As we plan our go-lives for the Mayo Clinic Platform, we recently discussed how best to measure what constitutes a go-live.
First, let's review what Platform thinking (technology, policy, people and process) can do for an organization.
*Facilitates collaborations and partnerships with external entities (i.e. participants on the Platform benefit from the presence of other participants)
*Connects assets (data, algorithms, expertise) with customers in ethical, privacy protecting ways
*Supports the development of ideas into products that may be licensed, spun out, or sold as services
*Has turnkey technology and policy approaches that empower innovators to incubate/accelerate their ideas with agility, such as assistance with validation/FDA clearance assessment or other common regulatory hurdles
Success can be measured in many ways - impact on patient care, the boldness of the innovation, value creation for all participants, public perception of the work, and time to market. Value creation could be licensing, transactional revenue, or equity growth.
Different audiences may have different perceptions of go-lives. While it would be tempting to conflate general availability (GA) of our Platform offerings with go-live, we believe that the Platform won't be live until an "active customer" or stakeholder actually uses what we have to offer.
With these ideas in mind, here are few straw definitions for the concept of go-live for the Mayo Platform businesses.
1. The Clinic Data Analytics Platform (CDAP) accelerates new insight discovery by enabling analysis of de-identified historical data stored within a secure cloud hosted container controlled by Mayo Clinic. A reasonable definition of go live is that CDAP data and tools become available such that a customer runs a data analysis that yields new insights for that customer, for example discovering a potential path forward for COVID-19 care or treatment (the "active customer" criterion)
2. The Home Hospital Platform enables high acuity care via telemetry, clinical care coordination, communication, supply chain, and record keeping. A go-live occurs when a home hospital discharge occurs with a patient restored to health after management facilitated by Platform components hosted on Mayo Clinic Cloud. (the "active patient" criterion)
3. The Remote Diagnostic and Management Platform accepts a signal/data via a Mayo hosted orchestration engine, sends it to an algorithm/interpretation service, and a high quality diagnosis/interpretative result is returned to a customer, for which a payment is generated (the "active orchestration" criterion)
4. We're thinking of developing some supportive functions such as FDA clearance services. An approved FDA clearance would constitute a go live (the "demonstrated expertise" criterion). The reason we are considering a standard function for FDA clearance as part of acceleration/incubation services is because of the significant complexity and expense of FDA clearance:
a. Regulatory Pathway Determination: $21-23K. Takes about 2 months to complete
b. Gap Analysis & QMS Implementation: $220K (800 hrs.) - $495K (1,800 hrs.), depending on results of Gap Analysis (how much needs to be done)
c. FDA Pre-submission prep & meetings: $98K (354 hrs.)
d. Complete FDA submission and clearance: $275-400K (1,000-1,200 hrs.)
A service that can pool experience, talent and technology to get synergies and scale to lower the unit cost and speed of FDA clearances would be a win for everyone.
5. As we create our staffing model, we'll have functions that cross all new Platform businesses and dedicated roles in each business. For example, across all businesses we'll have one team overseeing the communication plan and one team processing new business ideas/collaboration requests. If a new proposal can be reviewed, analyzed, a go/no go decision made, and a new business launched, that would constitute a go-live of the function being open for business. (the "process maturity" criterion)
In 2020, we're aiming for at least one go-live per quarter, celebrating the "ribbon cutting" of objectively measured Platform progress. Next quarter, we'll launch the CDAP tool for Mayo internal users and begin processing our first queries for external customers.
To me, our most "pure Platform" go-live will be when we have a generalizable model for ingesting data, interpreting it with novel analytics/algorithms/services and returning a result within the workflow of the customer. It's also one of the most challenging to assemble. I'll be writing about our journey for that go-live throughout 2020.
Saturday, March 7, 2020
Tuesday, February 25, 2020
What is the Architecture of a Modern Platform?
Platform businesses require technology that promotes interoperability and scalability. For those who live in platform companies day-to-day, my thinking below may sound obvious, but for those who are thinking about a cloud journey, the list of technologies below may be helpful.
Storage and compute functionality in the cloud enables agility via "infrastructure as code" products such as Terraform. Terraform enables virtual server spin up on demand within applications to provision and manage any cloud, infrastructure, or service. Each cloud provider has strengths. Customers like Google Cloud Platform because of BigQuery, which scales infinitely. Customers like Amazon because of the tools like Comprehend Medical and Sagemaker. Customers like Azure because of its integration with existing Microsoft components.
Similarly, database functionality such as MySQL or PostgreSQL can be rapidly deployed using a front end service such as Google's SQL Cloud that makes it easy to set up, maintain, manage, and administer relational databases on Google Cloud Platform.
Kubernetes is an open-source container-orchestration system for automating application deployment, scaling, and management. It was originally designed by Google, and is now maintained by the Cloud Native Computing Foundation.
For healthcare applications, it's clear that Fast Healthcare Interoperability Resources (FHIR) interfaces for inbound and outbound data exchange are the right approach to application/EHR integration. Highly scalable FHIR services are available via HAPI FHIR on Smile CDR . Google Health's FHIR endpoint is also a good choice.
FHIR is best for exchanging summary data, as well as making EHR data available to an application more broadly. For HL7 version 2, the Google Healthcare API supports a Minimal Lower Layer Protocol (MLLP) entry point and a message repository (along with cloud publication/subscription notifications).
And of course, modern network security requires data be stored in encrypted form as well as in transit in encrypted form. This simple idea will mitigate numerous security risks.
I recently met with well respected industry leaders and asked how Mayo Clinic can future proof its Platform efforts. I was told
"Ensure that infrastructure as code is used to deploy storage and compute. Ensure relational databases can be deployed and managed on the cloud hosting platform. Use Kubernetes to automate application deployment. Embrace hosted FHIR and API management services."
As we evaluate new partnerships and collaborations, we do a technical deep dive to avoid locally hosted, siloed, and proprietary approaches, instead favoring a cloud native architecture using Terraform, Kubernetes, and FHIR.
As Wayne Gretzky taught us, you need to skate where the puck will be. These cloud native architectures are clearly where the puck is going.
Storage and compute functionality in the cloud enables agility via "infrastructure as code" products such as Terraform. Terraform enables virtual server spin up on demand within applications to provision and manage any cloud, infrastructure, or service. Each cloud provider has strengths. Customers like Google Cloud Platform because of BigQuery, which scales infinitely. Customers like Amazon because of the tools like Comprehend Medical and Sagemaker. Customers like Azure because of its integration with existing Microsoft components.
Similarly, database functionality such as MySQL or PostgreSQL can be rapidly deployed using a front end service such as Google's SQL Cloud that makes it easy to set up, maintain, manage, and administer relational databases on Google Cloud Platform.
Kubernetes is an open-source container-orchestration system for automating application deployment, scaling, and management. It was originally designed by Google, and is now maintained by the Cloud Native Computing Foundation.
For healthcare applications, it's clear that Fast Healthcare Interoperability Resources (FHIR) interfaces for inbound and outbound data exchange are the right approach to application/EHR integration. Highly scalable FHIR services are available via HAPI FHIR on Smile CDR . Google Health's FHIR endpoint is also a good choice.
FHIR is best for exchanging summary data, as well as making EHR data available to an application more broadly. For HL7 version 2, the Google Healthcare API supports a Minimal Lower Layer Protocol (MLLP) entry point and a message repository (along with cloud publication/subscription notifications).
And of course, modern network security requires data be stored in encrypted form as well as in transit in encrypted form. This simple idea will mitigate numerous security risks.
I recently met with well respected industry leaders and asked how Mayo Clinic can future proof its Platform efforts. I was told
"Ensure that infrastructure as code is used to deploy storage and compute. Ensure relational databases can be deployed and managed on the cloud hosting platform. Use Kubernetes to automate application deployment. Embrace hosted FHIR and API management services."
As we evaluate new partnerships and collaborations, we do a technical deep dive to avoid locally hosted, siloed, and proprietary approaches, instead favoring a cloud native architecture using Terraform, Kubernetes, and FHIR.
As Wayne Gretzky taught us, you need to skate where the puck will be. These cloud native architectures are clearly where the puck is going.
Friday, February 14, 2020
The Future of Elder Care
Last weekend I moderated an amazing group of presenters for Harvard Business School's 17th Annual Healthcare Conference, debating the future of elder care throughout the world.
Discussants were
Geoff Price - Oak Street Health, Chief Operating Officer
Susan Diamond - Humana, President of Home Solutions
Neil Wagle - Devoted Health, Chief Medical Officer
We started with a statement of the problem - in many countries such as Japan, the Nordics, Germany, Italy, and the United States, societies are rapidly aging. Birth rates are declining. Costs are rising and access to clinicians is becoming more challenging
We delved into several major themes - the role of home care, the rise of digital health, and the evolution of financial models that incentivize wellness over sickness.
Mayo Clinic is building home hospital capabilities and, later this year, will evaluate these efforts in two sites. Through this early work, we'll learn about the supply chain, telemetry, command center capabilities, staffing, and the characteristics of patients best suited to home hospital care.
All of the panel members agreed that the future belongs to delivering high quality care in the right setting at the right cost. Medicare Advantage reimbursement models, accountable care organizations, and alternative quality contracts all focus on reducing total medical expense while sustaining quality/safety/patient satisfaction. If home hospital care reduces cost while improving outcomes, I believe that refined reimbursement models for home care will emerge.
Delivering digital capabilities - telemetry, communication, and care orchestration to elders requires a comprehensive technology strategy. Many homes do not have fast, reliable wifi. LTE and 5G cellular networks will be increasingly strategic for home care. It's likely that a technology services partner will be needed to keep home-based devices configured, secure and stable.
Just gathering the telemetry as part of elder home care is not enough. Algorithms and analytics are needed to turn raw data into action, filtering signal from noise. It's not yet entirely clear how to understand the precision/accuracy of remote monitoring, how to interpret individual variation, and when to ignore false positive signals.
Mayo Clinic is also launching a remote diagnostics and monitoring capability over the next year, via a platform approach that connects telemetry to novel machine learning algorithms, supporting patient wellness.
We also discussed the digital divide. As we create more digital interventions to the home, we must meet patients at their level of technology comfort, literacy, and affordability. We'll need organizations that can help patients access care, optimize the use of devices in their home, and encourage follow through with care plans.
The future of platform components to enhance elder care is bright and an ecosystem of supportive businesses will be needed. I look forward to being part of that journey.
Discussants were
Geoff Price - Oak Street Health, Chief Operating Officer
Susan Diamond - Humana, President of Home Solutions
Neil Wagle - Devoted Health, Chief Medical Officer
We started with a statement of the problem - in many countries such as Japan, the Nordics, Germany, Italy, and the United States, societies are rapidly aging. Birth rates are declining. Costs are rising and access to clinicians is becoming more challenging
We delved into several major themes - the role of home care, the rise of digital health, and the evolution of financial models that incentivize wellness over sickness.
Mayo Clinic is building home hospital capabilities and, later this year, will evaluate these efforts in two sites. Through this early work, we'll learn about the supply chain, telemetry, command center capabilities, staffing, and the characteristics of patients best suited to home hospital care.
All of the panel members agreed that the future belongs to delivering high quality care in the right setting at the right cost. Medicare Advantage reimbursement models, accountable care organizations, and alternative quality contracts all focus on reducing total medical expense while sustaining quality/safety/patient satisfaction. If home hospital care reduces cost while improving outcomes, I believe that refined reimbursement models for home care will emerge.
Delivering digital capabilities - telemetry, communication, and care orchestration to elders requires a comprehensive technology strategy. Many homes do not have fast, reliable wifi. LTE and 5G cellular networks will be increasingly strategic for home care. It's likely that a technology services partner will be needed to keep home-based devices configured, secure and stable.
Just gathering the telemetry as part of elder home care is not enough. Algorithms and analytics are needed to turn raw data into action, filtering signal from noise. It's not yet entirely clear how to understand the precision/accuracy of remote monitoring, how to interpret individual variation, and when to ignore false positive signals.
Mayo Clinic is also launching a remote diagnostics and monitoring capability over the next year, via a platform approach that connects telemetry to novel machine learning algorithms, supporting patient wellness.
We also discussed the digital divide. As we create more digital interventions to the home, we must meet patients at their level of technology comfort, literacy, and affordability. We'll need organizations that can help patients access care, optimize the use of devices in their home, and encourage follow through with care plans.
The future of platform components to enhance elder care is bright and an ecosystem of supportive businesses will be needed. I look forward to being part of that journey.
Tuesday, February 4, 2020
Innovation at Work
Over the past 40 years I've worked in a variety of workplace settings, each appropriately serving its intended purpose. I did not appreciate how much a workspace influences my productivity and mood until I starting working at Mayo. My new role focuses on convening stakeholders and facilitating discussion. A supportive workspace is transformational.
In my mid-teens, I worked in shared office space at TRW (a predecessor company to Raytheon) with large metal desks, filing cabinets and fluorescent tube lighting
In my late teens, I founded a company in a basement and worked at a drafting table next to a bed
In my 20's, while running the growing company and completing my medical education, I worked in a glass walled private office so I could watch the flow of daily activity.
In my 30's, 40's, and 50's as a CIO, clinician and professor, I worked in a cube but spent much of my time with customers in other people's offices.
For the past 2 years, I've worked in an open space ad hoc desk/meeting room arrangement that was efficient, attractive, and highly functional.
Now, as I approach 60 at Mayo Clinic, I work in the most innovative and collaborative space of my career, the recently remodeled Mayo 11 administrative floor. No one on the Mayo senior team has an office - not the CEO, COO, CFO nor Presidents. Everyone uses open plan hoteling desks. The desks are surrounded by huddle rooms and meeting spaces that can be reserved via touch screen or calendar invite. Everyone sees each other every day for hallway conversations. I can ask the CEO any question, any time, by just walking through the space. There's a common kitchen area with meeting tables and healthy food offerings
The furnishings are simple - a kind of Zen functional elegance. Reminders about Mayo's vision, mission and values adorn the walls. The lighting is all 5000K LED daylight. See photos below.
While rigorous days are common, the time never feels long because of the richness of human interaction that takes place in the Mayo 11 space.
Per my previous post, my apartment is a 6 minute walk from my bedroom to the Mayo 11 office. I've shaped my new life routine around these living and work spaces for maximal focus and impact. I leave the apartment at 6am, walk 2 minutes to the skyway, which is a heated walking corridor connecting buildings in downtown Rochester. I arrive in the office by 6:10am, have breakfast, write goals for the day in my journal then review the day's presentation materials and agendas. Every 30 minutes from 7am to noon, it's easy to move among meeting rooms, some on Mayo 11 and some in surrounding buildings. A shuttle that runs every 5 minutes takes me to nearby St. Mary's Hospital where I spend time with my clinical and laboratory colleagues. By noon I return to Mayo 11 for lunch and a catchup with my colleagues. Meetings and presentations continue from 12:30pm until evening. The walk back to my apartment passes by a great market, an all vegan restaurant, craft breweries, and a boutique wine store. Dinner is usually a simple bowl of rice, beans and vegetables. I spend the late evening writing plans and reading the briefing materials prepared by the Mayo Platform team, partners, and collaborators.
From 7pm on Sunday night until 7pm Thursday night, I'm in Minnesota, living this very productive and satisfying pattern. I return to Unity Farm Sanctuary in Massachusetts by midnight on Thursday. Friday is a mixture of calls, video chats, and writing in my farm office.
On Saturday, I work with the animals and do complicated/time consuming farm tasks from 6am until late evening, completing a task list that my wife writes in a notebook awaiting my return. On Sunday, the morning is filled with less complicated work, leaving me relaxed for my afternoon flight back to Minnesota.
Well engineered, highly ergonomic workspaces make this level of commitment possible in Minnesota and Massachusetts. In 2019 I flew 400,000 miles to 40 countries, while also spending 3 hours a day driving around Boston in traffic. Comparatively, my 5 hour commute to Mayo on Sunday and Thursday is a respite.
I'm a fan of a life that is constantly self-examined. At this point, I could not ask for a better workplace ecosystem that encourages accomplishment and engagement by design.
In my mid-teens, I worked in shared office space at TRW (a predecessor company to Raytheon) with large metal desks, filing cabinets and fluorescent tube lighting
In my late teens, I founded a company in a basement and worked at a drafting table next to a bed
In my 20's, while running the growing company and completing my medical education, I worked in a glass walled private office so I could watch the flow of daily activity.
In my 30's, 40's, and 50's as a CIO, clinician and professor, I worked in a cube but spent much of my time with customers in other people's offices.
For the past 2 years, I've worked in an open space ad hoc desk/meeting room arrangement that was efficient, attractive, and highly functional.
Now, as I approach 60 at Mayo Clinic, I work in the most innovative and collaborative space of my career, the recently remodeled Mayo 11 administrative floor. No one on the Mayo senior team has an office - not the CEO, COO, CFO nor Presidents. Everyone uses open plan hoteling desks. The desks are surrounded by huddle rooms and meeting spaces that can be reserved via touch screen or calendar invite. Everyone sees each other every day for hallway conversations. I can ask the CEO any question, any time, by just walking through the space. There's a common kitchen area with meeting tables and healthy food offerings
The furnishings are simple - a kind of Zen functional elegance. Reminders about Mayo's vision, mission and values adorn the walls. The lighting is all 5000K LED daylight. See photos below.
While rigorous days are common, the time never feels long because of the richness of human interaction that takes place in the Mayo 11 space.
Per my previous post, my apartment is a 6 minute walk from my bedroom to the Mayo 11 office. I've shaped my new life routine around these living and work spaces for maximal focus and impact. I leave the apartment at 6am, walk 2 minutes to the skyway, which is a heated walking corridor connecting buildings in downtown Rochester. I arrive in the office by 6:10am, have breakfast, write goals for the day in my journal then review the day's presentation materials and agendas. Every 30 minutes from 7am to noon, it's easy to move among meeting rooms, some on Mayo 11 and some in surrounding buildings. A shuttle that runs every 5 minutes takes me to nearby St. Mary's Hospital where I spend time with my clinical and laboratory colleagues. By noon I return to Mayo 11 for lunch and a catchup with my colleagues. Meetings and presentations continue from 12:30pm until evening. The walk back to my apartment passes by a great market, an all vegan restaurant, craft breweries, and a boutique wine store. Dinner is usually a simple bowl of rice, beans and vegetables. I spend the late evening writing plans and reading the briefing materials prepared by the Mayo Platform team, partners, and collaborators.
From 7pm on Sunday night until 7pm Thursday night, I'm in Minnesota, living this very productive and satisfying pattern. I return to Unity Farm Sanctuary in Massachusetts by midnight on Thursday. Friday is a mixture of calls, video chats, and writing in my farm office.
On Saturday, I work with the animals and do complicated/time consuming farm tasks from 6am until late evening, completing a task list that my wife writes in a notebook awaiting my return. On Sunday, the morning is filled with less complicated work, leaving me relaxed for my afternoon flight back to Minnesota.
Well engineered, highly ergonomic workspaces make this level of commitment possible in Minnesota and Massachusetts. In 2019 I flew 400,000 miles to 40 countries, while also spending 3 hours a day driving around Boston in traffic. Comparatively, my 5 hour commute to Mayo on Sunday and Thursday is a respite.
I'm a fan of a life that is constantly self-examined. At this point, I could not ask for a better workplace ecosystem that encourages accomplishment and engagement by design.
Innovation at Home
This is the first of a two part series that describes where I live and where I work at Mayo Clinic.
To me, life and work are inseparably intertwined. You cannot have a productive work life if your home life is unstable. You cannot have a balanced home life if your work life is unstable. When I decided to work at Mayo, my wife and I agreed that we would live in Massachusetts running Unity Farm Sanctuary but I would work in Rochester/Jacksonville/Scottsdale Sunday night through Thursday night.
Over the past month, I've organized a life in Minnesota, maximizing my well-being and efficiency. I rented a 600 square foot apartment that is a 2 minute walk from Mayo Clinic. I've moved those things from the farm that make the space uniquely mine - my morris chair, my desk, woodblock prints, green tea supplies, and a simple antique bed.
Outside the window I can see the Mayo building and the Plummer building. I'm near a great vegan restaurant and the local food coop. I have a small stacked washer/dryer in the apartment. Home Depot is 8 minutes away. I purchased a used Subaru for airport commuting.
All of this means that I can arrive each Sunday night and drive myself from Minneapolis to Rochester. Once in my apartment, I can create a simple dinner, write in my journal and prepare for the week ahead. My bedroom is 10x10 - a perfect place to retreat and rest.
Monday-Thursday I walk to work (and my workspace is the subject of the next blog) in the morning, spend the day with remarkable colleagues, then walk back to my apartment at night, stopping at the food coop to pick up fresh vegetables for dinner.
Thursday night I drive back to Minneapolis and fly to Boston, getting home about midnight.
Just as with Unity Farm Sanctuary, I've turned my Minnesota apartment into an internet of things demonstration site. I have a 100 megabit fiber connection to a Google mesh network. I replaced the apartment thermostat with a Nest device that I can control remotely, keeping the apartment at 60F when I'm gone but adjusting it to 65F when I'm in town. I've added smart plugs so that my morning routine turns on lights/music automatically while my evening routine prepares the space for sleep. The locks are RFID controlled.
The end result is that I have a stress free, highly functional environment around me when I'm not at the office. I can cook, clean my clothes, write at my desk, review strategic plans in my chair, and sleep comfortably, all within the 600 square foot layout. Pictures are attached below. My many years collaborating with Japan have taught me well and my home space at Mayo is simple, spiritual, and supportive.
To me, life and work are inseparably intertwined. You cannot have a productive work life if your home life is unstable. You cannot have a balanced home life if your work life is unstable. When I decided to work at Mayo, my wife and I agreed that we would live in Massachusetts running Unity Farm Sanctuary but I would work in Rochester/Jacksonville/Scottsdale Sunday night through Thursday night.
Over the past month, I've organized a life in Minnesota, maximizing my well-being and efficiency. I rented a 600 square foot apartment that is a 2 minute walk from Mayo Clinic. I've moved those things from the farm that make the space uniquely mine - my morris chair, my desk, woodblock prints, green tea supplies, and a simple antique bed.
Outside the window I can see the Mayo building and the Plummer building. I'm near a great vegan restaurant and the local food coop. I have a small stacked washer/dryer in the apartment. Home Depot is 8 minutes away. I purchased a used Subaru for airport commuting.
All of this means that I can arrive each Sunday night and drive myself from Minneapolis to Rochester. Once in my apartment, I can create a simple dinner, write in my journal and prepare for the week ahead. My bedroom is 10x10 - a perfect place to retreat and rest.
Monday-Thursday I walk to work (and my workspace is the subject of the next blog) in the morning, spend the day with remarkable colleagues, then walk back to my apartment at night, stopping at the food coop to pick up fresh vegetables for dinner.
Thursday night I drive back to Minneapolis and fly to Boston, getting home about midnight.
Just as with Unity Farm Sanctuary, I've turned my Minnesota apartment into an internet of things demonstration site. I have a 100 megabit fiber connection to a Google mesh network. I replaced the apartment thermostat with a Nest device that I can control remotely, keeping the apartment at 60F when I'm gone but adjusting it to 65F when I'm in town. I've added smart plugs so that my morning routine turns on lights/music automatically while my evening routine prepares the space for sleep. The locks are RFID controlled.
The end result is that I have a stress free, highly functional environment around me when I'm not at the office. I can cook, clean my clothes, write at my desk, review strategic plans in my chair, and sleep comfortably, all within the 600 square foot layout. Pictures are attached below. My many years collaborating with Japan have taught me well and my home space at Mayo is simple, spiritual, and supportive.
Thursday, January 30, 2020
Moving Complex Systems Toward a Goal
I recently told several of my Mayo colleagues that I'm an outsider who has landed in a new environment where the degree of collaboration, dialog, and friendly debate is amazing. The following a kind of guest blog, started by Dr. Michael Joyner, who is also a writer
He wrote to a number of us
"Great paper written by chairman of bank of England in middle of financial crisis. Pertinent to anyone interested in nudging complex systems towards a goal."
Below are the responses:
Let’s move away from risk prediction a bit and apply these concepts to our world. The world of innovating and translating new solutions (hugely complex and risky) in the medical care industry (more complex and regulated than even the financial industry) to treat human disease (much of it psychological/societal/evolutionary) is off the charts with risk.
I love the statement of fighting complexity with simplicity – it intrinsically feels correct - so what should our heuristics be for advancing medical care?
Modern medical innovation is complex, perhaps too complex. Regulation of modern translation of medical innovation to products is complex, almost certainly too complex. That configuration spells trouble. As you do not fight fire with fire, you do not fight complexity
with complexity. Because complexity generates uncertainty, not risk, it requires a regulatory response plan to enable innovation and translation grounded in simplicity, not complexity.
So what is our plan and our heuristics? My suggestion to get us started in honor of Mr. Haldane:
1) You must move out of the harbor and get in the race in order to win (win being to develop new solutions in medical care)
a. The race has been underway for some time, so you are behind already, so get going and move with speed
b. A race is the best analogy – we should move quickly in just about every respect. “Fail quickly” is a trite but true statement
c. How many things are stuck in endless cycles of planning or less than serious (not capitalized or staffed anywhere near the need) attempts?
2) Almost all of your strategies, plans, predictions will turn out to be incorrect along the way, no matter how much planning you do – you will assuredly have many failures as you progress - how you respond and your ability recalibrate course and keep progressing to the goal is all that matters in terms of achieving success
a. The good news is at this point you are at least in the race
b. As with the best entrepreneurs, if you have not failed at least a few times you should not be trusted with anything – very easy to say and terribly hard to live it when you are deploying capital
c. The art in all this is determining if the failure is due to execution, if it is then you have the wrong people and should switch out the team – or vision/goal, if it is then time to go back to the harbor. The first determination (execution) is not too hard to make but hard to execute (needing to switch out the team).
d. Extremely hard to determine if a group or individual that has failed should be cast aside or given new resources to try again – all of history teaches us that the best folks who we celebrate as geniuses failed many times before succeeding. Of course, fools will fail as many times as you allow them.
e. No easy answers here other than did the group or individual at least execute well and move with efficiency and speed, that is necessary component but not sufficient
3) You should study the strategies and successes and failures of others, but because successes and failures are the result of an enormously complex environment with variables too numerous to count, we should not study them so much or lend them credence to an extent that we “over-fit” our analysis and plan.
a. Successes are tainted with survivorship bias – be careful when determining why and how they were successful
b. Failures are often due to a lack of ability to recalibrate from the inevitable setback or a poor team in charge of executing than a mistake in vision/goal
4) You will need capital sufficient to start and recalibrate at least twice
a. Undercapitalization is a guaranteed route to total failure
b. Perfect Oscar Wilde quote in the article. We often know the price of everything (salaries and the cost of a team) but the value of nothing (if not a great team staffed as required then we will surely fail, so what are we tabulating)?
5) The humans involved in the endeavor will override everything else – need to find and bet on the best team possible
a. All of the above will be evaluated, capitalized, planned, recalibrated and executed by a team of humans – they will determine success or failure
b. What makes life exciting and fun is that this means complexity and unpredictability – how do we find and support the right folks? How do we determine that the inevitable failure is the result of the vision/plan or of the humans charged with executing it? Can we hand additional resources to the team/individual who have failed twice already? Bill Gates, Steve Jobs and Jeff Bezos, etc. failed many times – what did others see in them to continue to provide resources?
c. Key question for us all is how to identify and recruit the right team – from the very top to the bottom – and hold all accountable for efficient and effective progress (not success)
----
The Manhattan Project is a great example of survivorship bias – we celebrate it (in a way) because it was successful. However, that does not mean that throwing $22B and a lot of really smart people at an objective means you will succeed. Indeed, that approach has failed more often. It is in the intangibles – I would argue that the sheer pressure that it must succeed (because of the fear of what if we lost that race) meant the accountability and demand for speed was very large – folks got out of the harbor and recalibrated at high speed (or so I imagine). Pretty hard to re-create that environment – hence the Haldane teaching that it is dangerous to extrapolate characteristics in a complex world
-----
The keys to success when moving complex systems toward a goal are:
1) Engineering problem, not a theory problem.
2) Clear definition of success.
3) Response to a real existential threat.
4) One customer.
Much of what we propose as innovation does not clearly meet any of these criteria. Manhattan and Apollo did. The Transcontinental railroad is another example that meets several or all of these characteristics.
-----
And that's what a group of wonderful colleagues debated on a Sunday morning.
He wrote to a number of us
"Great paper written by chairman of bank of England in middle of financial crisis. Pertinent to anyone interested in nudging complex systems towards a goal."
Below are the responses:
Let’s move away from risk prediction a bit and apply these concepts to our world. The world of innovating and translating new solutions (hugely complex and risky) in the medical care industry (more complex and regulated than even the financial industry) to treat human disease (much of it psychological/societal/evolutionary) is off the charts with risk.
I love the statement of fighting complexity with simplicity – it intrinsically feels correct - so what should our heuristics be for advancing medical care?
Modern medical innovation is complex, perhaps too complex. Regulation of modern translation of medical innovation to products is complex, almost certainly too complex. That configuration spells trouble. As you do not fight fire with fire, you do not fight complexity
with complexity. Because complexity generates uncertainty, not risk, it requires a regulatory response plan to enable innovation and translation grounded in simplicity, not complexity.
So what is our plan and our heuristics? My suggestion to get us started in honor of Mr. Haldane:
1) You must move out of the harbor and get in the race in order to win (win being to develop new solutions in medical care)
a. The race has been underway for some time, so you are behind already, so get going and move with speed
b. A race is the best analogy – we should move quickly in just about every respect. “Fail quickly” is a trite but true statement
c. How many things are stuck in endless cycles of planning or less than serious (not capitalized or staffed anywhere near the need) attempts?
2) Almost all of your strategies, plans, predictions will turn out to be incorrect along the way, no matter how much planning you do – you will assuredly have many failures as you progress - how you respond and your ability recalibrate course and keep progressing to the goal is all that matters in terms of achieving success
a. The good news is at this point you are at least in the race
b. As with the best entrepreneurs, if you have not failed at least a few times you should not be trusted with anything – very easy to say and terribly hard to live it when you are deploying capital
c. The art in all this is determining if the failure is due to execution, if it is then you have the wrong people and should switch out the team – or vision/goal, if it is then time to go back to the harbor. The first determination (execution) is not too hard to make but hard to execute (needing to switch out the team).
d. Extremely hard to determine if a group or individual that has failed should be cast aside or given new resources to try again – all of history teaches us that the best folks who we celebrate as geniuses failed many times before succeeding. Of course, fools will fail as many times as you allow them.
e. No easy answers here other than did the group or individual at least execute well and move with efficiency and speed, that is necessary component but not sufficient
3) You should study the strategies and successes and failures of others, but because successes and failures are the result of an enormously complex environment with variables too numerous to count, we should not study them so much or lend them credence to an extent that we “over-fit” our analysis and plan.
a. Successes are tainted with survivorship bias – be careful when determining why and how they were successful
b. Failures are often due to a lack of ability to recalibrate from the inevitable setback or a poor team in charge of executing than a mistake in vision/goal
4) You will need capital sufficient to start and recalibrate at least twice
a. Undercapitalization is a guaranteed route to total failure
b. Perfect Oscar Wilde quote in the article. We often know the price of everything (salaries and the cost of a team) but the value of nothing (if not a great team staffed as required then we will surely fail, so what are we tabulating)?
5) The humans involved in the endeavor will override everything else – need to find and bet on the best team possible
a. All of the above will be evaluated, capitalized, planned, recalibrated and executed by a team of humans – they will determine success or failure
b. What makes life exciting and fun is that this means complexity and unpredictability – how do we find and support the right folks? How do we determine that the inevitable failure is the result of the vision/plan or of the humans charged with executing it? Can we hand additional resources to the team/individual who have failed twice already? Bill Gates, Steve Jobs and Jeff Bezos, etc. failed many times – what did others see in them to continue to provide resources?
c. Key question for us all is how to identify and recruit the right team – from the very top to the bottom – and hold all accountable for efficient and effective progress (not success)
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The Manhattan Project is a great example of survivorship bias – we celebrate it (in a way) because it was successful. However, that does not mean that throwing $22B and a lot of really smart people at an objective means you will succeed. Indeed, that approach has failed more often. It is in the intangibles – I would argue that the sheer pressure that it must succeed (because of the fear of what if we lost that race) meant the accountability and demand for speed was very large – folks got out of the harbor and recalibrated at high speed (or so I imagine). Pretty hard to re-create that environment – hence the Haldane teaching that it is dangerous to extrapolate characteristics in a complex world
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The keys to success when moving complex systems toward a goal are:
1) Engineering problem, not a theory problem.
2) Clear definition of success.
3) Response to a real existential threat.
4) One customer.
Much of what we propose as innovation does not clearly meet any of these criteria. Manhattan and Apollo did. The Transcontinental railroad is another example that meets several or all of these characteristics.
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And that's what a group of wonderful colleagues debated on a Sunday morning.
Wednesday, January 22, 2020
Advice for Aspiring CMIOs
Recently, my colleague Steve Peters, chief medical information officer, Mayo Clinic, and I discussed our life experiences as CMIOs. We talked about how the role has evolved along with changing technology and the transition to nearly universal adoption of electronic health records by large health centers.
I asked Steve to share his insights on 'what makes a great CMIO in 2020' and captured his thoughts for you.
"I have thought about the 'post-EHR' CMIO as most large centers and hospitals have moved on from the initial implementation. Here are a few thoughts:
1. Serves as the primary physician champion for all major clinical information technology projects, including EHR implementation and information security.
2. Assists in development of IT strategy and planning.
3. Acts as an advocate for protection of patient privacy and the security of protected health information.
4. Supports various regulatory compliance activities including HIPAA, Meaningful Use, and billing compliance.
5. Represents the medical community and serves as an advocate in the promoting the use of information technology in the clinical setting.
6. Partners with leaders in the effective adoption of information technology solutions in support of clinical care, research and education.
7. Serves as a physician champion in the development of the electronic medical record and practice management tools.
8. Maintains an awareness of existing and emerging technology, regulatory, and market factors that have an impact on healthcare information management.
9. Accountable for the identification, development and execution of education, training programs, and services in the area of computer skills and competencies in the use of electronic tools for patient care, quality, resource management, and performance improvement.
10. Going back to the 'grandfather' informatics board preparation, I found some broad texts like Biomedical Informatics (Shortliffe and Cimino) very valuable, especially for those areas in which I have less experience or expertise. The major meetings including HIMSS (from the industry standpoint) and AMIA (more academic) are valuable. Many areas have regional CMIO meetings to share ideas. And read blogs."
I asked Steve to share his insights on 'what makes a great CMIO in 2020' and captured his thoughts for you.
"I have thought about the 'post-EHR' CMIO as most large centers and hospitals have moved on from the initial implementation. Here are a few thoughts:
1. Serves as the primary physician champion for all major clinical information technology projects, including EHR implementation and information security.
2. Assists in development of IT strategy and planning.
3. Acts as an advocate for protection of patient privacy and the security of protected health information.
4. Supports various regulatory compliance activities including HIPAA, Meaningful Use, and billing compliance.
5. Represents the medical community and serves as an advocate in the promoting the use of information technology in the clinical setting.
6. Partners with leaders in the effective adoption of information technology solutions in support of clinical care, research and education.
7. Serves as a physician champion in the development of the electronic medical record and practice management tools.
8. Maintains an awareness of existing and emerging technology, regulatory, and market factors that have an impact on healthcare information management.
9. Accountable for the identification, development and execution of education, training programs, and services in the area of computer skills and competencies in the use of electronic tools for patient care, quality, resource management, and performance improvement.
10. Going back to the 'grandfather' informatics board preparation, I found some broad texts like Biomedical Informatics (Shortliffe and Cimino) very valuable, especially for those areas in which I have less experience or expertise. The major meetings including HIMSS (from the industry standpoint) and AMIA (more academic) are valuable. Many areas have regional CMIO meetings to share ideas. And read blogs."
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