The July HIT Standards Committee focused on a discussion of maturity and adoptability criteria for standards, a review of recent testimony regarding best practices for electronic identity authentication of providers, an update from ONC on the certification program, and a continuing discussion of the future processes needed to support the S&I Framework.
Dixie Baker presented the Initial Report on Criteria to Assess Maturity of Standards and Specifications.
A robust discussion followed noting that interpretation of readiness is contextual. Sometimes it is reasonable for standards to include optionality. Sometimes it is beneficial to require pre-coordination between trading partners. Sometimes it is reasonable to encourage adoption of emerging but not widely tested standards. The excellent framework that Dixie presented will be tested with a sample standard - the HL7 Infobutton implementation guide for knowledge retrieval. At our next meeting, Dixie will report on lessons learned from this evaluation and any refinements she would suggest to the maturity/adoptability criteria.
Dixie also presented an overview of a recent hearing on trusted identification for providers. In a world filled with malware, screen scrapers and keystroke loggers, it is important to consider the vulnerability of username and password as authentication credentials. The Standards Committee agreed on the importance of accurately identifying and protecting endpoints in healthcare information exchange, however they noted that healthcare workflows require more complexity than just authenticating individual users. Sometimes organizational credentials (a practice) are needed since a message is routed to a place not a person. Sometimes delegation is needed when routing a message to the staff supporting a clinician. We also discussed the workflow impact of two factor authentication. Strong authentication is part of a multi-layered defense protecting privacy. Significant work will be required to develop a family of solutions supporting the requirements of healthcare.
Next, Carol Bean provided an update on the Permanent Certification program. The existing temporary Authorized Testing and Certification Bodies (ATCBs) will be replaced by permanent certification and testing organizations. The certification organizations are accredited by ANSI and authorized by ONC. The testing organizations are accredited by National Voluntary Laboratory Accreditation Program (NVLAP) , a division of NIST, and authorized by ONC. To date, 5 organizations have been accredited as certifiers, and 5 organizations have been accredited as testers. ONC plans to authorize these organizations in August, so the temporary program can be sunsetted soon.
Jodi Daniel provided an overview of the national progress on health IT. 110,000 clinicians have attested to meaningful use. Numerous initiatives including BlueButton, Decision Support (HealthE Decisions) and a Cancer patient engagement program have been launched. The trajectory is good.
Finally, Doug Fridsma presented an update on the S&I Framework projects.
We discussed the success criteria for S&I efforts to date. We agreed that projects should be aligned with policy goals. We noted that a formal priority setting process is important to allocate limited resources among many competing projects. HITSC hopes to advise that process, using such tools as the maturity and adoptability criteria for standards to assess the level of effort and cost needed to close standards gaps, enabling ONC to optimize the portfolio of S&I projects.
We'll continue to the S&I discussion at the next meeting. As the end of ARRA funding nears there is an opportunity to reconsider how best ONC, HITSC, and S&I can work together to guide the work on standards for the United States.
Friday, July 20, 2012
Thursday, July 19, 2012
Our Cancer Journey Week 30
Today Kathy visited her oncologist to discuss a 5 year course of anti-estrogen (tamoxifen) therapy. I've said before that Cancer is chronic disease and although the first phase of our journey ends on July 31 after 8 final radiation treatments, the vigilance for reoccurrence and the medications to minimize risk begins thereafter.
Tamoxifen, a competitive inhibitor for estrogen, makes great sense for Kathy because her breast cancer is estrogen receptor positive - estrogen makes it grow. She'll have to watch for endometrial cancer (The American Cancer Society lists tamoxifen as a known carcinogen, stating that it increases the risk of some types of uterine cancer even though it lowers the risk of breast cancer recurrence) and possible memory changes. She'll start taking Tamoxifen about 10 days after the end of radiation therapy.
We're preparing to celebrate the end of her treatment phase (chemotherapy, surgery, radiation) and the transition to maintenance and prevention on July 31. One small complication - having just turned 50, my first ever colonoscopy is scheduled for that day so the champagne may have to wait until August 1.
Starting in August, Kathy's life becomes much easier since she no longer has to commute daily for radiation therapy. Since Boston has two seasons - winter and road construction - the fatigue of the past 6 weeks has been significantly compounded by sitting in traffic every day for up to 3 hours.
August will be much more settled than the rest of the year thus far. Treatment will be done, my office schedule will be iighter, my daughter will be away, and our previous home will have closed escrow. What will we do with all that free time?
Our llama and alpacas will move to Unity Farm the week of August 20 (assuming all our fences are finished, our hay arrives, and the folks transporting the herd will be available).
We just learned that our llama is likely pregnant, so we'll have a mama llama. The llama gestation period is 11.5 months, so she'll likely have the cria (baby llama) next Summer. I welcome suggestions for names. The suggestions I've had thus far are Dolly Llama and Ding Dong (as in 'who put the Mom in Mama Llama Ding Dong?')
This weekend we'll visit the alpaca herd in Maine to learn about toenail trimming, vaccinations, and general health assessment. I may be an emergency physician but doing procedures on a 150 pound furry camelid will be a learning experience.
After July 31, Kathy will not have another medical appointment until January 29, 2013 when she has a screening mammogram and a followup with her breast surgeon.
Next week will be my last post about this part of the cancer journey. It has been an emotional, anxiety-filled time for both of us. We're looking forward to maintaining wellness instead of treating illness.
Tamoxifen, a competitive inhibitor for estrogen, makes great sense for Kathy because her breast cancer is estrogen receptor positive - estrogen makes it grow. She'll have to watch for endometrial cancer (The American Cancer Society lists tamoxifen as a known carcinogen, stating that it increases the risk of some types of uterine cancer even though it lowers the risk of breast cancer recurrence) and possible memory changes. She'll start taking Tamoxifen about 10 days after the end of radiation therapy.
We're preparing to celebrate the end of her treatment phase (chemotherapy, surgery, radiation) and the transition to maintenance and prevention on July 31. One small complication - having just turned 50, my first ever colonoscopy is scheduled for that day so the champagne may have to wait until August 1.
Starting in August, Kathy's life becomes much easier since she no longer has to commute daily for radiation therapy. Since Boston has two seasons - winter and road construction - the fatigue of the past 6 weeks has been significantly compounded by sitting in traffic every day for up to 3 hours.
August will be much more settled than the rest of the year thus far. Treatment will be done, my office schedule will be iighter, my daughter will be away, and our previous home will have closed escrow. What will we do with all that free time?
Our llama and alpacas will move to Unity Farm the week of August 20 (assuming all our fences are finished, our hay arrives, and the folks transporting the herd will be available).
We just learned that our llama is likely pregnant, so we'll have a mama llama. The llama gestation period is 11.5 months, so she'll likely have the cria (baby llama) next Summer. I welcome suggestions for names. The suggestions I've had thus far are Dolly Llama and Ding Dong (as in 'who put the Mom in Mama Llama Ding Dong?')
This weekend we'll visit the alpaca herd in Maine to learn about toenail trimming, vaccinations, and general health assessment. I may be an emergency physician but doing procedures on a 150 pound furry camelid will be a learning experience.
After July 31, Kathy will not have another medical appointment until January 29, 2013 when she has a screening mammogram and a followup with her breast surgeon.
Next week will be my last post about this part of the cancer journey. It has been an emotional, anxiety-filled time for both of us. We're looking forward to maintaining wellness instead of treating illness.
Wednesday, July 18, 2012
Hospital Disaster Planning
In my role as CIO and a Professor of Medicine, I'm asked many questions about the policies, processes, and procedures of healthcare. Here's one I was recently asked about Hospital Disaster planning. Meg Femino, BIDMC Director of Emergency Management, prepared the answer.
The question:
Your hospital has been placed on alert for receiving patients from a local explosion at a large factory. Reports from the scene are spotty in terms of numbers killed or injured, and you do not know how many patients you may be getting. News reports are calling for casualties in the 100s, but local fire responders are sending in conflicting reports. You need to know what your ED will be receiving, so you can determine whether to close surgery to elective cases and to go on ED bypass for regular patients. Rumors are swirling inside the hospital and the chain of command about how severe the incident is and what it will do to your ability to function. What thoughts do you have about how to learn what you need to know in order to structure the hospital's preparations and continue regular functioning at the same time? What resources can you tap in order to learn more accurately about the situation at the scene and what you can expect to come to your ED? How would you manage this situation to cause the minimum disruption to regular hospital functioning?
When faced initially with a disaster situation in a health care setting, what do you think your first five steps need to be? Why?
Meg's answer:
This can be a common scenario, early information is always scant, unconfirmed and conflicting. Due to the mechanism of injury (explosion), chances are traumatic injuries will be present. That is what we would base our initial response on until credible information came in. We would immediately implement the following strategies:
* Activate the Emergency Operations Plan and the Incident Command System
* We would report to EMS via our disaster radio how many red (emergent), yellow (urgent) and green (non urgent) patients we can take. This is only a guide for EMS to distribute patients equally if they can, in a large mass casualty, you get what you get.
* Clear as many patients out of the Emergency Department as we could- admitted patients upstairs immediately, discharge others and decision make on the rest
* Alert the trauma teams with numbers expected, injuries, time to ED and any other pertinent information available
* Alert the OR's to hold any currently open rooms, do not start any other cases until we have more information and begin to assemble trauma teams. We know from previous drills we can open 17 OR rooms with staffed teams in 2 hours if we have to, this would involve canceling all non-emergent surgeries.
* We would see how many staffed in-patient beds are available in house and prepare for early discharges if we needed to. I call this the purge to surge.
* Alert the blood bank of potential incoming trauma to prepare for high volume of blood use
* Open the command center and assemble incident command team and begin gleaning information.
How we get information and share information during a citywide event:
* The Boston Hospitals have a emergency manager on call 24/7 for events like this. We would immediately be in touch with him, he liaisons with other citywide agencies and shares this information with hospitals.
* The TV provides information and usually pictures of the scene so we can get a better idea of the scope
* The city utilizes WebEOC which is a software system all hospitals, public safety, public health, EMS and others are linked in to. This system would be active within 15 minutes. Informations is shared here across disciplines and is great for situational awareness. We can also share our situation with others, make resource requests and monitor others.
* Boston also has a medical intelligence center housed at Boston EMS, they would be pushing out information as it comes available. They would be asking our needs and monitoring the situation.
* We (hospital emergency managers) receive information messages from state agencies via the HHAN (Health and Homeland Alert Network), if they activate the state EOC etc.
* We also monitor the disaster radio in the ED, they will update us on how many more patients on scene, where they are going etc.
We flex our incident command team up or down as needed for response and tailor our response strategies to the needs of the event. As far as the five first steps I would say
1. Activation of the Emergency Operations Plan and notification Incident Command- this brings the team approach to the response
2. Preparing the hospital for patient surge
3. Gleaning information and sharing information to establish accurate situational awareness
4. Monitoring of resources- finding the balance with staffing and burn rates of supply. This allows you to continue treating and know when to ccall for more.
5. Stabilizing the event- treating those from the event to return the hospital to normal operations
The question:
Your hospital has been placed on alert for receiving patients from a local explosion at a large factory. Reports from the scene are spotty in terms of numbers killed or injured, and you do not know how many patients you may be getting. News reports are calling for casualties in the 100s, but local fire responders are sending in conflicting reports. You need to know what your ED will be receiving, so you can determine whether to close surgery to elective cases and to go on ED bypass for regular patients. Rumors are swirling inside the hospital and the chain of command about how severe the incident is and what it will do to your ability to function. What thoughts do you have about how to learn what you need to know in order to structure the hospital's preparations and continue regular functioning at the same time? What resources can you tap in order to learn more accurately about the situation at the scene and what you can expect to come to your ED? How would you manage this situation to cause the minimum disruption to regular hospital functioning?
When faced initially with a disaster situation in a health care setting, what do you think your first five steps need to be? Why?
Meg's answer:
This can be a common scenario, early information is always scant, unconfirmed and conflicting. Due to the mechanism of injury (explosion), chances are traumatic injuries will be present. That is what we would base our initial response on until credible information came in. We would immediately implement the following strategies:
* Activate the Emergency Operations Plan and the Incident Command System
* We would report to EMS via our disaster radio how many red (emergent), yellow (urgent) and green (non urgent) patients we can take. This is only a guide for EMS to distribute patients equally if they can, in a large mass casualty, you get what you get.
* Clear as many patients out of the Emergency Department as we could- admitted patients upstairs immediately, discharge others and decision make on the rest
* Alert the trauma teams with numbers expected, injuries, time to ED and any other pertinent information available
* Alert the OR's to hold any currently open rooms, do not start any other cases until we have more information and begin to assemble trauma teams. We know from previous drills we can open 17 OR rooms with staffed teams in 2 hours if we have to, this would involve canceling all non-emergent surgeries.
* We would see how many staffed in-patient beds are available in house and prepare for early discharges if we needed to. I call this the purge to surge.
* Alert the blood bank of potential incoming trauma to prepare for high volume of blood use
* Open the command center and assemble incident command team and begin gleaning information.
How we get information and share information during a citywide event:
* The Boston Hospitals have a emergency manager on call 24/7 for events like this. We would immediately be in touch with him, he liaisons with other citywide agencies and shares this information with hospitals.
* The TV provides information and usually pictures of the scene so we can get a better idea of the scope
* The city utilizes WebEOC which is a software system all hospitals, public safety, public health, EMS and others are linked in to. This system would be active within 15 minutes. Informations is shared here across disciplines and is great for situational awareness. We can also share our situation with others, make resource requests and monitor others.
* Boston also has a medical intelligence center housed at Boston EMS, they would be pushing out information as it comes available. They would be asking our needs and monitoring the situation.
* We (hospital emergency managers) receive information messages from state agencies via the HHAN (Health and Homeland Alert Network), if they activate the state EOC etc.
* We also monitor the disaster radio in the ED, they will update us on how many more patients on scene, where they are going etc.
We flex our incident command team up or down as needed for response and tailor our response strategies to the needs of the event. As far as the five first steps I would say
1. Activation of the Emergency Operations Plan and notification Incident Command- this brings the team approach to the response
2. Preparing the hospital for patient surge
3. Gleaning information and sharing information to establish accurate situational awareness
4. Monitoring of resources- finding the balance with staffing and burn rates of supply. This allows you to continue treating and know when to ccall for more.
5. Stabilizing the event- treating those from the event to return the hospital to normal operations
Tuesday, July 17, 2012
The Return on Investment of Administrative Simplification
Since 1997, the New England Healthcare Exchange Network (NEHEN), a non-profit run by stakeholder board members, has provided community-wide collaborative payer-provider administrative transaction exchange for a fixed subscription fee.
I was recently asked about the return on investment of administrative healthcare information exchange.
The answer is summarized in this presentation.
NEHEN members use the exchange for benefits, eligibility, referral authorization, claim status inquiry, and claims transactions. There are no transaction fees.
Creative ways in which members use NEHEN include:
*45 days following service, self-pay accounts are passed through NEHEN to re-check for changes in insurance coverage, resulting in assignment of a payer to 15-20% of self-pay accounts
*Bad debt accounts are checked via NEHEN before write-off, resulting in assignment of a payer to 3-4% of bad debt accounts
*The accuracy of demographics and payer information is checked during inpatient hospitalizations so any corrections can be made while the patient is still receiving services.
The end result over the past decade is that denial rates have dropped from 5.5% to 3.25% of submitted claims. Bad debt is running at 0.6% of net revenue compared to the pre-NEHEN rate of 1.2%. Administrative write-offs due to delayed billing are at 0.02% of net revenue
Since payers and providers collaboratively run NEHEN without a middleman, the cost of supporting 100 million transactions per year is very low. For a large academic medical center, the NEHEN annual subscription is approximately $250,000. If the same transactions were processed by an outsourced revenue cycle vendor (.20 transaction fee) the cost would be about $952,000. If the same transactions were sent via a clearinghouse (.12 transaction fee), the cost would be about $571,000.
Lower administrative costs for payers and providers, more timely reimbursement, and fewer write-offs have created a return on investment for NEHEN that has resulted in sustained NEHEN membership for 50+ hospitals, 5000+ physicians, and 4.5M+ health plan members.
The is a clear ROI for administrative transaction exchange and NEHEN will continue to be a convener of payers and providers for years to come.
I was recently asked about the return on investment of administrative healthcare information exchange.
The answer is summarized in this presentation.
NEHEN members use the exchange for benefits, eligibility, referral authorization, claim status inquiry, and claims transactions. There are no transaction fees.
Creative ways in which members use NEHEN include:
*45 days following service, self-pay accounts are passed through NEHEN to re-check for changes in insurance coverage, resulting in assignment of a payer to 15-20% of self-pay accounts
*Bad debt accounts are checked via NEHEN before write-off, resulting in assignment of a payer to 3-4% of bad debt accounts
*The accuracy of demographics and payer information is checked during inpatient hospitalizations so any corrections can be made while the patient is still receiving services.
The end result over the past decade is that denial rates have dropped from 5.5% to 3.25% of submitted claims. Bad debt is running at 0.6% of net revenue compared to the pre-NEHEN rate of 1.2%. Administrative write-offs due to delayed billing are at 0.02% of net revenue
Since payers and providers collaboratively run NEHEN without a middleman, the cost of supporting 100 million transactions per year is very low. For a large academic medical center, the NEHEN annual subscription is approximately $250,000. If the same transactions were processed by an outsourced revenue cycle vendor (.20 transaction fee) the cost would be about $952,000. If the same transactions were sent via a clearinghouse (.12 transaction fee), the cost would be about $571,000.
Lower administrative costs for payers and providers, more timely reimbursement, and fewer write-offs have created a return on investment for NEHEN that has resulted in sustained NEHEN membership for 50+ hospitals, 5000+ physicians, and 4.5M+ health plan members.
The is a clear ROI for administrative transaction exchange and NEHEN will continue to be a convener of payers and providers for years to come.
Monday, July 16, 2012
Creative Uses of Active RFID
BIDMC implemented enterprise-wide Active RFID asset tracking over 5 years ago.
Initially this was done to reduce theft of wheelchairs, optimize the use of high inventory multi-departmental equipment such as ventilators/ekg machines/iv pumps, and reduce the time searching for devices in the emergency department.
Over the years, we've deployed thousands of tags and enabled tracking over 2 million square feet of BIDMC buildings.
My staff recently reviewed the utilization of Active RFID technologies to understand how broadly they have been adopted.
Their conclusion - the technology is highly functional, frequently used, and effective.
A few examples:
Radiology tracks lead aprons for JCAHO compliance.
The Emergency Department is using a temperature sensing RFID tag to monitor a refrigerator for JCAHO compliance.
Currently, there are 201 active users of the management software which enables viewing of tracked assets.
Clinical staff relies on that software to locate equipment with limited quantity and high demand - dialysis machines, scanners, and Arctic Sun temperature management systems.
Clinical Engineering continues to use RFID for locating equipment due for preventative maintenance.
As our wireless network has evolved, we've upgraded our access points and geolocation software. At this point we provide highly accurate location services based on triangulating wifi signal strength.
As with many technologies that are robust and easy to implement, the creative possibilities for geolocation are numerous. The examples above are just a few of the ways in which we're using the technology to improve quality, safety and efficiency.
Initially this was done to reduce theft of wheelchairs, optimize the use of high inventory multi-departmental equipment such as ventilators/ekg machines/iv pumps, and reduce the time searching for devices in the emergency department.
Over the years, we've deployed thousands of tags and enabled tracking over 2 million square feet of BIDMC buildings.
My staff recently reviewed the utilization of Active RFID technologies to understand how broadly they have been adopted.
Their conclusion - the technology is highly functional, frequently used, and effective.
A few examples:
Radiology tracks lead aprons for JCAHO compliance.
The Emergency Department is using a temperature sensing RFID tag to monitor a refrigerator for JCAHO compliance.
Currently, there are 201 active users of the management software which enables viewing of tracked assets.
Clinical staff relies on that software to locate equipment with limited quantity and high demand - dialysis machines, scanners, and Arctic Sun temperature management systems.
Clinical Engineering continues to use RFID for locating equipment due for preventative maintenance.
As our wireless network has evolved, we've upgraded our access points and geolocation software. At this point we provide highly accurate location services based on triangulating wifi signal strength.
As with many technologies that are robust and easy to implement, the creative possibilities for geolocation are numerous. The examples above are just a few of the ways in which we're using the technology to improve quality, safety and efficiency.
Friday, July 13, 2012
Cool Technology of the Week
Today's post is not about current cool technologies, but those that were cool. I feel nostalgic for my IBM XT with a 5 megabyte hard drive, my Motorola brick phone, my 5 1/4 floppy collection, my Atari console and my Epson dot matrix printer. There was a time when all of these technologies were uber-cool - only cutting edge technologists were willing to take the risk on early, unproven products.
The Boston Globe recently posted a cool technology retrospective using this classification
Ancient: seen in museums only, unusable, unfixable
Antique: unusable, unfixable
Vintage: usable, old, ironic, cool
Outdated: still available in stores, but barely used
It's amazing how fast cool technologies become outdated technologies. I was in a meeting of technology leaders yesterday and only one person had a Blackberry, lamenting that his organization had not yet moved on to something more modern.
What's your favorite vintage, formerly cool technology?
The Boston Globe recently posted a cool technology retrospective using this classification
Ancient: seen in museums only, unusable, unfixable
Antique: unusable, unfixable
Vintage: usable, old, ironic, cool
Outdated: still available in stores, but barely used
It's amazing how fast cool technologies become outdated technologies. I was in a meeting of technology leaders yesterday and only one person had a Blackberry, lamenting that his organization had not yet moved on to something more modern.
What's your favorite vintage, formerly cool technology?
Thursday, July 12, 2012
Our Cancer Journey Week 29
Kathy completes radiation therapy on July 31. On that date she moves from cancer patient to cancer survivor. I have only two more posts to write about this segment of our journey - Week 30 and Week 31.
At this point, radiation therapy is going well. Kathy feels bone pain under the radiation site and the skin of her left breast is slightly tender/irritated. The fatigue of each day limits her nighttime endurance and she longs for sleep at 9pm. However, being a survivor makes it all worthwhile.
Kathy has been reading several interesting New York Times articles about cancer as she prepares for the next stage - health maintenance and monitoring for recurrence. The role of survivor comes with its own emotions and responsibilities.
The past 29 weeks have taken their toll. Kathy still has limited hand strength and can only walk short distances because of the Taxol induced neuropathy. We could speculate that she did not need the taxol and that adriamycin/cytoxan would have been enough. We could speculate that new advances in therapy, personalized to the patient's and tumor's genome, will soon eliminate the need for Taxol. We could speculate that new testing methods would have detected her breast cancer before it became Stage IIIA and required aggressive chemotherapy.
However, all such speculation is unproductive. She's a survivor and that's what matters. We've both learned that asking 'what if' questions about the past can only lead to frustration. We live in the here and now, looking forward to a future in which she is cancer free and her neuropathy resolves over time.
Kathy, the survivor, is ordering 5 tons of second cutting Timothy Hay for our alpaca and llama herd which arrives August. She has plenty of time to plan for the future because she's a cancer survivor.
At this point, radiation therapy is going well. Kathy feels bone pain under the radiation site and the skin of her left breast is slightly tender/irritated. The fatigue of each day limits her nighttime endurance and she longs for sleep at 9pm. However, being a survivor makes it all worthwhile.
Kathy has been reading several interesting New York Times articles about cancer as she prepares for the next stage - health maintenance and monitoring for recurrence. The role of survivor comes with its own emotions and responsibilities.
The past 29 weeks have taken their toll. Kathy still has limited hand strength and can only walk short distances because of the Taxol induced neuropathy. We could speculate that she did not need the taxol and that adriamycin/cytoxan would have been enough. We could speculate that new advances in therapy, personalized to the patient's and tumor's genome, will soon eliminate the need for Taxol. We could speculate that new testing methods would have detected her breast cancer before it became Stage IIIA and required aggressive chemotherapy.
However, all such speculation is unproductive. She's a survivor and that's what matters. We've both learned that asking 'what if' questions about the past can only lead to frustration. We live in the here and now, looking forward to a future in which she is cancer free and her neuropathy resolves over time.
Kathy, the survivor, is ordering 5 tons of second cutting Timothy Hay for our alpaca and llama herd which arrives August. She has plenty of time to plan for the future because she's a cancer survivor.
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