Clinical Reminders

I've previously written about the importance of Inpatient and Outpatient Decision Support.

Yesterday, I joined an expert panel on Clinical Decision Support, hosted by Dr. David Bates at Partners. Part of this multidisciplinary effort is to review the clinical reminders that institutions have implemented in their electronic health records. The definition of a reminder is that a non-urgent notice appears on the EHR patient summary screen and the clinician's schedule. Reminders are suggestions for clinicians to follow so that best practice guidelines are followed. An alert, by contrast, is an urgent issue which must be escalated immediately. Alerts at BIDMC include such issues as critical lab values or a notice that a patient has been hospitalized. Here are the reminders in use today at BIDMC:

Mammogram
Women 40 and over: yearly

Pap Smear
All women: annually

Influenza Vaccine
Children under 2
Adults 50 and over
Patients with diabetes

Pneumovax
Children under 5 (PCV): 3 doses,
alert for each dose when due
Adults 65 and over (PPV): once
Patients with diabetes (PPV): once

Tetanus (Td)
Adults: Every ten years

Prostate Specific Antigen
Men 50 and over: yearly

Colonoscopy
Adults 50 and over: every 10 years

Bone Mineral Density
Women 65 and over: once

Health Care Proxy
All patients who do not have one on file

For HIV-patients only:
Ophthalmologist, H. Flu Vaccine, PPD, Baseline Labs

I look forward to working with this expert panel and broadly sharing the clinical reminders from all of our institutions.

Responding to Medical Error

Yesterday, Paul Levy posted an entry on his blog about a recent surgical error at BIDMC.

IS and the clinical departments of BIDMC have a very strong collaborative relationship. Working together, we first enhance processes, then automate them, since even the best technology is generally not the solution to workflow and communications problems.

Here's the application enhancement we're making as part of a process change in the Operating Room to prevent future patient harm.

Standard Operating Process in the OR includes a "time out" by all OR personnel in the moments before surgery to double check all aspects of safety - equipment, right surgical site, team readiness etc. Currently the "time out" is documented on the paper intra-operative record, which means that the scrub nurse needs to look at both the paper record and the electronic peri-operative information system during the "time out." We will add a "Time Out" button to the electronic OR journal screen containing the case times. When this button is clicked we will pop up a window with the "time out" fields. The nurse will fill in the time out information and enter her/his password. We will not allow the nurse to enter an incision time for the case unless the "time out" has been completed, with one exception - we will provide a check box on the time out screen to indicate the time out could not be completed prior to incision due to a life-threatening situation.

The standard process we've put in place to respond to sentinel events such as this one is that the root cause is reviewed with the Board (PCAC committee) and the Quality Improvement Directors. IS staff work with Quality Improvement Directors to determine which process improvements need to be made, then what additional automation should be added. Using this approach, we've created a balanced way to add new technology at the appropriate time.

The Surescripts/RxHub merger

Last week, I spoke with the Associated Press and Wall Street Journal about the recent merger of Surescripts and Rxhub.

My basic message was:

"The merger of Surescripts and RxHub provides a single medication data stream, supporting medication safety. It also provides an easy e-prescribing implementation path for electronic health record vendors and an enhanced medication workflow for clinicians nationwide."

Here's the reason I made these comments. In the world of e-Prescribing, the stakeholders are

- the patient
- the physician writing the prescription
- the retail pharmacy or mail order pharmacy
- the payer
- the pharmacy benefit manager (PBM), which acts on behalf of the payer to adjudicate claims
- RxHub: the connection to most PBMs
- SureScripts: the connection to most retail pharmacies

Here's the data flow:

1. A clinician begins to e-Prescribe and electronically queries for the patient's insurance eligibility and the appropriate payer's formulary. Before the merger, both RxHub and SureScripts had eligibility services but RxHub processed the majority of these transactions.

2. The clinician queries for medication history to check for drug/drug interactions. RxHub has medication history based upon claims data and SureScripts has the actual dispensed information from the pharmacies (which includes cash, third party claims and $4 generic programs). Before the merger, the clinician's EHR would have to issue separate queries via two separate interfaces to get a complete history.

3. The physician completes the prescription. Retail pharmacy transactions are transmitted to SureScripts for delivery to community pharmacies and smaller mail order firms. Mail order transactions served by one of the 3 large PBMs are transmitted to RxHub for fulfillment. Again, two separate interfaces were required.

As SureScripts-RxHub integrates its services, there will no longer be a need to send out 2 queries for eligibility/formulary, medication history or routing. Also, the two sources of medication history data will be de-duplicated, providing an accurate and usable medication data flow to all stakeholders.

In addition to the Surescripts-RxHub merger, two other important events will accelerate e-Prescribing in 2009.

1. Regulatory changes proposed by the Drug Enforcement Agency will enable electronic prescribing of scheduled/controlled medications. Having separate workflows for controlled medications verses all others has been a real barrier to process change in many medical care settings. I look forward to the regulatory change.

2. Incentives to adopt and use e-Precribing via the Medicare Electronic Medication Safety Protection Act of 2007. Clinicians have been reluctant to adopt electronic prescribing because of the investment and time commitment to change change their workflow. Currently only 4% of the clinicians in the country e-prescribe (although Massachusetts is at 13% and BIDMC is at 50%). A one time payment when e-prescribing is implemented helps a physician acquire the technology. An ongoing incentive ensures they continue to use it.

Let's hope 2009 is the year of e-prescribing. Everyone wins through reduced cost, enhanced quality and better workflow.

Cool Technology of the Week

Tonight, the Boston Pops will host another dazzling display of fireworks on the Esplanade in Boston. As cymbals crash, fireworks will explode on cue. Ever wonder what technology is behind the pyromusical synchronization? Computer controlled firing systems are the cool technology of the week. Here's a list of leading companies. I found Pyromate of Peterborough New Hampshire to be particularly impressive.

The components of a computer controlled firing system include

1. A laptop

2. Fireworks show designing software

3. Firing software

4. A firing control console.

5. Remote firing module boxes which active "electric matches" - nichrome wire and a small amount of gunpowder that ignites the fireworks when a current is applied.

6. A large battery to power the system

7. Cabling and WiFi access points to connect the entire system.

A show designer inputs the inventory of fireworks to be used into the show designing software, including the name and size of each firework. Interestingly, each explosive also has a known time delay between ignition and effect, which is also part of the show design database.

The show designer uses this software to develop a firing sequence. If the fireworks are to be synchronized to music, the music is converted to a time series such as a midi and uploaded to the fireworks design. Synchronizing an aerial bomb with a cymbal crash is easy - just launch the shell taking into account the time delay between ignition and effect.

On the day of the fireworks display, the fireworks are assembled in launching mortars, connected to electric matches, and cabled to firing models. The modules are in turn connected to the firing console. The entire system is checked for electrical integrity and the show is ready to begin.

The pyrotechnicians start the firing software on cue and the entire show is delivered automatically, without human intervention. If a fire or other problem occurs during the show, the program can be stopped and restarted once the hazard has been resolve

Of course, all this computerized complexity can introduce points of failure into fireworks shows.

As expected, Slashdot had the usual pointed commentary.

Next time you watch a fireworks show, you'll know all the cool technology behind it!

My Closet

Many people ask me about my black wardrobe, which I've written about as simply practical for the 24x7x365 CIO and not a Gentleman's Quarterly fashion statement. I was recently asked to share a glimpse of my closet.

I know this sounds like a strange blog topic, but my closet provides an insight into my brain, demonstrating that every minute of my existence is part of a complex lifestyle. Hopefully, the detail below will not sound too obsessive compulsive. Call it "the examined life".

My closet is organized into clothing for my lower extremity and clothing for my torso.

Everything I own for the lower half of my body is black. It's practical. Whether business attire, climbing clothing, or alpine ascent gear, various kind of black pants work well. For the office, my pants are rayon (it's vegan and derived from wood fiber). For climbing, I wear all Arcteryx gear made of thin but durable nylon. For alpine ascents, I wear Arcteryx gear made from Powershield, a Polartec softshell.

For my torso, I wear all black linen fabrics (a 5000 year old textile made by weaving Flax) in the office, since they are easy care, cool in summer and warm in winter. For the outdoors, all my upper extremity clothing is red for visibility. I have base layers of polyester, mid layers of Polartec Powerstretch and outer layers of Gortex. Each layer is engineered for specific temperatures and humidity conditions.

For footwear, I have specific shoes for specific tasks. Vegan microfiber polyester Monk shoes and Dealer Boots for the office, Five-ten climbing and approach shoes for the Crag, and Scarpa Double Plastic boots for Alpine travel.

My closet also stores my ropes, packs, climbing hardware, and helmet.

All of my clothing and most of my belongings fit into this one 8 foot space.

Over the years, I've tried to refine what I own and approach all my clothing from an engineering perspective, only carrying what is minimally necessary for the range of climatic conditions I'll encounter. Here's the complete inventory including the specific temperature and humidity conditions for each piece of clothing and the body measurements I use for my engineering approach to clothing. The dates are purely so I know when to replace a given piece, since polyester tends to decay over time.

This philosophy works very well in an era when travel is so expensive and difficult. Wearing black, and using the durable, breathable fabrics I've chosen, a week in Europe can be done from a single carry on satchel. A week in Yosemite takes a bit more, since I have 7 pounds of rope and climbing hardware to carry along, but 1 small duffel will do the trick.

That's my closet - another expression of my lifestyle that does not separate work, family, job, and avocations but comingles them all into one continuum.

Massachusetts Clinical Data Exchange Legal Agreements

Across the country, many towns, states, and regions are thinking about clinical data sharing. There is substantial variation in the business models, the data shared, and the stakeholders involved.

However, every clinical data sharing entity needs an operating agreement to create the organization and a customer agreement to add trading partners.

In the interest of transparency, I am posting the

Operating Agreement for MA-Share, our regional clinical data exchange

and the

Customer Agreement, which is used to sign up payers, providers, pharmacy benefit managers and other stakeholders.

Feel free to use these agreements for your data exchange activities.

Let me know about your successes, challenges, and lessons learned along the way as you implement clinical data exchange.

Technology Secrets of the Congressional Clock

On June 11, as part of Healthcare IT Advocacy Day in Washington DC, I visited several offices on Capital Hill (Ted Kennedy, John Kerry, Jim McGovern and Barney Frank) to discuss the importance of ePrescribing, data standards, and support of incentives for EHR adoption.

While wandering through the House (Cannon, Longworth, Rayburn) and Senate (Russell, Dirksen, Hart) buildings, I noticed that the clocks in all the offices had various lights and buzzers. I asked Congressional staffers to explain the secret code behind these signals and no one really knew.

After scouring the web for hours to no avail (Google has no information on Congressional clocks), one of our Advocacy team members found the following information buried on page 35 of an unindexed PDF on the Senate website.

1 long ring followed by a pause and then 3 rings and 3 lights on the left
Start or continuation of a notice or short quorum call in the Committee of the Whole that will be vacated if and when 100 Members appear on the floor. Bells are repeated every five minutes unless the call is vacated or the call is converted into a regular quorum call.

1 long ring and extinguishing of 3 lights on the left
Short or notice quorum call vacated.

2 rings and 2 lights on the left
15 minute recorded vote, yea-and-nay vote or automatic rollcall vote by electronic device. The bells are repeated five minutes after the first ring.

2 rings and 2 lights on the left followed by a pause and then 2 more rings
Automatic rollcall vote or yea-and-nay vote taken by a call of the roll in the House. The bells are repeated when the Clerk reaches the R’s in the first call of the roll.

2 rings followed by a pause and then 5 rings
First vote on clustered votes. Two bells are repeated five minutes after the first ring. The first vote will take 15 minutes with successive votes at intervals of not less than five minutes. Each successive vote is signaled by five rings.

3 rings and 3 lights on the left
15 minute quorum call in either the House or in the Committee of the Whole by electronic device. The bells are repeated five minutes after the first ring.

3 rings followed by a pause and then 3 more rings
15 minute quorum call by a call of the roll. The bells are repeated when the Clerk reaches the R’s in the first call of the roll.

3 rings followed by a pause and then 5 more rings
Quorum call in the Committee of the Whole that may be followed immediately by a five-minute recorded vote.

4 rings and 4 lights on the left
Adjournment of the House.

5 rings and 5 lights on the left
Any five-minute vote.

6 rings and 6 lights on the left
Recess of the House.

12 rings at 2-second intervals with 6 lights on the left
Civil Defense Warning.

The 7th light
indicates that the House is in session.

Thus, the picture above indicates that the House is in session (red light), but in recess (6 lights).

Now you know the secrets of the Congressional clock and how our elected officials know when to run from their offices to the House and Senate floors.