Cool Technology of the Week

Last week I had dinner with the CEO of a very successful software company.  He told me that 30% of all downtime for his products was caused by anti-virus software.

Given the sophistication of today's malware, it's clear that a new approach is needed to anti-virus software.

Intel introduced a virtualization component to their chipset a few years ago.   When they acquired anti-virus company McAfee, they collaborated to leverage their  "VT-x" chipset to catch advanced persistent threats and root kits, both of which run at the same privileged level as the typical anti-virus products.   The VT-x chip enables a security monitoring process which runs at a low level in a very highly privileged status in the chip.   It can monitor CPU and memory state changes and flag, quarantine or stop anything it sees as suspicious.      All new Intel-based, Windows 7 machines include this capabilities.  Here's a white paper about it.

For those of us who live in the trenches of information technology, malware and root kits are the bane of our desktop management staff because they cannot be cleaned with existing standard antivirus software and require re--imaging the machines.  

Anti-virus on a chip that cannot be disabled by malware.   That's cool!

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Building Unity Farm - The Guinea Fowl Who Lost His Mojo

Running a farm with 50 animals is like having 50 children.   There are going to be bumps and bruises, stumbles, and occasionally serious injury.

Last week, one of Guinea Fowl, named Piebald (because he's a patchy blend of black and white) flew into the male alpaca area which is guarded by our Great Pyrenees Mountain dogs, Bundle and Shiro.   Normally our dogs ignore our birds, since the dogs have lived with the poultry for most of their lives.  Piebald ran around the inside of the pasture fence and his fluttering attracted the dogs.  They wanted to "play" with Piebald by "fetching" him.    Within seconds of this happening, I ran to the pasture, body slammed the dogs to the ground with a sharp NO, indicating that eating a fellow citizen of Unity Farm is unacceptable behavior.

My wife picked up Piebald and began walking him back to the coop.   A few of his tail feathers were missing, his head had a few spots of blood, and he looked a bit traumatized but otherwise intact.    On the way back to the coop, he jumped from her hands and ran straight into the forest surrounding our farm.    Kathy and I spent an hour looking for him to no avail.   As darkness fell, we suspended our search.

The next morning he reappeared in the coop,  looking out of sorts.  That afternoon he disappeared again and spent the night in the forest.

The following day, he reappeared in the coop but his affect was very submissive.   Previously Piebald was high on the pecking order.   Now, he was being pecked at by his subordinates.  He lost his mojo.

He spent the day running away from the other Guineas and losing various pecking order battles.

His wounds had healed and he was eating/drinking vigorously.   He stayed in the coop overnight but slept with the chickens.

The next day he began cruising the property with the other guineas.   He regained his upright posture and assertiveness.

Today he's been leading the pack once again, completely comfortable with being a leader of  Guineas.   He's regained his stature.

Every day is an adventure at Unity Farm.  You never know what interpersonal dynamics will develop with the alpacas, llama, guineas, chickens, and dogs.   You never know who will squabble, who will have an injury/illness, and who will develop new behaviors.    If it wasn't for the rigors of being a CIO, I could spent the day watching the events of the barnyard - far more interesting than Fox News or CNN.

We've had life and death on the farm, sickness and health on the farm, joy and sorrow on the farm.    At the moment, everyone is healthy, happy, and knows their place in the pecking order.

As we prepare for the Christmas on the farm, it's good that our citizens are all at peace in their community.

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Rethinking Remote Access

As I travel the country, I find that CIOs everywhere are struggling with BYOD in particular but remote access more generally.   Who is responsible if

A personal unencrypted laptop with email containing personally identified/protected healthcare information is stolen?   The CIO of the institution providing email takes accountability and reports the theft to appropriate  government regulators.

An employee prints a web page on their home computer and patient data is discovered blowing around in a nearby dump?  The CIO of the institution hosting the patient data is responsible.

An employee with a malware infected but encrypted smartphone accesses a web application and a keystroke logger sends the username/password to hackers in Asia who use it to send spam.   The CIO is responsible for all the consequences.

Policy against using personal laptops, home desktops, and smartphones for processing of healthcare data is not sufficient.  CIOs must use technology controls to mitigate risk of data loss.

For example, BIDMC has already used AciveSync to enforce encryption of every smartphone accessing our network and to deny access to those smartphones that do not support encryption.

Personal laptops and home desktops are much harder to control.  Purchasing institutionally supported laptop/desktop devices for every user needing remote access would be cost prohibitive.  

Rather than try to manage the home clients that have multiple varieties of hardware, operating systems, and third party apps, it's more practical to impose restrictions on who can access resources remotely, where they can access resources from, and what they can do (block downloads and printing).   Solutions I've heard from industry experts include

1.  ActiveSync as the only means of smartphone email access with a configuration to require encryption of client devices.  Use Outlook Web Access as the only laptop email access method and close all other types of remote email access - WebDav, Web Exchange Services, and RPC over HTTPS, IMAP, POP
2.  SSLVPN for all remote access to all applications (including web portals) with configuration settings to prevent remote downloads and printing
3.  Citrix or Virtual Desktop Infrastructure, which typically does not persist data on local clients.

I've described security as a continuous improvement process - the journey is never done. I'm curious what you are doing to restrict remote access in a world of malware, BYOD, and enhanced regulatory enforcement.   Comments are welcome!

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Facebook Revisited: Does the Platform Help or Hurt Users (or Both)?

The benefits and challenges of social media for public health are a frequent topic on Pop Health.  For example, I've explored the influence of these platforms on emergency response, increasing the number of organ donors, and health activism.  However, one of the debates that I hear the most among public health colleagues relates to Facebook.

Does it isolate users?  Does it connect users?  Does it do both?

Earlier this year, my colleague Elana Premack Sandler explored this debate as it relates to loneliness.  Inspired by a feature in the Atlantic Magazine, Elana asks key questions like, "Is Facebook part of the separating or part of the congregating?"  She also mentions concerns about how Facebook (and other social media platforms) affect our social skills and therefore our friendships.

I thought of Elana's writing as I read a new post on the Atlantic website today, "Are Your Facebook Friends Stressing You Out?  (Yes.)".  This post highlights a new report out from the University of Edinburgh Business School.  The report caught my eye because it identified a very specific cause of stress for Facebook users.  The more groups of "friends" a user had (e.g., family, real life friends, co-workers, etc), the more anxiety they had because there was a greater chance of offending someone with their posts.  The report stated that the greatest anxiety came from adding parents or employers as Facebook "friends".  As Megan Garber writes so eloquently in her Atlantic post, the stress comes from Facebook forcing users to "conduct our digital lives with singular identities".  The way we speak or act around family or friends or co-workers must jive on Facebook, or we run the risk of offending someone.  I'm sure many of us saw this conflict a few weeks ago when political and election posts ran rampant on Facebook!

The anxiety described above is interesting, because ideally what we would hope is that Facebook provides a source of social support to users.  Social support occurs when one is cared for by others (via emotional, tangible, or informational support).  The presence or absence of social support is a factor related to public health issues, such as suicide.    

So after reading through the various posts/articles, what do I think about my opening questions about Facebook?

Does it isolate users?  Does it connect users?  Does it do both?

I think it does both.  I have seen it do both.  For example:

Isolation:  I have spoken to friends and colleagues who feel terrible about themselves or their lives after scrolling through their Facebook news feed.  A friend with chronic illness feels isolated hearing about the latest vacation or new job taken by her "friends".  A friend suffering from infertility can't bear one more picture of a "friend" and their newborn.  I think much of this results from the "whitewash" that many of us put on Facebook.  We often paint a picture for our Facebook friends, full of engagements and babies and fun events.  

Connection:  Earlier this year I watched a suicide intervention unfold on Facebook via the comment section under a post.  A friend of a friend posted a suicidal message on their Facebook wall.  Within minutes, "friends" reached out in the comments.  However, not only did they "speak" to the person, but they interacted with each other and followed up in real life.  One comment read, "Did someone go to his house?"  The next comment read, "I went to his house and I called his parents".  After he was taken to the hospital, a comment was posted to inform all the friends that he was safe.  As a public health practitioner that worked in suicide prevention for years, I was amazed with what I saw. 

So what can we do to reduce the isolation/anxiety and increase the connection?  You can certainly start by exerting your control over your Facebook account.  For example:

• Create a policy about "groups of friends" that you accept into your circle.  I know lots of people that do not accept requests from co-workers or parents.  They make it clear to the individual that it is nothing personal, they just have minimal friends with which they share intimate information.
• Use the privacy settings!  You can control who can see your posts.
• Find and use the unfriend button!  I have done this frequently.  If someone posts messages that are offensive or disrespectful regarding something that I've posted- I get rid of them quickly.
• Take a break from Facebook.  If you realize that Facebook is making you feel bad about yourself, take a break or disable your account.  Use that time to connect with your in real life (IRL) friends or family.

Tell me what you think!  

• Does Facebook isolate and stress us?  
• Does Facebook connect us?
• What other strategies can help to reduce the isolation and increase the connection on Facebook or other social media platforms?

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A Presentation to HIMSS in North Dakota

This morning, I joined a HIMSS group in North Dakota to discuss Meaningful Use Stage 2, Health Information Exchange, and Personal Health Records.

Here are the slides I used.

I was asked an interesting question about the transition from Stage 1 to Stage 2.

The Stage 2 Final Rule notes that as of 2014, any provider or hospital attesting to Stage 1 must use Stage 2 certified technology.   Since the capabilities of Stage 2 certified technology are different than Stage 1, the nature of meaningful use changes for those who begin the program late.

The details of the changes  to Stage 1 Core and Menu set objectives over time is summarized in this excerpt from the Stage 2 final rule.

A summary table of the effects is below, illustrating that the number of objectives changes as the certified technology changes.   I hope you find this useful.

EPs

	Stage 1 (2011-2012)	Stage 1 (2013)	Stage 1 (2014+)
Core	15	13	13
Menu	5 of 10	5 of 10	5 of 9

Hospitals

	Stage 1 (2011-2012)	Stage 1 (2013	Stage 1 (2014+)
Core	14	12	11
Menu	5 of 10	5 of 10	5 of 10

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Building Unity Farm - Thanksgiving on the Farm

Today was our first Thanksgiving at Unity Farm.   Although I've discussed the farm in detail, I've not described the home.   We live at the farm in a house adjacent to the pasture.   My father-in-law lives in the in-law wing, we live in the first floor. and our daughter has an area on the second floor.

The entire family selected vegetables from the farm and surrounding farms, then spent the day peeling, chopping, and preparing a vegan feast.  Just about everything but the Tofurkey was grown on the farm or within a mile of it.  We had

Tofurky with roasted potatoes and carrots
Celery and chestnut stuffing
Rutabegas
Mashed potatoes
Green beans
Brussells sprouts
Squash
Pickles/onions
Sweet potatoes

A remarkable meal.

During dinner 30 turkeys dropped by the farm for a visit and roosted in the trees above our alpacas.   It's clear to me that the best place for a turkey on Thanksgiving is a vegan/vegetarian farm!

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A Time for Giving Thanks

2012 has been a year of joys and sorrows.   My wife had breast cancer, my mother broke her hip,  my cat died of pancreatic cancer, I left my CIO role at Harvard Medical School to focus on BIDMC's emerging accountable care organization, and moved/consolidated two families from suburban houses into Unity Farm.

Some would consider this amount of change and challenge to be overwhelming.

I think of them as transformative.

It may sound strange to quote Marilyn Monroe when reflecting on Thanksgiving, but her words are appropriate:

“I believe that everything happens for a reason. People change so that you can learn to let go, things go wrong so that you appreciate them when they're right, you believe lies so you eventually learn to trust no one but yourself, and sometimes good things fall apart so better things can fall together.”

Without the catalyst of my wife's cancer diagnosis, we would not have sold our home and purchased the farm at a time when market conditions were ideal for both transactions.

My mother's hip fracture enabled us improve their house for accessibility and reconcile her medications.

My cat's unexpected illness educated us about animal care at a time when we took on the responsibility for 50 chickens, llamas/alpacas, and guinea fowl.

My job consolidation enabled me to channel all my passion and energy into healthcare information exchange at the federal, state, and local level such as the Massachusetts Golden Spike event.

Unity Farm has provided a healing environment for everyone in the family and the memories of the work required to sell two houses, close my wife's gallery and move her studio to the farm is fading fast.

BIDMC was ranked the #1 IT organization in America this year.  We were the first hospital in the country to attest to meaningful use and receive stimulus funding.  We achieved all our FY12 application and infrastructure goals.

Regardless of the events of any given day, temporary crises or urgencies pale in comparison to the well being of people.   As we approach Thanksgiving 2012, all the people in my world are good.

My wife and daughter are happy.   My parents are healthy.   My Federal and State colleagues are working hard on challenging projects they enjoy.   My BIDMC teammates are making a huge difference during the most exciting time in the history of healthcare IT.   The citizens of Unity Farm are loved and well cared for.

In 2012, the events of each day were sometimes negative, but the trajectory for the year has been overwhelmingly positive.

As I tell my daughter, it's unclear what the endpoint will be, but as long as the journey along the way is the best you can make it, everything will be ok.

After all the events of the past year, I remained convinced that the future will be bright.

Thanks to everyone who traveled the path with me this year.

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The Patient Experience of EHRs

I'm often asked if the use of EHRs diminish clinician-patient interactions in the exam room.

At BIDMC, Jan Walker and Tom Delbanco  have done focus groups with patients about technology. Generally, they found that patients will embrace technology that gives them access to information about their care.  At BIDMC, where we have both a patient portal and Wi-Fi throughout the hospital, doctors often arrive at the bedside to find a patient viewing lab results on an iPad, ready with questions about their tests.

The literature studying outpatient offices with computers in the exam room suggest computers do not get in the way as long as clinicians are facile with them and maintain eye contact with patients.

Here are three articles:

"The examination room computers appeared to have positive effects on physician-patient interactions related to medical communication without significant negative effects on other areas such as time available for patient concerns. Further study is needed to better understand HIT use during outpatient visits."  J Am Med Inform Assoc. 2005;12:474–480. DOI 10.1197/jamia.M1741.

"Studies examining physician EHR use have found mostly neutral or positive effects on patient satisfaction, but primary care researchers need to conduct further research for a more definitive answer." J Am Board Fam Med 2009;22:553–562.

"With the implementation of the electronic medical record—called HealthConnect—in all exam rooms throughout the Kaiser Permanente health care delivery system, how computers in the exam room affects physician-patient communication is a new concern. Patient satisfaction scores were obtained for all primary and specialty care physicians in a large medical center in Southern California to determine how scores changed as physicians started using HealthConnect in the exam room. Results show no significant changes in patient satisfaction for these physicians. Although concerns were not realized that patient satisfaction might decrease after HealthConnect was introduced, there was also no evidence that introducing an electronic medical record in outpatient clinics increased patient satisfaction."  The Permanente Journal / Spring 2007/ Volume 11 No. 2

Clinicians have different approaches to the use of technology in the exam room - iPads, typing into a laptop, or just taking notes then entering data outside of the exam room.    When clinicians and patients work together to ensure safe, accurate, and timely record keeping, everyone wins.   Certainly, there may be awkwardness when clinicians struggle with new technology and patients perceive a change in attentiveness.  However, it is highly likely that as clinicians spend their entire practice lives using EHRs and all patient records are recorded in EHRs, that this awkwardness will disappear.   Just as mobile devices have replaced newspapers and magazines as the favored way for adults to access media, the EHR and PHR, as well as the processes needed to use them, will become a standard part of every clinical encounter, supporting rather than detracting from the patient experience.

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A Novel Idea for Managing Consent

In 2008, I wrote about representing privacy preferences in an XML form that I called the Consent Assertion Markup language (CAML).

At the November HIT Standards Committee we discussed the draft Meaningful Use Stage 3 Request for Comment (RFC), which includes a measure relating to query for a patient's record.  The RFC suggests an exchange of authorization language to be signed by the patient in order to allow retrieval of the requested information.    Discussion elicited the suggestion that perhaps patient consent preferences might be included as metadata with the data exchanged so that the patient approved uses of the data - treatment/payment/operations, clinical trials, transmission to a third party - could be respected.

After the meeting, Dixie Baker proposed a simple, scalable and powerful approach to avoiding the necessity of either exchanging authorization language for signature, and the complexities involved in exchanging patient preferences as metadata.  Her suggested approach draws from both the CAML idea with the metadata idea, but simplifies privacy-management for both consumers and providers, while offering the kind of scalability needed for the dynamic, collaborative healthcare environment we envision.

Imagine that instead of having to fill out a new privacy-preferences form at each encounter, the consumer could select and manage her preferences with a single entity, and at every other encounter, would need only provide the URI to where her preferences were held.   Then, upon receipt of a request for her health information, an EHR would only need to query the privacy-management service at the URI she provided to determine whether the request could be honored.  Her preferences would be captured as structured, coded data to enable query, without having to exchange a complete "form" in order to adjudicate an access request.  Per the CAML idea, this XML could include queryable preferences about what data the patient consents to exchange with whom and in what circumstances.   This set of privacy preferences could be maintained by the patient and would include such concepts as institution-level permission to share data with partner insitituions, permission to send data using a health information exchange organization, and approval to use data for certain types of research.  

Instead of sending these preferences with the data itself, the metadata header in  Consolidated CDA summary exchange would include a Uniform Resource Identifier (URI) that points to the privacy-management service where the patient's privacy preferences are held.

This simple idea - represent patient's privacy preferences/consents in query-able XML at a specific URI - enables an entirely new approach to health information exchange, while making it easier for consumers to make meaningful choices, and manage them over time.

For example

1.   A hospital is "pushed" a patient record from a primary caregiver.   The hospital wants to push that data to a specialist.   Before any data transfer is done to an outside organization, the URI is retrieved from the metadata and the patient's current consent preferences are applied to the data exchange.

2.   An emergency department wants to pull data from multiple data sources to ensure safe, quality, efficient care of an unconscious patient.   The URI of service holding the patient's privacy preferences is available from the state HIE, and the data is retrieved from various sources per the patient's preferences.

3.  At discharge, the patient's information is to be pushed to the patient and the primary caregiver/referring clinician per meaningful use stage 2 requirements.   Before the push happens, the patient's URI is checked for current data exchange preferences.

As we continue to work on a variety of "meaningful consent" approaches and support complex state privacy policy variants, the notion of recording patient privacy preferences in a place that is under the control of the patient and is query-able via a simple XML makes great sense.

I look forward to continued discussion of Dixie's ideas at the next Standards Committee meeting.

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Cool Technology of the Week

My daughter and one of my blog followers recently told me about a Japanese cultural phenomena that is truly a cool technology.

One of the hottest concert pop stars in Japan is an anime hologram with a vocal synthesizer.  Meet Hatsune Miku who appears in live concerts, despite the fact that she does not exist.

She's a vocaloid created with software that anyone can use to create realistic rock performances.

Ms. Miku is not alone.  She's done duets with fellow vocaloid hologram Megurine Luka.

Wired Magazine described the technology behind the creation of a wholly digital pop star.
 
Hatsune Miku is a cultural phenomenon in Japan, yet she lives only in the digital world.

That's cool!

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Building Unity Farm - The Community

One of the most important aspects of choosing a farm property is the community around you
* What is the zoning?
* How will your neighbors react to wandering guinea fowl or an escaped llama?
* Are there other farms nearby?

For our farm, we chose Sherborn, a very agriculturally friendly town just west of Boston.

The Sherborn town bylaws indicate that no agricultural pursuit can be restricted.   Of course, various wetland restrictions and environmental controls apply, but if we wanted to raise ostriches and emus on our 15 acres, we could.  Our land was previously a 200 acre farm and our only current neighbors are a 55 acre apple orchard and a 15 acre property used for horse rescue/mini-donkeys.    Those neighbors admire and support our livestock.  

But what about nearby farms?

This week, we ate foods gathered or purchased from our farm and surrounding farms (photo above).

The western border of our property is the Dowse orchard.   At the Dowse Orchard Farm Stand  we purchased:
Romaine and red leaf lettuce
Field broccoli
Apples (Mac, Cortland and Empire)
Local seasonal pies
Fresh pressed apple cider

Just over the hill from us is a 1700's dairy farm - the Sunshine Farm.
We purchased:
Field turnips
Field carrots
Field onions
Homemade sweet corn veggie pizza

Just down the street from us is the Sweet Meadow Farm where we purchased sugar pumpkins and grain/hay for our animals.

At our own Unity Farm, we gather 8 eggs per day from our chickens.   This season we grew eggplant, garlic, onions, and potatoes in our raised beds.   In our kitchen garden we grew parsley, sage, rosemary and thyme.   We planted our own apple orchard and will be planting an acre of high bush blueberries in the Spring.  We're building  a 20 foot x 72 foot hoop house that will enable us to grow year round produce.

Nearby, the Boston Honey Company runs a Honey CSA.  Our share this year included fresh combs and local wildflower honey.

 If December 21, 2012 really does bring cataclysmic or transformative events, living in Sherborn is good preparation for self sufficiency.   From our perspective, it's an ideal farm community.

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The Next Generation of Entrepreneurs

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.

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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.

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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.

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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!

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A Superstorm of Social Media

Over the past week, there has been widespread discussion regarding the broad reach and value of social media during Superstorm Sandy.  Jim Garrow wrote about the emergency management field's adoption of social media and the powerful influx of images received through those channels.  In the New York Times, Brian Stelter and Jennifer Preston discussed how public officials use social media during a crisis.  Technology bloggers have posted analyses regarding the increase in internet use during the storm.

So what can Pop Health add?  I wanted to break down "social media use" even further.  I wanted to discuss the specific ways in which I saw it being used.  And although I think we all have a primarily positive view of social media's contribution during an emergency, I think it is also important to highlight some of the challenges that may appear with these communication channels.

Let's start with the good stuff!  During and after the storm, I saw social media being used for:

Individual-Level Advocacy

Affected residents used social media to communicate directly with local and state officials to report property damage, ask questions, and request direct assistance.  For example:

• As the screen shot above shows, Cory Booker (the Mayor of Newark, NJ) has been corresponding directly with his residents on twitter and following up with the necessary supplies or services.

• Locally in Philadelphia, I've seen the same thing with Mayor Michael Nutter.  He has been messaging with citizens about downed trees and power, in order to direct assistance to areas that need it the most.

Community-Level Advocacy

One thing that amazed me during Sandy was the power of social media in terms of advocacy on behalf of whole communities (whether they be particular neighborhoods or cities).

• When Margate, Longport, and Brigantine, NJ were reopened after the storm, there was immediate and overwhelming protest to the toll on the Margate bridge.  Residents felt that it was extremely insensitive (and selfish) for the bridge owners to charge storm refugees to get back onto the island (especially when they had no choice but to take that particular route).  Through protests on twitter and Facebook, the bridge owners were persuaded to reverse their decision to charge.

• The decision to cancel the NYC marathon was a difficult- and some would say delayed- decision.  While objections to the marathon (and the resources it would require) were widespread, much of the discussion happened on social media.  These channels were used to post online petitions and plan protests.  As you know, the race was finally canceled two days before the start.

Donations

Social media has been a key place to ask for donations to help the victims of Sandy.  Some strategies have been more traditional (e.g., asking for donations for the Red Cross).  Others have been quite creative!

• For example, runners in the canceled NYC marathon could follow a link posted on twitter in order to donate their hotel room to someone displaced by the storm.

The power of social media lies in its reach and ability to deliver information in real time.  On the flip side, the concern is that false information can spread quickly as well.  Here are a few examples that happened during Sandy:

• If you were using social media when the storm hit, you may remember seeing many unbelievable images.  One that I saw over and over was a group of soldiers guarding the Tomb of the Unknown Soldier.  However, we later learned that this image was taken back in September.  Mashable pulled together a list of "7 Fake Hurricane Sandy Photos You're Sharing on Social Media".  

• A congressional campaign manager in NYC resigned after sending out false information on twitter.  One of the rumors he started was that the trading floor of the New York Stock Exchange had 3 feet of flood water.  Many of his tweets are shown here.

As you can imagine, there is great danger to the public's health if incorrect information is widely shared.  Residents may panic and evacuate from a location that is actually safe.  Emergency management and public officials may be distracted from the work at hand, because they have to deal with clarifying a rampant and destructive rumor.

I think we can all agree that the value of social media in a crisis far outweighs the potential challenges.  However, this is an important conversation to keep having and I'd like to hear from you:

• In addition to the examples above, how did you see social media used during Sandy?
• How can we be even more innovative?  In what ways could we use social media during a crisis that we haven't yet tried?
• How can we prevent false information from spreading during a crisis?

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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.

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Conseils pour mettre fin à l'acné adulte

Nous voulons tous bien paraître et se sentir belle. Nous passons beaucoup de temps et d'effort sur les produits de beauté pour aider à obtenir une peau lisse et claire. Toutefois, il existe encore des cas où nous rencontrons des poussées d'acné, même à l'âge adulte.

Adulte l'acné peut se produire de plusieurs façons. D'autres personnes peuvent avoir de l'acné inflammatoire. Cela se produit lorsque les bactéries sur la peau produisent des substances qui irritent la peau et le follicule environnante. Cela provoque des rougeurs sur la peau et peut causer des blocages sur nos pores de la peau conduisant à boutons et points noirs.

Un grand nombre de facteurs peuvent influer chances d'un individu d'obtenir l'acné à l'âge adulte. Pour la plupart des femmes, le déséquilibre hormonal pendant la menstruation ou la grossesse peut causer la peau d'éclater. Les situations stressantes peuvent aussi causer poussée d'acné pour la plupart des gens.

Vous pouvez réduire l'acné en utilisant des anticorps anti-acné crèmes et hydratants. Bien que ces produits anti-acné peuvent être efficaces, ils peuvent venir avec des étiquettes de prix énormes. Comme pour tout traitement, il faut religieusement les appliquer sur votre visage pour éviter les ruptures récurrentes de rupture.

En dehors de crèmes pour le visage et astringentes, cliniques visage offrir des services tels que les gommages du visage, diamant peler et traitements de l'acné. Ces services sont destinés à garder votre visage regardant claire et lisse. Cependant, vous devez être prudent car vous pourriez être allergique à certains ingrédients actifs qu'ils utilisent au cours de ces traitements. De plus, ces traitements peuvent être coûteux en fonction de la gravité de votre problème d'acné et de la complexité de la procédure.

Alors, comment pouvons-nous aider à combattre l'acné des adultes naturellement? Voici cinq conseils qui vous aideront à les éliminer naturellement:

1. Assurez-vous de nettoyer votre visage au moins deux fois par jour. Si vous devez laver votre visage fréquemment pendant la journée, utilisez un savon doux ou de la mousse pour le visage afin de ne pas avoir la peau sèche. Profitez de astringent doux aussi bien entre les lavages pour empêcher le pétrole et les cellules mortes de boucher vos pores.

2. Buvez au moins huit verres d'eau par jour. C'est peut-être le meilleur moyen de se débarrasser de l'acné que l'eau garde votre peau hydratée et aide à éliminer les toxines du corps.

3. De l'exercice régulièrement en prenant un jogging de 30 minutes autour de votre voisinage. L'exercice régulier aide le corps à se débarrasser des toxines par la transpiration. L'exercice peut aussi vous aider à faire face au stress indu dans votre vie.

4. Vous pouvez acheter des crèmes anti-acné, hydratants et nettoyants disponibles dans le marché aujourd'hui. Ces produits de beauté aider à prévenir les cellules mortes s'accumulent sur vos pores et élimine les bactéries qui peuvent irriter votre peau.

5. Prenez le contrôle de votre vie et faire usage des mécanismes d'adaptation pour réduire votre niveau de stress. Évitez de fumer autant que vous le pouvez car il tue les cellules vivantes et peuvent être mauvais pour votre peau. Mangez le bon régime de fruits et légumes pour aider à diminuer l'accumulation de mauvaises toxines dans votre corps.

En faisant ces quelques étapes simples, vous pouvez conquérir l'acné des adultes tout au long de votre vie. En suivant un mode de vie sain, vous êtes un peu plus sur l'obtention d'une peau claire et tout le monde lisse aimeront sûrement.

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Comprendre cicatrices d'acné

Probablement l'une des parties les plus crève-cœur de l'acné est les cicatrices qu'elle
peut laisser derrière. Même après l'acné a guéri, certains points peuvent être laissés plus comme un rappel constant.

Comprendre pourquoi vous avez des cicatrices, vous aidera à traiter votre peau et minimiser les dommages à long terme.

Donc, ce qui cause exactement les cicatrices d'acné?

Tout simplement, les cicatrices sont le résultat de lésions tissulaires. Lorsque votre peau est mis sous stress, votre corps tente de «réparer» le site de la lésion. C'est presque comme si votre corps envoie une «équipe spéciale» pour travailler sur le problème.

Les globules blancs et des molécules infammatory travailler pour combattre l'infection et à guérir les tissus endommagés. Dans le cas de la cicatrisation, le tissu a été incapable de retourner à son état initial.

Tout le monde est susceptible de cicatrices d'acné?

Pourquoi certaines personnes ont plus de cicatrices que d'autres n'est pas complètement élucidé. Il est, comme la plupart des choses, personne variations des experts croient person.Some la génétique joue un rôle important dans cicatrices d'acné, en contribuant à la mesure de la cicatrisation.

Certaines personnes ont des cicatrices qui montrent pour le reste de leur vie, d'autres
des cicatrices qui diminuent au fil du temps. Les gens qui souffrent de formes sévères d'acné inflammatoire, ce qui signifie lésions profondes racines, ont tendance à avoir plus de cicatrices que d'autres formes d'acné.

Comment dois-je éviter les cicatrices d'acné?

Bien sûr, la meilleure façon d'éviter les cicatrices, est d'employer un excellent
système pour éliminer l'acné tous ensemble. Le plus tôt vous commencez le traitement
plus vos résultats seront. L'idée est de se concentrer sur la réduction de l'inflammation tout vous pouvez être confronté. Si cela est fait, il aide à prévenir les cicatrices parce que votre peau aura une chance de guérir correctement.

Si vous êtes confronté à l'acné grave, il est important de se rappeler de ne pas
presser ou aller les chercher. Toucher et sonder la peau, à l'aide de vos ongles pour presser et pousser, augmente de façon significative vos chances d'endommager les tissus autour de l'acné. Évitez l'idée d'utiliser une épingle pour percer un bouton, ce qui est très dommageable pour votre peau.

Rappelez-vous, vous essayez d'éviter les cicatrices. Un bouton qui semble laid jour, permettra d'améliorer la prochaine. Vous devez permettre à votre corps le temps de guérir de la région. En choisissant ou popping vous êtes réellement prolonger la quantité de temps que vous allez avoir affaire à la Pimple.

Voici quelques uns des meilleurs conseils que j'ai appris au cours de ma bataille avec l'acné: Un corps sain a une meilleure chance de guérison rapide et complète. Tant de gens oublient l'importance d'un mode de vie sain dans la bataille contre l'acné.

Assurez-vous d'avoir une alimentation équilibrée, boire beaucoup d'eau et obtenir beaucoup de sommeil. Si vous fumez, il est maintenant temps de cesser de fumer. Fumer épuise vos réserves d'oxygène peaux de collagène et provoque dommages des radicaux libres. Sans oublier les toxines qu'elle dépôts dans votre système. Cette «attaque» sur votre système prouve seulement de rendre votre peau plus vulnérable aux cicatrices d'acné et le vieillissement.

Tenter de rester en dehors du soleil autant que possible parce que les rayons UVA et UVB dure seulement ajouter de mal à votre peau déjà d'appel d'offres.

Types de cicatrices d'acné

Les bonnes nouvelles sur le processus de guérison d'acné, une fois que la zone de l'inflammation aplatit il laisse une tache rougeâtre. Au début, cela peut paraître comme une cicatrice, mais en fait c'est une macule - la dernière étape d'une lésion d'acné. Macules peuvent durer jusqu'à six mois, mais ne laissent pas de cicatrice permanente acné.

Dans le cas de post-inflammatoire hyper-pigmentation, la tache peut durer jusqu'à 18 mois. Ce type de cicatrice est plus souvent chez les personnes afro-américaines, asiatiques et latino-américains. Une bonne idée est de rester en dehors du soleil si vous souffrez de ce type de cicatrice. Macules et post-inflammatoire hyper-pigmentation sont connus comme des «pseudo-cicatrices» parce qu'ils finissent par disparaître pour de bon.

Les cicatrices chéloïdes semblent être héréditaire. Ils sont moins fréquents et sont généralement trouvés dans les Afro-Américains, les Asiatiques et les Latino personnes. Chéloïdes cicatrices se produit lorsque les cellules de la peau face aux blessures en produisant un excès de collagène, qui forme en masses fibreuses nodulaires le plus souvent le long de la ligne de la mâchoire et sur le dos ou la poitrine. Ces cicatrices d'acné apparaissent ferme et brillante, et peut persister pendant des années.

CNE cicatrices causées par la perte de tissu sont beaucoup plus fréquents, et peuvent prendre de nombreuses formes.
Douces cicatrices d'acné sont douces pentes des bords roulés qui se confondent avec le
la peau environnante. Ils sont de petite taille, circulaire ou linéaire en forme, et doux au toucher.
Pic à glace cicatrices d'acné se trouvent sur la joue. Ils sont généralement de petite taille, mais sont profondes. Ils ont un bord dentelé et des versants abrupts. Si elles sont douces, elles peuvent être améliorées par l'étirement de la peau. Dures pic à glace cicatrices sont difficiles à traiter.

Ice-pick cicatrices peuvent évoluer vers des cicatrices fibreuses déprimés. Eux aussi ont des bords tranchants et des versants abrupts, mais sont plus gros et fermes à la base.

Macules atrophiques, une forme de cicatrices d'acné la plus fréquente chez les Caucasiens sont doux, avec une base légèrement ridée. Les vaisseaux sanguins juste sous la surface de la cicatrice peut faire apparaître violacé quand ils sont récents, mais cette décoloration peut s'estomper avec le temps à un ivoire pâle. Macules atrophiques sont généralement de petite taille quand ils se produisent sur le visage, mais peut-être un centimètre ou plus ailleurs sur le corps.

Atrophie maculaire folliculaire est plus susceptible de se produire sur la poitrine ou le dos d'une personne souffrant d'acné. Ces petites lésions blanches, douces ressemblent
blancs qui n'ont pas de développer pleinement. Ils peuvent être autour pendant des mois ou des années.

Peut-être mes cicatrices d'acné traitée?

La réponse courte est oui - en général le conseil est à travers plus de médicaments en vente libre ou une méthode fournie par un dermatologue. Bien qu'il
peut ne pas être possible de retourner votre peau à son état d'avant l'acné,
améliorations peuvent être faites.

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The United States Health Information Knowledgebase

I have long suggested that we have a single place to access standards, implementation guides, test scripts, guidelines, and code sets.

The National Library of Medicine is building a national resource for vocabularies and code sets.

In the meantime, the best centralized resource we have for HIT related knowledge assets is the United States Health Information Knowledgebase (USHIK)

USHIK is an on-line, publicly accessible registry and repository of healthcare-related data, metadata and standards.

In particular, I think you will find the Meaningful Use Stage 2 criteria listed on the site (including the quality measures) to be particularly useful.

Go to the USHIK site and click on Meaningful Use box at the top left. You will be directed to that site.

Once there you can click on Value Sets or click on Download (on left-hand side) to get to the files.  

Thanks much to AHRQ and Michael Fitzmaurice for creating and curating USHIK.

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The AMIA Healthcare Information Exchange Debate

Today I'm in Chicago at the American Medical Informatics Association annual meeting, joining my colleagues Mark Frisse, Bill Yasnoff and Latanya Sweeney to debate the question:

"Resolved - Health information exchange organizations should shift their principal focus to consumer-mediated exchange in order to facilitate the rapid development of effective, scalable, and sustainable health information infrastructure."

Mark and I were assigned "oppose".   Bill and Latanya were assigned "support".   It was made clear that our positions were assigned and did not necessary reflect our personal opinions.  (Note to Christine Bechtel and Leslie Kelly Hall - you know how I feel about the question of patient and family engagement.)

Here's what I said:

I really like the idea of patient mediated exchange and eventually we will widely support both provider and patient mediated exchange (as Meaningful Use Stage 2 will require).  However, in the short term, there are implementation issues that will delay widespread use of patient mediated exchange.

a.  There are 500,000 providers in the US and 300 million patients.   Doing identity management on 500,000 licensed/credentialed professionals easier than issuing credentials to 300 million patients.
b.  Clinicians fear that loss of data integrity will result in increased liability.   How will we ensure the non-repudiatibility of data exchanged between providers if patients collect and edit it first i.e. might Tylenol #3 for pain be changed to Oxycontin for pain?  At present we lack the metadata and digital signatures that will guarantee provenance and integrity of patient mediated data
c.  Many EHRs include features that support provider to provider workflow, but few accept incoming patient generated or stewarded data

These are short term issues that will be address in the next few  years, but the resolution calls for "rapid development".  

Why will provider to provider exchange be more rapid to implement?

1.  Provider mediated exchange is simple

HIEs can push data from organizational entity to organizational entity without having to uniquely identify the patient on a community-wide level.   Although there are many Mary Smith's in the community, there are very few in an individual provider's practice. When a message arrives to a provider concerning Mary Smith, the provider can easily attach it to the correct record.    In Massachusetts there are 20,000 providers and many are associated with a few large organizations running about a dozen different EHRs.  In our HIE we can do connect everyone with a few hundred organization level network connections.   Compare this complexity with the issue of messaging to 7 million unique patients.    

2.  Public and Private provider-based exchanges are already implemented.  Per a recent survey completed at the School of Public Health, over 100 HIEs are actively exchanging real data in the US.  Massachusetts has been exchanging data since 1997 and its HIEs have always been sustainable.

3.  Pushing data between providers does not require complex consent frameworks, it simply replaces the fax machine used in today's processes.   Thus the policies around using an HIE for pushing data are already in place.

4.  Existing EHRs and PHRs support provider directed exchange, since many federal and state demonstration projects have focused on provider-based architectures.

5.  Although we ultimately need both provider and consumer mediated exchanges, I predict 80% of patients will defer to their provider.  My parents, like many older Americans believe  their providers should collect and organize the data, serving as a kind of patient-centered electronic medical home.   Patients can view the collected data via the PHR offered by their primary care clinician.

I wonderful set of point/counterpoint discussion on this topic filled 90 minutes.

The end result - the audience seemed evenly split on the resolution.   We were both right - provider and patient mediated exchanges are needed.

A great discussion.

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Remède contre l'acné - 4 conseils pour choix naturelles

Un remède contre l'acné qui s'appuie sur des produits naturels est un atout pour de nombreuses personnes qui souffrent de la maladie de la peau. Il ya beaucoup de remèdes efficaces qui ne reposent pas sur des traitements chimiques.

Toute personne à la recherche d'un remède acné a le choix d'utiliser des remèdes sur ordonnance ou en profitant des choix naturels qui sont disponibles. Cependant, il ya aussi des choix naturels qui peuvent être travaillées en même temps que les médicaments sur ordonnance les plus typiques produites pour le contrôle des symptômes de l'acné. Les types de choix naturels qui sont disponibles comprennent des herbes et de thés du peuvent être prises en interne, des crèmes topiques et onguents pour traiter les lésions, les soins de la peau qui empêche endommager davantage la peau, et aider par une bonne alimentation et beaucoup d'eau.

Herbal remèdes topiques

Un remède contre l'acné qui dispose d'une base de fines herbes a entraîné l'utilisation de nombreux produits différents au fil des ans. Par exemple, un mélange d'huile d'arbre à thé, Propolis, Huile essentielle de menthe poivrée, huile essentielle de clou de girofle application topique peut être un antiseptique grand, antifongique et d'antibiotiques. Le but de topiques est de garder la peau propre et douce sans endommager davantage la peau a déjà été souligné, en raison des ravages de la condition de l'acné elle-même. D'autres ingrédients naturels qui sont souvent utilisés pour améliorer la peau qui a été compromis par l'acné incluent la vitamine E, la bardane, et les feuilles de fraisier. Topiques à base de plantes sont utilisés pour nettoyer et adoucir la peau.

Voies de recours internes

Une voie de recours interne acné peut être un peu plus inhabituelle et difficile à trouver, mais sont disponibles et sont encore plus efficaces lorsqu'ils sont utilisés en combinaison avec des médicaments d'ordonnance. Les remèdes naturels travaillent habituellement parce qu'ils sont conçus pour régler le chimique et le déséquilibre hormonal qui entraîne le corps à réagir avec des poussées d'acné. L'acné kystique est une forme plus sévère de l'acné qui peuvent être aidés par l'intermédiaire de l'itinéraire à base de plantes. Pilules à base de plantes sont conçus pour traiter l'acné de l'intérieur du corps plutôt que de l'extérieur de calmer, d'ajuster et de désensibiliser les zones à problèmes.

Soins de la peau

Quel que soit le remède d'acné que vous choisissez, les soins de la peau quand vous êtes tourmenté par l'acné zits, des lésions, rougeur et gonflement est absolument vital de physique et bien-être émotionnel. Des choix naturels peuvent être sélectionnés qui sont doux dans la nature, qui apaisent la peau tout en effectuant le nettoyage doux mais efficace qui est si important en tant que composante du traitement de l'acné au total. Quels que soient les choix effectués, gardez à l'esprit que les choix naturels sont disponibles pour la plupart des problèmes associés aux problèmes de peau des problèmes d'acné. Rechercher lavante douce, légère action antiseptique et pas d'ingrédients lourds colmatage des pores comme le pétrole lourd.

La nutrition et de l'eau

Bien que ces deux choix remède contre l'acné sont les originaux, ils sont probablement la solution la plus actualisée disponible pour les personnes souffrant d'acné. La nutrition est importante pour la santé en général ainsi que plus de traitement spécifique pour les symptômes d'acné. Si vous prêtez attention aux lignes directrices pour la nutrition appropriée, vous serez en meilleure santé sur tout et qui aidera votre corps à combattre la maladie. L'eau est un autre souvent négligée remède naturel acné. L'eau utilisée en interne permettra d'améliorer votre système circulatoire et digestif. Bien sûr, l'eau à l'extérieur nettoie et aide à apaiser la peau surtout s'il est combiné avec d'autres herbes et des choix naturel.

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Remèdes naturels contre l'acné Comment se fait mieux

Utilisation des tas de gens aux prises avec l'acné, ils vont essayer n'importe quoi simplement pour éliminer le problème. Personne ne peut les blâmer pour cela cependant, éliminer l'acné a de nombreux problèmes de santé différents intervenants. Questions, par exemple, des remèdes naturels contre l'acné sont supérieurs aux scientifiquement prouvé remèdes médicaux pour l'acné.

C'est tout naturel

Les remèdes naturels contre l'acné est plus efficace en comparaison avec le traitement pour l'acné car il utilise les éléments naturels. Parce que le début de votre temps, personnage a donné à l'humanité de tous les remèdes et les traitements pour chacune des conditions et de l'acné est une maladie.

Les natures signifie en traitant l'acné consiste à utiliser les vitamines appropriées, les produits chimiques et les protéines naturelles avantageuses sur la peau affectée par l'acné. Autres remèdes naturels acné se compose également des minéraux intéressants pour zinc par exemple l'industrie solution éprouvée dans le traitement de différentes maladies de la peau de nos. Autres remèdes naturels contiennent du chrome qui est bénéfique contre l'acné. En général, les éléments naturels ont un mélange de personnes signalées ci-dessus en fournissant le soulagement de l'acné redoutée.

Quels sont exactement ces traitements?

Les traitements les plus populaires naturel pour l'acné sont souvent présentes dans les maisons. Ils ont été utilisés dans de nombreuses décennies et pourrait être prouvée scientifiquement. Les remèdes naturels contre l'acné pourrait être les fruits comme le citron, légumes comme la tomate et le concombre, les huiles de peau comme l'huile d'arbre t, des épices ou des herbes comme l'ail de clou de girofle extraits de plantes, comme de Natural Aloe vera et naturelles articles fermentés comme le miel et le vinaigre.

Pourraient-ils être efficaces?

En effet, les remèdes naturels pour l'acné sont impressionnants. Ils sont adaptés à une multitude de poussées d'acné. Les remèdes naturels contre l'acné peut diminuer l'inflammation, enlever les obstacles à la pollution, les cellules mortes de la peau, de la poussière making-up, se débarrasser des bactéries qui créent l'acné aussi lisse et hydrate votre peau. Les remèdes naturels qui sont pris par voie orale permet de contrôler l'écart hormonal dans votre corps le risque de l'industrie dans les poussées d'acné. Même si le traitement peut prendre du temps, l'utilisation continue de ces remèdes sera certainement effacer l'acné.

Le coût Prix moins

Pas de remèdes naturels contre l'acné sont coûteux. Ils peuvent être achetés n'importe où, à base de plantes cultivées ou mieux encore sont remplis dans le réfrigérateur. Des solutions naturelles pour à peu près n'importe quel problème d'acné peuvent être utilisés dans leur forme la plus simple et ne coûtera pas beaucoup de temps et d'efforts simplement pour se préparer.

Aucun effets secondaires dangereux

En comparaison avec les remèdes médicaux coûteux contre l'acné, le traitement natures n'a pas dangereux effets secondaires à personne. Certains remèdes médicaux qui sont utilisés dans votre peau peut provoquer une irritation, mal à votre peau, la sécheresse, les brûlures ainsi que des infections. Les individus consommés peut entraîner des problèmes urinaires, perte de cheveux, maux de tête, des nausées et des douleurs musculaires. Liées à la peau méthodes peuvent également causer des brûlures, des plaies, la décoloration sur la peau et des cicatrices permanentes. De plus, vous trouverez d'autres remèdes qui pourraient exposer votre peau aux rayons du soleil dangereuses Ultra-Violet du soleil est responsable du cancer de la peau.
Il est un fait que les techniques classiques de médecine dans le traitement de l'acné de travail, vous ne trouverez pas les arguments à ce sujet. Cependant, ils ont contrecoups indésirables et coûteux, il pourrait être douloureuse ou dure pour que la peau. Mais le caractère a donné aux individus qui souffrent de l'acné une autre réponse à faire face à leurs problèmes, sûrs, moins chers et avant tout efficace. C'est une raison suffisante remèdes naturels pour l'acné est plus efficace.

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Soin du corps acné: ce qui fonctionne le mieux?

Les problèmes de peau et les troubles de la peau ne sont pas la pire espèce, mais si elle affecte non seulement une partie de votre corps qui est quand elle devient un enfer d'un gros problème. L'acné est un problème de peau qui dérange plupart d'entre nous. En dehors de cela touchant le visage, l'acné peut aussi atteindre certaines zones de notre corps. Les sites les plus courants pour l'acné de se développer dans le corps d'un individu serait le dos, la poitrine, derrière la tête atteignant au cou, les avant-bras et les épaules pour certains cas et la place la plus maladroite serait collée sur les fesses. Oui cela arrive et ce n'est pas le sentiment le plus confortable.

Traiter avec l'acné visage est assez stressant et avoir à traiter avec l'acné du corps est bien pire. Alors, comment peut-on traiter l'acné et l'empêcher de jamais revenir? Il faut d'abord comprendre que l'acné a un cycle et qu'il exige trop d'un processus constant et continu pour guérir et éviter qu'il ne se reproduise. L'acné peut pas être simplement traitée par des médicaments en vente libre ou des remèdes naturels à la maison. L'acné a une cause profonde et il ne sera pas identifié simplement par ce que vous mangez ou ce que vos pratiques d'hygiène sont. Pour la plupart des personnes souffrant d'acné du visage ou l'acné de corps, ils ont acquis ces par la génétique. Dermatologues fondamentalement commencer par traiter l'acné en déterminant d'abord le type de peau de la personne qui cherche traitement de l'acné. Il existe quatre types de peau la peau, nommément sèche, peau grasse, peau normale et peau mixte qui est tout simplement grasse et la peau sèche.

Il ya beaucoup de pratiques et de traitements disponibles, soit sur l'Internet ou par le biais d'auto-assistance des livres, mais les traitements comme celui-ci ne durent pas longtemps. Quand il s'agit de traiter l'acné du visage et du corps, il est important de se rappeler que la solution ne doit pas seulement viser à nettoyer et enlever l'acné, mais aussi pour éradiquer complètement les bactéries qui causent l'acné.

Vous avez pu lire sur les traitements de l'acné utilisés à la maison qui peut inclure l'huile d'arbre à thé et de l'ail. Il s'agit bien sûr sont très efficaces, mais ces solutions ne sont que de courte durée sens qu'ils ne touchent pas la peau, mais il ne sera pas prévenir l'acné de jamais revenir.

Traitement de l'acné corps doit être à long terme. En va de même avec soin du visage acné. Les solutions ou les traitements devraient être en mesure d'éradiquer complètement les bactéries et garder la peau souple et saine pour longtemps et non pour seulement une courte période de temps. Heureusement, il existe un tel traitement à long terme qui va complètement aider à guérir les cicatrices d'acné, l'empêchant de se reproduire et de réduire les symptômes physiques de l'acné.

Qu'est-ce que ce traitement, vous demandez-vous? Fret pas plus, car avec le système de soins spécifiques Corps ZENMED Traitement de l'acné, l'acné sera le moindre de vos préoccupations. Ce système contient deux étapes de menthe, de lavage rafraîchissant granulé combiné à combattre les bactéries d'arbre à thé, plus d'un produit minéral médicamenteux argile qui nettoie et guérit l'acné. Il est également enrichi en huile d'origan qui tue les bactéries causant l'acné naturellement.

Qui aurait grandement bénéficier de ce traitement? Eh bien pour ceux qui souffrent de l'acné du corps, ce soin est idéal pour les passionnés de gym ou culturistes qui souffrent de poussées d'acné qui se produisent après de longues heures de formation ou d'entraînement. Il est également préférable pour les personnes qui souffrent de poussées hormonales Pimple. Ce système non seulement guérit l'acné, mais il empêche également la cicatrisation. Enfin, ce produit est idéal pour les personnes qui souffrent de beaucoup la peau excessivement grasse. Les personnes atteintes de type de peau tels subir les pires formes de l'acné sur le visage et le corps.

Alors, comment exactement fonctionne ce traitement acné du corps? Comme mentionné ci-dessus, le système en deux étapes consiste en un: un jardin botanique traitement de l'acné masque et spot et deux: un nettoyant pour le corps botaniques acné. Première étape, le masque à base d'argile botanique infusé sera lissé sur toute la peau qui doivent être secs avant d'entrer dans la douche. L'argile doit être séché pendant 5 minutes. Ceci permet aux agents anti-bactériens pour tuer les bactéries en surface acné. D'autres composants tels que l'acide salicylique haute qualité et de l'acide citrique pénétrer la peau qui ouvre les pores et adoucit la peau. Deuxième étape, le lavage du corps est utilisé pour retirer le masque. Le tout-naturel de noix composante nettoie efficacement la peau, plus tonifie la circulation sanguine vers les zones localisées du corps. Cela permet non seulement efface le corps de l'acné, mais rend la peau plus claire et plus lisse.

Alors qu'attendez-vous pour? L'acné du corps ou de l'acné visage ne doit pas être le pire de vos problèmes car avec Zenmed solutions d'acné, tout est plus clair que votre peau.

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