Preparing for a Meaningful Use Audit

ONC/CMS provides strong oversight of the Meaningful Use program by continuousy reexamining the quality of certified products and auditing hospitals and practices that have attested to meaningful use.

Last week, ONC "de-certified" a product for not supporting the functionality required by regulations .

Meaningful Use audits are done by Figliozzi and Company on behalf of CMS.   I've assisted one of our hospitals and one of our practices with such audits.

What do the auditors ask for?

*Proof of ownership of a certified EHR
*Reporting method used to incorporate Emergency Department (ED) patients (All ED Visits or Observation Services)
*Core and Menu Measure Meaningful Use Reports used to enter attestation data
*Documentation for “Yes” attestation measures to evidence the measure has been met
Based on the information received, Figliozzi and Company will prepare additional follow up requests as needed.  It's helpful to retain all supporting documentation used while preparing for attestation so that it can be readily available for auditor followup requests.  We've placed all our materials in a shared folder which is accessible to IT and Compliance staff.

The type of documentation we've stored includes

*Our Certification process and approvals (we self-certified our systems)
*Our actual attestation documents and receipts
*Reports from our EHR which reconcile exactly to the attestations made for each Core and Quality measure.
*Documentation for Public Health measures with confirmation emails from contacts at the Public Health Agencies
*A statement about change control and source code control systems which documents that functionality such as Drug/Allergy Interaction Checking, Drug Formularies and Clinical Decision Support Rules was enabled for the entire reporting period
*Documentation that explains the interpretations made by management for all measures.
*Documentation regarding the validation we did for quality and meaningful use measure reports

Most EHR vendors have experienced the auditing process and can provide letters/supporting documentation that Figliozzi and Company will find suitable as proof that proper procedures were followed.

I tell my staff that there is a process for everything and no matter how daunting/irritating an audit seems, you'll get through it if you maintain your equanimity and objectively respond to each request.

If you have not prepared or retained your Meaningful Use documentation, I recommend you prepare those binders and shared folders now.   You'll be thankful when the auditors arrive.

Building Unity Farm - The Year of Produce

I skipped my Unity Farm post last week due to the events in Boston that required undivided attention.

2012 was the year of animals at Unity Farm since we acquired our herds and flocks from May to August of that year.   2013 will be the year of produce as we create the mushroom farm, orchard, and hoop house.

Last weekend, after the Marathon related events subsided I finished cutting the 220 oak logs needed for the Spring inoculation of 11 types of Shitake and the 72 poplar logs needed for cultivating 6 types of Oyster mushrooms.

Using 85% shade cloth, my wife and I built the 10x30 foot shade house pictured above.   As the logs are inoculated the weekend of May 11-12, we'll stack them in the shade house for a yearlong mycelium run.  Next Spring, when the spawn has grown throughout the logs, we'll place them in the forest for fruiting.

Also, last weekend, we continued orchard preparation by placing erosion control tubes around the perimeter of the recently cleared 2 acres in preparation for grading.   The orchard borders a 100 foot wetland buffer so we do not want sediment running off into the wetland.

We added topsoil and loam through the area to smooth the topography and amend some of the poor quality soil that was used as fill during the original house and barn construction.

We rebuilt rock walls that were scattered due to erosion and forest growth over the past 100 years.  Those rock walls now provide stability to the hillside and will serve as a terrace between the fruit trees and the blueberries.

Next week, we'll install 1000 feet of 8 foot deer fencing around the perimeter including 3 gates that enable travel on the new dirt road we've graded through the orchard.

In two weeks, we'll plant 30 trees, blueberries, raspberries, and orchard grass between the tree rows.

Finally, we'll add drip irrigation to all the new plants.

In early Summer, I'll build a 20x48 foot hoop house for 20 raised beds of vegetables and create a raised platform for bee hives.

By mid-Summer, we'll have completed all the foundational components for produce.  We will have delayed gratification on fruit tree and mushroom harvesting, but the hoop house will provide us a bounty of Fall vegetables and year round lettuce, kale and spinach.

Optimizing Electronic Medication Administration Records

In June, BIDMC goes live with Electronic Medication Records (EMAR) on one ward to be followed
by 3 other wards, ensuring we meet our 10% Meaningful Use Stage 2 target by the reporting period October 1-December 31, 2013.

We built a web-based, mobile friendly EMAR system that includes many visual cues and seamless integration (not interfacing) with all our existing clinical information systems.

In modeling the workflow, we had to chose appropriate hardware devices to support various use cases.    Here's what we decided:

iPhones for mobile viewing of patients, upcoming medication tasks, and dashboards of medications given.

iPads mounted near the Omnicell devices for easy verification of medications to be dispensed.

Wall mounted computers with bar code readers on extension arms near each bed to enable easy scanning of patient wrist bands (bar code enabled positive patient ID), scanning of medications, and entry of confirming passwords.

Computers/Workstations on wheels (COWs/WOWs) as a backup only in the case of failure of wall mounted systems.  In general we've found that clinicians do not like COWs/WOWs because they are awkward to move around and also have to be recharged frequently.   They will only be used as backup systems.

The strategy is summarized in the graphic above.

We'll learn a great deal about the user experience by formally studying how often and when these various devices are used.   It will then inform our rollouts across the hospital.

We've also provided a few different user interface options for nurses including a "shopping cart" view of bar coded verified medications to be administered, a checklist which pre-populates the shopping cart with medications to be verified, and a grid of next doses that can be easily clicked to record administration or a reason for delay.

One of our residents has been assigned to document usage patterns and stakeholder feedback so that we can refine the user interface prior to broad rollout.

At BIDMC we build 25% of our applications and buy 75%.   EMAR is a perfect example of why we build.  How many iPhone/iPad friendly cloud-hosted web-based EMAR systems exist that are built by clinicians for clinicians with refinements to usability made after production experience?   We'll let you know what we learn in June.

Reflections on the Tragedy in Boston

Now that schedules are returning to normal, it's appropriate to review the events of last week and reflect on the lessons learned with the benefit of hindsight.

1.  Risk planning is forever altered

To me, risk is the likelihood of an event multiplied by the impact of that event.

Risk management for BIDMC IT now uses the NIST 800 framework, so areas of risk are formally enumerated, however, it still requires judgement about mitigation strategies.

At 2:50pm on April 15, seven BIDMC IT staff were volunteering in the medical tent/working at the Marathon finish line, a few feet from the explosions.   They were among the first responders assisting the injured.   Their work in a medical community gave them the strength to stay calm but could not have prepared them for the scenes of destruction they witnessed.   All my staff were safe and unharmed, but given their proximity to the bombs, the outcome could have been devastating.

As we think about risk planning in the future, we'll need to consider the events of last week when told something as innocent as "the  majority of the database administration team is going to volunteer at the Marathon"

2.  Secure remote access to all systems is critical to operations.

As we continue to enhance the security of our applications and networks, we're limiting remote access to those with a true need to use systems from off campus.    As the events of last week illustrated, we need to plan for future events which shut down the city for 5 days and require many people to work from home if travel is restricted or a "shelter in place" order is given.

3.  We need to consider restrictions on physical access to the data centers.

The restrictions on travel to and from communities plus restrictions on entering/leaving BIDMC were imposed with an unknown duration.   Our disaster recovery planning needs to include scenarios such as no staff able to enter the data center and no staff able to leave the data center.

4.  We may need to consider novel audit workflows.

We capture every lookup in real time and perform many analytics to ensure patient privacy preferences are respected.

We placed the following message at the top of our intranet for every staff member to see on every page:

"Urgent Reminder for All BIDMC Staff About Patient Privacy
Staff must completely protect patient privacy according to federal HIPAA regulations and BIDMC's own privacy policies. That means:
1. No sharing of ANY patient information through email, Twitter, Facebook, Flickr or other photo sites, any other social media, phone calls or conversations – or any other way.
2. Do not look at, or access by computer, medical records or other protected health information (PHI) or personal information (PI) unless you are authorized to access that information AND you need that information to care for the patient.
3. Send all media calls to the Communications Department or page the Media Relations staff on call.

Violation of these regulations and policies will lead to disciplinary action up to and including termination of employment.

Most importantly, thank you to the overwhelming majority of BIDMC staff who are doing an excellent job of keeping all patient information secure."

Might there be new workflows required in the future such that appropriate individuals are paged/notified within seconds after a lookup occurs?  In an emergency/mass casualty disaster, how can we balance the need for increased security/privacy and appropriate access with real time auditing alerts?

5.  The need for healthcare information exchange in a mass casualty disaster is very clear.

When patients have a choice of caregiver - a patient centered medical home or accountable care organization - a lifetime medical record is likely to be available, supporting safe, quality, efficient care.

The events of last week required patient routing based on acuity, urgency, and availability of resources.   BIDMC, Massachusetts General, Brigham and Womens, and Childrens did a remarkable job treating every patient even with incomplete medical information.   The Massachusetts Healthcare Information Exchange ("the MassHIWay") is currently in production for "pushing" summaries from organization to organization.   Last week's events illustrate the importance of our second phase, now under construction, for secure retrieval of information based on a record locator service and a patient consent registry.    By the second quarter of 2014, we should have the infrastructure in place to support the kind of data exchanges that would have been helpful last week - a first in the country kind of capability.

IT in general experiences more demands than supply.   Last week, we learned firsthand how technology can support a disaster. As we think about all the work on our plates,  our plans going forward must incorporate our recent experiences.

The April HIT Standards Committee

The April HIT Standards Committee focused on refining the work plan for 2013, ensuring that standards work is appropriately divided among SDOs, S&I initiatives, and HITSC committee workgroups.

Doug Fridsma presented ONC's recommended next steps, based on the feedback from the HITSC Workgroup chairs.  

In an hour long briefing call two weeks ago, the HISTC Workgroup chairs evaluated each HIT Policy Committee request for standards and suggested to ONC those standards harmonization activities, hearings, and educational sessions  that would be most helpful.    ONC incorporated all the recommendations of the chairs into its go forward planning.

The entire committee agreed with the plan, which includes agenda for the next several Standards Committee meetings, the scheduling of expert testimony, and a dialog with the HIT Policy Committee to seek clarification about several requests.

Farzad Mostashari then gave introductory remarks describing the budget request for ONC's work which is modestly higher than its 2012 request and has not substantially changed since 2007 despite a doubling of responsibilities.

Jodi Daniel presented an overview of ONC Policy and Planning efforts highlighting advances in testing tools, the HIE RFI, and LTAC/Post Acute Care IT adoption.

Doug then updated the group on the ONC Office of Science & Technology Plan for 2013
including S&I initiatives, implementation guide development, and new tools available to support the process.

Clinical Trials, Clinical Research, and quality measures often require structured data capture from providers and patients.   Evelyn Gallego and Doug Fridsma presented the structured data capture initiative which will require some basic ontologies in order to ensure data elements are comparable across studies and institutions.

Micky Tripathi joined by phone and summarized the HITPC Information Exchange Workgroup comments on the CMS/ONC RFI on Interoperability and Exchange.   His comments about payment policy incentives, infrastructure enablers, and state-level program opportunities was very well received.

Finally, Mary Jo Deering and Kory Mertz updated the committee on HIE Governance efforts including two cooperative agreements - New York eHealth Collaborative and DirectTrust to pilot standards and trust fabric approaches that may be scalable to the entire nation.

A very positive meeting.   Given that HITSC was created by ARRA (legislation), it will not sunset because of an administration change, as happened to HITSP.   I proudly concluded the meeting by noting that our work plans will continue to be filled with opportunities to accelerate interoperability for the next several years.

An IT Perspective on the Bombings in Boston

Many reporters have contacted me today for an IT perspective on the April 15 bombings in Boston.  

Within moments of the event, social media became the preferred mechanism for communication and coordination.   I was on a plane from Los Angeles to Boston at 36,000 feet when the bombs exploded and received real time twitter feeds, streaming video, and email from staff via GoGo WiFi.

As my experience illustrates, the most critical IT responsibility immediately after the event was maintaining robust, reliable, and secure infrastructure.  Given the peaks in traffic flow for communication and social media applications, many systems, such as the cell phone networks, were taxed beyond their design limits.   BIDMC networks, servers, storage, and client devices scaled well and there was no interruption of service.

Here's what my Director of Support Services said about the IT response on Monday afternoon.
 
"The IS Manager on Call was in phone contact with me within 20 minutes of the explosions.  Staff covering the Computer Operations/IS Alerting function did a great job.  Our desktop staff was paged by the BIDMC Command Center seeking media services support for LCD displays/projectors. The Emergency Response folks located the Command Center on the West Campus because of the ED activity (they usually locate it on the East Campus during storms, etc.).   We stood ready to deploy additional equipment but the Command Center was stocked with everything necessary.   We check and maintain Command Center equipment on a monthly basis.

I was in touch with all my managers and staff by 4pm.   There were no open IT issues.

We initiated a fan-out call list just to check on IS staff wellbeing – but also in case we needed them to come into the operations center for any reason.

Aside from the shock and eventual anger we all felt at having this happen in our home town, it was a typical operational day."

We continue to support our hard working doctors, nursing and staff who are treating  21 injured patients of which 7 are considered critical.

I'm sure there will be many lessons learned by the time these events have passed.  I will definitely post my experiences and reflections.

Supporting the Living

My father died a month ago and I flew to Los Angeles this weekend to help my mother during the grieving process.

She's doing very well.

The death of a spouse (or father) can be traumatic to everyone involved.  The tasks that follow the funeral are numerous - wills/trusts are acted upon, accounts are closed/changed, credit cards are cancelled, insurance policies are claimed or revised, IRAs are transferred, and death certificates are circulated to every appropriate public and private organization that needs legal notification.

But there is much more to supporting the living than the financial and legal "to do" list.

The life tasks performed by two people must now be performed by one.

We all depend on friends, family, and life partners to support our activities in life.  This weekend was about empowering my mother to manage my father's tasks.

What are the some of those responsibilities that seem trivial but require specialized knowledge?

The sprinkler system/irrigation controller needs to be managed, ensuring the gardens receive the right amount of water as weather changes.

The security system and smoke alarms/carbon dioxide detectors need battery changes.

Printers need toner and paper.

Internet routers and wireless devices need resetting.

Plumbing, electrical, and painting tasks need to be managed.

Light bulbs need changing (and some ceiling fixtures can be very challenging to access)

Entire digital lives need to be maintained, merged or erased.

Many items throughout the house need to be recycled, removed, or stored.

Cars need to be serviced or sold

This weekend was about supporting the living as the grieving process evolves into planning for the future.

My mother and I took numerous trips to Home Depot, worked on all the maintenance tasks that had accumulated over the past month, and prepared her to be the steward of the house/everything in it.

I brought her an iPad and an AirPrint enabled printer to improve her access to media and communications.    We worked so closely on planning all aspects of her next stage of life that I'll have no problem supporting her via email, texts, and phone calls.

We both miss my father but know that we cannot bring him back.   My mother's resilience and willingness to learn are truly inspiring.    I'll be back to Los Angeles again in a few weeks when I lecture at Pri-Med in Anaheim, but I'm completely confident my mother will thrive in my absence.

Thursday Building Unity Farm - Creating the Mushroom Farm

I recently wrote about the planning for our Shitake and Oyster mushroom farm.

 Last weekend we began to build it.

Using oak that we cleared during the orchard preparation process,  I cut 150 four foot logs and will cut 70 more next weekend.  A local farm hand and I moved them from the orchard to a shaded area under maple trees near the northern border of the farm property.   We created a log storage area between two old stone walls.

Next, I had to design the mushroom inoculation "assembly line".  The process of inoculating logs includes drilling 5/16 x 1.5 inch holes every 4 inches around the entire circumference of the log.   I used 7 inch wheels on 3 foot threaded rods to create a roller system for easy drilling around the entire log.   Once drilled, the log is rolled down the line to the next person who inserts sawdust spawn with a brass inoculator.   Finally, the log is rolled down to the end where melted cheese wax is applied to each hold to seal in the spawn and moisture.  The assembly line itself is created with eight 2x4s and Simpson tie down strapping to support logs up to 100 pounds.  

Once the logs are prepared - we'll do that May 11-12 and May 18-19, they'll be moved to the shade house , a 10x30 foot galvanized frame covered with 80% shade cloth.   Inside the shade house I created eleven 4x4 bases which will hold the 220 logs we plan to inoculate this year (11 different types of Shitake x 20 logs per type).

Over the next few weeks, I'll also add mist irrigation to the shade house to keep the ambient humidity at about 80%.

With advice from Leo Mondragon, an expert mushroom farmer at Forest Harvest  and 60 pounds of mushroom spawn from Field and Forest , we'll have our mushroom farm up and running by Memorial Day, at about the same time our 2 acre orchard is completed.    We'll expect our first harvest next Spring.

A Massachusetts HIE Update

In the next few weeks, BIDMC will begin sending 50,000 patient encounter records per week through the state HIE (the MassHIWay) to our quality measurement service operated by the Massachusetts eHealth Collaborative.    Also in a few weeks, all the daily reportable lab, syndromic surveillance, and immunization data required by Meaningful Use Stage 2 will be sent to the Massachusetts Department of Public Health via the state HIE.

On Monday, the governance body of the state's healthcare IT activities, the Massachusetts HIT Council, met to discuss the next phase of our state HIE work - creating the technology and policy to support community wide "pull" of records with patient consent, not just the pushing of records from place to place that is required by Meaningful Use Stage 2.

There are tricky policy issues to resolve.   Does the substance abuse treatment data sharing regulation 42 CFR Part 2 apply to hospitals and doctors without substance abuse treatment programs?   How will the Massachusetts HIV consent requirement (opt in to view at each episode of care) be implemented electronically?  How will the new HIPAA Omnibus rule requiring restricted flow of self-pay encounters be implemented electronically?  

Here are the slides we used to describe the inputs from our technology, consumer, provider, and legal policy workgroups.

Our next step is to continue our adoption acceleration grant program and build transaction volume.   We expect the pace of adoption to grow exponentially as organizations prepare for Meaningful Use Stage 2 attestation and must exchange transition of care summaries for 10% of their patient visits.

Commencement at Columbia University

I recently spoke at Columbia University to the graduates of their healthcare IT certificate program.    I used these slides.

I started with an overview of my top 10 buzzwords for 2013 describing a strategy for each of them:

Secure and Compliant - BIDMC has a multi-million dollar security enhancement program with 14 work streams

Hosted in the Cloud - BIDMC operates 3 private clouds to deliver web-based clinical applications to thousands of users

Service Oriented Architecture - BIDMC builds its own clinical systems using service oriented architectures and enterprise service bus approaches

Business Intelligence - 200 million observations on 2 million patients are searchable via innovative self service data mining tools

Social Networking - BIDMC uses social networking ideas in its clinical applications and uses commercial social networking sites extensively for marketing

Green - BIDMC's data centers support a 25%  annual increase in computing power and storage without increasing our power usage

Federated and Distributed - BIDMC's merger and acquisition strategy depends up on data sharing among peers rather than centralizing clinical applications into one common system

Patient Centered - BIDMC's patient and family engagement strategy includes Patientsite, OpenNotes, and new mobile friendly tools

Mobile BYOD - BIDMC applications run on iPhones, Android devices and iPads (with appropriate encryption)

Foundational for Healthcare Reform - BIDMC has embraced global captitated risk, with over 65% of patients in risk contracts in 2013.

I also described the leadership characteristics needed to implement all these concepts in large complex organizations:

Guidance - A consistent vision that everyone can understand and support.

Priority Setting - A sense of urgency that sets clear mandates for what to do and importantly want not to do.

Sponsorship - "Air Cover" when a project runs into difficulty.   Communication with the Board, Senior Leadership, and the general organization as needed.

Resources - A commitment to provide staff, operating budget, and capital to ensure project success.

Dispute resolution - Mediation when stakeholders cannot agree how or when to do a project.

Decision making - Active listening and participation when tough decisions need to be made.

Compassion - Empathy for the people involved in change management challenges.

Support - Trust for the managers overseeing work and respect for the plans they produce that balance stress creation and relief.

Responsiveness - Availability via email, phone,  or in person when issues need to be escalated.

Equanimity - Emotional evenness that is highly predictable no matter what happens day to day

The students were a great, energetic and inquisitive group.   I want to thank Columbia for the opportunity to speak with them.

Building Unity Farm - Creating the Orchard

In March, I wrote about our planning for the Unity Farm orchard.

Just as with any IT project, we needed to create a charter (aims, success factors), a Gantt chart, project management, and a team structure to successfully "go live" with our orchard.

Our charter is simple - use 1 acre of our 15 acres for fruit and and nut trees in support of self sufficiency and local fruit production.   Success will be clearing the weeds, vines, and shrubby trees that constitute young forest on the disturbed land below our pasture, which was likely cleared 20 years ago as part of the original grading of the land.   This section of forest is our most challenging to manage and is the area responsible for the total body poison ivy experience I had last Summer.

The project plan involved a comprehensive survey and wetland border analysis (done by GLM Engineering Consultants), a review of the land management plan with the town of Sherborn, an orchard planting plan (done by Tree Specialists), a deer fence design (done by River Valley Fencing), a forestry management company for tree removal (Stumpy's), an irrigation company (Bourque Brothers), and a site preparation/excavation company (will be selected by the end of the week).

With all the plans and approvals in place, we began clearing forest on Monday.   As of today, the majority of the 1 acre is cleared of poplar and the thick underbrush that was choking new growth.    There were 5 oaks, which I saved for mushroom farm Shitake production.   This weekend, I'll cut the 3-6" branches into 220 four foot logs in 22 stacks.   I've ordered 60 pounds of sawdust spawn to inoculate the logs the weekend of May 11-12.

Here are pictures of the orchard area before and after the clearing.

Our next step is to  grind stumps, prepare the land by removing rocks/roots, add topsoil, plant the 30 trees, and spread the orchard grass/meadow seed mix which will prevent erosion and support pollinators.    Our bees arrive later this spring.

By mid-May the entire project will be done and the 8 foot deer fence will be up.   Yes, it will take years before our apples, pecans, chestnuts, and blueberries will be in full production, but the sooner we start, the sooner we'll be harvesting!

The Importance of Giving Your Time

I've written about servant leadership and the special gift of sharing time with others .  (It's hard to believe that my father and I enjoyed that day meandering the mountains of Northern California just 5 years ago)

My wife recently emailed me a New York Times Magazine article entitled "Is Giving the Secret to Getting Ahead?"  and it really resonated with me.

Every day I receive numerous requests from students, colleagues, and community collaborators for meetings, phone calls, and speaking events.

Just as the New York Times article suggests, I do not see these requests for my time as a distraction getting in the way of my job.   I see serving the healthcare IT community and the stakeholders throughout the world as my job.  

It can be fatiguing to serve so many people in so many contexts, but time spent sharing a vision or helping break down a barrier makes a great difference to everyone involved.   The power of ideas communicated with clarity and enthusiasm may have a disproportionately  positive effect when the perfect storm for innovation occurs due to an alignment of people, processes, and possibilities.

I try every day to help and serve those around me, without an expectation that my energy and time will have a specific payback.    

However, enough odd coincidences happen to me that I know my time is having an impact.  Last week I was having breakfast at the Cambridge Hyatt with a few Canadian Healthcare Executives and a person I have never met approached our table and said  "Thank you for writing about Unity Farm and my condolences on the death of your father."

When random strangers are affected by the things you do, the thoughts you think, or the words you write, you know that your time is well spent.

My advice - when a young person ask for mentoring, a colleague asks for career advice, or a community contact asks you to speak to a group of concerned stakeholders, say yes.   Giving your time is your best opportunity to make the world a better place.

Printing From an iPhone/iPad

I was recently asked how to print directly from an iPhone or iPad.

Surprisingly, it is not sufficient to use a printer connected to an Airport Express or Airport Extreme wireless network.

To print directly from an iPad / iPhone you need an AirPrint compatible printer or another device to act as a print server.

Here's a list of AirPrint compatible printers  

If you want to use an existing printer, it is possible but requires third party products.

A Mac computer can function as a print server for iPhones/iPads if you buy Printopia or HandyPrint 

The Mac must be "on" but may be asleep for them to work.

You can also buy this standalone print server.

I recently AirPrint enabled my mother's household using an HP 1606dn Laser Printer which is AirPrint enabled.    It is very simple to use  and unlike software-based solutions, it is operating system version neutral.