Cool Technology of the Week

In an era of ubiquitous WiFi, many meeting rooms have guest wireless connections available for visitors.

However, some government agencies, some larger firms and some healthcare facilities are concerned about the security implications of uncontrolled wireless access points and do not offer connectivity to visitors.

How do you solve this problem? The Verizon Intelligent Mobile Hotspot (MiFi) brings a WiFi network wherever you need it.

I recently had the opportunity to test it in a meeting. I put the MiFi device (about the size of a pack of cards) in the room, turned it on and a few seconds later 5 people in the room had 802.11 b/g WiFi at 1 meg/second speeds.

How does it work? The small Novatel manufactured device is mostly battery (which lasts about 4 hours), an EVDO/3G Mobile Broadband chip that connects to the Verizon Cell Network, and an WiFi access point all packed into a 2 ounce package.

The price is under $100 with a 2 year contract and two plans are available. The 5 Gigabyte plan for $60 per month is the most attractive.

Here are the specs:
• 1x EV-DO Revision A (Rev. A) /0; 1xRTT; 800, 1900 MHz
• Wi-Fi Mode: 802.11 b/g

Security
• CDMA authentication and identification
• Dynamic MIP key update; CHAP
• Wi-Fi: WEP/WPA/WPA2-PSK, SPI firewall
• MAC/Port filtering
• NAPT/DHCP server enable
• VPN Pass-through

It's also usable as a USB connected device via the VZAccess Manager and support is available for both Windows and Mac platforms. OF course, in WiFI mode it's operating system neutral.

An ultraportable WiFi access point wherever you need it using a 3G cell phone network - that's cool.

Blog Spamming

As folks who visit my blog may have noticed, I have activated Word Verification for comments. This prevents automated systems from adding comments to my blog, since it takes a human being to read the word graphic and interpret it.

I also turned on Comment Moderation for comments older than 14 days.

A few weeks ago, blog spammers posted advertisements to every one of my 400+ blog entries. I've not found a way to bulk delete comments, so I've been reviewing every previous comment and deleting the spam.

With the new settings, I can bulk reject dozens of spammed comments that are posted to my blog each day.

It's a shame that spammers believe junk comments on blogs are an effective means of advertising. I apologize for the Word Verification and the Comment Moderation, but its the only way I can keep the blog maintained.

Let's hope that blog spammers find a better use of their time in the future!

It's the Era of ARRA

Today at the HITSP Panel meeting, we approved the work our Tiger Teams completed over the past 60 days to support ARRA:

*EHR-Centric Interoperability Specification

*Exchange Architecture & Harmonization Framework Technical Note

*Data Architecture Technical Note

*Access Control Service Collaboration

*Security Audit Service Collaboration

*Patient Identification Management Service Collaboration

*Knowledge and Vocabulary Service Collaboration

*Healthcare Document Management Service Collaboration

*Query for Existing Data Service Collaboration

*Administrative Transport to Health Plan Service Collaboration

*HL7 Messaging Service Collaboration

*Emergency Message Distribution Service Collaboration


What is a Capability?

A HITSP capability is an implementable business service that specifies interoperable information exchanges using HITSP constructs. It supports stakeholder requirements and as part of its design, it includes information content, infrastructure, security and privacy. Capabilities have options- subsets of the data content can be sent or received as appropriate by a system implementing a capability.

What is a Service Collaboration?

A service collaboration describes the orchestration of data flow such as publish/subscribe, query/response, patient identification, and audit trail creation.

This work is a great simplification of prior HITSP efforts, but there is still work to do.

We will continue to work on our Electronic Publishing framework so that these capabilities are more easily accessible to vendors, HIEs, and other interoperability stakeholders. It will also make them easier to maintain.

The Capabilities point to components, transactions, transaction packages, and base standards. Since SDOs license their content, we cannot include the Standards Development Organization implementation guides. We provide pointers to SDO work products and state the constraints that clarify the details needed to streamline interoperability. In the future, we'll provide additional constraints and work with SDOs to make the implementation guidance available electronically as simple as possible.

What about the future?

It is likely that additional work on standards will be needed to meet all the objectives and metrics of meaningful use for 2013 and 2015.

HITSP will work to address those gaps. HITSP Program Management will leverage the successes of the Tiger Teams and ensure our team structure and processes are optimized to support the HIT Policy and Standards Committees.

We'll also finish work already in process such as Remote Monitoring, Quality, and Clinical Research.

On July 16, the HIT Policy Committee will present the next revision of meaningful use.

On July 21, the HIT Standards Committee will present the standards and certification criteria that support meaningful use, incorporating HITSP work.

We're moving very fast, but we're doing it very openly and by consensus. My thanks to the hundreds of people and thousands of volunteer hours that resulted in the HITSP capabilities and service collaborations that were approved today.

A Single Point of Disclosure

The American Recovery and Reinvestment Act of 2009 (ARRA) states that the HIT Policy Committee shall make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas (the ARRA 8) including "Technologies that support accounting of disclosures made by a covered entity" .

The first draft of meaningful use includes three requirements for Population and Public Health data disclosure:

-Submit electronic data to immunization registries where required and can be accepted
-Submit electronic reportable lab results to public health agencies
-Submit electronic syndrome surveillance data to public health agencies according to applicable law and practice

How can Massachusetts enable these data exchanges and at the same time document disclosure?

The answer lies in the New England Healthcare Exchange Network which has served as the Massachusetts healthcare data exchange since 1998.

I've recently met with many stakeholders:

- the Boston Public Health Commission
- local, state and federal biosurveillance organizations
- quality registry hosting entities
- the Social Security Administration

All have agreed that instead of point to point heterogeneous interfaces, data should be disclosed via a standards-based gateway for secure electronic communication.

Here's a vision for Massachusetts:

- Today, all our payers and providers host a NEHEN gateway or have access to a hosted NEHEN Software as a Service called NEHEN.NET

- public health and population health organizations such as the Public Health Commission, Department of Public Health, Massachusetts eHealth Collaborative Quality Registry, and the Social Security Administration should add a NEHEN gateway to their organization. They could then stop using FTP, VPNs, leased lines, or proprietary web uploads for data collection.

- As part of our NEHEN architecture, we have a Participant Directory that contains gateway to gateway routing information. In addition to providers, this directory can contain public health and population health organizations.

- All future disclosures will be made from payers and providers to data collection organizations via NEHEN gateways.

-This means that one set of policies, one set of gateway software, and one set of standards is used for data transmission and disclosure logging throughout Massachusetts.

I have volunteered to move the BIDMC's Social Security Administration transmissions and the Public Health Commission data exchanges from proprietary transmission approaches to the NEHEN gateway.

Although there is still much work to do to ensure the NEHEN gateway can connect to all local, state and federal data gathering entities, the economies of scale of building one transmission/routing mechanism and just changing the payload as needed is appealing to everyone.

NEHEN is currently completing healthcare information exchange work in support of ARRA clinical coordination goals. Once that is done, it is clear that a single point of disclosure for Population and Public Health data exchange is a high priority next step.

International EHR Adoption

I was recently asked to compare EHR adoption in the US to other countries. Based on my own experience and the comments I received from colleagues, there are three aspects to consider:

* Use of Ambulatory EHR
* Use of Inpatient EHR
* Interoperability

Ambulatory
The most widely implemented are England, Denmark, Netherlands, and certain regions of Spain which are close to 100%. Sweden, Norway are at 80% and behind and Germany/France are at 50%. The US is somewhere between 2 and 20%, depending on how you classify a comprehensive EHR. Based on my definition - codified problem lists, e-prescribing, and decision support, the US is below 10% adoption.

Inpatient
Teaching institutions are generally well equipped, although less sophisticated on average than the US. Coverage in mid-low tier hospitals is high in England, Sweden, Norway, Denmark, and Finland, followed by Germany and Spain. In the US, CPOE adoption nationally is less than 25%

Interoperability
Denmark has the most signification implementation of production HIE with over 90% of encounters shared electronically. Certain regions in Spain, English, and Sweden have significant HIE. Canada Health Infoways has done excellent work with standards harmonization and incentivizing data exchange at the Province level. In the US, e-Prescribing is high is some states such as Massachusetts, Rhode Island and Nevada, but quite low in others. Clinical Summary exchange is done in some regions (Indiana, New York, Massachusetts, Tennessee, Minnesota, Arizona, Virginia) but most regions are just beginning implementation.

I've visited several sites in Sweden over the past 5 years, and the most innovative County is Jönköping

Qulturum is the organization in Jönköping that organizes the most innovative aspects of healthcare quality improvement including IT implementation.

As we think of lessons learned to guide US EHR installations, Scandinavia is definitely a region that has done IT right.

I welcome comments based on your own international experiences.

The Joy of a Local Hardware Store

Let me describe two experiences:

I walk into a big box home improvement store and ask for advice about screens for storm windows that were popular in Wellesley, Massachusetts in the 1960's. No one has any idea what I'm talking about. Not just about my storm windows, but any storm windows. The store is 40 aisles of 20 foot high racks without an easy to navigate map. Oddly, screens are not in the Windows section, they're in the Building Materials area. No one knows what tools I need or how much screen I should purchase, so I make several trips back and forth from home to store. I spend hours in the process and throw away an entire roll of screen I've wasted.

I walk into my neighborhood hardware store. A cheerful, experienced salesperson greets me at the door and asks to help with my project. The person instantly knows the type of windows I have, the tools needed, the best materials, and a few tips to get the job done right. The person wanders around the 5000 square foot store, picks up all the materials I need and rings me up. I spend minutes in the process, do the job perfectly the first time, and have no waste.

Just as I have extolled the virtues of embracing locavore food culture and community supported agriculture, I suggest supporting your local hardware store - let's take back the neighborhood from the big box stores.

Life is short and I really care about the quality of my day to day experiences. I want to shop locally from farmers, craftsmen, vendors, and salespeople that I know. I realize that in our complex world that is not always possible. If you have a choice of buying a bolt for fifty cents from a helpful, knowledgeable shopkeeper OR buying a bolt of lesser quality for forty cents that takes an hour to find a big box store, I suggest that you and your wallet shop locally.

I'm so impressed with Green's Hardware in Wellesley, that I actually seek out home projects to do on weekends, just so that I can enjoy the experience of getting sound advice and quality products from people who teach me how to maintain my home. My house was built in the 1930's but every part of it - from electrical to plumbing to carpentry - is perfectly maintained thanks to the partnership I've developed with Green's, my local hardware store.

The HIT Symposium at MIT

This morning I joined a panel discussion about Standards at the HIT Symposium at MIT.

We had a great panel discussion, moderated by Janet Marchibroda (Chief Healthcare Officer at IBM) that included Christine Bechtel (Vice President, National Partnership for Women and Families Patrick Gallagher (Deputy Director at NIST) and me.

Patrick provided an overview of NIST and the work the government is doing to ensure selected healthcare standards perform as advertised, are implementable, and usable.

Christine described the role of the HIT Policy Committee and its workgroups.

I described the current HITSP Tiger Team work, the standards committee/workgroups including their charge, purpose, milestones.

Here's my presentation that describes all the latest standards work for the country.

On the last slide, you'll see our deadlines:

HITSP ARRA Deliverables will be approved and delivered to ONC on July 8

The HIT Standards Committee Workgroups finish their initial naming of standards and certification criteria by July 15

All this work is presented publicly at the HIT Standards Committee on July 21.

The Notice of Proposed Rulemaking process then begins and we'll see a finished Interim Final Rule by December 31.

A whirlwind of activity!