Wednesday, June 24, 2009

Government 2.0

President Obama issued a Memorandum on Transparency and Open Government in which he called for recommendations on making the government more transparent, participatory, and collaborative. The Whitehouse has announced an Extension of Phase III: Drafting of Open Government Recommendations which gives every citizen a chance to participate and make comments to draft recommendations that translate good ideas and lofty principles into specific actions that can be taken to achieve open government. To join in working on these recommendations go to

Two of the goals of The Dalles City Council over the next few years are Civic Responsibility and Government Transparency. These areas actually go hand in hand. As citizens participate in the governing process and government is accountable to those they serve, this encourages more participation and promotes greater transparency. We are facing serious challenges and we will all need to work together to find solutions to help our community continue to thrive.

Responsibility cuts both ways, and every generation of Americans shares the responsibility of participating in the democratic process. One of the foremost responsibilities of a citizen is to vote. If someone is not involved, then they have little room to complain. Participation in roles of active citizenship through public service is an important aspect of a free society. Hopefully, we will see more names on the ballot in future local elections. Anyone interested in serving on a committee or commission should contact City Hall and submit their name for consideration by the Mayor.

It has been very satisfying to see so much interest lately in the governing process, particularly at our City Council meetings. Please do not be discouraged by the process. There are obviously some things that might be changed to allow every voice to be heard, while still following correct procedures. I am committed to giving the public greater opportunity to participate in decision making at all levels of our city government. Citizens have a duty and an obligation to respectfully communicate their views to those who serve them.

People should also consider becoming a member of a service organization that works to improve our world like the Rotary or Lions Clubs. Service clubs can perform many services for their community and also support other worthy causes. Civic responsibility extends beyond government service into all areas of our common life together: church, school and other organizations. Volunteering time with Big Brothers/Big Sisters, the Hospital, Hospice or Families First can make a huge impact on the lives of those around us. Greater participation by citizens will make our community a better place to live.

Of particular interest is the civic involvement of our community youth. Mayor Nikki Lesich will soon be unveiling exciting plans to create a Youth Advisory Council. We should encourage the next generation to prepare themselves to run the world, and it our responsibility to model for them how to be good citizens. Seeking information and serving the community is an attribute we should pass along to the next generation.

But civic responsibility can only happen in tandem with the government’s duty to operate transparently. Transparency in government increases citizen access to information and helps to facilitate their understanding of the decision making process. It helps to instill public confidence and allows the informed participation of citizens. Transparency promotes accountability and provides information for citizens about what their Government is doing.

There are some balancing needs which include the privacy rights and needs of employees and officials, other subjects of a confidential nature, and the ability of officials to discuss issues without fear of attack. Draft proposals and discussions of possibilities are not necessarily published. However, making information which is already available more accessible helps to provide sunlight through the window of government. Supreme Court Justice Louis Brandeis said, "Sunlight is said to be the best of disinfectants."

One of the best ways of providing transparency in government is through the use of technology. The Internet has changed the way many people obtain information and there are ways of providing a searchable database of public documents which can have a great effect on the ability of citizens to find the information they want. Publishing this data on the Internet can also provide the additional benefit of saving on printing costs and can help promote environmental sustainability by reducing paper use. Another important new goal of our city is to develop a comprehensive Information Technology strategy.

"The Government should not keep information confidential merely because public officials might be embarrassed by disclosure, because errors and failures might be revealed, or because of speculative or abstract fears," President Obama said in the recent memo ordering the director of the Office of Management and Budget to issue recommendations on making the federal government more transparent. And at the local level, greater transparency in government can be a great help in promoting more citizen involvement in governmental affairs.

I am very pleased that the City Council of The Dalles has adopted goals and corresponding objectives which will promote transparency in our city government and encourage civic responsibility. We will be continuing to work alongside City Staff and other elected officials to make our city government even more efficient and transparent. I hope that our efforts will coincide with federal efforts to make this dream a reality.

Tuesday, June 23, 2009

Transcripts From Government Meetings

To answer questions as to how I am able to post the transcripts from the HIT Policy and HIT Standards meetings immediately after the meeting is complete, Gregg Masters suggested I write a blog about it. The method for this relies on closed caption transcription provided by HHS. At the end of the transcription there is an option to save the transcript, which I then reformat for publishing on the web, adding in the appropriate presentation materials when available. The results are like this:

July 15th HIT Policy Committee Adoption/Certification Workgroup Meeting Day 2

July 14th HIT Policy Committee Adoption/Certification Workgroup Meeting Day 1

June 23rd HIT Standards Meeting

June 16th HIT Policy Meeting

May 15th HIT Standards Meeting

Government websites should comply with section 508 of the Rehabilitation Act. For web-based intranet and internet information and applications, it assures accessibility to web page graphics by the visually impaired using assistive technology such as screen readers and closed-caption transcription for the hearing impaired. Here is the guidance from Section 508, Subpart B -- Technical Standards, § 1194.24 (c)

“All training and informational video and multimedia productions which support the agency's mission, regardless of format, that contain speech or other audio information necessary for the comprehension of the content, shall be open or closed captioned.”

As an example the video when President Obama hosted a White House Forum on Health Reform at the White House includes an Open Captioned Version of the video.

The government should make every to effort comply with Section 508. Usually there is the option to view captions real-time, and then save the transcript in draft format. Real-time captions are created as an event takes place. A captioner (often trained as a court reporter or stenographer) uses a stenotype machine with a phonetic keyboard and special software. A computer translates the phonetic symbols into English captions almost instantaneously. The slight delay is based on the captioner’s need to hear the word and on the computer processing time. Although most real-time captioning is more than 98 percent accurate, the audience will see occasional errors. The captioner may mishear a word, hear an unfamiliar word, or there could be an error in the software dictionary. This is why the draft transcripts I post are very rough in form.

The value I hope to bring is that the transcript, while still containing errors, is more complete in raw form than the polished minutes which are archived. After a period of time the transcript results from the closed caption on the HHS web site will no longer be available, so I preserve them and make them available for people to look back on. I hope that this work is useful and provides greater transparency into the process.

Monday, June 22, 2009

Declaration of Health Data Rights

I am grateful for those working so patients can control their own health data. At Mid-Columbia Medical Center we have lived by the Planetree Philosophy of care, which includes an open chart policy. This policy encourages patients to read their medical records and write in the Patient’s Progress Notes. Access to understandable health information that can empower patients to participate in their health is one of the core values we live by. Patient's must control their own health data.

From, the
Declaration of Health Data Rights:

In an era when technology is allowing personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

• Have the right to their own health data
• Have the right to know the source of each health data element
• Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; If data exist in computable form, they must be made available in that form
• Have the right to share our health data with others as we see fit

Their should be NO LOSS OF RIGHTS with the transition from paper to electronic records. This may seem like common sense, but there are some that are trying to take control of our own health data, particularly with the advent of electronic health records. You can endorse the Declaration of Health Data Rights either by submitting your endorsement via this website or by entering the hash code #myhealthdata on Twitter. Please take a few moments to endorse this important declaration and let's make our voices heard loud and clear.

Sunday, June 21, 2009

It is a small world after all

We live on an incredibly shrinking globe that allows real time communication from almost anywhere on the planet. My wife can have a chat on Facebook with her friend in Denmark, while I am having a Google Talk conversation with my buddy from Australia, while monitoring updates from the streets of Iran on Twitter. I could watch a You Tube video from my brother’s birthday party yesterday over 3000 miles away, email my entire family all over the country simultaneously, and keep tabs on what is happening in the corridors of the Congress and the Whitehouse.
Web 2.0 tools have allowed us to be connected in ways scarcely imagined in previous generations. Social media has risen to new heights with the incredible use of Twitter, Facebook and You Tube as a means of twitterspondents (citizen journalists) providing news updates and images from the protests regarding the election results in Iran. Streaming video on the web allows for interactive content so that television cannot compete. People are building online communities and creating grassroots organizations around Internet sites that are having a huge impact on political structures around the world. Even the United States recent presidential election was heavily influenced by web 2.0 tools.
I am constantly amazed at how adeptly the next generation is mastering these tools. The digital age has begun and we are in for some very exciting times ahead…

Tuesday, June 16, 2009

"Meaningful Use" Almost Defined

HIT Policy Committee released the following draft definition (if you missed the meeting the transcript is here, along with presentation materials) of meaningful use today:

“Meaningful Use: A Definition”

Recommendations to the Health IT Policy Committee from the Meaningful Use Workgroup

The American Recovery and Reinvestment Act authorizes the Centers for Medicare & Medicaid Services (CMS) to provide a reimbursement incentive for physician and hospital providers who are successful in becoming “meaningful users” of an electronic health record (EHR). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing an EHR in compliance with the “meaningful use” definition or they will be subject to financial penalties under Medicare.


In 2008, the National Priorities Partnership, convened by the National Quality Forum (NQF), released a report entitled “National Priorities and Goals” which identified a set of national priorities to help focus performance improvement efforts. Among these priorities were patient engagement, reduction of racial disparities, improved safety, increased efficiency, coordination of care, and improved population health. These priorities were used to create the framework for “meaningful use” of an electronic health record. An additional area related to privacy and security has also been included to emphasize the importance of preserving patient protections and ensuring patient trust in the use of electronic health records. The matrix represents a set of objectives and care processes that the workgroup believes should inform the ultimate definition of meaningful use.


We recommend that the ultimate goal of meaningful use of an Electronic Health Record is to enable significant and measurable improvements in population health through a transformed health care delivery system. The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real‐time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities. This "north star" must guide our key policy objectives, the advanced care processes needed to achieve them, and lastly, the specific use of information technology that will enable the desired outcomes, and our ability to monitor them. For example, demonstrating improved performance and reduced disparities in blood pressure control among patients with diabetes will require a host of new care processes for many outpatient providers (e.g., monitoring medication adherence, use of evidence‐based order sets, clinical decision support tools at the point of care, patient outreach and reminders).
In order to effectively use the tools that undergird these processes, and to monitor progress towards the outcomes of interest, key information generated in the delivery of care (vital signs, problem lists, medications, procedures, lab tests) must be digitized and queriable. We recognize that changing products and changing workflows will be an evolving process, but providing a clear roadmap of the future (as we have attempted to do in this proposed definition of meaningful use) will help give purpose and meaning to these activities. We recommend a progression similar to the Electronic Health Record demonstration initiated by the Centers for Medicare and Medicaid (CMS) in 2008, wherein “meaningful use” is ultimately linked to achieving measurable outcomes in patient engagement, care coordination, and population health.
In developing the recommended criteria and prioritizing the progression towards a fully interoperable health information system, we have found it necessary to balance the competing goals of encouraging provider participation while promoting progress towards reform of our current health care system. We seek specific stakeholder feedback on whether the recommended timeline of requirements is overly aggressive based on the current state of technology and the demands on new provider workflows, or not challenging enough to result in significant transformation, in light of the declining level of Medicare incentives in future years.


As a result of increased effective use of health information technology, considerable improvements will be realized in the prevention and management of chronic diseases including diabetes and heart disease, preventing hundreds of thousands of unnecessary amputations and premature deaths. Medication errors will be averted. Patients will be able to promptly access their own health information, and their end of life preferences will be heard. The nation will be better prepared for the next pandemic. Health care disparities will be systematically identified and addressed. This transformed healthcare delivery system will also enable and amplify the effectiveness of a host of new reimbursement models that will reward more organized, more coordinated, and more efficient care.


The recommended definition of “meaningful use” will depend on the healthcare setting in which it is employed. Thus, some features and capabilities will be recommended as required in an ambulatory setting before similar functions are expected to be widely used in the hospital. This reflects both the availability of the technology in these different settings as well as the potential impact of these features on the health of the population served. Although some recommended measures used to assess meaningful use in 2011 may apply to specific chronic diseases, the recommended 2011 objectives are meant to establish a foundation for affecting a more comprehensive set of health outcomes in the future. Many of the current proposed EHR­generated quality measures apply to primary care providers and are derived from NQF‐endorsed measures. New measures under development, by NQF, and other recognized organizations will also address the work of specialists. The Workgroup anticipates that future recommended meaningful use objectives and measures will reflect emerging national priorities.


In identifying potential criteria for “meaningful use” of an electronic health record, it became apparent that there are considerable gaps in EHR‐generated measures available to monitor key desired policy outcomes, (e.g., efficiency, patient safety, care coordination). While these measures will not be required for Medicare and Medicaid incentive payments until 2013 , the Workgroup is seeking feedback on how to best frame these measures including measurement of key public health conditions, measuring health care efficiency, and measuring the avoidance of certain adverse events. These comments will be used to help revise the recommended measurement strategy to include more extensive and refined outcome measures for “meaningful use” in 2013 and beyond.

Saturday, June 13, 2009

The Convergence of #HealthIT and #Web2.0

At the intersection between Web 2.0, social media, Health IT and healthcare reform lies the tools of the new economy. Aside from the blogosphere, a whole host of social media tools can be useful to provide real time information, networking possibilities and develop grassroots efforts for reform. As Cascadia has said we now have a consumer voice in the ongoing Health Informatics conversation using the new social networking tools.

Tim O'Reilly, Founder and CEO of O'Reilly Media, was interviewed by Blaise Zerega of at Web 2.0 2009. In the clip below he argues that microblogging service Twitter is changing real-time information search and describes how Twitter is going to be such a powerful tool in the new digital economy.

Forrester Research CEO George Colony calls the current economic trouble the Gateway Recession, and end of the Gateway Recession will usher in a new technology era. In discussing the importance of social media in this new economy Rob Preston, Editor-in-Chief of Information Week makes a compelling argument that one "gateway realization is the need to give customers, partners, and employees freer access to one another via social media, Web 2.0 collaboration tools, consumer devices, and other contraband systems."

The discussion of hugging data and the video of Tim Berners-Lee's Ted Talks where he envisioned a "Semantic Web" - an evolved version of the same system that recognizes the meaning of the information it carries. As I said, we need to consider how we can best securely share data and develop open standards that work. Social media provides a wonderful framework for collaboration.

The conversation continues and you can jump in any time...

Thursday, June 11, 2009

Alphabet Soup

There are many commonly used abbreviations in discussing Health IT. I thought it might be helpful to list some here:

AHIC American Health Information Community

American Health Information Management Association

Agency for Healthcare Research and Quality

American National Standards Institute

Certification Commission for Healthcare Information Technology

Clinical Decision Support

Community Health Centers

Centers for Medicare and Medicaid Services

NHIN gateway

Computerized Physician Order Entry

Electronic Health Record

Electronic Medical Record

Federal Health Architecture

Department of Health & Human Services

Health Information Exchange

Healthcare Information Management Systems Society

Health Insurance Portability and Accountability Act

Health Information Technology

Health Information Technology Standards Panel

Health Level 7

Health Resources and Services Administration

International Statistical Classification of Diseases and Related Health Problems

Joint Commission on Accreditation of Healthcare Organizations

National Committee on Vital and Health Statistics

Nationwide Health Information Network

National Institutes of Health

National Library of Medicine

Office of the National Coordinator (usual abbreviation for ONCHIT)

Office of the National Coordinator for Health Information Technology

Personal Health Record

Physican Quality Reporting Initiative

Regional Health Information Network

State Level Health Information Exchange Consensus Project

Systematized Nomenclature of Medicine

Veterans Health Administration

Veterans Health Information Systems and Technology Architecture

I particularly would like to point out the differences between EMR, EHR and PHR. These terms tend to be used interchangeably, but they actually refer to different things. In fact the definition of EHR depends a lot on what the definiton of "meaningful use" is. You could define an EMR as just the physician interface and EHR including both a physician and patient interface (with some interoperability between systems). PHR is still an ill-defined concept that has been slowly developing over many years. Certainly PHR is a computerized application that stores an individual's personal health information. The key difference being that a PHR is typically a health record that is created, controlled and maintained by an individual patient, while the EMR is created, controlled and maintained by the provider. Hopefully one day we will have an intersection at truly meaningful EHR.

Tuesday, June 9, 2009

Affordable Health Choices Act

The Senate Committee on Health, Education, Labor and Pensions (HELP) has announced the Affordable Health Choices Act.

“Our health care system is a crisis for American families and President Obama and members of Congress of both parties recognize the urgency of the problem. Our goal is to strengthen what works and fix what doesn’t. Over the next few days, we will continue working with our Republican colleagues on common sense solutions that reduce skyrocketing health care costs, assure quality care for all and provide affordable health insurance choices. Much work remains, and the coming days and weeks won’t be easy. But we have a unique opportunity to give the American people, at long last, the health care they need and deserve,” said Senator Kennedy, Chariman of HELP.

Earlier this year, Kennedy and Senator Max Baucus, Chairman of the Finance Committee, which shares jurisdiction of health care reform with HELP, established a joint process that will lead to complementary legislation being marked-up next week. The full text of the bill is available here.

The bill is silent on the crucial questions of the employer mandate and a public health insurance option. The HELP bill proposes broader reform measure than expected in the Finance Committee's bill, expected to be released over the next few weeks. This summer is going to be an exciting time for healthcare reform!

Monday, June 8, 2009

Daschle and Gingrich discuss healthcare

Former Senate Majority Leader Tom Daschle and former House Speaker Newt Gingrich discussed healthcare reform during a panel discussion at the National Press Club sponsored by Volunteers of America. A video from an interview with the two men is below. It is nice to see both sides willing to have a reasonable discussion.

If President Barack Obama wants healthcare reform this year, he’s going to have to be flexible and accept “half a loaf” on certain issues Newt Gingrich, founder of the for-profit consultancy Center for Health Transformation, said. Congress and the administration “will get nothing” if they approach reform with an all-or-nothing attitude, he added. Gingrich acknowledged that the reform effort could get “locked up” by various demands, and possible push back from hospitals and doctors. Any healthcare-reform effort should emphasize wellness and best practices to eliminate waste from the system, Gingrich said, adding that he was in favor of 100% coverage—but not a single-payer system.

Tom Daschle, who had been nominated for HHS secretary, was not as optimistic about the chances of getting a bill through Congress. Cost, quality and access issues remain, “and so little attention has been given to long-term care” in this debate, said Daschle, who gave legislation a 50-50 chance of getting approved. He stressed the need for a priority for Health IT and stated that we need to "change the paradigm from illness to wellness" by addressing chronic care management.

Neither man thought Medicare was doomed, however, even though the trust fund is predicted to dry up in 2017. Congress will find a way to fix the problem, Gingrich said. “I don’t think it will run out of money.”

Thursday, June 4, 2009

Hospitals cutting off social media access

A disturbing trend in healthcare facilities is blocking social media sites for staff. I would be very interested in knowing how you are all dealing with this and what methods work best for allwoing access, yet controlling it so that it is appropriate and effective.
Some helpful resources are:

Wednesday, June 3, 2009

Faith and Healthcare

Many people claim that spirituality within the context of healthcare is mumbo jumbo and does not deserve to be part of the conversation. I think it is arrogant to assume that we have enough knowledge to discount the obvious benefits of including faith and spirituality in the healthcare dialogue. Reading through American Family Physician a peer reviewed journal of the American Academy of Family Physicians, along with other journals and research results, can give some insight into this thorny issue.

Attending to the spiritual dimension of the patient provides the physician with a deeper understanding of the patient and his or her needs. The provider might use a variety of spiritually informed therapeutic tools that could greatly facilitate the patient's coping ability, thus enhancing well being. A spiritual assessment as part of a medical encounter is a practical first step in incorporating consideration of a patient's spirituality into medical practice. The HOPE questions provide a formal tool that may be used in this process.

Barbara Apgar, M.D., M.S. in an article in American Family Physician discusses research on the significance of intercessory prayer for the sick, referencing the study by Harris WS, Gowda M, Kolb JW, Strychacz CP, Vacek JL, Jones PG, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. The authors conclude that supplementary, remote, blinded, intercessory prayer produced a measurable improvement in the medical outcomes of critically ill patients in the CCU. Clinical trials on the Effects of Meditation on Mechanism of Coronary Heart Disease seem to bear out the same conclusion. Prayer and meditation are very effective tools in the fight against disease and valuable to promote healing and wellness.

Walter L. Larimore, M.D., reports that 99% of surveyed family physicians believe that religious beliefs can heal, 75% believe other people’s prayers (i.e., intercessory prayer) can promote healing. Based on his own clinical practice and dialogue with other family physicians Larimore suggests that “infrequent religious attendance or “poverty of personal faith” should be regarded as a risk factor that is nearly equivalent to tobacco and alcohol abuse.

The impact of spiritual practices and disciplines such as prayer are obvious.  While issues of faith and beliefs and how to implement those in medical care, such as through prayer, are controversial they should not be ignored. In light of some of the research on spirituality in healthcare we can not dismiss prayer as a possible viable intervention. And since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), requires the administration of a spiritual assessment then it will be good to include standard templates for these assessments in an Electronic Health Record to be used for quality reporting. A good template for spiritual assessment and review of the JCAHO requirements and guidelines for implementation by Hodge can help social workers being called on to conduct spiritual assessments.

I am firm believer in technology enabled healthcare - but I also am absolutely certain that we should not try to push God out of the healthcare arena.

Tuesday, June 2, 2009

Courage to be first

Since the early 90s, numerous newspapers, magazines and radio and TV broadcasts have told the story of Mid-Columbia Medical Center’s efforts to change for the better the way patients experience hospitals.

MCMC appeared in a Bill Moyer’s PBS series called “Healing and the Mind” and was even featured in a book highlighting American companies noted for their outstanding customer service.

But now the hospital that many say has written the book on how to create a true patient-centered healing environment has had an entire book written about it. Courage to be First:  The Journey of Mid-Columbia Medical Center Becoming the First Planetree Hospital in America was released in March by Second River Healthcare Press.

The book tells the story of MCMC’s dramatic transformation over the last two decades, beginning with the hospital’s implementation of the Planetree model of care in the early 90s.  MCMC’s story was written by Dick Baltus, as told by former CEO Mark Scott, current CEO Duane Francis and many hospital employees, with Leland Kaiser, Ph.D., offering commentary after each chapter.

Baltus is a consultant and writer, who served as the MCMC’s part-time public relations director during the Planetree implementation and continues to work with the hospital today.  Kaiser is a renowned healthcare futurist, motivational speaker and authority on America’s healthcare system.  He was introduced to Scott after hearing about MCMC’s transformative work. 

Kaiser visited the hospital several times and, when Scott retired from MCMC in 2002, Kaiser proposed they collaborate on a book about the process of changing so profoundly their manner in which hospitals treated their patients.

Courage to be First is targeted at readers in the healthcare management industry, as well as any business committed to improving customer service.  Like the hospital itself, the book has received enthusiastic reviews. 

B. Joseph Pine, co-author of The Experience Economy (named one of The Best 100 Business Books of All Time) wrote:  “There is not a hospital in the world – or any company in the healthcare field, for that matter – that could not benefit from this enlightening book.  Read how Mid-Columbia Medical Center has transformed itself into a shining light so you, too, can inspire your employees, enhance your patient experience and improve your outcomes.”

And from John Nance, the author of Why Hospitals Should Fly:  “The very concept of a true patient-centered hospital – the vision of patients actually being partners in their own care – should have never been a radical idea.  But somehow along the evolution of healthcare, it became just that.  ‘Courage to be First’ is the story of how a visionary hospital CEO made it live again in the form of a Planetree Hospital.  What the concepts of St. Michael’s (Hospital) do for patient safety and quality, ‘Courage to be First’ does for the long-dormant soul of American Healthcare.”

President/CEO Francis says the book will serve as a lasting tribute to Scott, the hospital board and management team, and all the physicians, nurses and employees who over the years have remained committed to a vision that began as a bold experiment and has turned into a way of life at MCMC.

“It took a lot of vision, and frankly a lot of guts, to attempt something that was considered so revolutionary at the time,” Francis says.  “This was an industry that was not very comfortable with change in the early 90s, and to attempt to change the status quo, at least in this small corner of the world, really required a leap of faith.

“I think it’s very appropriate that the story of how that happened successfully at MCMC be chronicled. Courage to be First will serve as a lasting tribute to all the people who ensured this hospital became a true place of healing that was worth writing, and reading, about.”Courage to be First is available for purchase on-line at