The "Post EHR" Era

Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we've already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community.    Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the "post EHR" era.

What does this mean?

I've written previously about BIDMC's Accountable Care Organization strategy, which can be summed up as ACO=HIE + analytics

In a "post EHR" era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team.    That team will include PCPs, specialists, home care,  long term care, and family members.    The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.

How could this work?

Imagine that we define each patient's healthcare status in terms of "properties".    Data elements might include activities of daily living, functional status, current care plans, care preferences, diagnostic test results, and therapies, populated from many sources of data including every EHR containing patient data, hospital discharge data, and consumer generated data from PHRs/home health devices.

That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient).   The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.

My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.

This will require philanthropic funding, in kind contributions from selected vendor partners, and a willingness to take a risk on creating something that has never been operated at scale in the past.

I wrote previously about the reluctance of healthcare to change and adopt new delivery models.

BIDMC is a unique learning laboratory because 65% of its patients are already in global captivated risk arrangements.

If the CMMR can be created anywhere, it's at BIDMC which strives to be agile and transparently share all its early experiences with the world.

I'm willing to lead the CMMR effort.   In my discussions with many stakeholders over the next few months, I'm hoping to create a guiding coalition that will join me.

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So What Does 30 Inches of Snow Look Like?

For those who have been watching news of the New England weather,  here's a personal look at what 30 inches of snow in 12 hours looks like.   We shoveled and plowed through the night to keep our lanes open.    The alpaca/llama stayed in the barn eating hay.    The dogs played in the drifts all night.   The chickens/guinea fowl slept through the entire event.     We did not lose power, but we prepared for an extended outage by moving 50 gallons of water for the animals into the garage and 50 gallons for humans into the basement.   We moved a cord of firewood to the front and back porch.    At the moment, we're done with our morning farm chores, ensuring all the animals will have a warm and dry day.

The barnyard:

The chicken coop:

The front door:

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Building Unity Farm - The Hen That Went Broody

The world of Unity Farm is cold and frozen this week.   There's ice and snow on the ground and night time temps are approaching single digits.   It's not the right time to hatch chicks.

However, randomly throughout the year, egg laying hens decide that hatching eggs is their only priority.   They sit on the eggs 23+ hours a day, taking only a quick break once a day to eat and drink.   The go broody.

We're fine with the concept, but this week, our most maternal hen, an Ameraucana named Terra, decided to create a nest under the coop, 10 feet from any edge.   She was completely unreachable by us, but very vulnerable to local foxes, fisher cats, and raccoons.

Here's how it happened.   Every night we put our chickens to bed by bolting all internal doors/passageways from inside the coop to prevent predators from sneaking in.  Then we close the coop front door and put a carabiner on the latch to ensure it stays shut.   Before lockdown, I fill the water fountains and grain feeders, then count every bird (13 chickens, 18 guinea fowl).   All of our chickens have names, so we know exactly who is roosting in each section of the coop.   Generally, the large rooster, Lucky sits on low perch I built for him.   The small rooster, Rainbow, sits as far from Lucky as possible.   The hens except for Terra and Zephyr, roost above Lucky.   Terra and Zephyr sleep with the guinea fowl.

Last weekend, when I counted the chickens, I could not find Terra.   We saw her at noon on Sunday, but by twilight when we close up the coop, she was gone.    I spent an hour running all the trails looking for signs that a predator had eaten her.   I put the dogs on lead and we ran through the property looking for fox/coyote tracks or other predator activity.    We found nothing.   Odd.

The next morning, my wife spread scratch grains (think of it as candy for chickens) around the coop.   A few minutes later Terra appeared.   Then she disappeared again.   When I returned from work, I crawled under the coop with a flashlight and saw her nesting far beyond my reach.

I used a 10 foot bamboo pole to gently move her toward the side of the coop.   No luck.   She was committed to hatch the eggs she laid in that subterranean space.

My wife tried scratch again each day.   No luck.    I checked on her nightly to ensure she was still healthy.

Last night, a fisher cat ran by the paddocks and made a horrible screeching sound.   I had to protect Terra in her vulnerable position, so in Cask of Amontillado fashion, I walled her into her hiding place.

This morning I removed the barrier.    My wife and I used 2 bamboo poles to create a moving barrier.   We scooted her away from the nest and eventually she gave up, exiting in to the barnyard.    We gently picked her up and placed her in the coop, where she ate and drank her fill before roosting in her usual place.

Given the historic snowstorm that is impacting New England this weekend, we rescued her just in time.

Let's hope when other hens go broody in the winter, they have the sense to do it indoors!

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Testimony to the HIT Policy Committee

Today I testify to the HIT Policy Committee  and review the HIT Standards Committee responses to the HIT Policy Committee Request for Comment.

Although there are many detailed comments, they stratify into 5 general categories

*Because of the maturity of standards and EHR technology, the Stage 3 goal should be menu set rather than core
*Because of the maturity of workflows, the Stage 3 goal should be a certification requirement (the technology can do it) but not a meaningful use requirement
*Standards do not exist and it is premature to include the goal in Stage 3
*Workflow/experience with production system implementation does not exist and it is premature to include the goal in Stage 3
*We agree with the Policy Committee goal as worded

In general, the Standards Committee applauds the aspirational nature  of many of the goals.    They seem like a reasonable direction.   The challenge is timing.   18 month cycles to design, implement and adopt product require that mature standards exist and pilot workflows have proven efficacy.

I described the caveats raised by the Standards Committee when goals seemed too aspirational for Stage 3.  For example :

*No standards or technologies exist to represent knowledge/rules and enable their automated incorporation into EHR workflows.
*There is no way to electronically broadcast computable guidelines for immunization administration for children into EHR workflows.
*At present there are no standards for contraindications to immunizations
*The is no standard way to electronically broadcast computable guidelines for drug/drug interactions into EHR workflows.
*There is no way to broadcast rules that would create "smart problem lists" such as declaring everyone with a hemoglobin A1c greater than 9 to be a diabetic.
*Incorporating patient generated data into EHRs requires new patient friendly vocabularies and code sets that will map into EHR data structures and protect data integrity.

We agree with many of the goals and believe that progress with Meaningful Use Stage 2 should be extended with higher thresholds which enable organizations and professionals to consolidate our gains.

I am confident that the smart people at ONC will incorporate testimony from stakeholders, the deliberations of the policy committee, and the feedback from the standards committee into a set of go forward recommendations for Meaningful Use stage 3.  

Given that the country is in the midst of ICD-10, Accountable Care/Healthcare Reform implementation, value-based purchasing, Meaningful Use stage 2, and HIPAA revisions, many clinicians, vendors, and IT professionals are feeling overwhelmed.   If Meaningful Use Stage 3 follows existing timelines and focuses on a few key domains, raising the thresholds on existing criteria and incorporating more interoperability where standards are mature, we'll achieve a balance of benefit and burden.

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A New Sustainability Model for Healthcare Information Exchange

Many of us have worked hard on sustainability models for HIE over the last decade.    There is one model we likely never considered.

The Massachusetts Health Information Highway is abbreviated the MassHIway.   Its phone number is 1-800-MassHIway.

Unrelated to IT (or so we thought), Massachusetts legalized medical marijuana.

This is an actual transcript of a call we received today


Sean - “Hello, Mass HIway – how may I help you?”

Caller - “Yes, can you tell me how I become a marijuana grower/dispenser?”

It's clear we have to rethink the meaning of HIGH way.

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Building Unity Farm - Reflections on our First Winter

The third week of January is always the coldest time in New England.    Mt Washington was -70F and Unity Farm was 1.4F 

When we began this season I had no idea how to keep the animals happy and healthy in near zero temperatures.    We've learned a great deal and thus far, everything has worked.

Chickens and Guinea Fowl - I've written about keeping warm in New England,  highlighting that convective, conductive, and radiated heat loss need to be controlled.    For poultry, a dry, wind free coop with off ground roosting helps a great deal.   Our chicken breeds are very cold hardy due to their small combs and waddles.   However, to completely guard against frostbite, we added 150 watt sealed heating panels to the roof and baseboard of the coop (photo below).   These are thermostatically controlled and go on at 35F, off at 45F    They've worked perfectly, ensuing the coop is 10-15 degrees warmer than the outside temperature.     Keeping water supplies liquid at zero F requires planning.   For the chickens, their hanging bucket waterer now has a submersible thermostat controlled heater (photo to the right).    For the guinea fowl, their standalone waterer sits on a thermostat controlled heat plate.     In very cold weather, the guineas rarely leave the coop, enjoying the food, water, and warmth of their gently heated home.     I did have to wire the coop with tamper-proof (beak proof), weather resistant (from chicken droppings) outlets and rugged 14 gauge romex wire.   Everything has worked without a hitch.

Dogs - The Great Pyrenees have double coats and really enjoy snow and ice.   They eat the "popsicles" from the ice that falls from the barn roof.   Just as with the chickens, keeping dogs out of the wind and wet weather is important.   We've created spaces for them in the hayloft - they curl up among the bales, staying warm on blustery winter nights.  Also, we use a thermostatically controlled heated bucket to keep their water liquid.

Alpaca/Llama - The camelids seem impervious to cold but do not like the wind.   We created rubber floored stalls with sliding doors that provide a wind and rain barrier.    Their water buckets are heated.   We feed them hay with a high percentage of alfalfa (extra calories) on cold days.    We feed each of them a cup of high energy grain in the morning and evening of each winter day.  We supplement their diet with beet pulp. Shoveling manure during weeks that never rise about freezing has proven to be a challenge.   I can use a wrecking bar, pick, or hammer to break up manure, but I've found it more practical to wait until a thaw day to shovel.

The combination of appropriate housing, low wattage heaters, and water management, has proven to me that winter on Unity Farm will pass without any animal health and well-being issues.

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The Retirement of a Healthcare IT Legend

On Monday, I had the privilege of attending the retirement luncheon for G. Octo Barnett, the founder of the MGH Laboratory of Computer Science (LCS) and the inventor of the MUMPS (Massachusetts General Hospital Utility Multi-programming system).

Henry Chueh, Division Chief of LCS, served as master of ceremonies.

The attendees were the luminaries in the field of medical informatics - Donald Lindberg, Randy Miller, Clem MacDonald, Charlie Safran, Paul Egerman, Rita Zielstorff, Albert Mulley, Howard Bleich, Warner Slack, Chris Cimino, Peter Beaman and many more.

Everyone told stories about Octo's achievements inside and outside the lab.

In many ways, he is the catalyst that spawned companies such as Meditech, IDX, Epic, Intersystems, and many others.

Octo himself is a humble man and offered his sincere thanks to everyone who has worked with him over his 50+ year career.

He's a great man whose contribution to the healthcare IT industry is overwhelming.   I've said that in life the most important thing is to make a difference.   Octo made a difference.

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The Health Information Exchange Hearing

Today in Washington, the Standards and Policy Committees met in joint session to take testimony from expert stakeholders about health information exchange.

Farzad Mostashari, National Coordinator, introduced the day, noting that we've made great strides since the founding of HL7 in 1987 and the creation of ONC in 2004, but there is more work to do.  The includes early successes, a discussion of barriers/challenges, the elements needed to ensure trust, and the role of consumers.   The hope is that the foundation laid by Meaningful Use stage 2 will enable reduced costs (and reduced vendor pricing for interfaces), increased benefit, and privacy protections that have not been historically possible.

Micky Tripathi, CEO of the Massachusetts eHealth Collaborative provided an overview of the  current landscape in his presentation, The State of Health Information Exchange.  He described HIE 1.0 as the noun and HIE 2.0 as the verb with many models  (in order of increasing level of external coordination needed):

Point to patient
Point to point
Vendor specific
Transaction specific national level
Enterprise level HIE organizations
State and regional collaboratives
National level collaborative

Next, I moderated a panel, Health Information Exchange Enabling Healthcare Transformation, describing the technology and policies which have enabled successful health information exchanges.   The major lesson learned was workflow and business value are even more important enablers than technology.

We heard from
Michael Lee, Atrius Health
Sandy Seltzer, Camden Coalition
Keith Hepp, HealthBridge
John Blair, Hudson Valley Initiative
Karen VanWagner, Plus ACO/North Texas Specialty Physicians

Next Paul Tang moderated a panel, Technical and Business Barriers and Opportunities, which concluded that meaningful use stage 2 significant reduced technology and policy barriers by constraining optionality in standards and aligning incentives to exchange data.  We heard from

John Halamka, Beth Israel Deaconess Medical Center
David Horrocks, CRISP
Bill Spooner, Sharp
Tone Southerland, Greenway

After lunch, I moderated a panel, Governance Barriers and Opportunities, which focused on governance and trust fabric efforts necessary to ensure authentication and authorization of participants in health information exchange.   We heard from

David Kibbe, Direct Trust
Christopher Alban, Epic
Sid Thornton, Care Connectivity Consortium
Michael Matthews, Healtheway

Finally, Paul Tang moderated a panel, Consumer-Mediated Exchange, which emphasized the importance of provider-patient as well as provider-provider health information exchange using the Direct standards.   We heard from

Jeff Donnell, NoMoreClipboard
Mary Anne Sterling, Sterling Health
Neal Patterson, Cerner
Alan Blaustein, Care Planners

Paul Tang summarized the day and we agreed that the robust discussion will inform the work plans of the policy and standards committees as we all work hard to increase the volume and usefulness of health information exchange throughout the country.

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Building Unity Farm - Creating an Animal Community

On our journey to become small scale farmers, we've visited many New England farms, orchards, and CSAs.   We've had 3 major lessons learned:

*Create the infrastructure you need before adding animals to the property
*Do not acquire more animals than you can manage
*Ensure the animals are compatible with each other and that you'll have a healthy community with symbiotic relationships

Infrastructure - many farms we visited had inadequate or temporary fencing, created or patched after an animal escaped or was injured trying.    Often there was little advance thought to manure management, workflow, and access for humans and machines.    In laying out our fences we placed gates on every edge and sized them based on the need for animal and equipment flow patterns.   The inputs and outputs of food, water, and manure formed the requirements for design before anything was built.

Number of animals - Today we have 50 animals, which enables us to give personal attention to every one.   Each night we examine all our chickens and guinea fowl to ensure they are healthy.   Every day the Great Pyrenees get two runs around the forest and orchard.    For alpacas and llamas,  we trim their toenails, clean their ears, examine their skin, weigh, and measure their body scores every month. This month we found a small ear abscess on one of the alpacas and performed an incision and drainage to accelerate healing.   My wife and I, plus the monthly help of the original alpaca breeder,  constitute enough resources to give personalized attention to every animal.   Many farms we visited had sick, underweight, and overcrowded animals that exceeded the capacity of the farmers to care for them.

Community - we chose our animals carefully.   Our guard llama lived her entire life with alpacas and was familiar with guarding duties.   Our alpaca spent their entire lives together as a herd.   Our chickens were hatched together on the same day.   The guinea fowl were all part of the same flock.    The dogs have bloodlines from the same breeder and grew up together.    We were very careful to introduce the llama to the alpaca so that each had enough space to acclimate to each other.   We introduced the dogs one at a time to the alpaca, and separated the dogs from each other until they established a relationship through a fence.   The chickens and the guineas shared a two room coop for months until we opened the door and enabled them to interact.  They now roost with each other.

The end result has been a harmonious community at Unity Farm.  The photo above shows Shiro, our 83 pound Pyrenees puppy, sleeping with Stanley, our 106 pound alpaca "puppy".  The dogs and alpacas curl up together for warmth on cold winter days like today, when it's 6 degrees in the barn.

We're very satisfied with our community of animals and will be very judicious in adding more.   This spring and summer we are removing an old hot tub on the property and replacing it with a koi pond, engineered to stay partially unfrozen during the winter.   We may consider adding indian runner ducks 
once we have a small pond for them near the barnyard.

We will not add sheep or goats because they will bring unique diseases and parasites to the herd of llamas and alpacas.    Every expert we've spoken with has suggested that public health/population health management of barnyards is best when species diversity is limited.

That's our animal community.    Thus far, the citizens of Unity farm are thriving in it.

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Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules

On January 17, HHS released the Final Rule entitled: Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules

It's 563 pages long and contains 7 themes:

Covered entities must ensure that they obtain satisfactory assurances required by the rules from their business associates, and business associates must do the same with regard to subcontractors, no matter how far 'down the chain' the information flow

Increases penalties to $1.5 million per year

Tightens limitations on the use of patient records for marketing

Prohibits the sale of patient information without a patient's consent.

Provides patients with a right to insist that a provider not share their patient-care records with their insurance company if that care is paid for by the patient out-of-pocket in full.

Requires entities with patient record breaches to assess the likelihood that the information could be accessed in determining whether they must notify individuals of the breach.

Adds patient-safety organizations, health information exchange organizations and e-prescribing gateways to a specific list of HIPAA business associates liable under the rule. It also includes as business associates certain vendors of personal health records, those that provide a PHR to patients “on behalf of a covered entity,” but excludes other PHR providers, such as those working on behalf of consumers.

Much of the final rule is a restatement of requirements in ARRA/HITECH and GINA.   Generally the recommendations are very reasonable.   One challenging aspect of the final rule is the provision that provides patients with a right to insist that a provider not share their patient-care records with their insurance company if that care is paid for by the patient out-of-pocket in full.   At present this will be technically challenging to implement.   For example, if a patient pays for their outpatient treatment in cash and an e-prescription is generated, how do we flag the prescription to ensure it does not flow into a Pharmacy Benefit Management database?   If an inpatient hospitalization is paid in cash, how do we prevent a nurse case manager working for a payer from seeing any data related to that care episode?  Such data segmentation needs metadata around each data element so that data flows can be selectively restricted.   A great goal but definitely a work in process for which no products nor standards exist.

In the workplan for FY13 that I presented at the January HIT Standards Committee meeting, I highlighted the need for our workgroups to study standards supporting data segmentation for privacy, so hopefully we'll close this gap in the next year and have products in the marketplace which support such controls by 2014.

I know that many groups are hard at work analyzing the new rule, so I look forward to their wisdom.   The rule's 563 pages are rich with detail.

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One Degree of Separation

I have long believed that there is one degree of separation in the world of healthcare IT.   Everyone knows everyone and we're all connected in often amazing ways.   Here's one such story.

When I was in college, I looked at the daunting cost of Stanford tuition, room, board, and living expenses (almost $15,000 per year!) and thought that I should leverage the impending microcomputer revolution by writing tax computation software for early CP/M-based machines.   I did that from my dorm room (Kathy, my wife to be, wrote the manual).  As our "company" grew, I knew that I wanted to expand to other platforms, including mini-computers.   Only one problem - they were COBOL-based and I was not an expert in that language.  

I spoke with a few contacts in the accounting software industry and they referred me to a high school student in Davenport, Iowa who was writing financial applications as part of saving for college.

I contacted him and we agreed to a partnership.   My company would do sales, marketing, and support.   He would write the tax software for COBOL users.

Since I was born in Des Moines, Iowa and still had family in Iowa, I agreed to meet AR Weiler during one of my trips to visit my grandparents.   I recall meeting his parents and telling that I hoped our partnership would at least fund his college education.

The COBOL-based software sold a modest number of copies and was displaced by the emerging demand for MSDOS 1.0 applications when IBM introduced the PC and XT.   I dutifully sent checks to AR Weiler whenever COBOL software was sold.

I lost touch with AR but understood that he went to Harvard University and majored in computer science, presuming using the funds from his COBOL programming to partially fund his education.

After college he took a job with Oracle, working on several initiatives related to Japan.

Fast forward to 2013, it's 30+ years since I met AR in Davenport.

Last week, in response to my post about Consumer Electronics for Home Healthcare one of my colleagues forwarded information about an exciting new company, Healthsense,  that specializes in consumer sensors for home health applications including

Automatic fall detection
Emergency call pendant
Custom monitors designed for wandering, falls, or missed medication
Custom voice reminders for staff and residents
Activities of Daily Living (ADL) reports to track health and wellness indicators
Vital sign devices

I wanted to explore the company's senior management team.

Imagine my surprise when I found that the CEO was none other than AR Weiler.   His career since we worked together has included Emdeon, Ingenix, and Virgin Group.

It's truly a small world.

None of us can know exactly what will happen when we make choices and form relationships.  A partnership formed 30 years ago between a college student and a high school student somehow led to a convergence in healthcare IT.

Fate is a wonderful enabler.  Who knows what collaboration the future may bring.    Another important reason to continuously help those around you, since the person you empower today may be the person you depend on tomorrow.

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