Doctor Fakes Research and Goes to Jail

A prominent 51 year old anesthesiologist pled guilty to falsifying research on the analgesic medications Celebrex and Vioxx for post-op pain managment.  He was sentenced in Massachusetts federal court to 6 months in prison and given hefty fines to be paid to the pharmaceutical companies who financed his research and paid him to promote their drugs.

Dr. Scott Reuben just plain faked the results.

The June HIT Standards Committee meeting

Today's HIT Standards Committee meeting had a rich agenda.

The recurring themes were the importance of governance, the interdependency of policy and technology, and the need for objective criteria to measure the appropriateness of standards choices.

We began our discussion with a presentation by Doug Fridsma of the ONC Standards and Interoperability Framework which includes use case development, harmonization of core concepts, implementation specifications, reference implementation/pilots, certification, and testing.

The intent of the Framework is to ensure standards gaps are filled as necessary to support meaningful use and healthcare reform. The Framework provides the means for managing the standards lifecycle, enabling re-use, and ensuring standards meet functional requirements. Although the Framework is comprised of 11 RFPs, it will function as a single process, guided by a Concept of Operations plan (ConOps). The principles driving the ConOps include representative participation, transparency and openness, responsiveness, accountability, and measurable/planned results.

Next, Arien Malec reviewed the NHIN Direct consensus proposal of the NHIN Direct effort. The NHIN Direct groups have suggested SMTP/TLS as the backbone with SMTP/TLS, REST or SOAP at the edges to communicate with a Health Internet Service Provider, which provides backbone exchange services.

After hearing the NHIN Direct presentation, the committee emphasized the importance of providing policy guidance to constrain the NHIN Direct technology implementations, the need for the HIT Standards Committee to serve as a "Board of Directors" reviewing NHIN Direct progress at key checkpoints, and the need to communicate the scope of the NHIN Direct project - what is considered part of the NHIN Direct effort and what is an additional service provided outside the scope of the project.

A policy example includes the notion that a HISP routing service need not examine the contents of the message during the routing process. Technology should be chosen that makes this policy possible.

A scope example includes the idea that a SOAP/XDR to SMTP or SMTP to SOAP/XDR converter should be something provided by NHIN Connect or the EHR vendor and not by the NHIN Direct project which is simple point to point communication, not standards conversion.

Next, Mary Jo Deering discussed NHIN Governance. The important takeaway from her presentation is that there will be a unified approach to NHIN Governance - not a collection of disconnected NHIN projects with their own governance. There will be hearings and ultimately regulation issued in 2011 to define NHIN Governance. The Standards Committee applauded this approach as it addressed the governance concerns we had with the NHIN Direct project.

Next, Deven McGraw presented the Privacy & Security Tiger Team Update. She outlined the general principles enumerated by the Tiger Team to ensure data exchange, especially NHIN Direct routing, discloses the least amount of data possible during transport. The Tiger Team created a framework describing 4 different kinds of intermediaries which support data exchanges. The Standards Committee recommended that the concept of intermediaries be replaced by the notion of "services" and that policies should apply to the types of services offered.

Aneesh Chopra presented the Enrollment Workgroup Update, a comprehensive plan to specify the eligibility and enrollment standards needed to support Healthcare Reform. Numerous new tools will be available to payers, providers, and patients to streamline administrative data flows. An early example of the kind of tools that will be created is Healthcare.gov, a new website that makes insurance information available to patients and will soon include comparative costs of insurance.

Janet Corrigan presented the Clinical Quality Workgroup Update outlining the progress on retooling existing 2011 quality measures and selecting 2013 measures.

Jamie Ferguson presented the Clinical Operations Workgroup Update: Electronic Document Standards for Discharge Summary & Other Encounter Summaries, describing a means to reuse templates for the creation of summary documents which support meaningful use data exchanges. Keith Boone provided an excellent summary of the discussion on his blog.

Finally, Steve Posnack and Carol Bean updated the Committee on the Temporary Certification Program. Numerous organizations have expressed interest in serving as Authorized Certification and Testing Bodies, so unlike the past there will be multiple bodies with market competition on price and service quality for certification services.

A great meeting which clarified many aspects of the NHIN Direct project, the Interoperability Framework plan, and the evolving governance of healthcare information exchange in the US.

I look forward to our July meeting, which will hopefully review the final standards rule and final meaningful use rule.

6 Ways To Help Simplify Your Life

I like to pass on good tips and these six ways to simplify your life make a lot of sense.  The constant stress we feel because life is so complicated is not good for our health.  Here are six ways you can have a simpler lifestyle:

1. De-Clutter Your Home

Look around.  If you have piles of paper, too many "things" and nic-nacs laying around it is hard to think clearly and function. An open,

The Indian Health Service Interoperability Plan

As part of the Greater Boston Beacon Community Grant resubmission, the grant collaborators worked with the DOD/VA and Indian Health Service to ensure we could seamlessly exchange data required for care coordination and population health. Developing the plan required that we understood the interoperability strategy of the DOD/VA and Indian Health Service.

Today I'll focus on the Indian Health Service.

Here's a strategic overview of the IHS interoperability plan provided by IHS CTO Mike Danielson.

The architecture follows the NHIN Exchange approach using NHIN Connect software. Interactions with IHS will be "pulls" and "pushes" using XDS.b

IHS hopes to have widescale production use of their interoperability infrastructure by the end of 2011.

At the moment, they are watching the NHIN Direct project with great interest. Presumably, since the NHIN Direct effort will plug into the NHIN Exchange effort, small provider offices will be able to post clinical records to IHS via NHIN Direct. The strategy will become clearer as NHIN Direct evolves.

The ONC Privacy and Security Tiger Team

In many previous blogs, I've mentioned that privacy and security are foundational to healthcare information exchange. A suite of policies covering authentication, authorization, auditing, consent, transmission, and encryption constrains technology possibilities and thus empowers consensus processes to harmonize the security infrastructure that supports policy.

ONC has had many groups working on privacy in the Policy Committee, the Standards Committee, and the NHIN Workgroups. Now that Joy Pritts is the Privacy Officer for ONC (in essence the healthcare IT privacy officer for the country) she has unified all these disparate efforts into a single Tiger Team, focused on resolving many challenging healthcare information exchange policy issues over the next few months.

The members are all incredible people who really understand the domain

Paul Egerman, Co-Chair

Deven McGraw, Co-Chair, Center for Democracy & Technology

Dixie Baker, SAIC

Christine Bechtel, National Partnership for Women & Families

Rachel Block, NYS Department of Health

Neil Calman, The Institute for Family Health

Carol Diamond, Markle Foundation

Judy Faulkner, EPIC Systems Corp.

Gayle Harrell, Consumer Representative/Florida

John Houston, University of Pittsburgh Medical Center; NCVHS

David Lansky, Pacific Business Group on Health

David McCallie, Cerner Corp.

Wes Rishel, Gartner

Latanya Sweeney, Carnegie Mellon University

Micky Tripathi, Massachusetts eHealth Collaborative

They have already met numerous times, following a very aggressive schedule. Their early work has been to suggest policies that will support the NHIN Direct effort.

Their basic recommendation thus far is that protected healthcare information should not be exposed in routing, unless necessary for transmission from A to B. Standards that expose more information than necessary in metadata or mix metadata and content should be avoided.

Sometimes inspection of a content payload has value such as ensuring conformance with a standard or providing translation from one standard to another. However, from a policy perspective it is reasonable to say "The payload need not be inspected or changed during transmission”

Tomorrow, the Tiger Team is hosting an important Consumer Choice hearing.

The purpose of the hearing is to learn more about the capabilities of existing consumer choice technology and the potential for future development in this area. The morning session will focus on consumer choice technology in use today in health information exchange. A user of the technology will speak about their specific implementation of the technology, accompanied by a demonstration. The afternoon session will take a look at consumer choice technologies that are in the development stages for use within health information exchange. The developers have been invited to demonstrate either a prototype of the technology or its current use, and discuss its potential for further development within health information exchange.

I look forward to the work of the Tiger Team. When policy and technology are developed in parallel, each supporting the other, everyone wins.

Good Lessons Come from McChrystal Debacle

General Stanley McChrystal's loose lips and ultimate downfall can teach us all some valuable lessons.  He was a career military man (West Point Graduate) who rose to the top of the heap as Commander of the International Security Assistance Force and Commander of U.S. Forces in Afghanistan.  People are scratching their heads about how a man who was in such an esteemed position could be so stupid

Omega 3 FFA for Depression

A study published in the Journal of Clinical Psychiatry has shown that supplementing Omega-3 fatty acids (FFA) can significantly reduce symptoms for patients with major depression.  This study looked at 432 adult patients (mean age 46 years, 68.5% female) and randomized them to receive either 8 weeks of omega 3 FFA or placebo.  40% of the patients were also taking antidepressants when they

The final Temporary Certification Rule

In the past, I've posted bookmarked versions of the Standards IFR, the Meaningful Use NPRM, and the Certification NPRM.

The final Temporary Certification Rule has just been published.

Robin Raiford bookmarked the Federal Register version. Thanks!

Interesting points in this rule include :

*To qualify for stimulus incentives, providers must use EHRs certified by an Authorized Testing and Certification Body (ATCB).

*Organizations can apply to become ATCB's starting July 1. The rule describes the process.

*There is no restriction on the number of ATCB's.

*There is no grandfather clause for previously certified EHRs by CCHIT i.e. everyone must re-certify everything.

*CCHIT must apply to become an ATCB. I spoke with Karen Bell, the CEO of CCHIT, and they will be submitting an application.

*EHRs certified under the ATCB program will remain certified when the permanent certification program replaces the temporary certification program. HHS expects that a final rule for the permanent certification program will be issued by Fall 2010 and that the permanent program will be in place in 2012.

Reconnecting With My Past

My 30th High School Reunion is August 14, 2010 at the Point Vicente Lighthouse in Palos Verdes, CA. I've not attended previous reunions and my schedule will likely not permit me to attend this one. I've not stayed in regular contact with anyone from my high school class, but I've exchanged a few emails via Facebook with my 1976-1980 friends.

Now that we're all approaching 50, we're curious about each other. What have we become, where have we been, where are we going?

This week I've had the opportunity to meet with 2 people I had not seen in 30 years.

In many of my blogs, I share lessons learned from my experience. What can I share about exploring my youth by meeting with friends from 30 years ago?

1. Our memories for the past are selective and we tend to suppress anything unpleasant. When I was 18, I was indefatigable, my health was perfect, my responsibilities were few and my only anxieties included SATs scores, my GPA, and college applications. In retrospect, it seems an idyllic time, but was it? I've forgotten the adolescent angst of feeling rejected by the mainstream for being socially awkward. I've forgotten the uncertainty of not knowing what the future would bring. Trying to recapture the glories of the past is truly a quixotic task. Do I want to replay my high school years? Definitely not. I prefer living in present, savoring my family, worklife, and current dreams for the future.

2. Evaluating success is a subjective process. To me success is defined by the difference you make, not your bank account balance, the size of your house, the hot tub in your Learjet or your annual lifestyle burn rate. You can make a difference for a spouse, a child, a workplace or an industry. Only you can decide if you are satisfied with your life.

3. Asking "What if" questions is not useful. In my past I've made many choices - call them forks in the road. I was admitted to Yale, Brown, MIT, Johns Hopkins, Stanford, and UC Berkeley. I was rejected from Harvard. I chose to go to Stanford. I met my wife there. My daughter was born as a result. My early exposure to the computer industry, to entrepreneurship and leadership were a direct result of being in Silicon Valley from 1980-1984. In 1983, I turned down a leadership job at Microsoft (present value of stock options could be $100+ million). In 1983, I patented e-greeting cards and early multimedia technologies but the patents have not been enforced. I was admitted to several medical schools (but rejected from Harvard) and went to UCSF. I made a decision to pursue bioengineering and information technology even though I was advised in 1985 that these fields would not go anywhere. I could have chosen many other paths - I might be richer, I might be poorer, I might be famous, I might be unknown. It does not matter and there is no value in looking back.

4. You are as old as you think you are. I try to maintain a healthy lifestyle - vegan, caffeine-free, ensuring daily exercise, reserving time outdoors for mental health recovery, and limiting alcohol to a glass or two of wine per week. Rather than focus on the endurance I've lost or the increased recovery time I experience after strenuous workouts, I focus on how much better I feel than when I was a super-sized fast food, 2 latte a day, sedentary, overstressed person in my 30's. By thinking about wellness, I feel as good as I have ever felt. I look forward to increasing activities as my free time expands post retirement (whenever that might be) including walking the Appalachian Trail, trekking in Nepal, and exploring new activities that I've never had to time to investigate. Each of us measures our mental age differently. I think of 50 as the beginning of another stage of life, not a milestone of age.

5. The journey is more important than the destination. In my life, I've been a hobby shop clerk, a programmer, a manager, a leader, a doctor, a winemaker, a musician, a naturalist, a handyman, a father and a husband. Who knows what awaits. I treasure each of my experiences, and do not think of any of them as an endpoint. Along the way I've had some unusual experiences, great joys, and occasional sorrows. What defines me is not where I am today, but how I got here. Job titles, belongings, and the issues of the moment are ephemeral. A lifetime of experiences, relationships, and emotions define each individual.

It was great seeing old friends and thinking about our lives 30 years ago, but I'm happy to be who I am today, a result of all the good and bad decisions I've made.

Now forward, ever forward, to the next 30 years!

Black Spot Poison Ivy

I love learning something new in medicine and this was a new one for me...black spot poison ivy.   Poison ivy (also known as rhus dermatitis) is a common contact allergic dermatitis.  Like poison oak and poison sumac, the chemical that causes a reaction is called urushiol.  When this plant sap touches the skin a pruritic (itchy) red rash appears with little blisters that are often in a line.

Formal Authority

I was recently told by a newly promoted IT leader, "I have a great new job with more responsibility but lacking more authority"

My response - none of us really have authority or if we do, we seldom use it.

In thinking about my own leadership life over the past week, I've had to make numerous decisions based on incomplete and contradictory information from stakeholders.

If I said something like "I'm the CIO and a Senior Vice President. Since I hold the top technology job, I have authority over all technology decisions and by command we will do X", my stakeholders would lose all respect for me.

In each case this week, I was handed complex issues with "he said/she said" controversy. It would have been easy to resolve the issues with a simple "formal authority" email to remove the issue from my queue. And my decisions would have been completely wrong.

Although listening to each side of the story takes time, it's the only way to understand the nuances and technical complexity to make a sound decision. Email is not a good way to resolve controversy.

First, I identified the stakeholders on each side of each issue and called them. After listening to their input, I outlined a governance process with objective criteria to evaluate the options. The stakeholders agreed to the process, the criteria, and the authority of a governance workgroup to make a decision.

Then, we set up meetings or phone calls where all the stakeholders could speak with each other, make their points, and come to consensus. If consensus could not be achieved, then a vote would be taken. If the vote was a tie, I would decide based on pros/cons assigned to the objective criteria.

Using this approach, we've brought most of the issues of the past week to closure and I've not had to use formal authority.

One consequence of this approach is that it does not create passionate winners and losers. It does not make the CIO the bad guy. When the next issue arises, stakeholders will trust the process and not even remember the controversies of the past.

When I was young, I believed that leaders had it easy - they had such power that they could just exercise their authority to make decisions and get work done.

The reality is that the more responsibility and visibility you have, the less formal authority you can exercise.

So next time you get promoted, accept the mantle of leadership knowing that you're accountable, but your only true power is leveraging the trust of your stakeholders.

And remember, for everything there is a process.

Decision Support Service Providers

In my recent Leiter Lecture, I spoke about the idea that decision support services should be available in the cloud. BIDMC has 2000 decision support rules. Brigham and Women's has 2000 decision support rules. They are entirely different rules maintained by two teams of experts. That's lunacy.

Shouldn't we have have a single set of evidence-based rules that everyone in the country can use?

But how would it work and what standards would be used?

I serve on the Board of AnvitaHealth (note the Conflict of Interest), which is working on this problem.

1. First, rules need to be authored by experts or gleaned from the literature and represented electronically in a decision support cloud.

2. Second, an XML form of patient history needs to be sent to the Decision Support Service Provider. For example, the problem list, medication list, recent labs, age, and gender could be sent in a Continuity of Care Document without specific patient identifiers.

3. Third, the Decision Support Service Provider should respond with clinical care advice, such as drug/drug interactions, alerts/reminders, or wellness guidance

Here's a concrete example. For brevity, I included only pertinent portions of the XML input data. The XML could contain any arbitrary length of data elements and codes sets.

Here's an example of an XML patient data input file (CCD is also natively supported)

The XML response is a realtime answer to every rule set run. Thousands can be executed in realtime (milliseconds). Here's an XML response that indicates two drug safety issues – a drug-disease (MAO+Hypertension) interaction and a dangerous drug-drug combination at severity level 1 (fetanyl-containing meds and MAO inhibitors)

Here's an XML response that indicates a laboratory gap in care. In this case, the patient is taking an ACE Inhibitor and does not have recent serum electrolytes. The compliance to this rule is thus false (underlined).

Thus, Anvita has defined clinical decision support (CDS) standards to transmit decision support recommendations from the service provider back to the EHR. I am unaware any widely implemented standards that do this today.

Additionally, the XML response object is hierarchical. Any response (drug safety, gap in care, etc) can be drilled down further to any level of detail, including the drug package insert, for example. However, for speed of response, Anvita returns portions of the XML response initially.

Additional details from Anvita:

1. The patient data set (longitudinal health record) can be sent to Anvita’s web service as XML or CCD. Anvita’s XML anticipates and extends attributes necessary for decision support, such as presence or absence of different types of dialysis, which are not yet required by CCD.

2. Anvita’s engine includes (a) decision support function requests (e.g., check drug dose, get formulary, find safety-check therapeutic alternatives, find gaps in care) and also (b) utilities, such as: search functions using descriptions within codesets like CPT, NDCs, the ability to find all drugs within a therapeutic class, find all LOINCs that infer the same physiologic laboratory test, etc. Anvita utilitizes freely available vocabularies for maintaining local dictionaries, their synchronization, and taxonomies. The modularity of (a) and (b) allows homegrown systems and next-generation applications to be developed without having to deal with the complexity of thousands of pages of implementation guides pertaining to drug databases, industry codes like CPT, LOINC, NDC, semantic interoperability between non-congruent databases (due to the Anvita Thesaurus), as well as coding of hundreds of quality/ performance measures that Anvita provides out of the box (e.g., HEDIS), in a plug-and-play fashion.

3. A decision support request, posed as XML, returns a response object for that request. The response XML can include drug safety analysis, gaps in care analysis and scoring, formularies, cumulative radiation exposure, etc. Therefore, Anvita is a generalizable, semantic search engine that executes in realtime as a web service. Anvita’s realtime capability not only enables decision support at the Point of Care, but business functions such as electronic prior authorization using EHR data (e.g., high tech imaging).

4. The analytical responses can be delivered as either XML (for instantaneous consumption at the Point of Care) or written directly to an alerts database (for population analytics). The analytical database can be viewed/queried directly by Anvita’s web-based tool or it can mined by 3rd party business intelligence tools (e.g., Cognos, Business Objects, JasperSoft, Pentaho).

5. Anvita also has supporting tools that include:

a. A Rules Authoring application, so that a non-technical specialty society or policy group (e.g,. NQF-endorsed entities) can author computable performance measures without any software coding at the atomic level

b. A Rules Management application, so that local organizations and physicians can decide and configure which rules to run (e.g., Meaningful Use), including the rules they’ve authored themselves and that might be proprietary (e.g., electronic prior-authorization criteria).

I do not present this as an advertisement for Anvita, but as a generalizable, modular approach to decision support in the cloud that could be implemented by many companies instead of duplicating expert resources in every hospital and health information exchange.

Decision Support Service Providers is a concept that is ready for prime time.

Weight Loss from Activity Only Works in Thin Middle Age Women

Talk about a cruel trick of nature!  A study funded by the National Institutes of Health (NIH) and published in JAMA shows that physical activity prevents weight gain in middle-aged and older women ONLY IF THEY ARE ALREADY AT IDEAL WEIGHT.  Did you read that?  It means that the recommended guidelines advocating 150 minutes of exercise a week isn't sufficient to prevent weight gain in most middle

A Green Transformation

Over the weekend, while in Los Angeles visiting my parents, I had the opportunity to visit the Torrance, California home of Mary and Al Shadbourne who have embraced a do-it-yourself approach to Green living. Here's what they've done:

In 1983, they installed a passive thermosiphon solar hot water heating system which they converted to an active system in 1994. The cost for the original system was $5000.

Their natural gas bill is $302 per year, including 7 months with a bill under $12.

In 2003, they installed 219 square feet of AstroPower solar photovoltaics which cost $10635 after rebates and have a payback period of 12.9 years based on the current cost of energy from Southern California Edison.

The average power generation has been 8.8 kilowatt hours/day. Their home power consumption has been'

2007 13.6 kwh/day (65% solar generated)

2008 16.9 kwh/day (55% solar generated)

2009 16.2 kwh/day (54% solar generated)

Their power bill has averaged $35 per month.

In 2009 they

*added ecofriendly Orco permeable pavers to their driveway, which minimizes water run off into the street, keeping their local soil moist and reducing contamination of public draining systems.

*installed a rolling shutter system on the south and west facing windows which keeps heat out of the house on summer days (and increases sleep time by keeping bedrooms dark)

*installed TREX decking made from recycled wood and plastic, reducing their rear lawn size

*installed a retractable awning over the rear deck which keeps their outdoor areas cool

*reduced their front lawn size by replacing it with raised beds and mulch. The end result was a 48% reducing in water consumption

*Added a Solatube to bring the light of the sun directly into a windowless bathroom, eliminating the need for lights during the day.

In 2010 they

*installed 168 square feet of Sunpower solar photovoltaics at a net cost of $10,300. They are currently generated 15.44 kilowatts/day. Their electrical meter is running backwards and Southern California Edison will be paying for the electricity they add back to the grid

*installed rain barrels to collect rain from roof run off

*installed a hot water recirculation system

*installed a TIGO power maximizer system on the AstroPower photovoltaic array. This system automatically monitors each module and ensures that resistance/voltage is equalized throughout the system. This is important because a single module in the shade can reduce performance of the entire system by increasing resistance. The TIGO system can improve power yields up to 40%.

The combination of solar hot water, photovoltaics, insulating window treatments, reduced water use, and solar lighting is a great accomplishment, but they've gone further by really thinking about how to manage temperatures in their home using the weather variation of the day in their favor.

They installed SolarStar attic ventilation, which is entirely solar power venting.

They have an amazing "entire house" fan system built into their hall ceiling which enables them to open all the doors and windows and pull cool evening air throughout the house, venting the heat of the day.

To maximize the efficiency of these systems, they have installed new modular insulation in their attic, covering the existing fiberglass insulation and avoiding the mess of spray on insulation. This makes the attic a very friendly place to work in if they need to service any of the roof mounted electrical or ventilation equipment.

Mary and Al have great passion for what they do, volunteering their time for community and high school environmental education events. Their passion is infectious and I hope to implement some of their ideas myself over time.

SpaghettiOs Recalled

I know the readers of EverythingHealth would never eat Campbells SpaghettiOs but in case you know someone who does, you should know that the USDA has recalled 15,000,000 pounds of SpaghettiOs because of under processing. The recall includes 14.75-ounce cans with a use-by date between June 2010 and December 2011 of three varieties of the product: "SpaghettiOs with Meatballs," "SpaghettiOs A to Z

Email Alerts by Popular Demand

Dear EverythingHealth readers,
Many of you have requested an email alert when new blogs are posted.  It took me awhile, but now it is easy to sign up on the right hand side of the blog.  Check it out and never miss a fascinating topic.
Thanks for visiting and reading.

Senate Approves Last-Minute Delay for Medicare Physician Cuts

Yesterday's Medicare pay cuts for physicians have been delayed in a last-minute compromise deal today by the U.S. Senate.  The agreement was passed by "unanimous consent" without a roll call vote.  (I need to go back to 8th grade Government 101 to figure out how that is done!)

The last minute agreement means that the pay cuts will be reversed.  The House of Representatives will (hopefully) pass

Cool Technology of the Week

A great followup from last week's Cool Technology of the Week about the use of the iPad in healthcare. Thanks to Dr. Henry Feldman for the answer.

Question: Quick questions, the iPhone 4 is supposed to come out soon. Is it much better that the iPhone 3 phones? Also what makes the IPad so much better than just a regular lap top except the battery life and weight? Also, could I not just use an iphone in the same way you use the IPad? Are you still handwriting your notes or are you typing them into the IPad as you pre-round? Was it easy to write admit notes in the POE d/c summary with the Ipad?

Answer: When the iPad shipped everyone accused it of “just being a big iPhone” and now ironically the iPhone 4 is “just a small iPad”. I handwrite my progress notes [I find I think more about what I’m going to say], but type my admit notes (and do my own admit letters as I like to write a full descriptive letter to the PCP)

1. So what are the differences between the iPhone 3GS and the 4:
Speed: the iPad/iPhone 4 processor (the A4) is much faster than the prior ARM processor that was there before in the 3GS. You would not think you care, but you do, as particularly on a phone, lag during user interaction is annoying, and for things like turn-by-turn navigation unacceptable. Most literature places click-lag beyond 0.1 seconds as being annoying to users. Ironically with a much faster and more powerful processor, since it is physically smaller, they were able to jam a larger battery in there and so it lasts longer.
Screen: From all the online reviews, the “retina display” which has 4x the resolution is truly amazing, and shocking in its realism. This will be particularly good in email, where sharper text will increase contrast and readability. The online reviews of folks who played with them at WWDC said it was like looking at a photograph/page of text
Weight/Size: I never considered my iPhone large, but this new one is smaller
Keyboard: the iPhone 4 will support external keyboards like the iPad
Camera: way better. Just way better (not a lot more megapixels, but that’s a stupid measure of camera quality)l low-light performance, finally has a flash, records HD video, and of course has front facing camera for video calls

2. iPad vs. Laptop
Time to working from the off state: On an iPad it is well under a second from when you open/turn on to when you’re working, the best netbooks take 10 seconds. This is also helpful for roaming on the secure network (a netbook while asleep loses its connection, the iPad matains it)

Ability to work walking down the hall/Bedside: I wrote orders/browsed while walking around, in the elevator, on the stairs, etc. I can’t think of any ergonomic situation where I could use a laptop like that. They simply aren’t designed to be used on the go. If I’m already sitting at a desk then we have computers there. Having to search for a surface to work on defeats the purpose

Battery life: 4 days vs. 6 hours, ‘nuff said
Speed: The processor in a netbook is much less efficient, and having a real HD (or a large SSD), etc, even with the large battery packs which last 6 hours and add a pound, aren’t even close to the speed of the iPad. The iPad isn’t designed to be a general purpose computer per se (it’s actually a mac running a subset of Mac OSX, like the iPhone, under the scenes) so much of the overhead that exists on Windows, Linux or Mac OSX isn’t necessary when walking around. This all kills speed. In fact for web page rendering and rich emails, is actually even faster than my monster 8-core Mac Pro. It opens OMR pages instantly (faster than the desktops on the wards for instance)

Weight: Let’s take a typical netbook (nobody would walk around with a full sized notebook) such as a Dell Mini 10, which with a 8-9 hour battery life weighs 3 pounds (doesn’t sound heavy, but walk around with a 3Lb object all day and you’ll be beat, and you’ll notice that it wouldn’t last an entire night shift for all that weight (so you’d have to remember to bring a charger). The iPad for comparison weighs 1.5Lbs and lasts up to 4 days without charging. The iPad is also 0.5” thick, while a Mini 10 is 1.3 inches (doesn’t sound like a lot, but that’s a huge difference in carrying something for 12 hours)

Interface: Windows, Mac OSX or Linux is really designed to be used with a mouse/trackpad with multiple mouse buttons and is designed to be a full featured computer. You won’t be writing software, building 3D models or such while walking around, so a touch/multigesture interface is much more efficient (just pointing at the tab you want in OMR is way more efficient particularly in 1 handed mode while standing than scrolling around with a track pad). Of course if you want to use a full keyboard, the iPad does support it (I never used mine the entire week). The keypad in the iPad in landscape mode is the same size as my HP Mini 311 keyboard (yes, I do own a PC for programming a specific device), both are OK for typing, but as a touch typist for long documents I like a full 102-key keyboard, with full sized keys

Email: The iPad/iPhone have full push email/Calendar/Contacts from Exchange, which you only get on a PC with a full copy of office with Outlook

3. Iphone vs. iPad:
You CAN do everything on an iPhone that you can do on an iPad as they are the same thing with a different screen size. That being said, the zooming in/out gets tiresome REAL fast. If you need to put in a quick tylenol order while in a meeting, then yes it works. Anything longer than that, painful just due to the size. See the enclosed picture below of the same Kermit the Frog screen up on OMR, but I’m too old for seeing those small links/text, and my fingers are too big.
Of course you can’t make phone calls on an iPad (well you can but only via Skype, which actually works quite well)

No text messaging even on the 3G iPad

Doesn’t fit in a pocket (well depends on your fashion, but I don’t have 10” pockets), but the tradeoff is lots of zooming

4. Notes on the iPad:
I didn’t write the bulk of the admit note on the iPad. I did my chart biopsy in the nurses station with the paper chart in front of me into the DC summary, and typed the bulk of the stuff in with a real computer. This isn’t because the iPad couldn’t do it, it’s just way easier on a full size keyboard and a mouse/draggable windows interface is helpful for bulk cutting-and-pasting (cutting and pasting one thing is fine on an iPad, but all sorts of things from many sources becomes inefficient). So when I walk into the room it’s 85% done, and then I complete it right there in the room (vitals, physical exam and updating the HPI with info from the patient). This was very efficient.

I did do multiple DC plans on the iPad and that worked quite well, although since the iPad is not linked into the ITS Domain as a “clinical workstation” nothing prints, so for the Page 1, etc you need to finalize it on a clinical desktop (but this would be true of any non BIDMC PC, such as a laptop).

5. Rounding/POE
I found that when I left the person’s room the bulk of their orders were in, and lytes were corrected, diet advanced, etc all at the bedside. Patients also ask about their labs, etc, and having them right there in real time (printing them via the PTC doesn’t work at 6:30 as they aren’t back yet), so that was helpful

Patients loved seeing their ERCP reports, and between those pics and the Netter’s I have on my iPad (and iPhone) it made procedures very understandable

Handling the nurse snagging you in the hall for a coverage issue, etc was way better, as on the chaos of last week it was easy to get distracted and forget if you didn’t handle the problem then if it was some minor issue.

The Doctor is Out for Medicare Patients

Breaking news tonight that in a last minute shocker, the Senate voted today against postponing a scheduled 21% cut in Medicare reimbursement to physicians and other health providers.  60 senators were needed to end filibuster debate and stop the cuts under Senate rules.  Fifty-six voted in favor, with 40 opposed. There was no Republican support. (And, of course, no support from Senator Lieberman,

Reflections on Being a Father

As Father's Day approaches, I'm off to San Francisco to give Grand Rounds at Lucile Packard Children’s Hospital then to Los Angeles to spend Father's Day with my father.

My daughter is now 17, so I've had nearly 18 years of responsibilities as a father, along with 25 years of being a husband, and 30 years as a companion to my wife.

We live in an era when 50% of all marriages end in divorce and even apparently stable couples like Al and Tipper Gore give up after 40 years together.

What are my lessons learned from being a husband and father?

1. I am a different person at 48 than I was at 18. The good news is that my wife likes both of those people. I'm a very different person now than when my daughter was born. We've grown together.

2. I've lived with my daughter though all the stages of her development - from a dependent infant, an inquisitive toddler, an adoring young child, and a spirited teen to a young woman on her way to becoming independent at college in 2011. At each stage she has interacted with me differently. I love her journey to independence as much as I treasured our time together when I was her best friend. Every day I need to recognize and respect her evolution.

3. Communities like Wellesley, Massachusetts are filled with goal-directed professionals who want to ensure the success of their children. This leads to a fair amount of academic pressure and "helicopter parenting". Although it may seem more expedient to do things for my daughter, it also slows her path of building self confidence and internal drive. I see my role as helping with her trajectory and providing a safety net, but giving her as much latitude as possible. When my daughter seeks my help, I'm always there as an advisor, counselor, or academic consultant.

4. My values and experiences are different than my daughter's. It's hard to interpret her day to day challenges through the lens of my life. The high school and college application process was very different in the 1970's than in the 2010's. I need to accept that my perspective may not be aligned with today's realities. I grew up with land line telephones and IBM Selectric typewriters. She was born in 1993 and thus has was not lived a day without the internet.

5. Life is filled with stresses at work, at home, and with the world in general. It's really important to realize that a year from now, no one will remember today's issues, but family is forever. Being consistent and predictable as a father, immune to whatever external stresses might change my mood, works really well. Raising my voice, being critical, or getting frustrated diminishes me.

Have a great Father's Day and remember that The Gift of Time is best present you can give.

Surgery and Radiation Therapy for Prostate Cancer Cause Lack of Ejaculation

The American Urological Association 2010 Annual Scientific Meeting was held in San Francisco.  One of the reports at the meeting dealt with the fact that nearly 90% of men who undergo radiation therapy for prostate cancer will eventually develop anejaculation (inability to ejaculate).  Additionally radical prostatectomy (surgery) is almost always associated with loss of ability to ejaculate.  It

The Massachusetts Ad Hoc HIE Workgroup

Over the past 30 days, an ad hoc multi-stakeholder group convened by the Massachusetts eHealth Institute (MeHI) worked to inventory existing state HIE capabilities, develop a list of prioritized services, and define functional/geographic gaps in services.

Here's a summary of work thus far.

Core Services needed for meaningful use in 2011

Routing Services - includes point to point delivery, filtering to ensure the right content is delivered to the right recipient i.e. do not require every edge system to decide what labs are reportable as this may change over time, de-identification if the recipient does not require patient specific demographics and translation services such as mapping of different versions of standards into common over the wire packages. Routing is likely to be a combination of local edge/community routers such as eClinical Works EHX/SafeHealth/CHAPS and statewide routing such as Surescripts/NEHEN. The role of the HIE would be to ensure that all stakeholders are covered by a service provider.

Directory services

a. Provider/Facilities Directory - A centralized service leveraging existing databases such as CAQH's provider index or MHQP's provider index. This information can be used for routing messages to the right organization for delivery to the clinician.

b. Payer/Plan Directory - A centralized which offers routing information for each Payer and details about their plans which will facilitate administrative transactions.

c. Public Health entity Directory service - A centralized service which provides routing information for all reportable lab/syndromic surveillance/immunization data.

PKI/Identity Services - A centralized service which can support authentication of endpoints (people and organizations) as well as support e-prescribing of controlled substance workflows.

Immunization/Syndromic Surveillance/Reportable Lab Registry Service - State-level repositories which are aggregated centrally and shared with cities and providers per patient consent.

Quality Data Center includes aggregation, reporting, CMS/Payer submission - a distributed service that stores multi-institutional clinical and administrative data needed to compute HEDIS, PQRI, and pay for performance measures. A single organization may offer all three services (aggregation, reporting and quality data submission) or those tasks might be divided among multiple organizations. The point was made that hospitals already have services in place to report inpatient data to CMS - this would not need to be replaced, but instead leveraged to satisfy other data requirements for the state.

Consent services. There are two distinct kinds of consents - those which are obtained by providers for clinician to clinician exchange. It is likely such consents will remain decentralized. Another type of consent is a record of consumer preferences which is managed by the patient. That would ideally be a state-wide centralized service.

Needed for meaningful use in 2013 or beyond OR a high value service that is likely to contribute to HIE sustainability. While planning for these should be started promptly, completion is not necessary prior to implementing the High Priority services.

Master Patient Index/Record Locator Services - there are three basic types of master patient indexes

a. probabilistic matching based on demographics. There is no persistent linkage of medical record numbers or any unique ID used for the patient. Lookups do matching in real time

b. deterministic - There is persistent linkage of medical record numbers based on a unique ID that is used exclusively inside the database and not used by the patient. Staff is required to fix linkage problems - duplicates, wrong patient, demographic data problems etc.

c. unique identifier - The state issues a unique identifier that is presented to all caregivers and used as the identity management key for all HIE activities. There are significant privacy concerns and costs associated with this approach.

All Payer Database - a centralized repository that might include administrative and clinical data to support utilization review, case management, disease management, opportunities for efficiency improvement etc.

Radiology Image exchange services (could possibly include EKGs too) - this is likely to be a distributed offering from multiple private companies. The role of the HIE would be to provide a list of qualified companies offering such services.

Event notification service to identify payers or providers of patient status changes. For example, a Patient Death notification service would enable providers to cancel appointments and payers to stop paying claims. Hospitals know the birthdate of their patients but rarely know when they die because the place of death and the place of birth are often different. Could also include other status changes such as: Adoption, protective services, marriage, hospice, PCP changes, coordination of benefits, etc... A distributed service. The role of the HIE would be to identify these services and connect stakeholders to them.

Routing Service for Patients which includes routing CCDs and other data to patients. Patient Routing could take the form of a portal, secure email, or interactive voice response. This is likely to be a distributed offering from multiple private companies. The role of the HIE would be to provide a list of qualified companies offering such services.

Personally Controlled Health Record Services - a distributed service (such as that provided by Google, Microsoft, or Indivo) that can gather clinical information and serve as a patient controlled repository of their lifetime health record data. The role of the HIE would be to provide a list of qualified companies offering such services.

Important to consider as service options to sustain the HIE

Pharmacosurveillance services - a distributed service that could provide early detection for such issues as the Vioxx/Heart Attack association, as well as trends in medication use such as antibiotics.

Pre-auth approval rules service (such as radiology ordering) - a distributed service that incorporates payer rules into web services, eliminating call centers and enhancing workflow.

Pharmacy directory for fax-based pharmacies, a centralized service. Surescripts charges extra for e-prescriptions that must be rendered as faxes. It may be value added to provide a list of such pharmacies so that alternatives (NEHEN, other services) could be used. More research is needed.

Advanced Directives Service - a centralized repository that would store advanced directives on behalf of the patient and make them available to caregivers as needed.

Medication safety analysis service - a distributed service providing decision support about the safety of patient medications. Commercial companies do this today.

Formulary Service - a distributed service that offers access to those formularies not provided by Surescripts.

Patient Educational materials service - a distributed service that provides disease specific educational materials. Commercial companies offer such services today.

Disclosure logging services - the HIE could log data exchanges among stakeholders. In a sense, the HIE router could become a disclosure logging service. Although a central service can be offered, there will still need to be local services for exchanges that do not pass through the HIE such as plaintiff attorney record requests.

Vocabulary Services which includes access to/mapping of LOINC, SNOMED-CT, ICD9/10, RXNorm. This should be a combination of local and central services. The role of the state HIE would be to negotiate preferred rates with companies that offer vocabulary services. The Federal Government (ONC and NLM) are also working on vocabulary services repositories.

I2B2 clinical research services which include distributed data mining/searching tools using Open Source I2B2 approaches. This is central distribution of open source code/standards with local implementation. The role of the state HIE would be to educate stakeholders about this offering and provide links to the organizations supporting its implementation.

Our next step is to ensure all priorities and functional/geographic gap analysis is vetted with all stakeholders. We'll then determine the best governance options for the services we'll offer and complete our state operating plan to ensure that high priority services are available to every patient, provider, and payer as needed to support 2011 Meaningful Use data exchanges.

Addiction to Tanning

According to the Archives of Dermatology, there are people who are addicted to indoor tanning.  That journal reported on a study of 421 University students in the northeastern United States.  Using self-reported questionnaires, they screened for alcoholism and substance use as well as anxiety and depression.  They also had a questionnaire about addiction to indoor tanning. 
If you are

Doctors Offices Not Keeping Up with Online Demand from Patients

At a time when more and more patients are using the internet to research doctors, hospitals and medical conditions, there are still few physicians who utilize on-line services for patient care.  Thirty eight percent of  US adults have researched a medical problem online in the past 12 months, according to a Forrester Research Study.  The survey also showed that 26% of adults researched a specific

Standards for Discharge Summaries

I was recently asked about the standards for representing a discharge summary.

HL7 completed and balloted an implementation guide for discharge summaries in the Fall of 2009. It's CDA based and includes structured data elements as well as free text. Here's a sample using the HL7 style sheet.

BIDMC has used a CCD for the past two years to communicate discharge data to primary care clinicians, skilled nursing facilities and long term acute care organizations. We also provide a copy to the patient. This discharge format of CCD uses the same standard, but different contents than our lifetime medical record summary CCD which is what we use for our social security administration data exchange and what we give to patients to comply with meaningful use patient summary requirements.

Thus, for discharge summaries, the HL7 discharge summary implementation guide using CDA is the right standard to use, with CCD as a reasonable intermediate step.

NHIN Direct Update

Last week, I wrote about the way I select my outdoor gear. First, I define requirements such as:

What will the gear be used for?

How durable does it need to be?

How light is it?

I then search for a product that meets the requirements.

Sometimes products are available off the shelf.

Sometimes I have to modify commercially available products.

Sometimes products have to be made from scratch by specialists.

In my opinion, last week's NHIN Direct face to face meeting demonstrated that we do not have an off the shelf solution for simple point to point communication that meets all the requirements outlined by the NHIN Direct participants. Wes Rishel's blog further outlines the issues.

To review, requirements include:

*The NHIN Direct protocol relies on agreement that possession of the private key of an x.509 certificate with a particular subject assures compliance of the bearer with a set of arbitrary policies as defined by the issuing authority of the certificate. For example, Verisign assures that bearers of their "extended validation" certificates have been validated according to their official "Certification Practice Statement." Certificates can be used in many ways, but NHIN Direct relies on the embedded subject and issuing chain as indicated in the following points. Specific implementations may choose to go beyond these basic requirements.

*Implementations must allow configuration of one or more public certificates representing "anchors" that implement agreed-to message handing policies. Implementations should allow anchors for sending messages to be distinct from those for receiving messages.

*Implementations should allow these configurations to be unique per-address in addition to per-health-domain. This will ease integration for participants with an existing PKI infrastructure, and provides a path to more fine-grained assurance for future use cases. Implementations must be able to accept messages identified per-address or per-health-domain per the Sender Identification requirement below.

*When possible, implementations must frequently check the validity of configured or cached certificates through standard means. The definition of "frequently" should be defined by external policy.

*NHIN Direct messages must be reliably linked to the public certificates possessed by the sender, through standard digital signatures or other means that match the certificate subject to the sender's address or health domain. Implementations must reject messages that are not linked to valid, non-expired, non-revoked public certificates inheriting up to a configured Anchor certificate per the Certificate Anchor Configuration requirement above.

*NHIN Direct messages sent over unsecured channels must be protected by standard encryption techniques using key material from the recipient's valid, non-expired, non-revoked public certificate inheriting up to a configured Anchor certificate per the Certificate Anchor Configuration requirement above. Normally this will mean symmetric encryption with key exchange encrypted with PKI. Implementations must also be able to ensure that source and destination endpoint addresses used for routing purposes are not disclosed in transit.

*Implementations should attempt to ease the complexity of certificate management for end users and organizations. While this is not a hard protocol requirement, it is important to be aware that many systems leveraging certificate technology have failed to achieve adoption due to complexity of PKI management, so efforts here will be a key driver of success or failure for NHIN Direct. If possible implementations should enable NHIN Direct users to think in terms of "who do I trust" rather than "what certificates do I import". Implementations should also ensure that users can leverage existing credential management programs; for example, ICAM in the federal space.

*NHIN Direct messages must be protected using standard hashing techniques acceptable in current regulation.

Based on these security requirements, a workgroup of the HIT Standards Committee evaluated the 4 NHIN Direct reference implementations, REST, SOAP/IHE, SMTP and XMPP, to assess their compliance with these requirements and to propose the simplest, compliant solution for an initial NHIN Direct pilot.

We evaluated the reference implementations based on the current state of the standards, as they are today.

Our sense was that REST adhered to all the security requirements, decoupled transport from content, and kept the content secure without the need to inspect it during transport. Metadata was not disclosing since it was limited to just a from/to address for transport. We made our recommendations to the NHIN Direct team.

At the NHIN Direct meeting, there was wide acceptance of REST as an option, but stronger support for SOAP/IHE. This was based on technical considerations for some of the participants, but just as strongly was based on the current support nearly all of the EHR and HIE vendors have for the XDS profile. There was broad acceptance that the SOAP/IHE option should be changed as follows:

1. Separation of routing metadata from content data

2. Separation of content standards from routing standards

3. End to end content encryption

4. Ability to route any package - patient specific or not

5. Ease of implementation with simple documentation, fewer requirements, and rapid deployability for all stakeholders

There was also enthusiasm for using SMTP at the edges - enabling a small practice to send healthcare data content to a Health Information Service Provider via secure email.

So, where do we go from here?

Based on the requirements and the current state of standards, there is not an off the shelf solution that works for everyone.

Harmony seems to be broadly achievable by allowing SMTP at the edges to support the little guy and using SOAP/IHE as the backbone but only if it is changed in the 5 ways listed above. REST could bring everyone along, but it would also require new software development for all the participants.

Consensus is always hard to achieve among a large group debating complex issues. At the NHIN Direct meeting, a few vocal detractors refused to accept SOAP/IHE regardless of the modifications to it.

This week there will be a followup call with the group to try to reach consensus. With SMTP for the little guy at the edge and SOAP/IHE (modified to meet NHIN Direct requirements) as the backbone, hopefully the group can get to yes.

Eight Secrets You Should Tell Your Doctor

It is important to have an open relationship with your primary care physician because the more she knows about your health and lifestyle, the better able she is to diagnose illnesses as they come up.  You wouldn't take your car to a mechanic and not tell him that the brake is sticking.  And a human organism is thousands of times more complicated than a car.  But patients are shy. They are

Are We Overmedicating Our Kids?

One of the blogs I read by Maggie Mahar, pointed out that a new study found that 26% of kids under age 19 are now taking prescription drugs for a chronic condition. The drugs include asthma medication, anti-psychotics, diabetes, anti-hypertensives and heartburn medications.  According to the Medco study (the largest pharmacy benefit manager), the incidence of type 2 diabetes increased over 150%

Cool Technology of the Week

In a previous blog I described the potential of the iPad for healthcare. Here's another installment of that Cool Technology, an in the trenches experience by one of hospitalists and informaticians, Dr. Henry Feldman.

"I just spent a full week as a res-intern-attend on east and decided to try out my iPad (64gb 3G). It was a great experience mostly, and I fully intend to use it from now on. Here are my thoughts (sort of as they came along):

General:

Given that our service was spread out over 4 floors, we did a lot of walking around. Without interns, I did a few admits, many followups, coverage, triggers and discharges, so really got to use all the applications.

I use the "new portal" so I had single sign on. I was on the secure network for wireless. The portal worked well (or as well as it ever did).

In general it was incredibly useful and given that all of our clinical apps are web based it basically all worked perfectly. Probably the most useful was rounding (or the nurse snagging you as you walked by) and during a trigger where I could stay at the bedside and do/see everything and not leave my critically ill patient.

I have the apple case, which means that I can “wedge” the iPad so that it forms a useful keyboard. I typed fairly long notes, but certainly nothing like a DC summary, and it was perfect. On Friday evening had a late discharge, and up on 12R there wasn’t a computer free. I sat at the little round table and did it all sitting there, including all the DC instructions, scripts (except printing as below), etc...

Battery life is epic, and I finally had to charge today at 3pm (Monday), after last charging Thursday night. This is with frequent use for clinical care, along with the inevitable demos one has to give carrying around an iPad (OMG an iPad! Show me a movie, apps, etc...). On average a full 13 hour stretch with heavy use burned 28% of the battery over the week, best 20% worst 35%.

I was worried that it would be “heavy”, but found it wasn’t hard to carry all day (and we really moved around a lot). I propped it up in a tall wedge when sitting at a workstation so I could see email, etc). The apple case did not get slippery, and seemed washable with the infection control wipes (frequent). Alcohol gel on the hands seems to have left a slight white powdery buildup but that wiped off with a damp towel. I found I carried less other stuff.

You definitely will make heavy use of the rotation lock button, and 95% of the time I wanted it in landscape mode

I did not try the ED dashboard on it, but since Larry is also using an iPad I assume it works.

I have PACS on my iPhone and iPad, but we can only use the Java based WebPACS.

For any provider who is highly mobile this blows the doors off of the COWs (computer on wheels) which is like rolling a file cabinet around. It’s faster, more reliable, insanely long battery life, and goes up stairs (although I have often thought of testing the “down the stairs” mode on the COWS when they run out of batter halfway through rounds on CC7) this is the machine to get. If you are office based, there isn’t a reason for this, but if you round on more than a few patients, then it will be invaluable.

I brought my iPad bookarc (stand) and Keyboard dock, but never used them. Seemed like it is highly unlikely you would ever use them, as it’s just as easy to wedge the iPad and type right on it. I did have my charger in the car just in case, but never needed it.

When there was a bug in a MySQL database being used by folks for chart review, standing there on the wards, I was able to securely get into the MySQL server back in informatics and change the setting. I also needed to update a website text, and was able to do that as well roaming the wards. And I had all the MySQL manuals with me too! As the ultimate test, while walking down the hall I VPN’ed into our server in Dasman and changed a database item there (that’s way off campus!)

When God smote the earth on Sunday, WeatherBug was helpful in knowing when/where would be a good time/way to go home to avoid the get-out-the-ark flood with that get-out-the-ark flood

The device itself is very fast and wakeup from sleep or app switching is essentially instant

What worked really well:

The secure wireless network handoff was amazing. As I roved around it was seamless (there is a slight dead zone on 11 Reisman as there has been for years) and the best example is that I would use the elevator ride to catch up on news/tech websites, and every time the elevator doors would open it would reconnect and download some more prior to the door closing.

Omr, Poe, eticket worked essentially perfectly (see below in what didn’t work)

Running a trigger with the iPad at the bedside was amazing. Not having to leave the bedside and having OMR and POE right there was awesome (especially as the patient was new to me)

Showing patient’s their EGD/ERCP pics, results/trends and since I have Netter’s on my iPad the anatomy of the procedure, really helped with understanding by the patients. Med reconciliation was easier too. Diet changes were instant on patients (important given the number of ERCP patients we have)

Performance was amazing, with screens updating faster than many of the desktops on the wards.

Updating signout on PTC worked really well. Obviously you can’t print the signout, since there is A) no printing on the iPad and B) your printer isn’t signed into the domain so has no printing location set

Email is much easier to read/manage on the iPad. My iPhone is pretty good, but in reading something longer about a patient from another provider, the extra real estate was very helpful (and in portrait mode, I can triage the emails much more easily)

What didn’t work so well:

E-Ticket could not add a new diagnosis to a patient’s bill. If you wanted to submit a bill for the same problems as yesterday (or a procedure in addition to today’s bill) that all worked fine. If you tried to add a new one, you always got the first one on the list, regardless of what you picked.

You can’t select “other” for a schedule for a med in POE. Works fine with one of the “standard” med schedules.

There is a wifi dead zone on 11R in the nursing station (that was there before the 5S/11R swap, and many patients in the farther rooms used to complain). It is also down to 1 bar in the back of the 5S nursing station.

Strangely I could not paste the discharge appointments made by CareConnections into the discharge instruction sheet (very strange. It was even hard to select the text)

Like any POE screen on Safari, all the elements (buttons) bizarrely have a black box around them. Never understood what that was. It doesn’t interfere, just looks unattractive. I assume this is a CSS bug somewhere and has nothing to do with the iPad (since it occurs on desktops too)

Discharge instructions are great, but you need to get on a desktop to print the prescriptions as there is A) no printing on the iPad and B) your printer isn’t signed into the domain so has no printing location set (which means you couldn’t get Tray 1 with the controlled paper anyway). Same with personalized team census. You can update, just not print."

Selecting a Backpacking Shelter

To add balance to our lives, my family and I spend a great deal of time outdoors - hiking, climbing, skiing, kayaking, and cycling. I have specific approaches to each of my outdoor pursuits, based on 40 years of making mistakes, improving, and trying again.

Each August, we travel to the Eastern Sierra to climb, hike, and explore. This August I'll do a solo walk on 50 miles of the John Muir Trail over 2 days. My strategy is to travel fast and light, covering 3 miles/1000 feet of elevation gain per hour.

To maintain that speed, I'll need to limit my pack weight to less than 10 pounds for the trip including all food, water, clothing and shelter.

That's a bit tricky since I'll carry a liter of water (1000cc = 1 kg = 2.205lbs) and 30 ounces of food. That leaves 6 pounds for all my remaining gear and pack. Here's my gear list that achieves that.

I currently own everything on the list except the shelter, for which I've allocated a ridiculous 10 ounces. I could carry something heavier if needed, but that would slow me down. I could reduce the amount of hydration I'm carrying, but you lose a great deal of water hiking in the high sierra, given the dry air and intense UV, so I really do want to drink a lot of water. I use Katadyn MP1 tablets when I refill my water supply from Sierra streams to kill bacteria, viruses and cysts in 30 minutes.

The section of the John Muir trail that I'll hike - from Red's Meadow to Yosemite Valley, has several windy spots, numerous mosquitos, occasional rain, and cold nights, even in August.

Thus, my requirements are a shelter that is very lightweight, windproof, mosquito-proof, waterproof and warm.

What are my choices?

Tent - there are few ultra-lightweight tents. Tents like the Golite Shangri-La with optional floor at 26oz, the Outdoor Research NightHaven Shelter at 37.4oz, the MSR Hubba HP Tent at 41oz or the Nemo Gogo at 32oz are in the 2-3 pound range and meet all criteria except weighing 10 ounces.

Tarps - there are many lightweight tarps such as the Integral Designs Siltarp. Tarps are challenging to use in very windy conditions and they do not provide mosquito protection. Most require hiking poles for support and I do not carry hiking poles.

Hybrid Tent and Tarp - Tarptents by Henry Shires are a hybrid between a tarp and a tent that include mosquito netting, engineered windproof designs, and great protection from severe weather. I use a Tarptent Cloudburst whenever I hike with a partner, since my 2 person tent weighs 38 ounces - 19 ounces per person for a 4 season tent. The lightest Tarptent is 20 ounces, still a bit more than the 10 ounces I need. The Zpacks Hexamid with optional floor at 12 ounces is a possibility but it requires a hiking pole and I typically do not carry hiking poles.

Hammock - A hanging tarp/hammock such as the Hennessy Hammock Hyperlight A-Sym Hammock Shelter at 26 ounces is an innovative design. There are two challenges - finding perfectly spaced trees when hiking in the high Sierra and sleeping suspended in cold/windy weather with the ensuing convective heat loss.

Bivy - A Bivouac is waterproof yet breathable covering for sleeping bags. It may or may not include a supporting pole to keep the fabric off your face. Bivy weights vary widely from the Black Diamond Twilight at 10 ounces to the Outdoor Research Highland at 23 ounces. The Twilight is 10 ounces, warm, windproof, waterproof, and mosquito proof. We have a winner.

Thus, my choice for my quick 50 miles this summer is the minimalist Twilight bivy from Black Diamond. I'll let you know how it goes!

Keratosis Pilaris

This photo of the arm of a 17 year old girl showing tiny red rough bumps that were not painful or itchy.  She had similar bumps on her thighs.  This common condition is called Keratosis Pilaris and it peaks during adolescence in all races.  It goes away by itself as a person ages.

We don't know the cause of this strange phenomenon.  Since it is mainly seen in puberty there may be a hormonal

Update on the Mobile Device Strategy Project

As promised in my recent about about our mobile device strategy project, here is the finished report from the 30 days of analysis completed by our intern, Ankur Seth.

A few take home lessons:

It's clear that leading practice is to use 2D Bar codes to identify patients, medications, and labs. 3D Bar codes are not widely deployed in outpatient or inpatient areas in the US.

Devices are evolving rapidly and anything you buy today will be obsolete quickly. It's best to avoid device or vendor lock-in if possible, using standards-based or modular components that enable rapid replacement of the infrastructure.

There are many different use cases and requirements in different workflows - Emergency Department, ICU, Ward and Clinic.

There is not a one size fits all solution.

The recommendations in brief are:

Attempt to stay device neutral through the use of web-based or other thin client technologies. For example, Apple has committed to train our developers to create iPod/iPad applications that are just front ends for our underlying web-based applications. We could do the same for the recently announced Dell Streak, Google Nexus One , HP, and RIM mobile devices.

Put bar code reading equipment in each Emergency Department bay and ICU room, since these areas are limited in number and generate a large volume of lab samples.

Make bar code printers available at the bedside in the ED and ICUs, since any workflow which uses centralized printing or batch printing of labels at registration can cause mislabeling errors.

For the ward locations, make mobile printers available on carts so that labels can be printed at the bedside without buying and supporting 500+ printers.

Application and infrastructure ‘fit’ into the user work flow is important and is the major factor affecting the adoption of mobile devices in clinical settings.

Our next step to followup on this study is to test various devices and printers, evaluating usability, supportability, and cost in various clinical locations.

I hope you find this report useful. Comments are welcome.

A New Intranet for BIDMC

Today, BIDMC replaced its intranet with a modern, secure, content managed application (pictured above), enabling us to retire our original intranet from 1998.

It's been a joint effort of Corporate Communications and Information Systems.

The process started by gathering requirements from hundreds of stakeholders.

The requirements were turned into a site specification and information architecture (the site's organization and navigation).

From there we developed wireframes, then graphical mock ups.

We coded and tested the site then migrated thousands of pages, documents, and applications.

The end result includes numerous personalization and social networking features (favorites, tag clouds, departmental intranets), single signon, and secure remote access via an Imperva appliance that is invisible to the users, who have the same experience on and off the network. Here's the announcement we sent out, which highlights our change management strategy - the old and new intranets run in parallel for 60 days to enable mastery of the new before retirement of the old.

"Welcome to Your New BIDMC Portal

Tuesday, June 8, marks the beginning of a new era for staff as BIDMC launches its new Portal – portal.bidmc.org. The new Portal offers significant improvements for completing work-related tasks, as well as a host of new communications tools and opportunities.

“We’re excited to launch the new Portal and believe it will provide staff with a much more enjoyable web-based working experience,” said Judy Glasser, Senior Vice President, Communications. “Whether you are a clinician, researcher or administrative staff member, you will find the new Portal much easier to navigate. And, with the new Search function, you’ll be able to find everything you’re looking for much more quickly. You can also customize your ‘My Links’ on the homepage so you have immediate access to your most-used pages and forms. Set aside some time and explore all it has to offer.”

New security requirements mean that all staff now need to sign-in using their ITS username and password. The bonus for those who use multiple applications is that single sign-on means that once you sign-in you can use all the ITS-based applications you are authorized to use without having to repeatedly re-enter. “For physicians and nurses, especially, the new single sign-on function is a major time-saver,” said John Halamka, Chief Information Officer. “Clinicians have been asking for this for years, so it’s nice to finally be able to offer single sign-on for most applications.”

Note that just about every application is available remotely from home or while you're traveling. The Policies, Procedures, Guidelines and Directives (PPGD) and Paging links are not yet available remotely but will be soon, said Halamka.

The new Portal offers consistent, easy-to-follow navigation across all pages, such as:

Section Tabs – At the top of each page you’ll find tabs for the new Portal’s main sections; Applications, Clinical, Research, and Employee Central.

The top right corner of each page contains quick-links to a variety of important programs, including: Web Outlook E-mail, Phone Directory, Pager, PPGD, BIDMC Today and the Events Calendar.

The “Portal Help” button at the top of each page links to a help section that contains video tutorials, Frequently Asked Questions (FAQs), and more.

Text Size can be changed on any page by clicking on the A’s at the top of each page.

The countdown clock at the top of each page shows how much time you have left in your Portal session. You can work in the Portal for an unlimited amount of time, as long as you are actively working. Your Portal session will automatically expire if you stop working (clicking on a link or hitting “enter”) for 20 minutes. The 20-minute time-out clock automatically resets to 20-minutes after each mouse-click or “enter” stroke.

The “My Links” module on the homepage allows you to add customized links to Portal pages and forms, or external websites. The Clinical, Research, Education, and Employee Central also display your “5 Most Used Links” in those sections. (Note: IS is developing a “My Apps” module that will allow you to add your most-used applications that will be available for use by this fall.)

Since January, the Communications Web Team has trained more than 200 Portal Editors who are responsible for the publishing and upkeep of content on departmental pages, forms and Intranets. Click here to view a list of all Portal editors and their departments.

If you are having trouble finding something on the new Portal that you used on the old Portal, please use the new Search function, which includes a drop-down menu to narrow your search. If you still can’t find it, please e-mail the Communications team at portalhelp@bidmc.harvard.edu .

The old Portal is no longer being updated so it may contain documents and policies that are out of date or no longer in compliance. It will be retired in 60 days. As of June 8, we ask that you use the old Portal only when you can’t find an old document or access something you need on the new Portal."

Extra Fees Help Physicians Stay in Practice

I was interested in an article in USA Today about the growing number of physicians, especially primary care doctors, who are boosting their revenues by requiring patients to pay new fees for services that insurance doesn't cover.  No longer is your insurance payment "all-inclusive". These fees can include annual administration fees, no-show fees, medical report fees, and extra fees for email or

The Community Health Data Initiative

Institute of Medicine President Harvey Fineberg and HHS Secretary Kathleen Sebelius launched the Community Health Data Initiative on June 2 at an IOM Forum in Washington, D.C. The initiative represents the hard work of many people, especially HHS CTO Todd Park.

The idea is simple - make de-identified HHS data sets available free of charge and encourage developers/researchers/public health agencies to create innovative applications which share the data in novel ways on the web, your mobile phone, and via the iPhone app store. Clinicians, patients, and payers will all be informed and empowered by this new data liquidity.

What is the plan?

Per HHS

"We will be providing to the public, free of charge and without any intellectual property constraint, a Community Health Data Set harvested from across HHS – a wealth of easily accessible, standardized, structured, downloadable data on health care, health, and determinants of health performance at the national, state, regional, and county levels, as well as by age, gender, race/ethnicity, and income (where available). This data set will consist of hundreds (ultimately, thousands) of measures of health care quality, cost, access and public health (e.g., obesity rates, smoking rates, etc.), including data produced for the Community Health Status Indicators, County Health Rankings, and State of the USA programs."

For an example of the data sets available see the CDC's website.

For an overview of the launch including sample applications see this You Tube Video.

Per my earlier blog post, The Healthy Communities Institute has demonstrated the power of publicly available data to inform policymaking in cities and counties.

I look forward to the new products and positive impacts on quality, efficiency and safety catalyzed by the Community Health Data Initiative. Definitely worth watching over the next few months.

Start Talking - a book for Teens and Moms

Raising kids gets really challenging when they hit the pre-teen age and there are few books that really help moms understand how maintain closeness with their teen daughters.   Authors Mary Jo Rapini and Janine Sherman offer a helpful book for young girls and their moms to read individually and together.  "Start Talking - A girls guide for you and your mom about health, sex or whatever" is a

Cool Technology of the Week

BIDMC has been working hard to define its mobile device strategy over the past 4 weeks and we've learned a great deal from the work of our Intern, Ankur Seth. I'll post his findings soon.

One of the devices we considered was the iPod Touch with an integrated Barcode Scanner/Magstrip reader from Linea-Pro.

We have many varied use cases for laboratory and medication management workflow. All involve scanning patient wrist bands, scanning medications/tubes of blood and scanning/swiping employee badges.

Having a development platform with a graphic user interface, long battery life and WiFi capability gives us significant flexibility without investing in an expensive, limited dedicated device.

The iPod Touch is easy to purchase, support, and use. It's a consumer friendly device.

Adding a laser scanning bar code reader makes it an impressive clinical tool.

Here's a detailed specification.

An Apple consumer device improving clinical care workflow - that's cool!

More Medication Errors in July

We medical folks have always known that July is the worst time for a patient to be admitted to the hospital.  It has nothing to do with nice summer weather or staff vacations.  Although it cannot be proven, we think the answer to the mystery of July hospital errors is human...yes it's the new interns.

A new study published in the June issue of the Journal of General Internal Medicine looked at