Saturday, February 15, 2014

Today, maintaining health and fitness have become more important than ever before. With illnesses becoming more often, we have to equip ourselves with everything necessary to maintain health and have a good quality of life. One of the best ways to jumpstart your way to better health is through reading health and fitness magazines. These magazines offer helpful tips, advice and recent discoveries about health that should come handy. Note that although fitness magazines are aimed mainly at body- and health-conscious audience, everyone will surely benefit from all the information they provide. Here are some of the most popular health and fitness magazines today:
Muscle & Fitness Magazine
This magazine was released mainly for bodybuilders. However, if you are conscious about your health and do workouts, you can use vital information on this magazine. There is a version of this magazine called Muscle and Fitness Hers aimed mainly towards health-conscious ladies. This magazine contains tons of information that can range from bodybuilding foods, diet programs, weight loss strategies, workout information, supplements, and other recent discoveries.
Shape Magazine
Shape Magazine has been edited to help you get a better understanding of fitness. It features articles from experts in the fields of nutrition, exercise, beauty and psychology. Shape is mainly geared towards fitness enthusiasts who surely will benefit from each and every bit of information that the magazine contains. It highlights news, step-by-step guidelines, recipes, and tips in beauty, fashion, style, and everything in between.
Men's Fitness Magazine
Men's Fitness is also a magazine designed for the modern health conscious men. It contains articles containing important details on maximizing workout, optimal diet and nutrition necessary for perfect fitness. Each issue is aimed at showing you how to properly workout your specific body parts, look better, unleash your sexual drive, and essentially put adventure back into your life.
Subscribing Health and fitness magazines cover everything a health and body-conscious person needs to know. If you are aware of the importance of maintaining tiptop health, and are actually doing something about it, a subscription to these types of magazines will provide you great discounts than buying them at the newsstand. Health and fitness magazines are usually offered in an attractive price package through websites.
Consider subscribing to a health and fitness magazine as an investment for your health and yourself. There is nothing more important than valuing health. Today, it may seem like an added financial burden but the long-term benefits that reading about health can give are far worth it. Besides, you can get subscriptions at rock bottom, discounted prices. However, be careful with the website you will subscribe to. Trust only the most reliable website that has a good reputation online.

Thursday, February 13, 2014

I've written about our winter preparations and keeping the animals healthy in the 6 months of sub-freezing weather we have in New England.   It's been a particularly cold winter in Massachusetts.  It's currently 2 degrees F and we're expecting another foot of snow.

As the snow gets deeper, the icicles get longer, and all unheated water becomes a solid chunk of ice, how do we manage our weekly work routine on the farm?

Our 15 acres of woodland require constant maintenance - bucking fallen trees, removing broken branches, repairing trails/bridges, splitting wood, and making chip piles.

The new Terex PT30 compact track loader makes this job infinitely easier since I previously used a 6 cubic foot wheelbarrow and heavy duty cart to haul logs, branches, and chips.    I've removed trees, brush and rocks along our 1 mile of trails to accommodate the 48" width and 10" ground clearance of the Terex, so I now can reach any portion of the 15 acres with the Terex.   Last week, after a foot of snow, I used the Terex to clear working paths through the barnyard, manure management bins, and wood processing area.  Every week I split about 1/2 cord of wood by hand, which is challenging to do with a few feet of snow on the ground.   My solution is to clear trails with the Terex then use a snow sled to haul wood from the splitting area to the storage area and from the storage area to the fireplaces.    "Sledding" on the farm has definitely improved our winter work efficiency. The carts and wheelbarrow are getting a rest until the snow melts.

Manure management (10,000 pounds per year) is challenging at 2 degrees F in two feet of snow.   Although the manure is biologically warm, the sub-freezing weather yields a frozen blend of manure, hay and snow.   I use an ice chipper to break up the manure in the barn stalls and then move it to a sled dedicated to manure hauling.   As you'll see in the pictures below, we have our own bobsled tracks for manure management during the winter.    I doubt manure bobsled will ever be an Olympic event.

We have over 100,000 bees at Unity Farm, spread in 8 hives, each with 2 deep hive bodies and 10 frames.    We entered the winter with 7 strong hives, and 1 weak hive.   Although we stopped harvesting honey in August and left plenty of food stores for the bees in winter, we supplement the hives with bee tea  (in a 1 gallon tank that fits in the hive) and fondant.    Here are the recipes

Bee Tea
10 cups can sugar
6 cups hot water
fresh or dried chamomile and/or time
1 teaspoon sea salt

Combine sugar and salt.  Add hot water and stir thoroughly.   Boil 2 cups of water and add herbs.  Steep for 10 minutes.   Strain and mix into sugar water solution.  Cool and feed to bees.

5 pounds sugar
1 pint light Karo syrup
1 1/3 cups water

Heat in a saucepan to 242°F while stirring constantly – this mix will be boiling for about 5 to 8 minutes before it reaches 242°F . Take if off the heat and let it sit for about 10 minutes to start the cooling process. You then must start stirring until it completely cools. This will take about 20 minutes. It will get whitish in color and thicken up. Once this happens, then you can pour onto paper plats. Don’t wait too long or you will not be able to pour it and get it to the thickness that you need to put in the hives.
(1/4"). When ready to feed, remove paper, break in half and place both halves on the top of hive frames.

Finally, we think of Unity Farm as part of the Massachusetts agricultural community and immediately volunteered to help in this rescue situation.    I'll post additional details as we get more involved.

Wednesday, February 12, 2014

Readers of my blog know that over the past year, I've written several posts warning about the burden of 2014 certification, the  timing overlap of numerous federal programs including ICD10, and my observations that IT professionals/providers are at the breaking point.

However, I have reasons to be optimistic and it's not just the approach of Spring.

1.  There is a new national coordinator who is a great listener

I have every expectation that Karen DeSalvo will gather input from stakeholders and adjust the trajectory of national HIT policy within the limits of regulatory process constraints.  She understands the impact of the current federal programs and the challenges providers face getting through each day.  She knows there is a balance between appropriate regulation and over regulation.   She knows that cultural change, even driven with stimulus and urgency, requires incremental progress over time.   We've already seen a few timeline extensions (an extra year of Stage 2, extra time for hospitals and EPs to attest to 2013 reporting periods) and I expect more to come.

2.  There is an opportunity to rethink certification

With CCHIT's closure, delays in 2014 certified product availability, and significant stakeholder discussion about the certification process, all are aware of the need to revise certification.    I envision a day when ONC and its Federal Advisory Committees formulate policy goals for certification (i.e. quality improvement depends upon measurement), but then those actually doing the front line work (vendors, providers, payers, patients) develop practical certification scripts that ensure software supports the policy goal.

3.   The Sustainable Growth Rate (SGR) bills consolidate PQRS, Meaningful Use and the Value-Based Payment Modifier into a single program, eliminating penalties.

Meaningful Use has been a remarkable program, achieving rapid adoption of EHRs in hospitals/professional offices and fundamentally changing the cultural expectation of automation in healthcare.    The SGR bills transition the Meaningful Use construct from a special program to an operational part of value-based purchasing.    Making IT performance part of operational activities related to reimbursement will even out the pace of work.

4.  Meaningful Use might become a stretch goal instead of a floor

If Meaningful Use moves into a “Merit-based Incentive Payment System”, eliminating penalties, the program becomes a way for early adopters and innovators to be recognized for their efforts.    It was very appropriate that Meaningful Use Stage 1 and 2 set a floor and became a tide that floated all boats.  Going forward, it will be very challenging, if not impossible in a resource constrained world, to ensure every healthcare organization performs on the bleeding edge of innovation.   Merit based incentives enable organizations to evolve at their own pace.

5. Meaningful Use is not the solution to every problem and there are signs that other approaches may be used

It's been an honor to work on Meaningful Use, but by 2016, we need to declare victory to avoid having an ongoing special program through which every interested party inside and outside government sees an opportunity to accelerate their own priorities, creating meaningful use fatigue.   Pilots, grant programs, datapaloozas, pay for performance incentives, and competitions all enable us to move forward the technology agenda with a better balance of benefit/burden than an everlasting Meaningful Use program. 

Finally, as ONC and its committees focus more on interoperability that empowers innovation instead of prescriptive functionality (the EHR must do X, Y, Z), we need a roadmap.   I'm very optimistic that the schedule below (which I sense is developing organically among vendors, SDOs, and policy experts) will lead to much more data liquidity, care coordination and patient empowerment in a timeframe that enables us to overcome cultural resistance and policy barriers:

1.  CCD - unified CCR and CDA, first time vendors began exporting a summary, ad hoc device interoperability  (2011)
2.  CCDA - much more constrained, first time vendors began importing a summary,  Continua Alliance IEEE 11073 products emerge, FDA guidance issued (2014)
3.   FHIR/REST - much easier to implement, will result in a substantial increase in modular products connecting to monolithic EHRs, Continua Alliance IEEE standards recommended, no device data transport standards specified  (2017)
4.  APIs - will expand the number of shared data elements from hundreds to thousands and enable read/write workflows, Continue Alliance IEEE standards required, device data transport options recommended (2020)
5.  Detailed Clinical Models (ie. Clinical Information Modeling Initiative) which will begin to standardize the schemas underlying EHRs and then interoperability can happen via APIs linked to standard schemas, ensuring data integrity from point of origin to point of use, device data transport standards required (2023)

In times of struggle, there is opportunity.   2014 is the most stressful time in healthcare IT in our generation.   From that struggle will come a reasonable path forward we can all support.

Thursday, February 6, 2014

As I mentioned last week, my wife and I have enrolled in an evening Bee school to formalize the beekeeping knowledge that to date we've picked up from books and our early experiences with 8 hives at Unity Farm.

It's been a hard winter in Massachusetts.   Over the past 24 hours, Unity Farm has had over a foot of wet, heavy snow.   We're waiting for a warm day to open the hives and check on the bees.   Although we've provided supplemental food and kept the hives dry, there is a high overwinter bee mortality in New England, with about 80% of colonies dying.

The bee school will provide us with the best practices and a schedule to maximize the health of our bees.

In many ways, beekeeping is like IT - it requires infrastructure and ongoing maintenance.    Just as with tractors, asking 12 beekeepers for advice results in 13 different recommendations.  Based on all our reading, discussion, and training thus far, we're planning to standardize our hives and tools this Spring as follows:

Each hive
 2 Deep Hive Bodies
 2 Medium Hive Bodies as "Supers"
 20 Deep Frames/Foundation, Divided
 20 Medium Frames/Foundation, Divided
 Telescoping cover
 Inner cover
 Screened bottom board
 Entrance reducer
 Hive stand
 Hive top feeder
 Queen excluder
 Escape Board Screen

 Hive Tool
 Bee Brush
 Frame Grip
 Capping scratcher
 9 frame spacer tool

 Bee Suit
 Bee Veil/Helmet

We also may need to add new bees to our hives and there may be a shortage this year.  Many bee colonies are overwintered in Georgia.   The "polar vortex" brought freezing temperatures to the most dense apiary areas.    We've ordered several 3 pound "packages" with queens to ensure we're prepared.

We're very excited to take on the additional responsibility of supporting our bees, armed with new knowledge, just as we've taken responsibility for the 100 animals of Unity Farm, keeping them happy and healthy throughout the year.

Wednesday, February 5, 2014

At last week's Meaningful Use Workgroup meeting, Leslie Kelly Hall and I reviewed the HIT Standards Committee recommendations for patient generated healthcare data from online applications and devices.

We offered guiding principles for Meaningful Use Stage 3 in general.   Meaningful Use should avoid "certification only" items since requiring engineering in products to support untested workflows with immature standards is unlikely to accelerate progress.   We should only apply standards/certification to those processes where they are needed and useful.

For patient generated data sent from interfaced applications, CCDA is recommended as a container for  types of templates that are well understood (e.g. problems, meds, allergies).   CCDA over existing (Direct, Exchange) and other modes of transport are reasonable ways to get data in and out of EHRs, PHRs, and patient facing applications.

CCDA should not be required as the architecture that integrated applications must use.   The outcome goal is for the entire care team (patient/families/providers) to be able to contribute to a shared medical record and that can be achieved without CCDA in a fully integrated application.  We need to allow for innovation and flexibility in this area and not unduly constrain options for individuals to connect with their care teams in the ways they prefer.

For patient device generated data, we need to support innovation, as the marketplace is still rapidly evolving.

Continua implementation guides (and their underlying IEEE 11073 standards) are directionally appropriate, but ONC needs to align certification with FDA guidance and other regulatory or sub-regulatory policy without constraining the marketplace.

Due to the immaturity of the market,  we need to be flexible regarding incorporation of device data and other remote data sources.  Thus, we do not believe a specific standard should be mandated at this time, just an attestation requirement that some approach has been used successfully.

We are fully supportive of efforts to integrate patient generated healthcare data from applications and devices into provider workflows.    By using the CCDA and encouraging market-based innovative device integration, we believe burden and benefit can be balanced.

A person's health does not refer to his or her body only, but to every aspect of that person's well being.Health includes the physical aspect of an individual as well as his or her mental and emotional well being, too.The medical community strives to protect people from the damaging effects of both physical and mental illnesses, which is why the term "health" encompasses so much more than the physical. So, in order to live a fulfilling and rich life, a person must pay close attention to his or her overall health, not just individual aspects of it. This is why there are so many different health and fitness programs available to people today.
In order to maintain a healthy body and mind, you should definitely stick to a good fitness plan. This may mean joining the local fitness center, engaging in daily physical activity, or buying some home fitness equipment. Depending on your lifestyle, available time, and where you live will determine which type of health and fitness plan is best for you. Once you have decided on the right fitness plan or regimen, be sure to stick to it.As long as you adhere to your fitness program you will definitely begin to look, feel, and work better. Being physically fit will affect every aspect of your life in a very positive way.
When considering a new fitness program, it is important that you take into consideration your gender, age, eating habits, and level of current activity. It is important that you enter into a new fitness regimen carefully and always after you have discussed the plan with your doctor. Many times, people become very enthusiastic about the prospect of improving their overall health and fitness which makes them make poor choices and over exert themselves. Over exertion will do more harm than good, so even if your goal is to lose fifty pounds (as long as it is a healthy amount of weight to lose based on your height and body type), you should work consistently at it rather than obsessively.

Tuesday, February 4, 2014

Today at the HIT Policy Committee meeting, the Meaningful Use Workgroup will present its recommendations as part of the process leading to a final rule in 2015:

Feb 2014: Draft stage 3 recommendations reviewed with HITPC
March 2014: HITPC approval of stage 3 recommendations
Fall 2014: NPRM for stage 3
1st half 2015: Final Rule for stage 3
Effective: 2017

I presume the regulation writing will follow previous approaches with ONC writing the certification rule and CMS writing the attestation rule.

As I've written about recently, I think it is important to evaluate Meaningful Use Stage 3 from several perspectives including workflow impact, standards readiness, and the tension that such regulations create by prescribing functionality in products, reducing the ability of organizations and vendors to set their own priorities.

The certification criteria noted in the Meaningful Use Workgroup slides are enumerated below and I've added my own discussion questions.  It’s important to assess not only the merits of each of the criteria, but their cumulative effect.   Each hospital and physician office will have to trade-off meeting these requirements instead of doing something else, because few if any providers have the bandwidth to take on more.

In addition to the detailed discussion points below, I suggest that each of the criteria meet a three-part test before being considered for Meaningful Use Stage 3:   1) is there evidence that the specific technology function, if used, would substantially improve the quality, safety, efficiency, or affordability of care? 2) do we believe that the market will not adequately address the requirement on its own 3) will there be sufficient, uniformly available state-level and industry infrastructure in place to make the required technology achievable?.

When I write about such topics, I have to select my words very carefully.   Throughout much of my life, I've been viewed as an edgy innovator.   At this period in my career, some view me as the status quo, resistant to change.  When I propose discussion questions below, I am not taking a position for or against a policy goal.   I'm trying to weigh the cost/benefit of regulation at a time when many stakeholders in healthcare are resource constrained, time bankrupt, and struggling to comply with existing regulations.

I look forward to the open debate of these issues

1.  Clinical Decision Support (CDS)
Ability to track CDS interventions and user responses
Perform age-appropriate maximum daily-dose weight based calculation
Consume external CDS rules

Discussion questions:
a.  Will tracking every intervention and user response, a technically challenging activity, substantially impact healthcare quality/safety, research, or efficiency?
b.  Are standards sufficiently well described/mature to author and exchange externally authored rules?
c.  Must we require that all rules be transmitted or might we allow options such as decision support services in which rules reside in external modules and only questions/answers are exchanged?

2.  Advance Directives
CEHRT has the functionality to store the document in the record and/or include more information about the document (e.g., link to document or instructions regarding where to find the document or where to find more information about it).

Discussion questions:
a.  Given variations in state regulations for advance directives, will we require structured data standards or accept free text/pointers to free text?
b.  Can we eliminate the "OR" since such criteria become an "AND" for developers

3.  EMAR
CEHRT provides the ability to generate and report on discrepancies between what was ordered and what/when/how the medication  was actually administered to use for quality improvement

Discussion questions:
a.  Is tracking every variation/override, a technically challenging activity, a high priority for healthcare quality departments?
b.  Do discrepancies commonly occur and if so, are these discrepancies clinically relevant?

4.  Imaging
For both EPs (menu) and EHs (core) imaging results should be included in the EHR. Access to the images themselves should be available through the EHR (e.g., via a link).

Discussion questions:
a.  To clarify, does this imply a certification criteria to receive electronic radiology results, analogous to electronic lab results?
b.  If so, are the standards for receiving radiology results (including vocabularies for naming radiology tests/procedures) sufficiently mature to support such functionality?

5.  Clinical Documentation
Help the reader understand the origin of any copied text and identify relevant changes made to the original text.  Example method: provide functionality analogous to “track changes” in Microsoft Word? to make the original source of copied text clear and any subsequent changes made

Discussion questions:
a.  Today, many organizations address copy/paste with policy.   Must we enforce policy with technology?
b.  Given that many applications are web-based and not a "thick client" such as Microsoft Word, there may be significant technical challenges in distinguishing between typing and pasting.   Does the technology exist to support this requirement?

6.  Test Results Tracking
Display abnormal tests
Date complete
Notify when available or not completed
Record date and time results reviewed and by whom
Match results with the order to accurately result each order or detect when not been completed

Discussion questions:
a.  Does this imply implementation of closed loop ordering i.e. require electronic ordering of all tests and not use of an ordering portal, faxing, or order sheets?
b.  Who should be notified via what escalation method when a test is not reviewed or completed?

7.  Device documentation
EPs and EHs should record the FDA Unique Device Identifier (UDI) when patients have devices implanted for each newly implanted device

Discussion questions:
a.  What is the current timeline for UDI implementation in device products?
b.  What will be done with this information once in the EHR i.e. recall workflow?

8.  e-Prescribing
Access medication fill information from pharmacy benefit manger (PBM)
Access Prescription drug monitoring program (PDMP) data in a streamlined way (e.g., sign-in to PDMP system)

Discussion questions:
a.  What is the current state of fill status information standards and their implementation in PBMs/e-prescribing networks?
b.  Which states have a PDMP system and the capacity to support single sign on/patient context sharing?
c.  Are standards available for PDMP integration?

9.  Demographics
CEHRT provides the ability to capture
Patient preferred method of communication
occupation and industry codes
Sexual orientation, gender identity (optional fields)
Disability status
Differentiate between patient reported & medically determined
Communication preferences will be applied to the clinical summary, reminders, and patient education objectives
Providers should have the  ability to select options that are technically feasible for them, these could include:  Email, text, patient portal, telephone, regular mail

Discussion questions:
a.  Do we have appropriate vocabularies for capturing these elements as structured data?
b.  Given current workflows and personnel, do we believe that we can achieve sufficient accuracy in the recording of these elements to support the expected uses of the data?

10.  Record amendment
Provide patients with an easy way to request an amendment to their record online (e.g., offer corrections, additions, or updates to the record)

Discussion questions:
a.  How does this align with current workflow and practice?
b.  What standards are required to support this function i.e. structured approaches to requesting change versus free text i.e. an email request?

11.  Patient Generated Healthcare Data
Menu: Eligible Professionals and Eligible Hospitals receive provider-requested, electronically submitted patient-generated health information through either:
structured or semi-structured questionnaires (e.g., screening questionnaires, medication adherence surveys, intake forms, risk assessment, functional status)
or secure messaging

Discussion questions:
a.  As above, we have to be careful when we use the word "OR" since this  implies "AND" for developers, meaning that all possible variations of functionality must be implemented. What is the minimum functionality required?
b.  Are there standards that constrain the kinds of data submitted i.e. CCDA templates?

12.  Patient Summaries
CEHRT allows provider organizations to configure the summary reports to provide relevant, actionable information related to a visit.

Discussion questions:
a.  How would such rules be authored and what standards would be used to represent knowledge?
b.  What is the definition of relevant and actionable?

13.  Multi-language support
EHRs are capable of providing patient-specific non-English educational materials based on patient preference.  At least one patient receives non-English educational material according to the patient’s language preference

Discussion questions:
a.  Is only one non-English language required as a minimum and not a representative sample based on local populations?  
b.  Are standards  to support multi-lingual retrieval implemented by educational material providers?

14.  Transitions of Care
EPs/EHs/CAHs provide a summary of care record during transitions of care
Types of transitions:
Transfers of care from one site of care to another (e.g.. Hospital to: PCP, hospital, SNF, HHA, home, etc)
Consult (referral) request (e.g., PCP to Specialist;  PCP, SNF to ED) [pertains to EPs only]
Consult result note (e.g. consult note, ER note)
Summary of care may (at the discretion of the provider organization) include, as relevant:
A narrative (synopsis , expectations , results of a consult) [required for all transitions]
Overarching patient goals and/or problem-specific goals
Patient instructions (interventions for care )
Information about known care team members

a.  Are standards available to support these data elements such as patient goals or problem-specific goals?
b.  Are there closed loop workflows required i.e. tracking of completed referrals?

15.  Notifications
Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to known members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required
Significant events include:
Arrival at an Emergency Department (ED)
Admission to a hospital
Discharge from an ED or hospital

Discussion questions:
a.  Do we have a sufficient vocabulary (NPI, direct address etc.) to identify members of the care team and the means to notify them electronically?
b.  Are standards sufficiently mature to support each of these communications as structured data?

16.  Immunizations
CEHRT functionality provides ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice

Discussion questions:
a.  Are standards sufficiently mature to support query/response of this data?
b.  Do public health departments plan to support this functionality?

17.  Case Reporting
CEHRT is capable of using external knowledge (i.e., CDC/CSTE Reportable Conditions Knowledge Management System) to prompt an end-user when criteria are met for case reporting.   When case reporting criteria are met, CEHRT is capable of recording and maintaining an audit for the date and time of prompt.

CEHRT is capable of using external knowledge to collect standardized case reports (e.g., structured data capture) and preparing a standardized case report (e.g., consolidated CDA) that may be submitted to the state/local jurisdiction and the data/time of submission is available for audit.

a.  Is the CCDA the appropriate standard to support case reporting?
b.  Do state/local jurisdictions plan on implementing such workflows?
c.  Do the appropriate standards and rules for defining reportable conditions exist?

18.  Registry Reporting
Reuse CEHRT data to electronically submit standardized (i.e., data elements, structure and transport mechanisms) reports to one registry
Reporting should use one of the following mechanisms:
Upload information from EHR to registry using standard c-CDA
Leverage national or local networks using federated query technologies

Discussion questions:
a.  Is the CCDA the appropriate standard to support registry reporting?
b.  As with other "OR" criteria, will EHR vendors have to implement upload AND federated query approaches?

Once we answer these questions, we can weigh the impact on clinician workflow, the burden on development resources, and the balance of federal directives versus competing local organizational priorities.

Let the discussion begin!



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