Cool Technology of the Week
As readers of my blog know, my wife was diagnosed with Breast Cancer in December 2011 and is now in full remission.
She picked up the presence of the tumor (a very fast growing aggressive type) by self examination.
Recently, I heard about an electronic tool called SureTouch which records breast examination via an array of pressure transducers, producing a digital signal as the sensor is pressed and moved over the tissue. The data is then presented in a useful visualization.
The result is objective, repeatable, and painless.
Although this does not replace standard mammography screening exams, it is a very interesting electronic approach to performing and documenting the clinical breast exam.
Objective digital data gathered as part of the physical exam. That's cool!
Building Unity Farm - Hay and Other Foods
Over the past few months, we've become experts, purchasing five tons of fine, grassy, second cut hay from Western New York and a ton of legume rich hay. It's stacked neatly in the hayloft of our barn, pictured above.
Our first experience with hay was buying a small amount of first cut, harvested in June, which tended to have less green and more stems than our alpaca would eat. We had a lot of waste and our manure management pile filled fast because our barn sweepings included so much uneaten hay.
In August we found green, sweet, tender second cut hay - a mixture of timothy and orchard grass. The alpaca eat it out of our hands. It's high in protein and very low in waste. At this point, the alpaca eat their feeders clean. We saved a dozen bales of first cut hay to use as bedding material and donated the left over first cut to horse rescue.
We also purchased second cut orchard grass hay mixed with legumes (clover and alfalfa) for use in winter when the alpacas need a bit more fattening food.
Here's a great guide to evaluating hay quality
Now that we've experienced the difference between course, stem filled hay and fine, grassy hay, we'll never make the mistake of buying poor quality hay again.
We place the hay in feeders that minimize waste and protect it from the rain
As a special treat, we feed our alpacas and llama a small serving of grain pellets - Poulin Grain Milk and Cria. They have such an affinity for this food that we need to lock our storage bins.
We use Poulin and Blue Seal grain products to feed our chickens and guinea fowl. The guineas receive a high protein game bird mix as a supplement to their daily foraging for ticks and other insects.
We store all these food products in cool, dry, dark places. Our hayloft has a ventilator fan to minimize overheating and mold formation. Our grains are stored in waterproof metal trash cans, sealed with metal bungee cords to prevent our livestock and forest creatures from feeding on them.
After a few months, we've figured out what to feed, how much to feed, and how to feed.
The winter will be a great learning experience for us, since we've not had the opportunity to keep our animals fed and warm in blustery New England weather.
When you're running a farm, the learning never stops. And whoever thought rolling in the hay was a good idea has never had to do laundry after hauling 5 tons of hay into the loft!
Open Notes
An important article was published in the Annals of Internal Medicine yesterday about the OpenNotes study, Inviting Patients to Read Their Doctors' Notes: A Quasi-experimental Study and a Look Ahead
There are also two accompanying editorials:
A Patient's View of OpenNotes
Pushing the Envelope of Electronic Patient Portals to Engage Patients in Their Care
Here's a BIDMC video about it.
We're all enthusiastic about expanding this access to all BIDMC patients. Here's the press release:
BOSTON – Patients with access to notes written by their doctors feel more in control of their care and report a better understanding of their medical issues, improved recall of their care plan and being more likely to take their medications as prescribed, a Beth Israel Deaconess Medical Center-led study has found.
Doctors participating in the OpenNotes trial at BIDMC, Geisinger Health System in Danville, PA and Harborview Medical Center in Seattle reported that most of their fears about an additional time burden and offending or worrying patients did not materialize, and many reported enhanced trust, transparency, and communication with their patients.
The findings were published in the Oct. 2 issue of the Annals of Internal Medicine.
“Patients are enthusiastic about open access to their primary care doctors’ notes. More than 85 percent read them, and 99 percent of those completing surveys recommended that this transparency continue,” says Tom Delbanco, MD, co-first author, a primary care doctor at BIDMC and the Koplow-Tullis Professor of General Medicine and Primary Care at Harvard Medical School. “Open notes may both engage patients far more actively in their care and enhance safety when the patient reviews their records with a second set of eyes.”
“Perhaps most important clinically, a remarkable number of patients reported becoming more likely to take medications as prescribed,” adds Jan Walker, RN, MBA, co-first author and a Principal Associate in Medicine in the Division of General Medicine and Primary Care at BIDMC and Harvard Medical School. “And in contrast to the fears of many doctors, few patients reported being confused, worried or offended by what they read.”
The findings reflect the views of 105 primary care physicians and 13,564 of their patients who had at least one note available during a year-long voluntary program that provided patients at an urban academic medical center, a predominantly rural network of physicians, and an urban safety net hospital with electronic links to their doctors’ notes.
Of 5,391 patients who opened at least one note and returned surveys, between 77 and 87 percent reported open notes made them feel more in control of their care, with 60 to 78 percent reporting increased adherence to medications. Only 1 to 8 percent of patients reported worry, confusion or offense, three out of five felt they should be able to add comments to their doctors’ notes, and 86 percent agreed that availability of notes would influence their choice of providers in the future.
Among doctors, a maximum of 5 percent reported longer visits, and no more than 8 percent said they spent extra time addressing patients’ questions outside of visits. A maximum of 21 percent reported taking more time to write notes, while between 3 and 36 percent reported changing documentation content.
No doctor elected to stop providing access to notes after the experimental period ended.
“The benefits were achieved with far less impact on the work life of doctors and their staffs than anticipated,” says Delbanco. “While a sizeable minority reported changing the way their notes addressed substance abuse, mental health issues, malignancies and obesity, a smaller minority spent more time preparing their notes, and some commented that they were improved.”
“As one doctor noted: ‘My fears? Longer notes, more questions and messages from patients … In reality, it was not a big deal.’”
Walker suggests that so few patients were worried, confused or offended by the note because “fear or uncertainty of what’s in a doctor’s ‘black box’ may engender far more anxiety than what is actually written, and patients who are especially likely to react negatively to notes may self-select to not read them.”
“We anticipate that some patients may be disturbed in the short term by reading their notes and doctors will need to work with patients to prevent such harms, ideally by talking frankly with them or agreeing proactively that some things are at times best left unread.”
“When this study began, it was a fascinating idea in theory,” says Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, the primary funder of the study. “Now it’s tested and proven. The evidence is in: Patients support, use, and benefit from open medical notes. These results are exciting – and hold tremendous promise for transforming patient care.”
Security Assessment Kickoff
"Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1), including addressing the encryption/security of data at rest in accordance with requirements under 45 CFR 164.312 (a)(2)(iv) and 45 CFR 164.306(d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process."
Yesterday, we kicked off the enterprise security audit at BIDMC.
Every audit requires a framework. For security, framework choices include NIST, ISO 27002, HITRUST, PCI and COBIT. We've elected to use a NIST approach.
NIST is the National Institute of Standards and Technology, a component of the Department of Commerce (formerly National Bureau of Standards). One of the NIST subject areas is Information Technology - the "800" series.
NIST publishes hundreds of Bulletins, Standards and Guidelines related to Information Technology. Topics range from "What about Cloud Security" to "Smart Grid Interoperability". Relevant to security audits is the NIST 800-30 "Guide for Conducting Risk Assessments".
Why did we choose NIST?
NIST is mandated within the Federal Government. It is gradually being extended to contractors, including Medicare providers. Recently, several NIH grants I've reviewed have included the need for a NIST-based risk assessment. The Center for Medicare and Medicaid Services (CMS) increasingly refers to NIST assessments in their compliance efforts.
All security frameworks, including NIST 800, share common themes. For example, risk is defined in terms of threat, vulnerability, likelihood of occurrence, and impact.
"Threat" could be malware, a natural disaster, disgruntled employee or a myriad of other things
"Vulnerability" is a weakness that makes a system susceptible to the threat
"Likelihood" is the probability the threat and vulnerability will come together
"Impact" is the consequence to the organization of an occurrence
For example,
- Threat = thief
- Vulnerability = laptop visible on front seat of a car parked in a public lot
- Likelihood of Occurrence = high,
- Impact = significant if the laptop contains ePHI
NIST 800 also provides recommended controls for mitigating risk. NIST 800-53 describes 194 security controls that roll up into 18 families. (see the above graphic)
I'll report back on the results of our audit and lessons learned when it is completed in November.
Solving the Provider Directory Standards Gap
In 2012, the HIT Standards Committee evaluated the provider directory standards suggested for the Nationwide Health Information Network and concluded that none of the current implementation guides was sufficiently mature and adopted to mandate as a certification criteria for Meaningful Use Stage 2.
This means that vendors and HIEs will continue to pilot various approaches to provider directories until Stage 3.
In Massachusetts, we chose a simple web-friendly implementation that goes live across the Commonwealth in two weeks.
We created a SOAP 1.2-based API that enables any trusted partner to query the state-wide provider directory via HTTPS per this specification.
The provider search web service provides following parameters to search a provider.
First Name
Last Name
Middle Name
Specialty
Type
Gender
Street
City
State
Zip
Phone
Language
Id
but requires one of the elements in the list below in order to perform a successful search.
First Name
Last Name
ZIP
Specialty
Id
Street
Phone
With a simple SOAP query response approach and a WSDL, we have everything we need - no complicated implementation guide or non-standard use of LDAP/DNS required.
If this works well in production, it could be a model for the country.
How will we load the provider directory?
Each organization will be registered via an identity proofing process that ensures we have a fabric of trusted entities which have signed participant agreements.
As part of the registration process, the organizations will pre-load their provider data into the state directory using this spreadsheet.
Ongoing updates (adds/deletes/changes) can be sent via the same template.
Once in production, I'm sure we will refine our approach, but creating a simple SOAP-based query/response and a template for loading/updating data in batch seems to solve the Provider Directory standards gap nicely.
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