Wednesday, November 26, 2008

Engage with Grace

Today, you'll find that many healthcare bloggers have devoted their blog to the post below. My wife and I have have completed the exercise. In my case, I do not want end of life care in a hospital. When I cease to be me through brain injury or diminished mental capacity, I do not want to be supported. I want my ashes scattered from the top of Mt. Scowden on the Tioga Crest.

This guest post was written by Alexandra Drane and the Engage With Grace team.

We make choices throughout our lives - where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don't express our intent or tell our loved ones about it. This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones know exactly or have a good idea of what their wishes would be if they were in a persistent coma, but only 50% say they've talked to them about their preferences. But our end of life experiences are about a lot more than statistics. They're about all of us.

So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we're asking people to share this One Slide wherever and whenever they can ... at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Let's start a global discussion that, until now, most of us haven't had.

Here is what we are asking you: Download The One Slide and share it at any opportunity with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let's start a viral movement driven by the change we as individuals can effect...and the incredibly positive impact we could have collectively. Help ensure that all of us - and the people we care for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.

To learn more please go to

Tuesday, November 25, 2008


It's too cold for rock climbing and kayaking but not yet cold enough for ice climbing or skiing, so I'm using the time to read through the books on my nightstand and on my Kindle.

I just finished Outliers by Malcolm Gladwell (author of The Tipping Point) , a well written thought piece on what really produces the movers and shakers in each generation.

Darwin would have loved the heady questions raised by this book. Is success more about nature or nurture? What's more important the Intelligence quotient or Emotional quotient. Is the Stanford-Binet test a useful measure of your likelihood to succeed? Can Harvard really tell the differences among 3000 valedictorians with perfect SATs applying to college?

Here's my own story put in the context of the book.

When I was 12 years old (1974), my parents went to law school and I spent my free time after school scouring surplus stores in Southern California. Sunny Trading Company on Torrance Boulevard was my treasure trove. For 10 cents I could buy NAND gates, Shift Registers, and LM555 digital timing chips. Reading through National Semiconductor product catalogs and the entire contents of our local library's Dewey Decimal 620-622, I learned digital logic, analog to digital conversion, and the basics of microprocessor design.

Then, in 1975, a major breakthrough. The Popular Electronics January issue announced the Altair 8800, which made home computing possible and I devoted myself to learning about "personal computers".

I spent my high school years programming in numerous languages from Assembler to Fortran to Cobol to BASIC. I used minicomputers, microcomputers, and mainframe computers. In 1978, I designed the software and hardware for my first experimental medical device - a computer capable of gathering visual and audio evoked potentials then performing signal averaging and fast fourier transforms in real time.

All of this was possible because I lived in Southern California in the mid 1970's where surplus stores had cheap integrated circuits and because my local library gave me access to great books about emerging technology. I truly believe that this foundational portion of my career was more about time and place than me.

From high school I went to Stanford, started a software firm and began the parallel life of medicine and technology that leads to the present.

In Outliers, Gladwell points out that Bill Gates, Steve Jobs, Larry Ellison, Scott McNealy and Bill Joy - the leaders behind our largest technology companies - were all born in 1955. They were 20 when the Popular Electronics issue was published, just completing college (or dropping out of it). The were at the beginning of their careers but without families, a mortgage or an established job in a traditional technology firm. They were at the right place at the right time to ride the wave of emerging technologies.

Of course they were smart, but numerous people are smarter. Gladwell concludes that once you are "smart enough" then culture, circumstance, timing, and luck are key differentiators for success.

Our lives are complex paths with daily choices that lead to success or failure. I know that I could have ended up in a dozen different careers, lifestyles, and economic strata. However, as Outliers suggests, the world around me shaped my outcome and I can really link my Harvard faculty position to my parents choice of living near an electronics surplus store in the 1970's.

Outliers is worth reading to understand the external context which shaped some of the most successful people in our generation.

Monday, November 24, 2008

Reducing IT budgets

I oversee the budgets of several technology organizations, all of which are under pressure to react to the faltering economy. At BIDMC, capital budgets are constrained, operating budgets are being tightly managed, and no staff reductions are planned. At Harvard Medical School, senior leaders are seeking a 10% reduction in the school's operating budget. How can IT organizations approach operating budget reductions?

1. Engage all your staff. They can identify operational inefficiencies, redundancy, and savings opportunities. Any budget reduction results in rumors, speculation, and fear of job loss. Engaging your staff in the budget process empowers them, informs them, and reduces their worry.

2. Find the low hanging fruit - vacancies, travel/training, consulting fees, food/entertainment, and other "nice to have" expenditures are the first place to start any budget reductions. I passionately support training, but when faced with budget cuts, most staff would elect to support salaries and reduce training.

3. Identify service reductions - all IT projects are a function of scope, resources, and timing. Reducing the scope of service and determining what projects to cancel is an important part of budget reductions. One challenge is that organizations often have short memories. If you offer a budget reduction linked to a service reduction, you may find that the budget reduction is happily accepted but the service reduction is forgotten in a few weeks. In fact, many departments throughout the organization will suggest that budget reductions are possible if more automation and technology is added to their work processes. Reducing service at a time when customers need more service may not be the optimal approach, which I will discuss further below.

4. Extend timelines - assuming that resources are diminished and scope is already reduced, the last lever a CIO has is to extend the timelines of new projects. Instead of delivering new software this year, delay it to next year. Existing staff can take on more projects only if they have a longer time to do them.

5. Accept risk - Our job in IT is to ensure stability, reliability, and security. 99.99% uptime requires multiple redundant data centers, but there is not a precise cookbook as to how this should be done. I have implemented 2 data centers a few miles apart and not a grid of worldwide data centers. Why? Because risk = likelihood of a bad outcome * the impact of that outcome. When creating budgets, I decided that the likelihood of a regional disaster which destroys the IT capability of the entire Boston region is small. The likelihood of a single data center fire, flood or explosion is measurable, so I chose to mitigate that risk. In times of budget stress, a re-evaluation of risk is appropriate. Can network, server, storage and desktop components be kept for a year or two beyond their usual lifetimes? Can maintenance contracts be reduced or eliminated and mitigated by having spare components handy? Just as with service reductions, the strategy of increasing risk to reduce costs must be widely communicated, so when a failure occurs, everyone understands it was a risk accepted as a result of budget reductions.

In general, I do not recommend fighting budget reductions with overly dramatic stories of doom and gloom. That is not professional. Instead, CIOs should provide senior management with a list of services and a list of risks, then decide collaboratively what to do. This ensures that the CIO and IT is seen as an enabler and team player rather than a cause of the budget problem.

Having been through numerous budget reduction experiences over the past decade, I have witnessed the paradoxical effect that IT budgets are sometimes increased when organizational budgets are decreased. Savvy administrators know that economic downturns provide the urgency to re-engineer processes and accomplish politically difficult strategic changes. A short investment in automation can lead to long term reductions in operating costs. Thus, this downturn may be the opportunity to eliminate paper, streamline labor intensive manual methods, and consolidate/centralize for economies of scale.

Over the next 60 days, I will work with Harvard Medical School administration on all these issues and report back as to what we collectively decided to do.

Friday, November 21, 2008

Cool Technology of the Week

This week I had the opportunity to carry the ultimate geek utility belt - an iPhone 3G, a Blackberry Bold (AT&T) and a Blackberry Storm (Verizon). I tested all three devices in parallel for emailing, web browsing, and usability. Here are my first impressions:

The Bold has a bright 2.8-inch glass LCD screen with 480 x 320 resolution (same as the iPhone 3G) and is very easy to read. I started using bifocals last week and I really appreciated the Bold screen as compared to my Curve. The increased graphic density makes a big difference for the web browser since it's now possible to render an entire page on one screen. An easy to use zoom feature and scroll bars make browsing much more "desktop like" than previous Blackberries. The HSDPA 3G wireless over AT&T is fast and the coverage in Boston is quite good. The WiFi linked easily to my hospital infrastructure. The Bluetooth bonded seamlessly with my Prius. The only downsides - the battery life of the Bold is about a day and half, compared to 3 days on my Blackberry Curve. I could not find a way to turn off the 3G and use EDGE only. The QWERTY keypad is very similar to the 8800 series, without the generous key spacing of the Curve. I thought this would be a problem but after a few minutes of typing, I adapted and was able to type at my usual 60 words per minute without errors.

The Storm has a bright 3.25 inch glass touch screen with 480 x 360 resolution and tactile feedback. The entire screen is a mouse button that depresses but since your finger only contacts a small portion of the screen at time, your brain believes that the screen is a push button under your finger. The on screen keyboard is a full QWERTY keyboard when the device is tilted horizontally. When you hold the Storm vertically, it displays a "SureType" keyboard - the same doubled up keys found on the Blackberry Pearl. They question that I'm sure everyone is asking - was the typing experience on the Storm better than the iPhone 3G? The answer for me, is yes. My brain wants a key to click when I push it. Even though I really like the engineering of the iPhone screen, I have not achieved better than about 80% accuracy at 60 words per minute. With the Storm in full QWERTY mode, I easily adapted to the touch screen for typing. "The Quick Brown Fox Jumped Over the Lazy Dogs" actually appeared as typed, time after time.

In general, I found the Blackberry Storm easy to use although the multiple buttons on the case made navigation less obvious and elegant than the iPhone. The Storm has EVDO but no WiFi. For me, the WiFi is not a major need since most airports charge for WiFi and I prefer wide area networks. I've heard others complain about the lack of WiFi.

I'm sure many will ask - is the Storm an iPhone killer? I think this question is just as inappropriate as is the iPhone 3G a Blackberry killer?

They are different devices with different purposes. The Blackberry Storm is an email device that includes a great screen and a virtual keyboard with tactile feedback. The iPhone is a small computer running numerous lifestyle applications and an email client that is not optimized for high volume email use. They are both excellent devices for their respective niches.

What am I going to use? As with every technology this question needs to be answered with a specific set of requirements in mind. I need to email 21 hours a day while walking, commuting (only at stoplights), while in meetings, and while in airports. Although I really like the idea of touch screens and believe the next generation of handheld computers will focus on touch screen user interfaces, I still prefer the Bold's keyboard which is easier to use, faster, and more accurate for on the go typing than the Storm or the iPhone.

Next week I'll handoff these devices to my staff for testing and we'll see how they work for others with different requirements.

Thursday, November 20, 2008

The Culture Code

Every year, I travel a few hundred thousand miles through Europe, Asia, and the Middle East. I've observed that the cultural context of each society has a major impact on behavior.

Gathering with locals in Lyon, France to have a simple meal of bread, cheese, and vin de'table is very different from gathering with locals in Plymouth, New Hampshire to have a Subway sandwich. Not better or worse, just different.

Courtship rituals the Spanish Steps in Rome, Italy are very different than in a pub in Newcastle, England.

I recently read The Culture Code by Clotaire Rapaille, a cultural anthropologist who has developed a method for describing the reasons people around the world live and behave as they do. The book helped me understand some of the variation I've seen around the world.

For example, when purchasing a car, Americans seek a car that will express their identity. Germans will seek a car that optimizes engineering. American children will build a fantasy castle from Lego. German children will use Lego blueprints to build an exact scale model.

The chapters on relationships were fascinating. The descriptions are stereotypes, but interesting nonetheless. Culturally, Americans have unrealistic expectations of perfection in relationships (our 50% divorce rate is good evidence of this). English men spend a great deal of time with their mates at the pub and build a complex set of relationships outside the home that leads English women to fight for the attention of their men. Wander around Quayside in Newcastle on a Saturday night and you'll see the way that young women dress to attract the attention of their men. The Japanese view marriage as a practical partnership, often arranged by their parents. This does not imply marital bliss but the 2% divorce rate suggests it aligns with expectations.

Other chapters in the book explore Health, Youth, Home, Food, Work, Money, Shopping, and the way other cultures perceive America.

Although the idea of reducing complex cultural histories to a few key words (Culture Codes) is overly simplistic, several ideas ring as true

* Americans treat food as fuel rather than a high quality pleasurable experience to be savored
* Americans view buying over the internet as a focused task, while shopping at a mall is a social event
* Americans crave change, so making perfect products of high quality that last a long time does not align with our desire to have constantly improved products that work well enough for a short time and can then be replaced.

After reading the book, I have a new framework for approaching food, business meetings, and travel throughout the world.

Worth reading.

Wednesday, November 19, 2008

Harmonized Standards for the Genome and Family History

As one of the first humans to have my genome sequenced, I'm passionate about the standards used to record genomic and family history data. The initial national effort just completed the public comment phase and is not yet approved by the HITSP panel, but we hope to gain panel approval in December and present this work to the AHIC Successor on January 8, 2009 for acceptance by Secretary Leavitt before he leaves office. Here's a summary of the work thus far

IS08 Personalized Healthcare is the overall interoperability specification for exchanging genomic information and family history. It references several other HITSP components:

C32 HITSP Summary Documents Using HL7 Continuity of Care Document (CCD) Component is the lifetime medical record summary.

C80 Clinical Document and Message Terminology Component includes the vocabularies used to precisely describe the genome and family history.

C83 CDA and CCD Content Modules Component is a detailed overview of family history pedigrees and genetic test results in the lifetime medical record.

C90 Clinical Genomic Decision Support Component is used to communicate genetic and family history information from healthcare IT applications to clinical decision support systems which provide an assessment of risks of diseases.

During our discussion of genomic and family history data, we focused on privacy, since keeping this information confidential per the wishes of the patient is paramount.

Concerns we discussed include:

a) Based on Provider’s different needs, would there have to be an “all or nothing” option for the family member’s access authorization?
b) Who makes the decision about which information is relevant?
c) If the family member is not capable of authorization or has passed away, is legal representation required?
d) What guidance does a Provider use to evaluate the access authorization?

We selected two HITSP Privacy and Security Components to meet these needs.

TP20 HITSP Access Control Transaction Package
ensures only authorized people can view the data.

TP30 HITSP Manage Consent Directives Transaction Package provides an electronic record of patient privacy preferences and consents.

I look forward to engaging my own family in the use of these standards. My parents have agreed to share our histories and genomes as an example to accelerate adoption of these standards. More to come soon!

Tuesday, November 18, 2008

A Milestone for Personal Health Records

On November 12, Acting CMS administrator Kerry Weems and HHS Secretary Michael Leavitt made an announcement that has not been widely covered in the press, yet has deep significance.

The Center for Medicare and Medicaid Services (CMS) has embraced personal health records and will enable Medicare members in Arizona and Utah to access their own data from CMS databases via Google Health , NoMoreClipBoard , HealthTrio , and PassportMD . CMS pushes the data to the beneficiary's personal health record account upon the request of the beneficiary, rather than giving PHR vendors direct access to CMS databases.

Having worked with CMS for many years on transactions for treament/payment/operations and having worked with the CMS contracted Research Data Assistance Center (ResDac) for research datasets, I can say that CMS is very conservative about sharing its data and embracing new technologies.

The fact that CMS has linked the Medicare database to Google Health and other PHRs implies that CMS has embraced Healthcare 2.0 approaches to infrastructure and has validated the importance of personal health records. It also signifies that CMS has accepted secure transmission of healthcare data over the internet using HTTPS as secure enough. In the past, it's been challenging to transmit data from/to CMS via the public internet.

CMS, the funder of more than half of the healthcare in the US, generally drives adoption and change through reimbursement policy. In this case, by offering patients access to their own claims data, CMS will create patient expectations that will motivate the private payer community to do the same.

Linking Medicare over the internet to PHRs may be one of Secretary Leavitt's greatest accomplishments. Let's hope the Arizona and Utah pilots are successful.

Monday, November 17, 2008

The Economy and Academia

Last week, I wrote about the impact of the economy on my healthcare IT spending at Harvard Medical School and Beth Israel Deaconess Medical Center. Since that blog entry, Universities throughout the country have outlined their strategies for reduced capital and operating spending. The common features of these plans include hiring freezes, operational reductions, construction delays to avoid additional debt, and contingency planning for further reductions in the next fiscal year. However, all institutions have committed to maintain their current levels of financial aid, recognizing that the demand for aid in an economic downturn will increase.

Here are a few of the letters sent out by Deans and Presidents:


Includes a hiring slowdown, linking faculty recruitment to new endowment contributions, holding departmental budgets flat, delaying construction and reducing discretionary spending

Includes an optimistic view of operational budgets but suggests a delay in some construction projects

Includes a Hiring Pause,a Construction pause, and an operational review to identify cost savings opportunities

Includes a reduction in operational budget, planning for a three percent cut, a five percent cut and a seven percent cut, and a review of all construction project.

Includes a Hiring Freeze, 5% budget cuts, planning for a five percent cut, a ten percent cut and a fifteen percent cut, and delaying construction

Harvard's letter is below. My commitment is to maintain highly reliable, secure, and efficient applications and infrastructure, ensuring that all maintenance and appropriate replacement is done despite the economic climate. I will adjust project scope and timing so that my staff can continue to thrive in a resource constrained environment.

To Harvard Faculty, Students, and Staff:

I write today about the global economic crisis and its implications for us at Harvard.

We all know of the extraordinary turbulence still roiling the world's financial markets and the broader economy. The downturn is widely seen as the most serious in decades, and each day's headlines remind us that heightened volatility and persisting uncertainty have become our new economic reality.

For all the challenges such circumstances present, we are fortunate to be part of an institution remarkable for its resilience. Over centuries, Harvard has weathered many storms and sustained its strength through difficult times. We have done so by staying true to our academic values and our long-term ambitions, by carefully stewarding our resources and thoughtfully adapting to change. We will do so again.

But we must recognize that Harvard is not invulnerable to the seismic financial shocks in the larger world. Our own economic landscape has been significantly altered. We will need to plan and act in ways that reflect that reality, to assure that we continue to advance our priorities for teaching, research, and service.

Our principal sources of revenue are all likely to be affected by these new economic forces. Consider, first, the endowment. As a result of strong returns and the generosity of our alumni and friends, endowment income has come to fund more than a third of the University's annual operating budget. Our investments have often outperformed familiar market indexes, thanks to skillful management and broad diversification across asset classes. But given the breadth and the depth of the present downturn, even well-diversified portfolios are experiencing major losses. Moody's, a leading financial research and ratings service, recently projected a 30 percent decline in the value of college and university endowments in the current fiscal year. While we can hope that markets will improve, we need to be prepared to absorb unprecedented endowment losses and plan for a period of greater financial constraint.

The economic downturn also puts pressure on other revenues that fuel our annual budgets. Donors and foundations will be harder pressed to support our activities. Federal grants and contracts for sponsored research will be subject to the intensified stress on the federal budget. Tuition remains an important source of revenue, but in times like these we want to keep increases moderate, mindful that many students and families are facing economic strain.

Over the past several weeks I have been meeting individually and collectively with the deans of the faculties, as well as the Corporation, to share ideas on how we can best respond to this changed economic environment. We need to sustain our high academic ambitions at the same time that we bring greater financial discipline to all our activities. We have to think not just about what more we might wish to do, but what we might do at a different pace or do without. Tradeoffs and hard choices that can be avoided in times of plenty cannot be averted now. And, given the ongoing volatility and uncertainty, we need to plan and budget with a range of contingencies in view, including scenarios for reducing our spending both this year and next.

As we plan, we must also affirm our strong commitment to financial aid for our students. In Harvard College, that will mean carrying forward our recent years' initiatives to make a Harvard education affordable for outstanding students from low- and middle-income families. As before, families with incomes below $60,000 will pay nothing to send a child to Harvard College, and families with incomes up to $180,000 and typical assets can expect to pay no more than approximately 10 percent of income. Across our graduate and professional schools, we will maintain financial aid budgets at least at their current levels -- and ensure that our students still have access to needed loans, even though many banks are making them less readily available.

We have long been dedicated to research and the discovery of new knowledge across a wide range of fields of scientific and humanistic inquiry. In recent years we have made significant investments toward breaking down intellectual barriers across disciplines and across Schools to generate new knowledge and to develop new courses and educational opportunities for our students. These commitments must continue to guide us as we make decisions and choices in a significantly more constrained fiscal environment.

Harvard values its reputation as a stable and supportive employer, and we view our workforce as a critical part of all we do. We recognize as well the responsibility that comes with being one of the largest employers in the commonwealth of Massachusetts. At the same time, changing financial realities will require us to look carefully at compensation costs, which account for nearly half the University's budget.

We are assessing all aspects of our ambitious capital planning program, including the phasing and development of our campus in Allston.

We are working with administrative and financial deans from across the University to develop new approaches for generating both savings and new revenue sources, building on the ideas and best practices of each of the Schools.

Harvard is a famously decentralized place, and one size will not fit all. Each School will face its own particular challenges. But we must at the same time join together to address these new circumstances with creativity and a spirit of common enterprise.

Today, perhaps as never before, we need to work collectively to develop approaches and efficiencies that will allow every part of Harvard to thrive in the years to come. Together, we must continue to advance the priorities that define us.

For all that has changed in recent weeks, we remain devoted to attracting the very best students, faculty, and staff to Harvard. We will undertake the daily work of education and scholarship with the same intensity and imagination. We will set our academic sights just as high, and we will ensure that the ambitions and vibrancy of our community and the strength of its commitment to the pursuit of truth remain unsurpassed.

Drew Faust

Friday, November 14, 2008

Cool Technology of the Week

In my quest for creating a storage utility service for thousands of users, I've explored SAN, NAS, Content Addressable Storage, compression/de-duplication, and file virtualization.

One area that has been a struggle is providing a cloud of mid-tier storage at price that the community is willing to pay.

This week, EMC introduced Atmos, a policy-based information management solution for building cloud storage infrastructures. Atmos is a multi-petabyte information management solution designed to optimize the delivery of unstructured information (files rather than databases) across large-scale, global storage environments. Cloud Optimized Storage (COS), EMC's name for this new class of storage, is massively scalable and initially designed for Web 2.0, telecommunications, and media companies with significant storage demands such as YouTube, Picassa, Flickr, and Akamai.

EMC calculates that for every $1.00 spent on storage, $6.00 is spent on backup and recovery over the life of the information. The Atmos approach is to use large arrays of inexpensive drives without RAID - data is simply replicated within the Atmos cabinet or in a different cabinet across the coutry. Eliminating RAID enhances performance and reduces complexity. EMC also realized that archiving/restoring a petabyte of data is extremely challenging, but replication works well as a backup strategy.

EMC Atmos is made up of management software that is packaged with a low-cost, high-density storage system that offers ease of implementation and service in an efficient footprint (comprised of X86 servers and high-capacity SATA drives).

Per EMC, the features of Atmos include:

* Massive scalability: EMC Atmos scales effortlessly to accommodate the ever-expanding need for storage.
* Policy-based information management: EMC Atmos improves operational efficiency by automatically distributing information based on business policy. The user-defined policies dictate how, when, and where the information resides.
* Object metadata: EMC Atmos uses metadata to refine the content distribution and retention policy, improve searches, or build custom queries for cloud-based services.
* All-in-one data services: EMC Atmos includes built-in storage and information management features that include replication, versioning, compression, de-duplication, and disk spin-down. These features are native to the platform.
* Choice of access mechanisms: EMC Atmos provides flexible Web service APIs (REST/SOAP) for Internet-based applications or legacy protocols (CIFS/NFS/IFS) for file-based systems. This enables integration with virtually any application.
* Automated system management: EMC Atmos provides auto-configuring, auto-managing, and auto-healing capabilities to reduce administration and downtime.
* Multi-tenancy: EMC Atmos can allow multiple applications to be served from the same infrastructure. Each application is securely partitioned and can never access another application's data. Multi-tenancy is ideal for service providers or large enterprises who wish to provide cloud services for many customers or departments.
* Unified namespace: EMC Atmos uses a single view of the information to provide universal access regardless of location, reducing complexity and improving productivity.

These features seem to be a good fit for the image storage requirements of a large academic medical center and the increasing need for storing genomics data for the research community.

A cloud of inexpensive, massively scalable storage. That's cool!

Thursday, November 13, 2008

A Home Root Cellar

I've written about my efforts to eat regionally and locally by growing my own food and supporting a local CSA.

The challenge in New England is how to preserve food from November to May when the garden is bare (other than Kale, Chard, and Collards which grow well in cold frames).

During the month of October we pickled, canned, and froze our fruits and vegetables to prepare for the winter ahead.

We also created a root cellar in our basement to store turnips, potatoes, carrots, rutabegas and dozens of different types of squash. My favorite squash is Hubbard, which keeps for 6 months at 50-55 degrees. Hubbard squash used to be a very popular squash in the US, but today fewer people cook and the varieties available in supermarkets are limited.

Just about every home in New England has a basement. Most basements are too warm for winter food storage, but there are two techniques that work well. The first is easy - the bulkhead leading down to the cellar stays above freezing, so we loaded the steps down the basement with vegetables. The other is to create ventilation into a closed part of the basement.

Here's how it works.

Traditionally, the root cellar was an underground space built under or near the home, insulated by the ground and vented so cold air could flow in and warm air out in the fall. Then when winter temperatures arrived, the vents were closed, and the cellar stayed cold but not freezing. You can create an indoor version of the cellars that have long served homesteaders well by walling off a basement corner and adding the vents, allowing the temperature to remain near freezing through the winter months.

There are several good online resources describing how to build a root cellar

Mother Earth News

Earth House

Organic Gardening

Back to the Land

There are also several good books available for help in cellaring in the modern home or apartment.

Root Cellaring

Putting Food By

Over the next 6 months of cold weather, we'll see how long the root cellar lasts. I look forward to reliving the summer and fall harvest every time I cut open a squash or open a jar.

Wednesday, November 12, 2008

The Final Report to AHIC

Today is the last meeting of the American Health Information Community, the country's "Board of Directors" for Healthcare IT, established by President Bush's Executive Order.

The agenda includes the transition of the AHIC working groups to the AHIC Successor, an overview of the progress we've made as a country on interoperability, and a summary of everything that CCHIT has accomplished to establish certification of EHRs, PHRs, and HIEs.

Here's a summary of my remarks on interoperability

The Health Information Technology Standards Panel (HITSP) has created a forum for stakeholders to talk about standards and resolve their differences. Over the past three years, the work HITSP has done on Problem lists, Medications, Notes, Allergies, Reports, Microbiology and Labs have brought together many stakeholders and resolved many differences. Whenever possible, we've reduced the choices for standards to one single, unambiguous implementation guide. Of course, not every debate is fully resolved, but as a country we're much closer to harmony today than 3 years ago.

600 different government/academic/payer/provider/vendor/consumer organizations, both large and small, have volunteered their time to work on these issues.

We've organized HITSP to ensure that standards are reused to the greatest extent possible. Our Domain Committees select the fewest number of standards possible and package them so that our Perspective committees can select from a small library of possibilities.

As of January 2009, HITSP will report to the AHIC Successor and will work on their prioritized Value Cases. What's a Value Case?

My simple definition is that a Value Case is a use case which takes into account
Strategic value to business users
Transaction volume if adopted
Return on investment of automated transaction flows
Compliance requirements (such as HIPAA, Medicare Part D)

On November 10, the Value Case process began with a meeting of a working group to define the first Value Case priorities for Clinical Research/Clinical Trials, a special extra HITSP use case authorized by AHIC and the Successor. This Value Case is important for two reasons - it will serve as a model future Value Case development and thus will impact the way future healthcare IT priorities are developed by the AHIC Successor. The implementation of this Value Case will be funded by a combination of public and private sources, not just the Office of the National Coordinator. If stakeholders are willing to pay for standards harmonization in the future, it may provide a means to fund HITSP's function without depending entirely on government sources.

Secretary Leavitt deserves our thanks for being a tireless supporter of healthcare IT and standards harmonization. HITSP volunteers are working overtime to ensure we finish all our 2008 harmonization goals over the next few weeks so that Secretary Leavitt can accept this work as part of the national standards recognition process.

After January 20's change in adminisration, I look forward to leading HITSP in 2009 and working with the new secretary of HHS, whoever that may be.

Tuesday, November 11, 2008

Winners and Losers in 2009

I was recently asked to predict IT Winners and Losers in 2009.

Rather than name individual companies, I'd like to highlight categories.

1. Electronic Health Record vendors, especially web-based applications - The Obama administration has promised $50 billion for interoperable EHRs.

2. Software as a Service providers - SaaS providers offer lower cost of ownership and faster implementation than traditional software installation approaches.

3. Open Source - I'm embracing Open source operating systems, databases, and applications as long as they can provide the reliability and supportability that I need.

4. Green IT - Winners will be innovative techniques to adjust power draw, such as idle drive management, cpu voltage adjustments, and high efficiency power supplies.

5. Cloud Computing offerings - These are remote infrastructure utilities such as storage and high performance computing. Friday's Cool Technology of the Week will describe a new technology called Cloud Optimized Storage.


1. Client Server applications - the cost of deploying, supporting, and maintaining client server applications is no longer affordable.

2. Proprietary operating systems - I'm eliminating Solaris, AIX, HP-UX from my data centers.

3. High end SAN storage - I find that 90% of my storage needs are met with lower end SAN, NAS, and appliances which use low cost, high density drives (SAS and SATA).

4. Devices that do not offer energy efficient operations.

5. Applications that require a specific operating system or a specific browser on the client side. To be successful in 2009, applications should be operating system neutral, browser neutral, and easily hosted as a service accessible via the web.

I welcome your thoughts on your own winners and losers for 2009.

Monday, November 10, 2008

The Impact of the Economy on Healthcare IT Spending

I was recently asked to comment on the impact of the struggling economy on my IT spending.

In all my organizations, I have two kinds of budgets - capital and operating.

Capital is used to purchase durable equipment and to fund project implementations. We often capitalize the labor, consulting, and license costs incurred when acquiring and installing a product.

Capital in my organizations is based on the following equation:

Available capital spending = Operating Margin + Investment Performance + Donations + Depreciation - Debt Service

In today's economy, spending on elective surgical procedures is going down, energy costs are rising, and reimbursement is falling - all putting pressure on operating margin.

Investment performance for many organizations, especially those which invested in mortgage backed securities, is causing loss of principal. Luckily my organizations had invested conservatively.

Donations are more challenging when consumer confidence is low.

The end result is that 2009 will be a challenging capital year because of lower operating margins and investment performance. We will have enough to keep the trains running on time, to ensure our disaster recovery efforts continue, and to remain compliant with all our regulatory requirements. However, we will extend the timelines of some projects to conserve capital.

Operating budgets are used to fund salaries, maintenance contracts and supplies.

For now, operating budgets are stable, but the outlook is conservative. Adding new positions is challenging and we are managing all our contracts carefully. We're negotiating hard and thinking creatively about how to trim operating expenses by reducing the complexity of our hardware and software environment.

All projects are function of Scope, Time and Resources, so tight operating budgets mean fewer resources which means narrower scope and longer time for our projects.

All this being said, I believe that economic challenges are good for IT organizations because it forces customers to prioritize their projects, matching their demand to limited IT resource supplies.

In summary, we are limiting major capital purchases, extending timelines, and focusing on the highest priority projects. We are not expecting major new enterprise purchases, instead we will refine and improve what we have.

One last thought. In the spirit of buy low, sell high - the best time to purchase is when demand and prices are at a low point. We will keep looking for bargains that will reduce our capital and operating costs over the long term. Eventually, the economy will improve and we want to be in the best position when that occurs.

Friday, November 7, 2008

Cool Technology of the Week

There is a technology that I've used for several years that has been so successful, it merits discussion as a Cool Technology of the Week.

Getting data into an electronic health record is hard. Most clinicians do not want to type complex structured notes. We've tried macros and templates, which have helped some. However, dictation is the clear winner among clinicians for entry of free text.

The challenges with dictation are turn around time, expense, and lack of structure. BIDMC's solution to this problem as been server-based voice recognition from eScription.

Here's how it works:

* A clinician dictates into a phone or handheld
* The voice file is sent to the voice recognition server where we store the voice profiles of 3000 clinicians
* In near real time, the voice files are processed into text and inserted into the electronic health record as an unsigned note
* Correctionists (we no longer use transcriptionists) review the notes for accuracy. We achieve over 90% accuracy across all speakers and all note types
* Clinicians sign their corrected notes.

By using server-based voice recognition, we have reduced our transcriptions costs more then 50%, reduced turn around time to less than an hour, and used the technology to increase the structure of our free text notes. How?

When clinicians dictate operating room notes, history and physicals, outpatient notes, or radiology reports, they tend to dictate in their own preferred order, not via a universal template. Some clinicians may dictate chief complaint, history of present illness, physical exam, review of systems, assessment/plan. Others have completely different approaches. However, using voice recognition, we can recognize a key phrase like "physical exam" and automatically place it in a template. We've been able to increase the structure of our notes by 30% using voice recognition of subject headings.

Our total cost of implementation was about $500,000 and our savings over just the last year was over $1.5 million.

Happy clinicians, more structured notes, better turn around time and $5 million in savings since we implemented the technology. Now that's cool.

Thursday, November 6, 2008


Many people ask me if my vegan diet leads to continuous cravings for a Big Mac or a nice chunk of cheddar. I can honestly say that my diet of legumes, fresh fruits/vegetables, tofu, rice and green tea keeps me completely satisfied.

There is one other aspect of my diet that I've not discussed before - a little vegan chocolate every day.

Most chocolate contains milk products but a few producers make pure, dark chocolate that is 85% pure cocoa and does not contain any animal products such as milk or cream. My favorite vegan chocolates are

Lindt 85% Dark

Lake Champlain Dark Chocolate

Valrhona Dark Bitter Chocolate

Endangered Species Dark Chocolate

I have also found pure, unsweetened vegan drinking chocolate from single regions such as Peru, Kenya etc. packaged by Allegro

What are the benefits of Dark chocolate? It's rich in antioxidants, it lowers blood pressure, and it enhanced mood per WebMD and Dr. Weil's resources.

What is the downside to chocolate? It contains a bit of theobromine, a methylxanthine like caffeine. I try to avoid all stimulants. Chocolate is not for the locavore. I really try to limit all my foods to 100 miles of where I live.

Admittedly, eating .5 ounce of chocolate a day is vegan but not local, is healthy, but is still a stimulant. My only excuse is that I live in the cold, dark, and snowy Northeast. That little bit of chocolate every day is my cure for Seasonal Affective Disorder. It can also be socially responsible.

A few days ago while traveling, I ordered a microbrewed beer and was asked for my ID. Since I'm nearly 50 and was asked for my ID, I can only assume that those antioxidants in the chocolate must be really keeping me young.

Wednesday, November 5, 2008

Healthcare IT in the Early Obama Administration

When Obama takes office in January, the economy will be his first priority, followed by the war in Iraq. Healthcare will follow as his next major issue to address.

What will he do?

I imagine he'll take a phased approach to ensuring all Americans have access to healthcare. Given the change management needed to accomplish this, it will take a while.

However, Healthcare Information Technology has broad bipartisan support and is his best strategy to reduce healthcare costs, reimburse providers for quality instead of quantity, and to ensure coordination of care. Here are my predictions for healthcare IT in the first year of the Obama administration:

The AHIC Successor, with its board of 15 savvy operational people and 3 incorporators (John Tooker, John Glaser and Jonathan Perlin) will serve as the public/private collaboration for prioritization of healthcare IT initiatives during the first year of the Obama administration and likely beyond.

The Office of the National Coordinator (Rob Kolodner) will continue to coordinate Federal input into the public-private effort.

The Health Information Technology Standards Panel (HITSP) will continue to harmonize standards. Its work in 2009 will include

One new use case to harmonize the electronic standards needed to exchange data about newborn screening for treatable genetic, endocrinologic, metabolic and hematologic diseases.

Closing gaps in standards for
General Laboratory Orders
Medication Management
Advanced Device Interfacing
Clinical Notes
Order sets
Secure Data Transport for all clinical data
Consumer Preferences for care
Clinical Registries
Maternal/Child Health
Long Term Care Assessments
Prior Authorization for testing
Consumer Adverse Event Reporting

Additionally, HITSP has the AHIC Successor's endorsement to work on standards for Clinical Trials and Research in collaboration with CDISC and other stakeholders.

The Health Information Security and Privacy Collaboration (HISPC) working groups will continue to inventory and harmonize privacy standards for states and territories

Hopefully the Obama team will offer incentives to implement EHRs early in the administration, but in the meantime hospitals will subsidize 85% of EHR implementation costs via Stark safe harbors and private payers will offer pay for performance incentives for the outcomes resulting from the use of EHRs and e-Prescribing.

States such as New York, Massachusetts, Tennessee, Indiana and Utah will continue to implement regional data exchanges that meet the needs of their local stakeholders.

The Certification Commission for Healthcare Information Technology will continue to develop functional criteria for EHRs, PHRs and Health Information Exchanges. HITSP harmonized standards will be included in CCHIT criteria and incorporated into EHRs in an incremental way over the next few years.

Thus ONC, the AHIC Successor, CCHIT, HITSP and HISPC will continue their work for the next year. My personal leadership role of HITSP continues until October 2009, crossing between administrations.

After the year it takes to stand up a new administration, we may see additional resources for healthcare IT, a new federally regulated exchange where Americans not covered at work would be able to choose among a variety of private group policies and a new public program to compete with the private insurers. New public and private IT initiatives will be needed to support the workflow of these new programs.

Next week, I'll be in Washington for AMIA, the last meeting of the AHIC, and an FDA meeting. I'll report on how the transition teams are beginning their work and the implication for healthcare IT.

Tuesday, November 4, 2008

The Last Lecture

Today on a plane flight to Orlando for the eClinicalWorks National meeting, I read Randy Pausch's The Last Lecture, the wisdom of a Carnegie Mellon Professor dying of pancreatic cancer. I highly recommend this book as inspiration for engineering, computer science, and IT professionals.

Although I never met Randy, he and I had the same cultural context - we were born six months apart and grew up nerdy. His lifelong dreams were

Being in Zero Gravity
Playing in the NFL
Authoring an Article in World Book
Being Captain Kirk
Winning Stuffed Animals
Being a Disney Imagineer

I remember watching the original Stak Trek episodes when they were first broadcast, spending my free time reading 1960's era World Book Encyclopedias from A-Z, sitting in front of the television with my neighbors watching Neil Armstrong's first steps on the moon, and marveling at how the special effects in Disney's Haunted Mansion were created.

What dreams arose for me from my 1960's life as a young geek?

Building the first bionic limbs

In middle school and high school I dreamed about bionics - the idea that biological systems and mechanical systems could be seamlessly combined to restore lost limbs. Throughout my life I've worked on pieces of this dream. As a high school student (1978) I designed computers that could measure human body signals and do real time signal averaging/fast fourier transformers that could be used to interpret visual and audio stimuli. As a college student I worked in a neurosurgery labs trying to understand the signals in the brain that coordinate movement. As a graduate student I designed robotic control systems. When I realized that limitations of 1980's computing capabilities and the lack of long lasting lightweight power sources would defer my dream for a few years, I turned my attention to electronic health records. The systems I work on today are a direct result of my early dreams of bionics.

Building and conversing with an Artificial Intelligence

In high school and college I experimented with the source code of ELIZA, the LISP-based computer psychiatrist. Although I never developed a witty interactive virtual companion, I learned a great deal about pattern matching and rulesets. The AI programming of the 1970's was the inspiration for the many decision support systems I work on today.

Immersing myself in Virtual Reality

As I kid, I thought that the analog world could be broken up into tiny digital fragments. If those fragments got small enough, human senses would be unable to tell the difference between reality and imaginary images - you could no longer believe anything you see. When I talked about this in the 1970's, my peers thought I was a little crazy. Today, my dreams of virtual reality directly inspire my passion for educational technology and simulation at Harvard.

Flying with an anti-gravity device

Many people wish they could fly. As a kid I imagined flipping a switch and riding my bicycle over the treetops E.T. style. At this point in technology history, we do not have any anti-gravity capabilities, but I believe my love of rock climbing and mountaineering is the terrestrial expression of my flying dream.

Being Henry David Thoreau

In my blog I've described my quest for simplicity, my veganism, and my dreams of a more green lifestyle. If you visit Walden Pond, you'll find a reconstruction of Henry's cabin with a plain pine bed, a desk, and his wooden flute. Every year, I aim for more time in nature and less complexity. Henry died of TB and my genome suggests I'm particularly susceptible to TB. Let's hope we do not share that in common!

Randy's book inspired me to reflect on my own dreams and how they've played out in my adult life as a CIO. Many of these dreams are still works in progress, which is appropriate since I'm only half completed with my lifespan. I look forward to the dreams of the next 46 years!

Thanks to Katherine Williams (originally Katherine Hoy), a friend from high school who recommended The Last Lecture and inspired this blog entry.

Monday, November 3, 2008

McCain and Obama on Healthcare IT

My blog over the past year has been silent about the Presidential campaign. Given the election tomorrow, I will write one blog reviewing the candidates statements about healthcare IT.

Both candidates have made supportive statements about Healthcare IT in the debates. To my knowledge, neither has specifically mentioned AHIC, ONC, HITSP, CCHIT, NHIN, or RHIOs. My HITSP role will continue through the change in administration until October 1, 2009, so I do not have any particular partisan bias.

How do they compare? Probably the best resource is the New England Journal of Medicine articles written by McCain and Obama.

Here's a summary of these articles, based on a text search of the word "technology"


"Quality: Strengthening health care quality requires promoting research and development of new treatment models, promoting wellness, investing in technology, and empowering Americans with better information on quality."

"We need to use technology to share information on 'best practices' in health care so that every physician is up to date."


"I am committed to making the fundamental changes necessary to modernize the system to streamline medical practice with the goal of improved patient outcomes. My plan calls for investing $10 billion per year over 5 years in health information technology. This commitment is not just financial: we will ensure that physicians have the technical support they need to implement new systems for patient records and billing. By reducing medical errors and unnecessary duplication of tests, this investment will lead to a long-term reduction in our health care system's overall cost."

"Finally, I will address medical malpractice with the central goal of preventing medical errors in the first place. Through substantial investment in information and decision-support technology and other patient-safety initiatives, we will reduce the types of medical errors and oversights that lead to lawsuits."

How about the candidate's websites?


On the front page of McCain's website, I clicked on the Healthcare Plan link on the front page. The word technology does not appear on the Healthcare Plan page.

I then used the search engine on the website to search on the keyword "technology" which yielded "no documents found". I searched on "healthcare" and got

We're sorry. There appears to have been an error with your request. Please try again or if the problem continues, please contact us.
If you were trying to connect to a McCainSpace site, you may have entered the web address incorrectly. Please remember there is no www" in a McCainSpace site. Simply replace the www with the name of the McCainSpace site (i.e.:"

Through Google I found a healthcare technology reference on the McCain website:

"Health information technology will flourish because the market will demand it."

Based on my experience in Massachusetts, I have not yet seen this market demand because incentives are misaligned - he who pays is not he who gains from Healthcare Information Technology. However, McCain's advisors may have a different experience from other states.


The second major tenent of the Obama healthcare plan is:

"The Obama plan will lower health care costs by $2,500 for a typical family by investing in health information technology, prevention and care coordination."

As an unbiased observer, this brief review of the candidates suggests that McCain's plan for Healthcare Information Technology involves letting the market drive adoption because stakeholders will demand it. Additionally, physicians will be kept up to date. Obama's plan involves a $50 billion dollar investment in decision support, reduction of redundant testing, and minimizing medical error.

Whatever your decision, get out and vote tomorrow!