Sun and Surf

I'll be blogging from a vacation site. (If I have the time and creativity).  Nothing too exotic this year...can you guess where EverythingHealth will be?

Cool Technology of the Week

My daughter, Lara, served as an intern this Summer at the Tufts Center for Engineering Education and Outreach, testing and developing the next generation of LEGO Robotics. Her lab notebook is a daily blog, which includes a complete video record of all devices she's built.

Her final project and my Cool Technology of the week (I admit the conflict of interest in presenting my own daughter's work as a Cool Technology on my blog) is a mobile robot that traverses a garden, inserts a sensor into the soil, measures the moisture level in realtime, and selectively applies water as needed.

It's fully functional and demonstrated in these videos.

The interesting personal side effect of her engineering Summer was a life choice.

She has been debating a fork in the road - Environmental Science/Studies at places like Connecticut College/Middlebury or Environmental Engineering at places like Tufts/Dartmouth. Both are admirable careers. The Summer has led her to the pursuit of engineering. Per a recent article in the Boston Globe, environmental engineering will be one of the top 30 jobs by 2018, about the time Lara will be seeking employment. I will support whatever she decides, knowing that life will have many forks ahead for her two brains to explore.

Bystander CPR Saves Lives

Nearly 450 people die each day of sudden cardiac arrest. Many times the bystanders, who witness a person collapse don't know what to do. They are afraid they will hurt the victim or they feel nervous about doing traditional Cardio-pulmonary resuscitation (CPR) with mouth to mouth breathing and chest compressions.

New information is published in the New England Journal of Medicine that

Exploring the Charles River

On summer evenings and on weekends I kayak the Charles River, exploring its twists and turns through the western suburbs of Boston.

This section of the river is secluded, quiet, and filled with natural wonders. Here are a few of my favorite spots. Note that I paddle upstream first when I'm fresh, then enjoy the boost of the downstream current when I'm tired.

South Natick to Rocky Narrows - 5 miles/10 miles round trip

I put in my kayak just above the South Natick Dam and paddle upstream under Sargent's bridge, a beautiful oriental footbridge spanning the Charles. I continue past the praying woman statue, which Sargent placed on the south side of the river. For the next 3 miles, the river winds near the Audubon Broadmoor preserve, the Peters Reservation, and a few hidden houses. This section of the river is filled with Herons, Kingfishers, and Wood Ducks. I pass under the Farm Road Bridge and paddle to a narrow canyon in the river, Rocky Narrows, near King Phillip's overlook. When my daughter was young, we used an Old Town Pack single person canoe to paddle from the Farm Road Bridge to the Rocky Narrows Reservation. The entire length is tree lined, filled with muskrats, swallows, snapping turtles, and enormous carp.

Dover to South Natick - 5 miles/10 miles round trip

I put in my kayak at Redwing Bay in Dover. The 29 acre Charles River Peninsula reserve is a hidden gem on Fisher Street near the Cochrane Dam with a great boat launch and walking trails, filled with purple martins, hawks, and milkweed. This section of the Charles is laden with hidden coves and can be very challenging to navigate. It's anything but a straight line through Dover and Wellesley. I pass under the Central Street railroad bridge and along a wider, slower portion of the river going by fields, farms, and estates. I cross Charles River Street and enter Elm Bank Reservation, winding past the intersection of Fuller Brook and Waban Brook (the drainage from Lake Waban where my wife and I walk every morning) which run under an impressive stone bridge built in 1877.

Waltham to Wellesley - 6 miles/12 miles round trip

I put in at Charles River Canoe and Kayak and paddle upstream, quickly passing the freeway overpasses of 128 and entering the isolation of the Leo J. Martin Memorial Golf Course. Once I pass the Park Street bridge, the Charles is surrounded by meadows and secluded woodland, filled with water birds, fish, and muskrats. I paddle through the shallows (about 3 inches deep this time of year) all the way to Wellesley, then turn around at the Cordingly Dam. I retrace my steps and paddle back to my starting point, then continue for 3 miles along the "Lakes" area of the Charles, passing islands (E island, Fox island), the Forest Grove Park, the old Waltham Watch factory, and the Prospect Street Bridge. I turn around at the Moody Street Dam and return to my car. The only downside of the "Lakes" area is that powerboats are permitted. At times, their noise, wakes, and occasionally intoxicated skippers makes kayaking a bit challenging. Once this summer I had to leap from my kayak into the Charles to avoid a powerboat collision!

The Charles River is 80 miles long from its source in Hopkinton (same place the Boston Marathon starts) to the sea. The less traveled upper Charles from Medfield to Waltham is my paddling sanctuary.

The July HIT Standards Committee

The July HIT Standards Committee meeting focused on a review of the final Meaningful Use/Standards regulations and the processes for the next stage of our work.

Today, the Federal Register published the Meaningful Use Final Rule (down to 276 pages from 874) and the Standards and Certification Final Rule (down to 65 pages from 228).

Karen Trudel and Doug Fridsma began the meeting with an in-depth overview of Stage 1 Meaningful Use and Standards/Certification criteria.

Key discussion points included:

*EHRs do not have to be certified before the 90 day Stage 1 Meaningful Use demonstration period, just by the end. You can start the demonstration data collection before certification is completed. The entire CMS program begins January 2011, so it's possible to demonstrate Meaningful Use January 1 to March 31 using an EHR that is certified February 15.

*Although the Meaningful Use Menu set contains 10 choices from which Eligible Professionals(EPs) must choose 5, one of those five must be a public health/population health measure. Since there are only two choices for EPs, Immunization reporting and Syndromic Surveillance reporting, every professional must demonstrate one of these two public health transactions to qualify for meaningful use.

*Emergency Departments are now included in Hospital measure computation. This may create challenges for some organizations that have 100% CPOE use in the hospital but 0% CPOE use in the ED. Many hospitals have niche systems in the ED that may not integrate into hospital CPOE workflows. There is no question that the ED should have CPOE, but in 2011, not all EDs will. If a hospital has 60,000 ED visits without CPOE and 20,000 inpatient admissions with 100% CPOE use, the computation of 20,000 patients with medication orders entered via CPOE/(60,000 ED patients + 20,000 inpatient admissions) = .25 and thus will not qualify for meaningful use.

*EHRs must be capable of producing electronic Office visit summaries, as discussed in my previous blog, but meaningful use supports (and requires upon patient request) use of paper.

*It's unclear if Meaningful Use/Stimulus payments are taxable income to eligible professionals. No one has clarified this yet.

*The current standards required for patient summaries are CCR or CCD/C32. The current problem list vocabularies are ICD9 or SNOMED-CT. Although the CCR can use ICD9, the CCD/C32 implementation guide requires SNOMED-CT. It may be that the implementation guide will be relaxed to allow either ICD9 or SNOMED-CT for the problem list vocabulary in the CCD/C32.

*The Syndromic Surveillance Standards required are HL7 2.3.1 or HL 2.5.1. Although 2.5.1 has a detailed implementation guide (Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification), there is no current HL7 2.3.1 guide. It's been retired and is no longer used. Hence it may make sense for ONC to remove HL7 2.3.1 as a possible standard for this transaction. Otherwise it will be challenging to certify the transaction and guarantee interoperability.

*Although no transport standards are currently specified, enabling innovation in this area, it is important than in the future, after we learn more from HIE pilots, NHIN Direct, and Beacon Communities, that some specificity is provided to accelerate interoperability.

*A Smoking status vocabulary has been suggested, but is not a certification criterion.

*Eligible professionals have a choice of quality measures to report (3 core or 3 alternate core plus 3 from a list of 38 measures), thus EHRs have to produce at least 9 quality measures to be certified. The Meaningful Use Final Rule on page 238 states: “In order to permit greater participation by EHR vendors, including specialty EHRs, the certification program will permit EHRs to be certified if they are able to calculate at a minimum three clinical quality measures in addition to the six core and alternative core measures.”

*Medication Reconciliation needs only to be done between institutions not within an institution to satisfy the Meaningful Use measure.

Doug also informed the committee that of the 10 Standards and Interoperability Framework RFPs, two have been awarded - the NHIN RFP to Stanley (a large consulting company) and the Standards Harmonization RFP to Deloitte. It will be interesting to see how the Standards Harmonization activity serves as a successor to HITSP.

Next, Jamie Ferguson discussed the need for a framework to support clinical summaries of all kinds. The committee discussed that a modular, CDA-template-based approach would work well. Efforts such as hData and Green CDA are complementary to this idea. Basically, anyone needing to send a summary document for a particular purpose could assemble CDA templates as needed to create a human readable and computable content package. We also agreed to followup on any modular approaches the CCR authors may be working on.

Jamie updated us on the Vocabulary Task Force and its upcoming hearings. Our hope is to document the requirements for a vocabulary/codeset resource containing all intellectual property needed for Meaningful Use in a web-based repository.

Janet Corrigan and Floyd Eisenberg described the process of work group meetings and information gathering to specify the stage 2 and 3 quality metrics.

I had to leave the meeting to moderate the afternoon session of the ONC/Institute of Medicine Building a Learning Healthcare System conference. I'll blog about that on Monday.

Per Jon Perlin, the afternoon of the HIT Standards Committee meeting including a rich discussion of the Privacy and Security Tiger Team Update by Deven McGraw/Paul Egerman, an Enrollment Workgroup Update, and public comment. During the public comment period, the committee was deeply moved by a speech from the mother of a child with a serious illness. She thanked the committee for all their work to date to empower patients and improve the quality, safety and efficiency of care.

Regulations are final, stakeholders are thankful, and we're making progress! Thanks to everyone who has contributed the process thus far.

Meaningful Use, Standards, and Quality Measures

To help all stakeholders who want to better understand the latest HIT regulations:

1. Here's a quick summary of the Meaningful Use Core and Menu Set Objectives and Measures compiled by Robin Raiford.

2. Here's a quick summary of the Standards cross referenced to the Code of Federal Regulations Citations compiled by Robin Raiford.

3. I've been asked to summarize the Quality Measures as simply as possible

a. The Core Measures for All Eligible Professionals, Medicare and Medicaid are in the Final Rule Table 7, page 287. The Measures are

*Hypertension: Blood Pressure Measurement

*Tobacco Use Assessment and Tobacco Cessation Intervention

*Adult Weight Screening and Follow-up

b. If the denominator for one or more of the Core Measures is zero, EPs will be required to report results for up to three Alternate Core Measures. The Alternate Core Measures for Eligible Professionals are in the Final Rule Table 7, page 287. The Measures are

*Weight Assessment and Counseling for Children and Adolescents

*Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old

*Childhood Immunization Status

c. The Clinical Quality Measures for Submission by Medicare or Medicaid EPs for the 2011 and 2012 Payment Year (EPs must choose 3) are in the Final Rule Table 6, page 272 . Here's a summary of the 44 quality measures that CMS posted last week.

d. The Clinical Quality Measures for Submission by Eligible Hospitals and Critical Access Hospitals for Payment Year 2011-2012 are in the Final Rule Table 10, page 303. The Measures are

*Emergency Department Throughput – admitted patients Median time from ED arrival to ED departure for admitted patients

*Emergency Department Throughput – admitted patients Admission decision time to ED departure time for admitted patients

*Ischemic stroke – Discharge on anti-thrombotics

*Ischemic stroke – Anticoagulation for A-fib/flutter

*Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset

*Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2

*Ischemic stroke – Discharge on statins

*Ischemic or hemorrhagic stroke – Stroke education

*Ischemic or hemorrhagic stroke – Rehabilitation assessment

*VTE prophylaxis within 24 hours of arrival

*Intensive Care Unit VTE prophylaxis

*Anticoagulation overlap therapy

*Platelet monitoring on unfractionated heparin

*VTE discharge instructions

*Incidence of potentially preventable VTE

I hope these help!

Irritable Bowel Syndrome From Structural Brain Changes

Irritable bowel syndrome (IBS) is a common disorder that affects women twice as often as men.  It is commonly seen in a general medicine practice.  It is thought to be chronic and involves cramping, abdominal pain, gas, diarrhea and constipation.  An old term for it is "spastic colon".   It is one of those frustrating conditions where we "don't know what causes it" and that means doctors often

Protecting Privacy

As we all implement Meaningful Use stages 1, 2, and 3 from 2011-2015, we will increasingly share data among payers, providers and patients. Protecting privacy is foundational and we should only exchange data per patient preference. How will we achieve that in Massachusetts?

Stage 1

In the first stage of meaningful use, there are limited data exchanges - ePrescribing, a demonstration of pushing data from provider to provider, and public/population health exchanges for lab, immunizations, and syndromic surveillance.

These can be achieved using the consent mechanisms we have in place today i.e.

A clinician asks a patient (or the patient signs a paper-based general consent in the office or hospital) if the clinician can retrieve their national medication history from Surescripts during the course of e-prescribing.

A clinician asks a patient if the clinician can push a summary of their care to another clinician such as a primary caregiver/specialist or hospital/primary caregiver data exchange.

Aggregating de-identified data for public health purposes is permitted by HIPAA and ARRA without consent. Since no patient identifiers are involved there is a reduced risk for privacy breaches.

In our community EHR rollout of eClinicalWorks via our private cloud (a physically secure, environmentally controlled, generator supported co-location facility that is professionally operated and provides all the inbound interfaces needed for meaningful use), we've designed our infrastructure to support consent for Stage 1 exchanges.

1. Every practice has its own virtual server, separate eCW software, and isolated database instance. The data is owned and controlled by the practice

2. De-identified data is used for pay for performance and quality reporting, but BIDMC/BIDPO has no access to your EHR or billing system

3. Data can flow from provider to provider with NEHEN or the eCW push product (P2P), but that is at the provider's discretion after consent of the patient is obtained.

Stage 2

Although Stage 2 of Meaningful Use is still in the design stages, it is likely that increased provider to provider data sharing will be included. There will need to be a consent mechanism for providers to pull patient data from multiple data sources as needed for care. Push is great for some workflows, but pull is needed for emergency rooms to obtain critical treatment data in a timely fashion to ensure safe, quality care.

A push architecture supports provider initiated consent - the clinician can ask the patient before pushing data. Pull requires a different approach. The patient's data sharing preferences must be stored somewhere so that when data is pulled, only those data elements consistent with patient privacy preferences for that type of clinical encounter are shared.

In Stage 2, I expect that such consent will be federated, stored in various EHRs and community exchanges. At the moment there is no plan for a national health identifier or patient controlled national consent infrastructure.

In Massachusetts, we have legislation (Chapter 305) and a community standard which requires an opt-in consent for data sharing between healthcare organizations.

Some EHR vendors have created consent functionality within their produces to support the recording of consent for information exchange. Some community HIEs have created city-wide databases to record consent preferences.

In our community EHR rollout of eClinicalWorks, we've designed our infrastructure to support consent for Stage 2 exchanges.

We use the EHX product from eClinicalWorks which includes an opt in consent database, a clinical summary data store, and means for clinicians to pull data across practices if a patient opts in to support it.

This works great for the 1700 clinicians in BIDPO, but does not support pull transactions across competing organizations.

For that, we need to look to stage 3.

Stage 3

I believe that Stage 3 which include several community, state, and national data exchanges to support care coordination and population health. It will require master patient indices (given that a national identifier is unlikely). It will require a centralized patient controlled consent framework.

To ensure we are ready for patient controlled, centrally managed consent, the state of Massachusetts HIE ad hoc workgroup recommended that we begin work building a central consent management framework now using our ONC HIE funds.

Thus, we'll use provider initiated consent and patient opt in via EHRs and community exchanges for stage 1 and 2, but we hope to have a patient controlled state wide consent infrastructure ready for Stage 3.

Opt in consent that is patient controlled is the right approach and we need to build the infrastructure to support it. In the meantime we'll protect patient privacy preferences using the best technology available.

On Wednesday, I'll write about the July HIT Standards Committee meeting at which we'll discuss the latest ONC Privacy and Security Tiger Team work. Hopefully, our local, state and Federal policy and technology will converge to support the patient centric consent that ensures we support everyone's preferences for data exchange.

The Pesticide Dirty Dozen

The Environmental Working Group is a non-profit focused on public health.  We know that the long term consequences of eating chemicals from pesticides used on our foods is damaging to our health.  The EWG analyzed data from the FDA and  found that people who eat five fruits and vegetables a day from the dirty dozen are eating 10 pesticides a day.  We want people to eat more fruits and vegetables,

Caffeine is OK for Pregnant Women

The American College of Obstetricians and Gynecologists have issued a statement that moderate caffeine consumption (<200mg/day - about a cup of coffee) does not increase a woman's risk for miscarriage or preterm birth.  The review of recent studies was published in Obstetrics and Gynecology and should reassure women about drinking coffee when pregnant.

Caffeine does cross the placenta but there

Cool Technology of the Week

I hike in the ice and snow of the New Hampshire White Mountains in the Winter and I hike in heat and humidity of same peaks in the Summer.

In Winter, my glasses and goggles fog as they accumulate moisture from my breath and the moist heat radiating from my body.

In the Summer, my glasses fog in the humidity of trails that follow streams and waterfalls.

What technology do I use to keep my glasses fog free in subzero winter hiking and the blistering heat of summer?

The answer is not entirely obvious.

How do anti-fog products work?

They are hydrophilic - water vapor accumulates on glass as a thin layer of water, preventing fog.

However, in the winter, the thin layer of water freezes solid, rendering glasses entirely opaque.

After trying many anti-fog products to keep my eyewear clear in winter, I finally figured out that hydrophilic anti-fog products cannot work in winter. What you need is a hydrophobic product - Rain-X Glass Treatment.

It prevents water from accumulating on glass and in the winter, works perfectly as an anti-fog treatment.

However, as temperatures rise above freezing, hydrophilic is the right answer. I tested several different anti-fog products on my bathroom mirror. The winner, creating the clearest glass with the thinest layer of water was Rain-X Anti Fog.

Thus, my technology to keep my glasses clear in outdoor pursuits is simple

Hydrophobic Rain-X Glass for winter

Hydrophilic Rain-X Anti-Fog for summer.

Clear vision based on science. That's cool.

Burpless Cucumbers

This year, I planted three types of cucumbers - a Japanese variety called Satsuki , a slicing cucumber, and bush cucumber called Fanfare. As I was selecting seeds, the slicing cucumbers were highlighted as "Burpless". Evidently some people are adversely affected by cucumbers.

I've never had a problem with cucumbers, so I was curious. Is there such a thing a burp causing cucumber?

Inquiring minds want a clinical trial.

One was done by NC State University.

Cucumbers were divided into burpful and burpless.

Test subjects were divided into burp prone and burp resistant.

The outcome?

Asian trellis cucumbers do reduce burping in burp prone eaters.

Thus, burpless is really a marketing term for Asian trellis cucumbers and a small number of people will notice the difference.

Now you know!

Harvard Medical School's Green IT Initiatives

Harvard University has audacious goals for a Green campus and Harvard Medical School is doing all it can to support the initiative. Here's an overview:

Markley Data Center

The Markley Data Center utilizes and takes advantage of many infrastructure systems that support Harvard’s Green IT initiatives.

The Piller Rotary flywheel UPS system which has been serving Harvard Medical School's space for years is eco-friendly because it does not require batteries to support the power, thereby eliminating the hazardous waste generated through battery disposal.

The cooling system pumps are driving by VFD’s (Variable Frequency Drives) which are energy conservation tools which adjust the pump speed to meet the GPM flow required by the load. The VFD's save over $500 in energy costs per month (6-7 kw x 24hrs x 30days x $.125/kw).

The rooftop dry coolers are equipped with “free cooling” coils which allow us to shut down the compressors in the Computer Room Air Conditions (CRACs) when the temperature is cold enough.

The cooling system uses APC InRow Cooling (IRCs) which is significantly more energy efficient compared to CRACs. Rule of thumb says you will use approx 50-60% of the IT power for cooling. We have shown that with the IRCs it is approx 36%.

The chiller plant itself has a plate frame heat exchanger which is another device which provides for free cooling during the cooler months.

Markley is replacing all the emergency lighting ballasts throughout the building and connecting the emergency lighting to generator to eliminate batteries.

We adjusted the environmental conditions of the data center to reflect the 2010 ASHRAE standards (recommended environment range of 20 to 25 degrees Celsius, 68 to 77 degrees Farenheit and a relative humidity (RH) range of 40 to 55%).

Gordon Hall Data Center

We adjusted the environmental conditions of the data center to reflect the 2010 ASHRAE standards (recommended environment range of 20 to 25 degrees Celsius, 68 to 77 degrees Farenheit and a relative humidity (RH) range of 40 to 55%).

Virtualization

The Gordon Hall and Markley Data Center’s useful life has been extended dramatically through the use of server virtualization utilizing a product from VMWare. VMWare enables us to consolidate between 25 and 50 physical servers to virtual servers that now can reside on a single physical server, saving power, cooling and physical assets of your data centers. To date

95% of Harvard Medical School’s server environment has been virtualized

148 physical servers have been virtualized into 14 hosts.

We reduced the Gordon Hall Server room by 50 KW, saving HMS approximately $6,000 per month

All future requests for physical servers will be hosted on our remaining Virtual capacity.

Server Efficiency

The HMS IT staff utilize the HP Proliant DL380 G6 Server series for all of its Virtual Servers and applications that must remain today on physical servers (Exchange, Oracle, SQL, etc), which lead the industry for energy efficiency i.e.

Right-Sized ProLiant Power Supplies from 460Watts @ 92% efficiency, 750Watts @ 92% efficiency, to 1200Watts @90% efficiency.

“Intelligent Power & Cooling Savers” Smart power stops power delivery when components are not in use, adjusting fan control for efficient cooling. Smart Sensors allow intelligent actions to preserve, protect and enhance performance and power savings

Improve capacity up to 3x with Insight Control and Dynamic Power Capping. Dynamic Power Capping allows you to cap the server’s power use level, without impacting performance and still fully protecting the Circuit Breakers in the rack.

Research Computing Server Efficiency

The Research Computing staff utilizes the IBM Blade Center chassis in its deployment of 4000 cores in its support of research computing at the Medical School. The Research Computing staff will be utilizing IBM System X technology which is engineered for energy efficiency. In addition, selected systems are designed with provisioning software that can help reduce 80 percent of consumption on servers automatically by putting them in standby mode when they're not needed.

Our efforts to become green never stop and hopefully we'll be able to take advantage of the collaborative Massachusetts/BU/MIT/Northeastern/Harvard Green Data Center in Holyoke which is located near hydroelectric facilities when it is completed in 3 years.

ONC's New Consumer e-health Lead

The Office of the National Coordinator's Office of Policy and Planning has just posted the job for its "consumerista". The posting is open for 30 days from July 15 to August 16.

The job description includes

- Serve as the subject matter expert on consumer e-health.

- Forge alliances with consumer organizations, technology and care delivery innovators and consumer advocates to further the consumer e-health agenda.

- Develop consumer oriented strategies across the Office of the National Coordinator for Health Information Technology (ONC).

- Serve as Project Officer providing project management oversight for contracts, including designing, developing and coordinating project management plans for policy initiatives in conjunction with the Division Director and the Office of Policy and Planning Director.

Ensuring the voice of the consumer is represented in all HIT policy and technology efforts is really important. If you can think of anyone who would serve the country well in this role, please encourage them to apply!

When a Professional Turns His Back

A few weeks before Christmas, Eutisha Rennix, a pregnant restaurant worker,  collapsed while working.  She started having a seizure and her co-workers were screaming for help. There were two EMT workers in line at Au Bon Pain shop in Brooklyn and they refused to help.  They told on-lookers to call 911 and they walked out of the store after picking up their bagels, presumably because they were on

A Meaningful Use and Standards Rule FAQ

Since the Final Meaningful Use and Standards Rules were released last week, many people have emailed me questions, which I'd like to share generally. My blog is not reviewed by ONC or CMS, so these answers are my own opinion.

1. The Meaningful Use Rule identifies 15 Core Set required criteria and 10 Menu Set optional criteria (from which eligible professionals and hospitals must choose 5). Can they choose any 5?

You cannot choose any 5. Page 59 of the Meaningful Use final rule notes "all EPs and hospitals must choose at least one of the population and public health measures to demonstrate as part of the menu set. This is the only limitation placed on which five objectives can be deferred from the menu set."

This means that eligible professionals (EPs) must submit data to immunization registries or syndromic surveillance registries. Hospitals must submit data to immunization, syndromic surveillance or reportable lab registries. If such registries do not exist in your state/city (i.e. there is no repository to receive the data), CMS will not penalize the EP or Hospital.

2. The patient engagement aspects of the Meaningful Use Rule seem challenging to operationalize. Can I provide a paper copy of the visit summary or discharge summary to the patient? If not, how do I deliver a summary to the patient electronically? Can it be a PDF?

Patient engagement is probably the most complex area of the Meaningful Use and Standards Rule. Here's my understanding:

a. EHRs and Hospital Information Systems must have the capability of producing a human readable summary AND a computable summary that adheres to the Standards Final Rule (CCR or CCD). For some organizations, that would be two documents (a human readable PDF and a computable CCD, for example), or they could produce one electronic copy with an XSL style sheet that makes the CCD human readable. Thus, the Standards Rule requires a CCR/CCD at a minimum plus optional human readable PDF, Text, DOC etc. Here's the Standards Rule text:

"§170.304(f)

Electronic copy of health information. Enable a user to create an electronic copy of a patient’s clinical information, including, at a minimum, diagnostic test results, problem list, medication list, and medication allergy list in:

(1) Human readable format; and

(2) On electronic media or through some other electronic means in accordance with:

(i) The standard (and applicable implementation specifications) specified in §170.205(a)(1) or §170.205(a)(2); and

(ii) For the following data elements the applicable standard must be used:

(A) Problems. The standard specified in §170.207(a)(1) or, at a minimum, the version of the standard specified in §170.207(a)(2);

(B)Laboratory test results. At a minimum, the version of the standard specified in §170.207(c); and

(C) Medications. The standard specified in §170.207(d)."

b. To achieve Meaningful Use, you must give an encounter summary to 50% of outpatients and 50% of ED/Inpatients who ask —and that summary can be electronic or printed. Even though the EHR must be certified to produce a CCR or CCD, meaningful use does not require that the patient actually receive their information in these formats. Paper is fine. In fact, even if you were to provide a CCR or CCD, the patient still has the option of requesting paper and you must provide paper if asked.

c. If you do want to deliver summaries to the patient electronically. how can you do it? The answer - anyway you want per Page 179 of the Meaningful Use Final Rule:

"Comment: Several commenters requested changes to the media through which this information could be provided. Differing commenters recommended eliminating the paper option, while others recommended only the paper option.

Response: We believe that more options give the EP needed flexibility. The EP could choose any of the listed means from the proposed rule of PHR, patient portal on a web site, secure email, electronic media such as CD or USB fob, or printed copy. If the EP chooses an electronic media, they would be required to provide the patient a paper copy upon request. Both forms can be and should be produced by certified EHR technology."

3. Do Emergency Department Systems need to be certified?

The Final Meaningful Use Rule clarifies that Emergency Department professionals are part of hospital staff and hospital meaningful use. Specifically, the Emergency Department is mentioned as part of the patient summary and CPOE requirements. For example:

"* More than 50% of all patients who are discharged from an inpatient or ED of a hospital who request an electronic copy of their discharge instructions must be provided with it."

Thus, ED information systems are likely going to be certified as to their ability to export an electronic copy of discharge instructions/clinical summaries. I suspect that ordering and medication management will also be included in certification of ED systems. We'll know more over the next few months at the Authorized Testing and Certification Bodies begin their work.

4. At what points in care does Medication Reconciliation have to be done?

If patient is transitioned from the ED to the ICU to the inpatient ward of the same hospital, does medication reconciliation have to be done 3 times per the Meaningful Use Rule?

At BIDMC, our Joint Commission mandate for medication reconciliation has led us to verify medications at every external and internal care transition. However, Meaningful Use does not. Per Page 193:

"Comment: Commenters requested additional clarity of the term “transition of care.” A few suggestions were provided by commenters including expanding the description to include all transfers to different settings within a hospital or revising the definition to “the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another”.

Response: In the proposed rule we clarified “transition of care” as the transfer of a patient from one clinical setting (inpatient, outpatient, physician office, home health, rehab, longterm care facility, etc) to another or from one EP, eligible hospital, or CAH (as defined by CCN) to another. We believe that different settings within one hospital using certified EHR technology would have access to the same information so reconciliation would not be necessary. We modify our clarification to account for some of the revisions provided. We clarify 'transition of care' as the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory, specialty care practice, long-term care, home health, rehabilitation facility) to another. We also clarify that the receiving eligible hospital or EP would conduct the medication reconciliation."

5. Can I use multiple software applications to achieve Meaningful Use?

Meaningful Use can be achieved using any combination of systems. However, every application and module used to achieve meaningful use must be certified (or the combination of systems in use at the site must achieve site certification).

At BIDMC, we're doing a site certification of our EHR, CPOE, Lab/Pharmacy/Radiology, decision support and data warehousing systems, since all will be used to achieve Meaningful Use.

Commercial vendors will certify their products, but in my opinion, many hospitals will end up doing site certification because they have numerous built and bought applications that will be used to achieve Meaningful Use.

I hope these answers are useful. I also hope they are correct. Each time I'm asked a question, I forward it to CMS and ONC to include in their internal FAQ database, so there will eventually be official answers!

The Most Amazing Flower in the World

This Agave Century Plant has the most amazing flower in the world.  I've been photographing the initial bloom spike since early June.  The plant takes about 15-20 years to finally put out a flower. Because so much of the plant's energy goes into this amazing bloom, the plant dies afterward.  But in nature's amazing way there are new daughter plants spreading from the original to keep the

The Bookmarked Final Rules

Thanks to Robin Raiford of Eclipsys for bookmarking the Final Rules

Here's the Meaningful Use Final Rule.

Here's the Standards Final Rule.

How to Recognize a Competitive Medical Student

This cartoon is from a clever medical student blog.  I love finding out what medical students in 2010 are up to,  and reading about their struggles brings back my own nostalgic (read: horrific)  memories.  This cartoon of a Med School Gunner shows me that not much has changed and this type of student is still with us. 

(thanks Doc Cartoon)

19th Century Obesity Cure

I really really want to know what the treatment is that this "regular practicing physician" will send to the patient to reduce the surplus flesh. "Eat as much and as often as you please" and no "bandaging or tight lacing."  Bring it on!

(click on image to enlarge)

Cool Technology of the Week

My Cool Technology of the Week is very simple.

A solution to urban parking problems.

Check out this video of an automated parking system in Budapest.

Parking 400 cars underground in a limited space using a robotic control system for rapid car placement and retrieval. That's cool!

The Answer

The answer to yesterday's medical challenge is...(drum roll)...insect bites.  Many of you diagnosed correctly.  We don't know what type of insect caused the reaction because mosquito and chigger bites can look the same with red, indurated wheals.  The fact that they were on the exposed skin, and not under clothing gives a clue to insects too.

The photo here shows one of our nurses in Haiti with

My Outdoor Footwear

I choose my outdoor gear the same way I run IT projects - first I define requirements, then I write specifications, then I choose the right solution for the task to be done.

My 5 Summer activities are

*Walking with my wife in the mornings

*Kayaking the Charles in the late afternoons/evenings

*Cycling Dover/Sherborn/South Natick on weekends

*Hiking the Franconia/Kinsman/Presidential ranges in the White Mountains in Friday mornings. Instead of taking my customary last week of July vacation this year, I'm taking off Friday mornings in July to hike. Given all the Stimulus-related Healthcare IT activity in Washington and Massachusetts, it's easier for me to be available at least a portion of each day to ensure that I'm not a rate limiting step.

*Climbing in New Hampshire and Yosemite

I try to own and carry the most minimal gear possible for each activity. I want to be safe, capable of self-rescue, and reasonably comfortable, but I always want to be light and fast. In many activities, an agile response to changes in weather is safer than carrying a heavy load of equipment.

Each of my activities requires specialized footwear and I have selected shoes that meet my requirements, providing optimal function without a lot of complexity.

For Cycling, I use Pearl Izumi X-Alp Seek, a lightweight riding and running shoe that enables me ride on or off road, hike to my final destination, and portage my bike through mud/water.

For Hiking, I use the Five Ten Savant, an amphibious shoe what enables me to hike through rain, mud, river crossings, swamps, and canyons without worrying about getting my feet wet. The Savant drains so well that I arrive at my destination with dry and comfortable feet.

For Climbing, I use the Five Ten Prism that are optimally shaped for edging on small footholds and crack climbing.

For light treking/walking, I've used the Chaco Unaweep Z1 but their heavy sole is really more than I need for flat trails. For Kayaking, I've used NRS Kickers neoprene booties but they are really too hot for summer and neoprene really smells bad in warm, humid weather.

So, I needed a lightweight protective shoe that meets my light hiking and warm weather kayaking needs. My search led me to Vibram KSO Five Fingers. My daughter describes them as the strangest looking shoes she's every seen. Although they are indeed different than other footwear, they are light, durable, comfortable, and ideally suited for light trails and kayaking. Wearing Five Fingers feels like walking barefoot but without damaging your skin on rocks and roots. They dry rapidly, and their low volume means they are easy to fit into tight kayak hulls or narrow surfski footbraces. I would not have predicted that Five Fingers would work so well, but they are my favorite outdoor shoe at this point. Of course, I'm not likely to win any fashion awards, but I'm an engineer, so judge me for my efficiency, not my sense of style.

Since my feet are ultrawide (9EEE), I usually buy a half size larger shoe (9.5). However, the standard sizes of Five Fingers work perfectly for a wide foot. Check out the Vibram Five Fingers - together we'll make it a trend.

What is the Diagnosis?

This 24 year old patient had the onset of these very itchy lesions on both upper arms.  She takes no medication and has no other medical problems.  She had just returned from a vacation where they had lots of outdoor dining.  She recalls eating shellfish and strawberries.  You are the doctor.  Make a comment and tell us what is the diagnosis?  Can it be treated?

The answer will be posted

A Do it Yourself Presentation on the Meaningful Use Final Rule

Just as I did in January with the Meaningful Use NPRM, I've prepared a presentation that you can use for your Board and stakeholders to review the requirements the final Meaningful Use Rule. Feel free to use it without attribution to me.

This should save thousands of hours since everyone will be preparing the same material. Download it here.

Here's how I've organized it:

I've listed the Core Set 15 projects and their metrics for achieving stimulus funding followed by the 10 Menu Set projects, of which 5 must be chosen by eligible providers and hospitals.

Please let me know if I can clarify or add to this presentation to make it more useful for you.

A Do it Yourself Presentation on the Standards Rule

Just as I did with the Meaningful Use Rule, I've prepared a presentation that you can use for your Board and stakeholders to review the Standards Final Rule. Feel free to use it without attribution to me.

This should save thousands of hours since everyone will be preparing the same material. Download it here.

Here's how I've organized it:

I've listed the Content, Vocabulary and Privacy/Security Standards and Implementation Guidance.

Please let me know if I can clarify or add to this presentation to make it more useful for you.

An Analysis of the Final Standards Rule

At 10am today, the final Standards Rule was released as described on my previous blog. Here are additional details for stakeholders who want a technical analysis.

ONC received many comments on the balance between specificity (which can make certification and implementation easier) and generality (which can enable more rapid innovation). The Final Standards Rule achieves an optimal balance by providing very specific implementation guidance for mature standards and leaving flexibility for those still in evolution or without significant industry deployment

Content Standards

Patient Summary Record

Standard - HL7 Clinical Document Architecture (CDA) Release 2, Continuity of Care Document (CCD)

Implementation specifications - The Healthcare Information Technology Standards Panel (HITSP) Summary Documents Using HL7 CCD Component HITSP/C32

OR

Standard - ASTM E2369 Standard Specification for Continuity of Care Record and Adjunct to ASTM E2369

Electronic Prescribing

Standard - The National Council for the Prescription Drug

Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT standard, Implementation Guide Version 8, Release 1 (Version 8.1) October 2005

OR

Standard - NCPDP SCRIPT Standard, Implementation Guide, Version 10.6

Electronic Submission of Lab Results to Public Agencies

Standard - HL7 2.5.1

Implementation specifications - HL7 Version 2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1

Electronic submission to public health agencies for surveillance or reporting

Standard - HL7 2.3.1

OR

Standard - HL7 2.5.1

Implementation specifications - Public Health Information Network HL7 Version 2.5 Message Structure Specification for National Condition Reporting Final Version 1.0 and Errata and Clarifications National Notification Message Structural Specification

Electronic submission to immunization registries

Standard - HL7 2.3.1

Implementation specifications - Implementation Guide for Immunization Data Transactions using Version 2.3.1 of the Health Level Seven (HL7) Standard Protocol Implementation Guide Version 2.2

OR

Standard - HL7 2.5.1

Implementation specifications - HL7 2.5.1 Implementation Guide for Immunization Messaging Release 1.0

Quality Reporting

Standard - The CMS Physician Quality Reporting Initiative (PQRI) 2009 Registry XML Specification

Implementation specifications - Physician Quality Reporting Initiative Measure Specifications Manual for Claims and Registry

Vocabulary Standards

Problem List

Standard - The code set specified at 45 CFR 162.1002(a)(1) for the indicated conditions (i.e. ICD9-CM)

OR

Standard - International Health Terminology Standards Development Organization (IHTSDO) Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) July 2009 version

Procedures

Standard - The code set specified at 45 CFR 162.1002(a)(2). (2) Standard. The code set specified at 45 CFR 162.1002(a)(5) (i.e. CPT-4)

Laboratory test results

Standard - Logical Observation Identifiers Names and Codes (LOINC®) version 2.27

Medications

Any source vocabulary that is included in RxNorm, a standardized nomenclature for clinical drugs produced by the United States National Library of Medicine.

Immunizations

Standard - HL7 Standard Code Set CVX - Vaccines Administered, July 30, 2009 version

Race and Ethnicity

Standard - The Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, Statistical Policy Directory No. 15, October 30, 1997

Privacy and Security (includes transport standards)

Encryption and decryption of electronic health information

In general - Any encryption algorithm identified by the National Institute of Standards and Technology (NIST) as an approved security function in Annex A of the Federal Information Processing Standards (FIPS) Publication 140-2

For data exchange - Any encrypted and integrity protected link

Record actions related to electronic health information

The date, time, patient identification, and user identification must be recorded when electronic health information is created, modified, accessed, or deleted; and an indication of which action(s) occurred and by whom must also be recorded

Verification that electronic health information has not been altered in transit

Standard - A hashing algorithm with a security strength equal to or greater than SHA-1 (Secure Hash Algorithm (SHA-1) as specified by the National Institute of Standards and Technology (NIST) in FIPS PUB 180-3 (October, 2008)) must be used to verify that electronic health information has not been altered.

Record treatment, payment, and health care operations disclosures

The date, time, patient identification, user identification, and a description of the disclosure must be recorded for disclosures for treatment, payment, and health care operations, as these terms are defined at 45 CFR 164.501

Of note, REST and SOAP were removed as specified transport standards, enabling flexibility for secure transmission as long as data are encrypted and integrity assured. This will enable innovation such as we've seen with the NHIN Direct Project and several State HIE Efforts.

I'm quite pleased with the balance achieved by ONC. The major recommendations of the Federal Advisory Committees have all been incorporated, enabling the industry to move forward with enhanced interoperability in a way that is technologically achievable today.

Meaningful Use and the Standards are Finalized

Today at 10am, CMS and ONC released the final rules that will guide electronic health record rollouts for the next 5 years. Key resources include

New England Journal of Medicine overview. The table provides a detailed list of final meaningful use requirements.

Federal Register publication of the Meaningful Use regulation

Federal Register publication of the Standards regulation

Here's my analysis of the key changes in the Final Rule.

1. HHS has adopted the HIT Policy Committee recommendation to frame Meaningful Use as core requirements and discretionary requirements. In so doing, they have reduced the total number of requirements and introduced choice.

In the NPRM there were 25 requirements for Eligible Professionals and 23 for hospitals.

In the Final Rule there are 15 core requirements for Eligible Professionals and 14 for hospitals.

There are 10 discretionary requirements from which 5 must be chosen.

2. Thresholds have been reduced in many cases. For example, CPOE had a threshold of 80% of orders for Eligible Professionals and 10% of orders for hospitals. The language in the final rule focuses on order entry of medications and requires that 30% of patients with medication orders to have at least 1 medication order entered electronically. This requirement applies to both Eligible Professionals and Hospitals.

3. Administrative Simplification has been postponed to Stage 2.

4. Decision Support rules changed from 5 to 1

5. Required Clinical quality measures have been reduced to 6 for professionals and 15 for hospitals. For professionals, there are 3 core measures required, 3 alternative core measures, and a choice of 3 from a pool of discretionary measures. Reporting by attestation is required in 2011, electronic reporting is required in 2012. Clinical quality measurements for specialists have been eliminated for stage 1. There has been great effort to align meaningful use with PQRI measures.

6. The NPRM did not include the recording of advanced directives or a provision for providing patients with educational materials. The final rule includes these as discretionary meaningful use requirements.

Overall this final rule maintains a balance between the policy objectives sought and the technology changes possible that are achievable now. There will still be 3 stages of meaningful use and later stages will be more demanding. All the original stage 1 requirements will still be part of meaningful use by stage 2.

In January of 2011, the clinicians may begin the 90 day process of using a certified record per meaningful use requirements. Attestation of this use begins in April 2011. CMS payments will begin May 2011.

ONC also released the final rule on Standards and Certification today. They have done a remarkable job adding detailed implementation guidance specificity for patient care summaries, public health laboratory reporting, syndromic surveillance, and immunizations. It's a tricky balance to ensure there is enough specificity to test and certify EHRs and modules for interoperability while at the same time encouraging innovation. The final rule issued today achieves that balance perfectly, ensuring that only mature implementation guides are specified, leaving room for innovation in such as areas as how to transport data from point to point via NHIN Direct and other demonstration projects.

Overall, a very good day for ONC, HHS and stakeholders. The final rule means Meaningful Use will be achievable by many. The Standards and the process to certify their use are sufficiently specific. I'm impressed.

Dawn, Sunrise, Twilight, Sunset and Dusk

In last Thursday's blog, I described early morning walks with my wife after we rise at dawn. I promised to describe what "dawn" means.

Dawn is the time that marks the beginning of the twilight before sunrise. Per the definitions below, there is astronomical dawn, nautical dawn, and civil dawn.

Sunrise is the instant at which the upper edge of the Sun appears above the horizon in the east.

Twilight is the time between dawn and sunrise, and between sunset and dusk. Per the definitions below, there is astronomical twilight, nautical twilight, and civil twilight.

Sunset is the daily disappearance of the sun below the horizon as a result of the Earth's rotation.

Dusk is the beginning of darkness in the evening. Per the definitions below, there is astronomical dawn, nautical dawn and civil dusk.

Morning civil twilight begins when the geometric center of the sun is 6° below the horizon (the point of civil dawn), and ends at sunrise. Evening civil twilight begins at sunset and ends when the center of the sun reaches 6° below the horizon (the point of civil dusk). In general, civil twilight is the point where artificial illumination is required to read outside.

Nautical twilight is the time when the center of the sun is between 6° and 12° below the horizon. In general, nautical twilight ends when navigation via the horizon at sea is no longer possible.

Astronomical twilight is the time when the center of the Sun is between 12° and 18° below the horizon. In general, the end of astronomical twilight is the point where the sky is no longer illuminated by the sun and is dark enough for all astronomical observations.

All of this is summarized in the graphic above.

So when I say that I walk with my wife at dawn, I mean that we rise at civil dawn and begin our walk in civil twilight, ending it after sunrise.

Never again will you confuse dawn with sunrise or sunset with dusk!

Tips for Men Using Viagra

One of my journals, Mayo Clinic Proceedings,  (I read every night to keep up with the latest medical information) contained some clinical pearls that I wanted to pass on to my men readers who take medication for erectile dysfunction (ED).  They reported on a healthy 67 year old male who took 2 25mg doses of Viagra (sildenafil) but still did not get erections.  He was frustrated and inquired about

The HIPAA Privacy, Security, and Enforcement NPRM

On July 8, HHS released the Notice of Proposed Rulemaking on HIPAA Privacy, Security, and Enforcement. It will be published in the Federal Register on July 14.

What are the key points of these proposed HITECH HIPAA Modifications?

1. The rule updates the definition of Business Associates to include health information organizations, eRx gateways or other entities that provide protected health information transmission services to a covered entity and require access on a routine basis to such information. It also includes any Personal Health Record vendor acting on behalf of a covered entity. Note that Google and Microsoft act on behalf of the patient, not the covered entity, so this proposed rule does not change the status of Google Health or Microsoft HealthVault as they are currently structured. Finally, the rule also includes any subcontractor that creates, receives, maintains, or transmits protected health information on behalf of a Business Associate.

2. It stipulates that Business Associates must comply with all requirements of the HIPAA Security Rule. They may use or disclose protected health information as permitted by a business associate agreement or required by law. They may not use or disclose information in violation of the HIPAA Privacy Rule. They must provide electronic access to data to the covered entity, individual, or individual’s designee.

3. Business associates must enter into formal business associate agreements with subcontractors (subBAs). They must take corrective action if they learn of subBA noncompliance. They are liable for violations by subBAs (assuming that subBAs are acting within the scope of their agreement)

4. Covered entities and their business associates must obtain authorization for the sale of protected health information (even if use/disclosure is otherwise permissible), except:

Public health, treatment, payment, sale of Covered Entity/Business Associate activities on behalf of the Covered Entity, to an individual, required by law, or if remuneration is reasonable, cost-based fee to cover the cost of preparation/transmittal (includes research).

5. Covered Entities and their Business Associates must provide access in the electronic form and format requested if readily producible, otherwise in a readable electronic form and format as agreed to by the Covered Entity and individual (such as a PDF). They must provide an electronic copy to designee, if the request is in writing and clearly identifies designee and where to send the copy. They may charge for labor and media (if the copy is provided on physical media).

6. Covered Entities and their Business Associates must agree to requests to restrict disclosures to health plans if such disclosure is not otherwise required by law and the protected healthcare information relates to services for which individual (or 3rd party other than health plan) has paid the Covered Entity in full.

7. Other areas of proposed rule include

Marketing - does not require authorization if the communication discloses the fact that the covered health care provider is receiving financial remuneration in exchange for making the communication and provides the individual with a clear and conspicuous opportunity to elect not to receive any further such communications.

Fundraising - strengths provisions for patients to opt out of fund raising activities.

Compound research authorizations - allows combining an authorization for the use or disclosure of protected health information for a research study with another authorization for the same research study, with an authorization for the creation or maintenance of a research database or repository, or with a consent to participate in research.

Student immunization records - allows oral agreement of parents to authorize release of immunization data to schools.

Deceased individuals - disclosure requires consent of decendent's personal representative for 50 years following the date of death.

All of these additions are very patient centric and seem reasonable. It will be interesting to see the comments on this NPRM over the next 60 days.

Cool Technology of the Week

I recently had the pleasure of sitting next to EPA Deputy Regional Administrator, Ira Leighton, on a flight from Washington to Boston. We had a great discussion of the emerging technologies the EPA is using to create green, sustainable infrastructure.

You'll find an overview of their energy management techniques online, highlighting numerous regional efforts.

Massachusetts leads the way in many demonstration projects, creating zero energy waste water treatment plants. What does that mean?

Using specialized energy efficient pumps and values, photovoltaic solar energy sources, and wind power, these treatment plants are completely energy and carbon neutral.

If plants which treat wastewater via anaerobic digestion captured the Biogas released (mostly methane), an additional 340 megawatts of power could be generated.

Carbon neutral, energy neutral, water treatment that could even become an energy source via Biogas production. That's cool!

Morning Walks with my Wife

From Spring until Fall my wife and I rise with the early morning light of dawn (my blog next Thursday will define such seemingly ambiguous terms as dawn, dusk, twilight etc.) and walk 3 miles around Lake Waban at Wellesley College.

We have our ritual - we park at the College Club and start walking at the south end of the lake. We check out the family of swans that lives on a protected point to watch the progress of their groaning cygnets. We walk through the Hunnewell estate (pictured above) and it's "Dr. Seuss" forest of topiary trees and Japanese tea house. We watch for the purple martins feeding their young in a lakeside meadow. I look for the emerging mushrooms on the West side of the lake so I can prepare for the day's calls from poison control about the mushrooms kids are likely to ingest.

We check out the status of Catbird, Oriole and Robin's nests, watch the young broods of ducks feeding in the marshlands, and look for muskrats carrying greens to their lodges.

Most importantly, it's a quiet time to connect, reflect on the goals of the day, the state of our family, and plans for the future. In the quiet of the morning mist and blue light of sunrise we can solve every problem and address every concern without the distraction of a screen, a blackberry, or undone house chores.

Having this time is really important. I'm convinced that 90% of stress in life is a result of miscommunication - waiting to speak instead of listening. Walks are great way to listen - other than than birdsong, the splash of fish, or buzz of a dragonfly there are no distractions. Your muscles are moving, your brain is clear, and stress is low. A few years ago, I wrote about conflict resolution and suggested figurative Walks in the Woods.

30 years of walking with my wife has led to a romance, friendship, and partnership that is as strong as when we first met in the Summer of 1980. Last week, the Boston Globe wrote about the language of marriage. Our walks have been the place where that language has blossomed.

So find your own Lake Waban and make the most of your relationship, footstep by footstep.

Obama Makes Don Berwick Head of CMS

In a slick move, President Obama appointed Donald Berwick, a pediatrician, to the top post at CMS (Centers for Medicare and Medicaid).  I am happy about this because Dr. Berwick is eminently qualified and has been a leader in the quality and safety movement and patient protection for decades.   With his focus on quality and his passion for improving health care, he is the right person at this

Standards for Naming Medical Devices

Medical devices are an increasingly important part of care delivery. Discussion of medical device issues has become part of the mainstream press such as last week's Boston Globe article about their security.

A year ago, I wrote about a breakthrough in medical device interoperability standards for content, vocabulary and transmission.

Important work on device interoperability continues in IEEE, IHE, and the Continua Health Alliance.

As devices increase in number and complexity, the FDA wants to ensure devices are tracked with a standardized device nomenclature facilitating recall workflow and enabling easier patient followup over the lifecycle of the device. It should be simple to identify who has what kind of device and which subcomponents have been incorporated into the device.

What are the evolving standards for naming and identifying medical devices?

There are two popular approaches.

The first is the Universal Medical Device Nomenclature System (UMDNS), which is a standard international nomenclature and computer coding system for medical devices. It contains 8,842 unique medical device concepts and definitions (preferred terms), along with an additional 15,702 entry terms to facilitate classifying of biomedical information. UMDNS contains explicit relationships among the nearly 25,000 terms, including relationships among related devices (i.e. component devices versus the overall system). The National Library of Medicine has incorporated UMDNS into the Unified Medical Language System (UMLS)

The second is the Global Medical Device Nomenclature (GMDN). Its creation was mandated by the European Commission in order to provide the necessary tools to carry out many of the obligations required by the Medical Devices Directives. Its scope includes:

1. to give a common generic description for every general term that describes characteristics of a medical device. This is to be used for identifying similar devices to those involved in an adverse incident report;

2. to identify a device, using the generic term, for having been awarded a specific design or other certificate;

3. to serve as a basis for E-commerce – to provide a generic basis for purchasing individual types of manufactured devices, by establishing a heading for comparison of products from different manufacturers.

GMDN notes that UMDNS has been given special consideration within the GMDN. When a term selected from the UMDNS has been used as the preferred choice to create a GMDN term, the exact code of the UMDNS term has been retained.

Although the two systems share a significant common core from a past version of UMDNS, I have been told that the two have drifted apart over time.

Going forward, it would be helpful to have a single nomenclature for all devices and I expect that the HIT Standards Committee will be asked to recommend a single standard to support FDA regulatory needs.

Having a consistent device nomenclature supports quality, safety, and efficiency improvements such as

* Streamlining integration of EHRs and PHRs with home monitoring devices.

* Enhancing reporting from specialist EHRs to device registries (pacemakers, hip joints etc.)

* Reporting of adverse events from the EHR to Medwatch/FDA.

I look forward to the work ahead, harmonizing device naming to enable new functionality and provide increased safety monitoring for all the medical devices we use.

Doctor Sues for Lousy OnLine Ratings

I must say I think Dr. Kimberly Henry, cosmetic surgeon,  has made a big professional mistake.  She has filed a lawsuit to stop online reviewers from badmouthing her on the Internet.  She is seeking injunctions against at least 12 reviewers from sites such as Yelp.com  and DoctorScorecard.com.  Dr. Henry claims libel and defamation, invasion of privacy and interference with prospective economic

A Do it Yourself Meaningful Use Update Letter

In January, I wrote a Do it Yourself presentation on meaningful use for folks to use with their Board and Senior leaders.

Now that its July, there is a different kind of Do it Yourself document - a letter to your Board and Senior leaders outlining your plan and timeframe for certification, measurement of meaningful use, and collection of your stimulus funds. We cannot be completely certain about every detail, so its important to state what you do not know. The reason to start this communication now is that CFOs may be including stimulus dollars in budgets, not realizing that the timeframe to achieve the stimulus is still unknown.

Here's what I used.

"Dear Senior Leaders:

I want to update you on the effort in Washington to accelerate adoption of electronic health records by providing stimulus dollars to eligible professionals and hospitals.

There are three important regulations associated with this effort - the rule on standards, the rule on meaningful use, and the rule on certification. Electronic Health Records must include data standards in order to exchange data. To improve quality, safety, and efficiency, electronic health records must be used in meaningful ways. Products and self built systems must be certified as having the capabilities to support meaningful use and the standards.

Where are we are on the journey?

On June 24, the final temporary certification rule was published in the Federal Register.

It outlines the process for organizations to become authorized testing and certification bodies, but it does not provide the certification criteria. Those will be part of the final meaningful use rule.

On July 1, organizations began applying to serve as testers and certifiers. The timeline for approval of these organizations is unclear but likely it will be fast.

The Certification Commission for Health Information Technology is likely to be the first organization authorized based on its extensive past experience. It is likely that several organizations will eventually be authorized. We'll have to choose one to certify our suite of software, since it is a combination of built and bought systems.

The final rule on meaningful use has not yet been published, although it is likely to be completed by the end of July.

As soon as it is is published, we'll do a gap and risk analysis of our inpatient and ambulatory systems, just as I did with the interim rule.

Many organizations found aspects of the interim rule challenging for FY11 implementation. Meaningful use is not a cakewalk, it is a stretch goal for just about every organization. You should not presume that clinicians and hospitals will be able to use existing software and processes to achieve meaningful use. There will need to be upgrades and workflow change.

I've been working very aggressively to prepare us as much as possible, but until the final rule is issued, we cannot know how close or far we are.

Once the final rule is issued and certification bodies are authorized, we will proceed with certifying our inpatient and outpatient systems. If the certification process identifies gaps in functionality, we will need to enhance those systems to fill the gaps.

Once the systems are certified, then we'll need a significant education program for our clinicians, followed by a 90 day test period during which we document the use of all systems by our clinicians to achieve the thresholds required to demonstrate meaningful use.

As to timeframe, I am guessing August before certification bodies are ready, September for certification of our applications/education of our clinicians, October through December to document meaningful use, followed by initial stimulus payments in January.

If there are gaps in EHR or Health Information Exchange functionality we need to remediate, it will be later.

I've asked ONC if organizations can use a 90 day demonstration window before their systems are certified (since no software in the country is yet certified - all previous certifications have been declared void). ONC responded that the final rule will provide this clarification.

Thus, the bottom-line is that no hospital in the US yet has any idea when they'll receive stimulus payments, making inclusion of such payments in the FY11 budget very problematic.

I'll keep you updated over the next weeks and months. If there are ways to accelerate stimulus dollar payments by adding additional temporary or permanent resources, I will let you know.

John"

Feel free to use this as a template for your own letters.

Top Ten Things Going through Isner's Mind

 

Did you see the mental and physical strength these player's demonstrated during the historic tennis match?  It shows just how important the mind is.  RESPECT!

Rare Condition of Lizzie Velasquez

 


Lizzie Velasquez is 21 years old and lives in Austin, Texas.  She suffers from a rare condition that prevents her from gaining weight, even thought she eats up to 60 small meals and consumes between 5,000 and 8,000 calories daily. 

She was born premature at 2 lbs. 10oz and remained tiny as a child.  She has a syndrome that prevents her body from gaining weight and putting on body fat.  She

Attack of the Dust Mites

Have a happy 4th of July Holiday!  

Cool Technology of the Week

Last week, the Department of Homeland Security released its Draft National Strategy for Trusted Identities in Cyberspace

The strategy includes 4 goals.

Goal 1: Develop a comprehensive Identity Ecosystem Framework

Goal 2: Build and implement an interoperable identity infrastructure aligned with the Identity Ecosystem Framework

Goal 3: Enhance confidence and willingness to participate in the Identity Ecosystem

Goal 4: Ensure the long-term success of the Identity Ecosystem

Discussion and comments are online.

Such an ecosystem could address

*the multiple passwords problem we all face in our organizations

*the challenge of maintaining Public Key Infrastructure locally or regionally

*the complexity of securing the endpoints in health information exchange

*digital signature as needed for many compliance requirements

*federated authentication requirements among collaborators

An ecosystem of identity management that simplifies authentication in our local, regional and federal applications - that's cool!

Vegan Comfort Foods

What foods bring back positive memories of your childhood, your parents, or times when you've been particularly happy. Grilled Cheese and Tomato Soup? Brownies? Green Bean Casserole with crunchy onions?

In our household, we have numerous vegan comfort foods that we use for celebrations or to warm up after a day outdoors. My vegan comfort foods are:

*Homemade Vegan Curry

*Homemade Yakisoba

*Homemade Vegan Pizza

*Homemade Split Pea Soup from scratch

*Homemade Vegan Pot Pie

Their recipes are below:

Vegan Curry

1-2 teaspoons peanut or avocado oil

1 large onion, chopped

1 tub fresh tofu, firm or extra firm, cut into bite size cubes

5 large carrots, sliced into thin rounds, boiled or or steamed until slightly tender

2 large Yukon Gold or White potato, diced and boiled or steamed until slightly tender

1 3.5oz package Golden Curry mix (medium hot)

http://www.asianfoodgrocer.com/product/golden-curry-med-hot-3-5-oz

6 cups water (doubles the water called for in the package, but this reduces the sodium overall, and increases the curry gravy)

2 tablespoons non-GMO organic cornstarch

Saute the onion in the oil, then add the tofu, browning slightly. Add carrots and potatoes and saute for a few minutes. Add 5 1/2 cups water, add the curry paste and heat to boiling. Reduce heat and simmer to thicken. Mix cornstarch in remaining 1/2 cup water and add slowly to the mixture. Serve over hot rice, optionally garnish with salt-pickled ginger strips. Goes well with steamed broccoli or other green vegetable of choice.

Yakisoba

Use fresh yakisoba noodles from an Asian market, or substitute any chow mein noodle available. Stir fry in a wok or large frying pan, in 1 tablespoon of peanut or avocado oil, any 2 cups selection of finely chopped onions, celery, and carrots, plus peas and corn as desired.

If using the fresh yakisoba noodles, add them to the stir fry until soft and lightly browned, adding the flavor packets or use soy sauce to taste.

Vegan Hawaiian Pizza

1 fresh refrigerated Multigrain pizza dough from Whole Foods Market (or substitute any preferred pizza dough, commercial or homemade)

1/4 cup low sodium marinara or pizza sauce

1/3 package Daiya mozzarella style cheese substitute

1/4 to 1/2 package Lightlife Smart Bacon, chopped 

1/2 can organic pineaple chunks, or fresh pineapple as available

1 small can sliced black olives

cornmeal for base to prevent sticking

Preheat oven to 425 degrees F

Fresh dough should be left to warm slightly outside the fridge before you manipulate it.

Sprinkle cornmeal onto baking sheet. Take fresh dough and gently make into a round flat form. before any areas that are too thin happen place the dough on the cornmeal, and continue to stretch the dough out into a uniform round to fill the sheet. (of course, if you are skilled in spinning dough, go for it).

Thinly coat the surface with the tomato based sauce, then sprinkle Daiya uniformly over surface, and follow with chopped Smart Bacon, pineapple and olives. Add green bell peppers if desired.

Cook pizza for 25 minutes or until properly melted and browned. Slice and eat.

Vegan Split Pea Soup

1 teaspoon avocado oil or preferred vegetable oil

1 pound dried green split peas

6 cups water, add more as needed

one medium onion, chopped

three medium carrots chopped

one bay leaf

3 vegan no-salt added bouillon cubes (Rapunzel)

In soup-pot, saute onion in oil over medium heat. one softened add carrots and saute for a couple of minutes. Add dried peas, water, bouillon, and bay, bring to a boil. Reduce heat, cover and simmer for approximately an hour until peas are completely soft. Cook longer if needed, and add more hot water if too thick. Remove bay leaf and serve.

Vegan Pot Pie

2 Whole Wheat pie crusts (per pie) - find them in the freezer section of your local market, or if you are able to make ahead of time from scratch, that is always great too

1 large Yukon Gold or White potato, diced and parboiled until slightly tender

1 cup fresh or frozen organic peas

1 cup fresh or frozen organic corn kernels

1 cup thinly sliced rounds of carrots, parboiled or steamed until slightly tender

Optional variations include green beans or broccoli as desired to taste.

1/2 stick Earth Balance vegan margarine

approx 3/4 cup unbleached white flour

vegan no salt bouillon powder (or vegan no salt bouillon cube) to taste

approx 1/2 cup soy milk, unsweetened or sweetened (substitute vegetable broth or another kind of nut milk as preferred)

1 tablespoon soy sauce or Braggs Aminos

powdered, or fresh herbs if in season, including thyme, rosemary and sage

Preheat oven to 375 degrees F. Remove crusts from freezer to allow them to become flexible. If using frozen vegetable allow time to approach room temperature in advance. Pre-steam or parboil the carrots and potato. In a large saucepan, melt the margarine under medium heat and begin to stir in the flour until a gravy paste is formed. Sprinkle in vegan bouillon powder to taste. Slowly wisk in the soy milk, adding as much as is needed to create the thickness of gravy desired. add soy sauce and herbs. Add remaining vegetables, stirring to coat all the vegetable surfaces.

Pack the vegetable mixture spoonful by spoonful into one pie crust, and mound them in the center, creating a raised center. Rub water allow the rim of the crust, then tip over the second crust on top of the filled pie, and press the two rims together firmly to create a seal. Cut several slices in the top crust to allow for steam to vent.

Place the pie on atray or foil to catch any bubbling over gravy. Set into into the oven, and cook for 45 minutes approximately. It is easy to plan ahead and make two pies so that you have leftovers - they taste great rewarmed the next day.

You can add a Gardein vegan meat substitute if you wish to create a meat textured pie.