Wednesday, December 31, 2014

A Look Back at 2014

2014 was quite a year.   Thinking back to December 2013, I cannot believe that so much has happened.    Let’s take a look at the major HIT events that shaped 2014 and what they portend for 2015

Affordable Care Act - despite challenges with and state health insurance exchanges, the notion of moving forward with an open insurance marketplace and accountable care got traction.   The IT needed to meet the needs of the patient centered medical home, the ACO, and Care Management spawned a new type of software - the care management medical record.    Not many products exist and none are mature, but HIMSS was filled with promises of workflow engines, population health, and protocol driven care management tools.   2014 made it clear that the EHR is just a starting point and over time there will be a new generation of tools used by clinicians and non-clinician extenders to keep people healthy, not just record their encounters when they’re sick.   Hopefully we’ll see maturing products in 2015.

Meaningful Use/Standards - 2014 was really the first year we could take a look back at the Meaningful Use program.    I think we can conclude that Meaningful Use Stage 1 was generally perceived as a positive step, laying the foundation for EHR adoption by hospitals and professionals.   Stage 2 was aspirational and a few of the provisions - Direct-based summary exchange and patient view/download/transmit required an ecosystem that does not yet exist.    The goals were good but the standards were not yet mature based on the framework created by the Standards Committee.    At this point the only way out of the readiness/adoption challenge is to allow more time for the ecosystems to develop by changing the attestation period in 2015 to 90 days.    Although Direct/CCDA was a reasonable starting point for 2014, the future belongs to FHIR/REST/OAuth, which are going to be much easier to implement.    We need to be careful not to incorporate FHIR into any regulatory program until it has achieved an objective level of maturity/adoption

HIPAA Omnibus Rule - 2014 saw increased federal and state enforcement of the HIPAA Omnibus Rule with record fines for security breaches at a time when the nature of security attacks became increasingly sophisticated - witness the Home Depot, JP Morgan, and Target breaches as well as denial of service attacks on numerous healthcare and non-healthcare organizations.     Healthcare as an industry directed substantial resources toward improving the security protections of their networks in 2014.    It will be interesting to look back at this era in several years and ask the question if million dollar fines for stolen laptops/smartphones was a helpful policy or if other enablers such as the evolution of security technologies and culture change were more effective.

ICD10 - ICD10 was delayed until October 1, 2015 and it’s clear that stakeholders are divided about the concept.   One the hand, professional coders correctly identify that ICD9-CM is incomplete and does not include several important disease states.   On the other hand ICD10-PCS is so complex that it is unlikely clinicians will  not be able to produce the documentation needed to justify a code.   The cost to the country post implementation in lost productivity will be enormous.    If I could ask for a “do over” I would suggest that clinicians use SNOMED-CT to record clinical observations and that in a world of global capitated risk, not fee for service, the notion of using ICD for billing is no longer relevant.  ICD was intended as an epidemiological classification, not a billing vocabulary.   Only the United States uses ICD for billing and only the United States has proposed ICD10-PCS.   2015 will give us the next chapter in the debate.

In all industries, the concepts of social networking, mobile technology, analytics, and cloud hosting became increasingly important in 2014 for business and personal applications.    Healthcare has been slow to adopt these techniques but increasing cost pressures and new business models are motivating healthcare IT departments to embrace cloud services.   I believe that 2015 will be a tipping point, with increasing use of social networking concepts for care team communication, smart phones/tablets becoming the preferred tool for clinical work, real time decision support based on analysis of similar patients becoming mainstream, and cloud-based EHRs becoming essential for the agility of merging/changing organizations.  

2014 was a year of increasing stress for CIOs, accelerating workflow change, regulatory burden, unquenchable demand for automation, and rapid technology evolution.  2015 may see less new regulatory requirements, more mature products in the marketplace, and an increased role for the private sector to innovate.    As always, I remain optimistic for the future and am ready for the challenges ahead.

Thursday, December 25, 2014

Unity Farm Journal - Christmas at the Farm

It’s Christmas Day on Unity Farm and the every creature has had extra attention, special meals, and new toys.

What better gift for our livestock guardian dogs (Great Pyrenees) than soft fluffy beds in the barn loft?    As the pictures below illustrate, this was an ideal gift - the most fun they have had all year tearing each bed into a 1000 pieces.     It seems strange, but we made them deliriously happy with their gifts.

The ducks, chickens, and guinea fowl got fresh spinach greens from the hoop house, peas, mealworms, and oats.    Below you’ll see them grazing in poultry heaven.

The alpaca got alfalfa with molasses, grain, and freshly cleaned stalls.   Here’s a photo of Sunny, our baby alpaca, sitting in the Christmas Day sun with her grandma Ella.

The humans roasted root vegetables and Tofu.    Gifts including warm clothes for the cold barn chores of January, books (paper and electronic) to read by the fire during the 100 days of winter, and a few updates to the home electronics we use every day.

One strange observation today - in a Monty Python-like event, a “killer squirrel” caught a goldfinch and began eating it, shown below.   Comparisons to the “killer rabbit” of the Holy Grail abounded.

I spent the early afternoon with all the creatures given them extra play time and love.

Over the past 100 years, many cedar trees have lived and died on Unity Farm.   Since cedar does not decay, the Unity forest is filled with fallen cedar.   I spent the late afternoon hauling cedar trees to serve a trail edging along the Woodland trail.  The trail is a bit obscured with leaves/snow in the winter and the cedar trunks will now guide the way year round.

All of the family - Kathy and me, my daughter, her partner David, David’s parents, my mother, and one of  Lara’s friends are gathered together for the holidays.  Unity Farm is buzzing with activity and I stand ready as master of ceremonies, plumber, electrician, farmer, and friend to make sure the warmth of the holiday season is enjoyed by all  - a sort of Unity Farm bed and breakfast experience.

As I’ll write about next week, 2014 has been a year of remarkable change with new life, death, joy, sorrow, and endless activities.    The family, the creatures, and the natural world around us are all healthy and happy.  Who could ask for anything more?

Happy Holidays to everyone!

Wednesday, December 24, 2014

Present Future Tense

I’m often asked by hedge funds, investors, and private equity firms to evaluate start ups based on their management savvy, product maturity, and business models.

I’ve been on several calls with startups in 2014 in which the grammar was all “present future tense”

"We will have a product that does…"

My response to the investors is to clarify

1.  they will have a product that might...
2.  they have a product that does...

There is a great difference between

"We will invent a flying car that does improve commuting"


"We have prototyped a drivable plane that has demonstrated reduced commute times of 50%"

When I was in my late teens and early 20’s (I was at Stanford 1980-1984) the PC revolution enabled young entrepreneurs to invent technologies in their basements that made millions after years of hard work.

Earlier this week, the New York Times published an article reflecting on the generation of entrepreneurs that followed me at Stanford, graduating in 1994 as the web began its hyper growth.   Some made billions after months of work.

Now, there is a sense that an entrepreneur can write an app over a weekend and retire.  There are enough folks “winning the lottery” with this approach that many believe a career that lasts until age 30 is enough to fund a comfortable retirement.   That belief has led to present future tense, with folks promising that they have solved a complex problem before widespread adoption and customer satisfaction have really occurred.

Using a metric of adoption and satisfaction is a great countermeasure to present future tense.

KLAS recently issued a report about interoperability, defining  simple versus sophisticated data exchange objectively as simple=pushing summaries, sophisticated=pulling documents.   To me, getting simple interoperability  fully integrated into workflow with high provider satisfaction, maximizing the meaningful use stage 2 transaction volume, is a good metric for 2014.    You’ll see that using that metric reveals AthenaHealth and Epic achieved the combination of technology, adoption and satisfaction per the KLAS analysis.

Another framework to counter present future tense is Dixie Baker’s excellent JAMIA paper, “Evaluating and classifying the readiness of technology specifications for national standardization”

It identifies 3 Maturity criteria and 3 Adoptability criteria to objectively evaluate standards readiness.

Many of the present future tense entrepreneurs have products that require standards which do not exist or are not yet deployed.

My advice to all those pitching to investors - either clearly state what is and what will be, or if you are speaking in present future tense, enumerate the gaps in technology maturity, adoption, and user satisfaction, so that everyone understands the business potential for the product without overstating its true market readiness.

Thursday, December 18, 2014

Unity Farm Journal - Third Week of December 2014

On Sunday, December 21, 2014 astronomical winter begins in the Northern Hemisphere (and ends on March 19, 2015).

All the animals and vegetables will be stressed for the next 100 days.   It’s a cold and dark time that brings a struggle to survive.      Here's a photo of a chilly morning along the railroad tracks at Unity Farm, taken by Gary Beach, a Sherborn resident and author of "The U.S.Technology Skills Gap".

One of our ducks, Mulan (they are named by my daughter for Disney princesses) died of pneumonia yesterday.   She aspirated water while mating (ducks are rough) and although we  treated her successfully with antibiotics, she had a relapse and died in a few hours.   She’s buried in our Japanese shrine area.   She was the most colorful of our flock, an endangered Welsh Harlequin.   Her sister, Belle, lives on to carry forward the genome.  In the Spring we may add a rare Ancona duck pair to the flock.

Jack, our last surviving rabbit, is 13 years old and in his last days.   He’s blind in both eyes and recently had a stroke, paralyzing his lower body.   We keep him warm and hydrated, feeding him his favorite food, fresh broccoli.    He’s not suffering but is beginning to fade.

The local predators are finding it harder to stay warm and well fed, so they are venturing into the barnyard areas.   A large Cooper’s hawk tried to grab a guinea fowl yesterday but my wife was able to chase the hawk away.    Again today the hawk tried to capture a bird, but with 68 guinea fowl alarming, every one of them was able to get away.

The voles, moles, and mice continue to dig into the hoop house and I’ve placed peanut butter/carrots in the humane traps that enable me to keep the vegetables from being eaten.   This week the count is 2 voles, 1 mole and 2 field mice trapped and moved half a mile away.   I’ve cleared a few of the raised beds  - chard, spinach, and turnips - and replanted mache, purple choi, and red romaine lettuce, all vegetables that will germinate in the 50 degree temperatures of the winter hoop house.

The holidays are approaching and we’ll have a household of relatives from December 22-December 31.   There will be a few extra hands to help with the farm chores - tending the crops, caring for animals, and helping decorate the farm for the holidays.

There may even be some downtime to plan the projects of 2015, including the woodland planting of new permaculture food sources.  Of the 15 acres of Unity Farm,  5 are pasture/meadow and 10 are woodland.   By adding nut trees, berries, roots, herbs and flowers in the forest, we enhance the sustainability of the land while benefiting all nature's creatures that live here.  Over the past 2 years we’ve finished the infrastructure improvements to the farm and added all the tools we need to keep it maintained.   Our new frontier over the next few years will be creating a wonderland in the forest that surrounds us.

Wednesday, December 17, 2014

The Argonaut Project Charter

Yesterday, a group of private sector stakeholders including athenahealth, Beth Israel Deaconess Medical Center, Cerner, Epic, Intermountain Health, Mayo Clinic, McKesson, MEDITECH, Partners Healthcare System, SMART at Boston Children’s Hospital Informatics Program, and The Advisory Board Company met with HL7 and FHIR leadership to accelerate query/response interoperability under the auspices of ANSI-certified HL7 standards development organization processes.

All wanted to publicly release the charter we created.  It’s important that this charter is broadly circulated and understood.

As you’ll see from the charter, each of the participants has agreed that all specifications and artifacts developed during the course of the project will be made available to the entire community via an Open Content License.

The scope of the work includes three deliverables:

FHIR Data Query Profiles. A set of FHIR Resources and accompanying profiles that enables query/response of the discrete data elements contained in the Meaningful Use Common Data Set.  The work will be completed for inclusion in the May 2015 HL7 FHIR Draft Standard for Trial Use revision 2 ballot.

FHIR Document Query Profile. A FHIR resource and profile that enables query/response of IHE X* metadata resources, and specifically, transition of care and patient summary CCDAs.  The work will be completed for inclusion in the May 2015 HL7 FHIR Draft Standard for Trial Use revision 2 ballot.

Security Implementation Guide. Based on the SMART OAuth 2.0 and OpenID Connect profiles, a final guide will be completed the week of Apr 1, 2015.  The Security Implementation Guide will eventually be incorporated in the HL7 balloting process, but for this project will be developed in parallel to accompany the FHIR Data Query and Document Query Profiles and Implementation Guides.

The Argonaut project is time limited and focused on just those three specific deliverables in 2015.  It is not a new organization nor is it competitive with any other effort.

It leverages the existing Data Access Framework efforts from ONC, is compatible with the IHE MHD profile for document exchange, and provides incremental first steps in support of the broader Healthcare Services Platform Consortium initiative.   It is complementary to the CommonWell and the various state/regional HIE initiatives.

Participation in Argonaut includes sponsors, pilot participants, and the community (anyone who wants to stay in touch with the progress of the work).

We’re working on a one page summary which will illustrate the value of the work to patients, providers, and payers as well as innovators who will find it much easier to develop modular applications using FHIR than the current CCDA over Direct approach required in Meaningful Use Stage 2.

Finally, we’ve been very careful to decouple the Argonaut work from Meaningful Use.  Although we believe FHIR should be included in future certification testing, it should not be a regulatory requirement until appropriate pilots, testing, and revision are completed.   We’ll use the six objective maturity and adoptability criteria enumerated by the Standards Committee to evaluate the appropriateness of FHIR for the Meaningful Use program including:

Maturity of Specification
Maturity of Underlying Technology Components
Market Adoption
Ease of Implementation and Deployment
Ease of Operations
Fit for purpose

I believe the combination of FHIR/OAuth/REST will align well with the stated goals/objectives of the Federal Healthcare IT Strategic plan and the upcoming Interoperability Roadmap.    

FHIR will not solve every problem and we need to be careful to under promise, but the notion of a learning healthcare system based on the kind of data liquidity we have in other aspects of our lives (social media, electronic banking, smartphone apps) seems like the right trajectory to me.

Thursday, December 11, 2014

Unity Farm Journal - Second Week of December 2014

The reality of farming is that it creates dependency on the farmer - animals, plants, and infrastructure need to be supported 365 days a year.    This week, I had a failure of my personal anti-virus software (and my flu shot) and developed the 2014 flu.  My wife, who has been my life partner for 35 years, took over my tasks feeding, watering and cleaning all our animal areas while my energy was reduced. At nearly 53 years old, my endurance is boundless, but the flu does reduce my physical abilities.   Illness has caused us to realize that we have to be careful to balance to the joys of farming with our capacity to maintain what we’ve built.    Farming during winter with its cold, ice, snow, sleet, and wind takes a toll on even the most fit.

I did work from home two days this week as a courtesy to those around me - I did not want to infect anyone.  

As we head into the coldest part of winter, the tasks turn toward indoors.   Kathy and I emptied the pantry and root cellar then reorganized everything keeping only those foods that were still fresh and appealing.    We’ll do the same with our vegetable and mushroom supplies in the farm refrigerator this weekend.

I cleaned out the barn loft and did some electrical work in the barn in preparation for wiring the cider house to the power grid.

My father-in-law’s death a month ago provided us with several indoor projects as we go through his belongings and sort them into the donate, keep, and resell piles.    We’re busy working on trust accounts/wills, transfer of assets across two generations, and canceling credit cards/accounts.

There is alpaca fiber to sort, holiday decorations to put up, and attic/basement cleaning to do.

I continued vole patrol (and humane trapping) in the hoop house, ensuring that our winter vegetables are not being eaten.

There’s paperwork, taxes, and licenses to complete.   Last May I applied for Unity Farm to become a bonded winery so that we can sell our hard cider.   The application is multi-step and quite complex.   At this point all our applications are complete and we’re awaiting the scheduling of a site visit to inspect our cider house and fermentation/bottling facilities.

The alpaca, dogs, chickens, guinea fowl, ducks, and bees have all adapted to their winter life.   The mammals are clustered together in the barn at night keeping warm and dry.   The chickens and guinea fowl roost early in their heated coops.   The ducks seem to enjoy the wet, frozen mud and have no issue with inclement weather.  

The humans (include those of us recovering from the flu) are sitting next to a cozy fire, under a blanket, and using the winter months as a kind of hibernation, recharging our batteries for the rigors of the spring to come.

Wednesday, December 10, 2014

The December HIT Standards Committee

The December HIT Standards Committee included a review of the draft Federal Health IT Strategic Plan , recommendations about identity management from the Transport and Security Workgroup, an overview of the Prescription Drug Monitoring Program, and a discussion of upcoming task force work as we all prepare for the publication of the ONC interoperability roadmap and the Meaningful Use Stage 3 Notice of Proposed Rulemaking.

The meeting began with an introduction from Jon White, the new Acting Deputy National Coordinator.   We all know Jon from his leadership of IT initiatives at AHRQ.   He brings new energy and insight to ONC.   A great choice.

I summarized the agenda for the day but also told the group about the Argonaut Project, to clear up any misunderstanding.   The leadership of HL7 wanted to be responsive to work of the JASON task force and ensure HL7 had the necessary standards/implementation guides to support the emerging demand for query/response interoperability.    HL7 needed some additional funding to produce the deliverables by mid-2015.   A cross section of stakeholders passed the hat to provide HL7 extra funding.   Since we’re helping to accelerate JASON deliverables, we thought that those supporting HL7’s work could call themselves the Argonauts.

The Argonaut goal, which is complementary to other projects already in progress like the S&I Framework Data Access Framework (DAF) effort and the Healthcare Services Platform Consortium (HSPC) , is to create two profiles

1.  One which enables query/response of the discrete data elements in the Meaningful Use Stage 2 Common Data Set from an endpoint
2.  One which enables query/response of unstructured data  from an endpoint

using RESTful transport, and OAuth2 enforced authentication between the querier and the responder.

These initial deliverables are a subset of DAF and a subset of HSPC goals, scoped for May 2015 delivery.

Seth Pazinski and Gretchen Wyatt presented the draft Federal Health IT Strategic Plan which has 5 goals, 14 objectives and summarizes the input of 35 federal agencies.  It is well aligned with the triple aim and includes increased collection, sharing, and use of healthcare data.   The next step is for ONC to name two Standards Committee liaisons to the Health IT Policy Committee Strategy and Innovation workgroup, which is charged with providing comments on the plan.

Dixie Baker and Lisa Gallagher presented the identity management recommendations of the Transport and Security Workgroup, which can be summarized as

1. To strengthen the authentication currently certified in EHR technology
a. Continuously protect the integrity and confidentiality of information used to
authenticate users, using the standard specified in §170.210(a)(1) of the 2014
Edition EHR Standards, Implementation Specifications, and Certification Criteria.
b. If passwords are used for user authentication, accept only passwords that meet
the guessing entropy guidelines set forth in Appendix A of NIST 800-63-2.

2. To enable EHR technology to be certified for having implemented multi-factor
authentication, recommend the following certification criterion:
a. Restrict access to the system, or to one or more individual functions within the
system (e.g., prescribing controlled substances), to only those individuals who have presented at least two of the following three forms of authentication -- knowledge of a secret (e.g., password), possession of a physical object (e.g., hard token or smartcard), a biometric (e.g., fingerprint).

3. Recommend that the ONC:
a. Support NIST effort to revamp NIST Special Publication 800-63-2 (Electronic
Authentication Guideline)
b. Closely follow move from LOA to componentized trust
c. Recommend appropriate identity-proofing for query-based access
d. Consider Data Segmentation for Privacy (DS4P) for authorizing access to
behavioral data (TSSWG will address later in the work plan)
e. Track development and piloting of User Managed Access (UMA) profile of OAuth
2.0 as potential standard for consumer consent

We had a rich discussion about the intersection of security technology and policy.   Ultimately, we decided to be less prescriptive and removed 1b. password entropy as a requirement.  Instead, ONC, the Transport and Security Workgroup, and NIST will work together on an update to 800-63-2 which will include a risk-based framework.   Each healthcare organization will mitigate password risk using technologies and policies which adhere to the framework.

Jonathan Coleman and Jinhee Lee described the Prescription Drug Monitoring Program (PDMP) and highlighted some of the current challenges of integrating the state PDMP efforts with pharmacy systems and EHRs including:

-Healthcare Professionals adverse to separate logins and separated workflow
-Complex data workflows involving HIEs, PDMP Hubs, Pharmacy Networks, and HIT
-PDMP governance structure complicates Health IT systems’ ability to seamlessly
integrate into existing medication history patient reports
-PDMP data structures are not natively supported by EHR systems

The committee offered several recommendations to align the PDMP program with emerging standards activities such as FHIR.   Although the backend connections between PDMP sites and between pharmacies might use NCPDP or NIEM approaches, the EHR connections are better accomplished with FHIR approaches.

Finally Steve Posnack described two tasks forces, one for evaluation of the S&I Framework and another for a review of the S&I Provenance work done to date.   The HIT Standards Steering committee will work with Steve to assign workgroup members to these task forces.   He also described the  Certification Program Open Test Method Pilot.   We asked that any certification script writing be done using agile methods with pilot testing and engagement of the stakeholder community to achieve the minimum necessary burden in certification processes.

A great meeting with positive energy from all the Standards Committee members to support ONC at a time of great change.

Friday, December 5, 2014

Unity Farm Journal - First Week of December 2014

As the snow falls and windy/moist winter weather envelops the farm, the work has become a combination of managing warmth, tending the vegetables in the hoop house, and indoor activities.

Woodlot management has become my major winter exercise - walking the trails and inspecting the forest for fallen trees, broken branches, and pieces of long dead cedar that have not decayed.    I’m still working on processing ash trees that fell during Hurricane Sandy.   Ash does not need to be aged and becomes instant firewood.  I do my best to leave stable dead trees in place so they can become bird habitat .

I leave fallen/decaying logs in place as they are an important source of food and shelter to many species.   Up to 20% of the species living in the Unity Farm forest depend upon dead trees and fallen debris.

However, I do harvest freshly fallen trees/branches, cedar, and leaning trees that are caught by other trees.    The technique for cutting leaning trees is challenging and dangerous so I hire professionals to take down the larger trees that are likely to cause me harm.

I've divided the property in zones per the lessons I learned from The Resilient Farm and Homestead: An Innovative Permaculture and Whole Systems Design Approach by Ben Falk, which I read on my Kindle Paperwhite while traveling.      This weekend, I'll be in Zone 3, which includes areas accessible by our trails that I visit at least once per week.  In the upcoming weeks, I'll work in Zones 4 and 5, those in the deeper parts of the forest that accessible only by wandering off our trails.    Since the snow has melted the fallen cedar is again visible and I'll be cutting/stacking over 50 years of fallen cedar on the western border of the property.

The cold has had an unexpected effect on the hoop house.  Large numbers of voles have burrowed under the hoop house walls (and the 3 inch deep hardware cloth that surrounds the building).   A entire family set up a vole household in the bed of Japanese purple carrots.   Voles can eat a lot of carrots.    I placed humane traps in the raised beds, using carrots as bait.    Thus far I've removed 8 voles including this chubby fellow

This Spring we'll be repaving the 25 year old farm driveway and running electrical conduit from the barn to the cider house.  In anticipation, I'll begin wiring the cider house with a barn light (we generally clean up from a day of apple crushing in the dark), and provide power for our future expanded honey and cider production which are likely to overtake our ability to hand crank the extraction methods - 600 pounds of honey and 6000 pounds of apples.    Another typical farm weekend of woodlot management, vole removal, and electrical wiring!

Thursday, December 4, 2014

Kindling FHIR

Today, at the HL7 Policy Conference, Chuck Jaffe announced The Argonaut Project, an effort to accelerate Fast Health Interoperability Resources (FHIR) in response to the 2013 JASON report , A Robust Health Data Infrastructure, the 2014 JASON report, Data for Individual Health, and the JASON Task Force recommendations.

In a vendor neutral approach, Cerner, Epic, Meditech, Athena, McKesson, The Advisory Board and several provider organizations agreed to provide acceleration funding and political will to ensure that HL7 implementation guides which enhance query/response interoperability are available by May 2015.

Two FHIR profiles implemented via a public, RESTful Application Program Interface, protected by OAuth2 are needed.   The first is the discrete data elements specified by the Meaningful Use Common Data Set.   The second is document retrieval.

The Common Data Set includes, per the 2014 EHR Certification Criteria:

(1) Patient name.
(2) Sex.
(3) Date of birth.
(4) Race – the standard specified in § 170.207(f).
(5) Ethnicity – the standard specified in § 170.207(f).
(6) Preferred language – the standard specified in § 170.207(g).
(7) Smoking status – the standard specified in § 170.207(h).
(8) Problems – at a minimum, the version of the standard specified in § 170.207(a)(3)
(9) Medications– at a minimum, the version of the standard specified in § 170.207(d)(2).
(10) Medication allergies – at a minimum, the version of the standard specified in § 170.207(d)(2).
(11) Laboratory test(s) – at a minimum, the version of the standard specified in § 170.207(c)(2).
(12) Laboratory value(s)/result(s).
(13) Vital signs – height, weight, blood pressure, BMI.
(14) Care plan field(s), including goals and instructions.
(15) Procedures –
(i) At a minimum, the version of the standard specified in § 170.207(a)(3) or §
(ii) Optional. The standard specified at § 170.207(b)(3).
(iii) Optional. The standard specified at § 170.207(b)(4).
(16) Care team member(s).

Imagine the ecosystem of apps that could be created if simple read/write interoperability of these data elements was available in all mainstream EHR/PHRs with security controlled by the user of the EHR/PHR.

ONC also posted a blog describing on the importance of data liquidity among all patients, providers, and payers.

As I’ve written previously, it’s a perfect storm for innovation when stakeholders, resources, and political will align.

The Argonaut Project is a great example of policy and technology solving real problems in a reasonable timeframe driven by the value proposition that interoperability via open standards benefits all.

Thursday, November 27, 2014

Unity Farm Journal - Thanksgiving 2014

As a vegan farmer in a vegetarian household,  I’m always asked some thoughtful Thanksgiving questions.

“How do you serve Guinea Fowl?”

This is a very challenging question to answer because there is not much literature on the subject.   We serve all our 100 animals on Thanksgiving.

Two major issues when serving any guest  - where do you serve them and what do they want to be served?

Should we have an adult table, a kids table, and a guinea fowl table, since the birds tend to be noisy and messy?

To answer that question, I offered the poultry a choice of tables, chairs, walls, and logs.

As you can see below, the chickens prefer tables/chairs, while the guineas have a distinct preference for roosting in groups on walls or clusters of logs.

Guineas are herd animals, so when you send out invitations, you can be assured all will attend.   We have 68 guineas, so we’ve set up benches where they can sit while they are waiting to be served.

This morning I cut fifteen 18 inch lengths of maple logs and built 5 roosting areas so that the guineas can cluster with their friends and relations while we’re serving them.

These West African birds have different tastes than other poultry.  Some say Guinea fowl have tastes like Chickens and Ducks, but I do not think that is true.    As a test, I offered scratch grains, tasty mealworms, and fresh carrot tops to all the birds.

The chickens preferred the grains, the ducks preferred the greens, and the guineas ate the mealworms.

So the answer to the question about how to serve guinea fowl - create clusters of logs covered with mealworms.    Our guineas had a great Thanksgiving, along with all the other citizens of Unity Farm.

Happy Thanksgiving!

Thursday, November 20, 2014

Unity Farm Journal - Third Week of November 2014

The polar vortex has arrived at Unity Farm and it’s 20F.   All standing water has frozen and all outdoor plants have gone dormant.    The ducks are confused by their frozen pond but the Great Pyrenees and Alpacas are loving the cooler temperatures which approximate their native mountain environments.

As I’ve written about in previous years, preparing for winter on a farm takes a lot of planning.   All drinking water is now in heated buckets.    Wall mounted heating panels in the coops keep the birds from freezing at night.   Perennial beds are covered with salt marsh hay to insulate them from the ice and snow to come.

All fruits and vegetables are picked and the hoop house has been reduced to those greens which germinate and thrive at lower temperatures.    Although it’s 20F outside, the soil temperature of the hoop house is still nearly 60F.   Lettuces, mache, spinach, carrots, chard, kale, broccoli, brussels’ sprouts, radishes, turnips and beets all tolerate the early winter.     Here’s a view of the fresh vegetables still thriving while the weather outside is frightful.     We’ll have plenty of fresh foods for Thanksgiving.

We have placed temperature sensors in our outbuildings and growing areas for real time telemetry monitoring during the winter.    The chicken coop and duck house stay about 10F warmer than outside temps.   The hoop house gets up to 80F on a sunny day.

Now that the farm is prepared for winter, the nature of the work changes.    There is some vegetable harvesting in the hoop house left to do, but the bulk of my work in the upcoming weekend is keeping the flora, fauna, and family warm.   I've split 10 cords of wood and stacked it in our wood processing area, organized by species - cedar, oak, maple, black birch, ash, and hickory

After a summer of 16 hour days, we're looking forward to the hibernation which is winter in New England.   We'll catch up on conversation, indoor tasks, and  emotional recovery after the recent death of my father in law.

Wednesday, November 19, 2014

The November 2014 HIT Standards Committee

The November HIT Standards Committee focused on “asynchronous bilateral cutover” - the compatibility of different CCDA payloads, healthcare IT that supports long term services and support,  an update on the Standards & Interoperability projects, a discussion of data provenance efforts, and the HITSC workgroup organization.

We started the meeting by thanking Jacob Reider, Deputy National Coordinator, for his chairmanship of the Standards Committee.   He’s leaving ONC at the end of the month. He will be missed.

Charles Parisot provided an analysis of Consolidated-Clinical Document Architecture (C-CDA) Version Migration and Cutover Findings. The good news - many vendors can successfully generate and parse different CCDA versions.   We discussed two key takeaways.  When new versions of standards are introduced attention needs to be paid to backwards compatibility.  A bit of planning now can save significant EHR engineering complexity later.    Also, at some point, certification will need to codify what it means to be backward compatible.   Are older versions stored as human readable documents instead of structured data?   The HITSC members recommended to ONC that they seek the input of the EHR vendors as to the appropriate path for historical CDA variants (CCD, C32, CCDAr1, CCDAr2).

Next, Evelyn Gallego briefed us on the S&I Framework Initiative Electronic Long-Term Services and Support (eLTSS) .  This is a new initiative and it seeks to provide electronic tools for individuals with physical, cognitive, and/or mental impairments who never acquired, or have lost, the ability to function independently.   The committee discussion recommended that this work be done as “apps” outside the EHR, since it will likely incorporate data from several data sources and be used by stakeholders other than clinicians.

Steve Posnack updated us on Standards and Technology activities including new certification refinements.   He also provided valuable summary of ONC’s FHIR related efforts.   The alignment of government, industry, and academia around FHIR is truly a perfect storm for innovation.

Julie Chua and Jonathan Coleman presented the S&I Framework Data Provenance Use Case.  The committee recommended that this work be significantly narrowed in scope to achieve an implementable single use case which will inform the technology path forward.

Finally, Steve Posnack presented a HITSC Workgroups and Operations Discussion .   When the workgroups were reorganized there was concern about siloing - how do we avoid multiple duplicative work streams in the various workgroups.   Steve’s answer is to draw members from each workgroup into an ad hoc task force when multi-disciplinary problems need to be solved.  Thus, going forward, we’ll have some projects that are driven by workgroups and others addressed via ad hoc task forces of experts.

A good meeting.   We all look forward to the upcoming 2015 meetings in which we’ll review ONC’s 10 year interoperability roadmap and the next Notice of Proposed Rulemaking for Certification.

Friday, November 14, 2014

Unity Farm Journal Second Week of November 2014

The mood at Unity Farm has been somber this week with the death of my father-in-law on Sunday.   He was a significant part of seasonal farm activities and was a kind of third parent to my daughter.    His death from pancreatic cancer was so rapid that we’re all stuck in the first stage of grieving - denial that it happened so fast.

We find ourselves still calling for him to come to dinner, and expecting him to be sitting in his Morris chair as we gather around the hearth in the evening.   He will be missed.

The duties of farming - seasonal preparation, animal care, and the harvest do no wait for anyone, so despite our grief, we must continue with the routine around the farm.    We have pressed the last of our apples - about 450 pounds and now have 25 cases of hard apple cider in our fermenters.    I have applied for a bonded winery license so that we can sell Unity Farmhouse Cider.   Although this year was 25 cases, as our apple trees mature we’ll be able to produce about 200 cases per year - about 400 gallons.

We had our first snow this week and the temperatures are consistently below freezing at night.    We’ve blown out all the orchard irrigation and all above ground hose bibs.   We’ve prepared our ponds for winter mode.     We’ve blown a few tons of leaves from the barnyard to the forest.   We’ve harvested the last of the tomatoes, peppers, and eggplant.   All that remains in the hoop  house are greens and root vegetables - spinach, chard, cress, japanese mibuna, carrots, turnips, radishes, and beets.

The manure must be moved from the composting area before it freezes solid and we’ve created windrows below the orchard with the first 5000 pounds of it.

The farm will slow down a bit December-February as we turn our attention to indoor tasks -  skirting alpaca fiber, pickling/preserving the harvest, and planning for next season.

The alpaca/llamas, great pyrenees mountain dogs, and poultry are ready for the cold ahead,  having grown their winter coats/feathers.   The wood is stacked, the pantry is full, and every building has been prepared for stormy weather.

With all the events of 2014, time indoors for reflection, planning and rest is welcome.  We’ll schedule a time for my father-in-law’s memorial service when all the family has assembled for the holidays and celebrate his life surround by the bounty of our second year harvesting at Unity Farm.

Monday, November 10, 2014

Becoming the Oldest Living Generation

My father in law died yesterday.   His final days were surrounded by family, without pain, and guided by his wishes.   He spent 1 day in the ICU, 1 day in a hospital ward, and 1 day in hospice.   The journey from eating dinner with the family to death was 1 week.   His neuroendocrine pancreatic tumor was highly aggressive, and caused rapid weight loss, muscle wasting, and the inability to swallow without aspirating.    His path from life to death was just as I would want for my own - basic hydration, antibiotics for reversible infections, and a comfortable/caring environment with those closest to you standing by.

His death follows my father’s death a year and half ago.   That leaves only my mother as the living link to prior generations.   It means that I’m the oldest living male in the family.    In your 50’s it is common for you  to manage the declining health of parents.   It does feel early in life to become the oldest living generation.

Having worked with the transition of two fathers in two years, there is much I have learned about preparing for death

*Clearly document your wishes/preferences for physician orders for life sustaining treatment
*Ensure financial resources are well documented and understood by family members - bank accounts, retirement plans/pensions, and trusts
*If bills are unpaid, tax returns unsubmitted, or decisions unmade, ensure that a box of “to do” items is centralized.
*Making decisions about funeral arrangements is key
*Hospice is a good thing

My father and my father in law both benefited from caring/compassionate care in a hospice setting.    Hospice staff place the patient’s comfort first, reducing pain, alleviating anxiety, and providing a soothing environment.      We all die.   Spirituality aside, we’re a collection of biological systems that fail.   As walking fails, then eating fails, then thinking fails, vulnerability increases and control is lost.

A unified family, guided by the wishes of the patient and supported by a hospice setting brings a dignified, respectful death.  

All the emotion I expected was easier as the living members of the family gathered together for support.   Group hugs and gentle conversation helped calm the tears.

Over the next few weeks, there will be infinite details as accounts are closed, legal documents are executed, and the physical items associated with life are disbursed.   The death of a parent is never easy, but I am confident that the experience of my father’s death and the preparation for my father in law’s death will make the process as manageable as possible.

Thursday, November 6, 2014

Dispatch from Europe

I’ve been on the road for the past few days, describing the importance of patient and family engagement using mobile applications to healthcare leaders in Europe.  

The dialog has been bidirectional.  I learned a great deal about the technology and policy challenges in each country.   Patients, payers, and providers are struggling with issues such as usability, security, and supportability.  

My schedule has required several time zone changes - a keynote in Seattle on Saturday, a flight to London on Sunday for meetings with NHS leaders on Monday and a keynote in Birmingham on Tuesday.   In my discussion with UK leaders, they invoked the Chatham House Rule, something I had not heard about previously.  To encourage open dialog, anyone who attended the meeting was welcome to use information from the discussion, but not allowed to reveal who made any comment.

In the UK, I heard a great deal about misalignment between IT departments and clinicians.  IT departments are reluctant to embrace social, mobile, analytics, and cloud, instead insisting on centralized command and control of Windows desktop devices, often running Citrix/Virtual Desktop. Clinicians want mobile devices, universal access to applications anytime from anywhere on any device, and big data visualizations.   There is innovation, with forward thinking firms creating novel mobile apps and piloting them in several NHS sites.

In Berlin, I met with a diverse array of stakeholders from the entire EU and Russia.   All are facing the challenges of an aging society, chronic disease, and rising costs.   Several expressed frustration with the pace of healthcare IT innovation in Europe.  Regulators and IT departments are reluctant to be early adopters.  Windows and client/server platforms predominate.  Despite extraordinary engineering in Germany, there is still a fear of technology change.

Today marks the end of my travel for 2014.  I’ve cancelled planned speaking in Copenhagen and Amsterdam to support my father-in-law’s care.    As in previous years, my international collaborations have demonstrated to me that all our societies are making healthcare IT progress, but there is still a sense of urgency to do more.   Technologies move faster than politics and culture.   The work of John Kotter remains true in every location I visit - there must be a leader with vision, a guiding coalition, a reason for change, and an incremental step-wise approach to an idealized future state.    No technology, no matter how magic, can succeed without change management.

Tuesday, November 4, 2014

Unity Farm Journal - First Week of November 2014

When you’re a farmer, you’re often faced with the life, death, and sickness of those living things who depend on you.

Recently, my father in law was diagnosed with a Stage IV Neuroendocrine Tumor on the head of the pancreas.  Ironically, it’s the same disease that Steve Jobs experienced.   Chemotherapy began this week and we’re hopeful that shrinking the tumor will relieve some of his symptoms.   Cure is unlikely and many difficult decisions await us.

With Stage IV cancer, surgery is not an option.

If we do nothing, the highly aggressive tumor will cause rapid decline - weight loss, weakness, and susceptibility to falls/infections.

If we proceed with full cycles of chemotherapy, there may be reduction in tumor burden improving life quality or there may be side effects that make the situation worse.

We’ll work hard to respect all of his wishes on the journey ahead.  Chemotherapy and medications are meant to be palliative.   If complications occur, it’s likely that he will want minimal intervention.

He lives at the farm and needs to climb a few stairs, which is increasingly difficult,   We’ll need to think about mobility solutions, home care assistance, and possible relocation of his living spaces to the first floor.  We’re heading into cold and icy weather, so likely we’ll have to build a wheelchair ramp in and out of the house.

Having experienced the death of my father in March of 2013, the end of life process is still fresh in my mind.     As Atul Gawande outlines in Being Mortal, we’ll focus on life quality, not quantity.    My father-in-law and the dynamics of the entire family are paramount.     We’re rethinking the pattern of our duties and our activities.  I return to Boston from Europe tomorrow and I will not travel for the remainder of 2014, deferring all distant meetings and speaking responsibilities.   We’ll take each day one at a time, and I’ll creatively juggle my time using Skype, FaceTime, and teleconferencing to balance home/family needs with work needs.   My colleagues and BIDMC leaders are all very supportive.

Each of us will die.     The goal is to ensure that death is dignified and pain free.     My wife’s battle with breast cancer led to remission.    My father-in-law’s experience of pancreatic cancer will include the entire spectrum of emotion, from sadness to love and hope.   For now, medication, hydration, and spending time together is the most compassionate care we can deliver.

Thursday, October 30, 2014

Unity Farm Journal - 5th Week of October 2014

One challenge of being a farmer is that the animals, plants and infrastructure need you 24x7x365.   This Fall, I’ve had to travel to China (last week) and will be in Europe (London, Berlin, Copenhagen, and Amsterdam) next week.

Last weekend was filled with catchup for the time missed and preparing for the time to be missed.

Luckily, the farm was buzzing with activity - my daughter and her partner David, David’s parents,
 and Kathy were all able to join me for farm work.     Our tasks were

1.  Crush 450 pounds of apples.   We made 3 batches of hard cider, two of which will be for drinking and one of which will be cider vinegar for next year’s Unity Farm pickles.   Our small batch methods are labor intensive but we have total control of the process, ensuring a perfect blend of apples - sweet, tart, aromatic, and astringent.   This crush involved a combination of Spencer, Golden Delicious, Baldwin, Macoun, McIntosh, and Northern Spy.   I've moved the cider to our mud room since the cold nights could result in a stuck fermentation.

2.  Plant 4000 ginseng seeds and 100 ginseng roots in 1000 square feet of forest.   American Ginseng  (Panax quinquefolius) is a tricky plant to grow given its unique habitat requirements - a forest slope of 10-25% grade, covered in maple/oak/ash, with 70% shade, in moist leaf humus that is not too moist.    I raked a 1000 square foot area of the forest, clearing rocks and roots, then placed the roots at a 30 degree angle to the surface, cutting a v-shaped trench with a shovel.  I created  a template to plant 4 seeds per square foot over the area.   Then we spread 50 pounds of gypsum over the plantings, to add calcium, and covered the soil with 3 inches of leaf mulch.     We should see ginseng sprouts in the spring, and have harvestable roots in 6-8 years.   Why do this?  Part of goal at Unity Farm is forest farming with ginseng, paw paw, black cohosh, goldenseal and other challenging crops as part of permaculture - sustainable crops that have resale value.

3.  Plant 600 cloves of garlic - every October we plant hard necked garlic (about 10 different varieties) outdoors so that it can set roots, over winter, and the begin growing as soon as the Spring thaw arrives.   We harvest garlic every July and use it in the majority of our cooking/canning.    This year we created 7 beds and used a template to set the cloves in perfect 6 inch rows, 2 inches deep.   When then covered the beds with salt marsh hay to keep digging animals out and heat/warmth in.

4. Pick raspberries, turnips, daikon, beets, and peppers - all our crops are mature at this point and needed to be picked before the first freeze.   We picked a bucket of raspberries, a bushel basket of turnips, a picking box of daikon, an armful of beets, and a double peck of peppers.      Kathy combined fresh daikon, Japanese mibuna greens, and Japanese chrysanthemum leaves into a wonderful daikon soup pictured below.     The mushrooms continue to fruit and many of our Shitake logs are covered with emerging fungi.   The meadows are filled with shaggy manes, wine cap, and champignons.  Pictures are below

5.  Herd health - all the animals received their inoculations and we released our final flock of 8 week old guineas.   We have 68 to overwinter, so I built extra roosts in the coop.   Our 50 bird coop can now accommodate 80 birds and our multiple generations of guineas have bonded together as a single flock.    The mornings are crisp and the compost piles are steaming

At the moment, the farm is entirely ready for my absence next week.    The plants and animals are prepared for the possibility of snow and the harvest is complete, although we’ll continue to grow greens for the next few months.  2014 may very well be the last time I accept extensive foreign travel commitments.    Occasional trips are fine, Skype is better, and the farm needs my nights/weekends.

Wednesday, October 29, 2014

The Changes at ONC and Next Steps

In 2014, there have been many changes at the Office of the National Coordinator.

Although I do not have access to an organizational chart, I believe the leadership of ONC and the changes in 2014 are as follows

National Coordinator: Karen DeSalvo (Named Acting Assistant Secretary of Health)
Deputy National Coordinator: Jacob Reider (Leaving in November)
Office of Care Transformation:  Kelly Cronin
Office of the Chief Privacy Officer:   Lucia Savage
Office of the Chief Operating Officer:   Lisa Lewis (Named Acting National Coordinator)
Office of the Chief Scientist:  Doug Fridsma, MD, PhD (Became CEO of AMIA)
Office of Clinical Quality and Safety:  Judy Murphy, RN (Joined IBM)
Office of Planning, Evaluation, and Analysis:  Seth Pazinski
Office of Policy:  Jodi Daniel
Office of Programs:  Kim Lynch (Leaving in November)
Office of Public Affairs and Communications:  Peter Ashkenaz
Office of Standards and Technology:  Steve Posnack
Interoperability Portfolio Manager: Erica Galvez

Although some have voiced concerns about loss of momentum, I believe that in change there is opportunity.

ONC has a served as a catalyst, accelerating the adoption of electronic health records by hospitals and eligible professionals.   Guided by the certification regulation, EHRs now include robust interoperability for public health reporting, transition of care exchange, lab result incorporation, patient/family engagement and quality data submission.

We’ve achieved a new baseline that did not exist 4 years ago.

Now it’s time for the private sector to step up and lead the charge on the next generation of interoperability - query/response based on FHIR, OAuth2/Open ID, and REST.   We need two implementation guides - one for document level exchange and one for data element exchange of the Meaningful Use Common Data Set (see the last page of this document)

A coalition of the willing - vendors, HL7, providers, program management, and champions from the private sector can keep the momentum going as we all drive to a new set of FHIR specifications in 2015 - a second Draft Standard for Trial Use based on lessons learned with the first draft standard.

Over the past few days, I’ve seen new energy and enthusiasm for accelerating interoperability, following the roadmap described by the Jason Task Force.

Rahm Emanuel said “You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before.”

The combination of change at ONC, the Jason Task Force report, and new private sector urgency for interoperability is a perform storm for innovation

I think the weeks ahead will be filled with rich discussion about how all stakeholders can unify to accelerate the efforts already in progress.     It’s truly time for a new optimism 

Thursday, October 23, 2014

Unity Farm Journal - 4th week of October, 2014

While I was in China at the beginning of the week, Kathy maintained the farm and all its activities.  

To prepare for Monday’s night’s frost, she picked all the mushrooms from our Shitake logs.   Subtypes Miss Happiness, Native Harvest, and Night Velvet are all fruiting in large quantities.   We’ve developed Unity Farm branded packaging using recyclable cardboard containers and a small amount of perforated shrink wrap.    Kathy has been delivering mushrooms to local farm stands in my absence.

Before my departure I picked another peck of peppers, so we now have a pair of pepper pecks which Kathy chose to pickle.    She used our homemade apple cider vinegar and this simple recipe

On last week’s flight to Washington I read a great book about farming in the forest.  Since Unity Farm is about half forest, the notion of planting paw paw seemed very appealing.   So, this weekend we’ll plant paw paw and pack the pair of pickled pepper pecks.

Forest farming in the Northeast can also include American Ginseng, which although rare, grows near spicebush and jack in the pulpit in the Unity Farm forests.  Kathy ordered 75 one year old ginseng plants and 500 seeds which will plant in 5 test areas around the forest - north woodland, mid woodland, south woodland, north orchard, south orchard.  We’ll watch their growth carefully and then add more ginseng to the successful areas.  Ginseng is a slow grower and we’ll have to wait 6-8 years to harvest mature roots.

Now that Unity Farm is built, we’re entering the phase of daily operations - actively farming the forest, managing the trails, inspecting the bees, planting the hoop house, pressing cider, and caring for the animals.   Our to do list looks like this

Forest  -  farming crops,  thin/plant trees, marketing mushrooms
Trails - managing vegetation
Bees - inspecting, feeding, honey bottling
Hoop House - planting, weeding, harvesting, preserving
Orchard  -  pressing cider, making cider vinegar, canning Unity Blue (our blueberry, raspberry, elderberry jam)
Alpacas/Llamas - monthly care, yarn making
Poultry - monthly care, eggs

The path from farm to table is a daily process, always focused on the future harvest and working backwards to the tasks of today.      The leaves are falling and the seasons are changing fast.  The approaching winter will give us time to catchup on indoor tasks, ordering seeds for next year, and reflecting on our lessons learned.

The weekend ahead is filled with planning our ginseng crops,  pressing cider, planting garlic, herd health, and harvesting turnips.    I look forward to getting my hands in the soil instead of sitting on planes!

Wednesday, October 22, 2014

Dispatch from China

On Monday and Tuesday I met with government, industry, and academic stakeholders  in Qingdao and Shenzhen China to discuss healthcare technology,  patient empowerment, and process improvement in the rapidly expanding Chinese healthcare system.    Here's a photo of my visit to a hospital pharmacy in Shenzhen, dispensing ginseng and ling chi mushrooms.

Over the past few years, I’ve watched the Chinese government gradually change policy - from promoting a fully public healthcare system, to limited pilots of private facilities, to embracing public/private partnerships.

Foreign entities can now directly invest and operate joint venture hospitals in China, while Hong Kong and Macau based investors can own and operate hospitals in selected cities.

China faces the same challenges as the US and other industrialized nations - an aging society, increased demand for care, a limited supply of qualified professionals, shrinking budgets, and the need to improve quality.

I outlined a 5 fold approach for China

*Innovation in healthcare technology - universal adoption of EHRs, health information exchange, big data analytics, cloud delivery of services, wearables/mobile for patient/family engagement
*Education/Culture of Quality - ensuring every clinician has access to best practices and feedback on the quality of their practice
*Reputation building - creation of a regional center of excellence well known for  outcomes, great teaching, and cutting edge research
*Recruitment of mentors, mid career professionals and early achievers - to foster a supportive community of practice
*Public Health/Health Services research - to provide every clinician with the tools needed to support continuous wellness , population health, and care management.

As the American century draws to a close and China becomes the world’s strongest economy, collaboration between the US and China in the science of healthcare delivery will have mutual benefits.  

As I told the mayor of Shenzhen (below), my wife is Korean, and based on my love of the Far East, I am an Asian at heart.

I look forward to ongoing collaboration which improves the quality, safety, and efficiency of healthcare in China.

Monday, October 20, 2014

Wikipedia and Facebook for Clinical Documentation

Over the past several years I’ve written about the inadequate state of clinical documentation, which is largely unchanged since the days of Osler, (except for a bit more structure introduced by Larry Weed in the 1970s) and was created for billing/legal purposes not for care coordination.

One of the most frequent complaints in my email box these days is a sense that the current record is filled with data, but little knowledge and wisdom.  It’s hard to understand each patient’s individual story.   Notes are filled with cutting/pasting, inaccuracies, and redundancy.   Sometimes among the dozen notes written each day by the medical student, resident, fellow, attending, and consultants there is inconsistency.

The era of Ebola has accelerated the urgency for us to rethink the way we document.

In recent lectures, I’ve called on the country to adopt Wikipedia and Facebook for clinical documentation.

I don’t really mean that we should use those products, but we should embrace their principles.

Imagine if the team at Texas Health Presbyterian jointly authored a single note each day, forcing them to read and consider all the observations made by each clinician involved in a patient’s care. There would be no cut/paste, multiple eyes would confirm the facts, and redundancy would be eliminated.   As team members jointly crafted a common set of observations and a single care plan, the note would evolve into a refined consensus.   There would be a single daily narrative that told the patient story.     The accountable attending (there must be someone named as the team captain for treatment) would sign the jointly authored “Wikipedia” entry, attesting that is accurate and applying a time/date stamp for it to be added to the legal record.

After that note is authored each day, there will be key events - lab results, variation in vital signs, new patient/family care preferences, decision support alerts/reminders, and changes in condition.

Those will appear on the “Facebook” wall for each patient each day, showing the salient issues that occurred after the jointly authored note was signed.

With such an approach, every member of the Texas care team would have known that the patient traveled to Dallas from West Africa.     Every member of the care team would understand the alerts/reminders that appeared when CDC or hospital guidelines evolved.   Everyone would know the protocols for isolation and adhere to them.    Of course, the patient would be a part of the “Wikipedia” and “Facebook” process, adding their own entries in real time.

Yes, there are regulations from CMS enforcing the integrity of the medical record.    I’ve had preliminary discussions with folks in government who have signaled that as long as the “Wikipedia” authorship takes place outside of the medical record and then is posted/signed/timed/dated by a single accountable clinician, regulatory requirements will be met.  Once posted, the entry cannot be edited/changed, just amended, preserving data integrity.

It’s likely that the “Facebook” portion of the display would not be regulated,  but would require the same kind of validation we already do for lab result workflow.   The "wall" could also be certified for the Meaningful Use provisions that require viewing of the Meaningful Use Common Data Set.

Once there is a single place for all care team members to look when treating a patient, decision support based on analysis of structured and unstructured data will be easier to engineer.

Although I believe that the medical record coding we do today will become less relevant as we evolve from fee for service medicine to global capitated risk, the use of computer assisted coding and clinical documentation improvement tools will be easier with the “Wikipedia” plus “Facebook” approach.

I can even imagine that emerging Fast Healthcare Interoperability Resources (FHIR) work could represent the “Wikipedia” entry as part of document retrieval standards and the Facebook wall could be part of discrete data query/response, providing a timeline for the key events in a patient’s treatment.    I’ve already discussed the need for such timeline data with key FHIR architects.

A team at BIDMC is working on clinical documentation, structured and unstructured, in FY15. We’ll proceed incrementally, learning from each phase, and begin our journey toward an inpatient record that looks more like Wikipedia and Facebook than Osler’s notebook.    As Ebola and the tide of EHR dissatisfaction drive innovative documentation thinking, we'll need to move deliberatively.

And if we’re lucky, care team members will rekindle the spirit of working and talking together instead of starting at a screen, checking boxes for Meaningful Use.  

Thursday, October 16, 2014

Unity Farm Journal - Third Week of October 2014

Apple Season continues.   This weekend we crushed 152 pounds of apples yielding 8 gallons (2.2 gallons per bushel), down a little from our last crush which yielded 2.4 gallons per bushel, likely because Baldwin apples are less juicy than McIntosh.

The ph was 3.2 (a little more acid than usual) and the specific gravity was 1.050, yielding 6% alcohol.

Baldwin 55%  (Sweet)
Macoun 13% (Aromatic)
McIntosh 24% (Tart)
Crab 8% (Astringent)

We’re fermenting this batch indoors since the nightly temperatures in Sherborn are now falling into the 30’s, which can result in a stuck fermentation.

We racked our last cider batch and added malolactic bacteria.

Thus far, our cider production is proceeding flawlessly - with a year of experience under our belt, we’ve found our rhythm.

The Shitake mushroom logs are ready for an enormous fruiting over the next 2 weeks. Unfortunately, I will be in Washington, Philadelphia, Beijing, Qingdao, Shenzhen, Seattle, London, Berlin, Copenhagen, and Amsterdam on the weekends (yes, that’s a lot of red eye flights), so Kathy and I are dividing up the labor, with me doing all the hauling, cutting, and heavy lifting around the farm on the nights I’m there while she takes charge of the mushroom harvest, packaging, and delivery to local farm stands.    This is our first year of harvesting commercial quantities of mushrooms, so we’re learning every day.

The hoop house is thriving with the warm days and cool nights of Fall.  I’ve picked a peck of peppers (not pickled yet) - hungarian banana, poblano, and japanese chili pepper.   Here’s what a peck of peppers looks like:

All the animals are well - the dogs are growing their winter coat, the chickens have molted, the ducks are eating vigorously to prepare for the weather ahead, the alpaca are enjoying sunny cool days, and the bees are completing their winter honey stores (about 70 pounds of honey per hive).   My travels begin tomorrow and I’ll be caring for the menagerie by Skype for 4 days.

Wednesday, October 15, 2014

The October Joint Meeting of the Standards and Policy Committee

Today the future of interoperability was discussed and endorsed by a joint meeting of the Standards and Policy Committees.

We began with a preamble clearly stating that the roadmap we’re working on is a process not a finished product.

Karen DeSalvo, Jacob Reider, Paul Tang and I offered framing comments for the day.

I suggested that Health IT is in its “trough of disillusionment” moment before it moves toward the “slope of enlightenment”.  In the past two weeks, many of my incoming emails have been punctuated with negative feelings about EHRs - Ebola caused by a lack of interoperability, physician/patient relationships strained by the distraction of new electronic workflow requirements, and poor usability.  The work ahead is to focus on interoperability, building on the lessons learned and progress made to address key workflow issues.

Erica Galvez from ONC provided initial interoperability framing, illustrating the progress we’ve made thus far.

It’s clear that millions of transactions are being exchanged today, addressing many use cases including public health, quality measurement, and transitions of care.

Erica then continued with the draft 10 year shared interoperability roadmap.

Key milestones included

2017 - providers and individuals send, receive, find, use a basic set of essential health information

2020 - granular information access, expanded uses of information.

2024 - learning healthcare system

This effort will be based on a foundation of standards, certification, security, culture change, and governance.

We broadly discussed the presentation.  Commenters described the tension between functional requirements and overly prescriptive standards, the need for innovation and the desire for adoption of mature standards, and the need for privacy and while at the same time fostering increased sharing.

In the afternoon we discussed governance, recognizing that both top down and bottom up models have their supporters.   Additional work will be down by the Policy Committee’s HIE Workgroup.

The capstone of the day was a presentation by the Jason Task Force, reviewing the Jason Report.

The six key points  from that presentation were:

*Focus on Interoperability. ONC and CMS should focus their efforts on interoperability, realizing that healthcare IT stakeholders cannot accomplish every goal simultaneously given limited time and resources
*Industry-Based Ecosystem. A Coordinated Architecture based on market-based arrangements should be defined to create an ecosystem to support interoperability .
*Data Sharing Networks in a Coordinated Architecture. The architecture should be based on a Coordinated Architecture that loosely couples market-based Data Sharing Networks (which might also be called Data Sharing Arrangements)
*Public Application Programming Interfaces (APIs) as a basic conduit of interoperability. The Public API should enable data- and document-level access to clinical and financial systems according to contemporary internet principles.
*Priority API Services. Core Data Services and Profiles should define the minimal data and document types supported by Public APIs.
*Government as market motivator. ONC should assertively monitor the progress of exchange and implement non-regulatory steps to catalyze the adoption of Public APIs.

The group discussed the challenge of focusing on interoperability while also pursing the prescriptive goals of meaningful use.   One commenter proposed examining the collective burden/impact of all ONC/CMS requirements and then deciding on phasing.

The group approved these 6 points by consensus as part of a transmittal letter from the federal advisory committees to ONC.

The key takeaway - the approval of these 6 points begins the movement away from a model in which data is extracted from an EHR and then pushed from point to point.   Instead the future belongs to real time query of document-based and discrete data from the point of origin where it is stored, to the point of use, such as another EHR, patient mobile device, or population health registry.  Standards that are generally used on the internet such as JSON, OAuth, and REST are likely candidates, especially as implemented in FHIR (Fast Healthcare Interoperability Resources).

The next step at the government level is joint federal advisory committee/ONC work over the next 90 days to finalize the roadmap combined with private sector work (industry, standards organizations, academia, patients, providers, payers) to accelerate standards that support the 6 points in Jason Task Force report.

A remarkable day with great energy and enthusiasm to move healthcare toward the same interoperability approach used by Facebook, Amazon, Google,  Apple App Store, and most non-healthcare industries.  2015 will be a pivotal year for real time query-based data exchange.

Thursday, October 9, 2014

Unity Farm Journal - Second Week of October 2014

Several important updates.

Mint, one of our pregnant alpacas, had a false pregnancy.   Although she gained weight and had all the features of a pregnant camelid, she is no longer pregnant.   However, she is 30 pounds overweight and we’ll now have to restrict her access to grain.  Time for the alpaca stairmaster.

Mulan, our Harlequin duck with aspiration pneumonia is improving after 10 days on tetracycline.  She’s regaining her quack (for almost 2 weeks she’s been voiceless) and is now running with the other ducks.   She’s still a bit fatigued, but is on the mend.

It’s apple picking time.    My daughter and I picked six varieties of cider apples and organized an apple tasting at the farm to inform our cider making activities.

We decided that Empire was our favorite eating apple, followed by Rome Beaty and Macoun.    Our heirloom cider apples - Ben Davis, Northern Spy, and Roxbury Russet were good but had a very firm consistency with a bittersharp taste.    Our plan for the upcoming weekend is to crush cider using 1 bushel of Macoun (aromatic), 3 bushels of Baldwin (sweet), 1 bushel of McIntosh (tart), and 1 bushel of crab apples (astringent).   Although our apple harvest this year is in the hundreds of pounds, we’ll hopefully have thousands of pounds when the trees mature in 5 years.

Our existing cider fermentation is going well and we have developed a standard process - crush, ferment for 2 weeks, rack, add malolactic fermentation cultures, age for 4 months, bottle, age for 2 months, drink!

As winter approaches, all the creatures of the forest are storing up reserves for winter.   The squirrels are storing the acorns that are falling at a fast clip.    The bees are stockpiling nectar and pollen.    Even the preying mantis (find it in the picture below) are eating their fill.

 Leaves are falling, birds are migrating, and mushrooms are popping everywhere.  

This weekend (Columbus Day) is all about manure management - moving 10000 pounds of “llama beans” into windrows, a new squash planting area, and our garlic beds.   During all that hauling I’ll also move one of our wood chip piles into a new mushroom area using a new technique to first grow Agaricus spawn on cardboard then inoculating chips.   I’m hoping for a great spring crop as we expand the number of mushroom species on the farm.   Japanese Nameko and Shimeji are my next experiments.