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With the Supreme Court justices sounding like they might strike the mandate down, this is a question I've been getting a lot lately.I have pointed to New Jersey as a real life example of what can happen when insurance reforms take place but there is no incentive for consumers to buy it until the day they need it.In 1992, New Jersey passed health insurance reform that required insurance carriers

Kathy can no longer feel her hands and feet.   The good, good, good days have become challenging days.    Kathy would normally push through it, but her oncologist advised us that being stoic increases the risk of permanent nerve damage. Based on the advice of her care team, Kathy is taking a break from chemotherapy this week to enable her body to recover. She's also taking Vitamin B6 (100mg daily) based on anecdotal evidence that B6 reduces numbness and tingling in patients receiving Taxol. Together, we continue to pack up our house for the April 27th move to our farm.   We make a great team with Kathy doing logistics/operations planning and with me doing heavy lifting.    It's quite a "spa treatment" - I've lost 6 pounds in the past few weeks and gained significant upper body strength.   However, I do not recommend moving as a long term fitness strategy since the mental cost of displacing your entire household is high. Although our move is proceeding on schedul

First, trying to predict how the Court will rule is at best just speculation. I know what Justice Kennedy said both today and yesterday and it certainly doesn’t look good for the Obama administration and upholding at least the mandate.But I will remind everyone, based upon oral arguments, most Court watchers expected a ruling in favor of the biotech industry on a recent case involving health care

In my 15 years as CIO, I've experienced a gamut of sales techniques - the "end of quarter deal never to be repeated", the "we're your partner and you always get our best price", and the selling of products that don't yet exist. However, today I experienced one of the most reprehensible - The Salesman End Run Around IT. Don't like the answer IT is giving you?  Go to the CFO and try to convince financial leadership that IT leadership is squandering budgets. Here's the redacted email that the salesman sent the CFO. "From: Storage Sales Specialist at a large company Sent: Wednesday, March 28, 2012 9:00 AM To:  BIDMC Chief Financial Officer Subject: Lower Storage Costs I am the Storage Sales rep for the Caregroup hospitals.  We have been working with healthcare organizations that are typically XXX shops and saving them $500,000+ in storage cost and associated resources. We will guarantee that we migrate your current environment to 50% or less sto

The March HIT Standards Committee meeting focused on a review of the Standards and Certification NPRM, as well as planning for our upcoming second quarter work on the NwHIN portfolio, QueryHealth, Radiology image exchange standards, and governance. Doug Fridsma began with an ONC update .  He described S&I Framework activities in 2011 that resulted in a single lab results implementation guide, merging the work of HITSP and CHCF/ELINCS.   This same approach will be used to create a single lab ordering implementing guide, including a standardized compendium of the most commonly ordered tests.   He described the plans for S&I Framework efforts on Clinical Decision Support standards.    He noted that ONC is looking at RESTful transport standards and the use of TLS for consumer mediated exchange.  He described further refinements to the NPRM that are needed to constrain Consolidated CDA (CCDA) in sufficient detail to ensure interoperability, such as the requirement to have specific t

On March 22, ONC issued important privacy and security guidance to State Designated Entities.  It addresses concerns from State leaders and other stakeholders that health information exchange efforts have been hampered and slowed by the lack of consistent approaches to core privacy and security issues.  The Program Information Notice (PIN) provides clear national guidance. It covers eight Core Domains 1. Individual access 2. Correction 3. Openness and transparency 4. Individual choice 5. Collection, use and disclosure limitation 6. Data quality and integrity 7. Safeguards 8. Accountability Here's a summary of the highlights: Access and Correction Where HIE entities store, assemble or aggregate individually identifiable health information (IIHI), such as longitudinal patient records with data from multiple providers, HIE entities should make concrete plans to give patients electronic access to their compiled IIHI and develop clearly defined processes (1) for individuals to request

I've often posted about transport standards and the need to accelerate interoperability by mandating a  method for EHRs to send/receive data from each other. The Meaningful Use Stage 2 NPRM includes such a requirement for transport standards, making healthcare information exchange real.  Here's a capsule summary of what it says: The NPRM proposes that EHR technology be required to implement the Direct specifications  - §170.202(a)(1) Applicability Statement for Secure Health Transport - SMTP/SMIME and §170.202(a)(2) XDR/XDM for Direct Messaging.  Products cannot be certified unless they support these transport standards. Transport is also referenced in the Transitions of Care Meaningful Use objective.  To support this objective, ONC’s 2014 Edition standards and certification criteria proposed rule includes a certification criterion at § 170.314(b)(2) which would require EHR technology to be certified to the Direct specifications (mentioned above).  However, for this certific

Taxol's major side effect is peripheral neuropathy .    Kathy will receive the 4th cycle of Taxol this week.  At this point, she can no longer feel her fingers and toes. As an artist, she depends on a fine sense of touch.   The peripheral neuropathy was the side effect we dreaded most.   She'll meet with her doctors on Friday to discuss next steps - possible change in medications and addition of other medications to reduce the intensity of numbness/pain. She's tolerated the Taxol well, keeping up with her daily activities with the usual verve.  One other complication is that her nails are black and brittle.  The slightest impact causes extreme pain - imagine that brushing your nails against a counter feels like slamming your hand in car door. As we continue with treatment, we're planning ahead for the end of chemotherapy in May, the imaging studies to evaluate the results of chemotherapy and the surgery to come.     I've cancelled all my international travel for the

I've written many posts about the importance of IT governance to set priorities, align stakeholders, and allocate budgets. Today, I will meet with the Clinical IT Governance Committee to discuss the 5 major IS projects in the BIDMC Annual Operating Plan, brief them about the Meaningful Use Stage 2 NPRM, and discuss 2012 State HIE initiatives. Here's an overview of what I'll say *Electronic Medication Administration Records - at BIDMC, we wanted to eliminate all handwritten orders in every care setting, so we aggressively implemented CPOE before automating Medication Administration Records.   Now that we have 100% electronic ordering, we're implementing projects that close the loop - checking patients, medications, staff ID, and active orders when medications are given to the patient.   We've developed a scope, a timeline, and a workflow that embraces both fixed bedside devices and mobile technology to document when, where, and how medications are administered, reco

The Office of the National Coordinator asked me to present the Massachusetts Provider Directory approach to the Provider Directory Community of Practice (CoP) on March 21. Here's the powerpoint that I'll present tomorrow . It highlights the decisions we had to make (Entity v. Individual, Central v. Federated, web API verses LDAP, etc) Issue: Should we include organizations, individuals or both in the provider directory? Answer: The directory should have a schema that enables lookup of entities (e.g., Organizations, Departments, State Agencies, Payer Organizations, Patient Health Record services) AND an individual's affiliation with an entity trusted by the HIE.  You can lookup John Halamka to discover that I'm affiliated with BIDMC, then lookup BIDMC to determine how to exchange data with my organization. Issue: Should the Provider Directory be centralized or federated? Answer:  The Provider Directory should be centralized at the State level, given lack of proven scala

While in Chicago last Thursday, I was asked how we validated our quality measures when we moved from chart abstraction to automated computation of PRQS, Meaningful Use, Pioneer ACO, and Alternative Quality Contract measures via the Massachusetts eHealth Collaborative Quality Data Center (QDC) .   This is an important question because Meaningful Use Stage 2 enables easy use of modular components outside the EHR such that data can be captured in the EHR and sent to a cloud based analytics engine via standards such as CCD/C32 for content and Direct for transport. Initially we did spot checks to validate the integrity of the Continuity of Care Document data flows from electronic health records to the normalized QDC schema. When Mitre Corporation offered to test their popHealth tool against 2 million BIDMC patient records to validate the Meaningful Use quality measures computed by our QDC, we jumped at the opportunity. First, we ensured appropriate business associate agreements were in pla

On Thursday, I met with the Chief Medical Officers working group of the Metro Chicago Healthcare Council to discuss Healthcare Information Exchange strategy in a world rapidly moving toward accountable care organizations, patient centered medical homes, and global capitation. Chicago has created a consolidated summary record for patients using technologies from Microsoft (aggregation and analytics) and HealthUnity (master patient index services).   CSC provides Systems Integration and Program Management. Importantly, they've built governance, trust, a policy framework, engagement, and commitment from stakeholders in the greater Chicago metro area. Their architecture is a bit different from the Massachusetts approach and it will be very interesting to compare lessons learned over the next year.   They are receiving HL7 feeds from participating hospitals, matching identical patient records together, and  aggregating the data using the kind of data-atomic attribute-value pairs suggest

It's week 13 since diagnosis and Kathy's will receive the 7th cycle of chemotherapy tomorrow. (3rd cycle of Taxol) Kathy's hematocrit continues to trend downward (from 42 at diagnosis to 29 last week), her nails have turned black/brittle, and her eyelashes have disappeared, but the worst is over.   She's feeling fine, the tumor is undetectable, and she's tolerating Taxol very well. Taxol typically does not cause a drop in hematocrit, so why the gradual downward trend over the past few weeks?   Kathy received Neulasta as part of her 4 cycles of Adriamycin/Cytoxan.  Neulasta is a colony-stimulating factor  that encourages hemopoietic stem cells to produce white blood cells, avoiding the neutropenia and susceptibility to infection that was previously a serious problem with chemotherapy.   One issue with Neulasta is that it may encourage so many stem cells to differentiate into white blood cells that fewer red blood cells are produced, leading to a mild anemia.    Over

What is a payer/insurer? Typically, payer organizations collect premiums from employers and individuals, process claims, and engage in a variety of case management/disease management activities to encourage the appropriate use of medical resources.   If they collect more premiums than claims paid,  their medical loss ratio  is less than 100% and they earn a profit. In a world of accountable care organizations and healthcare reform, new reimbursement methods will include global payments to providers, which implies the risk of loss will shift from the payer to hospitals and clinicians.   Payers will no longer need their large claims processing staff, nor create complex actuarial models.   They'll become very different organizations. How different? My prediction is that payers will become the health information exchange and analytics organizations that help hospitals and clinicians manage risk in a world of capitation. I've said before that ACO=HIE+Analytics. The payers are alread

Yesterday, Surescripts announced a national approach to sharing clinical summaries and public health data via its Clinical Interoperability Network: "WALGREENS AND SURESCRIPTS IMPROVE COORDINATION OF CARE BY ELECTRONICALLY DELIVERING IMMUNIZATION AND PATIENT SUMMARY RECORDS TO PRIMARY CARE PROVIDERS Surescripts Network Accelerates Interoperability Between Physicians, Pharmacists and Take Care Health Providers by Making It Easier to Supply Information Often Missing During Patient Visits" According to the release, the Surescripts Clinical Interoperability Network supports all federal and state policies and standards for health information exchange, including privacy and security standards (such as HIPAA and state law), technology interoperability standards (such as Direct) and various message types.   The service is being rolled out to 500 hospital labs to connect to public health under a grant from the Centers for Disease Control and Prevention, and is also being used by phys

Recently, Alex Knapp wrote a brilliant article entitled "Five Leadership Lessons From James T. Kirk" in Forbes.  For those of us who have watched every episode and can recite every line of dialog from memory, these 5 lessons are a great distillation of the series. On April 29, I'm speaking at the American College of Physician Executives about Leading Innovation.   These same 5 points are a great framework for that event. 1. Never Stop Learning 30 years ago I befriended one of the great thinkers from the vacuum tube era.  I showed him the miracle of a modern integrated circuit - one of his most complex tube designs fit into a dime sized chip.   He told me that he was not interested because he could not comprehend the silicon-based technology. As I've told my staff, if I ever become an impediment to innovation because I'm stuck in a technology era of the past, it's time for me to move on. 2. Have Advisors With Different Worldviews I try very hard not be dogmati

As readers of my blog may know, I'm a consulting mycologist , treating over 600 patients who ingest toxic mushrooms every year. Now there's a novel way to use mushrooms to create custom packing materials. Imagine choosing your packaging based on its absorptive, cushioning, and strength criteria, then just growing the package you need. It seems like science fiction but a  New York company is doing this. Ecovative Design  "grows"  packaging components for Dell Inc. servers and Crate and Barrel furniture, among others. Mushroom-based packaging you can custom grow for each customer.  That's cool!

I thought it was worth passing along the comments by Jim Tallon, president of New York's United Hospital Fund, in a recent post.Tallon reflected on an international meeting he attended with health care leaders from a number of industrial nations--"nations whose health care systems, indeed underlying philosophies, ranged from market orientation through hybrids to government authority:" "Across

Last week Kathy started Taxol.   She's tolerated it well and did not have any of the fatigue, appetite changes, or anemia that came with Adriamycin/Cytoxan. The short term challenge with Taxol is not the medication, but the solvent (called Cremophor) used to create an injectable solution.   Solvent-related hypersensitivity reactions are relatively common, so Kathy's pre-chemotherapy medications included: *Dexamethasone 20 mg IV 30 minutes prior to chemotherapy. *Diphenhydramine (Benadryl) 25-50 mg IV 30 - 60 minutes prior to chemotherapy. 50 mg for first dose. May reduce dose to 25 mg on subsequent doses if tolerated *Famotidine (Pepcid) 20 mg IV infuse over 15 minutes. 30 minutes prior to chemotherapy. She had no reaction of any kind, so tomorrow's Taxol dose will include 25mg of Diphenhydramine, yielding less Benadryl-induced sleepiness. Her usual pattern of chemotherapy, one good day, one moderate day, two bad days, then back to good days has been replaced with che

As HIT stakeholders review the Meaningful Use Stage 2 NPRMs in detail, questions about the intent of the language are circulating throughout the industry. The two most common questions I've heard are related to image display (is it viewing via an EHR, through an EHR, DICOM required etc.) and Healthcare Information Exchange transport standards. Here's a very thoughtful blog post from David Clunie that summarizes the issues of image viewing in the Stage 2 NPRMs. Healthcare Information Exchange transport is now required per this provision in the CMS NPRM: "The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care electronically transmits a summary of care record using certified EHR technology to a recipient with no organizational affiliation and using a different Certified EHR Technology vendor than the sender for more than 10 percent of transitions of care and referrals." Many are asking what standards and

Thanks for Robin Raiford of the Advisory Board for these resources She's created a poster comparing Meaningful Use Stage 1 to Stage 2 as currently proposed. This is a 48” x 66” wall poster if you want to render it at a commercial printing service, or zoom to 75% to see it on your screen. Here's the bookmarked CMS Notice of Proposed Rule Making Stage 2 EHR Incentive Program Here's the bookmarked ONC Notice of Proposed Rule Making Standards and Certification Criteria I hope you find these useful.

In my recent post about consent policy for HIEs , I reflected that opt in consent to disclose at each institution generating data is patient centric and implementable.    One challenge with trying to implement a special "consent to view data at each encounter" workflow for HIV is the difficulty of segmenting the medical record to isolate HIV data.   Here's a sample record that illustrates the problem: Medications 1.  Tylenol 2.  Sudafed 3.  AZT 4.  Bactrim Problem List 1.  Headache 2.  Sinus Infection 3.  HIV positive 4.  UTI Letter I hope you and your partner had a great weekend in Provincetown and that the thrush has improved with the mouthwash sample I gave you We can create filters for medications that are related to HIV treatment such as AZT.   However, some medications are ambiguous.  Is the Bactrim being used as prophylaxis against an HIV-related respiratory illness or something else?   We see from the problem list that the patient has a UTI, so likely the Bactrim

 Although I did not attend HIMSS this year because of my wife's chemotherapy timing, I did send several of my staff.    I asked them to summarize the cool technologies, most frequently heard buzzwords, and the overall conference trends. Just as "Plastics" was the catchword from The Graduate , this year's HIMSS Conference theme was a combination "Cloud-based EHRs" and "HIE". Cloud-based EHRs which follow the model pioneered by AthenaHeath for minimal hardware and minimal configuration in the office now include a number of new entrants including CareCloud and iPatientCare .   It will be interesting to see how these companies address the issue of integration with hardware in the office, the desire for customization, and the need for unique interfacing/integration with third party products. HIE companies are appearing on the landscape faster than ever before.   Companies such as Orion, Intersystems, RelayHealth, United/OptumInsight, Aenta/Medicity, DB

Tomorrow, Kathy starts her next round of chemotherapy - 12 weeks of Taxol administered every Friday at noon. As with Adriamycin/Cytoxan (AC), we fear the unknown - what symptoms will it bring, how will it affect day to day and long term physical well being (since Taxol causes numbness that can be permanent).      Kathy reacted very well to AC so we're hopeful that she'll tolerate Taxol. The process of treating breast cancer - 20 weeks of chemotherapy followed by surgery and radiation, can be wearing.   Of course, we are focused on optimizing the therapy, but at the same time we've needed a long term goal that brings joy and passion for the future, minimizing the day to day challenges of treatment. Together we've been looking for a farm property, discussing the plans/projects ahead, and preparing for our next stage of life.   We moved to Massachusetts 16 years ago and raised our daughter in a family neighborhood, nearby to great public schools and a local library.   We b