The Health Information Technology Platform Meeting

Today at Harvard Medical School, Zak Kohane and Ken Mandl assembled 100 folks to discuss "Substitutability" - the notion that EHRs of the future will be more modular and more iPhone app-like, possibly with common Application Programming Interfaces.

Some of the speakers at the conference were Mitch Kapor (Lotus founder), Sean Nolan (Microsoft), David McCallie (Cerner), Alfred Spector (Google), Rob Kolodner (formerly of ONC), David Liss (New York Presbyterian), Charles Friedman (currently at ONC), Mark Frisse (Vanderbilt), Clay Christensen (HBS), David Kibbe (Senior Advisor to AAFP), Aneesh Chopra (US CTO), Todd Park (HHS CTO), and Regina Herzlinger (HBS)

I served on the opening panel called Open or Closed Platforms? One or More Platforms.

Here are a few of the key points.

I suggested that standards can be required at different levels of specificity depending on the transaction. e-Prescribing transactions should be highly specified to ensure the right drug, right dose, right form, right patient are transmitted securely with data integrity from provider to pharmacy. Sharing an office note might be done with less specificity - a secure transport layer plus a human readable payload that might be XML such as a CCD document, PDF, or a scanned TIF image. Quality measures are very precise and require a high degree of specificity to ensure comparability among clinicians and institutions. Even though these examples have different levels of specificity required for interoperability, the architecture is left open to innovation - these transactions could be done in comprehensive EHRs, iPhone apps, or PHRs with point to point data exchange or via a healthcare information exchange.

Several of the panelists thought a common API in front of various EHR vendor products was unlikely. Exchange at the data layer was viewed by all as very possible and most thought the meaningful use plan for 2011,2013, and 2015 data exchanges made sense.

All agreed that common data transport with appropriate security is important.

The general theme of the panel was openness. Microsoft offers a standards-based way to enter and retrieve data from healthvault. Cerner is supporting XDR, XDM and XDS as well as Cerner proprietary APIs which enable custom plugin applications to work with their products. OpenMRS is an open source platform for electronic health record development, embraced widely in developing countries.

The move toward more openness - regardless of architecture, platform, or open source/proprietary product type - was refreshing. To me, being able to extract data out of an EHR (even via a proprietary API) combined with common data transport standards and translation into structured vocabularies gives us a path forward for health information exchange in the near term.

The industry is changing, motivated by meaningful use, a business case for data sharing, and patients expecting coordination of care. Add to that healthcare reform which requires quality measures and H1N1 surveillance which requires public health data exchange, and the pace will accelerate.

It's clear the we'll have many product choices in the future - some integrated, some interfaced, some modular, and some platform-based. My take home message from the conference is that innovation and data standardization can co-exist.

Preparing for ICD-10

In 2013, CMS will require the use of ICD-10 for coding of diagnoses in billing/administrative transactions. The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion of the 17,000 codes available in ICD-9. How can we best prepare for this transition?

1. Improve electronic clinical documentation

The granularity of ICD-10 requires precise clinical documentation. Unstructured paper-based notes are unlikely to enable coding beyond the most general code for each diagnosis. ARRA incentives require ambulatory EHR implementation with structured problem lists, medication management, and clinical documentation as well as hospital CPOE use. These electronic systems will provide the foundation for the detail needed by billers/coders to accurately select the most specific diagnoses.

Here's an example - in ICD-10-CM, the code L89.133 is for a pressure ulcer of right lower back, stage 111. This single code in ICD 10 is specific to the right lower back and stage. Detailed electronic clinical documentation is needed to select the right code.

2. Train HIM professionals

The American Health Information Management Association (AHIMA) is the leading advocate for ICD-10 and training HIM professionals.

You'll find their training materials and courses online

Here's an example illustrating the training needed:

The ICD 10 code for Pathological fracture, right radius, initial encounter is M84.433A. This code is specific as to the location of the fracture, including laterality. The seventh character extension identifies the episode of care. Separate code categories are available for pathologic fractures specified due to a neoplasm or osteoporosis.

3. Embrace SNOMED-CT

Meaningful Use specifies ICD9 or SNOMED-CT for problem list management in 2011, ICD10 or SNOMED-CT for problem list management in 2013, and SNOMED-CT for problem list management in 2015. SNOMED-CT enables a clinician to document signs/symptoms, rule-out diagnoses, and problems, not just diagnoses. The structured clinical observations embodied in SNOMED-CT encoded clinical document will facilitate the accurate coding of ICD-10 diagnoses. The NLM's SNOMED-CT Core Set will include an ICD-10 crosswalk in the future.

4. Ensure we have the right vocabulary tools

Just as with the NLM SNOMED-CT Core set, it's important that the country has easy access to ICD9-ICD10-SNOMED-LOINC mappings that enable fluid translation of one codeset to another for various purposes. Many companies are working on such resources such as

Intelligent Medical Objects, which provides such services inside the EPIC EHR

AnvitaHealth (disclosure: I serve on the Board) which provides such services to Google Health

Apelon which has provided terminology services to Intersystems, Intel and the New Zealand Ministry of Health.

SNOMED Terminology Solutions not only maintains SNOMED CT on behalf of the IHTSDO but also provides mapping and consulting services to help provider organizations, vendors, various agencies of HHS, and other HIT-related companies with the successful implementation of terminology standards.

Over the next year, the HIT Standards Committee Clinical Operations Workgroup will discuss the vocabulary tools needed to support meaningful use.

5. Work with vendors to ensure EHRs and Hospital Information Systems are capable of supporting ICD-10 and X12 5010.

Existing EHRs and HISs will need to be upgraded to support ICD-10 coding and the transmission of transactions to payers via X12 5010 (replacing 4010). Vendors will provide one piece of the puzzle - software that is capable of supporting the new standards. Vendor efforts need to be supplemented with all the other strategies mentioned above to ensure successful ICD-10 implementation/meaningful use.

I realize that the dual transition of ICD-10 and SNOMED-CT over the next 5 years seems daunting. In my view, embracing SNOMED-CT for clinical observation encoding as part of electronic documentation provides the foundation for ICD-10 implementation by providing the clinical detail needed by billers/coders to accurately select the proper ICD-10 code. If we think of SNOMED-CT as the clinician facing vocabulary and ICD-10 as the administrative billing vocabulary for HIM professionals, adopting both codes is part of a single project plan to enhance the quality of healthcare data for all stakeholders.

Building the Nationwide Healthcare Information Network

I describe interoperability as a set of business partners with aligned incentives who exchange data to enhance efficiency, reduce costs, and improve coordination of care. Generally healthcare information exchange is local - hospitals, labs, pharmacies, clinician offices, and public health in a region exchange data for a specific purpose. Privacy and data use concerns are resolved locally. I do not believe that an architecture that requires a monolithic central database in the basement of the Whitehouse is going to be acceptable to stakeholders.

So what is the Nationwide Healthcare Information Network (NHIN) likely to be?

It will be a federated network of networks based on a common set of policies and data standards, enabling local, regional and domain specific (VA, DOD, Children's Hospitals) networks to connect with each other. Think of HIE's as similar to local phone exchanges and the NHIN as long distance service. What is required for a successful implementation of a "long distance carrier" for healthcare data?

1. Governance - A national framework for setting policy and technology for the NHIN. The HIT Policy and HIT Standards Committee could serve this purpose.

2. Education/Promotion - We need to ensure all state HIEs think of the NHIN as a connector between regional activities and understand how to use it. ONC could do this or partner with an organization such as the National eHealth Collaborative (NaeHC) or the e-Health Initiative (eHI).

3. Incentives - Meaningful use provides a powerful set of incentives to foster healthcare information exchange. Ideally, communications with Federal stakeholders such as CDC, SSA, FDA, and CMS would be done via the NHIN. This will incentivize all stakeholders to purchase EHRs and build HIEs which are compliant with NHIN policies and data standards.

4. Common transport, content and vocabulary standards - When EHR and HIE data exchanges are built, implementers have a choice of architectures and standards to implement. The work of HITSP and the HIT Standards Committee is architecture neutral, but provides enough constraints in the standards to reduce the number of choices, enhancing interoperability. Ideally, EHRs, HIEs, and the NHIN should should the same data transport (SOAP or REST over TLS), the same content (HL7 2.51, CCD, NCPDP Script 10.x, X12 4010 or 5010), and the same vocabularies (LOINC, SNOMED-CT, RxNorm, UNII) ensuring easy integration of regional and national efforts.

5. An agreed-upon set of security and privacy rules, including data use and reciprocal support agreements to which everyone who links to the NHIN must conform. Entities that link into the NHIN, and consumers who allow their information to be sent over the network, should be able to safely assume that some well defined, basic protection rules are enforced throughout, and that some well defined rules for representing, exchanging, and enforcing authorizations and consents are in place throughout the network.

Over the next year, the HIT Policy and Standards Committees are likely to work on NHIN related issues. I look forward to a secure nationwide network of networks with common policies and data standards that supports healthcare reform, public health, and the needs of patients, providers and payers. This is something we will create - we do not need to wait for our children to build it!

Cool Technology of the Week

As clinicians implement electronic tools to achieve meaningful use, it's likely that a diversity of approaches will be used in 2011 - some comprehensive EHRs, some hosted Software As a Service applications, and some modular applications. What are modular applications? Imagine that a clinician assembles a collection of iPhone apps and hosted interoperability services (Surescripts, Quest, Emdeon) to achieve e-prescribing, lab viewing, quality reporting, and administrative data exchange with payers. Such an approach would fall under CCHIT's notion of modular certification. Think of it as a "Project" rather than "Product" certification, ensuring that the collection of applications has the capabilities needed to achieve meaningful use.

This week, Quest introduced a six month trial of its web-based Care360 e-prescribing application, a Surescripts-certified solution which enables clinicians to access formulary information, route prescriptions, process refills and act upon FDA alerts.

Quest also announced that clinicians can now access these services from an Apple iPhone or iPod touch using Care360 Mobile. With Care360 Mobile, clinicians can create and send a new prescription from an iPhone in three simple steps and can also renew existing prescriptions. The application is available in the Apple App Store under Medical Applications and can be downloaded at no charge.

An e-prescribing application with formulary, routing, and refills that is part of a suite of web-based and iPhone products which assist with meaningful use. That's cool.

How I Eat

It's time for a Thursday blog where I turn introspective an examine my life experience.

I've written about what I eat and where it's from but not about how I eat.

What do I mean?

In the US, meals are often considered a meat-based main dish plus sides or trimmings i.e. we're having chicken for dinner.

Taking a lesson from Japanese cuisine, there is no main dish to any my meals. I typically have 4-5 or five small plates that include salad, soup, rice, and vegetables.

Here's tonight's dinner

1. A bowl of Coconut Barley Pilaf with Corn, Tofu and Cashews (I replaced the chicken in the recipe with tofu)

2. A bowl of Braised Yuba and Bok Choy from our CSA

3. A bowl of Curried Summer Squash with Yuba and Cilantro

4. A cup of Sencha Fukamushi green tea

I savor every dish equally and consider them part of the palette which makes up the meal. The family gathers to discuss the events of the day, the schedule for the next day, and the challenges/frustrations we face at school/office/studio. We often read the Dave Barry calendar page of the day at dinner and comment how the day's Dilbert parallels real life. We serve ourselves individually in the kitchen, picking from a large assortment of random Japanese bowls and plates, so that every meal is a completely different visual experience, sized to the appetite of the day, the seasons, and personal whim.

Grazing rather than eating, enjoying several small plates rather than a main disk, and making dinner the family time of the day works well to keep us together, keep us communicating, and keep us appreciating the wonderful myriad of foods available to vegans.

Meaningful Use for Specialists

I was recently asked how specialists, such as pediatric surgeons with few Medicare or Medicaid patients, can participate in ARRA and implement EHRs with meaningful use.

First, let's review how ARRA stimulus payments work:

Medicare
Medicare incentive payments are capped at 75% of allowable Medicare charges, up to $18,000 for the first payment year. Incentive payments are reduced in subsequent years: $15,000, $12,000, $8,000, $4,000, and $2000.

For eligible professionals in a rural health professional shortage area, the incentive payment amounts are increased by 10 percent.

Physicians who do not adopt/use a certified EHR will face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. ARRA allows HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions can be made on a case-by-case basis for significant hardships (i.e. rural areas without sufficient Internet access).

What does 75% of allowable Medicare charges really mean? A provider's office which has allowable Medicare charges totaling $24k or more can receive the full $18k in ARRA stimulus money. A provider with $13.3k in allowable Medicare charges is eligible for only $10k in ARRA stimulus money. Several providers have told me that an office needs about 7-8% of their patients to be Medicare beneficiaries to receive the full stimulus.

Medicaid
Office-based physicians whose patient mix includes at least 30 percent Medicaid beneficiaries are eligible for up to $63,750 over six years, as long as they are able to demonstrate "meaningful use" of healthcare IT. A lower 20 percent threshold applies to pediatricians.

Physicians who predominantly practice at Federally Qualified Health Centers and other settings can qualify if 30 percent of their patient base is characterized as "needy," including those covered by Medicaid, those who receive uncompensated care and patients who are charged income-related, sliding-scale fees.

Providers cannot participate in both the Medicare and Medicaid programs - they must choose one.

My interpretation of ARRA and everything I'm hearing from Washington suggests that the Interim Final Rule and Notice of Proposed Rulemaking planned for December are not likely to change this.

What is the alternative?

In my experience, the private sector and government need to collaborate to accomplish societal change. Private payers need to support clinicians who do not qualified for ARRA incentives. Why?

EHRs reduce cost and enhance quality via care coordination, reduction of redundant testing, and decision support that results in the right care at the right time. The largest portion of the financial benefits of EHRs accrue to payers. Payers should gainshare this savings with clinicians.

Malpractice insurers are another possible source of incentives. The Harvard affiliated clinicians are covered by a self insured risk management pool administered by CRICO/Risk Management Foundation. In discussions with CRICO, I learned that a large proportion of malpractice assertions arise from test results that are not reviewed/acted upon and by referral workflow that is never completed i.e. a PCP and specialist do not coordinate the patient's care. Meaningful use emphasizes the need to implement electronic lab workflow, decision support, and care coordination. If specialists, such as those with few Medicare and Medicaid patients, participate in EHR implementation and healthcare information exchange, it is highly likely that malpractice assertions will decrease.

This blog is a call to the private sector - private payers and malpractice insurers have much to gain from EHR and Healthcare Information Exchange adoption. It's time to gainshare and fill the ARRA donut hole, ensuring that all clinicians, including specialists with few Medicare and Medicaid patients, are meaningful users of healthcare information technology.

Guidelines and Protocols

I'm often asked about decision support capabilities in the BIDMC inpatient and outpatient EHR. I've previously written about our general principles of decision support and our priorities for implementing electronic guidelines and protocols.

I thought it would be interesting to show you the screens from our self-built Provider Entry System. I've included the protocol for Complex antibiotic ordering per protocol, our protocol for Heparin Dependent Antibodies, our Hydration Protocol to minimize risk of Iodinated Contrast Neprhropathy, Red Cell ordering, and TPN ordering.

I've also included an overview of our web-based ambulatory EHR, called webOMR. You'll see all the meaningful use features - vocabulary controlled problem lists, medication management (including medication reconciliation, e-prescribing, drug/drug interaction checking), clinical documentation, screening sheets which display all results and quality measures specific to treatment of a disease process, and ordering with complete decision support to ensure labs and radiology orders follow best practice guidelines.

The thematic definition of meaningful use is:

2011: To electronically capture in coded format, and to report health information, and to use that information to track key clinical conditions

2013: To guide and support care processes and care coordination

2015: To achieve and improve performance and support care processes and on key health system outcomes

Our inpatient and ambulatory systems are evolving constantly to meet these goals.

To Wait or not to Wait?

I'm often asked by clinicians and hospitals if they should wait to purchase an EHR because of the uncertainty regarding meaningful use and certification.

I tell them to move forward now.

Meaningful Use is complete for 2011 and you'll find the finished matrix online.

Although the HIT Policy and Standards Committees only make recommendations/advise the Office of the National Coordinator and HHS, I believe that the regulations issued in the next few months will follow the spirit of the Commmittee work.

Here's my understanding of the events of the next few months:

1. In mid December, CMS will issue a Notice of Proposed Rulemaking (NPRM) regarding meaningful use, then provide a 60 day public comment period. A final rule on meaningful use will be issued in the Spring.

2. In mid December, the Office of the National Coordinator will issue an Interim Final Rule (IFR) regarding certification criteria and standards. A public comment period of 30-60 days will follow and the final rule on certification criteria/standards will be issued by Spring. This is law the day it is issued (unlike a NPRM which is proposed law). While the IFR will solicit comments, the Secretary is not required to respond to the comments or make changes based on them. Hence, for all practical purposes, the industry should treat the IFR as "final" even though HHS reserves the right to make subsequent changes The certification criteria in the IFR are likely to emphasize privacy/security and data exchange standards. They will replace previous CCHIT criteria, but in the interim you will be well served to pick vendors that have passed CCHIT regular criteria and the additional CCHIT Meaningful Use criteria.

3. In mid December, the Office of the National Coordinator will issue an NPRM defining the Certification process. A public comment period of 30-60 days will follow and the final rule on the certification process will be issued by Spring. CCHIT will likely be one of several conformance testing organizations, coordinated by NIST, that will certify products using the new ONC criteria.

Thus, completely clarity in the form of rulemaking will be available in the Spring.

However, the longer your wait to get started, the more challenging it will be achieve meaningful use in practice by 2011. Also, it's important to get vendor commitments and hire staff now before the real competition for resources begins.

Start by purchasing a fully functional EHR or a hosted solution that was certified using previous CCHIT criteria. Also, ensure it supports data exchange. The interoperability goals for 2011 are likely to be

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

so, you'll want to be sure that the product or the product plus third party services support those functions.

If you're a hospital organization, develop a governance structure for prioritizing projects, a budget, a training plan, and a communication plan. Spring will be here soon and any ambiguity will be resolved.

Thus, I think we can predict what meaningful use and certification criteria will be based on existing HIT Policy and Standards Committee work, so you should move forward now without delay. When 2011 stimulus payments begin, you'll be thankful you had the time to prepare.

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.