The Moons of the Month

This weekend is Halloween and I did not find an appropriately thematic cool technology.  Looking out my window at the waning full moon, I realized that I did not know the traditional monthly moon names.  This weekend will you be trick or treating under the Corn Moon, Harvest Moon, or Beaver Moon (the answer is Harvest).  Here's the Farmer's Almanac guide to the names of the monthly full moons.  Enjoy your Halloween weekend.

*Full Wolf Moon – January Amid the cold and deep snows of midwinter, the wolf packs howled hungrily outside Indian villages. Thus, the name for January’s full Moon. Sometimes it was also referred to as the Old Moon, or the Moon After Yule. Some called it the Full Snow Moon, but most tribes applied that name to the next Moon.

*Full Snow Moon – February Since the heaviest snow usually falls during this month, native tribes of the north and east most often called February’s full Moon the Full Snow Moon. Some tribes also referred to this Moon as the Full Hunger Moon, since harsh weather conditions in their areas made hunting very difficult.

*Full Worm Moon – March As the temperature begins to warm and the ground begins to thaw, earthworm casts appear, heralding the return of the robins. The more northern tribes knew this Moon as the Full Crow Moon, when the cawing of crows signaled the end of winter; or the Full Crust Moon, because the snow cover becomes crusted from thawing by day and freezing at night. The Full Sap Moon, marking the time of tapping maple trees, is another variation. To the settlers, it was also known as the Lenten Moon, and was considered to be the last full Moon of winter.

*Full Pink Moon – April This name came from the herb moss pink, or wild ground phlox, which is one of the earliest widespread flowers of the spring. Other names for this month’s celestial body include the Full Sprouting Grass Moon, the Egg Moon, and among coastal tribes the Full Fish Moon, because this was the time that the shad swam upstream to spawn.

*Full Flower Moon – May In most areas, flowers are abundant everywhere during this time. Thus, the name of this Moon. Other names include the Full Corn Planting Moon, or the Milk Moon.

*Full Strawberry Moon – June This name was universal to every Algonquin tribe. However, in Europe they called it the Rose Moon. Also because the relatively short season for harvesting strawberries comes each year during the month of June . . . so the full Moon that occurs during that month was christened for the strawberry!

*The Full Buck Moon – July July is normally the month when the new antlers of buck deer push out of their foreheads in coatings of velvety fur. It was also often called the Full Thunder Moon, for the reason that thunderstorms are most frequent during this time. Another name for this month’s Moon was the Full Hay Moon.

*Full Sturgeon Moon – August The fishing tribes are given credit for the naming of this Moon, since sturgeon, a large fish of the Great Lakes and other major bodies of water, were most readily caught during this month. A few tribes knew it as the Full Red Moon because, as the Moon rises, it appears reddish through any sultry haze. It was also called the Green Corn Moon or Grain Moon.

*Full Corn Moon – September This full moon’s name is attributed to Native Americans because it marked when corn was supposed to be harvested. Most often, the September full moon is actually the Harvest Moon.

*Full Harvest Moon – October This is the full Moon that occurs closest to the autumn equinox. In two years out of three, the Harvest Moon comes in September, but in some years it occurs in October. At the peak of harvest, farmers can work late into the night by the light of this Moon. Usually the full Moon rises an average of 50 minutes later each night, but for the few nights around the Harvest Moon, the Moon seems to rise at nearly the same time each night: just 25 to 30 minutes later across the U.S., and only 10 to 20 minutes later for much of Canada and Europe. Corn, pumpkins, squash, beans, and wild rice the chief Indian staples are now ready for gathering.

*Full Beaver Moon – November This was the time to set beaver traps before the swamps froze, to ensure a supply of warm winter furs. Another interpretation suggests that the name Full Beaver Moon comes from the fact that the beavers are now actively preparing for winter. It is sometimes also referred to as the Frosty Moon.

*The Full Cold Moon; or the Full Long Nights Moon – December During this month the winter cold fastens its grip, and nights are at their longest and darkest. It is also sometimes called the Moon before Yule. The term Long Night Moon is a doubly appropriate name because the midwinter night is indeed long, and because the Moon is above the horizon for a long time. The midwinter full Moon has a high trajectory across the sky because it is opposite a low Sun.

What am I, Who am I, What will I be?

In 1979, as a senior in high school, I watched the movie and TV Series "Buck Rogers in the 25th Century".

The theme song lyrics begin

What am I, Who am I, What will I be?
Where am I going and What will I see?

As a teen applying to college and about to embark on the next step toward adulthood, I deeply pondered these questions.    Today, I still do, although it's 30 years later and I've traveled through many stages of life since then.

Here's my framework for thinking about "What am I, who am I, what will I be?"

1.  My roles through the stages of life  as a son, a husband, a father, a doctor,  and a public figure of sorts.

2.  My job as CIO of provider organizations.

3.  My job as CIO of a medical school.

4.  My volunteer work as a Federal and State convener.

5.  My self, what really makes me an individual
*My outdoor activities including kayaking, biking, hiking, skiing,  and climbing.

*My Japanese traditions including playing the Shakuhachi,  drinking tea, burning incense,  appreciating the traditional arts,  and living a simple Asian lifestyle.

*My black clothing

*My Vegan diet

*My gardening throughout the year, appreciating every variation of the seasons in New England.

In 1979, I could never have answered the question as completely, but now I truly know what makes me an individual and who I am.

What will I be?  I hopefully have many years to find out, but being satisfied with the journey is all I can hope for.

The October HIT Standards Committee meeting

This month's meeting focused on the planning for standards which will support meaningful use stage 2 and 3, as well a review of NHIN Direct and its future plans to provide simple transmission of data among stakeholders.

We began the meeting with Jamie Ferguson's Vocabulary Workgroup report.   He highlighted the work that has been done to reduce the intellectual property barriers which have slowed the creation of centralized, web-based resources containing all vocabularies, codesets, and mappings needed by eligible providers and hospitals to achieve meaningful use.  Several financial models have been considered, including federal government funding of vocabulary licensing fees and the establishment of a single administrative group to centrally collect a single fee from providers in return for providing them all the meaningful use vocabulary resources they need.    We discussed two related issues 1) identifying who pays licensing fees and we determined it should be those who generate data not those who receive it or manipulate it as a business associate of the data generator.  2) identifying the need for proprietary code set vendors to create free mappings to federally mandated standards.   For example, RxNorm includes proprietary medication codesets and the vendors of these codesets should offer free mappings from ALL their proprietary codes to RxNorm codes.

Next, Liz Johnson updated the group on the Implementation Workgroup activities.   She highlighted the need for hearings, to be held in December or January, on five topics - the role of RECS in attaining meaningful use, certification experiences, lessons learned from early adopters seeking meaningful use attestation in 2011, experience with performance/quality measures, and the status of health information exchanges.   I discussed two barriers to certification - the fact that the syndromic surveillance implementation guide in the Final Standards Rule is incorrect.   It was updated via an interim final rule  so that has been addressed.   Also that the NIST testing tools for e-prescribing transactions did not include the XML forms of NCPDP standards.   On October 24, NIST issued version 1.1 of those tools, addressing the issue.

Paul Tang and George Hripcsak then presented the guiding principles behind Stage 2 and 3 meaningful use.   Summarizing the key points
*Some aspects of stage 2 will be incremental changes to stage 1 (i.e. raising the thresholds)
*Some will be a stepping stone on the way to stage 3
*Stage 3 will likely including outcomes measures as well as process measures.
*Stage 2 and 3 will likely require analysis of data across a community and not just within an institution, increasing the amount of HIE enablement to be demonstrated.
*Patient engagement in future stages will clarify methods to share data with patients - "access/download" which is real time on demand, "copy" which is a point in time summary of available information including specific use documents/datasets.

Our discussion included the need to clarify the term "document".  Most people concurred that "document" meant a collection of data elements, in electronic form, capable of many reuses.   Ideally, the standards committee will suggest a common container for assembly of structured and unstructured information that does not require creating numerous standards for individual document types.

Arien Malec then updated the group on NHIN Direct.   The consensus of the Direct collaborators is to require secure email (SMTP/TLS/certificates) as the backbone but allow SOAP (XDR) or SMTP at the edges.  This means that senders and receivers can decide how to transmit/receive data (SMTP or SOAP) as long as they have a way to communicate with the SMTP backbone.   Finally, an exception was made for those senders and receivers who agree to use SOAP from point to point by previous agreement.  This approach enables existing vendor products which already support SOAP to continue to do so, while enabling innovative approaches using secure email.   Specifications will be finalized by next month and live implementations will be evaluated by the Standards Committee in March.

Doug Fridsma reviewed the current state of the Standards and Interoperability framework, noting that it now has a set of tools and processes to support health information exchange project development including use case writing, harmonization, implementation guide writing, reference implementation and testing.   Priorities will focus on Meaningful Use data exchanges and the Virtual Lifetime Electronic Record (VLER) project.   Much discussion followed about the best way to incorporate the HIT Policy Committee, the HIT Standards Committee, NHIN, and the Standards and Interoperability Framework into a more coordinated set of activities.   The Concept of Operations document which guides the Standards and Interoperability Framework is being updated to knit all these activities together and we will discuss that at our November meeting.

The November and December meetings will be teleconferences, so I look forward to hearing you all on the phone.

Surescripts goes beyond e-Prescribing

In my many blogs about standards, I've concluded that content and vocabulary standards are well specified but transmission standards are not.   We've required the basics of security but have left the actual transmission up to each set of trading partners.   Approaches include REST, SOAP and  SMTP/TLS.

NHIN Direct is a project to create implementation guides and running open source prototypes which facilitate transmission.

Surescripts is partnering with Kryptiq to create a commercial product that leverages the existing e-prescribing connections in clinician offices and NHIN Direct to create a healthcare information exchange.

I believe this commercial effort is complementary and not competitive with state healthcare information exchanges and the stimulus funds given for states to accelerate interoperability.

NEHEN connects 10,000 providers in Massachusetts, but that leaves 10,000  doctors, mostly in small practices, unconnected.

Our vision is to connect every provider with every provider.

Of the unconnected providers, the majority using EHRs have e-prescribing capabilities.   Connecting e-prescribing providers with the state health information exchange backbone is a win/win division of labor among NEHEN, Surescripts and other vendors.

Here's the detailed announcement of Surescripts' vision for federated, network of networks health information exchange.

High Performance Computing and the Latest Applications

Last week, I keynoted the Harvard High Performance Computing Summit and updated the attendees on the latest research computing and novel applications at Harvard Medical School.

1.   Orchestra - is our 6000 core high performance computing infrastructure that is shared by all research departments.  They key to its success has been the sense of community we've developed around a shared utility.   The school funds the power/cooling/hosting/basic infrastructure as well as an expert staff to serve the faculty.   Researchers use their grants to add computing power and storage to the community utility instead of building small clusters under desks and in local mini-data centers.

2.   Novel Sources of Data  - The American Recovery and Reinvestment Act (ARRA) and its related healthcare IT regulations are encouraging clinicians and patients to record healthcare data in electronic form.   With proper privacy controls and institutional review board oversight, this new data can provide support for comparative effectiveness research, population health monitoring, and pharmacosurveillance.

3.   Mining those novel sources of data with Shrine - Petabytes of data does not change healthcare, but transforming that data into information, knowledge and wisdom does.   Shrine enables researchers, with appropriate oversight and approval,   to study the de-identified data  of 10 million patients at Harvard affiliates.

4.  Building collaborations with Profiles - The path to wisdom requires that researchers ask the right questions.   Assembling a team of colleagues into an optimal multidisciplinary combination is easy with our Profiles social networking application.   It mines the literature, Harvard directories, and the connections among all Harvard faculty to identify the right people to ask the right questions.

5.  Sustaining the research infrastructure and applications with an NIH compliant, researcher  friendly business model is challenging.   Computing power, data, tools, and collaborators are great but they must be supported with operating budgets, grant dollars, and philanthropy.   Harvard has retained an expert consultant and is moving forward on an aggressive schedule (60 days) to analyze all the potential sustainable business models (direct grant funding, indirect overhead, chargebacks, school operating budgets, transaction fees, subscription fees) that will support growth in infrastructure and staff over time.

The high performance computing summit was a great opportunity to share ideas and learn from each other.    I look forward to sharing the sustainable business model for research computing as it is finalized by the end of 2010.

Cool Technology of the Week

Last week, I met with Patientsafe Solutions, a San Diego-based startup founded by serial entrepreneur James Sweeney.

Their idea is simple - leverage the iPod Touch 4G form factor and the iOS 4 SDK to create an all in one mobile device for healthcare.   Their work thus far has included medication management workflow including bedside medication verification and electronic medication admission records.   Their future vision encompasses numerous aspects of nursing workflow, pre-admission testing, admission, discharge and home care.

Here's an overview of their initial PatientTouch product.

In the past, nurses have told that they really did not want to carry devices, which have the potential for getting in the way of the nurse-patient interaction.

Today, the ubiquity of smart phones makes the notion of carrying a pocket sized device more palatable.

Imagine one device that is rugged, lightweight, secure, and easily cleanable for supporting medication workflow (positive patient ID, eMAR, medication verification),  laboratory workflow (positive patient ID, front end labeling),  alerts/reminders, and voice over IP communications via hospital WiFi networks.

An iPod touch in every clinician's pocket, fully connected to hospital information systems and other caregivers.   That's cool.

Making Pesto

The temperatures in Massachusetts are dropping into the mid 30's every night and the days are growing short.   It's time to harvest the last of our summer planting before the first hard freeze of Fall.   Although I'll keep oak leaf and red fire lettuce growing under the cold frame for another month, our bush-sized basil plants need to be harvested before they wither from the nightly low temperatures.

What do you do with 20 pounds of basil?   Make enough pesto to last all winter.   As vegans, we'll be eating pesto pizza, pesto linguine, and pesto covered toasted breads as the weather gets cold.

My wife has diligently plucked all the best leaves, visited Trader Joe's to stock up on pine nuts, and bought a box of Yellingbo olive oil.   Here's our recipe:

Vegan Pesto

2 cups fresh basil leaves
1/3 cup organic extra virgin olive oil
1 cup pine nuts
1-2 tablespoons garlic
1/3 cup nutritional yeast

Combine all ingredients except oil in a food processor until nuts are ground. Add oil until texture is creamy. Pesto should still have some texture (not too pureed).  Freeze extra in small containers for future use.

The Year of Governance

If my epitaph had to be written tomorrow, what pithy quote would I select from my blog?

Possibilities include:
"For everything there is a process" 
"The happiest stage of life is wherever I am today" 
"The nice guy can finish first"

However, for 2011, I'd suggest "Governance is the solution to all your problems".  

I've committed to make 2011 the year of Governance.

At Harvard Medical School, we're expanding our Governance Committees to ensure administration, education, and research stakeholders have governance committees which roll up to an executive governance committee of the individual committee chairs.   Together, these committees will set the departmental and overall IT priorities for the school.

At BIDMC, we've created a new overall IT Governance Committee in addition to the existing subcommittees that prioritize departmentally focused efforts:

*Laboratory Information Systems chaired by the SVP/VP overseeing the lab
*Radiology Information Systems chaired by the the SVP/VP overseeing radiology
*Enterprise Image Management chaired by the CIO
*Emergency Department Information Systems chaired by the SVP overseeing Ambulatory & Emergency Services
*Critical Care Information Systems chaired by the Director Trauma, Anesthesia and Critical Care
*Peri-operative Information Systems chaired by the Director of Perioperative Service
*Inpatient Clinical Applications (includes Provider Order Entry) co-chaired by Chief Nursing Officer and VP for Clinical Systems
*Ambulatory (WebOM) users group chaired by the SVP overseeing Ambulatory & Emergency Services
*Health Information Management Information Systems chaired by the Director of the Hospital Medicine Program
*Community Information Systems chaired by the Executive Director of the Physician's Organization
*Decision Support Steering Committee chaired by the Director of Business Planning & Decision Support and the Vice Chair of General Medicine
*Enterprise Resource Planning (ERP) Information Systems chaired by the Director of Business Services and the Controller
*Human Resources Information Systems chaired by the SVP of Human Resources

The role of the overall IT Governance Committee includes:
*Communication about prioritization and resource decisions.
*Articulating, prioritizing, and monitoring the overall vision for  IT at BIDMC.  
*Achieving the right balance between built and bought systems including adequate staffing for maintenance to ensure high customer satisfaction.

Why is governance so important for BIDMC in 2011?

*2011 is the most stressful time in the entire history of healthcare IT in the US.   Certification and Meaningful Use requires significant application, infrastructure, and change management efforts.
*2011 is the time to begin planning for healthcare reform and the new world of accountable care organizations and the electronic systems we'll need for the future.
*2011 is a time of many new regulatory/compliance mandates including planning for ICD-10, new data protection regulations, and increasing oversight from the Joint Commission/CMS/FDA etc.

My first overall IT Governance Committee is November 10.   To support it, I'm creating a new IT Governance website.   I'll be sure to share the outcome of the meeting and all my presentation materials in November.

The Massachusetts HIE Use Cases

Yesterday I met with the Massachusetts Secretary of Health and Human Services and the HIT Council (our state HIT governance body) to review the Massachusetts Health Information Exchange (HIE) use cases - how will the patient experience differ when the HIE is fully functional.

In the past, we've presented the HIE gaps that need to be filled via procurement.

The Secretary asked for a complete vision, complemented by use cases illustrating e-prescribing, care coordination, public health, consumer engagement, and emergency department query workflow.   Here's what I presented.

For each use case, you'll see current state in 2010, then future state in 2011-2013.  

In our HIE discussion with the HIT Council thus far, we've used the following framework

Establish governance characteristics and consider governance structure operations
Establish priorities for healthcare information exchange
Identify functional gaps in technology and adoption
Broadly communicate the multi-year HIE vision
Describe the operating model (in our case that's Governing Body, Program Management Office, Service Providers)
Define the characteristics of the RFP(s)
Procure
Operationalize
Evaluate

So far, this framework has serve us well.    We currently have 10,000 providers connected to our existing HIEs.   In 2011, we will hopefully ensure the remaining 10,000 have all the services they need to connect every provider to every other provider in the Commonwealth.

The FY11 BIDMC IS Operating Plan

The Beth Israel Deaconess fiscal year is October 1 to September 30, so FY11 capital and operating budgets are now approved, enabling us to finalize the yearly IS Operating Plan.   My team and I complete it and widely communicate it every October.

Today, I've posted the FY11 BIDMC IS Operating plan including clinical systems, financial systems,  infrastructure, health information management, knowledge services, media services, academic computing, and our community sites.

Highlights include:

Achieving Meaningful Use for 1700 clinicians

Go live of our new suite of laboratory information systems, replacing 13 major applications.

Go live of MyTime - an enterprise labor time tracking solution

Numerous infrastructure upgrades to networking, storage, and security

Rollout of an electronic forms solution throughout the enterprise

Acceleration of our automated scanning project to digitize paper records we receive from outside the institution.

Retirement of all our legacy intranet sites, providing single signon access to all applications and knowledge resources

Continued rollout of streaming and video teleconferencing technologies

Advanced research administration support tools.

Meditech upgrades at our community hospital necessary to achieving meaningful use including CPOE.

The task of building better applications and more reliable infrastructure is never done, but each year we get better and better.  This year, we'll be guided by a new omnibus clinical governance committee which I'll write about later this week as part of my FY11 focus on governance at both BIDMC and Harvard Medical  School.

Cool Technology of the Week

Next week I'll cover a truly unique iPod Touch-based suite of applications for healthcare.   In the meantime, check out this list of cool gadgets from David Pogue's New York Times Column this week.

The Green Acres Criteria

Last week, I spent Wednesday in Manhattan and Sunday at East Hill Farm near the base of Mt. Monadnock in New Hampshire (my family always spends Columbus Day weekend in New Hampshire).

I have many friends and colleagues in New York City, so I have great respect for the people, culture, and environs of the Big Apple.

Here's a few of the contrasts I experienced.

Manhattan: As I boarded the Subway, a few folks walked into me as if I was invisible.
Monadnock: As I climbed, everyone stopped to chat, commented on the changing leaves, and reveled in the beautiful day.

Manhattan: People ran from the Acela to the Subway looking stressed and overwhelmed
Monadnock: People looked forward to their journey and their destination

Manhattan: People wore stylish heels and designer attire
Monadnock: People wore flannel shirts and boots

Is one better than the other?  That's a function of the weighting criteria of the observer.

If I had to make a personal judgement based on "Green Acres"  criteria:

"Green acres is the place for me.
Farm livin' is the life for me.
Land spreadin' out so far and wide.
Keep Manhattan, just give me that countryside.
New York is where I'd rather stay.
I get allergic smelling hay.
I just adore a penthouse view.
Dah-ling I love you but give me Park Avenue.
...The chores.
...The stores.
...Fresh air.
...Times Square
You are my wife.
Good bye, city life.
Green Acres we are there. "

then I'm a farm, land, hay, chores, fresh air kind of guy.

I love to visit New York, but the back roads of New England feel like home.

Clarifying Certification Part II

I was recently asked a few more questions about certification and I'll share my answers with the HIT community.

1.  Per your first blog about certification, I understand that all hospitals and eligible providers need to have certified EHR technology, which means that they must acquire software (complete or modular) that supports all Meaningful Use functions (25 for Eligible Professionals and 24 for hospitals – 15 core/10 menu, 14 core/10 menu respectively).   Since Meaningful Use only requires attestation for 5 of the 10 menu set items, does the unused technology need to be installed?

The answer, based on every conversation I've had with vendors and government staffers,  seems to be Yes.   In the Meaningful Use Final Rule, the term is  “utilize” – so all the technology has to be purchased and installed.   However, providers will just report on the use of those functions they select from the menu set.

Here is the relevant sentence from the Meaningful Use Final Rule -  "Under all three EHR incentive programs, EPs, eligible hospitals, and CAHs must utilize certified EHR technology if they are to be considered eligible for the incentive payments."

HITECH defines “certified EHR technology” as a “qualified EHR” that is certified pursuant to the certification program(s) established by the National Coordinator as meeting the standards adopted by the Secretary.  Here’s the statutory definition verbatim and note how Congress made a distinction between ambulatory and inpatient - “CERTIFIED EHR TECHNOLOGY.—The term ‘certified EHR technology’ means a qualified electronic health record that is certified pursuant to section 3001(c)(5) as meeting standards adopted under section 3004 that are applicable to the type of record involved (as determined by the Secretary, such as an ambulatory electronic health record for office-based physicians or an inpatient hospital electronic health record for hospitals).”

The flexibility in the menu set is reporting on Meaningful Use measures in Stage 1, not the flexibility to use an incomplete EHR.  Certification is not associated with the core/menu flexibility.  Also in the first year of meaningful use under the Medicaid program there is no core/menu analysis, as the statute permits Medicaid providers to receive the EHR incentives for “adopting, implementing or upgrading to certified EHR technology” in their first participation year (a provider’s first participation year may be any year between 2011 through 2016).

Here are some examples of how hospitals and providers might attest to Meaningful Use:
a.  An eligible hospital may choose to defer meeting the advance directive measure for a variety of reasons that would prevent them from achieving the 50% requirement, but their Certified EHR Technology would need to include that capability.
b.  An eligible professional may choose to defer meeting the send patient reminders for preventative and follow-up care measure for variety of reasons that would prevent them from achieving the 20% requirement, but their Certified EHR Technology would need to include that capability.
c.  In either case if the eligible professional/hospital defers it for 2011, nothing precludes them from using that capability or electing to make that one of their reported menu measures for 2012 in addition to or in lieu of one of their five 2011 menu measures.

2.  NIST testing procedure for §170.302 (a) Drug-drug, drug-allergy interaction checks includes the language "Provide certain users with the ability to adjust notifications provided for drug-drug and drug-allergy interaction checks."   What do you think about that?

I agree that drug-drug interaction notification requires tuning to avoid alert fatigue.  Sometimes even minor interactions with trivial clinical consequences pop up, interrupting workflow.   There should be tuning allowed to adjust such alerts to the level of severity optimized for a given practice.   However, I cannot think of a use case in which an allergy alert should be altered/suppressed.

The test procedure developed by NIST is faithful to the certification criterion adopted in the Standards and Certification final rule.  ONC has received comments on this issue from several stakeholders and is reviewing them.

3.  In many ambulatory settings, clinicians use a hospital information system to route medication prescriptions to in hospital pharmacies.   Hospital-based systems are more likely to use HL7 for in hospital message routing instead of NCPDP, the standard used for e-prescribing.  Is this acceptable?

The Standards and Certification final rule does not specify the standards to be used for in hospital medication workflows, so HL7 routing from ambulatory care clinics to an internal outpatient pharmacy is fine.  However,  to be designated as  "Certified EHR technology", the hospital information system must also have the capability (used or unused) of routing prescriptions to external retail or mail order pharmacies using NCPDP Script.

I hope this is helpful.

A Customer Emotion Dashboard

The job of a CIO is filled with challenges.   There's a delicate balance in constant flux among:

*Short term urgencies  
*Long term strategies
*Ever changing compliance/regulatory requirements
*Day to day operations
*Budgets

What's the right objective measure of success?

Uptime?
On time, on budget project performance?
Positive feedback from your Governance groups?

All of these can look rosy but customers can still be unhappy.   The juggling of IT supply and customer demand means than not all projects can be done.   The complexity of IT work means that projects will take longer than customers expect.   All communications plans, no matter how comprehensive will still miss some stakeholders.    The end result of all of this is customer dissatisfaction.

A CIO can never achieve 100% customer satisfaction.   In fact, if only 10% of my customers dislike me on a given day, then I've achieved a stellar approval rating.

By human nature, we want to make everyone happy and avoid conflict.  When I lecture about my top 10 leadership principles for surviving as a CIO:

10. Select your change and what not to change
9. Identify those who will lose
8. Acknowledge their loss
7. Over Communicate
6. Be Honest and Consistent
5. Consensus is not essential
4. Embrace conflict
3. Focus on your detractors
2. The last two minutes of the meeting are the most important
1. You cannot please everyone

#1 is that you cannot please everyone.   There will never be enough budget, enough staff, or enough governance to ensure everything is perfect.

Normally, the naysaying can be addressed through focused customer service, planning, and conversation.

However, it's getting harder now that the economy is challenging and expectations of technology support are escalating i.e. "I just bought a new smartphone yesterday, how come you do not provide application support for it?'

The level of tension in every sector is increasing.   Civility is diminishing.

This means that I must carefully monitor the pulse of all my customers.

I've emailed my staff that at our next leadership meeting, I'd like to develop a new type of scorecard for each major stakeholder group.   I will empower my staff to rate the emotional trajectory of each group as red/yellow/green.  With such a scorecard, I'll be able to anticipate growing discontent before it escalates and then focus my time and energy on detractors, embracing conflict to proactively change strategy and tactics before it's too late to change.

A customer dashboard based on the trajectory of stakeholder emotion rather than budgets, projects and timelines - I have a feeling that it will be very effective in directing my management focus, especially in trying times.

I'll let you know how it works by the end of 2010.

Cool Technology of the Week

Over the past year, I've tested the Cisco Telepresence CTS 500 and Tandberg EX-90 video teleconferencing technologies in my home.   They've worked very well to reduce my travel schedule but they are more expensive than a typical consumer would want to spend.

This week, Cisco introduced the umi (You-Me) a home telepresence unit that will be sold by Best Buy for $599 starting October 18.   It requires an internet connection, an HDMI connection to an existing HDTV, and a PC or Mac for checking video voice mail.

HDTV video conferencing in the home for $599.    That's cool!

Forming, Storming, and Norming

In my Palos Verdes High School AP US History class (1979),  I studied the writings of Alexis de Tocqueville, the Frenchman who observed American life and then wrote Democracy in America. Ask anyone what he said, and you'll hear some variation of "America is a nation of joiners."


In my career as an IT leader, I've convened many groups, governance bodies, and new organizations.    As new groups gather, everyone wants to participate to avoid being left out of the new, new thing.

The Forming is easy, but soon after, as issues such as governance, strategy, business/operations, and priorities are discussed, there's Storming.

Everyone wants to ensure their point of view, their authority, and their visibility is preserved.    In large, multi-stakeholder organizations, this can be challenging.

Eventually, a stable governance group emerges, priorities are developed by consensus, and relationships are fostered, creating a level of stability - the Norming of the greater good.

One everything is humming, the group begins Performing, embracing change and achieving its goals.

This Forming, Storming, Norming and Performing pattern is called Tuckman's Stages of Group Development.

Since it's Thursday, a day for my personal blogs, here's my advice on Tuckman's stages.

When you're forming or joining a new group, expect conflict.  Don't fear it and don't fight it.    Acknowledge it and work with it.  Conflict (the "Storming") can create a sense of urgency among participants to solve problems.   Conflict can lead to stronger relationships and catalyze change.

During the Storming phase, the only thing that can hurt your reputation is a public outburst of emotion.   As I've said many times before, for everything there is a process that will resolve today's problems.    A year from now, no one will even remember today's problems.

Our job as leaders is to navigate the conflict that comes with Storming, listen to the stakeholders, and steer the group toward Norming.   It takes time and energy.   It takes patience.

I recently talked to a colleague about a particularly emotional public meeting that had dozens of highly charged stakeholders.   My colleague did not remember the nature of the conflict, but did remember that I listened, acknowledged the speakers, and suggested a process to move us forward.

As long as you know to expect conflict whenever you form a group, you can remain unaffected by it.

Put another way - your adversaries only win if you let them get to you.

Go forward and Norm!

The Harvard High Performance Computing Summit

This is as close as I get to advertising on my blog - my group at Harvard Medical School (HMS) runs a yearly high performance computing summit to foster information exchange among colleagues.  Here's the story:

Over the past 5 years, the dramatic increase in biomedical data has catalyzed a need for high performance storage, high performance compute clouds, and new approaches to making information technology accessible to researchers.  At HMS, we have made great progress in addressing these needs and we continue to plan for the future.

The availability of genomic data and new information-rich data collection approaches of all kinds (such as imaging) require new approaches and new methodologies.  Computational methods, once a sideline for biomedical researchers, have become a required enabler of discovery.  Some laboratories no longer  have a wet-lab component, but instead use computational methods as their primary research method.  The scope and scale of research computing is no longer supportable by systems sequestered under the lab bench or in ad-hoc data closets.  The resources that are needed now require skilled IT professionals, scalable and fault tolerant infrastructure, and adaptive learning from other fields that have already undergone this transformation such as high energy physics. Storage requirements have grown from gigabytes to terabytes to the petabyte scale.   Processing power has grown from clusters of a dozen computers to thousands of simultaneous processing cores.

Unfortunately few of my colleagues in high performance computing have the time to share approaches and learn from their fellow leaders at other institutions. Four years ago we set out to solve this problem by creating the Biomedical High Performance Leadership Summit to exchange ideas, approaches and solutions to the challenges facing biomedical IT organizations. We are convening it again this year with the hope that the biomedical researchers and service providers can learn from other computational fields and build infrastructure to meet research needs.

This year's conference has four themes:

    * Scaling storage: managing storage in the age of the petabyte (and beyond)
    * Organizational scaling: building sustainable HPC centers
    * Collaborative computing: grids, clouds and open computing
    * Getting science done: making HPC work for researchers

I invite leaders in biomedical high performance computing to join me at the summit,  which includes keynotes from myself and George Church, industry updates from Chris Dagdigian and Addison Snell, and key lessons learned from John (Jay) R. Boisseau and Phil Papadopoulos.

For more information check out the website.

I hope to see you at Harvard for the Summit on October 17-19!

Wall Poster Resources for Meaningful Use and Standards

Robin Raiford from Allscripts has created 32"x48" and 42"x60" wall posters which illustrate all the Meaningful Use Stage 1 Measures and the Standards associated with them.  You can have them printed at FedEx Office (formerly Kinko's) or other poster printing shop.

If you want to view them on a small screen, you'll need to use the zoom feature of your PDF reader and scroll around to see the content.

I hope you find these useful.

Clarifying Certification

NOTE  - this post was extensively revised at 3pm on October 4, 2010 based on new information from authoritative sources.

On October 1, CCHIT announced certification of 33 complete and modular EHRs.  Drummond Group announced 3 certifications.

Meaningful Users must utilize "Certified EHR Technology".   Many folks are asking about the terms "complete EHR certification", "modular EHR certification", and "site certification". Let's start with the regulatory definition of “Certified EHR Technology” and what it takes to meet that definition.  How this certification is achieved - complete, modular, or site does not make a difference.

45 CFR 170.102
Certified EHR Technology means:
(1) A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary; or
(2) A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.

Complete EHR means EHR technology that has been developed to meet, at a minimum, all applicable certification criteria adopted by the Secretary.

EHR Module means any service, component, or combination thereof that can meet the requirements of at least one certification criterion adopted by the Secretary.

For example “all applicable certification criteria” for an Certified EHR Technology designed for an ambulatory setting would be to all certification criteria adopted at 45 CFR 170.302 and 170.304 (general certification criteria, and ambulatory specific certification criteria).  For inpatient EHRs it would be 45 CFR 170.302 and 170.306 (general certification criteria, and inpatient specific certification criteria)

Regardless of whether one uses a Complete EHR, a combination of EHR Modules or a Site certification, all certification criteria need to be met in all settings.  In other words, a proper combination of EHR Modules, if seen as a black box, would be a Complete EHR.  In order to meet the definition of Certified EHR Technology, no matter how one achieves it (using a Complete EHR, combination of EHR Modules, or Site Certification) all the boxes need to be checked.   See this FAQ posted by ONC.

It's likely that many existing EHRs will achieve modular certification - having most but not all needed functionality.   It's perfectly reasonable to use your existing EHR for the majority of the functionality you need, then supplement it with a data warehouse or health information exchange to achieve all the certifications necessary.

There will be many interesting lessons learned in this first round of certification.

1.  As I've reported previously, the Syndromic Surveillance implementation guide in the Standards Final rule is incorrect.   However, until it is fixed, vendors must implement the wrong data exchange in order to be certified because that is what the NIST testing site specifies.

2.  Some vendors may opt to be modular EHRs now and evolve to become complete EHRs as data exchange issues are clarified.  

3.  Testing procedures are going to evolve in these early days of certification and that is going to be challenging for vendors to support.   For example, NIST currently offers an e-prescribing validation procedure for NCPDP e-Prescribing formats using EDI but not XML implementations.  The HIT Standards Committee and the Standards Final Rule did not limit the transaction to just the EDI type.   Thus, it's likely NIST will change their testing criteria to support both EDI and XML.

  In the end, it will fall to the purchaser to ensure their goals are aligned with vendor plans.     If purchasers are seeking modules to expand the capabilities of an existing EHR, that should be clear.   If purchasers want a complete EHR and their preferred vendor is currently a module,  purchasers should request an agreement that the vendor will offer a complete EHR in a set period of time.

Cool Technology of the Week

For years, I've said that the ideal computing device for clinicians is simple:

1.  Under 1 pound
2.  8-12 hour battery life
3.  5x7 inch form factor that can fit into an white coat pocket
4.  Easy to disinfect (medicine is messy)
5.  Can be dropped 5 feet onto carpet without significant damage

I predict that the iPad and the plethora of new similar devices are going to be the emerging clinical platform of choice for healthcare in 2011.

The latest announcement from RIM, the Playbook, seems to address my requirements list very well - it's small, lightweight, and advertised as stable/reliable/secure/enterprise ready.

Of course, it will be interesting to watch how the developer marketplace responds given that its operating system (QNX) is not Android nor the iPhone/Ipad iOS.

However, since all my applications are browser-based, in many ways we do not care what device users choose as long as it is secure.

Nirvana for clinical computing devices is finally arriving.   That's cool