phenomenalplace

In my recent blog about the Standards Work Ahead in 2012 , I called DICOM a non-standard standard. This generated numerous email messages, phone calls, and blog comments. Let me clarify what I meant. DICOM is a great standard that has unified many processes within organizations, linking radiology modalities and PACS systems. Why do I believe additional work is needed? In December, my wife visited a hospital near our home for a diagnostic mammogram. It was clear she needed followup care with a cancer care team. We decided that Beth Israel Deaconess would be ideal because of its electronic health records and personal health records that would help Kathy coordinate her care. We asked for the images to be transmitted to BIDMC and we were told that we needed to visit the radiology department Monday-Friday 9am-5pm for a CD to be created so that Kathy could drive is 20 miles to BIDMC. The CD contained a proprietary viewer that required Windows and hence was not visible on our home comp...

Last week’s State of the Union speech was notable because the President hardly mentioned the new health care reform law.Avoiding what is supposed to be the centerpiece domestic accomplishment of President Obama’s first term stuck out like a sore thumb.He said almost nothing because the Obama team simply doesn’t know what to say.The fact is the Affordable Care Act (ACA) is generally unpopular, and

I've written extensively about the challenge of implementing ICD10 and my belief that the billions of dollars required to implement it will not improve quality, safety, or efficiency. I've spoken to many people at HHS, CMS and the White House about the need to rethink the ICD10 timeline, deferring it until after Meaningful Use Stage 3  which enables us to focus on improving our clinical documentation and adopt   SNOMED-CT   to capture structured signs and symptoms. However, I've been told that the Affordable Care Act (ACA) includes cost savings from reduction in healthcare costs/fraud/abuse that require the implementation of ICD10.  Thus, it's not likely going to be delayed. At Beth Israel Deaconess, we're moving forward, assuming that ICD10 must be implemented by October 1, 2013.     We held our kickoff meeting in June, hired external resources to create a project management office, and hired subject matter expert consultants to assist with the gap analy...

As Harvard thinks about how best to enable authentication across multiple schools, organizations, affiliates and populations, it has choices to make - centralize all authentication, allow every group to pursue its own strategy, or coordinated federation that includes the best of centralized and localized approaches. Federated authentication requires a fabric of trust.   Among University collaborators, InCommon.org has been a leader in creating tools, technologies and policies that enables multiple groups within institutions and among institutions to share data based on role-based access.   It does not require organizations to issue unique credentials to every collaborator.  Instead it delegates authentication to trusted institutions and then creates an ecosystem of access built on trust relathonships. The underlying technology is Shibboleth . University collaboration via policies and technologies that support federated authentication.  That's cool!

We're halfway through the most challenging cycles of chemotherapy, Kathy has lost her hair,  and her fatigue is getting worse but her mood is still very positive. On Friday January 20th, Kathy received Cyclophosphamide (Cytoxan) 1200 mg, Doxorubicin (Adriamycin)  120 mg and her pre-chemotherapy supportive medications Fosaprepitant 150 mg, Dexamethasone 12 mg and Ondansetron 8 mg. She tolerated it well. Her Complete Blood Count shows that her Granulocyte Count has dropped from 6690 to 3610 since the chemotherapy affects her fast multiplying white cells as a side effect of targeting the cancer.   Her hematocrit has fallen from 42 to 32.   She tires more easily but her appetite is good.   Small frequent meals enable her to overcome any GI symptoms. We've been told that the Adriamycin/Cytoxan is the most difficult chemotherapy.  Only two more cycles to go. The photograph above shows Kathy and me at age 21 in our Stanford graduation photo.  She's always had...

The January HIT Standards Committee focused on the first quarter goals - Quality Measurement, NwHIN Exchange implementation, and Value Sets/Vocabularies. Doug Fridsma presented the HITSC 2012 Workplan and Updates from ONC .  Importantly, he outlined a comprehensive portfolio of building blocks (pictured above) that categorizes the work done to date and illustrates the work done in the future. Jim Walker presented the work of the Clinical Quality Workgroup including the scope of effort needed to support the quality improvement efforts of Meaningful Use. Doug and Betsy Humphreys from NLM presented an Update on Value Sets and Vocabulary Mapping including the work on "one stop shopping" for downloadable and web service addressable resources. Finally, Rob Anthony and Jessica Kahn from CMS presented an update on Meaningful Use activities including attestation achievements. A very important meeting that sets the agenda for FY12 and creates a foundation for our preparatory work on ...

Time is of the essence. In a contract this means that failure to complete the work by the agreed up deadline constitutes a breach.  Deadlines enable cost controls and ensure predictability.  In yesterday's post I talked briefly about Federal Engagement in Standards development.  One of the key phrases used in communication at the Federal level about their standards strategy is " Impatient Convener ".  There are a number of other activities where speed seems to be essential. A counterpoint to this focus on "speed" is doing it right. There is never enough  time to do it right, but there's always enough time to do it over.  -- Jack Bergman Make Haste Slowly - Anonymous Only that which is well done is quickly done. -- Augustus How do you balance the imperatives of time and quality?  In the three-legged triangle of project management, you must be able to balance resources, quality and functionality.  When any two are fixed, the other must be variable....

Every day, I receive over 1000 legitimate, business-related emails.   I've written about my email triage techniques  and the notion of handling each email only once . Over the past few months, the number of "business spam" emails has increased significantly.   Whether its the economy, the death of paper-based advertising, or availability of bulk email newsletter creation applications in the cloud, it's getting overwhelming - about 500 unwanted, but vendor related emails per day. Business spam is hard to filter since it represents professional communication from some of the largest technology companies on the planet.  I purchase products from many of these companies.  However, I do not want to receive any business spam from anyone. I have never purchased a product based on business spam.   In fact, the more business spam I receive, the less likely I will purchase products from advertisers filling my inbox. I've spent the past two weeks unsubscribing from e...

The following showed up in my inbox this morning. In general, I think this is great policy advice, especially the section on Agency Responsibilities starting at the bottom of page 3. What I'd liked to emphasize is this statement found on the middle of page 2: To accomplish these objectives, the Federal Government, as directed by Congress, is taking a convening role to accelerate standards development, by working closely with domestic and international private sector standards organizations. I work closely with SDOs, and I know what it means to do so.  I cannot give the Federal Government high marks here, although I have to admit that they've gotten better over the last year.  If they mean to sustain the good work going on in the S&I Framework activities, they'll have to do better.   The S&I  contracts will end, and that means someone will have to maintain the outputs. I hope we won't have another situation like the one where HITSP wound up orphaning documen...

The Blue Button idea is simple - a large visible button on payer, provider, lab, or pharmacy websites enables patients to download their records in plain text. The Veterans Administration has used it extensively.   The Office of Personnel Management asked all health insurance carriers in the Federal Employees Health Benefit Program (FEHBP) to add Blue Button functions to personal health record systems.  OPM administers health benefit programs for the civilian sector of the federal government, including all executive agencies, Members of Congress and their staffs, and the federal judiciary on their websites. The Blue Button is one of several models of health information exchange being implemented. I've summarized HIE models as: View - a website or web service enables authorized patients, providers or payers to view data in plain text or HTML.   A modest amount of programming is needed, but significant attention to security issues is important to protect the website...

With Kodak's bankruptcy filing  and Polaroid's bankruptcy/decline, is the stand-alone camera a thing of the past? At the Consumer Electronics Show this year, one camera product received a lot of press - a 360 degree digital imager from Tamaggo .   Taking an image with Tamaggo gives shows the environment you're in and the perspective you have at the moment.   I can visualize some amazing nature photography.  Imagine the 360 view from Dark Shadows one of my favorite rock climbs in Red Rocks, Nevada. Here's a YouTube overview of the product . A portable 360 degree digital imager for consumers - that's cool!

Most Health IT folks today are concerned about Meaningful Use for Stage 2, but they should also be concerned about stage 1 as well.   Under new Federal Regulation for meaningful use, it is certainly possible that the definition of stage 1 meaningful use can change.   As the Meaningful Use Standards final rule stated : The stages of criteria of meaningful use and how they are demonstrated are described further in this final rule and will be updated in subsequent rulemaking to reflect advances in HIT products and infrastructure. We note that such future rulemaking might also include updates to the Stage 1 criteria. The real question for many is what that will mean for vendors implementing products, and providers attesting to meaningful use at a particular stage.   For vendors, it is very clear that EHR products will need to be certified against the new criteria as soon as possible, because again, according to both the final rule for temporary certification  and for ...

I will suggest that most of us believe the way to control health care costs, and at the same time maintain or improve quality, is to both use the managed care tools we have developed over the years, and perhaps more importantly, change the payment incentives so that both cost control and quality are upper most in the minds of providers and payers.The Congressional Budget Office (CBO) has just

This week we completed the genetic sequencing that answered two important questions: *Should Kathy consider bilateral mastectomy? *Should our daughter, Lara, consider early mastectomy to reduce her lifetime risk of breast cancer? Here's how we asked the questions. On December 20, Kathy met with Genetic Counselor Kathleen Swenson to discuss the risk of hereditary Breast Cancer.  Kathleen wrote: "Note Date: 12/20/11 BETH ISRAEL DEACONESS MEDICAL CENTER CANCER GENETICS AND PREVENTION PROGRAM Risk of Hereditary Breast Cancer VISIT SUMMARY:  49yo with recent dx of breast cancer.  Blood was drawn today for BRCA1 and BRCA2 analysis.  Results expected in 2-3 weeks. ANCESTRY/RACE:  Korean/Scottish/Irish __ AJ  _X_ non-AJ Indication:  Recent diagnosis of breast cancer; limited maternal family history. Personal History              Family History __ None                     ...

Graham Grieve shot down my HTML5 + Microdata proposal Tuesday with a well-placed comment on the ease of writing micro-data [or actually the lack there-of]. I’m borrowing from Calvin Beebe’s suggestion (he’s an HL7 Structured Document Workgroup Chair) that there be a way to transform back and forth between formats to support some of the capabilities provided by HTML5 + Microdata, and still maintain the ease of writing (and validating) CDA documents in XML. While, I’m still convinced that we need to use HTML5 for the text portion of the document, and still really like what Microdata does for you with the document in the browser. But now I acknowledge that we will probably need to allow HTML5 and some RIM (or perhaps FHIR [pronounced Fire]) based XML representation of content. Whether it be RIM-based or FHIR-based, call it HL7 XML and lets move on. In order to resolve Graham’s issue though, I’ll need a way to translate back and forth between HTML5 + HL7 XML and HTML5 + Microdata. The...

This showed up in my inbox today... it is a long overdue and welcome change.  As I read it, it means that organizations that aren't contracting with the government can take advantage of the NwHIN in the US. A key goal of the HITECH Act is to enable the secure exchange of health information to improve health and care.  ONC, its Federal partners, and other stakeholders have been working through many programs to achieve this goal, including work on the nationwide health information network (NwHIN), the NwHIN Exchange, and the Direct Project.  Until now, participation in the Exchange has been limited to Federal agencies and outside organizations that have contracts, grants, or cooperative agreements with them.  However, with the evolution of both the NwHIN and the Exchange, ONC has determined that this limitation is no longer needed.   Participants who currently participate under contracts, grants, or cooperative agreements can continue in t...

Insurance exchanges have to be up and running in all of the states by October 2013 in order to be able to cover people by January 1, 2014.If the states don't do it, the feds have to be ready with a fallback exchange. States have to tell HHS if they intend to be ready by January 1, 2013.The White House just released a report saying that good progress is being made in 28 states. That begs the

In my recent post Work Induced Attention Deficit Disorder , several commenters asked how I stay focused and productive, speculating that I leverage my limited need for sleep. Although having a 20 hour day helps, the real secret is that I end each day with an empty inbox.    I have no paper in my office.    I do not keep files other than those that are required for compliance purposes. The end result is that for every document I'm asked to read, every report I'm ask to write, and every situation I'm asked to management, I only handle the materials once. What does this mean? In a typical week, I'm asked to review 4 or 5 articles for journals.   Rather than leaving them to be read at some later time or reading them then deferring the review, I read and review them the day they are assigned.    This enables me to read them once and write the review very efficiently since all the facts are fresh in my mind. I'm asked to review budgets for various grants, st...

Rene Spronk had a great post on the HL7 Affiliate Life Cycle a few weeks back.  Yesterday Catherine Chronaki displayed a simple slide based on that model at the HL7 Working Group meeting.  While Rene talks about it from an HL7 Perspective, I think about it from a national perspective.  There are essentially five levels in Rene's model: Raising Awareness Creating Consensus Based Localization Paid Development Official Endorsement Standards Collaborative So far, only Canada is at level 5.  The US through Meaningful Use is sort of at level 4 for endorsement of HL7 standards, and the ONC S&I Framework is certainly a level 2 activity, if not officially acting as an HL7 Affiliate. The S&I Framework contracts (there are at least 10) will eventually end.  There are a lot of activities which have produced outputs that still need maintenance (e.g., the Clinical Element Data Dictionary).  One of the tasks for the S&I Framework is to establish a long term...

Although my business cards and my CV list the title Chief Information Officer, I was given the title Chief Medical Information Officer (CMIO) when I was hired at BIDMC in 1998.   Today, I serve three kinds of roles: CIO - Responsible for strategy, structure, staffing, and processes for a 300 person IT organization CTO - Responsible for the architecture of our applications and infrastructure, ensuring reliability, security, and affordability CMIO - Responsible for the adoption of the applications by clinicians, optimizing quality, safety, and efficiency in their workflows Although I've been able to balance these three roles because of the extraordinary IS staff at BIDMC, good governance, and a supportive CEO, it's challenging for one person to perform all these tasks.  Many hospitals and health systems are expanding their management team to include a CMIO. Here are a few thoughts about the role of the CMIO. *Clinical applications are only as good as the processes they automate....

Tonight I thought I would write a little script to black out this site on January 18th in protest against proposed US SOPA legislation. After about 5 minutes of research, I found the work that someone else had done and freely shared on the Internet.  This is all it takes: <script type="text/javascript" src="http://js.sopablackout.org/sopablackout.js"></script> If you are running Blogger (as this site is), you can simply insert this code inside an HTML Widget that appears on your blog page on January 18th, and take it down later. Feel free to pirate this page for your own use.

I've been reading quite a bit about all of the consumer oriented mobile health apps that have shown up lately.  There's been a lot of buzz around this especially given the recent Consumer Electronics Show that just concluded (thankfully).  There's also been quite a bit of discussion about a recent mobile health app that works with Health Vault. All these apps are simply creating new mobile silos of information, or worse yet, requiring us to go through some third party cloud storage in order to manage and view it.  I want my damn data and I want you to give it to ME so that I can analyze it.  It's my health.  Let me do with the data what I want easily, without having to hack my tablet , or use your website.  At the very least, give me the ability to export the data to a spreadsheet. Patients (and consumers) want to use a variety of different applications.  We want to be able to collect that data and do stuff with it.  Right now, I've got two separa...

I have an iPhone 4S and to conserve power, I've turned off WiFi, location services, and Bluetooth. Nonetheless, with my volume of email, I cannot get more than 12 hours of use from an iPhone.   I charge it overnight, use it during the day, then begin recharging it as soon as I get home. QYG has a solution - a thin iPhone 4S protective case that contains a lightweight flat battery which doubles battery life. Several of my staff members use these and note that the mini-USB port can be used with a standard USB cable to charge the battery. A lightweight, protective case that doubles the battery life of an iPhone - that's cool.

Chris W. brings up  Blue Button  on the  Ask me a Question  page, and a few weeks ago it popped up again into my radar screen.  In case you've been in hiding for the past year, Blue Button is the name of a VA initiative to enable vets to download their clinical information in an ASCII text format from the VA patient portal MyHealtheVet .  It's based on a Markle Foundation specification which has gotten quite a bit of attention . Recently the Office of Personnel Management sent a letter   to health plans participating in the Federal Employee Health Benefit Program (FEHBP).  I found an interesting quote in the letter (I underlined the interesting part): Supplying your members with the simple, low-cost and readily available Blue Button  function will strengthen your contractual HIT obligations under FEHBP, align with the  Meaningful Use standards laid out by Health and Human Services (HHS), and most  importantly, empower your mem...

Today, the Department of Health and Human Services announced that, "Trustmark Life Insurance Company has proposed unreasonable health insurance premium increases in five states—Alabama, Arizona, Pennsylvania, Virginia, and Wyoming. The excessive rate hikes would affect nearly 10,000 residents across these five states."The HHS statement continued, "In these five states, Trustmark has raised

This week, we learned about the reality of chemotherapy. On Friday, Kathy received her first cycle of Cytoxan and Adriamycin, a few days ahead of the schedule I posted on my blog last week .  I drove her to BIDMC.  We checked into the ambulatory Heme/Onc clinic and she was given a warm pack to increase circulation to her hands.  The lab staff drew a Complete Blood Count (CBC) via a finger stick to avoid creating punctures in her veins, given that her chemotherapy medications are vesicants that cause a chemical cellulitis if they leak into tissue. The CBC was excellent - a white count of 10 and an hematocrit of 41.   We'll follow this closely as the chemotherapeutic agents affect her white blood cells. Her remarkable nurse, Dianne Holland-Sullivan, spent time getting to know us, then expertly inserted an IV without any issues. I promised to reflect on the BIDMC electronic health record in describing Kathy's care. All of her providers share data among themselves and ...

I read every comment posted to my blog and do my best to learn from the wisdom of the community.   Two comments made about my recent post Honey or Vinegar deserve special highlight. Tony Parham posted a comment comparing Management and Leadership, quoting the work of John Kotter and Colin Powell.  "MANAGEMENT: Control mechanisms to compare system behavior with the plan and take action when a deviation is detected. LEADERSHIP: Achieving grand visions. Motivation and inspiration to energize people, not by pushing them in the right direction as control mechanisms do, but by satisfying basic human needs for achievement, a sense of belonging, recognition, self-esteem, a feeling of control over one's life, and the ability to live up to one's ideals. Such feelings touch us deeply and elicit a powerful response." - John P. Kotter, Professor of organizational behavior at the Harvard Business School “LEADERSHIP is the art of accomplishing more than the science of MANAGEMENT say...

2013 may be the most significant year in health care policy ever.But we have to get through 2012 first.Once the 2012 election results are in there will be the very real opportunity to address a long list of health care issues.If Republicans win, the top of the list will include “repealing and replacing” the Affordable Care Act. If Obama is reelected, but Republicans capture both houses of

Logistic Growth Curve (courtesy of Wikipedia) Students of economics will likely be familiar with the logistic growth curve.  The curve has been used to model population growth, in modeling of stochastic processes and  adoption of new technology . The early part of the curve is nearly exponential in the early stages, then moves to linear, and finally into exponential decay. Recently, HHS released data on Meaningful Use attestations (through November of last year) on Data.gov . Brian Ahier posted a couple of extractions from this data earlier today.  The data includes the following elements: Variable Name Definition Vendor Name Name of EHR vendor EHR Product Name Name of EHR product EHR Product Version Version of EHR product Product Classification Whether product meets all Meaningful Use requirements (Complete) or meets only part of the Meaningful Use requirements (Modular) Product Setting Practice setting for which...