Cool Technology of the Week

Yesterday, I wrote about the technology I own. I'm constantly evaluating what works and what does not work. Call it my personal application of Kaizen.

Of all the technologies that I outlined yesterday, only one is having significant quality issues - the AT&T 3G cellular signal on my cell phone. Since I rarely use a land line, this can be particularly challenging during winter months. It's 20 degrees outside and I have to stand in 3 feet of snow on the front lawn to make or receive a call from my home.

I absolutely understand AT&T's issue. There are only 5000 households in Wellesley, MA. Implementing a robust cell phone network in a suburban community is less profitable than in a dense urban work environment. As I tell my staff, AT&T is the best network in the world, just not Wellesley.

What can I do? The answer is a home micro-cell tower which plugs into my FIOS internet connection and offers 5000 square feet of cellular coverage, enabling my home cell phones to communicate via voice over IP to the micro-cell tower, then link over broadband to the AT&T network.

The cool technology of the week is the Cisco/AT&T personal 3G mini cellular tower for home
Features include:

* Seamless roaming from the micro-cell to a real cell tower when I leave home
* Works with any AT&T supported 3G cell phone (Blackberry Bold, iPhone 3G)
* Available unlimited minute plans when connected to the micro-cell

No details have been released on the availability date or pricing structure, but I'll be watching this cool technology very closely.

The Technology I Own

In 2008, I wrote about the technology I own to support my work and home life.

Here's an update for 2009.

My philosophy is to purchase the fewest number of devices that meet my computing, media management, and communication needs.

Why?

Every device you own creates a maintenance burden. You have to update it, repair hardware failures, ensure interoperability with other devices, and learn to use it effectively. As the number of devices you own increases, the impact on the Home CIO expands geometrically.

Here's the parsimonious set of technologies that comprise my personal tools:

Laptop - I need a single, lightweight, highly reliable, rugged laptop. I've tested just about every available lightweight Windows/Mac OS X/Linux laptop and there is only one that meets my criteria for weight, size, battery life, durability and reliability - the Macbook Air. My Air has traveled over 100,000 miles with me and has met my every need without downtime. Although I do not travel with the external CD/DVD Superdrive, owning one is a necessity because the Remote Disk sharing capabilities of the Macbook Air do not work with Audio CDs or Video DVDs. My application set is simple - my productivity suite is iWork '09 (Office 2008 is too cumbersome for getting the basics done) and my email client is Entourage 2008 for connection to Exchange 2007. However, Entourage is a less than perfect application that corrupts my entire email store every few months. As soon as the next version of Mac OS X, Snow Leopard, is released (possibly June 2009), I will replace Entourage with Apple Mail/iCal/Addressbook which will be Exchange compatible. At that point, my laptop will consist of Mac OS X built-in applications, Apple iWork'09, Apple Aperture (described below for photography management) and nothing more.

Desktop - I do not own a desktop, so the Macbook Air is the only computing device I use. At home, my daughter uses an iMac 20" and my wife uses a Macbook Pro 15" (just replaced and now highly reliable)

Backup - As described in my recent blog about recovering my wife's laptop. I have installed a Western Digital My Book Studio II 2 Terabyte home backup drive, configured with RAID 1 mirroring, to backup all our work and home data.

Mobile devices - I use a Blackberry Bold for all telephone and email communications. The iPhone 3G's touch screen keyboard is problematic for high volume email users. The Blackberry Storm has not integrated its touch screen keyboard into the applications with the same finesse as the iPhone. The Bold is the one perfect Blackberry device with 3G network support (even in Japan), Bluetooth, a great web browser, and seamless Exchange integration.

Printer - At the office, I use an HP Color LaserJet 4700 shared among an entire floor of IT staff. At home I use an HP K5400 OfficeJet Pro Color Printer connected to my home wireless router (ActionTec MI424WR Rev. D provided by Verizon FIOS) for all the printing done in the household. We rarely print anything.

Photography - I use a Canon SD550 camera with a 1 Gigabyte SD card for all my indoor and outdoor photography, including the photos I take at subzero temperatures while winter mountaineering. I manage my photos using Apple's Aperture software, which is much better than iPhoto, enabling me to keep my photos as JPEGs in directories on my hard drive, referencing them in Aperature rather than copying them redundantly into a library (such as iPhoto does).

Video - I have elected not to purchase a Blu-Ray DVD player. I believe the current devices are overly complex and are likely to be replaced by a new generation of media in a few years. For me, DVD is good enough. I use a Sony DVP-NS700H/B 1080p Upscaling DVD Player and a Sharp Aquos 46" Sharp Aquos LC46D62U 46-Inch 1080p LCD HDTV.

Media Management - I use an iPod Touch (2nd Generation) for all my personal media management. My photographs from Aperture, my video files, and my iTunes library are synched from my Macbook Air to my iPod Touch. This year I eliminated all the other audio components in my home (a NAD receiver, amplifier, CD player and KEF 103.2 Speakers) and replaced them with a single Bose Sound Dock II for use with my iPod Touch. I also have a Mini DisplayPort Adapter to DVI to HDMI cable for my Macbook Air and an Apple Component cable for my iPod that enables me to connect these devices to my HDTV.

Although I am an early adopter of many healthcare information technologies, I am not an early adopter of most consumer electronics. I'll lifecycle manage a minimal number of devices to meet the needs of my family and my collaborators. With gadgets, as with many things in life, less is more.

Five Reasons to Have Hope

Over the past decade as a CIO, I've had successes and failures. I've learned about leadership in a crisis , how to resolve disputes, and how to serve my customers/employees/superiors . As I watch the first few days of the Obama administration, I have a great deal of respect for the initial activity, as seen through the lens of my own leadership experience. Here are five reasons I have great optimism for the new administration:

1. Smart People - Obama is surrounding himself with smart people, regardless of party affiliation or ideology. In my experience, A-level leaders surround themselves with A-level staff, since they are not intimidated by people who are smarter or more experienced. However, B-level leaders surround themselves with C-level staff who do not question the ideas and actions of their leader, resulting in sycophants rather than a strong leadership team. Of course, as we learned from Jimmy Carter's presidency (he's been a great post-president), the smartest people are not always the most successful people, but I have great faith in the new team!

2. Listening - As I've described in my blog about leading change , the most important part of Kotter's principles is to build a guiding coalition. By engaging the stakeholders and listening to their priorities for change, Obama has created powerful grass roots momentum.

3. Doing the right thing - A wise person once said "When one bases his life on principle, 99 percent of his decisions are already made." Should we drill for oil in the Arctic? Should government decide what therapeutic options doctors and their female patients can talk about? Should government decide science policy based on religious beliefs? The answers to these questions should be clear if we objectively ask ourselves what seems like the right thing to do based on the best objective evidence. The Obama administration is doing that.

4. Let the ideas flow - The web "democratizes data". Ideas need to flow freely and as country we need to come to consensus about our priorities based on open and transparent communications. The Obama team, with the able assistance of Blue State Digital and other technology partners, has created Change.gov and Whitehouse.gov to reduce information silos.

5. Embrace technology - Obama is the first president to have a computer on his desk. Obama will keep his Blackberry. The communication systems in the Whitehouse will be upgraded to Web 2.0 technologies. Working with better technology will result in better,faster decisions and more enlightened management.

Will the Obama administration be perfect? No. Will the change management ahead be easy? No. Will we get to the right decisions faster and regain the respect of the world. Absolutely.

Have hope.

Gartner's Top 10 Predictions

Today, a colleague forwarded me Gartner's Top 10 predictions for 2009. Here's the list and my commentary:

1. By 2012, high-definition-based video meeting solutions will replace 2.1 million airline seats annually

I completely agree. Cisco is installing a Telepresence solution in my home as a pilot

I plan on using these technologies to reduce my travel miles per my 2008 and 2009 goals

2. By 2012, 30 percent of mobile PCs sold in the worldwide consumer market will be priced at less than US$300.

Partially agree - it depends on the application requirements. For web browsing, online storage such as Google's Gdrive, and email, an inexpensive netbook is fine.

For multimedia management or intensive computation, a netbook is not sufficient. Using Photoshop CS4, Final Cut Pro, or MatLab requires more processing power and graphics capability than will be available via netbooks and software as a service solutions.

Thus, if 70% of use will be the basics of browsing and email, the $300 netbook could account for 30% of worldwide mobile PCs.

3. In 2012, the major PC vendors will recycle only one PC for every five they ship.

I partially agree. Recycling is dependent on policy. The Obama administration is likely to encourage Green IT initiatives including recycling. Often, recycling is not cost effective, so subsidies and disposal fees are needed to encourage recycling rather than waste disposal.

4. By 2012, successful enterprises will actively encourage and reward more failures in order to find the optimal approach they want more quickly.

I completely agree. My Signature projects often have audacious goals that have a great deal of ambiguity because so much innovation is required. I explain to my staff that such projects have only general expectations of timeline and deliverables. We iterate by implementing prototypes based on customer requirements, then test, improve and test again. Setbacks are always forgiven.

5. By 2012, as many as one in three of the top 20 business process outsourcing providers will no longer exist.

Business Process Outsourcing differs from Application Service Providers/Software as a Service by transferring some of the risk of operations to the outsourcer. In tough economic times and with the rapid evolution of technology, it's clear that some of these Business Process outsourcers will be on the losing side of the risk equation and will go out of business.

6. By 2011, 30 percent of consulting and systems integration revenue will be delivered via 'cloud computing'.

I completely agree. All my recent efforts to offer scalable applications and storage to large numbers of customers have been based on software as a service/cloud computing principles.

7. From 2009 to 2013, the server virtualisation software market will grow with a compound annual growth rate of 28 percent, rising from US$1.8bn to US$6.2bn.

I completely agree. All my green IT initiatives at BIDMC and Harvard Medical School depend upon massively consolidating physical servers into virtualized farms of geographically dispersed servers. In a recent study by VMWare at Harvard, we believe a 10:1 reduction in physical servers is possible.

8. By year end 2013, 40 percent of enterprise knowledge workers will have abandoned or removed their desk phone.

Last week at Harvard Medical School, I retired my personal desk phone as well as 30% of the landlines in the IT department as a cost saving measure. I use a desk phone about once a month for delivering webinars. Otherwise I'm purely mobile.

As employees become increasing virtual, the idea of a desk with a computer and a phone no longer makes sense.

9. By the end of next year 2010, wireless operators will cease to offer unlimited (flat-rate) mobile data plans.

I partially agree. I use the Blackberry Bold 3G phone and I've found levels of congestion (likely induced by iPhone use). My answer has been to enable WiFi on my Blackberry, roaming on WiFi networks while in buildings and then switching to 3G only while I'm driving. If more folks balance their use of networks between private WiFi networks and the public 3G network, then 3G demand will better match supply and rates may stay flat.

10. By year end 2012, physical sensors will create 20 per cent of non-video Internet traffic.

The internet is an increasingly ubiquitous way to connect everyone and everything. Home healthcare will include blood pressure, weight, and pulse oximeter sensors. Wireless sensor networks will monitoring everything from weather to earthquake activity. The semantic web will be more about data than web pages.


Overall, the Gartner folks have identified important trends. I find that my own life is increasing virtual, traveling the world always connected to a cloud of IT resources via my Macbook Air, Blackberry Bold, and iPod Touch.

The Conficker Virus

In recent weeks, a worm called Conficker has infected 9 million Microsoft Windows desktops and servers throughout the world via a Windows security flaw identified in October 2008.

The BIDMC Security team has provided me with several briefings that I'd like to share with you.

Day 1
We are still looking at how to identify the infection from network based activity. Our managed workstations are not at risk as they have the Windows MS08-067 patch applied. This is of course assuming that the MS08-067 vulnerability is the only vector.

The larger risk is the introduction by a non-patched, non-managed workstation that then passes this on to other systems on the network that are vulnerable.

This is a very well written and nasty virus. It has an extensive list of dynamic DNS entries to phone home to - the list is ever changing. The list for last week was over 1000 entries long. I have not seen the new list for this week.

My biggest fear are the medical devices. Vendors often claim that FDA 510k approval does not allow application of operating system patches. This makes the ability to detect this via network behavior very critical.

Day 2
We have kicked off a type of scan that will identify all our systems that are susceptible to the Conficker attack ie systems that do not have the MS08-067 patch applied.

The risk an infected system posses is still an unknown as it still is unclear what the intent of the virus is.

Day 3
The approach we are taking is:

1. Looking back 4 weeks into the web content filters to see if any systems that we monitor had accessed any of the suspect 1000 urls. The results of that are that there were no hits as of the late Friday night. We have set a job up that will run at midnight and examine the prior 24 hours of web activity for any hits.

2. We are running a scan process that looking at all systems that are online. This scan is a non-invasive scan that can conclusively determine if the system is missing the Microsoft patch that closes the vulnerability.

3. We have also found some information on how to examine a systems registry and identify systems that might be infected. This will work only managed systems. This is important due to the nature of the virus. The virus can infect via a usb key. Once on the system it shuts down the Anti-virus on the system as well as a wide range of anti-spyware programs.

4. We alerted the help desk to be on the look out for a rise in user complaints about their anti-virus not working correctly. The latest on the virus also indicates that it then attempts dictionary type attacks to break into the accounts it finds on the systems. This would show up as a rise in user password resets or account unlocks.

Desktops and servers need to be monitored since one of the targets of the virus is file servers located via mapped drives.

We are members of HTCIA and InfraGard. These organizations, particularly InfraGard, provide information that is often not immediately available to the general public. We are keeping an eye out for any early additional information regarding the viruses behaviour. IfraGard is a tasked with protection of the national infrastructure from both physical and cyber threat - this virus has gotten their full attention.

Day 4
We now have a copy of the Conficker code. It is VMWare aware and shuts itself down and hides when it detects that it is running under VM. This is new tactic of the better written viruses and trojans - it means you can not load it up onto a Virtual Desktop to examine it's behavior making it slower to generate AV signatures.

It also has built in code to detect that the Windows debugger has been invoked to examine it. If it detects the debugger it again shuts itself down and "hides" to disable the ability to use the debugger to examine its behavior.

There has been some press about the believe that the payload of the code may be flawed and that only the delivery mechanism is well written. That may be the case but assuming that position is very risky. There are already growing variants of the code. I think we have not seen the true purpose of the virus yet. This has a IRCbot component to it, it is pulling content and instructions from command and control sites. We can only hope that the ultimate purpose and payload are flawed as this still spreading rapidly.


Clearly, this is a very nasty virus and we are on the highest alert since the SQL Slammer Worm in 2003. All CIOs should ensure their security staff are briefed on this new worm and are proactively defending against it.

Cool Technology of the Week

When I travel to the Far East or Scandinavia, it's common that hotel rooms have a master power switch. When you enter your room, you slide the room key into a slot, which activates a breaker and powers on the lights and sockets. The energy savings occurs when you leave the room and take your key - it's impossible to leave on a light, air conditioner or television.

Throughout Harvard Medical School and Beth Israel Deaconess we use Energy Star compliant devices which power down when unused. However, computers and monitors are only one element of the total power drain. Printers, speakers, and scanners continue to draw power, even when unused.

How about using a power strip that senses when the CPU hibernates and then powers down all peripherals?

The APC Power-Saving Essential SurgeArrest 7 outlet is such a device.

The Power-Saving SurgeArrest not only safeguards your equipment from damaging power transients, it also helps lower total power usage. "Master/Controlled" outlets are designed to detect when your computer is asleep and it automatically powers "off" connected peripherals. Other features include:

• Noise filtering
• Protection Working Indicator
• Resettable circuit breaker
• Right Angle Plug
• Site wiring fault indicator

As I wrote about in my previous Green IT blog entries such as Kill-a-Watt, we're approaching power reduction holistically. I oversee 20,000+ computers and 10,000+ printers, so a power strip that shuts off all connected devices when the computer is not in use is really cool!

Safe Eating Discounts

As I drove into work today, I listened to Boston's WROR FM (105.7) and heard an advertisement for 2 Sausage McMuffins with Egg and a cup of Newman's Organic Coffee.

I had just finished a breakfast of Bob's Red Mill Organic Thick Rolled Oats and a cup of green tea. My breakfast was

Nutrient Facts
Calories 190
Calories from Fat 30

	Amount Per Serving	% Daily
Total Fat	3.50g	5%
Saturated Fat	0.50g	3%
Trans Fat	0.00g	0%
Cholesterol	0.00mg	0%
Sodium	0.00mg	0%
Total Carbohydrate	32.00g	11%
Dietary Fiber	5.00g	20%
Sugars	1.00g	3%
Protein	7.00g	14%

The advertised McDonald's special was

Nutrient Facts
Calories 900
Calories from Fat 468

	Amount Per Serving	% Daily
Total Fat	52.0g	80%
Saturated Fat	20.0g	100%
Cholesterol	520mg	174%
Sodium	1860mg	78%
Total Carbohydrates	62g	20%
Dietary Fiber	4g	16%
Sugars	4g	12%
Protein	40g	84%

Essentially the McDonald's meal is diabetes and heart disease in a bag, exceeding the entire daily recommendation for Saturated Fat and Cholesterol. And with the Sodium load, you'll gain a pound or two of water weight.

While driving, it occurred to me that I get a safe driver discount, since I've never had a moving violation or accident claim.

Why not a Safe Eating Discount from my Health Insurer?

If I choose to be a vegan and have a diet that has zero cholesterol by definition, essentially no saturated fat, and almost no sodium, I am extending my life by making a disciplined lifestyle choice.

By keeping a body mass index of 20 via veganism and daily exercise, I am preventing future disease.

I know that Charlie Baker, the CEO of my insurer Harvard Pilgrim Healthcare, is a very smart man and will have a very reasonable analysis. It takes dozens of people like me to support the medical care of the McDonald's eater, so it's really not possible to give a Safe Eating discount. However, if we're really going to have healthcare reform in the US, I would advocate a carrot and stick approach based on personal accountability.

Give folks with low fat, low sodium, low cholesterol diets a Safe Eating discount.

Put a tax on McDonald's meals, just as we do with tobacco products, to cover the cost of medical care incurred by eating more fat and cholesterol in a single meal than the FDA recommends for the entire day.

I realize that this may sound harsh and I will not make friends in the beef and dairy industry. However, at some point we need to be accountable for our own health.

Just as President Obama has encouraged us to take responsibility for reinventing America, we must take personal action to reduce the healthcare costs that reduce the competitiveness of the economy.

Rewarding healthful behaviors and penalizing harmful ones seems like a good idea.

Next time I see Charlie Baker, I'll ask him.

What is a Federal Advisory Committee?

The country had a great day yesterday, inspired by the inauguration. Now it's time to get to work.

The House Ways and Means Committee Healthcare IT Bill includes language chartering two new Federal Advisory Committees - the HIT Policy Committee and the HIT Standards Committee.

What is a Federal Advisory Committee?

The Federal Advisory Committee Act became law in 1972 and is the legal foundation defining how Federal Advisory Committees operate. Characteristics of a Federal Advisory Committee include:

Open and Inclusive
Such regulations shall provide that -
(A) no member of any advisory committee or of the staff of any advisory committee shall receive compensation at a rate in excess of the rate specified for GS-18 of the General Schedule under section 5332 of title 5, United States Code;
(B) such members, while engaged in the performance of their duties away from their homes or regular places of business, may be allowed travel expenses, including per diem in lieu of subsistence, as authorized by section 5703 of title 5, United States Code, for persons employed intermittently in the Government service; and
(C) such members -
(i) who are blind or deaf or who otherwise qualify as handicapped individuals (within the meaning of section 501 of the Rehabilitation Act of 1973 (29 U.S.C. 794)), and
(ii) who do not otherwise qualify for assistance under section 3102 of title 5, United States Code, by reason of being an employee of an agency (within the meaning of section 3102(a)(1) of such title 5), may be provided services pursuant to section 3102 of such title 5 while in performance of their advisory committee duties.
(2) Nothing in this subsection shall prevent -
(A) an individual who (without regard to his service with an advisory committee) is a full-time employee of the United States, or
(B) an individual who immediately before his service with an advisory committee was such an employee, from receiving compensation at the rate at which he otherwise would be compensated (or was compensated) as a full-time employee of the United States.
(e) The Administrator shall include in budget recommendations a summary of the amounts he deems necessary for the expenses of advisory committees, including the expenses for publication of reports where appropriate.

Governance
a) No advisory committee shall be established unless such establishment is -
(1) specifically authorized by statute or by the President; or
(2) determined as a matter of formal record, by the head of the agency involved after consultation with the Administrator, with timely notice published in the Federal Register, to be in the public interest in connection with the performance of duties imposed on that agency by law.
(b) Unless otherwise specifically provided by statute or Presidential directive, advisory committees shall be utilized solely for advisory functions. Determinations of action to be taken and policy to be expressed with respect to matters upon which an advisory committee reports or makes recommendations shall be made solely by the President or an officer of the Federal Government.
(c) No advisory committee shall meet or take any action until an advisory committee charter has been filed with
(1) the Administrator, in the case of Presidential advisory committees, or
(2) with the head of the agency to whom any advisory committee reports and with the standing committees of the Senate and of the House of Representatives having legislative jurisdiction of such agency. Such charter shall contain the following information:
(A) the committee's official designation;
(B) the committee's objectives and the scope of its activity;
(C) the period of time necessary for the committee to carry out its purposes;
(D) the agency or official to whom the committee reports;
(E) the agency responsible for providing the necessary support for the committee;
(F) a description of the duties for which the committee is responsible, and, if such duties are not solely advisory, a specification of the authority for such functions;
(G) the estimated annual operating costs in dollars and man-years for such committee;
(H) the estimated number and frequency of committee meetings;
(I) the committee's termination date, if less than two years from the date of the committee's establishment; and
(J) the date the charter is filed.
A copy of any such charter shall also be furnished to the Library of Congress.

Transparency
Sec. 10. Advisory committee procedures; meetings; notice, publication in Federal Register; regulations; minutes; certification; annual report; Federal officer or employee, attendance

-STATUTE-
(a)(1) Each advisory committee meeting shall be open to the public.
(2) Except when the President determines otherwise for reasons of national security, timely notice of each such meeting shall be published in the Federal Register, and the Administrator shall prescribe regulations to provide for other types of public notice to insure that all interested persons are notified of such meeting prior thereto.
(3) Interested persons shall be permitted to attend, appear before, or file statements with any advisory committee, subject to such reasonable rules or regulations as the Administrator may prescribe.
(b) Subject to section 552 of title 5, United States Code, the records, reports, transcripts, minutes, appendixes, working papers, drafts, studies, agenda, or other documents which were made available to or prepared for or by each advisory committee shall be available for public inspection and copying at a single location in the offices of the advisory committee or the agency to which the advisory committee reports until the advisory committee ceases to exist.
(c) Detailed minutes of each meeting of each advisory committee shall be kept and shall contain a record of the persons present, a complete and accurate description of matters discussed and conclusions reached, and copies of all reports received, issued, or approved by the advisory committee. The accuracy of all minutes shall be certified to by the chairman of the advisory committee.
(d) Subsections (a)(1) and (a)(3) of this section shall not apply to any portion of an advisory committee meeting where the President, or the head of the agency to which the advisory committee reports, determines that such portion of such meeting may be closed to the public in accordance with subsection (c) of section 552b of title 5, United States Code. Any such determination shall be in writing and shall contain the reasons for such determination. If such a determination is made, the advisory committee shall issue a report at least annually setting forth a summary of its activities and such related matters as would be informative to the public consistent with the policy of section 552(b) of title 5, United States Code.
(e) There shall be designated an officer or employee of the Federal Government to chair or attend each meeting of each advisory committee. The officer or employee so designated is authorized, whenever he determines it to be in the public interest, to adjourn any such meeting. No advisory committee shall conduct any meeting in the absence of that officer or employee.
(f) Advisory committees shall not hold any meetings except at the call of, or with the advance approval of, a designated officer or employee of the Federal Government, and in the case of advisory committees (other than Presidential advisory committees), with an agenda approved by such officer or employee.

Termination, Renewal, Timeframe
Sec. 14. Termination of advisory committees; renewal; continuation

-STATUTE-
(a)(1) Each advisory committee which is in existence on the effective date of this Act shall terminate not later than the expiration of the two-year period following such effective date unless -
(A) in the case of an advisory committee established by the President or an officer of the Federal Government, such advisory committee is renewed by the President or that officer by appropriate action prior to the expiration of such two-year period; or
(B) in the case of an advisory committee established by an Act of Congress, its duration is otherwise provided for by law.
(2) Each advisory committee established after such effective date shall terminate not later than the expiration of the two-year period beginning on the date of its establishment unless -
(A) in the case of an advisory committee established by the President or an officer of the Federal Government such advisory committee is renewed by the President or such officer by appropriate action prior to the end of such period; or
(B) in the case of an advisory committee established by an Act of Congress, its duration is otherwise provided for by law.
(b)(1) Upon the renewal of any advisory committee, such advisory committee shall file a charter in accordance with section 9(c).
(2) Any advisory committee established by an Act of Congress shall file a charter in accordance with such section upon the expiration of each successive two-year period following the date of enactment of the Act establishing such advisory committee.
(3) No advisory committee required under this subsection to file a charter shall take any action (other than preparation and filing of such charter) prior to the date on which such charter is filed.
(c) Any advisory committee which is renewed by the President or any officer of the Federal Government may be continued only for successive two-year periods by appropriate action taken by the President or such officer prior to the date on which such advisory committee would otherwise terminate.

I serve on the Social Security Administration Future Systems Tecnology Federal Advisory Committee. All meetings must be open to the public and published in Federal Register. All members have to be vetted by the Federal government and members are actually federal government employees on the days their group meets. The most challenging requirement is the comprehensive financial disclosures that members must do. FACA rules are set by Federal law and very exacting to ensure that there is transparency.

I am speaking with many stakeholders about the impact of this FACA construct and the proposed Standards and Policy Committees on CCHIT, HITSP, NeHC (the AHIC Successor), HISPC, ONC and all the work we've done for the past 3 years. More to come!

Hail to the Chief!

It's inauguration day. The energy is palpable.

Dozens of people have emailed me about their sense of optimism, their commitment to personal responsibility, and their "Yes We Can" attitude toward the audacious healthcare reform work ahead.

What's it like to be the Chief Executive of the United States?

My friends Jeff Stamps and Jessica Lipnack have created a Java-based hyperbolic viewer of the Obama Org Chart

He has nearly 20 direct reports and an undetermined number of dotted-line reports - a big job at performance-review time. Hopefully as the first wired president (a computer on his desk in the Oval Office, possibly a Blackberry), he'll be able to keep up with the overwhelming input from all his senior team.

He faces many challenges
1. The economy
2. The ongoing actions in Iraq and Afghanistan
3. A healthcare system that is not a system but a disconnected series of providers, payers, labs, pharmacies and hospitals.

His greatest challenge will be maintaining focus. There is so much to do and so many competing priorities.

In my own field of Healthcare Information Technology, imagine developing a project plan for spending $2 billion in 2009 and 2010, and a total of $20 billion starting in 2011.

My advice is that the journey of 1000 miles begins with one step. A focus on getting the basics right will move us all forward i.e.

1. Roll out electronic health records to each provider in the country, one implementation at a time.
2. Require interoperability for e-prescribing, laboratory ordering/results, clinical summary exchange and quality reporting.
3. Get very specific about the way that interoperability will happen i.e. a set of web services or an appliance in every healthcare data center that can securely exchange payloads for clinical and administrative data sharing with full audit trails/authentication/authorization to protect privacy.

Today my staff at Harvard Medical School and Beth Israel Deaconess are broadcasting the inauguration to all the employees of both organizations. We have large screen televisions in numerous public gathering points so that folks can gather together to celebrate the change ahead.

I am committed to do my part to volunteer my time locally, regionally and nationally. It's my duty and my responsibility.

Hail to the Chief!

The Greatest Healthcare IT Generation

In Washington, Healthcare Information Technology policy planning is accelerating at a pace that is faster than at any time in history (at least my 30 years in healthcare IT).

Over the past few days, the House Ways and Means Committee completed the Health Information Technology for Economic and Clinical Health Act (HITECH), as part of the American Economic Recovery and Reinvestment Plan.

At the same time, the House Appropriations Committee has completed a bill that is not meant to stand alone. It outlines $2 billion in funding for the programs authorized by section 4301 of the Ways and Means Committee bill.

Here are the high points of the Ways and Means Committee bill.

* It codifies the Office of the National Coordinator (ONC), ensuring its continued funding and authority. To date it has existed only because of executive order.

*It creates a Chief Privacy Officer within ONC.

*It establishes and funds an HIT Policy Committee (Federal Advisory Committee)

*It establishes and funds an HIT Standards Committee (Federal Advisory Committee)

*It specifically mentions that the AHIC Successor, now known as the National eHealth Collaborative (NeHC), can be modified to become either the HIT Policy or HIT Standards Committee.

*Interestingly, it notes that the National Coordinator shall support the development and implementation of a qualified EHR platform (imagine an open source software as a service system for the country), unless the Secretary of HHS determines that the needs concerning EHRs are met in the private market.

*NIST is to coordinate with the HIT Standards Committee to test standards and establish a conformance testing infrastructure (NIST can contract with independent non-federal labs to conduct performance testing).

* NIST and NSF are to establish a program of assistance to Institutes of Higher Education to establish multidisciplinary centers for Healthcare Information Enterprise Integration (centers to conduct research on applications for HIT)

*It authorizes and appropriates $300 million in Grants and Loans for state based demonstration programs. Grants can focus on such areas as health IT and the underserved, HIEs, technical assistance, and medical informatics education.

*It establishes HIT Regional Extension Centers, non-profit, public/private partner organizations that can have up to 50% of operations funded for up to 4 years.

*It specifies $20 billion in incentives to support health IT through Medicare and Medicaid, beginning in 2011. It outlines Medicare reimbursement incentives to eligible professionals, eligible Medicare Advantage Organizations, and eligible hospitals that exhibit a meaningful use of certified EHR. It outlines Medicaid reimbursement incentives to eligible Medicaid providers that exhibit a meaningful use of certified EHR

*It addresses the Privacy and Security of protected healthcare information to include breach notifications, relationship of business associates, and accounting for disclosures.

The bill is very well written and includes significant input from all the stakeholders - payers, providers, patients, CCHIT, HITSP, vendors, and government.

I support the notion of planning, expansion of our standards work, acceleration of the Nationwide Health Information Network and a focus on enhanced privacy policy in 2009-2010 followed by rapid implementation beginning in 2011. Some states are ready for rapid implementation now, so my only suggestion would be early additional funding for those states with a plan, staff, and experience doing large EHR rollouts.

Here are the next steps:

* The Ways and Means and Energy and Commerce Committees will mark-up their respective economic recovery packages (which include identical health IT language) on Thursday. A mark-up means the two Committees will go through their respective bills title by title and members will be allowed to offer amendments to the introduced language.

* The bills that come out of Ways and Means, Energy and Commerce and Appropriations will then be merged together, along with parts of the economic recovery package being considered by other House Committees.

* The entire economic recovery bill will go to the House floor the week of January 26.

* Assuming it passes the House, committees will reconcile the bill with whatever economic recovery package gets approved by the Senate. By all indications, both the House and Senate bills will contain similarly strong health IT provisions.

* Once the House and Senate bills get reconciled, they will go back to the full House and Senate.

* Assuming they are approved, they will go to the President for his signature. The plan is that will happen by President’s Day weekend.

I will do all I can to support this effort. With appropriate policies and requirements to implement interoperable, certified EHRs, the dream of a fully electronic healthcare system in the US will move forward more in the next few years than in my entire career to date.

One caveat. The entire healthcare IT industry had an estimated budget of $26 billion in 2008. Thus, these acceleration funds will nearly match the entire budget of the current industry. As Healthcare IT professionals we will be given the challenge of our lives to implement this much change this fast. It will be like running continuous IT marathons at the peak of our abilities.

My grandparent's generation was known as the "Greatest Generation". We will be the "Greatest Healthcare IT Generation."

Are you ready to change the world? I'm looking forward to it!

Cool Technology of the Week

My Cool Technology of the Week is Disk Rescue II and my cool staff at BIDMC (Alex Priest) and Harvard Medical School (Jason Obedzinski) who provided all the advice and effort that led to 100% recovery of the wife's data from her new MacBook Pro.

Here's what we did after the crash on Friday.

Alex and Jason suggested that we start with Disk Warrior.

On Monday and Tuesday we ran Disk Warrior and it enumerated a few thousand files by reconstructing metadata from the files on the damaged hard drive. However, the pace of recovery was such it would have taken several weeks to finish the enumeration.

On Wednesday we moved on to Disk Rescue II which enumerated the files by using the existing metadata on the drive rather than trying to reconstruct it from the files. My sense is that Disk Rescue is optimized for data recovery while Disk Warrior is optimized for disk repair/elimination of errors.

Within 24 hours Disk Rescue had enumerated 60 Gigabytes of files. Once this was done, copying them to an external drive took about an hour.

My wife reviewed the files and 100% of her powerpoint, documents, and photoshop archives were retrieved intact.

As an added bonus, 100% of her 5000 iTunes songs were also perfect.

I copied the data to our new Western Digital My Book Studio II 2 Terabyte home backup drive, configured with RAID 1 mirroring.

At 4pm today, I'll swap the defective Macbook Pro for a new one, reinstall Photoshop CS4, copy my wife's data from the backup drive, and run Time Machine to ensure a complete backup.

By tonight, domestic tranquility will be restored. That's cool!

Facebook, Twitter and Connecting to My Past

I graduated from High School in 1980. I've missed countless reunions and not stayed in touch with anyone from my West Coast past at St. James Catholic Elementary School, St. John Bosco, Palos Verdes High School, Stanford, UCSF, UC Berkeley, or Harbor-UCLA. As I approach 50, I have a nostalgic curiosity about what happened to my friends, my competitors, and my detractors.

In the era before social networking I would have had to fly to California for my 30th reunion in 2010. However, we're now in the era of Facebook, Twitter and complete connectivity that I believe has eliminated the need for reunions or other reasons to rediscover your past.

Over the last month, Facebook and Twitter have reconnected me to the 1980's.

My best friend from High School, Will Snow, an engineer at Sun, has linked to me on Facebook and updated me about his two young children, his hobbies and his life in Northern California.

Will's High School girlfiend, Katherine Hoy, linked to me and told me about her family, her life in the UK and her planned move back to the US.

My next door neighbor and grade school friend, Mark Poncher, linked to me and told me about his career in theater, as an event producer, and life in Southern California.

My elementary school friend from 4th grade, John Webber, linked to me and talked about his family and career.

My Stanford friend, Rod Beckstrom, linked to me and described his career as Director of the National Cyber Security Center in Homeland Security.

On Facebook I have nearly 200 friends and on Twitter I have nearly 300 followers (who are these people?). I've passed 500 connections on Plaxo and LinkedIn. Every day, I'm updated on the actions of nearly 1000 people that I've been close to for the past 50 years.

My email signature gives everyone easy access to my social networking sites:

John D. Halamka MD
CIO, Beth Israel Deaconess and Harvard Medical School
Blog: http://geekdoctor.blogspot.com
Facebook: http://www.facebook.com/people/John-D-Halamka/666982008
Twitter: http://twitter.com/jhalamka
Plaxo: http://jhalamka.myplaxo.com/
LinkedIn: http://www.linkedin.com/pub/0/bb0/804

The end result of all this is that my digital life transcends time, jobs, and geography. I can just as easily talk to Harvard colleague as I can an elementary school lunch buddy. There is no need for a reunion, no need for nostalgia, and no need for a scrapbook of 40 year old photographs.

Social networking enables me to constantly live in the present, linked to the contacts of my life with constant updates, personal messages, and reconnections.

I do wonder what happened to a few folks in my High School past - David Kratz, Phil Talbert, Glenn Seidman, Susan Kattlove, and Hillary Stoltz.

Chances are they will appear on one of my social networking sites soon.

The reunion is dead. The memories of the past are now the lunch date of the future.

A Telecommuting Progress Report

I've written several blogs about flexible work arrangements and telecommuting. As an early adopter of the technologies and policies which support remote workers, here's an update on our progress over the past year.

Some staff members are working from home on a full-time basis and others are doing so only one or two days a week. We have about 10-15% of the IT workforce (35 of our 350 staff) who work at home on any given day.

What is the impact? 35 people x 260 workdays = 9,100 days per year saved in commuting. That's 9,100 car-days off the road. This reduces the demand for parking, office space, and most importantly the employee stress/strain of fighting traffic.

From a management perspective, the past year has been very successful. Employee turnover is at 2%, employee satisfaction is high, and productivity has improved. Employees spend 2-3 hours a day working instead of preparing for their workday, commuting, and returning home.

Costs of the technology to empower home workers has been low - a partial subsidy of home internet connections, a fixed amount of prepaid cell phone time added to employee paychecks, and the use of the Juniper SSLVPN for secure remote access/desktop sharing.

Personally, I have reduced travel, but not quite as much as I would like. Cisco has agreed to work with me on a Telepresence pilot in my home. I'll be using a CTS 500 Telepresence unit over my Verizon FIOS connection to have virtual meetings with collaborators in Washington, Japan, and throughout the Harvard empire. Harvard is currently installing 5 Telepresence units at its various schools and I will have seamless access to all these locations from my home network. Ideally, I will use this device to improvement my carbon footprint, reduce the burden of airline travel in today's challenging security environment, and most importantly recover the time it takes just to get to my meeting destinations.

Overall, I could not be happier. The policies and technologies of flexible work arrangements work well and we have yet to discover a downside.

Update from Washington

Many people have asked me to comment about the latest Washington plans for healthcare IT.

The best and brightest on the Obama transition team, the House Committee on Science and Technology, and the Senate HELP Committee have been talking to academic, industry and government healthcare IT experts.

I believe the message from experts is consistent. The dollars allocated need to fund education, training, and implementation of interoperable CCHIT certified EHRs. What do I mean by interoperable? For 2009 it means result reporting, e-prescribing, and clinical summary exchange. For 2010 it means quality measures, population health, and personal health record exchange. For 2011 it means clinical research/trials support. Here is a document describing the the current CCHIT certification requirements written by Mark Leavitt and containing my thoughts on the interoperability that is available now.

Many in the press and in Washington have just read the pre-publication of "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions" by William W. Stead and Herbert S. Lin, editors from the Committee on Engaging the Computer Science Research Community in Health Care Informatics of the Computer Science and Telecommunications Board, National Research Council of the National Academies. Some believe that the report concludes we should not invest in healthcare IT now.

What does the editor believe? In an email yesterday to the American College of Medical Informatics, Bill wrote:

"We do not need to wait for better IT before we move aggressively forward. However, near term success will require a fresh approach to managing the investment by health care organizations, our health care IT vendors and the government."

Here's my interpretation of the report and Bill's comments:

The National Academy does not call for a halt in health IT investment, rather for a balanced mix of investments that supports 'incremental progress' with real IT systems today, combined with long-term research that can revolutionize the medical decision-making process. The Academy suggests near-term use of clinical information systems that enable doctors to move toward higher-quality, data-driven medical decisions. Along with that, they recommend long-term research that will provide doctors with the tools necessary to support treatment decisions that draw on large amounts of data both from the individual patient they are treating and relevant research and treatment data from a broad range of research and clinical data.

Investments should pay for the improvement in outcomes resulting from the use of healthcare IT.

To my knowledge, the Obama Administration Economic Recovery proposal for HIT spending will support investment in electronic medical record systems for doctors with funds disbursed as Medicare incentive payments. It doesn't just pay for IT, it pays for quality-of-care outcomes facilitated by IT.

The Academy worries that if we fund large-scale deployment of electronic medical record systems for all doctors, we will implement systems that lack the most advanced features yet to be developed through the research they propose. However, Bill's letter to the informatics community suggests deploying now and my experience is that systems evolve incrementally as clinical workflow changes and new technologies become available. In Massachusetts, I have installed eClinicalWorks version 8.033 for my community-based physicians. It has all the decision support features and interoperability the report suggests, so I know the vendor community can deliver what it is needed.

What else am I hearing in Washington?

*The entire stimulus package is expected to cost between $700 billion - $1 trillion. Reportedly, Obama now wants to include up to $300 billion in tax cuts, primarily aimed at individuals and small businesses, in part to gain Republican support. The timing of the completed package seems to be targeted to late February.

*The dollars to be allocated to healthcare IT range from $5-$25 billion.

*In my conversation with Senators, the dollars allocated will not just fund hardware and software. They will include funding for quality measurement, evaluation, training, education, privacy/security, interoperability, and incentives to use the technology to improve care. There is not consensus between the Senate and House of Representatives on the final approach, but hearings are likely to begin soon.

I will watch the unfolding events and relay my interpretation of what is happening in the transition teams and Congress. If you are asked to testify, I hope you offer similar advice to my own:

The products available in the market today are good enough and continue to evolve to include more decision support and interoperability per the CCHIT roadmap.

The standards for labs, medications, and clinical summary exchange harmonized by HITSP are recognized by the US government and are good enough.

Now is the time to invest. We're at the tipping point. Wise investment, with accountability for use of EHRs and incentives to achieve coordinated quality care, is needed to transform healthcare in the US.

The Home CIO Gets in Trouble

For Christmas, I gave my wife a Macbook Pro 15" with 4 gigabytes of RAM and 320 gigs of storage, running Adobe Creative Suite 4. A great machine.

Whenever I get a new device for the family, I apply all updates, install printer drivers, and move all data from the old machine to the new machine.

In this case, I moved 60 gigabytes from my wife's old machine to this new machine - all her documents, all her powerpoints, all her photoshop work, and all her 5000 song iTunes library. I migrated her digital life.

My daughter has an iMac 20" with 320 gigabytes of storage and I have a Macbook Air with 80 gigabytes. We use Time Machine and an external USB hard drive for backup, but it's only a 280 gigabyte drive, without enough room to backup my wife's system. I planned to buy a Western Digital My Book Studio Edition II 2 Terabyte Dual-Drive Storage System (900 Gigabytes usable with RAID 1) this week to support all our backup needs. In the meantime, I was confident that the new Macbook Pro would keep my wife's data safe.

Remember that Risk = likelihood of bad events * consequence of bad events.

The likelihood of a new Macbook Pro having a catastrophic hard drive failure is near zero.

Last Friday morning, my wife opened the lid of her Macbook and a Flashing Question Mark appeared instead of the usual OS X screen. The consequence of this bad event is that my wife lost her entire digital existence and had no backup.

I desperately tried everything suggested by Apple - booting from the DVD, doing a disk repair with the Disk utility, reseting Parameter RAM, reinstalling OS X etc. but the hard disk could not be mounted.

I consulted with my best Mac engineers at BIDMC and Harvard.

They recommended Disk Warrior. It's been running all weekend without success.

Our next step is Data Rescue II

If that fails, then Drive Savers will rebuild the drive by inserting the platters into a new drive.

The good folks at Apple have been very supportive and have offered to replace my Mac book at no charge.

Along the way, I've learned many important lessons

1. All hard drives can fail. Back them up.
2. Hard drives fail most often when they're very new or very old. A failure within the first week of operation is not uncommon.
3. If you need to copy your iTunes library back from your iPod to iTunes, it is possible despite the digital rights management design which attempts to make this difficult. Here are the simple instructions to do this.

This week I'll get my wife a new Macbook, get a backup drive with built in RAID 1 protection, restore her iTunes from her iPod and hopefully recover her documents/powerpoints/photoshop work.

Even the home CIO is held accountable!

Cool Technology of the Week

Recently, while discussing standards with a group of colleagues, I received the following email:

"Having a simple web service interface for problems, medications, allergies, etc. is a great goal. We have seen the value of this as this is what Google Health has done using the CCR and ATOM standards. Since it is a RESTful service and not SOAP, there is no WSDL. Creating a web service interface does not solve the underlying problem though. One still needs to clearly and simply define the XML structure of a problem, medication, and allergy. WSDLs point to XML Schemas to define the inputs and outputs of the services."

I realized that the array of acronyms in this paragraph merited a blog on it's own. The gist of the discussion is how to use the web and HTTP to send structured data from application to application. SOAP and REST are two approaches to web services. Here's a brief overview of the pros and cons of these two cool technologies:

The Simple Object Access Protocol (SOAP) was developed at Microsoft in 1998 as a platform neutral alternative to middleware techologies like CORBA and DCOM. It was first introduced in 1999, modified in May 2000 when it was submitted to the W3C and the current version was finalized in 2005. Since then, SOAP has become the most popular approach for exchanging XML message.

The basic structure of SOAP is similar to HTML itself - a header and body. Here's a fictitious example of a SOAP exchange for requesting a patient's hematocrit from a lab system:

Typically, there are tools available to help generate valid SOAP messages, because the syntax can be a bit complex.

Representative State Transfer (REST) was first described in Roy Fielding's Thesis in 2000. REST is an architectural style that can be summed up as four verbs (GET, POST, PUT, and DELETE from HTTP 1.1) which act upon the resources available on the network (Uniform Resource Identifiers - URIs). REST is easier to implement than SOAP for programmers familiar with the basic techniques of the web itself. Here's a fictitious example of a REST exchange for requesting a patient's hematocrit from a lab system:

REST is similar to the way you request a web page from a browser, but instead of unstructured data, the response is computer readable discrete data. REST does lack some of the advanced features of SOAP such as security, policy, and reliable messaging.

Here's a great comparison from an article comparing SOAP and REST.

SOAP

Pros:
* Langauge, platform, and transport agnostic
* Designed to handle distributed computing environments
* Is the prevailing standard for web services, and hence has better support from other standards (WSDL, WS-*) and tooling from vendors
* Built-in error handling (faults)
* Extensibility

Cons:
* Conceptually more difficult, more "heavy-weight" than REST
* More verbose
* Harder to develop, requires tools

REST

Pros:
* Language and platform agnostic
* Simpler to develop than SOAP
* Small learning curve, less reliance on tools
* Concise, no need for additional messaging layer
* Closer in design and philosophy to the Web

Cons:
* Assumes a point-to-point communication model--not usable for distributed computing environment where message may go through one or more intermediaries
* Lack of standards support for security, policy, reliable messaging, etc., so services that have more sophisticated requirements are harder to develop ("roll your own")
* Tied to the HTTP transport model


Like everything in the standards world, requirements and use cases suggest the best approach to implement.

Now let's decode the email that was sent to me. The author suggests using a simple representation of medical data sent over a simple REST approach as means to easily transmit problem lists, medications, and allergies. Certainly there are some use cases, such as what Google Health is doing, where that works well.

As I've said in my 2009 Goals, I hope to work with all interested stakeholders this year to ensure the US has a clear path for transmission of clinical summaries between applications that meets complex and simple use cases. My hope is that the next generation of the Continuity of Care Document and the Continuity of Care Record will be developed jointly so that all the requirements are defined and met in a harmonious process.

Chasing the Rabbit

As readers of my blog may have figured out, I try to read at least one book per week and generally I write about it.

This week's book is Chasing the Rabbit by Steven M. Spear, a former Harvard Business School professor and current MIT faculty member.

He examines the reasons that market leaders stay market leaders, constantly innovating and staying in front of the pack.

These high velocity organizations share 4 common characteristics:

Capability 1: Specifying design to capture existing knowledge and building in tests to reveal problems.
Capability 2: Swarming and solving problems to build new knowledge.
Capability 3: Sharing new knowledge throughout the organization.
Capability 4: Leading by developing capabilities 1, 2, and 3.

The book includes in-depth studies of Toyota, Alcoa, the US Navy's Nuclear Power Propulsion Program and several leading healthcare organizations. Understanding the people and process differences between Toyota and GM makes it clear that technology is not the issue that has lead to 70+ years of profitability in one company and a bailout of the other.

The book contains a great deal of detail, but I can summarize my lessons learned by relating my experience running IT organizations:

1. Empower every person to suggest new ways of doing their work
2. Create a non-punitive culture which openly explores failure/downtime/accidents rapidly after the incident and does not penalize the person, but asks how processes, procedures, and the organization enabled the problem to happen.
3. Favor continuous small change rather than big bang change. This enables corrections to optimize each change before making another change.
4. Embrace openness and transparency in every level of the organization to enhance communication and break down silos.
5. Vigorously support training budgets as the best way to preserve institutional knowledge and grow internal candidates for succession planning.

A worthwhile read!

Paying for Patient Telephone Calls

For years, BIDMC has required patients to pay for toll calls. Local calling was made free to them over a decade ago. Periodically, I receive complaints from patients about having to use telephone debit cards, credit cards or collect calling to reach parties in Massachusetts area codes. Today, we use a hospitality service to handle outgoing toll calls from patient rooms. When a patient calls a toll number (9-0-xxx-xxx-xxxx), the hospitality service handles the billing. Their charges for this service tend to be high, e.g. several dollars per toll call regardless of duration.

With the rates for in-State toll calls at only twice that of local calls, we have elected to pilot free calling to all Massachusetts area codes from a limited number of patient room phones. Once fully implemented, there are 360 patient room phones that could have free in-State calling.

It is difficult to estimate what may be the financial impact of this action. We asked the hospitality service how many calls were made to in-State area codes that involve toll charges. They show only 70 calls. The use of the service, however, is likely impacted by their high charges and the complexity of making an outgoing toll call. Also, many friends and relatives call patients which incur no charge since they originate outside the hospital. Similarly, many patients use cell phones for out-dialing.

To gauge what may be the calling activity for other MA areas, we looked at call activity occurring to the existing "local" calling area today from the patient room phones that would be impacted. Today, patients can call toll free to 617/857 and parts of 781/339. During the month of November, there were 12,593 calls totaling 35,672 minutes.

We estimate that 80 percent of non-critical care days are for patients residing in the current local calling area. The other areas in Massachusetts represent only 12 percent of non-critical care days. Although this represents residence zip codes of the patients and not zip codes of friends/relatives they would call in Massachusetts, I believe it provides some assurance the extended in-State calling will not be high volume or high cost. Many patients use personal cell phones and will likely continue to do so.

I'll report back on the cost of our pilot and the impact on patient satisfaction. I am curious - what are other hospitals doing? Feel free to post a comment with your hospital's approach to patient toll calls.

Auditing Medication Reconciliation

BIDMC has a major focus on process improvement and lean approaches to workflow.

When we declare a goal we develop metrics to track our processes and remeasure our performance to ensure our changes have a lasting effect.

I was recently asked about our adherence to medication reconciliation, a Joint Commission requirement and a pay for performance goal for us.

We have 3 major medication reconciliation workflows - Emergency Department, Inpatient and Outpatient - which ensure we document a complete medication list at every transition and communicate that list to the next provider, ensuring continuity of care.

Our last audit was completed on November 19, 2008.

* A total of 1326 records across the various areas were reviewed
* We found 95% compliance with Communication of Updated List of Medications to Next Provider of Care.

Each time we do an inpatient review, we select a date and then review discharges from the prior two days. In the last round, the date selected was 11/19, and we reviewed 161 discharges from 11/17 and 11/18. There were 263 discharges on those days, so the % reviewed was 61%.

Our full results are below:

Service Line	Visits Reviewed	Medications Added	Sent to Next Provider	%
ED	76	39	38	97%
Inpatient	161	144	133	92%
Same Day Surg	55	38	35	92%
Procedure	168	10	10	100%
Ambulatory	866	341	328	96%
Total	1326	572	544	95%

We will continue this quarterly monitoring into 2009 and the dates to save include:
Wednesday, February 11, 2009
Wednesday, May 20, 2009
Wednesday, August 19, 2009
Wednesday, November 18, 2009

When an audit is conducted, the number of charts reviewed per clinic varies based on the clinic's volume on the selected day:

Clinics w/ <30 visits review 100% of cases.
Clinics w/ 31-100 visits review 30 cases.
Clinics w/ >100 visits review 50 cases.

We've found that this level of monitoring rigor is necessary to demonstrate and sustain real process change.

As many have said "What gets measured gets done"

The Post Holiday FAQ

As a CIO, I'm asked to do many diverse things, but after the holidays the pace accelerates when I'm called by family, friends, and colleagues to give them advice about all the new complex technology they've purchased over the holidays. Here are a few post holiday FAQs.

I have new DVD player that can record DVDs. Can you explain the differences between DVD-R/DVD-RW and DVD+R/DVD+RW?

DVD's exist in two basic forms

a. DVD-ROM which includes DVD-Video, the read only media which stores commercially produced movies
b. Recordable DVD's

Recordable DVDs are divided into three incompatible formats:

DVD-R/DVD-RW - this was the first DVD recordable media released into the market in 1997. It was developed by Pioneer and then backed by the DVD Forum, a consortium of industry stakeholders. Because it was first to market, older DVD players/recorders tend to support this format. This format does not have advanced error correcting capabilities and tends to be less robust at higher speeds. DVD-R is recordable once and DVD-RW is recordable/rewriteable approximately 1000 times.

DVD+R/DVD+RW - this was developed by Philips and Sony via their DVD+RW Alliance in 2002. It was recognized by the DVD Forum as an official DVD format in January 2008. As with the DVD-R standards, DVD+R is recordable once and DVD+RW is recordable approximately 1000 times. DVD+RW had advanced error correcting features and is robust at high speeds.

DVD-RAM - this format has not been widely embraced by computer manufacturers but is used commonly in video cameras as re-writable removable media.

The bottomline - most modern DVD recorders can read/write DVD+RW. It's the most modern, robust and reusable recording media. Use DVD+RW for recording.


Should I upgrade to Blu-Ray?

First a bit about capacity. CD's hold 700 Megabytes, DVD's hold 4.7 Gigabytes, and Blu-Ray disks hold 50 Gigabytes.

CD uses a 780nm wavelength laser diode, DVD uses 650nm and Blu-ray uses 405nm. Smaller wavelengths permit a smaller pit to be etched on the media surface ( 1.6 µm for CD, 1.32 µm for DVD, and .160µm for Blu-Ray). The high capacity of Blu-Ray disks supports the density needed for true HDTV (1080p) video. DVDs play in standard TV densities (480p).

Blu-ray players are designed to be backwards compatible, allowing older DVDs to be played in the same player.

Although VCR tapes were rapidly replaced by DVDs because of their robustness and convenience, the transition from DVD to Blu-Ray has been slower. Only 3% of videos sold today are Blu-Ray because many consumers are satisfied with the performance and video quality of their standard DVDs. If you do not have a 1080p HDTV, Blu-Ray does not really offer you much.

Bottomline - At this point, Blu-Ray is more expensive than DVDs and does not offer much to the average consumer. I recommend you hold off unless you really want a really high end video player to complement a really high end HDTV and are willing to pay the higher price for movies on Blu-Ray discs.


I received a Bose Sounddock, a Belkin iPod FM modulator (for using your iPod over you're car's radio), and other iPod accessories. Will they work with my iPod?

There are more iPod variants than Carters has little pills. Wikipedia has a great table comparing all models sold to date.

Accessory manufacturers need to keep up with the ever changing collection of yearly new model releases.

For Bose, there is a hard to find online guide to iPod compatibility. Note that Bose provides a free adapter for the 2nd generation iPod that has a different connector position than other iPods.

In general, it's challenging to buy iPod accessories that keep up with the iPod product line. Plan to rebuy accessories when you upgrade you iPod.

That's it for the first round of post holiday consultations for the home CIO. I'm sure there are more to come and I'll post them here.

Cool Technology of the Week

As part of the Harvard Clinical and Translational Science Awards, we've built a number of social networking tools while also leveraging components built by others such as NetAge.

These tools typically work by analyzing collaborators on publications, co-PIs on grant funding, and subject matter interests.

A possibly more precise way to identify networks and communities is by analyzing email traffic patterns - senders, receivers and subjects. A novel social networking tool from Metasight called Morphix, does this.

MetaSight Communities of Interest and Communities of Relationships are web applications which can be implemented as standalone applications or integrated with a corporate portal or intranet.

The tools work by automatically analysing e-mail subject titles and recipients. Personal, private and confidential e-mails are excluded.

Per the Metasight website, social networking applications of this analysis include:

Innovation- Facilitate connections between communities that are separated by function, department, or location

Communities of Practice - Proactively include interested staff in communities, and identify new community practice areas

Relationships with customers, partners and suppliers - Make relationships visible and network with colleagues around external business relationships

Team formation - Search for team members who have key skills or networks

Internal communications -Create distribution lists based on interest in topics or external relationships

Succession planning - Build knowledge and relationship profiles of individuals can be used to support knowledge and relationship transfer

Expertise location - Automatically maintain profiles of staff knowledge and relationships

Mergers & Acquisitions - Use maps of expertise and relationships of each party to accelerate integration

Litigation support - Quickly identify who is involved from internal and external relationships

Analyzing connectedness in organizations based on who emails whom and what they email about. That's cool!