Featured Pose: Simple Chair Twist (Rerun)

by Baxter and Nina

The Simple Chair Twist is one of our five essential office yoga poses. It releases back muscles that are stiff or sore from sitting at a desk or from traveling, or from everyday activities that stress the back and increase the rotational mobility in your spine, such as gardening and painting. Twisting also helps nourish the spine—movement of the spine helps maintain the health of the discs—and it strengthens the bones themselves as your back muscles pull on the bony insertions of the spine. It also strengthens the oblique muscles of your core (and we could all use a little of that).

Traditional yoga teachers recommend twists for the health of your internal organs, improving circulation to and function of the abdominal organs, although no studies have been conducted to confirm this. And finally, for many of us, twists can release physical and emotional tension, providing relief from stress.

The Simple Chair Twist has the additional bonus of being accessible to almost everyone in any location, whether office chair, airplane seat, or even a car seat (except, as Baxter noted while sitting in Nina’s backyard, a 50s-style butterfly chair).

Baxter prescribes Simple Chair Twist for:

• general back tension
• stiffness
• people with balance issues (or who are unable to stand)
• certain low back conditions
• digestive difficulties (constipation or sluggishness)
• strengthening the oblique muscles
• arthritis of the spine
• people who engage in sports or other activities that involve rotation (all you golfers can restore symmetry to your body by twisting on both sides instead of one)

Instructions: Sit sideways on the chair, with your feet resting comfortably on the floor (if your chair has arms or is attached to another chair, see below for an alternative). Your thighs should be parallel to the floor, so if you’re tall you may need to sit on top of something and if you’re short you may need to place something (like a book) under your feet.

Keeping your thighs parallel to each other, lift your spine and turn toward the back of the chair, placing your hands on either side of the chair’s back. Inhale and create an inner lift from your sitting bones through the crown of your head. Then exhale and encourage the twist from your upper belly (above the navel) and chest. Continue lifting on your inhalation and twisting slightly deeper on the exhalation for about 1 minute. Then change sides and twist in the opposite direction. When you’ve finished the pose, pause for a moment to assess how the pose affected your body.

If you can’t sit on the side of your chair, you can sit facing forward as shown below.

As you twist to the right, place your right hand on the chair’s back and your bring your left hand across your right leg. To twist on the other side, simply switch your arm positions.

Cautions: With certain low back conditions (such as severe arthritis, bulging disc, spinal stenosis or sciatica) you should approach twisting cautiously and skip it entirely if it aggravates your symptoms. If you have osteoporosis, twist gently and don’t move through your full range of motion (stay within 50 to 70 percent). If you feel pain, please stop and when you get a chance, ask your yoga teacher for help.

Unity Farm Journal - 5th Week of July 2014

The great thing about running a farm is that every day is filled with the unexpected.

Sunny, our new baby alpaca did not consume her first meal of mother’s milk in time to receive the antibodies that are necessary to keep her healthy.   She was not gaining weight.   We had only one choice - a transfusion of alpaca plasma containing IgG (about $150).     We drove to Tufts Veterinary School and picked up 500cc of plasma.   There are two ways to transfuse a baby alpaca - jugular vein IV or peritoneal infusion.   Inserting an IV in a baby alpaca is like wrestling an alligator.  We chose the peritoneal approach which required shaving her belly, a bit of anesthetic, and a quick puncture to insert a blunt tube for infusion.   After 10 minutes of infusion she was back to the paddock.   Since the infusion, she has gained weight, had boundless energy and is on her way to becoming a healthy adult alpaca.   Here are before and after pictures, illustrating the use of our kitchen as an operating room.

Over the weekend, I put on my bee suit to help my wife and daughter inspect the hives and move heavy honey filled frames.   As I walked past the cider house I noticed a grey guinea fowl that had disappeared in the forest about a month ago.  We were convinced that a coyote had taken her.   Behind her were 17 babies that she successfully raised in the forest and now was leading back to the coop.   Other guineas in the flock do not seem to recognize their own young species and tend to harass babies, sometimes to the point of killing them.  I ran to the hives and asked for my daughter’s help.   Together we wrangled all 17 babies into a large farming bucket and placed them in a 100 degree F brooder where they ate, drank, and warmed up after their travel through wet grass.    Today they are happy and healthy and we’ll move them to one of the mini-coops on August 16.   Mom is a little disturbed that we took her babies away, but she’s returned to the coop and settled in with the other guineas.    We still have two nests in the forest and if they are successful, we’ll have over 100 guineas on the farm.     We’ve already put up notices at local farm stands offering guinea chicks for sale.

All of this guinea mania required a bit of new construction.    I built another mini coop in the larger coop, so now we have 5 areas for poultry.

brooder - 3 levels, can hold 100 chicks
mini-coop #1 - can hold 5 “teenagers”
mini-coop #2 - can hold 10 “pre-teens”
coop side #1 - can hold 25 adults
coop side #2 - can hold 25 adults

Today we have 17 chicks, 3 teens, 9 pre-teens, and 27 adults.   We’re going to run out of space if they forest nests are successful.

The hoop house continues to produce massive quantities of cucumbers, tomatoes, chard, squash, and eggplant.   One of my favorite vegetables is Japanese pumpkin (Kabocha) and I’ll harvest 25 pounds of it this weekend.

All is well on the farm as Fall approaches.   The ducks are eating worms in the compost pile and the joyful chaos continues.

Featured Sequence: Brain Health Practice

by Baxter

Here's our new Brain Health sequence, which combines physical exercise and stress management to promote health of the organ in general with "brain aerobics" to challenge you mentally. If you want to practice this sequence on a regular basis, you'll need to change it up periodically (see Yoga Sequences Are Brain Aerobics for information).

1. Checking-In: Start by sitting and checking in with your mind: is your mind busy or quiet today? Is your focus good or scattered? What is your mood? As you take a few moments to observe your thoughts, notice if they have one of the following qualities: pleasant, neutral, or unpleasant. Can you notice this without necessarily having to act on this insight?

Next, choose a single yoga sutra, either from your Yoga Sutras book or by finding a sutra online, and read the Sanskrit aloud. Then, repeat the translation aloud three times in a row.

Now you’re ready for your asana practice. Set you mat up so the short end is touching a wall. Then stand at the front of your mat in Mountain pose, facing away from the wall.

2. Mini Sun Salutations (Surya Namaskar): Practice the Sanskrit name for Sun Salutations. For general instructions on how to practice our Mini Sun Salutation, see Mini Sun Salutation. Start by practicing one round with your eyes open. Then attempt to do several rounds with your eyes closed, relying on senses other than vision to guide you. Because exercise is as important for the brain as it is for the heart, these Sun Salutations enhance basic brain health as well as stimulating brain function.

3. Warrior 2 (Virabhadrasana 2): Practice the Sanskrit name of the pose. Then, facing the long edge of your mat, step your feet wide apart so that the outer edge of your left foot is flush against the wall (or only the heel if this is a problem for your hips). Then turn your right foot and leg out 90 degrees, towards the center of the room. Now, bend your right knee and raise your arms to come into the pose. Instead of looking toward your front arm, look back at your left hand as you enter, stay in the pose for 6-12 breaths, and then exit the pose. Turn to the other long edge of your mat and repeat on the second side.

Imagine the Wall!

4. Standing Forward Bend with the Wall (Uttanasana): Practice the Sanskrit name of the pose. Now, stand with your back to the wall with your hips and shoulders touching the wall but your heels about 12 inches away from the wall. Bend your knees slightly and then tip forward from your hip joints to come into the forward fold, keeping your buttocks flesh on the wall and lowering down as far as you safely can. Caution: If you have osteopenia or osteoporosis, perhaps come only half way down. Stay for 12 breaths, and come up on an inhalation.

5. Triangle Pose (Utthita Trikonasana): Practice the Sanskrit name of the pose. Then, turn around on your mat so you can practice the left side of Triangle pose first. Facing the long edge of your mat, step your feet wide apart so that the outer edge of your right foot is flush against the wall (or only the heel if this is a problem for your hips). Then turn your left foot and leg out 90 degrees, towards the center of the room. Next, inhale your arms up to parallel with the floor, and keeping your attention on your left hand, come into full Triangle pose, using a prop for your bottom hand if necessary. As you stay in the pose for 6-12 breaths, keep looking at your left hand (your bottom hand) and continue to focus on your left hand as you come out of the pose. Then turn towards the other long edge of your mat and repeat the pose on the right side, following your right hand as you move into, stay in, and move out of the pose.

Imagine the Wall!

6. Powerful Pose (Utkatasana): Practice the Sanskrit name of the pose. Then, standing as you did for Wall Standing Forward Bend, keep your buttocks on the wall as you inhale your arms overhead, bend your knees, and tip your torso and spine forward over your thighs into the Powerful pose shape. See Powerful Pose for instructions about Powerful pose. Stay for 6 breaths. 

Imagine the Wall!

7. Extended Side Angle Pose (Utthita Parsva Konasana): Practice the Sanskrit name of the pose. Next, align your feet for the pose the same way you did for Warrior 2, with your left outer foot (or heel) at the wall. As you come into the pose to the right, using a prop for your bottom hand if necessary, keep your eyes fixed on your right hand (your lower hand), throughout the pose. For additional instructions, see Upper Body Strength Practice Stay for 6-12 breaths, and repeat on the second side.

Imagine the Wall!

8. Half Downward-Facing Dog Pose at the Wall (Ardha Adho Muka Svanasana): Practice the Sanskrit name of the pose. Then stand facing the wall with your hands on the wall at shoulder height. Bend your knees a bit and slowly back your feet and hips towards the center of the room until your arms and torso are parallel with the floor and your hips are positioned directly over your heels. If your back and hamstrings permit, slowly straighten your legs without rounding your lower back towards the ceiling. Float your head between your arms as you actively push your hands into the wall and your hips away from the wall. Stay in the pose for 6-12 breaths. To come out, bend the knees a bit and walk the feet back towards the wall as you lift your torso up to vertical. For additional instructions, see Half Downward-Facing Dog Pose at the Wall. 

9. Warrior 1 to 3 (Virabhadrasana 1, 3): Practice the Sanskrit name of the two poses. Now, stand facing the wall about halfway back on your mat (you will need to experiment with the distance to get it just right). Step your left foot back about three feet, and turn it out a bit to the left. Then, inhale your arms up alongside your head and bend your front knee forward over your right ankle, coming into Warrior 1. Then, tip forward from your hips and lean forward, bringing your weight onto the right leg, your hands to the wall and your left leg up behind you into Warrior 3. Try to keep your hips square with the floor beneath you and your head floating between your arms. This can be quite a vigorous pose, so stay for just 3-6 breaths. See Warrior 3 Pose (Wall Version) for further instructions. To come out of the pose, on an inhalation, step back to Warrior 1 as lightly as you can. On your exhalation, come out of Warrior 1 and step back to Mountain pose. Repeat on the second side.

10. Reclined Leg Stretch Pose (Supta Padangustasana): Practice the Sanskrit name of the pose. Then, lie down on your back with the soles of your feet against the wall. Practice version 1 of Reclined Leg Stretch on your right side (see (Reclined Leg Stretch Sequence ), keeping good contact of the sole of the left foot against the wall throughout the pose. The key difference here is the tactile awareness of the bottom leg foot on the wall. Stay for 6-12 breaths. Then repeat on the other side. 

Imagine the Wall!

11. Legs Up the Wall Pose (Vipariti Karani): Practice the Sanskrit name of the pose. Then, set up for a supported version of Legs Up the Wall pose, using whatever propping would feel good for you today. See Legs Up the Wall pose for instructions on practicing this pose. After going up into the pose, change the typical position of your arms today, and notice how that affects the pose on the level of sensation, breath, and emotions. Stay for 5-10 minutes if your schedule permits. This pose is great for managing stress levels, which is important for maintaining brain health as it helps reduce strokes (see Brain Health Interview with Ram Rao).

12. Simple Seated Pose (Sukasana): Practice the Sanskrit name of the pose. Then sit in Sukasana with your back against the wall and as much support under your hips as you need for your back to feel comfortable. See if you can recall the sutra you learned for today. If not, re-read it now. Then, use the translation of the sutra as a mantra for a short meditation session, repeating the sutra mentally to yourself as you breathe in and out comfortably. I usually set a timer for how long I want to do my final meditation, typically at least 10 minutes, but feel free to start with 3-5 minutes at first. Any type of meditation can be beneficial for brain health, as it may help build brain strength (see Meditation and Brain Strength).

Real Time Big Data Analytics for Clinical Care

Over the summer, I’ve given many lectures about SMAC - social media, mobile, analytics and cloud computing.

The most popular analytics topics are business intelligence, big data, and novel data visualizations.

Recently, Dr. Chris Longhurst, chief medical information officer at Lucile Packard Children's Hospital, and colleagues wrote an article in the Big Data Issue of Health Affairs, that suggests a very practical approach for enabling real time analytics within an EHR.   They call it the Green Button.

The Blue Button is for patient view/download/transmit of medical records.

The Green Button is for instant access to outcomes, cost, and risk information for patients that match a given profile.

Here’s a personal example.

When my wife was diagnosed with Stage IIIA Breast Cancer in December of 2011, the biomarkers of the tumor were HER2 -, Estrogen +, Progesterone +.    Imagine that while in her record, a Green Button enabled access to the de-identified records of all 50 year old, Asian females with similar tumors and showed the treatment protocol used, the side effects, the cure rate, the cost, and the complications.

Although not completely scientific, such an approach does not identify causality, it does demonstrate experience and standard practices in the community.   The Green Button idea is foundational to the learning healthcare system we’re all trying to build.

We do need to be careful.   Here’s one example from our work with I2B2/Shrine.

Did you know that the average human white blood cell count is 5 at noon but 13 at 3am?

Scientifically we know that white count does not vary with circadian rhythm.   However, who has a white blood cell count drawn at 3am?  Sick people.

You cannot conclude that white count varies over the course of a day because the data has confounding complexities.

However, there is an interesting possible conclusion.   People who get white counts drawn at 3am, get blood cultures at 4am, and antibiotics at 5am.   We can suggest that if you order a white count at 3am then you want to order a blood culture and antibiotics at the same time, since you’ll end up doing it anyway.

The Green button idea is to present valuable historical observational data at the point of care.

I2B2 is a great tool for clinical research and clinical trial enrollment, but imperfect for point of care advice.

How might the Green button be developed?

Emerging companies like QPID are creating new tools that summarize structured and unstructured data into unique visualizations.   I'm on their Advisory Board.

The BIDMC experience with care management using a third party registry populated via the state HIE also provides promise.

I look forward to experimenting with the Green Button concept - another item on my to do list for the next year.

Yoga Sequences Are Brain Aerobics

by Baxter

Do you like my brain? by Niki de Saint Phalle*

Brain Health is a topic we here at YFHA have addressed on numerous occasions. Research clearly points out that your mind like your body needs to be exercised regularly. I recently grabbed a flyer from my family doctor’s office that caught my eye. It was titled “The Power of Brain Aerobics: Maximize Your Memory.” As I read through it, I could not help but recall (good sign, eh?) the two excellent posts Ram did a while back on brain exercise  According to the group who published my flyer, the Alzheimer’s Research & Prevention Foundation, there are three conditions your brain workout must meet in order for an activity to be considered “brain aerobics”:

• It needs to engage your attention
• It must break a routine activity in an unexpected, nontrivial way
• It must involve more than one of the senses

You can see that attending a regular yoga class or practicing yoga at home likely meets all three of the criteria. First, you are actively encouraged to bring your attention to the practice at hand, whether it is the physical poses, breathing patterns or meditation. Second, because you classes are likely changing each week (unless you do a style of yoga that repeats the same sequence week to week), there will be some familiar components of a practice, but an ever-changing sequence of poses, with a goal for each class that is a bit different from the previous week’s class, breaking the routine in a nontrivial way. And if you’re practicing at home, you can consciously try to add new poses or change up your sequences to keep things fresh. Finally, not only does the successful practice of yoga involve more than one of our senses (most obviously visual, tactile, auditory), but involves the mind taking in information and acting on it in the moment.

Tomorrow I’ll be posting my new Brain Health Sequence. If you are going to practice this sequence on a regular basis, it may be more challenging to meet the second requirement of breaking the routine activity in an unexpected way. You will have to find ways to creatively modify the sequence every few times you practice. So in this post, I’ll make several recommendations for how you can do can make this or any sequence more stimulating for your brain.

To re-iterate why we want to do these mental aerobics, Ram says:

“Mental fitness is exactly what it sounds like: keeping the brain and emotional health in a healthy state by performing mentally stimulating tasks. Mental exercises refer to a series of exercises that help you to be more alert, think rationally and logically, make sound and correct decisions and boost a declining memory.”

Here, here! Now for some ideas about how to apply these concepts to your brain health (and other) sequence:1. Each time you practice, pick one or two of the poses in the sequence and commit to learning the name of the pose in Sanskrit. We typically include the Sanskrit names of the poses in our sequences, so you can find the names right on the post. And if you want to know the Sanskrit name for a pose that is not included on the blog, there are many resources to help you with this, including my teacher Donald Moyer’s book Yoga: Awaking the Inner Body and Light on Yoga by B.K.S. Iyengar. Nicholai Bachman has a sweet little book and audio CD “The Language of Yoga” to assist in learning the most common yoga pose names, as well.

Note from Nina: Gosh, Baxter, you forgot to mention the second book I wrote with Rodney Yee, Moving Toward Balance—which has Sanskrit names for all the poses in the book! And, everyone, if you don’t have a yoga book on hand, Google or any internet search facility works very nicely for finding articles that include both English and Sanskrit pose names, such as those on Yoga Journal's site or even wikipedia.

2. Using your memory is a great mental exercise. So look over the sequence first and try to do it from memory. If you use the post while practicing, 30 minutes or so after you are done practicing, try to write out the sequence as accurately as you can.

3. A simple way to stimulate new nerve connections in the brain is by using the opposite or non-dominant hand/side for routine tasks. When it comes specifically to yoga asana, if you have a habit of doing the poses right side first, practice the same by starting on the left side before the right and vice versa. Or, as I do in class and at home, alternate which side you go to first in asymmetric poses.

4. Changing your daily habits and routines will allow mental stimulation to occur as well. So try practicing in a different room or space in your house. Something I often do is change the direction of practice by re-orienting my mat in my practice space to point in different directions. When you do this, notice what appears around you and how it feels to practice with the new orientation. Another way to change up a sequence is to tinker with it a bit by adding a new pose or substituting one pose for another 

5. Stimulate new neural network connections and brain growth by learning something new. I recommend that you have a yoga book at your mat and you take a few minutes to read a paragraph or two about yoga. Recently, I’ve been reading one sutra from Pandit Rajmani Tigunait, PhD’s new book The Secret of the Yoga Sutra, pronoucing the sutra to the best of my ability and memorizing the English translation. For your learning pleasure today, I share with you Sutra 1.2 and his translation:

yogascittavrittinirodhah: Complete mastery over the roaming tendencies of the mind is Yoga.

I will typically reread the sutra for several days in a row, and continue to practice saying the Sanskrit phrase out loud.

Post-Traumatic Stress Disorder: Yoga to the Rescue

by Ram

Tokugawa with help from the Jodo monks of the Daijuji temple in Okizaki,
defeats the Ikkō ikki at the battle of Azukizaka by Yoshitoshi

Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops after a person is exposed to a traumatic event. The individual could be either experiencing or witnessing the event.  Generally, people who are exposed to a traumatic event have difficulty adjusting and coping for a while but the symptoms get better with time and good care. However, if the symptoms get worse and protracted and interfere with daily tasks, the individual may have PTSD. Symptoms may include: recurring flashbacks of the event, hyperarousal, nightmares, severe anxiety, difficulty concentrating, feeling "jumpy" or getting easily startled, insomnia, uncontrollable thoughts about the event, self destructive behavior or withdrawing from social relationship. Women in general are more likely to develop PTSD than men, children are less likely to experience PTSD-like symptoms after a traumatic event than adults, especially if they are under ten years of age, and war veterans are at high risk for PTSD.

Anyone who is exposed to a dangerous situation naturally feels frightened.  The fear triggers the Fight or Flight response in the body to defend against the incoming danger or to evade it. This is a normal and healthy response of the body to protect the individual. But in PTSD, the Fight or Flight response is abnormally altered and as a result the individual may feel stressed or frightened even when they’re no longer in danger. Though PTSD was first recognized in war veterans, it can also result from a variety of incidents, including brutal assault, rape, torture, child abuse, abusive relationships, accidents, such as, car crashes, bombings, natural disasters, kidnapping or long-term captivity. The symptoms of PTSD may show up following the traumatic event or, surprisingly, may appear several years after the event. The symptoms cause significant problems at home, work, or in a social situations and can affect the individual’s normal functioning. 

What’s intriguing is why only some people suffer from PTSD. As with most mental health problems, PTSD is probably exacerbated in those who have:

• inherited some mental health risks (genes that play a role in fear associated-memory formation and acquisition)
• exposed themselves to frequent episodes of traumatic events
• dysregulation in the release of chemicals and hormones in response to stress

The primary treatment for PTSD is psychotherapy in combination with suitable medication. This type of combinatorial treatment approach seems to improve the symptoms, help individuals feel better about themselves and enable the individuals to adopt lifestyle changes to manage the symptoms that recur. Medications include antidepressants and/or anti-anxiety medications. The drawback is that these medications have the potential for abuse and patients complain of several non-specific side effects. So non-pharmacological remedies could serve as a perfect add-on treatment. Fortunately, there are now nearly a dozen research studies describing mind-body intervention therapies, including yoga and meditation, for management of PTSD symptoms that arise from exposure to various stress stimuli. See Managing Mental Health Disorders Resulting from Trauma through Yoga: A Review.

Yoga for War Veterans with PTSD: The effectiveness of a yoga program for improving PTSD symptoms was conducted in a pilot study involving twelve war veterans who suffered from military-related PTSD. The veterans participated in a six-week yoga intervention that was held twice a week. The researchers noted a significant improvement only in a subset of PTSD symptoms, including hyperarousal symptoms, overall sleep quality, and daytime dysfunction related to sleep. 

Yoga for Tsunami Survivors: In another study, the effect of a yoga breath program alone or in combination with a trauma-reduction exposure technique was evaluated on the 2004 tsunami survivors who were confirmed to exhibit PTSD symptoms. The 183 tsunami survivors were divided into three groups: 1) yoga breath intervention, 2) yoga breath intervention followed by 3–8 hours of trauma-reduction exposure technique, and 3) six-week wait list that served as a control group. PTSD measures (17-item PTSD checklist and depression) were checked at the start of the study and at 6, 12 and 24 weeks.  Eight months after the 2004 tsunami, survivors who performed the yoga program alone or in combination with the exposure therapy had significantly reduced scores on PTSD symptoms checklist compared with the control group. Additionally, the yoga group alone or in combination with the exposure therapy had significantly reduced scores on depression measurements compared with the control group. The benefits from the yoga program alone or in combination with the exposure therapy were maintained for 24 weeks, even without a regular practice. 

Yoga for Youth Incarcerated in a Correctional Facility: Juvenile delinquency requires interventions to help the youth cope with the stress.  A randomized controlled trial was carried out on 28 girls between 12 and 16 years of age, all of whom had a history of committing legal offences. The 28 girls were divided into two groups:  1) yoga and 2) games. The girls in the yoga group received training in postures and guided relaxation sessions for 60 minutes daily for 5 days a week. At the end of 6 months, both groups’ heart rate and breath rate were assessed to evaluate their physiological stress levels. While both groups showed significantly reduced heart rate, the yoga group also showed a significant decrease in breath rate, suggesting that a combination of yoga and meditation was helpful in combating fear, anxiety and hyper arousal like symptoms associated with PTSD.

Similar mind-body intervention programs were conducted on people exposed to civil wars, tsunami, hurricanes, interpersonal violence, combat, and terrorism in several places, including Kosovo and Sri Lanka. And in all such cases it was noted that yoga and meditation were extremely useful in reducing mental health disorders and other PTSD symptoms. Researchers believe that yoga and meditation may improve the functioning of traumatized individuals by relieving their psychological distress, increasing their mental awareness, and helping them to tolerate physical and sensory experiences associated with fear and helplessness. So if you know of someone who is experiencing PTSD or similar symptoms, kindly roll out the mat and encourage the individual to incorporate yoga and meditation into their lives. Both these practices do not require extensive hospital visits, expensive gear, space or setup and do not have any baggage of side effects. And the benefits are immense. Furthermore the healing power is in its simplicity!

 

There’s More to ePrescribing Standards Than You Think

In followup to my guest post from Dr. Marvin Harper about e-Prescribing gaps, John Klimek, R.Ph., Senior VP, Standards and Information Technology, NCPDP wrote the following helpful guest post:

The National Council for Prescription Drug Programs (NCPDP) leaders and members read with interest the guest post from Dr. Marvin Harper, CMIO at Boston Children's Hospital, entitled “Limitations of e-Prescribing Standards.” Dr. Harper’s thoughtful post brings a critical issue to light: the need for increased industry awareness and adoption of the full functionality that already exists in ePrescribing standards – going beyond the core requirements of Meaningful Use. ePrescribing is important in improving both the quality of patient care and patient safety. It provides a key point of communication between care providers, and can help improve patient compliance with treatment regimens.

ePrescribing Standards: What’s Covered

Three standards are used in ePrescribing – the NCPDP SCRIPT Standard and the NCPDP Formulary and Benefit Standard, and the ASC X12 Standards for Electronic Data Interchange Technical Report 3 - Health Care Eligibility Benefit Inquiry and Response - 270/271. The eligibility transaction is typically exchanged prior to the patient encounter and can supply the prescriber system with information about the patient’s pharmacy benefit, including the payer, member ID, formulary and coverage pointers, and other details. The Formulary and Benefit Standard provides a means for pharmacy benefit payers to communicate formulary and benefit information to prescribers via technology vendor systems at the point of prescribing. The file exchange includes information on formulary status, alternative drugs, co-pays and other information.

The healthcare industry is currently using SCRIPT Standard version 10.6 which contains thirteen different transactional exchanges for ePrescribing functions, including:
• Sending a New Prescription;
• Changes to a Prescription;
• Renewals and Resupply Exchanges;
• Cancellation of a Prescription;
• Fill Status Notifications;
• Medication History; and
• Census Exchanges.

Most of these transactions have been named in the regulations associated with the Medicare Modernization Act. While the electronic exchange of new prescriptions, renewals and medication history have grown exponentially, implementation of other transactions has been very slow.

Other capabilities, including the specific issues raised by Dr. Harper, are also available in the existing standard, underscoring the urgent need to increase awareness and industry-wide adoption of the breadth of functionality afforded by the ePrescribing standards. Among them are:

• Structured and codified sig - promotes greater consistency in specifying directions and for clinical review/analysis. The current version used by the industry contains a 140 byte free text field, along with fields to describe the route, indication, vehicle, site, timing, and duration. The structured and codified sig format present in SCRIPT version 10.6 was not intended to support 100% of sigs; however a pilot found that 95% of the fully parsed sig strings were accommodated by the format. Enhancements incorporated in SCRIPT version 2012+ include a more robust Structured Sig Segment which supports a text field size of 1000, as well as other enhancements, recommendations and clarifications from the pilot.
• Support for patient observations - allows prescribers to supply Patient Height, Weight, Diastolic and Systolic Blood Pressure. Patient Weight is useful for validating proper pediatric dosing. Based on questions posed by a Council on Clinical Information Technology Executive Committee article, recommendations for pediatric prescriptions were included in the SCRIPT Implementation Recommendations document publicly available for implementers at http://www.ncpdp.org/Resources/ePrescribing under NCPDP Resources. A challenge is for the prescribing systems to send this information. Enhancements for more observation measurements were included in a more recent version.
• Support for scheduled medications - provides fields necessary to enable ePrescribing of controlled substances.
• Compound prescription support - approved in SCRIPT version 10.8 when industry champions came forward to analyze the needs and work through the requirements.
• Adverse events/reactions - the NCPDP SCRIPT Standard supports the exchange of drug use review (DUR) fields. The industry is actively exploring adding the use of adverse events/reactions/etc., which is used in other transactions, for the use in the ePrescribing transactions via the NCPDP WG11 ePrescribing Best Practices Task Group.
• Support for prior authorizations – provides the means to exchange information needed in prior authorization (PA) requirements, including access to information on covered medications at the point of care, information on PA approvals and denials. The ePA transactions were added in a more recent version that industry participants are actively implementing.

Moving the Needle on Adoption and Implementation of ePrescribing Standards
ePrescribing standards have been enhanced based on requests by the industry which has opted to build functionality in layers. For example, the SCRIPT Standard version 10.6 was published in 2008, with enhancements that are approved and published at least twice a year. But publication is one action; implementation is another. So the question is: How do we move the needle to increase adoption and implementation of the ePrescribing standards?

1. Technology/System Vendors Can Take the Lead or Wait for a Mandate - There are many demands on industry vendors for impact analysis, development, implementation, testing and distribution. Then there is coordination of both prescribing and pharmacy systems implementation, and all within regulatory requirements. In an effort to build a predictable, repeatable process, the industry will be examining if a cyclical implementation timeframe could be adopted to move versions in a more timely and expected manner. In the absence of a mandate, uptake on adoption and implementation depends on technology vendor priorities.

2. Share Lessons Learned to Improve Implementation Guidance – Implementation can be slow when you are blazing new trails. The data itself is complex. It may be pulled from data that is not discrete or doesn’t use the same nomenclature or requires the use of an unfamiliar vocabulary. The electronic exchange can be complicated. It forces analysis of manual workflows. Trading partners may be at different stages of implementation maturity. Benefits are seen from different perspectives. Industry experience in the use of the functionality available is needed, with lessons learned to improve future implementation. NCPDP has active task groups including ePrescribing Best Practices Task Group, Implementation of Structured and Codified Sig Task Group, and many others that are open to materially interested parties to come together in consensus to develop industry guidance, implementation guidance, and future enhancements to the standards.

The complex but vital enhancements to industry standards are developed by the dedicated volunteers across the healthcare industry who share questions, findings, and recommendations. NCPDP, the standards development organization, provides the forum for this important work. See http://www.ncpdp.org/Resources/ePrescribing for more information, including how to get involved.