phenomenalplace

The February meeting of the HIT Standards Committee included an in depth discussion of the Stage 2 Standards and Certification NPRM , updates from the projects in our 2012 HITSC work plan , and an overview of HITPC plans for 2012.   It was one of the highest energy, most optimistic meetings we've had. We began the meeting with a review of the Standards and Certification NPRM by Steve Posnack and Doug Fridsma.  As I noted in my recent post about the NPRM, most of the HITSC "Summer Camp" recommendations were accepted.   Highlights from their presentation: *In Stage 2, Certified Electronic Health Record Technology (CEHRT) will be "just enough" to support the functions documented during attestation.     In Stage 1, certified technology  was required for menu set items that were not part of an organization's attestation i.e. even if you did not plan to submit syndromic surveillance data, you needed to buy that technology anyway.   *Every eligible professio...

Now that the Stage 2 Standards and Certification NPRM has been released, many people are asking me for the detailed implementation guides that will support it. The S&I Framework website is being enhanced to make their work products easier to find. In the meantime, here are some of the major S&I Framework resources Final DNS/LDAP Hybrid Specification for Direct Project Certificate Discovery Final Data Model for Query/Response to the Provider Directory for electronic service information (implementation guidance forthcoming): Latest Laboratory Reporting Implementation Guide (will be balloted a second time at HL7 this spring) Final Consolidated CDA Implementation Guide We're getting closer to our goal of one stop shopping - a single website with all the content, vocabulary, and transport standards needed for certification.

On Friday, ONC released the Standards and Certification NPRM , the companion to the the CMS Meaningful Use Stage 2 NPRM. Here's a bookmarked PDF  - thanks to Tony Panjamapirom of the Advisory Board. In my view, the NPRM is a work of art, reflecting the work of the HIT Standards Committee, the S&I Framework, and  the multi-stakeholder consensus that fewer, more complete standards with less optionality will lead to greater interoperability. I've always thought of healthcare standards as having three components -  content, vocabulary, and transport. For content, the NPRM specifies HL7 2.51 for lab results, syndromic surveillance, reportable lab, and immunizations (HL7 2.31 is not longer an option).   For summary transactions, the Consolidated CDA is the only recommended standard.   (CCR and CCD/C32 are no longer specified).    NCPDP is specified as standard for the exchange of prescription information between entities, including for discharge me...

I recommend you read John Rother's recent op-ed in the Washington Post, "Five Myths About Medicare."John argues that each of these statements is a myth:Medicare is inefficient and fails to control costs--the CBO has projected that per capita spending will grow only 1% more than inflation over the next decade.The well-off don't pay enough for their Medicare benefits--working age premiums as well

The Meaningful Use Stage 2 Notice of Proposed Rulemaking was released today at 4:15pm.  It represents the work of hundreds of people from every healthcare stakeholder group.   I'll summarize all 455 pages this weekend and give two webinars next week (Greater New York Hospital Association and a special session for the Harvard School of Public Health).   For now, I recommend you read this  summary on pages 156-163 to understand that EPs must meet or qualify for an exclusion to 17 core objectives and 3 of 5 menu objectives.   Also that eligible hospitals and Critical Access Hospitals must meet or qualify for an exclusion to 16 core objectives and 2 of 4 menu objectives. Other key points from the executive summary: *For EPs, we propose a set of clinical quality measures beginning in 2014 that align with existing quality programs such as measures used for the Physician Quality Reporting System (PQRS), CMS Shared Savings Program, and National Council for Quality Assu...

Kathy is now finished with the hardest part of her chemotherapy regimen, Adriamycin/Cytoxan.   Next week, she begins Taxol every week for the next 12 weeks.    Taxol is typically far less fatiguing than AC.    It does have a problem that it is suspended in an solvent that can cause allergic reactions.   Her regimen will include supportive doses of diphenhydramine (benadryl) and dexamethasone (a steroid). At last week's checkup, Kathy's oncologist could no longer locate the tumor. Her breast surgeon will order an MRI at the completion of the Taxol cycles and if the tumor is undetectable, Kathy may be able to have to breast conserving surgery rather than a complete mastectomy. On Taxol, her hair will begin to grow back and her energy is likely to rebound.   However, she is quite concerned about one side effect - a neuropathy causing numbness in her hands.    As an artist, she depends on a keen sense of touch to create her work. She will no long...

On Sunday I returned from a week in Shanghai and Hangzhou.   A remarkable trip that included daily meetings with government, academic, and clinical leaders.   What did I learn? In China, about 5% of the GDP is spent on healthcare per year compared to 16% in the US.    Although there is wide variation in lifespan and other population health measures between rural and urban settings, there are few interesting observations about Chinese healthcare *It's a single payer, publicly funded system that provides universal healthcare via a 14% payroll tax. *There is a single national set of regulations and policies applied to all hospitals, clinics, and doctors *There is a single set of national privacy laws *Immunization is mandatory for the entire population *There's a single national healthcare identifier EHRs are widely used in China, however they are optimized for episodes of care, using templates for capture of selected data elements specific to a disease i.e. hypertensio...

I was recently asked how consent policy can evolve in Massachusetts to balance patient privacy preferences and the need to coordinate care/optimize population health.    Here's the letter I wrote to stakeholders about it: "My name is John D. Halamka MD and I serve as chief information officer of Beth Israel Deaconess Medical Center, co-chair of the Massachusetts HIT/HIE Advisory Committee, and co-chair of the  HIT Standards Committee. In my role as a CIO and clinician, I have been passionate about the need to electronically coordinate care to improve quality, safety, and efficiency. My wife was recently diagnosed with Breast Cancer and her treatment has relied on the secure exchange of healthcare records with her consent. The consent model that has worked best throughout the Commonwealth is 'Opt in consent to disclose at each institution'.    This means that no data is exchanged between organizations until the patient consents to the release of information from ...

I've recently been asked how healthcare information exchange can simplify compliance processes such as the delivery of electronic summaries, instead of thousands of sheets of paper, to CMS in support of audits. I've described the ONC Standards and Interoperability Framework (S&I) process several times previously in my blog.  S&I convenes stakeholders to assemble new implementation guides and do technical work to polish existing standards.  The HIT Standards Committee makes recommendations and evaluates standards implementation, but does not create implementation guides. The S&I Framework Electronic Submission of Medical Documentation (ESMD) project supports the CMS vision for automating audit processes . The S&I ESMD workgroup continues to work on the implementation guides which support the exchange of the relevant data from hospitalizations that would replace the paper-based audits of today.   I'm guessing they will choose the Consolidated CDA  (...

My travel in China was timed for Kathy's good days, the end of one chemotherapy cycle and the beginning of the next.   She's had a busy week, with a visit to her surgeon (check in after 6 weeks of chemotherapy), her last cycle of Adriamycin/Cytoxan, and continuing our farm search as new properties begin coming onto the market in the Spring. As I mentioned last week, I knew that traveling would make me uneasy.   I made a commitment to friends and colleagues over a year ago.  Backing out would impact the plans of many people who had agreed to 5 days of meetings in Shanghai as part of an effort to share US lessons learned in care processes and technology.   With Kathy's consent and perfect timing, I did the trip. Kathy's support system includes her father, several fellow cancer survivors, and our next door neighbor, whn is a heme/onc nurse from Dana Farber with 35 years of experience.     Our next door neighbor was very interested in visiting old friends at BI...

This week I'm in Shanghai meeting with government, academic, and industry experts to discuss the implementation of electronic health records, healthcare information exchange, and business intelligence applications supporting the care of 23 million people. Our team of 4 (Dr. Mitch Rabkin, Mt. Auburn hospital CEO Jeanette Clough, Architect Martha Rothman and I) flew to China February 12-13, losing 24 hours because of the international date line and 18 hours of flying.   We're staying in the eastern area of Shanghai, called Pudong, home to the economic miracle of the past 20 years - more skyscrapers than any other municipality in the world. On February 14, we visited Huashan Hospital, a major teaching affiliate of Fudan University Medical School.  We learned a great deal about leading practices in China, specifically in the areas of neurology, neurosurgery, and infectious disease.    Huashan leads the country in many ways, but not in IT, since it only invests .8% of its...

After years of telling us they are serious this time and everyone in the health care system had better be ready on time to implement the new disease coding system, CMS said today the whole project is going to be delayed indefinitely.The new ICD-10 system requires payers and providers to convert from the old system of 13,000 codes to the new system of 68,000 codes.All payers and providers were

I support over 3000 clinicians in heterogeneous sites of care - solo practitioners, small offices, multi-specialty facilities, community hospitals, academic medical centers, and large group practices. In every location there is some level of dissatisfaction with their EHR.   Complaints about usability, speed of documentation, training, performance, and personalization limitations are typical.   Most interesting is that users believe the grass will be greener by selecting another EHR. I've heard from GE users who want Allscripts, eClinicalworks users who want Epic, Allscripts users who want AthenaHealth, and NextGen users who want eClinicalWorks. The bottom line from every product I've used and everyone I've spoken with is that there is no current "perfect" EHR.   We're still very early in the EHR maturity lifecycle. What is the perfect EHR?   I've written about my best thinking , which has been incorporated into the BIDMC home built record, webOMR.   (and ...

Recently, ONC’s Office of the Chief Privacy Officer (OCPO), in collaboration with the HHS Office for Civil Rights (OCR), launched a Privacy & Security Mobile Device project. The project goal is to better secure and protect health information on mobile devices (e.g., laptops, tablets, and smartphones). Building on the existing HHS HIPAA Security Rule - Remote Use Guidance , the project is designed to identify privacy and security best practices for devices that are are used outside healthcare facilities or not directly under IT department control. The HHS Remote Use Guidance may not be familiar to clinicians and IT professionals.   It was issued on 12/28/2006 and includes specific recommendations for the use of Electronic Protected Health Information (EPHI) on mobile devices, specifically (1) the use of portable media/devices (such as USB flash drives) that store EPHI and (2) offsite access or transport of EPHI via laptops, smart phones, home computers or other non corporate equ...

The otherworldy Obama Administration solution to the contraception firestorm might work politically but it makes no sense in the real world.The President, hoping to quell a growing political firestorm, today announced a new policy that no longer requires religiously affiliated organizations to provide employees with contraception coverage in health-insurance plans.Under the new policy, insurance

I recently did an interview about distracted doctoring for National Public Radio.  Typically, when I speak on Morning Edition or All Things Considered, I travel to our local  NPR affiliate (WBUR) and use their high fidelity dedicated ISDN lines in a soundproof booth.   This time, I used my iPhone 4S. How does it work?   I used a free application called Report IT Live which NPR has selected to capture interviews in the field via the high fidelity microphones built into the iPhone and a high digital sampling rate. When the interview was complete, I uploaded the file securely to NPR servers. Here's an overview of how it works in the field . High fidelity radio interview recording on your iPhone with all the sound quality of a studio.  That's cool!

Kathy finished Cycle 3 of Adriamycin/Cytoxan, has weathered the most difficult treatment symptoms, had a positive rebound of her blood cell counts, and continued to receive an outpouring of support from the community. Per the screen print above from BIDMC's web-based Online Medical Record, her neutrophil count increased from 3610 to 5660, ensuring she can fight infection.   Neutrophils are significantly affected by chemotherapeutic agents but Neulasta, a bone marrow stimulant, prevents cancer patients from the neutropenic nadirs that once caused multi-day hospitalizations requiring antibiotics. Dr. Robin Schoenthaler, a Radiation Oncologist in the MGH Department of Radiation Oncology at Emerson Hospital and Director of Medical Education  at Emerson wrote to me with very helpful advice for husbands and families supporting breast cancer patients:     "I am a radiation oncologist at MGH specializing in the treatment of women with breast cancer and I have been following ...

I have no idea which way the Supreme Court will rule this year on the Affordable Care Act. Let me go out on a limb and predict a 5-4 vote on the question of whether the individual mandate is Constitutional. Just don’t ask me which way the vote goes.I found the recent Obama administration brief submitted to the Court on the mandate question somewhat ironic. Not surprisingly, the Obama Justice

I've previously written about innovative approaches to strong identity management which we're investigating. SAFE-BioPharma has implemented a thoughtful two factor authentication solution that leverages mobile devices and is provisionally certified as a trust framework provider for NIST level of assurance 2 and 3 by the General Service's Administration FICAM program . Their solution is cross certified with the Federal Bridge Certificate authority.  Thus, their credentials are trusted in both the Public Key Infrastructure (PKI) and non-PKI sectors for authentication to any Federal application or infrastructure. Here's how credentials are issued per Richard Furr, Head of Global Regulatory Affairs, Policy and  Compliance, SAFE-BioPharma Association: The applicant is nominated for a credential by a sponsoring SAFE-BioPharma member.  It is important to note here that SAFE-BioPharma is a member driven non-profit association and only members of the association can nominate ...

I was recently asked how eligible professionals should report the Meaningful Use Clinical Quality Measures if there are zero denominators (i.e. you do not have any hypertensives, adults, or patients with 2 or more visits in the measurement period) Here's the answer as I understand the regulations and FAQs: 1.  Report on the 3 Core measures if you can, which include *Hypertension: Blood Pressure Measurement *Tobacco Use Assessment and Tobacco Cessation Intervention *Adult Weight Screening and Follow-up 2.  If any of the 3 Core measures has a zero denominator, replace them one-for-one with one of the 3 alternate core measures.   If you can’t get to 3 non-zero denominators between the core and alternate core, report on all 6 (even if it means that you have to report 6 zero denominators) *Weight Assessment and Counseling for Children and Adolescents *Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old *Childhood Immunization Status 3.  Regar...

Medicare Advantage would appear to be a fantastic success—senior premiums are dropping and enrollment is increasing.Listening to Health and Human Services Secretary Sebelius last week, you would think private Medicare plans were a Democratic idea and this is their success. Many industry observers, including me, have worried that Medicare Advantage benefits would shrink and premiums would rise

In my career, there have been a few perfect storms , defined as "a confluence, resulting in an event of unusual magnitude". When I was an undergraduate at Stanford University in 1980, two geeky guys named Jobs and Wozniak dropped by the Homebrew Computer Club to demonstrate a kit designed in their garage.   IBM introduced the Personal Computer and MSDOS 1.0.   I purchased an early copy of Microsoft Basic and began creating software in my dorm room including early versions of tax calculation software, an econometric modeling language, and electronic data interchange tools.   Every day brought a new opportunity. The energies of hundreds of entrepreneurs created an industry in a few intensely creative months that laid the foundation for the architecture and tools still in use today.   A guy named Gates offered me a job and I decided to stay in school instead. In 2001 when I was first hired at Harvard, a visionary Dean for Medical Education, a supportive Dean of the Medi...

I recently wrote about the explosion of business spam . One of my blog commenters introduced me to Unsubscribe.com which provides a free, timesaving, easy to use unsubscribe utility. Numerous times a day, I click on an email scroll to the unsubscribe area, have to figure out the proprietary unsubscribe functionality of the business spammer, retype my email address, and hope it works since unsubscribe sites are generally slow and unreliable. With Unsubscribe.com, I just download a plug in for my email client (apple mail), and simply click on the unsubscribe icon whenever unwanted email appears in my inbox.   The unsubscribe servers use natural language processing to figure out the unsubscribe methodology and send the unsubscribe request. It has easily saved me 15 minutes a day. Of course the ultimate answer would be for advertisers to act more ethically.   I had a great conversation with Dave Smith, Compliance Officer for Constant Contact about their efforts to enforce email...

Tomorrow we begin the third cycle of Cytoxan/Adriamycin.   In the journey thus far, Kathy has had good days and bad days.   High energy and low energy days.    Meal days and BRAT (Bananas, Rice, Apples, Toast) days.    We frequently discuss the factors that put Kathy at risk for cancer at this point in her life.   We talk a lot about the future. Kathy's typical pattern is Friday - Chemotherapy infusion day, good energy, good appetite, some jitters from the steroids Saturday - Good energy, good appetite, some jitters from the steroids Sunday - Waning energy, moderate appetite, bone pain Monday - No energy, moderate appetite, extra sleep needed, bone pain, bland diet Tuesday - Low energy, extra sleep needed, bone pain, bland diet Wednesday - Low energy, bland diet, extra rest needed Thursday - Moderate energy, bland diet Friday - Moderate energy, stomach pain, bland diet Saturday - Moderate energy, stomach pain, bland diet Sunday - Moderate energy, stoma...

In two companion articles in January’s New England Journal of Medicine, Henry Aaron with Austin Frakt, and Joe Antos critique the Wyden-Ryan Medicare reform proposal.Senator Ron Wyden (D-OR) and Representative Paul Ryan (R-WI) are proposing a hybrid Medicare reform proposal combing both Republican defined contribution free market principles—a premium support scheme—with Democratic defined

As Massachusetts prepares a Request for Response (RFR)  to procure healthcare information exchange infrastructure and applications,  many stakeholders have been hard at work documenting requirements. The Provider Directory and Public Key infrastructure are some of the hardest specifications to write since they have not yet been widely deployed for healthcare information exchange anywhere in the country. The leaders of the Massachusetts HIE effort have held 3 major vendor and user forums over the past month and have been told that no vendor has a standards-based provider directory in production at any customer site. Here's our best thinking about Provider Directory and Public Key infrastructure services. Provider Directory The Directory will have a schema within a relational database that enables lookup of entities, which could include a person (John Halamka),  an organization (BIDMC), a department (The BIDMC Department of Emergency Medicine), a state entity (Massachusetts...