Cool Technology of the Week

The recent work by the HIT Standards Committee requires the encryption of patient identified data on mobile devices (laptops, USB drives) to ensure confidentiality is protected. This is already required by the Massachusetts Data Protection Regulations.

At BIDMC, we use McAfee's Endpoint Encryption as our enterprise solution for encrypting mobile devices.

Though the product is good for the enterprise, there are alternatives for the home user (taking into consideration factors such as usability, supportability, performance, cost). For personal use, PGP Whole Disk Encryption is my cool technology of the week.

PGP Whole Disk Encryption provides continuous disk encryption for Windows and OS X, enabling data protection on desktops, laptops, and removable media.

The PGP Whole Disk Encryption engine operates at a system level between the operating system and the disk drive, providing user-transparent, sector-by-sector disk encryption and decryption.

The only change in the end-user experience with PGP Whole Disk Encryption is the addition of a pre-boot authentication screen. The pre-boot authentication screen protects the system from being accessed by unauthorized users by disabling their ability to attack operating system–level authentication mechanisms. Once the end user provides valid authentication, encryption and decryption of the disk are transparent to both the user and the operating system.

PGP Whole Disk Encryption uses the Advanced Encryption Standard (AES), which is the standard recommended by HITSP and the HIT Standards Committee.

A personal encryption system for mobile devices that is compatible with all the privacy and security protections suggested by national committees to comply with ARRA/Meaningful Use requirements - that's cool.

Traditional Japanese Clothing

This is another entry in my series about Kyoto.

Although I wear black in the office, at home I wear season appropriate traditional Japanese clothing.

Kyoto is a wonderful place for traditional crafts including fabric weaving, dying, and clothes making.

Here's a few of my experiences:

Samue - The most incredible fabrics and Indigo dyeing is done by Ken-ichi Utsuki, owner of Aizenkobo workshop, a traditional Japanese natural indigo dying and textile firm. He and his son fitted me with a Samue (Japanese workclothes for Zen monks and tradespeople). Indigo naturally repels mosquitos, and imparts a wonderful feel and odor to the fabric. I wear my samue while gardening, doing weekend chores, and while playing the Japanese flute.

Geta - Remarkable Japanese wooden sandals made from Kiri wood and Sugi (cryptomeria wood) are created by Kunimi Naito and her family in the Gion (Geisha) district of Kyoto at the Naito Geta shop (they do not have a website). They carefully studied my feet and are making a custom pair of geta for my 27cm western-sized foot. Standard geta available in tourist shops or online just do not fit my foot correctly because my arch is too high. Custom made geta are perfectly sized to my anatomy and enable me to walk comfortably. I wear Geta with my Samue.

Tabi - In Diane Durston's book, Old Kyoto, she highlights Fundo-ya, maker of custom tabi socks for Kyoto's kabuki actors and tea masters. If you use her book, note that the maps are wrong and that you should just find Fundo-ya by its address - Sakai-machi-kado, Sanjo-dori which means the corner of Sakaimachi and Sanjo street. Addresses in Kyoto are often very obscure, which was done purposefully to confuse invaders who might threaten the emperor/his resources when Kyoto was the capital of Japan. The owner of Fundo-ya carefully measured my foot and noted that I'm the largest Japanese size made - 27cm. Fundo-ya specializes in custom Tabi, so those with larger feet can be accommodated. I bought white and black Tabi to wear with my Geta.

Noragi - The clothing I wear most often around the house in the evening are traditional farmer's clothes. My favorite are Ikat Kasuri Hippari - Ikat Kasuri is a process of dying threads before they are woven. Hippari is a wrap around style of top. It's becoming increasingly hard to find antique traditional clothes in Japan, so I purchase them from 3 sources

Blue Moon

Ichiroya

Kimono Boy

Although I may be the man in black, you may find me on a mountain with a flute and Indigo dyed Samue or Ikat Hippari. Although there are other wonderful Japanese clothes - Kimono, Obi, Yukata, the clothes I've listed above are those that work best with my active lifestyle.

The Draft FY10 IS Clinical Systems Plan

Every year, BIDMC IS leadership gathers input from all our governance committees to produce an IS operating plan. The Clinical Systems area is the most challenging since we need to balance limited resources with ever increasing demand. Here is the draft FY10 IS Clinical Systems Plan based on the priorities of all our stakeholders. You'll notice an emphasis on projects which support meaningful use criteria for 2011 and 2013, accelerate national standards implementation, and provide increased interoperability.

Inpatient/CPOE/Pharmacy

* Implement pharmacy, charging and other revisions to support Pharmacy 340B requirements.

* Complete implementation of CPOE for NICU

* Complete implementation of CPOE for ED

* Implement outpatient pharmacy for oncology/chemotherapy

* Enhance inpatient applications as prioritized by the Inpatient Clinical Applications Committee

* Expand project and application support for in-house developed systems

Ambulatory (webOMR is our self-built EHR)

* Complete referral tracking to “close the loop” for outpatient referrals

* Continue to develop and expand the roll out of test results tracking

* Expand the roll out of pharmacy-initiated renewals

* Enhance problem lists to improve user interface and support SNOMED-CT

* Support implementation of PatientSite Personal Health Record patient-provider encounter summary sharing (Open Notes)

* Pilot expanded healthcare information exchange technologies in Cancer Center to push outpatient notes to referring MDs

* Pilot online surgical booking orders

* Enhance webOMR as prioritized by webOMR Users Group

Clinical Documentation

* Develop a strategy, plan and timeline, in conjunction with Clinical Leadership, to implement meaningful use standards for 2011 and future years.

* Begin planning for acute care documentation, standardized problem list and eMAR

* Complete medication reconciliation modules

* Complete enhancements supporting multidisciplinary collaboration in discharge applications

* Continue expansion of NEHEN notification and communication systems

Operating Room

* Implement intra-operative documentation in PIMS (Perioperative Information Management System)

* Implement “sign out” and related safety enhancements in PIMS

* Enhance PIMS as prioritized by OREC (O.R. Executive Committee)

Health Information Management/Scanning

* Integrate scanned notes and reports in webOMR as prioritized by the webOMR Users Group

* Integrate faxed documents in PIMS to support Preadmission Testing and OR in managing documents faxed from external sites

Radiology

* Expand roll out of web-based report signing (currently in pilot)

* Develop a strategy for displaying preliminary reports (with Radiology)

* Implement multi-year roadmap to enhance our in-house developed RIS and optimize RIS-based workflow

* Continue project management and technical support for projects / enhancements as prioritized by department governance including:

* Installation of new Radiology modalities

* Image sharing with Children's hospital

* Needham Hospital PIX (Patient Identity Cross Reference system)

* Front-end Voice Recognition

* RIS/PACS integrator

* Nuclear Medicine enhancements / upgrades

Laboratory Information System

* Continue implementation of the Soft Laboratory system including:

interface development and testing

integrated test planning and execution

* Continued management of the application environment including software upgrades and implementation of a new server environment

Critical Care/Anesthesia

* Perform major upgrade to MetaVision (MV ICU) version 5.46

* Evaluate and implement MV ICU enhancements as prioritized by ICU governance

* Continue to support MV ICU Application Administrator activities until the role is fully transitioned to the department of Critical Care

* Develop a plan and budget for implementation of an enhanced Anesthesia

* Information Management system

* Support existing systems including Patient Safety Reporting System, OB-TraceVue, Transplant and Trauma Registry.

Cardiology

* Participate in planning, analysis, budget, and timeline development for:

Cath Lab Reporting

Vascular Reporting

* Continue implementing/supporting CVI Registries

* Support Apollo, MACLab/CardioLab and Echo

Enterprise Image Management

* Advance enterprise PACS efforts in conjunction with the IS infrastructure teams, including:

Provide consultative and project and technical management to Radiology, OB, GI, CVI and other medical center PACS projects as prioritized by the Enterprise PACS committee

Continue to explore strategy for Enterprise Archive management

* Complete CardioPACS Migration Including:

GemNet Upgrade

Echo DVD Migration

CVI Cath / Echo Web Images

Complete Radiology PACS Disaster Recovery

Support G-Care/G-Med

Radiation Oncology

* Continue project management and technical support for projects / enhancements as prioritized by department governance including:

* Completion of Mosaic Phase II (Digital Images)

* Implementation of Radiation-Oncology HIS/ADT Interface

* Upgrade Philips Pinnacle Treatment Planning System Workstations

* Upgrade Elekta CMS/Focal Treatment Planning System

* Support existing systems including: Impac, Cyberknife and associated treatment planning systems.

Infection Control Surveillance

* Develop plan and approach for implementation of infection control surveillance software

Ambulatory/Community EHR

* Continue to support efforts to implement the eClinicalWorks EHR to non-owned BIDPO clinicians

* Analysis and planning for BID Lab Results interface to BIDPO eClinicalWorks

* Migrate existing Logician practices to eCW as appropriate

* Analysis and planning for BID Radiology Results interface to the Fenway CHC

* Design and implement an online archive system for all Logician retired systems and practices.

* Support community systems

Decision Support

* Implement Performance Manager reports and dashboards as needed to support organizational needs.

* Implement clinical data marts as needed to enable quality measurement, pay for performance goals, and other decision support needs.

* Enhance the Community Provider Index to better support Health Information Exchange via NEHEN gateways.

* Implement enhancements to the Patient Activity Profile to support enhanced reviews required by JCAHO.

* Enhance SOAR (Accounts Receivable workflow) to support denial tracking and appeals workflow

* Explore the introduction of new Business Intelligence tools as funding permits

* Support Cactus and NEHEN Express users

Web Applications

* Continue to enhance the Adverse Events Manager as prioritized by Healthcare Quality.

* Continue the migration of account provisioning and metadirectory services to SQL Server and ASP.NET.

* Develop services to support document scanning, metadata capture, and document display.

* Continue to support implementation of a new BIDMC intranet portal

* Create web services as needed for integration of BIDMC applications and for interactivity with external collaborators

* Support PatientSite for clinicians and the end-user community

We're also updating our 5 year plan to reflect new ARRA priorities and new compliance requirements. I'll publish that soon.

The Latest Deliverables from the HIT Standards Committee

Today, the HIT Standards Committee received the latest deliverables from its workgroups.

The Quality Workgroup presented its updated matrix of measures, data types and recommendations. Of the 29 measures listed, 17 are measures of quality which are being retooled by quality measure authors to be based on data elements captured in an EHR. Two are privacy/security related (Full compliance with HIPAA Privacy and Security Rules, Conduct or update a security risk assessment and implement security updates as necessary) and 10 are related to the adoption of EHR function (i.e. % of orders for medications, lab tests, procedures, radiology, and referrals entered directly by physicians through CPOE). The actual data standards needed to measure quality and the implementation guidance for these standards are summarized in the Clinical Operations matrix discussed below.

A very important discussion about quality measurement reporting is summarized on slide 3 in this presentation. There are a number of stakeholders for quality data exchange

Measure definition entities such as the National Quality Forum or its associated measure authoring groups.

Providers who record clinical data in electronic health records.

Data Collection Assistant entities such as Healthcare Information Exchanges which gather data from EHRs and transport it for a multitude of purposes.

Quality Report Processing entities such as registry providers, performance analysis companies, or specialty societies which gather benchmarking data.

Receiver entities which collect quality reports as part of a reimbursement process.

Among these stakeholders, you can imagine 5 kinds of data exchange

1. Transport of measure definitions from measure authors to all the other stakeholders

2. Transport of patient level quality data from EHRs to HIEs

3. Transport of data from HIEs to a quality registry

4. Transport of quality reports to CMS in patient level detail format

5. Transport of quality reports to CMS in summary (numerator/denominator) format.

The HIT Standards Committee has recommended standards for 2-5, but these standards have varying degrees of maturity. The work of the next several months will be to work with ONC, HITSP, and SDOs to fill gaps and accelerate adoption of the standards needed for these exchanges.

The Security Workgroup presented its latest standards selection, certification criteria, and implementation guidance. The first matrix includes functionality, standards, a timeframe for adoption, and certification criteria. The second matrix includes functionality, standards, implementation guidance, and gaps.

The importance difference in these documents from previous work is the reformatting to clarify where options exist – standards that are required jointly (standard A + standard B) and standards for which the implementer is given a choice (standard A or standard B)

The Clinical Operations Workgroup presented two matrices - a summary of the standards required for meaningful use (subject area, 2011 standards, 2013 standards, future trajectory) and the detailed implementation guidance (health outcomes priority, meaningful use measure, subject area, 2011 implementation guidance, 2013 implementation guidance, and future trajectory),

The standards selected do not vary significantly from previous matrices, but the implementation guidance is significantly expanded and clarified based on input from many stakeholders.

What are the next steps for the workgroups?

For privacy and security we will incorporate guidance from existing NIST documents regarding the capabilities required in products to implement the standards selected in a manner that supports security best practices.

For clinical quality we need to ensure all 5 transaction types (described above) among quality measurement stakeholders are supported

For clinical operations, we need to ensure vocabulary gaps are closed (Orderable laboratory compendium, SNOMED-CT subsets, SNOMED crossmaps to ICD-9, ICD-10 and LOINC. We need to provide additional guidance to support patient access to electronic records and work on implementation guidance for 2013 meaningful use measures.

As helpful background to all the HIT Standards Committee members, Lee Jones presented an overview of the implementation guidance efforts of HITSP which aim to provide as much specificity and as little optionality as possible, to enhance interoperability by reducing variably.

A very positive meeting. We have now provided all of this guidance to ONC and HHS as input to the interim final rule regulations which will be issued in December. I look forward to seeing those regulations as they represent the culmination of 4 years of HITSP work and nearly a year of HIT Standards Committee work.

I also know that there is much work to do providing the additional guidance necessary to achieve 2013 and 2015 meaningful use goals. Onward!

Security for Healthcare Information Exchange

In my role as vice-Chair of the HIT Standards Committee, I join many of the subcommittee calls debating the standards and implementation guidance needed to support meaningful use. Over the past few months, I've learned a great deal from the Privacy and Security Working group.

Here are my top 5 lessons about security for healthcare information exchange.

1. Security is not just about using the right standards or purchasing products that implement those standards, it's also about the infrastructure on which those products run and policies that define how they'll be used. A great software system that supports role-based security is not so useful if everyone is given the same role/access permissions. Running great software on a completely open wireless network could lead to compromise of privacy.

2. Security is an end to end process. The healthcare ecosystem is as vulnerable as its weakest link. Thus, each application, workstation, network, and server within an enterprise must be secured to a reasonable extent. Only by creating a secure enterprise can healthcare information exchange be secured between enterprises.

3. As stated in #1, policies define how security technology is used. However, the US does not have a single, unified healthcare privacy policy - we have 50 of them since state law pre-empts HIPAA. This means that products will need to have the technology capabilities to support heterogeneous policies. For example, a clinician may have simple username/password authentication, while a government agency might require a smart card, biometrics, or hardware token.

4. Security is a process, not a product. Every year hackers will innovate and security practices will need to be enhanced to protect confidentiality. Security is also a balance between ease of use and absolute protection. The most secure library in the world would be one that never checked out books.

5. Security is a function of budgets. I spend over $1 million per year on security work at BIDMC. Knowing that rural hospitals and small practitioners have limited budgets, we need to set security requirements at a pace they can afford. Imposing Department of Defense 'nuclear secrets' security technology on a small doctor's office is not feasible. Thus, the Privacy and Security Workgroup has developed a matrix of required minimum security standards to be implemented in 2011, 2013, 2015, realizing that some users will go beyond these minimums.

Privacy and Security is foundational to ARRA and Meaningful Use. Since patients will only trust EHRs if they believe their confidentiality is protected via good security, there will be increasing emphasis on better security technology and implementation over the next few years.

Although some may find increased security cumbersome, our goal of care coordination through health information exchange depends on robust security technology, infrastructure and best practices.

Reflections on 9/11

My schedule for the next few days includes flights to Denver, Las Vegas, San Francisco and Washington.

I spent all of Thursday afternoon in Logan airport waiting for a delayed flight to take off.

What happened and what was the root cause?

My 2:45pm flight was originally reported on time. Then it became slightly delayed to 3:15pm because of a late departure of the inbound aircraft. Then it became indefinitely delayed due to a "mechanical failure" that occurred in flight. The only information given was that the plane would land, mechanics would diagnose the problem, and then propose a departure time based on their findings.

At 4pm, they announced that the problem would require a spare part to be flown in from Washington, which would arrive at 5pm and be installed by 6pm. A go/no go decision would be made at 6pm.

At 6pm the plane was fixed, but no one could find the pilots. They had checked into a hotel while waiting for the mechanics to finish.

At 6:30pm we boarded. At 7:15 pm we took off, a modest 4.5 hour delay.

We landed in Colorado at 9:30pm local time, I rented a car and drove to Keystone, CO for a keynote to the Colorado Hospital Association, arriving at midnight (2:00 am for me).

What was the root cause?

Since today is 9/11, it is important the we reflect on the downstream effects those events have had on all of us. 9/11 resulted in increased security, additional labor expense, and more financial pressure on the airlines. They downsized staff, planes, and schedules. They eliminated spare aircraft and reduced stocks of spare parts. The increase in energy costs exacerbated the situation - more overbooking, fewer seats, and less excess capacity to respond to cancelled/delayed flights. If a flight is cancelled, it can take a day or two to reroute passengers via other already overbooked flights.

In my case, all other flights to Denver on 9/10 were overbooked and could not accommodate standbys. No spare aircraft were available. The right spare parts were not stocked in Boston.

Not only did 9/11 have a devastating impact on the people involved and their families, it caused all of us to set different expectations for our ability to travel. My response to this is to offer words of kindness to the airline employees who are on the front lines responding to stressed passengers. I try to bring a sense of optimism to my fellow passengers and explain to them from all my experience traveling that the best approach is to wait for the repair even if that takes several hours. Trying heroic multi-airport rerouting rarely works or saves time. I try to turn my observations of the repair process into progress reports for those around me.

If you're traveling and you experience a delay or cancellation, be kind to the airline staff who are not empowered to fix the economic circumstances that caused the recalibration of the entire airline industry. Be optimistic and helpful with your fellow passengers. Stretch, have a cup of tea, and always bring a good book or computer to pass the time.

Our economy, national psyche, and travel flexibility have all been changed. Let's support each other to make the best we can from the series of events (9/11, energy prices, and the economy) we've been dealt.

In Praise of Japanese Food

When you think of Japanese cuisine, what foods come to mind - sushi, sashimi, teriyaki?

Remember that Japan has long embraced Buddhism, a philosophy that includes vegetarian specialty foods.

When I think of Japanese cuisine here's what comes to mind:

Okara - to make tofu, soybeans are boiled and then ground to make soymilk which is then turned into tofu by adding nigari coagulant that produces "soy curds". The leftover ground soybeans are okara. It's a great dish served cold with mixed vegetables.

Yuba - when soy milk is boiled, a film appears on the surface, which can be served fresh or dried into sheets. This soymilk film is called yuba. It's high in protein and is a great chewy, flavorful dish served with a bit of soy sauce.

Fresh tofu - Kyoto has remarkable tofu restaurants. My favorite tofu restaurant, Kiko, sits a dozen people and is so hard to find that even the Japanese cannot locate it. Here's a hint - it's just south of Shijo-dori between the Kamagawa River and Kawaramachi-dori behind the Hankyu Department Store, 30 meters south of the Murakami-Ju Japanese pickle store. Above, I've included a picture of the noren, the curtain over the doorway, which is a painting school of minnows from the Kamagawa river. Their Aoi tofu (naturally blue green tofu) is remarkable.

Shojin Ryori is formal Zen Buddhist cuisine. My favorite Zen restaurants are adjacent to the Kiyomizudera temple in Southeast Kyoto and surrounding Nanzenji on the Philosopher's Walk in Northeast Kyoto.

During the summer, fresh cold somen noodles, such as those served at Shinshin-an in Kifune are truly refreshing. In Kifune, a mountain town north of Kyoto, you can eat on tatami mats suspended over the flowing river. The somen is sent from the kitchen in tubes that flow in front of you and you catch the noodles with your chopsticks as they pass by.

There are numerous great vegetarian Japanese sweets

*Momiji Manju, a maple leaf 'waffle' filled with beanpaste.

*Wagashi are Japanese sweets made from pounded rice and bean paste. Here's a photo of the sweets I made in Kyoto during a wagashi lesson arranged for my family by Michiko Yoshida

*Fu Manju (wheat gluten with azuki bean filling - buy it from Fuka on the Nishiki market street)

Other favorite Japanese foods are rice crackers (buy them from Funahashi-ya on the Sanjo bridge, but be careful with the Sansho pepper crackers which numb your tongue) and fresh pickles (buy from Murakami-Ju on Shijo dori)

Of course, Japan prides itself on seasonal specialties. During the Fall look for Matsutake mushrooms and during the winter enjoy boiled tofu (Yodofu)

I could easily retire to Kyoto and enjoy the multitude of vegan friendly cuisines for breakfast, lunch and dinner.

Next time you think of Japanese foods, realize that the American Japanese restaurant experience pales in comparison to the fresh, seasonal celebration of remarkable traditional foods available in Kyoto!

HITSP's Next Priorities

Today I led a HITSP Board meeting and we discussed the work being done in collaboration with the HIT Standards Committee. On September 15, the HIT Standards Committee and its workgroups will release the finished 3 matrices documenting the chosen standards for Clinical Operations, Clinical Quality and Security/Privacy including certification criteria and implementation guidance.

There are very few standards gaps for 2011, but there is work ahead for 2013 and 2015 standards, including ensuring all the necessary content standards and vocabularies are ready for ordering labs, reporting summary quality measures, and representing consumer preferences for care and consent.

The HITSP work ahead is focused on 3 waves as outlined in this Powerpoint Presentation.

Wave 1

Quality Measures

Common Data Transport

Newborn Screening

Consumer Preferences

Clinical Research

General Lab Orders

Medication Gaps

Prior-Authorization

Wave 2

Clinical Encounter Notes

Common Device Connectivity

Long Term Care

Maternal and Child Health

Medical Home: Co-Morbidity & Registries

Order Sets

Scheduling

Wave 3

Consumer Adverse Event Reporting

HITSP is funded through the end of January and hopefully ONC will issue an RFP for additional standards harmonization work. I believe that ongoing HITSP activities are necessary to

- Ensure standards are harmonized to support clinical research

- Help triage requests for the commissioning of new standards which will be needed to support meaningful use

- Provide implementation guidance for standards required as part of certification

- Continue to serve as the convener for all the standards development organizations and profile enforcement organizations

On September 15, I'll post the latest HIT Standards Committee deliverables which incorporate all HITSP tiger team implementation guidance. I think you'll be impressed.

Replacing a Stolen iPhone

Yesterday my daughter's 32 GB iPhone 3GS was stolen. She set her purse down for a moment while walking with a friend in a park and when she looked back it was gone.

It contained minimal cash, no credit cards, but it did have a $299 iPhone 3GS 32 GB. We filed a police report and searched the web for the possibilities, finding much contradictory information. What should you do? Here's my experience:

1. The credit card we used to buy it does not offer purchase protection - no luck.

2. Our home insurance deductible is larger than the iPhone price - no luck

3. Apple Care does not cover stolen iPhones - no luck

4. Apple and AT&T do not offer replacement insurance on iPhones - no luck

5. We stopped by the Apple store and found out that the retail price of a 32GB iPhone is really $699, but AT&T subsidizes a new purchase with a 2 year voice/data contract for $299. If the iPhone is stolen, AT&T customers can check the Apple website to find out if they are eligible for"early upgrade pricing": $299 (8GB), $399 (16GB), or $499 (32GB) with a new two-year contract. Thus, to replace a stolen $299 iPhone 3GS 32 GB costs $499. At least that's better than $699. Thanks for the additional subsidy AT&T.

Here's the language from the Apple site

"Requires new two-year AT&T wireless service contract, sold separately to qualified customers; credit check required; must be 18 or older. Existing AT&T customers who want to upgrade from another phone or replace an iPhone 3G should check with AT&T or use www.apple.com/iphone/buy to find out if they are eligible for early upgrade pricing: $299 (8GB), $399 (16GB), or $499 (32GB) with a new two-year contract.

For those who are not eligible for an early upgrade or who wish to buy iPhone as a gift, the prices are $499 (8GB), $599 (16GB), or $699 (32GB). In CA, MA, and RI, sales tax is collected on the unbundled price of iPhone."

Tomorrow we're going to call our home insurance agent to ask if there are any affordable riders to our policy that cover iPhones.

We're going to check on the purchase protection capability of all our credit cards to better plan for future purchases.

We're going to chat with Apple about discontinuing the AppleCare extended warranty on the old iPhone, since we no longer own it.

Thus, if your iPhone is lost or stolen, expect that you can get early upgrade pricing at the Apple store with a partial subsidy from AT&T. Definitely try to buy your iPhone with a credit card that provides purchase protection. Check your homeowner's policy for affordable coverage.

While I'm discussing iPhones, a lesson learned from using an iPhone in Japan. We found the 3G service to be excellent and making phone calls between our US-based phones (2 iPhones and 1 Blackberry) was simply dialing a local US call.

Data roaming, however, is extremely expensive - $5.00 per megabyte. You definitely want to buy a pre-paid international roaming plan which costs about $1.00 per megabyte.

From AT&T

"Purchasing an international data package can significantly reduce the cost of using data abroad. AT&T now offers four discount international data packages. The 20 MB package is $24.99 per month, the 50 MB package is $59.99 per month, 100 MB package is $119.99 per month, and the 200 MB package is $199.99 per month. See the AT&T website for details and international roaming rates."

Also, here a few tips for minimizing international data roaming cost

The iPhone is a great device. Keeping it affordable takes work!

Addendum:

1. We're applying for new credit cards that offer purchase protection

2. Applecare was very helpful and refunded the purchase of Applecare on the stolen iPhone

3. Our insurance agent is investigating options that are affordable. More to come.

Cool Technology of the Week

Before I became the CIO of Beth Israel Deaconess, I was the Executive Director of the CareGroup Center for Quality and Value, responsible for dashboards and business intelligence for BIDMC and several other hospitals. Building dashboards is challenging. Data must be acquired from multiple sources, cleaned up, normalized, and analyzed. Displaying data in a form that is actionable takes talent, such as per the work of Edward Tufte

Analyzing community health data provides policymakers with guidance to prioritize funding and public programs. The Healthy Communities Institute has developed a set of visual dashboards that are my cool technology of the week. Check out

San Francisco

Marin County

Sonoma County

San Bernardino County

Whatcom County

and click on See all Indicators.

You'll find some amazing data on the environment, disease prevalence, safety, and education with speedometer-like gauges.

Marin County has a great environment and quality of life, but does have issues with drug and alcohol use.

Having community snapshots like these for every county in America would make choosing a healthy place to live much easier. Sites like Sperling's Best Places provide cost of living, schools, crime, and climate info, but do not really describe the lifestyle and attitudes toward health in each locale.

Dashboards for healthy living on the web - that's cool.

The Experience of Tea

This is the first of many Thursday blogs about my recent trip to Japan. That trip was an exploration and appreciation of Japanese traditions.

Some of my favorite traditions are tea (cha-no-yū), incense (Kōdō), Japanese textiles (Samue and Farmer's jackets called Noragi), Zen cuisine (Shojin Ryori), and music (Shakuhachi).

Today's blog is about tea. While in Kyoto, I spent an afternoon with Nagahiro Yasumori, owner of Horaido Tea on the Teramachi shopping street in Kyoto. I traveled to the oldest tea store on the planet, Tsuen, located next to the Uji River bridge for the past 850 years. I also walked the hillsides of Uji (photo above) to wander among the bushes that produce the world's finest tea.

I drink 4 kinds of Japanese tea - Sencha, Gyokuro, Genmaicha, and Houjicha. I'll cover Matcha and tea ceremony in its own blog entry.

Sencha is traditional Japanese green tea. The leaves are picked, steamed, rolled, shaped, and dried. It has a grassy aroma and a bitter taste. Sencha Fukamushi is steamed a bit longer than regular Sencha and has a more intense flavor.

Gyokuro is a rare/fine tea grown in the shade rather than full sun. It's brewed in small quantities at lower temperatures and has a sweet, intense taste.

Genmaicha is Sencha mixed with roasted rice. It has a light, mellow flavor.

Houjicha is a roasted tea with a smoky flavor.

To make tea, I use a traditional Japanese ceramic teapot (a Kyusu) made of Banko ware. I preheat the teapot and brew the tea with dechlorinated hot water. I keep all my teas in airtight cherry bark tea caddies. Here are the proportions of water/tea, and the temperature I use:

Sencha

Tea leaves: 3 teaspoons (7 - 8g)

Water temperature: 176F (80C)

Amount of water: 200ml (7.04fl oz)

Brewing time: 1 minute

Sencha Fukamushi

Tea leaves: 3 teaspoons (7 - 8g)

Water temperature: 176F (80C)

Amount of water: 200ml (7.04fl oz)

Brewing time: 40 - 45 seconds

Gyokuro

Tea leaves: 3 teaspoons (7 - 8g)

Water temperature: 104 F

Amount of water: 100ml (3.5 fl oz)

Brewing time: 2 minutes

Genmaicha

Tea leaves: 3 teaspoons (7-8g)

Water temperature: 176F (80C)

Amount of water: 200ml (7.04fl oz)

Brewing time: 1 minute

Houjicha

Tea leaves: 3 teaspoons (7-8g)

Water temperature: boiling water

Amount of water: 200ml (7.04fl oz)

Brewing time: 15 - 30 seconds

Nagahiro Yasumori made us an extraordinary pot of Gyokuro by brewing it for several minutes at a very low temperature. The flavor was sweet, intense and almost wine-like in its persistent finish. We bought Kame-no-yowai Gyokuro and I'm sure I'll be buying from him frequently.

During my travels I consumed many great cups of tea and learned how to choose my tea wisely (buy from Horaido or Tsuen), care for my tea (use only fresh tea, kept in airtight containers), and brew the perfect cup (as above). If you visit me in any of my offices, you can be sure I'll greet you with a fresh pot of Sencha.

Snow Leopard is Up and Running

Over the weekend, I purchased a family 5 pack of Mac OSX 10.6 Snow Leopard and upgraded my wife's Macbook Pro, my daughter's iMac and my Macbook Air.

Although I did the simple automated upgrade for my wife and daughter, I used the opportunity to return my Macbook Air to its original factory settings and start from scratch - call it a technology spa day.

Over the past year, I've added many applications to my Macbook Air including HP printer drivers (which are often unstable and buggy), Office 2008 with Entourage (Entourage is always unstable and buggy), and several versions of Citrix/Webex/Gotomeeting etc.

The end result of adding many applications, many upgrades and many configuration changes during my Mac learning curve resulted in less than optimal performance. Thus, I backed up my important files to a USB drive then booted the Snow Leopard DVD, selected Utilities, Disk Utility and formatted/erased my hard drive by overwriting its contents with zeros.

Snow Leopard installed itself in about 30 minutes without a single error. I installed iWork '09 as my productivity suite and Aperture 2 to serve as my photo manager. I restored my files, added the HP network printer (without having to install HP software), and configured Mail, iCal and Addressbook to work with Exchange 2007.

The end result - a completely stable, fast computer with a very trim OS/application footprint - about 10 gigs, leaving 70 gigs free on my hard drive.

I've been running Snow Leopard/iWork/Aperture for 3 days now. I'm using Safari 4.0.3 as my browser and Preview as my document/PDF viewer - all 100% Apple software. The experience thus far has been a joy - very fast boot times, very fast application launch times, perfect hiberation/wake and seamless Exchange 2007 integration.

One of the great features in Snow Leopard is Screen Recording with automated You Tube uploads - a great feature for creating educational materials. As a test, I created a demonstration video of Google Health/Beth Israel Deaconess Personal Health Record integration.

I highly recommend Snow Leopard. My family gave the home CIO a big thumbs up.

Running Away to Join the Circus

Last night I joined the circus and danced center stage in Cirque du Soleil's Alegria with the White Singer.

My family tells me that the contrast of my all black clothing with her all white clothing looked elegant and refined, making up for my complete lack of ballroom dancing skills.

The story about how this happened is an amazing chain of events, illustrating the powerful forces of fate that shape our lives.

Here's the tale:

In September of 1980, I arrived at Stanford and moved into Granada, a dorm that's part of the Lagunita complex. I met a woman named Kathy Greene who lived in Eucalypto, another Lagunita dorm. She was Korean American, an artist, and could do everything I could not. She had a perfect right brain to complement my clumsy left brain. We've never been apart since and just celebrated our 25th wedding anniversary. She introduced me to Asian culture, food, and traditions. In my youth, I traveled by car throughout the continental United States, but I had no experience with the Orient.

Our daughter, Lara (named after the Dr. Zhivago character, not Lara Croft/Tomb Raider) was born in 1993 and she has always travelled with us around the world. She's been to Japan six times in her 16 years of life and has developed a love of people, the country, and the language.

This summer, she spent 8 weeks in Japan doing intensive language study. While she was there, one of her fellow students was Sam Allen, a high school senior who happens to live in Brookline, Massachusetts. They had great experiences together and shared anime, Akihabara, and Asakusa. After a month they decided to become a couple, going out together.

Which brings us to Cirque du Soleil. Early in the summer, we bought tickets to the August 30 performance of Alegria in Boston.

Lara and Sam are back from Japan and Lara invited him to the show. However, we lacked a ticket. We went online and found a seat available, but it was a single in the front row.

Being a devoted Dad, I volunteered to sit apart in the single seat. When we arrived at the theater, I was amazed to discover the single seat was 3 feet from the stage, next to the main stage entrance, on a corner, making it the most likely seat to host a "volunteer" from the audience.

Having attended Cirque du Soleil performances a few times in the past, I knew the audience members could be picked to join clown routines, magic acts, and various skits.

I waited in the hot seat for my moment of fame. After intermission, all the major characters assembled on the stage and the White Singer walked throughout the audience. She approached my chair and reached for my hand.

She led me to the center of the stage and we danced, surrounded by all the other characters. No photography was allowed, so alas, there is no evidence other than the several thousand people (including my family and Sam) who watched. At the end of our dance, the main character, Fleur, tapped me on the shoulder and motioned me back to my seat. I bowed and waved, then headed off stage.

The moral of the story? There is a direct causal thread between meeting my wife in 1980, developing a love of Japan which I passed on to my daughter, enabling her to meet Sam, resulting in my being placed in the one seat of thousands that would be selected for the on stage appearance.

My professional life is very similar. Becoming a CIO was the culmination of hundreds of events over 20 years that resulted in my being in the right place at the right time with the right colleagues and the right experience.

I believe that life is a wonderful combination of genetics and nurturing, planning and random chance, and a spiritual thread that leads us in and out of various eddies of opportunity throughout our lives.

Last night I joined the circus. I do not know what tomorrow will bring, but I'm looking forward to it!

Quality, Meaningful Use, and Interoperability

A reporter recently asked me to describe the quality measures and standards that are part of meaningful use. Floyd Eisenberg, Senior Vice President, Health Information Technology at the National Quality Forum, summarized the work nicely:

"The National Quality Forum (NQF), with support from the Agency for Healthcare Research and Quality (AHRQ) convened the Health Information Technology Expert Panel (HITEP) to develop a data model for quality measurement. The HITEP developed a framework, the quality data set (QDS), to manage the terms (value set), the context of use (quality data type) and the data flow (data source, recorder, setting, health record field) for each element used to build a quality measure. A quality data element combines the value set with the quality data type to directly express the definition of every term used to calculate a measure. HITEP finalized the quality data types July 31, 2009. During the August 25-27 face-to-face meeting HITSP reviewed all of these data types, defining the standard interoperable segment and taxonomy to represent each. While some areas require harmonization and others represent gaps, a significant portion of data types were sufficiently defined to allow their use in quality measures in the near term. These findings are reflected in updates to the IS 06 Quality Interoperability Specification to be presented to the HITSP Panel September 15. These data type interoperability determinations will also be used in the retooling process for those quality measures recommended for meaningful use by the HIT Standards Committee based on areas for measurement identified by the HIT Policy Committee. Completion of the retooling effort before the end of 2009 will allow time for EHR vendors and local EHR implementations to address these retooled measures in 2010 for reporting in 2011.

HITSP has also established constructs to address two prior gaps in the IS 06 interoperability specifications. There had previously been no standard for reporting of quality measures to a requesting entity. HITSP has now completed public comment for C105 (Patient Level Quality Document Using HL7 Quality Reporting Document Architecture (QRDA)) and revisions will be presented to the HITSP Panel on September 15. This component allows standardization of reporting structure. The HIT Standards Committee elected to allow more testing of QRDA before requiring its use will reconsider it for 2013 based on testing. HITSP also published a provisional component, C106 (Measure Criteria Document) that addresses a currently balloted HL7 to standardize the structure of all quality measures. The HL7 ballot, eMeasure, addresses the HITEP quality data types mentioned above.

In addition to these efforts, under contract from ONC, HITSP has retooled 16 inpatient measures for electronic use, each has also addressed the HITEP data types. A technical note with the details of these retooled measures will be available for public comment in September. Two of these measures are in the list of meaningful use measures suggested by the HIT Policy and Standards Committees. "

Thanks Floyd!

A HITSP Town Hall

Today at 2pm, I'll be running a HITSP Town Hall public webinar about ARRA, health information exchange, and standards.

Here are a few resources I'll reference:

My Slides

The approved HIT Standards Committee Clinical Quality Standards Matrix

The approved HIT Standards Committee Clinical Operations Standards Matrix

The approved HIT Standards Committee Security and Privacy Matrix

The approved HIT Policy Committee Meaningful Use Matrix

The approved HIT Policy Committee HIE priorities which are:

2011
Lab results delivery
ePrescribing
Claims and eligibility checking
Quality & immunization reporting

2013
Registry reporting and reporting to public health
Electronic ordering
Health summaries for continuity of care
Receive public health alerts
Home monitoring
Populate PHRs

2015
Access comprehensive data from all available sources
Experience of care reporting
Medical device interoperability

All of these materials have been transmitted from the HIT Policy and Standards Committees to ONC where they are being used to write the regulations which will be issued by HHS on December 31, 2009.

A Milestone for Device Interoperability

What is standards harmonization?

I describe it as the parsimonious number of standards required to meet the requirements of stakeholders. It is achieved by closing gaps and eliminating redundancy.

Can we always reduce the number of standards in a domain to 1? Not necessarily. Sometimes the best we can achieve is 2 with mapping between them or 2 initially converging over time to 1.

In the past, we've had multiple interoperability standards for devices. Earlier this year, HITSP challenged IHE and Continua to converge their work as part of the HITSP Remote Monitoring Use Case.

The Continua Alliance, a non-profit, open industry coalition of the more than 200 healthcare and technology companies joined together in collaboration to improve the quality of personal healthcare, has been focused on interoperability standards for consumer products. It wanted "fast and light" device standards that could easily be deployed with products in the home.

Integrating the Healthcare Enterprise (IHE), an initiative of healthcare professionals and industry to improve the way computer systems in healthcare share information, has focused on more complex devices such as those used by providers in hospitals and clinics.

Yesterday, Continua and IHE announced a breakthrough. They have agreed to a single set of content, transport, and vocabulary standards that work for all devices - home-based and hospital-based, simple and complex. This means that the industry is free to innovate and regardless of the devices created, they will be interoperable.

What standards did they choose?

Content - HL7 v2.6 messages using IHE PCD-01
Vocabulary - Constrained to IEEE/ISO 11073-20601/11073-104xx nomenclature
Transport - Web Services transport based on WS-I Basic Profile

Here are few comments by the leaders of this effort:

"IHE believes that this collaborative breakthrough offers enormous benefits to US citizens and their physicians. This helps accelerate the deployment of convenient and reliable home-based health monitoring and care, and facilitates many other forms of remote monitoring as well. Together, Continua and IHE have finally made it possible for vendors of Medical Devices and Personal Health Devices to efficiently send patient data to the Personal and Electronic Health Records vendors using a single unified interoperability standard that is endorsed by HITSP."

Elliot B. Sloane, PhD
Co-Chair, Integrating the Healthcare Enterprise (IHE) International Executive Director, Center for Healthcare Information Research and Policy


"The Continua Health Alliance appreciates the opportunity HITSP has afforded to work with IHE to provide a harmonized approach for the Remote Patient Monitoring Use Case with an open architecture, international, standards-based solution. This will facilitate an ecosystem of connected technologies, devices, and services that provide a compelling way to meet the challenges of increased access, improve outcomes for patients, and ultimately reduce overall healthcare costs."

Rick Cnossen
Director, Personal Health Enabling, Intel Digital Health Group (DHeG)
President, Continua Health Alliance (www.continuaalliance.org)


I want to offer my congratulations and thanks to IHE and Continua for this achievement. Their leadership illustrates the finest characteristics of harmonization achieved by assembling smart technical people, aligning mutual interests, then moving forward to converge on a single approach.

Bravo! All device stakeholders will now benefit from a single universal set of standards used to connect devices to EHRs and PHRs.

The FY10 HMS IT Operating Plan

Every year I work with all the stakeholders at Harvard Medical School to develop an operating plan. Here are a few observations about the process:

-In an economic downturn, governance is very important to triage projects, set timelines, and allocate resources. Budgets define the supply of resources. Governance helps balance supply and demand. During my tenure as CIO, we've had workgroups for research, education, and administrative customers, but this year I'm formalizing governance by creating an overall IT Steering Committee comprised of research faculty, educational leadership, and administrative Deans. My educational, administrative and research workgroups will report to this overall IT Steering Committee.

-I have 5 direct reports at HMS who serve as the single point of accountability for Administration/Finance, Education, Research/Customer Service, Infrastructure, and Technology. Each is responsible for translating the strategic and business priorities of their customers into the tactics listed in the operating plan.

-Once the operating plan is complete, my role as CIO is to ensure appropriate capital budgets, operating budgets, and staffing are in place to execute the plan. 2010 will require especially close collaboration with the leaders at HMS to balance the necessary resources with the need to be frugal in a challenging economy.

-Major themes in the FY10 IT Operating Plan include enhanced enterprise infrastructure (especially storage), workflow applications to promote departmental efficiency, and web-based software as a service tools that reduce costs while improving service to all stakeholders.

-I summarize the yearly effort to develop the plan as

Strategy - document the goals and business strategy of all stakeholders, translating them into operating tactics.

Structure - ensure the IT organization is optimally configured to execute the tactics.

Staffing - populate the structure with the best people to do the work.

Budget - put the capital and operating budgets in place so that the necessary resources are available to execute the scope of work in the timeline needed.

Processes - Define the workflow and procedures that are needed to support project management, customer service, and continuous improvement.

Here's the initial version of the FY10 HMS IT Operating Plan. I look forward to a great year ahead.

Cool Technology of the Week

Before my trip to Japan, I attended the New England Healthcare Institute Medication Adherence Expert Roundtable on Thursday July 23rd, 2009. The purpose of the roundtable was to prioritize activities that would encourage patients to be more compliant with the medications, especially those with chronic diseases such as diabetes, congestive heart failure and COPD. Recommendations from the group included better patient education, enhanced use of IT such as medication reconciliation, and healthcare reform which ensures clinicians have the time and incentives to coordinate and manage all medications for their patients.

One technology that we discussed was an intelligent pill bottle for the home from rxvitality.com and it's my cool technology of the week. Using technology similar to the Ambient Orb, the intelligent pill bottle flashes to indicate when it's time to take the medication inside the bottle. When the bottle is opened it sends telemetry back to a portal which can be used to track patient medication adherence.

The device includes a small wireless access point for the home, making the device plug and play. No cell phone plan, configuration or special software is needed - just an internet connection.

A pill bottle that notifies the patient when medications are to be taken and informs the clinician when medications are actually taken.

That's cool!

Funding for HIEs and RHITECs arrives

Yesterday was a landmark day - the HIT Standards Committee approved the quality, clinical care, and privacy/security standards that serve as certification criteria and support meaningful use. At the same time, HHS released $564 million for Healthcare Information Exchange to be given to States/State Designated Entities to accelerate interoperability implementation and $598 million for Regional Healthcare IT Extension Centers (RHITECs) which are applied for competitively (not distributed via state government) to accelerate EHR adoption.

Of interest, the range of award for HIE is $4,000,000 to $40,000,000. Fifty awards will be given.

The range of award for RHITECs is $1,000,000 to $30,000,000 with an average of 8,543,000
Award Floor $ 1,000,000. Seventy awards will be given.

The press release is below.

CHICAGO, IL – Vice President Joe Biden today announced the availability of grants worth nearly $1.2 billion to help hospitals and health care providers implement and use electronic health records. The grants will be funded by the American Recovery and Reinvestment Act of 2009 (ARRA) and will help health care providers qualify for new incentives that will be made available in 2010 to doctors and hospitals that meaningfully use electronic health records.

“With electronic health records, we are making health care safer; we’re making it more efficient; we’re making you healthier; and we’re saving money along the way, ”said Vice President Biden. “These are four necessities we need for healthcare in the 21st-century.”

“Expanding the use of electronic health records is fundamental to reforming our health care system,” said HHS Secretary Sebelius. “Electronic health records can help reduce medical errors, make health care more efficient and improve the quality of medical care for all Americans. These grants will help ensure more doctors and hospitals have the tools they need to use this critical technology.”

The grants made available today include:

Grants totaling $598 million to establish approximately 70 Health Information Technology Regional Extension Centers, which will provide hospitals and clinicians with hands-on technical assistance in the selection, acquisition, implementation, and meaningful use of certified electronic health record systems.

Grants totaling $564 million to States and Qualified State Designated Entities (SDEs) to support the development of mechanisms for information sharing within an emerging nationwide system of networks.

The Extension Center grants will be awarded on a rolling basis, with the first awards being issued in fiscal year 2010. Grants to States will be made in fiscal year 2010. Those interested in applying for these grants may visit http://HealthIT.HHS.gov for more information.

“With these programs, we begin the process of creating a national, private and secure electronic health information system. The grants are designed to help doctors and hospitals acquire electronic health records and use them in meaningful ways to improve the health of patients and reduce waste and inefficiency,” said Dr. David Blumenthal, National Coordinator for Health Information Technology. “They will also help states lead the way in creating the infrastructure for health information exchange, which enables information to follow patients within and across communities, wherever the information is needed to help doctors and patients make the best decisions about medical care.”

The Department of Health and Human Services will also provide additional assistance to health care providers through the Health Information Technology Research Center (HITRC). The HITRC will gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support.

The Next Deliverables of the HIT Standards Committee

Today in Washington the HIT Standards Committee met to discuss the latest deliverables from its workgroups - Clinical Quality, Clinical Operations and Privacy/Security.

A few highlights:

*The workgroups presented the standards needed to support meaningful use and certification criteria. A certified EHR must meet the functionality criteria currently being developed by ONC but also must be capable of supporting the standards defined by the HIT Standards Committee workgroups.

*The standards themselves apply to capabilities that need to be included in the products for certification, and the use of those capabilities to codify patient data, and to calculate and report quality measures constitutes the 'meaningful use'.

*The theme for the meeting was convergence - after countless hours of work, today's deliverables included the synthesis of the efforts of all three workgroups, recommendations of the policy committee, and public comment.

The Clinical Quality workgroup presented 30 measures of quality and the data types required for each. Working collaboratively with Clinical Operations, specific content and vocabulary standards were selected all but 6 data elements, 3 of which are for one quality measure.

The Clinical Operations workgroup presented the content and vocabulary standards supporting meaningful use. Importantly, there were no gaps in standards needed to support all 2011 meaningful use criteria. The workgroup was very thoughtful about the maturity of standards and presented a gradual transition plan, allowing some variation (PDF, document images, free text) in 2011, but eliminating these unstructured documents for 2013. Their work included messaging formats (such as HL7 2.51) and document formats (such CDA/CCD), and all the vocabularies necessary for semantic interoperability (such as SNOMED-CT, RXNORM, UNII for allergies, and LOINC for labs). Note that the work of Clinical Operations describes the exchange of data between organizations, not the data model, architecture or implementation details within an organization.

The Privacy and Security workgroup presented the authentication, authorization, auditing and secure data transmission standards. Note that Privacy and Security includes standards for use in EHR products, the infrastructure that hosts them and best practices. Their work does include protecting data inside an enterprise as well as data exchange between enterprises because security is an end to end process. Security is as strong as the weakest link in the data exchange. Just as with the Clinical Operations workgroup, a great deal of thought went into the timeline when standards should be adopted, enabling a glide path from the present to stronger security. There were no gaps in the standards needed for 2011, although additional work on consent management and consumer preferences will be done to support later years, ONC, the Standards Committee and HITSP will work on consumer preference standards together in upcoming meetings.

The HIT Standards Committee also decided to establish a workgroup to focus on adoption/implementation issues.

All of the workgroup deliverables were accepted by the Committee and have been submitted to ONC as guidance for the regulation writing process.

A very impressive body of work. Thanks to all the workgroup members, the HITSP tiger teams, and ONC for making it all possible.

The Road Less Traveled

I'm back from Japan, physically and spiritually refreshed, ready to embrace my jobs , my blogging, and my outdoor activities with new vigor.

In previous years, my vacations have been about movement - hiking the John Muir trail, climbing in Yosemite, and exploring the outdoors with my family.

This year's trip to Japan was about people. My family and I had remarkable experiences that were not about traveling to every tourist spot, taking a few photographs, then shuttling to the next location. Instead, we based our ourselves in Kyoto for 2 weeks and in the Inland Sea (Miyajima) for 3 days, spending time with shopkeepers, craftsman and friends. Here a few examples:

We had the opportunity to spend a few hours with the President of Shoyeido Incense, Masataka Hata, the 12th generation leader of the company. He led us in a traditional Japanese incense ceremony (Koh-do), teaching us the details of refined arts from the 1600's.

We had the opportunity to meet with the owner of Horaido Tea, Nagahiro Yasumori, whose family has sold tea in Kyoto since 1803. He taught us how to make the ideal cup of Gyokuro and Sencha green tea.

We spent an afternoon with Ken-ichi Utsuki, owner of Aizenkobo workshop, a traditional Japanese natural indigo dying and textile firm. He and his son fitted me with a Samue (Japanese workclothes for Zen monks and tradespeople).

We met with Kunimi Naito and her family, makers of traditional Japanese Geta (wooden sandals) in the Gion (Geisha) district of Kyoto. They carefully studied my feet and are making a custom pair of geta for my 27cm western-sized foot.

We met with a Sake brewer and tasted the range of his handmade Ginjo and Daiginjo sakes.

We viewed the bonfires of Obon with faculty members from Kyoto and Keio University.

I played Shakuhachi in a 500 year old mountaintop temple overlooking the Inland Sea with a Zen monk who played a Conch shell.

We made traditional Japanese sweets (Wagashi) with a master craftsman.

We had incredible Zen meals in small family run restaurants such as Kiko

I want to thank our Japanese hosts, Dr. Hiroyuki Yoshihara and Michiko Yoshida for making it all possible.

There are so many memories and spiritual experiences to describe that I will use the next several months on my Thursday blogs to share everything I learned about traditional Japanese culture from the master craftsman who taught me over the past two weeks.

On the Road

For the next two weeks my wife and I will be on the road in Japan, meeting our 16 year old daughter in Japan, where she's spent the summer in intensive Japanese language study. My blog entries will be episodic but I'll remain connected via my 3G Blackberry. I'll be giving a lecture at Kyoto University but most of the trip will be seeing a side of traditional Japan that most tourists will not see.

We'll celebrate our 25th wedding anniversary in temples with a history of bringing good luck to relationships.

We'll make traditional Japanese rice confections in a small shop in the Gion.

We'll eat blue-green Tofu, okara in yuba handmade in a 10 seat restaurant on the banks of the Kamagawa.

We'll join a sake maker on the roof of his factory for a view of the bonfires of Obon lit on the mountains around Kyoto.

We'll shop for mountain yam and daikon pickles in the mile long farmers market hidden in the arcades of Teramachi.

We'll drink Green Tea at Uji in the oldest teashop on the planet.

We'll stroll Zen gardens in Ohara north of Kyoto.

We'll explore the temples west of Kyoto and then board a small boat to ride the rapids back to the city

We'll travel to Miyajima and kayak the Inland Sea and visit shrines only accessible by boat built by fisherman and pirates.

I'll play the Shakuhachi from the top of Mt. Misen near the fire that Kobo Daishi lit in the 1600's and is still burning.

During our entire trip, we'll stay in small traditional Japanese inns - Ryokan.

Normally, I would go climbing in the Eastern Sierra for my yearly August time away, but the opportunity to travel with my wife and daughter in Japan is a very special opportunity. My daughter heads off to college in 2 more years, so we'll treasure the time with her as our Japanese interpreter and sometimes tour guide, given her experience spending the entire summer there.

I'm hoping the new few weeks are quiet in Washington, as HHS moves to regulation writing mode. You can be sure I'll keep you informed via my blog and Twitter.

Cycling to Meetings - a Progress Report

The month of July is drawing to a close. Here's a report on my experiment to replace car travel with bike travel for a month.

What did I find?

*There is no place in the city of Boston that is faster to reach by car than bike. I average 15 miles per hour on bike and 10 miles per hour by car. A car on Fenway Red Sox days can be a painful 5 mph experience.

*My Harvard and CareGroup offices are 1.2 miles apart. I can go from desk to desk in 6 minutes, since my Strida folding bike travels in and out of the building with me. Car travel is between 15 and 30 minutes, depending on traffic.

*Parking in downtown Boston runs about $30 for the first hour. I saved more than the cost of the bike in one month of cycling.

* The streets of Boston are narrow, the potholes are deep, and the drivers are psychotic. I wore a helmet at all times, even for 1 mile rides between offices. The key to my success was to cycle in a predictable straight line, never darting in and out of traffic.

*Pedestrians and other bikes are even more hazardous than cars. I had numerous pedestrians (often walking into traffic while talking on their cell phones) nearly run into me.

*Rain can make cycling problematic. My Strida has fenders which protect me from tire spray, but wearing a suit while cycling in the rain can be tricky.

The bottomline - using a bike to commute in Boston saves me 30 minutes per day, saves gas, saves parking, and burns calories. If the rain stops, the pedestrians get off the phone, and the potholes are filled, life will be grand.

The experiment has been a success and I will continue to bike to all my meetings in Boston, April to November, weather permitting.

Next Steps for the HIT Standards Committee

At the July 21 meeting of the HIT Standards, we approved an initial set of standards for quality, clinical operations and security/privacy. We were told to refine these initial efforts by the next meeting of the Committee, August 20, so that ONC and CMS can incorporate the work into the interim final rule. Here's an update on the deliberations of the workgroups.

Privacy and Security
We received several public comments about our selected privacy and security standards - those used for authentication, authorization, auditing, encryption, and secure transmission. It's important to note that the sending and receiving of transactions for healthcare information exchange is part of the scope of the Privacy and Security Workgroup. Clinical Operations specifies the vocabulary/codesets/value sets and the actual message or document to send. Privacy and Security ensures it is sent in a secure fashion, consistent with HIPAA and ARRA. Our recent decisions in response to comments are

*Although the IHE ATNA profile for securing transmission via TLS allows use of Null Cipher (i.e. no encryption) as an option for private networks, we will require all health information exchange transactions between organizations, even those running on private networks to be encrypted via the AES_SHA cipher by 2011.

*SOAP is an approach to data exchange that enables programmers to use the web to call remote servers using the HTTP POST syntax. POST means the URL does not contain any specific information i.e.

I use POST to talk to a server at http://mymedicalrecords.com and request information about my medical record number and the kind of information I want to retrieve using hidden exchanges between the servers, not by embedding the details of my request in the URL.

SOAP has a learning curve and generally requires a toolkit to make the implementation easier. It has been a favored approach in healthcare because it has many standardized security tools.

*REST is an approach to data exchange the enables programmers to use the web to call remote servers using the HTTP GET syntax. It's easy to use without a toolkit. For example, you could use a browser to call a URL like the following to retrieve your allergies

http://mymedicalrecords.com?myMRN=1234567&show=allergies

Although it's simple, there are fewer standardized security tools. REST is increasingly popular and Amazon, Google, and most e-commerce companies have embraced REST, creating their own unique security tools.

*The Security and Privacy Workgroup recognizes that both approaches, SOAP and REST, should be allowable for data exchange. Here's a list of the HITSP Capabilities and Services supporting these transactions

TP13 - Manage Sharing of Documents (XDS.a), SOAP and REST
TP13 - Manage Sharing of Documents (XDS.b), SOAP
TP13 - Cross-Community Access (XCA), SOAP
TP21 - Query for Existing Data, SOAP
T31 - Document Reliable Interchange, SOAP
T42 - Medication Dispensing Status, SOAP
TP49 Sharing Radiology Results, SOAP and REST
TP50 - Retrieve Form for Data Capture, REST
T63 - Emergency Message Distribution Element, SOAP
T66 - Terminology Service, SOAP and REST
T81 - Retrieval of Medical Knowledge, REST
T85 - Administrative Transport to Health Plan, SOAP
TP89 - Sharing Imaging Results, SOAP and REST

For a more detailed discussion of the pros/cons of SOAP and REST, see my blog entry on the topic.

Clinical Quality
Leveraging the completed HITEP report, the Clinical Quality Workgroup has proposed 27 initial quality measures and the data types required to capture each electronically. The challenge is that several quality measures contain exclusionary criteria i.e. when considering HbA1c levels, remove patients on comfort care measures from the denominator. When considering tobacco cessation counseling, remove patients who really like smoking and lack readiness to quit from the denominator. Such exclusionary criteria are really challenging to support with existing EHRs. It is likely that either these exclusions will have to be removed from the measures until EHRs and standards support them, or that self attestation of quality measures rather than electronic measurement be done in the short term until EHRs can capture these more esoteric data elements. The Clinical Quality workgroup is examining every data type for its readiness/adoption and will then make final recommendations on the quality measures and data types to use in 2011.

Clinical Operations
We're refining the matrix of vocabulary, messaging and document standards to respond to comments from HIT Standards Committee members and the public. We've heard such things as

*Allow HL7 2.51 messaging as well as XML-based document formats for transmission of data in HIEs, at least for the next several years

*Although care coordination and patient experience data exchanges may benefit from unstructured documents such as a PDF exchanged electronically along with metadata, quality measurement really requires codified data, even if it is just ICD9. SNOMED-CT is the preferred vocabulary for clinical observations and eventually should be used for all quality measures, but it will take several years for SNOMED-CT to be fully implemented in healthcare information exchanges, so ICD9 and ICD10 will be allowed along the way

*The HIT Standards Committee focuses on healthcare information exchange - from the edge of one organization to another organization. All the vocabularies we are discussing - LOINC, RxNorm, SNOMED-CT and UNII (for allergies) are for exchange, not necessarily required within internal systems of organizations. This is the realistic approach that is needed to give organizations the time they need to implement controlled vocabularies for data exchange.

We'll continue our work for the next two weeks and then present it publicly on August 20. Thanks to all the Committee, Workgroup, and HITSP volunteers who have spent many hours on this effort.

The Making of the Third Generation Prius Ad

It's Summer, so time for some lighter fare (don't worry, more news from Washington is coming later this week.)

I'm a Prius driver and will likely be replacing our older Toyota Highlander with another Prius, which will be my wife's and my daughter's car.

The Third Generation Prius advertisement features a unique combination of people, amazing graphics, and digital assembly - over 1,000,000 people were created from 200 extras.

Here's a You Tube Video that explains how the entire commerical was created. Incredible.

A Glossary of the Data Center

I'm serving as a subject matter expert for a panel studying the IT capabilities of the Food and Drug Administration. In preparing our report, the team recognized that many FDA stakeholders are not well versed in the terms used to describe data centers. Here's the glossary that the team developmented, which I thought you might find useful for your own reports and presentations.

Classification of Data Centers (Tier 1 – 4). The Telecommunication Industry Association (TIA) has published the TIA-942 standard for classification of data center capabilities.

Tier 1 – Basic: 99.671% Availability
Susceptible to disruptions from both planned and unplanned activity
Single path for power and cooling distribution, no redundant components (N)
May or may not have a raised floor, UPS, or generator
Takes 3 months to implement
Annual downtime of 28.8 hours
Must be shut down completely for perform preventive maintenance

Tier 2 – Redundant Components: 99.741% Availability
Less susceptible to disruption from both planned and unplanned activity
Single path for power and cooling direction, includes redundant components (N+1)
Includes raised floor, UPS, generator
Takes 3 to 6 months to implement
Annual downtime of 22.0 hours
Maintenance of power path and other parts of the infrastructure require a processing shutdown

Tier 3 – Concurrently Maintainable: 99.982% Availability
Enables planned activity without disrupting computer hardware operation, but unplanned events will still cause disruption
Multiple power and cooling distribution paths but with only one path active, includes redundant components (N+1)
Takes 15 to 20 months to implement
Annual downtime of 1.6 hours
Includes raised floor sufficient capacity and distribution to carry load on one path while performing maintenance on the other.

Tier 4 – Fault Tolerant: 99.995% Availability
Planned activity does not disrupt critical load and data center can sustain at least one worst-case unplanned event with no critical load impact
Multiple active power and cooling distribution paths, includes redundant components (2 (N+1), i.e. 2 UPS each with N+1 redundancy)
Takes 15 to 20 months to implement
Annual downtime of 0.4 hours


Cloud Computing (and Storage). Cloud computing is a style of computing in which dynamically scalable and often virtualized resources are provided as a service over the Internet.

NAS (Network Attached Storage). The Network Attached Storage is file-level computer data storage connected to a computer network providing data access to heterogeneous network clients.

Reference Architecture. The reference architecture provides a proven template solution for an architecture for a particular domain. It also provides a common vocabulary with which to discuss implementations, often with the aim to stress commonality.

Reference Architecture can be defined as different levels of abstraction. A highly abstract one might show different pieces of equipment on a communications network, each providing different functions. A lower level one might demonstrate the interactions of procedures (or methods) within a computer program defined to perform a very specific task.

SAN (Storage Area Network). The Storage Area Network (SAN) is an architecture to attach remote computer storage devices (such as disk arrays, tape libraries, and optical jukeboxes) to servers in such a way that the devices appear as locally attached to the operating system. Although the cost and complexity of SANs are dropping, they are uncommon outside larger enterprises. Network attached storage (NAS), in contrast to SAN, uses file-based protocols where it is clear that the storage is remote, and computers request a portion of an abstract file rather than a disk block.

Virtualization (Server Virtualization). Virtualization is a method of partitioning a physical server computer into multiple servers such that each has the appearance and capabilities of running on its own dedicated machine. Each virtual server can run its own full-fledged operating system, and each server can be independently rebooted. (Best practice for reducing cost and increasing performance in large enterprises).

Documents and Messages, a Guest Blog

Yesterday on a call of the HIT Standards Committee Privacy and Security Workgroup, we had a great discussion about Common Data Transport and Health Information Exchange. This is a guest blog describing that conversation by David McCallie at Cerner, a member of the Committee.

"These are some principles that we try to follow in our work.

*Be aware of the difference between a document and a message

*A document should ideally contain data that is assembled to represent a specific clinical context – the data in the document should cohere in some meaningful way. For example, a document (e.g., a CCD) could represent a summary of an encounter, or a response to a query for a current_medication_profile, or you could have a CDA representing a radiology report with structured findings, etc.

*A message communicates some kind of discrete change in state, and is capable of standing in isolation from other messages. For example, a reference lab sends a test result back to the ordering physician via messages. Messages should have sufficient metadata to allow for idempotency (timestamps to avoid duplicate data errors on replay) and to allow for transactional updates to the discrete content of the message (externally-valid identifiers that can be used to send corrections or amendments, etc.) Documents do not need to contain idempotency or transactional information about the discrete structures contained within. The arrival of a document does not imply that all of the contained structures have been updated, whereas the arrival of a discrete message usually does indicate a change in state of the discrete.

*Of course, a message could be used to send a document, in which case the message will have metadata about the overall document (though that does not imply that the metadata is relevant to each discrete element within the document.)

*However, in general, a document should not be used to send a message. For example, a document (like a CCD) should not be used to update discrete information such as specific problems in an external problem list. If a provider chooses to (manually) extract discrete data from the document into his EMR, he should be aware of the context of the overall document to determine the validity of making the extraction. (He may reject the extraction because he is already aware of the discrete information, or his EMR already contains more accurate or more refined knowledge than what is contained in the document.)

*Discrete information should not be automatically extracted from a structured document (except under carefully controlled circumstances.)

*It is tempting to consider a structured document to be the same thing as a structured message, but the semantics are different and trouble will follow

*An HIE that allows only for document submission will be unable to accommodate capture of messages (unless some of the above principles are violated.)

*Yet messages are far more common in HIT transactions today than are documents (labs, claims, eRx, etc.)

Ideally, an HIE should be able to utilize both documents and messages to capture and share patient clinical state."

I thought that these ideas were important to share with the Health Information Exchange and Standards stakeholders who read my blog.

The SNOMED-CT Problem List has arrived

As promised in my earlier blog, the National Library of Medicine has created a "best practices" subset of SNOMED-CT which is highly usable by clinicians for documenting the symptoms and conditions used on a typical Problem List.

I've discussed previously the hazards of using ICD-9 as problem list vocabulary. It's an administrative billing vocabulary, not a clinical observation vocabulary.

You need a free SNOMED license (if you're in one of the countries that has licensed SNOMED, such as the US) to retrieve the SNOMED Problem List document.

The present subset is based on datasets submitted by 7 institutions - Beth Israel Deaconess Medical Center, Intermountain Healthcare, Kaiser Permanente, Mayo Clinic, Nebraska University Medical Center, Regenstrief Institute and Hong Kong Hospital Authority.

We're implementing this problem list vocabulary in our home grown systems first, then we'll work with eClinicalWorks to incorporate it into their EHR. We'll test it extensively with a few clinicians and then roll it out broadly if we achieve a good balance of functionality and clinician satisfaction.

The HIT Standards Committee will likely recommend SNOMED-CT as the preferred problem list vocabulary, so this release by the NLM is very important to all EHR stakeholders.