Friday, June 26, 2015

Cool Technology of the Week Special Edition

BIDMC has 4 Apple Watches (the inexpensive Sport model) for development and evaluation.    Our programmers have 3 of them and I’m passing the 4th around to various folks including a 65 year old techie and a 22 year old digital native (my daughter Lara).    Here’s Lara’s review:

“As the Apple Watch arrives at retail stores, a lot of people will be asking 'How is it? Is it worth buying?' I think a question that needs to be asked first, however, is ‘What is it?’ The Apple Watch is not a new, independent Apple product. It is a watch that pairs with your iPhone and acts as a mirror of sorts, enabling you to access select apps and features from your phone.  It is not an independent product. I was certainly surprised by that!

Just as the iPhone functions very well as a phone, the watch also functions very well as a watch. The Sport Band is incredibly comfortable, and easily adjustable. It has a very clear, readable face with both digital and analog options, as well as a small selection of customizable watch faces. (Honestly, I hope they add more selection over time- its currently quite limited.) You can display a few other bits of information on the screen, such as the date, weather, and other time zones. The customizability here is definitely a highlight, and a feature that goes beyond a standard wristwatch.

But let’s be honest here- nobody cares much about the iPhone’s phone capabilities. They care about the apps. I imagine the Apple Watch will be viewed in the same way. ‘What nifty non-watch things can I do on my Apple Watch?’  Well, this is where the product falls slightly short at the moment. The Apple Watch is an interface for some select apps, but with less features than that of the iPhone. You can read your texts and emails, but you cannot write them (Unless you do so through dictation, but talking to your wrist in public does not look as cool as it does in the movies, trust me.) You can activate the camera on your phone with it, but it doesn’t have a camera of its own. (Funny story- I thought the camera was on the watch itself, and took plenty of lovely pictures of the wall while trying to figure out what was going on.)

On the flip side, some apps are designed very well for the watch. The health app in particular does a great job of utilizing what the watch has to offer. I was especially fond of the little notification it gives you when you’ve been sitting down for over 50 minutes. It’s a perfect reminder for when I lose track of time on my computer. I’ve also found some nifty vocabulary and kanji flashcards that have helped me with my Japanese studies. I’m sure that over time, more apps will be released that are compatible with and suited to the Apple Watch, and I’m looking forward to trying them out.

On a final note, for anyone worried about the battery life- the first time you use it, while setting up the watch itself, the battery drains quickly. Every time after that, it will last you the entire day. Have the charger set up on your bedside and you’re good to go.

So, is the Apple Watch worth the price tag? Well, that depends on what you’re looking for. If you’re looking to replace your iPhone, then no. But if you’re looking for a very high quality watch with limited iPhone features and app use, then yes. I love my watch for what it is- a watch with some perks. "

Thursday, June 25, 2015

Unity Farm Journal - Fourth Week of June 2015

We brought our alpaca mom and new baby, Daisy and Danny, home after a brief thunderstorm cleared.   Nature concluded what we’ve always known - Unity Farm is the end of the rainbow.

Mom and baby are healthy, happy and content.   Daisy has become an overprotective mom and Danny eats vigorously every hour.   We’ve kept them in a shaded pen to give them quiet recovery time from the trauma of being driven to a hospital and kept away from the farm for 4 days.    Danny’s IgG is nearly 1700, which means he has a fully intact immune system.  He’s gained a few pounds and is a non-stop bundle of energy.

What a great outcome.

We moved the geese outdoors into the duck pen.   The geese are happy but the ducks are not sure.    They tend to hide inside the duck house.   We’ll keep the geese in the pen for a few days so that they recognize it as home before letting them free range.   We’ve had a female coyote visiting a few times a day this week, so we want to be conservative on releasing new animals to free range.

We moved 17 chicks into our mini-coops inside the main coop.   We added buff orpingtons, barred rocks, cuckoo marans, americaunas, and andalusians    In another 6 weeks, they’ll also free range.

The mead is nearly fully fermented.   It started with a specific gravity of 1.100 and now is at 1.010.   We expect about 14% alcohol.   I’ll age it for one year before bottling.

The bees continue to gather nectar from the acres of summer wildflowers growing in the orchard.    The hives are so large and healthy that Kathy needs a ladder to maintain them.  So far, no swarms from the Unity Farm hives!

We are harvesting strawberries, peas, cucumbers, broccoli, and chard this week.   The garlic harvest is approaching and many of our tomatoes are large and plump.

Inspired by our bounty of tomatoes, mushrooms, fresh basil, and more garlic than we can consume, I’m convinced my next project should be building a wood-fired pizza oven.   I have to do something with the extra cords of wood we store for winter every year - why not whole wheat thin crust!

This weekend will be filled with trimming and trail maintenance tasks now that the burst of Summer growth has turned our orchard and trails into a wilderness.    Some weekends are animal focused and some are plant focused.    Not a single weekend goes by without a new adventure.

Wednesday, June 24, 2015

The June 2015 HIT Standards Committee

The June 2015 HIT Standards Committee focused on celebrating the accomplishments of those individuals who have reached their federal advisory committee term limits.  Most served 6 years:

Dixie Baker
Anne Castro
Marty Harris
David McCallie
Stan Huff
Liz Johnson
John Derr
Sharon Terry
Jon Perlin
Jeremy Delinsky

Karen DeSalvo thanked each one and I offered comments about their unique contributions, changing the fundamental trajectory of standards in the US from a 1990’s “EDI” payload model to a 2015 “Facebook” Application Program Interface model.   Their leadership has brought modern, open web standards to the healthcare domain, specified controlled vocabularies, and established appropriate security. They will be missed.

Next, John Feikema and Dragon Bashyam presented a summary of the Data Access Framework project.   We thanked them for the foundational work that has been incorporated into the private sector Argonaut project.

Chris Muir provided an Interoperability Standards Advisory Update and described the process by which a task force will refine the FY16 sub regulatory guidance.   While regulation generally includes only mature standards, sub regulatory guidance can enumerate emerging standards that are likely to become mature.

The next portion of the meeting focused on the  final recommendations of the committee for the standards to include in regulation and those to specifically exclude from regulation.

We highlighted the measures of maturity that Dixie Baker outlined in her paper about standards readiness.

We emphasized that standards require a business case, policy enablers, and supporting infrastructure.  As David McCallie wrote, Standards Alone are not the Answer for Interoperability.

In that spirit, Rich Elmore presented the recommendations from the Content Standards Workgroup

Mitra Rocca presented the recommendations of the Semantic Standards Workgroup
David McCallie and Arien Malec presented the recommendations of the Architecture, Services, and APIs Workgroup

Liz Johnson and Cris Ross presented the recommendations of the Implementation, Certification, and Testing Workgroup 

The themes included:

*CCDA is mature but needs to significantly constrained
*FHIR is nearly ready for widespread use and should be highlighted as directional
*Quality standards such as HQMF and QRDA will be refined in their next version
*Many standards are just not ready for regulatory or sub regulatory recommendation including HPD+ (provider directory), eSMD (electronic submission of medical documentation), DS4P (data segmentation for privacy), and HeD (Healthy Decisions)
*Providing a laundry list of immature standards is not going to accelerate interoperability

After the meeting I spoke with several members about writing a journal article that will summarize the lessons we’ve learned providing standards advice for the Obama administration.  The most significant point is that interoperability doesn’t happen when standards are named.   Interoperability happens when there is a business case, trust between two parties, and governance over the process.    It generally takes a few years to achieve all the enablers  and there is no magic standard that will make the cultural and policy changes needed to accelerate information flow.

Monday, June 22, 2015

Driving Miss Daisy

It’s been a long weekend.   Here’s the story of the birth of our new Alpaca, Dandelion Wine (Danny)

On Thursday at 12:03pm, Kathy texted me the picture below and the message “HELP!”   Mom had delivered the long legs of a new baby.   I rushed back to the farm and by the time I arrived, baby and placenta had been successfully delivered by Daisy Mae, with Kathy’s help.     The newborn weighed 18 pounds.    Typical for an alpaca is 10-17 pounds.   Since Daisy Mae is a small alpaca (140 pounds), the birth was very difficult.    You can see how big he is - my daughter is 5 foot 5 inches and she is holding him shortly after birth.

I examined Daisy and she had no tears or bleeding.  However, she was very tired and rejected the baby’s attempts to nurse.   Alpaca babies generally start nursing within 90 minutes and have about 24 hours to consume colostrum - the early mother’s milk that provides them with an immune system.  If they do not eat, they have no immune system and can easily die of infection.  

We gently haltered Daisy Mae and held her while encouraging Danny to eat.   Mom and baby just could not collaborate.   We tried restraining Daisy.   No luck.   We had to initiate bottle feeding to keep Danny hydrated.   We put him in a cria coat (a down jacket for baby alpaca) for the night since mom was not keeping him warm.      However, the rest of the herd protected him.

All day Friday we tried keeping them together and encouraging bonding.   It did not work.  As the window closed for colostrum transfer, we had to proceed to plan B - transfusion with alpaca plasma to provide the IgG he needed to fight off infection.    We drove him to Tufts large animal hospital in Grafton, MA.   They infused plasma and his IgG counts rose slowly.   He did not develop a fever and his white count was normal.

While Danny was being treated, we also had to treat Daisy - she was not nursing and she was at risk for mastitis.   We had to massage her teets every two hours to express milk and reduce the risk of infection.    She became more agitated with every treatment.   Clearly she was not dealing with motherhood very well, which is typical for first time alpaca moms.

Transfusions continued for Danny on Saturday and counts were rising but slower than expected, although he looked clinically well.  Thus, we had two patients, a young patient with IgG counts rising slowly and a mom increasingly agitated.   Saturday was frustrating.

We made a decision that we had to bring them together so that as his counts became normal, he could be re-introduced to her and she could be sedated if necessary so that nursing could proceed.   It’s typical for horses that a few hours of sedation can lead to a successful mother-baby feeding/bonding experience.    We lifted all 140 pounds of Daisy into the Ford Transit truck and drove her to the Tufts facility.   We checked her in, and spent an hour with Danny.  Clearly he missed his herd.

Mother and baby were re-united on Sunday night.    Danny was joyful, Daisy was skeptical.   She was mildly sedated and he began to feed.  By late Sunday night, Daisy was mothering him without sedation.

If all goes well, Danny’s transfusions will be done today and Daisy will be a fully functional mother.     If we’re lucky, tonight we’ll put them both in the van and bring them back to Unity Farm.

Such is the life of a farmer - you never know what the future will bring.

Thursday, June 18, 2015

It's a Boy!

Born at 12:25pm at Unity Farm today

Unity Farm Journal - Third Week of June 2015

Last week’s 3 inches of rain yielded this week’s 50 pounds of Shitake.   Here’s a few photos of the massive mushroom harvest.

The winecaps, agaricus, and wild mushrooms in our forest are also fruiting abundantly.   Our permaculture efforts, including the recently planted paw-paw trees, are fully leafed out      We’ve not yet seen much activity in our ginseng beds.   I have a feeling that the deer and wild turkeys are eating them.

Now that all our ciders are fully mature, Kathy and I did a tasting of 7 different five gallon batches.   All were technically perfect and had no off flavors.   We are now able to focus our future efforts based on the aroma, complexity, and mouth feel we can achieve using different combinations of sweet, tart, aromatic, and astringent apples.

   Sweet - Golden, Gala
   Tart - McIntosh, Rhode Island Greening, Gravenstein
   Aromatic -
   Astringent  -
   lightly carbonated, clean/dry, primarily tart character

   Sweet -  Honey Crisp
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, complex/complete/balanced, aromatic

   Sweet -  Baldwin
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, less complex

  10/25 *****The Winner
   Sweet -  Baldwin, Golden Delicious
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, complex/complete/balanced, aromatic

   Sweet -  Baldwin
   Tart -  Winesap
   Aromatic -
   Astringent - Crab
   moderately carbonated, clean/dry, more tart, less complex

   Sweet -  Baldwin
   Tart - Red Spy
   Aromatic - Macoun
   Astringent -  Russet
   moderatedly carbonated, clean/dry, rounded, buttery, very wine like

   Sweet -  Baldwin, Golden Delicious
   Tart -  Winesap, Cortland
   Aromatic -
   Astringent -
   moderatedly carbonated, clean/dry, lacks complexity

We also ordered another 4 kegs so that we can keep 8 different kinds of beverages on our tap system as part of our product development.   I’m adding a keg of honey lager next week and a keg of sparkling mead this Summer.

We’re still on cria  (baby alpaca) watch - Daisy Mae has not yet given birth, although it is clear she is near.  He’s a photo of Sunny, who is 1 year old this month.

We continue to raise our young Spring birds - chickens, geese, and pheasants.   At the moment, our bird count is

Ducks - 8
Chickens - 26
Geese - 3
Guinea Fowl - 65

Our goal is to keep the guinea fowl population from expanding.    We try to discover their hidden forest nests and gather their eggs on a daily basis.

The hives continue to grow and Kathy now has to use a step ladder to take off the honey supers.    We have 22 hives, 12 at Unity Farm and 10 at five distributed locations within a few miles.   Below is a photo of one of our queens - look at the center of the picture for the bee with the black thorax.

Our vegetables continue to be prolific and we’re harvesting 20 pounds per day for family, friends, and creatures.     The strawberries are ripe and I’m eating them for breakfast, lunch and dinner.    The monarch butterfly caterpillars are feasting on milkweed and the wild flowers are in bloom all over the pastures.   It's almost Summer.

Wednesday, June 17, 2015

Setting Clinical IT Priorities

In my previous writing, I’ve suggested that the federal government co-opted our Clinical IT agenda over the past three years with Meaningful Use Stage 2, ICD-10, the HIPAA Omnibus Rule, and the Affordable Care Act (ACA).

Now that Stage 2 attestation is done, ICD-10 is on a trajectory for October go live, OCR/OIG/internal security audit activities are done for the moment, and the care management medical record we need to support the Affordable Care Act is live, we can once again ask our customers to help set priorities.

Here’s the process we’re following:

In June, we’re convening a group of senior VPs, clinicians, and IT professionals to jointly review the current HIMSS Electronic Medical Record Adoption Model (EMRAM) Stage 7 criteria and benchmark ourselves.   It’s likely that we’ll amend the HIMSS criteria in a few areas where BIDMC considers itself a market leader - patient family engagement, mobile technologies, big data analytics, and cloud adoption.     We’ll then identify gaps in functionality/workflow to focus our strategic goals for FY16.

Once we have identified the goals, we’ll ensure we have the right organizational structure and staffing to accomplish those goals.    We’ll verify the operating and capital budgets required.    We’ll create Gantt charts and resource leveling artifacts to illustrate the relationship among the scope of projects, timing, and resources.

These artifacts will be used in FY16 by all our clinical governance bodies.    As new projects are mandated by government, mergers/acquisitions, or changes in local requirements, additions will be weighed against the scope, timelines, and resources already allocated.

I expect FY16 to be  focused on the clinical documentation needed to support ICD-10, quality measurement, and care coordination.

It will be interesting to see what  projects bubble up to the top and  to identify the gaps between the ideal state of an academic medical center and our current state.

I’m hopeful that the process will have such transparency and inclusiveness that it will be an effective means to align supply and demand in FY16, increasing customer satisfaction by documenting the prioritized goals and communicating the progress we’re making.

Thursday, June 11, 2015

Unity Farm Journal - Second Week of June 2015

It’s mid-June so the farm is filled with Summer greenery, rapidly growing fruits, new animal babies, a flurry of harvesting/planting activity, and beekeeping.

Here’s a view of chives near the hoop house, ready for harvest.  The orchard grass is growing so fast, we mow it weekly.

Our baby geese continue to feather out and in a few weeks we’ll add them to the barnyard.   We’re also raising baby pheasants per the picture below.   They are the size of ping pong balls and constantly bouncing around the brooder.   Our intent is to release them into the wild of our forests once they are mature enough to defend themselves.

We check on Daisy, our pregnant alpaca, multiple times per day.   She’s nearly at term and spends her time lying comfortably in the hay.   The baby is so large that I’m sure she’s anticipating the birth.

On Tuesday, all of the alpaca began alarming and Peter, who helps us when I’m out of town,  explored the cause of their concern.    On the lawn outside the paddock, a newborn fawn lay resting, temporarily abandoned by its mother.    Peter examined the fawn to ensure it was not sick/injured and then carefully placed it in the nearby forest.   Within the hour, mom returned and the unsteady fawn rambled along behind its mother.    Mother and baby are doing well, feeding on grass at the edge of the paddock.

All our 22 hives in 4 locations are doing well.   Kathy believes we’ll have significant honey production this year.   What to do with all that honey?

Our mead recipe calls for 22 pounds of honey in each 6 gallon batch.  Last Sunday’s batch is fermenting vigorously.

Our honey lager recipe calls for 10 pounds of honey in each 15 gallon batch.  This could become our Unity Farm signature beer.   I’ll keg it in 3 weeks and know for sure.

This weekend we’ll harvest snap peas,  shitake mushrooms, lettuce, and chard.   The tomatoes are doing well and a few cucumbers are nearly ready.    Kathy is attending a queen bee rearing class and I’ll do the usual weekend farm chores.   Maybe for the first time this year, I’ll sit down on Saturday afternoon and enjoy a glass of cider while overlooking the fruits of our labor.  Then again, there will always be something to do at Unity Farm.

Wednesday, June 10, 2015

Standards Alone are not the Answer for Interoperability

Today I have the honor of presenting a guest blog by David McCallie MD, SVP Medical Informatics, Cerner.   He summarizes the collective feeling of the industry about the trajectory of interoperability.

"I have been honored to have served on the HIT Standards Committee from its beginning in 2009. As I reach my term limits, I have reflected on what we have all learned over the past six years of helping to define the standards for the certified EHR technology that lies behind the Meaningful Use program.

But before diving into those reflections, we should acknowledge what we have accomplished.  It's fashionable to complain that we haven't 'solved interoperability.'  This is certainly true, but we have come a long way, and have achieved significant and lasting advances.

In particular, we have mostly settled the vocabulary questions for encoding the record.  We have widely deployed a good ePrescribing standard. We have established a standard for secure email that will eventually replace the fax machine, and we have widely (but not yet universally) deployed a good standard for document-centric query exchange.  We are close to broad support for a stable standard for encoding complex clinical data into summary documents.  And perhaps most interestingly, we have opened the door to the promising world of API-based interoperability.

Nonetheless, the refrain we hear from Capitol Hill is that we have failed to achieve the seamless interoperability that many had expected. This has lead to numerous legislative attempts to 'fix' the problem by re-thinking government approaches to the standard setting processes authorized by HITECH.

We should be careful not to overreact in light of any disappointments and perceived failures around interoperability.  There are many things we must improve, but we should not inadvertently take steps backwards.

I think the biggest mistake Congress appears to be legislating is to assume that standards alone are what creates interoperability.

Standards are necessary, but are not sufficient, for interoperability to occur.

Standards organizations (SDOs) can create standards, but they do not create the additional entities that are necessary for standards to deliver useful interoperability.

I believe that the sufficient conditions for interoperability include the following:

*A business process must exist for which standardization is needed. As Arien Malec put it recently, 'SDOs don't create standards de novo. They standardize working practices.'

*A proven standard then needs to be developed, via an iterative process that involves repeated real-world testing and validation.

*A group of healthcare entities must choose to deploy and use the standard, in service of some business purpose. The business purpose may include satisfying regulatory requirements, or meeting market pressures, or both.

*A 'network architecture' must be defined that provides for the identity, trust, and security frameworks necessary for data sharing in the complex world of healthcare.

*A 'business architecture' must exist that manages the contractual and legal arrangements necessary for healthcare data sharing to occur.

*A governance mechanism with sufficient authority over the participants must ensure that the network and business frameworks are followed.

*And almost no healthcare standard can be deployed in isolation, so all of the ancillary infrastructure (such as directory services, certificate authorities, and certification tests) must be organized and deployed in support of the standard.

The Jason Task Force (which I was privileged to co-chair with Micky Tripathi) summed up these requirements into what they called a 'Data Sharing Arrangement (DSA).' DSAs do not emerge from SDOs. DSAs cannot be simply created by legislative fiat.  They require the active engagement and collaboration of the many entities who are willing to do the hard work to create the necessary infrastructure for an interoperability standard to find real-world, widespread use.

We've learned that forcing providers to simply deploy standards and then to expect interoperability to happen is ineffective policy. The most rapid progress has happened when DSAs have emerged because provider organizations, Health IT developers and SDOs agree to work together to achieve a clear mission, focused on meaningful outcomes. Congress should accordingly define the 'what' and let the U.S. health care stakeholders define and achieve the 'how.'"

Thursday, June 4, 2015

Unity Farm Journal - First Week of June 2015

As I’ve written previously, running a farm is about life and death.   When you’re supporting over 100 creatures, every day is filled with unpredictable events.   This week, one of our chickens, Terra, developed “sour crop”.

We treated her by inducing vomiting, feeding her olive oil, offering apple cider vinegar in water, and isolating her from the other chickens.   Despite 2 days of treatment, she passed away.   She’s buried in our forest garden, near the Shinto shrine.

With the death of our rooster, Lucky, by coyote and Terra by infection, we’re down two Ameraucana chickens.

Kathy and I discussed our last three years of chicken raising and decided that we should supplement our flock.   This week we added 6 Barred Rock hens (1 week old) and 3 Buff Orpingtons (2 weeks old).    Although our Guinea Fowl have multiplied on their own (they lay 40 fertile eggs per day), we’ve not hatched our chicken eggs.    With 9 adult chickens and 9 new chicks, the population should be stable despite occasional losses.

We also had another thought.   Our guineas, Great Pyrenees and llamas sound an alarm when predators threaten.    However, one of the best watch dogs for the barnyard is a goose.   Here’s a photo of the 3 geese babies that recently joined the farm ecosystem.   In another 6-8 weeks, they’ll be added to our existing poultry flocks and begin defending them all.

Last week, the IEEE Spectrum published Kathy’s cancer story in the context of big data.   Here’s the article.   IEEE took a family portrait to illustrate Kathy and I in our natural state.

Daisy Mae, one of our alpaca, is nearing the 11th month of her pregnancy.   As alpaca approach delivery, they develop a condition that some call “alien butt” - the features of the soon to be born young alpaca appear on the rear of the mom.   I consider this a clinical photograph, educating the public about the appearance of a gravid alpaca.

Shiro, our 150 pound male Great Pyrenees,  is always looking for toys.   He figured out a way to bury his bowl in a hay bale.  Very artistic

This weekend will include mead making with 21 pounds of honey and harvesting mushrooms after the 3 inches of rain this week.    I’ve also signed up with a local brewer to create a honey lager next week - my honey, his hops.   Now that we’re a bonded winery from a federal and state perspective, the test batches of interesting beverages are beginning to multiply.

Wednesday, June 3, 2015

So What is Interoperability Anyway?

One of my most memorable experiences as an IT leader was working with with a dissatisfied customer.   I asked what requirements were unmet, what features were priorities, and what future state was desired.   The answer was “I’m not sure, but I know I’m not getting what I need”.

The use of the term interoperability is being tossed around in ways that makes it seem like the test for obscenity used by Supreme Court Justice Potter Stewart in 1964 when he wrote “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"], and perhaps I could never succeed in intelligibly doing so. But I know it when I see it…”

Congress is angry about the lack of interoperability.   What does that mean?

House and Senate stakeholders believe that vendors enjoyed a government funded windfall yet are building proprietary networks.   They have heard that vendors are blocking information sharing by charging significant interface fees and that HITECH distributed $30 billion with minimal requirements for information sharing. Many in the House feel after all this investment, the country is not prepared for new payment models.

Some in the House have stated that Americans can communicate because "we speak English" so interoperability is about picking a common language.

Senate HELP Committee Chairman Lamar Alexander plans to take up this issue, working closely with Ranking Member Senator Patty Murray through a bipartisan effort over the coming months. 

So what is the real issue causing providers anxiety and resulting in Congress wanting to take action?

Providers are fed up with interface fees and at how hard it is to accomplish the workflow required by Accountable Care business models including care management and population health. They are unsatisfied with the kind of summaries we’re exchanging today which are often lengthy, missing clinical narrative and hard to incorporate/reconcile with existing records.

All these things are true.

So what is our next step to help providers do their job and improve satisfaction to the point that Congress no longer wants to legislate the solution to the problem?

I think we all have to step back, carefully define the requirements for care coordination and care management in an ACO world and admit that the Meaningful Use regulations did not address those requirements.   We should allow the private sector initiatives already in progress (Argonaut, Commonwell, eHealthExchange) to address these market needs in collaboration with vendors, entrepreneurs, and innovators.   The economic incentives of the Affordable Care Act and the Sustainable Growth Rate fix will result in hospitals and professionals demanding different kinds of technology than was prescribed in regulation.

The role for Congress should be to hold us accountable for the outcomes we want to achieve.

At a recent AMIA presentation in Boston, Zak Kohane, Ken Mandl and I were asked to be provocative - to go rogue.

I suggested that the Meaningful Use program should be eliminated.    Yes, there should be Merit-based incentives for achieving stretch goals, but those can be created in another CMS program. Meaningful Use is no longer necessary.

ONC should focus on the 5 enablers I’ve written about

1.  Facilitating the creation of a national provider directory for message routing

2.   Encouraging the adoption of a voluntary national identifier for healthcare

3.  Providing guidance to streamline the heterogeneous patchwork of state privacy laws that are impeding information exchange

4.  Serve as the coordinating body for aligning federal government health IT priorities.

5.  Supporting private sector initiatives such as Argonaut that are simplifying the tools for health information exchange.

It's not a problem of "language".  We have the terminologies we need, already included in certified EHRs. We have standards for content and transport, again written into certification requirements. So what's the gap? We need to make the standards better, and build interoperability into EHR workflow. That doesn't require top down regulation, it takes the kind of  goal-oriented interaction between providers, developers, and standards bodies that characterizes efforts like the Argonaut Project.

No more regulation, no more legislation.   Those will only crush innovation.

Instead of saying we need interoperability, the conversation needs to include a crisp set of requirements for care management and care coordination with defined metrics of success, supported by government enablers, and accelerated with the economic incentives provided by new reimbursement models.

To paraphrase Justice Potter, if patients and providers are happier, I’ll know it when I see it.