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Thursday, April 30, 2009

Touring Boston

Now that Spring has arrived, many folks in the country are planning their vacations. I've had numerous requests about the best places to see in Boston. Here's my top 10 list

1. Boston Museum of Fine Arts - check out John White Alexander's "Isabella and the Pot of Basil" (the photo above) and explore the Japanese Temple Room
2. Isabella Stewart Gardner Museum - check out John Singer Sargent's "El Jaleo" in the entryway. Stop for lunch at the Cafe.
3. The Institute for Contemporary Art - check out the Shepard Fairey exhibit
4. The New England Aquarium - check out the jellyfish
5. The Museum of Science - check out the Electrical wing
6. Harvard Square and the Harvard Museums - check out the glass flowers
7. Faneuil Hall Marketplace is a great site for walking. For shopping, check out Prudential Center/Copley Square or Newbury Street.
8. Take a walk in the Boston Common - check out the Granary Cemetery, the Freedom trail, the Boston Statehouse, and the Swan Boats. The Theater district is nearby - check out the Blue Man Group
9. Farther afield, check out Concord and Walden Pond to the West, Plymouth Rock to the South and Salem/Marblehead to the North.
10. I often stroll the many forested lands of the Audubon Society nature preserves. Also, the beaches in Ipswich, Manchester by the Sea, and Duxbury are wonderful spots.

Wednesday, April 29, 2009

Rock-O, the Peanut Sniffing Dog

The Obama family choose a Portuguese Water Dog for a pet. The Mers' family has one for a very different reason.

Hats off to Sherry- one creative mom! She noticed dogs sniffing luggage at an airport customs counter. They were searching for fruits and vegetables being brought into the country illegally. Then, light bulb moment...why not use dogs as a service animal to sniff out allergens for severely allergic children like her daughter Riley?

It turns out that this idea has been floating around for several years. In 2005, a Jacksonville FL teen hoped her peanut sniffing dog would enable her attend school. The price tag is high- $12,000-$15,000 for a dog. Several communities have begun fund raising efforts to help severely allergic children in their town afford a dog.

For more information, check out Angel Service Dogs, a website created by the Mers.

Learn more about these peanut dogs from the trainers at
Peanut Detector Dogs.

What a great idea!

As always, turn to the Food Allergy Assistant for food allergy news.

NCVHS Testimony about Meaningful Use

Yesterday, I attended the NCVHS public hearing about meaningful use. Here's the agenda and my presentation.

I've described the importance of meaningful use in prior blog posts.

Much depends on the definition of meaningful use, including the characteristics of the EHRs which will qualify for stimulus dollars, the kind of interoperability we'll implement regionally/nationally, and the policies that will be required to support health information exchange.

My specific testimony included an overview of the interoperability needed for quality.

I highlighted the work of the NQF Health Information Technology Expert Panel (HITEP) which selected 84 metrics supported by 35 data types as an initial minimum dataset for quality measurement in 13 care processes. HITEP II will meet next week to further refine this work into a core minimum Quality Data Set (QDS).

I also highlighted the work done in Massachusetts on data exchange including the Massachusetts eHealth Collaborative Quality Data Warehouse.

My summary of the day, based on the testimony of 25 folks is

1. The country must rollout EHRs with baseline functionality that at a minimum includes e-prescribing, automated lab workflow, clinical summary exchange, and quality data reporting.

2. Health Information Exchanges will evolve locally based on business cases in communities. The services offered may include e-prescribing, diagnostic test results delivery, quality data warehousing, data normalization into common formats and vocabularies, and "convening services" to create data use agreements for the community.

3. Quality warehouses are needed to provide caregivers with rapid feedback and serve as population health registries. They will often be local based on the political feasibility of co-mingling data.

4. Standards will continue to evolve, but existing standards wrapped in a service oriented architecture using a common data transport approach are good enough. We should use clinical data preferentially over administrative data for quality reporting, population health analysis, and PHRs.

5. Policies in support of this technology will continue to evolve locally. Although there should some common national policies, regional variation must be allowed.

Several of my colleagues will testify today. I'll update this blog entry after their testimony.

Tuesday, April 28, 2009

Point to Point Messaging and Persistent Document Exchange

In a recent letter to the HITSP panel describing the interoperability needed for meaningful use, I discussed point to point messaging and persistent document exchange. Here are a few additional details about these approaches.

Point to point does not imply that one EHR is communicating with one recipient via a specialized interface for that interaction. Requiring a custom interface for every connection between two stakeholders would not be scalable. Point to point simply implies that a transient message is sent from a data source such as a cloud computing EHR hosting center to a data recipient such as an e-prescribing gateway, a healthcare information exchange, or payer.

In Massachusetts we use interface engines, gateways such as NEHEN, and community-based health information exchanges such as EHX created by eClinicalWorks to connect thousands of users in dozens of organizations via transient messages.

There has been debate in the informatics community about using point to point messaging as a means of interoperability. Some suggest that all EHRs should have consistent data elements to foster the most complete interoperability. Although a common information model will be helpful in the future, we need to implement "good enough" standards now to improve quality and efficiency in the short term.

Sending packages of content between organizations using a common web-based transport mechanism enables such high value data exchanges such as e-prescribing, lab data sharing, and administrative workflow.

Point to point messaging works very well for secure transmission of a content package between two stakeholders. To ensure that HITSP interoperability specifications using point to point approaches are sufficiently complete to test, we need to be very specific about the transport mechanism, as complete as possible listing the vocabularies/code sets, and as constrained as possible describing the package contents. ONC will soon release a Common Data Transport Extension/Gap document which illustrates the kinds of secure transport transactions we'll need to harmonize.

What are the disadvantages of the point to point approach?

a. It does not work for complex scenarios such as an Emergency Department requesting the lifetime clinical record of a person from all the places their data exists in the country. That requires a master patient index, a record locator service, or a national healthcare identifier. In the short term, there are enough high value provider to pharmacy, provider to provider, and provider to payer exchanges that waiting to solve the unique patient identifier problem is not necessary.

b. Auditing the transfer of clinical records between two organizations based on transient messages may be more challenging than exchanging persistent documents with a non-reputiable time/date stamp and signature.

c. Reconstructing a damaged clinical record by replaying transient messages from an interface engine may be harder than simply reassembling persistent documents.

While point to point messaging uses a transient message from source to destination, a persistent document transfer uses the HL7 Clinical Document Architecture (CDA r2) to transfer an XML document between two stakeholders. That signed document is persisted by the recipient, providing a very clear audit trail about what information was transferred, by whom, and for what purpose. Examples of persistent document exchange include discharge summaries, quality data sets, and population health metrics being sent from one organization to another.

To support meaningful use such as medication workflow, laboratory exchange, clinical summaries for coordination of care, and quality reporting, it's clear to me that we need both point to point messaging and exchange of persistent documents.

I hope this discussion clarifies the kind of short term exchanges that will accelerate interoperability. This morning I'll be in Washington at the NCVHS meeting testifying about meaningful use. I'll post my testimony on my blog as soon as it is delivered.

My personal opinion is that metrics for meaningful use of point to point messaging and persistent document exchange may include

* Using a product that incorporates HITSP specifications and is certified by CCHIT using its Laika tool to validate conformance
* Passing an online test with a vendor recognized as compliant with HITSP interoperability specifications such as Surescripts
* Participating in a production health information exchange organization which incorporates HITSP standards such as NEHEN

Over the next few months, the entire healthcare IT community will engage in a very important dialog which will finalize these details.

Monday, April 27, 2009

Dispute Resolution in Healthcare

At the recent Health 2.0 conference, I was asked an interesting question. If there is a dispute about any data in healthcare - PHR, EHR, or Health Information Exchange, how is it resolved?

eBay does millions of transactions via the internet and it has automated, web-based dispute resolution workflows. Can healthcare learn something from eBay?

On May 5, I will be attending a workshop in Washington called "Online Dispute Resolution in a Technology-oriented Healthcare World.�

The attendees are evenly split between representatives of the Healthcare, Dispute Resolution and Computer Science communities.

The goals of the meeting are:
*Identify the key risks of disputes in the networked health information technology environment.
*Identify the best practices in avoiding and resolving such disputes and the need for new dispute prevention/resolution approaches in problem areas.
*Identify the computing and other research challenges inherent in supporting these practices.

You'll find a list of attendees and the conference background materials online.

As the recent work with I've done with e-Patient Dave illustrates, Personal Health Records should have a process for resolving data issues. If such a feature would have been built into Patientsite, Google Health or Microsoft Health, we might have identified the issues with administrative data and PHRs sooner.

I will report back next week with lessons learned from the conference, included recommended next steps for the software we use with patients at BIDMC.

Sunday, April 26, 2009

Monday Review- Allergy Alert Clothing

This week's Monday Review is brought to you by Alert Clothing Company. Summer camps and changes in caregiver schedules are right around the corner. Protect young children with Alert Clothing.

Company founder, Rebecca Nelson, has three children- two with severe food allergies. In an effort to keep her children safe, Rebbecca designed several colorful t-shirts for her kids to wear to preschool. The shirts were a big hit and in 2005, Rebecca launched the Alert Clothing Company so that food allergic children everywhere can be identified and protected.

What do I love about Rebecca's designs? The sweatshirts, t-shirts and tote bags are bold, colorful and kid-friendly. They grab an adult's attention right away and send a simple message. I also like that the Alert Clothing logo is printed on the back of the shirt. Young kids don't typically sit still, so with a reminder on front and back, it's sure to be seen.

Show your child the designs. Let them pick out a few to wear when they're at daycare, preschool, camp or other places away from home. As Rebecca Nelson says, "A parent cannot be present constantly, and a two, three or four year old cannot be held responsible for advocating for themselves."

Grandparents, buy some for your grandchildren with food allergies. Allergy Alert Clothing is another tool in the food allergy arsenal.

Check out Alert Clothing Company. They even offer a fundraising program for preschools . Contact Rebecca by e-mail for more information.

As always, visit the Food Allergy Assistant for more information about everything related to food allergies.

Friday, April 24, 2009

Friday Feature: Raising Food Allergic Kids.org

This Friday Feature showcases Lissa, the founder of Raising Food Allergic Kids, a website packed with information to help raise your food allergic child. As you'll see in our interview below, Lissa's site is a must-read if you're planning a Disney World trip.

What is your food allergy background?

My daughter, Caroline, had her first reaction shortly after she turned one. It was her second exposure to egg. I had no idea that it’s very common for a sensitivity to manifest not in a first exposure, but in the second. I was taken completely by surprise. When I plopped a hard boiled egg on her high chair tray about a week after her first scrambled egg, I thought nothing of it. Within five minutes even the whites of her eyes were red and we were on our way to the doctor in a panic.

In the year since this first exposure she's have had multiple blood tests, skin tests and oral challenges. We've also learned that Caroline has severe asthma. I now know that asthma and allergies are often connected.

What are you passionate about in the food allergy field?

To be honest, I am passionate most about finding workable solutions for our everyday life. I really don’t care about the ongoing fight that seems to be happening in our world over what causes allergies and what has caused the rise in incidence. Finding that out won’t change the fact that we are living with it.

I want Caroline to have a normal, happy and safe childhood. So, I am passionate about finding ways to make that our reality. It often means that I do a lot of extra work behind the scenes, but it’s worth it to me so that she can experience life the way it’s meant to be experienced.

I'm also passionate about sharing with other parents. With diagnoses coming earlier in our children’s lives, it is overwhelming to think of raising your child in a world that seems suddenly scarier than it used to be. I’m all about trying to break our kids out of the protective bubbles that we instinctively want to put them in when we first hear that diagnosis.

What else are you working on in the food allergy area?

It’s a strange melding of my two major interests: food allergies and Disney World. Yes, I know that’s random, but I grew up in Florida and Disney is a huge part of my life. I am inspired by the way the Disney cast members accommodate guests with food allergies (and many other special needs, too).

It’s my hope to be able to bring their model to other vacation destinations and kid-centered activities like summer camps. We leave on our next trip in just a couple of weeks and I’ve reached out to Sea World Orlando and Universal Studios Orlando to see what kinds of accommodations they make and to start a dialogue about ways to open up their experiences to more kids with these potentially life threatening limitations.

Food Allergy Assistant: I love this idea. Whenever we travel to Disney World, I think, "Why can't everyone, everywhere, be this accommodating?"

What are your favorite food allergy friendly food staples?

Our egg-free banana pancakes are an absolute favorite in our house – recipe is on our site and Caroline can eat them three meals a day if we let her. We are very lucky to not have wheat allergies as I think that has to be one of the most limiting of the major 8, so Annie’s Bunnies crackers are also a great snack on the go for us. I like them better than the goldfish crackers since they don’t have any additives. Van’s Waffles saved our lives when she was first diagnosed, and remain a staple in our freezer.

What did you do before life with food allergies?

I worked for five years for the United States Chamber of Commerce, the number one lobbying organization in the country. That experience is proving to be very helpful now that I’m following the legislation pertaining to food labeling and protections for our kids.

What are some of your other interests/hobbies?

As mentioned, I love Disney and everything related to it. I help lots of people plan trips to Disney World- with or without food allergies. I love to cook, bargain hunt and can play a mean game of Ring Around the Rosie with Caroline.

Thank you, Lissa, for creating your website to help parents who feel overwhelmed with a food allergy diagnosis. I plan to try out your egg-free French toast recipe as my son has never had French toast!

Check out Lissa's site at www.rfak.org.

Cool Technology of the Week

The New England Health EDI Network (NEHEN) and MA-Share are completing their merger over the next month into a new non-profit LLC called the New England Healthcare Exchange Network. The resulting merged organization will provide a single appliance for exchange of benefits/eligibility, referral/authorization, claims/remittance, the full suite of e-prescribing functionality (eligibility, formulary, history, routing, refills), and clinical summary exchange of continuity of care documents.

Many recent articles in the popular press have questioned the cost savings of health information exchange. Here's more data from our experience in Massachusetts.

The quantifiable savings are different for each provider organization depending on what their starting point is, however here are some example of significant savings:

*For Brigham & Women's and Mass General their 'Total Denial Write Off
Rates as a Percent of Net Revenue' has reduced from 3.78% to 0.88% and
from 4.17% to 1.28% respectively.
* For Brigham & Women's and Mass General their 'A/R Days' have reduced from
81 days to 55.6 days and from 99 days to 54 days respectively.
*Since Baystate's go live with NEHEN in January 2007, they have saved over
$1.5M by avoiding per transaction fees.

In general, NEHEN users have experienced the following clinical and administrative benefits

*Reduction of ambulatory medication errors
*Enhanced communication among providers
*Improvement in the Patient Experience
*Reduction in claim denials due to lack of good information
�Correcting insufficient or inaccurate eligibility or referral information
�Correcting invalid PCP, DOB
*Reduction in write-offs due to eligibility and exceeding the filing limit
*Improved collection of Copays
*Labor savings
_Reduction in ambulatory care staff needed to manage medications.
�Reduction in time spent on manual transactions: eligibility, claim
status inquiry
�Focusing on the exception processing
*Reduction in �Days in A/R� & claims rework
�Focus on front-end weighted, clinically driven revenue cycle
operations
*Reduction in bad-debt

A single healthcare information interchange platform that pays for itself via cost avoidance. That's cool!

Thursday, April 23, 2009

My Work Spaces

I've written about the technologies I use personally, but I've not written about the places I use them.

I have three primary workspaces - my Harvard office, my BIDMC office, and my home. Since being a CIO is a 24x7x365 lifestyle, I do not store paper, supplies or technologies in any of my offices. I can work equally well wherever I am. Here's the overview of where I work:

Harvard office - I'm in Vanderbilt Hall, built by George and Cornelius Vanderbilt in 1927. Everything in my office is from that era. In my twenties I collected Arts and Crafts/Mission furniture from flea markets and estate sales. Back in the 80's no one really wanted old dark oak pieces, so everything was inexpensive. My desk is a deposition table from the Milwaukee County Courthouse. You can image Clarence Darrow pounding his fist on its well worn oak top. There's a supply of green tea and a whiteboard. Otherwise, there is no paper, no technology and no phone. I use this office for meetings with Harvard faculty and staff from the Longwood medical area, since it's centrally located near BIDMC, Joslin, Dana Faber and Brigham and Women's.

BIDMC office
- I'm in the Renaissance Center, a 9 story office building next to the Boston Police Station. Because Renaissance has a large conference room, this is the office I generally use to host visiting groups and foreign dignitaries. It's typical for international visitors to bring some momento from their country, so my office is a shrine to dozens of countries - Japan, China, the UK, Scandinavia, Dubai, Switzerland, and even sub-saharan Africa. As with my other offices, there is no paper or technology specific to the office.

Home office
- At home, I do not have a separate office, but work from the family room. All of my blogs and articles are written in my Morris Chair, which I've used for the past 15 years. I also have a small writing desk, an incense burner, and a fragment of a tree that's hundreds of years old. While climbing, I found the tree at 13,000 feet and noticed something remarkable about it. As a seedling, the tree grew from under a rock, eventually surrounded the rock, and split the rock in half. To me, that's a great metaphor for perseverance. You'll find a cup of green tea but no papers, files, or clutter in my home office space.

It's taken years for me to create workspaces that foster creativity, productivity, and peace of mind. As you'll see from all the photos, less stuff can bring more efficiency.

Wednesday, April 22, 2009

Food Allergy Thrive Expo

Chicago hosted the Thrive Allergy & Gluten-Free Expo on Saturday and Sunday (April 18 and 19). More than 3,000 tickets were sold. Check out this Chicago Tribune article listing many of the vendors

Did you attend, or hear any news about it? I thought this would be big news among bloggers and I haven't seen much. Am I missing something?

Enhancing our Problem Lists

In my recent posts about the Limitations of Administrative Data and the Lessons Learned, I've concluded that clinical observations of symptoms and conditions coded in SNOMED-CT are the most relevant problem list data to share with patients and use for data analysis.

We have a 3 step approach to implementing SNOMED-CT in BIDMC clinical systems

1. Our existing problem list dictionary was developed in 1998 and hence it's called BI-98. We contributed it to the National Library of Medicine and it was incorporated into the Metathesaurus.

About 70% of the terms we used are easily mapable to SNOMED-CT Codes. The National Library of Medicine will send us a BI-98 to SNOMED-CT mapping in the next few days and we'll incorporate it into our existing dictionary, giving us a SNOMED-CT vocabulary for 70% of the existing problem list entries in our system.

2. The NLM will be giving us a compendium of the 6000 most commonly used terms in the local problem list vocabularies of large health care institutions, and their equivalent SNOMED CT codes. We'll incorporate that list into our systems and create a novel "Problem List Picker" using AJAX technologies that will assist doctors in choosing the best problem description associated with a SNOMED-CT term. This will give us a great framework for the terminology of newly entered problems.

3. I'm working with other organizations, such as Kaiser Permanente, to gather problem list "best practices". We'll leverage their experience to innovate at BIDMC and I'll share the experience broadly via my blog. I'll post their problem list dictionaries as I receive permission to do so.

I look forward to your participation and feedback as we work together to improve the usefulness of data in EHRs and PHRs nationwide.

Tuesday, April 21, 2009

Apologizing with Candor and Grace

As readers of my blog know, I've adopted many aspects of Japanese lifestyle in my household - food, music, and clothing.

Learning to apologize is also something I've learned from the Japanese. You'll find a great description in the Etiquette Guide to Japan by Boye De Mente.

A typical corporate apology in Japan is accompanied by a low bow, a sincere apology, and a possible resignation.

Atoning for a mistake in the US does not require the loss of your job (or anything more extreme).

As I mentioned in yesterday's blog about being a public figure, bad things can happen. You may or may not be able to control them.

When bad things happen, here is the approach I use:

1. Encourage openness and transparency in your staff i.e. do not shoot the messenger. By empowering every person to communicate the events objectively, you'll get to the root cause more rapidly.

2. Ask what can be done to improve the organization rather than blaming any one individual. If an error occurs in medication administration, ask what systems and processes should be improved rather than fire people.

3. Broadly communicate the issue in terms of the lessons learned and continuous quality improvement. The Institute for Healthcare Improvement (IHI) espouses Plan, Do, Study, Act (PDSA). Many IT projects are cutting edge and require incremental fine tuning. We try, we evaluate, we revise, and we try again. Unintended negative consequences during the learning process require full disclosure and an apology.

4. Do not hide information or sugar coat the events. It is far worse to deny the truth, then have to explain the facts later. In a world of instant communication via email, IM, blogs, and Twitter, assume that everyone knows the facts as soon as they happen.

5. Openly discuss the events, their cause, the immediate corrective action taken and the long term changes made to prevent the issue from happening again. Declare that you've made a mistake and that you apologize for it. This may be painful and could result in a great deal of short term publicity, but it's better than a long term investigation and future disclosure of management misdeeds. Imagine what would have happened to Bill Clinton if he said "I did have an affair with that woman and it was wrong. I have taken short term steps to prevent any such incidents from happening again and I will seek counseling from religious mentors and mental health experts to ensure my future behavior is exemplary". The issue would have disappeared in a few weeks.

In my many years of leading change and making mistakes along the way, I've found that great communication, openness, candor, and admission of mistakes, followed by a sincere apology results in healing the organization and bringing rapid closure to the issue.

Monday, April 20, 2009

The Challenge of Being a Public Figure

Although I'm not really a public figure, I do enough presentations in my roles at BIDMC, Harvard, NEHEN, and HITSP to appreciate the challenges of highly visible corporate and government public figures. Here are my top 10 observations:

1. There is no downtime

While on a plane, train, or in any public space, you cannot be freewheeling with your opinions. Your communications must be thoughtful regardless of venue. Emails must be written with the assumption they will appear in The New York Times. While going about the activities of day to day living, you must always be "on". I've had deep conversations about IT strategy and government policy at the Wellesley Dump.

2. You must be a good listener

Public figures are assumed to have power and there will be many opinions about how to best use that power. Employees, colleagues, and the blogosphere will offer continuous advice as to the best path forward. All of this input should be gathered and acknowledged. Since every action you take will be documented and scrutinized, it's important to incorporate multi-stakeholder input into your decision-making.

3. You must hold yourself to high standards.

Watching the confirmation activities as candidates have been vetted in the new administration, we know that you must be a tax expert, avoid hiring domestic help, and shun association with lobbyists. The good news for me is that my tax returns are simple, I've never had domestic help, and I rarely get out much, so I have few opportunities for any conflicts of interest with lobbyists or other nefarious characters. I married the first woman I dated in college and this year is our 25th wedding anniversary. There are no experiences in my life thus far that Dr. Phil or Jerry Springer would find interesting.

4. You cannot be too extreme in your views

The press has recently observed that some of Obama's bold proposals have been tempered by political reality

Public figures listen to all sides of an issue then select a path forward that works for most people.

In a recent keynote I did with Senator Whitehouse (D-RI), he noted that politics is like topography - there are peaks and valleys of political issues. Some mountains, like single payer healthcare, cannot be climbed in the short term.

5. You rarely use formal authority

In many societies, policy can be made by benign dictators at an accelerated pace without debate. That's not the way policy is made in the US. Whether in institutions like Harvard University or in government, there is a process for everything. A leader can communicate a vision or assemble a guiding coalition, but rarely can a public figure just declare an action to be done by fiat.

6. It's more about responsibility than power

Public figures take responsibility for all the actions and events that take place in their sphere of influence. My experience has been that lofty positions come with huge responsibility but little power. Many public figures are like the General Secretary of the UN - charged with communicating a vision, organizing people, and moving issues forward, but without significant power to orchestrate rapid change.

7. Your communications will be interpreted in ways you never intended.

In my own small world of healthcare IT, I find it interesting to read blogs, articles, and news stories which interpret my actions and comments. People will find support for their own views, will extend my opinions to meet their needs, or will create controversy where none exists. I'm always amused when I read headlines such as "Was HITSP work shift a political maneuver?" since politics never crossed my mind when I thought about transport standards and simple EHR data content exchange.

8. There will be good days and bad days

As I begin each day, I never know what press, email, and unexpected events will occur. Some days have a relaxed schedule but turn into a firestorm of communication about controversies I did not anticipate. There is no potential for completing a day without some measure of angry emails, hostile phone calls, and unresolved issues. Each day, I look at the trajectory and the issues that were moved more forward than backward. On balance, if I feel that I've done everything possible to bring closure to my open issues, it's a good day.

9. You'll receive credit for things you did not do and blame for things you cannot control

Whenever I'm introduced at keynote addresses, my life summary sounds like I'm super human. The reality of being a public figure is that you'll get credit for many things done by people working for you or done by colleagues working with you. I constantly credit the team and institution with the accomplishments, not myself. Spreading the credit for success is easy since "Success has a 1000 fathers". However, when bad things happen, it's expected that the public figure will accept responsibility, even if the events were not directly controllable. Apologizing with candor and grace will be the subject of another blog. It's an important skill to have.

10. You cannot make everyone happy

There are so many special interests in the world today that there is no such thing as a policy or idea that everyone will accept. A solution based on 90% consensus means that 10% will feel wronged and will opposed the path forward. The best a public figure can do is listen, facilitate, communicate and then move forward with the optimal thinking at the time. Even while executing a well orchestrated plan, there will be naysayers, continued debate, and controversy. The public figure should continue to listen, provide mid-course correction as needed, and support forward progress.


I've known many public figures in my career - Milton Friedman, Edward Teller, Condoleezza Rice. I have some sense of the energy they require(d) just to be themselves. Next time you're feeling angst for a public figure, take a moment to empathize with their challenges.

Sunday, April 19, 2009

Monday Review- Grill Charms


This Monday Review is brought to you by Grill Charms- think wine charm for your grilled meats.

Founder and mom, Leslie Haywood, had an "A-ha moment" when her husband mistakenly gave her the extra-hot Jamaican grilled chicken, instead of the mild chicken she requested. Leslie created Grill Charms to help barbecuers everywhere identify different preferences and dietary needs.

Back in February, Leslie sent me a Grill Charm from her Pink Collection (these charms benefit breast cancer research- love that!). Finally a balmy week-end arrived and we pulled out the grill. I must admit to feeling skeptical at first that these little charms would stay in ground beef. They did. Even through my clumsy burger flipping. It worked great for my grilled chicken the next night too. It was very easy to identify the meat with the charm.

So, how does this relate to food allergies? Of course, depending upon the specific allergy, special precautions must be made when barbecuing. Marinades may contain unsafe ingredients for a person with food allergies. Certain seasonings may be unsafe and foods may look the same on the grill. By inserting a Grill Charm, mix-ups are avoided.

A few tips when grilling where food allergies are a concern:
Consider several layers of foil between the food and the grate. This prevents contamination from the grilling surface.
Use separate grilling tools to avoid cross-contamination.
Do not mix up the meats. A tool such as Grill Charms will help keep meats differentiated.

Check out Grill Charms' website. They offer several collections for steak doneness, seasoning types, Charmed Life (may be great for food allergies) and the Pink Collection (10% of the proceeds from sales goes to breast cancer research). Individual charms can be ordered with free shipping.

Leslie is offering $5.00 off your order for Food Allergy Assistant readers. Type "grilling" as the coupon code when you place your order.

Great gift for Father's Day!

As always, visit the Food Allergy Assistant for more help dealing with food allergies.

Friday, April 17, 2009

Food Allergy Guidelines for PA schools

This article is of particular interest to me.

I spent many hours working with our school district so my child could be safe at school. As I've said before, he's carried an Epi-Pen around his waist since his first day of kindergarten. If the school had denied us this right, it would have been a deal breaker resulting in a search for alternative educational opportunities. Every child and every situation is different, but schools and parents need to have some basic understandings and rights when it comes to food allergies.

I fully support State Rep. Tom Murt in his efforts to require Pennsylvania to develop food allergy guidelines for schools. I'm going to write to him right now and see how I can help.

How is your school handling food allergies?

Lessons Learned from e-Patient Dave

I started the week with a blog about the Limitations of Administrative Data, so it's fitting to end the week with lessons learned and next steps.

e-Patient Dave, his doctor Danny Sands, Roni Zeiger from Google, and I spent many hours in online and phone conversation about the data elements in healthcare that are of greatest use to e-patients. Since the American Recovery and Reinvestment Act requires patients be given access to their electronic data, I have wanted to share all data with patients, both clinical and administrative. It's clear from our discussions that sharing billing data with patients is unreliable for clinical history, and it was a mistake to do that.

Administrative data is a coded summary of the clinical care that lacks perfect specificity and time references i.e. just because you had a diagnosis of low potassium 5 years ago does not imply it is a problem today.

Thus, we must be careful about what data we send to PHRs and how that data is presented to patients. Here's the action plan that Dave, Danny, Roni, and I developed to optimize the PHR experience for e-patients:

Problem List
This is useful clinical information as long as clinicians keep it current. Danny has done that with Dave's data, so it's Dave's best current source of relevant diagnoses and ongoing treatment.

Plan
1. Remove our ICD9 administrative data feed from Google so that the clinician's problem list is the only data which populates the Conditions area
2. Continue to improve our problem list functionality in webOMR so that it maps to SNOMED-CT, enabling Google and other PHR vendors to provide medical information and decision support based on a controlled vocabulary instead of just free text
3. Change the BIDMC Google Health Upload screen from "Diagnoses" to "Problem List"

Medication List
Name (with NDC coding), Dosage/Frequency, Prescription, Date provides good "data liquidity" of active medications. We will continue to investigate the utility of sending inactive medications.

Allergy List
Name, reaction, and level of certainty of the reaction has worked well. However, Google Health does not display the detailed reaction information. We will either insert this information into the Google Allergy notes or work with Google to add a new field.

Procedures
We do not currently send procedures to Google Health, nor do they appear in Patientsite. However, Dave feels they may be useful to e-patients. We will add Procedure name and date as a pilot

A great week of discussion with many lessons learned. We look forward to our ongoing work with e-patients, doctors, and Google.

Thursday, April 16, 2009

A Winter's Tale

Recently, my friend John Winship was caught in poor visibility, strong winds, freezing rain/snow and was missing for two days in New Hampshire's White Mountains. I asked him about his lessons learned and this is what he wrote (published with his permission). I think you'll find it meaningful and profound.

"Solo expedition to Mt. Rainier in May: Cancelled.
Solo expedition to Mt. Cook/NZ winter 2010: Cancelled.

Although I did not request a rescue, I know that the damage to my body would have been exponential with one more overnight. I have already made a gift to New Hampshire Fish and Game for double the estimated rescue cost. I have also commended them to Governor Lynch for their selflessness and heroism.

This had to happen. I was addicted. I have been pushing the envelope for two years with ever more audacious speed climbs. Last year I survived a slab avalanche on Washington and went on to summit on the same day. Even that experience wasn't enough to wake me up. Although I have promised my wife that I would never go higher than 18,000 feet, I know that at this rate I would have found myself on Everest or worse within three years.

So many armchair critics, and hindsight advice! I carried 90 pounds of gear up! One critic pointed out that snowshoes would have helped on Day 2, and I retorted that a kayak would have been ideal on Day 4! Another well-wisher asked why I did not have a phone and GPS. Apart from the unreliability of lithium above tree line, I pointed out that I might have been tempted, innumerable times on Day 2, to call for a rescue, thus needlessly endangering strangers, when clearly I had the power to get out on my own. That person then had the temerity to reply, "But that's their job." To which I said, "Dying for me is not their job."

The critics have a difficult time comprehending (1) the ethos of self-reliance inherent to the solo alpine style; (2) the calculus of risk, error, and severe consequences in our risk-adverse society; and (3) the fact that being "lost" has a novel, unfamiliar definition for alpinists. I was only "lost" for the three hour duration through which I had been executing an unworkable plan, because I was not where I thought I was. The problem for speed climbers is that "getting lost" usually means getting lost big. At my pace, I had passed a point of no return far too quickly. Once I fully comprehended my peril, I made several adjustments to plan, and made a severe attempt to get out of Dry River Valley (and nearly died in the attempt) before conceding defeat and deciding instead to mixed-climb down the river.

I have the solace of knowing that no one was hurt rescuing me from my blunder. I will continue to day-hike, once I can feel my feet again, but no more pushing the envelope. I have too much to live for."

Wednesday, April 15, 2009

Food Allergies? Discounts and Coupons

Uno's Chicago Grill now offers a gluten-free pizza. Here's a coupon. Check out their entire gluten-free menu.

Softress Body Oils perfect for those with food allergies, sensitive skin, eczema. 15% discount with code: "FOODALY". Good until Dec. 31, 2009.

Olinda Ridge Oils- if you sign up to receive their newsletter, you'll get a 15% discount on your order.

Go Picnic Snackboxes- 25% discount for your first order. Just use coupon code "GPTHANKS"

Ener G's poundcake, free of gluten, wheat, casein, dairy, yeast, soy, and nuts, is 15% off.

Do you know you can order Ener G and other food allergy safe foods through Amazon.com? Free shipping with your $25 order- not to hard to spend $25!

Any other coupons or discounts we should know about? Let me know.

What are you waiting for...get shopping!!!

Combating Malware

Every day we're reading about new viruses, trojans, spyware and other malware on the internet. I was recently asked about the need to reinstall the operating system from scratch on a virus infected machine. Here is the answer from Security Officer at BIDMC:

Is there a valid technical reason for requiring a rebuild? The answer to this is yes. The thing to focus on here is the Anti in the title of Anti-Virus. These applications are intended to stop an infection. Most of them also include a cleaning component and there are many products marketed solely as cleaning products - spybot-SD is a good example. The problem with these products is that malware is constantly morphing. You see this often in the names of the malware , they will contain .a, .b. .c etc. The longer the malware is out the more variants. This means that the cleaning tools need to keep up as well. The fact of the matter is is that they can not. If a system has critical content on it and it appears to be compromised the only way to ensure it is clean is to completely rebuild the system. The more sophisticated viruses will hide in the boot sector of a drive, others will replace O/S files with variants that contain the virus. The former will load on system startup and have not tracks for the AV or file cleaning applications to locate and clean. The later will look like standard files and be skipped over. We also take the precaution of a system rebuild here at BIDMC when we have a system with clinical or privacy content on it that is believed to have been compromised.

On the discovery component - we are also seeing a uptick in Torpig and mebroot. Torpig and mebroot are of the same family - sinowal. These trojans are a high risk trojan as their objective is to steal identity information - and they are good at it. These are of the type that imbed themselves in the boot sector of the system. As I mentioned above it is very difficult to both detect and to clean this type of trojan. I had a family member with this. As an exercise I attempted to clean the boot sector rather then rebuild. I logged over 40 hours of labor on this effort with a wide range of tools - even down to using a disk sector editor to attempt to clean it with no success.

There is no way to determine the original source of the infection without detailed examination of the system. But, this system is used to browse the web, it has Google desktop loaded and it is running MS Office. The infection could be sourced from a web site that is believed to be good. We saw this on Boston.com not to long ago. These pages link to active advertising sites that are not in their control. Those advertising sites can and often do have malware in them. Google desktop in itself is not an issue - but the actions/benefits it provides automatically link the system to sites in a more automated fashion that increases the exposure of a system. Lastly is Windows itself. During the time between the discovery of a vulnerability and the release of a match all systems are vulnerable. In many cases the exposure time is lengthy. Keeping up with patches is critical but in itself does not ensure protection.

There are companies that offer system analysis. In general you can look to pay $350 - $400 per hour from a quality service. For an 80 Gig drive you are looking at about 4 hours of time for a basic pass over the system. A more detailed analysis will take in excess of 10 hours. As an example we are performing an analysis now on a system. The forensic copy of the disk to perform the analysis took 2 hours. The first pass analysis took an additional 6 hours. We are now starting the second pass and that will be 10 to 12 hours. Our times are about 30% more then a commercial provider due to the equipment we use. This is not a cheap process in money or time.

Due to the high risk that the torpig and mebroot trojans present I would highly recommend to completely rebuild the system ensuring that the boot sector is wiped and re-written. I would then ensure before the system goes back into usage that all windows, Internet Explorer, and office patches are applied.

Tuesday, April 14, 2009

A Followup on Wal-Mart's EHR effort

I've recently written about Wal-mart's effort to reduce the cost of EHR acquisition. Many folks have asked for more details about how the product will be promoted and sold. Here's the answer based on followup calls with the Wal-mart folks running the project.

Sam's Club currently has "feet on the street" visiting with small business operators. In particular, there are individuals from the Health and Wellness business group that are currently calling on physician members. In the past, they would have spoken to physicians about the $4 Pharmacy program and office supplies. That same group will also be used to promote the EHR Solution. However, that is not enough to spread the word.

In partnering with eClinicalWorks and Dell, Sam's Club will be leveraging their "feet on the street" to get out the message. Sam's will rely on eClinicalWorks to communicate the technical details of how the software product works. ECW will do all the demos. Sam's is working with them to streamline that demo process. A first step is to do a web-demo which is relatively low cost.

Sam's is also beginning the process to partner with state governmental organizations and professional organizations to communicate the value of the program. Those partnerships will also spread the word.

Sam's will eventually create traveling demos so that physicians can be invited to clubs for a more interactive event targeted to their needs.

Per Sam's, all of this may not be enough. Depending on the pace of demand, they may also leverage existing infrastructure from other organizations to get the word out.

So, in summary, you'll not find a doctor at Sam's getting a case of toilet paper and an EHR, you'll find one on one discussion, demonstrations, and the involvement of many professional groups. Just as with the rollout and support, Sam's seems to have really thought this out.

Monday, April 13, 2009

The Limitations of Administrative Data

The data issue described in the Boston Globe this morning is really unrelated to Google, Microsoft, or any Personal Health Record (PHR) provider. In the US, there are two kinds of healthcare data - clinical data in Electronic Health Records (EHRs) and administrative billing data that is used by payers, researchers, and the government. Billing data is imprecise, but it is a starting point to describe the care given by a doctor or hospital. The only thing that's new in 2009 is that PHRs now enable patients to see the kind of billing data that's been used for 20 years for reimbursement, quality measurement, and population health. Blue Cross of Massachusetts and Medicare (in a few pilot states) share billing data with patients via Google Health, so this is not just a BIDMC implementation.

As a society we're likely to see increased data transparency between patients and providers, which will lead to several improvements:

1. Doctors will likely begin using more structured problem lists based on SNOMED-CT, a standardized clinical vocabulary of symptoms and conditions. This will enable their EHRs to better share data with PHRs as well as to more accurately measure quality. The Healthcare Information Technology Standards Panel (HITSP) has harmonized the national standards needed to reduce the dependency on billing data for PHRs, quality measurement, and population health.

2. Eventually, billing data will become more detailed as ICD-10 replaces ICD-9 billing codes in 2013. It will take several years for ICD-10 to be widely adopted and improve data granularity.

3. In the future, patients and doctors will work together to ensure records are up to date and accurate. It's a shared responsibility. Now that the Stimulus Bill requires doctors to make records available electronically to patients, the limitations of billing data will become more widely understood.

In the meantime, BIDMC will take the following actions to accelerate this work:

1. I'm working with the National Library of Medicine to map the most common Problem List terms used at BIDMC to SNOMED-CT, enabling BIDMC to use a clinical vocabulary and not just a billing vocabulary.

2. I'm working with Google to evaluate the impact of sending our existing free text problem lists instead of billing codes. It will reduce the number of features available to patients, since Google's educational materials are based on billing codes, but it may be more informative to patients to see the text their clinician wrote, not the diagnosis on the bill. Showing problem lists is what we've done in Patientsite for 10 years.

3. We'll hold a conference call with e-Patient Dave, his doctor, Google, and me to review Dave's clinical and administrative data (with his permission), to capture a real world example of the differences between these data sources.

What is Meaningful Use?

The definition of "Meaningful Use" in ARRA is one of the most critical decision points of the new administration's healthcare IT efforts. That definition will influence the types of products that will be implemented in clinician offices and the types of standards used for healthcare exchange to qualify for stimulus dollars.

For example, if meaningful use is defined as e-prescribing, then standalone products such as Dr. First's Rcopia could be used as part of a clinician's office compliance in lieu of a complete EHR.

If meaningful use is defined as the basics of ordering/viewing labs, then products like 4medica could constitute meaningful use.

If meaningful use requires sophisticated quality measurement, decision support, and workflow redesign to enhance efficiency, then a CCHIT certified comprehensive EHR may be required.

My prediction of meaningful use is that it will focus on quality and efficiency. It will require electronic exchange of quality measures including process and outcome metrics. It will require coordination of care through the transmission of clinical summaries. It will require decision support driven medication management with comprehensive eRx implementation (eligibility, formulary, history, drug/drug interaction, routing, refills).

Each year, the definition of meaningful use will be expanded, setting the bar higher and requiring more features and more data exchange.

Thus, in the short term, meaningful use may be a combination of products or an EHR lite. However, over the longer term, a comprehensive EHR will be the best foundation for meaningful use.

The definition of "certified" is also important. Today, CCHIT includes those criteria that make an EHR capable of supporting an optimal set of functionality. If certification is redefined as a baseline set of functionality, then more basic EHR lites may meet the definition of "certified". If certification is based on the criteria as written today and the likely evolving criteria for usability and interoperability, then a comprehensive EHR will be the best foundation.

There are many stakeholders on both sides of this discussion. Small clinician offices with few resources want stand alone e-prescribing and lightweight EHRs to get them started on e-health. Hospitals, larger practices, population health experts, and researchers favor a more comprehensive EHR.

As background, here's the HIMSS strawman proposal for meaningful use.

The next few months will settle this question once and for all. If you have an opinion about meaningful use, I expect the first recommendations to come from the new HIT Policy Committee and possibly NCVHS, an existing FACA advising HHS. Participation in any call for public comment will be the best opportunity to contribute your opinion.

Sunday, April 12, 2009

Monday Review- Stuck on You




This Monday Review is brought to you by "Stuck on You", a company specializing in labels and organizational tools to help parents and teachers keep children healthier and more organized. Couldn't we all use a little more organization?

They now offer a special line of allergy-free labels to help create zones to prevent inadvertent exposure to substances that can be dangerous to children with allergies. Stuck on You offers customized labels and wristbands for any allergy. The brightly colored vinyl labels, stickers, and wristbands are waterproof, as well as microwave and dishwasher safe.

I love these labels. Our first, and fortunately, only (knocking on wood right now), ambulance ride due to an allergic reaction occurred when we were traveling and my food allergic son ate a muffin from the wrong bag. This was the early days of our food allergy journey. I learned a painful lesson that day. My son's life was in danger if I couldn't make sure things were well organized. Stuck on You has created a product to help do just that.

Use these stickers on everything you send to daycare, camp and school. They're a great help at home or at grandma's house or when traveling. Plus, you can customize them and they're so darn cute!

Check out the Allergy Pack. Click on "Stuck on You Value Pack", then "Stuck on You Allergy Pack".

Stuck on You offers other products. Go to their website and click on your home country.

Labeling helps your child and the adults around your child quickly identify what belongs to them. It's another way to keep kids with food allergies safe.

Happy Holiday!

Randall Cattle Breed


I stumbled across an interesting breed of cattle this past week - Randall Cattle. The following is an excerpt from the breed association's web site:

The Randall Cattle Breed

"Randall cattle are a rare breed of purebred cattle developed in Sunderland, Vermont, on the farm of the late Everett Randall. They are considered to be a landrace breed, descended from the indigenous landrace cattle common in New England in the nineteenth century. Randalls have historically been used as a dairy breed, although they also possess meat and draft qualities.
Randall cattle are variable in size and conformation and have a constitution that is uniquely adapted to extensive or low input farming systems. Historically, the most suitable and natural environment for these cattle has been on small scale forage-based farms, subsistence farms, and homesteads. It is on such farms and homesteads that the unique genetic attributes of the Randalls can be fully expressed."


"Randall cattle are classified as "Critical" by the American Livestock Breeds Conservancy (ALBC), although their numbers, once fewer than 20 total animals, have increased since they were first rescued from extinction in 1985. Randall cattle originated on the farm of Everett Randall of Sunderland, Vermont, starting with his father, Samuel J. Randall, around the turn of the 20th Century. Much of the breed's history is surmised, based on anecdotal and other evidence, but the common thread seems to be that the Randall family kept, bred, and selected their cattle in virtual isolation for over eighty years. This selection and isolation resulted in the Randall breed of today, a distinct animal uniquely adapted to its environment."

The Randall Breed web site has a very large collection of photos, in particular a quite lengthy slide show that seems a thorough representation of the population of these cattle. Reviewing the slideshow you see from time to time white cattle in the mix. It's like a mirror image of a British White herd of cattle where they are predominantly white with black points and you find as well limited numbers of the black-sided example of the British White breed, what we consider 'line-backed' markings.

Also of particular interest to me is the beautifully lyre-shaped horns of this breed that are tipped with black. A review of the photos reflects black-tipped horns not being occasional, but rather most predominant, as is the lyre shape of the horns. The ancient Park Cattle of the British Isles originally had lyre shaped horns, based on the surviving literary references to the breed, and they were tipped in black.

". . . when the milk-white bull with gilded horns. . ." The Georgics of Virgil (c.29 BCE)

Today, you often times see more of a spreading type horn in the remaining horned Park Cattle herds in the USA as well as in Britain, which would be the result of the introduction of English Longhorn into herds of horned Park Cattle most likely in the 18th and early 19th centuries. An example of this would be the photos of horned Park Cattle presented at the Seedsavers Exchange web site. While the verbiage indicates the cattle have the traditional lyre shaped horn, the photos are clearly of the wide spreading variety of horn, not a distinctive upward rising lyre shape.

The Randall cattle were kept and bred in isolation and this perpetuated a distinct type, not unlike the Chillingham herd of England. The critical difference being that this herd was not kept in human isolation, and it is apparent that they are intelligent and gentle animals. The Randall family likely had an original fondness for the line-backed markings and thus they are the predominant physical appearance of this breed today. But, it is very informative to the genetics of this breed to find the occasional Randall that is white with black points. Kevyn Miller of Conner Prairie in Fishers, Indiana with his Randall working steers



One day I hope that someone with both the interest in the antiquity of these genetics and the wealth to take on such a project, will decide to pursue a thorough genetic analysis of the polled British White, the horned White Park of England and the USA, and this very interesting Randall breed of cattle. Perhaps we could try to get some of that federal stimulus money for such a project!

The photo above shows both a red and a black point Randall steer. Apparently, when the breed was originally taken on for rescue there were no red-pointed animals, but over time the recessive red gene presented itself. This is also consistent with the ancient Park Cattle we know today as British White and White Park.

Do you know anyone with deep pockets and an interest in exploring and preserving the ancient genetics of these special breeds? I'll give you a beautiful heifer if you can find someone who will commit to seeing this done and done right!

Friday, April 10, 2009

Friday Feature: Linda Coss

This Friday Feature showcases Linda Coss. I am not exaggerating when I say that Linda's food allergy books were a lifesaver for us when our son was first diagnosed with multiple food allergies. Her recipe books taught me how to make safe foods our whole family could enjoy. Linda's "Practical Tips" book guided us through many situations related to school, travel and holidays.

Learn more about Linda through our recent interview:

How did you first become involved in food allergies?

Eighteen years ago I shared a bowl of ice cream that changed my life. I dipped a taster spoon into the melted bit at the bottom of the bowl and let my 8 month old son lick it off. Then I went home and put him down for a nap.

A little while later, that “mother’s intuition” voice told me to go check on him. He was beet red from head to toe. I picked him up and he started projectile vomiting. It was like a devil baby in a horror movie the way this stuff was shooting across the room! His ear began to swell and so began my life in the food allergy lane.

When I first started on this path, life-threatening food allergies were practically unheard of. Almost no resources were available, the internet didn’t exist (or if it did no one in the general public had heard of it), food manufacturers weren’t required to include ingredient panels on their packaging, and the Americans with Disabilities Act was so new that it was not yet widely enforced.

I am very happy that so many people have been successful in their efforts to change this, and make things easier for those who have to cope with this very challenging condition.

Over the years I’ve started a local food allergy support group (which I ran for 13 years), written and self-published three food allergy books (“How To Manage Your Child’s Life-Threatening Food Allergies: Practical Tips For Everyday Life,” “What’s to Eat? The Milk-Free, Egg-Free, Nut-Free Food Allergy Cookbook,” and “What Else is to Eat? The Dairy-, Egg-, and Nut-Free Food Allergy Cookbook”), and – most recently sent my food-allergic son off to college.

What are you passionate about in the food allergy field?
I am passionate about making it easier for others to manage their child’s life-threatening food allergies. Through my books, it is my goal to help others parents create a safe and enjoyable life for their food-allergic children, and to make safe/easy/delicious food that the entire family can enjoy.

People often write to me with questions, and then are shocked when I write back – usually the same day. When I say in my books that “I’m here for you,” I really mean it. I am passionate about helping people.

What else are you working on in the food allergy area?
Last week-end I gave the keynote address at the AFAA’s 6th Annual Food Allergy Conference and Expo. I would love to have more speaking opportunities such as this. Unfortunately, few event organizers have the budget to fly me out from Southern California!

What are your favorite food allergy friendly foods/products?
There are a number of food allergy friendly treats that I think are terrific but rarely purchase because of the high cost of shipping to California (such as Vermont Nut-Free Chocolates, Divvies’ cookies, and Home Free’s coffee cakes). I also think Cherrybrook Kitchen’s new ready-made cookies are truly delicious.

Of course, my favorite food allergy friendly products are my books! Even now that Jason has moved off to college and I theoretically can cook anything I want, I still find that I cook most of my meals using the recipes in my cookbooks.

“What else do you do for a living besides write and publish food allergy books?”

In addition to running my book publishing business, I am also a freelance marketing writer. I help businesses reach their goals by writing targeted and effective websites, brochures, letters, newsletters, articles, and other written materials for them. You can learn more about this at Plumtree Marketing.

What are some of your other interests/hobbies?
Well, I really do enjoy cooking, and after all those years of creating recipes it seems strange not to be doing so any more! I also enjoy gardening, walking (my morning walk is often a highlight of my day), entertaining, reading, and going to lots of different types of live entertainment (concerts, theatre, lectures, comedy shows, etc.).

Note from the Food Allergy Assistant: Some of our family favorites are recipes from your books (Spaghetti and Meatball soup, Cinnamon Roll Biscuits, and Glazed Sweet Potatoes with Marshmallow Topping- to name a few!), so we hope you keep creating great recipes and sharing them with us!

Linda's books are available at FoodAllergyBooks.com. She says, "I’m always happy to personally autograph books, or include a gift enclosure card in the package. Just write in your special request in the “special instructions” section of the order form".

Also, Linda now posts near-daily food allergy management tips on Twitter and she's got a Food Allergy Books fan page on Facebook.

Thanks Linda for all you do to help make coping with food allergies easier.

Cool Technology of the Week

Although Google does not generally share the details of its infrastructure, Google's hardware architect recently shared the secrets of its servers, data centers and power management.

Having been involved on the advisory council for Google Health, I know that Google runs hundreds of thousands of servers. What I did not know is that it designs and builds its own. The real innovation - each server has a 12 volt battery attached the motherboard to keep the CPU running in case of power failure. Google does not use centralized uninterruptible power supplies. Building the power supply into the server means costs are matched directly to the number of servers. Google also uses the battery design on its network equipment.

Also interesting is that its data centers are standard metal shipping containers, each containing 1,160 servers and drawing 250 kilowatts of power. These shipping containers optimize power distribution, cooling and efficiency to reduced waste heat. For example, Google uses ultra-efficient power supplies that convert AC current to 12 volts DC. It's more efficient to transmit 12 volts over copper wires than 5 volts. All other power conversions take place on the motherboard.

Google servers, pictured above are 3.5 inches thick and contain two processors, two hard drives and 8 memory slots.

Incredible attention to detail to create highly scalable, very reliable, and maximally "green" server farms. That's cool!

Thursday, April 9, 2009

Vegan Dining in Chicago

While at HIMSS, you can munch on the usual gourmet convention center cuisine - Hamburgers, Cappuccino, Pretzels, or Jumbo dogs. Or you could a walk a mile or two and enjoy Vegan Chicago. Most folks think of Chicago as deep dish pizza, ribs or steaks. However, there are a remarkable array of Vegan friendly restaurants and delis.

I walked from the Convention Center to Opera at 1301 S. Wabash to sample their vegan specialties. On Friday night I had a starter of a Vegan Corn fritter, followed by Spicy Shitake Wontons surrounding an asparagus salad, and then an entree not on the menu but made by the chef for me as a experimental future addition to the vegan menu - Pressed Tofu Kung Pao style. However, a side of Bok Choy provided a cool counterpoint.

On Monday night, I dropped by for a reprise and had a starter of fresh vegetable Moo Shu in two spicy sauces followed by an entree of Mapo Tofu. Another remarkable meal.

Here are a few resources for Chicago Vegan dining:

The Chicago Diner

Vegan Living overview of dining in Chicago

EcoBusinessLinks overview of dining in Chicago

The Happy Cow overview of dining in Chicago

Next time you're at HIMSS, go for something vegan. It gives you the endurance to run through the HIMSS exhibits in record time!

Wednesday, April 8, 2009

Food Challenges

Did you get to see Nightline last week when they featured food allergies and food challenges?

It's a heart-wrenching story about a 5-year-old who has been fed through a feeding tube for the past 2 years since he seemed to be allergic to everything. The piece implies that food challenges offer a new way to control food allergies, which is a mis-leading portrayl. Hopefully people will read the article and watch the video to understand what a food challenge is, and what it isn't.

We're visiting the allergiest Friday for an egg challenge. We haven't done a food challenge in over 5 years. There are many emotions associated with a food challenge-excitement in possibly being able to introduce a new food, fear that something will go wrong, anxiety about the process...

I'm making scrambled eggs and french toast to take to the office. My son has really been looking forward to eating french toast and I've been stumped over how to make it egg-free. Anyway, on Friday, he'll at least get one tiny bite of it. My hope is that he'll be able to eat the whole thing and then come home for a towering plate of golden, crisply-fried, cinnamon-sugar french toast.

Whoops! I just drooled on my keyboard.

The Data Elements of an EHR

I've recently been asked to provide a list of the data elements of an EHR which might be used as part of the ARRA mandate to exchange data as part of meaningful use. There are a nearly infinite number of actors, actions and events for data exchange, but in the interest of getting "data liquidity" in healthcare, here are the elements that are most commonly used and represent a great starting point for healthcare information exchange. I always strive for parsimony of standards - the fewest that we need for the purpose. Below you'll see that I've included the standards that support the systems we have in place today as well as the XML/Web-based standards that support newer web-centric systems and healthcare information exchanges.

Demographics
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: HITSP Harmonized codesets for gender, marital status

Problem List
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: SNOMED-CT

Medications
Content: NCPDP script for messaging, CCD for document summaries
Vocabulary: RxNorm and Structured SIG

Allergies
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: UNII for foods and substances, NDF-RT for medication class, RxNorm for Medications

Progress Notes and Other Narrative Documents (History and Physical, Operative Notes, Discharge Summary)
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: CDA Templates

Departmental Reports (Pathology/Cytology, GI, Pulmonary, Cardiology etc.)
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: SNOMED-CT

Laboratory Results
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: LOINC for lab name, UCUM for units of measure, SNOMED-CT for test ordering reason

Microbiology
Content: HL7 2.x for messaging, CCD for document summaries
Vocabulary: LOINC for lab name/observation

Images
Content: DICOM

Administrative Transactions (Benefits/Eligibility, Referral/Authorization, Claims/Remittance)
Content: X12
Vocabulary: X12, CAQH CORE

Quality Measures
Content: Derived from all the data elements above
Vocabulary: Derived from all the data elements above

Privacy and Security
Transport: HTTPS, SOAP/REST
Transport Orchestration: WS*
Authorization/Access Control: XACML

Given that meaningful use needs to be achieved by 2011-2012, it's clear that we cannot rip and replace existing hospital information systems and EHRs. We need to leverage them, upgrade them over time, and install new systems in an incremental fashion. This is really true of any change in healthcare. If we had a greenfield, we would design healthcare delivery, payment, and infrastructure entirely differently. Unfortunately, we do not have a greenfield, we have limited resources, and limited time to achieve healthcare reform, so we need to leverage what we have and evolve it in phases.

HITSP will be reformatting and streamlining its previous work over the next 90 days to support ARRA, the HIT Standards and Policies Committees, and ONC. I hope you agree that the list of EHR data elements above is practical, achievable now, and reasonable.

Tuesday, April 7, 2009

Dispatch from HIMSS

Every year, I walk the floor of HIMSS and summarize the broad trends I see in the industry. Here are my 2009 observations

1. The Stimulus - There's energy and optimism at HIMSS this year caused by the prospect of $34 billion dollars of stimulus funding for Healthcare IT. Since the current healthcare IT annual spend is somewhere between $15-25 billion, this could double the entire industry.

2. The Economy - the euphoria of the stimulus is tempered by the challenging economy - downsizing, wage cuts, and the collapse of 401k's are a stark contrast to the hope of new EHR rollouts.

3. Software as a Service - It's clear that all these new EHRs are not going to be hosted in the offices of rural solo practitioners. Web-based software as a service hosting centers for EHRs are being discussed by many companies - software producers, infrastructure providers and consulting companies. Many server, storage and virtualization suppliers are offering new products to support the Cloud Computing infrastructure needed to support Software as a Service hosting.

4. Security - with the prospect of every patient in the country having an interoperable EHR by 2014, there are increasing concerns about protecting confidentiality. Companies are creating new security tools, new consent management systems, and new audit reporting systems.

5. Open Source - Just as Linux has become mainstream in corporate data centers, open source EHR and HIE products are becoming more mainstream. A group of open source vendors met with CCHIT to discuss their role in the EHR ecosystem.

6. PHRs - with more EHRs comes the prospect of more PHRs to share electronic data with patients. Google announced its Medicare data sharing pilot. A really interesting question to be answered is the role of PHRs in the meaningful use of EHRs. Will EHR to PHR data sharing qualify for the interoperability requirements of meaningful use? To be determined.

7. Appliances for HIE - In previous years, folks exchanging data among stakeholders focused on content - shall we use HL7 2.x or 3.x, shall we use LOINC or SNOMED-CT? This year, the focus has been on infrastructure - how do we transport data securely from one stakeholder to another? A few companies are offering integration engines and health information exchange appliances to address this secure transport requirement. HHS released its CONNECT open source Nationwide Health Information Network gateway, built by 20 members of the Federal Health Architecture team.

8. Home Healthcare Care/Telemedicine - Continua Alliance, GE and Intel have all embraced remote monitoring and home care as one strategy to reduce healthcare costs while improving quality.

9. Performance Measurement and Outcomes - Tools for quality warehousing, business intelligence/reporting, and risk adjustment are being offered by many vendors.

10. Decision Support - As more EHRs are rolled out, we'll need decision support rules and services. Several companies offer order sets, knowledgebases, and decision support web services.

A good show with many innovative interoperability products, especially in the interoperability showcase. It was good to catchup with colleagues and vendors - 24,000 of my closest friends!

Monday, April 6, 2009

Saving the Boston Globe

I've joined a dozen other bloggers in posting this message simultaneously:

"We have all read recently about the threat of possible closure faced by the Boston Globe. A number of Boston-based bloggers who care about the continued existence of the Globe have banded together in conducting a blog rally. We are simultaneously posting this paragraph to solicit your ideas of steps the Globe could take to improve its financial picture.

"We view the Globe as an important community resource, and we think that lots of people in the region agree and might have creative ideas that might help in this situation. So, here's your chance. Please don't write with nasty comments and sarcasm: Use this forum for thoughtful and interesting steps you would recommend to the management that would improve readership, enhance the Globe's community presence, and make money. Who knows, someone here might come up with an idea that will work, or at least help. Thank you."

Monday Review: Softress


This Monday Review is brought to you by Softress body oils.

Nina Birnbaum was dissatisfied with the options available to treat her daughter's eczema. She developed a body oil made from whole, food-grade oils and a blend of antioxidant vitamin C and natural vitamin E. Her company, Softress, Inc., now manufactures a full line of vegan-certified, fragrance-free, preservative-free moisturizing oils for dry, sensitive skin.

I applaud Nina's efforts to create a safe alternative to treat her daughter's eczema. Over the years, doctors prescribed many steroid creams to treat my son's eczema. We used them as directed and he now has white patches on parts of his skin. The allergist said, "Oh that's just permanent loss of pigment due to the steroid creams." Huh??? We weren't told this in advance? Question every cream, oil, lotion you are given to treat your child's eczema. Find the safest product that works.

The Softress line includes:
E-Blend- for care of eczema and extremely dry skin
Deep Moisture- for sensitive skin and dry hair care
Love Your Hair- a natural conditioner/detangler for dry, damaged hair and curly hair
SoftBaby- for soothing baby dry skin and infant eczema
SoftHands- which contains macadamia oil. It is made/bottled separately from the other products.

All products (with the exception of SoftHands) are free of the top eight allergens, including nut oils.

Disclaimer from owner, Nina Birnbaum:
Some people's nut allergies cross-react with sunflower oil, and a latex allergy may cross-react with avocado oil. People with those allergies should patch-test before use. I do offer a full refund to people who find the products don't work for them.

I had the opportunity to sample the Deep Moisture product throughout this winter. When I purchase a moisturizer, I look for one that is fragrance-free and doesn't contain the almond oils, milk proteins and other common allergens found in many products. I also need something that works well.

I find, as perhaps many mothers of food allergic kids find, that I wash my hands- a lot. I worry about cross-contamination in my kitchen. Due to so much hand washing, the skin on my hands is often dry and cracked. Oils seem to work best, but finding one without nut oils has been difficult. The other problem with oils is how it leaves my hands slick and, well, oily. Not helpful for a multi-tasking mother.

Deep Moisture to the rescue. This product literally melts into your skin leaving no residue. I put a squirt or two of the oil on my freshly washed hands, rub them together and I'm off. My hands feel, and look, soft and smooth.

Some of Nina's customers report that her products, when applied to freshly shaven legs, inhibits hair growth, allowing more time between shaving. I love a time-saving product!

Softress products are available on their website at Softress, Inc.'s website

Enter code "FOODALY" for a 15% discount, good until Dec 31st 2009.

For some great information about eczema, check out Nina Birnbaum's personal story.

See the Food Allergy Assistant's site for more information about food allergies.

My Telepresence Experience

I returned to Boston from HIMSS to spend the day with my daughter on her 16th birthday. We had a great day cooking, hiking, and enjoying a fabulous Japanese meal as a family. However, I was also in Chicago for 2 hours, speaking with the press about the Stimulus Bill, Interoperability, and Decision Support.

The press gathered at the Cisco booth on the floor of HIMSS and I welcomed them to my basement via Telepresence. We chatted for an hour with full life-sized 1080p real time video. Truly, there was no difference from sitting in a room together, other than the fact that my basement had a bubbling fish tank and 2 rabbits running around.

My Telepresence experience was different from traditional video conferencing in that it did not feel like a video conference. All the other units I've used in the past have had a small grainy picture with tinny sound, often displaying picture within a picture. Telepresence is just high definition video and audio with the feeling that you are in room with the other participants, not on a video conference.

All the eye contact, gestures, and common courtesy you'd use in an in person meeting are natural in Telepresence. I changed my body position, my eye focus and my voice direction as I spoke to various participants.

The technology worked perfectly over my home Verizon FIOS 20 megabit connection.

I really enjoyed using the technology to connect with HIMSS while being in Boston with my daughter. At 4am I'm heading back to HIMSS for a day of meetings with many stakeholders. I'm working on becoming 100% virtual, but our culture is not quite ready for that!

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