Thursday, March 13, 2014

The Meaningful Use Stage 2 Hardship Application

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Many people have emailed me about the Meaningful Use Stage 2 Hardship application for hospitals and eligible professionals.

The most common question is - if I apply for hardship, what happens to my incentives and penalties?  Here is my understanding:

Put simply, if you want to get an incentive you have to do MU.  For *Medicare* providers once they start their first payment year their yearly clock for incentives keeps ticking regardless of whether they do MU or not.  So miss a year = no incentive. The following year would be whatever the next available incentive is scheduled to be, NOT the one that was just missed.   So there is no such thing as deferred incentives.

Applying for hardship means not doing MU, which means no incentive for that year (which means gone forever). If a provider is favorably granted the hardship then they would not be subject to the penalty to which that hardship is applicable.  In the case of 2014 performance, it is the basis for the 2016 penalty.

So to make it real.

If a (non-first-time) provider applies for a hardship for 2014 performance, presumably that means they cannot demonstrate MU, which means no 2014 incentive, but when granted the hardship it means they avoid being penalized in 2016.

If a provider does MU in 2014, they get the 2014 incentive AND avoid the 2016 penalty.

Building Unity Farm - Winter Hive Maintenance

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The 2014 winter has been brutal with more single degree days than any winter during my 20 years living in Massachusetts.   Our bees are resilient, started from colonies overwintered in New Hampshire last year.  Keeping them alive has required careful management and we’ve learned a great deal in our first year as beekeepers.

We began the winter with 8 hives, 7 of which were strong and one of which had very few bees.

Our hives started as “nucs” 5 frame mini hives purchased from an apiary.   We placed the frames in 10 frame deep body boxes last May.   After a few months, we added another layer of 10 frames deep body boxes as the colony expanded.

We’ve tried to care for the bees organically and not introduced any chemical treatments for bee diseases like varroa mites, nosema, and hive beetles.

In November, we added division board feeders with 2:1 sugar syrup, and placed fondant under the inner cover on the top of the hive.   Typically we examine the health of the hive on days when the temperature is 50F or greater.

Our problem is that December-February had no 50F days, so we listened to the hives for signs of internal activity.

In January we lost the weak hive - it could not sustain itself through the bitter cold.

Last weekend, we opened each hive (pictured above), and examined each hive body to get a sense of bee health.  

Our South facing hives were vigorous and active.   Our Southeast facing hives were vigorous and less active.   Our Northeast facing hives were sick with Nosema, a unicellular parasitic disease of the bee gut that gives them dysentery-like symptoms.

The bees in the north facing hives died.

We’ve learned an important lesson - all bee hives should be south facing and we should treat with Fumagilin B proactively in the Fall to reduce the threat of Nosema.

We need to be more aggressive with supplemental feeding of hives with limited honey stores - hive top feeders in the Spring, jars of bee tea in the Fall, fondant, and pollen patties.

We need to standardize our components to enhance hive ventilation and reduce moisture.   We’re replacing our solid bottom boards with screened bottom boards as part of an integrated pest management/ventilation strategy.   We’re also drilling 3/4 inch holes in each hive to provide an escape/ventilation when snow drifts block the primary entrance.

Our bees are very gentle.   Although I’m wearing a bee suit and gloves in the pictures above, our bees have never stung me and seem content to land on me and check out the white suited invader.  

When the snow melts we’ll relocate all our hives to a flat, unshaded, dry, south facing spot in the corner of the orchard, protected from creatures that might attack the hive, wind, running water, and falling branches.  

Many of our colleagues lost all their bees this winter, so we’re happy six of eight hives survived.    Hopefully next year, with our lessons learned, we’ll overwinter 100% successfully.

Wednesday, March 12, 2014

Wearable Computing at BIDMC

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Over the past few months, Beth Israel Deaconess has been exploring the use of wearable computing.

In the Emergency Department we’ve been evaluating an early unit of Google Glass, a high tech pair of glasses that includes a video camera, video screen, speaker, microphone, touch pad, and motion sensor.

We have been able to access our internal web-based ED Dashboard on Glass, in a secure manner that ensures all data stays within the BIDMC firewall.  Clinicians can now speak with the patient, examine them, and perform procedures while simultaneously seeing data from the ED Dashboard in their field of view.

Beyond the technical challenges of bringing wearable computers to BIDMC, we had other concerns—protecting security, evaluating patient reaction, and ensuring clinician usability.

Here’s what we’ve learned thus far:

Patients have been intrigued by Google Glass, but no one has expressed a concern about them. Boston is home to many techies and a few patients asked detailed questions about the technology. The bright orange pair of Glass we have been testing is as subtle as a neon hunter's vest, so it was hard to miss.

Staff members have definitely noticed them and responded with a mixture of intrigue and skepticism. Those who tried them on briefly did seem impressed.

Glass is a new medium that seems best suited for retrieval of summarized information and it really differentiates itself when it comes to real-time updates and notifications.  When paired with location services, it will be able to truly deliver actionable information to clinicians in real time.  We believe the ability to access and confirm clinical information at the bedside is one of the strongest features of Google Glass.

Our Google Glass unit has been tested by a limited set of four emergency physicians serving as beta users since 12/17/13. In addition to our four beta users, we've also had impromptu testing with at least 10 other staff members since 1/24/14 to get feedback to refine the user experience.  We needed to rigorously test our setup to ensure that the application is not only reliable and intuitive, but improved the workflow of clinicians rather than impede it.  We have learned a lot, and will continue testing with more interested clinical providers going forward.

I believe wearable computing will replace tablet-based computing for many clinicians who need their hands free and instant access to information.

Thursday, March 6, 2014

A Primer on Meaningful Use and HISPs

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The Massachusetts State government offers low cost HIE services including Direct transport to all the stakeholders of the Commonwealth.    Recently. Micky Tripathi wrote this FAQ which is so good that I wanted to share it on my blog.   Feel free to use it with your stakeholders.

1. What is a HISP?
A Health Information Services Provider (HISP) is an organization that manages security and transport for health information exchange among health care entities or individuals using the Direct standard for transport.  There is no specific legal designation for a HISP, nor are HISPs specifically regulated by Meaningful Use certification rules.  The term HISP was coined to describe specific message transport functions that need to be performed to support scaled deployment of the Direct standard in the market.  HISP functions can be performed by existing organizations (such as EHR vendors or hospitals or HIE organizations) or by standalone organizations specializing in HISP services.

HISPs perform two key functions that support scalability of exchange using the Direct standard.

a. Issue security certificates.  HISPs establish trust networks by defining policies for network participation and issuing security certificates tied to a HISP anchor certificate to enforce such policies
b. Issue direct addresses.   HISPs issue direct addresses tied to the HISP anchor certificate in accordance with conventions defined by the Direct standard

2. Do I need to use a certified HISP to attest for Meaningful Use Stage 2?
No, because there is no such thing as a certified HISP.  Meaningful Use certification applies to technology, not to organizations.  In order to attest for Meaningful Use Stage 2, you need perform certain activities using certified EHR technology (CEHRT).  For most EHR users, their EHR is certified for all of the functions that they need.  If it is not, you will need to incorporate specific additional certified technology solutions to fill the remaining gaps.  It doesn’t matter whether that additional technology comes from an EHR company or a HISP company – the only thing that matters is that the technology is certified.

3. Doesn’t DirectTrust certify HISPs?
DirectTrust is a private, non-profit organization that offers voluntarily accreditation of HISPs through its EHNAC DTAAP program.  This private, voluntary accreditation program often gets confused with Federal Meaningful Use certification.  DirectTrust is NOT a Federal certification entity, and its EHNAC DTAAP accreditation process is purely private and voluntary and has no relationship with Meaningful Use Stage 2 attestation or certification requirements.

4. What role does a HISP play in Meaningful Use Stage 2?
A HISP provides specialized network services that connect your EHR to other EHRs that are also using the Direct standard for communications.  You don’t need a HISP in order to create Direct-compliant messages, but you do need to be connected to a HISP in order to send and receive Direct messages with other parties.  Using an email analogy, you may have Microsoft Outlook installed on your computer, but if it isn’t connected to an email network, your emails can’t go anywhere and none can get to you.  Similarly, your CEHRT can send and receive Direct-compliant messages, but those messages won’t go anywhere unless you and those who you are communicating with have valid
Direct addresses and are connected to a secure network that can get the messages safely and reliably from one endpoint to another.  These are the message transport functions that HISPs perform.

There are two Meaningful Use Stage 2 attestation requirements that require Direct transport:

Summary care record for transitions of care (TOC)
Patient ability to view, download, transmit their medical record (VDT)

Most HISPs (including the Mass HIway) do not yet have the ability to connect directly with patients, so they are not able to assist with the VDT requirement.

For the purposes of attestation, the Meaningful Use Stage 2 TOC requirement specifies that you must electronically send a standardized summary care document to another care setting, and that you must have reasonable assurance that the other care setting actually received the document.  The HISP performs the message transport functions to provide you with the assurance that your messages have been delivered to their intended recipients.

In order to attest for the TOC requirement, you need to send CCDA care summaries containing at least problem lists, medications, and medication allergies.  These summaries must be transmitted with your CEHRT using either the SMTP/SMIME or XDR/SOAP protocol.  There is no Federal certification for HISPs, so you can send your message to its intended recipient using any HISP or any number of HISPs, as long as you have assurance that the message will get delivered.  The only certified system that you need to use is the one that creates the Direct-compliant SMTP or XDR message – after that, your message may take any number of “hops” between your EHR and its final destination, and as long as you’re confident that the message will get delivered, you will have completely fulfilled your Meaningful Use Stage 2 attestation requirement.

5. How do I get assurance that my messages are delivered?
Meaningful use attestation requirements do NOT specify how you get assurance of delivery, they specify only that you have taken reasonable steps to be confident of delivery.  The most robust way for you to be assured of message delivery is for your system to receive message disposition notifications (MDNs) for each message sent by your EHR to the intended recipient.  However, not all receiving systems or HISPs can generate MDNs, and not all EHR systems can consume MDNs even if they are returned.

Fortunately, you are not required to receive MDNs in order to be assured of delivery.  Other acceptable methods of assurance are through HISP guarantees of delivery after successful setup testing and/or notification of failure of delivery (like emails) and/or HISP central maintenance of delivery logs that can be made available as needed.

The Mass HIway provides you with assurance of delivery through rigorous setup testing, and maintenance of a central log of delivery successes and failures.  This log is made available to participants as necessary in the event of an audit.  The Mass HIway will also return any MDNs or application-specific responses or acknowledgements generated by receiving endpoints, however, the Mass HIway cannot guarantee that any receiving endpoint will generate notifications, acknowledgements, or responses.

The one exception where delivery notification is available and required is public health.  The Massachusetts Department of Public Health requires that participants receive delivery notifications in order to satisfactorily meet the Meaningful Use Stage 2 public health requirements.  Massachusetts DPH does generate automated acknowledgements, which are sent automatically via the Mass HIway in response to each message successfully received.

6. Is the Mass HIway a HISP?
Yes.  The MA HIway is a trust community that issues security certificates and Direct addresses to eligible participants and provides Direct-compliant message transport services for its participants.

7. Is the Mass HIway certified as an EHR module for Meaningful Use Stage 2?
No, the Mass HIway is not certified as an EHR module for Meaningful Use Stage 2.  Most providers will not require the Mass HIway to be certified in order to use it to help fulfill their Meaningful Use Stage 2 attestation requirements.  (See discussion above in FAQ on HISP roles.)  As long as your CEHRT delivers a Direct-compliant SMTP or XDR message to the Mass HIway (either to the LAND appliance or directly to the central site), you do not need the Mass HIway to be certified.

If your CEHRT does not send a Direct-compliant SMTP or XDR message to the Mass HIway (for example, if you are sending messages to the LAND appliance in a format other than SMTP or XDR), then you will need to change your interface to send Direct-compliant SMTP or XDR to the Mass HIway (including the LAND appliance) in order to count any of these transactions for Meaningful Use Stage 2 TOC requirements.

Even though you do not need the Mass HIway to be certified for Meaningful Stage 2 in most cases, you will still need to have assurance of delivery of messages sent over the Mass HIway to meet your Stage 2 TOC attestation requirements.  The Mass HIway provides this assurance by delivery after successful setup testing.

8. Must I be connected to the Mass HIway in order to attest for Meaningful Use Stage 2?
Yes, you need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 public health requirements for immunization and cancer registries, and syndromic surveillance.  The Massachusetts Department of Public Health will accept public health transactions only through the Mass HIway.  Thus, though there is no Federal requirement that you be connected to the Mass HIway for Meaningful Use Stage 2, you will not be able to meet core public health requirements for Meaningful Use Stage 2 without being connected to the Mass HIway.

You do not need to be connected to the Mass HIway in order to meet the Meaningful Use Stage 2 TOC requirement.  However, over 100 providers and payers are already live on the Mass HIway HISP.  Thus, connecting to the Mass HIway will likely make it easier for you to meet your TOC requirements because you will be immediately connected with many of the providers you share patients with.

9. The Meaningful Use Stage 2 rules refer to the eHealth Exchange – is that the same as the Mass HIway?

No.  The eHealth Exchange is a health information exchange network comprising federal agencies and other large non-federal organizations.  The Mass HIway is not connected with the eHealth Exchange in any way.

10. Do I have to be connected to the eHealth Exchange in order to meet my Meaningful Use Stage 2 attestation requirements?

Absolutely not.  While the Meaningful Use Stage 2 rules do allow special dispensation for eHealth Exchange members, few providers will attest using this mechanism.  No Massachusetts providers or payers are currently members of the eHealth Exchange.

11. Who are the other HISPs in Massachusetts, and can I join any HISP that I want?
There are a wide variety of HISPs operating in the Commonwealth.  Whether you join any particular HISP depends on a number of factors.  The biggest factor is which HISPs your EHR vendor allows you to join.  Some vendors require that you use a specific HISP (either their own or the one they are integrated with), while other vendors (such as Meditech and Epic) allow the provider to choose which HISP they would like to connect to.  CMS and ONC do not require that you use any particular HISP for meaningful use, but in practice, your EHR vendor will dictate which HISP options are available to you.

If your vendor allows you to choose which HISP to connect to, you can connect directly to the Mass HIway HISP.  If your vendor requires that you use their designated HISP, you will have to connect to the Mass HIway through their HISP, as long as their HISP is connected to the Mass HIway.
Please contact the Mass HIway (http://www.masshiway.net) if you have any questions about your connection options.

12. Is the Mass HIway part of DirectTrust?
No, the Mass HIway is currently not a member of DirectTrust.  DirectTrust is a voluntary private non-profit collaborative that is helping HISPs to connect with each other.  The Mass HIway is connecting directly with the major HISPs operating in the Massachusetts market.  The Mass HIway may join DirectTrust at some point in the future if it provides additional value to participants.  Providers, EHRs, or HISPs do NOT need to be part of DirectTrust in order to meet their Meaningful Use Stage 2 certification and attestation requirements.

13. If I’m in another HISP, can I still be on the Mass HIway?
Yes.  You can connect to the Mass HIway even if you are a member of another HISP.   The Mass HIway is actively connecting with the major HISPs operating in the Massachusetts market so that messages can be sent between HISPs.  You do still have to join the Mass HIway by signing a participation agreement even if you are in another HISP.  As a member of another HISP, you will pay whatever fees are charged by your local HISP and your Mass HIway fees will be waived.  Once you have joined the Mass HIway, your local HISP will configure your system to enable access to the Mass HIway network.  Your local HISP will still provide you with your security certificate and your Direct address, but you will be able to send and receive messages over the Mass HIway network.

Below is a current list of HISPs that are expected to be connected to the Mass HIway.  The HISP market is evolving rapidly so more HISPs will be added as demand grows.  Please contact the Mass HIway (http://www.masshiway.net) if you would like to discuss your connection options.

HISP Live date
eClinicalWorks April 2014
Surescripts April 2014
eLINC/SES April 2014
Allscripts/MedAllies TBD
Athenahealth TBD
Wellport/Alere TBD

Building Unity Farm - The Ducks

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As the weather begins to improve (we’ve even had an afternoon above freezing - wahoo!), the ducks are beginning to wander farther from their duck house.   This week, they discovered the rain cistern that collects runoff from our farmhouse roof.

For hours, they’ll bathe, preen, and drink their fill of the circulating rainwater.  They’re very social and tend to travel in groups.  They’re calm and have learned to recognize us as helpful rather than threatening.

We have 10 ducks at the moment -
2 Chocolate Indian Runner ducks
2 Fawn Indian Runner ducks
2 Welsh Harlequin ducks
2 Swedish Blue ducks
2 Rouen ducks

They spend the day wandering the farm yard, finding insects in the compost pile, eating the tender sprouts of any greens they can find, and playing in puddles.   As dusk approaches, we walk near them and they know it’s time to return to their duck house, a 4x8 building with food, wind protected warmth, and hay bedding.   We keep their water sources outside the duck house to reduce the mess.   Ducks can turn any pasture into mud.

They have a heated 50 gallon stock pond and a 5 gallon waterer in the 14x10 foot pen built around the duck house, caged on 5 sides to prevent predators from reaching the ducks at night.    A duck house with 3 square feet per duck seems about the right density.

Our large pond is about 50 feet from the duck house and the surface is still covered with ice and snow.  It’s 6 feet deep so water is still circulating but the ducks cannot reach it.   We’re confident that with the arrival of Spring, the ducks are going to be spending all day in the large pond.

Each member of our poultry family - the chickens, the guinea fowl, and the ducks show mutual respect for each other.   All the species wander into each other’s spaces, huddle together for warmth, and get along.    About the only difference is that the ducks do not roost for the evening - they prefer an outdoor space to an indoor space and only seek the warmth of the duck house during snow and wind.    Rain is prime duck weather.

Duck care is easy - refill their water sources, provide them fresh greens (we make “duck soup” with lettuce, peas, and spinach in water), and fill their multi-flock crumble containers.   As a treat we feed them mealworms and scratch grains.  

At the moment, our 29 guinea fowl, 10 ducks, and 11 chickens - 50 birds in total, seems like an ideal number for our property.    All are disease free, uncrowded, and follow a highly predictable routine.   Unity farm has poultry living in unity.

Wednesday, March 5, 2014

ACO Systemness and Integration

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As Accountable Care Organizations take on risk contracts which align incentives to create continuous wellness rather than treat episodic sickness, there is a drive to create “systemness” by moving from acquisitions of practices and hospitals to integration.   There are many ways to accomplish this such as moving to a single EHR with a single database for all sites, by enhancing interoperability of existing software, and by building care management databases that incorporate data from every care location.  

Developing a strategy requires a multi-factorial analysis - requirements, cost, competing priorities, regulatory imperatives, and cultural barriers to change.      From March to July, Beth Israel Deaconess will be working on an integration plan for its acquired and affiliated clinical sites.   From an IT perspective, I’ll create a task force that will design an analytic framework for decision making and then develop a prioritized list of projects.

Here’s the early thinking.

A analytic framework might include:
*Impact factor (number of providers, staff, patients)
*Workflow implications
*Degree of implementation difficulty
*Cost/return on investment
*Benefit (safety/quality, security/compliance, efficiency)
*Cultural/Behavioral factors (i.e. politics that can be an enabler or barrier)

Projects could include
*Hospital Information System consolidation (fewer silos than we have today)
*Ambulatory EHR consolidation (less heterogeneity than we have today)
*EHR replacement (new software that works better for evolving requirements)
*New Care Management capabilities (social, mobile, analytics, cloud)
*New enterprise-wide decision support capabilities (clinical and financial)
*Physical network consolidation
*eMail consolidation
*Telephone consolidation
*Domain consolidation (identity management via a single platform)
*Administrative system consolidation (supply chain, human resources, learning management)
*Desktop image standardization
*Storage consolidation
*Data Center consolidation
*Single PACS/Enterprise archive
*Integration engine consolidation
*Outsourcing selected functions
*Centrally managed security tools and staffing

Of course, priorities have to be driven by requirements, given that time and resources are limited.   Our hope that is a July strategy deliverable can be turned into FY15 budgets that enable us to tackle the highest priorities, knowing that the journey to systemness will take years.

Thursday, February 27, 2014

Building Unity Farm - Managing wood

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Last weekend I drove to West Bridgewater, MA and picked up a 500 pound SuperSplitter  (J Model 6.5hp Honda engine).  It’s now installed in the wood processing area with 10 cords of wood to be split on one side and 10 cords of self-built storage racks on the other.

Here’s our wood management plan by tree species:

Eastern Red Cedar - we never cut cedar, which is a slow growing resinous tree that lives for 800 years.   We have hundreds of cedars on the farm, some of which were planted at the edges of pastures in the 1800’s.   Cedar waxwings eat the berries and spread the seeds.   As our Revolutionary War era pastures returned to woodlands, the cedars were crowded out and shaded, weakening them.   Hurricane Sandy knocked over several old cedars and we split the fast burning wood to use as fire starters, moth repellant, and incense.

Red Oak - Hurricane Sandy damaged an enormous red oak on the southwest corner of the farm.   We cut it down to ensure a controlled fall and now have thousands of pounds of red oak to split.   I prefer white oak which is easier to split and faster to dry into firewood, but after 2 years of aging, red oak supports hot, long lasting fires.

White Oak - when we cleared land for our orchard, we harvested over 1000 linear feet of white oak, which I cut into 4 foot logs for Shitake growing.   There are a few thousand pounds of logs too heavy for mushroom farming so I’ll process those with the new wood splitter.

Maple - The largest tree on the property is an enormous maple (6 foot diameter trunk) that is near end of life.  We have a large number of birds that nest in old trees, so we’ve cut off the branches and left a snag for wildlife.   The photo above is splitting some of the maple branches.

Ash - Dozens of large ash trees have fallen on the farm over the past few years due to the Emerald Ash Borer.   Ash is an amazing wood since it burns without any aging.   We’ve cut up all the fallen ash and I’m in the process of splitting it with the new splitter.

Black Birch - In a particularly violent winter storm (we’ve had 15 storms this winter) a large black birch with shallow roots fell into one of our paddock fences.    We have a few thousand pounds of black birch ready to split - it smells like root beer (birch beer) when cut.

Poplar - poplar wood is soft, burns poorly, and smells like glue.    Poplar grows very fast and falls frequently.  We process all of our fallen poplar into oyster mushroom logs or chips for the trails.

My upcoming wood management projects include:

Splitting the fallen cedar, red oak, white oak, maple, ash and birch then stacking firewood into 20 wood racks.

Collecting old fallen poplar (many tons to move with the Terex compact front loader) and chipping it into 5 strategically placed piles around the property for spreading on the mile of trails.

Creating a new mushroom farming area from fresh fallen poplar

Cutting new forest paths to the mushroom farming areas so that I can move logs around with the Terex.

Clearing fallen branches from the trails for kindling

There is still 2 feet of frozen snow and ice crust on the ground, but I’ve been able to dig out the maple and ash logs that I cut before Snow-mageddon.   The new splitter, which is flywheel-based, does not have a delay to refill a hydraulic piston.   Thus far, I’ve been able to split 1 cord an hour instead of 1 cord per weekend!

I look forward to the wood management weekends ahead as soon as we have a thaw.   It was 3 degrees F this morning while I was shoveling manure.   Managing anything on a farm at 3 degrees F is challenging.