e-HealthExpert.org - Primum non nocere

A quick but eventful trip to Japan from March 3-7. My trip was funded by the University of Tokyo as part of an academic visit and not related to any company or product.
Two hours after landing in Narita, I had dinner with my hosts in Tokyo at La Rochelle, a French-Japanese fusion restaurant run by Iron Chef Hiroyuki Sakai . Chef Sakai prepared several novel vegan dishes for me using fresh Japanese mushrooms and vegetables.
The joy of the 14 hour time difference between the US East Coast and Japan is that I can work the Japanese day and the Boston day in the same 24 hour period. After the welcome dinner, the Boston business day began and I worked on several projects related to Meaningful Use- Federal, State and Local.
The morning brought 12 hours of lecturing, meeting, and greeting with Japanese healthcare policy and technology experts, discussing the Japanese version of the healthcare stimulus plan. (250 billion Yen, which is approximately 2.8 billion dollars). Critical issues for the Japanese are data security, data sharing consent, standards, reducing competitive disincentives to healthcare information exchange, and lack of EHR adoption among ambulatory clinicians.
After a great conference day, I said goodbye to my hosts and had 36 hours on my own before my flight left. My evening was filled with collaboration among members of the HIT Standards Committee to finish the comments on the Interim Final Rule (will be my blog tomorrow) and putting the finishing touches on a Health Affairs article (it seems to be a yearly tradition that I go to Japan and spend my nights writing a Health Affairs article for the annual Healthcare IT issue). At 7am I left the hotel and began the adventure I described in Friday's blog - a traverse of the Takao ridges. A truly remarkable experience.
In case you find yourself in Tokyo, here's my brief description of the hike.
From anywhere in Tokyo, take the Yamanote line to Shinjuku station. From there, transfer to the Keio line, and take a limited express bound for Kitano. Once there, take a local bound for Takao-san-guchi. Exit the station to the right and you'll find yourself at the the trailhead. There are 6 possible trails up Mt. Takao. I recommend trail #1 - the longest, most scenic and less traveled. However, Mt. Takao is a very popular destination, so less crowded is relative. The good news is that few people travel the ridge beyond Mt. Takao. After reaching the top, go to the East end of the summit and take the trail to Shiro-yama, the next summit. At that point, the crowds disappear. The trail to the next peak, Kagenobo-yama is an amazing ridge filled with cedar trees (sugi). The trail to Meio-toge is isolated, wild, and follows the track of the Japanese version of the Appalachian Trail (Kanto Fureai-no-michi). The final peak is Jimba-san and its famous war horse statue. A descent via Wada pass to the Jimba Kogen-shita bus stop, a bus ride on the #32 and #5 buses to Hachioji, and a train from either Keio or JR Hachioji station to Shinjuku completes the day. Book time for the hike is 5-7 hours (plus 3 hours for train/bus travel) and the distance covered is 12 miles, with a few thousand feet of elevation gain.
This morning, I checked out at 6am, took the Chuo line to Shinjuku, stashed my bags in a locker (fully electronic - you are given a PIN number to open the locker instead of a key), took the Yamanote line to Shinagawa station, then the Keihin Kyuko Rapid Limited Express to Miura-kaigan on the Miura Peninsula, an area of wide sandy beaches, rocky coastline, and a great old lighthouse. After walking the Peninsula, I took the Zushi line train to Jimmu station and hiked the temple route (the photo above), passing plum blossoms in bloom, Jizo statues, and the peak of Mt. Takatori. I was completely alone the entire trip.
From there, I took the Keikyu line back to Shinagawa, the Yamanote line back to Shinjuku, picked up my bags, and took the Narita Express to the airport, changing from my hiking clothes into a suit while on the train. I just landed from my 18 hour commute back to Boston.
In all my travels above, a rudimentary knowledge of Japanese really helped, since most signs in the wilderness are only in Japanese, such as this one which indicates the way to the train station (good luck figuring it out since both West and South seem to the be right answers). How did I get by? The following expression:
Sumimasen (fill in the name of where you want to go) wa doko desu ka?
which translates into
Excuse me, (placename) it where is?
This saved the day many times, since maps, signs, and guidebooks were often wrong.
The Japanese people are gracious, helpful, and eager to provide directions to foreign travelers.
I succeeded in my quest to find the road less traveled. Of course, the fact that it was 38 degrees, raining and trails were ankle deep with mud may be have been a disincentive to other travelers.
A great trip! Thanks so much to my friends in Japan who made it happen.

My trip to Japan this week is a 15 hour commute, two days in Tokyo speaking/meeting with colleagues, one day hiking along mountain ridges 2 hours west of Tokyo, and then a flight back to Boston.
In my travels around the world, I'm always looking for the road less traveled. In the past few years, that's included walking the Seven Hills of Rome, exploring archeological sites in the Middle East, climbing mountains in Austria, and kayaking across the Baltic Sea.
Because of the logistics, physical conditions, and specialized gear needed to do these activities, I've often traveled alone, going Into the Wild.
When I travel alone I take extra precautions, packing a bit of extra food, a spare layer of warm clothing, and posting my itinerary with someone who can call for a rescue party if needed.
I will not do solo unroped climbing, solo travel in avalanche areas or solo kayaking in water that is colder than 50 degrees.
There are a few pleasures to travel alone - a pace that you define yourself based on your personal energy level, no time commitments, and simpler logistics.
There are risks - an injury while on a cold mountain ridge can lead to hypothermia, frostbite, or death. The margin of safety while hiking alone in wilderness areas, especially in winter, can be thin.
A hiking partner enables you to share the memories and relive the experiences. This winter, I've hiked alone many weekends, but also hiked with one of my colleagues from BIDMC who is an experienced alpinist.
Tomorrow's hike in Japan will cover 20 kilometers of the North Takao Ridge, from Mt. Takao to Jimba-san, traversing 3 peaks and stretching my knowledge of the Japanese rail and bus systems to get to the trailhead. (Addendum - I added a photo above of the Ridge and cedars in the mist that I captured on my Blackberry while hiking)
So, I'm off to experience the Japanese wilderness alone, with minimal risk, and play my Japanese flute from the peaks.
Buckaroo Banzai would be proud.

The last of three HITECH related regulations was released by HHS on March 2 - the NPRM on Certification. It's 184 pages and will soon be published in the Federal Register.
Its major feature is that it creates two certification processes - a temporary one to ensure there is a path to certification in time for Stage 1 of Meaningful Use and a more permanent one.
My sense is that ONC consulted NIST and realized that the time to set up a comprehensive multi-organizational certification process would take until late 2010, giving no time for products to be certified before the Stage 1 Meaningful Use funding milestone (January 2011)
Here's a brief overview of the Certification NPRM from the FAQ Section of the HHS IT Website.
As I've posted for the other regulations, here's a bookmarked version of the NPRM on Certification. Thanks to Michelle Wood for this one.

I've just finished my day in Atlanta and am beginning a commute to Tokyo.
Every year, I describe my top 10 impressions from HIMSS. Here's my summary of the event for 2010
1. Meaningful Use is everywhere. Vendors are promising EHRs, modules, appliances, and services to help clinicians achieve it. I had dinner on Monday night in a small Indian vegetarian restaurant. Sitting next to me were 3 engineers from Bangalore who were arguing about the details of Meaningful Use in between bites of vegetable curry. I could not escape Meaningful Use anywhere!
2. Certification is everywhere. It's particularly ironic that many vendors claimed their systems were certified, even though the certification NPRM was just released today, making compliance with the new certification process in time for HIMSS impossible.
3. Cloud computing, Software as a Service and ASP models are popular tactics to accelerate EHR rollouts. There are still lingering concerns about how to ensure privacy in a cloud environment.
4. Several firms such as Intersystems, Axolotol, and Medicity are offering HIE platforms that include many of the standards noted in the IFR. The marketplace for HIE products is just emerging and it's hard to predict who will become the market leader.
5. The Continuity of Care Document is gaining traction. I found many vendors supporting CCD exports from their EHRs. A company called M*Modal , has developed natural language processing technology that captures dictated content in its original context (ontology-drivenrules) as a CDA document.
6. Consultants abound. It's clear that Regional Extension Centers and Health Information Exchanges will require expertise and staffing from professional firms. They all had large booths at HIMSS.
7. 30,000 people attended, including 10,000 I did not recognize (just kidding). It's clear to me that many IT professionals, even those with limited healthcare domain expertise, attended HIMSS to better understand how they could participate in the euphoria of HITECH stimulus dollars.
8. Self service kiosks for patient identification and self-registration are now mainstream. Just as we print our airline boarding passes, we can now use credit cards or biometrics to check into ambulatory care appointments and automatically settle all co-pay balances.
9. Image exchange in the cloud is being offered by several vendors. As I mentioned in Monday's blog, Symantec announced an appliance for small clinician offices that cloud enables all imaging modalities using a facebook-like social networking invitation to share/view images.
10. PHRs and patient engagement are becoming more mainstream. Google and Microsoft continue to innovate in the non-tethered PHR marketplace.
I left HIMSS with a feeling of hope. Our industry is vibrant, clinicians are engaged, our goals are clear, and resources are becoming available.
I'll be commuting over the next 24 hours, but when I land, I'll publish my analysis of the Certification NPRM.

I've just arrived at HIMSS and will begin my day with a breakfast meeting, the Standards Town Hall keynote in Building C Georgia Ballroom 3 from 8:30-9:30am, and numerous chats with colleagues, vendors, and media. I hope to see you at the Convention Center or at the Meet the Bloggers event from 3:30pm-4:30pm at the Social Media Center. I'll be wearing a coal (slightly gray) Kevlar suit.
Yesterday, the new Massachusetts data protection regulations went into effect. Given the increased compliance demands in our state and nationally, I'm often asked to describe the structure and staffing of the BIDMC IS Security Team.
BIDMC spends over $1 million dollars per year on people and infrastructure to protect the confidentiality and integrity of healthcare data.
The Chief Information Security Officer (CISO) reports to my second in command, the Chief Administrative Information Officer (essentially the COO of IT).
The Security Team includes the CISO and two other technical staff. Both are CISSP certified and SANS Audit certified.
At a high level the IS Security Team is responsible for the overall information security program throughout the hospital. To deliver on such a charge they create security policy and controls in collaboration with business owners. They also perform audits and control all of our specialized security equipment.
The Security Team is a close partner with other aspects of the IT organization. For example, the desktop organization deploys, operates, and manages the antivirus solution. They are responsible for ensuring the .DAT files are current and that managed systems have the antivirus loaded and operational. The Security Team has built a scripted audit that runs on a daily basis. The audit verifies that systems are still properly communicating with the centralized service. If not, email alerts are issued and the appropriate IS teams can follow up. Similar audits are in place for firewall rules, (the firewalls are operated by the network team using rules which are developed by the security team ), user access to clinical content, and remote vendor access to systems.
The team has operational responsibilities for 12 intrusion detection sensors located throughout the core network, 8 intrusion protection devices, 2 SSLVPN appliances, a secure file transfer service, and 2 web content filtering systems. These systems all report back to a centralized syslog service that all IS teams can access as needed to ensure the reliability and integrity of systems they maintain.
The Security Team has just celebrated its 4 year anniversary. Along the way they have written many Perl scripts, and numerous workflow applications in .NET that use SQLServer repositories. Automated forms and workflow management help drive our audits.
If you are starting your own IS security team, you may find the job descriptions we use to be helpful.
Technical Security EngineerTechnical Security Engineer IInformation Security Analyst
Security is a journey and we must innovate constantly. The IS Security Team keeps us on the right path.

I was recently asked to describe our clinical storage growth.
*In 2009, we consumed 12 Terabytes for clinical image storage and 3 Terabytes for non-image clinical storage
*This storage is also replicated in our disaster recover data center
*Our growth rate is approximate 25% per year
*We started 2010 with 175 Terabytes of storage
*We've used electronic records since 1977
*We have approximately 60,000 inpatient hospitalizations per year
*We have approximately 250,000 active patients
*If you divide our 2009 consumption (15 Terabytes total) by our total number of active patients (250,000), you get 60 megabytes/patient/year as the rough of amount of storage to be provisioned. To my knowledge, I've not heard of an industry statistic for Average Storage Annually per Patient, so we'll need to create a catchy name for this - the ASAP rate. You heard it here first.
Our infrastructure includes EMC Atmos NAS, Clariion NAS, and Clariion SAN. We use Data Domain for data deplication/compression archiving and F5/Acopia for storage virtualization. The infrastructure is designed and maintained by 1 full time Storage Architect and several part time support engineers who together constitute about 1 FTE.
As you can see medical images are the major element of our storage growth. We have several strategies to manage image storage growth including
*Using a centralized image management infrastructure with tiered storage for short term cache, long term cache and archiving. Our enterprise image management steering committee ensures strong governance and minimizes the spread of mini-PACS and departmental solutions.
*Partnering with GE, EMC and F5 we've created a private cloud of archival storage
*Partnering with Symantec, we've developed a cloud-based community image sharing solution that does not require local storage to exchange images among our affiliated clinicians. More on that tomorrow from HIMSS.
Speaking of HIMSS, I'll arrive in Atlanta on Monday night at 10pm, do a Standards Town Hall keynote from 8:30am-9:30am, attend a series of private meetings until 3:30pm, and then join the Meet the Bloggers event from 3:30pm-4:30pm. Feel free to drop by and say hello. I'm flying from Atlanta to Tokyo at 7pm, so my stay at HIMSS this year will be abbreviated.

I try to be an early adopter of emerging technologies so that I can assess their readiness for the marketplace, reporting on the good and the bad in an effort to benefit my colleagues.
On the green energy front, I retired incandescent bulbs in my household and converted to compact fluorescents (CFL) very early in the product development cycle. All in all it was a great experience, although the first CFLs had a harsh cool white light.
Recently, I've explored the next generation of replaceable home light bulbs - Ultra LEDs. Sylvania has introduced 40 watt LED light bulbs with an essentially infinite lifespan, no mercury, little heat, and a perfect 2700K spectrum of warm white light.
It's an exciting development because there are no moving parts, nothing to burn out, and nothing to break. I've replaced an entire room (a studio that my wife, my daughter and I share for art, music and studying) with LEDs.
For ceiling and track lights, I used Sylvania Parabolic Aluminum Reflector (PAR20) 210 lumens, 7 watt, 40 watt equivalent bulbs.
For the table lamp, I used a Sylvania A19 (standard light bulb shape) 350 lumen, 8 watt, 40 watt bulb.
Above is a photo of the room in LED lighting.
So, what's the downside of light bulbs that last forever, use very little energy, and have a great soft white spectrum? The cost is currently $30-40 per bulb. Of course, over the life of the bulb, plus the energy saved, that's not significantly different than incandescents or compact fluorescent.
I asked my favorite local hardware store about emerging LED technology. Their view is that the economics will not yet quite work. The room pictured above uses six 7 watt reflectors and one 8 watt A19 bulb. Total energy expenditure to brightly light the entire space with LEDs - 50 watts. Total cost $230.00, amortized over the life of the house i.e. the bulbs will last longer than I will.
Like any new technology, the price will drop as economies of scale, competition, and manufacturing advances reduce production costs.
Although the capital cost to convert a room is currently high, I'm impressed by the technology. Given that one of my long term goals is to build a small, carbon neutral retirement cottage and that my daughter may become an environmental engineer, LED lighting technologies are likely to play an important role in our future.

I've written about my daughter's exploration of colleges and my sense that college fit for her including teaching style, student peers, setting, culture, and extracurricular activities is more important than US News and World Report rankings or the parental ego boost from the college prestige beauty contest.
As an experiment, I asked several of my staff where they went to college.
There was no correlation between their current roles and the prestige ranking of their college. College was a nurturing experience that enabled them to explore their interests, find themselves, and build the skills to succeed in life. Graduate school did correlate a bit. Aiming for a great Master's program (MS, MBA, MPH, MPA) is an enabler to find a good job.
Interestingly, of the folks I work with in Washington, most identify themselves with the institution of their final degree and not their college experience. After a few years in recognizable positions, any mention of even graduate educational institutions fades away.
As I look as my evolving CVs through the years, the pedigree of my 20's is no longer relevant to my trajectory at 50.
The point - where you start is not where you end.
I disagree with those who believe the right kindergarten leads to the right elementary school leads to the right high school leads to the famous college, which immediately produces fame and fortune. From my limited experience of managing 500 people, it's the person and their individual journey that leads to success, not their pedigree.
My own life has been filled with twists, random acts of kindness from others, good karma, and Brownian motion that as led me to my current positions.
My daughter's passions are mathematics, Japanese culture/language, archery, the outdoors, and art. Might she be an environmental engineer working in Japan and studying Kyudo, the mediative archery martial art? Could she be the designer of the next generation of Lego toys? Might she teach English to Japanese elementary school students after college, then work in Japanese government as a liaison to visiting technologists? All are possible - the world is her oyster.
In life thus far, I've been a son, programmer, author, editor, manager, winemaker, physician, technologist, politician, husband, and father. Fate usually reinvents my role every few years and the final chapter of my story has not yet been written.
So, Lara, go write your story. You're at Chapter 1. I look forward to reading the novel of your life as you write it, your way, in the years to come.

On February 17, the HIT Policy Committee held an important meeting to discuss its recommended revisions to meaningful use.
The handouts are
Meaningful Use Workgroup: Comments & Discussion on the NPRM
NPRM Recommendations
Adoption/Certification Workgroup: Comments & Discussion on the NPRM and IFR on Certification Criteria
Information Exchange Workgroup: Comments & Discussion on Health Information Exchange in the NPRM
Privacy & Security Policy Workgroup: Comments & Discussion on the Privacy & Security Objective in the NPRM
NHIN Workgroup Recommendations
Update: Strategic Plan Workgroup
The important summary to read is the NPRM recommendations, but here's my Cliffs Notes version:
Recommendation 1.0: Include “Document a progress note for each encounter” for Stage 1 EP MU definition. This highlights the importance of unstructured text to communicate the thought process used when developing a treatment plan.
Recommendation 1.1: Signal clinical documentation as a required MU criterion in Stage 2 for hospitals. Today few hospitals have fully electronic progress notes, but eventually they will be needed to eliminate the inefficiencies of hybrid electronic/paper workflows.
Recommendation 2.0: Remove three proposed quality measures (inquiry regarding tobacco use, blood pressure measurement, drugs to be avoided in the elderly) from Stage 1 criteria. Since these are process measures not outcome measures they do not meet the quality measurement criteria specified by the Policy Committee.
Recommendation 3.0: Providers should produce quality reports stratified by race, ethnicity, gender, primary language, and insurance type. To meet the ARRA goal of reducing disparities in care, there needs to be measurement and feedback to providers.
Recommendation 4.0: EPs and hospitals should report the percentage of patients with up-to-date problem lists, medication lists, and medication allergy lists. Rather than just record the presence of a list, it is more important to ensure these lists are up to date.
Recommendation 5.0: EPs and hospitals should record whether the patient has an advance directive as part of the Stage 1 MU criteria. Given that ARRA focuses on the Medicare population, it is especially important that all patients over 65 have recorded their advance directive preferences.
Recommendation 6.0: EPs and hospitals should report on the percentage of patients for whom they use the EHR to suggest patient-specific education resources. Physician vetted education resources, such as those that a clinician personalizes in an EHR are more valuable than internet sourced resources a patient discovers by random searching.
Recommendation 7.0: All EPs should report to CMS the percentage of all medication, entered into the EHR as a generic formulation, when generic options exist in the relevant drug class. Such a measure would encourage efficiency in drug prescribing.
Recommendation 7.1: CMS should explicitly require that at least one of the five clinical decision support rules address efficient diagnostic test ordering. Such a measure would encourage efficiency in high cost radiology test ordering.
Recommendation 8.0: CMS should advance its timetable for the release of future MU NPRMs in order to allow adequate ramp-up time for vendors and providers. Without a glide path, vendors will struggle to create multi-year product plans.
Recommendation 9.0: The numerator for the CPOE measure should define a qualifying CPOE order as one that is directly entered by the authorizing provider for the order. It's not appropriate for nurses, clerks, or other extenders to enter orders on behalf of the clinician.
Recommendation 10.0: Change the measure to read, “For a chosen preventive health service or follow up (the EP chooses a relevant preventive or follow up service for their specialty), report on the percent of patients who were eligible for that service who were reminded.” This enables the reminder criteria to apply to all patients in practice, not just a subset over 50 as stated in the NPRM.
Recommendation 11.0: Delete “relevant encounter” from the medication reconciliation measure
Recommendation 11.1: Define “transition of care” to be the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another. This ensures that the timing of medication reconciliation is clear - when the patient goes from one care setting to another.
Recommendation 12.0: Eligible professionals and hospitals should be given the flexibility to defer up to 6 meaningful-use criteria as described in the table below, but must meet all mandatory objectives. This is the partial credit recommendation, that uses the chart pictured above. It enables local variation in implementation, because it is hard to know which aspects of meaningful use will be hard to achieve in each locality.
I agree with these recommendations - they provide clarity, restore some important criteria, and enable an easier glide path by removing some requirements and allowing partial credit on others.
Well done!

At the February 24 meeting of the HIT Standards Committee we heard reports from each of our workgroups reviewing the Interim Final Rule.
Clinical Operations*If regulatory language allows, the best way to support standards specificity while still enabling standards to evolve is to list general classes of standards in the regulation i.e. HL7 Version 2 and then provide very specific implementation guidance outside the regulation. If specificity is needed within the regulation, then the inclusion of a single implementation guide as a floor, with the intent that it will evolve, would meet this need.
*Standards should refer to data exchanges between organizations, not within an organization. An entity should be free to use whatever proprietary approaches to content and vocabulary standards support the needs of internal workflows as long as these can be translated into the standards specified in the Interim Final Rule when exchanging data.
*The standards in the Interim Final Rule, a regulation, replace previously "approved" or "recognized" standards published in the Federal Register if conflicts exist. This is important because Executive Order 13410 requires Federal agencies to use recognized standards when installing or upgrading their systems. The IFR will be the new source of truth.
Clinical Quality*An allergy vocabulary is needed in 2011 to comply with quality measurement requirements
*A standard for recording vital signs is required in 2011 to compely with quality measurement requirements
*The nature of the datatypes needed to support some quality measures constrains the choice of summary exchange standards because of the need to capture actions, actors and events in a granular fashion i.e. for some quality measurement purposes, CCD is a better choice than CCR. CCR remains a very reasonable choice for exchange of summary information for care coordination.
Security and Privacy* For Modular EHRs, security requirements should be "addressable" for every EHR Module submitted for certification. This means that not every module needs to meet every security criterion i.e. a module which calculates body mass index may not exchange data outside the organization and thus does not need to include encryption technology.
*For encryption, the committee recommended that symmetric and asymmetric encryption both be supported and that AES be specified as the symmetric encryption standard.
*Since data transmission may take many forms (MLLP, TCP/IP, HTTPS POST, SOAP and REST), providing a requirement to use SOAP and REST without specifying details is not helpful. Either provide very specific guidance for each transaction type or none at all. The committee recommended removing transmission standards from the IFR at this time, leaving security standards intact i.e. you can use HTTP, SMTP, FTP, etc but requirements for encryption and auditing still apply.
Implementation WorkgroupThe implementation workgroup discussed March 8 hearing on "starter toolkits" to ease EHR adoption. We'll be taking testimony from the Public Sector, an array of stakeholders with implementation experiences, and innovators. We're specifically asking the testifiers to contribute white papers, software, and others enablers to a Starter Toolkit that could be used by providers, communities, and vendors to accelerate meaningful use.
The comments made at the meeting will be codified into recommendation letters for committee review and then signature by the co-chairs in time for ONC to include them in the comment process (first week of March).

In my 20's I was immortal (not immoral!), in my 30's I became obese and in my 40's I'm now aware of my own health and wellness.
I believe you truly are what you eat.
I think that Michael Pollan and T. Colin Campbell are right when they say "Eat food, not too much, mostly (or all) plants."
Vegan eating works for me and certainly is worth trying yourself.
I recently received the following email:
"I ran across your blog through a google search for 'Vegan Physicians. I see that you are not a practicing (primary care) physician (to my chagrin ;-), so I wonder if you could recommend any vegan physicians who practice and/or support the vegan lifestyle through their practice?"
I emailed noted author Neal Barnard for his advice. Neal responded:
"We often receive requests from people looking for a doctor who is knowledgeable about plant-based diets or sympathetic to other issues that PCRM deals with. At PCRM, we actually recommend something a bit different. We suggest that people select the best doctor they can find and that the doctor provide the very best information about diagnosis and possible treatments. People will generally not need to rely on a physician to provide nutritional information. That will come from a good Registered Dietitian or other nutrition counselor, as well as from the books, DVDs, and other materials that we make available. As people plan to modify their diets, their doctors can track their progress and modifying their medicines along the way if need be. For this reason, PCRM does not maintain a referral list. For anyone dealing with a particularly difficult medical problem, we encourage them to seek a second opinion, or to consult the relevant department of a major teaching hospital in the community. I hope this is helpful. Neal"
Neal is a smart man. Great advice.
Eat well per whatever approach works best for you. Exercise. Find a great doctor that can diagnose and treat any conditions you may develop. All will be well.

Ok, you're going to think this is the strangest cool technology blog to date.
In my travels, I visit a large number restrooms throughout the world. Recently, I've noticed a significant rollout of "waterless" urinals.
There must be some serious technology behind this, since no "input" plumbing is required at all. I often used the analogy that the paperless hospital is as likely as the paperless bathroom, until the Japanese introduced me to a paperless high-tech bathroom. Now we have the waterless bathroom.
How does it work? A special cartridge contains a lighter than water liquid that floats on top of urine, providing an airtight seal between the urinal and plumbing - no odor of urine or sewer gas enters the room. A typical office building can save millions of gallons of water every year by installing these units. No water supply is needed so the capital costs of installing them are less than standard fixtures.
An environmentally sound, waterless urinal that uses the physical properties of fluids to create an airtight seal and eliminate odors, saving millions of gallons of water per year. That's cool!

As I was driving to a winter hike last weekend, I saw a profound bumper sticker - "Wag More, Bark Less".
These are words to live by.
Barking may yield short term gains, but wagging builds lasting relationships. When leaders bark, it diminishes them.
All my lives - parent, husband, and CIO - benefit from wagging.
As a father, there is the formal authority of parenthood. However, I rarely use formal authority and instead create a loving environment based on mutual respect and open communication. It worked with lions in Born Free and it works well in our household.
In the office, outbursts of emotion may win the battle, but lose the war. Employees, customers, and bosses rapidly tire of emotional lability. A decade ago, a hospital CEO began swearing during a senior management meeting in an effort to demonstrate authority. Within a year he was gone.
In my blogs over the past year, I've suggested that we're the Greatest Health IT generation, that these are the good old days, and that we're all suffering from stress acceleration. Despite the stress, the lack of sleep, the traffic, the cold, and the economy, we all need to keep our composure.
I recently had a storage issue that could have escalating into a yelling match between my staff and the vendor staff. Instead of barking, I used it as a teachable moment to bring the teams closer together, strengthening the relationship, and enhancing the channels of communication. This effort to wag instead of bark laid a foundation for years of collaboration to come.
As a parent, as a CIO, and as a human, I cannot think of any situation that is made better by barking than wagging.
So next time, you're given the choice, remember the outcome of the bark verses the wag. A bark may be satisfying for the short term, but a wag is the sign of leadership, stability, and expertise for the long term.

I regularly write about the need to converge CCR and CCD into a common, simple to use, XML construct that incorporates structured and unstructured clinical summary information.

CCD itself would be a good endpoint if the XML were more readable and the overhead of the CDA was reduced. The other option is for CCR to be expanded to include more metadata and support unstructured documents such as discharge summaries and operative notes. The CCR folks have been working on PDF for healthcare to support document capability.

Simpler but full featured is exactly what Green CDA tries to do.

It's a streamlined, human readable and computable lighter version of CDA that includes just the data and metadata necessary to do the job of representing a clinical summary.

Here's an example of the Problems section and Patient data section in Green CDA.

There are tools available to convert green CDA into a full CDA document

There are also tools available to convert CDA into Green CDA

Additional tools are are being developed to enable easy creation of Green CDA constructs by navigating the RIM, selecting attributes, and selecting associations to consolidate to make the XML flatter.

When I first saw the Green CDA XML, I was so impressed that I asked the question - why not use Green CDA as CDA, getting rid of MoodCode, many of the OIDs and other overhead in the CDA?

In the past, the idea was that the CDA was capable of representing any aspect of the medical record for any purpose. That sounds like a noble idea but in practice it creates a fixed overhead for even the simplest data exchange.

Folks at HL7 are working hard on CDA templates, tools for creating CDA documents and simplifying the CDA (and the XML used in CDA).

The Green CDA initiative is a great start. I look forward to watching its development and the industry reaction.

The Interim Final Rule supports both CCR and CCD for 2011, but recommends convergence by 2013. Over the next 24 months, we'll see what convergence of XML standards for structured and unstructured data is technically and politically possible.

In several previous blogs, I've identified the availability of free vocabulary codesets/valuesets as a key enabler of interoperability.
The National Library of Medicine has produced the SNOMED-CT Core subset for problem lists, RxNorm for medication terms, and a LOINC subset for ordering labs.
To ensure the right subsets are available and maintained, we need governance - who decides what goes into the vocabularies, what mappings are created, and how disputes/redundancies are resolved? We need a place to store vocabularies that makes them easily accessible to all. We need a roadmap for future work.
The HIT Standards Committee's Vocabulary Task Force is holding three hearings. The first hearing on February 23 will focus on governance "rules of the road" for vocabularies. The second hearing, in March, will consider vocabulary infrastructure requirements. The next hearing will focus on end user needs for specific vocabularies included in meaningful use as well as future requirements. Additional hearings and meetings will be scheduled to address priority issues as they are identified.
The February 23 meeting will include three panels: (1) EHR vendors; (2) vocabulary service providers; and (3) vocabulary standards organizations.
Jamie Ferguson, who chairs the task force, has prepared useful background information for the hearing.
If you'd like to send advance comments about vocabulary governance as part of the hearing process, please send them to Judy Sparrow (judy.sparrow@hhs.gov)

At noon today, HHS announced nearly $1 Billion in grant funding for Healthcare IT.
Here's the Press Release.
Massachusetts received $10.6 million for health information exchange and $13.4 million for regional extension center activities.
Now the next phase of our work can begin. We look forward to the challenges and achievements ahead.

Do you have an iPhone? Do you live in a place that has 4 seasons?
Using a capacitance-based touch screen with gloves just doesn't work.
Do you have large fingers and find typing on the iPhone to be a problematic experience?
Both problems are solved by a capacitance friendly stylus from Ten One Design.
This device uses proprietary materials to emulate the touch of finger and works on all Apple iPhones. You'll find that a pencil or paperclip will not provide the same capacitance characteristics and does not work with Apple touch screens
Making your iPhone work with accuracy while wearing gloves, having long nails or large fingers - that's cool!

My daughter is 16 going on 17, a junior in high school. We've begun discussions of colleges, SAT scores, and her future.
Many of my peers in healthcare management have college bound children and are having the same dinner table conversations - what constitutes success, what college to choose, how to work together over the next year to guard against the stress acceleration every high school student is feeling.
College admissions should not be a beauty contest for parents to judge their success in child rearing based on acceptance letters from Ivy League institutions. College admissions should be about matching the needs of the individual with an institutional culture, location, and teaching style that builds self-confidence and resilience.
What do I mean?
I attended Stanford, UCSF, UC Berkeley, UCLA, Harvard, and MIT. My post secondary education lasted 17 years from 1980-1997.
My personality type was a bit odd - I majored in those topics that were most confusing to me. I speculated that if I could master my weakest areas, I would become a resilient life long learner of anything that would come my way.
My daughter is talented in ways that I am not (the visual arts, foreign languages, and mathematics that requires spatial sense). No doubt this is because my left brain (math, science, engineering) combined with my wife's right brain (arts, philosophy, creativity) to create a whole brain. My daughter is seeking to define herself, discover those areas in which she can be truly excellent, and build self-confidence.
She would not thrive at a large, urban school, filled with thousands of anonymous peers. She would not thrive in a competitive academic culture which rewards privation, suggesting that if you're not suffering, you're not learning.
She's seeking a school that is small to medium sized, rural or suburban, located in New England, with a supportive culture that can polish a lovely and intelligent young woman into an assertive but not aggressive adult.
With the right encouragement and opportunities, she'll be challenged but not overwhelmed, hard working but not fatigued, and encouraged to find her unique place in the world.
I do not define success as fame, fortune, or Google hit count. I define success as resilience to navigate the world, enthusiasm to get up each day because you love what you do, and happiness with the people around you.
So, you go girl. Find a college that makes you blossom. Your parents will be there, proud of its fit for you, not its ranking in US News and World Report.

The comment period for the Interim Final Rule on Standards runs from January 15 to March 15. I've spoken to many stakeholders in industry, hospital IT departments, and government. Here are the five general themes I'm hearing from the comments they'll be submitting:
1. Need for additional guidance on content standardsAs I've noted in earlier posts, the IFR is a regulation and ONC did not want to provide too much specificity that would require changing regulation to support evolving implementation guidance. Although this was the right thing to do, the lack of constraints on HL7 2.51 and CCD creates ambiguity that could result in a tower of Babel - thousands of incompatible implementations of these standards. ONC needs to rapidly provide HL7 2.51 and CCD implementation guides (such as the HITSP Lab and HITSP C32 specifications)
2. Need for additional guidance on vocabulary standardsDo the vocabularies required - RxNorm, SNOMED-CT and LOINC apply to EHRs themselves or just the transactions sent between EHRs? What if a proprietary, self built medication vocabulary is integrated to the EHR but is mapped to RxNorm for all health information exchange? What about a proprietary problem list vocabulary that is mapped to SNOMED-CT? If mapping is allowed, what subset of these vocabularies should be used i.e. NLM's SNOMED-CT Core problem list subset, LOINC Lab ordering compendium etc.
3. Need for additional guidance on transmission standardsTransmission approaches need implementation guidance, per my previous blog posts. Stating that REST and SOAP are acceptable does not foster interoperability among various implementations.
4. Need for additional guidance on security standardsEncryption needs clarification. Is encryption of EHR data at rest required in certified EHRs? Although the intent is that data in transit and data on mobile devices needs to be encrypted, should vendors provide encryption in their products because they cannot know how they will be installed and used.
5. Need for additional guidance on quality measurementThe NQF Healthcare Information Technology Expert Panel work on quality measures is based entirely on CDA/CCD, yet patient summaries are summary may be sent in CCR or CCD. Thus, the NPRM's quality measures cannot be extracted from CCR using the current retooling. How do we reconcile incompatible definitions of patient summaries and quality measures?
I look forward to reviewing all the public comments, which will be made available by ONC via the web.

In my recent Top 10 EHR Barriers blog, I identified usability of EHR software as a key issue.
It appears that NIST, with ARRA funding and ONC guidance is doing something about it.
This Sources Sought request is to identify organizations with the capabilities to accelerate usability testing and guidance. Specifically:
1. Tasks, Users, and Systems Research Componenta. Perform cognitive task analysis of the health care delivery task environmentb. Determine user characteristicsc. Perform human factors analysis of representative sample of existing HIT systemsd. Develop hypotheses about critical HIT design featurese. Evaluate hypotheses with usability testing
2. Organizational Usability Processes Research Componenta. Study existing HIT industry usability practicesb. Investigate current usability evaluation methods being used in healthcare information technology as well as other areasc. Conduct a workshop of acknowledged experts in HIT usability and have them analyze the findings of steps 2a and 2b.d. Using the recommendations of the experts in step 2c and the principles identified in steps 1a through 1e, create a well-defined usability evaluation process that includes a roadmap for implementation and indicates where policy decisions are required.e. Evaluate a representative sample of HIT systems using the evaluation process developed in step 2df. Develop a common format for HIT formative and summative usability test reporting
3. Development Methodologya. Define, develop, and scope requirements.b. Define and develop the project approach and description.c. Adopt and refine methodologies following standard usability engineering principles.d. Define and manage organizational requirements.e. Perform cognitive task analyses and develop user profiles.f. Conduct human factors analysis of systems and do hypothesis testing.g. Identify existing usability practices in HIT development.h. Organize and facilitate HIT usability expert workshop.i. Develop, refine and harmonize usability and certification principles and frameworks.j. Provide documentation and communication.
There is not yet a solicitation for funding, but I'm confident that funding opportunities will be announced soon.
Usability must be a key aspect of the national EHR program. Clinicians note that current products are hard to use/learn and this lack of usability can lead to errors. Senator Grassley's investigation of the current state of EHR products is in part related to usability issues.
My own experience is that usability is journey. Several years ago when the Joint Commission asked hospitals to implement medication reconciliation for all transitions of care, my development groups built innovative software that leveraged inpatient, outpatient, ED systems, and Surescripts/RxHub medication history to support the process. It took us a year to get the usability right by engaging stakeholders, studying the workflow, and iteratively revising the user interface. Only after extensive usability improvements did the application get deployed and adopted.
I welcome the NIST work and hope that we can develop objective usability metrics as part of the certification process. Software should be capable and usable to qualify for certification.