The "Post EHR" Era

Over the next few months, the majority of my time will be spent discussing topics such as care coordination, healthcare information exchange, care management, real time analytics, and population health. At BIDMC, we've already achieved 100% EHR adoption and 90% Meaningful Use attestation among our clinician community.    Now that the foundation is laid, I believe our next body of work is to craft the technology and workflow solutions which will be hallmarks of the "post EHR" era.

What does this mean?

I've written previously about BIDMC's Accountable Care Organization strategy, which can be summed up as ACO=HIE + analytics

In a "post EHR" era we need to go beyond simple data capture and reporting, we need care management that ensures patients with specific diseases follow standardized guidelines and protocols, escalating deviations to the care team.    That team will include PCPs, specialists, home care,  long term care, and family members.    The goal of a Care Management Medical Record (CMMR) will be to provide a dashboard that overlays hospital and professional data with a higher level of management.

How could this work?

Imagine that we define each patient's healthcare status in terms of "properties".    Data elements might include activities of daily living, functional status, current care plans, care preferences, diagnostic test results, and therapies, populated from many sources of data including every EHR containing patient data, hospital discharge data, and consumer generated data from PHRs/home health devices.

That data will be used in conjunction with rules that generate alerts and reminders to care managers and other members of the care team (plus the patient).   The result is a Care Management Medical Record system based on a foundation of EHRs that provides much more than any one EHR.

My challenge in 2013-2014 will be to build and buy components that turn multiple EHRs into a CMMR at the community level.

This will require philanthropic funding, in kind contributions from selected vendor partners, and a willingness to take a risk on creating something that has never been operated at scale in the past.

I wrote previously about the reluctance of healthcare to change and adopt new delivery models.

BIDMC is a unique learning laboratory because 65% of its patients are already in global captivated risk arrangements.

If the CMMR can be created anywhere, it's at BIDMC which strives to be agile and transparently share all its early experiences with the world.

I'm willing to lead the CMMR effort.   In my discussions with many stakeholders over the next few months, I'm hoping to create a guiding coalition that will join me.

So What Does 30 Inches of Snow Look Like?

For those who have been watching news of the New England weather,  here's a personal look at what 30 inches of snow in 12 hours looks like.   We shoveled and plowed through the night to keep our lanes open.    The alpaca/llama stayed in the barn eating hay.    The dogs played in the drifts all night.   The chickens/guinea fowl slept through the entire event.     We did not lose power, but we prepared for an extended outage by moving 50 gallons of water for the animals into the garage and 50 gallons for humans into the basement.   We moved a cord of firewood to the front and back porch.    At the moment, we're done with our morning farm chores, ensuring all the animals will have a warm and dry day.

The barnyard:

The chicken coop:

The front door:

Building Unity Farm - The Hen That Went Broody

The world of Unity Farm is cold and frozen this week.   There's ice and snow on the ground and night time temps are approaching single digits.   It's not the right time to hatch chicks.

However, randomly throughout the year, egg laying hens decide that hatching eggs is their only priority.   They sit on the eggs 23+ hours a day, taking only a quick break once a day to eat and drink.   The go broody.

We're fine with the concept, but this week, our most maternal hen, an Ameraucana named Terra, decided to create a nest under the coop, 10 feet from any edge.   She was completely unreachable by us, but very vulnerable to local foxes, fisher cats, and raccoons.

Here's how it happened.   Every night we put our chickens to bed by bolting all internal doors/passageways from inside the coop to prevent predators from sneaking in.  Then we close the coop front door and put a carabiner on the latch to ensure it stays shut.   Before lockdown, I fill the water fountains and grain feeders, then count every bird (13 chickens, 18 guinea fowl).   All of our chickens have names, so we know exactly who is roosting in each section of the coop.   Generally, the large rooster, Lucky sits on low perch I built for him.   The small rooster, Rainbow, sits as far from Lucky as possible.   The hens except for Terra and Zephyr, roost above Lucky.   Terra and Zephyr sleep with the guinea fowl.

Last weekend, when I counted the chickens, I could not find Terra.   We saw her at noon on Sunday, but by twilight when we close up the coop, she was gone.    I spent an hour running all the trails looking for signs that a predator had eaten her.   I put the dogs on lead and we ran through the property looking for fox/coyote tracks or other predator activity.    We found nothing.   Odd.

The next morning, my wife spread scratch grains (think of it as candy for chickens) around the coop.   A few minutes later Terra appeared.   Then she disappeared again.   When I returned from work, I crawled under the coop with a flashlight and saw her nesting far beyond my reach.

I used a 10 foot bamboo pole to gently move her toward the side of the coop.   No luck.   She was committed to hatch the eggs she laid in that subterranean space.

My wife tried scratch again each day.   No luck.    I checked on her nightly to ensure she was still healthy.

Last night, a fisher cat ran by the paddocks and made a horrible screeching sound.   I had to protect Terra in her vulnerable position, so in Cask of Amontillado fashion, I walled her into her hiding place.

This morning I removed the barrier.    My wife and I used 2 bamboo poles to create a moving barrier.   We scooted her away from the nest and eventually she gave up, exiting in to the barnyard.    We gently picked her up and placed her in the coop, where she ate and drank her fill before roosting in her usual place.

Given the historic snowstorm that is impacting New England this weekend, we rescued her just in time.

Let's hope when other hens go broody in the winter, they have the sense to do it indoors!

Testimony to the HIT Policy Committee

Today I testify to the HIT Policy Committee  and review the HIT Standards Committee responses to the HIT Policy Committee Request for Comment.

Although there are many detailed comments, they stratify into 5 general categories

*Because of the maturity of standards and EHR technology, the Stage 3 goal should be menu set rather than core
*Because of the maturity of workflows, the Stage 3 goal should be a certification requirement (the technology can do it) but not a meaningful use requirement
*Standards do not exist and it is premature to include the goal in Stage 3
*Workflow/experience with production system implementation does not exist and it is premature to include the goal in Stage 3
*We agree with the Policy Committee goal as worded

In general, the Standards Committee applauds the aspirational nature  of many of the goals.    They seem like a reasonable direction.   The challenge is timing.   18 month cycles to design, implement and adopt product require that mature standards exist and pilot workflows have proven efficacy.

I described the caveats raised by the Standards Committee when goals seemed too aspirational for Stage 3.  For example :

*No standards or technologies exist to represent knowledge/rules and enable their automated incorporation into EHR workflows.
*There is no way to electronically broadcast computable guidelines for immunization administration for children into EHR workflows.
*At present there are no standards for contraindications to immunizations
*The is no standard way to electronically broadcast computable guidelines for drug/drug interactions into EHR workflows.
*There is no way to broadcast rules that would create "smart problem lists" such as declaring everyone with a hemoglobin A1c greater than 9 to be a diabetic.
*Incorporating patient generated data into EHRs requires new patient friendly vocabularies and code sets that will map into EHR data structures and protect data integrity.

We agree with many of the goals and believe that progress with Meaningful Use Stage 2 should be extended with higher thresholds which enable organizations and professionals to consolidate our gains.

I am confident that the smart people at ONC will incorporate testimony from stakeholders, the deliberations of the policy committee, and the feedback from the standards committee into a set of go forward recommendations for Meaningful Use stage 3.  

Given that the country is in the midst of ICD-10, Accountable Care/Healthcare Reform implementation, value-based purchasing, Meaningful Use stage 2, and HIPAA revisions, many clinicians, vendors, and IT professionals are feeling overwhelmed.   If Meaningful Use Stage 3 follows existing timelines and focuses on a few key domains, raising the thresholds on existing criteria and incorporating more interoperability where standards are mature, we'll achieve a balance of benefit and burden.

A New Sustainability Model for Healthcare Information Exchange

Many of us have worked hard on sustainability models for HIE over the last decade.    There is one model we likely never considered.

The Massachusetts Health Information Highway is abbreviated the MassHIway.   Its phone number is 1-800-MassHIway.

Unrelated to IT (or so we thought), Massachusetts legalized medical marijuana.

This is an actual transcript of a call we received today


Sean - “Hello, Mass HIway – how may I help you?”

Caller - “Yes, can you tell me how I become a marijuana grower/dispenser?”

It's clear we have to rethink the meaning of HIGH way.

Building Unity Farm - Reflections on our First Winter

The third week of January is always the coldest time in New England.    Mt Washington was -70F and Unity Farm was 1.4F 

When we began this season I had no idea how to keep the animals happy and healthy in near zero temperatures.    We've learned a great deal and thus far, everything has worked.

Chickens and Guinea Fowl - I've written about keeping warm in New England,  highlighting that convective, conductive, and radiated heat loss need to be controlled.    For poultry, a dry, wind free coop with off ground roosting helps a great deal.   Our chicken breeds are very cold hardy due to their small combs and waddles.   However, to completely guard against frostbite, we added 150 watt sealed heating panels to the roof and baseboard of the coop (photo below).   These are thermostatically controlled and go on at 35F, off at 45F    They've worked perfectly, ensuing the coop is 10-15 degrees warmer than the outside temperature.     Keeping water supplies liquid at zero F requires planning.   For the chickens, their hanging bucket waterer now has a submersible thermostat controlled heater (photo to the right).    For the guinea fowl, their standalone waterer sits on a thermostat controlled heat plate.     In very cold weather, the guineas rarely leave the coop, enjoying the food, water, and warmth of their gently heated home.     I did have to wire the coop with tamper-proof (beak proof), weather resistant (from chicken droppings) outlets and rugged 14 gauge romex wire.   Everything has worked without a hitch.

Dogs - The Great Pyrenees have double coats and really enjoy snow and ice.   They eat the "popsicles" from the ice that falls from the barn roof.   Just as with the chickens, keeping dogs out of the wind and wet weather is important.   We've created spaces for them in the hayloft - they curl up among the bales, staying warm on blustery winter nights.  Also, we use a thermostatically controlled heated bucket to keep their water liquid.

Alpaca/Llama - The camelids seem impervious to cold but do not like the wind.   We created rubber floored stalls with sliding doors that provide a wind and rain barrier.    Their water buckets are heated.   We feed them hay with a high percentage of alfalfa (extra calories) on cold days.    We feed each of them a cup of high energy grain in the morning and evening of each winter day.  We supplement their diet with beet pulp. Shoveling manure during weeks that never rise about freezing has proven to be a challenge.   I can use a wrecking bar, pick, or hammer to break up manure, but I've found it more practical to wait until a thaw day to shovel.

The combination of appropriate housing, low wattage heaters, and water management, has proven to me that winter on Unity Farm will pass without any animal health and well-being issues.

The Retirement of a Healthcare IT Legend

On Monday, I had the privilege of attending the retirement luncheon for G. Octo Barnett, the founder of the MGH Laboratory of Computer Science (LCS) and the inventor of the MUMPS (Massachusetts General Hospital Utility Multi-programming system).

Henry Chueh, Division Chief of LCS, served as master of ceremonies.

The attendees were the luminaries in the field of medical informatics - Donald Lindberg, Randy Miller, Clem MacDonald, Charlie Safran, Paul Egerman, Rita Zielstorff, Albert Mulley, Howard Bleich, Warner Slack, Chris Cimino, Peter Beaman and many more.

Everyone told stories about Octo's achievements inside and outside the lab.

In many ways, he is the catalyst that spawned companies such as Meditech, IDX, Epic, Intersystems, and many others.

Octo himself is a humble man and offered his sincere thanks to everyone who has worked with him over his 50+ year career.

He's a great man whose contribution to the healthcare IT industry is overwhelming.   I've said that in life the most important thing is to make a difference.   Octo made a difference.