The November HIT Standards Committee meeting focused on existing implementations of point to point transport standards as a foundation for its evaluation of the Direct project.
We began the meeting with a report from the Implementation Workgroup, which will gather testimony on January 10-11, 2011 about the experience of implementing standards in certified systems and achieving meaningful use goals.
We discussed the work of the other HIT Standards Committee workgroups including the upcoming effort by the Vocabulary Task Force to take testimony on device content and vocabulary standards. Given the evolving importance of home care devices, implantable devices, and mHealth, ensuring robust standards in this area is important.
We started the day's testimony noting that we will be discussing just point to point "push" use cases this month. Typical components of such an approach are a routing method, a provider directory, certificate management, auditing, and acknowledgement of delivery. Use cases covered by the "push" approach include PCP to specialist referrals, routing to registries, e-prescribing data exchanges between providers/pharmacies, and sending summaries to patients.
Here are links to the testimony:
Peter Tippett, Verizon
John Feikema, Visionshare
Joseph Carlson, Covisint
Anand Shroff, Axolotl
Cris Ross, Surescripts
Eric Dishman & Gary Binder, Intel
After the testimony we summarized the major themes.
Directories - Proposed directory options ranged from a nationally centralized yellow pages of organizations to a federated white pages of persons/departments/machines to undiscoverable local directories. Email is an example of a directory which is generally undiscoverable outside an organization. Once you know the email address of a person, email gateways route from organization to organization. Once email arrives at the organization, it is routed to the recipient using a local directory. Whatever directory and addressing scheme is chosen, it is very important that all vendors support it to achieve a network of networks that enables any provider to connect to any other provider.
Identity/Trust - Each of the vendors is using X.509 certificate-based approaches to secure organization to organization transport plus a formal certificate management approach (based on policy) to verifying identity and achieving a trust fabric. Creating a chain of trust among vendors is very important to supporting network to network transport.
Transport - SMTP/SMIME, REST, and SOAP have all been used successfully in the real world as transport standards for health information exchange. Achieving common directories and a trust fabric are more important than settling on a single transport protocol. However, in the interest of keeping the architecture simple, there should be few, not many standards options for transport. Having at least one common transport approach to enable universal addressing is desirable.
The internet itself is based on a small number of standards specifying directories such as the Domain Naming System (DNS) system, which is implemented in a federated architecture. The internet has a small set of standards enabling certificate authorities to act as "electronic notaries", establishing identity and trust. On top of this foundation of directories and trust, there are multiple transport protocols that used to support specific use cases such as HTTPS, FTP, SMTP, etc. Push-based healthcare information exchange should use an analogous approach - get the directory/addressing and identify/trust right, then use the transport standards that best support workflow and are easy to implement.
Our next steps are to get policy guidance from the HIT Policy Committee Provider Directory Workgroup, review the Implementation guides from the testifying vendors who have successfully implemented a trust fabric, and assemble a multi-stakeholder team of interested participants from the HIT Standards Committee to evaluate NHIN Direct. We'll use objective criteria, informed by today's testimony to consider NHIN Direct on its own merits, evaluating its implementation specifications against the project goals to be simple, direct, scalable, and secure transport for the little guy.
Tuesday, November 30, 2010
Monday, November 29, 2010
A Milestone for the Direct Project
Nine months ago, I wrote about the NHIN Direct project and its effort to enable health information exchange for the little guy.
Since then, I've written many times about the need to transport standard specifications to accelerate interoperability. It's even one of my FY11 keep me awake at night topics.
Today, the Direct Project team issued this press release.
As Arien Malec, Coordinator of the Direct Project, noted in his Thanksgiving message to the project participants:
"We have two specifications that are content complete (needing editorial review and revision); two reference implementations that are at a 1.0 state and can "out of the box, just add trust" enable exchange with a simple install and configuration; some amazing documentation, from the elegant generalist overview, to the most geeked out installation and programming guides; a compelling presentation; solid best practices and security reviews to protect privacy, security and trust; and some incredible implementation geographies integrating directed exchange into physician workflow to enable meaningful use and improved quality."
This effort is terrific and I look forward to the thorough analysis of the implementation specifications that the HIT Standards Committee will do over the next month to ensure the work meets the design requirements for simple, direct, scalable, and secure transport.
Tomorrow, the HIT Standards Committee begins that process by taking public testimony from six leading HIE vendors. It will be interesting to see who commits to implementing Direct and how they compare its specifications to other implementations of SOAP, REST, and SMTP for point to point data exchange.
There is no question that having alignment and energy behind a data transport solution is a critical need for the industry. You don’t need to go any further than a hospital referral department, awash in paper and fax machines, to know that this is really important.
Since then, I've written many times about the need to transport standard specifications to accelerate interoperability. It's even one of my FY11 keep me awake at night topics.
Today, the Direct Project team issued this press release.
As Arien Malec, Coordinator of the Direct Project, noted in his Thanksgiving message to the project participants:
"We have two specifications that are content complete (needing editorial review and revision); two reference implementations that are at a 1.0 state and can "out of the box, just add trust" enable exchange with a simple install and configuration; some amazing documentation, from the elegant generalist overview, to the most geeked out installation and programming guides; a compelling presentation; solid best practices and security reviews to protect privacy, security and trust; and some incredible implementation geographies integrating directed exchange into physician workflow to enable meaningful use and improved quality."
This effort is terrific and I look forward to the thorough analysis of the implementation specifications that the HIT Standards Committee will do over the next month to ensure the work meets the design requirements for simple, direct, scalable, and secure transport.
Tomorrow, the HIT Standards Committee begins that process by taking public testimony from six leading HIE vendors. It will be interesting to see who commits to implementing Direct and how they compare its specifications to other implementations of SOAP, REST, and SMTP for point to point data exchange.
There is no question that having alignment and energy behind a data transport solution is a critical need for the industry. You don’t need to go any further than a hospital referral department, awash in paper and fax machines, to know that this is really important.
Friday, November 26, 2010
Cool Technology of the Week
I've written about my goal to be as low impact as I can be over the rest of my life, eventually retiring to a small, green engineered cabin in the woods and taking inspiration from early architectural innovators.
To support that goal, I'm always learning about new technologies that support green living.
In February I wrote about innovative lighting using LEDs. Since then, I've learned a great deal about building codes, efficiency measures, and physics. Here's how to be an intelligent consumer of emerging LED lighting technology.
You'll find that LED bulbs from Sylvania, Philips, and EcoSmart are sold based on wattage i.e. it's a replacement for a 40W bulb.
That really does not mean anything.
The amount of light produced for the wattage consumed is the measure of interest.
The "40W" LED bulbs produced by Sylvania in February produced 350 lumens of light using 8 watts of power. The current Sylvania bulbs produce 450 lumens of light using 8 watts of power. How does that compare to an incandescent? A typical incandescent 40 watt bulb produces 500 lumens of light. How about compact fluorescents? A typical compact fluorescent equivalent to a 40W incandescent bulb produces 450 lumens of light using 9 watts of power.
How do we evaluate the lighting efficiency of these bulbs? The right measure is lumens/watt (lm/w)
Incandescent - 500lm/40w = 12.5 lm/w
Compact Fluorescent - 450lm/9w = 50 lm/w
First generation LED 350lm/8w = 43.75 lm/w
Second generation LED 450lm/8w = 56.25 lm/w
Just announced LED products include a downlight with 1439 lumens at 82 lm/w and a new LED "60W" bulb with 810 lumens at 67.5 lm/w.
With LEDs producing more light and less heat for less energy than compact fluorescents without mercury or other toxic concerns, they are clearly the future. Also, the bulb life of LEDs is 25,000 hours. Compact fluorescents typically have a rated lifespan of between 6,000 and 15,000 hours, whereas incandescent lamps have a lifespan of 750 hours or 1,000 hours.
The only issue is acquisition cost of LEDs, since total cost of ownership based on energy savings and bulb life has a reasonable return on investment. Current industry predictions are that LEDs will match the cost of compact fluorescents within 2 years.
All of this is good news for compliance with the 2009 International Energy Conservation Code (which I'll follow for my cabin in the woods). It requires:
60 lm/w for bulbs over 40W
50 lm/w for bulbs 16W to 40W
40 lm/w for bulbs 15W and under
The LEDs coming into the marketplace now accomplish this nicely. Lighting an entire house with 100 watts of power- that's cool!
Thursday, November 25, 2010
A Time to Give Thanks
Last week I was on a flight to Dallas and forgot my airplane reading, so I purchased a copy of The Economist 2011 Forecast Issue.
While perusing articles about war, population growth, economic struggle, environmental challenges, and the growing divide between the haves and have nots, I had the sobering realization that the things keeping me up at night are truly minor in comparison.
Reflecting on the past year, I do not even remember the projects, problems, and conflicts that seemed so urgent 12 months ago. I do not remember the meetings I felt guilty about missing because I triaged other things first. I do not remember the times I was late and felt too rushed to let in that driver trying to merge.
Our jobs are important and can define much of our self worth. But jobs are transient. Bosses come and go, organizational priorities change, and your personal star can rise and fall. No one has a gravestone the reads "my only regret is that I did not attend more meetings". I do remember those times I brought stress home, missed a family event, or stared at email while my family waited to start dinner.
So put away your Blackberry, stop the tweeting, change your Facebook status to 'focusing on my family' and embrace your loved ones. Today is a day for giving thanks to the people around us, the relationships we've made, and the effort we need to put into sustaining them.
We're carving the roasted vegetables, ladling the squash soup and filing the rice bowls. Everyone is healthy and our trajectory is good.
It's time to give thanks.
While perusing articles about war, population growth, economic struggle, environmental challenges, and the growing divide between the haves and have nots, I had the sobering realization that the things keeping me up at night are truly minor in comparison.
Reflecting on the past year, I do not even remember the projects, problems, and conflicts that seemed so urgent 12 months ago. I do not remember the meetings I felt guilty about missing because I triaged other things first. I do not remember the times I was late and felt too rushed to let in that driver trying to merge.
Our jobs are important and can define much of our self worth. But jobs are transient. Bosses come and go, organizational priorities change, and your personal star can rise and fall. No one has a gravestone the reads "my only regret is that I did not attend more meetings". I do remember those times I brought stress home, missed a family event, or stared at email while my family waited to start dinner.
So put away your Blackberry, stop the tweeting, change your Facebook status to 'focusing on my family' and embrace your loved ones. Today is a day for giving thanks to the people around us, the relationships we've made, and the effort we need to put into sustaining them.
We're carving the roasted vegetables, ladling the squash soup and filing the rice bowls. Everyone is healthy and our trajectory is good.
It's time to give thanks.
Wednesday, November 24, 2010
What Keeps Me Up at Night - FY11 edition
Every year, I reflect on those projects that are risky or so fraught with change management peril that they keep me up at night (it's a metaphor, since I sleep soundly for 4 hours a night). Here's the FY11 edition of my concerns in each of my 5 lives:
Federal
*Transport Standards - the Standards and Certification Final Rule provided detailed implementation guides for Content, Vocabulary, and Security standards but nothing for Transport standards. NHIN Direct and numerous private sector approaches are piloting REST, SOAP, and SMTP approaches to send data from point A to point B. We need to converge on a single approach for Transport by 2011 to accelerate interoperability and avoid the chaos of 50 different state HIE implementations.
*Mobile and Homecare Devices - As Ray Ozzie described in his farewell memo to Microsoft staff, mobile devices such as phones, iPads, smart appliances, and wearable sensors are likely to serve as the human-application interface in the future. We need content, vocabulary, security, and transmission standards to support interoperability of all the devices we'll use.
*Vocabulary Resources - We need a one stop shop for all the vocabularies and code sets required to support Meaningful Use Stages 1, 2, and 3. This resource needs to be easy to use and free (see Intellectual Property issues below)
*Intellectual property issues - Today, most standards implementation guides are incomplete because they cannot include the intellectual property from Standards Development Organizations (SDOs) without disrupting the business models of those organizations. We need a new model - government funding, a simple annual assessment paid to a government agency/administrative organization to enable download of complete implementation specifications, or some combination of public/private funding. Otherwise we'll suffer the problem of indirection - incomplete implementation guides which refer to proprietary information which refer to proprietary information etc. Here's an example of a perfect implementation guide from the Social Security Administration - everything you need to create seamless interoperability without indirection.
*Adoption and Implementation - Standards are not imposed, they are adopted. The measure of success for all Federal standards efforts will be the number of transactions flowing in 2011, 2013 and 2015 using the harmonized standards selected to support meaningful use.
State
*Governance - The Commonwealth of Massachusetts is exploring several HIE Governance models and needs to implement open, transparent, public/private governance to ensure trust and investment from the private sector.
*Procurement - The Commonwealth needs to procure directory services, certificate management services, and routing services to support all unconnected stakeholders.
*Sustainability - The Commonwealth needs to consider subscription, transaction, assessment, government subsidy, and bond offerings to provide a sustainability model for the HIE which connects all stakeholders
*Connecting the little guy - A public good HISP (healthcare information services provider) needs to provide healthcare information exchange at low cost to small practices that may not be served by the private sector because of the expense of implementing connectivity to a small, isolated site.
*Moving at meaningful use speed - The Commonwealth needs to have these solutions in place by 2011. Hospital meaningful use attestation needs to be done by November 2011, so we need to act now on Governance, Procurement, and Sustainability.
Harvard Medical School
*Research liaison - The research community at Harvard needs a scientist and a team of experts who can translate challenging scientific problems into creative IT solutions. Our traditional method of providing storage services, high performance computing, and software licensing is no longer sufficient. We need to merge science and IT in novel ways.
*Extranet migration to a content management system - Like many organizations, Harvard's web presence is a collection of sites created by departments, labs, and administrators. It needs to be completely transformed into a content management system with a common look and feel, Google search, and federated authoring/editing.
*Sustainability model for staff and infrastructure - In challenging economic times, getting additional FTEs/operating budget is problematic. However, ARRA funds have brought new demands, new infrastructure, and new services to Harvard, all of which require additional staff. There needs to be an NIH compliant direct and indirect cost chargeback model which enables IT to grow organically as new grants are received.
*Compliance and Security - In all my organizations, 2011 is going to be a year of increased compliance. Harvard has new data security rules. Internal audit is focusing on applications which manipulate person identified data. Conflict of Interest tracking requires new reporting capabilities. The reaccreditation of Harvard Medical School in 2011 will bring increased scrutiny to business processes. Labs require new training and certifications for safety, administered electronically.
*Matching IT supply and demand through Governance - In all my organizations, 2011 is the year of Governance. As we emerge from the economic doldrums of 2009-2010 we have the potential to increase FTEs. Governance committees for research, administration, and education can balance supply and demand as well as advocate for new resources.
BIDMC
*Certification/Behavioral Change for Meaningful Use - During the week of December 6, I'll work with CCHIT to certify all the hospital and ambulatory systems of BIDMC, both built and bought, as part of their Site Certification program. I'll document the experience so that other hospitals with heterogeneous systems will be successful in achieving certification. The real risk is that private clinicians in the community will not find incentives compelling and will not use EHRs in a meaningful way over the next several years, making quality measurement, global payments, and accountable care organization implementation difficult.
*Preparing for healthcare reform and accountable care organizations - Is it better to create a strategic plan to become an Accountable Care Organization or be an opportunist, creating affiliations and IT integration on the path of healthcare reform over the next few years, given the continuously changing policy landscape? We're creating the foundation by ensuring BIDMC can send and receive healthcare data with patient consent to any provider organization, public health entity, or registry which measures outcomes on our behalf.
*Clinical Documentation (including ICD-10 and Medication Management) - 2013 is right around the corner and we need full compliance with 5010 and ICD-10 standards in our clinical and financial systems. More importantly, we need robust clinical documentation in all areas of care to be able to justify the ICD-10 codes that our HIM professionals select. We also need robust medication management including bedside medication verification and electronic medication administration records to support Stage 2 and Stage 3 of meaningful use in 2013 and 2015. This will require a substantial effort by business owners to define new workflows and automation requirements.
*Ever Increasing Demands for Compliance and Security - Just as with HMS, there will be numerous compliance efforts in the next year - FLSA compliance with advanced time keeping systems, followup to our Joint Commission and CMS visits to ensure we meet all their criteria, and increasingly sophisticated monitors/audits to address new Massachusetts Data Protection requirements.
*Matching IT supply and demand through Governance - The BIDMC IS Governance Committees help match supply and demand, set priorities/timing, and support the need for additional resources. Increased resources for project management, allocation of appropriate resources for ongoing support/maintenance of technology, and reduction of mid-year unplanned projects are essential to our success.
Personal
*Parents - After their recent hospitalizations, I need to support them in any way I can to keep them healthy and happy.
*Daughter - As my daughter approaches adulthood (she'll be 18 in 2011), I need to provide a balance of guidance and independence. We'll hear about her college application (early decision to Tufts) in 3 weeks.
*Wife - My wife and I have been together for 30 years. In 2011, we'll transition to empty nesters, entering a new stage of our lives. We'll continue our morning walks, our moonlight conversations, and our enjoyment of the world around us.
*Self - In 2011, I'll continue allocating time for mental and physical health. My outdoor activities - hiking, biking, kayaking, climbing, and skiing ensure I keep a clear mind and fit body.
*The world around me - In the interesting of leaving my daughter with a world she can thrive in, I'm reducing my carbon footprint by eliminating travel whenever possible, focusing on Green energy, and maximizing sustainability in my lifestyle choices.
That's what keeping me up at night this year. The great joy about life is that I never know what next year will bring!
Federal
*Transport Standards - the Standards and Certification Final Rule provided detailed implementation guides for Content, Vocabulary, and Security standards but nothing for Transport standards. NHIN Direct and numerous private sector approaches are piloting REST, SOAP, and SMTP approaches to send data from point A to point B. We need to converge on a single approach for Transport by 2011 to accelerate interoperability and avoid the chaos of 50 different state HIE implementations.
*Mobile and Homecare Devices - As Ray Ozzie described in his farewell memo to Microsoft staff, mobile devices such as phones, iPads, smart appliances, and wearable sensors are likely to serve as the human-application interface in the future. We need content, vocabulary, security, and transmission standards to support interoperability of all the devices we'll use.
*Vocabulary Resources - We need a one stop shop for all the vocabularies and code sets required to support Meaningful Use Stages 1, 2, and 3. This resource needs to be easy to use and free (see Intellectual Property issues below)
*Intellectual property issues - Today, most standards implementation guides are incomplete because they cannot include the intellectual property from Standards Development Organizations (SDOs) without disrupting the business models of those organizations. We need a new model - government funding, a simple annual assessment paid to a government agency/administrative organization to enable download of complete implementation specifications, or some combination of public/private funding. Otherwise we'll suffer the problem of indirection - incomplete implementation guides which refer to proprietary information which refer to proprietary information etc. Here's an example of a perfect implementation guide from the Social Security Administration - everything you need to create seamless interoperability without indirection.
*Adoption and Implementation - Standards are not imposed, they are adopted. The measure of success for all Federal standards efforts will be the number of transactions flowing in 2011, 2013 and 2015 using the harmonized standards selected to support meaningful use.
State
*Governance - The Commonwealth of Massachusetts is exploring several HIE Governance models and needs to implement open, transparent, public/private governance to ensure trust and investment from the private sector.
*Procurement - The Commonwealth needs to procure directory services, certificate management services, and routing services to support all unconnected stakeholders.
*Sustainability - The Commonwealth needs to consider subscription, transaction, assessment, government subsidy, and bond offerings to provide a sustainability model for the HIE which connects all stakeholders
*Connecting the little guy - A public good HISP (healthcare information services provider) needs to provide healthcare information exchange at low cost to small practices that may not be served by the private sector because of the expense of implementing connectivity to a small, isolated site.
*Moving at meaningful use speed - The Commonwealth needs to have these solutions in place by 2011. Hospital meaningful use attestation needs to be done by November 2011, so we need to act now on Governance, Procurement, and Sustainability.
Harvard Medical School
*Research liaison - The research community at Harvard needs a scientist and a team of experts who can translate challenging scientific problems into creative IT solutions. Our traditional method of providing storage services, high performance computing, and software licensing is no longer sufficient. We need to merge science and IT in novel ways.
*Extranet migration to a content management system - Like many organizations, Harvard's web presence is a collection of sites created by departments, labs, and administrators. It needs to be completely transformed into a content management system with a common look and feel, Google search, and federated authoring/editing.
*Sustainability model for staff and infrastructure - In challenging economic times, getting additional FTEs/operating budget is problematic. However, ARRA funds have brought new demands, new infrastructure, and new services to Harvard, all of which require additional staff. There needs to be an NIH compliant direct and indirect cost chargeback model which enables IT to grow organically as new grants are received.
*Compliance and Security - In all my organizations, 2011 is going to be a year of increased compliance. Harvard has new data security rules. Internal audit is focusing on applications which manipulate person identified data. Conflict of Interest tracking requires new reporting capabilities. The reaccreditation of Harvard Medical School in 2011 will bring increased scrutiny to business processes. Labs require new training and certifications for safety, administered electronically.
*Matching IT supply and demand through Governance - In all my organizations, 2011 is the year of Governance. As we emerge from the economic doldrums of 2009-2010 we have the potential to increase FTEs. Governance committees for research, administration, and education can balance supply and demand as well as advocate for new resources.
BIDMC
*Certification/Behavioral Change for Meaningful Use - During the week of December 6, I'll work with CCHIT to certify all the hospital and ambulatory systems of BIDMC, both built and bought, as part of their Site Certification program. I'll document the experience so that other hospitals with heterogeneous systems will be successful in achieving certification. The real risk is that private clinicians in the community will not find incentives compelling and will not use EHRs in a meaningful way over the next several years, making quality measurement, global payments, and accountable care organization implementation difficult.
*Preparing for healthcare reform and accountable care organizations - Is it better to create a strategic plan to become an Accountable Care Organization or be an opportunist, creating affiliations and IT integration on the path of healthcare reform over the next few years, given the continuously changing policy landscape? We're creating the foundation by ensuring BIDMC can send and receive healthcare data with patient consent to any provider organization, public health entity, or registry which measures outcomes on our behalf.
*Clinical Documentation (including ICD-10 and Medication Management) - 2013 is right around the corner and we need full compliance with 5010 and ICD-10 standards in our clinical and financial systems. More importantly, we need robust clinical documentation in all areas of care to be able to justify the ICD-10 codes that our HIM professionals select. We also need robust medication management including bedside medication verification and electronic medication administration records to support Stage 2 and Stage 3 of meaningful use in 2013 and 2015. This will require a substantial effort by business owners to define new workflows and automation requirements.
*Ever Increasing Demands for Compliance and Security - Just as with HMS, there will be numerous compliance efforts in the next year - FLSA compliance with advanced time keeping systems, followup to our Joint Commission and CMS visits to ensure we meet all their criteria, and increasingly sophisticated monitors/audits to address new Massachusetts Data Protection requirements.
*Matching IT supply and demand through Governance - The BIDMC IS Governance Committees help match supply and demand, set priorities/timing, and support the need for additional resources. Increased resources for project management, allocation of appropriate resources for ongoing support/maintenance of technology, and reduction of mid-year unplanned projects are essential to our success.
Personal
*Parents - After their recent hospitalizations, I need to support them in any way I can to keep them healthy and happy.
*Daughter - As my daughter approaches adulthood (she'll be 18 in 2011), I need to provide a balance of guidance and independence. We'll hear about her college application (early decision to Tufts) in 3 weeks.
*Wife - My wife and I have been together for 30 years. In 2011, we'll transition to empty nesters, entering a new stage of our lives. We'll continue our morning walks, our moonlight conversations, and our enjoyment of the world around us.
*Self - In 2011, I'll continue allocating time for mental and physical health. My outdoor activities - hiking, biking, kayaking, climbing, and skiing ensure I keep a clear mind and fit body.
*The world around me - In the interesting of leaving my daughter with a world she can thrive in, I'm reducing my carbon footprint by eliminating travel whenever possible, focusing on Green energy, and maximizing sustainability in my lifestyle choices.
That's what keeping me up at night this year. The great joy about life is that I never know what next year will bring!
Tuesday, November 23, 2010
Clinical Systems Goals for FY11
Every year, the IS governance committees of BIDMC translate the organization's short term and long term strategy into IS priorities and projects. Clinical Systems is a particularly challenging area because so many of the workflow innovations require inventing automation that is not commonplace in US hospitals and clinics.
Here's our complete Clinical Systems strategy and staffing for FY11. We have a very lean team given that we support 6000 clinicians and staff at BIDMC plus over 10,000 affiliated users.
For FY11, major areas of innovation include
*Elimination of the last handwritten orders in the organization, which requires innovative CPOE approaches in the NICU and ED
*Innovative surveillance and analytic approaches to support infection control and anti-microbial management
*Closing the loop between PCPs and specialists to ensure referrals are completed and documented including alerting PCPs if patients do not schedule a specialist appointment
*Ensure all diagnostic test results are delivered to the person who ordered them and signed off, with followup arranged for abnormal results.
*Enhanced Healthcare Information Exchange in support of meaningful use
*Creative approaches to clinical documentation in the acute care setting including templates, macros, wikis, and social networking approaches to collaboration
*Move us closer to a completely electronic inpatient ("paperless charts") workflow by automating paper forms
*Scanning paper from outside organizations so that even non-electronic referrals are added to our electronic documentation
*Enterprise image management that archives all modalities (radiology, cardiology, pulmonology, ob/gyn etc.) in one repository for viewing anywhere, anytime, using a common viewer
*Business Intelligence that turns data into information, knowledge, and wisdom using advanced reporting and analysis tools in MS SQLServer and related technologies.
*Intranet and Extranet enhancements that move us from a reliance on shared files and email to blogs, wikis, tag clouds, and crowdsourcing
For 2011, we'll be adding three programmers, one analyst, an enterprise PMO director, and 2 infrastructure support staff, so resources are coming after the economic doldrums of 2009.
Our next step is to achieve certification of all inpatient and outpatient built and bought systems, which will complete by the end of the year. Our Meaningful Use reporting period will be January-March followed by attestation in April. Our complete replacement of all laboratory information systems goes live in June and we'll be done with all our community EHR rollouts, supporting 1700 clinicians by Summer.
2011 will be a banner year for Clinical Systems.
Here's our complete Clinical Systems strategy and staffing for FY11. We have a very lean team given that we support 6000 clinicians and staff at BIDMC plus over 10,000 affiliated users.
For FY11, major areas of innovation include
*Elimination of the last handwritten orders in the organization, which requires innovative CPOE approaches in the NICU and ED
*Innovative surveillance and analytic approaches to support infection control and anti-microbial management
*Closing the loop between PCPs and specialists to ensure referrals are completed and documented including alerting PCPs if patients do not schedule a specialist appointment
*Ensure all diagnostic test results are delivered to the person who ordered them and signed off, with followup arranged for abnormal results.
*Enhanced Healthcare Information Exchange in support of meaningful use
*Creative approaches to clinical documentation in the acute care setting including templates, macros, wikis, and social networking approaches to collaboration
*Move us closer to a completely electronic inpatient ("paperless charts") workflow by automating paper forms
*Scanning paper from outside organizations so that even non-electronic referrals are added to our electronic documentation
*Enterprise image management that archives all modalities (radiology, cardiology, pulmonology, ob/gyn etc.) in one repository for viewing anywhere, anytime, using a common viewer
*Business Intelligence that turns data into information, knowledge, and wisdom using advanced reporting and analysis tools in MS SQLServer and related technologies.
*Intranet and Extranet enhancements that move us from a reliance on shared files and email to blogs, wikis, tag clouds, and crowdsourcing
For 2011, we'll be adding three programmers, one analyst, an enterprise PMO director, and 2 infrastructure support staff, so resources are coming after the economic doldrums of 2009.
Our next step is to achieve certification of all inpatient and outpatient built and bought systems, which will complete by the end of the year. Our Meaningful Use reporting period will be January-March followed by attestation in April. Our complete replacement of all laboratory information systems goes live in June and we'll be done with all our community EHR rollouts, supporting 1700 clinicians by Summer.
2011 will be a banner year for Clinical Systems.
Monday, November 22, 2010
Smart Medication Reconciliation and Problem Lists
Last week, I spent a few days in California when both my parents ended up in the hospital with different issues. They're home, settled and doing well at this point.
Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.
As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.
Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family. What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.
My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.
Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.
The result is that my parents received unnecessary medications as well as did not receive necessary ones.
The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.
How do we solve this?
1. Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.
2. Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes. Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.
3. At its very simplest, carry a wallet card with an active medication list and problem list.
While in California, I isolated every medication in the house, current and historical. I documented active medications, active problems and the relationship between the medications and the problems. I reviewed the resulting lists will all family members (with their consent). My parents will ensure all their clinicians update their records to reflect this accurate information. They will carry with them to any future hospitalizations. I disposed of historical medications (safely) to prevent any future confusion. I isolated medications for each person so there would be no accidental taking of medications intended for other people.
Admittedly as a clinician, I have the training that enables me to do this.
For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.
As we build electronic systems, the outpatient to inpatient transition will become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.
Just as when I first wrote about experiencing healthcare with my family, there are important lessons to learn about this trip.
As we strive to achieve meaningful use and create health information exchange in the US, the need for smart medication is critical.
Our current national systems do a good job of retrieving a history of medications that were filled or reimbursed, but they do not do a good job of identifying those medications which are active - that is left to the patient or their family. What do you do if the patient is unable to answer, the family is unavailable, or the patient/family does not really know what medications are current.
My family was able to provide history such as "the green capsules, or the pink pill", which were insufficient to achieve accurate medication lists.
Similarly, it can be challenging to retrieve an active problem list from claims data, which is often inaccurate or imprecise.
The result is that my parents received unnecessary medications as well as did not receive necessary ones.
The hospital focused on the acute inpatient problems without attending to the more chronic outpatient ones.
How do we solve this?
1. Ensure every patient has a personal health record, an electronic medical home with an updated medication list and problem list.
2. Implement novel decision support that infers active medications by examining recent refill history and active problems by examining available data sources such as lab history, recent diagnostic studies which imply active diagnoses i.e. a recent high hemoglobin A1c in a patient on insulin implies diabetes. Here's a design from AnvitaHealth, a decision support services provider for which I serve as a Board member.
3. At its very simplest, carry a wallet card with an active medication list and problem list.
While in California, I isolated every medication in the house, current and historical. I documented active medications, active problems and the relationship between the medications and the problems. I reviewed the resulting lists will all family members (with their consent). My parents will ensure all their clinicians update their records to reflect this accurate information. They will carry with them to any future hospitalizations. I disposed of historical medications (safely) to prevent any future confusion. I isolated medications for each person so there would be no accidental taking of medications intended for other people.
Admittedly as a clinician, I have the training that enables me to do this.
For families without clinicians, create a shopping bag of medications and take it to a primary care visit for a family medication reconciliation exercise or ask for the help of health coach.
As we build electronic systems, the outpatient to inpatient transition will become more seamless and accurate, but during this time of evolving connectivity and less than perfect use of electronic health records, I encourage everyone to reconcile their medications and problems, get them into a PHR, and share them widely with family members and caregivers.
Friday, November 19, 2010
Cool Technology of the Week
Today's Cool Technology is more about a trend than a mature product.
In the past few weeks, my email box has been filling up with large organizations announcing new functionality to connect payers, providers, patients, public health, and analytics organizations.
Quest/MedPlus announced its Centergy Data Exchange
Verizon announced its Healthcare Information Exchange and Identity Management products.
AT&T - Announced a suite of healthcare services and the American Hospital Association endorsed AT&T's Healthcare Information Exchange solutions.
Surescripts announced its plans to support clinical information exchange using NHIN Direct implementation guides.
Intersystems announced a contract to implement its HIE solution for the US Army's Implementation of the Virtual Lifetime Electronic Record (VLER)
On November 30, the HIT Standards Committee will seek testimony about emerging commercial HIE solutions. We want to know more about the standards used for secure point-to-point transport of health data between provider organizations. Typical approaches include:
1) A means of authenticating end points (and managing end-point identities and certificates)
2) An encryption solution
3) A means of assuring that data are not modified in transit
4) A messaging protocol (e.g., SMTP, SOAP, REST), and
5) A means of confirming the receipt of messages
As the Committee evaluates NHIN Direct and harmonizes standards to inform future regulatory activity, it would benefit from hearing a summary of the standards chosen to fulfill these needs. The Committee is interested in knowing the approaches to the above, as well as answers to questions such as:
-What factors affected decisions to implement point to point messaging as you did? Would you make the same decision if you were designing it today?
-What do you consider essential requirements for simple, point to point exchanges between two provider organizations?
-Do you exchange information with any federal organizations using the NHIN CONNECT gateway? If so, how is that accomplished?
We'll learn what is real technology and what is in the "powerpoint" stage. I'm hoping we'll hear about real, deployed, standards-based infrastructure to support all the stakeholders in healthcare. With the right policies and infrastructure, we'll achieve the vision of connected healthcare we need to reach accountable care organization nirvana. That's cool.
In the past few weeks, my email box has been filling up with large organizations announcing new functionality to connect payers, providers, patients, public health, and analytics organizations.
Quest/MedPlus announced its Centergy Data Exchange
Verizon announced its Healthcare Information Exchange and Identity Management products.
AT&T - Announced a suite of healthcare services and the American Hospital Association endorsed AT&T's Healthcare Information Exchange solutions.
Surescripts announced its plans to support clinical information exchange using NHIN Direct implementation guides.
Intersystems announced a contract to implement its HIE solution for the US Army's Implementation of the Virtual Lifetime Electronic Record (VLER)
On November 30, the HIT Standards Committee will seek testimony about emerging commercial HIE solutions. We want to know more about the standards used for secure point-to-point transport of health data between provider organizations. Typical approaches include:
1) A means of authenticating end points (and managing end-point identities and certificates)
2) An encryption solution
3) A means of assuring that data are not modified in transit
4) A messaging protocol (e.g., SMTP, SOAP, REST), and
5) A means of confirming the receipt of messages
As the Committee evaluates NHIN Direct and harmonizes standards to inform future regulatory activity, it would benefit from hearing a summary of the standards chosen to fulfill these needs. The Committee is interested in knowing the approaches to the above, as well as answers to questions such as:
-What factors affected decisions to implement point to point messaging as you did? Would you make the same decision if you were designing it today?
-What do you consider essential requirements for simple, point to point exchanges between two provider organizations?
-Do you exchange information with any federal organizations using the NHIN CONNECT gateway? If so, how is that accomplished?
We'll learn what is real technology and what is in the "powerpoint" stage. I'm hoping we'll hear about real, deployed, standards-based infrastructure to support all the stakeholders in healthcare. With the right policies and infrastructure, we'll achieve the vision of connected healthcare we need to reach accountable care organization nirvana. That's cool.
Thursday, November 18, 2010
Japanese Beer
On a mid-winter night in Kyoto in 2009, I enjoyed homemade Tofu at Kiko, my favorite restaurant in Kyoto, just south of Shijo-dori between the Kamagawa River and Kawaramachi-dori behind the Hankyu Department Store, 30 meters south of the Murakami-Ju Japanese pickle store. Mr. Chino (pictured above), who I met for the first time that night, bought me an Asahi "Super Dry".
While sitting with friends from Tokyo Medical University in March of 2010, we shared a Kirin Ichiban.
While enjoying Okonomiyaki in the Gion (Geisha district) of Kyoto, we toasted Suntory during Obon in August of 2009.
Japan is home to many great sakes and beers. The big four beers are Sapporo, Asahi, Kirin, and Suntory.
In the US, most of our Japanese beers come from Canada or US breweries that make beer under license from the Japanese companies, but they pale in comparison to the fresh brews available in Japan.
My favorite Japanese Beer is Sapporo - it has a great hoppy character, a full body, and amazing texture.
Here's a brief history of Japanese beer.
My advice when enjoying beer with your Japanese friends. Due to a polymorphism in alcohol dehydrogenase many Japanese show the effects of alcohol early but tend to clear rapidly. Caucasians tend to show few effects of alcohol early but clear very slowly, meaning that your Japanese friends have much more drinking endurance than you do! Thus, like many things in life, moderation is your best bet to success while enjoying Japanese beer with friends. Kampai!
Wednesday, November 17, 2010
Health Information Exchange Sustainability
As Massachusetts works through Health Information Exchange governance, use cases, and procurement to connect all stakeholders in the Commonwealth, it must ensure sustainability by attracting funding from both the public and private sector. What are possibilities?
Subscription based on value realized - The New England Healthcare Exchange Network (NEHEN) model over the past 13 years has been based on cost avoidance. It used to cost $5.00 per claim to support phone/fax/email/paper workflow. It now costs 25 cents. NEHEN was funded in its first decade by gain sharing - payers and providers funded HIE by contributing a small portion of their savings. We found that subscription models encouraged adoption and innovation since increased data flows meant more value for the subscription fee. Novel uses emerged such as scanning all payers simultaneously to identify eligibility for patients with multiple or ambiguous coverage. Subscription fees for e-Prescribing and clinical exchange are now justified by meaningful use requirements, pay for performance programs, and evolving accountable care organization needs.
Transaction fees - In some states, transaction fees have worked because each transaction creates a cost savings. If it costs you $1.00 to print a lab result and put it in an envelope but only a 20 cent transaction fee to send it electronically, you'll be motivated to accept the transaction fee and pocket the 80 cent savings.
Assessment - Some states have assessed a temporary fee, such as .1 cent per claim, to generate the revenue to build HIE capabilities.
Public funds - since states can run their Medicaid operations more efficiently with automated administrative transactions, care coordination, diseases management, all payer databases etc. they are motivated to invest in HIE construction and operation. Also, given the 90/10 Federal match for Medicaid system enhancement, states can realize substantial benefit through strategic HIE investment.
Bonds - some states have thought about HIEs like highways. A bond measure funds the construction, then "tolls" are charged to pay back the bond. This is a variation on the transaction fee model.
Ultimately the HIE needs to have the trust of the community to encourage investment by all stakeholders. Massachusetts has 10 million in ONC funds for HIE but likely about $50 million in HIE work to connect every stakeholder. That means that $40 million dollars in private sector funds need to be committed to HIE activities over the next few years. NEHEN already attracts $7 million from Eastern Massachusetts and connectis half the providers in the state. If we want to achieve a connected state by 2013 that means our funding gap is $50 million - (3 years * 7 million in private funds + $10 million in ONC funds) = $19 million.
As we complete our governance, vision, use cases, procurement, and a sustainability model, we'll be able to move forward in the next few months. My goal is to maintain the leadership we've shown in HIE and share our experience with the nation for the benefit of all.
Subscription based on value realized - The New England Healthcare Exchange Network (NEHEN) model over the past 13 years has been based on cost avoidance. It used to cost $5.00 per claim to support phone/fax/email/paper workflow. It now costs 25 cents. NEHEN was funded in its first decade by gain sharing - payers and providers funded HIE by contributing a small portion of their savings. We found that subscription models encouraged adoption and innovation since increased data flows meant more value for the subscription fee. Novel uses emerged such as scanning all payers simultaneously to identify eligibility for patients with multiple or ambiguous coverage. Subscription fees for e-Prescribing and clinical exchange are now justified by meaningful use requirements, pay for performance programs, and evolving accountable care organization needs.
Transaction fees - In some states, transaction fees have worked because each transaction creates a cost savings. If it costs you $1.00 to print a lab result and put it in an envelope but only a 20 cent transaction fee to send it electronically, you'll be motivated to accept the transaction fee and pocket the 80 cent savings.
Assessment - Some states have assessed a temporary fee, such as .1 cent per claim, to generate the revenue to build HIE capabilities.
Public funds - since states can run their Medicaid operations more efficiently with automated administrative transactions, care coordination, diseases management, all payer databases etc. they are motivated to invest in HIE construction and operation. Also, given the 90/10 Federal match for Medicaid system enhancement, states can realize substantial benefit through strategic HIE investment.
Bonds - some states have thought about HIEs like highways. A bond measure funds the construction, then "tolls" are charged to pay back the bond. This is a variation on the transaction fee model.
Ultimately the HIE needs to have the trust of the community to encourage investment by all stakeholders. Massachusetts has 10 million in ONC funds for HIE but likely about $50 million in HIE work to connect every stakeholder. That means that $40 million dollars in private sector funds need to be committed to HIE activities over the next few years. NEHEN already attracts $7 million from Eastern Massachusetts and connectis half the providers in the state. If we want to achieve a connected state by 2013 that means our funding gap is $50 million - (3 years * 7 million in private funds + $10 million in ONC funds) = $19 million.
As we complete our governance, vision, use cases, procurement, and a sustainability model, we'll be able to move forward in the next few months. My goal is to maintain the leadership we've shown in HIE and share our experience with the nation for the benefit of all.
Tuesday, November 16, 2010
EHRs in Surgical Practices
I was recently asked to offer advice about implementing EHRs in surgical practices. Here are the lessons learned from our Massachusetts EHR rollout experts.
1) Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them. They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.
2) The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation. Unfortunately shifting practice roles/responsibilities is not easy.
3) Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.
4) Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.
5) Interoperability should be implemented as quickly as possible: diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be integrated into workflow during implementation.
6) Voice recognition with products such as Dragon creates an immediate benefit from savings in dictation costs, enhancing EHR adoption.
An unstated source of difficulty with surgeons is that the EHR illustrates a relative light document style with less of a focus on continuity of care that is typical of most high volume ambulatory surgical practices. EHRs require them to increase their level of documentation and attention to process generally, in addition to converting to an electronic workflow. I've met a few surgeons who had very little documentation in their offices and the EHR implementation process put us in the awkward position of having to tell them that they needed to do more documentation generally.
With templates, division of labor among practice staff, and interoperability, surgical practice EHR implementation can be successful, especially if incentives are aligned so that costs decrease and stimulus dollars flow.
1) Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them. They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.
2) The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation. Unfortunately shifting practice roles/responsibilities is not easy.
3) Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.
4) Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.
5) Interoperability should be implemented as quickly as possible: diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be integrated into workflow during implementation.
6) Voice recognition with products such as Dragon creates an immediate benefit from savings in dictation costs, enhancing EHR adoption.
An unstated source of difficulty with surgeons is that the EHR illustrates a relative light document style with less of a focus on continuity of care that is typical of most high volume ambulatory surgical practices. EHRs require them to increase their level of documentation and attention to process generally, in addition to converting to an electronic workflow. I've met a few surgeons who had very little documentation in their offices and the EHR implementation process put us in the awkward position of having to tell them that they needed to do more documentation generally.
With templates, division of labor among practice staff, and interoperability, surgical practice EHR implementation can be successful, especially if incentives are aligned so that costs decrease and stimulus dollars flow.
Monday, November 15, 2010
Enterprise Image Management
I've written about our multi-year effort to archive all types of medical images in a single storage platform across the enterprise, making every image viewable everywhere to authorized clinicians. Here's an overview of my lessons learned thus far on the journey.
Image systems have been notorious for being isolated pockets of technology. They are often supported by mini-IS sections at the department level. Vendor support requirements have been significant, often requiring a dedicated on-site engineer at larger institutions. Infrastructure components such as storage, network switches, and workstations have often been only available through the image application vendor. Configurations have often been proprietary and have not lent themselves to substitution by technologies of the customer's choice.
There has been rapid transition from analog to digital imaging, advancements in imaging (32 and 64 slice), and growth in procedure volumes. The desire to archive digital images for medical, research and legal reasons has increased. The above has made image storage a costly line item in capital budgets.
Thus, rather than continue managing imaging systems as isolated environments, our goal is to create a common storage archive and I've achieved unified departmental support.
Attributes of the archive include
*Low cost - a total cost of ownership less than $1/raw GB initially and less than $.50/raw GB within four years.
*Response times that exceed those of departmental archives in use today.
*Support for both DICOM and non-DICOM images.
*Support for life cycle image management (purge, compress, tier migration)
*High availability and disaster recovery protection
*Multi-protocol support (CIFS, NFS, REST)
*Central IT management and budgeting.
There are many emerging products from companies such as Teramedica, CareStreanm GE, EMC, and Dell. There are cloud services available from Symantec, Life Images, and Accelarad. The past few years have seen a gradual migration of image management backends from departments to central IS organizations. In the next few years, I expect departmental experts to focus on imaging modalities and specialized front end applications leaving servers and storage systems to be managed by IS.
Image systems have been notorious for being isolated pockets of technology. They are often supported by mini-IS sections at the department level. Vendor support requirements have been significant, often requiring a dedicated on-site engineer at larger institutions. Infrastructure components such as storage, network switches, and workstations have often been only available through the image application vendor. Configurations have often been proprietary and have not lent themselves to substitution by technologies of the customer's choice.
There has been rapid transition from analog to digital imaging, advancements in imaging (32 and 64 slice), and growth in procedure volumes. The desire to archive digital images for medical, research and legal reasons has increased. The above has made image storage a costly line item in capital budgets.
Thus, rather than continue managing imaging systems as isolated environments, our goal is to create a common storage archive and I've achieved unified departmental support.
Attributes of the archive include
*Low cost - a total cost of ownership less than $1/raw GB initially and less than $.50/raw GB within four years.
*Response times that exceed those of departmental archives in use today.
*Support for both DICOM and non-DICOM images.
*Support for life cycle image management (purge, compress, tier migration)
*High availability and disaster recovery protection
*Multi-protocol support (CIFS, NFS, REST)
*Central IT management and budgeting.
There are many emerging products from companies such as Teramedica, CareStreanm GE, EMC, and Dell. There are cloud services available from Symantec, Life Images, and Accelarad. The past few years have seen a gradual migration of image management backends from departments to central IS organizations. In the next few years, I expect departmental experts to focus on imaging modalities and specialized front end applications leaving servers and storage systems to be managed by IS.
Friday, November 12, 2010
Cool Technology of the Week
Part of this dream is live off grid and achieve a minimal carbon footprint through Green Engineering principles.
Recently, my second in command of IT at BIDMC, John Powers, went to a Green Engineering seminar, since he's pursuing the Green construction dream too.
Here are his lessons learned:
"The conference was an educational session for builders, architects and others on the new NH building code based on the International Energy Conservation Codes for 2009 (IECC 2009).
It was not a LEED or Energy Star course. These are far more comprehensive and cover building standards plus many other “green living” topics such as sustainable landscaping, pest control alternatives, water re-use, green appliances and so forth.
ARRA incentivized States such as NH to more aggressively adopt stringent energy conservation codes. My goal was to become a more educated consumer in preparation for building our “cabin” on a farm we purchased in northern NH.
Among lessons learned was green building was THE topic at the annual NH Builder’s Conference. This year’s banner was “Energy Efficient, Sustainable Building”. See the “Building NH Show Guide” a
Other States have similar organizations into which home owners can tap. Unfortunately, I had only time to attend the day long session on the new code. Looking over the Show Guide made me realize how much learning is still ahead. It emphasized the need to work with a builder and architect who understand the topic well.
The good news is there is an abundance of free material on the topic. Among the sites that have relevant content are
www.usgbc.org
www.energystar.gov
www.resnet.us
www.greenbuilding.com
A refresher in basic building science, especially types of heat transfer. Radiation and conduction are important, but convection (heat transfer through air motion) is most important. Air leakage is the focus of many parts of the energy code. To drive home the point, the instructor provided an example. A 4’x8’ sheet of wall board will diffuse 1/3 of a quart of water a year. Punch a one square inch hole in it and it will exfiltrate (air leakage) 30 quarts of water a year.
The code refers to a “thermal envelope”. It’s the space you heat and/or cool. The envelope needs to be surrounded by a very, very tight thermal and air barrier. These barriers need to be next to one another (as in touching) and contiguous (no gaps). Use of strapping, odd structures such as dormers, stairs, rim joists, chases, shafts, penetrations, and the like require special attention.
With common use of 2”x6” for outside walls, it may no longer be necessary to use 16” on center studding for structural soundness. A typical outside wall may be 20 percent wood using routine construction standards. The “R” value of wood is 1 for every 1 inch thickness. Compare that to R22 for high density spray foam. Reducing outside wood surface, if structural soundness is not sacrificed, promotes a better thermal barrier.
Heat moves from areas of high temp to low temp. Heat does not always rise. Warm air rises, but heat can move in any direction. If you intend to heat your basement, it needs to be insulated and included in the thermal envelope.
You cannot average “R” values. For example, an attic insulated with one-half R-50 insulation and one-half R-10 insulation is not equivalent to (50+10)/2 or R-30. It’s far less or the equivalent of R-17.
There is a home energy rating system (HERS) that was developed by the Residential Energy Services Network (www.resnet.us). It rates the energy efficiency of a building relative to one built using the IECC 2006 codes. The latter would have a value of 100. A “zero energy” home would be rated “0”. The lower the score the better. For every point drop, there is a 1 percent reduction in energy compared to the index house.
The Department of Energy has issued a builders’ challenge to have, by 2030, cost-neutral, net-zero (NZEH) energy houses available in every location in the US."
Green Engineering is exciting stuff and I'm looking forward to the sheer geekiness of re-learning my thermodynamics and participating in the engineering of an energy efficient cabin in the woods. For now, I'll live vicariously through John Powers' project, but in another 10-15 years, I'll pursue my own. Green Engineering to save the planet - that's cool!
Thursday, November 11, 2010
My Favorite Sci-Fi movies
I've been a lifelong Sci-Fi and Fantasy junkie, spending hours in my teenage years with novels by Arthur C. Clarke, Robert A. Heinlein, Isaac Asimov, Ray Bradbury and Larry Niven.
Here are my favorite Sci-Fi films. I watch them again every few years and never grow tired of these timeless classics.
2001: A Space Odyssey
Metropolis
Blade Runner
Alien
Spirited Away
Star Wars
Close Encounters of the Third Kind
The Terminator
The Matrix
Back to the Future
Planet of the Apes
Dark Star
The Day the Earth Stood Still
Akira
The Princess Bride
Wednesday, November 10, 2010
Past Experience with HIE Governance
As Massachusetts stakeholders work through the governance options for the statewide HIE, it's important to learn from the work we've done in the past to build HIE governance in Eastern Massachusetts.
Here's an overview of 13 years of governance experience from the New England Healthcare Exchange Network (NEHEN).
The current NEHEN is a non-profit corporation resulting from the merger of the previous NEHEN (LLC) and MA-SHARE (non-profit). NEHEN has applied for 501(c)(3) tax-exempt status. Predecessor NEHEN was owned by its members; MA-SHARE was owned by Massachusetts Health Data Consortium.
CSC has been the contracted "Program Manager" of NEHEN since its inception in 1998 and has never been an owner. CSC is responsible, however, for facilitating most governance activities. Boards were "combined" in an agreed model and NEHEN re-incorporated as a non-profit.
NEHEN governance has evolved over time and continues to evolve:
From its inception in 1998 (with 5 members) until early 2006, each new payer or provider member became an equal owner of the LLC with a seat on the board. The governance was summarized as "one member, one vote" during this period.
The Commonwealth of Mass. was given an ex officio seat despite state law or policy prohibiting the state from participating in ownership. In 2005, governance and board proceedings in particular had become unwieldy with 25+ members. More active members proposed creating task force to study NEHEN's business model and governance. Based on the recommendations of the task force, NEHEN changed to a representative 11-member board after a vote following the annual meeting in early 2006. The Commonwealth resigned its ex officio board seat in 2008 to avoid any potential conflicts of interest under Chapter 305. The board was reconstituted as described in the merger agreement with MA-SHARE.
Sub-board Advisory Committees were recommended in 2010 and are being instituted to increase stakeholder participation in developing board recommendations (previously developed by CSC with input from ad hoc task forces).
Over the life of NEHEN, key governance activities have included an annual planning process facilitated by CSC and an annual open meeting open to all members.
Key lessons learned have been open, transparent, multi-stakeholder meetings with a "one member one vote" democratic model to ensure all voices are equally heard. The success of NEHEN depended in building trusted governance and although the structure of the governance body has evolved, the trust of the community has remained constant.
Here's an overview of 13 years of governance experience from the New England Healthcare Exchange Network (NEHEN).
The current NEHEN is a non-profit corporation resulting from the merger of the previous NEHEN (LLC) and MA-SHARE (non-profit). NEHEN has applied for 501(c)(3) tax-exempt status. Predecessor NEHEN was owned by its members; MA-SHARE was owned by Massachusetts Health Data Consortium.
CSC has been the contracted "Program Manager" of NEHEN since its inception in 1998 and has never been an owner. CSC is responsible, however, for facilitating most governance activities. Boards were "combined" in an agreed model and NEHEN re-incorporated as a non-profit.
NEHEN governance has evolved over time and continues to evolve:
From its inception in 1998 (with 5 members) until early 2006, each new payer or provider member became an equal owner of the LLC with a seat on the board. The governance was summarized as "one member, one vote" during this period.
The Commonwealth of Mass. was given an ex officio seat despite state law or policy prohibiting the state from participating in ownership. In 2005, governance and board proceedings in particular had become unwieldy with 25+ members. More active members proposed creating task force to study NEHEN's business model and governance. Based on the recommendations of the task force, NEHEN changed to a representative 11-member board after a vote following the annual meeting in early 2006. The Commonwealth resigned its ex officio board seat in 2008 to avoid any potential conflicts of interest under Chapter 305. The board was reconstituted as described in the merger agreement with MA-SHARE.
Sub-board Advisory Committees were recommended in 2010 and are being instituted to increase stakeholder participation in developing board recommendations (previously developed by CSC with input from ad hoc task forces).
Over the life of NEHEN, key governance activities have included an annual planning process facilitated by CSC and an annual open meeting open to all members.
Key lessons learned have been open, transparent, multi-stakeholder meetings with a "one member one vote" democratic model to ensure all voices are equally heard. The success of NEHEN depended in building trusted governance and although the structure of the governance body has evolved, the trust of the community has remained constant.
Tuesday, November 9, 2010
Provider Directories
Provider directories are a very hot national topic right now. The HIT Policy Committee's HIE Workgroup created the Provider Dictionary Task Force to recommend strategies and policies.
Why are provider directories important?
When you think of the 3 necessary components to transport healthcare data from point A to point B, you need a routing method (REST, SOAP, SMTP), a directory that tells you where to route, and certificate management to ensure the message is not read or modified during transmission.
The granularity of the directory(organization level or person level) has been a major part of the discussion.
If you want to route a message to John Halamka, do you route it to me as a person or BIDMC as my provider organization? My EHR is hosted at the organizational level, so if you want to route it into my EHR, you should send it to my organization. I may have different preferences for communication depending on the urgency and the time of day/day of week. Such detailed communication preferences are best implemented at the local organization level, so once the data arrives at the organization it can be further routed.
Another advantage of organization to organization communication is that fewer certificates are needed. There are 70 hospitals in Massachusetts with 20,000 doctors. It's much easier to manage 70 certificates than 20,000.
The details of how organization to organization directories should work is outlined in the Provider Directory task force materials.
In Massachusetts, we've implemented a slightly different approach. The New England Healthcare Exchange Network (NEHEN) is a set of organization to organization gateways. It works well for administrative data exchange and e-prescribing. Although it is being used for clinical summary exchange, the challenge from a user's viewpoint is figuring out the right organization to receive data for a given clinician. If I want to route a clinical summary to Dr. Bob, how do I know what organization hosts his EHR? What if he works at multiple organizations?
Here's what NEHEN has done per Greg Debor's testimony to the Provider Directory Workgroup.
'NEHEN administrative message handling and e-prescribing are based on preconfigured addressing schemes designed to deliver a message to a predetermined organization. Program management staff maintain addressing tables and distribute them with NEHEN software. This method easily supports routing an insurance eligibility request or claim to a payer, for example, or an electronic prescription to Surescripts for machine-to-machine processing.
Clinical health information exchange, however, is not nearly as straightforward. There are multiple orders of magnitude more potential recipients, making centralized maintenance impractical and costly. Many recipients may not be known to the sender, requiring a lookup capability akin to using an online Yellow Pages or White Pages directory. In addition, not all processing by the recipient will be machine-to-machine, requiring some knowledge of the receiver’s preferences for fax, e-mail, human readable documents or EHR integration. Recipients may delegate processing to certain staff, requiring knowledge of individuals rather than simply organizations. Finally, the more sensitive nature of clinical information requires more complex access control to track and determine who at a recipient organization has been authorized to handle and view the information.
NEHEN has developed and deployed a Community Participant / Provider Directory to support these aspects of clinical HIE, along with tools to allow delegated, self-managed registration and maintenance of directory entries. The NEHEN directory supports both Yellow Page / White Page lookup and HIE routing. Participants can use the NEHEN toolset to:
*Register and maintain organization, location, provider, clinical affiliation (practice hierarchies, etc.), receiving / message delivery preferences and other data using the NEHENExpress web-based user interface
*Delegate a person or destination specified by a provider to receive an electronic clinical message in addition to or instead of the provider (e.g., another covering physician, a practice assistant or practice e-mail inbox, a fax number an EHR URL, etc.)
*Upload provider, delegation and preference data in bulk (new and updates) via a NEHEN-specified web service
*Search for participating organizations, individual providers and delegates to add and maintain affiliations and delegate instructions
*NEHEN participants can now use the data in the directory in the course of data exchange to:
Determine whether another provider is eligible to participate in clinical data exchange via NEHEN
*Obtain routing information for a provider
*Select among multiple clinical affiliations to determine where an electronic message should be routed
*View provider data, clinical affiliation data, delivery preference and delegate data
These capabilities enable a number of functions critical to solving for the complexities inherent in clinical exchange such as allowing a patient or other person, such as a registration clerk, to accurately identify a patient’s provider of care to whom clinical messages should be routed. For example, if two physicians named Smith practice in the same town, the practice name or address may be used to identify the Dr. Smith who provides care for the patient.
Allowing a receiving participant to route an incoming clinical message to the correct internal system for the provider to whom the message is addressed. For example, if a participant’s providers use separate physical instances of an EMR, the location identified on an incoming message may be used to identify the EMR instance the message should be routed to. If Dr. Smith is associated with Location A, a message for Dr. Smith can be routed to the EMR instance associated with Location A.
Discovering information about other participants’ availability for clinical HIE and their routing requirements. This is equivalent to looking up a financial institution’s Bank Routing Number to determine how to accomplish a wire transfer, etc.
In designing the Community Participant / Provider Directory and functionality, NEHEN determined that no standards or comprehensive data sources are present today in the industry or cross-industry. This led to the design of a simple data scheme, the elements of which are consistent with HL7 naming and data types.
NEHEN is now in discussion with leading providers of self-managed sources of provider data to pre-populate provider tables via web services for a richer data set for NEHEN users and to simplify database maintenance. In pursuing this strategy, which NEHEN anticipates executing on in late-2010, NEHEN intends to provide its participants with provider, organization and routing data on a national level to enable data exchange across the NHIN."
Given the evolving national work on provider directories, heterogeneous state directory implementations, and emerging commercial products, it will be a very interesting year. It's too early to tell if we'll have directory convergence or chaos.
Why are provider directories important?
When you think of the 3 necessary components to transport healthcare data from point A to point B, you need a routing method (REST, SOAP, SMTP), a directory that tells you where to route, and certificate management to ensure the message is not read or modified during transmission.
The granularity of the directory(organization level or person level) has been a major part of the discussion.
If you want to route a message to John Halamka, do you route it to me as a person or BIDMC as my provider organization? My EHR is hosted at the organizational level, so if you want to route it into my EHR, you should send it to my organization. I may have different preferences for communication depending on the urgency and the time of day/day of week. Such detailed communication preferences are best implemented at the local organization level, so once the data arrives at the organization it can be further routed.
Another advantage of organization to organization communication is that fewer certificates are needed. There are 70 hospitals in Massachusetts with 20,000 doctors. It's much easier to manage 70 certificates than 20,000.
The details of how organization to organization directories should work is outlined in the Provider Directory task force materials.
In Massachusetts, we've implemented a slightly different approach. The New England Healthcare Exchange Network (NEHEN) is a set of organization to organization gateways. It works well for administrative data exchange and e-prescribing. Although it is being used for clinical summary exchange, the challenge from a user's viewpoint is figuring out the right organization to receive data for a given clinician. If I want to route a clinical summary to Dr. Bob, how do I know what organization hosts his EHR? What if he works at multiple organizations?
Here's what NEHEN has done per Greg Debor's testimony to the Provider Directory Workgroup.
'NEHEN administrative message handling and e-prescribing are based on preconfigured addressing schemes designed to deliver a message to a predetermined organization. Program management staff maintain addressing tables and distribute them with NEHEN software. This method easily supports routing an insurance eligibility request or claim to a payer, for example, or an electronic prescription to Surescripts for machine-to-machine processing.
Clinical health information exchange, however, is not nearly as straightforward. There are multiple orders of magnitude more potential recipients, making centralized maintenance impractical and costly. Many recipients may not be known to the sender, requiring a lookup capability akin to using an online Yellow Pages or White Pages directory. In addition, not all processing by the recipient will be machine-to-machine, requiring some knowledge of the receiver’s preferences for fax, e-mail, human readable documents or EHR integration. Recipients may delegate processing to certain staff, requiring knowledge of individuals rather than simply organizations. Finally, the more sensitive nature of clinical information requires more complex access control to track and determine who at a recipient organization has been authorized to handle and view the information.
NEHEN has developed and deployed a Community Participant / Provider Directory to support these aspects of clinical HIE, along with tools to allow delegated, self-managed registration and maintenance of directory entries. The NEHEN directory supports both Yellow Page / White Page lookup and HIE routing. Participants can use the NEHEN toolset to:
*Register and maintain organization, location, provider, clinical affiliation (practice hierarchies, etc.), receiving / message delivery preferences and other data using the NEHENExpress web-based user interface
*Delegate a person or destination specified by a provider to receive an electronic clinical message in addition to or instead of the provider (e.g., another covering physician, a practice assistant or practice e-mail inbox, a fax number an EHR URL, etc.)
*Upload provider, delegation and preference data in bulk (new and updates) via a NEHEN-specified web service
*Search for participating organizations, individual providers and delegates to add and maintain affiliations and delegate instructions
*NEHEN participants can now use the data in the directory in the course of data exchange to:
Determine whether another provider is eligible to participate in clinical data exchange via NEHEN
*Obtain routing information for a provider
*Select among multiple clinical affiliations to determine where an electronic message should be routed
*View provider data, clinical affiliation data, delivery preference and delegate data
These capabilities enable a number of functions critical to solving for the complexities inherent in clinical exchange such as allowing a patient or other person, such as a registration clerk, to accurately identify a patient’s provider of care to whom clinical messages should be routed. For example, if two physicians named Smith practice in the same town, the practice name or address may be used to identify the Dr. Smith who provides care for the patient.
Allowing a receiving participant to route an incoming clinical message to the correct internal system for the provider to whom the message is addressed. For example, if a participant’s providers use separate physical instances of an EMR, the location identified on an incoming message may be used to identify the EMR instance the message should be routed to. If Dr. Smith is associated with Location A, a message for Dr. Smith can be routed to the EMR instance associated with Location A.
Discovering information about other participants’ availability for clinical HIE and their routing requirements. This is equivalent to looking up a financial institution’s Bank Routing Number to determine how to accomplish a wire transfer, etc.
In designing the Community Participant / Provider Directory and functionality, NEHEN determined that no standards or comprehensive data sources are present today in the industry or cross-industry. This led to the design of a simple data scheme, the elements of which are consistent with HL7 naming and data types.
NEHEN is now in discussion with leading providers of self-managed sources of provider data to pre-populate provider tables via web services for a richer data set for NEHEN users and to simplify database maintenance. In pursuing this strategy, which NEHEN anticipates executing on in late-2010, NEHEN intends to provide its participants with provider, organization and routing data on a national level to enable data exchange across the NHIN."
Given the evolving national work on provider directories, heterogeneous state directory implementations, and emerging commercial products, it will be a very interesting year. It's too early to tell if we'll have directory convergence or chaos.
Monday, November 8, 2010
The Cousin Jimmy Syndrome
I have great respect for my colleagues in the IT industry. It's a challenging profession that requires a mixture of technical knowledge, people skills, and the emotional stability to deal with customer dissatisfaction when technology fails.
However, there's a downside to being an IT professional. No matter how much expertise you have or what your reputation may be, many customers will not be able to distinguish between a polished industry expert and a self-promoting IT groupie.
I call this the "Cousin Jimmy Syndrome".
Here's how it happens. You join a meeting to discuss a major IT project. You talk about issues such as security, disaster recovery, change management, training, and support.
Then someone says, "Oh yeah, we've got 'Cousin Jimmy' doing that." Or Bob who lives in his parents' basement. Or Carol who knows how to use Excel and serves as the go to technology guru.
Unfortunately, when Jimmy, Bob, or Carol have an opinion, their colleagues trust them over you, since professional IT organizations may appear less nimble, less focused, and less accommodating than dedicated local experts.
Not to imply that IT professionals in large organizations are perfect, they have their flaws. However, good management and oversight usually creates a culture in which there is division of labor, escalation, and few single points of human failure. Cousin Jimmy does not know what he does not know. His solutions may be fast or cheap but ultimately they are unsustainable, unmaintainable, and unsupportable.
How should the IT professional deal with Cousin Jimmy Syndrome?
1. Let Cousin Jimmy fail - it may take a while, but eventually there will be a major outage, security breach, or data loss. Although this may transiently feel like a win, it's really a loss for the customers. It's a win the battle, lose the war tactic.
2. Make Cousin Jimmy part of your team - this sometimes works and it's worth a try. Success has a 1000 fathers, so if you can create a sense of team in which Jimmy gets all the credit but others do all the work, so be it. The customers win. Of course, it's hard to let Jimmy take the credit for what you've done, but I've learned over the years that anything is possible if you are willing to give others the credit for success.
3. Offer a service so good, so inexpensive, and so reliable that eventually Jimmy moves on - this works much of the time. I believe that hard work, innovation, and honesty eventually pay off and win the game. True, sometimes politics triumph over expertise but you can outlast the naysayers. By selflessly focusing on the customers, the technology, and your staff, you'll end up with a service that's really hard to beat at any price. Jimmy may be omni-present, but he'll have a difficult time keeping up as technology evolves.
So, when the meetings are awkward, keep your composure, stick to your principles, and put the customers first. Nine times out of ten, you'll eventually beat the Cousin Jimmy Syndrome.
If you need inspiration, you can always watch Verizon commercials in which the polished FIOS engineer wins over the meddlesome Cable Guy. Next time you're debating technology with Cousin Jimmy, just think of him as the cable guy!
However, there's a downside to being an IT professional. No matter how much expertise you have or what your reputation may be, many customers will not be able to distinguish between a polished industry expert and a self-promoting IT groupie.
I call this the "Cousin Jimmy Syndrome".
Here's how it happens. You join a meeting to discuss a major IT project. You talk about issues such as security, disaster recovery, change management, training, and support.
Then someone says, "Oh yeah, we've got 'Cousin Jimmy' doing that." Or Bob who lives in his parents' basement. Or Carol who knows how to use Excel and serves as the go to technology guru.
Unfortunately, when Jimmy, Bob, or Carol have an opinion, their colleagues trust them over you, since professional IT organizations may appear less nimble, less focused, and less accommodating than dedicated local experts.
Not to imply that IT professionals in large organizations are perfect, they have their flaws. However, good management and oversight usually creates a culture in which there is division of labor, escalation, and few single points of human failure. Cousin Jimmy does not know what he does not know. His solutions may be fast or cheap but ultimately they are unsustainable, unmaintainable, and unsupportable.
How should the IT professional deal with Cousin Jimmy Syndrome?
1. Let Cousin Jimmy fail - it may take a while, but eventually there will be a major outage, security breach, or data loss. Although this may transiently feel like a win, it's really a loss for the customers. It's a win the battle, lose the war tactic.
2. Make Cousin Jimmy part of your team - this sometimes works and it's worth a try. Success has a 1000 fathers, so if you can create a sense of team in which Jimmy gets all the credit but others do all the work, so be it. The customers win. Of course, it's hard to let Jimmy take the credit for what you've done, but I've learned over the years that anything is possible if you are willing to give others the credit for success.
3. Offer a service so good, so inexpensive, and so reliable that eventually Jimmy moves on - this works much of the time. I believe that hard work, innovation, and honesty eventually pay off and win the game. True, sometimes politics triumph over expertise but you can outlast the naysayers. By selflessly focusing on the customers, the technology, and your staff, you'll end up with a service that's really hard to beat at any price. Jimmy may be omni-present, but he'll have a difficult time keeping up as technology evolves.
So, when the meetings are awkward, keep your composure, stick to your principles, and put the customers first. Nine times out of ten, you'll eventually beat the Cousin Jimmy Syndrome.
If you need inspiration, you can always watch Verizon commercials in which the polished FIOS engineer wins over the meddlesome Cable Guy. Next time you're debating technology with Cousin Jimmy, just think of him as the cable guy!
Friday, November 5, 2010
Cool Technology of the Week
As readers of my blog know, I'm passionate about mobile technology.I believe that iPhone/Android smartphones, iPod Touch, and the Ipad, Playbook, Galaxy, Streak will become the platform for healthcare Desktops with complex operating systems, antivirus, and heavy "thick client" applications will disappear. Ray Ozzie's farewell message to Microsoft describes a post PC world.
As we think about EHRs in the post PC world, I can envision an App Store for modular EHR components. The Harvard SHARP grant SMArt team is working on this idea.
What about a healthcare App Store for patients that brings the PHR to the iPhone/iPod/iPad/Android etc.
Last week, Quest introduced Gazelle which brings powerful PHR functionality to smart phones. It's my cool technology of the week.
Gazelle includes automated lab results and educational materials, medication list, immunization list, allergy list, medical contacts, in case of emergency information - everything you need to share your medical records in an emergency.
CLIA rules complicated that delivery of lab data directly to patients, but new revisions to regulations have made this easier.
A lifetime medical record with educational materials on smartphones - that's cool.
Thursday, November 4, 2010
What Makes Me Happy?
I was recently in a meeting with senior managers who commented on my generally even temperament. I rarely express extremes of emotion (joy, sadness, anger, despair) in the workplace. They asked me what makes me happy.
Here's my own version of "Raindrops on roses and whiskers on kittens".
What makes me happy
1. Innovation - Operations is really important, but if I can spend dedicated time each week creating something new, I feel invigorated and inspired.
2. Focusing on one thing and doing it really well - In our multitasking world, it's hard to meet everyone's expectations for real time response if you are focused on a single task at a time.
3. Teaching a willing student - Sharing the lessons I've learned with my family, friends, and colleagues is very fulfilling for me. Teaching my daughter has been one of my life's great joys.
4. Experiencing the world with a friend - I enjoy exploring exotic locales from museums to mountaintops with my best friend - my wife.
5. Time in the wilderness and outdoors in general - Every week I try to spend time hiking, biking, skiing, kayaking or climbing.
6. A breakfast of rice, tsukemono, vegan miso soup and big cup of Gyokuro green tea from Uji - It's healthy, low calorie, and satisfying.
7. Vegan Pot Pie or Split Pea Soup after a day working outside - These are definitely my comfort foods.
8. A Saturday morning at home with a coil of blue incense from the Kungyokudo Incense shop (near the Kyoto train station)
9. A glass of red wine on a cold winter's night.
10. Growing Japanese cucumbers, eggplant and shiso. The taste of cucumber salad (sunomono), grilled eggplant with miso (nasu dengaku), or shiso on soft tofu reminds me of summer nights in Japan.
What makes me unhappy
1. Unplanned work that increases scope without a change in resources or timeline
2. Needless administrative or bureaucratic processes imposed by those who are not actually doing the work
3. The guy behind you who honks 2 milliseconds after the light turns green
4. Flights that are delayed or cancelled due to equipment failure when the airlines run so lean that no spare aircraft or parts are available.
5. Cold callers from organizations you do not support
6. Your neighbor whose dog barks continuously and whose children play loud musical instruments, but who objects to the sounds created by garden maintenance at noon on a Saturday.
7. Staff at home improvement stores who have never done home improvement
8. Monday morning quarterbacks who lack the expertise to do work but are happy to criticize others' work.
9. People who believe that the louder they yell the faster those around them will work
10. Machiavellian people who use politics, relationships, and manipulation rather than hard work to get ahead.
There you have it.
Last night it was 25F and I enjoyed a glass of Syrah with a vegan pot pie, spent the evening with my family, and then focused on writing a book preface. That makes me happy.
Here's my own version of "Raindrops on roses and whiskers on kittens".
What makes me happy
1. Innovation - Operations is really important, but if I can spend dedicated time each week creating something new, I feel invigorated and inspired.
2. Focusing on one thing and doing it really well - In our multitasking world, it's hard to meet everyone's expectations for real time response if you are focused on a single task at a time.
3. Teaching a willing student - Sharing the lessons I've learned with my family, friends, and colleagues is very fulfilling for me. Teaching my daughter has been one of my life's great joys.
4. Experiencing the world with a friend - I enjoy exploring exotic locales from museums to mountaintops with my best friend - my wife.
5. Time in the wilderness and outdoors in general - Every week I try to spend time hiking, biking, skiing, kayaking or climbing.
6. A breakfast of rice, tsukemono, vegan miso soup and big cup of Gyokuro green tea from Uji - It's healthy, low calorie, and satisfying.
7. Vegan Pot Pie or Split Pea Soup after a day working outside - These are definitely my comfort foods.
8. A Saturday morning at home with a coil of blue incense from the Kungyokudo Incense shop (near the Kyoto train station)
9. A glass of red wine on a cold winter's night.
10. Growing Japanese cucumbers, eggplant and shiso. The taste of cucumber salad (sunomono), grilled eggplant with miso (nasu dengaku), or shiso on soft tofu reminds me of summer nights in Japan.
What makes me unhappy
1. Unplanned work that increases scope without a change in resources or timeline
2. Needless administrative or bureaucratic processes imposed by those who are not actually doing the work
3. The guy behind you who honks 2 milliseconds after the light turns green
4. Flights that are delayed or cancelled due to equipment failure when the airlines run so lean that no spare aircraft or parts are available.
5. Cold callers from organizations you do not support
6. Your neighbor whose dog barks continuously and whose children play loud musical instruments, but who objects to the sounds created by garden maintenance at noon on a Saturday.
7. Staff at home improvement stores who have never done home improvement
8. Monday morning quarterbacks who lack the expertise to do work but are happy to criticize others' work.
9. People who believe that the louder they yell the faster those around them will work
10. Machiavellian people who use politics, relationships, and manipulation rather than hard work to get ahead.
There you have it.
Last night it was 25F and I enjoyed a glass of Syrah with a vegan pot pie, spent the evening with my family, and then focused on writing a book preface. That makes me happy.
Wednesday, November 3, 2010
Losing the Battle but Winning the War
Over the past 2 months since Labor Day, I've been given hundreds of challenging controversies to resolve. I'm not sure if it's the economy, healthcare reform, or the uncertainties of an election year, but in general, the Fall of 2010 has had more emotion, discontent, and chaos than most years.
Whenever I'm asked to play Solomon, I always ask myself - do I want to win the battle or win the war?
I could use formal authority to force a short term outcome.
I could raise my voice, leverage my reputation, or utilize negative commentary (think political advertising) to win the day.
All such victories are temporary and I would never use such tactics.
Imagine that I forced customers to use a technology solution without gaining their buy in. I'd win the battle. Inevitably, the users would try as hard as they could to make the project fail, blaming all negative consequences on the products I mandated. I'd lose the war.
It is far better to take the long view, devising a solution that stakeholders will embrace as their own and feel motivated to make successful.
The day to day battles rarely matter. The trajectory over years is the best measure of success.
Similarly, in the world of technology, if you go live a few months late because you focused on user acceptance, no one will ever remember. If you go live too early to meet an arbitrary deadline, no one will every forget.
Thus, pick your battles. Ignore most of them. Keep your eye on your long term vision and work toward it incrementally, focusing on change management and stakeholder alignment.
It's the war, not the battle, that people will remember long after you're gone.
Whenever I'm asked to play Solomon, I always ask myself - do I want to win the battle or win the war?
I could use formal authority to force a short term outcome.
I could raise my voice, leverage my reputation, or utilize negative commentary (think political advertising) to win the day.
All such victories are temporary and I would never use such tactics.
Imagine that I forced customers to use a technology solution without gaining their buy in. I'd win the battle. Inevitably, the users would try as hard as they could to make the project fail, blaming all negative consequences on the products I mandated. I'd lose the war.
It is far better to take the long view, devising a solution that stakeholders will embrace as their own and feel motivated to make successful.
The day to day battles rarely matter. The trajectory over years is the best measure of success.
Similarly, in the world of technology, if you go live a few months late because you focused on user acceptance, no one will ever remember. If you go live too early to meet an arbitrary deadline, no one will every forget.
Thus, pick your battles. Ignore most of them. Keep your eye on your long term vision and work toward it incrementally, focusing on change management and stakeholder alignment.
It's the war, not the battle, that people will remember long after you're gone.
Tuesday, November 2, 2010
The Electronic Medical Home
In previous blog posts, I've mentioned an idea deserves its own dedicated post.
Over the weekend, I keynoted the eClinicalWorks National User's Conference in Florida. One of the attendees emailed me the following question:
"I have a number of questions regarding certain types of patient-level data that might cause us problems in the future of HIE. No one, to date, has been able to answer these and I thought I might ask you.
The first, and easiest, is how we we going to handle the following situation:
1) I am seen in Boston as a child and my mother says that I am allergic to Penicillin (or pick your drug of choice). The nurse-practitioner asks a few questions of my mother, who isn't terribly forthcoming with information but insists that I am allergic. While he/she has reservations, they record it as an allergy in their eclinicalworks EMR. It goes to the Massachusetts HIE.
2) I move to Washington DC to go to college and the family practitioner hears my allergy story. He asks more detailed questions and decides that I DON'T have an allergy. He records it in his Epic system and it goes to the DC HIE.
3) I get my first job in Dallas. Unfortunately, I wind up unconscious in the Dallas Ed and the doctor queries my records - in our future super-connected world, he/she sees that I am both allergic and not allergic to Penicillin.
How do I, as a patient, protect myself from this happening?"
The best way to accomplish this is for each patient in the country to choose an Electronic Medical Home (EMH) which stores a copy of their electronic data as gathered by clinicians, pharmacies, labs, payers, and other data generators.
The concept is simple. An Electronic Medical Home vendor would create a URL or secure email address for each participating patient.
The patient would provide this URL or secure email address to every caregiver.
At the end of each visit, test or hospitalization the data would be sent securely to the Electronic Medical Home of the patient's choice.
These Electronic Medical Homes could be offered by primary care givers, EHR vendors (such as eClinicalWorks' 100millionpatients.com), or non-tethered EHR vendors such as Google Heath, Microsoft Healthvault, or Dossia.
Over the next few weeks, I predict that even telecoms like AT&T and Verizon will announce eHealth offerings.
All we need to get started is for one of these groups to create simple software capable of receiving clinical data via a RESTful URL or via SMTP/TLS Secure email/XDR as suggested by NHIN Direct.
Electronic Medical Homes nicely solve the problem of consolidating multiple disparate records in one place. They solve the Meaningful Use requirement to deliver summaries and educational materials to patients. The make the patient the steward of their own lifetime records, simplifying consent issues for data sharing.
But what if a patient does not want to be the steward of their Electronic Medical Home? That's ok. It will give rise to a new professional service, the healthcare knowledge navigator, an expert who manages your Electronic Medical Home on your behalf. This could be a primary care clinician, a midlevel (Nurse Practitioner/Physician Assistant) or a trusted vendor.
Here's my challenge to the industry.
Create an Electronic Medical Home using a RESTful URL or the NHIN Direct specification.
As long as you protect privacy, ensure technical security, and obtain patient consent, I will send data to you on behalf of the patient.
Over the weekend, I keynoted the eClinicalWorks National User's Conference in Florida. One of the attendees emailed me the following question:
"I have a number of questions regarding certain types of patient-level data that might cause us problems in the future of HIE. No one, to date, has been able to answer these and I thought I might ask you.
The first, and easiest, is how we we going to handle the following situation:
1) I am seen in Boston as a child and my mother says that I am allergic to Penicillin (or pick your drug of choice). The nurse-practitioner asks a few questions of my mother, who isn't terribly forthcoming with information but insists that I am allergic. While he/she has reservations, they record it as an allergy in their eclinicalworks EMR. It goes to the Massachusetts HIE.
2) I move to Washington DC to go to college and the family practitioner hears my allergy story. He asks more detailed questions and decides that I DON'T have an allergy. He records it in his Epic system and it goes to the DC HIE.
3) I get my first job in Dallas. Unfortunately, I wind up unconscious in the Dallas Ed and the doctor queries my records - in our future super-connected world, he/she sees that I am both allergic and not allergic to Penicillin.
How do I, as a patient, protect myself from this happening?"
The best way to accomplish this is for each patient in the country to choose an Electronic Medical Home (EMH) which stores a copy of their electronic data as gathered by clinicians, pharmacies, labs, payers, and other data generators.
The concept is simple. An Electronic Medical Home vendor would create a URL or secure email address for each participating patient.
The patient would provide this URL or secure email address to every caregiver.
At the end of each visit, test or hospitalization the data would be sent securely to the Electronic Medical Home of the patient's choice.
These Electronic Medical Homes could be offered by primary care givers, EHR vendors (such as eClinicalWorks' 100millionpatients.com), or non-tethered EHR vendors such as Google Heath, Microsoft Healthvault, or Dossia.
Over the next few weeks, I predict that even telecoms like AT&T and Verizon will announce eHealth offerings.
All we need to get started is for one of these groups to create simple software capable of receiving clinical data via a RESTful URL or via SMTP/TLS Secure email/XDR as suggested by NHIN Direct.
Electronic Medical Homes nicely solve the problem of consolidating multiple disparate records in one place. They solve the Meaningful Use requirement to deliver summaries and educational materials to patients. The make the patient the steward of their own lifetime records, simplifying consent issues for data sharing.
But what if a patient does not want to be the steward of their Electronic Medical Home? That's ok. It will give rise to a new professional service, the healthcare knowledge navigator, an expert who manages your Electronic Medical Home on your behalf. This could be a primary care clinician, a midlevel (Nurse Practitioner/Physician Assistant) or a trusted vendor.
Here's my challenge to the industry.
Create an Electronic Medical Home using a RESTful URL or the NHIN Direct specification.
As long as you protect privacy, ensure technical security, and obtain patient consent, I will send data to you on behalf of the patient.
Monday, November 1, 2010
The FY11 HMS Operating Plan
Every year I work with all the stakeholders at Harvard Medical School to develop an operating plan.
This year, we have additional governance input http://geekdoctor.blogspot.com/2010/10/year-of-governance.html as well as additional funding from Stimulus grants
Although budgets are still constrained, the limits imposed by the 2008-2009 economic downturn are relaxing a bit. We're hiring more staff, moving to new space, and expanding our infrastructure capacity.
My current direct reports include experts overseeing education, administration, research, innovation, infrastructure, and customer service. They work closely with governance groups to develop yearly priorities.
It's a year of reaccreditation by the Liaison Committee on Medical Education (LCME), so we've supported applications and infrastructure in preparation for our March visit.
Harvard is planning it's 5 year capital expenditures and we're forecasting IT capital needs as part of that process.
A much greater focus on enterprise security has resulted in policies for data protection and oversight. We've completed this with new infrastructure tools to monitor data flows and isolate confidential information.
Major priorities for this year include
*developing a Harvard-wide strategy for reporting and analyzing conflicts of interest
*further expanding our innovative research social networking and data mining technologies
*piloting new procurement and funding strategies
*expanding our support for the administrative workflows that support students and faculty in the educational process
*implementing new firewalls, antivirus, intrusion detection and prevent technologies
*expanding our high performance computing facility to 6000 CPU cores and a petabyte of storage
Here's the initial version of the FY11 HMS IT Operating Plan. I look forward to a great year ahead.
This year, we have additional governance input http://geekdoctor.blogspot.com/2010/10/year-of-governance.html as well as additional funding from Stimulus grants
Although budgets are still constrained, the limits imposed by the 2008-2009 economic downturn are relaxing a bit. We're hiring more staff, moving to new space, and expanding our infrastructure capacity.
My current direct reports include experts overseeing education, administration, research, innovation, infrastructure, and customer service. They work closely with governance groups to develop yearly priorities.
It's a year of reaccreditation by the Liaison Committee on Medical Education (LCME), so we've supported applications and infrastructure in preparation for our March visit.
Harvard is planning it's 5 year capital expenditures and we're forecasting IT capital needs as part of that process.
A much greater focus on enterprise security has resulted in policies for data protection and oversight. We've completed this with new infrastructure tools to monitor data flows and isolate confidential information.
Major priorities for this year include
*developing a Harvard-wide strategy for reporting and analyzing conflicts of interest
*further expanding our innovative research social networking and data mining technologies
*piloting new procurement and funding strategies
*expanding our support for the administrative workflows that support students and faculty in the educational process
*implementing new firewalls, antivirus, intrusion detection and prevent technologies
*expanding our high performance computing facility to 6000 CPU cores and a petabyte of storage
Here's the initial version of the FY11 HMS IT Operating Plan. I look forward to a great year ahead.