at the peak of our mental and physical capabilities, ensuring the health of our parents, and supporting our daughter's early career. Phase 2 - 15 years as retirees (and possible grandparents), continuing to write, lecture, and consult but without a "9 to 5" office schedule.
In Phase 1, we're eager to take on the physical labor and mental creativity needed to expand our production of organic vegetables and raise a few chickens/alpaca/llama/goats/sheep.
The quest for a farm property has provided us with enough positive activity to energize our nights and weekends.
Plans and projects for the future are important to sustain optimism, but they're also essential to grow and develop our 30+ year relationship.
As noted in the recent New York Times article Love and Death, having plans and projects for the future is what sustains love beyond the physical attraction, infatuation, and novelty of the initial relationship.
Our farm vision has provided that. To keep patients and families psychologically healthy during cancer treatment it's really important to focus on life after cancer and not let the cancer rule your life. As you'll hear in the new few weeks, we found our farm and now we're planning our move there by May, ensuring that the end of chemotherapy marks the beginning of our new life chapter together.
As with Adriamycin/Cytoxan (AC), we fear the unknown - what symptoms will it bring, how will it affect day to day and long term physical well being (since Taxol causes numbness that can be permanent). Kathy reacted very well to AC so we're hopeful that she'll tolerate Taxol.
The process of treating breast cancer - 20 weeks of chemotherapy followed by surgery and radiation, can be wearing. Of course, we are focused on optimizing the therapy, but at the same time we've needed a long term goal that brings joy and passion for the future, minimizing the day to day challenges of treatment.
Together we've been looking for a farm property, discussing the plans/projects ahead, and preparing for our next stage of life. We moved to Massachusetts 16 years ago and raised our daughter in a family neighborhood, nearby to great public schools and a local library. We believe that we have at least 2 more phases in our lives. Phase 1 - 15 years as empty nesters at the peak of our mental and physical capabilities, ensuring the health of our parents, and supporting our daughter's early career. Phase 2 - 15 years as retirees (and possible grandparents), continuing to write, lecture, and consult but without a "9 to 5" office schedule.
In Phase 1, we're eager to take on the physical labor and mental creativity needed to expand our production of organic vegetables and raise a few chickens/alpaca/llama/goats/sheep.
The quest for a farm property has provided us with enough positive activity to energize our nights and weekends.
Plans and projects for the future are important to sustain optimism, but they're also essential to grow and develop our 30+ year relationship.
As noted in the recent New York Times article Love and Death, having plans and projects for the future is what sustains love beyond the physical attraction, infatuation, and novelty of the initial relationship.
Our farm vision has provided that. To keep patients and families psychologically healthy during cancer treatment it's really important to focus on life after cancer and not let the cancer rule your life. As you'll hear in the new few weeks, we found our farm and now we're planning our move there by May, ensuring that the end of chemotherapy marks the beginning of our new life chapter together.
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