Wednesday, May 31, 2017

What’s Next for Electronic Health Records?

With the Department of Justice announcement of the $155 million dollar eClinicalWorks settlement (including personal liability for the CEO, CMO and COO), many stakeholders are wondering what’s next for EHRs.

Clearly the industry is in a state of transition.   eCW will be distracted by its 5 year corporate integrity agreement.    AthenaHealth will have to focus on the activist investors at Elliott Management   who now own 10% of the company and have a track record of changing management/preparing companies for sale.    As mergers and acquisitions result in more enterprise solutions, Epic (and to some extent Cerner) will displace other vendors in large healthcare systems.   However, the ongoing operational cost of these enterprise solutions will cause many to re-examine alternatives such as Meditech.

As an engineer, I select products and services based on requirements and not based on marketing materials, procurements by other local institutions, or the sentiment that “no one gets fired by buying vendor X”.

I have a sense that EHR requirements are changing and we’re in transition from EHR 1.0 to EHR 2.0.   Here’s what I’m experiencing:

1.  (Fewer government mandates) The era of prescriptive government regulation requiring specific EHR functionality is ending.   In my conversations with government (executive branch, legislative branch), providers/payers, and academia, I’ve heard over and over that it is better to focus on results achieved than to do something like count the number the CCDA documents sent via the Direct protocol.    If you want to use mobile devices to monitor patients in their homes - great!  If you want to use telemedicine to do wellness checks - great!  If you want to send off duty EMS workers using iPads to evaluate the activities of daily living for elderly patients  - great!  Reducing hospital readmissions is the goal and there are many enabling technologies.    Suggesting that one size fits all in every geography for every patient no longer works as we move from a data recording focus (EHR 1.0) to an outcomes focus (EHR 2.0)

2.  (Team-based care) Clinicians can no longer get through their day when the requirements are to see a patient every 15 minutes, enter 140 structured data elements, submit 40 quality measures, satisfy the patient, and never commit malpractice.  A team of people is needed to maintain health and a new generation of communication tools is needed to support clinical groupware.   This isn’t just HIPAA compliant messaging.   We need workflow integration, rules based escalation of messages, and routing based on time of day/location/schedules/urgency/licensure.  We need automated clinical documentation tools that record what each team member does and then requires a review/signoff by an accountable professional, not writing War and Peace from scratch until midnight (as is the current practice for many primary care clinicians)

3.  (Value-based purchasing) Fee for service is dying and is being replaced by alternative quality contracts based on risk sharing.

Dr. Allan H. Goroll’s excellent New England Journal of Medicine article notes that EHR 1.0 has achieved exactly the result that historical regulation has required - a tool that supports billing and government reporting - not clinician and patient satisfaction.

Our electronic tools for EHR 2.0  should include the functionality necessary to document care plans, variation from those plans, and outcomes reported from patient generated healthcare data.    Components of such software would include the elements that compromise the “Care Management Medical Record” - enrolling patients in protocols based on signs/symptoms/diagnosis, then using customer relationship management concepts to ensure patients receive the services recommended.

ICD-10, CPT, and HCPCS would no longer be necessary.    Bills will no longer be generated.   Payments would be fixed per patient per year and all care team members would be judged on wellness achieved for total medical expense incurred.   SNOMED-CT would be the vocabulary used to record clinical observations for quality measurement.

4. (Usability)  I do not fault EHR developers for the lack of usability in medical software.  They were given thousands of pages of regulations then told to author new software, certify it, and deploy it in 18 months.   I call this the “ask 9 women to have a baby in 1 month” concept, since Meaningful Use timeframes violated the “gestation period” for innovation.   How can we achieve better usability in the future?   My view is that EHRs are platforms (think iPhone) and legions of entrepreneurs creating add on functionality author the apps that run on that platform.  Every week, I work with young people creating the next generation of highly usable clinical functionality that improves usability.     They need to be empowered to get/put data from EHR platforms and emerging FHIR standards will help with that.  

I was recently asked to define HIT innovation.  I said it was the novel application of people, processes and technologies to improve quality, safety and efficiency.    Creating modules that layer on top of existing EHR transactional systems embraces this definition.

5.  (Consumer driven)  In a recent keynote, I joked that my medical school training (30 years ago) in customer service mirrored that provided by the US domestic airlines.   Healthcare experiences can be like boarding a crowded aircraft where your presence is considered an inconvenience to the staff.    We’re entering a new era with evolving  models that are moving care to the home including internet of things monitoring, supporting convenient ambulatory locations near you,  offering urgent care clinics with long hours, enabling electronic self scheduling, and encouraging virtual visits.    Although existing EHR 1.0 products have patient portals, they have not made the patient/family an equal member of the care team, providing them with care navigation tools.  BIDMC is working on an Amazon Echo/Alexa service backed by microservices/Bots that brings ambient listening technologies to the home for coordination with care teams.  When see you articles like this one, you know that the technology tools we have to support patients as consumers are not yet sufficient.


The US has been working on EHR 1.0 for a long time.   57 years ago, the New England Deaconess computerized its pharmacy using an IBM Mainframe.  Here’s the original document from 1960 describing the achievement.   Of note, the document highlights that the overall hospital budget reached a new high - $5.4 million and the increased salary, clinical care and IT expense meant that hospital rates would have to be raised to $25/bed/day.     After nearly six decades of work on EHR 1.0, let’s declare victory and move onto social networking-like groupware supporting teams of caregivers focused on value while treating patients as customers using mobile and ambient listening tools.  Government and private payers need to align incentives to support this future based on outcomes, putting the era of prescriptive EHR 1.0 functionality (and the energy enforcing the regulations) behind us.

Thursday, May 25, 2017

Building Unity Farm Sanctuary - 4th week of May 2017

Spring’s warmth and rain is accelerating our plant and mushroom growth such that every day is a balance between  agricultural management and sanctuary development activities like trail building as pictured below.   The stone bridge you see was built in the early 1800's.


The adventuresome project of last weekend was replacing the 20 year old heating oil tanks in the Sanctuary.   The seams were weeping and oil was accumulating on the sides of the tanks.   I recently heard a nightmarish story about an oil delivery of 500 gallons into a 250 gallon tank that had a newly ruptured seam.   With new tanks, we’ve avoided that risk.   The challenge is that the sanctuary has no basement - just a 4 foot crawl space.   To extract the old oil tanks we had to remove the staircase in the crawl space and lift the tanks to the first floor without spilling old oil or scratching the wood floors.    Not fun, but we were successful.

The other not fun project was replacing all the fiberglass insulation in the crawl space.   In the past, the roof gutters directed water immediately down the side of the building and into the basement causing annual flooding and mold.    We’ve redone the gutters to direct all water away from the foundation.  The crawl space has stayed completely dry this spring.   I pulled 200 linear feet of fiberglass insulation out from the crawlspace, bagging it to avoid dragging mold, mouse droppings and fiberglass through the building.    Lying on my back in the dirt of the crawlspace, I reapplied rolls of R19 insulation and a vapor barrier.   I wore goggles, a mask and full body loose fitting clothing, minimizing fiberglass misery.

While doing the fiberglass project I found a few more hundred feet of old wiring and rusted electrical boxes.   At this point, the only wires in the entire crawlspace are active electrical lines, fire detection sensors, and internet fiber.   Victory!

The next great archeological challenge will be replacing the entire water system and all the plumbing in the crawlspace.   At the moment the plumbing is like the city of troy - built in layers.   What needs to be done?  I’ll take a sawzall at the input pipe from the well and at the main distribution for the building, removing everything in between - a maze of copper and valves installed 1959-1995.    Much of our work on the sanctuary is not about adding infrastructure, it’s about removing 50+ years of infrastructure layers.    The only water system that is needed is a simple pressure tank with a small debris filter directly connected to the house and paddocks.    No water treatment, softeners, or iron removal are needed, massively reducing complexity.   There’s no need for segregated filtered and unfiltered plumbing.  The water test shows that the well is perfect - 10 gallons per minute of sterile, iron free water, so we’ll go from a deep underground stream to house and animals without anything in between.



As unexciting as it sounds, we’ll also be replacing the toilets which date from 1960 to 1990.     In the early 1990s toilets went from high flow to low flow and the models from that era are incredibly unreliable.   Given that the sanctuary is a public space, having a plunger in every room is not the right solution.   Toto toilets will be in place by June.

In the mid 1990s a carriage house/workshop for storage and vehicles was built on the sanctuary property but it was never finished.    There were live electrical wires hanging from the ceiling, walls were primed but never painted, and the fire/smoke alarms were disconnected.     I’ve redone all the electrical/lighting, connected fully wired fire/smoke alarms to the main house by running cable through an underground conduit, and begun the process of wall/ceiling finish work.    The carriage house will become our honey processing area and serve as one of our teaching areas for beekeeping, beer making, and mushroom cultivation.    By July it should be finished to perfection.

This week, the stone dust necessary to finish the paddocks arrives.  How much do we need?  The paddocks are a trapezoid 300 feet on one side, 225 on the other side and 200 feet wide.  If you remember your geometry, the area is (300+225)/2*200=52500 square feet.  Just how much stone dust will cover 52,500 square feet at 3 inches thick (recommended for horses) - just go to this website and you’ll discover we need 700 tons i.e. 1.5 million pounds.    The first 200 tons arrived yesterday.

Once the stone dust is placed, the fencing goes in and by mid June we’ll have four quarter acre paddocks for new rescues.  As soon as its done, I’ll post pictures.

By the time the Summer gives way to Fall, the building of the sanctuary should be complete and my blog posts can return to the joys of running a farm and sanctuary, since maintaining is much easier than creating.

Thursday, May 18, 2017

Building Unity Farm Sanctuary - Third Week of May 2017

In case it seems that my posting frequency has dropped, it’s a combination of a hectic spring farming/sanctuary schedule and writing requests from outside organizations.   For my views on the recent cybersecurity/ransomware events see the PBS Newshour blog.

Unity Farm Sanctuary work clothes have arrived in our closets.   This was my wife’s idea to identify mentors and experienced volunteers on the property.   We have so many visitors every day who are walking the trails, visiting the animals, and offering to help that we need to separate those with experience from those who are new to the sanctuary.    The shirts make it easy to find someone knowledgeable.


Our 501(c)(3) charitable designation should be approved soon, but in the meantime, we're receiving donations of equipment and items considered useful for the sanctuary.   For example, this 1800’s wheelbarrow seemed just the right tool for an 1833 meeting house.  It was dropped off earlier this week.    Some has just donated a canoe for sanctuary visitors who want to explore the upper marshes of the Charles River which has a canoe put in a few minutes drive from the sanctuary.



Later this week, another Welsh Pony,  named Grace will arrive at the Sanctuary.   We’re building new paddocks as fast as we can but they will not be ready until the end of June/early July.     Grace will live with the goats in the short term.   The goat paddock has two run ins so the pony can have a private space.

The process of creating 2 acres of new paddocks that are safe for horses takes diligence.   First, we cleared brush and leveled out the land.  Then we applied a layer of “tailings” rocks and dirt that provide a layer of drainage.   Then “stone dust” provides the finished surface which is solid and smooth but still promotes drainage.   Once that is done, we’re adding some additional fencing and gates so that we can easily bring in food and remove manure.    Then we add south-facing run in buildings to protect the animals from inclement weather.   Finally, we trench for electrical and water supplies to each building.   I’ll be doing all the electrical and plumbing, so we keep expenses to a minimum.   When completed, the 4 new paddocks, each about a half acre, will enable us to take on a few more creatures that need rescuing such as a donkey and a few sheep that we were recently told need a new home.   We’re very careful to take on new animal responsibilities selectively so that we can provide each the daily attention it needs.  As I’ve said before, we provide “forever homes” and thus we need to budget our time and resources for the long term support of any animal that arrives.

Next week, a “rafter” of turkeys arrives at the sanctuary, which will provide an instant family for Palmer, our Royal Palm tom turkey.   Palmer is extremely social and follows humans on long walks into the woods.   It will be fascinating to see how he adapts to young poults.    Thus far, the 20 wild turkeys at the sanctuary do not interact much with Palmer, although they call to each other in the night.

The work on the sanctuary buildings continue and last weekend I removed all the obsolete electrical circuitry from the 1960’s.   The 1833 Sanctuary building was moved to its current site in 1959 and the area underneath is only 3 feet high because of all the unmovable ledge rocks at the site that prevented digging a full basement.   I found numerous open electrical boxes with exposed wiring in the crawlspace that looked a bit dangerous for anyone doing work on heaters, plumbing or other under building infrastructure.   I carefully traced every wire and found that they were unconnected at both ends - just hundreds of feet of old cable and numerous electrical boxes with no purpose whatsoever.    I removed everything.   The good news is that neither the building’s electrical system nor my body was harmed in the process, although I did emerge from the crawlspace covered with mud, cobwebs, and decades of accumulated dust.    I also removed old thermostat wires, door bell wires, and phone lines that have not been used in decades.    I’m fairly confident that the work I’ve done thus far under the building - removing about half a mile of old wiring - is now done.   Maybe I’ll never have to spend another weekend day crawling under the building.    Luckily Claustrophobia and Arachnophobia are not issues for me.


This weekend will include the usual extra time with the animals, providing them companionship and extra exercise plus the tasks of spring - mushroom inoculation, planting warm weather seedlings (cucumbers/peppers/tomatoes).   All of the apple trees are in bloom, all of the hoop house vegetables are thriving, and the mushroom logs are fruiting.   2017 should be a bumper crop.

Thursday, May 4, 2017

Building Unity Farm Sanctuary - First Week of May 2017

We continue to work on the forests and trails surrounding the Unity property to create a community resource.

 The map below shows the current status of the land (water is in blue) - 18 trails, 10 bridges, 3 ponds, and 5 streams.   We’re clearing invasive non-native plants, removing decades of scrap metal/pottery/plastic midden piles, and taken down unstable dead trees that are a safety issue.  With every passing week, the land becomes more and more accessible.  Every time I go to the rural foundation meadow, I find it filled with wild turkeys, deer, raptors, coyotes, and rabbits.   Our goal is to protect the local natural ecosystems while also offering educational opportunities to the community.   The cattail loop and brook path are the new trails we built this week.   All the remains to be done is spreading wood chips on all the new trails, which we’ll do over the next few months.  Well,  I do have to clear one fallen oak tree on the brook path that's 8 feet in circumference (pictured below).   I need a bigger chain saw!




On Saturday, with town permission,  I cleared all the fallen trees and overgrowth from the Sherborn portion of the Bay Circuit Trail (the complete trail runs from Newburyport to Duxbury - 200 miles).   The portion of trail I have volunteered to maintain is the 4 miles between Perry Street and Route 27.   This seldomly used trail is just a few minutes from the Unity trails and has a great wilderness feel to it.   After a few hours with chainsaw and hedge trimmers, the trail is in great shape.

The warmth of spring has brought an early crop of flies and we’ve implemented our usual prevention measures - organic/pesticide-free fly traps,  fly tapes in the barn, and 20000 fly predator wasps (they don’t sting).   We have fly masks for the horses if needed, but thus far we’re keeping the fly problem at bay.

The produce from the farm this time of year includes asparagus, mushrooms, and eggs.  The longer days mean that all hens are laying and I delivered 22 dozen eggs to Tilly and Salvy’s farmstand last night.   I’m picking daily fresh asparagus and just harvested 20 pounds of Shiitake mushrooms.    Soon, our spring greens will be ready in the hoophouse and they’ll be replaced with cucumber, tomato, and pepper transplants, which are growing in the greenhouse now.

The weekend ahead includes the usual farm and sanctuary related tasks - animal care, repairs, planting, wood cutting, and trail mulching.   As stewards of 150 animals and 60 acres, the joyful work is never done.