Donna M. Zulman, MD, MS^1,2; Nigam H. Shah, MBBS, PhD³; Abraham Verghese, MD⁴

Frances Peabody’s timeless lecture to Harvard Medical School students, published in JAMA almost 90 years ago,¹ spoke of the complex and deeply human experience of illness, as epitomized by the powerful observation “for the secret of the care of the patient is in caring for the patient.”

By Frank Konkel
Nextgov | August 29, 2016

Unless the Defense Department and its military components levy increased importance on software development, they risk losing military technical superiority, according to a new report from the Center for a New American Security.

The Health and Human Services Department wants the public’s input on a document that might help patients’ medical records follow them between health systems.

HHS published a draft “Interoperability Standards Advisory” last week, part of its efforts to make the country’s electronic medical records systems compatible with each other. In a fully interoperable health system, a patient hospitalized in a new city could look up and transfer their records from their previous health care provider.

Broadly, HHS’ Office of the National Coordinator for Health Information Technology aims for consumers to be able easily send their health information “to any desired location, learn how their information can be shared and used, and be assured that this information will be effectively and safely used,” according to HHS.

The agency also aims to create and implement national standards for the companies that create electronic health records systems, including for privacy and security.

With the new draft, which sketches out standards for recording information such as patient allergies or lab tests, ONC is working toward nationwide interoperability. It’s a multiyear process—in 2014, ONC published its “10-Year Vision to Achieve an Interoperable Health IT Infrastructure.”

The interoperability draft is open for comment until Oct. 24.

HHS has also been trying to make the interoperability standards more interactive so records providers and other groups can navigate it easily. This version intends to “shift the ISA experience from a static, PDF to an interactive, wiki style product,” an HHS blog post said.

A more interoperable health system might also help public health organizations, including parts of the government, with “real-time disease surveillance and disaster response,” as well as “value-based payment that rewards higher quality care, not necessarily a higher quantity of care,” according to HHS’ 10-year vision.

Article link: http://www.nextgov.com/health/2016/08/hhs-posts-draft-electronic-health-record-standards/131127/?oref=nextgov_healthit_nl

Nothing sounds like a hospital. The incessant beep of monitors. The squeak of clogs on the tile floor. The whir of automatic doors and rolling cots. The moan of suffering patients and the drone of families huddled in a waiting room.

Anyone who’s spent a night in a hospital knows it’s hard to find a few moments of quiet—let alone sleep through the night. And when patients don’t sleep, they don’t heal.

There is now a small but diverse group of experts—electronic musicians, acousticians, researchers and health care providers—devoted to improving the sound experience of hospitals. Already, they have begun to change the soundscape of the hospital.

Based largely on patient feedback, these experts are working to create environments that will be less cacophonous and more harmonious. Wearables could silently alert nurses to a change in patient vitals instead of the beep of monitors; patients would wait for surgery in their own private rooms; and the vexing din of voices and TVs playing talk shows are replaced by ambient music.

Hospitals have always been noisy places. In 1859, Florence Nightingale wrote a section devoted to noise and its hazard to patients in her Notes on Nursing. But in the U.S., the noise problem has been getting worse and worse.

A 2005 study of global hospitals found that compared to 1960, daytime noise levels rose from 57 decibels to 72 and nighttime levels from 42 to 60. The World Health Organization says nighttime noise levels above 55 decibels can routinely cause sleep disturbance and increase risk for heart disease. It recommends decibel levels of 30 or less for sleeping. In the 2005 study, some hospitals were found to have noise over 100 decibels at night, which is as loud as a chainsaw.

The 2008 Hospital Consumer Assessment of Healthcare Providers and Systems patient survey, administered by the Centers for Medicare and Medicaid Services, highlighted the problem. The survey asked patients to grade their hospital experiences on a number of factors, ranging from cleanliness to communication with nurses; each one was given a score out of 100. The average U.S. hospital received a quietness score of 54—the lowest of all 10 survey traits.

Smart design goes a long way

Today, America’s hospitals are going through a design renaissance. The confluence of a few factors—portions of the Affordable Care Act that reward outcomes and reposition patients as consumers, combined with the infusion of design-thinking, with attention paid to the end user (in this case, the patient), into various industries—are leading to facilities that focus on patient experience.

“It’s not any one particular thing” driving the shift in hospital design, says Nick Dawson, executive director of the Johns Hopkins Sibley Innovation Hub. “Some organizations are motivated by revenue streams from intellectual property. Some are looking at it as a way to mitigate HCAPHPS. And some are looking at it and saying, ‘There’s this untapped voice of the patient out there and we need to re-tailor our business toward them.’”

Yoko Kamitani Sen is an electronic musician and founder of Sen Sound, a startup reimagining the sound environment in hospitals. She proposes that in the future nurses might use wearables to alert them to a patient in need rather than an alarm.

For years now, many health care experts and reports have been predicting that wearables will revamp the clinical setting. That’s yet to fully come into practice. But eliminating the ubiquitous beeps of the hospital floor might be what finally brings wearables to the clinic.

https://player.vimeo.com/video/140277104

The Future of Hospital Sound from Yoko K. on Vimeo.

A 2013 report by the Joint Commission, a health care nonprofit, found an estimated 85 to 99 percent of all hospital alarms did not require clinical intervention. That same year, Boston Medical Center set out to tackle “alarm fatigue,” a phenomenon that occurs in hospitals where there is so much beeping, nurses and support staff become desensitized to it.

The excess of alarms not only contributes to the jarring environmental soundscape, but can also result in death when nurses fail to respond to alarms that are actually urgent. In a 24-bed cardiac care unit, the hospital was able to reduce alarms from 88,000 a week to 10,000 essential beeps.

Eliminating alarms is a good start, but it won’t solve everything. A recent survey asked 40 patients and 10 nurses and administrators at Johns Hopkins to explain the most annoying sound they regularly experienced at the hospital.

“Oftentimes, we assume it’s the sound of alarms, which is actually the sound that really got me interested in this noise issue as a whole,” Sen says. “But repeatedly, the answer we got [from patients] was the voice of somebody who is suffering in pain. Lots of patients expressed that across the hallway they can hear others in pain moaning, screaming.”

No single technology will fix that, though design changes, like private rooms, can help. And many of newly built or recently designed hospitals have recognized that. The Josie Robertson Surgery Center, an outpatient facility of Memorial Sloan Kettering Cancer Center in New York, opened earlier this year and completely upends traditional hospital design.

For example, patients, family and staff are given badges connected to a real-time locating system. That facilitates quieter and more efficient communication—instead of calling on an overhead pager, a nurse can go directly to the family when a patient is out of surgery.

But perhaps even more importantly, patients at Josie Robertson also have their own private rooms. Combined with the tracking system, this means they don’t have to be herded from group pre-op rooms to operating rooms to group post-op rooms—they can actually get some peace and quiet throughout treatment.

Others are following suit: Cleveland Clinic is in the process of building a new cancer center due to open in March of next year, which will have a private room for each patient receiving chemotherapy. Shannon Faulhaber, director of strategic growth for Cleveland Clinic Taussig Cancer Institute says, “We tried really hard to separate the medical from the patient space in all of our rooms.”

Silence isn’t the sound you actually want

Individualization extends beyond the physical room to how the actual soundscape of those patient spaces are designed. Everyone’s perception of what constitutes “noise” is different. The sound of your own baby crying is an important signal—to others, it’s an irksome racket that disturbs their sense of peace and wellbeing. In other words, it’s noise.

“People’s preferences are very, very different,” Sen says. “On the same floor, on the exact day, we have one patient say, ‘Oh, it’s very quiet, nothing bothered me,’ and this other patient in the next room who says, ‘It’s so loud, I can’t stand it.’ Everybody is really different in terms of their perception of noise and their perception of sound.”

Ideally, you could give patients the ability to choose how they want their room to sound.

Susan Mazer, the president and CEO of Healing HealthCare Systems, points out we don’t want complete silence where accidental noise—a dropped cup, for example— becomes amplified. We don’t want to “merely mask other sounds, [but] add positive, therapeutic sounds where there are none.”

Mazer has helped to makeover the range of sounds available to patients through development of the C.A.R.E channel, an option on TVs in over 900 hospitals and care facilities around the world with relaxing imagery and soothing and ambient sounds.

The hospital people problem

While many hospitals have added white noise machines or other soundscapes to rooms, made improvements in construction to help with the acoustics, and even invested in more private rooms, there’s still one thing missing: Specialists have realized that changing behaviors in hospitals is fundamental to fixing the sound problem.

Gary Madaras, founder of the consultancy Making Hospitals Quiet, says we need to work on the “physical environment, the culture and the behavior, and hospital policies and procedures. We tell [clients] that all three of these need to be addressed. You can’t go to Home Depot and buy some magic acoustic paint and paint your walls.”

“For the most part, I think the design world is further ahead in the environment than anybody is in the culture/behavior or the policies and procedures,” Madaras says.

You can’t completely control patients and their families. But you can direct the behavior of the health care workers in a hospital. In her treatise, Nightingale wrote: “Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep.”

Through his consulting work, Madaras has put sound monitors in patient rooms and hallways and found in some hospitals throughout the night there are very few 45 minutes segments where someone isn’t going into the patient room.

He teaches hospital clients there’s active care and there’s passive care—and the latter is just as important as the drugs and procedures patients receive. Passive care is basically: “Leave me alone to sleep so I can heal.” Madaras works to rearrange care routines across the myriad schedules and departments—phlebotomists, nurses, doctors—so there’s less need to go into patients’ rooms while they sleep.

While the promise of wearables and other forms of technology present potential to reduce sound, simple behaviors could have the greatest impact. Currently, typical practice is to keep doors open so health care providers can easily access patients. But, says Madaras, “something so simple as closing the patient room door does a tremendous amount for the ability for that patient to sleep and not be disrupted. There’s a strong reluctance to do that.”

He’s working with a few institutions to implement technology that remotely monitor vitals so nurses would be comfortable having the door closed all night long.

“The next move in technology I see is not just remote monitoring of vital signs but actually remote monitoring of sleep,” he says. Systems could tell nurses what stage of sleep a patient is in—if they’ve reached stage three or four, deep sleep, they shouldn’t be bothered.

The things beyond our control

Underneath much of the anxiety and discomfort most of us feel about hospitals is the specter of death. We don’t like the sights and sounds of the sick because they presage our own eventual decline.

Between hospitals and nursing homes, the majority of Americans are still dying in institutions where the environment, and its sounds, is traditionally beyond our control.

Slowly, discussion of death is becoming less taboo, and patients and advocacy groups are pushing for more than just advance directives to plan what their finals days and hours will be like. Sound may soon be a part of that, too.

For example, Sen’s Sound Will Project was selected by OpenIDEO as one of its “challenge” projects, where the site hosts innovative ideas for a few months so community members can collaborate on solutions to pressing world issues. She’s now asking people what sounds they’d like to hear during their final days; the responses will serve as inspiration for a composition Sen will present at an interactive performance during Stanford Medicine X conference in September.

So far, answers include the sounds of crashing waves and thunder, song and songs like Radiohead’s “Nice Dream” and hearing “I love you” from family members.

The point isn’t to use sound to hide the reality that eventually, all of us die. Rather, it is to emphasize the meaning and even the potential beauty of an end-of-life experience that has been thoughtfully composed. Similarly, the goal of changing the soundscape of hospitals isn’t to cover up suffering, but rather to make them more healing environments for those who work and receive treatment there. We may never get to a place where a hospital has the full comfort of home, but this is sounding like a start.

Article link: http://www.nextgov.com/health/2016/08/what-hospital-future-sounds/131181/?oref=nextgov_today_nl

By David Blumenthal
The Wall Street Journal
Jun 28, 2016 6:15 am ET

Dr. David Blumenthal (@DavidBlumenthal) is the president of the Commonwealth Fund, a national health-care philanthropy based in New York.

The digitization of our health-care system is well under way, but several obstacles frustrate efforts to take full advantage of the health information revolution.  Perhaps the most important is our difficulty moving patients’ data, so that records can follow patients as they go from one site of care to another.

Moving health data goes by the technical term “health information exchange” or HIE. There are some technical barriers to HIE, but they are not the big problems. The big problems are economic and cultural.

The American health system consists of competing economic entities: health systems, hospitals, nursing homes and doctors, to name a few. State and federal authorities zealously enforce antitrust laws to assure that local health-care competition remains strong. But health providers’ data about their patients is a valuable economic asset that some doctors and hospitals are understandably reluctant to share with their competitors down the street. Many patients stick with clinicians and hospitals in part because that’s where their records are. If the records can travel, so may patients, taking their business with them. Also, many providers believe that they – not patients — own that information, and have no obligation to share it.

A recent federal report cites this “information blocking” by providers as an important obstacle to HIE. Legislative and regulatory remedies to information blocking are under review, but there may be another, equally powerful route to HIE: giving patients their records so they can decide who can have them and when.The idea is simple. Under provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), providers must share patients’ records within 30 days on request. Instead of doctors or hospitals totally controlling their health information, patients could take charge. Managing this information may be challenging for some patients, but they could retain third parties that, for a fee, would steward and distribute health-care data as directed. Patients could designate particular clinicians or institutions, or family members and caretakers, as entitled to access. If so inclined, patients could also share their health information with researchers or public health authorities. Some call this “consumer-mediated health information exchange.” A robust new business sector could provide these data services to interested patients.

To move forward with consumer-mediated HIE, several steps will be required. First, the federal government needs to more aggressively enforce HIPAA’s information-sharing provisions. Second, we need a new cohort of health-data stewards who can help patients manage their own data. Some process of private certification or public regulation will likely be necessary to assure that these new entities can be trusted to discharge this sensitive and complex responsibility. Third, we will need to perfect the technical ability of these new data stewards to access the electronic-data repositories of health-care providers.

All these steps are feasible. Several are already under way. If we can accomplish them, we may be able to realize the full potential of the digital health-care revolution. The benefits for individual patients and the larger society will be huge.

Article link: http://blogs.wsj.com/experts/2016/06/28/how-to-make-health-care-records-as-mobile-as-patients/

Read the latest Health Report

By Mohana Ravindranath
Nextgov | July 12, 2016

The same technology that lets people securely exchange Bitcoin could be useful in protecting health records from intruders, some technologists say.

Perhaps in an effort to test this theory, the Health and Human Services Department is collecting ideas about ways blockchain — the automated, digital ledger system used to record Bitcoin and other cryptocurrency transactions — could be used in health care.

Proponents of blockchain — defined by HHS as a “data structure” that may be time-stamped “and signed using a private key to prevent tampering” — see its benefits in securing personal information. But critics think blockchain deployment would require large amounts of processing power and equipment, according to a Federal Register posting.

Still, “most would acknowledge blockchain’s potential . . . is still evolving and maturing, especially with respect to its applicability to the health care,” the notice says.

HHS is just the latest federal organization to express interest in blockchain. The Pentagon’s research and development team, DARPA, wants a secure messaging service based on the technology; the Postal Service’s Office of the Inspector General issued a report suggesting blockchain could help the agency transfer money more efficiently, or help it ascertain the identity of citizens logging into websites, notarizing documents, or signing digital contracts.

A successful white paper would need to address the cryptographical aspects of blockchain; how it could help disparate health records systems communicate with each other; and how the technology could benefit precision medicine, an effort to deliver medical treatment tailored to an individual’s genetic makeup and lifestyle, among other topics.

HHS is collecting white papers on blockchain until July 29. Winning authors will be invited to present their ideas at a workshop in September.

Article link: read:http://www.nextgov.com/emerging-tech/2016/07/hhs-might-be-climbing-blockchain-bandwagon/129836/?oref=nextgov_healthit_nl

Federal health IT spending grew 27 percent annually from fiscal 2011-2015, with the market jumping from $2 billion four years ago to $6.5 billion in fiscal 2015, according to research from big data and analytics firm Govini.

Civilian health agencies fueled health IT spending the most. The Health and Human Services Department increased its annual health IT spend by a compound annual growth rate of 34 percent, with about half of its total obligations driven by the Centers for Medicare and Medicaid Services, which is preparing for a major modernization effort and call center upgrade.

Not surprisingly, the Veterans Affairs Department also upped its spending. Since 2011, health IT spending jumped an average of 25 percent annually, though some this growth

According to Govini, the health IT federal market is only going to get stronger. The Defense Health Agency, which actually spent less on health IT under sequestration constraints, is about to start shelling out money for its Defense Healthcare Management Systems Modernization contract, with a life cycle value of some $9 billion.

“DHMSM is now the marquee [electronic health records] program across the federal government,” the report states. “DHA will have a leading role in driving patient-focused systems modernization with DHMSM and other interoperability initiatives.”

Office of the National Coordinator for Health Information Technology; Announcement of Requirements and Registration for “Blockchain and Its Emerging Role in Healthcare and Health-related Research”

Article link: https://www.federalregister.gov/articles/2016/07/08/2016-16133/office-of-the-national-coordinator-for-health-information-technology-announcement-of-requirements

The Health and Human Services Department has filled its long-vacant chief information officer seat.

Beth Anne Killoran, previously the acting deputy CIO and executive director of HHS’ Office of IT Strategy, Policy and Governance, will take on the title, according to an HHS blog post. Frank Baitman, the previous CIO, stepped down in November.

Killoran will direct efforts related to cybersecurity and privacy protection, according to the HHS blog post written by Mary Wakefield, HHS’ acting deputy secretary.

HHS had posted the position on USAJOBS in February, months after Baitman’s departure. According to that posting, the CIO’s duties would involve implementing the Federal Information Technology Acquisition Reform Act — legislation passed in 2014 that gives CIOs more authority over budgets — and creating a 5-year strategic IT investment plan.

Killoran’s priorities will include a “Cybersecurity Communication, Awareness, Response and Education” program that sends staff weekly tips about guarding against cyberthreats; running simulated phishing attempts to reduce the effectiveness of those campaigns; and pilot projects that would help HHS build a workforce “as tech-savvy as possible,” Wakefield wrote.

“To protect all of our IT systems — from desktops to the personally identifiable information and protected health information our department works with — we need more than an investment in funding or new technology. We need a cyber-savvy workforce,” the blog post said.

Killoran joined HHS in 2014 from the Homeland Security Department, where she held several positions over 11 years.

Article link: http://www.nextgov.com/health/2016/07/new-hhs-cio-focus-cyber/129795/