Lessons Learned from Alpine Mountaineering

As I recently described in my Into the Wild blog entry, I spent a few days last week in New Hampshire with family. Every hike and climb I do is filled with lessons learned that make me a more responsive CIO.

Here are a few of my experiences.

On Monday, I expected to climb the Whitney Gilman ridge on Mt. Cannon in Franconia Notch. Unfortunately, we've had a very rainy July in New England, filled with pop-up thunderstorms. Monday had a 70% chance of Thunderstorms in the Franconia area, which is well known for its uniquely bad weather. Alpine mountaineering is often a race against bad weather, requiring pre-dawn starts and early afternoon descents off the mountain before afternoon thunderstorms put the climbers at risk. On most climbs there is always the possibility of retreat, which is part of the trip planning. Whitney Gilman has a lot of loose rock, no bolted anchors for rappeling, and is bordered by the 1000 foot 'black dike', a wet, mossy abyss. There is no retreat from this climb.

In my blog about risk, I described the Morts involved in each of my activities. Risk in my view is the likelihood of a bad event times the consequences of the bad event. Climbing a 1000 foot rock face without a possibility of descent with 70% thunderstorm risk in an area known for very bad weather, created a level of risk that I judged unacceptable. Summitting the mountain is optional, returning to the car is mandatory. I elected to skip all climbing and hike at low elevations on Monday.

The weighing of risks and benefits, evaluation of contingencies, and triage of all available options is something a CIO must do every day. Using my CIO behaviors in the intense world of alpine mountaineering makes me a better climber and visa versa.

On Tuesday, I climbed the Pinnacle Buttress (8 pitches, 5.8, picture above) to the summit of Mt. Washington. Although 5.8 climbing is only moderately difficult, the week of thunderstorms had created a thin sheet of moss over the entire climb, making handholds and footholds very tenuous. There were two options - become overwhelmed by the poor climbing conditions or just focus, trust myself and move to the top step by step. Often, when doing projects as a CIO, the politics, limited resources, software quality issues, and changes in scope can be very daunting. By focusing on the task at hand, realizing there is a process for everything, projects eventually succeed. Apply the same patience and perseverance I use in climbing to my work as an IT leader makes me a better CIO.

On Thursday, I hiked Mt. Monadnock from each compass direction, doing 4 ascents over the course of the day. On my final descent, I passed a gentleman who was moving slowly with his two young children, one 5 and one 8. The five year old was quite tired and having difficulty with the trail. The 8 year old asked her father which direction to go and he told her to follow me as I seemed to know where I was going. She took this as a command and ran down the mountain with me for 3 miles. It was 6pm, most hikers had left for the day and I was alone with an 8 year old girl I did not know, who was probably going to have to wait 2 hours for her family. I accepted responsibility for the situation, ensured she was fed and hydrated, then explained the situation to her. We walked to the Mt. Monadnock State Park headquarters where I filled out an incident report, asked the state park rangers to supervise her, gave them all my contact information, and asked them to followup. At 11pm, her father called me to say that the family was down the mountain, reunited and all was well.

By accepting responsibility for situations that are often not caused by me or are beyond my control (whether in the office or in the wild), I can ensure the satisfaction of all stakeholders.

A great vacation in New Hampshire. My next excursion into the wild begins on August 8 with the John Muir trail.

Automating the Disability Process with National Standards

At BIDMC and in Massachusetts, we use the structured, vocabulary controlled, XML-based Continuity of Care Document for data exchange between organizations. We've used it for direct clinical care to exchange discharge summaries between hospitals and clinicians. We've used it for Personal Health Record data exchange with Microsoft Health Vault. Our latest go live is the real time exchange of data with the Social Security Administration for disability adjudication.

Here's how it works:
1. A patient signs a consent to release records at an SSA office. That consent is digitized.
2. A SOAP/XML transaction is issued to BIDMC specifying patient demographics and including a base-64 encoded binary copy of the digitized consent.
3. BIDMC responds with a SOAP message containing the Continuity of Care Document of the patient's lifetime medical record.

Last week, we exchanged 1000 Continuity of Care Documents with the SSA after obtaining full patient consent. Here is a sample.

These documents include the following structured data

Problems (diagnoses) – coded
Lab Results (Chem-Heme-Urinalysis-Blood Gases) - coded
Procedures – coded
Encounters section which includes text documents:
Inpatient discharge documents
ED discharge summary
Operative notes
Letters – to patient, referral and referral reply
Progress Notes
Other notes and comments

using the HITSP C32 Continuity of Care Document format which has been recognized as the national standard by HHS for exchange of clinical summary data. These CCDs validate with the Schematron produced to ensure they conform to the standard.

CCD was created by informaticians from ASTM and HL7 working collaboratively to combine the structured tabular data from the ASTM Continuity of Care Record with the narrative document structures of the HL7 Clinical Document Architecture.

These groups are continuing to work together and in 2009 will produce CCD release 2.0 which will re-synchronize CCD with enhancements made to CCR, and address a number of other requirements for stakeholders in government, academia, industry, standards development organizations.

The Social Security Administration spends $500 million per year requesting paper records and disability adjudication can take 1 year. This new process, based on the Continuity of Care Document takes a few seconds, does not require human intervention and will lead to adjudication of many cases in near real time through the use of a business rules engine.

This kind of automation has a value proposition for everyone, reducing cost, saving time, and enhancing patient satisfaction. I look forward to many more such uses of the Continuity of Care Document as we build a Nationwide Health Information Network.

Removing the Emotion from IT

Every day as a CIO, I experience a range of emotions - great joy at watching my staff grow their skills, sadness when politics take time away from the fun work to be done, anxiety when the balance between IT supply and demand requires that I must say "not now" to a stakeholder request, and frustration when an unplanned project becomes a priority.

In my 25 years of leading people, one lesson I learn over and over is never to react with emotion to any of these events. How do I do it?

Although I am not a religious person, I use a variation of the idea from Ecclesiastes 3:1 (also set set to music in 1952 by Pete Seeger in his song 'Turn!, Turn!, Turn!') "To every thing there is a season, and a time to every purpose under the heaven".

The IT version is "To every thing there is a process which will resolve every problem under the heaven".

A conflict with a customer - try a kind email. If that does not work, meet face to face. If that does not work, ask your governance committees to consider the issue and develop a compromise that serves all stakeholders.

A conflict with an employee - try a kind email. If that does not work, meet face to face. If that does not work, involve HR.

A conflict with a colleague - try a kind email. If that does not work, go to lunch. If that does not work, escalate to senior management.

A conflict with senior management - try a kind email. If that does not work, meet face to face. If that does not work, ask the CEO. If that does not work, realize that eventually all senior managers move on and through kindness and the support of your stakeholders, you will outlast your naysayers.

Why is the life of a CIO filled with conflict and emotion? Demand for IT increases exponentially but IT budgets increase linearly (about 3-4% per year if you're lucky). Competition for resources creates conflict and conflict creates emotion.

Every day I receive hostile email, negative phone calls, and political challenges from various customers, employees, and colleagues. As I've said before, if I ever feel emotion, I "save as draft".

I always respond with a positive email, phone call or meeting suggesting a path forward.

If I were to ever respond emotionally, I would be burning bridges or giving my naysayers documentation to use against me. Healthcare is a small world. Healthcare IT is an even smaller world. The person who you alienate today may be your boss tomorrow. The person who you insult may be the decision maker on your next grant or promotion.

In a world of IM and Blackberry, we're all tempted to resolve complex issues with a few keystrokes. Generally that does not work. A supportive, positive email followed by a face to face meeting generally does work. Even if you feel the person emailing you is completely unreasonable, do not EVER react with emotion. It can only hurt you.

In addition to my credo that "to every thing there is a process", I also realize that time heals all conflict.

Can you even remember the problems that made you angry one year ago?

Are the people who caused the issue still around?

Does anyone remember the conflict and frustration?

Probably not. Will history record the masterful way you dealt with the conflict. Nope. If you reacted emotionally, will someone have a copy of that email filled with vitriol that you'd rather not see again. Absolutely.

It may take days or weeks to solve complex problems. An emotional email will only make the problem harder to solve.

Recognizing that solving complex problems will take several iterations, you need to accept the multi-step process needed to ensure you get a good outcome.

My previous blogs on related topics are helpful to removing the emotion from IT. See:

Management Lessons Learned as a Parent
Resolving Conflict
How to be a bad CIO
How to be a great boss
IT Governance

Unified Communications

I'm back from my first "into the wild" vacation and returning to the blog.

I was recently asked about the plan for implementing "Unified Communications" at BIDMC and HMS.

First, let's define Unified communications

1. Per Wikipedia

"An evolving communications technology architecture which automates and unifies all forms of human and device communications in context, and with a common experience. Its purpose is to optimize business processes and enhance human communications by reducing latency, managing flows, and eliminating device and media dependencies."

2. Per Microsoft

"Bridging the gap between telephony and computing to deliver real-time messaging, voice, presence, e-mail, and conferencing."

3. Per Gartner's Unified Communications roadmap

• Voice and Telecommunications: Includes fixed voice, mobile voice and softphones. Can include within building as well as remote access.

• Conferencing: Includes audio, video, and Web conferencing. Can also include meeting room technologies, multipoint Webcam approaches, and unified or integrated conferencing solutions.

• Messaging: Includes e-mail, voice mail and unified messaging.

• Instant Messaging (IM)/Presence: Includes IM, presence and rich presence
aggregation (the ability to aggregate and publish presence and location information from multiple sources).

• Clients: Includes thick clients, thin Web clients and mobile clients. This may also include limited software dashboard clients for embedding within IT applications.

• Applications: Includes applications that have integrated communication functions. Four key application areas are consolidated administration tools, collaboration applications, notification applications and contact center applications. Over time, however, many other applications will be communication-enabled.

What are we doing at BIDMC and HMS?

1. Enterprise Wifi is deployed over 2 million square feet, ensuring that Wifi enabled Blackberries, iPhones, and subnotebooks can connect anywhere at anytime.
2. Blackberry and iPhone 3G are supported for the enterprise via our Blackberry Enterprise Server (BES) and Active Sync.
3. Exchange 2007 is supported for the enterprise
4. IM via Meebo.com is supported for the enterprise via our new intranet portal which launches later this year.
5. Blogs are supported and encouraged
6. Wikis are supported and encouraged
7. Our Enterprise portals deliver RSS feeds, News, Blogs, and Wikis
8. Our Enterprise quality improvement efforts are managed via Forums and Wikis
9. We support Telemedicine and Teleconferencing extensively using both IP and ISDN teleconferencing.
10. We use Webex and other virtual meeting tools extensively. I have personally championed the idea of virtual meetings, flexible work arrangements, and remote access technologies which enable employees to work anywhere, anytime.

We have looked at Microsoft's Unified Communications platform and Office Communications Server 2007. These products integrate the experiences you associate with the telephone such as phone calls, voice mail, and conferencing with IM, email, and calendars. There has not been significant demand from my stakeholders to have voice mail or faxes delivered to email boxes. Most folks seem to consider their desktop applications to be separate from their phone, using their computer for social networking/virtual meetings/email/IM most of the time and their phone for voice calls on occasion, having little demand to integrate the two. Since the iPhone blurs the line between computer and phone, it will be interesting to watch how demand for different types of unified communication evolve.

Cool Technology of the week

We live in a connected world. With email, IM, Facebook, Twitter, MySpace, Blogger, etc., many folks are tied to wired or WiFi connection most of the day. The recent Verizon commercials highlight their USB EVDO cards so that you can get out of Internet Cafe jail and take your mobile devices on the road. However, this approach requires a data plan for every USB device you own and requires special software to be installed on your laptop.

The cool technology of the week is mobile WiFi for your car that takes the complexity out of mobile connectivity. AutoNet Mobile is a WiFi access point with built in 3G (EVDO) connectivity that enables any existing WiFi compliant device (desktops, laptops, Macs, PDAs, servers, iPhones) to connect to the web while in your car for $29.00 per month.

Access speeds range from 600Kbps-800Kbps with upload speeds about 200Kbps. The Wi-Fi connection is secured with WEP encryption, MAC address restriction or WAN port restriction. It also supports VPN pass-through. No software is needed to use the device, since it uses existing WiFi connections resident on mobile devices and thus it is compatible with all operating systems and devices. No additional attennas are needed.

Chrysler plans to offer this service on all of its 2009 models starting in August.

Of course, this connectivity is to be used by passengers sharing your commute, family members who want to stay connected on long car trips or as an access point once you've reached your destination. WiFi connectivity while driving is a bad idea - keep your attention on the road.

Always on mobile broadband for your car which works with existing WiFi devices - that's cool!

Into the Wild

In Jon Krakauer's novel Into the Wild, Christopher McCandless shrugs off the trappings of conventional society and seeks adventure on the road like a modern day Jack Kerouac. He ends his Journey in Alaska where he spends 100 days alone in the wilderness and dies by consuming poisonous plants (or the poisonous mold growing on the them).

I'm a bit more conventional than Chris McCandless but the notion of going into the wild to recharge your body and invigorate the mind is a good one.

Here's my schedule for going Into the Wild this summer, which will explain a few gaps in my blogging days:

July 21 - Ascent of Whitney Gilman Ridge (5.7) on Cannon, Franconia Notch, New Hampshire. Every year in July, I ascend Whitney Gilman, the classic alpine climb in New England. The climb rises 2000 feet above highway 93 near where the Old Man of the Mountain recently fell off Cannon mountain. The challenge of climbing on Cannon is that the rock is exfoliating granite, which, like the Old Man, tends to fall off over time. The route is known for the "pipe pitch", where a lack of places to place protection led the first ascent party to hammer a pipe in a crack to support their ropes. On the pipe pitch you stand on a 6 inch square of rock looking down 1000 feet into the Black Dike, then you make a few gymnastic and strenuous moves to pull your body over a ridge by your fingertips. Needless to say, I will not not be bringing my Blackberry.

July 22 - Ascent of Pinnacle Buttress (5.7) in Huntington Ravine to the top of Mount Washington. Pinnacle is another classic climb in New England, known for its particularly challenging and strenuous Allis Chimney, two vertical walls of rock with few hand and foot holds.

July 23-25 For the past ten years, my family has stayed at a local farm, East Hill in Troy, New Hampshire during the last full week of July. East Hill is at the base of Mt. Monadnock (elevation 3165 feet), the most climbed mountain in the United States. Each day that we're at East Hill, I ascend the mountain 4 times, once from each compass direction via the Dublin or Pumpelly trail (North), White Cross or White Dot (South), Birchtoft trail (East), and White Arrow (West) trails. I play my traditional flutes while on the trail, creating an echo of haunting music that traverses the canyons and forests of the mountain. This year I'll play the Japanese flute, the Anasazi flute, and the Woodlands Native American flute.

August 8-11 My own version of the Chris McCandless adventure, I'm walking 100 miles on the John Muir Trail over 4 days. 25 miles per day is an aggressive schedule which requires that I travel fast and light. My gear list ensures my pack about 15 pounds during the entire trip. Since all my food will be vegan, I do carry a bit of extra weight given the reduced calorie density of lentils, rice, and dried beans. During these 4 days, I will not have access to a cellular signal.

August 12 Ascent of Mt. Tenaya (5.6 variations) in Tuolumne Meadows. Tenaya is an extraordinary climb with 18 pitches of high quality granite overlooking Tenaya Lake in Yosemite. Last year, a trick of the light made the summit (picture above) look like heaven was shining on me (no photoshop used).

August 13 Ascent of Cathedral Peak (5.8 variations) and Eichorn Pinnacle (5.9) in Tuolumne Meadows. Per my New Year's resolution, I'll be playing a Japanese flute concert from the summit. Barry Higgins, a master flutemaker , has agreed to build me a special Shakuhachi for climbing made of "Urban Elderwood" otherwise known as PVC pipe. He made my Anasazi flute and I'm confident his PVC Shakuhachi will be extraordinary.

August 14 Hike up the Tioga Crest. At 13000 feet, the Tioga Crest overlooks Saddlebag Lake, Tioga Pass, Mt. Dana, Ada Lake, Mt. Warren, Mt. Gibbs, and Mt. Scowden. I'll follow old mining switchbacks to ascend the crest near the TipTop and Summit Mines. The Summit is still filled with the beds, clothes, and work table from 19th century miners. It's so hard to reach that no one has touched their belongings.

August 15 Ascent of North Ridge of Conness (5.6). Mt. Conness has a two classic climbs - the West face (which I did last year) and the North Ridge. It's a long day of climbing (15 hours car to car), with a highly exposed knife edge ridge leading to the summit.

For all my friends in the Blogosphere, my staff, the folks at the Poison Control Center who work with me on mushroom ingestions, and my customers, these are the days this year I'll be slow to the respond.

And now I go into the wild.

Open Source Medical Records

Last week, I had lunch with the CEO of MedSphere, Mike Doyle, to learn about the company's plans for OpenVista. The idea is simple - take the the publicly available code from the Veterans Administration clinical information system, add new modules such as revenue cycle interfaces that are needed in practices outside the VA system and include support/implementation services. In effect, you'll have the "Red Hat Linux" of the electronic health record world.

Medsphere has chosen to package Vista in two forms - Enterprise for large hospitals/integrated delivery systems needing departmental system and Clinic for small offices/multi-specialty clinics needing strong outpatient functionality.

Enterprise includes

* Patient Information Management System
* Health Information Management System
* Clinical Information System
* Laboratory
* Pharmacy
* Radiology
* Nutrition and Food Service
* Interface Suite

Clinic includes

* Patient Information Management System
* Health Information Management System
* Clinical Information System
* Laboratory
* Pharmacy
* Radiology

Medsphere has several live deployments in the US and internationally.

The VA's Vista system is well known for its integration, functionality and sophisticated decision support. I spoke with several for profit vendors about their opinion of an Open Source EHR based on Vista. They had a very reasonable response - the real cost of providing a comprehensive clinical IT solution is not really the code (since most vendor products development costs have already been recouped). The cost is in the service.

Implementation, practice transformation, workflow support, and interfaces are the really resource intensive aspects of implementing EHRs and hospital information systems.

Medsphere's true measure of success will be its ability to deliver high touch support in a scalable way as its market expands. Mike shared the Medsphere core values, vision, value proposition with me (the picture above). You'll see that their ideology is very noble - reduce costs, improve quality, and make a difference in healthcare. Decoding the slide, BHAG means Big Hairy Audacious Goals from the Jim Collins article Building Your Company's Vision. The Hedgehog Concept refers to the understanding of the one thing you can be best at. Jim Collins discusses it in Good to Great based on Isaiah Berlin's essay “The Hedgehog and the Fox".

In addition to Jim Collins work, Mike Doyle has great respect for the books "The Blue Ocean Strategy" and "The Culture Code" .

I believe Medsphere is a valuable stakeholder in the eHealth marketplace. As a strong advocate for open source, I wish them the best in their quest to redefine healthcare.

Healthcare IT Supporting our Troops

I spent yesterday in Washington with Major General Elder Granger, Deputy Director in the Office of the Assistant Secretary of Defense for Health Affairs.

We discussed electronic health records, personal health records, decision support, and interoperability. Here's a brief overview of the electronic systems supporting our troops. See http://www.health.mil for additional details.

AHLTA-T is a PDA version of the Department of Defense Health Record running on Windows CE devices. The DOD tests all of its battlefield technology at Fort Detrick for ruggedness in battlefield conditions - heat, sand, ice, water, and physical abuse. A shock resistant enclosure keeps the PDAs safe. The AHLTA-T record itself has an iPhone-like interface with radio buttons and touchable graphics to rapidly record a battlefield assessment. It generates a structured history and physical, then creates a care plan based on triage rules and best practice protocols. The user interface is designed to be easily navigatible in high stress conditions. Given the lack of WiFi and reliable cellular in battlefield conditions, cradle synch is used to transfer all the medical records to AHLTA system.

Once in AHLTA, battlefield data joins the patient's lifetime health record and is available worldwide for clinical care. Patients may be evacuated to Germany and upon arrival, their entire updated record is available to the care team.

AHLTA data is transferred to a Clinical Data Repository where it is available for IRB approved clinical research, surveillance, and quality reporting. DOD leadership has real time dashboards showing injury, biosurveillance, and medical supply data.

The DOD also has an integrated pharmaceutical repository with over 1 billion records from pharmacies and pharmacy benefit managers which dispense medications to the armed forces and their families.

When a patient leaves the armed forces and becomes a Veteran, their lifetime medical record is available in the Veteran's Administration VISTA system via the Bidirectional Health Information Exchange (BHIE) built to connect the DOD and VA systems.

An impressive system, incorporating national standards, serving our troops throughout their lifetime.

As I left, General Granger shook my hand and passed along his personal coin (photo above), just as Dr. Koop had done with me a few months ago.

I look forward to a productive collaboration between the DOD and the non-profit healthcare world I live in everyday. I'm confident there are decision support alerts/reminders, mobile device implementations, and data exchange experiences that we'll be able to share for our mutual benefit.

Implementing New Applications

I've previously written about selecting new applications and the infrastructure reviews we do whenever new applications are added to BIDMC.

Once an application is selected, my role as a CIO is to set expectations about what happens between product selection and go live. On occasion, some stakeholders think of applications like installing a spreadsheet on their home computer - you just buy the application, type "setup", and then begin using it.

I've even heard of examples where a CIO tried this. At one institution I visited, they purchased Peoplesoft, copied it to a server and then "turned it on". To their surprise, it was not used.

We try to standardize the steps between product selection and go live, ensuring that IS manages that process with strong governance oversight by the stakeholders. Here's our framework:

Kick off meeting for all stakeholders
Identify the business process owner and the individual who makes decisions for the users
Identify the Project management in IS (note that every project needs a named project
manager in IS)
Agreement on scope - may include phased implementation such as pilots
Agreement on timing
Agreement on staffing and budgets

Schedule Steering and Working group meetings

Identify needed Infrastructure - network impact, servers, storage/archiving

Acquire the application including negotiation and legal approval of terms/conditions

Configure the application and establish any needed interfaces

Perform integrated testing of the application

Train support staff and stakeholders on the use of the application

Go live

Support and life cycle manage the application

This framework ensures a successful go live, provides 24x7 support, and ensures the application is maintained over time. Although the process typically takes 6-12 months from start to finish (except for the simplest software as a service applications hosted externally), it's a worthwhile investment if you plan to use the application for decade.

I hope this is helpful to you.

Cool Technology of the Week

Since every other technology blogger is going to discuss the iPhone 3G launch, it's a day to blog about cool phone technologies. Yes CareGroup/BIDMC and Harvard Medical School will support the iPhone 3G with our Exchange 2007 systems, ensuring equal treatment of Blackberry and iPhone for email and calendar synch. I will test the iPhone 3G using a loaner from Apple that arrives on July 18. I'll report on my feature by feature comparison of the Blackberry Curve (I've not been able to test a Blackberry Bold yet) and the iPhone in a post later this month.

While traveling internationally with my Blackberry 8320, I make and receive numerous calls. Roaming charges can be extreme - $1 to $2 dollars per minute. How do you travel internationally with your smartphone and avoid the high cost?

My cool technology of the week is iSkoot , a downloadable Skype client for the Blackberry and other smartphones (HP, Treo, Nokia, Motorola etc). The iSkoot client places a regular local phone call to an iSkoot gateway server, then the gateway server places a Skype call, bypassing all long distance charges. While connected to the iSkoot gateway, the iSkoot client enables you to

* See who is signed in and view their online status
* Manage your own online status
* Click to call a contact
* Click to chat with a contact
* Make low-cost calls to any phone number, anywhere in the world using SkypeOut
* Receive calls from Skype users
* Add or remove friends from your contact list
* Refresh your contact list automatically or on demand

One other technique I find useful when traveling internationally is to use an inexpensive quad band mobile phone ($30 on eBay) with a local Sim Card, purchased in the country I'm visiting. This enables folks in the country to call you and you to call them at low cost. Also, you can receive calls from international callers at no cost to you. The caller pays a bit more to reach your roaming local cell phone, but you incur no long distance charges.

iSkoot and local Sim Cards - a Cool Technology solution for the international traveler.

Making Herbal Extracts

It's Thursday, so it's time for another personal blog entry that's a change of pace from IT.

Every year in August, when I climb in Yosemite, I stay in an isolated riperian wilderness on the eastern escarpment of the Sierra, called Lundy Canyon.

At 7808 feet, the area around Lundy varies from a Sagebrush steppe to a sub-alpine zone. Sagebrush (Artemisia tridentata) and White Sage (Salvia Apiana) have been used by Native Americans in the area for centuries as ceremonial smudge sticks and for "space clearing" - freshening their homes, their belongings and their bodies.

Taking a lead from their experience, I gather a few pounds of sagebrush every year, then make my own toiletries and scent diffusers for my home from the dried herb.

Here's how I do it.

First, I gather the sagebrush and dry it in the sun for transport home.

To make an herbal extract for aftershave/cologne, I remove the sagebrush florets from the stalks and place them in an 8 ounce Nalgene polyethylene container. I fill the container approximately one third full with sagebrush and then add 6 ounces of 100 proof Absolut Vodka, although any strong grain alcohol will work.

I completely cover the herbal material with alcohol. If you are using dried herbs you should add more alcohol over the next day or two as the dried herbs absorb and expand. A good ratio for dried material is about 1 part herb to 5 parts alcohol and with fresh material 1 part herb to 3 parts alcohol.

I close the lid tightly, shake well and place the mixture in a dark place for 4 weeks, shaking it again every few days.

The alcohol extracts the active constituents from the herbs. After 4 weeks, I strain the herbs in a sieve, lined with cheesecloth. I then pour the liquid into another Nalgene container and tightly squeeze the cheesecloth to extract the remaining liquid, since the saturated herbal material has the strongest concentration of active constituents. For aftershave/cologne I poor the liquid into 2 ounce spray bottles, which I use at home and on the road after a workout such as climbing or kayaking. The alcohol cools the skin and the sagebrush refreshes the body.

For my home, I make reed diffusers in much the same way. A natural reed contains 20 capillaries that can absorb liquid and slowly disperse the fragrance.

Instead of grain alcohol, I use a diffuser oil and place the sagebrush saturated oil in small glass bottles filled with reeds. I get a subtle "space clearing" effect in my home without using chemical or electrical air fresheners.

Other plant material such as cedar chips, juniper berries or bay leaves make great herbal extracts. Just as wearing black is my signature clothing, sagebrush is my signature scent. I hope you enjoy finding your own.

Clinical Reminders

I've previously written about the importance of Inpatient and Outpatient Decision Support.

Yesterday, I joined an expert panel on Clinical Decision Support, hosted by Dr. David Bates at Partners. Part of this multidisciplinary effort is to review the clinical reminders that institutions have implemented in their electronic health records. The definition of a reminder is that a non-urgent notice appears on the EHR patient summary screen and the clinician's schedule. Reminders are suggestions for clinicians to follow so that best practice guidelines are followed. An alert, by contrast, is an urgent issue which must be escalated immediately. Alerts at BIDMC include such issues as critical lab values or a notice that a patient has been hospitalized. Here are the reminders in use today at BIDMC:

Mammogram
Women 40 and over: yearly

Pap Smear
All women: annually

Influenza Vaccine
Children under 2
Adults 50 and over
Patients with diabetes

Pneumovax
Children under 5 (PCV): 3 doses,
alert for each dose when due
Adults 65 and over (PPV): once
Patients with diabetes (PPV): once

Tetanus (Td)
Adults: Every ten years

Prostate Specific Antigen
Men 50 and over: yearly

Colonoscopy
Adults 50 and over: every 10 years

Bone Mineral Density
Women 65 and over: once

Health Care Proxy
All patients who do not have one on file

For HIV-patients only:
Ophthalmologist, H. Flu Vaccine, PPD, Baseline Labs

I look forward to working with this expert panel and broadly sharing the clinical reminders from all of our institutions.

Responding to Medical Error

Yesterday, Paul Levy posted an entry on his blog about a recent surgical error at BIDMC.

IS and the clinical departments of BIDMC have a very strong collaborative relationship. Working together, we first enhance processes, then automate them, since even the best technology is generally not the solution to workflow and communications problems.

Here's the application enhancement we're making as part of a process change in the Operating Room to prevent future patient harm.

Standard Operating Process in the OR includes a "time out" by all OR personnel in the moments before surgery to double check all aspects of safety - equipment, right surgical site, team readiness etc. Currently the "time out" is documented on the paper intra-operative record, which means that the scrub nurse needs to look at both the paper record and the electronic peri-operative information system during the "time out." We will add a "Time Out" button to the electronic OR journal screen containing the case times. When this button is clicked we will pop up a window with the "time out" fields. The nurse will fill in the time out information and enter her/his password. We will not allow the nurse to enter an incision time for the case unless the "time out" has been completed, with one exception - we will provide a check box on the time out screen to indicate the time out could not be completed prior to incision due to a life-threatening situation.

The standard process we've put in place to respond to sentinel events such as this one is that the root cause is reviewed with the Board (PCAC committee) and the Quality Improvement Directors. IS staff work with Quality Improvement Directors to determine which process improvements need to be made, then what additional automation should be added. Using this approach, we've created a balanced way to add new technology at the appropriate time.

The Surescripts/RxHub merger

Last week, I spoke with the Associated Press and Wall Street Journal about the recent merger of Surescripts and Rxhub.

My basic message was:

"The merger of Surescripts and RxHub provides a single medication data stream, supporting medication safety. It also provides an easy e-prescribing implementation path for electronic health record vendors and an enhanced medication workflow for clinicians nationwide."

Here's the reason I made these comments. In the world of e-Prescribing, the stakeholders are

- the patient
- the physician writing the prescription
- the retail pharmacy or mail order pharmacy
- the payer
- the pharmacy benefit manager (PBM), which acts on behalf of the payer to adjudicate claims
- RxHub: the connection to most PBMs
- SureScripts: the connection to most retail pharmacies

Here's the data flow:

1. A clinician begins to e-Prescribe and electronically queries for the patient's insurance eligibility and the appropriate payer's formulary. Before the merger, both RxHub and SureScripts had eligibility services but RxHub processed the majority of these transactions.

2. The clinician queries for medication history to check for drug/drug interactions. RxHub has medication history based upon claims data and SureScripts has the actual dispensed information from the pharmacies (which includes cash, third party claims and $4 generic programs). Before the merger, the clinician's EHR would have to issue separate queries via two separate interfaces to get a complete history.

3. The physician completes the prescription. Retail pharmacy transactions are transmitted to SureScripts for delivery to community pharmacies and smaller mail order firms. Mail order transactions served by one of the 3 large PBMs are transmitted to RxHub for fulfillment. Again, two separate interfaces were required.

As SureScripts-RxHub integrates its services, there will no longer be a need to send out 2 queries for eligibility/formulary, medication history or routing. Also, the two sources of medication history data will be de-duplicated, providing an accurate and usable medication data flow to all stakeholders.

In addition to the Surescripts-RxHub merger, two other important events will accelerate e-Prescribing in 2009.

1. Regulatory changes proposed by the Drug Enforcement Agency will enable electronic prescribing of scheduled/controlled medications. Having separate workflows for controlled medications verses all others has been a real barrier to process change in many medical care settings. I look forward to the regulatory change.

2. Incentives to adopt and use e-Precribing via the Medicare Electronic Medication Safety Protection Act of 2007. Clinicians have been reluctant to adopt electronic prescribing because of the investment and time commitment to change change their workflow. Currently only 4% of the clinicians in the country e-prescribe (although Massachusetts is at 13% and BIDMC is at 50%). A one time payment when e-prescribing is implemented helps a physician acquire the technology. An ongoing incentive ensures they continue to use it.

Let's hope 2009 is the year of e-prescribing. Everyone wins through reduced cost, enhanced quality and better workflow.

Cool Technology of the Week

Tonight, the Boston Pops will host another dazzling display of fireworks on the Esplanade in Boston. As cymbals crash, fireworks will explode on cue. Ever wonder what technology is behind the pyromusical synchronization? Computer controlled firing systems are the cool technology of the week. Here's a list of leading companies. I found Pyromate of Peterborough New Hampshire to be particularly impressive.

The components of a computer controlled firing system include

1. A laptop

2. Fireworks show designing software

3. Firing software

4. A firing control console.

5. Remote firing module boxes which active "electric matches" - nichrome wire and a small amount of gunpowder that ignites the fireworks when a current is applied.

6. A large battery to power the system

7. Cabling and WiFi access points to connect the entire system.

A show designer inputs the inventory of fireworks to be used into the show designing software, including the name and size of each firework. Interestingly, each explosive also has a known time delay between ignition and effect, which is also part of the show design database.

The show designer uses this software to develop a firing sequence. If the fireworks are to be synchronized to music, the music is converted to a time series such as a midi and uploaded to the fireworks design. Synchronizing an aerial bomb with a cymbal crash is easy - just launch the shell taking into account the time delay between ignition and effect.

On the day of the fireworks display, the fireworks are assembled in launching mortars, connected to electric matches, and cabled to firing models. The modules are in turn connected to the firing console. The entire system is checked for electrical integrity and the show is ready to begin.

The pyrotechnicians start the firing software on cue and the entire show is delivered automatically, without human intervention. If a fire or other problem occurs during the show, the program can be stopped and restarted once the hazard has been resolve

Of course, all this computerized complexity can introduce points of failure into fireworks shows.

As expected, Slashdot had the usual pointed commentary.

Next time you watch a fireworks show, you'll know all the cool technology behind it!

My Closet

Many people ask me about my black wardrobe, which I've written about as simply practical for the 24x7x365 CIO and not a Gentleman's Quarterly fashion statement. I was recently asked to share a glimpse of my closet.

I know this sounds like a strange blog topic, but my closet provides an insight into my brain, demonstrating that every minute of my existence is part of a complex lifestyle. Hopefully, the detail below will not sound too obsessive compulsive. Call it "the examined life".

My closet is organized into clothing for my lower extremity and clothing for my torso.

Everything I own for the lower half of my body is black. It's practical. Whether business attire, climbing clothing, or alpine ascent gear, various kind of black pants work well. For the office, my pants are rayon (it's vegan and derived from wood fiber). For climbing, I wear all Arcteryx gear made of thin but durable nylon. For alpine ascents, I wear Arcteryx gear made from Powershield, a Polartec softshell.

For my torso, I wear all black linen fabrics (a 5000 year old textile made by weaving Flax) in the office, since they are easy care, cool in summer and warm in winter. For the outdoors, all my upper extremity clothing is red for visibility. I have base layers of polyester, mid layers of Polartec Powerstretch and outer layers of Gortex. Each layer is engineered for specific temperatures and humidity conditions.

For footwear, I have specific shoes for specific tasks. Vegan microfiber polyester Monk shoes and Dealer Boots for the office, Five-ten climbing and approach shoes for the Crag, and Scarpa Double Plastic boots for Alpine travel.

My closet also stores my ropes, packs, climbing hardware, and helmet.

All of my clothing and most of my belongings fit into this one 8 foot space.

Over the years, I've tried to refine what I own and approach all my clothing from an engineering perspective, only carrying what is minimally necessary for the range of climatic conditions I'll encounter. Here's the complete inventory including the specific temperature and humidity conditions for each piece of clothing and the body measurements I use for my engineering approach to clothing. The dates are purely so I know when to replace a given piece, since polyester tends to decay over time.

This philosophy works very well in an era when travel is so expensive and difficult. Wearing black, and using the durable, breathable fabrics I've chosen, a week in Europe can be done from a single carry on satchel. A week in Yosemite takes a bit more, since I have 7 pounds of rope and climbing hardware to carry along, but 1 small duffel will do the trick.

That's my closet - another expression of my lifestyle that does not separate work, family, job, and avocations but comingles them all into one continuum.

Massachusetts Clinical Data Exchange Legal Agreements

Across the country, many towns, states, and regions are thinking about clinical data sharing. There is substantial variation in the business models, the data shared, and the stakeholders involved.

However, every clinical data sharing entity needs an operating agreement to create the organization and a customer agreement to add trading partners.

In the interest of transparency, I am posting the

Operating Agreement for MA-Share, our regional clinical data exchange

and the

Customer Agreement, which is used to sign up payers, providers, pharmacy benefit managers and other stakeholders.

Feel free to use these agreements for your data exchange activities.

Let me know about your successes, challenges, and lessons learned along the way as you implement clinical data exchange.

Technology Secrets of the Congressional Clock

On June 11, as part of Healthcare IT Advocacy Day in Washington DC, I visited several offices on Capital Hill (Ted Kennedy, John Kerry, Jim McGovern and Barney Frank) to discuss the importance of ePrescribing, data standards, and support of incentives for EHR adoption.

While wandering through the House (Cannon, Longworth, Rayburn) and Senate (Russell, Dirksen, Hart) buildings, I noticed that the clocks in all the offices had various lights and buzzers. I asked Congressional staffers to explain the secret code behind these signals and no one really knew.

After scouring the web for hours to no avail (Google has no information on Congressional clocks), one of our Advocacy team members found the following information buried on page 35 of an unindexed PDF on the Senate website.

1 long ring followed by a pause and then 3 rings and 3 lights on the left
Start or continuation of a notice or short quorum call in the Committee of the Whole that will be vacated if and when 100 Members appear on the floor. Bells are repeated every five minutes unless the call is vacated or the call is converted into a regular quorum call.

1 long ring and extinguishing of 3 lights on the left
Short or notice quorum call vacated.

2 rings and 2 lights on the left
15 minute recorded vote, yea-and-nay vote or automatic rollcall vote by electronic device. The bells are repeated five minutes after the first ring.

2 rings and 2 lights on the left followed by a pause and then 2 more rings
Automatic rollcall vote or yea-and-nay vote taken by a call of the roll in the House. The bells are repeated when the Clerk reaches the R’s in the first call of the roll.

2 rings followed by a pause and then 5 rings
First vote on clustered votes. Two bells are repeated five minutes after the first ring. The first vote will take 15 minutes with successive votes at intervals of not less than five minutes. Each successive vote is signaled by five rings.

3 rings and 3 lights on the left
15 minute quorum call in either the House or in the Committee of the Whole by electronic device. The bells are repeated five minutes after the first ring.

3 rings followed by a pause and then 3 more rings
15 minute quorum call by a call of the roll. The bells are repeated when the Clerk reaches the R’s in the first call of the roll.

3 rings followed by a pause and then 5 more rings
Quorum call in the Committee of the Whole that may be followed immediately by a five-minute recorded vote.

4 rings and 4 lights on the left
Adjournment of the House.

5 rings and 5 lights on the left
Any five-minute vote.

6 rings and 6 lights on the left
Recess of the House.

12 rings at 2-second intervals with 6 lights on the left
Civil Defense Warning.

The 7th light
indicates that the House is in session.

Thus, the picture above indicates that the House is in session (red light), but in recess (6 lights).

Now you know the secrets of the Congressional clock and how our elected officials know when to run from their offices to the House and Senate floors.