When I was 13 years old, the Altair 8800 appeared on the cover of Popular Electronics. By 16, I was building enough hardware and software that I achieved the Malcolm Gladwell 10,000 hours of competency by age 18. By 19, I founded a company that produced tax calculation software for the Kaypro, Osborne, and new IBM PC. Every week in the Silicon Valley of the early 1980's brought a new startup into the nascent desktop computer industry.
To me, we're in a similar era - a perfect storm for innovation fueled by several factors. Young entrepreneurs are identifying problems to be rapidly solved by evolving technologies in an economy where existing "old school" businesses are offering few opportunities.
This morning, I lectured to an entire classroom of MIT Sloan school entrepreneurs . Today the Boston Globe published articles about the Harvard Innovation Lab and the Mayor's efforts to connect entrepreneurial students with mentors.
Tonight I'll introduce a Harvard Medical School entrepreneurial team at the Boston TechStars event .
This pace of innovation reminds of that time 30 years ago when Sand Hill Road was just beginning its evolution to the hotbed of venture investing it is today.
Who are these new entrepreneurs and what kind of work are they doing? Tonight I'll be introducing Lissy Hu and Gretchen Fuller.
Lissy Hu is passionate about helping patients find the right care. Her clinical experiences at leading Boston and New York hospitals have shown her first-hand the frustrations her patients and their families face when finding after-care. Lissy previously worked on a Medicare demonstration project involving transitions in care for 3,000 medically-complex patients. She is currently on-leave from the Harvard Medical School and Harvard Business School joint-degree program. Lissy hopes to leverage her clinical and business insights to engage in social entrepreneurship and tackle healthcare’s most challenging problems. Lissy graduated from Columbia University Phi Beta Kappa, Summa Cum Laude, and with Honors in her major.
Gretchen Fuller is committed to improving healthcare quality and communication amongst providers and patients. At Harvard Medical School, she co-directed a student group (Improvehealthcare.org) dedicated to improving medical school education on healthcare policy: this organization was responsible for creating course material that is now part of a mandatory Health Policy course. She spent the last year spearheading three healthcare quality investigations at 5 hospitals in Buenos Aires, Argentina, including projects on problematic patient handoffs, barriers to the use of surgical checklists, and medical school curricula on patient safety. Gretchen graduated Cum Laude in Biology at Harvard University, where she also captained the Division I Field Hockey team.
They will be presenting CarePort, a software startup improving patient transitions from hospitals to post-acute care providers though an easy-to-use online booking engine.
As I know well from my mother's recent hip fracture, many patients require additional care after a hospital stay. The current process of discharging patients to post-hospital care providers is complex, confusing, and cumbersome. Careport connects patients, hospitals, and care facilities directly. Patients and their families, along with hospitals, can search for care facilities that meet their clinical needs and book reservations immediately. Careport also tracks patient care in the hospital and post-acute care settings and communicates critical clinical information back to primary caregivers, thereby ensuring effective care coordination. Careport identifies variables driving medical complications, readmissions, and patient satisfaction.
I am convinced that Meaningful Use Stage 2, with its focus on increased interoperability, and Meaningful Use Stage 3, with its proposed enhancements to patient and family engagement, will accelerate the demand for products like Careport. Modular certification will make it much easier for young entrepreneurs to make their products part of the physician and hospital software set used for attestation.
It's an exciting time to watch the creativity of the next generation fixing healthcare. With Techstars, Rock Health, Healthbox and other incubators/accelerators combined with Datapaloozas and innovation competitions, I'm convinced the breakthroughs we need in healthcare process improvement will be invented by the twenty-somethings and not mid career professionals in established companies.
So immerse yourself in advising and mentoring these people. Tonight, I will be.
The November HIT Standards Committee Meeting
The 42nd meeting of the HIT Standards Committee began with an inspirational introduction from Farzad Mostashari. He told us that the HIT Standards Committee members should keep their "eyes on the prize and feet on the ground". We should be aspirational in reviewing the Meaningful Use Stage 3 criteria, identifying standards recommendations for 2016 which are likely, which are possible with focus, and which are unrealistic. We should not be intimated by all the ideas in the Meaningful Use Stage 3 request for comment, but realize that unless all ideas are considered, we'll regret not thinking broadly about important safety, quality, and efficiency improvements. As the request for comments process progresses, the doable priorities will emerge. The public release of the Stage 3 request for comment will occur later this week, with comments due in January.
Michelle Nelson, ONC Meaningful Use Workgroup Lead, presented the Meaningful Use Stage 3 recommendations, assisted by Doug Fridsma and Jodi Daniel. We reviewed the Stage 3 recommendations line by line, noting that the Policy Committee had included some data exchanges that the Standards Committee suggested were unlikely to occur by 2016. Although most of the Standards Committee advice was incorporated, the Policy Committee felt some goals were so important they were worth pushing. Overall, the Standards Committee commented that the Meaningful Use Stage 3 recommendations need to be grouped into common policy goals, be less workflow prescriptive and more outcomes oriented, take into account the burden of implementation, and focus on a few significant improvements to EHRs that would accelerate several goals. For example, if all EHRs became QueryHealth compliant then clinical trials, quality measures, and population health reporting would all be simplified. As a next step, ONC will reorganize the Stage 3 material into policy clusters and themes for assignment to the Standards Committee for detailed standards recommendations.
Next, Dixie Baker presented a Privacy and Security Workgroup Update regarding security and privacy criteria for modular EHR certification. Their concern is that without security and privacy guidelines, we could end up with a module that weakens protections and data integrity of the enterprise. Dixie suggested several paths forward and the Committee decided that Modular EHRs should be required to demonstrate compliance with the Meaningful Use security criteria by either including features within the module or by making calls (standards-based or non-standards based) to other applications which provide the needed security.
Doug Fridsma provided an update on S&I Framework projects and focused on the Automate Blue Button initiative to support patient "subscription" to their healthcare data or automated requests for delivery of their data.
Kate Goodrich from CMS provided an overview of efforts to "re-boot" Clinical Quality Measures by
*Eliminating abstracting and skip methods that based on paper
*Using new measures that are EHR-based, not old measures that are retooled to work with EHRs
*Reducing complex exclusionary criteria in numerators and denominators
*Consolidating measures across various programs - ACO, PQRS, CMS Core etc.
We then heard three presentations that are part of efforts to simplify future stages of Meaningful Use by providing national infrastructure.
Ivor D'Souza from the National Library of Medicine presented the Value Set Authority Center , which is now open for business. This valuable resource provides downloadable/searchable vocabularies and code sets that support Meaningful Use Stage 2.
Christopher Chute from Mayo Clinic presented Common Terminology Services 2 (CTS2) which provide an easy way to exchange code sets in batch from sources such as the Value Set Authority Center. I've posted previously about CTS2.
Michael Fitzmaurice presented the United States Health Information Knowledgebase. It includes access to Chris Chute's Value Set Authority Center Common Terminology Services application. I've posted previously about USHIK.
Lastly, we heard from Carol Bean about the Meaningful Use Stage 2 Testing and Certification details. We look forward to piloting the scripts before they are placed into production.
An important meeting that set the stage for deliberations on Stage 3. I look forward to simplifying the Stage 3 recommendations into common themes that reduce the burden on implementers.
Michelle Nelson, ONC Meaningful Use Workgroup Lead, presented the Meaningful Use Stage 3 recommendations, assisted by Doug Fridsma and Jodi Daniel. We reviewed the Stage 3 recommendations line by line, noting that the Policy Committee had included some data exchanges that the Standards Committee suggested were unlikely to occur by 2016. Although most of the Standards Committee advice was incorporated, the Policy Committee felt some goals were so important they were worth pushing. Overall, the Standards Committee commented that the Meaningful Use Stage 3 recommendations need to be grouped into common policy goals, be less workflow prescriptive and more outcomes oriented, take into account the burden of implementation, and focus on a few significant improvements to EHRs that would accelerate several goals. For example, if all EHRs became QueryHealth compliant then clinical trials, quality measures, and population health reporting would all be simplified. As a next step, ONC will reorganize the Stage 3 material into policy clusters and themes for assignment to the Standards Committee for detailed standards recommendations.
Next, Dixie Baker presented a Privacy and Security Workgroup Update regarding security and privacy criteria for modular EHR certification. Their concern is that without security and privacy guidelines, we could end up with a module that weakens protections and data integrity of the enterprise. Dixie suggested several paths forward and the Committee decided that Modular EHRs should be required to demonstrate compliance with the Meaningful Use security criteria by either including features within the module or by making calls (standards-based or non-standards based) to other applications which provide the needed security.
Doug Fridsma provided an update on S&I Framework projects and focused on the Automate Blue Button initiative to support patient "subscription" to their healthcare data or automated requests for delivery of their data.
Kate Goodrich from CMS provided an overview of efforts to "re-boot" Clinical Quality Measures by
*Eliminating abstracting and skip methods that based on paper
*Using new measures that are EHR-based, not old measures that are retooled to work with EHRs
*Reducing complex exclusionary criteria in numerators and denominators
*Consolidating measures across various programs - ACO, PQRS, CMS Core etc.
We then heard three presentations that are part of efforts to simplify future stages of Meaningful Use by providing national infrastructure.
Ivor D'Souza from the National Library of Medicine presented the Value Set Authority Center , which is now open for business. This valuable resource provides downloadable/searchable vocabularies and code sets that support Meaningful Use Stage 2.
Christopher Chute from Mayo Clinic presented Common Terminology Services 2 (CTS2) which provide an easy way to exchange code sets in batch from sources such as the Value Set Authority Center. I've posted previously about CTS2.
Michael Fitzmaurice presented the United States Health Information Knowledgebase. It includes access to Chris Chute's Value Set Authority Center Common Terminology Services application. I've posted previously about USHIK.
Lastly, we heard from Carol Bean about the Meaningful Use Stage 2 Testing and Certification details. We look forward to piloting the scripts before they are placed into production.
An important meeting that set the stage for deliberations on Stage 3. I look forward to simplifying the Stage 3 recommendations into common themes that reduce the burden on implementers.
Protect, Protect, Protect. Now Share
Later this week, I'm joining a healthsystemCIO.com webinar about security and health information exchange.
A theme I discuss frequently in my keynotes and lectures is the current regulatory challenge which suggests we should engage patients/families, share data for care coordination in accountable care organizations, and use registries to analyze population health/public health all while keeping the data security and respecting patient privacy preferences. It's a tall order.
As I've posted previously, BIDMC hired Deloitte to perform a security assessment of our policies and technologies. Going through the assessment has given me a great opportunity to review the security standard practices in the healthcare industry and the best practices across all industries.
We've reviewed emerging techniques in Data Loss Prevention (DLP), Governance/Risk/Compliance (GRC) tools, Enterprise audit log analysis tools, Learning Management Systems, and Network Access Control.
BIDMC has implemented or is implementing most of these.
At the same time, we're passionate about healthcare information exchange technologies for provider/provider summaries and patient/provider communications (portals, automated blue button, and state hie connections to patients).
Here are the slides I'll use in the webinar, illustrating that it possible to secure the enterprise and at the same time use Direct-enabled, certificate protected, health information exchange with patients, providers, and payers.
The most secure library in the world would not check out any books - it would be a secure but useless library. We must protect privacy and at the some time share information. It is possible to achieve a balance that does both.
I look forward to the webinar.
A theme I discuss frequently in my keynotes and lectures is the current regulatory challenge which suggests we should engage patients/families, share data for care coordination in accountable care organizations, and use registries to analyze population health/public health all while keeping the data security and respecting patient privacy preferences. It's a tall order.
As I've posted previously, BIDMC hired Deloitte to perform a security assessment of our policies and technologies. Going through the assessment has given me a great opportunity to review the security standard practices in the healthcare industry and the best practices across all industries.
We've reviewed emerging techniques in Data Loss Prevention (DLP), Governance/Risk/Compliance (GRC) tools, Enterprise audit log analysis tools, Learning Management Systems, and Network Access Control.
BIDMC has implemented or is implementing most of these.
At the same time, we're passionate about healthcare information exchange technologies for provider/provider summaries and patient/provider communications (portals, automated blue button, and state hie connections to patients).
Here are the slides I'll use in the webinar, illustrating that it possible to secure the enterprise and at the same time use Direct-enabled, certificate protected, health information exchange with patients, providers, and payers.
The most secure library in the world would not check out any books - it would be a secure but useless library. We must protect privacy and at the some time share information. It is possible to achieve a balance that does both.
I look forward to the webinar.
Cool Technology of the Week
While I was at AMIA this week, Will Ross of Redwood MedNet, introduced me to a low cost interoperability solution for small practices in rural locations. It's similar in concept to the interoperability appliances that Massachusetts has used in its HIE. Will calls his appliance the
"HIE Plug".
The HIE Plug is a secure health data endpoint built on a generic small form factor hardware device. The all open source software stack runs on a Marvel Kirkwood ARM CPU @ 1.2Ghz with 512M RAM. The hardware draws under 5 watts of power.
• 2 x Gigabit Ethernet 10/100/1000 Mbps
• 2 x USB 2.0 ports (Host)
• 1 x eSATA 2.0 port- 3Gbps SATAII
• 1 x SD Socket for user expansion/application
• WiFi: 802.11 b/g/n
• Bluetooth: Bluetooth 2.1 + EDR
This hardware is marketed under the trade name "DreamPlug".
The HIE Plug open source software stack installed on the device includes:
1. Debian Wheezy with the Linux 3.* kernel.
2. EncFS provides an encrypted filesystem in user-space running without any special permissions and with the FUSE library and Linux kernel module to provide the filesystem interface.
3. Mirth Connect - health data integration engine, a robust Enterprise Service Bus tool fluent in all common health data formats and communication services. Mirth Connect includes a robust dashboard to manage many individual integration engine channels, which can be taught variously to listen for data, push data, pull data, transform data, etc. Mirth Connect channels are written in Javascript.
4. Apache Derby database stores the health data messages prior to forwarding to the HIE. The database runs in the encrypted filesystem. If power to the device is lost the part of the filesystem where the database resides cannot be re-mounted and unencrypted without the proper credentials. Local storage can be configured to trim/remove its local store of messages at a pre-defined time.
5. OpenVPN client bundle for secure TLS connectivity back to the managed VPN Access Server.
6. Samba (file server) and CUPS (print server) installed. Either one or both can be configured and deployed as needed - - no services are enabled by default. This allows delivery or consumption of a file through a shared folder on the HIE Plug, or delivery of a print job to an internal network printer or a remote network printer.
7. lighttpd webserver - to provide web based applications or information to clients.
The HIE Plug was tested in a pilot deployment at three sites in early 2012, and is now rolling out to general production across dozens of health care facilities participating in Redwood MedNet. Up front deployment cost is $300 per practice. Technical support by Redwood MedNet is included under the standard HIE bidirectional data service subscription fee, which is $200/provider/year for outpatient practices.
Mirth has been used for Direct demonstrations, so it is a very reasonable choice as an integration engine supporting Meaningful Use Stage 2 exchanges.
A $300 HISP in a box - that's cool!
Building Unity Farm - Preparing for Winter
This week we've had our first hard freeze in Massachusetts - 22 degree temperatures last night. How have we prepared the farm for winter?
1. All outside water supplies are off and drained. A yard hydrant provides water inside the barn and since its water supply is 4 feet below ground, deeper than the frost line, it does not freeze.
2. All barn doors and windows are closed to minimize wind inside. Extra straw provides a layer of insulation. The animals are fully fleeced. Llama/Alpaca and Great Pyrenees Mountain dogs enjoy the cold weather - it's the wind and the rain that is problematic. The barn protects them.
3. All our over wintering raised bed plants (such as garlic and various herbs) have been protected under salt marsh hay or moved indoors.
4. We use heated buckets to keep water from freezing in the barn. We use a thermostatically controlled chicken waterer base to keep the coop water from freezing.
5. Although the coop keeps the chickens out of the wind and rain, we need to protect their sensitive combs and waddles. We put 150 watt heater panels near their nightly roosting area and near their daily eating area. They can always seek a warm up when the temperature plummets.
One issue we're still addressing - what to do if power fails. We are currently installing a propane fueled generator to ensure our animals have heat, light and water even if falling trees or severe winds bring down power lines. During Hurricane Sandy we lost power for 7 hours. We stored a few days of water in the barn just in case, but did not need them.
We have enough food stored in our barn loft to last until Spring for all the animals.
The first hard freeze went well. I think we're ready for our first winter on Unity Farm.
1. All outside water supplies are off and drained. A yard hydrant provides water inside the barn and since its water supply is 4 feet below ground, deeper than the frost line, it does not freeze.
2. All barn doors and windows are closed to minimize wind inside. Extra straw provides a layer of insulation. The animals are fully fleeced. Llama/Alpaca and Great Pyrenees Mountain dogs enjoy the cold weather - it's the wind and the rain that is problematic. The barn protects them.
3. All our over wintering raised bed plants (such as garlic and various herbs) have been protected under salt marsh hay or moved indoors.
4. We use heated buckets to keep water from freezing in the barn. We use a thermostatically controlled chicken waterer base to keep the coop water from freezing.
5. Although the coop keeps the chickens out of the wind and rain, we need to protect their sensitive combs and waddles. We put 150 watt heater panels near their nightly roosting area and near their daily eating area. They can always seek a warm up when the temperature plummets.
One issue we're still addressing - what to do if power fails. We are currently installing a propane fueled generator to ensure our animals have heat, light and water even if falling trees or severe winds bring down power lines. During Hurricane Sandy we lost power for 7 hours. We stored a few days of water in the barn just in case, but did not need them.
We have enough food stored in our barn loft to last until Spring for all the animals.
The first hard freeze went well. I think we're ready for our first winter on Unity Farm.
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