Life as a Healthcare CIO

Cool Technology of the Week

2009-11-20T03:00:00.000-08:00

Cool Technology of the Week

We've all used Google products - Search, Gmail, Blogger, You Tube, Docs, and Analytics. Along the way, we've provided information about ourselves - our preferences, our searches, and our customizations.

Google has created a dashboard that serves as a "disclosure log" of everything they know about each user.

To access it, go to Google Dashboard

It's fascinating to see the accumulated data. Google does have strong policies to provide the Google Personal Health Record (Google Health). Any information related to that product is not mined, resold, distributed or used for advertising in any way.

With the Dashboard, I can better understand the data Google gathers about me and be a better informed user.

A dashboard that consolidates all information about my use of Google products - that's cool.

The November HIT Standards Committee Meeting

2009-11-19T18:21:00.000-08:00

The two major agenda items of the November HIT Standards Committee were the lessons learned from the Implementation Workgroup activities and security testimony from multiple industry experts in four panels - Stability/Reliability, Cybersecurity, Data Theft/Loss/Misuse, and Building Trust.

We began the day with an overview of the 10 major themes from the Implementation Workgroup testimony. We discussed the ways in which these themes could inform our future work in the upcoming months as we review comments on the interim final rule, consider incremental improvements to the standards supporting meaningful use in 2013/2015, and we consider tools/technologies/education to enhance adoption.

Specific action items include:

*Work hard on vocabularies and try to get them open sourced for the entire community of stakeholders.

*Consider adding a simple REST-based transport method for point to point exchanges between organizations. We already have recommended SOAP (as constrained by HITSP Service Collaborations) and REST as approaches to transport. At present there is no specific guidance as to how REST shoud be used from a policy or technology standpoint.

*Work jointly with the HIT Policy Committee to establish a privacy framework that enables us to constrain the number of security standards.

*As we continue our work, try to use the simplest, fewest standards to meet the need.

*Continue to gather feedback on the 2011 exchanges (ePrescribing, Lab, Quality, Administrative) to determine if there are opportunities to enhance testing platforms and implementation guidance that will accelerate adoption.

Interestingly, several people approached me at the meeting to discuss rumors that the HIT Standards Committee would significantly change the existing 2011 recommendations based on the Implementation Workgroup activities. The purpose of the Implementation Workgroup was to gather feedback, create a set of guiding principles, and ensure we have the best process going forward to ensure the most appropriate standards are chosen. The Implementation Workgroup activities including the blogs, the testimony and hours of discussion have raised awareness of all committee members that will support our future decision making, not revision of the work of the past.

The security testimony was extremely valuable. Here are some of the "Gold Star" ideas

Stability/Reliability

* Many existing clinical products do not provide the functionality needed to support security best practices

* Systems with FDA 501k certifications are often managed by vendors and lack updated operating systems and anti-virus software

* The least important systems are often those which are compromised and provide hackers access to more important systems.

Cybersecurity

*Security is journey and many healthcare organizations are not well resourced to implement security best practices.

*Security awareness among providers is low.

*We should focus on "Evidence-based security policies and practices". Per the testimony, some dogma in security is not supported by evidence i.e.

- Passwords longer than about 5 characters do not reduce risk in any meaningful way

- Encryption of data at rest in databases and other large systems in data centers typically provide little additional security protection

Data Theft/Loss/Misuse

*Portable devices/Wireless are a major vulnerability

*Audit logs from vendor systems may be insufficient to detect misuse of data

*Role-based security is important. Roles vary in institutions, so it will be challenging to create a one size fits all standard.

Building Trust

*Security should be layered to create an in depth defense

*Data integrity is important to protect patient safety (ensure the record is accurate)

*We need baseline policies and standards for Authorization, Authentication (including identity proofing), Access Control, Audit

A great meeting. I look forward to our next steps - reviewing the interim final rule in mid December based on all the testimony and learning we've had to date.

Guiding Principles for the HIT Standards Committee

2009-11-18T03:00:00.000-08:00

In the past few weeks, the HIT Standards Committee has gathered a significant amount of written and in person testimony from standards stakeholders. We've run the FACA blog and multiple personal blogs.

On Thursday November 19, we'll present a complete distillation of everything we've learned but there are several recurring themes can could be called Guiding Principles. Just as HITSP was guided by Harmonization Readiness principles to choose standards that were good enough, the HIT Standards Committee has a been told to think about the following whenever it recommends standards:

• Keep it simple; think big, but start small; recommend standards as minimal as possible to support the business goal and then build as you go

• Don’t let “perfect” be the enemy of “good enough”; go for the 80% that everyone can agree on; get everyone to send the basics (medications, problem list, allergies, labs) before focusing on the more obscure

• Keep the implementation cost as low as possible; eliminate any royalties or other expenses associated with the use of standards

• Design for the little guy so that all participants can adopt the standard and not just the best resourced

• Do not try to create a one size fits all standard, it will be too heavy for the simple use cases

• Separate content standards from transmission standards; i.e., if CCD is the html, what is the https?

• Create publicly available controlled vocabularies & code sets that are easily accessible / downloadable

• Leverage the web for transport whenever possible to decrease complexity & the implementers’ learning curve (“health internet”)

• Position quality measures so that they will encourage adoption of standards

• Create Implementation Guides that are human readable, have working examples, and include testing tools

We'll refine this during our meeting on Thursday and the end result should be a polished list of guidance for all our future work.

An Open Access Scheduling Model for Management

2009-11-17T03:00:00.000-08:00

Wouldn't it be great if we could solve today's problems today?

Every day I receive over 1000 emails. A small number of those emails are complex problems that require multi-stakeholder coordination. Although I can try to solve such problems via email, my rule is that if more than 3 rounds of emails go back and forth about an issue, it's time to pick up the phone or have a meeting.

However, scheduling a meeting among senior managers in a large organization can take a month. By that time, the issue has either become a much larger problem or the opportunity to rapidly move forward has been lost. So much for nimble decisionmaking.

How can we improve this situation?

I suggest we learn from the Open Access Scheduling model used in primary care.

Patients who are sick today do not want an appointment in three weeks - they need to be seen today.

In the past, clinicians noted they were so busy that their calendars were backlogged weeks to months.

But wait - if you see 15 patients a per day, a backlogged calendar does not imply you are seeing more patients. Why not work through the backlog and then leave 50% of the calendar open each day for the patients who are sick each day - solve today's problems today.

The same thing can be applied to our administrative lives. Each day there are challenges created by customers, employees, and the external world. If we left 50% of our calendars open each day for solving today's problems today, we would reduce stress, enhance communication, and improve efficiency. We could even develop metrics for senior executives which measure "time to problem resolution" as a means to drive incentive compensation.

Today, we pay doctors for quantity of care delivered instead of quality. Healthcare reform is intended to change that. Administratively, we should be paid for the problems we solve, the chaos we eliminate, and the processes we improve.

Open Access Scheduling for Management - In December, I'll give it a try and report back how it works.

CatDog

2009-11-14T06:54:00.000-08:00

When my daughter was growing up, she watched a program called CatDog about the seamless integration of the two animals. "Their" life required constant communication and mutual understanding of the underlying cat and dog cultures.

During the work of the last 4 years, the "healthcare informatics crowd" has been labeled the cats and "internet/health 2.0 crowd" has been labeled the dogs.

At times, I've even been called the leader of the cats.

On Friday November 13, during an HIT Standards Committee Implementation Workgroup call, we reviewed the FACA blog and related postings on the blogs of Sean Nolan, Wes Rishel, Adam Bosworth. One of the participants commented that David Kibbe and I wrote blogs that converged on the same ideas. This is an achievement worth reflection.

Harmonization is the decision by consensus of a path forward that is good enough for everyone.

Compromise is the acceptance by everyone of a path forward that leaves everyone equally unhappy. If often occurs when two stakeholder groups become fatigued enough to put their differences aside.

In my blog this week, I suggested we change "No, because" to "Yes, if" and define the right tool for the job, recognizing the roles of CCD/CDA and CCR/PDF. David Kibbe did the same on the FACA blog.

Also, on the FACA blog, a posting called this right tool for the right job approach "a mistake". The comment received 48 supporting votes and 45 opposing votes - a nearly perfect balance between two points of view.

I think this means we got to 90% of the answer through harmonization and the last 10% through compromise. At the November 19 HIT Standards Committee meeting, we'll discuss all the lessons we learned in the Implementation Workgroup that led us to develop guiding principles such as embracing the simplest standards needed for the specific business need. Yes, there is a role for CCD/CDA and CCR/PDF.

David - welcome to CatDog. We'll have a great life together.

Cool Technology of the Week

2009-11-13T03:00:00.000-08:00

Recently, Harvard Medical School implemented a secure password reset architecture that is my cool technology of the week.

Forgotten password processes typically work by asking the user to answer a secret question. However, the answers to such questions may be weak or may be findable on social networking sites, which often disclose detailed personal information (favorite vacation spot, favorite food, favorite car etc.)

We elected to use a two factor approach - something that you have and something that you know. Since more the 90% of Harvard faculty, staff, and students have mobile devices, we elected to send a PIN code for password resetting to their cell phones.

The technology is very simple. Each telephone carrier has a way to transfer an email message to a text message via a normal convention such as (phonenumber@phonecarrier.com). We send a random code via email(translated to SMS via carrier) to the user's device which is validated when the user enters the code into our site. The codes are time sensitive, which reduces the possibility of compromising a code.

All password resets at Harvard Medical School now require this approach. We implemented it for 22,000 users and have thus far received a dozen calls to the help desk. Here's the email I sent to the community about it.

"To the HMS Community:

To comply with new Massachusetts data protection regulations, which take effect on March 1, 2010, we must make several changes to our policies and technologies. The new regulations require all HMS mobile devices be encrypted; govern how employees are allowed to keep, access and transport records containing personal information outside of business premises; require that an institution knows where every computing system -- including laptops and portable devices -- containing personal information is located; and require reasonable monitoring of systems for unauthorized use/access to personal information. You can read more about the new regulations on my blog.

To ensure the integrity of all personal data, we will be begin making some of the changes now. Effective today, password resetting at HMS includes an optional feature called SafeCode, which we have piloted over the past year. Whenever a password reset is requested, a code to complete the reset will be sent to your cell phone to protect your account.

Over the next month, we'll complete an evaluation of products that will help ensure the safety of laptops and other mobile devices. We'll keep you informed of software applications and services that will be available to the HMS community to ensure compliance with the new regulations.

If you have questions about any aspect of these regulations, please see the Harvard Enterprise Information Security Policy or contact the Help Desk. Thank you for your support of our efforts to further protect the privacy of personal information.

Sincerely,

John D. Halamka, MD

Chief Information Officer

Harvard Medical School"

The China Study

2009-11-12T03:00:00.000-08:00

As readers of my blog know I'm a vegan, a locovore, and grow my own vegetables organically. I avoid caffeine and exercise by climbing, cycling, hiking, kayaking, and skiing.

As a vegan, I cannot get B12 from vegetables, so I take a B supplement.

Living in the Northeast, wearing sunscreen while outdoors, and working indoors during the week, I do not produce all the Vitamin D my body needs. Of course, this is just an artifact of a modern office-bound existence. I take Vitamin D each day. Vitamin D toxicity can be problem, since it is a fat soluble vitamin retained in the body (along with Vitamin A,E and K), so more is not better. Take the amount recommended by your doctor.

There are many books about healthy living, but the one book that incorporates all the elements that I have found to work for me is The China Study by T. Colin Campbell. The book examines the relationship between food and health, incorporating data about cancer rates, heart disease, diabetes and their prevalence among different societies with different diets. The data is compelling - an all vegetable, high fiber diet markedly reduces and reverses the lifestyle diseases which afflict our affluent industrial society.

I highly recommend the book, as well as the work of Michael Pollan.

You'll discover that the food industry is not our friend - highly processed, high calorie foods, rich in high fructose corn syrup are killing us, but making profits for the agribusiness, the meat industry, and food packaging conglomerates. The food industry lobby is one of the strongest in Washington, making the status quo very challenging to change.

Healthcare reform starts at home - read The China Study and decide for your self.

Try an organic, locally grown, all vegetable diet with minimal Vitamin B12 and Vitamin D supplements and no caffeine. Your body will thank you for it. I realize that such a diet is not possible in some urban locations where food choices may be limited to convenience stores. I know that fresh vegetables may be more expensive per calorie and thus unaffordable.

My hope is that by putting more government resources into diet education and support for the right foods, we'll be able to eat our way back to health, a better economy, and higher quality lives.

The Magic of Middleware

2009-11-11T03:00:00.000-08:00

As I mentioned in my blog about Certification verses Meaningful Use, there will be 9 data exchanges required in 2011

ePrescribing

Sending reminders to patients

Checking insurance eligibility

Submitting claims

Providing patients with an electronic copy of their record

Providing patients electronic access to their records

Capability to exchange key clinical information (e.g., problem list, medication list, allergies, test results) among care providers and patient authorized entities

Capability to submit data to immunization registries

Capability to provide syndromic surveillance data to public health agencies

It's unlikely that clinician offices and hospitals will rip and replace existing systems. It will take several years for vendors to create upgraded software versions which support all these exchanges and for organizations to deploy them. That means that in the interim, it's likely that we'll need middleware at the border of organizations which translates legacy standards and proprietary vocabularies into the data exchange standards which will be required by the December interim final rule.

Over the past few months, I'm met with many middleware companies. Here are the ones to watch:

Emdeon - provides clearinghouse services and analytics. Although it typically has focused on X12 administrative transactions, its infrastructure could easily be leveraged to transport clinical content

Surescripts - provides the eRx transactions among payers, providers, and pharmacies. Although this infrastructure transports chiefly NCPDP content, it could easily be leveraged to transport other types of clinical content

Intersystems - provides an integration engine for communication within and between enterprises

Edifecs - provides data transport and data mining/business intelligence services on transported data

Orion Healthcare - provides software which maps various standards from one to another and provides transport

Health Language Inc. - provides vocabulary translation services

Intelligent Medical Objects - provides vocabulary translation services and tools which enable clinicians to translate free text into controlled vocabularies.

Visionshare - provides transport of data to Medicare (CMS) using the internet and not a proprietary network. You can imagine a company like Visionshare providing a secure front end from clinician offices to the Nationwide Health Information Network.

Covisint - originally provided supply chain integration for the auto industry, but is now expanding into healthcare transactions such as automated clinician credential verification for the AMA.

Although at some future point, EHR software vendors will include standard content/vocabulary interfaces and the NHIN (aka "the Healthcare Internet) will provide secure transport, these middleware companies will help us with the glide path from the present to the future. I'm confident there will be disruptive innovation in the middleware market, including the notion of using PHRs such as Microsoft Healthvault and Google Health as hubs to collect patient data and exchange it as the patient wishes.

It's hard to predict the future, but if HIPAA administrative simplification provides us with lessons learned about adoption and implementation, middleware vendors will be very important in the years ahead.

The Genius of the AND

2009-11-10T03:00:00.000-08:00

Recently in Washington, an important political figure asked me why I had the reputation of resisting change.

Since I've spent my life catalyzing change and embracing the latest technology, I found this a very strange statement.

I have no idea how history will record my life and work, but I think the answer is - it depends who you ask.

Wes Rishel wrote a great blog today that reduces the debate about standards and interoperability into two points of view - “the healthcare informatics crowd" and "the Internet crowd".

I've spent the past 4 years facilitating standards harmonization in HITSP, bringing together 800 organizations to discuss the parsimonious number of standards needed to facilitate the data exchanges which will support meaningful use.

From the point of view of the healthcare informatics crowd, the harmonization of disparate approaches into CDA/CCD with XDS.b, XDR, XCA and XDM represents significant simplification and convergence of the major stakeholders in healthcare IT.

From the point of view of the Internet crowd, it represents a set of complex content and security constructs that puts the SDOs in the HTTP business.

The work I've done for the past 4 years aimed at unifying the industry on a web services approach, embracing web-centric standards such as SOAP, XML, and HTTPS. In 2006-2007, this was considered very forward looking. In 2009, RESTful data exchange of simple payloads with TLS and application level security is considered cutting edge.

Thus, my challenge as a leader is to bring together both the healthcare informatics crowd and the internet crowd, without having to take sides and choose either/or.

The answer to me is that we need to embrace both approaches - the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google's CCRg or PDF can do the job.

On the FACA blog today, Marc Overhage wrote about good enough standards for a particular purpose.

This blog posting is likely to generate debates from both the healthcare informatics crowd and the Internet crowd.

Certainly, I believe that a single standard with templates or subsets for a particular purpose would reduce costs and ease the vendor burden of having to support multiple standards, but the trick to accomplishing this is to ensure that the standard be simple enough to be easily implementable for "the little guy", the iPhone, and the use cases of EHR to PHR exchange where the goal is to provide basic summaries to patients. As I said in my blog last week, I'm convinced that the SDOs will continue to refine their content standards such as CDA and CCD to clean up the XML (get rid of moodCode) and provide templates to support a range of applications, both complex and simple (hide the OIDs so that most implementers do not need to deal with them).

Until then, we need a glide path that embraces the healthcare informatics crowd and the internet crowd, respecting the hard work and best thinking of both.

My proposal, as a private citizen and not in any of my committee roles is that we take the advice of Jim Collins in Built to Last in which he describes the "the tyranny of the OR verses the genius of the AND"

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, we use the CDA/CCD.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs such as would be used by Microsoft, Google or Keas, the CCR or PDF is good enough.

We separate content and transport, recognizing that some organizations will use XDS.b and XDR for SOAP-based transport, while others will use RESTful approaches, enforcing privacy policy with security features at the application level.

As standards evolve we can revisit this with the aim of convergence as long as further parsimony does not impede innovation.

It is my hope, that by embracing the right tool for the right purpose, we can balance standardization, ease of implementation, and innovation.

The genius of the AND - I hope that both the healthcare informatics crowd and the Internet crowd can embrace this path forward.

Certification Verses Meaningful Use

2009-11-09T03:00:00.000-08:00

Recently, clinicians have asked me "why should I implement my organization's preferred EHR when I've found a less expensive vendor that promises meaningful use?"

This illustrates a basic misunderstanding of the difference between Certification and Meaningful Use.

The certification process will be codified in a December 2009 Notice of Proposed Rulekmaking (NPRM) and will define the process for certifying electronic health records including modular and open source approaches. (The Standards for data exchange will be codified in a December 2009 Interim Final Rule and become law immediately.) We know that ONC will specify certification criteria and that NIST will oversee certification conformance testing which will be performed by multiple organizations. However, we will not have the final certification criteria or the defined process until Spring after a period of comment on the NPRM.

Meaningful Use is about electronic documentation to enhance quality/efficiency and actual data exchange among payers, providers and patients. The definition of meaningful use will be codified in a December 2009 Notice of Proposed Rulemaking. We will not have the final meaningful use criteria until Spring after a period of comment on the NPRM.

Thus, it is too early for any software company to declare their product will meet all Certification criteria. In the interim, a vendor can claim product conformance with the latest CCHIT criteria, which is the best indicator of functionality we have at the moment.

Meaningful Use is not about products but about processes - how the software is used and how data flows in an ecosystem of stakeholders. Vendors should not be making claims about meaningful use.

Take a look at the data exchanges in the August 2009 recommendations for meaningful use:

ePrescribing

Sending reminders to patients

Checking insurance eligibility

Submitting claims

Providing patients with an electronic copy of their record

Providing patients electronic access to their records

Capability to exchange key clinical information (e.g., problem list, medication list, allergies, test results) among care providers and patient authorized entities

Capability to submit data to immunization registries

Capability to provide syndromic surveillance data to public health agencies

To achieve these 9 data exchanges, multiple sending and receiving parties need to participate.

In the case of Beth Israel Deaconess, achieving this level of interoperability by 2011 will require that we focus on a small number of software vendors. Over time, as standards and implementation guides become more specific and widely implemented, it will be easier to add additional vendors. However for now, we are focusing on getting the work done with our home built EHR and one purchased EHR (eClinicalWorks). Given scope, time, and resources, there is no way we can implement all 9 data exchanges among payers, providers and patients with another purchased EHR in time for Stimulus funding.

Thus, as you make decisions about what EHR to use, remember that certification describes the features of a product. Meaningful use describes actual data capture and exchange among multiple stakeholders in an entire healthcare ecosystem.

Products may be certified in a single clinician office, but meaningful use "takes a village". It cannot be promised by a vendor.

Cool Technology of the Week

2009-11-06T03:00:00.000-08:00

On November 4, I met with my director of IS at Needham hospital and we discussed the effort involved in creating a lab ordering/resulting dictionary that links together clinician offices, Meditech sites, and commercial labs. Imagine a spreadsheet with 3 columns of lab codes that is 12000 lines long!

Clem McDonald, who oversees the Lister Hill National Center for Biomedical Communications at NLM and is the developer of Logical Observation Identifiers, Names, Codes (LOINC). Using data from several sources, including the Indiana HIE, United Healthcare and a few other sources, Clem and his team were able to identify a set of about 300 LOINC order codes that cover about 98 - 99% of the most common laboratory orders.

On November 2, several members of the HITSP Care Management and Health Records TC met at the National Library of Medicine to discuss the development of a value set for creating an common interoperable set of laboratory order codes. Present at this meeting was an unprecedented collaboration of people representing healthcare providers, laboratory vendors, HIT Vendors, HIE developers and payers.

You'll find the details in Keith Boone's blog.

When I described the notion of a single lab compendium for the country, eliminating the need for custom mappings at every institution and clinician's office, my Director of IS agreed - that's cool!

Let's hope we can get rapid adoption of a universal lab ordering compendium in labs, hospitals, and clinician offices. Time and money will be saved, quality and safety will improve.

The H1N1 and Seasonal Flu Vaccines

2009-11-05T03:00:00.000-08:00

On Monday, I received the 2009 Live Attenuated Intranasal (LAIV) H1N1 vaccine and the 2009 injectable seasonal flu vaccine.

As a healthy clinician under 50 who sees pediatric patients (mushroom and plant toxicology cases), I'm in the initial tier who qualify to receive the intranasal H1N1 live attenuated vaccine.

The experience of intranasal administration is interesting - inhaling an aerosolized liquid that slowly drips from your nasopharynx down your throat is not the most pleasant sensation. I suspect that pediatric patients will prefer the intranasal approach to an injection.

For 12 hours after receiving the vaccine, I experienced slight nasal congestion and mild fatigue. The complete fact sheet about risks and side effects is given to every patient.

During the same visit I received the 2009 Seasonal flu injection, an inactivated (killed virus) vaccine. Other than mild soreness at the injection site, I had no symptoms.

For me, the vaccines were a positive experience and will ensure that I am not a viral vector (call it personal anti-virus software) in the season ahead.

Since vaccine supplies are limited, it is important to understand the epidemiology of H1N1 (rates of reported cases per 100,000 population)

0 to 4 years — 22.9
5 to 24 years — 26.7
25 to 49 years — 6.97
50 to 64 years — 3.9
≥65 years — 1.3

You'll find a great UptoDate summary online.

Also, Harvard Health Publications has launched an iPhone App to provided the latest information about H1N1.

Standards Lessons from the Web

2009-11-04T03:00:00.000-08:00

Following last week's HIT Standards Committee Implementation Workgroup Hearing , Microsoft's Sean Nolan and Gartner's Wes Rishel wrote thoughtful blogs.

They point out that the web has two basic standards - content (HTML) and transport (HTTP). Of course there are several other supporting standards such as DNS, TLS/SSL, URL syntax, CSS, etc. but to get started all you need is basic content and transport. You can learn everything you need to know to create a web page in under an hour.

At the hearings, I got that sense that much of the content we've (HITSP, HIT Standards Committee, the industry in general) proposed for healthcare such as NCPDP Script for eRx, HL7 2.x for lab, and X12 for administrative transactions is fine. There is some debate about the right level of simplification for a clinical summary standard, but I'm convinced that the SDOs will continue to refine clinical summaries in a way that ensures suitable content packages will be available for simple and complex use cases. There is additional vocabulary work to do, but that is already is in progress.

On the transport side, let's explore the options:

1. Do nothing and let the market develop a transport mechanism - after all that is what happened with HIPAA (it specified the content as X12 4010 and left implementation of transport up to the market)

I do not favor this option. In Massachusetts, NEHEN implemented secure appliances to solve the problem of data transport. We spent millions and took years to do this. HIPAA transactions are not as widely implemented as the industry would like, largely because transport standards were missing and implementation guidance for the content was not detailed enough. Of course, you could force everyone to sign up for the clearinghouse/intermediary of their choice but this creates heterogeneity, click fees, and unnecessary middlemen.

2. Specify all the standards and policies necessary for end to end secure transport.

Thus far, we've stayed architecturally neutral and provided a suite of standards for transport that ensure authentication, authorization, role-based access control, and auditing to support all policy variations. This approach has been a fine starting point, but it needs to be refined via policy so the number of standards can be constrained. For example, a policy which states that audit trails must be available showing who looked at what when is probably sufficient instead of requiring every organization to implement a standards-based audit trail. It's unclear what the business case is for a completely standardized, interoperable audit trail. Another example - If policy requires segmentation of the record into standard care, HIV care, mental health care, and substance abuse care, as well as requires that the application enables patients to record their preferences for release of these 4 segments, do we need access control standards or accept that the application adequately protects privacy?

If policies and certification ensure appropriate application behavior then point to point transport might be as simple as TLS with bilateral certificate exchange at the infrastructure level, substantially reducing the burden of implementation.

Of course, some may argue that an approach that uses simple web standards for securing transmission and leaves other privacy controls to the application cannot ensure "chain of trust" end to end security. It is true that each organization and stakeholder would have to decide if they trust the applications used by their trading partners. Our experience with NEHEN is that policy, data use and reciprocal support agreements (DURSA), and simple transport standards can facilitate rapid implementation of healthcare information exchange.

3. Deploy appliances that serve as secure gateways between organizations.

With policies and over the wire security standards, the market can develop appliances that securely transport packages of content. Some may be SOAP-based using CAQH Core or XDS/XDR and some may be REST-based. The folks at FHA Connect have done a great job creating an open source application that can serve as such an appliance.

One thing I've learned from negotiation (my Walks in the Woods) is that being dogmatic about one solution is rarely the right answer. Folks who know me often hear the word "parsimonious" - the smallest number of solutions needed to meet the needs of stakeholders. The answer is not 100 variations but a small number that provides business value - the right tool for the right job. From the work I've seen thus far, I think the transport solutions that will work for stakeholders include:

1. For those who want end to end standards controlled secure transport that guarantees integrity of documents - XDS, XDR, XDM and XCA fulfill the need. These standards are SOAP-based and enable use of WS* security controls, so they are useful for protecting privacy at the standards level.

2. For those who want standards-based security with simple implementation, an appliance such as FHA Connect, NEHEN, Intersystems' Ensemble, or Orion Health's Rhapsody is a very reasonable approach.

3. For those who want a secure channel for transporting data elements such as a problem lists, medication lists, and labs from EHR to PHR, a simple TLS and REST approach is good enough. Ideally, HITSP and the HIT Standards Committee workgroups will provide an implementation guide with standard URIs/querystrings so that we'll not have huge variation in REST APIs. Some have used the term "Healthcare Internet" to describe such an approach.

I look forward to the work of the next several months. I'm confident that HITSP, the HIT Standards Committee Workgroups, and the new HIT Policy Committee NHIN Workgroup will evaluate the options and make recommendations.

The FY10 BIDMC IS Operating Plan

2009-11-03T03:00:00.000-08:00

I've previously posted the Draft Clinical Systems Operating Plan for BIDMC Information Systems.

Today, I've posted the entire FY10 BIDMC IS Operating plan for infrastructure, clinical systems, financial systems, HIM, knowledge services, media services, academic computing, and our community sites.

Highlights include:

Numerous infrastructure upgrades to networking, storage, and security

Meaningful Use of EHRs for inpatient and outpatient clinical care

Upgraded supply chain, revenue cycle, and payroll functionality to support enhanced workflow and efficiency

Continued migration from a hybrid paper/electronic record to fully electronic

Enhancement to consent management education, plain language educational resources, and on- line knowledgebases

Expanded telemedicine and collaboration tools

Advanced research administration support tools.

Meditech upgrades including CPOE, eMAR, and interfaces.

The task of building better applications and more reliable infrastructure is never done, but each year we get better and better. Setting priorities that balance available resources, quality and safety is the challenge. I hope our customers and employees agree that we've set a reasonable balance.

Next Steps for our Community Quality Registry

2009-11-02T03:00:00.000-08:00

I've previously described the Beth Israel Deaconess Physician Organization's (BIDPO) decision to create a community registry for quality data warehousing in support of meaningful use.

As the project has progressed, we've made several decisions that I'd like to share.

What quality indicators will we store?

We've inventoried all the pay for performance reporting requirements of our local payers and crosswalked it with the 17 quality metrics required for meaningful use, as documented on the new HHS Blog.

In summary, the measures will include treatment process and outcomes data for:

Acute Bronchitis

Adverse drug events

Asthma

Cancer Screening

Cardiovascular Conditions

Depression

Diabetes

HIV

Hypertension

Immunizations

Lead Screening

Medical Home

Pediatrics

Pharyngitis

Reproductive Health

Substance Abuse

Surgery Patients

Tobacco

URI

Vital Signs

You'll find the details in this presentation.

Other decisions we've made include:

1. All our data content transfers from eClinicalWorks and our home built EHR will be done using the HITSP C32 implementation guide of CCD.

2. Transport will be done using the HITSP Service Collaboration 112, specifically using TLS with certificate exchange. We will use the NEHEN network (diagramed above) for routing from our EHR hosting site to the quality data center.

3. To protect confidentiality we will pseudonymise the data, separating identifiers from the data itself. BIDPO will be able to re-identify data for queries such as assembling quality measures from different data sources, but a breach of the registry itself will not release any patient identified information.

This project will enable us to implement and refine many of the standards recommended by HITSP and the HIT Standards Committee. I will continue to report experiences from our implementation efforts which I hope will be used to enhance the standards implementation guides.

The Implementation Workgroup Testimony

2009-10-30T03:00:00.000-07:00

Yesterday I spent the day in Washington with the HIT Standards Committee's Implementation Workgroup . The online forum to comment about standards adoption and implementation is now available.

The first article was posted by Aneesh Chopra, the US CTO. The second, my summary of the standards work thus far, will be posted this morning. Additional articles will be posted by others members of the HIT Standards Committee in the next week.

Whenever I hear testimony from teams of smart people, I try to distill everything I've heard into "Gold Star Ideas" - those themes that surfaced over and over. Here are a few:

1. We've learned from other industries that starting with simple standards works well. Mastering web transport standards such as REST takes minutes. Learning RSS takes an hour. Learning HTML takes a day. In the healthcare domain, I learned the basics of HL7 2.x, X12 and NCPDP in about a day.

2. Keep the standards as minimal as possible to support the business goal. Design for the little guy so that all participants can adopt the standard and not just the best resourced. Do not try to create a one size fits all standard - it will be too heavy for the simple use cases.

3. Start immediately rather than waiting for the perfect standard. Use early implementation experiences to create great documentation. Leave aspects of the standard open for future expansion and let innovation occur after adoption.

4. Declare a long term goal for new standards implementation but in the short term map what exists to new standards at the border of the organization rather than convert all existing legacy systems.

5. In early phases of implementation, allow ambiguity in the standard (what Adam Bosworth called Hysteresis) so that implementers can start simply and improve the completeness of their interfaces over time.

These are all reasonable principles. How do we apply them to the meaningful use standards we're all working on?

I asked one group of testifiers to tell me their views about the maturity of standards for the 4 required data exchanges in 2011. Here are their answers, interpreted against the 5 criteria above

ePrescribing - we have a mature standard (NCPDP Script 8.x) that is being enhanced to support new features (NCPDP Script 10.x) on a reasonable timeframe with minimal burden. We have test harnesses, middleware and clearinghouses that will accelerate adoption. We have an ecosystem of application developers. There is work to do to encourage more transactions to flow, but we're in generally good shape.

Lab - we have a mature standard for messaging (HL7 2.x), however we have numerous versions already implemented that will require mapping to HL7 2.51, since replacing all HL7 2.x in legacy systems will be burdensome. The real problem is not the HL7 but the lack of a single national lab compendium of the minimal set of LOINC codes for the most commonly ordered tests that should be implemented by all labs (commercial and hospital). CLIA is also an issue, requiring validation of every interface even if the same interfaced is cloned over and over for the same products. HITSP has already prepared a LOINC subset (700 codes instead of 20,000). The work ahead is part policy (reform CLIA) and part standards. The HIT Standards Committee has established a new workgroup on vocabularies and one of its first charges should be to ensure the appropriate LOINC subsets are available for general use. Regulation should require use of these subsets for lab ordering in 2013.

Administrative transactions (Benefits/Eligibility, Claims etc) - we have a mature standard for messaging (X12 4010) and transport (CAQH Core II). We have new enhancements on the way (X12 5010) that provide value. We have test harnesses, middleware, and clearinghouses that will accelerate adoption. We have many companies that build applications to support administrative transaction exchange. There is work to do to encourage more transactions to flow, but we're in generally good shape.

Quality - a consistent complaint is that every stakeholder (payers, government, specialty specific registries) require different quality measures with different data elements and definitions. There was broad agreement that the work the NQF has done and is doing to select a few consistent measures, with clearly defined data types, and retooling them to be EHR-based (not paper record) is the right thing to do. The measures will likely require controlled vocabularies and we need to be sure the right SNOMED-CT, LOINC, and RXNorm vocabularies plus mapping tools are available to report data in a normalized format for quality measurement.

My synthesis of the advice we received from all the panels is:

Creating controlled vocabularies/code sets is consistent with the simple standards goal. You can imagine an implementation guide that defines an XML format and then points to a website that contains publicly available vocabulary content (such as that developed by NLM or licensed for public use such as SNOMED-CT). Engineers would have no problem downloading and implementing a publicly available vocabulary code set.

Keep transport simple. Several testifiers noted that content and transmission should be separate standards, leveraging the web when possible for transport so that implementers do not need to learn new transport standards.

Get everyone to send the basics - medications (highlighted by everyone as a high value data exchange), problem lists, and labs before focusing on the esoteric.

Security is very important but privacy policy is even more urgent. We can very significantly constrain the number of security standards if a policy framework outlines our goals. For example - do we need a standard-based audit trail for every organization or is it sufficient to create a policy that an audit trail must be available to patients showing who accessed what and when?

What action items should we take?

I would like to get the input from other HIT Standards Committee members, but action items seem to be

1. Work hard on vocabularies and try to get them open sourced for the entire community of stakeholders

2. Consider adding a simple REST-based transport method for point to point exchanges

3. Work jointly with the HIT Policy Committee to establish a privacy framework that enables us to constrain the number of security standards

4. As we continue our work, try to use the simplest, fewest standards to meet the need

5. Continue to gather feedback on the 2011 exchanges - eRx, Lab, Quality, Administrative - to determine if there are opportunities to enhance testing platforms and implementation guidance that will accelerate adoption.

I look forward to continued discussion.

That 70's Show

2009-10-29T03:00:00.000-07:00

My parents recently remodeled their 1970's home, removing the formica, shag carpeting, and textured ceilings.

Seeing their modern home made me reflect on my personal history in 1976 when their home was built.

I had just started high school at Palos Verdes High. I was a cross country runner and a geeky engineering type wearing aviator glasses, a shaggy haircut and weighing 120 pounds. This photo is of me, Will Snow (my best friend from high school), and a team of engineers from Rockwell. We had the opportunity to tour the Columbia Space shuttle and explore its engine components as they were being built in Southern California. Will and I stay in touch and he recently completed a 125 mile bicycle ride for Multiple Sclerosis in honor of his first wife and my father. He's a senior engineer at SUN (now Oracle).

To give you a real flavor of the 1970's, take a look at my Prom picture (above), now 30 years old. Hillary Stoltz and I attended the prom in Santa Monica, with me in blue velvet including a frilly 1970's tuxedo shirt. By this time, my haircut was evolving to the short and simple way I wear it today. Hillary went to Georgetown and I went to Stanford. I've not reconnected with her since 1980.

The 1970's were a simpler time - no email, no mobile devices, no global village. The competition to get into college was easier and the pace of life was slower. The economy had its ups and downs, we had gas lines, and we had the disco craze (which I ignored). The folk music was soulful, the living was casual, and the fashions were awful.

It was a generally happy time that prepared me well for the challenges to come.

If any folks from my 1970's past are readers of my blog feel free to comment! I'd welcome an update from any of my high school cohort - Phil Talbert, David Kratz, Adrienne Lee, Hillary Stoltz, Gretchen Zimmerman, or Marcia Rorty.

Implementation and Adoption Hearings

2009-10-28T03:00:00.000-07:00

Tomorrow from 9am to 4pm at the Omni Shoreham Hotel in Washington DC, the Implementation Workgroup of the HIT Standards Committee will hold hearings to identify enablers and barriers to the adoption and implementation and standards.

We've assembled a great group from non-healthcare industries, providers, vendors and quality measurement organizations. Testimony will include

Non-Healthcare Industries Panel

Skip Best and Davis Miller, Covisint

Adam Bosworth, XML and SQL

Clarence So, Salesforce.com

Providers Panel

Andy Wiesenthal, MD, Kaiser Permanente (IDN)

Dick Taylor, MD, CMIO, Providence Health, Portland, OR (IDN)

Rick Warren, VP/CIO, Allegiance Health, MI (Community Hospital)

Lisa Bewley, RN, VP/CIO, Regional West Medical Center, Scotts Bluff, NE (Community Hospital)

Louis Spikol, MD, Allentown, PA (Small Practice)

Floyd "Tripp" Bradd, MD, Front Royal, VA (Small Practice)

Vendors Panel

Rick Ratliff, SureScripts

Arien Malec, Relay Health

Sean Nolan, MicroSoft

Girish Kuman, eClinicalWorks

Chris Stevens, Orion Health

Quality Measures Panel

Ralph Brindis, American College of Cardiology

Richard Gliklich, CEO, Outcome Sciences

Jesse Singer, NYC Health

Barbara Rabson, Massachusetts Health Quality Partners

Jack Bowhan, Wisconsin Collaborative for Healthcare Quality

What kind of testimony can you expect?

In non-healthcare industries, standards have been used to coordinate the supply chain. What tools and techniques were used to encourage the entire manufacturing ecosystem to participate?

Do we need better educational materials such as implementation guides that include all the base standards so that there is no "indirection" - jumping between implementation guide websites and standards development organization websites?

Are there gaps in standards that need to be filled to encourage adoption in different healthcare environments?

The real purpose to the meeting is to encourage transparency and build a feedback loop that connects real world users of standards with the organizations that govern and create standards development.

During the meeting we'll kick off a new website that will enable the public to post comments about standards, privacy, and implementation experiences, including the ability to rank ideas via social networking tools. I'll post the URL to the new website tomorrow.

To participate in the meeting, join by audio conference or webcast.

I look forward to hearing your feedback!

"Project" and "Product" Certification

2009-10-27T03:00:00.000-07:00

Last Friday night I testified to the President's Council on Science and Technology (PCAST). Many issues were discussed, but one of the most interesting was the idea of "project" verses "product" certification.

Here's the significance.

In Massachusetts, Partners Healthcare and Beth Israel Deaconess use home built EHR solutions based on Intersystems Cache. We both use Sun's eGate (now Oracle) and Intersystems Ensemble as middleware. We both use datamarts/data warehouses based on extracts from our clinical systems to support quality reporting, performance measurement and research. We both use NEHEN as our healthcare information exchange.

We'll achieve meaningful use via this combination of applications with many moving parts. Its totality provides the tools our stakeholders need. We need to certify the sum of the "project" and not the individual "products".

"Project" certification can be empowering in other ways.

Imagine that innovative products such as Microsoft Healthvault/Amalga or Google Health offer services to aggregate data from multiple data sources as part of quality reporting. They can become accelerators of meaningful use.

Imagine that a Modular EHR (such as Quest's Care360) plus a Healthcare Information Exchange can store the lab and medication data needed to coordinate care. Quest and iPhone app innovators can accelerate meaningful use.

My experience is that federated authorship - harnessing the talents of many companies and individuals - leads to the most rapid innovation.

Of course, some of the most advanced aspects of meaningful use, such as comprehensive decision support, may require larger, fully integrated EHRs. But other aspects such as the data exchanges required for 2011 - eRx, Lab, Quality reporting, and administrative transactions - can be empowered by assembling multiple products and services.

Since the theme of the work of the HIT Standards Committee for the next few months will be accelerating standards adoption and implementation (more on this in my blog tomorrow), encouraging all stakeholders to innovate by creating reusable components in support of meaningful use seems timely.

As the Notice of Proposed Rulemaking (NPRM) is written to define the certification process, I encourage policymakers to certify "projects" in addition to "products", encouraging innovation. I have no direct influence on this work, but I am hopeful that industry and clinician stakeholders will provide this input to those writing the policies.

Accelerating Implementation of Laboratory Standards

2009-10-26T03:00:00.000-07:00

On October 20, the Information Exchange Workgroup of the HIT Policy Committee heard testimony from laboratory information exchange experts and stakeholders.

The agenda and testifiers included:

Business Issues related to the Electronic Exchange of Laboratory Data

▪ Mike Nolte, GE Health Systems

▪ Vasu Manjrekar, eClinicalWorks

▪ Phil Marshall, WebMD

▪ Tim Ryan, Quest Diagnostics

▪ Susan Neill, Texas Department of State Health Services

Business Issues related to the Electronic Exchange of Laboratory Data

▪ Laura Rosas, New York City Primary Care Information Project

▪ Sarah Chouinard, Primary Care Systems, Inc. and Community Health Network

▪ Raymond Scott, Axolotl Corporation

▪ Areg Boyamyan and Jim Timmons, Foundation Library

Regulatory and Policy Issues

▪ Joy Pritts, Georgetown University Health Policy Institute

▪ Don Horton, LabCorp

▪ Jonah Frohlich, California Health and Human Service Agency

▪ Walter Sujansky, Sujansky & Associates

You'll find an unofficial transcript here. (Thanks Brian!)

The major themes of the day were

1) Labs are complicated - there is great variation in the standards used, vocabularies adopted, and the way labs are ordered (there is no universal ordering compendium, but this is a project that HITSP and the HIT Standards Committee are working on)

2) CLIA is considering allowing “simultaneous delivery” of results to a Health Information Exchange instead of just to the ordering clinician

3) State laws are highly heterogeneous, as is enforcement

4) We need adoption and implementation of robust messaging and vocabulary standards. We should focus on the 300-400 tests that make up the vast majority of ambulatory lab transactions, and create a national mapping for those.

5) Lab results/ordering according to a well-defined national standard should be part of EHR certification

6) Meaningful use payments to hospitals should be contingent on their delivering outpatient labs according to the same standards recommended for EHR vendor certification. (I agree with this - BIDMC has committed that all its lab delivery to external organizations will use HITSP and HIT Standards Committee recommended standards in time for 2011 Meaningful Use payments.)

7) EHRs need to be conformance tested against specific standards to reduce the cost of interfaces.

A great day of testimony. I know that change is difficult but universal adoption of the HITSP Lab Result Capabilities, which provide significant implementation guidance for HL7 2.51 messaging, LOINC, UCUM, and SNOMED-CT will reduce the cost of lab interfacing. This, combined with the HITSP Lab ordering Capabilities to be completed by January, will accelerate adoption and implementation.

I support universal conformance testing of products for certification and a requirement for all stakeholders to use these standards as part of meaningful use criteria to claim stimulus funds.

Since 2011 data exchanges for meaningful use require Laboratory result exchange, there is urgency to do this. Over the next few months, the HIT Standards Committee will be spending a great deal of time discussing the ways to reduce barriers and enhance adoption so that we achieve the interoperability we need.

Cool Technology of the Week

2009-10-23T11:30:00.000-07:00

I'm sitting at Logan Airport awaiting a plane to Washington to testify at a meeting of the President's Council of Advisors on Science and Technology at the National Academic of Sciences.

A few minutes ago, I noticed that the tarmac was empty of planes and numerous black SUVs appeared. Then I noticed a few military folks running around the roof of Terminal C. I looked to the north and saw a large 747 approaching - Air Force One.

Realizing that today is Friday and its time for my Cool Technology blog, I'd like to declare Air Force One the cool technology of the week. I've always wondered what electronics are on board. Here's an overview from HowStuffWorks

"The most remarkable feature on the plane is it's extensive electronics. It has 85 onboard telephones, a collection of two-way radios, fax machines and computer connections. It also has 19 televisions and assorted office equipment. The phone system is set up for normal air to ground connections and secure lines. The president and his staff can reach just about anybody in the world while cruising tens of thousands of feet in the air.

The onboard electronics include about 238 miles of wiring (twice the amount you'd find in a normal 747). Heavy shielding is tough enough to protect the wiring and crucial electronics from the electromagnetic pulse associated with a nuclear blast.

Some of the most interesting parts of the plane -- it's advanced avionics and defenses -- are classified. But the Air Force asserts the two planes are definitely military aircraft, designed to withstand an air attack. Among other things, the plane is outfitted with electronic counter measures (ECM) to jam enemy radar. The plane can also eject flares to throw heat-seeking missiles off course."

And where did all those black SUVs and support equipment come from? In advance of every Air Force One flight, the Air Force crew sends C141 Starlifter cargo carrier planes, carrying the president's motorcade to the destination. This collection of bulletproof limousines and vans, loaded with weaponry, keeps the president safe on the ground.

Air Force One is effectively a secure, mobile data center - that's cool!

The Books on My Nightstand

2009-10-22T03:00:00.000-07:00

A year ago I wrote about the books on my nightstand. Here's an update of what I'm currently reading:

The Deadly Dinner Party by Jonathan Edlow - a great collection of medical mysteries written by my colleague in the BIDMC emergency department. You'll find hard to solve cases with diagnoses such as botulism, typhoid, and bath water infected with tropical organisms from piraña. House meets Sherlock Holmes.

The Lady and the Monk by Pico Iyer - The story of world traveler Pico Iyer's year in Kyoto and his immersion into Japanese culture. As a fan of Japan, I can certainly relate to the rich experiences he describes in his travels. Some folks have suggested that my disciplined life, black attire, and continual pursuit of a simpler existence gives me a monk-like character.

The China Study by T. Colin Campbell - A great overview of the relationship between nutrition and health, including the consequences of eating an animal-based diet.

Food for Life by Neal Barnard - I've been chatting with a few policymakers about the importance of nutrition and recently exchange emails with Dr. Barnard. In the book, he suggests his own food groups (grains, vegetables, fruits, and legumes), then discusses the positive impact of a vegan diet on health.

Blue Book of Bike Repair by Calvin Jones - Having recently replaced my hybrid mountain bike drive train , I found this book by the Park Tool Company to be an invaluable guide to modern bicycle components and repair.

Mushrooms Demystified by David Aurora - This book is the mycologists bible and is what I use for the hundreds of mushroom consults I do every year. I recently worked with the ICU team at BIDMC on an Amanita ingestion and this book was a great guide for me.

Dogs and Demons by Alex Kerr - Alex is a great observer of Japanese culture and he explains how the Japanese economy is built on public works projects that are destroying the natural beauty of the country.

Anthology of Japanese Literature by Donald Keene - Donald Keene is the finest editor of Japanese traditional literature for English Language readers. This book contains selections of just about every genre of Japanese literature from No plays to novels.

A self published book of sonnets - 30 years ago when I was 17 I wrote sonnets in memory while cycling up and down the California coast one summer. My 16 year old daughter is writing sonnets in her AP English class, so I pulled my collection from my archives. Here's a sample (I was 17 at the time, so be kind)

An Ageless Plea

If old age brings the wisdom new lives seek,

Then why am I here writing all alone?

With well earned trophies of triumphs to speak,

An withered hands that built your cornerstone.

For pity I won't grovel or request,

Remember - what I've done you'll later do.

And if you somehow think your youth is best,

Remember - what I am will soon be you.

Through years of angst and conflict I have run,

Though now in worthless solace I'm confined.

Replaced as some machine whose task is done,

An obsolescent prisoner of time.

I stare through frozen windows in self doubt,

Wondering if it's colder in or out.

The books I wrote a little later in college were actually published and you'll find them on Amazon.

Other than my own works, I can highly recommend these books as great reads.

National eHealth Collaborative Forums

2009-10-21T06:00:00.000-07:00

I'm posting this on behalf of the National eHealth Collaborative.

Please join the National eHealth Collaborative (NeHC) Board of Directors as it hosts a series of interactive discussions with experts and stakeholders on important and timely topics in health information technology.

Bedside to Bench: How Health IT Can Power Better Clinical Research
NeHC Board Member Stephen Ruberg, PhD will talk with a panel of experts about how interoperable electronic health records and other technology tools can significantly improve the quality and efficiency of clinical research. The discussion will cover a number of perspectives in this area, from clinical trials and drug surveillance to government-funded research to cure chronic disease.

The Backbone of the Healthcare System: Nurses’ Critical Role in Health IT Implementation
NeHC Federal Liaison Linda Fischetti, RN will lead a discussion among national nurse leaders about how including nurses in health IT implementation projects can mean the difference between success and failure. Panelists will bring a wide variety of perspectives gleaned from years of experience in improving the quality of patient-centered care through the use of health IT.

WHERE: Sheraton Crystal City
1800 Jefferson Davis Highway
Arlington, VA 22202
Metro Stop: Crystal City

WHEN: Wednesday, October 21, 2009
9:00 am – 12:30 pm ET

9:10 – 10:40 am: Bedside to Bench: How Health IT Can Power Better Clinical Research

10:50 am – 12:20 pm: The Backbone of the Healthcare System: Nurses’ Critical Role in Health IT Implementation

WHO: National eHealth Collaborative Board of Directors
Chair: John Tooker, MD, MBA – Executive Vice President and Chief Executive Officer, American College of Physicians

Bedside to Bench: How Health IT Can Power Better Clinical Research
Moderator: Stephen Ruberg, PhD – NeHC Board Member and Senior Research Fellow, Eli Lilly & Company
Panelists:
• Gregory Downing, DO, PhD – Director, Personalized Health Care Initiative, U.S. Department of Health and Human Services
• Daniel Ford, MD, MPH – Vice Dean of Clinical Investigation, Johns Hopkins University
• Stephen Ruberg, PhD – NeHC Board Member and Senior Research Fellow, Eli Lilly & Company
• Steve Schwartz – Senior Vice President, Corporate Business Development, Allscripts

The Backbone of the Healthcare System: Nurses’ Critical Role in Health IT Implementation
Moderator: Linda Fischetti, RN, MS – NeHC Federal Liaison and Chief Health Informatics Officer, U.S. Department of Veterans Affairs
Panelists:
• Victoria Bradley, DNP, RN – Chief Nursing Informatics Officer, Eclipsys Corporation (Representing American Nursing Informatics Association and CARING)
• Curtis Dikes, RN, MSN, ACNP-BC – National Director, Clinical Informatics Technology Integration, Kaiser Permanente Foundation Hospitals
• Rosemary Kennedy, RN, MBA, FAAN – Senior Director, Nursing and Healthcare Informatics, National Quality Forum
• Joyce Sensmeier, MS, RN-BC – Vice President, Informatics, HIMSS (Representing Alliance for Nursing Informatics)

VISUALS: Recorded video, webinar and presentation slides will be available live and on the NeHC website (www.nationalehealth.org) following the event.

Webinar: https://nationalehealthevents.webex.com/nationalehealthevents/onstage/g.php?d=669279178&t=a

Audioconference: (866) 699-3239 or (408) 792-6300
(Please join the event with a computer system first and follow the audio instructions on the screen.)
Access/Event Code: 669 279 178
Attendee ID: You will receive this number when you join the event first with a computer connection.

Streaming Video: http://www.freedocast.com/nationalehealth

My conflicts of interest - FY10 edition

2009-10-21T03:00:00.000-07:00

Every year I publish my conflicts of interest publicly, such 2008 and 2009

It's that time again.

My salary is paid by Beth Israel Deaconess Medical Center for my duties as CIO.

BIDMC invoices Harvard Medical School for the time I spend there.

In 2009, NEHEN and MA-Share merged, so my only position in state-level healthcare IT is Chair of NEHEN, an unpaid position with no benefits/authority/special treatment of any kind.

I will serve as the chair of HITSP until January 31, 2010 when my term expires. For the past 4 years of HITSP service, I have not received any compensation or benefits. My plane flights to Washington have been reimbursed at cost.

I will serve at the vice-chair of the HIT Standards Committee for as long as it suits ONC and the Committee. I will not receive any compensation or benefits.

In the past I have served on many Boards and advisory panels. Knowing that ARRA would completely consume my free time at BIDMC, NEHEN, and the Federal standards committees, I resigned from all Boards and advisory panels except one - AnvitaHealth, a decision support service provider. The only reason I continue to serve on this Board is because I so strongly believe in their work which normalizes disparate data streams from clinical and administrative sources then provides real time decision support to clinicians at the point of care and to administrative decision makers. All this is done via a web-services architecture. I wish more companies provided Software as a Service decision support via web services that could be easily plugged into existing applications without significant IT effort. I have received a grant of options, none of which I have executed. Thus, I receive no compensation and have no stock ownership in the company.

With regard to other stocks I own, I established a family trust in 1993 and all my investments are managed by a third party. I do not directly control these investments, nor track their day to day variation. I do not make any business decisions in any of my professional roles based on stocks held by the trust. On a day to day basis I do not even know what stocks are in the trust, although I have suggested that healthcare IT stocks be avoided to eliminate even the appearance of a conflict of interest. I checked this morning and the trust has no healthcare IT holdings.

That's it - in 2010, I will receive a BIDMC W2 and a series of travel reimbursements at cost - nothing more. Should there be any other income that I cannot yet forecast, I will donate it to BIDMC/Harvard for the benefit of my employees as I have done in the past.

What keeps me up at night - FY10 edition

2009-10-20T03:00:00.000-07:00

Life as a CIO is never boring.

In Sunday's Boston Globe, Microsoft CEO Steve Ballmer said “What’s the old movie line from ‘Annie Hall’? Relationships are like sharks; they move forward, or they die. Well, technology companies either move forward, too, or they die. They become less relevant.”

No matter what an IT organization has accomplished in the past, what matters is daily infrastructure performance and the ability to constantly improve applications. I call this problem "changing the wings on 747 while its flying". Rapid change and complete stability must be achieved at the same time.

Here are the change management issues keeping me up at night in my various organizations.

BIDMC

Intranet - we're introducing a new intranet organized around social media concepts : tag clouds, blogs, and new media. Creating the security infrastructure to provide data confidentiality while at the same time encouraging use of social media anywhere on any browser is a delicate balance. We're looking at several new security appliances to help with this effort and I'll share the details in a future blog. Also, changing an intranet is one of the hardest projects that an institution can do, since so many people use it for their work every day. Even if the change is for the better, it's still a change. Balancing new functionality with ease of use and rapid adoption is challenging.

Enterprise Image Management - as storage needs increase and image exchange becomes a requirement throughout the organization and with our business associates, IT is becoming the focal point for image storage and life cycle management of all modalities. The days of local DVDs and departmental storage are gone. Using a combination of EMC products, IT is hosting short term cache, long term archiving, backup, and disaster recovery. Our projects over the next year will serve radiology, cardiology, and likely several other ologies that are seeking assistance. The challenge is building an infrastructure that is scalable, affordable and maintainable. We're using cutting edge products and technologies. There is always risk in implementing a new service based on highly innovative products.

EHR rollouts for meaningful use - I've described our EHR rollout efforts in several previous blogs, which are summarized in this document. We've solved the technology issues, but motivating clinicians to rapidly adopt EHRs is hard. Stimulus dollars help, but sometimes they are not enough, such as for specialists or "concierge medicine" PCPs. As a leadership team, the EHR steering committee needs to provide carrots and sticks to stimulate change.

Business Intelligence - I've written about the need to look beyond data and find information, knowledge and wisdom. We need to provide our stakeholders with innovative access to knowledge in our clinical and administrative systems using tools that are self service and do not require programming/IT expertise. The challenge is how to enable tools that anyone can use without requiring expert knowledge of the data itself - how it was gathered, who entered it, how accurate it is etc.

Interoperability - BIDMC strives to be one of the most interconnected healthcare organizations in the country. We have new projects that ensure we achieve meaningful use data exchanges in 2011 and beyond such as a exchanging quality metrics with the Massachusetts eHealth Collaborative Quality Data Center, exchanging clinical summaries with community EHRs, and enhancing our public health reporting using HITSP standards, all with the NEHEN gateway. This effort requires that we adopt new standards, enforce controlled vocabularies as the data is entered and appropriately address privacy/security concerns for data moving between organizations.

Harvard Medical School

High Performance Computing - The demand for computing is increasing exponentially and our challenge is not real estate but power/cooling. Over the next year, we need to substantially increase our electrical capacity and we're considering many options including a data center near hydroelectric power.

Storage - the research community at Harvard Medical School demands high performance, highly reliable storage at a low price. We've been able to offer high quality NAS with replication, attached to our high performance computing cluster for .67/gigabyte per year. Our challenge is to keep up with demand, always ensuring we have enough storage, but not over provisioning.

Content Management - Last year, I worked with BIDMC Corporate Communications to move BIDMC's web content to a commercial content management system with delegated content management. In FY10, we'll need to do the same with Harvard medical school including administrative websites, research websites, and departmental content. The stakeholders at Harvard Medical School are very diverse so the challenge will be selecting an information architecture and navigation approach that works for everyone.

Social Networking for research - Over the past year, we've worked as part of the Clinical and Translational Science Awards (CTSA) to build transparent access to researchers with active and passive social networking techniques. Expanding this work requires that we build trust among all our collaborating institutions and encourage transparency with the sharing of personal intellectual property. The more you share about your thinking, the better the social networking.

Governance - I'm a strong believer in IT governance. At HMS, I've always had good input from research, administrative, and educational stakeholders but this year I've worked with the Administrative Dean to launch an overall IT Governance Committee to ensure the needs of all stakeholders are balanced. Governance takes a great deal of time and energy, but it does mitigate surprises such as delayed projects, budget variances, and misaligned priorities.

NEHEN/State activities - The Office of the National Coordinator is distributing $600 million in Federal funds for health information exchange. In my role as chair of NEHEN, I want to be sure our state has a good strategic plan and stakeholder alignment to create health information exchange in support of meaningful use goals. As with many of my other projects, this work requires a huge commitment to governance and working with highly innovative technologies and emerging standards. It's all high risk.

HITSP/HITSC/Federal activities - The Standards Harmonization work at HITSP and the Implementation/Adoption work at the Healthcare IT Standards Committee requires constant communication, balancing of stakeholder interests, and embracing innovation. Like any Washington task, achieving consensus among all the various points of view requires patience, an open mind, and a steady hand. I'm learning every day how best to serve the country as a facilitator and communicator. The task is never easy.

Personal - On the personal side, my daughter is 16 and we've begun college planning. Applying to college these days is much different than in my youth. I'm convinced that if I applied now to the schools I attended (Stanford, UCSF, UC Berkeley, UCLA, Harvard, and MIT), I would not be admitted!

My parents recently retired and we helped move them to a new house where the living is easy and maintenance free. My wife and I have begun to think about our retirement 20 years from now.

My 2009 work schedule has reduced my outdoor activities a bit, so I've had less climbing and hiking opportunities. This winter, I'm committed to getting back on trail in the 4000 footers of New Hampshire

My flute playing has taken a backseat to Washington travel. This winter I'm committed to playing the Japanese flute at least 3 times per week.

Thus, overall my challenges are keeping customers happy, managing the risks of change, embracing innovation, and keeping my family/personal life balanced with a worklife that has no downtime.

That's what keeps me awake a night. It's a lifestyle, not a job, and I enjoy every minute.