Google Glass - the Details

I’m now able to publicly write about the work that Beth Israel Deaconess Medical Center has been doing with stealthy start up, Wearable Intelligence. We’ve been working over the past 4 months on pilots that I believe will improve the  safety, quality  and efficiency of patient care through the integration of wearable technology such as Google Glass in the hospital environment. I believe that wearable tech enables providers  to deliver better clinical care by supporting them with contextually-relevant data and decision support wisdom.

 One of our Emergency Department physicians, Dr. Steve Horng, said it best:

 "Over the past 3 months, I have been using Google Glass clinically while working in the Emergency Department. This user experience has been fundamentally different than our previous experiences with Tablets and Smartphones. As a wearable device that is always on and ready, it has remarkably streamlined clinical workflows that involve information gathering.

For example, I was paged emergently to one of our resuscitation bays to take care of a patient who was having a massive brain bleed. One of the management priorities for brain bleeds is to quickly control blood pressure to slow down progression of the bleed. All he could tell us was that he had severe allergic reactions to blood pressure medications, but couldn’t remember their names, but that it was all in the computer.

Unfortunately, this scenario is not unusual. Patients in extremis are often unable to provide information as they normally would.  We must often assess and mitigate life threats before having fully reviewed a patient’s previous history. Google Glass enabled me to view this patient’s allergy information and current medication regimen without having to excuse myself to login to a computer, or even loose eye contact. It turned out that he was also on blood thinners that needed to be emergently reversed. By having this information readily available at the bedside, we were able to quickly start both antihypertensive therapy and reversal medications for his blood thinners, treatments that if delayed could lead to permanent disability and even death. I believe the ability to access and confirm clinical information at the bedside is one of the strongest features of Google Glass.”

As procedure oriented specialists, emergency medicine clinicians must stay visually engaged with their patients while also using their hands to complete critical tasks.  Wearing a device that enables clinicians to view different forms of information without having to disrupt workflow to access a computing device is  empowering.

 This video demonstrates the value and impact that the technology can have.

 Here’s how we are currently using it:

When a clinician walks into an emergency department troom, he or she looks at bar code (a QR or Quick Response code) placed on the wall. Wearable Intelligence’s software running on Google Glass immediately recognizes the room and then the ED Dashboard sends information about the patient in that room to the glasses, appearing in the clinician’s field of vision. The clinician can speak with the patient, examine the patient, and perform procedures while seeing problems, vital signs, lab results and other data.

Beyond the technical challenges of bringing wearable computers to BIDMC, we had other concerns—protecting security, evaluating patient reaction, and ensuring clinician usability.

We have fully integrated with the ED Dashboard using a custom application to ensure secure communication and the same privacy safeguards as our existing web interface.  All data stays within the BIDMC firewall.

Wearable Intelligence has designed a custom user interface to take advantage of the Glass’ unique features such as gestures (single tap, double tap, 1 and 2 finger swipes, etc.), scrolling by looking up/down, camera to use QR codes, and voice commands. Information displays also needed to be simplified and re-organized.

We implemented real-time voice dictation of pages to staff members to facilitate communication among clinicians.

 After several months of testing, we have deployed the product to clinical providers in the ED and are completing the first IRB approved study (to our knowledge) of the technology’s impact on clinical medicine.

Working on novel technology with Wearable Intelligence provides respite from an agenda that has been filled with meaningful use, ICD-10, ACA, and the HIPAA Omnibus rule.   I look forward to reporting further about our experience.

Building Unity Farm - The Farm Journal begins

This month marks the two year anniversary of our move to Unity Farm. We planned the farm with the desire to be as self sufficient as possible.  Kathy closed her art gallery and now works on the farm full time.

In the past two years, we have installed a poultry yard, created paddocks for the animals, and removed 2 acres of trees to plant the orchard.  We built a hoop house for produce and inoculated shitake/oyster mushroom logs from our woodland management work. We  developed a 1 mile trail system and planted a diverse range of multi-season annuals, perennials, shrubs and trees for the bees.  We've worked the property and orchard/blueberries organically.

At some point, “Building Unity Farm” must transition into an operational and maintenance phase.   Given our two year anniversary as a working farm, today I’m turning my Thursday blog posts into the Unity Farm Journal, describing the weekly activities that are involved in running the farm.  It’s not art, romance or glamour.    It’s mud, heavy lifting, and joyful chaos.  Here’s my first entry in the Unity Farm Journal:

First week of April 2014

Our daytime temperatures are consistently in the 50’s with nighttime temperatures hovering at freezing.   The snow has melted and the paddocks have become a sea of mud.   The ducks can swim across the female alpaca compound which reflects the amount of snow we had this winter and the amount of rain we’ve had in Spring.

As usual the weekend was filled with farm tasks.     We finished the spring planting in the hoop house and now have beds of garlic, romaine, spinach, chard, peas, carrots, and bok choi.  We’ll plant beans and cucumbers in the next few weeks.      Here’s what the hoop house looks like with greenhouse blankets to protect the early seedlings from cool nighttime temperatures.

 I created templates, pictured below, for seed planting to ensure appropriate spacing between rows and plants.

Now that the ground is thawed, work on the farm trails can continue.   When I first laid out the trails, I traversed uneven ground just to bring access to every corner of the 15 acres.   Now I’m refining the trails, adding landscape timbers driven into the ground with rebar to terrace sloping paths, like the one below.

Last week I described my effort to create a trail to our vernal ponds.    We also have a cattail area - an acre of skunk cabbage, cattails, and forget me nots.   It would be very disruptive to walk through such an environmentally sensitive area.   To bring access to this area, I built a bridge and floating pier from the Marsh trail into “cattail hollow” which I’ll finish next weekend.  Here’s the general layout

Our major project last weekend was to complete our reconstruction of the bee yard.   We now have 10 hives set up, all outfitted with a landing board, a ventilated base, 2 deep boxes, an imrie shim to enable pollen patty and fondant feeding, a hive top “bee tea” feeder, an inner cover and outer cover.    Here’s what the bee yard looks like and a closeup the girls coming back to the hives covered with pollen.

The upcoming weekend will be filled with more animal/bee care and bottling of our hard cider if time permits.   My daughter turns 21 this weekend, so we’ll toast her with Unity Farm Cider.

ICD-10, What next?

After the senate vote  on HR 4302  last night , I sent an email to the CIOs of payers and providers in Massachusetts, suggesting that we need to capture the millions spent locally in ICD-10 preparations before mothballing our projects.    I suggested that we should continue with testing and go live with as much technology as we can in 2014, minimizing risk to our revenue cycles.    Here are some of the responses I received, edited to protect anonymity:

It would be nice if a couple of us in Mass. could at least say we completed testing and validation and next year we will just regression test.

I am completely supportive of us maintaining momentum to protect the investments to date.  I was also thinking through the ICD-10 transition and potential to down coding to ICD-9 until 10/15.  This would require a lot of testing to validate that there is no revenue risks related to the coding conversion.  I am not sure if the teams would want to invest the time in that exercise but would support the evaluation process if there is support from coding and finance departments.

I agree if we could keep provider/payer testing going that would be good.   It would also be great if we could get native coding from providers versus using a tool to  get manufactured data.  This doesn't give us a very good test.  I don't agree with accepting ICD-10s and mapping to ICD-9.  This concept introduces too much risk and it's additional work that we've have to take on.  I wouldn't be able to get internal buy-in on this approach.

We are still discussing internally but I had assumed we would continue with the current test plan.  I am not sure we will continue the same level of testing efforts after 10/1/14.

Technically, Oct. 1st, 2015 is not the new date, it is the earliest date.  We could lobby our legislators to rescind the move to ICD-10 altogether and work towards ICD-11 in 2018.

On April 7, the CIOs will have a community-wide planning call.  I’m hopeful that we’ll complete our 2014 ICD-10 projects, do end to end testing, and then stand ready to go live fully with ICD10 in the future without significant additional work.

Although I know that many small practices were not ready for ICD10, the majority of hospitals and payers were ready for 2014.   A delay in 2013 may have been helpful, but a delay in 2014 is just going to cost hospitals more as timelines and consulting engagements are extended.

Thursday Building Unity Farm - The Land Awakens

Now that we’ve had a few days above freezing, work on the land can finally begin.

In April, the ponds and streams of Unity Farm begin to fill with spring peepers, salamanders, and wood frogs.     The melting snow recharges the wetlands and turns the low lying trails into mud.  In an effort to protect the land from the erosion of foot traffic during mud season, I built two new removable bridges that enable travel for woodland maintenance.   I added a new trail off the Woodland Trail called the Vernal Pool trail, pictured below.   Those with a natural curiosity who visit the farm can watch the developing amphibians of Spring.

Last weekend provided enough warmth to open the cider house for bottling.   I moved the mead and cyser (half mead, half cider) from the indoor fermentation areas to the cider house and let them settle for a day to maximize clarity during the final bottling.  Using a racking wand, my wife bottled while I capped.    We’ve cellared the finished bottles and they’ll be ready to serve chilled this Summer.    It's called Queen's Mead because Queen Elizabeth I preferred a lighter, less alcoholic mead and that's what we made.  We also have 60 liters of hard cider to bottle this Spring, likely over an April weekend.

The duck pond has been covered with ice for the past 5 months.    Last Fall, the ducks were too young to travel across the barnyard and swim in the pond,  but now that they’re mature and wandering, the pond is within reach.   For the first time last weekend, the pond was thawed enough for the ducks to discover it, pictured below.   Kathy and I are convinced that they’re in duck paradise and may never leave.

Also last weekend, the ground was soft enough that we were able to create 10 level blue stone bases for the bee yard and move our meadow hives to the orchard, as pictured below.    We placed pine branches in front the them, forcing the bees to "reorient" to their new location instead of flying back to their old hive spot.  I built bases for ten hives while Kathy nailed together new hive bodies and painted bases, landing boards, and covers.    We’ll move two more hives into the bee yard this weekend and add new bees/queens to the remaining hives in April, May and June.

The weekend ahead will be filled with herd health, beginning the Spring health maintenance for the alpacas and llama, with toenail trimming, vaccinations, physical exams, and weighing.    Thus far, it appears all animals made it through the brutal winter with no ill effects.  

We’ll also do additional trail work, new mushroom area inoculation, and wood splitting.   Those 4 pounds I gained over the winter will disappear with the longer days and the endless physical activity of farming.

The March HIT Standards Committee

The March HIT Standards Committee focused on the Standards and Interoperability (S&I) Framework projects for 2014, an overview of the 2015 Certification Notice of Proposed Rulemaking, and a first review of the standards maturity for the proposed Meaningful Use Stage 3 criteria.

Doug Fridsma presented the S&I update.  Importantly, a new initiative has been launched to coordinate decision support and clinical quality measures as related activities. EHRs should provide alerts and reminders from pathways, protocols, and guidelines intended to improve quality.  Also, a new initiative will connect EHRs and the Prescription Drug Monitoring Program (PDMP) to improve workflow, hopefully supporting single sign on and patient context passing so that PDMP data is one click away from any EHR.

Steve Posnack reviewed the 2015 Certification Notice of Proposed Rule Making, highlighting the changes from 2014.  He noted that the concept of the Complete EHR is no longer needed.   Providers buy the certified technology they need to attest and it may be that modules, an EHR, and an HIE meet all the attestation needs, not a single monolithic product.  The Implementation Workgroup will review the impact of the 50 new proposals in detail and we will discuss them at the April meeting.

I presented a task force review of the 19 Meaningful Use Stage 3 proposals.

Below are a few comments from the task force and the Standards Committee members.   Although the bulk of our comments focused on standards maturity, we also commented on provider impact and development difficulty, hoping to offer helpful “in the field” feedback to the Policy Committee.

Clinical decision support - it would be very challenging for an EHR to track every response to every decision support intervention and no standards exist for such tracking.  Maybe the best way to encourage decision support is via payment reform which links outcomes to pay.

Order tracking - there are standards for closed loop lab ordering but not closed loop referral workflow.   The Harvard Risk Management Foundation recently funded a project to define all the steps in closed loop referral management, pictured below.   Given the lack of standards and the development burden of this workflow, a focus on lab seems most appropriate.

Demographics/patient information - although standards exist for occupation and industry, other new demographic standards such as gender identify and sexual orientation are a work in process.  Here’s a great reference describing one approach. There could be a significant impact on EHR development if new demographics selections affect patient education materials, decision support, and quality measures.

Advance directive - a pointer to an advanced directive such as a URL would require little development and the standards are mature.

Electronic notes - Although the standards to transmit free text within a clinical summary are mature, the “high threshold” (likely over 50% of patients to have notes) could be a high burden first step.

Hospital labs - The HL7 2.51 standards are mature but a minority of hospital reference labs support comprehensive LOINC codes.

Unique device identifiers - The standard is well described but the implementation difficulty could be high if the electronic record had to validate the UDI against a national database and enable reporting on UDIs in the case of recalls.

View, download, transmit - the standards for clinical summaries are mature except for the representation of structured family history.  The requirement to make data available to patients within 24 hours could present workflow challenges.

Patient generated health data - certifying multiple methods of data capture creates a burden on developers.  Maybe a less prescriptive approach, focusing on the ability to receive patient data in some fashion would be best.

Secure messaging - overly prescriptive workflows could force the retooling of existing high functioning products.    Maybe a less prescriptive approach, focusing on the ability to support effective patient communication would be best.

Visit Summary/clinical summary - the nature of the clinical summary text (structured, unstructured, timeliness) could have workflow and development implications.

Patient education - the requirement is for only one language other than English and the Infobutton standard can support this.   A single language other than English may not achieve the policy outcome desired.

Notifications - although the HL7 admit/discharge/transfer standards are mature, the notion of gathering the Direct addresses of care team members and sending event data via Direct is a novel workflow.

Medication Reconciliation - identical to stage 2, no concerns

Immunization history - The HL7 2.51 content and CVX vocabulary standards are mature.  The transport specification created by the CDC (SOAP) is well tested.   The questions we raised - is there a role for Direct in transmitting immunization data to registries since Direct is used for other transmissions in Meaningful Use?   Is REST an alternative to all Meaningful Use “push” and “pull” transactions.   The public health community is passionate about the use of SOAP.   There are pros and cons to using something different for public health transport than other areas of Meaningful Use, so it is likely there will be further discussion.

Registries - the development effort required to submit provider chosen data elements to  registries would be significant.   Standards do not exist for this purpose.

Electronic lab reporting - identical to stage 2, no concerns

Syndromic surveillance - identical to stage 2, no concerns

There will be more discussion in upcoming meetings as both FACAs recommend iterative improvements as input before rule making.

Building Unity Farm - Signs of Spring

Today is the vernal equinox and many people in New England are suffering from seasonal affective disorder after the coldest, snowiest, most relentless winter on record.

The 100 animals of Unity Farm are relishing the first 24 hours since November with temperatures above freezing.

Around the farm, signs of early spring are upon us.    When I walked the Marsh trail this morning I saw skunk cabbage poking through the icy ground.   Skunk cabbage is biologically warm and is generally the first plant to leaf out in the wetlands.   Our bees are likely to fly today and bring skunk cabbage pollen back to the hives.

I borrowed a friend’s motion sensing camera and attached it to a tree on the Woodland trail.   It captured the spring mating dance of wild turkeys - in the picture above you can see the male shaking his snood and the disinterested female looking for breakfast.

Our ducks laid the first eggs in the lives (they where born last year).  Like guinea fowl, ducks are not the best parents and they left the eggs in the frozen mud of their pen.   As we plan for the Farmer’s market sales of Summer, we’ll include duck eggs along with the chicken eggs, fresh mushrooms, garlic, and alpaca yarn we planned to sell.

Since we’ll have three to four days of weather above freezing, my wife and I prepared to bottle our mead and cyser (half honey/half cider).   We fermented the mead from October to March from a specific gravity of 1.090 to 1.000, yielding 12% alcohol by volume.    Since we prefer a hydromel, a lighter mead, we’ll bottle it diluted with spring water to 6% alcohol in 187ml (6 ounce) champagne bottles.   Last night we racked the mead and cyser off the bed of yeast into sterilized gallon jugs, where all remaining sediment from fermentation will settle until we bottle this weekend.  Since the mead was an experiment based on our first year harvesting honey, we’ll only have 100 bottles of our 2013 vintage.   So far, so good.   I prefer the taste of Unity Farm mead to most of the commercial meads I have tried.

The thaw will enable us to install the new bee infrastructure we’ve been building over the winter.   My wife painted (with low volatility primer) enough deep boxes, medium boxes, outer covers, and hive top feeders to build 10 new hives.   I created hive stands using 4x4s, 2x6s and carriage bolts.   We have learned a great deal during our winter nighttime Bee School program and designed the new bee yard to maximize warmth, minimize moisture, and support the bees through whatever malady they encounter (colony collapse, nosema, varroa mites, food shortages, hive beetles etc).    This weekend, I’ll begin to place the new hives on a south facing corner of the orchard, using 2x2 foot bluestone to create level building pads.   The picture below illustrates what the standard setup for each hive will look like.   We’ll add three types of bees this year.  In April, we’re getting four packages of 10000 bees+queens that overwintered in Vermont.      In June, we’re getting two packages of 10000 bees+queens from Wilbanks in Georgia.   We’re also getting two “nucs” from New Hampshire in May.

A five frame bee nucleus (nuc) consists of:
a "laying" queen that has already been accepted by the hive
3 inner frames containing brood in all stages
2 outer frames containing honey, pollen, and adhering bees.

We’ll move our existing bees into the new bee infrastructure, so we’ll have 10 completely updated hives ready for the explosion of flowers in our orchard during May.   I’m confident that our intensive preparation of the new bee yard will give the bees a better overwintering environment next year.

Last night, as I walked through the orchard listening to the coyotes howl at the moon, with my feet slipping in the first mud of Spring, I realized that winter is finally waning.  The weekends ahead will be filled with planting, mushroom log inoculation, and awaiting the birth of baby Alpaca.   I can’t wait to work the unfrozen earth.

Is Continuous Partial Attention part of Human Evolution?

During my Freshman year in high school, I was asked to write a major project paper.  Armed with only a electric typewriter and access to a local library, I decided to write a comprehensive summary of the engineering principles used in Leonardo Da Vinci’s inventions spanning 80 single spaced pages.   The only way I could do this was to focus completely on the task for hours at a time, reading, analyzing, writing, typing.  There was no internet, no mobile devices, and no personal computer which enabled easy editing.

As an undergraduate at Stanford I wrote 3 books by isolating myself from all distractions and using an early word processor, finishing the manuscripts by pure strength of will.

Throughout my adult life, I’ve avoided multitasking, since I’ve found that I cannot produce a quality product while thinking about many topics simultaneously.

I’m a product of the 1960’s, growing up without technology, taught via lecture style classwork without the benefit of multimedia.

I advise many millenials, including my daughter, who was born in 1993, the same year Tim Berners Lee invented the world wide web.   She has not experienced a day on earth without an internet connection.

My mother grew up in an era before the fax machine when the handwritten letter and the land line telephone were the only means of communication.

Each of us has a different approach to work, communication, and learning.    We represent the voice mail, email, and texting generations.

As I interact with many young people, I find that they cannot easily disconnect or focus on a single task.   They believe that staying up all night, surfing the internet, watching youtube and texting while doing school work is an effective means of learning.

They truly think differently.

I’ve met many young people with ADHD.   I’ve watched many young people who struggle with depression and lack the resilience to deal with adversity, often because they expect instant gratification and immediate solutions to every problem they encounter.

At first, I thought such behavior was a failure of society to train the next generation, but I’ve come to realize that humans are evolving to develop a different set of values, cognitive processes, and workflow.

The challenges that my brain was optimized to solve no longer exist.   Creating an 80 page thesis in 1976 was more a battle with an electric typewriter and correction tape than an information synthesis exercise.   Searching through old paper books in a library is a skill that most do not need and required hours of inefficient throw away work because separating the intellectual wheat from the chaff was a manual exercise.   A search engine does in seconds what took me weeks.

Today’s student needs superior data filtering skills and needs to know the appropriate uses of internet resources from Wikipedia (crowd sourced non-authoritative commentary) to Google Scholar.   Today’s student needs to master social media to leverage the wisdom of the crowd.    Today’s student has no need to memorize vast quantities of material because it is fully indexed and always available at the touch of a button.

The capacity to multi-task, to have the reflexes to navigate a fast paced highly graphical user interface, and to leverage the filtering done by machines rather than the human brain is adaptive to excel in the future of human civilization.

Today’s young people are artistic, humble, creative, and lower key than my generation.  They do not expect to own as much stuff as their parents and they do not plan to pursue the same career options.

Ultimately it will require years to understand the consequences of the continuous partial attention, multi-tasking and the values of the millenials.  However, considering the skills needed in a world with global interconnectedness, instantaneous viral communication of every event, and infinite authorship with limited editing, I am increasingly convinced that humans are evolving and we are witnessing the future of human kind, not a pathology that needs to be cured.