Cool Technology of the Week

My parents recently moved to a new home on a hillside in Southern California. It has a great view and frequent gentle breeze. My father and I were talking about windpower as means of adding green energy to their property. Green energy sounded great, but I was not sure it was ready for the mainstream of the average homeowner. It's not as if you can buy wind turbines or Bloom boxes at Home Depot.

Whoops - it never pays to bet against the rapid advancement of technology. You can buy a complete home wind turbine at Lowe's right now for under $600.

The Southwest Windpower 400 Watt Wind Generator generates 400 Watts at 28mph, has 3 Carbon fiber composite blades to ensure low wind noise, and electronic torque control for overspeed protection up to 110mph

What can you do with 400 watts?

Remember back to physics - Watts= Amps * Voltage i.e. work is done at a rate of one watt when one ampere flows through a potential difference of one volt. 1W=1V×1A

In my cool technology of the week on February 26, I outlined my effort to replace the light bulbs in my house with high efficiency LEDs.

I've found that I can light an entire room brightly with 50 watts of LED power (each 40 watt equivalent bulb uses only 8 watts to generate 350 lumens of light)

That means I could easily light my entire home with wind power.

Hey Dad, maybe wind power from Lowe's for Father's Day?

The Yin to my Yang

Thirty years ago this month (at 17), I won a speaking contest in a California statewide competition. Kathy Greene won a related statewide art competition. At the time I remember marveling at her use of color in oil paintings of California's missions. She recalled a geeky public speaker who could spin an interesting story.

On August 31, 1980, I was assigned to the Lagunita dorm at Stanford. So was Kathy Greene.

We started dating on September 1, 1980. We just celebrated our 25th wedding anniversary.

Within 24 hours of our time together, I realized that she was the Yin to my Yang. I was math, science, engineering, black and white, digital 0's and 1's, Zen, and monk-like asceticism. She was art, music, culture, color, analog, Victorian clutter, and Joie de vivre. I was completely left brain, she was completely right brain. Together we were a whole brain. On September 2, 1980 we agreed to support each other throughout our education - I would do her math and she would do my art. Together, we could do everything.

Back then, Stanford cost almost $15,000 per year and we needed funding after our scholarships ran out. I went to the Stanford Law library, studied the US tax code and wrote a tax computation program (call it early TurboTax) that businesses could use to write payroll checks on CP/M and early DOS computers. Kathy wrote the manual, designed the advertising, and did all the corporate graphics. We sold thousands of copies from my dorm room.

I was asked to create something special for Steve Wozniak's 33rd birthday and I designed electronic greeting cards with synchronized audio and video that ran on 1980's computers. I patented the idea and included the odd concept that someday there will be a big network connecting everyone that would enable sending of electronic greeting cards between computers. (Next time you send an e-card, you can thank me for the royalty free license!). Kathy created all the graphics and digital artwork.

We've traveled the world, survived medical education, and raised a 17 year old together. She's introduced me to the cultures of the Far East, the music of Simon and Garfunkel, and the art of Maxfield Parrish.

She's been faculty at the School of the Boston Museum of Fine Arts, faculty at Bentley College, and a studio artist in South Boston.

She recently started her own blog - Art that is Life and opened the NK Gallery in Boston's South End.

She's my best friend.

It's great to marry the first person you date - I've been able to invest all my energy in a single life relationship. I think it will last.

Purging Files

I was recently asked if we purge older, untouched files from our storage systems.

This is a very tricky question because of the many compliance, medical-legal, and privacy requirements of a healthcare institution.

Short answer - we do not purge data for active employees. With the number of organizations (4 hospitals, 3 physician organizations, a community health center etc.), home directories and department shares we have it is almost impossible for us to determine centrally within IT what has business value and what is obsolete personal data that should be deleted.

How should organizations approach the complex of problem of what data to save and what to delete?

In my opinion, the best way to manage this is to setup storage quotas and increase them as people needed more space. The pro - it discourages unbridled storage growth. The con - it does cause additional overhead for the Help Desk and Storage Team, and from a compliance/e-Discovery standpoint would encourage users to permanently destroy files.

At BIDMC, we have tried desktop archiving and run into issues with archive software products not supporting all desktop clients equally (works on Windows but not on Mac or Linux). The solution we now are pursuing is to move the older files to the cheapest tier of storage (although maintaining anything we find forever) with relative transparency to the end customer. We use a storage virtualization appliance from F5 (formerly Acopia) to do this.

A purging/archiving policy should include a defined policy that states files are archived for x years, after which files should be moved into an extended retention folder which we will archive and keep, all other folders will be periodically purged of data beyond the stated policy retention period.

We have a data retention policy that governs our business records including paper and electronic for clinical, financial and administrative records. These retentions are governed by applicable law, e.g. 20 years for clinical record content. The retention schedules are included as an appendix to the policy.

We have some log content that is overwritten as storage runs out, i.e. first-in, first-out. How long we save log files is dependent on the content involved. For logs related to clinical record access, we save forever.

We do delete files and email accounts for terminated employees after a grace period. The grace period is to make sure there is no need for the data by the person's manager and the employee will not return to work at BIDMC or an affiliate. The current grace period is 270 days.

Periodically, we have litigation hold involving a subset of our records; primarily Windows files and email. For those accounts subject to the lit hold, we retain them for whatever duration Legal requests.

We are including a capital budget request for next FY for a more robust eDiscovery capability that will allow us to index and search our backup copies of our email and Windows files.

Purging/archiving requires a great deal of thought, senior management/board sponsorship and and rigid enforcement to be effective. With the cost of storage dropping, we will continue to store everything in the short term. However, in the long term this becomes challenging to maintain, so ideally we'll use a combination of quotas and cost effective tiering of data to balance the need for retention, compliance, and business value.

Partial Credit for Meaningful Use

Over the past few weeks, I've had the opportunity to review numerous NPRM comment letters from professional groups and hospitals. Although the issues vary widely depending on the size, IT sophistication, and resources of the commenting organizations, one theme is clear throughout - the desire for partial credit if meaningful use best efforts do not quite meet the threshold required for stimulus funding.

All believe that it is unfair to ask for 25 projects to be done perfectly in order to qualify for the first dollar of stimulus funding i.e. what if 23 projects are done perfectly but 2 are not achievable due to local market or infrastructure issues? What if 70% of all ambulatory prescriptions are e-prescribed instead of the required 75%?

Comments have included:

*The requirement that ALL measures be met will slow the adoption and meaningful use of EHRs

*The number of required measures is unrealistic for Stage 1

*The thresholds for measures are too high

All conclude CMS should maintain strong incentives for high levels of use, but eliminate the “all or none” thresholds for providers to qualify as meaningful users, at least for Stage 1.

I've seen two detailed proposals to address the partial credit problem - one from the HIT Policy Committee and one from the American Hospital Association.

The HIT Policy Committee has recommended a partial credit approach called the 3-1-1-1-0 proposal. You can read their recommendations on the ONC website.

The idea is that organizations should be permitted to defer fulfillment of a small number of meaningful use criteria and still qualify for incentive payment. The deferment would last until Stage 2 criteria apply. To prevent providers from bypassing an entire priority area (e.g., skip all of patient engagement), the 3-1-1-1-0 proposal allows professionals and hospitals to qualify for Stage 1 incentives if they defer no more than the specified number of objectives in each category, as indicated in this table.

The HIT Policy Committee idea includes the 2011 recommendations as they are written today and takes into account the fact that 2013 and 2015 recommendations are still a work in progress.

The American Hospital Association has recommended a different approach - suggesting that all criteria for meaningful use (stage 1,2,3) be specified now and enabling hospitals to travel a glide path of implementation from 25% to 100% until 2017 (the graphic above).

The logic is that software implementation life cycles take 24 months and it's hard to change software 3 times for 3 stages. Rather, working on all stages over a multi-year period provides time for technology, policy, and process changes to be coordinated in a phased way.

The only problem with this idea is that we really do not know what technology capabilities and policy priorities we'll have in 2017, so declaring them all now seems premature.

My opinion, aligned with the HIT Policy Committee recommendations, is that we should designate a core set of meaningful use requirements (i.e. 10 or so must haves), permit providers to select a given number of additional qualifying measures among a set of optional measures (i.e. choose any 5 from a menu of 10), and enable providers who meet substantially all of a measure to be considered meaningful users.

Furthermore, CMS could scale payment amounts to the level of use. For example, a provider who demonstrates ambulatory CPOE usage at 25% would receive partial credit for that metric. Usage at 50% ,75%, and 80% (the NPRM) goal would receive increasingly higher levels of credit.

Regardless of the approach chosen, it's clear that small and large providers alike want some provision for partial credit. I look forward to the CMS comment disposition process which will address this theme.

In ONC I Trust

It's my nature to question authority.

Whether it's religion, politics, or even my local administrative leadership, authority figures must earn my trust.

Earning that trust is not easy. As folks who work closest with me know, I believe that much of Dilbert is based on true case studies.

Over the past year, I've worked very closely with many people at ONC - David Blumenthal, John Glaser, Judy Sparrow, Farzad Mostashari, Chuck Friedman, Carol Bean, Doug Fridsma, Chris Brancato, Jonathan Ishee, Arien Malec (on loan to ONC for 8 months), and Jodi Daniel. I've worked with HHS CTO Todd Park. I've worked with US CTO Aneesh Chopra.

They've earned my trust.

The ONC folks work long hours, nights, and weekends. They do not have a dogmatic philosophical, industry, or architectural bias. They are simply trying to move the ball forward to improve healthcare quality and efficiency using IT tools.

Meaningful Use is a brilliant construct. If it were not for meaningful use, the stimulus would simply be a hardware and software purchasing program. Clinicians would waste government dollars buying technology and never use it (or use it in limited ways such as revenue cycle automation). I've seen numerous technology programs fail because clinicians just give the technology to their kids or sell it on eBay. Meaningful use requires metrics of adoption of the measure of success. Clinicians only receive stimulus dollars AFTER they have fully adopted the technology.

NHIN Direct is a powerful idea. My blog is filled with entries suggesting that we need a reference implementation for simple transport of data packages (X12, NCPDP, HL7 v2, CDA, CCR) among payers, providers and patients. NHIN Direct will assemble energetic, well intentioned people to create open source software that solves real world transport problems. I'm serving on the NHIN Direct Implementation Group. We'll have running code, implementation guidance, and data use agreements by October.

I've enjoyed my 5 years harmonizing standards as part of HITSP. The tireless volunteers really made a difference. But there were issues. The AHIC Use Cases were overly complex. The Interoperability Specifications, which were designed to support the AHIC Use Cases, tightly coupled transport and content standards. It was challenging to use a portion of a use case to solve a limited real world problem. In HITSP's final contract year, the Tiger Teams did remarkable work creating highly reusable content, vocabulary, transport and security modules called capabilities and service collaborations that were much more aligned with ARRA and easier for implementers to understand.

The new Standards Harmonization framework being proposed by ONC using the National Information Exchange Model (NIEM) is something to be embraced, not feared. I've been misquoted saying something like "we'll extend the Department of Justine infrastructure to include healthcare." That's not at all what I said. My actual comments reflected on the wisdom of the NIEM methodology which follows the HITSP Tiger Team approach - define the business needs and find the parsimonious data content, vocabulary and transport standards to meet that need. NIEM methodology is consistent with CDA, CCR, and simple transport. It does not replace the decades of work that have already been done. Instead it provides a methodology for defining needs, selecting and developing standards, and implementing those standards in a testable, sustainable way. Over the next few weeks, I'll write about the several recent RFPs that embrace NIEM methodologies issued including

*Office of the National Coordinator (ONC) CIO-SP2i Solicitation Number 10-233-SOL-00070 entitled "Standards and Interoperability Framework – Use Case Development and Functional Requirements for Interoperability

*Office of the National Coordinator (ONC) CIO-SP2i Solicitation Number 10-233-SOL-00072 entitled "Harmonization of Standards and Interoperability Specifications."

*Office of the National Coordinator (ONC) CIO-SP2i Solicitation Number 10-233-SOL-00080 entitled "Standards and Interoperability Framework Standards Development."

I've written letters of support for responses to all these RFPs.

I was recently asked about the Certification NPRM and if the temporary process and permanent process might create market confusion by changing certification criteria after 2 years and requiring that clinicians replace the systems acquired under the temporary process. My answer was simple - ONC leaders would not let that happen. The people there understand that this is a journey and will ensure that change is managed as evolutionary phases, not revolutionary quantum leaps.

Finally, I trust the HIT Policy Committee and HIT Standards Committees. These folks are good people, with diverse backgrounds, and different points of view. You will not see hegemony of any single person or organization. All their calls and work are done in open public forums. They have included the best people with the greatest good of patients as their driving motivation.

We live in remarkable times, which I've called the "Greatest Healthcare IT generation" and the "Healthcare IT Good Old Days"

My advice - trust the ONC folks and Federal Advisory Committees. Join the process. Be open about your opinions. Feel free to disagree with any idea or policy. Democracy is messy, but the folks at ONC today have the right people and processes in place to harness our energy and turn it into guidance we can all embrace.