Passing the Baton

After 10 years of work, today I passed the baton of leadership for US standards harmonization efforts to Arien Malec and Lisa Gallagher.   Here’s  a brief synopsis of the journey.

In 2005, Fran Schrotter, COO of ANSI, met with me in my Harvard office and asked if I would be willing to spend a few hours per YEAR chairing the Healthcare Information Technology Standards Panel (HITSP), a public/private partnership run by ANSI at the request of the federal government.   I agreed and within a few months, standards harmonization became a multi-hour per DAY commitment.

HITSP convened many stakeholders and worked directly with the Secretary of Health and Human Services, Michael Leavitt, via the American Health Information Community (AHIC).   Controversies at the time included the integration of the Continuity of Care Record (CCR) with the HL7 Clinical Document Architecture (CDA) to create the Continuity of Care Document (CCD/C32), debates about the right terminology for problems/medications/allergies, and selection of structured lab data reporting implementation guides.   Standards were harmonized and progress was made, but much work was left to do.

HITSP ended when the Obama administration began and was replaced by the Health IT Standards Committee (HITSC), a Federal Advisory Committee.  I became co-chair with Jon Perlin and the committee was populated with a diverse group of stakeholders, many of whom had served HITSP.    Controversies included the refinement of document content standards (CCDA), the broad implementation of vocabularies (Value Set Authority Center), and the decision to use SMTP/SOAP (Direct) as transport.   In 2015, the movement to FHIR, REST and OAuth/OpenID accelerated.   Government driven regulatory change began to shift to private sector driven innovation.   Much work is left to do.

What advice can I offer to Arien and Lisa?

As I handed actual running batons to them, here’s what I said:

Welcome to the leadership of the HIT Standards Committee.   You now have the privilege of facilitating the harmonization of standards nationwide.    Everything you say and write will be deemed influential.   You will aggregate karma - some good, some bad .  You will receive credit for things you did not do, while also receiving blame for issues you had little to with.

Just as in my days running track, my task has not been to win this race, but to avoid slowing down those who come after me.

Godspeed!

It has been an honor to serve.

The Future of Meaningful Use Stage 3

This morning, thirty-one healthcare organizations sent the following letter to HHS Secretary Sylvia Burwell.   Given the recent comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, we remain optimistic.

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January 14, 2016
The Honorable Sylvia Burwell
Secretary
Department of Health and Human Services
200 Independence Ave., S.W.
Washington, DC 20201

Dear Secretary Burwell:

On behalf of the undersigned organizations, we are writing to express our concerns with the Meaningful Use (MU) program and the current state of electronic health records (EHRs). We recognize that the MU program has successfully driven the adoption of EHRs, with over 80 percent of hospitals and physicians now using these systems. We must now turn our attention to ensuring that all of the practices in our respective communities have high-functioning technology to achieve interoperability across all care settings. Yet, with the release of Stage 3, we fear the current trajectory of the MU program will hinder efforts to move forward.

Our collective experience with MU has shown that the current measures and pass-fail approach deter participation. In particular, the MU program has diverted clinician, staff, and other resources away from activities with greater patient benefit and has forced technology to develop in a way that limits innovation. The MU Modifications rule addressed these concerns by reducing some of the pressure physicians and hospitals face in trying to meet MU program requirements. These modifications, however, should not be looked at as a cure but as temporary relief while we work to restructure the MU program to fit future care needs and focus on improving interoperability and usability.

Despite the written comments of numerous stakeholders and data on provider experience with Stage 2 of the program, Stage 3 continues to press forward with the current, ineffectual Meaningful Use structure—the one-size-fits-all approach that lacks accommodations for the different needs of our practices and our patients. The Stage 3 final rule, like its predecessor rules, is too focused on pass-fail requirements and lacks emphasis on outcomes. By maintaining this flawed structure, we do not believe Stage 3 will support movement towards more innovative care models or encourage continued participation.

Stage 3 also fails to prioritize foundational issues to improve interoperability, which is imperative for our medical communities to function at their highest levels. By using MU as an enforcement tool, there has been little improvement in data exchange. Many in our communities are facing excessive costs to purchase EHR interfaces and upgrades, which only support limited interoperability. Patient medical information is also shoehorned into a format that was designed for MU measures, and not in a way that accommodates the needs of physicians and patients. Addressing these issues must be a priority, but what is required in the Stage 3 rule limits progress while diverting needed resources. Regrettably, we believe the Stage 3 final rule maintains the same problematic measures in Stage 2 and will not put the nation on a path to reach these goals.

Lastly, the MU program has been the driving factor behind the design of EHR technology. Health IT vendors routinely state that meeting MU requirements monopolizes most of their development and testing time and that many of the upgrades or features most requested by their customers are put on the backburner until the complex process of certifying for MU takes place. We believe Stage 2 EHR design requirements have been a fundamental drag on interoperability and that Stage 3 will worsen these problems.

Given the above concerns, we urge you to reconsider Stage 3 and refocus the Administration’s efforts on the infrastructure needed to promote adoption, enhance interoperability and improve usability. We are of the collective mindset that this is an opportunity to improve the current trajectory of EHRs and the MU program to best support technical innovations and outcomes-based care. Navigating the digital landscape is a constant learning process. As health care providers who are at the forefront of incorporating these digital health tools, we appreciate the opportunity to share our thoughts on a path forward for the MU program.

Sincerely,

Advocate Health Care, IL
Aurora Health Care, WI
Austin Regional Clinic, TX
Baptist Health, KY
Baylor Scott & White, TX
Beth Israel Deaconess Medical Center, MA
Billings Clinic, MT
Boston Children’s Hospital, MA
Collaborative Health Partners of Virginia and Central Virginia Family Physicians, VA Confluence Health, WA
Cornerstone Healthcare, NC
Crystal Run Healthcare, NY
Dreyer Clinic, IL
Eastern Virginia Medical School Medical Group, VA
EmCare, TX
Emory Healthcare, GA
Fairview Health Services, MN
Geisinger Health System, PA
Henry Ford Health System, MI
InterMed, ME
Intermountain Healthcare, UT
The Iowa Clinic, IA
Marshfield Clinic Health System, WI
Mount Auburn IPA, MA
Partners HealthCare, MA
TEAMHealth, Inc., TN
Trinity Health—New England, CT
UMass Memorial Health Care, MA
University of South Florida Health, FL
Vanderbilt University Medical Center, TN
Weill Cornell Medicine, NY

Unity Farm Journal - Second Week of January 2016

I’ve finished the University of Massachusetts winter semester and submitted my final homestead map - pictured below.

It contains:

*Woodshed - store 8 cords of wood for heating
*Storage Barn - 20x24 structure for equipment
*Animal Housing which includes workshop - small barns for alpaca, llama, dogs and pigs providing weather protection, hay storage, and workshop
*Roof Catchment with cisterns - keyline design which results in water flow from gutters into the swales which irrigates cropland and feeds the vernal pond. A cistern under the front house gutter could store 900 gallons of water (based on the available space in that area)
*Cart Paths and Lanes - 1.5 miles of paths, some dating to the Revolutionary War which provide access to all agricultural and water features
*Contour Planting - sunchokes and ginseng in the understory of our forests using the partial shade on hillsides to produce crops
*Ponds and Dams with Swales and Terraces - Water management is an inter-related connection of house, land/hardscaping, streams, ponds and wetland.
*South Facing Outdoors - bee yard and all animal housing is south facing to capture
solar heat
*Greenhouse - 3 season food growth (with some winter production of lettuce/spinach/
chard)
*Food storage and  root cellar - storage for our canned/preserved foods and
onions/potatoes/squash to provide calories over the winter
*Wetland Water Cells - to absorb winter snow melt and heavy rains/prevent erosion
*Small Paddocks - for llama/alpaca, dogs, pigs
*Patch gardens - Herb Spiral near the kitchen to provide a convenient cutting garden,
perennial food crop planting throughout the property , mushroom logs
*Fertility Crops and Mulch and Compost - clover/legumes are grown as part of
polyculture in the orchard. Soil is amended by sources of manure and decaying mushroom logs

My Spring course is 13 weeks of farm marketing and management.   I’ve always said that you can make a small fortune in farming, as long as you start with a large fortune.   We’ll see.

Now that the weather has turned cold and wet, it’s time for indoor maintenance work such as sharpening tools, organizing, and streamlining.    I rebuilt 5 kegs by replacing all their gaskets, set up a bottling/label gluing area in the cider house, and re-organized all the cider and lager plumbing to make it easier to serve our hand crafted beverages.     Here’s a view of the re-built kegs and the new Unity Farm label.

We’ve divided the pig paddock into two half acre portions so that we have free area for letting the dogs run, isolating a sick animal or stacking snow if we have no other place to put it.   The pigs are very happy in their south facing sunny barn with a half acre of grass.   They come when called, recognize our faces, and are incredibly affectionate.    I realize that it is important in any herd to show the leadership of humans.    Here’s Tofu, standing on my chest, eating my nose.    Who is dominating whom?

Unity Farm Journal - First Week of January 2016

The citizens of Unity Farm have experienced a deep freeze this week - nightly temperatures in the single digits.   How have they fared?

The geese and ducks have a heated house but choose to stay outside - those down jackets they are wearing have done a good job.  No signs of frostbite on their bills or feet.

The chickens and guinea fowl have a heated coop and every bird has been roosting near the sources of warmth.   Tyrion, our bantam rooster has slight frostbite at the rear of his comb from the time he spends outside of the coop during the day with the hens.   Swayze, our buff orpington rooster, also has a few discolorations on his comb.    Otherwise, every bird has done well through the cold.

The alpaca and llama have stayed close to the ground to avoid wind chill and to soak up the biological warmth of decomposing hay.

The pigs really do not like the cold and have been nesting deep in hay bales, under blankets, next to their heaters.   Although they wag their tails while grazing in the sun on 20 degree days, as the shadows of night approach they squeal and run for warmth.

Hazel and Tofu, our new pigs, are now best buddies.   We’ve removed the dog barriers we used to separate them during acclimation.   They eat, sleep and play together in the pasture all day.     Both enjoy their belly rubs. come when called, and look forward to visits from their humans.    In some ways, pigs are more social than dogs and really want to spend time with us.   They are good, good pigs.   Photos below

The rain, snow, and freezing temperatures have made the alpaca paddocks an icy, muddy mess.   I thought the issue was poor drainage due to compacted soil but the issue was our last hay delivery.  The alfalfa bales, although eaten completely by horses , are only nibbled by alpaca, creating enormous piles of chaff.    That chaff accumulates on the ground and absorbs water, creating a foot thick sponge of composting alfalfa stems.   Over the weekend, I spent 6 hours with a pitchfork removing 18 wheelbarrow loads of alfalfa from the paddocks.

We finished up the tree house and two observation platforms last weekend.   All the safety features are now installed and family members feel much more comfortable with railings, hang grips, and benches in place.   The next step is the tree house roof to minimize snow accumulation.

With the coldest weeks of winter approaching, I’m spending more time indoors.   I reorganized the farm library, sorting it by animal and plant type for easy access.  I’ve cleaned and replaced all the gaskets on the cider/winemaking/beer equipment.    I’ll be brewing winter celebration ale next week.

There’s something special about reading next to a roaring fire on a cold winter night.  I’ve been reviewing selections from the permaculture literature to help me with the homestead design I’m doing as part of my University of Massachusetts coursework.    This week’s assignment was to analyze the food we consume every year and determine the layout of farmland necessary to grow it.  Here’s my analysis

We determined that it is possible to grow 100% of our yearly food at the farm, although we will still be dependent on the community  around us for supplies such as seeds, tools and electricity.  

The weekend ahead will be filled with freezing rain, so after I care for the animals and plants, I’ll be putting away the final holiday decor and catching up on my writing - a few book prefaces and my winter semester  final homestead design project.    The third week of January generally brings -10 to -15 temperatures on the farm.    We’re getting ready to hibernate.

Keeping Your Equanimity in 2016

2016 is a year when CIOs will feel even more overwhelmed than last year - demand will exceed supply (no matter what your budget), the pressure to deliver faster/cheaper/better will accelerate, and security concerns will dominate the agenda.   I’ve been asked how I maintain my equanimity given all that is going on.

Every year I refine the guiding principles that keep my life in order.   Here’s the 2016 edition:

1.  Minimize lost time - There are 168 hours in a week and I must use them wisely.   Commuting time in cars and planes is not very efficient.   How many meetings do we attend every year in person that could be done equally well by conference call or webinar?  Sure, there are some meetings that require in person contact to build trust or resolve a controversy, but many standing meetings, especially those which are largely presentation-based, can be done without the commute and parking hassles so common in today’s metropolitan areas.   Similarly, what is the time cost of a flight in the modern era?    An hour commute to the airport, arrival 1.5 hours before the flight so that you can navigate security lines and baggage handling, then waiting for the inevitable 1 hour flight delay that translates into commuting heroics upon arrival to get your meeting on time.   An entire day can be lost flying to and from a one hour presentation.    In 2016, I will minimize lost time by opening a new community-based IT office for my staff working on projects in suburban areas.   That new facility will be filled with  swing spaces and ad hoc meeting rooms that provide infrastructure to those who do not physically need to be in a downtown location.    Teleconferencing and virtual presentations will be encouraged.    Although I must be in Boston 2 days a week for such things as in person Board meetings, I will work in the new community office 3 days a week, eliminating about 10 hours per week of unproductive car time.    Similarly, I will limit air travel to impactful events - meetings with industry, government or academic leaders in a forum where discussion, rather than pure presentation, requires a personal presence.    I hope to reduce my time in airports by at least 10 hours a month in 2016.

2.  Do satisfying work each day  - I’ve written previously that there is no difference between my job and my life.   It’s not as if I’m an IT professional 9am-5pm then hand off the responsibilities to someone else.     All I can ask for is having a legacy of past activities that I feel good about, having satisfying work each day, and looking forward to future challenges.  In 2016 my international work will focus on (in alphabetical order) Canada/China/Japan/New Zealand/UK where I’ll do policy and technology education for government leaders.   My US national work will focus on writing about the challenges and opportunities facing the new president.    My regional/local work will focus on innovation projects such as embracing the internet of things, patient/family engagement, and advanced analytics in the BIDMC Health System.

3.  Family comes first - My family is also a continuous responsibility.   I am a father/husband/son 24x7x365.    In 2016 I will help my daughter (who is getting married in May) establish a self reliant future.   I will help my wife with fulfilling activities supported by the tools and infrastructure she needs.  I will help my mother with fulfilling activities in a stress free living environment (her one story home in California which I maintain).

4.  Be well - My personal physical and mental health directly impacts my ability to be productive.   I will continue to be a decaffeinated, substance free, vegan and get my daily exercise from the rhythm of running a farm with 150 animals and 15 acres of agriculture.   In my professional and personal lives I will continuously improve life processes to reduce anxiety/stress while also engaging in constant learning and experimentation such as the University of Massachusetts Sustainable Food and Farming certificate program.

5.  It takes a village - we often hear about the impending collapse of modern society and the need to become self sufficient.   I do not believe in the concept of self sufficiency.  I believe we need to work together as a community to maximize our self reliance, recognizing our dependence on each other.    I may grow 50% of my food, but I still need others in the community to supply the seeds, the tools, and the electricity I use in the process.  The same thing can be said of healthcare.  There is no way for a clinician to enter 114 structured data items per encounter of which 71 are user-documented (at BIDMC) in support of Meaningful Use, Quality Measures, and Alternative Payment Models.   We need a team of caregivers, IT professionals, and patients to gather the data needed to maximize safety, quality, and efficiency.   The only way any of us can get through the day is to spread the strain in a thin layer over many people.

If I can meet the needs of my professional life with a lot of help from my friends, help my family achieve their goals, and end each day with my physical and mental agility intact, equanimity will follow.

May all of you keep your optimism and your livers intact in 2016 despite the challenges.

Unity Farm Journal - 5th week of December 2015

It’s been a great first week with pigs.  Hazel Marie, the 100 pound two year old pot belly, experienced her first snowfall.   Although I’m building all season dutch doors for the pig barn, they are not finished yet, so I installed a piece of plywood in the doorway, cutting out a piece so that she can easily access the entry ramp.     The end result has been a warm, dry, snow-free pig barn filled with fresh hay, a heater, and a blanket.   Hazel arranges a deep pile of hay then burrows into the blanket.   Every morning we play find the pig - she’s invisible curled up in her nest.

I mentioned last week that we would be getting Hazel a companion.    Meet Tofu, a three month old pot belly pig that weighs 20 pounds.   Don’t be fooled by his diminutive appearance - he’ll outweigh hazel soon.     He’s very outgoing and enjoys the same fresh fruits, vegetables, and grains as Hazel.   They ate dinner together separated by a square of dog fencing in the pig barn we’ll use to keep them apart until they adjust to each other.

The freezing rain, sleet, and melting snow have covered the farm in a sheet of ice.  Every surface is slick and challenging to navigate.   Walking the dogs is an extreme sport - imagine 250 pounds of dogs pulling 170 pounds of me on a sheet of glass covered with butter.    I call it “boot skiing”.    So far, no orthopedic injuries.

All the families have left post Christmas and life has returned to normal.   What is normal on Unity Farm?  Wake up at dawn, dig a 40 foot trench for a ground wire, install electric fence cable with the help of a pig, and  connect the power supply to a new circuit in the pig barn.    Hazel and Tofu now have a hot wire on the top of their paddock fence to keep out coyotes.

This weekend, I’ll finish up the pig barn door and continue my work on tree house railings and stairs.   We’ll have temperatures in the 40’s without snow this weekend, making outdoor carpentry possible.

Of course, when the weather turns cold and snowy, there is always indoor work to do on my winter semester Umass coursework - Backyard Homesteading.    This week we created maps of our homesteads and did a water analysis.    Here’s my finished presentation of the material.

Next week will be a caloric analysis - what do we need to grow to feed ourselves based on daily requirements for protein, carbohydrates, and fats?   Today we grow about half our food and with each passing year we get better at raising crops on a predictable schedule.

Next week I’ll post our farm goals for 2016.

Happy New Year!

The 2016 Standards Advisory

ONC recently released the 2016 Standards Advisory.  I think this document is more important than Meaningful Use or Certification in accelerating interoperability.  Why?

Many view Meaningful Use as no longer aligned with the work we need to do for population health, care management, and alternative payment models.   The more aligned activities - the Affordable Care Act (ACA), Medicare Access & CHIP Reauthorization Act of 2015 (MACRA),  and private payer risk-based payment models  - require health information exchange for care coordination and quality/financial benchmarking.   These programs create a business need for interoperability affecting a large percentage of an organization’s income versus Meaningful Use which at this point is a penalty program creating a small reduction in an organization’s income.  When there is a business need and enabling technology, interoperability happens.   The Standards Advisory gives developers, providers, and patients a list of enabling technologies, documenting their level of maturity and adoption for a given purpose.   The marketplace can decide which standards are good enough, what risks to take on promising evolving standards, and which standards to retire as technology progresses.

Standards making is all about reduction of optionality - constraining the methods to represent information and transport it.   To me, the Standards Advisory is exactly what government should do - convene experts to determine which standards are appropriate for purpose - then let industry decide what to implement based on the business need.

The process used to create and refine the Standards Advisory is a good one, in part based on this paper by Dixie Baker,

Importantly, the Standards Advisory is a continuous process, not one that sets a standard in the concrete of regulation/legislation that is hard to change.  The advisory process is agile and likely to be more transparent than the regulation making done behind closed doors.   The list of best available standards can include some standards that are not yet ready for production since the document is just a roadmap to what is available at a given time, not a regulation.  

In the past, many HIT Standards Committee experts have advised ONC not to include standards like HPD (a provider directory standard) because it is not suitable for purpose in an internet connected, cloud-based, mobile friendly EHR world.   Standards Committee members prefer the FHIR-based directory services that are being piloted in the Argonaut project (www.argonautproject.org).    With the Standards Advisory, the debate of HPD over FHIR becomes moot since both can be listed as available standards along with descriptions of their functionality, maturity and adoption.   The industry can then decide which is more fit for purpose.

As I’ve written about previously, it is my hope that CMS eliminates the Meaningful Use Stage 3 penalty, uses pay for performance incentives based on outcomes as part of MACRA to replace Meaningful Use goals, and that certification for stage 3 will rarely be done because it is a purely voluntary program.   Redirecting our focus to customer requirements rather than regulatory compliance will accelerate innovation.     The combination of outcomes-based performance incentives and the yearly publication of a standards advisory is a great path for the future.