Help is Needed Again for Food Allergy Bill in PA

I wrote about house Bill 1148 last Monday. The bill was sent to PA Education Committee members Weds. June 24. It was tabled. Here's the latest information from Rep. Murt's office about the future of this important bill:

The PA House Education Committee met on 6/24/09 and discussed HB 1148 - Food Allergy Guidelines. This bill directs the Pennsylvania Department of Education to research and publish guidelines for the successful management of food allergies in our schools. The committee raised questions regarding how the legislation would impact existing laws and no bill vote was taken. Since last Wednesday, the legislation was re-written. We choose to clarify the impact on exiting school code by clearly illustrating the changes to the existing code. Changes to the Local Wellness Policy clause 1422.1 allowed us to identify Food Allergy Management as being as important as child health, nutrition, and physical education. Adding an additional dictate to Section 1422.3 allow us to outline the need for Food Allergy Guidelines and what they must accomplish.

The next meeting of the PA Education Committee where they will vote on HB 1148 is now this Wednesday, 7/01/09. Please forward this message to your membership and friends asking them to re-edit it to their liking and forward it to the following list of Education Committee members.

JRoebuck@pahouse.net, ksmith@pahouse.net, LCurry@pahouse.net, JYudicha@pahouse.net, bsmith@pahouse.net, mcarroll@pahouse.net, sconklin@pahouse.net, RGrucela@pahouse.net, pharkins@pahouse.net, mlongietti@pahouse.net, MOBrien@pahouse.net, JPallone@pahouse.net, cwagner@pahouse.net, JWheatle@pahouse.net, RYoungbl@pahouse.net, Pclymer@pahousegop.com, mfleck@pahousegop.com, Dmetcalf@pahousegop.com, dmilne@pahousegop.com, Boneill@pahousegop.com, Tquigley@pahousegop.com, Klrapp@pahousegop.com, MReese@pahousegop.com, trock@pahousegop.com, WTallman@pahousegop.com

Thank you again for your continued support.

Bill Dixon
Legislative Aide
PA State Representative Thomas Murt's District Office
(215)674-3755

****************************************************************************

I have the document that will be presented to the committee. If you're interested in reading it, e-mail me and I'll send it to you.

*****************************************************************************

Help is needed- even if you don't live in PA. Please consider copying and pasting the e-mail addresses and letter into an e-mail and send it to our PA Reps. There is power in numbers and if all of us band together, no matter where we live, we can make all of our schools safer for those with food allergies.

Here's the letter I re-sent:

Dear Representative,

House Bill 1148 is a public health necessity. We have young students hiding their life-saving medications in backpacks because some schools require medications to be kept locked in the nurse's office. We have students exposed to potentially dangerous allergens because schools are reluctant to engage in dialogue with parents about food allergies. School buses and after-school activities are, at minimum challenging and sometimes not possible, for children with food allergies.

The incidence of food allergies has been growing exponentially in recent years and about seven percent of the student population is affected by food allergies. At present, many schools are managing these students on a case by case basis, and the results are mixed. As a result, families are forced to seek private or home schooling for their food allergic children to keep them safe.

Accommodations for food allergic students can be made easily and effectively in the classrooms and school communities. By law, all children are guaranteed an appropriate and free public education, and students with food allergies are legally entitled to appropriate protections. We just want to have the opportunity to talk with our schools about what is best for all children.

I am asking you to vote yes to HB 1148 on July 1, 2009.

Thank you.

Sincerely,

YOUR NAME AND ADDRESS HERE

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Standards Deployability

I've described the taxonomy that we're using in the HIT Standards Committee to characterize "deployability":

Category I- Known/Certain for 2011
Standards are well-accepted and generally seen as deployable

Category II- Known/Certain for 2013
Standards exist, are determined, but are not in the market yet

Category III- Work In Process for 2013 or 2015
Need to converge/refine standards for 2013 or develop for 2015

Category IV- Standards to be determined
�Gleam in the eye,� some concepts exist but no clear path

Providing a measure of vendor, clinician, lab, pharmacy, hospital, and HIE ability to implement standards is just as important as naming the standards to be used in support of meaningful use.

During our recent HIT Standards Committee meeting we discussed other interpretations of deployability including implementation experience to date, known costs of implementation, and trading partner willingness to implement.

Dr. Jim Walker MD, Chief Healthcare Information Officer of Geisinger Health System, summarized the discussion as:

I. Mature � Implemented in 20% (inspired by Gartner's metric that 20% represents a tipping point of acceptance) of relevant healthcare organizations. Implementation methods and costs well specified. Success is dependent on factors external to the implementing organization at most minimally.

II. Ready for Introduction � Widely agreed on and thoroughly tested in detail. Implementation methods and costs are variable and difficult to predict. Ready for widespread implementation in production health IT. Success is largely dependent on internal factors.

III. Well Developed � Widely agreed in concept. Needs detailed specification and testing. Implementation methods and costs are largely unknown. Success is largely dependent on factors external to the implementing organization.

IV. In Development


Over the next month, the HIT Standards Committee will ensure that the concept of deployability accompanies each standard in the meaningful use matrix. This consensus assessment will enable the HIT Policy Committee, ONC, and HHS to make the final decision on meaningful use implementation phasing after weighing the impact of deployability Although it is likely that 2011 meaningful use criteria will be Category I's, there may be a few Category II's if the value/impact of early implementation justifies the effort.

As David Blumenthal said at last HIT Standards Committee meeting, stimulus dollars and the urgency to change may accelerate the ability of all stakeholders to deploy health information exchange and we should not set the bar too low.

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Implementing a Modern Hospital Website

Over the past two years, I've witnessed a transition in modern website design from plain text and static information to multimedia centric and interactive. I've written about the new BIDMC website we implemented to meet patient expectations for a modern website.

Many healthcare organizations I work with are considering content managed, new media, highly interactive web 2.0 sites. I thought it would be useful to describe how we approached the BIDMC website so you can leverage our experience.

Content Management - BIDMC has a great deal of .NET expertise, so we wanted a content management system that worked well in our .NET/SQL Server 2008 environment. SiteCore has been ideal for us, providing content templates, distributed content management, and publishing workflow in a load balanced, secure, virtualized environment. At HMS we use Drupal and Wordpress for content management. They also work well for hosting institutional web sites.

Interactive features - The Corporate Communications folks at BIDMC really wanted to highly interactivity. We built and bought the components they needed as follows

Blogs - Uses a SiteCore provided blogging module

Chat - a commercial application called Cute Chat from CuteSoft.

BIDMC TV (news and information videos produced by BIDMC)- Hosted by BrightCove.

Medical Edge (videos about innovation produced by BIDMC)- Hosted by BrightCove.

Podcast Gallery - Hosted on BIDMC servers.

Health Quizzes - created using a commercial application called SelectSurvey.NET from ClassApps.

Social Networking - entirely hosted by outside service providers (Facebook/Twitter/You Tube).

Secure patient web pages for communication with their families - a commercial application provided by CarePages.

Conditions A-Z - a web-based encyclopedia branded for BIDMC using commercial reference provided by Ebsco.

Search Engine - We're using a Google Appliance

Thus, the combination of SiteCore plus purchased interactive applications and externally hosted streaming video has worked very well to provide our patients with an information rich, interactive experience.

I hope this is useful to you as you implement your own hospital websites.

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Update on Food Allergy Bill in PA

Here's the latest on HB 1148. According to my contact at PA State Representative Thomas Murt's District Office,

"HB 1148 was tabled because several Education Committee members were concerned about the wording on the the bill and it's impact on existing laws. The bill was tabled to allow for further research and clarification. We are working with the Harrisburg legislation unit to resolve the concerns. We may have a vote as soon as July 1."

I just sent a response asking if they needed any help from families who deal with food allergies every day. I believe in the power of the moms and dads who know what kind of help they need when trying to manage their child's food allergies in a school setting.

I'll keep you posted if there are ways we can help.

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Cool Technology of the Week

I work in the Longwood Medical Area - a former cowpath that is now the only access to the center of biomedical research, healthcare, and informatics. It's a very challenging place to commute, especially on Red Sox games days. I carry a red sox schedule in my wallet to help me plan commutes - leaving an hour earlier in the morning or an hour later at night.

There must be a better way than trying to drive through a nightmare of red sox traffic, commuters, and road construction.

In July I'm going to try a bold experiment with a cool technology. I'm going to park my car away from the madness and use a foldable bicycle that weighs under 20 pounds for all my Boston city commuting.

I've investigating many folding bicycle technologies - Bike Friday, Brompton, and Dahon, but none is light enough, small enough, or quick to fold enough to just toss in and our of car/office/train in a few seconds. The Strida is.

The Strida was invented by Mark Sanders in the UK in the 1980's as part of his graduate work. It's use case is not long distance travel or hill climbing. It's a greaseless, chainless, gearless bike that folds in 10 seconds and is perfect for Park and Bike or Train and Bike travel.

My goal in July is to leave the car 2 miles from the Longwood Medical area in a place that's easy to commute to/from, then bike to all my remaining destinations. Admittedly our unusually wet Summer this year in Boston will make this a bit challenging, but my rayon and linen clothes drive fast. I have a messenger bag for my Macbook Air and meeting materials.

So if you're in Boston, look for me on a Strida, dressed in black and carrying a computer on my back. My only reservation is that rock climbing, ice climbing, and kayaking are completely safe compared to bicycling in Boston. My Mort level may go up a bit during this experiment. Those disc brakes on the Strida are likely to come in handy.

A lightweight, folding, greaseless bike to solve your commuting nightmares. That's cool!

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Avoid Certain Allergy Medications if you Have Food Allergies

I've said it before, I'll shout it again:

If you have a dairy allergy, do not take certain tablets of Zyrtec, Benadryl and Singulair. Do not use the inhaler Advair. All contain dairy.

They're not labelled clearly, but a call to the customer service departments of these drugs confirms that those with a milk allergy should not take these forms of the medications.

Allergists, other doctors and pharmacists I've spoken to were unaware of dairy in these tablets and in the inhaler.

Do not take samples of medications in the doctor's office until you have checked all medication ingredients through a label, company website or contacting the company directly.

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The Future of Personal Genomics

I recently participated in an panel discussion at Bio-IT World on the future of personal genomics.

As one of the PGP-10, I'm a passionate supporter of full genome sequencing as a means to empower patients to work with their clinicians in formulating a plan for lifelong wellness.

You'll find my personal comments in this webcast.

Within the next year, the $1000 per person genome will be a reality. Our next challenge will not be the science but the need for robust patient decision support tools which translate base pair variation into probabilities for pathology. Further, we'll need to provide the educational materials which will enable patients to turn these probabilities into informed decisions about proactive lifestyle changes and therapies.

I hope you enjoy the hour long discussion from Bio-IT world from folks who are actively working on Personal Genomics science, policy, and education.

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Food Safety News

Phyllis Entis, a food safety microbiologist and author of "Food Safety: Old Habits, New Perspectives" and "Food Microbiology - The Laboratory", maintains a very informative blog about food safety. She wrote a thorough discussion about the TollHouse Cookie dough re-call and provides a food recall round-up each week.

Her blog isn't necessarily directed toward food allergies, but it is helpful for anyone who eats food.

Take a look.

Also, check out her discussion about the Food Safety Enhancement Act of 2009. There's even a link if you want to read all 116 pages of the act.

Wouldn't it be wonderful to live in a world where all foods must be labelled with their country of origin and where food manufacturers can't refuse the FDA's request to recall foods. Oh yeah, and how about out-of compliance facilities having to pay for their own recalls and re-inspections rather than the FDA (meaning the government...translation, your money and mine through taxes)?

That's in there too.

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The Second Meeting of the HIT Standards Committee

Today, Jonathan Perlin and I ran the second meeting of the HIT Standards Committee.

Here's a report on presentations and the work ahead.

Jamie Ferguson presented the work of the Clinical Operations Working Group. There are three major threads of effort
- Clearly define the standards work to be completed by the Clinical Operations Workgroup and the Clinical Quality Workgroup, since quality measures depend upon clinical operations data
- Select the specific standards and certification criteria supporting Meaningful Use Objectives and Measures
- Create a taxonomy for standards maturity and industry readiness to deploy standards. The draft taxonomy we discussed is:

Category I- Known/Certain for 2011
Standards are well-accepted and generally seen as deployable

Category II- Known/Certain for 2013
Standards exist, are determined, but are not in the market yet

Category III- Work In Process for 2013 or 2015
Need to converge/refine standards for 2013 or develop for 2015

Category IV- Standards to be determined
�Gleam in the eye,� some concepts exist but no clear path

David Blumenthal noted that the stimulus may motivate stakeholders to adopt data exchange more quickly than the past, making stretch goals possible. As a group we discussed the challenge of the healthcare ecosystem - motivating just one segment of the industry may not be sufficient to achieve data exchange i.e. standardizing EHRs to accept specific lab data standards is not sufficient unless the labs also agree to send data in a single standard format.

Janet Corrigan presented the work of the Clinical Quality Working Group. Her group is building on the work of the National Quality Forum's Health Information Technology Expert Panel to identify the Quality Data Set needed to support measurement and reporting. They are not choosing new standards or vocabularies, instead they are developing a framework of datatypes that enable the measures to be expressed in terms of EHR capabilities. For example

% of Hypertensive Patients with BP under Control [OP] requires EHR datatypes for

Age
Hypertension diagnosis
Ambulatory encounter
Systolic blood pressure result
Systolic blood pressure result

The Clinical Quality Workgroup will spend the next month specifying the precise measures in terms of datatypes that will meet the quality measurement requirements of meaningful use. They will work closely with the Clinical Operations Workgroup to ensure the needed data exchanges supporting collection of these datatypes are included in the standards chosen.

Dixie Baker presented the work of the Privacy and Security Working Group. Her group identified three categories of standards and best practices supporting security:

1) Products that can be purchased (certified by CCHIT outside the real-life setting)
2) IT infrastructure necessary to enable the product to be meaningfully used
3) Operational environment in which the product will be used meaningfully

She also described recommended wording improvements to the meaningful use matrix items that will be forwarded to the HIT Policy Committee.

Their work over the next month will be to name the security standards and best practices for each meaningful use item and the ARRA 8 items.

The entire Committee discussed some of the existing gaps in standards. These included
-Standards for ordering including lab orders
-Standards for supporting electronic reporting of some of the meaningful use measures i.e. what percentage of prescriptions were written electronically - how do you calculate the number of prescriptions written manually?
-Standards supporting some of the patient/family engagement provisions of meaningful use

Our plan is to complete the efforts of our 3 Workgroups by the next meeting of the HIT Standards Committee on July 21. The end result will be a matrix of standards, an estimate of the readiness for deployment of each standard, quality measures, and privacy/security best practices for each meaningful use objective.

This work will give ONC and HHS the lead time they need for legal review, budget impact, and rule writing by the appropriate federal agencies.

The next month will be a whirlwind of activity. My thanks and appreciation to everyone involved!

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Copyleft, All Rights Reversed

I want my blog to be used for education, training, and research. I hope that its contents appear in derivative works such as other blogs, websites, and wikis. I'd prefer that these derivative works be openly shared.

I would also ask that any material that is repurposed has attribution to me as the author.

Content from my blog should not be sold. Charging for access to that which I make freely available seems wrong.

How do I express these preferences legally?

There are a variety of licensing approaches that enable the author to declare preferences beyond "(c) copyright all rights reserved". In my case, I want "some rights reserved".

I recently me with the CEO of Wikidoc, a community supported medical reference, and he handed me a presentation with the term "Copyleft".

What is Copyleft? From Wikipedia:

"Copyleft is a form of licensing and can be used to modify copyrights for works such as computer software, documents, music and art. In general, copyright law allows an author to prohibit others from reproducing, adapting, or distributing copies of the author's work. In contrast, an author may, through a copyleft licensing scheme, give every person who receives a copy of a work permission to reproduce, adapt or distribute the work as long as any resulting copies or adaptations are also bound by the same copyleft licensing scheme. A widely used and originating copyleft license is the GNU General Public License. Creative Commons provides a similar license called ShareAlike."

Creative Commons licenses contain four major permissions:

* Attribution (by) requires users to attribute a work's original author.
* Share-alike (sa), which is a copyleft requirement that requires that any derived works be licensed under the same license,
* No derivatives (nd), which requires that the work not be modified.
* Non-commercial (nc) requires that the work not be used for commercial purposes.

There's an automatic license generator on the Creative Commons site. I entered my preferences as

Allow commercial uses of your work - No

Allow modifications of your work - Yes, as long as others share alike

And it generated the License that now appears in the upper right hand corner of my blog - "Life as a CIO Blog by John D. Halamka MD is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License."

Now you can feel free to use my blog under Creative Commons license. Help yourself.

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House Bill 1148

Even if you don't live in PA, please consider copying and pasting the following e-mail addresses and letter into an e-mail and send it to our PA Reps. There is power in numbers and if all of us band together, no matter where we live, we can make all of our schools safer for those with food allergies.

Just copy, paste and put your name and address at the bottom of the letter. The vote is this Weds. June 24, so please do this today or tomorrow. Thank you.

Send to:
JRoebuck@pahouse.net, ksmith@pahouse.net, LCurry@pahouse.net, JYudicha@pahouse.net, bsmith@pahouse.net, mcarroll@pahouse.net, sconklin@pahouse.net, RGrucela@pahouse.net, pharkins@pahouse.net, mlongietti@pahouse.net, MOBrien@pahouse.net, JPallone@pahouse.net, cwagner@pahouse.net, JWheatle@pahouse.net, RYoungbl@pahouse.net, Pclymer@pahousegop.com, mfleck@pahousegop.com, Dmetcalf@pahousegop.com, dmilne@pahousegop.com, Boneill@pahousegop.com, Tquigley@pahousegop.com, Klrapp@pahousegop.com, MReese@pahousegop.com, trock@pahousegop.com, WTallman@pahousegop.com

Letter:

Dear Representative,

House Bill 1148 is a public health necessity. We have young students hiding their life-saving medications in backpacks because some schools require medications to be kept locked in the nurse's office. We have students exposed to potentially dangerous allergens because schools are reluctant to engage in dialogue with parents about food allergies. School buses and after-school activities are, at minimum challenging and sometimes not possible, for children with food allergies.

The incidence of food allergies has been growing exponentially in recent years and about seven percent of the student population is affected by food allergies. At present, many schools are managing these students on a case by case basis, and the results are mixed. As a result, families are forced to seek private or home schooling for their food allergic children to keep them safe.

Accommodations for food allergic students can be made easily and effectively in the classrooms and school communities. By law, all children are guaranteed an appropriate and free public education, and students with food allergies are legally entitled to appropriate protections. We just want to have the opportunity to talk with our schools about what is best for all children.

I am asking you to vote yes to HB 1148.

Thank you.

Sincerely,

YOUR NAME AND ADDRESS HERE

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Rough Recovery

It's been a hard week for my little guy (and the rest of the family) as he recovers from tonsillectomy and adenoidectomy. The doctors are very nice, but quite casual about the whole recovery process.

We wound up going to the emergency room Thursday night. He had been having such a hard time swallowing he needed fluids, morphine for pain and a steroid to shrink the swelling. There was talk of admitting him as he still wasn't swallowing easier after several hours. We decided to go home (for reasons explained below) and we had an okay week-end. Still not out of the woods yet. Dr. said we may need to take him back again for more fluids- ugh!

So we opted not to stay overnight...here's why. When we walked into the ER, we saw signs posted- "If you've been to Mexico, Texas or New York City recently and have flu-like symptoms, alert the staff immediately". At registration we were offered masks. People in the waiting area were wearing masks and several looked very sick with flu-like symptoms.

It looked like a scene in a movie.

Later, when an overnight stay was being discussed, the pediatrician from the floor talked to our ER nurse. The pediatrician advised that we try to take him home as there was "a lot of flu on the pediatric unit". We high-tailed it out of there.

So, we're managing, but still lots of pain, especially in the morning. A popsicle and pain medicine helps that. Then I begin my mantra for the rest of the day, "Drink, swallow, drink, swallow". After I say that about 10,000 times it's time for bed and we begin the whole thing the next morning.

This too shall pass...

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A New Approach to Certification

Last week I spoke with Mark Leavitt, the CEO of CCHIT, about his best thinking regarding certification in a post-ARRA world.

In the past there have been 3 groups who have requested improvements to existing certification criteria:

1. Self developers who achieve a high degree of functionality through continuous improvement of home built software

2. The Open Source community

3. The Health 2.0/iPhone as application platform/multiple thin web-application combined to provide EHR-Lite functionality community

CCHIT held 2 Town Halls, each with 500 people, to publicly discuss a new approach to certification.

Mark's slides are available online

The New path to certification has three branches:

EHR-C The Certification of a Comprehensive EHR. This is what has been done to date. The product itself is certified, not the specific implementation at a specific site. EHR-C products should be able to meet all meaningful use criteria if implemented properly. The cost to the vendor for certification is $30,000-50,000 per product. EHR-C is for providers who seek maximal assurance of EHR compliance and capabilities.

EHR-M The Certification of a Module such as e-prescribing, lab ordering/resulting, clinical charting and data exchange. A clinician could assemble multiple modules and be certified regarding the specific functions they perform. Integration of data between modules is the clinician's responsibility. Meaningful use may be possible, but depends upon how the modules are used together. The cost to the vendor for certification is $5000-$35,000 per module. EHR-M is for providers who prefer to integrate technologies from multiple certified sources.

EHR-S The Certification of Site for the functionality that can be achieved using the software installed there. A screen capture function is used to document capabilities and this capture will be reviewed by an expert remotely. The cost is $150-300 per licensed provider. EHR-S is for providers who self- develop or assemble EHRs from non-certified sources.


In addition to these three paths, �version lockdown� is no longer needed or relevant. For EHR-C and EHR-Mcertifications, updated or enhanced versions of a code base would inherit certified status without need for CCHIT approval. For EHR-S sites, updates or enhancements would not require recertification.

I've heard a great deal of positive feedback about this new approach. The work of CCHIT to enhance its approach, the work of the HIT Standards Committee to define the certification criteria needed for meaningful use, and the work of the HIT Policy Committee to review certification in general will result in a comprehensive certification plan aligned with ARRA by the end of of 2009.

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Free Pretzels! Really Yummy Pretzels!

Check out this fun contest sponsored by RFAK.com (Raising Food Allergic Kids). RFAK author, Lissa, is celebrating her birthday by giving a gift.

Enter to win a 10 Pretzel Gourmet Sampler Gift Set from Kim and Scott's Gourmet Pretzels.

Good Luck!

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Cool Technology of the Week

Several very innovative healthcare applications were shown last week at Apple�s Worldwide Developers Conference 2009.

One was from a company called Air Touch that offers secure, patient data in real-time to smart phones. Their products were FDA approved in April 2009.

Here's the description from their website:

�The development of the AirStrip Technologies platform was driven by the desire to improve the speed and quality of communication in healthcare.
The AirStrip Technologies platform securely delivers critical patient information, including virtual real-time waveform data, directly from hospital monitoring systems to a doctor or nurse�s smart phone, laptop or desktop. The platform is completely reusable, scalable and data independent, and can be employed throughout the healthcare enterprise. The AirStrip service is provided to physicians by the hospital.

AirStrip Technologies offers mobile, medical software applications that deliver this vital data directly to mobile devices, including smart phones. The applications are powered over wired and wireless networks. Patient information is available anytime, anywhere, on virtually any carrier, with any device on any platform.�

Their iPhone offering includes

Critical Care

OB

Cardiology

Imaging

Lab


The iPhone is quickly turning into a major resource for accessing mobile health applications.

Although I find the iPhone a challenging device for data entry, it's a great device for data viewing. Realtime viewing of waveform, imaging and text data via a handheld mobile device. That's cool!

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My Favorite Wines

In my recent blog about staying healthy, I mentioned that I drink a glass of wine with dinner each night.

My history with wine, that not many know, is that my wife and I ran a winery called Woodcliff on the Marin/Sonoma County Border from 1986-1993. We planted Syrah grapes (grafts from Randy Graham at Bonny Doon vineyard). I learned that you can make a small fortune in the wine business...as long as you start with a large fortune. It's challenging agricultural work. I served as a winemaker and chemist, tending barrels and doing chromatography to ensure malolactic fermentation proceeded appropriately. Running a winery taught me a great deal about the industry, grapes, and wine tasting. I learned that the price of wine and the quality of wine are rarely related. Drink what you like, not what the critics like. A $200 dollar bottle of wine is not 10 times more enjoyable than a $20 dollar bottle of wine.

Here's a list of the wines I drink most frequently - yeasty Chardonnays, high acid food wines, Syrah/Shiraz that makes your tongue explode with raspberries, Bordeaux with an aroma so alluring you grin from ear to ear before tasting, and dry sparkling wines.

Whites
1. Newton Unfiltered Chardonnay

2. Pillot Chassagne Montrachet

3. Chateau de Sancerre

4. Marc Bredif Vouvray

5. Fat Bastard Chardonnay


Reds
1. Jaboulet Parallel 45

2. Elan Vineyards Cabernet

3. Three Rings Barossa Valley Shiraz

4. Leoville Las Cases

5. Cos D'Estournel


Sparkling Wine
1. Roederer Estate Anderson Valley Brut

2. Domaine Chandon Brut

3. Adami Valdobbiadene Prosecco

4. Schramsberg Blanc de Blancs

5. Domaine Carneros Brut

In Massachusetts, we have restrictions on receiving shipments of wine, so I purchase these wines from Marty's, Costco, Trader Joe's, Newton Lower Falls Wine Company, and Nine East Wine Emporium.

Enjoy!

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Holy Cow Food Allergy News

Tech savvy Saffie Farris is the mother of a child with a severe milk allergy. She created a site that uses RSS feeds to pull articles from online sources and places them in a "custom e-newspaper." In other words, no need to surf for food allergy news, websites and blogs. This site contains it all.

I don't know how she did it, but I love it! Check out the site and sign up for the newsletter. Contact Saffie to add your website and/or blog.

One-stop shopping...it's a beautiful thing!

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Our Storage and Backup Strategy

Over the past year, Harvard Medical School has worked with research, administrative, and educational stakeholders to develop a set of storage policies and technologies that support demand, are achievable in the short term and are affordable.

I recently gave a keynote at Bio-IT World where I described the HMS storage strategy to ensure scalability, high performance, and reliability.

Since that presentation, we've refined our strategy for replication/backup/restoration of data for disaster recovery. In many ways backup is a harder problem to solve and a more expensive project than data storage itself.

Our best thinking (a strawman for now that we are still reviewing with customers) is outlined on this slide

For databases and Microsoft exchange, we're using Data Domain appliances to replace tape and using the following backup schedule - 3 days of checkpoints, 14 days of incremental backups, 60 days of weekly cumulative incremental backups and 3 months of full backups

For research data and administrative data, we're creating 1 checkpoint daily for 14 days and 1 checkpoint weekly for 60 days. Data is fully replicated between two datacenters.

The reason we have chosen replication and checkpoints is 3 fold:
1. Costs - We are able to reduce costs significantly using large quantities of a single reasonably priced storage system. It's actually cheaper for us to have a large quantity of a single storage type, then replicate our data using simple tools than it is to have multiple tiers of storage for short term, backup, and long term storage. The research community is very sensitive to the cost of storage, so we need to balance risk and cost. Replication with checkpoints does that nicely.

2. Technological simplicity - With every different storage type comes a different set of tools and a learning curve. Having one set of storage and one set of tools for our administrative files and research community results in a much easier environment to maintain.

3. Requirements of customers are met - We have asked our customers for their input on the need for file recovery and retention. Using checkpoints and replication meets the majority of their needs. Some departments have asked not to replicate at all, since it is cheaper to rerun an experiment than to replicate the terabytes of data each experiment generates.

Storage is a journey. The needs of BIDMC and the needs of Harvard Medical School are different so the choice of technologies and the balance of reliability/cost is different. By working with customers and embracing evolving storage technologies we believe we can meet the demand for storage at a price the institution/our customers are willing to pay.

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Meaningful Use has Arrived

After months of anticipation, the definition of Meaningful Use has arrived.

Today at the meeting of the HIT Policy Committee, the Workgroup on Meaningful Use presented its work, as a preamble and a matrix.

The meaningful use matrix is organized into specific meaningful use goals to be achieved by 2011, 2013, and 2015. It also lists metrics for these goals to evaluate hospital and clinician progress in meeting them.

Over the past 60 days, HITSP Tiger Teams have been hard at work simplifying the HITSP Interoperability Specifications by creating a small set of services which we call Capabilities. You'll see that these capabilities support all the data exchanges needed for meaningful use, including clinical operations (lab, rad, eRx, clinical summary), clinical quality (quality/performance measures, public health reporting, biosurveillance, immunization registries), and privacy/security (encryption, authorization, auditing are built into the HITSP capabilities).

If you need an elevator speech about meaningful use, slides 22-32 in the HIT Policy Committee meeting presentation provides a great overview of the criteria supporting five focus areas

Improve Quality, Safety, Efficiency?
Engage Patients and Families
?Improve Care Coordination?
Improve Population and Public Health?
Ensure Privacy and Security Protections?

Now that the initial definition of meaningful use is available, the HIT Standards Committee workgroups and HITSP will work through the month of July to ensure the matrix is populated with the most up to date standards and implementation guide detail.

Hospitals and Clinician offices now know what is expected for 2011, so the time is now to begin your software implementations.

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Update: Food Allergies and Surgery

Today was the big day- surgery to remove tonsils and adenoids. Rather than a hospital, the surgery took place at an outpatient surgical center. I really weighed the pros and cons of doing the surgery in this location instead of a hospital, but after touring the facility, I felt good about this choice. So far so good, as my son is recovering nicely at home.

During the tour, I asked to see ingredient labels for all medications. They were very accommodating. Some I had to check at home on-line as the ingredients weren't available on the container. I also checked out the labels for the popsicles and water ice they offer after the operation. The labels looked fine, but we decided to bring our own.

When we arrived, my son received a special red band with all his food and medication allergies clearly listed.

Even though the nurses and doctors were well aware of his allergies, we still got instructions such as "give him lots of pudding, macaroni and cheese, milkshakes, scrambled eggs"...hmmm...can't serve any of those. I also ran into another gotcha when the surgeon prescribed Zofran, an anti-nausea medication. The tablets contain lactose, a no-no for the milk allergic. He switched it to the orally dissolving tablets which don't contain lactose. I only found this out after a thorough internet search. Don't rely on medical professionals to manage your food allergy.

Well, off to re-fill the water ice cup! Thank you for all of your well-wishes as we faced this procedure.

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Being There, Virtually

In several blog posts, I've discussed my desire to travel less but still stay connected to all my colleagues, the industry, and government via technologies that support virtual meetings. Last week was a great example of all these technologies in action. I did not set foot in Logan Airport on a single day, yet I traveled all over the world. Here's how I did it:

Monday - Madison, Wisconsin via Webex. Patty Brennan led an interactive planning teleconference and presentation with 20 people to prepare for evaluation of nearly 150 proposals as part of Project HealthDesign. We had a great dialog about Patty's presentation using only a phone and browser (Firefox on Mac OS X in my case).

Tuesday - Washington DC via Adobe Connect. The Office of the National Coordinator convened the first meeting of the HIT Standards Committee Clinical Operations Workgroup using virtual meeting technology. Previous versions of Adobe Connect were problematic on Mac OS X, but the current version works flawlessly.

Wednesday Washington DC via Adobe Connect for the HIT Standards Committee Clinical Quality Workgroup. Wednesday was a tricky day for me. I had to be in Boston for a meeting of the Board of the Personal Genomes Project, then in Washington for the Workgroup call, then in Washington for a meet and greet with HITSP volunteers. There was no way I could complete all that needed to be done with physical travel. Adobe Connect was great for the Workgroup meeting, but what about the meet and greet? The event was in a hotel with slow and expensive internet connectivity, making high definition video conferencing out of the question. We implemented "poor man's telepresence" - a life-sized photograph of me (the photo above), a speaker system (looks like a Darth Vader helmet), and a telephone. I spoke to the 200 guests, then had "virtual cocktail hour" with several individuals for 1:1 conversations.

Thursday - Washington DC via Adobe Connect for the HIT Standards Committee Privacy Workgroup in the morning, then the world via a live webcast in the afternoon, then San Jose via Telepresence in the evening. Better Management.Com/SAS asked me to speak about HITECH and the upcoming efforts to computerize 70% of all hospitals and 90% of all clinician offices by 2014. You'll find a stream of the live broadcast online. Webcasting is a very effective way to reach a large audience. In this case, the newscaster was in a studio in North Carolina and I was in a studio in Boston. I ended the day with a Telepresence conversation from my basement to San Jose with Pamela Hymel, Senior Corporate Director of Integrated Health and Global Medical Director for Cisco Systems, regarding the use of virtual health visits to improve employee health.

Friday - Not a virtual meeting, but related. I met with Paul Sagan (cousin of Carl Sagan), CEO of Akamai Technologies, in Cambridge to discuss a number of BIDMC related projects. He explained that 20% of the entire web passes through Akamai's infrastructure as of 2009, given the need for bursts of bandwidth with a guaranteed quality of service, especially streams, webcasts and audio content delivery (Akamai hosts all of iTunes for example).

As airline seats shrink and the time/expense of air travel becomes more problematic, it's clear to me that Webex, Adobe Connect, Telepresence, Webinars, Webcasts, and even good old fashion phone teleconferencing must become the 'new normal' for the way we work.

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Another Key to the Food Allergy Puzzle?

A study recently released indicates that black male children have an increased risk of food allergy compared to other groups.

The study involved over 8200 participants ages 1-85. Peanut and shrimp were the most common food allergies and a study of demographics revealed that blacks, males and children, especially black male children, were found to have higher levels of sensitization associated with clinical food allergy.

I don't know what that means, but I don't feel too dumb since the researchers don't either. I just appreciate that studies are being conducted and hope that somewhere there's a big room with notes, scribbles and arrows all over the walls as scientists try to unlock the mysteries of food allergy.

Here's the full report from the Academy of Allergy, Asthma and Immunology.

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The First meeting of the Privacy and Security Workgroup

Today, the HIT Standards Committee Privacy and Security Workgroup met for the first time to discuss our charge, our deliverables, and our workplan.

The broad charge to the workgroup is to make recommendations to the HIT Standards Committee on privacy and security requirements for standards, implementation specifications, and certification criteria.

The specific charge is to make recommendations to the HIT Standards Committee on specific privacy and security safeguards that should be included in the definition of Meaningful Use, with a specific focus on the eight (8) areas listed in Section 3002(b)(2)(B), within two (2) months of the workgroup�s first meeting.

Dixie Baker from SAIC and Steve Findlay from Consumer's Union co-chair the workgroup. Dixie began the meeting with a few remarks that frame the work ahead very well:

"I welcome the opportunity to lead this workgroup in specifying the privacy and security safeguards that should be included in the definition of 'meaningful use.' Health IT can be used meaningfully only if the caregiver trusts it to deliver the services and information she needs to help make sound decisions at the point of care, and if the patient trusts it to protect his privacy.

Specifying safeguards is always an exercise in risk management, and in addressing our task, we�ll need to consider patient privacy risks balanced against safety and quality risks associated with unavailable, incomplete or corrupted information, as well as public trust risks associated with systems that lack integrity or accountability � all driven by the policy direction we�ll be receiving from the Policy Committee. The HITECH Act clearly recognizes the importance of trust in attaining �meaningfulness� � privacy and security are addressed in three of the Act�s eight priority areas of focus. So our workgroup clearly has an important challenge in specifying what is required for health IT to be trustworthy enough to be used meaningfully. And as we discussed at the full Committee meeting, I would expect the bar to be raised over time.

I�m looking forward to learning more about the ONC�s needs and expectations from our workgroup and from the full Standards Committee. "

As with the other groups, the Privacy and Security Workgroup will be reviewing meaningful use after it is discussed on June 16 at the HIT Policy Committee. The workgroup chairs will coordinate their initial workplans via a call on June 19 and will present the first reactions of their workgroups at the June 23 public meeting of the HIT Standards Committee. The workgroups will complete their work, editing/amending the meaningful use matrix with standards, implementation guidance, and certification criteria by August 1.

The Privacy and Security Workgroup is a bit different than Clinical Operations and Clinical Quality in that specific practices at each EHR site can reduce or increase security risk. The workgroup will try hard to provide guidance that is widely implementable in an attempt to reduce security risks for each EHR site, both large and small.

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The First meeting of the Clinical Quality Workgroup

Today, the HIT Standards Committee Clinical Quality Workgroup met for the first time to discuss our charge, our deliverables, and our workplan.

The broad charge to the workgroup is to make recommendations to the HIT Standards Committee on quality measures that should be included in the Meaningful Use definition and for future EHR requirements. Also to make recommendations to the HIT Standards Committee on requirements for standards, implementation specifications, and certification related to EHRs and clinical quality.

The specific charge is make recommendations to the HIT Standards Committee on specific quality measures that should be included in the definition of Meaningful Use for 2011 within two (2) months of the workgroup�s first meeting. The workgroup will also take into consideration the eight (8) areas listed in Section 3002(b)(2)(B) when developing recommendations for the committee.

As I discussed in yesterday's blog, the HIT Policy Committee will discuss a matrix of meaningful use, standards, certification criteria, and meaningful use measures at their June 16th meeting. The Quality Workgroup will review this matrix and edit/amend it with appropriate accepted/recognized standards over the next 60 days.

For Quality measures, the important work to date includes HITEP I, HITEP II, and HITSP's efforts to create services with the capbilities to exchange raw data and computed measures.

NQF released the draft of HITEP II's work for public comment yesterday. It includes an important framework for describing quality measures based on EHR data types.

HITSP Tiger Teams are hard at work this week finishing a set of services which include 4 capabilities supporting quality:

-Collect and Communicate Quality Measure Data for a Hospital
-Collect and Communicate Quality Measure Data for Clinicians
-Quality Measures for Hospital Quality Information Reporting
-Quality Measures for Clinical Quality Information Reporting

The first two capabilities include the raw data needed to compute quality measures i.e. meds, labs, and process data

The second two capabilities include pre-computed patient level quality measurement numerators and denominators, a summary rather than the raw data. These services use the Quality Reporting Document Architecture (QRDA), a constrained form of CDA

On June 16th, the Quality workgroup will receive meaningful use guidance from the HIT Policy Committee. We'll work hard over the following week and will present our strawman standards, implementation guidance, and certification criteria at the June 23rd public meeting of the HIT Standards Workgroup. We'll continue to refine the matrix in July and complete our work in August.

As I said yesterday, it's going to be a fun summer for everyone in healthcare IT!

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The Mother of all Food Allergies

Now, I know when you're going through something, it doesn't help much to hear, "if you think you have it bad, listen to this one...".

But if food allergies are getting you down, you gotta listen to this one...

A California teen is allergic to ALL food. Her symptoms of difficulty breathing, weight loss, extreme fatigue and facial swelling, baffled family and doctors alike. As her health continued to deteriorate, an answer was finally found. The teen was diagnosed with Eosinophilic gastrointestinal disorder or EGID. This condition causes eosinophil (one of the body's white blood cells) to treat food as an invader, causing an allergic reaction.

In order to get nutrients into her body, she was given the choice of a stomach pump, or drinking a foul-smelling, foul-tasting liquid. She chose the liquid which had to be ingested several times a day.

After several months, her body has healed enough to begin to re-introduce foods- one at a time. Her father says, "It's like Russian roulette".

I know the trauma we went through with our recent, unsuccessful egg challenge. I can't even imagine going through this process over and over.

Apparently little is known about EGID and there is virtually no funding available for it. According to the teen's father, "This isn't just a food allergy. It's the mother of all food allergies. If you go to any kind of allergy conference nowadays, this is the hot topic. This is what they're all talking about."

Did any of you hear about this at FAAN conferences this year?

So, the next time I grumble about making egg and dairy-free cupcakes for another party, remind me about this story. Sometimes it does make things easier when you think, "Okay, this isn't SO bad".

Check out the full story.

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The First Meeting of the Clinical Operations Workgroup

Today, the HIT Standards Committee Clinical Operations Workgroup met for the first time to discuss our charge, our deliverables, and our workplan.

As I discussed in Monday's blog, the broad charge of the workgroup is to make recommendations to the HIT Standards Committee on requirements for standards, implementation specifications, and certification criteria related to EHRs and clinical operations. The specific charge is to make recommendations to the HIT Standards Committee on the role of EHRs and e-prescribing, clinical summaries, laboratory and radiology report functionality within two (2) months of the workgroup�s first meeting.

That means that by August 9, we must complete our initial work.

What will that work be?

On the call we discussed that the HIT Policy Committee will review a draft of meaningful use criteria at its June 16th meeting. Once this draft is delivered to the HIT Standards Committee, its workgroups can review the standards and certification criteria which map to meaningful use. Imagine a 4 column table

Column 1 - An aspect of meaningful use i.e. e-Prescribing

Column 2 - The standards and implementation guidance needed for meaningful use i.e. NCPDP Script 10.5 and RxNorm as implemented in the HITSP Capability document "Issue Ambulatory and Long-term Prescriptions"

Column 3 - The certification criteria i.e. Conformance testing using the CCHIT Laika tool for appropriate implementation of NCPDP Script 10.5

Column 4 - The meaningful use measure i.e. what percentage of prescriptions in a practice were e-prescribed?

The above examples are illustrative only - they are not work products of any committee.

Note that certification criteria and meaningful use measures are decoupled. Certification verifies the capability while the meaningful use measure documents the integration of the capability into daily workflow.

In addition to mapping all aspects of meaningful use to standards and certification criteria (leveraging all the work done by HITSP and CCHIT to date), the HIT Standards Committee and its workgroups will also consider the "ARRA 8" and how standards and certification support them.

1. Technologies that protect the privacy of health information i.e. common data transport, auditing, authentication, authorization

2. A nationwide health information technology infrastructure i.e. enveloping and delivery standards

3. The utilization of a certified electronic record for each person in the US by 2014 i.e. standards in support of meaningful use

4. Technologies that support accounting of disclosures made by a covered entity i.e. standards similar to audit trails that also include disclosures made to third party

5. The use of electronic records to improve quality i.e. aspects of meaningful use that enhance safety and standards which support quality measurement

6. Technologies that enable identifiable health information to be rendered unusable/unreadable i.e. encryption

7. Demographic data collection including race, ethnicity, primary language, and gender i.e. standards which support demographic exchange

8. Technologies that address the needs of children and other vulnerable populations i.e. standards supporting immunization registries

Thus, the Clinical Operations Workgroup will complete two documents over the next 60 days - one which provides the standards/certification guidance needed for implementation and measurement of meaningful use and one supporting the ARRA statutory requirements. The documents will be forwarded to the HIT Standards Committee for review/approval and then forwarded to ONC.

It's going to be a busy summer. The pace of the Clinical Operations Workgroup accelerates as soon as the HIT Policy Committee completes its meeting on June 16.

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My Top 10 Tips for Staying Healthy

My blogs for the remainder of the week will cover the first meetings of the HIT Standards Committee Workgroups - Clinical Operations, Clinical Quality, and Privacy/Security. Thus, I'm doing my more personal blog of the week today.

Now that I'm 47, I'm learning to appreciate the challenges of staying healthy as I age. Based on my personal experience, here are my top 10 tips.

1. Maintain a normal Body Mass Index
A Body Mass Index between 18.5 and 24.9 is ideal. An ideal BMI is more about lifestyle than diet. It takes effort!

For me, the combination of daily exercise, a vegan diet, and green tea for the past 8 years has worked well to keep my BMI in the mid-normal range at 21.7

2. Exercise daily
I try to exercise every day through a combination of Kayaking on the Charles River, Cycling through the rural byways of Needham/Dover/Sherborn, Hiking in the White Mountains of New Hampshire, Nordic Skiing in Noanet Reservation, and very vigorous gardening (hauling, digging, mulching etc)

My goal is 3500 calories burned via exercise every week. This seems to keep my BMI stable.

3. Eat a vegan diet
It's easy to eat badly as a vegetarian. Ben and Jerry's Chunky Monkey is Vegetarian. Chili-cheese dip is vegetarian. Eggnog is vegetarian. Trying eating badly as a vegan (only foods that grow in the ground) . You could drink pure olive oil, but it's really hard to eat badly. If you further limit yourself to locally grown, organic foods (for the majority of your diet - tea and chocolate are not locally grown), you're going to eat a high fiber, low calorie, low fat diet. That's good for your heart and good for your BMI.

4. Drink green tea
I drink two pots of green tea every day, usually Gyokuro Asahi tea from Kyoto. It's very low in caffeine and high in polyphenols, reducing cholesterol and providing anti-oxidants. It has zero calories without the artificial sweeteners and chemicals found in diet drinks. Staying hydrated keeps your energy up and your mind clear.

5. Drink red wine in moderation
I drink 6 ounces of red wine with dinner each night. It do not consume wine as thirst quencher or as a stress reliever, I drink it as a complement to food. It's high in polyphenols and reduces heart attack/stroke risk.

6. Eat dark chocolate
Dark Chocolate is very high in anti-oxidants and has several health benefits including reduced cholesterol and blood pressure.

7. Use sunscreen
The time I spend outdoors can dry out my skin and increase my chance of skin cancer. I use SPF 45 on my face, neck and arms whenever I'm doing outdoor activities.

8. Take Vitamin D and a Multivitamin daily
Since I use sunscreen generously and do not drink milk, I do not get all the Vitamin D I need. Also, as a vegan, I get limited B12 (it does not exist in plants but small amounts are found in soil, which inevitably makes it way into our diet when we eat root vegetables). Taking Vitamin D and a Centrum Silver daily works for me.

9. Avoid caffeine and lifestyle medications
Rather than starting each day with a boost of caffeine and ending each day with a mixed drink, I just stay even all the time. I also avoid 'lifestyle medications' such as mood enhancing drugs, nicotine, energy drinks, sleeping aids, etc. Although they may have positive short term effects, the long term effects and side effects are ultimately deleterious.

10. Have a positive attitude
Each day is filled with success and failure, joy and sorrow, energy and fatigue. Having a positive attitude about the complexities of life and realizing that all will be well goes far to keep you healthy, active, and energized.

Maybe I should package these 10 items into a best selling book called "The CIO Diet - a prescription for a healthy lifestyle"!

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Biking for Food Allergies

I love this story! Bill Arendt (Willie) is pedaling for food allergies. Willie left Los Angeles on May 10 and he plans to bike to Boston- 3415 miles to benefit FAAN (Food Allergy and Anaphylaxis Network). He charts his progress online every night. Make a monetary pledge or just leave a note of encouragement. Check out the full story.

How cool is that????

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The National HIT organizations - How it all works

Several blog readers have asked me to take a fresh look at all the organizations related to ARRA and explain how it all works. Here's my understanding:

Office of the National Coordinator
The Obama administration's ONC is different from the Bush administration's ONC in several ways. It's now funded with $2 billion to accelerate healthcare IT adoption. Its new leader, Dr. David Blumenthal has a policy focus, so we'll see broad policy guidance and specific healthcare outcome goals rather than technology for technology's sake. It has regulation - ARRA is law and there are several new privacy, standards, and implementation requirements that were only voluntary or market-driven previously. You can expect that ONC will have a major role in coordinating federal agencies' use of healthcare IT as well as adoption in the private sector. By controlling the definition of meaningful use of healthcare IT as the gatekeeping function for paying stimulus dollars to clinicians, ONC has real power.

HIT Standards Committee
The Health IT Standards 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. Initially, the HIT Standards Committee will focus on the policies developed by the Health IT Policy Committee�s initial eight areas (listed below). The HIT Standards Committee will also provide for the testing of standards by the National Institute for Standards and Technology (NIST). In its first meeting, the HIT Standards Committee created three workgroups. Below are their Broad and Specific charges:

Clinical Operations Workgroup:
Broad Charge �
Make recommendations to the HIT Standards Committee on requirements for standards, implementation specifications, and certification criteria related to EHRs and clinical operations.

Specific Charge �
Make recommendations to the HIT Standards Committee on the role of EHRs and e-prescribing, clinical summaries, laboratory and radiology report functionality within two (2) months of the workgroup�s first meeting. The workgroup will also take into consideration the eight (8) areas listed in Section 3002(b)(2)(B) when developing recommendations for the committee.

Clinical Quality Workgroup:
Broad Charge �
Make recommendations to the HIT Standards Committee on quality measures that should be included in the Meaningful Use definition and for future EHR requirements. Make recommendations to the HIT Standards Committee on requirements for standards, implementation specifications, and certification related to EHRs and clinical quality.

Specific Charge �
Make recommendations to the HIT Standards Committee on specific quality measures that should be included in the definition of Meaningful Use for 2011 within two (2) months of the workgroup�s first meeting. The workgroup will also take into consideration the eight (8) areas listed in Section 3002(b)(2)(B) when developing recommendations for the committee.

Privacy and Security Workgroup:
Broad Charge �
Make recommendations to the HIT Standards Committee on privacy and security requirements for standards, implementation specifications, and certification criteria.

Specific Charge �
Make recommendations to the HIT Standards Committee on specific privacy and security safeguards that should be included in the definition of Meaningful Use, with a specific focus on the eight (8) areas listed in Section 3002(b)(2)(B), within two (2) months of the workgroup�s first meeting.


HIT Policy Committee
The Health IT Policy Committee will make recommendations to the National Coordinator on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 (ARRA) provides that the HIT Policy Committee shall at least make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas:
-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

At it's first meeting, The HIT Policy Committee created three workgroups - Meaningful Use, Information Exchange, and Certification.

Here's the broad and specific charge for the Information Exchange workgroup. I'll add the details for the others as soon as I receive it.

Information Exchange Workgroup:
Broad Charge-
Make recommendations to the HIT Policy Committee on policies, guidance governance, sustainability, and architectural, and implementation approaches to enable the exchange of health information and increase capacity for health information exchange over time.

Specific Charge-
Make recommendations to the HIT Policy Committee within six (6) months regarding priority policy areas and other issues that are necessary in the short term to advance the exchange of health information through implementation of HITECH. Make recommendations to the HIT Policy Committee to inform and provide guidance on the implementation of the Nationwide Health Information Network (NHIN)


Health Information Technology Standards Panel
HITSP provides an important consultative role to the HIT Standards Committee. As the HIT Standards Committee and its workgroups prioritize the transactions needed to support meaningful use, they will consult standards harmonization organizations (HITSP), Standards Development Organizations, and Implementation Guide writers. HITSP volunteers and staff have been placed on each of the HIT Standards Committee workgroups to provide technical assistance.

National eHealth Collaborative
NeHC, based on their recent meeting, will focus on implementation topics such as regional healthcare IT extension centers and the reality of increasing EHR adoption in the country.

Certification Commission for Health Information Technology
I'm confident that CCHIT will continue to be the leading HIT certification organization in the US, but its certification criteria will evolve. The HIT Policy Committee's workgroup on certification is likely to provide valuable input about certification by the Fall.

I hope this helps clarify how all these organizations relate to one another as they all work together to support ARRA, improve healthcare quality, and enhance efficiency, all through the implementation of interoperable healthcare IT.

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Cool Technology of the Week

Today's Cool Technology blog entry is not about a product, but a concept.

I've had numerous companies (more than 5) approach me in the last 90 days with a product in development that I'll call "Image Exchange in the Cloud".

One of the great challenges we have in healthcare is that radiology/cardiology/GI/pulmonary/Ob-Gyn images are not easily sharable between organizations. Although DICOM is a generally accepted standard, there is not an easy to use health information exchange in most communities to send DICOM data from place to place.

Sure, we could engineer numerous point to point solutions i.e. one organization's imaging modalities push DICOM images to another organizations image archive. However, such an approach is complex. Who owns the medical record? How long should the image be retained? What security should be used to transmit the image between organizations? How should the patient be uniquely identified if we want to storage all images for a given patient from multiple institutions together?

Here's the solution that all the companies entering this marketplace are suggesting:

1. A cloud computing offering is made available on the web for image exchange. No IT department has to host data, manage images, or deal with security issues.

2. A DICOM image is sent to the cloud along with a list of email addresses of individuals who can access the image and the length of time they can access it i.e. 30 days

3. The named individuals receive an email along with a URL and password to access their images on the cloud. For example, such individuals could be a consulting radiologist or cardiologist who may be over-reading the study.

4. A universal web-based DICOM viewer enables the authorized individuals to view the image without installing additional software i.e. there is no need to run proprietary workstation software from GE, Siemens, Philips, Agfa, Kodak etc.

5. After the reading is done, the username/password used to access the cloud computing site expires after the duration specified.

This solution is appealing for image sharing because it is low impact on IT departments, requires no local storage, is secure, requires no special software, and is simple to implement.

I look forward to many product offerings for healthcare imaging sharing via the cloud over the next year. That's cool.

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Food Allergies in the Hospital

We're making plans. Tonsils and adenoids need to come out, and we'll be in the hospital with food allergies. This is something I've thought about, late at night, when all is quiet and I should be sleeping.

What if my son ever had to be hospitalized?
How would we deal with his food allergies in the hospital?

I guess the good news is that we have some time to plan. I can talk to someone in patient dining services at the hospital in advance and find out what they can offer. We can bring in safe foods. With a tonsillectomy, we're probably just looking at juices, popsicles, safe ice cream and jell-o anyway.

Of course then there's all the medication to worry about. What's in it? Are there any inactive ingredients he may be allergic to? I see another sleepless night coming on...

Any experience in this?

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Our Garden

In New England, you never know what the weather will bring, so my family and I are always conservative about planting our garden. Every year for the past 13 years we've planted on Memorial day weekend.

When we first moved to New England, the first thing we did was remove much of our lawn - it wastes water, uses chemical fertilizer, and various herbicides/insecticides to keep it green. Instead we planted a variety of perennials and native shrubs.

Our five mini-gardens are:

1. Japanese Garden - filled with Japanese ferns, bamboo, cedar, a Shinto Shrine, a meandering river of rock, and a Jizo statue.

2. Vegetable Garden - we grow many of our own vegetables including 5 varieties of heirloom tomatoes, eggplant, bok choi, cucumbers, lettuce, edamame, pumpkins, peas, and herbs.

3. Cottage Garden - A butterfly garden filled with white blooming perennials and a clematis trellis

4. Rhododendron Forest - a thicket of rhododendrons under the shade of old hemlock trees.

5. Iris Garden - bearded and beardless irises set among sedges, sedum, and maples.

My approach to gardening is phased and incremental, rather than big bang. I start in early April by cleaning up the yard from winter, removing branches, leaves, and accumulated debris. In mid April, I mulch heavily to eliminate any weed growth before the warm weather arrives. In late April, I place all the garden statuary, pots and bird houses that were stored away during the winter. In early May, I add fresh soil from my compost pile to the pots and raised beds. In mid May, I tune all the irrigation systems. Finally, at the end of May we plant - organic vegetables from Russell's, annuals from Volante Farms, and seeds from Seeds of Change .

The warm and temperate Spring has been great for 5 gardening areas. All of the photos above were taken today, so you have a real time view from June 3.

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Service Level Agreements

I was recently asked about our approach to Service Level Agreements (SLAs) at BIDMC.

We develop customer facing SLA's for every new infrastructure and application as part of our standard project management methodology. We work collaboratively with the application owner and subject matter experts to develop a mutually acceptable process for support escalation, with defined availability and response times.

The end result is a series of documents which outline customer and IS responsibilities, as well as provide enough detail about the application to understand its scope and uses.

Customer Facing Documents:
1. Customer Project and Post Project Responsibilities - This document serves as a foundation for each project and sets customer expectations for support roles and responsibilities.
2. Service Level Agreement - I've attached an SLA for a live application to illustrate the types of service level documentation we provide.

Internal IT Documents:
1. Business Impact Analysis - a worksheet used by our managers to facilitate discussions with application owners and document service level of objectives based on business requirements.
2. Service Level Objectives - availability and disaster recovery service levels by class of application

A few general observations about our SLAs.

1. Much of our planned downtime is now done as a background task thanks to improvements in our configurations. For example, we have clustered servers, redundant network components and Internet connections, mirrored storage devices, shadowed or mirrored data bases, and other improvements that have remarkably decreased the need for disruptive, planned outages.

2. Escalation processes differ slightly for our mission critical clinical applications, such that downtime over two hours triggers implementation of paper-based downtime procedures.

3. In addition to our own hosted applications, we have a few Software as a Service applications. Our SLAs with hosting vendors include:

a. Expected uptime. In some cases this is backed by a well-defined formula that states the goal, e.g. 99.9%, and any other qualifiers such as excluding planned downtime that is done at a mutually agreed upon times. Whatever is set as an uptime goal usually drives the high availability and disaster recovery configurations.

b. Transaction performance. This has traditionally not been a problem for us, but for applications that may have not been engineered well, it's an important component of an SLA.

c. Escalation. Defining the event levels (priority one, priority two etc.), contacts, and what response time (phone vs on-site) and repair time can be expected is a key component. Time to repair is usually a tough negotiation in hosted application SLAs.

d. Remedies. This is not usually defined in internal agreements, but is for vendor agreements. The typical remedy is a credit on future maintenance payments, which is not always satisfying if you lose an application for a prolonged period.

Feel free to use my SLA documents as templates in support of your own service level documentation needs.

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School Carnivals, Picnics and Parties, Oh My!

The school carnival is this week. I'm in charge of food this year, because I figured if I organized it, I'd be in the know. Yeah, not so fast. "We must have popcorn", I was told because the smell of the popcorn popping is "so carnival-like". Okay, I rented the machine and got the popcorn. Does artificial butter flavor contain any dairy? "No" says the popcorn company representative. Of course I have no way of knowing what else has been put in the rented machine and no idea how well it's been cleaned. Confidence level on a scale of 1-10 with 10 being totally confident?- a 2. I'll bring safe popcorn.

We're also serving water ice which is basically sugar, high fructose corn syrup and dyes. Our school has started distributing, via e-mail, ingredient lists of foods served to students at these special events. Interesting responses. Some parents who don't need to look at food labels on a regular basis are surprised about what's in some of these foods (ie: long chemical names, high fructose corn syrup, etc.) One mother of a diabetic son asked if carbohydrate and sugar content could be included in the lists going to parents.

I think our school needs to develop a form that captures all food concerns that families have. That information then goes out to all families so they can plan appropriately.

How do your schools handle this? Is it working?

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An Update to the National eHealth Collaborative

Today I'm in Washington presenting a HITSP update to the National eHealth Collaborative. My slides are available.

A few highlights:

1. HITSP has "turned on a dime" to focus on meaningful use and ARRA's 8 priorities:
-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

2. HITSP has embraced a service oriented architecture which enables reuse of capabilities instead of requiring new value cases for each novel requirement. Our initial services include:
- Issue Ambulatory Prescriptions
- Query for Medication History
- Communication of Structured Documents
- Communication of Unstructured Documents
- Clinical Referral Request
- Retrieval of Medical Knowledge
- Return Laboratory Results Message
- Communication of Laboratory Reports
- Communication of Imaging Information
- Quality Measures for Hospital based Quality Information Collection and Reporting
- Quality Measures for Clinician Quality Information Collection and Reporting
- Immunization Registry Update
- Immunization Registry Query
- Communication of Immunization Documents
- Vaccine and Drug Inventory Reporting
- Public Health Case Reporting
- Emergency Common Alerting
- Send and Receive Relevant Bio-Surveillance Data
- Communicate Resource Utilization
- Exchange Administrative Benefits/Eligibility Transactions
- Exchange Administrative Referral/Authorization Transactions
- Provider Directory

3. HITSP is moving to an electronic publication approach for all its implementation guidance.

4. HITSP has embraced USHIK as a respository for its harmonized standards and codesets

5. The July 15 deliverables will directly support the needs of the HIT Standards Committee and its workgroups to identify standards, implementation guidance, and certification criteria in support of meaningful use.

Next week, the HIT Standards Committee Workgroups will meet for the first time. HITSP volunteers and staff will ensure all this ARRA specific work is communicated to those groups.

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