Germs- A Traveler's Companion

I read an article about the top places to find "germs" and travel is a big exposure.I am not afraid of germs because I know they are ubiquitous and there is no way to eradicate bacteria, but having just returned from an overnight in a Hotel...I realize I have been in the midst of a virtual hothouse of germs. Think about these bacteria and virus infested environments:Hotel room remote control:

Devices for Bedside Computing

We're currently evaluating several devices for mobile bedside computing including subnotebooks (Dell D420, Lenovo X61), tablets (Motion Computing LE1600), and small form factor devices (the Apple iPhone/iPod Touch, Emano-Tec MedTab ). I will write another blog entry on stationary bedside computing devices such as wall mounted thin client devices.

Our early results are that nothing on the market yet meets our ideal requirements:
8 hour battery life
Can be easily disinfected to prevent the transmission of disease
Can be dropped 5 feet without significant damage
Under 2 pounds

Here's a list of those machines which attempt to fill the niche for mobile bedside computers

DellD420
Battery Life - 3 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 11.6 x 1/ 3.0 pounds

Lenovo X61
Battery Life - 6 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 10.5 x 1.4 / 3.6 pounds

Motion Computing C5 (Also known as the Intel Mobile Clinical Assistant)
Battery Life - 3 hours
Ability to disinfect - excellent
Drop resistance - good
Size/Weight - 10.0" x 10.0" x .95” / 3.3 pounds

Motion Computing LS800
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 8.94” x 6.69” x 0.87”/ 2.2 pounds

Motion Computing LE1700
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 11.65" x 9.64" x 0.74” / 3.3 pounds

Apple iPhone/iPod Touch
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - fair
Size/Weight - 2.4 x 4.5 x .46/ 4.8 ounces

Emano-Tec MedTab(a startup which is just entering the market)
Battery Life - 24 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 5.5" X 7.5" X 0.5"/12 ounces

I'm personally carrying around the Dell D420 and Lenovo X61 to assess their reliability and durability.

We're piloting 5 LE1700's in our Emergency Department. The LE1700 has a 12.1" screen size compared to a 10.4" in the C5 and 8.4" i the LS800. We're testing it with a medication reconciliation application and will soon know more about its support of clinician workflow. In general, all the Motion Computing devices seem rugged, relatively easy to disinfect, and well engineered. However, battery life is limited to 3 hours, so we'll need to keep charging stations handy throughout the department.

The Emano-tec MedTab form factor and battery life are ideal. It uses an eInk display just like the recently announced Amazon Kindle. The lack of color may be a major limitation for some applications. At present, the device is not available in large quantities, so we're testing a prototype, also in our Emergency Department.

The iPod Touch is promising. A slightly larger form factor and better power management (longer life and/or hot swappable batteries) could make this an ideal medical device. Apple's attention to human interface features really shows here, but it's clearly intended to be a device for personal, not business use. We're testing it with our Emergency Department dashboard application.

Size and battery life for laptops is not as relevant if used as a Computer on Wheels on carts. We use two kinds of carts - The unpowered Ergoton StyleView and the powered Infologix SL Ultra Cart

The hardware and software development efforts of the past few years are getting us closer to the ideal mobile clinical device. At BIDMC one challenge is the difficulty involved in secure authentication. We use secure passwords (requiring capital letters, numbers, symbols, etc) which are difficult to rapidly enter via a tablet. Solutions include biometrics (we are testing Omnipass) and novel login mechanisms such as graphical authentication.

More to come as we complete our evaluation by the end of the year. I welcome any comments on other's experiences with mobile bedside computing devices.

Are Regional Health Information Organizations (RHIOs) Sustainable?

As CEO of the Massachusetts Regional Health Information Organization (RHIO) called MA-SHARE, I have spent 4 years working with stakeholders in Massachusetts to create a sustainable business model for health information exchange.

MA-SHARE’s first effort in 2004 was the MedsInfo project, a state-wide medication history exchange pilot based on payer claims data. We learned a great deal about privacy, workflow, data expectations, and health information exchange operations. The project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations given the lack of integration of the data into clinician workflow and the inherent incompleteness of the data (only 66% of patients had medication data in our regional payer databases as of 2004). As of 2007, the two largest national e-Prescribing exchanges, RxHub and SureScripts, have much more complete networks and we've integrated the former MedsInfo functionality into our e-Prescribing utility, described below.

In 2005 and 2006, working with the Markle Foundation and the Office of the National Coordinator, we developed a Nationwide Health Information Network implementation pilot based on a state-wide master patient index called the Record Locator Service. The pilot demonstrated the value of the emerging clinical data exchange architecture to support provider-to-provider data exchange, personal health records, and biosurveillance. The architecture worked well, but the project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations required to maintain the Record Locator Service.

In 2006 and 2007, we implemented a state-wide e-Prescribing gateway. We've transmitted over 100,000 electronic prescription transactions through our exchange and we are live with formulary enforcement, eligibility checking, dispensed medication history including drug/drug interaction checking and routing to retail/mail order pharmacies. The stakeholders have found value in paying for the cost of ongoing operations of this infrastructure since it reduces costs to the payers by enhancing the use of generics/formulary medications, it reduces costs to pharmacies by eliminating paper workflows and it improves workflow for providers by streamlining renewal workflow. We've implemented our e-Prescribing gateway at CareGroup, Partners and soon Children's Hospital. We will work in 2008 to expand the use of the gateway to connect to vendor systems such as Cerner and Meditech, as well as to encourage its use in more institutions.

In 2007, we implemented our "push pilot" using national standards to share discharge summaries and emergency department summaries among caregivers. We use the same software application that routes prescriptions between providers and pharmacies to securely route documents provider to provider. This clinical data exchange approach is truly low cost and simple. All that is required is a sender which can summarize tabular and narrative data in the format specified by HITSP and an organization which can receive this data via direct integration into an electronic health record, secure email or fax. Cerner, MEDITECH, eClinicalWorks and GE Centricity are among the EMR vendors supporting the design and implementation of this project. We are optimistic that the value to the stakeholders of exchanging clinical summaries will be sustainable based on cost avoidance. By eliminating the expense of chart copying, mailing, and paper-based record storage, hospitals seem willing to fund health information exchange of summaries out of projected cost savings. It's also a great political win for the hospital, since pushing clinical summaries keeps the primary caregivers and referring physicians well informed, enhancing their satisfaction. It provides care continuity by ensuring all caregivers (inpatient, outpatient, Emergency Department, rehabilitation, and long term care facilities) are given a consistent medication list, problem list, laboratory summary, and discharge narrative. As personal health record services such as Microsoft HealthVault, Google's Health efforts and Dossia through Indivo Health are more widely deployed, we may also push data directly into personal health repositories at patient request.

MA-SHARE’s budget in 2008 is approaching the same kind of sustainablity we've achieved with our financial data exchange, NEHEN. All 'lights on' operations are funded by the stakeholders plus $250,000 is available each year for new projects and enhancements. No grant funding or soft money source will be used in 2008. Our hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for our community. The big lesson learned in our statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. To achieve sustainability, the initial efforts must be expanded to meet the needs of the common marketplace. We believe our push model addresses this issue.

Health Information Exchanges in the US are in tenuous financial shape. We've been exploring sustainable business models in Massachusetts for 4 years. Many RHIOs still depend on grants, which eventually end and thus are not a good business model. I believe that Health Information Exchanges will evolve to meet the local business needs of many communities but that a nationwide health information network linking together these local exchanges will not be widely deployed until more consistent funding is available. In many ways, data exchange is a public good, which is hard to support entirely from local stakeholders. Additional funding from federal and state sources would help. The level of investment in healthcare information exchange in Canada and the UK far exceeds that in the US. I hope that Bush's 2004 commitment to have every clinician in the country wired by 2014 will be met with increases in funding to support it.

Quality Metrics for the Country

I recently had the privilege of participating in the Health Information Technology Expert Panel (HITEP) of the National Quality Forum (NQF), part of a joint effort of many stakeholders to rethink the way quality is measured from data in Electronic Health Records and Hospital Information Systems.

This week, the draft report will describe an analysis of data types commonly used in quality measures, as part of the quality metric "harmonization" process to be implemented by HITSP, NQF, AMA/NCQA and the Quality Metric authoring organizations (Joint Commission, AQA, HQA etc.)

The idea is simple. In the past, quality metric authors have produced carefully specified, evidence-based quality measures. The challenge is that these carefully designed indicators are not computable from existing hospital information systems and ambulatory care records. There are so many exclusions in the measurements that manual chart abstraction, an expensive and time consuming approach, is the only way to collect data for these measurements.

For example, excluding all patients on “comfort measures only” from quality measures creates a very accurate denominator, but no hospital information system in production today uses the SNOMED vocabulary term for “comfort measures only” in the electronic patient record. This begs the question - if this exclusion were eliminated would it really matter? If we assume that “comfort measures only” is a reasonably evenly distributed event at all hospitals in the country, then the metrics will be very slightly off for every hospital. Similarly, exclusing women with a history of polycystic ovarian syndrome from diabetic measures can be challenging. Assuming polycystic disease is evenly distributed in the country, why use this exclusionary criteria?

With the idea that we should create the best quality measures possible given the data we can gather electronically, here's the new process. As part of the NQF-endorsement process, Quality measure developers will submit their proposed measures to the NQF. The NQF will analyze the data types needed to complete the measures (i.e. labs, medications, problems, allergies, demographics) and forward a request for standards harmonization to HITSP. HITSP will recommend the standards for each of these data types and will report on gaps. Further, HITSP and NQF will work together to report on data quality/adoption - even with good standards, how much of the data is available today with reasonably good data integrity. Based on the analysis of data types, standards readiness, and data avalability analysis, NQF will offer feedback to the quality measure developers to refine the measures to ensure they are computable.

With easily calculated quality metrics, hospitals and ambulatory care facilities can deploy real time dashboards and decision support to offer clinicians the just-in-time information they need to improve quality. Compare that to manual chart abstraction which takes months and $20/chart in labor.

As a first step, NQF and HITSP have worked through 84 NQF-endorsed AQA/HQA measures that exist for the IOM Priority Areas listed below:

1. Asthma
2. Cancer screening
3. Care coordination
4. Diabetes
5. End-of-life with advanced organ system failure
6. Frailty associated with old age
7. Immunization
8. Ischemic heart disease
9. Major depression
10. Medication management
11. Pregnancy and childbirth
12. Stroke
13. Tobacco dependence treatment in adults

and derived 35 data types requiring standards. The HITSP Population Health Technical Committee will deliver the harmonized standards for these data types on December 13, 2007 at the HITSP Panel meeting in Washington.

Working together, NQF/HITEP, HITSP, AMA/NCQA, and the quality metric authoring organizations are well along the way to producing computable quality measures for the country. As these are implemented in hospitals and ambulatory care centers in 2008-2009, the burden of data collection will be reduced and the amount of actionable knowledge (see my previous blog entry here) about the care we deliver will markedly increase.

High Intensity Interval Training

Now that the big feast is over, many people turn to exercise to try and burn off those extra calories. High-Intensity Interval Training (HIT) is one way to rev up your metabolism and get aerobic benefit in short bursts of time.HIT is repeated sessions of relatively brief, intermittent exercise that is done with "all out" effort. A single HIT can last from a few seconds to several minutes,

Dennis Quaid's Twins-Preventable Error

Hollywood and the tabloids were rocked this week with the report of actor Dennis Quaid's two week old twins receiving a lethal dose of Heparin at the prestigious Cedars-Sinai Medical Center in Los Angeles.It shows that VIPS are not immune to preventable hospital errors, no matter how much staff attention, privacy and spa-like treatment they receive from hospitals (and they do!)This case is not

Cool technology of the week

Last week I started a Cool Technology post which I intend to do every Friday.

As part of my flexible work arrangement research, I've been testing video conferencing technologies. The coolest technology is Cisco's Telepresence infrastructure. John Chambers demonstrates it here

I've tested H323 software and hardware, Video IM chat, and iChat via Jabber. The big question raised by all of these technologies is best described in this email sent to me by Paul Gray, Professor Emeritus of Information Science, Claremont Graduate University:

"Being retired, I receive my copies of Computerworld in batches from my office. Hence I only now read your September 15 article on flexible schedules. I was pleased to see that you found the need for initial meetings important in your thinking. I thought you would like to know that this concept is not a new idea. When we first proposed telecommuting (Telecommuting-Transportation Tradeoffs: Options for Tomorrow, Wiley 1975) we quoted results that we found in the literature on the dispersal of government workers out of central London and central Stockholm in the 1960s. The dispersal was the result of, for example in London, of the concentration of office jobs that wound up depopulating the hinterlands of young people. Everybody complained that they could not be moved out because they needed continual face to face contact with people in other agencies. Studies were done that found that once there is an initial meeting, which coupled a human face and body language with voice and correspondence, people were able to work in dispersed mode with no loss of effectiveness. However, they did need periodic (typically 6 month) refreshing of the initial contact so that the ties would be maintained"

It may turn out that audio via phone, combined with desktop sharing/whiteboards/IM will be good enough without video. My full report will be complete in January.