Thursday, December 29, 2016

Building Unity Farm Sanctuary - Fifth Week of December 2016

The holidays are a time of joy and family gathering, bringing together multiple generations at Unity Farm.  This year we introduced all our visitors to the sanctuary.   My mother was eager to help out with the horses, pigs, and goats.   Here are a few photos of her greeting, feeding, and generally being a part of the daily rituals at the farm and sanctuary.




Much of work over the holidays involved preparing for our upcoming new arrivals.   Amber, the 20 year old Arabian horse, arrives on Monday January 2.   We had to rebuild the main horse paddock and electric fence at Unity Farm Sanctuary, replacing rotted posts and a failed solar powered fence power supply.   We wired a heated watering trough and created a weatherproof enclosure for the new AC powered fence charger.   We built two gates in the paddock to accommodate the tree work we’ll be doing to expand the paddock space between the farm and sanctuary, adding 3 new fenced areas and run ins.   At this point we’re ready for Amber’s arrival.   She’ll live in the stall adjacent to Pippin, our Welsh pony, and they will run out in the large paddock together.

It’s truly an adventure doing all this work during the chilly temperatures of winter with frozen ground and weekly ice storms.    Although we’re deferring some work to the Spring thaw, everything we’ve done thus far makes the sanctuary good enough to support 3 horses, 3 goats, and a donkey (we’re still working on that) over the winter.

Inside the sanctuary building, we’ve been preparing the plumbing and electrical for the public uses to come.   We’ve gone through each room and repaired/replaced those items the public will frequently use trying to use commercial rather than residential hardware when we can.     We’ll be refinishing all the floors in January with a commercial matte polyurethane finish that can stand up to high traffic.

I continue to plan trails and a forest layout that will be safe and maintainable.   Also in January we’ll be cutting down dead trees that are a risk to animals and buildings.   Their wood will provide the chips for all our new trails.

The weekend ahead will be spent hosting New Year's visitors,  restocking all the supplies and foods we'll need for the coldest few weeks of winter to come, and creating the daily rituals we'll use to keep the sanctuary and all its creatures warm, safe, and happy.

Wednesday, December 28, 2016

2016 in Review

Many people are yearning for the end of 2016 - too many unexpected deaths of notable people, too many unexpected acts of violence,  too many unexpected election results.

However, 2016 did have its highlights.   In early 2016, I wrote about the five pillars of the BIDMC strategic plan for the year  - social media-like documentation, mobile technologies for patients/providers, analytics for care management, cloud hosted interoperability and and enhanced security.  

Here’s my top 10 list from 2016 as to how these concepts actually played out.

1.  In early 2016, a guiding coalition of developers and providers suggested a path forward for national interoperability.  By the end of 2016, all the EHR vendors agreed to openly share data among their platforms using a query/response architecture.  

2.  MACRA/MIPS as implemented in the Quality Payment Program final rule reversed the trend of overly prescriptive healthcare IT regulations.   Clinicians have choices instead of endless data entry.

3.  Apple has accelerated the use of consumer products as middleware.   880 million people carry a supercomputer with them (their iPhone) and it can be used to gather objective data from internet of things devices in the home.   BIDMC@Home would never have been possible without simple to use middleware on phones.

4.  Cloud hosting became a reality for mission critical healthcare applications.  Google, Amazon and Dell/NTTData agreed to sign business associate agreements.

5.  FHIR standards were implemented in production systems and radically simplified interoperability.  In 2017, FHIR will enable third parties to create add on modules to EHRs, accelerating innovation.

6.  Surescripts introduced its national record locator service and made it available for free.
21st Century Cures requires a federal study of a national healthcare identifier.

7.  Care management/population Health applications including novel workflow solutions became a reality.   As the country moves from fee for service to value-based purchasing, incentives are finally aligned to coordinate care across competing facilities.

8.  Over 50% of doctors want to quit the practice of medicine because of the burden of clinical documentation.   There is a growing consensus that new approaches to spread the work and enhance usability are key.  Secure texting and other forms of social-media like communications are gaining traction.   BIDMC has prototyped a “facebook-like” approach to team documentation, giving every patient a “wall” that every member of the care team can edit.

9. When my father died in 2013, I lamented the lack of patient and family engagement in ICUs
Today, every ICU at BIDMC offers the MyICU app to patients and families providing a comprehensive platform for care planning and communication

10.  Numerous security enhancements went into production at BIDMC in 2016 including various kinds of malware protection.   We also created a prototype application with colleagues at MIT using Blockchain for cryptographically securing health information exchange in the community.
Although it’s at the peak of the hype cycle, I believe Blockchain will truly provide a novel architecture for health information exchange in 2017

So there you have it.  For all its ups and downs, 2016 had major breakthroughs.   As I always tell my colleagues - we have to look at our trajectory and not just our position.  From the beginning to the end of 2016, the healthcare IT trajectory was good.  

What about my predictions for 2017?  I’ll write about that next week.

Thursday, December 22, 2016

Building Unity Farm Sanctuary - Fourth Week of December 2016

As the end of the year approaches, I’m reflecting on the changes that 2016 has brought.   Unity Farm Sanctuary was a distant strategy for leaving a legacy at the end of our lives.  Now it is a reality with a population of wonderful creatures who will be able enjoy their days in the pastures, forests, and gardens of a  safe, vegan, organic space surrounded by permanently protected rural trust land.

The current capacity of the sanctuary is a 5 stall barn, a two adult horse run in, and a pony/donkey/goat run in.    Our theoretical maximum capacity is 4 adult horses, 3 ponies, 3 donkeys, and 3 goats.

Next week, we will remove a few trees between Unity Farm and Unity Farm Sanctuary, creating a few acres of additional paddocks connected by lanes that will enable us to rotate animal locations easily and sustain natural grasses throughout the year.   Once completed, these new paddocks will support a dozen more horses, cows, pigs, goats and other farmland creatures in need of rescuing.   Sherborn has no restrictions on hosting farm animals - we could rescue elephants and emus - so we do not know what possibilities each day will bring.

At the time we’re developing the new paddocks, we’re repairing fences, putting up electrical fence tape and carefully thinning trees near the barn and existing paddocks to keep the animals safe from falling branches.

We’re also preparing the Unity Meeting House for public use.   Although we are not zoned commercial, there are no restrictions on our use of the property for farming and educational purposes.   To host seminars, retreats, and group events, we’re making a few improvements to the infrastructure.    This week, we replaced the heating and hot water system of the building with an Energy Kinetics System 2000 boiler.   This enables us heat all aspects of the structure which has a combination of state of the art radiators, warm floors, and a very old ventilation system.    Here’s what the new central heating and water plant looks like.


The floors of the meeting house include pine from 1830s, beech, chestnut, oak, and maple.   We’re refinishing all of them with a tough high traffic finish to accommodate the wear of public traffic.

The structures on the property have a total of 150 light bulbs inside and out.   This week, we replaced every lighting fixture with LED technology, recognizing that the public visitors are likely to use a lot of light and leave them on.  At this point, all incandescent, fluorescent, and halogen lights have been removed.  


Antique furniture seems to be falling in popularity - millennials don’t want it and trendy middle aged folks are seeking mid-century modern.    That means that a vast amount of 19th century furniture is available at low cost in New England right now as people downsize and clean out their attics.    Since the Unity Meeting House was built in 1830s, we’re trying to furnish all the public spaces with items that would have been present in the house when it was fist used.    Over the next few weeks, we’ll be moving the 19th century items from estate sales and moving sales into the Sanctuary.   For example, here’s the work in progress in the sanctuary library.


Whenever Kathy and I take on a property, we use our accumulated life skills to make it more robust.   I do electrical, plumbing, and carpentry.   Kathy does painting, decor, and furnishings.    We have a number of public events scheduled for 2017 and we’ll be ready.  You can expect the next year will be building inside and out, followed by a daily influx of volunteers, students, and educators who will keep the property vibrant.

Kathy and I are contributing 50% of our income to the sanctuary this year and we hope that over the course of our lives we will leave the sanctuary with an endowment that sustains it in perpetuity.    Our daughter is completely comfortable with the notion that her inheritance will be smaller so that the sanctuary can last beyond us all.    As Warren Buffet says, you should leave your children the resources so they can do anything, but not so much that they can do nothing.  

Soon, all the family will arrive for the holidays and we’ll put them to work, brushing the pony,  smashing pumpkins for the pigs, and hauling hay.   Time on the farm with physical work and the joy of sustaining living things bring me all the holiday spirit I need.

Wednesday, December 21, 2016

The Most Important Interoperability Story of 2016

You may have missed or not understood the implications of this press release.  Here's a guest post from Micky Tripathi, the CEO of the Massachusetts eHealth Collaborative that explains everything you need to know:

"This summary provides some additional information on the recently announced interoperability agreement between CommonWell and The Sequoia Project (Carequality).  For full disclosure, I am on the Board of Directors of The Sequoia Project, a contractor to CommonWell, and participated in the discussions leading to the agreement.  The description below does not necessarily reflect the views of either of these organizations or any of the named vendors.  It is based on my understanding and analysis of the implications, does not reveal any confidential information, and has not been pre-vetted by either CommonWell or The Sequoia Project or any EHR vendor.  It was originally developed in response to questions from provider organizations whom I work with and who, after reading it, felt that it would be valuable to others.

Current situation:
CommonWell is a network that provides a record locator service (RLS) and query/retrieve capability among participating vendors/providers.  
*   Exchange concept.  The network architecture is patient-centric in the sense that one searches for a patient first, and then executes a query to retrieve a CCDA record from any of the returned locations that are connected and for which the patient has authorized being listed in the RLS. 

*   Architecture.  The network -- which brokers all transactions, manages patient identity-matching, and hosts the RLS -- is a central infrastructure owned by CommonWell (a non-profit organization) and developed & operated under contract by RelayHealth. 

*   Participation.  The main vendors in CommonWell today are athenahealth, Allscripts, Cerner, eClinicalWorks, Greenway, and Meditech.  More are listed here:  http://www.commonwellalliance.org/members/

*   Pricing.  CommonWell members by agreement don’t charge each other for transactions.  Each member charges its own customers according to their own policies.  So far, the bigger participating vendors such as athenahealth, Allscripts, Cerner, eClinicalWorks, Greenway, and Meditech are not charging their customers separately for access to CommonWell services as far as I know.

Carequality is a framework that provides a governance structure, legal foundation, and technical standards for network-to-network exchange.  
*   Exchange concept.  The architecture of exchange is provider-centric in the sense that one searches a provider directory for a care delivery organization, and then executes a query to retrieve a CCDA from that individual provider organization (a directed query).  In terms of architecture, it is very similar to how Epic CareEverywhere works today, except now extended to the entire Carequality membership.  Carequality currently supports 2 interoperability functions.  Directed query is the core function.  There is also an RLS function that is optional, meaning that it isn’t subject to some of the same policy constraints (namely pricing) as directed query.  Surescripts is currently the only RLS service available through the Carequality framework.

*   Architecture.  Carequality does not have any central infrastructure to broker transactions, however, it does maintain an XCA endpoint provider directory and it acts as an RA/CA for certificate management to enforce its rules.  Each node implements IHE XCA/XDS specifications and executes point-to-point transactions with other nodes, leveraging XCA endpoints from the provider directory and the certs issued by Carequality.

*   Participation.  The main vendors in Carequality today are athenahealth, eClinicalWorks, Epic, GE, NextGen, and Surescripts (RLS).  More are listed here:  http://sequoiaproject.org/carequality/members-and-supporters/

*   Pricing.  Carequality does not allow members to charge each other for directed query transactions for treatment purposes.  Each member is allowed to charge their own customers according to their own policies.  From what we’ve seen in the market so far, the major vendors such as athenahealth, eClinicalWorks, and Epic are not charging their customers separately for access to Carequality.  

The future:
CommonWell and Carequality will “connect” in the following way:
*   CommonWell will join the Carequality framework for directed query and RLS.

*   CommonWell will create a single gateway that will allow any non-CommonWell Carequality participant to query any CommonWell Carequality participant at the provider/site level (a directed query).  CommonWell member organizations will be listed in the Carequality provider directory at the individual site level, even though they will be connected via a single CommonWell gateway.

*   CommonWell will offer its RLS as a separate subscription service that can be purchased by a Carequality participant; since it’s based on open standards, it will be integrated into the workflow of a Carequality-compliant EHR.

The implication for a Cerner (or any other) CommonWell user is:
*  Once you agree to be a Carequality participant, you can search the provider directory from within your EHR’s CommonWell function and request a record from any other provider listed in the provider directory.  This will include any existing CommonWell members who agree to become Carequality participants, as well as current Carequality members (such as Epic, GE, and NextGen sites who have already signed on).

*   The CommonWell RLS will now also include patient listings from any Carequality member who purchases the CommonWell RLS service.

The implication for an Epic (or any other) Carequality user is:
*  Once you agree to be a Carequality participant, you will be able to search the provider directory and request a record from any other provider listed in the provider directory.  This will now include CommonWell members (such as Cerner, Allscripts, Meditech).

*   In addition to your current ability to subscribe to the Surescripts RLS service integrated into the Epic workflow, you will now also be able to subscribe to the CommonWell RLS service integrated into the Epic workflow.  Both are fee-based services.

What’s the difference between the CommonWell and Surescripts RLS services?
*   Each is founded on a different principle for determining record location, so each has its own peculiarities and gaps.

*   CommonWell receives ADTs from all participating sites, so provider-patient relationships are based on encounter information.  Every listing in the RLS is an active query/retrieve link to a record; no patient is listed without at least one active link to a record.  The biggest gap is that some vendors – such as Epic, GE, NextGen – do not belong to CommonWell.  In this sense, one might say that it is currently deeper than it is broad.  This is not a criticism – just an observation on where it is today.

*   Surescripts determines provider-patient relationships based on prescription information.  After a query it provides back a document listing the providers (and contact information) who have prescribed to the patient through the Surescripts network.  They enable active links to live Carequality endpoints to allow smoother transition from record location to query/retrieve.  The biggest gap is that not all provider-patient relationships can be found in the Surescripts network (for example, hospitals or ambulatory providers who do not use the Surescripts network for any or all of their patients), and not all returned relationships have electronic query/retrieve capability.  In this sense, one might say it is currently broader than it is deep.  This is not a criticism – just an observation on where it is today.

*   Both Surescripts and CommonWell RLS services are fee-based.  Surescripts has announced that they will not charge EHR vendors for access to their RLS until at least 2019; EHR vendors can of course charge their customers, but I am not aware of any vendors doing so to date.  CommonWell is currently developing its pricing model.

*   In the future we might imagine interoperability among RLS systems, so that a CommonWell member could benefit from the additional information that a Surescripts RLS provides, or a non-CommonWell Carequality member wouldn’t have to subscribe to both CommonWell and Surescripts RLS services to cover as much as ground as possible.  One step at a time……

The implication for providers in general:
*  This agreement is a significant step toward basic nationwide interoperability – for most of the major EHR vendors, you will be able to electronically request and retrieve a medical record from any other provider in the country from within your EHR.

*  The agreement is constrained right now to a single type of transaction – query for an individual CCDA patient record for treatment purposes.  It does not cover high volume aggregation of multiple patient records for analytics or population health or research, for example.  And it doesn’t cover other types of data such as images, or genetic information.

*   The agreement does not do anything explicit to normalize or improve the quality of CCDAs.  The CCDAs delivered are the same ones that are now being pushed via Direct Messaging; it just provides another avenue for getting them.

*   This doesn’t replace Direct Messaging – it is an additional interoperability option that enhances certain clinical use cases, such as when a patient shows up and records have not been sent in advance.

*   This also does not replace state and regional HIEs.  Any HIE can join either CommonWell or Carequality (or both), allowing them to offer nationwide service to their customers (kind of like FTD does for florists).  It does mean that some HIEs will have to refine their business models if they rely on basic query/retrieve.  With basic query/retrieve now effectively commoditized, these HIEs may need to focus more on higher value services such as payload normalization/improvement and population health.

*   Any organization that is investing in HIE capabilities should pause and evaluate before investing any more time and money.  This agreement doesn’t “solve” interoperability, not by a long-shot, but it does solve a lot of the daily headaches that plague CIOs and providers today, and it’s worth taking a hard pause to reevaluate your strategy before proceeding."

Thursday, December 15, 2016

Unity Farm Sanctuary Begins

Today we completed the purchase of the Unity Farm Sanctuary, established Unity Farm Sanctuary Inc. (a non-profit charity) and opened for animal rescue.    Our first new citizens arrived on our first day.

Pippin is a 30 year Welsh Pony who is healthy, friendly, and outgoing.    He has Cushing’s disease so he needs daily Pergolide mesylate, a dopamine agonist. It works by taking over regulation of the pituitary gland, helping to decrease ACTH release and lower blood cortisol levels. Although Cushing's can't be cured, administration of this medication can help control symptoms, and possibly slow the progression of the disease.


Billy and Marky are weathered (gelding) Alpine goats.   They have an unclear history other than being found thin and unloved on a run down farm.   They are incredibly friendly and love human companionship.  They are very gentle and will do well with visiting children.


Napoleon is a weathered (gelding) pygmy goat.    He’s a bit shy but we’re sure he’ll gain confidence over time.    Although Napoleon was not at the same farm as Billy and Marky, he’s become an equal member of the herd.   When Kathy and I each led Billy and Marky from the barn to paddock, we left Napoleon in the barn for a few minutes.   He really missed his buddies and when we returned for him, he ran to the paddock to join Billy and Marky.

We had 6 inches of snow today and now that we’re clearing 30 acres, multiple paddocks and multiple roads, we had a chance to test out the new plow on the Terex front loader.   Peter, who helps us out on the farm, declared our equipment to be ideal for purpose.  With a Terex PT 30 tracked vehicle and appropriate attachments - snow blower, plow, bucket, forks - we’re ready for anything.

Last week we sold my Toyota Prius and replaced it with a Ford 150 3.5L 4x4, which has been wonderful in the snow and ice of our first major winter storm.

We’ve stocked the Sanctuary barn with timothy hay, goat grain, and a special high fiber horse grain for Pippin.   We purchased a size 54 insulated/waterproof horse blanket so that Pippin will be more comfortable during his winter days in the paddock,

Closing escrow and becoming operational within 24 hours was challenging, but such is the reality of rescue operations.   You have to be agile to respond to evolving situations.  We have a 20 year old Arabian arriving on December 26 and we were just asked to take on an 18 year old Quarterhorse the same day.     We’re being very careful to avoid taking on too much too soon and needing rescue outselves!

As the holidays approach, we’ll have a few days with family and friends who can all help with sanctuary building.    There are fences to repair and paddocks to amend with stone dust.   There are trails to cut.    As we prepare to receive the public there is electrical, plumbing, and carpentry.   There is painting and floor refinishing.    Here's the almost 200 year old Unity Meeting Hall on the property.


In that spirit, my Thursday blogs for the next year will be called “Building Unity Farm Sanctuary”, explaining all the work we’re doing to create a legacy for the town of Sherborn and the region offering rescue, education, and community services from a publicly available center just 500 feet from downtown.

The sanctuary building was created in 1830 and served initially as a meeting hall for the Unitarian church (hence Unity Lane, our access road).   As we build the sanctuary, the building will return to its tradition as a public meeting space.   The Thursday blog will document the journey ahead.

The adventure begins!

Wednesday, December 14, 2016

Dispatch from Israel

This week Massachusetts Governor Charlie Baker led a trip of clinicians, industry leaders, government officials, academics, and entrepreneurs to visit Israel (not at taxpayer expense) on a mission to establish Massachusetts as an incubator for the US growth of Israeli companies.  I represented the healthcare IT innovation work we’re doing at Beth Israel Deaconess and Harvard Medical School.

Israel is a remarkable place.   With 8 million people in a nation the size of New Jersey situated in an unstable part of the world, Israel has no choice but to be a start up nation, creating companies that generate economic impact world wide.

Our agenda was focused on Digital Health and Cybersecurity.   We attended briefings.   We heard pitches.  We gave lectures and ran a summit.  Many friendships were made and opportunities discovered.

What lessons did I learn from Israel?

First - a caveat.   I’m an American and my observations may be completely wrong, but here’s what I saw.

At sunset last night, I waded in the Mediterranean.  I saw a cluster of small sail boats 100 yards from shore practicing maneuvers.    A few minutes later, the boats came back to port and I noticed the sailors were probably 8 years old.   The one adult around the 20 sailors told them to pick up their boats, dissemble the sails and carry the parts into a storage area, completely unassisted.  The children were completely self sufficient and confident.    That’s an interesting contrast to the US where we've become helicopter parents and consider child self sufficiency a risk.


In Israel, the majority of the population participates in military service from age 18-21, not applying to college until they have had real world experience that involves physical and intellectual challenges.    They have resilience before even attending college and have an opportunity to mature enough to get more out of the college experience.

The presentations I heard from young people were remarkably polished and mature.  They were honest about the work that had been done and had yet to be done.  In the US, I’m often faced with the “Theranos” approach.   I'm asked to trust that the technology works perfectly.

Over the next few months, I’m going work to create a test bed for Israeli companies to pilot their applications in Boston.   I’m going to seek volunteers, philanthropy, and industry funding to support the effort.

There are many lessons to be learned from innovators in Israel and just as with other countries I serve, the experience I gain outweighs the advice I freely give.


Thursday, December 8, 2016

Unity Farm Journal - Second Week of December 2016

Every night, Kathy and I sit by the fire and debrief on the events of the day.    What rescue animals did we take on?  What new projects need to be started? Is there new infrastructure required?  Were their notable events at Unity Farm and Unity Farm Sanctuary? On our to do list, have we addressed the needs of all living things?

This week we agreed to take on 3 goats - Charlie (black alpine), Billy (white alpine) and Napoli (black pygmy cross), three wethered (gelded) males.  We do not have a lot of history on them, (not even their ages) since they came from an unfortunate situation where they weren't receiving proper care.   Charlie and Billy are very affectionate.   Napoli is a bit shy but with time will trust us.    They’ll arrive at the Sanctuary next week.


There has been a heart breaking abuse situation with 1400 animals at a farm in Westport, MA  and we stand ready to take on some of the rehabilitation tasks, even if it is just fostering.   We never intended to host cows at the Unity Farm Sanctuary but given the rescue need, we’re evaluating the requirements of bovine habitats.

We had our first snow of season this week and the pigs are not happy with cold feet.    Hazel and Tofu, who lived alone before coming to Unity Farm, have developed a mutual tolerance for each other and sleep together for warmth.    Lunchbox, our newest pig, is friendly and outgoing but Hazel still has not accepted him into the herd.   We’ve put a panel heater in his temporary housing (a large doghouse) and he’s staying comfortable through the snow and ice.   The family of the young Yorkshire pig we're assisting will visit next weekend and we'll determine together if our farm can help.


I’m heading to Israel this afternoon as part of the governor’s delegation which means Kathy will manage the farm for the next few days.   As I was leaving, we got a call about additional goats to rescue (before they are eaten).    Kathy may take the Ford Transit van to Southern Massachusetts to pick them up.   I’m sure the drive home will be interesting.  Let’s hope her passengers cooperate.  


This week we traded in our 2012 Prius C for a 2016 Ford 150 Truck.  I know that sounds like a very strange swap, but our needs have changed.   Pulling a trailer full of horses, cows, llamas, goats, or donkeys doesn’t work so well with a Prius.   The Farm and Sanctuary will have the Transit van for small animals and food pickup/delivery, a truck and trailer for hauling large animals, and my wife’s Prius V for transporting people.    It’s a good balance.

This weekend we’ll have temperatures in the 20’s and all our surface water will freeze, so we’ve put out all our bucket heaters and electric waterer bases.   We now begin 8 weeks of bitter cold that will challenge every creature on the farm.   We’ll keep them well fed/hydrated, put out extra bedding material and close each building in the evening to minimize wind/moisture.    We’ll do our chores in parkas and thick gloves.   As a farmer, you cannot fear the cold and dark mornings, you must accept the responsibility of serving the living things that depend on you.   That’s what gets us out of bed every morning!

Wednesday, December 7, 2016

21st Century Cures and the Road Ahead

I’ve been writing fewer posts recently because the trajectory forward for healthcare and healthcare IT seems to be evolving very rapidly.   In just the past week, we’ve had

*The American Hospital Association letter suggesting that 21,000 pages of regulations be rolled back including Meaningful Use Stage Three concepts and quality measurement in many care settings.

*The passage of the 21st Century Cures bill and its many IT related mandates

*The nomination of Tom Price for HHS Secretary  and Seema Verma for CMS administrator

As I’ve written about previously, I believe that value-based purchasing and the move to reimbursement based on quality measurement will still continue.    QPP , IPPS  and OPPS  will rollout as scheduled.

What can we expected from 21st Century Cures?   Here’s an IT centric evaluation:

*The HIT Policy Committee and HIT Standards Committee will be consolidated into the HIT Advisory Committee.  Thus, we’ve gone from HITSP in the Bush administration to HITSC in the Obama Administration to HITAC in the Trump administration.

*Sec. 4001. Assisting Doctors and Hospital in Improving Quality of Care for Patients -  ONC shall encourage, keep or recognize voluntary certification of health information technology for use in medical specialties and sites of service for which no such technology is available or where more advancement is needed. Requires the Secretary of HHS to submit a report to the HIT Advisory Committee on the attestation statistics for the Medicare and Medicaid EHR Meaningful Use Incentive programs to assist in standards adoption.

*Sec. 4002. Transparent Reporting on Usability, Security, and Functionality.  One year after the enactment of Cures, the Secretary through rule making, shall require that a health information technology developer or entity does not take any action that constitutes information blocking, does not prohibit or restrict communications, has published application programming interfaces (API), has successfully tested the real world use of the technology for interoperability, has provided the Secretary with certain performance attestations, and has submitted reporting criteria.  The Secretary may encourage compliance with the conditions of certification and take action to discourage noncompliance, as appropriate.  Eligible professionals maybe exempt from the application of the payment adjustment if the Secretary determines that compliance with meaningful EHR use is not possible because the certified EHR technology used by a professional has been decertified. This may also applicable to MIPS eligible professionals.

*Sec. 3009A. Electronic Health Record Reporting Program . No later than 1 year after the enactment of Cures, the Secretary must convene relevant stakeholders for the purpose of developing a wide range of reporting criteria including interoperability, security, and certification testing.  Relevant stakeholders include health care providers, including primary care and specialty care health professionals; hospitals and hospital systems; health information technology developers; patients, consumers, and their advocates; data sharing networks, such as health information exchanges; authorized certification bodies and testing laboratories; security experts; relevant manufacturers of medical devices; experts in health information technology market economics; public and private entities engaged in the evaluation of HIT performance; quality organizations; experts in human factors engineering and the measurement of user-centered design; and other entities the Secretary determines appropriate. The Secretary shall award grants, contracts or agreements to independent entities to collect the information required to be reported. Includes the authorization of $15 million to support the ONC’s certification process.

*Sec. 4003. Interoperability. Includes new language instructing the ONC, NIST, and other relevant agencies within the Department of HHS to convene “public-private and public-public partnerships to build consensus and develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” Includes rules of construction language and states that the trusted exchange framework and common agreement shall “take into account existing trusted exchange frameworks and agreements used by health information networks to avoid the disruption of existing exchanges between participants of health information networks.” Defines interoperability as HIT that:

“Enables the secure exchange of electronic health information with, and use of electronic health information from, other health information technology without special effort on the part of the user”

“Allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law”

“Does not constitute information blocking”

ONC shall publish the trusted exchange framework and common agreement developed one year after the convening of stakeholders. ONC must publish a list of health information networks that have adopted the common agreement and are capable of trusted exchange no later than 2 years after the convening of stakeholders and annually thereafter. Federal agencies contracting or entering into agreements with health information exchange networks may require that each network adopts the trusted exchange framework and common agreement

* Sec. 3003. Setting Priorities for Standards Adoption. The HIT Advisory Committee will identify priority uses for HIT focusing on priorities arising from the implementation of the incentive programs for the meaningful use of certified EHR technology, MIPS, Alternative Payment Models, the Hospital Value-Based Purchasing Program, and any other payment programs. Committee will also identify priorities related to a number of different issues including public health, privacy and security of electronic health information, and individual access. Committee will also identify existing standards and implementation specifications that support the use and exchange of electronic health information.

*Sec. 3022. Information Blocking
Defines information blocking  as a practice that “is likely to interfere with, prevent, or materially discourage access, exchange, or use of electronic health information; and if conducted by a health information technology developer, exchange, or network, such developer, exchange, or network knows, or should know, that such practice is likely to interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information; or if conducted by a health care provider, such provider knows that such practice is unreasonable and is likely to interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information.”   The Secretary, through rule making, may also identify reasonable and necessary activities that do not constitute information blocking.  The HHS Office of the Inspector General may investigate claims of information blocking or false attestations and may issue penalties up to $1 million per violation.

*Sec. 4005. Leveraging Electronic Health Records to Improve Patient Care  Requires that electronic health records be able to transmit data to and from registries, such as clinician-led clinical data registries. Adds that health information technology developers shall be treated as patient safety organizations for the purposes of reporting and conducting patient safety activities concerning improving clinical care.

*Sec. 4006. Empowering Patients and Improving Patient Access to Their Electronic Health Information. The ONC shall promote policies that ensure that a patient’s electronic health information is accessible to the patient and/or designees to facilitate communication with other health care providers and other individuals, including researchers, consistent with such patient’s consent.  Lays out an educational effort for health care providers and patients on allowable sharing of patient health information.

* Sec. 4007. GAO Study on Patient Matching  Requires the GAO to conduct a study on the policies and activities of the ONC and must specifically focus on efforts related to patient matching.

* Sec. 4008. GAO Study on Patient Access to Health Information  Requires the GAO to conduct a study to review patient access to their own protected health information, including barriers to access and complications providers experience in providing access to patients.

*Additional Changes.  The new version does not contain the three-star rating system that was part of Senator Bill Cassidy’s TRUST-IT Act and included in a previous version of Cures.

There is good and bad in the IT provisions of Cures.  

I’ve written in the past that interoperability really means getting the information necessary for coordination of care to those who need it without too much difficulty.   You could read the Cures language as making available every data element for every purpose to every stakeholder with no effort.   That is just not realistic.

I recently spoke with the CEO of a leading EHR company who noted that he has committed 600 person years of resources to support the healthcare regulations already issued in the past 10 months.   Asking the EHR vendors to do something vague like support all registries and provide for “complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law” is like boiling the ocean with a lighter.   Although I applaud the GAO report on patient matching (and I support a voluntary national healthcare identifier),  I cannot support legislation that co-opts the agenda of developers to the point they cannot meet customer needs because they are too busy creating functionality mandated by Congress.

Over the next 4 years, you’ll find me serving the Governor of Massachusetts, the New England region, and multiple international governments.     I remain optimistic that the private sector will be allowed to innovate in response to demands from clinicians.    I will do my best to serve all stakeholders, working hard at every level of government to do no harm, as mandated by the oath I took as a doctor.

Thursday, December 1, 2016

Unity Farm Journal - First Week of December 2016

As winter approaches each year, we work hard to prepare the farm property for the cold, dark, snowy days ahead.    Weekends and nights are spent clearing brush, /storing all irrigation infrastructure, and doing the last digging/hauling/siftng before soil freezes solid.   At this point the barnyard,  trails and  the sanctuary next door are ready.   All farm equipment is freshly oiled and filled with winter-ready fluids.  We purchased a snow blade attachment for the Terex front loader since we’re responsible for snow removal on our 1/2 mile of local roads.   The Terex snow blower attachment is ready for paddock clearing and removing snow from those areas that a plow cannot reach.


Winter is a hard time for animals and we’re readying for new arrivals.   All three pigs (Hazel, Tofu, and Lunchbox) are now living together in harmony and we’re preparing for a potential fourth pig, Penny, who we’ll visit this weekend.   She’s a Yorkshire with a rough history and she’s underweight for her age (about 40 pounds at one year old).  We’ve been reluctant to take on Yorkshires because they can grow to 600 pounds.   What does a 600 pound pig do?  Anything it wants to!


We’ll also be meeting two groups of goats this weekend.   In December, three horses will arrive at the sanctuary - Amber, a 20 year old female Arabian; Sweetie, a 20 year old female Welsh Pony; and Pippin, a 30 year old male Welsh Pony.  


We’re being very careful to avoid over extending ourselves, our resources, and our community volunteers.   Every day we’re presented with a new rescue inquiry.

As a certified organic farm, commercial kitchen, and bonded farmer winery, we’re very familiar with legal paperwork.   This week we submitted our final paperwork to establish a new non-profit corporation - Unity Farm Sanctuary Inc, a public charity devoted to animal rescue and public education.    We’ve selected our initial board of directors, and established early funding streams to ensure the Sanctuary persists beyond our lifetimes.

Although it’s cold, we’re still having late fall rain and so the Shiitake mushrooms have be fruiting nicely.   Here’s what a mushroom delivery to the farmstand looks like


Now that Thanksgiving has passed, local businesses are donating their pumpkins to us by the pallet.   When a forklift loads a pallet of pumpkins into your farm truck, this is what it looks like.


Speaking of Thanksgiving, here’s what the traditional holiday meal looks like on an organic vegan farm - plates of local vegetables, Unity Farm ciders/beers, and a vegetable-based field roast.   No animal products of any kind, virtually no fats, and no processed sugars.  There is much to be thankful for in 2016.


Thursday, November 24, 2016

Unity Farm Journal - Fourth Week of November 2016

Happy Thanksgiving from Unity Farm!

A new pig has joined the herd - Lunchbox.  He’s 3 years old and has a remarkable personality.    He loves humans and is very good with children.   We’re gradually introducing him to Hazel and Tofu  through a livestock fence.   In a week or so, we’ll bring them together snout to snout once they have had the opportunity to learn each other’s smells and temperament.    Creating harmony in a pig herd is an art form and there’s a great deal of literature about it.   We’re seeing the expected behaviors - grunting/chewing, side stepping, and a bit of mouth foaming.

Here’s a photo of the pigs enjoying an organic Unity Farm pumpkin together on either side of a fence.



We’ve continuing to prepare the land between the Farm and the Sanctuary with new trails and roads.   We’ve chipped all our old mushroom logs to create a base for new trails.   The Sanctuary Road and Coyote Run are finished.   We’ll work on the Pond Trail and Pine Loop once we take ownership of the Sanctuary property in December.

Kathy’s vision is to create large paddocks in the forest between the two properties over the next few years so that we’ll eventually have a much larger animal rescue capacity.

All of this takes careful consideration of how all the creatures will interact in a community, ensuring we have the time and resources to offer each an enriching life.

For the moment, we’re planning to add two donkeys, two ponies, and a horse.  Although Kathy and I had significant horse experience as teens, that was 40 years ago.   We’re comfortable around all barnyard animals, but we're not experts in equine care.

 Choosing which animals to take on requires that we stay focused on our goals.  Here’s what Kathy wrote to the adoption specialist who we’re working with at the MSPCA Nevins Farm:

“The mission of the Sanctuary is focused on rescue and education. Three experienced program advisors to our project will make sure we do not take on more than we can handle with respect to health, fitness, and behavior of the various animals.

I have two good friends who are experienced current horse riders who will volunteer at our sanctuary.  My personal focus is not riding-readiness.  Temperament is important because we want leading and grooming to be educational options.”

We continue to study all the possibilities and likely we’ll soon take on two Welsh Ponies who will retire to the Sanctuary and be companions to each other.

This weekend we'll visit a rescue horse in Southern Massachusetts.   We're learning a lot about thoroughbreds, quarter horses, standard breds, arabians and Morgans as we expand our scope to include a more diverse array of inhabitants at Unity Farm.

Wednesday, November 23, 2016

The BIDMC CareKit app

The following is a guest blog post from Seth Berkowitz, MD, who authors many of the innovative apps in the BIDMC Crowdsourcing program:

Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School, has developed BIDMC@home, a new app for engaging patients using Apple’s CareKit and ResearchKit frameworks and the HealthKit API. The app provides a flexible framework to help patients manage their health from home, as directed by their physicians. The app will be piloted in several specific patient populations and will eventually be offered to BIDMC’s entire network of over 250,000 patients.

BIDMC@home provides personalized home monitoring in many different conditions. HealthKit allows the app to collect data from various sensors and 3rd party apps to gain a holistic picture of health and help prevent hospital readmissions. Together with HealthKit-enabled wireless devices such as scales and blood pressure cuffs, patients with congestive heart failure can use BIDMC@Home to monitor vital signs and symptoms. Daily fluid, sodium intake and important predictors of fluid retention, can also be imported via HealthKit. Connected thermometers allow patients with autoimmune diseases such as lupus and rheumatoid arthritis to better predict infections and monitor inflammation. Outpatient chemotherapy is associated with varied symptoms and side effects. The app allows these patients to better monitor their health during treatment.

BIDMC@Home simplifies complicated post-operative instructions given to patients after orthopedic surgery by utilizing the dynamic care card and allowing them to track their recovery. Major bowel surgery can place patients at risk of severe dehydration. Connected scales and electronic patient reported outcomes will help prevent complications in these patients in between visits to the doctor’s office.

The app contains several key functions:

Care Card:

Every patient has a customized care plan that is seamlessly synced from the electronic medical record via FHIR interfaces. All outpatient medications are listed and updated in real time when a provider makes a change. Patients are encouraged to adhere to their prescribed medication regimen and can also track their intake of “as needed” medications. Providers can also define a care plan for non-medication activities, such as: diet, exercise, sleep or other instructions tailored to their individual care.

An essential part of staying healthy is the plan and thought process laid out in the health care providers’ notes. All too often these are hidden in the silos of individual electronic health record systems. BIDMC@home harnesses the capabilities of the Health app in iOS 10 to serve as a secure, patient controlled, shareable database of medical records. Under the umbrella of the Open Notes initiative pioneered at BIDMC, patients will be able to view and download their physician’s notes from BIDMC, transforming their phones into true personalized health records.

Assessments:

As part of each patient’s individualized care plan, he/she is prompted to provide subjective and objective data to monitor health. These data include values that are synced via HealthKit from connected sensors or other apps (e.g. weight, blood pressure, heart rate, temperature, daily sodium intake) and subjective assessments. Using the ResearchKit framework, the app collects meaningful patient reported outcomes using simple questions (e.g. shortness of breath on a 0-10 scale) or more elaborate validated survey instruments.

Insights:

To empower patients to take control of their own care, the app provides a dynamic graphing engine so that patients can see the relationship between measurements, medication adherence, or amount of “as needed” medications taken and the direct results. By reinforcing the relationship between treatment and outcome, we hope to reinforce positive behaviors and improve treatment compliance.


Connect:

The app syncs with our secure messaging system and allows patients to quickly contact their care team members.

Thursday, November 17, 2016

Unity Farm Journal - Third Week of November 2016

This week we had the Supermoon - the largest/brightest moon since 1948 

The pigs enjoyed basking in the moonlight while rooting and hunting for grubs/worms.   Here’s a picture of hazel in the moonlight


Pigs are hedonists and there are three things that make them happy

1. Food
2. Warmth
3. Belly rubs

Here are a few pictures

Tofu enjoying a fall sugar pumpkin
Hazel stealing a piece of Tofu’s pumpkin
Hazel in the winter pig palace warming her posterior in the mid morning sun






A television film crew dropped by the farm this week to get closeups of the alpaca.  Here’s what it looked like.   The alpaca are demanding royalties.


We’ve racked our last cider of the season, and now all our fermented beverages begin their overwinter malolactic (secondary) fermentation until we bottle them in the spring.   We’ll continue to brew honey lager over the winter and we’re studying how best to scale up our capacity to produce 5 kegs a week to meet growing demand.

At this time of year we’ve harvesting lettuce, spinach, and carrots for ourselves and the animals.   We’re selling eggs, honey, and mushrooms.   We’re preparing the farm for winter, keeping every animal area clean, dry, and filled with warm bedding.   Our weekend work begins to shift indoors where we repair equipment, build new infrastructure, and catch up on paperwork.    We're also making Unity Farm soaps and lip balms from honey, wax, and organic herbs.



Our sanctuary plan remains on track and we’ll double the size of the farm on December 15.   We’re already beginning to plan events for the sanctuary - artists retreats, educational offerings, and infrastructure upgrades.    Five years ago we were living in a small cape home in Wellesley and tending a small community garden.   Who would have thought that we’ve been running 30 acres of agricultural production, caring for 150 animals, and producing organic fruits/vegetables/mushrooms while educating the public about sustainable agriculture.    Truly, the journey in life, and not the destination, is the reward.

Wednesday, November 16, 2016

What Does the Trump Presidency Imply for Healthcare and Healthcare IT?

Many organizations have asked me to comment on the impact of the Trump Presidency on Healthcare and Healthcare IT.    I served the Bush administration for 4 years and the Obama administration for 6 years.   I know that change in Washington happens incrementally.   There is always an evolution, not a revolution, regardless of speechmaking hyperbole.

What am I doing in Massachusetts?   I’m staying the course, continuing my focus on social networking for healthcare, mobile, care management analytics, cloud, and security while leaving the strategic plan/budget as is.

I have no inside information and no involvement with the Trump campaign/transition team.   From talking to people in Washington and reading publicly available resources, I believe there are 10 themes that will guide us over the next two years.

1.   It’s likely that some corporate and personal taxes will be reduced, possibly increasing the funds available for innovation.

2.   It’s likely that some regulations will be simplified, possibly creating more free time/attention span for innovation.

3.   It’s likely that free market competition will increase and some of the political infighting around issues such as Medicare’s inability to negotiate drug prices may dissipate.  I'm hearing that Medicare may be encouraged to negotiate drug prices in the Trump administration.

4.   As corporate taxes are restructured, we may see repatriation of funds currently sequestered offshore.   The tax cost of bringing such funds back to the US today is 40%.   It may be 10% in the near future.

5.   Although much has been said about replacing the Affordable Care Act, it’s likely that it will simply be amended to reduce the focus on Health Insurance Exchanges.  There will be no “public option” for health coverage.   Private payers will be encouraged to offer products across state lines.   Pre-existing conditions will still be covered.   Children will be covered on their parents health plans until age 26.

6.  Medicaid will be moved closer to the states.   States will have more funds to invest in innovation.   Since states will directly benefit from cost savings resulting from investments in innovation incentives will be aligned.

7.  FDA scrutiny of new products may be streamlined.

8.  FTC enforcement actions may be relaxed.

9.  NIH funding may be cut and projects like the Cancer Moonshot, Precision Medicine, and the Center for Medicare and Medicaid Innovation may be scaled back.

10.  Most importantly, the transition from fee for service to value based purchasing will continue unmodified.   This means that all the work we’re doing to improve quality, safety, efficiency, patient/family engagement, and population health will still be high priorities.

I recently spoke with administrators in Washington and they reminded me that although political appointees all resign on January 20th, career appointees will continue doing the work already in progress.   Regulation can be changed in the medium term, but legislative changes (even with a Republican House and Senate) takes a long time.    MACRA/MIPS is legislation.  The Quality Payment Program is regulation implementing MACRA/MIPS.   The career employees are on track to implement the Quality Payment Program as scheduled  2017-2019.

My advice is to remain agile, keep calm, and assume that many Obama era healthcare IT programs will persist.    Focus on reducing total medical expense, measuring quality across the community, providing stakeholders with tools that are valuable to them, spreading the burden of data capture among teams of caregivers, and enhancing interoperability.

Working together and staying focused, above the fray of politics, we can make a difference.

Thursday, November 10, 2016

Thursday Unity Farm Journal - Second Week of November 2016

Yesterday in Massachusetts all my colleagues were fatigued from a long night of watching election results.  

Everyone was asking about the impact of the surprising outcome.   What will happen to the economy, the stock market, mood, culture, and domestic tranquility?

The questions we asked at Unity Farm were basic -  should the election change our thinking about enhancing the farm and sanctuary?  Will we be able to continue to fund the programs we’ve put in place?   Should we continue to focus our efforts in the United States?

Our answer after speaking with career government employees, who will be serving the next administration, is to stay the course.

Continuing our mission of producing food, rescuing animals, and educating the public about sustainable agriculture is more important than ever.   All of our plans and programs will move forward with enthusiasm.    The relationship we have with our land, our community and our animals are stronger than any political event.   We may focus more locally than on Washington DC over the next few years, but we believe we can make a difference.

Here’s what Kathy wrote on her Facebook page:

"My plans and dreams have not changed. I will not change the core of who I am. Here is where I will make my stand. I will not run, I will provide sanctuary and make that fight the important one. We have so clearly failed those that felt they needed such deep changes, we need to unite our world through the lifting of despair and feelings of unfairness or uselessness and fear. Leaving is not an answer, truly the grass is not greener elsewhere. Hating is not the answer, it will lead nowhere we truly want to go. Drowning out deep feelings with crutches like alcohol, mass entertainment, or drugs that blunt the emotions won’t solve the problems. Let us not fail the vulnerable - shelter them, speak for them. Stand, stay and fight for what you believe in even if it is hard. Courage; the efforts toward peace and unity are not the easy road."

What does life on the farm look like this time of year?

Here’s what the sunrise looked like on the morning after the election


Here’s what the coop opening looked like as the chickens and guinea fowl began their day.

video

Here’s what the paddocks looked like as the Fall leaves continued to fade.


This weekend, we’ll be racking cider, continuing our winter preparations and serving as a filming location for a TV show.   You never know what each day on the farm will bring.

Be well.

Wednesday, November 9, 2016

What is Patient and Family Engagement?

I recently participated in a nationwide (not the United States) healthcare IT planning effort and one recommendation was universal availability of patient portals.    Several reviewers commented that patient portal is a loaded term - it implies that clinicians control the data and patients are given a view into it.   One person said, “that’s so 10 years ago”

BIDMC has been working with patient/family shared medical records, Open Notes and various consumer-facing apps since 1999.      Over that time we've discovered that patients typically do not want raw data, they want something actionable - the tools necessary to assist their navigation through the healthcare process.

A few years ago, Adam Bosworth, the leader of Google Health and later KEAS, met with me to explain his journey with patient and family engagement.  He spent a few million in venture funds to build a website that helped patients understand their lab results.   Patients visited once and never again.   He then spent a few million creating online care plans.  Patients visited once and never again.  He then spent millions creating a social network for healthcare that enabled teams of people to come together to support each other’s wellness.   That worked!

Our challenge is that we do not know precisely what patients want.  It would be hubris for any IT leader to speak for all patients.   We need to try many different technologies and let the patients decide.

My friend e-patient Dave pointed out in a recent post that my comments about downloads sounded very patient unfriendly.   I explained that the context of my comments was a reaction to the Meaningful Use requirement for View/Download/Transmit.    I completely support the notion that patients and families should have fluid access to all their data, but in 2014 when the Meaningful Use Stage 2 regulation was written, it felt too early to dictate just how that should happen and I commented that download and transmit required more thought.

I made the comment that no patient at BIDMC has asked for the CCDA download of their medical record, a raw xml file of data, since there are few tools that make such a download useful.  Patients  do ask for improved healthcare enabled by technologies that turn the data into wisdom.

Now that it’s 2016 and we have more experience, we’re seeing the emergence of apps such as Apple’s Healthkit and CareKit that put the patient in charge of healthcare data downloaded to their phone.    I wrote this about HealthKit's  ability to make View/Download/Transmit truly useful to all.    We’re releasing our first HealthKit/CareKit app and here’s a description of some of the “data spigot” features:

“Every patient has a customized care plan that is seamlessly synced from the electronic medical record via FHIR interfaces.  All outpatient medications are listed and updated in real time when a provider makes a change.  Patients are encouraged to adhere to their prescribed medication regimen and can also track their intake of “as needed” medications.  Providers define a care plan of non-medication activities that are part of a patient’s treatment.  These may include diet, exercise, or special instructions.

An essential part of staying healthy is the plan and thought process laid out in the health care providers’ notes.  All too often these are hidden in the silos of individual electronic health record systems.  BIDMC@home will harness the capabilities of iOS 10 HealthKit Health Records to serve as a secure, patient controlled, shareable database of medical records.  Under the umbrella of the Open Notes initiative pioneered at BIDMC, patients will be able to view and download their notes from BIDMC, transforming their phones into true personalized health records, and giving patients control of how their health data is shared.”

The BIDMC approach is to create application programming interfaces (APIs) using FHIR for structured data, unstructured data, and images that enable an ecosystem of crowdsourced apps to put the data under patient control.     In my discussions with e-patient Dave, he pointed out that FHIR does not yet include every element in the health record.   He's right but we need to pick some standard for information exchange and I believe FHIR is our best hope for data liquidity.    Today it includes the Meaningful Use Common Data Set and with every HL7 ballot its completeness will improve.

If anyone interpreted my comments about downloads to mean that patients don’t want shared medical records, I apologize.   I meant to say that I believe patients want more than raw data - that they want tools that help them more easily interact with the healthcare system.    As BIDMC moves beyond portals to patient controlled apps, we hope to make that happen.

In the meantime, we do make the Meaningful Use downloads available in our patient portal, Patientsite for those who want the CCDA-based XML summaries of each visit.   We also have the tools to create a download of a patient’s longitudinal record in the CCDA XML format upon request.    We’re all on this journey together and just as the early Blackberry was replaced by the modern iPhone, I’m guessing that CCDA view/download/transmit will be replaced by apps that deliver great functionality to patients from APIs for data access.