Next Tuesday, my daughter turns 18. She becomes an adult with the ability to vote, take legal responsibility for her actions, and assert her own independence.
In some ways, my job as a parent is done. She has a good moral compass, feels good about herself, and is resilient. She knows when to ask for help and is open with us about her feelings, challenges, and goals. She's decided to skip much of adolescence and go directly from child to adult, bypassing most of the rebelliousness and occasional self destructive behavior of teens.
She's learned to balance work and play, limit texting and use of electronic devices, and how to build and grow relationships. She has the tools she needs to navigate the next stage of life as she enters college at Tufts University this Fall.
What have I learned from our past 18 years together?
1. Create a non-punitive climate of trust. It's far better to encourage discussion of tough issues than to "shoot the messenger" and create a fear of communication.
2. Strike a balance between too much oversight and too little. In 4 months, she'll leave home and make decisions for herself. She'll decide what to eat and drink, who to spend her time with, and how to balance academics with leisure. Managing her every moment at home with strict oversight may produce short term success but does not enable her to take ownership of the decisions she makes - good and bad. Providing no oversight can lead to risky and destructive behaviors. We've tried to set wide and reasonable limits, then give her free reign to run her life within those limits. She's learned from her mistakes and is a stronger, more self-reliant person because she had the freedom to choose her own path.
3. As with my professional life, I pay more attention to her trajectory than her position. Humans between 12 and 19 can have highly variable moods, rapidly changing ideas, and contrary behaviors. Reacting to every event day to day is likely to cause frustration on both sides. Chances are that today's troubling issue will be gone tomorrow or next week. Focus on the big picture, not the brushstrokes.
4. Strong negative emotions accomplish nothing. In the past 18 years, I can only remember a few times that I've raised my voice. Not only was it ineffective, I spent substantial time repairing the emotional damage done. The term I've used before is "Save as Draft". If you ever feel negative emotions and want to yell, Save as Draft. Have a thoughtful discussion and rethink your emotions based on winning the war, not the battle.
5. Family experiences last a lifetime. Although it may not be immediately clear that time spent together has a profound affect, I can see that my daughter will pursue activities throughout her life inspired by the things we've done together over the past 18 years. Her love of nature, mountains, Japan, gardening, and beaches all come from those hours we spent experiencing the world together.
Of course, she'll have triumphs and tribulations in college. She'll seek our advice and support when she needs it. We'll help her launch a family of her own and continue to share our 50 years of life lessons when they can aid her decision making.
In August, we become empty nesters. Just as we transitioned from the spontaneity of our 20's to the parental responsibilities of our 30's, we're now headed into our next phase.
Thank you Lara for the past 18 years. You've made me a better person and I am confident you'll fledge into a magnificent young woman.
Thursday, 31 March 2011
Wednesday, 30 March 2011
The March HIT Standards Committee Meeting
The March HIT Standards Committee meeting focused on the Stage 2 Meaningful Use work ahead, the Direct Project, certificate management, provider directories, devices, and plans to ensure the certification process has the tools and scripts it needs to reduce the burden on vendors and self-certifiers.
Farzad Mostashari, Acting National Coordinator, began the meeting with a discussion of the trajectory we're on. We're guided by policy outcomes - improved quality, safety, and efficiency. The work in 2011 will include the regulatory effort to finalize Stage 2 of Meaningful Use and its accompanying standards and certification criteria. Efforts will be guided by the new Federal HIT Strategic Plan and will require the hard working teams of volunteers that staff the Policy committee, the Standards committee and numerous other working groups such as the Institute of Medicine Learning Healthcare System group, the PCAST workgroup, and the Privacy/Security Tiger Team. It will be a busy year.
Doug Fridsma reviewed the Timeline and Milestones for NPRM Stage 2, noting the NPRM draft needs to be completed in Q3 2011, the NPRM will be published Q4 2011, and the final rule will be published Q1 2012. This means that the work on the standards needs to be completed this Summer. Timing for Stage 2 is going to be tight because certification tests must be developed, vetted, and implemented by certification bodies so that EHRs have lead-time for software development, certification, upgrade/installation, and training by October 1, 2012. The work ahead is in 4 areas:
1. Vocabulary - we need to reduce the optionality and alternatives for vocabularies and code sets. Multiple vocabularies create significant complexity for vendors and users. We need a library of constrained codesets that comprise 95% of transactional volume and value i.e. 300 LOINC codes are sufficient for 98% of all ordered lab tests.
2. Upgrade from paper to electronic data transmission - we need to increase the specificity of data transmission standards (i.e. Direct, Connect, Exchange should support most point to point and query/response use cases). A major focus of standards work should be the content, vocabulary and transmission standards needed for care transitions.
3. President's Council of Advisors on Science and Technology (PCAST) - we should implement pilots and experiments which will provide the foundation for the kinds of query/response transactions suggested by the PCAST report.
4. The Nationwide Health Information Network specifications should be upgraded to include content and transport standards needed for meaningful use.
Next, Arien Malec reviewed the real world experience deploying Direct. Feedback has been generally positive and lessons learned include issues of certificate management and challenges of integration into complex corporate email systems. The Standards Committee was very pleased with the progress and looks forward to upcoming Best Practices and Compliance guides.
Jim Walker accepted the position of Chair of the Clinical Quality Workgroup. The Workgroup scope includes reducing barriers to implementation of quality measures, focusing on the cost/benefit of gathering the necessary data elements from the EHR including exclusionary criteria.
Dixie Baker presented the Privacy & Security Standards Workgroup Recommendations for Certificate Management The committee accepted all 3 recommendations made by the Workgroup including:
*Requirements and evaluation criteria for digital certificates
*Need for investigation of alternatives for cross-certifying digital certificate issuers with the Federal Bridge (important for interoperability between non-Federal and Federal organizations)
*Policy Questions for the HIT Policy Committee related to creating a trust fabric for health information exchange
Next, Walter Suarez presented the specifications for entity level provider directories based on input from the HIT Policy Committee. Standards will be needed for
*Directory Structure and Content
*Submission of directory entries to a National Registry via a publication/posting protocol
*A directory query language
On April 13, the Policy Committee will finish its requirements for Individual Level Provider Directories (ILPDs). By May, the Privacy and Security Workgroup will present its standards recommendations for both entity level and individual level provider directories. Although there is much work needed to harmonize standards for the entire directory ecosystem. In the short term, the most important work is the ability of an EHR to query a provider directory. That is likely to be a stage 2 certification item.
Jamie Ferguson presented a summary of the March 28 Device Hearings. Major themes were
*Consumers and patients need device interoperability to be inexpensive and easy
*The last mile of connectivity into home devices is currently a barrier
*EHRs need a place to collect device and patient submitted data
*Incentives need to be aligned so that clinicians are willing to accept and review device data
*Patient identity needs to be specified in the transactions between the device and the EHR/PHR
*Standards need to support end to end communication from the device to the EHR and not just to/from intermediaries/hubs/service providers.
*Device interoperability should be included in Stage 3, not Stage 2
Finally, Judy Murphy and Liz Johnson presented their plan for ensuring future NIST scripts and supporting tools reduce the burden of certification including such items as
*the need to pilot scripts
*the need to ensure medications and labs in the scripts are clinically reasonable
*the need to ensure certification criteria such as security requirements are easily testable
*clarifying how modules can be assembled, inheriting the certification characteristics of each
*ensuring the availability of tools needed to test every standards-based transaction
A great meeting. We're all committed to creating standards and certification criteria for Stage 2 that will address the needs of all our stakeholders.
Farzad Mostashari, Acting National Coordinator, began the meeting with a discussion of the trajectory we're on. We're guided by policy outcomes - improved quality, safety, and efficiency. The work in 2011 will include the regulatory effort to finalize Stage 2 of Meaningful Use and its accompanying standards and certification criteria. Efforts will be guided by the new Federal HIT Strategic Plan and will require the hard working teams of volunteers that staff the Policy committee, the Standards committee and numerous other working groups such as the Institute of Medicine Learning Healthcare System group, the PCAST workgroup, and the Privacy/Security Tiger Team. It will be a busy year.
Doug Fridsma reviewed the Timeline and Milestones for NPRM Stage 2, noting the NPRM draft needs to be completed in Q3 2011, the NPRM will be published Q4 2011, and the final rule will be published Q1 2012. This means that the work on the standards needs to be completed this Summer. Timing for Stage 2 is going to be tight because certification tests must be developed, vetted, and implemented by certification bodies so that EHRs have lead-time for software development, certification, upgrade/installation, and training by October 1, 2012. The work ahead is in 4 areas:
1. Vocabulary - we need to reduce the optionality and alternatives for vocabularies and code sets. Multiple vocabularies create significant complexity for vendors and users. We need a library of constrained codesets that comprise 95% of transactional volume and value i.e. 300 LOINC codes are sufficient for 98% of all ordered lab tests.
2. Upgrade from paper to electronic data transmission - we need to increase the specificity of data transmission standards (i.e. Direct, Connect, Exchange should support most point to point and query/response use cases). A major focus of standards work should be the content, vocabulary and transmission standards needed for care transitions.
3. President's Council of Advisors on Science and Technology (PCAST) - we should implement pilots and experiments which will provide the foundation for the kinds of query/response transactions suggested by the PCAST report.
4. The Nationwide Health Information Network specifications should be upgraded to include content and transport standards needed for meaningful use.
Next, Arien Malec reviewed the real world experience deploying Direct. Feedback has been generally positive and lessons learned include issues of certificate management and challenges of integration into complex corporate email systems. The Standards Committee was very pleased with the progress and looks forward to upcoming Best Practices and Compliance guides.
Jim Walker accepted the position of Chair of the Clinical Quality Workgroup. The Workgroup scope includes reducing barriers to implementation of quality measures, focusing on the cost/benefit of gathering the necessary data elements from the EHR including exclusionary criteria.
Dixie Baker presented the Privacy & Security Standards Workgroup Recommendations for Certificate Management The committee accepted all 3 recommendations made by the Workgroup including:
*Requirements and evaluation criteria for digital certificates
*Need for investigation of alternatives for cross-certifying digital certificate issuers with the Federal Bridge (important for interoperability between non-Federal and Federal organizations)
*Policy Questions for the HIT Policy Committee related to creating a trust fabric for health information exchange
Next, Walter Suarez presented the specifications for entity level provider directories based on input from the HIT Policy Committee. Standards will be needed for
*Directory Structure and Content
*Submission of directory entries to a National Registry via a publication/posting protocol
*A directory query language
On April 13, the Policy Committee will finish its requirements for Individual Level Provider Directories (ILPDs). By May, the Privacy and Security Workgroup will present its standards recommendations for both entity level and individual level provider directories. Although there is much work needed to harmonize standards for the entire directory ecosystem. In the short term, the most important work is the ability of an EHR to query a provider directory. That is likely to be a stage 2 certification item.
Jamie Ferguson presented a summary of the March 28 Device Hearings. Major themes were
*Consumers and patients need device interoperability to be inexpensive and easy
*The last mile of connectivity into home devices is currently a barrier
*EHRs need a place to collect device and patient submitted data
*Incentives need to be aligned so that clinicians are willing to accept and review device data
*Patient identity needs to be specified in the transactions between the device and the EHR/PHR
*Standards need to support end to end communication from the device to the EHR and not just to/from intermediaries/hubs/service providers.
*Device interoperability should be included in Stage 3, not Stage 2
Finally, Judy Murphy and Liz Johnson presented their plan for ensuring future NIST scripts and supporting tools reduce the burden of certification including such items as
*the need to pilot scripts
*the need to ensure medications and labs in the scripts are clinically reasonable
*the need to ensure certification criteria such as security requirements are easily testable
*clarifying how modules can be assembled, inheriting the certification characteristics of each
*ensuring the availability of tools needed to test every standards-based transaction
A great meeting. We're all committed to creating standards and certification criteria for Stage 2 that will address the needs of all our stakeholders.
Tuesday, 29 March 2011
The HIT Standards Committee Device Hearing
Yesterday, the Clinical Operations Workgroup of the HIT Standards Committee held an all day hearing to identify barriers and enablers for device interoperability including those used in clinical settings and the home.
Here are the questions we asked.
We started with a Patient/Consumer Panel
Rob Havasy, Partners Center for Connected Health
Courtney Rees Lyles, MD, Group Health Cooperative
Robert Jarrin, co-chair Continua Health Alliance
We then continued with a Provider Panel
Julian Goldman, MD, Partners Healthcare
Scott Evans, Intermountain Healthcare
Jo Carol Hiatt, MD, Kaiser Permanente
Sara Toscano, RN, BSN, Clinical Informatics Coordinator & Coordinator for IntelliVue Clinical Information Portfolio, VA Maryland Healthcares System, Veterans Health Administration
We then reviewed the current work on interoperability and data integration standards
Dale Wiggins, Chief Technology Officer, Philips Healthcare
Charles Jaffe, HL7
Elliot B. Sloane, PhD, Drexel University, IHE
Charles Parisot, GE Healthcare IT
John Garguilo, NIST
We reviewed the issues of Data Accuracy & Integrity
Tim Escher, Epic
John Zaleski, PhD, CPHIMS, Chief Technology Officer, Nuvon
Marlene Haddad, Office of Health Informatics Management, Veterans Health Administration
Karen Thomas, Advanced TeleHealth Solutions
We next heard from exports on Device Security
Patrick Heim, Kaiser Permanente, Healthcare Security Alliance
Todd Cooper, 80001 Experts, LLC
David Fisher, Medical and Imaging Technology Alliance
We had an important discussion of Unique Device Identification
Jay Crowley, Food and Drug Administration, HHS
Betsy Humphreys, National Library of Medicine
James P. Keller, Jr., ECRI Institute
Elliot B. Sloane, PhD, Drexel University, IHE
Michael Howells, Bosch Healthcare
A great day with many thoughtful presentations. I'll review the major themes tomorrow when I wrote about the March HIT Standards Committee meeting.
Here are the questions we asked.
We started with a Patient/Consumer Panel
Rob Havasy, Partners Center for Connected Health
Courtney Rees Lyles, MD, Group Health Cooperative
Robert Jarrin, co-chair Continua Health Alliance
We then continued with a Provider Panel
Julian Goldman, MD, Partners Healthcare
Scott Evans, Intermountain Healthcare
Jo Carol Hiatt, MD, Kaiser Permanente
Sara Toscano, RN, BSN, Clinical Informatics Coordinator & Coordinator for IntelliVue Clinical Information Portfolio, VA Maryland Healthcares System, Veterans Health Administration
We then reviewed the current work on interoperability and data integration standards
Dale Wiggins, Chief Technology Officer, Philips Healthcare
Charles Jaffe, HL7
Elliot B. Sloane, PhD, Drexel University, IHE
Charles Parisot, GE Healthcare IT
John Garguilo, NIST
We reviewed the issues of Data Accuracy & Integrity
Tim Escher, Epic
John Zaleski, PhD, CPHIMS, Chief Technology Officer, Nuvon
Marlene Haddad, Office of Health Informatics Management, Veterans Health Administration
Karen Thomas, Advanced TeleHealth Solutions
We next heard from exports on Device Security
Patrick Heim, Kaiser Permanente, Healthcare Security Alliance
Todd Cooper, 80001 Experts, LLC
David Fisher, Medical and Imaging Technology Alliance
We had an important discussion of Unique Device Identification
Jay Crowley, Food and Drug Administration, HHS
Betsy Humphreys, National Library of Medicine
James P. Keller, Jr., ECRI Institute
Elliot B. Sloane, PhD, Drexel University, IHE
Michael Howells, Bosch Healthcare
A great day with many thoughtful presentations. I'll review the major themes tomorrow when I wrote about the March HIT Standards Committee meeting.
Monday, 28 March 2011
The Federal Health IT Strategic Plan
On Friday, March 25, ONC released the Federal Healthcare IT Strategic Plan 2011-2015.
Here's an outline of the five goals and a bit of commentary:
Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT
A. Accelerate adoption of electronic health records
*Provide financial incentive payments for the adoption and meaningful use of certified EHR technology.
*Provide implementation support to health care providers to help them adopt, implement, and use certified EHR technology.
*Support the development of a trained workforce to implement and use health IT technologies.
*Encourage the inclusion of meaningful use in professional certification and medical education.
*Establish criteria and a process to certify EHR technology that can support meaningful use criteria.
*Communicate the value of EHRs and the benefits of achieving meaningful use.
*Align federal programs and services with the adoption and meaningful use of certified EHR technology.
*Work with private sector payers and provider groups to encourage providers to achieve meaningful use.
*Encourage and facilitate improved usability of EHR technology.
B. Facilitate information exchange to support meaningful use of electronic health records
*Foster business models that create health information exchange.
*Monitor health information exchange options and fill the gaps for providers that do not have viable options.
*Ensure that health information exchange takes place across individual exchange models, and advance health systems and data interoperability.
C. Support health IT adoption and information exchange for public health and populations with unique needs
*Ensure public health agencies are able to receive and share information with providers using certified EHR technology.
*Track health disparities and promote health IT that reduces them.
*Support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings.
Goal II: Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT
A. Support more sophisticated uses of EHRs and other health IT to improve health system performance
*Identify and implement best practices that use EHRs and other health IT to improve care, efficiency, and population health.
*Create administrative efficiencies to reduce cost and burden for providers, payers, and government health programs.
B. Better manage care, efficiency, and population health through EHR-generated reporting measures
*Identify specific measures that align with the National Health Care Quality Strategy and Plan.
*Establish standards, specifications, and certification criteria for collecting and reporting measures through certified EHR technology.
C. Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management
*Fund and administer demonstration communities to show how the advanced use of health IT can achieve measurable improvements in care, efficiency, and population health.
*Align health IT initiatives and clinical and payment reform pilots and demonstrations.
D. Support new approaches to the use of health IT in research, public and population health, and national health security
*Establish new approaches to and identify ways health IT can support national prevention, health promotion, public health, and national health security.
*Invest in health IT infrastructure to support the National Prevention and Health Promotion Strategy.
*Ensure a mechanism for information exchange in support of research and the translation of research findings back into clinical practice.
Goal III: Inspire Confidence and Trust in Health IT
A. Protect confidentiality, integrity, and availability of health information
*Promulgate appropriate and enforceable federal policies to protect the privacy and security of health information.
*Enforce existing federal privacy and security laws and maintain consistency with federal confidentiality, policy.
*Encourage the incorporation of privacy and security functionality into health IT.
*Identify health IT system security vulnerabilities and develop strategic solutions.
*Identify health IT privacy and security requirements and best practices, and communicate them through health IT programs.
B. Inform individuals of their rights and increase transparency regarding the uses of protected health information
*Inform individuals about their privacy and security rights and how their information may be used and shared.
*Increase transparency regarding the development of policies and standards related to uses and sharing of protected health information.
*Require easy to understand reporting of breach notifications.
C. Improve safety and effectiveness of health IT
*Provide implementation and best practice tools for the effective use of health IT.
*Evaluate safety concerns and update approach to health IT safety.
*Monitor patient safety issues related to health IT and address concerns.
Goal IV: Empower Individuals with Health IT to Improve their Health and the Health Care System
A. Engage individuals with health IT
*Listen to individuals and implement health IT policies and programs to meet their interests.
* Communicate with individuals openly and spread messages through existing communication networks and dialogues.
B. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse
*Through Medicare and Medicaid EHR Incentive Programs, encourage providers to give patients access to their health information in an electronic format.
*Through federal agencies that deliver or pay for health care, act as a model for sharing information with individuals and make available tools to do so.
*Establish public policies that foster individual and caregiver access to their health information while protecting privacy and security.
C. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care
*Support the development of standards and tools that make EHR technology capable of interacting with consumer health IT and build these requirements for the use of standards and tools into EHR certification.
*Solicit and integrate patient-generated health information into EHRs and quality measurements.
*Encourage the use of consumer health IT to move toward patient-centered care.
Goal V: Achieve Rapid Learning and Technological Advancement
A. Lead the creation of a learning health system to support quality, research, and public/population health
*Establish an initial group of learning health system participants.
*Develop standards, policies, and technologies to connect individual participants within the learning health system.
*Engage patients, providers, researchers, and institutions to exchange information through the learning health system.
*Grow the learning health system by adding more members and expanding policies and
population standards as needed.
B. Broaden the capacity of health IT through innovation and research
*Liberate health data to enable health IT innovation.
*Make targeted investments in health IT research.
*Employ government programs and services as test beds for innovative health IT.
*Monitor and promote industry innovation.
*Provide clear direction to the health IT industry regarding government roles and policies for protecting individuals while not stifling innovation.
As I read the report, there were a few paragraphs I found particularly interesting. I believe they suggest important directions to watch:
*Stages two and three are anticipated to transition gradually away from further process requirements like those included in stage one, to requirements for improvement in outcomes and quality of care.
*For providers ineligible for incentive payments (for example, long-term and post-acute care facilities, community mental health centers, or substance use disorder treatment providers), the government is developing technology and policy solutions that build on meaningful use and fit their unique needs.
*The health information exchange strategy in Goal I focuses on first fostering exchange that is already happening today, supporting exchange where it is not taking place, and creating means for exchange between local initiatives.
*Goal IV recognizes the importance of engaging and empowering individuals with electronic health information in order to move to patient-centered care, and proposes strategies for doing so.
*Goal V includes a clear vision and path forward for building a “learning health system" that will become increasingly prominent over the next several years.
Of note, ICD-10 is mentioned only once (page 24) and X12 5010 is not mentioned at all. The justification for work on ICD-10 is "ICD-10-CM/PCS code sets will enable a more granular understanding of health care treatments and outcomes, and more complete analyses of treatment costs, ultimately allowing for better disease management and more efficient health care delivery." My personal opinion is that we should defer the work on ICD-10 while we're navigating meaningful use stage 1, 2 and 3. Accurate coding requires comprehensive clinical documentation on the front end including adoption of clinical vocabularies such as SNOMED-CT. Let's enhance our front end documentation before thinking about the back end coding.
Overall the Federal Strategic plan is a winner - it melds Meaningful Use, Certification, Health Information Exchange, PCAST, and the Institute of Medicine work on creating a learning healthcare system.
The next National Coordinator will have the benefit of a great strategic plan - David Blumenthal's parting gift.
Here's an outline of the five goals and a bit of commentary:
Goal I: Achieve Adoption and Information Exchange through Meaningful Use of Health IT
A. Accelerate adoption of electronic health records
*Provide financial incentive payments for the adoption and meaningful use of certified EHR technology.
*Provide implementation support to health care providers to help them adopt, implement, and use certified EHR technology.
*Support the development of a trained workforce to implement and use health IT technologies.
*Encourage the inclusion of meaningful use in professional certification and medical education.
*Establish criteria and a process to certify EHR technology that can support meaningful use criteria.
*Communicate the value of EHRs and the benefits of achieving meaningful use.
*Align federal programs and services with the adoption and meaningful use of certified EHR technology.
*Work with private sector payers and provider groups to encourage providers to achieve meaningful use.
*Encourage and facilitate improved usability of EHR technology.
B. Facilitate information exchange to support meaningful use of electronic health records
*Foster business models that create health information exchange.
*Monitor health information exchange options and fill the gaps for providers that do not have viable options.
*Ensure that health information exchange takes place across individual exchange models, and advance health systems and data interoperability.
C. Support health IT adoption and information exchange for public health and populations with unique needs
*Ensure public health agencies are able to receive and share information with providers using certified EHR technology.
*Track health disparities and promote health IT that reduces them.
*Support health IT adoption and information exchange in long-term/post-acute, behavioral health, and emergency care settings.
Goal II: Improve Care, Improve Population Health, and Reduce Health Care Costs through the Use of Health IT
A. Support more sophisticated uses of EHRs and other health IT to improve health system performance
*Identify and implement best practices that use EHRs and other health IT to improve care, efficiency, and population health.
*Create administrative efficiencies to reduce cost and burden for providers, payers, and government health programs.
B. Better manage care, efficiency, and population health through EHR-generated reporting measures
*Identify specific measures that align with the National Health Care Quality Strategy and Plan.
*Establish standards, specifications, and certification criteria for collecting and reporting measures through certified EHR technology.
C. Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management
*Fund and administer demonstration communities to show how the advanced use of health IT can achieve measurable improvements in care, efficiency, and population health.
*Align health IT initiatives and clinical and payment reform pilots and demonstrations.
D. Support new approaches to the use of health IT in research, public and population health, and national health security
*Establish new approaches to and identify ways health IT can support national prevention, health promotion, public health, and national health security.
*Invest in health IT infrastructure to support the National Prevention and Health Promotion Strategy.
*Ensure a mechanism for information exchange in support of research and the translation of research findings back into clinical practice.
Goal III: Inspire Confidence and Trust in Health IT
A. Protect confidentiality, integrity, and availability of health information
*Promulgate appropriate and enforceable federal policies to protect the privacy and security of health information.
*Enforce existing federal privacy and security laws and maintain consistency with federal confidentiality, policy.
*Encourage the incorporation of privacy and security functionality into health IT.
*Identify health IT system security vulnerabilities and develop strategic solutions.
*Identify health IT privacy and security requirements and best practices, and communicate them through health IT programs.
B. Inform individuals of their rights and increase transparency regarding the uses of protected health information
*Inform individuals about their privacy and security rights and how their information may be used and shared.
*Increase transparency regarding the development of policies and standards related to uses and sharing of protected health information.
*Require easy to understand reporting of breach notifications.
C. Improve safety and effectiveness of health IT
*Provide implementation and best practice tools for the effective use of health IT.
*Evaluate safety concerns and update approach to health IT safety.
*Monitor patient safety issues related to health IT and address concerns.
Goal IV: Empower Individuals with Health IT to Improve their Health and the Health Care System
A. Engage individuals with health IT
*Listen to individuals and implement health IT policies and programs to meet their interests.
* Communicate with individuals openly and spread messages through existing communication networks and dialogues.
B. Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse
*Through Medicare and Medicaid EHR Incentive Programs, encourage providers to give patients access to their health information in an electronic format.
*Through federal agencies that deliver or pay for health care, act as a model for sharing information with individuals and make available tools to do so.
*Establish public policies that foster individual and caregiver access to their health information while protecting privacy and security.
C. Integrate patient-generated health information and consumer health IT with clinical applications to support patient-centered care
*Support the development of standards and tools that make EHR technology capable of interacting with consumer health IT and build these requirements for the use of standards and tools into EHR certification.
*Solicit and integrate patient-generated health information into EHRs and quality measurements.
*Encourage the use of consumer health IT to move toward patient-centered care.
Goal V: Achieve Rapid Learning and Technological Advancement
A. Lead the creation of a learning health system to support quality, research, and public/population health
*Establish an initial group of learning health system participants.
*Develop standards, policies, and technologies to connect individual participants within the learning health system.
*Engage patients, providers, researchers, and institutions to exchange information through the learning health system.
*Grow the learning health system by adding more members and expanding policies and
population standards as needed.
B. Broaden the capacity of health IT through innovation and research
*Liberate health data to enable health IT innovation.
*Make targeted investments in health IT research.
*Employ government programs and services as test beds for innovative health IT.
*Monitor and promote industry innovation.
*Provide clear direction to the health IT industry regarding government roles and policies for protecting individuals while not stifling innovation.
As I read the report, there were a few paragraphs I found particularly interesting. I believe they suggest important directions to watch:
*Stages two and three are anticipated to transition gradually away from further process requirements like those included in stage one, to requirements for improvement in outcomes and quality of care.
*For providers ineligible for incentive payments (for example, long-term and post-acute care facilities, community mental health centers, or substance use disorder treatment providers), the government is developing technology and policy solutions that build on meaningful use and fit their unique needs.
*The health information exchange strategy in Goal I focuses on first fostering exchange that is already happening today, supporting exchange where it is not taking place, and creating means for exchange between local initiatives.
*Goal IV recognizes the importance of engaging and empowering individuals with electronic health information in order to move to patient-centered care, and proposes strategies for doing so.
*Goal V includes a clear vision and path forward for building a “learning health system" that will become increasingly prominent over the next several years.
Of note, ICD-10 is mentioned only once (page 24) and X12 5010 is not mentioned at all. The justification for work on ICD-10 is "ICD-10-CM/PCS code sets will enable a more granular understanding of health care treatments and outcomes, and more complete analyses of treatment costs, ultimately allowing for better disease management and more efficient health care delivery." My personal opinion is that we should defer the work on ICD-10 while we're navigating meaningful use stage 1, 2 and 3. Accurate coding requires comprehensive clinical documentation on the front end including adoption of clinical vocabularies such as SNOMED-CT. Let's enhance our front end documentation before thinking about the back end coding.
Overall the Federal Strategic plan is a winner - it melds Meaningful Use, Certification, Health Information Exchange, PCAST, and the Institute of Medicine work on creating a learning healthcare system.
The next National Coordinator will have the benefit of a great strategic plan - David Blumenthal's parting gift.
Friday, 25 March 2011
Cool Technology of the Week
As a Prius driver since 2005, I've closely watched the evolution of hybrid vehicles. The FY10 Prius included an optional solar powered cooling system. The FY11 Prius offers a plug in option to charge the batteries from household current overnight.
This week, Google installed a wireless induction unit at its Mountain View headquarters to charge a specially equipped Prius.
The charging system is a prototype product from Plugless Power which works on the principle of electromagnetic induction. A coil in the charging station is connected to an electrical source and another coil is placed in the Prius. Electric current flowing through a primary coil creates a magnetic field that acts on the secondary coil producing a current within it, charging the Prius battery.
A Prius driver parks the car near a charging station. A paddle on the charging station moves to align the two coils and charging begins. The end result is a fully charged battery without wires.
A zero emission vehicle with automatic charging in your parking space.
That's cool!
This week, Google installed a wireless induction unit at its Mountain View headquarters to charge a specially equipped Prius.
The charging system is a prototype product from Plugless Power which works on the principle of electromagnetic induction. A coil in the charging station is connected to an electrical source and another coil is placed in the Prius. Electric current flowing through a primary coil creates a magnetic field that acts on the secondary coil producing a current within it, charging the Prius battery.
A Prius driver parks the car near a charging station. A paddle on the charging station moves to align the two coils and charging begins. The end result is a fully charged battery without wires.
A zero emission vehicle with automatic charging in your parking space.
That's cool!
Thursday, 24 March 2011
What is Leadership?
Thousands of books have been written about leadership. I've posted many blogs about my leadership lessons learned as a CIO. As I mature (I turn 50 next year), my view of leadership has become increasingly clear. Here's what I look for in a leader (and what I aspire to do myself)
1. Guidance - A consistent vision that everyone can understand and support.
2. Priority Setting - A sense of urgency that sets clear mandates for what to do and importantly want not to do.
3. Sponsorship - "Air Cover" when a project runs into difficulty. Communication with the Board, Senior Leadership, and the general organization as needed.
4. Resources - A commitment to provide staff, operating budget, and capital to ensure project success.
5. Dispute resolution - Mediation when stakeholders cannot agree how or when to do a project.
6. Decision making - Active listening and participation when tough decisions need to be made.
7. Compassion - Empathy for the people involved in change management challenges.
8. Support - Trust for the managers overseeing work and respect for the plans they produce that balance stress creation and relief.
9. Responsiveness - Availability via email, phone, or in person when issues need to be escalated.
10. Equanimity - Emotional evenness that is highly predictable no matter what happens day to day
When my daughter asks me what I do every day, I tell her that I provide guidance and priority setting for my staff, resolve disputes, and continuously communicate. Of the 10 items above, the Resource part is the only item I cannot personally control, since organizational processes beyond my pay grade set budgets (which always seem to mismatch supply with demand - it's a curse of IT.)
When I think about the best times in my own career, the real breakthroughs occurred when leaders created a sense of urgency, provided resources, and broadly communicated. These circumstances led to such innovations as the Mycourses educational portal at Harvard Medical School, the widespread adoption of Provider Order Entry in CareGroup hospitals, and implementation of the BIDMC disaster recovery data center.
Healthcare reform will give us all many opportunities for leadership. We'll have increasing Volatility, Uncertainty, Complexity and Ambiguity ahead and by embracing the 10 characteristics above, I'm confident we will succeed.
Maybe we should add "optimism" as the 11th characteristic of leadership. Colin Powell says that optimism is a force multiplier. When workload seems overwhelming, budgets look bleak, a complex project struggles toward completion, or a key staff member departs, a leader will buoy morale by offering words of encouragement that inspire optimism. When I think of the great leaders in history, optimism in the face of seemingly impossible odds (Winston Churchill at the Battle of Britain, FDR in the Great Depression, John Kennedy during the race to the moon) has made it possible for people and nations to accomplish things never believed possible.
1. Guidance - A consistent vision that everyone can understand and support.
2. Priority Setting - A sense of urgency that sets clear mandates for what to do and importantly want not to do.
3. Sponsorship - "Air Cover" when a project runs into difficulty. Communication with the Board, Senior Leadership, and the general organization as needed.
4. Resources - A commitment to provide staff, operating budget, and capital to ensure project success.
5. Dispute resolution - Mediation when stakeholders cannot agree how or when to do a project.
6. Decision making - Active listening and participation when tough decisions need to be made.
7. Compassion - Empathy for the people involved in change management challenges.
8. Support - Trust for the managers overseeing work and respect for the plans they produce that balance stress creation and relief.
9. Responsiveness - Availability via email, phone, or in person when issues need to be escalated.
10. Equanimity - Emotional evenness that is highly predictable no matter what happens day to day
When my daughter asks me what I do every day, I tell her that I provide guidance and priority setting for my staff, resolve disputes, and continuously communicate. Of the 10 items above, the Resource part is the only item I cannot personally control, since organizational processes beyond my pay grade set budgets (which always seem to mismatch supply with demand - it's a curse of IT.)
When I think about the best times in my own career, the real breakthroughs occurred when leaders created a sense of urgency, provided resources, and broadly communicated. These circumstances led to such innovations as the Mycourses educational portal at Harvard Medical School, the widespread adoption of Provider Order Entry in CareGroup hospitals, and implementation of the BIDMC disaster recovery data center.
Healthcare reform will give us all many opportunities for leadership. We'll have increasing Volatility, Uncertainty, Complexity and Ambiguity ahead and by embracing the 10 characteristics above, I'm confident we will succeed.
Maybe we should add "optimism" as the 11th characteristic of leadership. Colin Powell says that optimism is a force multiplier. When workload seems overwhelming, budgets look bleak, a complex project struggles toward completion, or a key staff member departs, a leader will buoy morale by offering words of encouragement that inspire optimism. When I think of the great leaders in history, optimism in the face of seemingly impossible odds (Winston Churchill at the Battle of Britain, FDR in the Great Depression, John Kennedy during the race to the moon) has made it possible for people and nations to accomplish things never believed possible.
Wednesday, 23 March 2011
The PCAST Use Cases
As I posted yesterday, the PCAST Workgroup has discussed use cases which correspond to three levels of healthcare information exchange supported by a Universal Exchange Language (UEL) and Data Element Access Service (DEAS) - "push by patient of data between two points", "simple search for data", and "complex search for data". They are intended to support PHR and EHR health information exchanges for a multitude of uses, include clinical care, population health and clinical research. A 4th Use Case incorporates de-identified data.
Use Case 1 - Push by patient between two points.
The patient logs into a tethered PHR via username/password or other authentication mechanism provided by the clinical organization hosting the data. The patient chooses to push the data to the non-tethered PHR of their choice. Many possible architectures and approaches can support this including download from the tethered PHR with upload to the un-tethered PHR, a push directly from the tethered PHR to the un-tethered PHR (as Google Health and Microsoft Health support today), or the use of secure email from the tethered PHR to the un-tethered PHR using the Direct standards via a secure health email address. In each case, the data sent wrapped in a UEL envelope containing patient identity, provenance, and privacy metadata information. UEL Metadata might also include non-disclosing information about the categories health data available in the content package i.e. medication list, problem list, allergy list, labs, radiology images etc.
When the UEL arrives at the non-tethered EHR, data is shown to the patient, who can elect to incorporate structured and unstructured data into their existing un-tethered PHR dataset. Then, the patient can then choose to share PHR data with clinicians, clinical researchers, or public health by pushing selective PHR data wrapped in an UEL envelope via secure transmission (such as Direct) to recipients of their choice. Organizational certificates are needed for the senders (un-tethered PHR hosting organization) and the recipients (clinician offices, clinical research organizations, public health organizations). Audit trails are held by senders, recipients and any Health Information Service Providers used as part of Direct transport. Patient authentication is username/password as required by the PHRs. Provider authentication is username/password or other modality as required by the EHR.
Summarizing the infrastructure for this approach, we will need
:
*A UEL that includes patient identity, provenance, privacy metadata, and categories of health data available in the content package. There will need to be semantic standards for this metadata including the content/vocabulary of identity, providence, privacy metadata, and categories of health data
*Applications which are capable of wrapping content packages of clinical data in the UEL
*Applications which are capable of receiving the UEL and unwrapping content packages
*Certificate management to secure the endpoints and support privacy controls
*Policies that support push of data between two points.
Use Case 2 - Simple Search
A patient presents to an Emergency Department and notes their records are stored at a specific clinician office and a specific hospital. An Emergency Physician obtains patient consent to retrieve their records. A query is created that includes patient identity, consent information, and provider authentication data. A Data Element Access Service which serves as an entity level provider directory is securely queried to determine the Uniform Resource Identifiers (URIs) of the clinician office and hospital. The query is sent to the URIs, which return a UEL wrapper containing identity information, provenance, patient privacy metadata based on any consents on file at the organizations hosting patient records, and non-disclosing information about the categories health data available in the content package. The content package inside the UEL includes numerous appropriate vocabularies. The receiving clinician can choose to incorporate structured and unstructured data into the Emergency Department record. All exchanges are query/response. Organizational certificates are needed for the Emergency Department, the clinician office and the hospital. Audit trails are held by all these organizations. Provider authentication is username/password or other modality as required by the ED information system or national policy.
Summarizing the infrastructure for this approach, in addition to the infrastructure of Use Case 1, we will need:
*Policy for issuing queries to organizations hosting patient records
*A DEAS that includes entity level provider directory information to provide the URIs of provider data sources
*The syntax and semantics of a query for clinical data including identity information that is sent to provider organizations hosting patient information
*Applications which are capable of issuing a query to known URIs
*An approach to disambiguate identity conflicts if the query results in multiple patient matches
Use Case 3 - Complex Search
A patient presents to an Emergency Department and is non-responsive. However, her wallet contains an ID with name and date of birth. An Emergency Physician, based on policy which grants implied consent for unconscious patients, clicks the external search icon in their EHR. The EHR creates a query containing patient identity, implied consent information, and provider authentication and role, then sends it to a Data Element Access Service. The DEAS returns a list of Uniform Resource Identifiers of the organizations which hold the patient's records. The Emergency Physician’s EHR sends a query containing patient identity, consent information, provider authentication and role to each of the URIs, with a request for problems, medications or allergies. Each organization returns as many UEL wrapped data packages as match the query and pass the conditions of patient privacy metadata based on any consents they have on file. Each UEL wrapped package includes identity, provenance and privacy metadata and non-disclosing information about the categories health data available in the content package. The content package inside the UELs includes numerous appropriate vocabularies. The receiving EHR filters and organizes the information for the clinician who can choose to incorporate structured and unstructured data into the local Emergency Department record. All exchanges are query/response. Organizational certificates are needed for the Emergency Department, the DEAS provider, and the organizations which contain patient records. Audit trails are held by all these organizations. Provider authentication is username/password or other modality as required by the ED information system or national policy.
Summarizing the infrastructure for this approach, in addition to the infrastructure of Use Case 2, we will need:
*Policy for issuing a query to the DEAS
*A DEAS which contains patient identity information, provider URIs and potentially more granular information about the types of data available at those URIs
*The syntax and semantics of a query including identity information that is sent to the DEAS.
*Applications which are capable of querying a DEAS and then querying URIs of provider data sources specified by the DEAS, assembling the data returned into a meaningful display
*Support for privacy metadata that are returned by the DEAS and provider data sources
Interoperation among Use Cases 1-3
The Use Cases and the Levels of Exchange are not mutually exclusive. If all three are supported, the patient in Use Case 1 can use the simple search of Use Case 2 to query for the URI of a provider they would like to push their information to; and the complex search of Use Case 3 to expose a UEL wrapped subset of their PHR to the DEAS tagged with a privacy tag indicating their desire that it be made available to someone giving them care and a provenance tag indicating that she had edited it.
Use Case 4 - De-identified aggregate data mining
A researcher wants to retrieve de-identified mammograms to investigate a new technology that provides computer assisted interpretation. The researcher issues a query to the DEAS requesting de-identified mammograms that are reusable for research based on patient consent. A list of URIs is returned including pointers to mammograms. The researcher queries the URIs and receives de-identified mammograms.
Summarizing the infrastructure for this approach
*Policy for issuing a research queries to the DEAS
*A DEAS which supports de-identified queries for a specific type of data
*The syntax and semantics of a query including data type information that is sent to the DEAS.
*Provider data sources that are capable of returning de-identified data
*An application that can query a DEAS and query provider data sources
*Support for privacy metadata that include consent to release data for research and ensure de-identification
The combination of these use cases and the security model described in yesterday's post provides a clear path forward that enables pilots and research to be done in parallel with the meaningful use activities already in progress.
As I think about the exciting years ahead - a PCAST inspired expansion of health information exchange, meaningful use stage 2 & 3, and healthcare reform, I am concerned that doing ICD-10 in the middle of all these other activities will overwhelm healthcare systems and IT organizations. My thoughts on rebalancing and aligning all of the projects in front of us will be a blog post for next week.
Subscribe to:
Posts (Atom)
