The Golden Spike Part 1
Tomorrow at 11am, Massachusetts Governor Deval Patrick will drive the Golden Spike into the Statewide Healthcare Information Exchange, the MassHIway, by sending a record between an Eastern Massachusetts hospital and a Western Massachusetts hospital.
We'll then commence transactions that demonstrate:
ACO to ACO transmission - two large healthcare systems breaking down silos and exchanging lifetime summary records for care coordination
Provider to Registry transmission - EHR data sent to a third party for computation of quality and performance metrics
Provider to Plan transmission - EHR encounter data sent from a provider organizations to a payer for care management
Pediatric Care Coordination - EHR transmission between a community provider and a tertiary referral hospital
Suburban to Urban Specialist referral - A PCP at a community site sends referral data to an urban specialist, electronically closing the loop between the two
These transactions will flow over the production state HIE and the production EHRs of
Partners Healthcare
Baystate Health
Beth Israel Deaconess Medical Center
Mass eHealth Collaborative
Tufts Medical Center
Network Health
Childrens Hospital Boston
Atrius Health
Vanguard Health Systems New England
Vendors involved include Orion, Cerner, Siemens, Epic, Meditech and eClinicalWorks as well as the home built systems Partners' LMR and BIDMC's webOMR.
Tomorrow I'll let you know how it went.
If all goes well, no patient will again be told that the only information highway in Massachusetts is the turnpike!
Cool Technology of the Week
Last week I joined several industry experts to discuss the future of Big Data, Analytics, and Healthcare IT in general with a moderator from Intel.
Here's a preview clip on You Tube.
If you'd like to register to view the entire discussion, which will be broadcast on October 23, just click here.
What else is cool this week?
.
As many of my readers know, I cycle between meetings on a foldable bike.
The only challenge is that it's pricy and prone to theft.
What if you could buy an ecofriendly "disposable" bicycle for under $10?
Sound impossible?
This cardboard bicycle is an engineering miracle. Now that functional prototypes have demonstrated the possibilities, I look forward to seeing such low cost, recyclable, and robust vehicles on the road. At $10, it's unlikely they'll be stolen. Maybe cities could make racks of them available for generalized use at no charge?
That's cool!
Building Unity Farm - the Economics
The economics of agriculture are challenging.
At Unity Farm, what can we expect to earn for our efforts?
Alpaca - Alpaca fiber is the softest animal fiber available. It's in high demand by fiber artists and weavers. A spring alpaca shearing may bring $200 for the fiber from each animal. I've calculated our cost of feeding and healthcare for the animals. It's about $200 per year - breakeven at best. Alpaca cost anywhere from $500 to $50,000 per animal, although most are in the $1000-$2000 range. Breeding alpaca might be more profitable that fiber harvesting, but we are not planning an alpaca breeding program at this time. There have been various tax deduction schemes associated with alpaca farms, but we have no interest in those. About the most we'll do is investigate options for property tax reduction given that we now have a working agricultural property.
Chickens - Chickens raised for meat live 14 weeks. Chickens raised for eggs live 2 to 3 years before they are "retired". As vegans (my wife is a vegetarian and eats eggs), we do not plan to slaughter our chickens. Each has a name, a personality, and unique place in the ecosystem of our barnyard family. Our chickens will live 10-14 YEARS, not weeks. During the peak of egg laying, we'll get an egg from each chicken every 25 hours (such as the brightly colored eggs pictured above laid by our Ameraucanas). We can sell a dozen eggs for $3.50 and given the 8 month egg laying season (chickens do not lay during the dark of winter or when they are molting), we can earn about $70 per chicken per year. The cost of raising a chicken for us is about $50/year. The economics might work if the chickens lived 2-3 years, but with a 10 year lifespan and 5-6 egg laying years, they are likely a loss.
Dogs - Great Pyrenees are wonderful livestock guardian dogs. They cost between $500-$2000 with a mean of about $800. However, we do not plan to run a dog breeding program.
Thus, for the animals of Unity Farm, raised in a free range/long life environment, the likely income is related to tax credits or property tax reduction.
Fruits, vegetables, and flowers are another potential income source. This fall we're planting an apple orchard and 400 high bush blueberry plants.
Apples will not be ready for 5-10 years and although we could charge up to $25 per peck, profitability is very dependent on weather conditions and competition since there are many apple sellers in Massachusetts
Blueberries can fetch $2.50 a pound at a U-pick. We might be able to generate $10,000 per year for 400 plants after 10 years, but that will require significant up front capital investment and labor.
We're also creating a 30x72 foot hoophouse - hoophouses, high tunnels and cold frames will be featured in another post about extending the growing season for our vegetables. What kind of prices can you realize for such crops (per Growing for Market by Lynn Byczynski)?
Arugula $1.31 per square foot
Cilantro $.95
Cucumbers $1.34
Tomatoes $3.55
Leeks $1.10
Given the labor and initial capital for the raised beds/hoophouse, you can see that growing 2000 square feet of vegetables will not generate much.
So, what are the economics of running a small farm?
Since I began my morning and evening tasks on the farm in April 2012, I've lost 10 pounds, but gained upper body strength. My gray hair has disappeared. My optimism and equanimity are peaking higher than every before. I'm guessing the benefits from healthcare cost avoidance (mental and physical) could be substantial over a decade.
The seasonal expectations of pressing your own cider, picking crisp vegetables for every meal (lettuces and kale grow in the hoophouse in winter), and waking up every morning knowing that 50 animals depend on you for their survival - priceless.
Farming at small scale is truly a labor of love. If you believe in losing a dollar on every tomato, but making it up with joy, you'll understand why we created Unity Farm.
Why Meaningful Use Stage 2 is So Important
Last week my mother fell and broke her hip.
She was taken to a very good local hospital and received excellent orthopedic care.
The hospital used certified EHR technology and did their best to reconcile her medications.
They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).
Although are her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard). There was no way to seamlessly exchange and synthesize all her data from various sites of care.
Meaningful Use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation. OpenNotes is not yet universally adopted across the country.
When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.
After receiving medication, she was not able to accurately reconcile her own medications.
My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list. The best he could do in addition to his notes was to bring in every medication bottle he could find at home.
By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.
Her mental status on 22 medications was such that she was not oriented to person, place, or situation.
To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status. Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans.
My role as her son and her healthcare advocate was to assemble the care team and explain that she was TWO medications at home, not TWENTY-TWO. How did this happen? In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications. In an effort to be complete, the hospital placed her on all of them in standing doses. Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking. She ceased to be able to participate in physical therapy because of difficulty understanding the training.
Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.
The next morning, my mother asked why she felt so foggy. She had no recollection of the previous two days or any of the visitors who spoke with her. She regained her involvement with the rehabilitation process and became a partner in her care planning.
Under stage 2 of Meaningful Use, patient and family view/access/download/transmit to her various data sources will be required. Data exchange at transitions of care will be required. Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.
As I wrote yesterday, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory. We need to walk before we can run. Clinicians throughout the country are rapidly adopting more advanced EHRs which support the workflow needed to prevent the problems my mother experienced. Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support. These changes are occurring at fast pace but an appropriate pace. The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe Meaningful Use can or should be done faster than the current timelines.
To those who say that the industry should have solved all these issues years ago, I respond that 9 women cannot grow a baby in a month. It takes the focused energy of 1 woman for 9 months.
I look forward to Meaningful Use Stage 2 and 3. My own family experiences illustrates why the path we're on is so appropriate and so essential.
She was taken to a very good local hospital and received excellent orthopedic care.
The hospital used certified EHR technology and did their best to reconcile her medications.
They used data sources such as historical prescribing records, previous hospitalization records, and calls to a few of her physicians who are not affiliated with the hospital (her primary caregiver is in downtown Los Angeles where she worked, not near the South Bay where she lives).
Although are her physicians use electronic health records, the state of California does not yet have a widely deployed healthcare information exchange (although they are trying hard). There was no way to seamlessly exchange and synthesize all her data from various sites of care.
Meaningful Use Stage 1 did not mandate view/access/download/transmit data for patient/family mediated data reconciliation. OpenNotes is not yet universally adopted across the country.
When she arrived at the ED with a right hip femoral neck fracture, she was in a great deal of pain and was given morphine IV.
After receiving medication, she was not able to accurately reconcile her own medications.
My father had handwritten notes, but did not have the benefit of electronically accessing her records and had limited knowledge of her current medication list. The best he could do in addition to his notes was to bring in every medication bottle he could find at home.
By the time I arrived at the hospital she had been placed on 22 medications because there was history that she had been on them at some time.
Her mental status on 22 medications was such that she was not oriented to person, place, or situation.
To give family members access to her hospitalization records, she needed to sign a consent. This was challenging because "meaningful consent" requires a full understanding of what she was signing at the same time she had an altered mental status. Once she signed, I reviewed her problem list, medication list, operative notes, history/physical, and care plans.
My role as her son and her healthcare advocate was to assemble the care team and explain that she was TWO medications at home, not TWENTY-TWO. How did this happen? In an effort to address various symptoms because of last year's gall bladder surgery and recurring headaches, various doctors had tried short "as needed" courses of various medications. In an effort to be complete, the hospital placed her on all of them in standing doses. Complying with this regimen caused mental status changes and further made it impossible for her to offer input as to what she should be taking. She ceased to be able to participate in physical therapy because of difficulty understanding the training.
Once each member of the care team understood the poor quality of the data they had reconciled and the lack of coordination among caregivers, they agreed with me to discontinue everything except Tylenol and an anti-hypertensive.
The next morning, my mother asked why she felt so foggy. She had no recollection of the previous two days or any of the visitors who spoke with her. She regained her involvement with the rehabilitation process and became a partner in her care planning.
Under stage 2 of Meaningful Use, patient and family view/access/download/transmit to her various data sources will be required. Data exchange at transitions of care will be required. Decision support that would likely have offered best practices for medication management in the elderly would have prevented the cocktail that altered her mental status.
As I wrote yesterday, while reflecting on the need for optimism, the country is on a great healthcare IT trajectory. We need to walk before we can run. Clinicians throughout the country are rapidly adopting more advanced EHRs which support the workflow needed to prevent the problems my mother experienced. Stage 2 is a natural evolutionary step that requires data sharing, patient/family engagement, and decision support. These changes are occurring at fast pace but an appropriate pace. The technology, policy, and education/training needed to safely implement them is straining all healthcare stakeholders, so I do not believe Meaningful Use can or should be done faster than the current timelines.
To those who say that the industry should have solved all these issues years ago, I respond that 9 women cannot grow a baby in a month. It takes the focused energy of 1 woman for 9 months.
I look forward to Meaningful Use Stage 2 and 3. My own family experiences illustrates why the path we're on is so appropriate and so essential.
A Time for Boundless Energy and Optimism
On the personal side, my wife had cancer. Together we moved two households, relocated her studio, and closed her gallery. This week my mother broke her hip in Los Angeles and I'm writing from her hospital room as we finalize her discharge and home care plan before I fly back to Boston.
On the business side, the IT community around me has worked hard on Meaningful Use Stage 2, the Massachusetts State Health Information Exchange, improvements in data security, groundbreaking new applications, and complex projects like ICD10 with enormous scope.
We did all this with boundless energy and optimism, knowing that every day we're creating a foundation that will improve the future for our country, communities, and families.
My personal life has never been better - Kathy's cancer is in remission, our farm is thriving, and our daughter is maturing into a fine young woman at Tufts University.
My business life has never been better - Meaningful Use Stage 2 provides new rigorous standards for content/vocabulary/transport at a time when EHR use has doubled since 2008, the State HIE goes live in one week, and BIDMC was voted the number #1 IT organization the country.
It's clear that many have discounted the amazing accomplishments that we've all made, overcoming technology and political barriers with questions such as "how can we?" and "why not?" rather than "why is it taking so long?" They would rather pursue their own goals - be they election year politics, academic recognition, or readership traffic on a website.
As many have seen, this letter from the Ways and Means Committee makes comments about standards that clearly have no other purpose than election year politics. These House members are very smart people and I have great respect for their staff. I'm happy to walk them through the Standards and Certification Regulations (MU stage 1 and stage 2) so they understand that the majority of their letter is simply not true - it ignores the work of hundreds of people over thousands of hours to close the standards gaps via open, transparent, and bipartisan harmonization in both the Bush and Obama administrations.
I spoke with the authors of the Wall Street Journal article "A Major Glitch for Digitized Health-Care Records" and discovered that their issue was not interoperability standards but a lack of usability in non-standard EHR user interface design. When a clinician goes from Epic to Cerner to Meditech and tries to perform the same task (e-prescribing, managing a problem list, or looking up a lab), the learning curve can be steep. The authors and I reviewed the Consolidated CDA specification that is required by Meaningful Use Stage 2 and they are completely satisfied that interoperability standards gaps are no longer a rate limiting step.
Many reporters have asked me about the New York Times article "Medicare Bills Rise as Records Turn Electronic"
I've said three things:
1. In the past, paper documentation lacked details to accurately document acuity. As we make the multi-year journey from simple EHRs that support electronic billing to complex EHRs that include decision support, interoperability, and patient/family engagement, there will be an interim period when increasing detail in documentation results in higher acuity, which results in increased reimbursement.
2. These trends long pre-date the health IT incentive program. Meaningful Use re-orients the healthcare IT industry away EHRs supporting billing to EHRs which focus on prevention, care coordination, population health management. It is these functionalities that will both enable, and be incentivized by the shift in payment policies towards value, and away from volume. In a healthcare reform world, clinicians will be paid for wellness not sickness and the EHR will help them increase efficiency, safety, and quality, which will be required for reimbursement.
3. As quoted in the Center for Public Integrity's Cracking the Code series, Donald Berwick said he believes that only a small portion of the upswing in coding is the result of fraud. In most cases, he said, the hospitals have learned “how to play the game,” and are targeting the vulnerabilities of the Medicare payment system. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get”.
As the cartoon above illustrates, our current society tries to find fault in everyone and everything. Social media and our increased connectedness has turned criticism into a spectator sport.
If everyone could align their efforts into an agenda of optimism, we'd all be better for it.
I may be asking too much to expect positive energy and optimism from Congress, the Wall Street Journal, and the New York Times, but as 2012 has proven to me, anything is possible if you try hard enough.
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