How Do Vegans Get Enough Protein?

As a vegan, one of the more frequent questions I'm asked is "if you eat only plants, how do you get enough protein?"

A recent movie review of Forks Over Knives in the Boston Globe speculated that vegans must have a hard time with protein and essential nutrients.

Somehow the average consumer has forgotten that plants are filled with protein (i.e. have you ever heard the term "textured vegetable protein"?)

As a vegan for over 10 years, I've never had any issues with protein, necessary amino acids, or essential nutrients.  I get everything I need from  a simple balanced diet that includes protein rich plants such as spinach, soy, and peanuts.

Here's a useful resource about the protein content in vegetables.

How do vegans get enough protein?  Just pass the spinach!

Here's a few favorite protein rich recipes.

About the only issue vegans have is getting enough B12.   I need about a thimbleful per year!  I can just get it from B12 found naturally in the topsoil that sticks to root vegetables (no matter how much you clean them) or take an occasional supplement extracted from yeast.

No meat, milk, or cheese required!

The May HIT Standards Committee meeting

The May HIT Standards Committee meeting focused on the schedule of work ahead to provide ONC with the standards needed for Meaningful Use Stage 2 regulation writing.

We began the meeting by reviewing the meeting topics for April to September, shown in the table below.

To ensure all the necessary standards are included in our project plan, we asked Paul Tang to present the latest proposed MU stage 2 criteria. His presentation included several new recommendations:

*CPOE requirements should be expanded to 60% of medication and lab orders as well as demonstration of radiology orders

*Clinicians should be able to refine drug/drug interaction alerts so that alerts are accurate and actionable.  In Stage 3, EHRs should be able to access national lists of drug/drug interaction rules

*20% of hospital discharge medication orders should be e-prescribed

*Demographic capture should include expanded race/ethnicity as noted in the IOM Report Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement.

*Stage 3 should include second hand smoke exposure as a tobacco use type

*40% of hospital labs sent to outpatient providers should be electronic and include LOINC vocabularies

*Eligible professionals should document electronic notes on 30% of visits.  Hospitals should have electronic notes for 30% of patient days

*The Electronic Medication Administration Record should be in use 

*Standards-based Family History documentation should be included in stage 3

*For Hospitals, greater than 25 patients should receive electronic discharge instructions and 10% of patients should view and download information about a hospital admission

*For Eligible Professionals, 10% of patients should view and download their health information

*10% of all patients should receive educational materials

*Eligible Professionals should use secure messaging with greater than 25 patients 

*Eligible Professionals should record communication preferences (secure email, PHR, snail mail etc) for 20% of patients

*Stage 3 should include a mechanism for capturing patient entered data in the EHR

*Medication reconciliation should be done for 50% of care transitions

*Hospitals should send summary of care records to professionals or long term care facilities for 10% of all discharges 

*Eligible professionals should send at least 25 care summaries to other providers electronically

*10% of patients should have a list of care team members (unstructured text for now, structured data for stage 3) 

*A care plan should be included with summary of care transmissions

*Hospitals and eligible professionals should submit at least one live immunization transaction

*Hospitals should submit at least one live reportable lab transaction

*Hospitals should submit at least one live syndromic surveillance transaction

*Cancer conditions should be reported to registries by eligible professionals 

*Data on mobile devices should be encrypted

These new Stage 2 requirements require new standards for

*Extended race/ethnicity codesets

*Discharge medication e-prescribing

*Extended smoking codeset  

*Possible new data exchanges supporting electronic medication administration record workflow (need to  clarify the scope of the EMAR requirement)

*Representing care plans

*Reporting cancer conditions

*Encrypting mobile devices

These will be assigned to workgroups and power teams.

Dixie Baker presented the Privacy and Security Workgroup report focusing on provider directories.   The scope of this work includes entity (i.e. organization) level directory queries from EHRs.   After much discussion, we concluded that the Direct project protocols for DNS query in support of certificate exchange are good enough for the short term, while web-based query/response connections to enterprise LDAP queries is a reasonable future direction.   We'll work with the Policy Committee and ONC to refine the business requirements then produce a series of standards requirements as input to the S&I framework.   The consensus of the committee is that a community based directory is helpful but not necessary for exchange, just as there is no national directory of email addresses, but yet we successfully exchange billions of email per year.

Jim Walker presented the Clinical Quality Workgroup report outlining the work ahead to provide CMS with the standards needed to support quality measures by August.

Judy Murphy and Liz Johnson presented Implementation Workgroup report including their certification experience survey.        

Jamie Ferguson presented Clinical Operations Vocabulary Task Force report.  The Task Force is specifying the vocabulary and codesets needed to accelerate semantic interoperability.  The Implementation Workgroup and the Vocabulary Task Force will also make statements about certification queries such as support for Postel's Law - if a new vocabulary term is introduced, existing systems should continue to function.

           

Doug Fridsma led a discussion of the Summer Power Team activities

Stan Huff presented the Metadata Analysis Power Team report.   There was general consensus that simple XML forms which support patient identity and provenance (who sent the message, when was it sent etc) using CDA R2 and X.509 signatures was good enough.

Marc Overhage submitted the Patient Matching Power Team report.

We will get updates on the Surveillance Implementation Guide (Chris Chute), e-prescribing of discharge needs (Jamie Ferguson) and NwHIN (Dixie Baker) at the next meeting.

A very productive meeting.   The HIT Standards Committee is truly an effective team, representing varied interests but always able to chart a path forward that balances all points of view.

The Status of e-Prescribing in the US

On May 12, Surescripts released the National Progress Report on e-Prescribing and Interoperable Healthcare.

For the past 3 years, Massachusetts has led the country in e-prescribing due to the combined efforts of our payers and our healthcare information exchange.    I follow the evolution of e-prescribing with great interest.

Key findings in the Surescripts report include:

Electronic Prescribing Use
* Prescription Benefit: Electronic responses to requests for prescription benefit information grew 125% from 188 million in 2009 to 423 million in 2010.
* Medication History: Prescription histories delivered to prescribers grew 184% from 81 million in 2009 to 230 million in 2010.
* Prescription Routing: Prescriptions routed electron- ically grew 72% from 191 million in 2009 to 326 mil- lion in 2010.
* EMR vs. Standalone E-Prescribing Software: About 79 percent of prescribers used EMRs in 2010, up from 70 percent in 2009.

Electronic Prescribing Adoption
* Prescribers: The number of prescribers routing prescriptions electronically grew from 156,000 at the end of 2009 to 234,000 by the end of 2010—representing about 34 percent of all office-based prescribers.
* Payers: At the end of 2010, Surescripts could provide access to prescription benefit and history information for more than 66 percent of patients in the U.S.
* Community and Mail Order Pharmacies: At the end of 2010, approximately 91 percent of community pharmacies in the U.S. were connected for prescription routing and six of the largest mail order pharmacies were able to receive prescriptions electronically.

Surprising findings to me include
*Family practitioners and small practices have high rates of e-prescribing compared to other specialties and practice sizes
*Specialists including cardiologists and ophthalmologists are using e-prescribing more often that I expected

E-prescribing is a unique interoperability success story.  The standards are clear (NCPDP) and are required by regulation (Medicare Part D and the Standards and Certification Final Rule).   Incentives are aligned (saves clinicians time and saves pharmacies money while making the entire process safer and more convenient for the patient).       Let's hope our other interoperability efforts such as clinical summary exchange follow this same adoption trajectory over time as we provide unambiguous standards and change the culture to make interoperability an expectation of patients and providers.

Should We Abandon the Cloud?

It's been a bad month for the cloud.

First there was the major Amazon EC2 (Elastic Cloud) outage April 21-22 that brought down many business and websites.  Some of the data was unrecoverable and transactions were lost.

Next, the May 10-13 outage of Microsoft's cloud based email and Office services (Business Productivity Online Suite) caused major angst among its customers who thought that the cloud offered increased reliability

Then we had the May 11-13 Google Blogger outage which brought down editing, commenting, and content for thousands of blogs.

Outages from the 3 largest providers of cloud services within a 2 week period does not bode well.

Yesterday, Twitter went down as well.

Many have suggested we abandon a cloud only strategy.

Should we abandon the cloud for healthcare?  Absolutely not.

Should we reset our expectations that highly reliable, secure computing can be provided at very low cost by "top men" in the cloud?  Absolutely yes.

I am a cloud provider.   At my Harvard Medical School Data Center, I provide 4000 Cores and 2 petabytes of data to thousands of faculty and staff.   At BIDMC, I provide 500 virtualized servers and a petabyte of data to 12,000 users.   Our BIDPO/BIDMC Community EHR Private Cloud provides electronic health records to 300 providers.

I know what it takes to provide 99.999% uptime.  Multiple redundant data centers, clustered servers, arrays of tiered storage, and extraordinary power engineering.

With all of this amazing infrastructure comes complexity.   With complexity comes unanticipated consequences, change control challenges, and human causes of failure.

Let's look at the downtime I've had this year.

1.  BIDMC has a highly redundant, geographically dispersed Domain Name System (DNS) architecture.   It theory it should not be able to fail.  In practice it did.  The vendor was attempting to add features that would make us even more resilient.  Instead of making changes to a test DNS appliance, they accidentally made changes to a production DNS appliance.   We experienced downtime in several of our applications.

2.  HMS has clustered thousands of computing cores together to create a highly robust community resource connected to a petabyte of distributed storage nodes.   In theory is should be invincible.   In practice it went down.   A user with limited high performance computing experience launched a poorly written job to  400 cores in parallel that caused a core dump every second contending for the same disk space.   Storage was overwhelmed and went offline for numerous applications.

3.  BIDMC has a highly available cluster to support clinical applications.    We've upgraded to the most advanced and feature rich Linux operating system.  Unfortunately, it had a bug that when used in a very high performance clustered environment, the entire storage filesystem became unavailable.  We had downtime.

4.  BIDMC has one of the most sophisticated power management systems in the industry - every component is redundant.   As we added features to make us even more redundant, we needed to temporarily reroute power, which is not an issue for us because every network router and switch has two power supplies.   We had competed 4 of 5 data center switch migrations when the redundant power supply failed on the 5th switch, bringing down several applications.

5.  The BIDPO EHR hosting center has a highly redundant and secure network.  Unfortunately, bugs in the network operating system on some of the key components led to failure of all traffic to flow.

These examples illustrate that even the most well engineered infrastructure can fail due to human mistakes, operating system bugs, and unanticipated consequences of change.

The cloud is truly no different.  Believing that Microsoft, Google, Amazon or anyone else can engineer perfection at low cost is fantasy.   Technology is changing so fast and increasing demand requires so much change that every day is like replacing the wings on a 747 while it's flying.   On occasion bad things will happen.   We need to have robust downtime procedures and business continuity planning to respond to failures when they occur.

The idea of creating big data in the cloud, clusters of processors, and leveraging the internet to support software as a service applications is sound.

There will be problems.   New approaches to troubleshooting issues in the cloud will make "diagnosis and treatment" of slowness and downtime faster.

Problems on a centralized cloud architecture that is homogenous, well documented, and highly staffed can be more rapidly resolved than problems in distributed, poorly staffed, one-off installations.

Thus, I'm a believer in the public cloud and private clouds.  I will continue to use them for EHRs and other healthcare applications.   However, I have no belief that the public cloud will have substantially less downtime or lower cost than I can engineer myself.

The reason to use the public cloud is so that my limited staff can spend their time innovating - creating infrastructure and applications that the public cloud has not yet envisioned or refuses to support because of regulatory requirements  (such as HIPAA).

Despite the black cloud of the past two weeks, the future of the cloud, tempered by a dose of reality to reset expectations, is bright.

Cool Technology of the Week

How many times have you heard the complaint "the application is slow" but lack data about server, network, or desktop performance to facilitate diagnosis and resolution?

In a cloud environment, debugging application issues becomes ever more challenging.

As we all rollout EHRs to small provider offices, often with challenging internet connections, remote monitoring of cloud network performance becomes even more critical.

AppNeta's PathView microAppliance provides an easy to deploy zero administration network monitoring tool. It's about the same size as a cell phone and can be placed at remote business locations, requiring only power and an ethernet connection.

You place one of their devices in the locationyou want to monitor network activity.   When you plug it into the wall and an ethernet connection,  it uploads network performance data to AppNeta cloud servers.  You can also place two or more devices in separate locations, and monitor the traffic between those locations.   For EHR cloud providers, it's simple to configure the device, send it via UPS to a provider practice with instructions to plug into the wall, and gather performance data without complicated onsite network sniffing setups and configuration.

Currently we have deployed these devices at our central EHR private cloud site and two of major remote practices  The level of detail and depth of available metrics and reports is amazing.  

A low cost, zero administration, cloud-based, network sniffer that is truly plug and play.  That's cool!

The Community Garden - Before and After

Last month, I posted my 2011 gardening plan including a design for a new community garden plot in Wellesley.

Here's what we started with:

After a few weekends of hauling debris, pounding fence posts, pouring concrete, and a bit of woodworking with Japanese handsaws, it's finished.

All of the improvements are now the property of the town of Wellesley, since the community garden is shared public space.

Here's what we did:

On April 30, we rented a U-Haul and moved 2000 pounds of rotting wood, metal scraps, plant debris, plastic, and paper from the community garden space to the Wellesley recycling center. We purchased 4x4 fence posts, T-posts, wire fencing, hardware cloth, and lumber for an arbor at Home Depot. We rototilled the space, dug post holes, and poured concrete. On May 1, we completed the wire fencing and built the arbor.

On May 7-8, we hauled soil and bark, created 5 raised beds, and planted our seeds/seedlings. We built a small bird house and added a thistle feeder. We added irrigation.

$500 and two weekends later, here's the result.

Trellis: Canadice and Himrod grapes

Long Fence: Mammoth Sunflowers

Rear Fence: Sweet peas (flowering) and morning glory

Bed #1 (near gate)
Early lettuce as green mulch
Cucumber (1 Midori)
Summer Squash (1 Kousa and 1 yellow)
Brussels Sprouts (6 center row)
Cabbage (3 purple and 3 savoy)
Romanesco Veronica Cauliflower
Broccoli (6)
Violet Cauliflower
Basil
Dill
Borage
Celery (1)
Nasturtium (1 corner)
Marigold Little Gem (3 corner)

Bed #2
Cutting flowers (calendula, zinnia, cosmos, bachelor buttons, nigella, salvia, stock, aster, snapdragon, gomphrena)
Nasturtium (1 corner)
Marigold Little Gem (3 corners)

Bed #3
Asparagus (20 Jersey Supreme  one year crowns, and 50 Purple Passion)

Bed #4
Early lettuce as green mulch
Winter Squash (1 red kabocha, 1 delica kabocha)
“Gita” Long Bean (tower)
Rosemary
Costata Romanesco Zucchini (1)
3 Broccoli
carrots
Daikon
Borage
Celery (1)
Nasturtium (corner)
Marigold Little Gem (3 corners)

Bed #5 (near hose) - (use for Lettuce in early spring)
Early lettuce as green mulch
Tomatoes (1 Principe Borghese, 1 Costoluto Genovese, 1 German Striped)
Eggplant (1 Kermit, 1 Turkish Red, 4 Asian Wonder)
Husk groundcherry (6)
Peppers (1 Boris Banana, 1 Sweet Italian)
6 Kale
Onions
Borage
Sage
Basil
Nasturtium (1 corner)
Marigold Little Gem (3 corners)

I look forward to a bountiful harvest this season.

On Becoming a Harvard Professor

Almost 15 years ago on June 15, 1996, I moved from California to Massachusetts.   I began practicing Emergency Medicine at Beth Israel Deaconess Medical Center.   On that day, I wrote in my journal:

"Today I've started work at one of the best hospitals in the country.  I'm surrounded by smart people, amazing technology, and incredible possibilities.   What am I, who am I, what will I be?   I'm an instructor and the path to Harvard Professor seems insurmountable."

Today, I joined several friends and colleagues to celebrate my becoming a Harvard Professor.

Along the journey, I've learned many lessons.   Professorship is not about fame, fortune,  or what I know.  It's about community.   Early in my Harvard career, Dr. Tom Delbanco, Sam Fleming, Warren McFarlan, Marvin Schorr,  and others advised me to focus on creating teams of smart people to change the world.     From my discussion with Deans and faculty, here are the top 5 roles of a Harvard Professor:

*Training the next generation -  I have 20 years left in my career.  Now is the right time to develop the next generation of informatics and IT leaders by sharing my experience and giving them an opportunity to thrive.  I'll do my best to inspire and mentor students, residents, fellows and junior faculty by always being available to them.

*Communicating ideas - publishing, lecturing, meeting, blogging, and serving on expert panels ensures that ideas and innovation are widely disseminated.   Today's blog is my 900th post, creating  a permanent record of the key ideas I encounter in my life as a healthcare CIO.

*Serving as role model - a strong sense of ethics and equanimity, always being moral and fair in every conversation and relationship, fosters an environment that encourages people to excel.

*Building teams - assembling and resourcing the best people, especially those with differing opinions and experiences, leads to innovation.

*Creating an ideal work and learning environment - accepting accountability for resolving personnel conflicts, budget shortfalls, strategic ambiguity, political barriers, and impediments to the free exchange of ideas empowers teams to succeed.

So now the next phase of my career begins.  I feel humbled by the responsibility and will do my best to train, communicate, serve, build, and create!