Enhancing Health Information Exchange in Massachusetts

The HIT Policy Committee and its Meaningful Use Working Group will be defining meaningful use very soon. Although I have no inside knowledge of what meaningful use will be, I think it will likely include several elements of health information exchange.

To me, health information exchange is three things

1. Policies for exchange which protect confidentiality, ensure compliance with regulations, and meet the service expectations of stakeholders.

2. Workflow which supports the business processes of payers, providers and patients.

3. A technical architecture which implements the workflow.

To achieve meaningfully useful health information exchange, Massachusetts has recently convened three committees under the auspices of the Eastern Massachusetts Healthcare Initiative. During May and June, we'll complete meetings of our Policy Committee, the Workflow Committee and the Architecture Committee which will take our existing health information exchanges to the next level.

I'm an active participant in these activities and want to share our work in progress with you.

Policy Committee - we're working through complex issues of consent, liability, service levels, and the division of responsibility between the health information exchange and local organizations sending/receiving data. Last Friday, we discussed these issues in detail. Here's the powerpoint outlining the issues and the draft policy for health information exchange we have developed thus far, based on our experience with NEHEN.

Workflow Committee - There are several high priority workflows among our stakeholders including clinical summary exchange, referral management, admission notification, results exchange, and quality reporting. Here's an overview of our workflow activities in progress.

Architecture Committee - In Massachusetts, we've tended to implement a service oriented architecture using CAQH Core Phase II common data transport and XML constructs such as CCD. I'll post the details of our implementation guides when they are complete.

With sound policies, prioritized workflow, and a single architecture including content, vocabulary, and secure transmission standards, Massachusetts will be "shovel ready" for health information exchange supporting meaningful use by this Summer.

Read More

I Had a Brain Freeze, but Brain Thaw Arrived in the Nick of Time

So we spent Memorial Day week-end at the shore. My son is taking Zyrtec daily for seasonal allergies. We ran out of his Zyrtec syrup during the week-end. No problem. We stopped at the closest CVS and picked up more. My brain freeze resulted in my thinking that we should get the children's chewable tablets instead of syrup. As I opened the package, my brain thaw occurred and I read over the inactive ingredients. Duh! I wrote a while back about Zyrtec tablets containing lactose monohydrate. I even sent a letter to them. It went unanswered.

Today I called Zyrtec and chatted with Malika, Zyrtec Customer Service Representative. She confirmed that lactose monohydrate contains bovine milk. She went on to say that the manufacturer of the lactose monohydrate had issued a "Certificate of Suitability." When I asked what that meant, I was put on hold- for 8 minutes. Finally Malika came back and apologized for the long wait. She said, "It contains milk, so those allergic to milk should avoid the product." Okay, I still don't know what a "Certificate of Suitability" is , but I guess it doesn't really matter.

I told her that I wanted to register a complaint that the label doesn't clearly state "Contains Milk" in big bold letters- make that super size letters so even those of us in a brain freeze can't miss it. She apologized and said she would forward my complaint to the appropriate department. Uh, huh- I'm watching...

If you want to register your concern to Zyrtec, call 1-800-343-7805.

Why don't medication manufacturers have to follow the same labeling rules that food manufacturers must follow?

Read More

Cool Technology of the Week

In my recent blog about the Red Flags rule, GreenLeaves commented that biometric checking would help reduce errors by establishing identity and uncovering fraud.

Using biometrics to verify identity seems like a good idea, so I met with Jim Sullivan from BIO-key, a leading provider of biometric solutions.

In the past, I've been reluctant to adopt biometrics because of the expense of buying fingerprint or Iris scanners for each of my 8000 client devices.

However, now that many laptops and hospital ready tablets include embedded fingerprint swipe scanners and that the price of USB fingerprint scanners has dropped significantly, it is realistic to consider biometrics.

BIO-key has developed a next-generation algorithm that reduces the fingerprint to set of calculated unique identifiers. A person�s fingerprint graphic is not the credential; their finger is. BIO-key ensures that only a real finger is being scanned to produce these unique identifiers, making a stolen fingerprint graphic useless to a potential imposter. It's the computed values that are stored when the user's finger is scanned at enrollment, and is later used for comparison with future scans. To me, it's similar to the way NTLM authentication works - there is no need to store or exchange the actual password, it's a mathematical hash of the password that is compared to a stored mathematical hash of the original password. BIO-key allows you to enroll and identify on most of the different fingerprint scanners in the market, allowing an open, heterogeneous fingerprint hardware environment.

There are several interesting ways that biometrics could be used in healthcare:

1. As an alternative authentication method for clinicians instead of having to constantly type a username and password. BIO-key provides a web-enabled fingerprint scanning authentication method that interfaces seamlessly between web applications and an enrollee database or Active Directory. Every authentication, from connecting initially to a secure Wi-Fi hub, to authenticating to Active Directory, to authenticating to web-based or thick client applications, can be done using a finger scan.
2. As a two factor authentication mechanism for secure remote access to sensitive data - instead of a token, you carry your finger with you wherever you go. Note that modern fingerprint scanners include measurement of living tissue, so your finger cannot be stolen and used as an authenticator.
3. As a way to protect patients from identity theft or mis-identification. The first time you register for care, you present your passport and your finger for scanning. On every successive visit, your fingerprint scan is used to verify your identity, without the need to hand-check the paper credentials again.

Some people may think that fingerprints are used to identify criminals and thus be reluctant to use a fingerprint scanner. As noted above, we're not using the fingerprint itself - this is not an FBI comparison to a stored library of fingerprints. Instead, it's comparing the scan of finger to specific computations made on earlier scans of the finger when the patient first registered. Hopefully, this will make patients accept scanning as a positive way to protect their identity instead of a negative "police-like" search of their past.

If you'd like to try this yourself, just get a USB fingerprint scanner or use a laptop with a built in fingerprint swipe reader such as HP, Lenovo, or Dell. Go to http://www.bio-key.com/hitdemo.asp and follow the instructions to download the web client and test the fingerprint enabled applications. Note that it only works in Windows at this time.

A simple way to prevent identity theft and to authenticate web applications using your finger. That's cool!

Read More

Data Center Space in the Northeast

Yesterday I wrote my personal blog for the week, so today's blog is a return the typical issues of a CIO - building and renting data centers in the Northeast.

I was recently asked about a report being published this week on health care data center costs in Boston compared with other U.S. metropolitan areas. The report claims that, although huge opportunities exist for data center providers to house growing amounts of health care data, the high costs of running a data center in Boston and other Northeast cities will drive providers to house their data in low-cost areas in the Midwest.

Here's my view of the needs of healthcare CIOs for data center space in the Northeast.

My sense is that most IT organizations are embracing virtualization which reduces server space needs. However storage needs are increasing 25% per year, consuming more space.

Thus, the demand for data center real estate, on average, will experience modest growth. Healthcare data center space is not likely to cost much more than typical data center space.

The choice of build/owned verses co-located data center space is mostly a function of network connectivity and capital availability.

The breakout of BIDMC data center expenses, not including the operating and capital needed to suppport our applications is roughly as follows:

Space and Utilities 15%
Salaries & Benefits 29%
Elect Wiring/KVM/LAN Cabling/Racks/Etc. 5%
Storage 18%
Tape/Backup 4%
Servers 14%
Monitoring Software 3%
Network 1%
UPS/PDU/CRAC 11%

Moving the data center to the Midwest MAY save on space cost and would likely save on energy. Most of the other costs would be the same whether we were located in Boston or Lincoln, Nebraska. Some costs may actually be higher in the Midwest as we are within driving distance of engineering support centers for some of our OEM's such as EMC. We currently have a favorable space rental rate compared to the square foot cost of hosting facilities in Boston. Consequently, savings for us is not going to be as great as it may be for other companies who use hosted space. Moving the data center MAY also reduce computer operations salaries, but that's questionable and assumes the labor pool is readily available in the Midwest.

I estimate the annual savings for space, utilities, and salaries, in our case, would be $150k to $300k per year. Offsetting this would be increases in wide area networking expenses and, given the distance, there would need to be dual paths for redundancy which would increase the expense. There would be a significant one time expense for the relocation cost. The combination of these could easily overwhelm any projected savings.

Relocating the data center would also require a major project that would absorb much of IT's time thereby causing us to halt or slow down other, more pressing requirements of the Medical Center. There would also be a risk element in that we would be placing our IT assets in the hands of a party we do not directly control except through contract terms and conditions.

Unlike some companies that have national or international presence, we are limited to metro-Boston. The incentives to relocate the data center to the Midwest are not compelling for us.

I predict Boston and Northeast data center space will continue to be well utilized.

Read More

Teen Clinic - HEALTHSPACE!

 The Petersburg Health Department is home to a teen clinic - HEALTHSPACE!

If you're a teen with a health concern, just stop by on Tuesday or Thursday and speak to a health care professional. No appointment necessary.
Location: Petersburg Health Dept., 301 Halifax St.
Hours: Noon to 6:00pm, Tuesday and Thursday
Phone: (804) 862-7600

Read More

The Number 5

In the movie "The Number 23", the main character played by Jim Carrey is obsessed with the idea that all incidents and events are directly connected to the number 23, some permutation of the number 23, or a number related to the number 23.

I'm not obsessed, nor do I have OCD in any way, but much of my life is neatly organized into groups of 5.

Why 5?

I find that 5 is the maximum number of tasks I can do simultaneously without losing track of the details. Here's my framework for my career and personal life

Career
1. BIDMC - As CIO of BIDMC, I have 5 direct reports
a. Clinical Systems
b. Financial Systems
c. Infrastructure
d. Knowledge Services (includes medical library and all online
e. Media Services

2. Harvard Medical School - As CIO of HMS, I have 5 direct reports
a. Administrative IT
b. Educational IT
c. Informatics
d. Infrastructure
e. Research IT

3. Standards- Chair of HITSP and Vice-chair of the HIT Standards Committee (Although the work we're doing includes 5 Tiger Teams,that was not a conscious choice on my part!)

4. Healthcare Information Exchange - Chair of NEHEN and CEO of MA-Share (MA-Share and NEHEN merger will be finalized in June) which supports 5 different use cases for data sharing.

5. Advisory Councils - I have 5 advisory positions
a. Food and Drug Administration Subcommittee on IT
b. Social Security Administration Future Technology Advisory Panel
c. Anvita Health Board of Directors
d. Epocrates IT Advisory Council
e. Robert Wood Johnson Foundation National Advisory Committee for Project HealthDesign

Personal Life
1. Family - (wife, daughter, mother, father and me)
2. Home and Garden (my Thursday blog will describe my 5 small gardens)
3. Japanese Flutes (I have 5 instruments)
4. Outdoors - (Hiking, Kayaking, Climbing, Running, and Biking)
5. Writing (blogs, IT journals, academic publications, popular press, lectures)

Each night before bed, I review my 5 career organizations and my 5 direct reports in each of my jobs to ensure I've resolved all the issues of each day. By always balancing five tasks, five people, and five projects in every area, I maximize my breadth without sacrificing the depth of my attention span.

There's no need to worry about my sanity, the number 5 is just a convenient mnemonic and not a pre-requisite for getting through the day. And now it's time to prepare for my 5 meetings tomorrow...

Read More

As a Guest, I'm a Pest

As a follow-up to last week's post, "Hostess With the Mostest...Stress That Is", I must note that being a guest isn't easy either. This is something many of you pointed out in your recent comments.

Both Jes and Sabrina K. commented that they think it's harder to be a guest in someone else's house. They prefer to host because they have more control over what foods come in.

Nowheymama keeps everyone out of her kitchen to ease her stress. ChupieandJ'smama is already stressed about hosting an upcoming company Christmas party where traditionally shrimp and crab legs are served. Infant Bibliophile just starves her houseguests rather than dealing with the stress. Col has a list of rules for her guests. Liz uses red stickers to identify unsafe foods in her house and Karen keeps very few unsafe items in her kitchen.

This week-end we brought most of our own food when we visited family. I baked up a storm before we left- chocolate chip cookies, granola bars, doughnuts and chocolate cake. I marinated chicken, prepared burgers, precooked pancakes and made bread. We were well prepared and yet still hit a few stumbling blocks in our host's kitchen.

Just a few of my rants:
"Don't use that olive oil! It's in an old pickle jar and who knows what else that jar has been used for."
"Don't touch those pretzels. I know they look friendly, but they're stored in a chocolate covered raisin jar."
"I know you're trying to help, but please don't cut my son's roll with the knife that just cut those bakery rolls."
"No, don't put those birthday candles in my safe cake! Do you have any idea where those candles have been before?!"

We all survived the week-end, but I think this glimpse into each other's lives made us all grateful to go back to our own kitchens. I know I hugged my toaster as soon as I got home!

Read More

A Personal Reflection on Standards Harmonization

As HITSP prepares for the demands of ARRA by reorganizing its work around meaningful use rather than use cases, here is my view of the state of standards harmonization in the US. This is my personal opinion, not a statement from HITSP or ONC.

1. Medication management and e-prescribing

This area is very mature and widely implemented.

NCPDP Script 10.5 is the right messaging standard to support e-prescribing workflow in ambulatory and long term care settings.

The National Library of Medicine's RxNorm is the right vocabulary to specify medication names.

The Food and Drug Administration's Unique Ingredient Identifier (UNII) is the right vocabulary for chemical substances and is especially useful in allergy checking.

Structured SIG, although still evolving, is good enough to describe the way to take a medication.

The Veterans Administration's National Drug File Reference Terminology (NDF-RT) is the right vocabulary for medication class and is especially useful in drug/drug interaction checking and formulary enforcement.

There are few controversies in the medication standards area. The only outstanding issues are the fact that some of these standards such as Structured SIG and RxNorm are relatively new and continue to evolve.

2. Laboratory

HL7 2.51 is good enough for results reporting to EHRs, public health, and biosurveillance.

LOINC is the right vocabulary for lab test names.

UCUM, although very new, is a reasonable vocabulary to describe units of measure.

The only controversy around lab is the timing of implementation, given that thousands of commercial labs in the US need to update their interfaces to support HL7 2.51, LOINC and UCUM. Of these, standardizing units of measure with UCUM is probably the most controversial, given that using UCUM is new for lab stakeholders. I've recently spoken with healthcare IT leaders from other countries and all agree that standardizing units of measure for labs is a priority and should move forward.

3. Clinical Summaries

Just about all stakeholders agree that clinical summaries (problem list, medication list, allergy list, diagnostic test reports, discharge summaries, other documents) should be represented in XML.

The question is what flavor of XML - HL7's Clinical Document Architecture or ASTM's Continuity of Care Record.

HITSP harmonized these two approaches with the HL7 Continuity of Care Document (CCD).

The major controversy in the area of clinical summaries is the nature of the XML format and schema. Some have described the CDA as overly complex XML. I've also heard that some believe CCR's XML could be improved. My hope is that all stakeholders continue to work together to converge on a single, simple XML representation of a clinical summary that works for everyone and is more similar to the typical XML structures used widely on the web.

4. Quality Measures

The National Quality Forum's HITEP efforts have fostered a new way to represent quality measures in terms of a collection of data types. Additional work needs to be done to uniformly map these data types to specific standards. It's likely that the same standards mentioned above for medications, laboratory and clinical summaries will be suitable for transmitting quality measures to data marts.

The only controversy in the world of quality measures is the need to rewrite existing measures in terms of EHR data types. The National Quality Forum will be the catalyst for such a project.

5. Common Data Transport

The above discussion on medications, labs, summaries and quality has been about content and vocabularies, not the secure transmission of data from place to place. How should transport work for all healthcare data exchange?

Just about everyone agrees that the internet/TCPIP/HTTPS is the right approach. However, there are controversies about the other standards to be used - enveloping, authorization/authentication, and architecture.

Some have proposed simple RESTful web services. Some have suggested that SOAP with WS* constructs provides a more solid security framework.

In Massachusetts, we've used CAQH CORE Phase II with SOAP over HTTPS and X.509 certificates. We do nearly 100 million transactions a year with this approach and it works very well.

HITSP will work on harmonizing common data transport as part of its 2009 Extensions and Gaps efforts. It will harmonize the transport work done to date, the efforts of the NHIN pilots and the requirements of the Common Data Transport Use Case recently released to HITSP by ONC.


In general, how do we resolve remaining standards controversies by the end of 2009 when a interim final rule must be finalized per ARRA? Here's my understanding of the process:

1. The HIT Policy Committee will propose a set of priorities for "meaningful use", likely in the next 60 days. The National Coordinator will deliver these to the HIT Standards Committee.

2. The HIT Standards Committee and its 3 workgroups (Clinical Operations, Clinical Quality, Privacy and Security) will determine what existing accepted /recognized standards best support the HIT Policy Committee's priorities, likely in the next 90 days. The HIT Standards Committee will draw on the work of harmonization organizations (including HITSP), standards development organizations, and implementation guide writers. The Standards Committee will also engage NIST for standards testing.

3. The National Coordinator will review this work and if it is appropriate deliver it to the Secretary of HHS for acceptance and publication in the interim final rule.

There will be several periods of public comment and administrative review along the way.

What will HITSP's role be in this process? Initially it will provide expert testimony about harmonized standards to the HIT Standards Committee. In general, HITSP responds to the priorities established by the Office of the National Coordinator. It is independent of any particular administration/political party. If there is a need to approach priorities in a different way, HITSP will align to do that, just as it has with the ARRA focused efforts of the past 60 days.

Read More

Friday Feature: The Food Allergy Coach

Meet Kim Hopkins, founder of Food Sensitivity Resources, a website dedicated to helping people live full lives despite having food allergies, intolerance, and sensitivities. Learn about Kim and how she coaches people with food issues through our interview below.

What is your food allergy background?

I thank my nephew. He has autism, and was really the "whistle-blower" in our family regarding food challenges and their effects. It was through my sister's research on his behalf that we all learned about our own food challenges.

I have always suffered from environmental allergies, asthma, and being overweight. At one point, I was prescribed two inhalers, two nasal sprays, two allergy pills, and three weekly allergy shots! As a kid, I can remember leaving school via ambulance several times because I could not breathe. I had chronic sinus infections that would return as soon as my course of antibiotics was finished.

In 2001, I had both a primary care doctor and an allergist. When I told them that I was experiencing scary symptoms after eating, they both said a version of "well, next time you need blood work done, we'll check for food allergies." Not good enough. Needless to say, that's the last time I saw both of them.

I educated myself and did an elimination diet on my own. I found that foods containing gluten were the culprit. This was later confirmed by conclusive testing: Celiac Disease. Once my body began to recover, I no longer needed the inhalers, nasal sprays, allergy shots - I was just using one allergy medication.

Flash forward a few years - I was managing the gluten issue beautifully but began experiencing unpleasant symptoms. My holistic doctor made many suggestions. When nothing improved, she said, "do some research." ...and off I went, determined to get myself well. I discovered information about Candida and the work of Dr. Crook. I literally cried when I read his book because I knew I had found answers - finally! I embarked on another elimination diet and found that I needed to add sugar, cherries, peanuts, and tree nuts to the list of things to avoid. Soon after these discoveries, I kicked my one allergy medication to the curb - 15 years of taking something to help with allergy symptoms and now I needed nothing! It was quite liberating! This began a new chapter of getting educated and adjusting - I have a sneaking suspicion that it won't be my last...

What are you passionate about in the food allergy field?

I am passionate about education and proper diagnoses. I meet many people who are experiencing poor health effects that can likely be traced back to food sensitivities. I want to help spread the word about the symptoms and what to do. I am a big proponent of the elimination diet to help discover hidden food sensitivities because I have seen people recover from complex symptoms by figuring out which foods they need to avoid.

I also want to continue the quest to make this world an easier place for those with food challenges to live a full life. This includes targeting the food service industry, schools, work places, recreational activities, getting involved in advocacy activities to promote and fund research...you name it!


You are certified in the "Practical Application of Food Allergy Guidelines"? Can you tell us more about this certification?

To obtain certification, I completed a course that covered information about food allergies, symptoms, testing, and their relationship to common health conditions. Other topics included dietary restrictions by food allergy type and recommended substitutions, chemicals in food supply that can cause reactions, meal planning guidelines, as well as emergency planning guidelines. I believe that having this foundation of knowledge assists me with my personal coaching and consultation practice.

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

I have formalized my efforts to assist others coping with food challenges by creating a website, Food Sensitivity Resources. Through FSR, I offer personal coaching for individuals and families, which can include phone calls, face to face meetings, food shopping trips, cooking together, practice with advocating for yourself at restaurants, emotional support...whatever is needed to assist with making necessary dietary adjustments as easy as possible. I also offer consultation to schools and businesses to help them to "get it" so they can better serve the growing population of people with food challenges.

Recently, I began a blog, The Food Allergy Coach, to help pass on up-to-date information in this rapidly changing field, and to share my continued personal journey of discovering food sensitivities and restoring good health.

Ultimately, I would like to replicate what only one other community in the world (in Germany) has done: create an entire community that is allergy-friendly and market this to attract both tourism and new residents.

What are your favorite food allergy friendly food staples?

I would say plain, organic yogurt - I eat it just about every day. I try to be good about always having cut up fresh veggies on hand. I make my own sausage patties, which I devour any time of day. Sweet potatoes in any form - roasted, french fries, chips - so yummy! My #1 favorite treat right now is Luna & Larry's coconut-based ice cream made with agave nectar....YUM! For baking with rice flour, I have found the best brand to be Authentic Foods Brown Rice Four Superfine. It is finely ground, which makes the texture perfectly undetectable as being gluten free.

What are some of your other interests/hobbies?

I love going to the gym, taking walks, riding bikes, and playing tennis. I am a voracious reader. I am fortunate to live near the beach, so I try to get there for some peace and quiet as often as I can. My husband and I are both major foodies - we enjoy cooking, baking, and entertaining friends and family.

Check out Kim's site at Food Sensitivity Resources. Kim also writes a blog as the Food Allergy Coach.

Read More

Cool Technology of the Week

Massachusetts Data Protection regulations require that data on portable devices be encrypted. As I've written about previously, we have encrypted all our laptops with McAfee Safeboot/Endpoint

However, it's commonplace for folks to backup their data on removable USB drives. How can we ensure portable drives are protected?

The answer is hardware encryption. I tested the Maxtor BlackArmor 160GB Encrypted Portable Drive and it's my cool technology of the week.

Here are the specs:

� Hardware-Based Full-Disc Encryption: Prohibits access without a password, no exceptions-not even a professional data recovery service can access the data without the password.

� KeyErase�: Permanent removal of encryption key allows secure redeployment of the drive.

� USB Powered: Powers your drive and ensures fast data transfer-

� 5400RPM, 8MB Cache Buffer: For fast drive performance and fast access to your files.

� Backup Software: Maxtor Manager software lets you easily set your automated backup schedule, sync to multiple computers, and restore files.

� Capacity (Model #): 160GB (STM901603BAA1E1-RK)
� RPM: 5400
� Cache Buffer: 8MB
� Interface: USB 2.0
� Bus Transfer Rate: USB 2.0 480MB/sec
� Dimensions: 5.17" H x 3.32" W x 0.67" L [131.2 mm x 84.2 mm x 16.9 mm]
� Weight: 7.20 oz [204.12 g]
� Warranty: 5 years

The software provided autostarts upon USB connection and sets the drive password. It only runs on Windows, so I had to test the device on one of our clinical subnotebooks - a Dell laptop running XP.

The drive mounted without a problem, queried for a password, and enabled me to place data on the device without error. Each time I reconnect the device it queries for my password. Without the password, the data is completely unreadable - I cannot even see the file names.

A portable, inexpensive, removable, hardware encrypted data store that complies with all current federal and state data protection regulations.

That's cool!

Read More

Kayaking the Charles River

From Spring to Fall each year, I kayak 6 miles a day on the Charles River between route 128 and the Moody Street Dam.

My general rule of thumb is that I kayak when the sum of water temperature plus air temperature is greater than 120. The risk of hypothermia is much less when the water temperature is above 55 and the air temperature is above 65. This usually occurs sometime in May and lasts until October. Today's water temperature was 65 and the air temperature was 75F with a very light wind - perfect conditions.

The route I take passes through the "Lakes District" of the Charles - a wide, shallow, and particularly beautiful stretch for flatwater paddling.

I generally kayak between 5:30-6:30pm, stopping at the Charles River Canoe and Kayak boathouse on my way home. It's a great way to get some exercise and decompress - I can work a full day, kayak, have dinner with my family, and the continue to read and write until bedtime.

The early evening on the Charles is a perfect time to view widelife - Great Blue Herons, Trumpeter Swans, American River Otters, Snapping Turtles, and enormous Carp. The river is different every time I kayak with variable weather, changing wildlife, and new people. Today I did a rescue of a mother and daughter from Montreal who tipped their kayak in the deepest part of Charles. We did a T-rescue and all is well.

The boat I prefer is the Epic Kayaks V10 Surf Ski, a fast 17" wide boat that's a racing and fitness kayak, just unstable enough to keep the trip very challenging. In windy or turbulent conditions, I'll pick the Epic 18X. Here's my guide to choosing a kayak.

The other advantage of daily kayaking is the calorie burn - greater than 500 calories per hour.

Incredible sights, a relaxing river, 2500 calories of aerobic exercise, and an ever-changing riverscape. Highly recommended!

Read More

The Adventures of an IT Leader

In January of 2003, F. Warren McFarlan and Robert D. Austin of Harvard Business School wrote a great case study about the CareGroup Network Outage.

One of my blog readers, Brian Ahier, suggested that I read the new book by one of the same authors, Robert D. Austin, called "The Adventures of an IT Leader" .

From the HBS website:

"Becoming an effective IT manager presents a host of challenges�from anticipating emerging technology to managing relationships with vendors, employees, and other managers. A good IT manager must also be a strong business leader.

This book invites you to accompany new CIO Jim Barton to better understand the role of IT in your organization. You�ll see Jim struggle through a challenging first year, handling (and fumbling) situations that, although fictional, are based on true events.

You can read this book from beginning to end, or treat is as a series of cases. You can also skip around to address your most pressing needs. For example, need to learn about crisis management and security? Read chapters 10-12. You can formulate your own responses to a CIO�s obstacles by reading the authors� regular 'reflection' questions.

You�ll turn to this book many times as you face IT-related issues in your own career."

Imagine my surprise when I turned to page 48, where the main character Jim Barton is listening to the radio and hears a mini-biography about "a critical care physician who still took his turn in the ER; PhD from MIT in bioinformatics; former entrepreneur who had started, grown, and sold a company while in medical school; and former student of a Nobel Prize winning economist. He was the author of four books on computer programming and had written the first version of many of the hospital's software applications. This CIO earned kudos for his transparency during a network crisis...."

Thanks to Robert Austin for my first appearance in a "novel"!

It's a great book with many practical suggestions about IT leadership, governance, and budget allocation.

In the spirit of the book's Chapter 4 on budgeting, I'm sharing the document I used last week to justify my FY10 capital budget. I always present a narrative written in non-technical terms which supplements my budget spreadsheets by highlighting quality, safety, return on investment and strategic alignment. I hope you'll find the format useful for defending your own capital budgets.

When presenting my operating budget, I use benchmarks from HIMSS, the American Hospital Association, and the Association of American Medical Colleges. I benchmark growth of the entire organization and the growth of IT. Currently the IT organization is 1.78% of the BIDMC operating budget. BIDMC has grown by 38% over the past 5 yeas, but IT staffing has stayed constant, supporting growth in demands and technological complexity by working harder and smarter. IT is lean and mean. In tough budget times, presenting data rather than emotion is the best way to objectively justify a budget.

Read More

The Hostess With the Mostess...Stress, That Is.

I fear that I'm not a very good hostess. If we have people over for a meal, I'm usually fine. I can prepare the meal in advance and take my normal kitchen precautions. The problem arises when we have guests who stay for a few days over multiple meals. Suddenly my kitchen isn't my own. Unfamiliar food arrives and concern over cross-contamination boils over.

"STOP! You can't dip that knife back into our dairy free butter after using it on that unsafe (read: poisonous) bread."

"NO!" Don't cut into that dairy, egg and nut-free cake with that tainted knife you just used on that unsafe (read: poisonous)angel food cake.

"WAIT!You can't leave crumbs from that peanut butter and jelly sandwich (read: poisonous)all over the table. And please- go wash you hands- immediately. And I want to hear you sing "Happy Birthday" while you're doing it- twice!"

I can't help it. My frantic tone bubbles over. Of course if I keep this up, I won't have to worry about it because no one will want to come visit!

Now, all of you families with food allergies, you get it. You're welcome anytime.

How do you deal with guests in your kitchen?

Read More

The ONC ARRA Implementation Plan

Yesterday, ONC released its implementation and operating plan in fulfillment of the 90-day deadline established by Div. A, Title XIII of ARRA.

The plan is posted to the HHS Recovery Website.

Here are a few highlights:

$24 million is budgeted for enhanced privacy and security including $9.5 million for the Office of Civil Rights and CMS for auditing and for complaint resolution.

$20 million is budgeted for NIST to test technical standards and establish a conformance testing infrastructure.

$300 million is allocated for Regional Healthcare Information Exchange, but no details are provided about timelines for distribution.

The plan for Standards is consistent with the charter of the HIT Standards Committee - HHS shall adopt and publish an initial set of standards, implementation specifications, and certification criteria by December 31, 2009. Today in the Federal Register, you'll find a Notice of the HIT Standards Committee Schedule for the Assessment of HIT Policy Committee Recommendations.

To refine the Federal HIT Strategic Plan, ONC will develop a draft update, receive input from stakeholders, review the impact on other projects, adjust the operating plan as needed, and publish the updated plan on the HHS website by December 31, 2009.

Additionally, a notification for funding availability for the regional extension center grants will be published by the end of FY 2009. Awards are anticipated to be made in early FY 2010.

And of course, meaningful use will be defined soon. HHS is developing milestones for major phases of the program�s activities with planned delivery dates.

With each passing day, more and more details of the new plan are published at a remarkable pace. The magnitude of the work ahead for ONC is summarized nicely by the document

"With the arrival of the new National Coordinator, decisions about how to best address standards development and harmonization, the certification and testing processes, privacy and security policy development, issues around governance, workforce training, and education for health care providers and consumers will be made. "

Read More

Monday Review: Beyond a Peanut Flashcards

When my kids were really young, they loved flashcards. We used alphabet cards to learn letters and number cards to learn simple math. One enterprising mom has created special flashcards to teach people how to stay safe with food allergies.

Dina Clifford created the cards after her children were diagnosed with a peanut allergy. This small packet carries a ton of information about reading labels, cross contamination and carrying emergency medications.

The cards have four color-coded borders. Green cards show foods or situations that are relatively safe for someone who is peanut or nut allergic. They stress caution and introduce the idea of cross-contamination. Red cards show foods or situations that have a greater risk for someone with a peanut or nut allergy. Yellow cards show potential danger and are designed to create awareness. Cards outlined in blue contain safety information to help people with any type of food allergy.

"What a great idea for young kids!" was my initial thought when I looked through the flashcards. As I went through them again, I started thinking about how helpful these cards would be for grandparents, caretakers, daycares, teachers and others who have contact with peanut and nut allergies. They are easy to read and understand and offer a quick way to educate others about food allergies.

Thank you, Dina!

Check out the cards at Beyond a Peanut.com. I'm thrilled to report that Dina is working on Dairy cards next. Stay tuned for that announcement.

Read More

The Red Flags Rule

You may have seen the recent headlines "FTC delays Red Flags Rule implementation until August 2009". What is the Red Flags Rule and how does it relate to healthcare?

The FTC has a great website that it explains it all in detail.

Basically, the FTC requires most clinical offices, hospitals, and other health care providers to develop a written program to spot the warning signs of identity theft - �red flags�

If a patient's name on a photo ID and on their insurance card do not match, that's a red flag.

If a patient visited last week as John Smith but today is Fred Jones, that's a red flag.

If patient seems to travel from provider to provider seeking numerous expensive treatments, that's a reg flag.

The law was initially designed to cover creditors and it seems odd for healthcare providers to be considered creditors. The FTC defines a creditor as anyone who enables the customer to carry a balance after services are rendered. Unless a clinician asks for payment upfront (all balances not covered by insurance), the clinician is a creditor.

The FTC will be begin enforcement August 1, 2009, so it's important to develop policies and procedures to address red flags in healthcare settings.

What is BIDMC doing?

We are actively working to develop procedures and an educational plan. We created an interdisciplinary group that includes IS, Compliance, Finance, Patient Financial Services, clinicians, Human Resources , Ambulatory Services, Health Information Management, and others to examine Red Flags, but also the broader issues of HITECH/ARRA privacy provisions, and new Massachusetts Data Protection regulations. First, we will finish our Red Flags program and implement it, then we will move on to working on the other issues. We have not finalized our specific policy, but have already reported to the Board of Directors and to senior leadership about the issues and the work we are doing. As soon as the policy is finalized, I will post it on my blog.

If you have not begun a program to address compliance with the Red Flag rule, now is the time!

Read More

The First Meeting of the HIT Standards Committee

Today, Jonathan Perlin and I ran the first meeting of the new HIT Standards Committee. The members are:

Jonathan Perlin, MD, Chair
Healthcare Corporation of America

John Halamka, MD. Vice-Chair
Harvard Medical School

Dixie Baker, PhD
Science Applications International Corporation

Anne Castro
BlueCross BlueShield of South Carolina

Christopher Chute, MD
Mayo Clinic College of Medicine

Janet Corrigan, PhD
National Quality Forum

John Derr, R.Ph.
Golden Living, LLC

Linda Dillman
Wal-Mart Stores, Inc.

James Ferguson
Kaiser Permanente

Steven Findlay, MPH
Consumers Union

Douglas Fridsma, MD, PhD
Arizona Biomedical Collaborataive 1

C. Martin Harris, MD, MBA
Cleveland Clinic Foundation

Stanley M. Huff, MD
Intermountain Healthcare

Kevin Hutchinson
Prematics, Inc.

Elizabeth O. Johnson, RN
Tenet Health

John Klimek, R.Ph.
National Council for Prescription Drug Programs

David McCallie, Jr., MD
Cerner Corporation

Judy Murphy, RN
Aurora Health Care

J. Marc Overhage, MD, PhD
Regenstrief Institute

Gina Perez, MPA
Delaware Health Information Network

Wes Rishel
Gartner, Inc.

Richard Stephens
Boeing

Sharon Terry, MA
Genetic Alliance

James Walker, MD
Geisinger Health System

We began the meeting with introductory remarks from Dr. Blumenthal. He emphasized the need to improve care quality, efficiency, and the scope of healthcare coverage. He noted that technology is a tool that facilitates meaningful use and leads to better care. The goal is better health, not implementation of IT for technology's sake.

Jodi Daniel provided us with important statutory background on the committee. Here are few key points from her presentation and the discussion which followed

1. The purpose of the committee is to recommend standards, implementation specifications, and certification criteria to the National Coordinator for the electronic exchange and use of health information. The committee is not limited to standards selection, it covers the process from end to end - standards, implementation, and certification criteria. It will gather input from standards harmonization and development organizations, implementation guide writers, and certifying organizations to make recommendations which enable data exchange in support of meaningful use.

2. There are 8 areas of policy focus
-Technologies that protect the privacy of health information
-A nationwide health information technology infrastructure
-The utilization of a certified electronic record for each person in the US by 2014
-Technologies that support accounting of disclosures made by a covered entity
-The use of electronic records to improve quality
-Technologies that enable identifiable health information to be rendered unusable/unreadable
-Demographic data collection including race, ethnicity, primary language, and gender
-Technologies that address the needs of children and other vulnerable populations

You'll see a great deal of discussion in the HIT Policy and Standards Committees about these issues. These 8 areas are our guiding principles!

3. The HIT Standards Committee will have two standards adoption processes
- expedited, in support of the statutory deadline for HHS to publish an interim file rule on initial standards, implementation specifications and certification criteria by 12/31/09. For this process, we'll leverage the already approved/recognized standards.

- normal, the committee will receive guidance from the HIT Policy Committee and typically within 90 days will make recommendations. Note that these recommendations may include naming standards, identifying gaps, and asking standards harmonization/development organizations to do further work.

4. NIST will serve a role to test the standards. To clarify, this work is to ensure the standards are appropriately documented and technically adequate for their intended purpose. NIST will not certify products - that will be left to certification organizations.

5. The summary of the entire process is illustrated in picture above.

We then discussed the types of data exchanges which might constitute meaningful use. ONC and HHS have not yet provided official guidance on meaningful use, so these are contingencies - our best guess as to the data exchanges likely to enable meaningful use.

Clinical Operations - ePrescribing/medication management, lab ordering/resulting, clinical summary exchange (problem list, medication list, allergies, text based reports including op notes, diagnostic testing reports, discharge summaries)

Quality - Process, outcomes, treatment plans, medical decisionmaking, health behaviors

Security - Transport, secure messaging, authentication, authorization, auditing

We elected to form three working groups to focus on these areas. These groups will conduct phone meetings and include additional experts as needed.

In the discussion that followed a few major themes emerged:

a. We need a high level roadmap of milestones to ensure we meet our statuary deadlines for initial deliverables in time for the 12/31/09 interim rule.
b. We also need a roadmap which takes into account the other mandates/compliance requirements already imposed on healthcare stakeholders such as ICD-10 and X12 5010. We need to ensure our clinical work is in synch with administrative data exchange activities already in progress.
c. Although we should provide for the exchange of basic text, we should strive for semantic interoperability whenever possible, using controlled vocabularies which are foundational to decision support and quality reporting.
d. We should set the bar for interoperability higher than the status quo but also make it achievable, realizing that rural providers and small clinician offices have less capabilities than large academic health centers. We'll need to retrofit many existing systems - healthcare IT is not a greenfield and thus we need to be realistic about the capabilities of existing software, while also encouraging forward progress and innovation.
e. Meaningful use will change over time. Data exchange and the standards we select must evolve. To ensure successful adoption throughout the industry, our work must be continuous incremental progress with phased adoption of standards.

I will serve as Chair of HITSP and Vice-Chair of the HIT Standards Committee simultaneously, coordinating communication between these two organizations. I look forward to the work ahead.

Read More

Closing out Food Allergy Awareness Week

Don't forget the Food Allergy Twitter Party at noon and 10:30 pm (Eastern Time) today! Go to tweetgrid.com and type in #foodallergy.

As we wrap-up Food Allergy Awareness Week, check out this list put together by Linda Coss. She's right on target. In light of our experience this week, I must add a #11:

Better Methods to Diagnosis Food Allergies- skin tests are unreliable in most allergenic children. Blood tests give too many false positives. Food challenges are filled with subjective evaluation and are traumatic for the allergic person and their family. We need some kind or x-ray or MRI-type machine to scan for food allergies in a non-invasive way.

Is that too much to ask?

Here's Linda's list...

Top 10 Things Parents of Children with Life-Threatening Food Allergies Want

By Food Allergy Author Linda Coss

#10: Delicious and Easy Recipes – For those who must eliminate multiple and/or common ingredients, cooking can be an enormous challenge.

#9: To Be Able to Easily Dine Out – We understand that it is not easy to prepare allergen-free food in the typical busy restaurant kitchen. But it would be nice if we could easily get correct answers regarding what’s in the food.

#8: Nut-Free Flights – Airlines cannot control the food brought on board a flight by their passengers, but why must they serve little bags of peanuts? How about crackers, pretzels, raisins, licorice, tortilla chips, or just about any other popular snack food?

#7: Empowered EMTs – In many parts of the country emergency medical technicians do not carry – and are forbidden from administering – potentially life-saving shots of epinephrine. This is ridiculous.

#6: Appropriate ER Protocols – Because up to 40-50% of severe reactions are biphasic, those who go to the hospital for treatment should always be kept under observation for at least 5 hours. Unfortunately many emergency rooms discharge these patients as soon as they first stabilize.

#5: Understanding – We want the people in our lives to understand that we are not a bunch of paranoid hysterical oddballs who are making all of this up for the purpose of calling attention to ourselves and our children. Life-threatening food allergies are a very real condition. And yes, we really do have to take a lot of precautions to keep our kids safe.

#4: Knowledge – Currently the only treatment for life-threatening food allergies is complete avoidance of the offending allergens. Since food, and food residue, is everywhere, parents want to know exactly how to accomplish this seemingly impossible task. What steps do they need to take? What hidden dangers do they need to avoid?

#3: Clear Labels on Packaged Food Products – If there is a chance that a product may contain an allergen that is not included in the ingredient label, the package should say so. But if not, companies should not put “may contain” verbiage on the package.

#2: Safe School Environments – Our kids are not learning disabled and do not need “special education.” But they do need a school environment that is not covered with allergenic food residue, and teachers who are prepared to recognize and treat an allergic reaction.

And the number one thing parents of children with life-threatening food allergies want?

Drum Roll.....

#1: A Cure – Most of all, we want a cure. A real cure – the type of cure that would result in our children being able to eat whatever they wanted to eat, without any risk of an adverse reaction.




Ms. Coss is the author of “How to Manage Your Child’s Life-Threatening Food Allergies,” as well as two popular food allergy cookbooks, “What’s to Eat?” and “What Else is to Eat?” – both of which provide recipes for cooking without dairy, egg, peanut or tree nut ingredients. All three books are available at www.FoodAllergyBooks.com, at Amazon.com, and at various retailers nationwide.

Read More

More Vegan Dining

Over the past two weeks I've been traveling up and down the Northeast Corridor from Boston to New York City to Philadelphia to Washington for various meetings related to healthcare IT. When I arrive in a city and check into a hotel, I Google "vegan" followed by the city name. I scan the Google map that appears and walk to the most appealing vegan restaurant nearby. Here are a few of my recent finds:

Philadelphia
Mi Lah is a great mix of oriental vegan foods from Cambodia, Japan, and Thailand as well as classic ethnic dishes such as Greek butternut squash moussake and African peanut stew. I had the Cambodian Amok with spinach, eggplant, and tofu in coconut lemongrass sauce. Great service, a warm atmosphere, and an all vegan menu.

Horizons is an internationally famous vegan restaurant specializing in Mediterranean flavors. I highly recommend the tempeh and seitan dishes.

I recently had a wonderful evening with Dr. Sidney Zubrow and his team from Philadelphia Hospital. We dined at the classic steakhouse in Philadelphia, The Prime Rib. A steakhouse for a vegan? Surprisingly, steakhouses such as Morton's, Capital Grille, and The Prime Rib have great vegan side dishes including fresh broccoli, green beans, roasted tomatoes, spinach, and roasted potatoes. I order everything steamed and without butter or any sauce.

Washington DC
My favorite vegan restaurant in Washington is Vegetate near the Convention Center. The menu is divided into three sections: bites, small plates and large plates. Great small plates include golden beets, spring vegetable shepherd's pie, and seasonal salads. Great large plates are Sesame Crusted Tofu and Seasonal Vegetable Risotto.

I've not had much experience with Mezzes, small plates of Eastern Mediterranean food (similar to Spanish Tapas). Zaytinya is a fabulous restaurant with many vegan entrees. I had great humus, eggplant, couscous, and mushroom dishes. The staff is very vegan friendly and even brought me fresh cucumber slides for dipping instead of pita, which is made with dairy.

If you find me in a vegan restaurant sitting alone, you'll notice that I'm photographing every course on my Blackberry. I email them to my wife in real time, so that we can enjoy dinner together, even when I'm hundreds of miles away.

Read More

Food Challenge: A Distress Signal

I'm still feeling damaged as I write this post. The trauma of Monday’s food challenge still lingers. It began innocently enough with the allergist saying, “Let’s do a food challenge for egg.”

Great idea, thought the parents. Our nine-year old called the scheduled challenge “the day I’m going to die”.

It’s hard to explain to a child that they should eat a food they’ve been told could make them very sick. We really worked hard to manage his anxiety. We’d been through food challenges with him before, but he’s too young to remember. We explained, and the doctor re-explained, the process. A tiny amount of egg would be given, with increasing amounts over five ingestions. We would wait 20 minutes between each ingestion to see if there would be a reaction.

The hard part was separating the anxiety symptoms from physical symptoms. The first level- no problem. After the second ingestion, he asked if his tongue was swelling. We said no, doctor said no, we proceeded. On to level 3. He asked if there was something on the side of his lip. He thought it felt funny. Nothing there. Proceed to level 4. He said it was hard to breathe. We called the nurse. Breathing fine. His heart rate was up, but everyone thought that was due to anxiety. For the final ingestion, he had to eat the rest of the egg. There were tears and “I hate this. I don’t want to do this.” Doctor came in and said that all was going really well and she expected he’d be able to eat eggs on a regular basis. He forced it down and we waited. A minute later, he vomited a little. Everyone studied the projectile and determined it was mucous. No problem...for a few minutes.

Things began to go downhill and then gathered a fierce pace for a fast descent. He started scratching his back. A little red, no problem. A few minutes later, there was a hive. We wait. Soon, another hive on his stomach. The nurse brought in Benadryl. We wait. Soon he began scratching furiously- all over- and said he felt like he was going to be sick. His skin turned bright red and become rough. Eczema everywhere. He looked really bad. Is there anything more painful than watching your child suffer?

The doctor gave him Zyrtec and a steroid. Minutes later, violent vomiting. The egg came up, but so did the medicine. Apparently the Benadryl had enough time to start to work because over the next hour the skin symptoms started to recede a bit. After four hours with strict instructions to avoid egg, we went home. We had more steroids and antihistamines to give throughout the next 12 hours.

Amazingly, he looked like himself again the following morning.

“That was the worst day of my life,” he said the next day. I remember a few rougher days in his early years, but for him, I agree, this was the worst.

We did learn some things, though:

He now really understands what an allergic reaction is and how he feels when it happens.

I would do a single or double blind challenge IF we ever do a challenge for him again. With an older child who is anxious already, it would be best if the child did not know if they were getting the food or a placebo.

We know without a doubt, that eggs need to be avoided.

He was already dealing with spring allergy symptoms, so we also learned not to schedule a challenge during a season of allergy symptoms.

So, I lost some faith in medical science this week. When it comes to food allergies, we know that skin tests results are often unreliable and that blood test results have a lot of false positives. The true test is a food challenge, but isn’t there a better way to do this? No one should have to go through this- especially our children. I’m still upset, but I know over time this sadness will turn into action. We need better diagnostic tools for food allergy. We must keep pushing education and awareness which will result in more funding and more research. We can do better. I know we can.

Read More

The BIDMC Problem List Vocabulary

In several blog entries, I've been discussing the adoption of SNOMED-CT as the vocabulary to support BIDMC problem lists and our Google Health interface.

The National Library of medicine has mapped 93% of BIDMC problem list terms to SNOMED. The International Health Terminology Standards Development Organization (IHTSDO) has given me permission to share the BIDMC problem list vocabulary and the SNOMED-CT codes on my blog via the following terms

"The SNOMED CT� identifiers are posted with permission from the International Health Terminology Standards Development Organisation (IHTSDO). SNOMED CT is available for use under the terms of the IHTSDO Affiliate License Agreement, which is also Appendix 2 of the License Agreement for Use of the UMLS Metathesaurus. Use of SNOMED CT is free in IHTSDO Member countries (12 countries as of May 2009, including the US), in an additional 49 countries characterized as low-income economies by the World Bank, and for qualifying research projects worldwide. The National Library of Medicine (NLM) is the US Member of the IHTSDO. For more information, those in the US should contact NLM. Those in other countries should consult the IHTSDO for appropriate contact information."

Our plan is to load these terms into our electronic health record and code all our matching historical problem list data into SNOMED-CT. Our Google and Microsoft interfaces will be changed to send SNOMED-CT so that all problem list data can be mapped to disease monographs and consumer decision support tools.

In June, the NLM will forward us their consolidated list of the 6000 SNOMED-CT coded problems from the leading early adopters of SNOMED in the US. If we find any gaps in this problem list, we'll work with NLM and IHTSDO to fill them.

I hope the BIDMC problem list is helpful to your applications and institutions!

Read More

The First Meeting of the HIT Policy Committee

Today, the HIT Policy Committee met for the first time. Dr. Walter Suarez, CEO of the Institute for HIPAA/HIT Education, and the co-leader of the HITSP Education and Communication Committee, attended on my behalf. Here are his notes.

The meeting began with an introduction by Dr. David Blumenthal. He highlighted six priority areas for the HIT Policy Committee
* Meaningful Use
* Certification
* Infrastructure
* Privacy and Security
* Health Information Exchange
* Public Health

A question was asked about the recent NCVHS meaningful use hearings. Dr. Blumenthal responded that the HIT Policy Committee will be the venue for discussion of the NCVHS report.

A question was asked about the Office of National Coordinator (ONC) Strategic Plan. Dr. Blumenthal responded that ONC must revise its plan to reflect the statuary requirements of ARRA. For example, by May 18 it must establish a process for identifying Regional Healthcare IT Extension Centers.

Jodi Daniels, ONC Director of Office for Policy and Research, briefed the Committee about ARRA.

* The HIT Policy Committee is expected to advise ONC on priorities
* The National Coordinator will ensure communication with the HIT Standards Committee
* ARRA calls for two standards-related activities for the HIT Policy Committee
- Identify where standards are needed, not setting standards
- Recommend a policy framework for adoption of electronic standards, including:
Meaningful use
Utilization of EHRs
Accounting for Disclosure
Using certified EHRs for quality improvement and patient safety
Technologies that render protected healthcare information unusable
Collection of demographic data including race and ethnicity
Data to benefit vulnerable populations including children
HIT and telemedicine
HIT and public health
HIT and home health care

Dr. Blumenthal discussed the priorities for early work
* ARRA includes an enormous mandate that extends from privacy and security to monitoring public health threats to getting doctors and hospitals to adopt certified qualified EHRs
* It is impossible to do everything at once. We need to set priorities.
* Congress has given guidance by setting some priority topics and deadlines, but also by allocating billions of dollars in payments to help support adoption, starting 2011 and extending through 2018
* These funds focus attention and create important benefits/risks
* This is the first time in history that Congress has acted to correct some of the market errors in the healthcare information technology industry
* There are a series of tasks that need to be accomplished to make meaningful use a meaningful idea
- First, define meaningful use. This is an unprecedented task. The HIT Policy Committee will need to pick-up where NCVHS left off. ONC also has an internal group working on this.
- Second, review certification, which is tied to meaningful use.
- Third, infrastructure. Congress has allocated billions to accelerate industry adoption including extension centers, money to support information exchanges, training workers, training health professionals who will use these technologies and funding to states to help providers not eligible for Medicare/Medicaid payments.
- Fourth, privacy and security. ONC will appoint a privacy officer
- Fifth, public health and disease surveillance

There were a few questions:
*Shall we build upon activities already in progress?
Dr. Blumenthal noted that the NCVHS work on neaningful use is important; Certification needs to be reviewed; privacy and security � a lot of work done; HIE � modest literature about RHIOs and local adoption.

*What happens when the HIT Standards Committee receives input from the HIT Policy Committee?
Dr. Blumenthal noted this is something ONC is working on. The Standards Committee must recommend to the HHS Secretary the standards to achieve meaningful use. The Secretary will publish interim rules by end of year. The HIT Policy Committee is charged with the areas where standards are needed and perhaps the general approach to standards but not to define the standards.

*Summary of Priorities
- First, privacy and security
- Second, how to define meaningful use in an effective way
- Third, designing a certification process that facilitates adoption
- Others:
Supporting research
Measuring quality
Training and education of workforce (such as extension centers)
Demonstrating and documenting success. Show Congress, the industry, and the public that this does make a difference
Need to keep an eye on implementation via an incremental approach
Need to involve the workforce from the beginning. Workforce training is a priority.

* Discussion of Goals and Principles of Working Groups
- HIT Policy committee is charged to make recommendation to ONC
- Workgroups will support the detail work that needs to be done, then brought back to the full Committee

*Is Meaningful Use, for example, a time-limited issue? As it deals with the immediate needs to define and set parameters and metrics, yes; but it will also need to be reviewed periodically

*Where are we putting HIEs? Meaningful Use or Infrastructure?
- There is an aspect of HIE that comes under infrastructure (there is funding tied to it, question is for what)
- There is also a Meaningful Use aspect � that is, what are the requirements HIE for meaningful use
- There is also a Certification component � that is, what are the certification aspects of HIE that are tied to Meaningful Use and EHRs

*Privacy
- Some concern expressed about creating a privacy and security workgroup, it should be foundational across all groups
- But perhaps it should be immersed into an Information Sharing Workgroup which covers architectural, functionality and covers also privacy and security

*Another cross-cutting element for all workgroups: Patient centeredness

*Summary of discussion: recommendation for four working groups
-Meaningful Use
-Certification/Adoption including infrastructure issues, workforce, adoption strategy
-Information Exchange/Sharing
-Cross-cutting issues - Privacy and Security, Patient centeredness, Measurement

*Message to the HIT Standards Committee
Tell the HIT Standards Committee that the HIT Policy Committee is working on Meaningful Use, Certification/Adoption, and Information Sharing. The HIT Standards Committee can identify standards to support these goals.

I look forward to the first meeting of the HIT Standards Committee on Friday. I'll summarize the meeting on my blog.

Read More

Monday Review: A Look Back

After four months of Monday Reviews, I wanted to take a look back. Have you tried any of these products as a result of a review? Please share your experience. We can all help each other.

Thank you!

Home Free
Manitoba Harvest: Hemp Products
Mary's Gone Crackers
Go Picnic
ZenSoy Puddings and Evolve Kefir
Thai Kitchen
Nature's Path
Simply Boulder Sauces
"Matters of Faith", by Kristy Kiernan
Happikins
Olinda Ridge Olive Oils
Kettle Cuisine
Softress
Stuck on You
Grill Charms
Allergy Alert Clothing
"Flourishing with Food Allergies" by A.Anderson

Don't forget the Food ALlergy Twitter Party to wrap up Food Allergy Awareness Week! Join us at noon and 10:30 pm this Friday, May 15.

Read More

The Healthcare Information Technology Expert Panel II

Last week, I joined an amazing group of colleagues at the National Quality Forum's Healthcare Information Technology Expert Panel to work on a next generation quality data set. They key breakthrough was the development of a universal terminology for the design of quality measures which captures process and outcome data from electronic systems.

Elements which are captured include:

Datatype (e.g., medication order)

Data (e.g., aspirin)

Attributes (e.g., date/time)

Data Source (e.g., physician, patient, lab)

Data Recorder (e.g., physician, lab, monitor)

Data Setting (e.g., home, hospital, rehab facility)

Health Record Field (e.g., problem list, med list, allergy)

In the original HITEP work last year, 35 datatypes were defined such as encounter, diagnosis, diagnostic study, laboratory, device, intervention, medication, symptom etc. Each datatype can have subtypes describing specific events. Here's an example of the subtypes of the medication datatype

medication administered
medication adverse event
medication allergy
medication discontinued
medication dispensed
medication intolerance
medication order
medication prescribed
medication offered
medication refused

A traditional measure of quality might be

"Was Aspirin administered within 5 minutes of ED arrival in diagnosis of acute MI?"

If an EHR transmits datatypes for encounter, diagnosis, and medication to a quality data warehouse, we could capture the following data:

Datatype - encounter
Data - ED arrival
Attribute - date/time of arrival
Source - registration system
Recorder - ED ward clerk
Setting - ED
Health record field - ED arrival date/time

Datatype - diagnosis
Data - MI
Codelist - SNOMED code 12345
Attribute - date/time of diagnosis
Source - physician
Recorder - physician
Setting - ED
Health record field - encounter diagnosis

Datatype - medication administered
Data - ASA
Codelist - RxNorm code 123456
Attribute - date/time of administration
Source - nurse
Recorder - nurse
Setting - ED
Health record field - medication administered

then the quality measure could be defined as

Diagnosis="SNOMED 12345" AND (medication administered="RxNorm 123456" date/time - ED arrival encounter date/time) < 5 minutes

Such an approach makes quality measures more clearly defined, more directly related to data elements in EHRs, and more easily maintained.

The next steps for NQF include review of their existing 500 quality measures to determine which could be placed into such a framework. If there are gaps or revisions needed, the NQF will work with quality measure development organizations.

Meaningful use of EHRs will likely include quality measurement. Having a framework for recording quality data and computing measures is foundational.

Read More

Happy Mother's Day

Fo the constant label reading, special ingredient cake baking, party planning (especially those you're not even hosting), teacher training, medicine carrying food allergy moms...

Happy Mother's Day!

Read More

Cocci study group, Lupus scare

Denise continues to heal and we continue to enjoy her presence. As happens from time to time, we had a little point of concern. In the spring, Denise had some wacky liver labs that showed positive results that were consistent with lupus. More focused testing showed that she has mild case of a thyroid problem called Hashimoto's disease. Between the two, we'll take the Hashimoto's over the lupus.

I attended the 53rd Annual Coccidiodomycosis Study Group in early April. This is an annual gathering of the leading professionals in the study and treatment of valley fever. This year it was held at Cal State University Bakersfield (yup, in a cocci-endemic region). As was the case for the last couple years, my aunt that's an RN went with me to explain the medical jargon, and we got to rub elbows and discuss Denise's case with the big-hitters that were there. We had a mixed bag of good and bad news, but all interesting.

• The vaccine project is in effect stalled due to funding & politics.
• Nikkomycin Z, which has cured cocci in mice, is in human trials, but the remaining drug will be used up in the trials. It's very expensive to make and seeing it to market will be a long process if it happens at all.
• Cocci meningitis patients have a higher risk of stroke and neurological damage than previously thought (or at least what I had previously heard). While not good news, it does make us even more grateful that Denise has been doing so well.
  
• The geologist (the one guy I can understand unassisted) related that he can dig in one spot and find cocci in the soil, move over a foot, dig, and find nothing. He also pointed out that west Texas is an endemic region, and there are major population centers just to the east of where the endemic region tapers off. There's a concern that weather patterns may bring cocci to the central Texas cities of San Antonio, Austin, Abilene, etc. in greater numbers in coming years.
• At the dinner concluding the conference, Dr. Hans Einstein (who's been in cocci research a long time) narrated a slide show about the history of cocci study and the personalities involved. One of the stories: Johnny Bench played at a golf tournament fundraiser hosted by Buck Owens in Bakersfield on a windy day in the early 1970s. He contracted cocci and started exhibiting respiratory distress a few weeks later with the Cincinnati Reds. The doctors out there weren't familiar with Valley Fever, and before the possibility of cocci (and a simple treatment with antifungals) was suggested, he had already undergone a lung biopsy to remove the lesion, which was suspected at the time to be cancer.

Read More

Friday Feature: The Nut-Free Mom

This Friday Feature is an interview with Jenny Kale, The Nut-Free Mom. Learn more about Jenny through our Q&A's.

What is your food allergy background?

My food allergy journey began 5 years ago when my then 4-year-old daughter had a bite of a peanut butter sandwich at preschool. She never wanted peanut butter when we offered it to her, but we didn't think much of it.
On this day, I went to pick my daughter up at school after lunch and found her eyes swollen to 3 times their normal size. Her face was covered in hives. I got her home and called the doctor. She appeared to be asleep, but now I know she probably fainted from low blood pressure. She "woke" up when she began violently vomiting. Luckily her airway didn't close, though she began wheezing. I know now that she was having a full-blown anaphylactic reaction. Before this, I had a vague idea of what food allergies were but didn't think it could happen to us.

The pediatrician diagnosed peanut allergy. At a follow up with an allergist, my daughter was also found to have tree nut allergies. The doctor said that based on her reaction, we were lucky my daughter had survived.

I remember staggering home that day in shock with my baby and 4-year-old in tow wondering how I'd ever cope with the situation. I thought my daughter was perfectly healthy--it was a blow to learn that she had a life-threatening medical condition. I was terrified she'd have an even worse reaction and die. It was a sobering time for me and my husband.

What are you passionate about in the food allergy field?

I'm passionate about educating others--especially non-allergic families--about what food allergies are. I unknowingly put my daughter in a life-threatening situation. Had I understood peanut allergies, I would have called 911 immediately. I want other parents to know about this.

Also, I want everyone with a seriously food-allergic child to know that life can be mostly normal with food allergies. I advise caution, but not fear. Teach them from a young age to "own" their allergies and they will be much more confident. My daughter does everything that other kids do--except eat certain foods. That's very important to me, and to her.

And I'm also passionate about advocating for food allergic people, especially in light of recent OpEds and blogs that claim nut allergies are manufactured by neurotic parents and are not real. I've seen with my own eyes how real they are and this type of media backlash is dangerous. Laws, public perception and public policy have come a long way toward accommodating food-allergic people and I want that to continue.

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

I'm a writer, so in addition to my blog, I'm in the process pitching some mainstream print media such as articles, essays and more. I work hard in my daily life to educate the school and those around me about food allergies. There are a lot of fears and misconceptions that I hope to dispel.

What are your favorite food allergy friendly food staples?

Fresh fruits and veggies--can't push those enough with my two daughters! Also, my kids eat a lot of yogurt and things like Teddy Grahams. My daughter likes to make fruit smoothies and snack on raisins and "safe" popcorn. And Vermont Nut-Free Chocolate--we can't live without that. Of course, Mom's from-scratch cookies and cakes are favorite staples. We "only" deal with nut allergies so we may have more options than some other food-allergic families.

What did you do before life with food allergies?

I was a stay-at-home mom working as a freelance writer--I still am doing that. One thing we no longer have is the sense of spontaneity . My husband and I are "foodies" and love ethnic restaurants, exotic travel, etc. A lot of this has had to be curtailed. Asian food is out--bakeries in Paris are out. However, we can still do so much. We just need to plan ahead and be prepared with medications, etc. But I miss the whole concept of thinking that we can do things on the spur of the moment --that's pretty much gone!

What are some of your other interests/hobbies?

I'm an avid reader, I love museums, French films and British TV shows--especially the cooking ones like Kitchen Nightmares. I like to travel and would love to go back and travel in Europe with my family. I love to cook, bake and entertain (this has come in handy with nut allergies) and I enjoy writing fiction and poetry in addition to my non-fiction freelance gigs. And the whole blogging thing has been really fun for me. If I had time, I'd do a writing blog as well!

Thank you, Jenny for sharing your world with us. We appreciate all you do to educate others about food allergies.

Visit Jenny's blog here.

Read More

Followup on Dispute Resolution

In my earlier blog about Dispute Resolution, I described the planned gathering of computer scientists, electronic health record experts, and dispute resolution professionals called "Online Dispute Resolution in a Technology-oriented Healthcare World"

I attended the event and enjoyed the multidisciplinary discussion, learning a great deal about possible disputes among the data stakeholders in healthcare - patients, providers, payers, employers, compliance organizations, public health, government, national security, research etc.

Here are a few lessons learned

1. There's a need to web enable dispute workflow in healthcare. As e-patient Dave pointed out, I did not hear about any data concerns regarding personal health records likely because there was no easy way to raise the issue. Hospitals have policies regarding medical record disputes. Generally the workflow involves writing letters, making phone calls, and resolving disputes via committee. As the country implements more electronic records and shares more data (with patient consent), among more stakeholders, we need to embrace automated dispute resolution workflows such as are used by eBay. In healthcare, the issues are complex because the medical record is a legal record and there are many compliance issues involved in annotating it. However, I can imagine adding a comment field to the problem list which could be electronically annotated by the patient, so a clinician examining the record could understand the patient's point of view if data is disputed. In our medication reconciliation application, we give clinicians the ability to make notations about patient compliance with medications i.e. discontinued, taken infrequently, changed to a different medication etc. I can imagine gathering this input directly from patients.

Thus, the work of the dispute resolution community working with the healthcare data community will be to think through the workflow that can be supported via web-based dispute resolution tools, while still ensuring the non-repudiability of the medical record and complying with federal, state, and local medical record policies.

2. For issues that cannot be resolved via automated tools, an electronic escalation to an Ombudsman is a reasonable workflow. Complex issues are generally more easily resolved when two people speak directly rather than virtually. However, a web application could be used to identify the issues, exchange background information, and schedule the discussion.

3. If there is assertion of malpractice or harm caused to the patient, then workflows involving risk management and insurance organizations are appropriate.

The full report of the meeting will be available soon, but in the meantime, I will be more sensitive to the need to consider the modes of failure in electronic health records, especially those which are shared with patients, and the desirability of automated dispute resolution workflow.

Read More

Your Karma Account Balance

It's a tough time for everyone right now.

The economy is troubled, there's an H1N1 flu outbreak, and there's increased competition for scarce resources.

This causes people to be edgy, angry, and impatient.

I encounter a sense of frenzy when I board airplanes, when I search for parking, and when I commute on busy highways.

It's time to dust ourselves off, make the most of each day, and strive for more good Karma.

What do I mean?

Conflict happens every day. I have always believed that the nice guy can finish first in any conflict by doing the right thing.

1. By trying to win every competition you may win the battle of office politics but lose the Karma war. I've found that those who are Machiavellian live by the sword and eventually die by the sword. Thus, do not grandstand, take credit inappropriately, or demean others to enhance your own stature.

2. Rather than worrying about fame, fortune, or glory, just try to make a difference. Treat everyone with respect, listen to their concerns, and make decisions based on the greatest good for the greatest number.

3. Use email as a communication tool, not a weapon. If you feel emotion, save as draft and send it later. Never use blind cc's or use email to make others look bad to their superiors.

4. At the end of every day, look back on each open issue and ask if you've moved the issue forward. Many conflicts are not easily resolvable, but can be moved forward over time via gradual change and aligning the interests of stakeholders.

5. Stick to your principles. Integrity, honesty, and consistency should guide your actions.

If everyone looked at the balance in their Karma account at the end of every week, the world would be a much more positive place.

Yesterday in a meeting, someone asked how I was doing. My answer what that my 401k may be bad, but my Karma account is looking good. I have my health, a happy marriage , a loving daughter, and a set of really interesting challenges that enable me to make a difference.

I do not know where the future will lead, but when I look back in 30 years, I'll feel good about the journey. Along the way I'll be optimistic, kind, and fair.

Speaking of journeys, I'm at NASDAQ today doing a live webcast at 2:00pm Eastern. You can watch it at http://bit.ly/5Zm1P

Read More

We're Having a Twitter Party!

Okay, I'll admit, I'm not sure exactly what that means yet, but I'm learning. This party is being hosted by Jennifer of Food Allergy Buzz and Ruth of Best Allergy Sites.

To join in the fun, on Friday May 15 at noon and again at 10:30 pm (Eastern Time), visit tweetgrid.com and type in #foodallergy. You can use another Twitter real-time dashboard of your choosing, but "tweetgrid" works and that's good enough for me.

This will take you to the party where you will see streaming conversation. During the two party times, you can ask questions or make comments on anything food allergy related. I'm participating in the noon party and I plan to be sleeping during the 10:30 pm one- yeah, I know, quite the party animal.

Anyway, I hope you'll join us.

The participating panelists are:

@chupieandjsmama
@foodallergyassistant
@foodallergymama
@allergicgirl
@nut_freemom
@foodallergybuzz
@bestallergysite

Send a note to Jennifer B. if you have food allergy products available for prizes- yes there are even prizes at this party!

Read More

Next Steps on the HIT Policy and Standards Committees

Last week, ONC formally established the HIT Policy and Standards Committees via publication in the Federal Register. Here are the announcements:

ACTION: Notification of the Establishment of the HIT Policy Committee.

SUMMARY: This notice announces the establishment of the HIT Policy Committee. The American Recovery and Reinvestment Act of 2009 (Pub. L. 111-5), section 13101, directs the establishment of the HIT Policy Committee. The HIT Policy Committee (also referred to as the
"Committee'') is charged with recommending to the National Coordinator a policy framework for the development and adoption of a nationwide health information technology infrastructure that permits the electronic exchange and use of health information as is consistent with the Federal Health IT Strategic Plan and that includes recommendations on the areas in which standards, implementation specifications, and certification criteria are needed. The HIT Policy Committee is also charged with recommending to the National Coordinator an order of priority for the development, harmonization, and recognition of such standards, specifications, and certification criteria.

FOR FURTHER INFORMATION CONTACT: Judith Sparrow, Office of the National Coordinator for Health Information Technology, e-mail judy.sparrow@hhs.gov

SUPPLEMENTARY INFORMATION:
I. Background
The Committee and its staff are governed by the provisions of the Federal Advisory Committee Act (FACA) (Pub. L. 92-463), as amended (5 U.S.C. App.), which sets forth standards for the formation and use of federal advisory committees.

The Committee shall determine a schedule of meetings following an election of a Chairperson and a Vice Chairperson from among its members.

II. Criteria for Members
The Committee shall be comprised of the following, including a Chair and Vice Chair, and represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of the Committee. Committee members shall be appointed in the following manner:
3 members shall be appointed by the Secretary of Health and Human Services, 1 of whom shall be appointed to represent the Department of Health and Human Services and 1 of whom shall be a public health official;
1 member shall be appointed by the majority leader of the Senate;
1 member shall be appointed by the minority leader of the Senate;
1 member shall be appointed by the Speaker of the House of Representatives;
1 member shall be appointed by the minority leader of the House of Representatives;
Such other members as shall be appointed by the President as representatives of other relevant Federal agencies;
13 members shall be appointed by the Comptroller General of the United States of whom-
3 members shall be advocates for patients or consumers;
2 members shall represent health care providers, one of which shall be a physician;
1 member shall be from a labor organization representing health care workers;
1 member shall have expertise in health information privacy and security;
1 member shall have expertise in improving the health of vulnerable populations;
1 member shall be from the research community;
1 member shall represent health plans or other third-party payers;
1 member shall represent information technology vendors;
1 member shall represent purchasers or employers; and
1 member shall have expertise in health care quality measurement and reporting.
Non-federal members of the Committee shall be Special Government
Employees, unless classified as representatives.

III. Copies of the Charter
To obtain a copy of the Committee's charter, submit a written request to the above contact.
Dated: April 23, 2009.
David Blumenthal,
National Coordinator for Health Information Technology, Office of the
National Coordinator for Health Information Technology.
[FR Doc. E9-9839 Filed 4-24-09; 4:15 pm]
------------

ACTION: Notification of the Establishment of the HIT Standards Committee.

SUMMARY: This notice announces the establishment of the HIT Standards Committee. The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub. L. 111-5), section 13101, directs the establishment of the HIT Standards Committee. The HIT Standards Committee (also referred to as the "Committee'') is charged with making recommendations to the National Coordinator on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information for purposes of adoption, consistent with the implementation of the Federal Health IT Strategic Plan, and in accordance with policies developed by the HIT Policy Committee.

FOR FURTHER INFORMATION CONTACT: Judith Sparrow, Office of the National Coordinator for Health Information Technology, e-mail judy.sparrow@hhs.gov

SUPPLEMENTARY INFORMATION:
I. Background
The Committee and its staff are governed by the provisions of the Federal Advisory Committee Act (FACA) (Pub. L. 92-463), as amended, (5 U.S.C. App.), which sets forth standards for the formation and use of federal advisory committees. The Committee shall determine a schedule of meetings following an election of a Chairperson and a Vice Chairperson from among its members. An initial meeting of the Committee shall take place not later than 90 days from passage of the ARRA.

II. Criteria for Members
The HIT Standards Committee shall not exceed thirty (30) voting members, including a Chair and Vice Chair, and members are appointed by the Secretary with input from the National Coordinator. Membership of the Committee shall at least reflect providers, ancillary healthcare workers, consumers, purchasers, health plans, technology vendors, researchers, relevant Federal agencies, and individuals with technical expertise on health care quality, privacy and security, and on the electronic exchange and use of health information and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of the Committee. Non-Federal members of the Committee shall be Special Government Employees, unless classified as representatives.

III. Copies of the Charter
To obtain a copy of the Committee's charter, submit a written request to the above contact.
Dated: April 23, 2009.
David Blumenthal,
National Coordinator for Health Information Technology, Office of the
National Coordinator for Health Information Technology.
[FR Doc. E9-9838 Filed 4-24-09; 4:15 pm]
------------

We'll hear more about these committees soon, since their meetings are mandated by ARRA to occur in the month of May. Watch the ONC Website for announcements of the meetings and the members to be named.

Read More