Sunday, March 22, 2020

Coming Together to Save Lives

The following is a post from the members of the COVID-19 Healthcare Coalition #C19Coalition co-chaired by  Dr. Jay Schnitzer, Chief Medical and Technology Officer at MITRE  @MITREcorp who directs initiatives in health/life sciences and Dr. John Halamka @jhalamka, President of Mayo Clinic Platform who leads a portfolio of platform businesses focused on transforming health.

Pandemics thrive in confusion.

Not because diseases like COVID-19 have intent, but because the lack of a focused response makes the spread of disease so much easier.

Pandemics stress our healthcare delivery system. We are now familiar with the generalized public health measures that help contain the spread of infectious disease including social distancing, hand washing, self-quarantine, cancellation of large public events, and school closures.    More targeted measures are needed and that requires coordination.

We need to leverage the strengths of the private sector. By bringing together healthcare organizations, technology companies, non-profits, academia, and startups we can leverage their unique strengths  for the benefit of all.

Over the past week, we've launched the Covid-19 Healthcare Coalition involving Amazon Web Services, Arcadia Health, athenahealth, Buoy Health, the CommonWell Health Alliance, HCA Healthcare, Intermountain Healthcare, LabCorp, Leavitt Partners, MassChallenge, Mayo Clinic, Microsoft, MITRE, Rush University System for Health, Salesforce, University of California Healthcare System and many others.

We've already begun focused efforts to increase COVID-19 testing capacity for the country, to coordinate early therapies, and to accelerate vaccine development.

We established guiding principles for the coalition:

1. Everyone participates for the benefit of those impacted by COVID-19

2. Everyone cooperates and openly seeks to assist each other when possible

3. Nobody will get paid. Bring your resources and no money will be exchanged

4. Verbal agreements will suffice to get us started

5. If you agree to these terms and conditions, you’re in

Our first task is to share learnings and encourage innovation across the coalition.

We’re moving fast to support technology and policy innovations.   MITRE, a national research and development center, is serving as program manager.

Pandemics thrive in confusion and wither against a united, clear-eyed attack.

Let’s shut down COVID-19 together.

Saturday, March 21, 2020

Unity Farm Sanctuary and COVID Planning

You might think a farm sanctuary doesn't need cyber-liability insurance (we do because we track social security numbers associated with donations).  You may not think that a Farm Sanctuary needs a comprehensive COVID plan.

We need a plan for five reasons
1.  We are a community gathering point for over 100 volunteers and hundreds of people taking enrichment classes including Yoga, Tai Chi, Meditation, Beekeeping, and Council on Aging activities.
2.  We are an employer with full time and part time workers
3.  We are accountable for the health of more than 250 creatures.   Without humans, these creatures would lack daily care
4.   As the economic impact of job losses reduces the ability of the community to support its animals, sanctuary services become increasingly important
5.   The community is looking to us for guidance

So what did we do?    Weeks ago, we realized that aggressive measures were needed.   We closed the farm sanctuary to the public.   We paused all classes.    We put the volunteer program on hold.    We began an aggressive disinfection/biological isolation protocol. 

At this point, only my wife and I plus 3 key employees come to the property.   Here is the email we sent to the community a few weeks ago

"My valued friends,
Effective immediately, Unity Farm Sanctuary is limiting access to the Sanctuary

Here's important background information

Currently, the vast majority of sanctuaries surveyed (on the two international sanctuary groups I belong to) have eliminated all volunteers and only have the smallest number of staff possible to run their sanctuaries. They all state that the owners and the core staff must stay as healthy as possible and limit their exposure. Most of us who run sanctuaries are most concerned too about feed supply-chain. Core staff will be focused on this this week.

If our core staff is sick, we will be in a VERY difficult place. (I am actually in a higher risk group from my own immune system - I am a breast cancer survivor, I have Graves Disease, I have had pneumonia in the past, I am very vulnerable to upper respiratory virus as a general rule, and I am nearing 60.)

Starting Monday, no volunteers will be onsite, no visitors, no tours, no classes. Staff will be pared down to the smallest group of core people we can manage. This will hold at minimum to April 6, and based on what I know from our connections through John's connections to experts, in our country you can expect at least an 8 week timeframe on groups, gatherings and interpersonal contact limits.

Please take social distancing seriously. I am restricting volunteers here so that I keep you healthy too. I want to hear that every single one of you is doing well and safe. I will be posting on newsletters, Instagram and FB as much as possible so that people do not feel disconnected.

Kathy Halamka"

And here is what we communicated to the staff

"Staff that is remaining on schedule will be following these precautions:
-All plastic and metal surfaces outside the house will be wiped down at noon and 7pm with bleach wipes.  Inside the Unity Meeting House we will focus on kitchen, bathroom, laundry room, and tables (handles, knobs, hayboxes, steering wheels,,,,)
-Staff should have no reason to go upstairs, so please stay on the first floor of the house so we do not need to wipedown the entire 2nd and 3rd floor as well.
-Wash hands thoroughly throughout your shift (and at home!)
-Keep distance between staff members (per CDC recommendations)
-If you or a family member are not feeling well or you believe you have come in contact with someone with COVID-19, stay home and self quarantine! (Let me know asap so we can find coverage)

In addition, we have been working hard to stock up on supplies (hay, grain, cleaning supplies)

Remember this is all temporary, and an effort to keep everyone healthy and safe so we can continue to care for our animal residents. If anyone has any questions please feel free to email, text, or call. "

The COVID pandemic will be filled with stories of amazing leadership and inspiration.    This once in century event effects all of us, even the citizens of Unity Farm Sanctuary.    We're doing our best to ensure every creature is comforted as we shelter in place.

Bringing Out the Best in Us

In the upcoming week you'll see numerous writings about national private sector efforts to enhance COVID response, communication, and collaboration.

As part of doing this work, one of my colleagues noted that the she's seen many recent examples of current events bringing out the best in people.     There's a willingness to help, a eagerness to volunteer, and a sense of belonging by banding together for a common cause.    Yes there are stories about hoarding toilet paper and purell, but those are minor distractions compared to the good things happening around us.

Here are examples of what I've seen in the past 24 hours.

1.  A major data analytics company focused on COVID modeling asked to collaborate with a major vaccine lab to accelerate development

2.  A group of competing companies aligned to create national policy requests that enable more virtual care

3.  Two competing big tech companies agreed to work together on helpful web-based resources for the country

4.  Big tech companies are offering expertise and credits for cloud resources

5.  An EHR company is working on a heat map showing orders placed for COVID testing as a proxy for virus spread

6.  An AI company is creating a map of national searches for COVID symptoms as a proxy for virus spread

7.  Many companies are offering free/reduced cost services in support of COVID response

8.  A non-profit recognized that we'll likely need a national vaccine registry linked by a nationwide patient matching strategy when a vaccine is available 12-18 months from now.    They will assemble a guiding coalition for that effort.

9.  A group of investigators is working on a trial of using convalescent plasma as a mechanism of conferring immunity. 

10.  A laboratory is seeking coronavirus positive blood to accelerate the development an easy to run, highly specific serology-based blood test

For all the anxiety we feel, it's clear that many people are working for the common good.    So if you're feeling that the future will be more Mad Max than Star Trek, realize that people around the world are working together to create the best possible outcome.

Working together, we can make a difference.

Saturday, March 7, 2020

What's a Platform Go Live?

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.

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.

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.

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.