Tuesday, January 31, 2012

Radiology Image Exchange

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 computers (all Mac OSX).

What would have happened in an ideal world?

1. An implementation guide for DICOM would specify required vendor neutral content - a basic set of metadata (patient identifiers, name of the radiology study, imaging techniques used etc.) that would work with any viewer - Siemens, Agfa, Philips, GE, Kodak, etc. Any vendor specific/proprietary metadata would be stored separately from the required basic content, so that extensions do not impact generic viewers. CDs with proprietary viewers and media formats should become a thing of the past.

2. DICOM combines content and transport in a single standard. Although that is create for communication within an organization, it is not sufficient for a healthcare information exchange world that uses the Direct implementation guide (SMTP/SMIME, XDR) for content exchange among organizations. The fact that vendors such as LifeImage, Accelarad, and Merge Healthcare have created their own image sharing networks suggests that more standards work is needed to create an open ecosystem of image sharing among organizations.

3. We should not require organizations who want to receive images to have PACS systems. Instead, EHRs with vendor neutral DICOM viewers should be able to incorporate DICOM content sent via Direct into patient records.

Thus our work on imaging standards should build upon the DICOM foundation we have today, but eliminate optionality for a basic set of metadata, ensure that any proprietary extensions to metadata do not interfere with vendor-neutral viewing, embrace simple transport approaches for cross organizational exchange, and enable even the simplest of EHRs to be participants in image exchange.

We'll do this work in the Healthcare IT Standards Committee from April to June, engaging the industry experts who have worked so hard on DICOM to date.

I hope that makes sense!

Monday, January 30, 2012

The New Health Law Needs to Be Repealed, Expanded, and Replaced—So Long As It Doesn’t Have a Mandate

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

Update on the BIDMC ICD10 Project

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 analysis, project plan and budget.

Today, I'm posting two resources for the benefit of other organizations planning their ICD-10 projects.

The first is the RFA we used to hire a consulting partner.   In our case, we elected to create a single unified project for the academic medical center, community hospitals, physician organization, faculty practice, and owned community practice.   We felt that creating one project for all the stakeholders would reduce costs while eliminating redundancy and aligning resources.

The second is the letter we sent to all our stakeholders, asking them to create an inventory of the software applications and processes that incorporate ICD9 and need to support ICD10.

In the next few weeks, we'll complete our detailed project plan, budgets, staffing model, and timeline.    I'll share as much as I can as soon as it is available.

ICD-10 is a costly project that will have no benefits and if we're truly successful, the best we can hope for is that no one will be too upset that we implemented it.

Given a project with this many negatives (here's the AMA letter to Speaker of the House John  Boehner), the least I can do is share everything we're implementing in the hopes that others will benefit from our experience.

Friday, January 27, 2012

Cool Technology of the Week

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,
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!

Thursday, January 26, 2012

Our Cancer Journey - Week 6

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 long, luxuriant hair, even a waist length braid at one point.

On January 21st, her hair began falling out in clumps.   It was not exactly painful, but felt very odd, as if her hair had not been washed in months and just did not lie on her scalp properly.   In consultation with her cancer survivor friends, she decided to shave it off.    Her hairdresser gave her a "GI Jane" cut realizing that the small hairs left will fall out soon, but in a more manageable and comfortable way.    I seriously considered shaving my head in solidarity, but she asked me not to.

She's wearing wraps and hats to keep her head warm in the chill of winter.   The colors and shapes of her hats give her an artistic and vibrant look.

Dropping blood counts, lack of energy, and no hair may sound depressing.   How have we supported her mood?

She's avoided caffeine, alcohol and mood related medications.  Instead she's remained positive because of the weekly activities we've planned and the future we're designing that goes beyond the statistics of 5 year survival rates.

In my professional life, I've written extensively about SOAP verses REST as standards for transport.   In my personal life, Kathy and I have explored SOAP as Rest via a course on traditional soap making from Back Porch Soap.   We've really enjoyed the art and chemistry of saponification, creating our own cold process soaps.

Although we're put our thoughts about Vermont farmland on hold, we've continued to think about how we can move to a more rural location which enables us to plan a long term life together raising  vegetables and animals as part of self sufficiency, a lower carbon footprint, and sustainability.  This dream of the future creates a guiding vision for fighting the cancer.

Finally, an interesting experience from our role as patients.   Kathy has received her care in the middle of the X12 5010 transition which required every payer and provider to change their billing systems.   Purely as a side effect of a payer eligibility error during the conversion, she received an $18,000 bill for her care to date.   It was remedied quickly, but it illustrates the events that can occur while navigating healthcare in the US.

Wednesday, January 25, 2012

The January HIT Standards Committee Meeting

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 Meaningful Use Stage 3.

Tuesday, January 24, 2012

Balance is of the Essence

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.

According to the triangle inequality (|A| + |B| > |C|), there are collections of triangle sides that don't work.

We (standards professionals) have to be careful with how we address issues where time is of the essence.  A failure to meet the deadline is certainly a problem, but even worse would be a failure to deliver on quality or worse yet, to deliver something that doesn't add the necessary value.

What is truly essential to success is balance.

Preparing for a Wall of Shame

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 every newsletter, every mailing list, and every advertising campaign.    It's challenging because companies send their advertising content to multiple variations of my email address - jhalamka, john.halamka, john_halamka at multiple variations of my domains, requiring me to unsubscribe more than 5 times in some cases.

Even more irritating are the unsubscribe functions that do not enable one click unsubscribe and require that type in your email address - how do I know what variation of my email address they used?

After a few weeks of unsubscribing as fast as I can, I'll post a list of those companies that are causing me to click delete so many times per day that I'm getting a repetitive stress injury.

I have never opted in to any business spam, so some of these companies have sunk to new lows with fine print such as  "we're sending you this email and unless you unsubscribe, you've opted in to our future email".   Even unsubscribing does not work because you are often opting out of a single marketing campaign and not all future communications.

The best I can do is create my own blacklist of these companies.   Coming soon, the Geekdoctor Business Spam Wall of Shame!

Monday, January 23, 2012

On Principles for Federal Engagement in Standards Activities to Address National Priorities

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 documents that were the result of more than 100,000 hours of community expertise.  We really do need to figure out how to get to level 5 in this country.

Another Shade of Blue Button

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 and data sources.

Push - an EHR sends data to another EHR via the Direct standard.   Since this is secure email, a modest infrastructure investment is needed to create directories, certificate management, and gateways.

Pull - an EHR queries a master patient index/record locator service to identify a patient and the locations of their records.   The EHR then queries all the data sources to assemble a comprehensive medical history.   NwHIN Exchange is an example of such an approach.   Significant infrastructure must be built to support and maintain a pull architecture.

Since Push and Pull models require HIEs, which are still evolving, some organizations, including BIDMC and its affiliates have temporarily implemented View approaches inside Epic, Meditech, eClinical Works and self built applications.

Here's how it works:

1.  The clinician clicks on a button inside their EHR.   This click launches a query containing Name, Gender, Date of Birth, and Zip Code to a responding EHR.    The physician does not need to respecify the patient or log in to a separate portal since the patient identity information and security credentials are sent from the querying EHR automatically.
2.  The responding EHR checks the security, looks up the patient, and responds with a medical record number if the patient is found.
3.  The querying EHR sends a new query incorporating the returned medical record number.
4.  The responding EHR launches a web-page which displays clinical data for that medical record number.
5.  All transactions are audited in the responding EHRs.

Since this approach works like magic, requires no HIE, and is fast/inexpensive to implement, our clinicians have described it as the "Magic button"

In effect, it serves as a web-based single sign application that retains patient context and enables clinicians to view data from any EHR that adheres to the Magic button implementation guide.

We see it as a temporary solution because it does not result in persistent exchange of  semantically interoperable data.   It simply enables a clinician to see data such as problem lists, medication lists, allergies, labs, radiology studies, EKRs, reports, and notes in remote systems without requiring a lot of training. It's better than having silos of data and sending faxes.

As HIEs come on line, push and pull models will enable the same kind of data exchange but will incorporate data from sending EHRs into receiving EHRs, enhancing workflow and improving the integrity of the record.

One other problem with the Magic button is that it does not scale very well - we now have buttons for Atrius, Needham, Milton, and eClinicalWorks practices.   Clinicians ask the patient where they've received care, get their consent to view the data, and click on the appropriate magic button.  As we add more affiliates, the number of Magic buttons will be hard to manage.

In future pull models, record locator services will keep an index of all the locations where patients have consented their data to be accessed.

But for now, having a kind of Blue Button that enables clinicians to view each other's records with patient consent is truly magic for those who use it.

Friday, January 20, 2012

Cool Technology of the Week

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!

Thursday, January 19, 2012

New MeaningfulUse Rule will likely impact Stage 1 Criteria

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 permanent certification:
Regardless of the year and meaningful use stage at which an eligible professional or eligible hospital enters the Medicare or Medicaid EHR Incentive Program, the Certified EHR Technology that they would need to use would have to include the capabilities necessary to meet the most current certification criteria adopted by the Secretary at 45 CFR 170 subpart C. 
When Stage 2 becomes effective (anticipated for 2014), providers will need to upgrade to EHR technology that is certified to that criteria, regardless of whether they are attesting to Stage 1 or Stage 2 of Meaningful Use criteria.  The new incentives rule will contain criteria defined for those organizations who are a “Stage 1” Meaningful User and for those who are a “Stage 2” Meaningful User.  Stage 2 users will have more criteria to attest to, and for those capabilities already existing in stage 1, a higher degree of use of those capabilities (e.g., A higher percentage of orders performed electronically at stage 2 than stage 1).  Regardless of whether they are at Stage 1 or Stage 2, both kinds of organizations will have to use EHR technology that has been certified to support the Stage 2 criteria.  

The table below shows the current Stage 1 standards and the stage 2 standards that I’m currently projecting for the new Meaningful Use Standards rule.

Stage 1
Stage 2

January 2011 – December 2013
January 2014 – ?
Implementation Guide
Implementation Guide
Generating a Clinical Summary
CCD 1.0
HITSP C32 V2.5
CDA R2.0
CCD 1.1
(Stage 1)

CDA Consolidation Guide (Stage 2)
Viewing a Clinical Summary
Both CCR and HITSP C32 V2.5
CDA Consolidation Guide, CCR and HITSP C32 V2.5
HL7 V2.3.1
CDC 2.3.1 Guide

HL7 V2.5.1
CDC 2.5.1 Guide
HL7 2.5.1
CDC 2.5.1 Guide
Public Health Lab Reporting
HL7 V2.5.1
ELR Guide

ELR Guide and/or updated LRI Guide
Disease Surveillance
HL7 V2.3.1
No Guide Selected

HL7 V2.5.1
HL7 V2.5.1
PHIN Guide

The new certification criteria for Stage 1 and Stage 2 will almost assuredly require use of new standards, and some standards previously acceptable will be dropped.  The biggest challenge for many will be the change from CCR/HITSP C32 V2.5 to CDA® and the CDA Consolidation Guide, and that is what this post will focus upon.    The key question is how systems conforming to the new standards will address the issue of the legacy data stored using either CCR or the HITSP C32 2.5.  

Fortunately, ONC cleverly created two separate criteria for the clinical summary.  The first was generating (and subsequently transmitting) an electronic summary.  ONC allowed two formats for that capability: CCR or the HITSP C32 2.5, of which a provider need choose only one (but could support both).  However, all systems must support viewing both (and need not do any more than that).

In order to support viewing of legacy documents, I fully expect that the new certification criteria will require certified systems to support viewing of legacy content.  I also expect it to support viewing of any document found in the CDA Consolidation guide.  With the exception of the Unstructured Document, viewing is not a challenge.  IHE implementers have learned over the years to sign up for the “Content Consumer” actor for all PCC Profiles of the HL7 CDA if they can support content consumer for ANY document because you get it nearly for free.  Most implementations transform CDA to HTML or XHTML and display the results.  A good stylesheet handles all bontent equally well.  Thus, it is reasonable to ask these systems to support viewing of any CDA based content under the new certification criteria.  If you can view one kind of CDA document using an XSL stylesheet, you should be able to view many.  There are numerous sources of code for CDA stylesheets freely available. 

The Unstructured Document in the CDA Consolidation guide needs more work for viewing but there are plenty of viewing technologies available to support its requirements as well.  There's another whole post that I will devote to that topic.

On the creation side, I expect that systems must be able to create content using the CDA Consolidation Guide.  A stage 1 meaningful user might only be required to generated CCD 1.1 documents, but a Stage 2 user might be required to support not just CCD 1.1 but could be permitted or even required to generate other document types in the CDA Consolidation Guide (e.g., discharge summary).

Where backwards compatibility becomes a problem for organizations that are exceeding the meaningful use requirements, such as the Beacon programs.  Those organizations have been working with CCD 1.0 and will now need to support CCD 1.1.  That is one of the penalties of getting out in front.  The key for those programs will be adapting their technology that uses the HITSP C32 V2.5 to use CCD 1.1.  It may be a PITA, but this is really not a hard challenge. 

Given the origins of CCD 1.1, it should certainly be feasible to transform from CCD 1.0 to CCD 1.1 automatically.  While there are some incompatibilities between the two versions, a valid HITSP C32 Version 2.5 will almost certainly transform into a valid CCD 1.1 for the purpose of importing, reconciliation, et cetera.  The transition to CCD 1.1 even prior to its adoption as a certification requirement could be done within the context of the single system that makes use of it, enabling innovators to take advantage of it before it becomes a requirement.

Shortly HL7 will be releasing the latest CDA Consolidation template database, and the Model Driven Health Tools project will be releasing a version which includes the CDA Consolidation rules.  Those two model driven tools will provide engineers (including me) with a lot more information than we’ve ever had previously to make the transition to the new format easier.

-- Keith

Important Research From Medicare Demonstration Projects: Almost Nothing Works

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

Our Cancer Journey - Week 5

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
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                       _X_ None
_X_ Breast Cancer; Age 49     __ Family Hx Breast
__ Ovarian Cancer; Age        __ Family Hx Ovarian
__ Colon Cancer; Age          __ Family Hx Colon
__ Other                      __ Family Hx Other

Risk Assessment:  49yo at age of diagnosis; premenopausal. Limited family structure on maternal side of the family limits risk assessment.

Counseling - We discussed the following issues:

_X_ Sporadic vs. hereditary cancer

_X_ Autosomal dominant inheritance

_X_ BRCA1/2 & cancer risks (breast, ovary, and other)

_X_ Risks, benefits and limitations of genetic testing

_X_ Possible Results and implications

_X_ Practicalities of testing (timing, costs)

_X_ Insurance/discrimination concerns

_X_ Testing is most informative with a known mutation in family; importance of sharing information

_X_ Testing is more informative when the first relative tested is an individual who has had cancer

_X_ Medical management options (increased surveillance, chemoprevention, and prophylactic surgery)

Implications of a Positive result (for patient and family):  Management as appropriate; implications for first degree relatives.

Implications of a Negative result (for patient and family):  Likely sporadic cancer.  No further testing indicated at this time.

Other Notes:  Kathy is a lovely woman who is an artist and owns a gallery in Boston's South End.  Her husband works here at BIDMC.    Kathy felt that it was important and ideal to have this information for the purpose of having a complete picture when it comes to determining her care plan moving forward.  There is very little information regarding the maternal family history and limited family structure as she is an only child.  We discussed testing in detail, including the issue of variants of uncertain significance.  BRCA1 and BRCA2 comprehensive analysis was ordered, as was BART analysis for completeness.  I will notify Kathy upon receipt of her results as well as the physicians caring for her."

This week,  we received the report

"Ms. Halamka was seen previously and elected to proceed with genetic testing for BRCA1 and BRCA2.  Results are NEGATIVE.  No mutations were identified in either of these genes.  Both comprehensive analysis and BART analysis was completed."

Thus, her cancer is environmental and not the result of specific BRCA mutations.   She will not need to consider bilateral mastectomy at this time.   We explained the results to our daughter and she will follow whatever best practice is recommended for standard breast cancer screening over her lifetime.

Since Kathy will lose her hair next week, we purchased a simple wig in addition to the hat and head wrap we bought last week.

Finally, Kathy has begun to have gastrointestinal symptoms .  Small, frequent, bland meals work. Anything else causes abdominal discomfort and mild pain as the rapidly dividing cells in her GI tract begin to die as a result of chemotherapy.

Tomorrow, we return to BIDMC for Cycle 2 of Adriamycin/Cytoxan.   Kathy was very strong and rested when she started Cycle 1.   For Cycle 2, she'll be a little weaker.

Every week has its positives and negatives.   Knowing that her cancer is environmental and not genetic is this week's good news for Kathy and our family.

Wednesday, January 18, 2012

Microdata Shot Down but still flying for CDA

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 only thing I can count on being in common between FHIR and another HL7 XML format is that they are XML, so I’m just going to work on Microdata to XML and back transformation.

Here is some of my initial thinking on the transformation:

  • The transformation may be guided by an XML schema, but this is not a requirement.
  • Transformation to Microdata and back should be possible.
  • The itemprop attribute represents the name of the element or attribute. When the value of itemprop begins with an @ character, it will be represented as an attribute in the XML. When it begins with any other character it will be represented as an element. Since @ isn’t a legal name start in XML, this seems like it should work.
  • The itemtype attribute must represent the Schema type of the element or attribute in the form URL#typename, where URL is the namespace URL associated with element or attribute in the schema, and the typename is the name of the complex or simple type in the schema.
  • When there is no namespace URL associated with the Schema, the URL shall be TBD.
  • Properties which are represented in the XML as attributes are given names of the form: @name where name is the attribute name.
  • An attribute can be assigned more than one property value if its schema simple type is defined using
  • Properties which are represented in the XML as elements are given names of the form: name where name is the element name.

What is cool about this transformation is that I also get (for free), a JSON and RDF interpretation along with the Microdata representation of the machine readable metadata.

Associating an XML Document with an HTML 5 element as microdata without an Schema is pretty easy. You traverse the DOM of the XML Document an:
  1. Start with the HTML 5 element to which the XML document is to be associated as Microdata.
  2. Add itemscope to the HTML 5 element.
  3. Add itemprop to the HTML 5 element using the name of the element.
  4. If there is an xsi:type attribute associated with the element, set the itemtype to be the namespace URL for the type, followed by # followed by the type name.
  5. For each attribute of the element, add a new item to the item associated with the HTML 5 element. That item will have an itemprop value of @ plus the attribute name. Set itemValue to be the value of the attribute.
  6. For each child element, add a new item to the item associated with the HTML 5 element. Recurse at step 1 above.
There are some details still to be worked out, like the tricky bits of Schemas without a namespace (because the itemtype would become #typename), but  not to hard even for a freshman programming project.  Reversing this transformation is just little bit harder, but not impossible. I’ll be working out the details a bit later this year, and leave it as an exercise for the reader until then.  If you figure it out, do let me know.

NwHIN open to Non-Federal Partners

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 that capacity, and when those formal relationships expire, their signature on the Data Use and Reciprocal Support Agreement (DURSA) is sufficient (along with other specified requirements).  New entities wishing to join need only sign the DURSA and fulfill other requirements.  This is effective immediately,  and the number of new participants is expected to grow steadily over the course of 2012.   This is an important step in supporting wider health information exchange for Meaningful Use and broader national goals for better health and health care. 

Mary Jo Deering, Ph.D.
Senior Policy Advisor
Office of the National Coordinator for Health Information Technology
U.S. Department of Health and Human Services
300 C Street, S.W., #1103
Washington, DC 20201

Will the Feds Be Ready With the Fallback Insurance Exchanges by October 2013?

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

Only Handle It Once (OHIO)

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, state, and local projects multiple times per week.   I read the budget, ask questions while the numbers are at my fingertips, and await responses.

In my 1000+ emails each day there are 10-20 that require detailed responses.   I leave these to the end of the day when I know I'll have uninterrupted time.   I write the responses and send them while all the details of the issues are clear to me.

Paperwork does occasionally find its way to my desk.  Since all payroll and all purchasing functions are electronic at BIDMC, the paperwork I have to do is mostly for externally regulatory agencies.    I read the paperwork, answer everything, and give it to my assistant to package and mail.

Each day I'm asked to find time for calls, meetings, lectures, travel, and special events.   I look at my calendar in real time and respond with availability - making a decision on the spot if I can or cannot participate.

The end result of this approach is that I truly only handle each issue, document, or phone call once.   It's processed and it's done without delay or a growing inbox.   I work hard not to be the rate limiting step to any process.

Yes,  it can be difficult to juggle the Only Handle it Once (OHIO) approach during a day packed with meetings.    Given that unplanned work and the management of email has become 50% of our jobs, I try to structure my day with no more than 5 hours of planned meetings, leaving the rest of the time to bring closure to the issues discussed in the meetings and complete the other work that arrives.  It's the administrative equivalent of Open Access clinical scheduling.

It's tempting, especially after a long and emotionally tiring day, to break the OHIO principle.   However, doing so only removes time from the next day and makes it even more challenging to process the incoming flow of events.

One last caveat.   OHIO does not mean compromising quality or thoughtfulness.  Simply passing along issues to others without careful consideration does not increase efficiency.   I focus on doing it once to the best of my ability.  For larger projects, I use my "handle it once" approach to set aside a defined time on the weekend when I can do them in one sitting.

OHIO - give it a try and see if the free time it creates enables you to regain depth and counter the evils of work induced attention deficit disorder.

Tuesday, January 17, 2012

A National Standards Maturity Model

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:

  1. Raising Awareness
  2. Creating Consensus Based Localization
  3. Paid Development
  4. Official Endorsement
  5. 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, public-private mechanism to sustain these activities, which could push the US to level 5.

When I think about all the national standards activities impacting the US:

  • S&I Framework (US Localization)
  • IHE USA (US Deployment and Testing)
  • SCO (National Coordination)
  • US TAG to ISO TC215 (International Coordination)
  • HIMSS Interoperability Workgroup
  • NCPDP (eRX)
  • X12N (Insurance and Payment)
  • NeHC (Education)
And several of the International ones:
It becomes pretty clear that we need a US Standards Collaborative.  Here are some of my thoughts on it from two years ago.

The Role of the CMIO

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.   Automating a broken process does not make it better.  Clinician stakeholders working with a CMIO should re-engineer workflows, document requirements, then begin software implementation.  

*Achieving consensus among clinicians is challenging.   Medical education is an apprenticeship that is part art and part science.   It's unlikely that one automated best practice, care plan, or guideline will be acceptable to everyone.   The role of the CMIO, as a trusted practicing clinician, is to create consensus around software configuration and decision support rules.

*Selecting new applications can be a daunting experience.   Integrated or interfaced?  Complete or modular? Best of suite or best of breed?   What may be the best solution for a department may be less than optimal for the entire institution.   The CMIO can weigh the pros/cons, cost/benefits, and the overall  integration into the enterprise portfolio during application selection.

*Nothing is perfect and clinical systems implementation will always be a journey, balancing compliance, security, ease of use, automation of manual processes, and safety.  Clinicians have constantly evolving needs and they will frequently feel that the IT organization does not have the supply to meet their short term demands.   The CMIO can run processes which engage clinicians in priority setting and resource allocation decision making.    Although the projects they want will likely be done at a slower pace than they'd prefer, they will understand the balance of time, resources, and scope because they were involved in creating the plan.

*Often, there are no right answers in clinical IT.   Given fixed time and resources, what is the top priority - Meaningful Use, ICD-10, healthcare reform, Joint Commission mandates, or quality improvement agendas?   Some may answer, all of them.   The CMIO can advise senior management how to phase an endless stream of projects so that the greatest good is done for the greatest number over the long term.

Who should the CMIO report to?  Choices include the CIO, the CMO, the COO, the CEO, or some governance group i.e. the Medical Executive Committee.     Every organization is different and the reporting relationship should be a function of where the CMIO can have the greatest impact, visibility, and support.

In my view, Meaningful Use, increasing demands for clinical workflow automation, and healthcare reform necessitate that every hospital larger than 50 beds have a  full or part time designated CMIO.    Given the daunting array of clinical IT requirements over the next 5 years, CMIOs will be increasingly important.

Sunday, January 15, 2012

Blacking out for SOPA Script

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=""></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.

Friday, January 13, 2012

Give it to ME

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 separate apps, one to track my weight, and the other to track my blood pressure.  In order to see the impact of one on the other, I've got to go through quite a bit of gyration just to put it together in one place.

Cool Technology of the Week

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.

Thursday, January 12, 2012

Blue Button

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 members to know their health information and make informed choices based on that information. 
According to the letter, you would assume that you could download the records in the electronic standard formats suggested by HHS under Meaningful Use.  But wait, the Blue Button specification is just ASCII text.  It doesn't follow that standard at all, and many provider and payer organizations have already implemented according the HITSP C32 Version 2.5 (one of the two allowed standards under Meaningful Use Stage 1).  Sometimes I wish the left hand and the right hand would communicate a little bit better.

Chris's main point is this (and I quote):
... it occurs to me that the effort is promising (for the intended use cases) precisely because of the standardization that HL7 has been driving behind the scenes. That is, the tag sets and value formats (and vocabularies) will have a fairly high level of consistency across organizations right out of the box because of their prior work on adopting a variety of standards internally, and especially HL7 standards
In fact, there's an HL7 project which is working its way through channels to create an XSL Stylesheet that will translate the semantically interoperable, Meaningful Use conforming HITSP C32 into the Blue Button format. Structured Documents approved it today, and it goes next to the steering division and then the TSC for final approval.

The scope of the project is to:
... produce a sample XSLT schema and background text on usage that will transform a CDA R2 CCD file into a U.S. Department of Veteran Affairs (VA) Blue Button ASCII text file. 
It's likely going to have to make some sacrifices to fit within the specifications required for Blue Button, because there's more that you can say and do in CDA and CCD that Blue Button accounts for.

From my perspective, Blue Button is beneficial to patients, but not as big a step forward as it could be.  (my S4PM friends may want to disown me for saying so, but hey, that's the way I feel).  I'd much rather spend my energy on CDA Release 3 and HTML 5.

Given the importance of this project, I will be paying attention to it, and Chris is so right.  Because of all the work that has already been done in CCD, this will be pretty easy.  I just wish I could get some focused time on what will really move things forward.

I Hope Trustmark Tells HHS to Go Pound Sand

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

Our Cancer Journey - Week 4

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 with Kathy.    Here's a view of Kathy's electronic profile, showing her problem list, medication list, allergies, appointments, labs, and social history (yes, we've been together 33 years from age 17 to age 50).   She's given full consent to share this data publicly as it illustrates the importance of an electronic health record for care coordination.

She can view the same data via her personal health record.   The only difference is a few delayed staging results to ensure patients and doctors speak about cancer diagnoses before the data appears on the web.

All of Kathy's chemotherapy orders were written electronically via the BIDMC Oncology Management System.     Humans do not dose chemotherapy, computers calculate everything based on protocols that humans maintain based on clinical trial evidence.    In Kathy's case, the oncologists designed and made the clinical decision to place her on the "Breast Oncology - CA - Dose Dense" care path.

The computer wrote these orders for her based on her height, weight, age, kidney function, and allergies.

The dedicated chemotherapy pharmacy in the heme/onc clinic prepared the medications, bar codes them, and delivers them to the chemotherapy nurse.    Two chemotherapy nurses validated the medications, the dose, and the patient using bar coded patient wrist bands and verbal confirmation from Kathy.   An automated medication admission record recorded when the chemotherapy agents were administered.

Kathy first received three pre-medications:

Fosaprepitant - an anti-nausea drug
Ondansetron - an anti-nausea drug
Dexamethasone - a steroid to reduce inflammation and synergistically work with Odansetron to prevent nausea

She also received 500cc's of normal saline as supportive hydration during chemotherapy.

After pre-medication, Dianne pushed 118mg of Adriamycin (doxorubicin) via two syringes over a few minutes.

She then administered 1180mg of Cytoxan (cyclophosphamide) over 45 minutes.

During the medication delivery, Dianne stayed at Kathy's side to discuss side effects, the rationale for the treatment, the likely events to follow medication administration, and the planning for the additional cycles to come over the next 8 weeks.    I provided Kathy with a banana, almonds, water, and companionship.

After chemotherapy, we headed home.  Kathy took .5mg of Ativan in the evening as directed to help her sleep.

On Saturday, Kathy felt fine - we walked a few miles around Lake Waban, prepared meals, and shopped together.   We drove into Boston for a subcutaneous dose of Neulasta (Pegfilgrastim), a white blood cell stimulant to bolster her ability to fight infection as the chemotherapy kills her white blood cells.   She took a dose of Dexamethasone in the morning and at night.

On Sunday, Kathy felt prodromal - as if she had the early symptoms of a virus.   We walked in the woods near our home and selected a few logs for me to split.  As romantic as it sounds, Kathy bought me a Swedish Forest Axe and Splitting Maul from Gransfors Bruks for Christmas.   We carried a few hundred pounds of wood to the car together.    Yes, I know that sounds odd, but we have a three decade history of doing the unusual together.

By Monday, she felt significant fatigue.

At no time did she feel any nausea.

In her words:

"Overall good reaction to the chemo materials, minimal problem with the steroids
Very light use of Ativan for first night to sleep
No use of anti-nausea meds yet.
Appetite reduced but adequate, sensation of salt tastes reduced
Digestive tract still normal, no use of any aids. Credit vegetarian diet high in fiber, legumes and leafy greens/cruciferous (eliminated all soy and added an egg to breakfast), no dairy, meat or fish consumed.
Fatigue set in hard on Sunday night from a Friday chemo session.
Early mornings and evenings are low energy, one faint period during eye exam.
Neulasta induced muscle myalgia/bone pain disturbs sleep cycle.
Evenings I feel like I am coming down with the flu (chills and aches), mornings  I feel like I am recovering from the flu.
Ordered new glasses to get away from contacts during chemotherapy, warned of changes in moisture in the eyes (given Systane eye drops by opthamologist)"

Her general pattern is moderate sleep, the need for a nap after breakfast, a great afternoon, and early evening fatigue, leading to bedtime an hour earlier than normal.

I've changed my schedule to get home by 4pm, walk with her, and support her in the early evening.

I've cancelled meetings on nights and weekends.

Every other Friday is a chemotherapy day, so I've cleared Fridays.

I've cancelled my travel for the next few months.

My colleagues have been incredibly supportive of my running late afternoon and Friday meetings by phone so I can be at home.

We're on the path of treatment and the cancer cells are dying.   Kathy's greatest fear has been the chemotherapy.   Thus far, the anticipation has been worse than the reality.  However, she started the first cycle in perfect health.   As the second cycle begins on January 20, she'll be a little more vulnerable.  

Today she's back at work in her Boston South End Gallery, NKG.  Her spirits are good and she's fighting cancer with boundless optimism.

Wednesday, January 11, 2012

Servant Leadership

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 says is possible."
- Colin Powell

My experience is that as long as a leader unites a team with a clear common goal and enables the team to do their work while supporting their self-esteem and their decisions about scope/time/resources, people thrive.   Even recent medical evidence suggests that "Honey" and the positive support of a leader yields healthy, productive, and happy staff.   Lack of such a leader can lead to negative health and reduced longevity.   It seems intuitive that our moods are linked closely to our job satisfaction and that positive mood improves health, but now we have evidence to prove it.

Katherina Holzhauser, a fellow Stanford graduate from the Czech Republic wrote to me about Servant Leadership  as part of her philosophy of favoring "Honey" over "Vinegar".  

The important take home lesson about Servant Leadership is the classic organization chart really needs to be rewritten, making staff who interact with customers the most important people in the organization.   The role of a leader to serve and support those staff so that they have the resources and processes they need to optimize customer experiences.   I completely agree with the statement that the highest priority of a servant leader is to encourage, support and enable subordinates to unfold their full potential and abilities. This leads to an obligation to delegate responsibility and engage in participative decision-making.

The goals of a servant leader - listening, empathy, healing, awareness, persuasion (which I call informal authority), conceptualization (which I call continuous self re-examination), foresight, stewardship, commitment to penple (which I call loyalty), and building community - are what guide my day to day interactions in all aspects of my life.

As we take on more work in less time at faster pace than every before, let's all strive to be servant leaders for the benefit of those who do the work and serve on the front lines healthcare and healthcare IT in our quest to alleviate human suffering caused by disease.

Tuesday, January 10, 2012

2012: A Year of Huge Uncertainty in Health Care Policy

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 of EHR users under MeaningfulUse

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 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 product is designed for (Ambulatory or Inpatient)
Attestation month Month that the provider successfully attested to MU
Business State/Territory Business location of provider who successfully attested to MU (state/territory)
Provider Type Whether attestor was an eligible professional (EP) or eligible hospital (Hospital)
Specialty Specialty or provider type
Program Year Year of EHR Incentive Program
Payment Year Payment year of EHR Incentive Program
Program Type Whether the attestor registered under Medicare or Medicare/Medicaid
ID Unique ID for each Attestor

I put together a quick pivot chart report which showed the number of attestations by month for Meaningful Use, and looked at the growth trend.  Here is how it looked:

And here is the raw data for this chart:

Month Attestations
4 506
5 812
6 1045
7 1461
8 2268
9 3774
10 5754
11 7341

What this chart clearly shows is that we are still in the exponential growth stage for attestations.  I found some information on logistic curve fitting data.  It required an estimation of the saturation point for the population, so I looked up the number of physician practices from Wikipedia and applied it to the model.  Given the the disparity between EP attestations (21,461) and Hospital attestations (1,500), I figured that an estimate of 250,000 was sufficient.

What I wanted to find out by this was when MU would be "done" (i.e., CMS would be "saturated" with attestations), and my results were rather surprising.  So I went back and checked it again with two other estimates (125K and 500K).  Then I took the 95% confidence interval on my low and high estimates.  I plotted it out so that you could see the range of possible answers here:

What this shows me is that by mid-year of 2012, we'll be halfway to saturation, and by the end of 2013, we'll have reached saturation. And if I'm too high on my estimate of providers, it will be by October of 2012, and if I'm to low it will be by October of 2013.

Now, my 95% bands were on the transformed linear equation, so I don't know how that impacts things with respect to confidence bands (I could figure it out, but I'm not that deeply interested).  What this tells me is that Meaningful Use, rather than being "off schedule" appears to be ahead of schedule.  I still don't know if I believe that.

One thing this model doesn't account for is how many providers attesting were already EHR users, and so were ready to attest, vs. those that have yet to adopt.  I suspect that the market is just a bit more complex than a simple logistic curve can account for, but even if it is, there's still another whole year before "Meaningful Use" is over using the figures I went with.  I'd stick with the "ahead of schedule" estimate at this point.

So, 2012 should see EHR adoption rates at several multiples of the current rate.  We'll look at the numbers again when they've released new data to see how things are going.