Wednesday, November 30, 2011

Creating the Office Space of the Future

Today I met with a multi-disciplinary group at BIDMC that is rethinking traditional academic medical center office space and is planning the office space of the future with innovations such as shared open floor plan workspaces, "huddle rooms" for ad hoc meetings, shared IT infrastructure, easy to use wall mounted displays,  electronic conference room availability indicators, and ubiquitous use of scanners to eliminate paper.

Like many academic medical centers, BIDMC has a high demand for closed door offices but has a limited supply of real estate.   Most clinicians are in the their office less than 10% of the time, so conventional approaches to academic departmental space are very inefficient.

Today's meeting focused on work flow. How is clinical and administrative paperwork eliminated in a shared office space environment?  Who does scanning/metadata tagging/quality control of scanned documents?  What regulatory/compliance issues need to be addressed as paper filing cabinets are turned into electronic folder systems?

Clinical scanning is easy - we already have a comprehensive approach that uses high speed scanners, Captiva software, and an automated upload directly into our medical record.

Administrative scanning is harder - we have not implemented a document management system such as Documentum.    I welcome advice from my readers - how you eliminated administrative paper storage with scanning?  What are your retention and security policies?   How do you query and retrieve selected documents?

Since there are no closed door offices in the new design, several small "huddle areas" enable ad hoc private meetings with automated electronic display of room availability and appropriate wall mounted LCDs supporting presentations from laptops and iPads.

Finally, since new data will be entered electronically and not on paper, we've deployed eScription voice recognition software in our data center.   Clinicians can use a phone or an iPad/iPhone app to upload voice files for immediate voice recognition and insertion into our electronic record.

There will be many lessons learned from this office space of the future.  Hopefully we'll offer a very attractive space with high productivity in a smaller real estate footprint that is used efficiently    More to come as we go live.

Tuesday, November 29, 2011

Green CDA Over The Wire

Over the past decade, I've been closely involved in the evolution of clinical summary/transition of care content standards.    We started with CDA, then merged the CDA and CCR to create the CCD, which we further constrained with the C32 implementation guide.  This year, the Consolidated CDA initiative refined/constrained/optimized the CCD/C32 specifications from IHE, HITSP and HL7 into one easy to use implementation guide.

The only problem with CDA-based standards is that implementation requires expert knowledge of the HL7 Reference Information Model (RIM), a steep learning curve for new developers.    Ideally, HL7 and informatics experts would use the RIM or Detailed Clinical Models to develop templates containing easy to read and parse XML that does not require knowledge of the underlying information model.

Green CDA aims to do that - the simplicity of CCR XML tagging with the expandability and modeling of CDA.    However, there is a controversy.  What do we send on the wire - full CDA or Green CDA?

At the November HIT Standards Committee meeting we endorsed moving forward with GreenCDA as the single over the wire format.

It's likely that existing users of full CDA over the wire will be concerned about the costs and effort required to move to Green CDA on the wire.

Robert Worden, an expert on HL7 mapping tools, wrote a great summary that explains the path forward through the use of transforms:

"There is now tooling which can define a Green CDA and generate 100% reliable transforms to full CDA, all in the same step.  That tooling is being used in the UK for the NHS Interoperability Toolkit; and it has been linked to MDHT, so it could be used to Green consolidated CDA and generate the transforms.

Once you have reliable, maintainable transforms, the question “Green CDA or full CDA on the wire?” becomes much less crucial. Any organization, such as ONC, which wishes to endorse Green CDA over the wire (to make life much easier for implementers), can do so, provided they make the transforms readily available. Then, people can use Green CDA over the wire – but anyone who prefers to receive full CDA can always do so, by applying the transform to the Green CDA he receives. RIM experts and non-experts can both be happy.

It is like using banknotes instead of gold for currency, as has been done for several hundred years. Using gold bars for every transaction would be very clumsy, so people used notes which were backed by gold. The bank “promises to pay the bearer on demand” the equivalent in gold. Similarly the Green=>full transform “promises to pay the bearer on demand” a full CDA, if he wants it.

HL7 has now realized that its CDA gold bars are rather clunky, and should encourage the use of banknotes, backed by its RIM-based gold semantics. CDA is the reserve currency, and Green CDAs are the banknotes that people want to use (but counterfeit notes, not backed by the gold transforms, would be worthless!)."

Green CDA over the wire is the right future state.  Transforms will help us get there without requiring stakeholders to rip and replace what they have already built.

We have a plan!

Monday, November 28, 2011

Ambulatory IT Priorities

The BIDMC Clinical IT Governance Committee was chartered to prioritize project requests and ensure our clinical applications work together as a managed portfolio.

Today we met to discuss ambulatory/outpatient priorities for FY12.

Here's the presentation and the list of ambulatory priorities.

Our top priorities include those workflow enhancements that are necessary to support all the stages of Meaningful Use and emerging healthcare reform requirements.

Key items include many "close the loop initiatives" such as enhancing electronic bidirectional referral communications between primary care givers and specialists.

Also we want to ensure that every diagnostic result - radiology, lab, and pathology/cytology is "signed off" by the ordering clinicians and followup is arranged for any abnormal findings.

Health Information Exchange is always a priority for BIDMC and we continue to be the pilot site for many community efforts which support care coordination, population health and public health.

We're been a leader in e-prescribing and medication management workflow.   Electronic pharmacy initiated renewals (rather than calling your physician) for all our patients will be complete in FY12.

We'll continue to implement novel decision support tools so that clinicians are given the right actionable information at the point of care.

We know that population/panel management tools are important to support accountable care organizations and we'll use tools outside of ambulatory systems to produce the necessary reports but make them available inside our ambulatory systems.

Governance is key to demand management and per my recent Thanksgiving post, our governance committees try to complete 80% of the requests we receive.   This is not triage, it is stratification.   Per the presentation at today's Clinical IT Governance meeting, we'll definitely do our high priorities this year, but lower priorities may or may not be completed based on the unplanned work that arrives, especially "must do" compliance requirements.

Thursday, November 24, 2011

There is Hope

Every Thanksgiving I reflect on the state of the world, the state of Healthcare IT, the state of my various roles, my family, and my life.

My message this year - there is hope.

Some may think that the tone of my blog has changed in 2011 - from a focus on cutting edge technology that will revolutionize healthcare to themes of compliance, limited resources, unbridled demand, urgent unplanned projects, and security challenges.

That's a valid observation.

In my 15 years as CIO, I've evolved from creating innovative applications to maintaining customer relationships.     I've gone from strategic visionary to resource planner.

This transformation is not about me or my jobs, it's about the world we live in.   According to the Center for Health System Change, households with Broadband in the US increased from 47% to 66% from 2007-2010.  Smartphones are ubiquitous and the majority of households in the US are IT savvy.  That creates a very different expectation for Healthcare IT service delivery.

When I first started as a CIO, mobile devices had not yet been invented, computers were the domain of geeky early adopters, and solutions to problems involved workflow change, not automation.

Today, most of my work is managing demand.   I aim to complete 80% of the requests I'm given.   I've been told that 50% is typical.  Few other industries move so fast and yet have so little tolerance for mistakes.

So, why do I have hope?

I recently met with a Clinical Fellow who is very likely going to be chair of an academic department or a senior hospital administrator some day.

We spoke about the need to understand workflow, the need change behavior, and the critical role of piloting new processes before automating them.

We talked about the need to balance functionality, security, and maintainability.   We talked about defining requirements before selecting a solution.

In my blog about Content verses Context, I described the job of the CIO as becoming increasingly impossible because many people expect flying cars when we live in an era of IT bicycles.

However, it is clear that the next generation of leaders, who were born in the 1980's personal computing era, understand that technology is the easy part - policy and process are the hard part.

Also, I have hope because I believe the BIDMC FY12 IT Operating Plan is well aligned with the needs of the business.  Today I did a "Venn analysis" of 5 resources

*The BIDMC FY12 IT Operating Plan
*BIDMC FY12 requirements from key customers
*The BIDMC FY12 Annual Operating Plan
*The Meaningful Use Stage 1 and recommended Stage 2 Standards and Certification criteria
*Emerging Compliance projects

I found that the existing BIDMC FY12 IT Operating Plan addresses the needs of all these stakeholders.  There are only a few items to defer or reconsider.

Today, the CEO of BIDMC, Kevin Tabb, sent out his Thanksgiving message and highlighted BIDMC Information Systems: "We were named the #1 health care IT organization in the United States for 2011 by Information Week 500, and BIDMC was the first hospital in the country to achieve Meaningful Use of electronic health records, meeting a key set of new federal government standards."

I'll transition my Harvard Medical School CIO role by February 2012.  I serve on the search committee, which is following a multi-stakeholder process to find a visionary CIO to lead a great organization.

In my International, National, and State lives, I've worked with incredible people and the trajectory is very good.   In 2011, we completed a  healthcare IT plan for Japan and for New Zealand.    The content, vocabulary, and transport standards for the US are submitted to ONC, completing the foundational work for Meaningful Use Stage 2.   The State of Massachusetts has submitted a new State Medicaid Health Plan and completed a new HIT Strategic and Operational plan.

But most importantly, my family life is earning an A.

My daughter has blossomed into a resilient college woman with clear goals, deep friendships, and a very positive self-worth.   She's excelling in her coursework, immersing herself in the culture of Tufts University, and traveling to Japan as part of study abroad program this winter.    I'm so proud that she has left the nest and is building a life on her own.

My wife and I are planning the next stage of our lives and we'll be in Vermont this weekend visiting farm properties.   I'll be 50 this year and  although I have many years to go before retirement,  it seems the right time to find a property to grow organic vegetables, raise chickens/goats/llamas, and revel in a self sufficient lifestyle, learning to live nearly off grid.

My parents are doing well in a new house and enjoying time with friends, cultural events, and gardening time.

So, there is hope.   The world is experiencing a challenging time marked by economic fragility and social unrest.   The Occupy movement is raising our consciousness about the disparities in the US.    However, it is possible for a strong team of people working hard to excel in healthcare IT.   It is possible for your family to thrive based on love, trust, and lifelong learning.

Revel in the next few days of Thanksgiving (we're roasting root vegetables, Brussel spouts and tofu).   When you receive your next challenging email or are asked to define a timeline before you understand requirements, scope, or resources, take a breath.  There is hope!

Wednesday, November 23, 2011

More BYOD Worries

I've written about the increasing trend to Bring Your Own Devices (BYOD)  to work and the accountability it brings to the CIO.

Every day I receive articles highlighting the increasing risk of mobile devices on the network

The explosion of Android malware 

The hacking of Siri 

The vulnerabilities of the iPad 

It's very clear that in 2012 and beyond we will have to move beyond policy-based controls  and we'll have to implement technology based controls that may cost up to $10 per device per month.   Given our 1000+ mobile devices, that could be a $150,000/year increased operating expense to protect consumer devices brought from home.

In many ways, 2012 at BIDMC will be the year of increased compliance and we've just named an interim Senior VP of Compliance to build an enterprise-wide compliance team.

CIOs - it's time to tell your CFO to expect an unplanned 6 figure expense to protect your institutional data while at the same time embracing the mobile devices that will enhance productivity and user satisfaction.

Tuesday, November 22, 2011

The Job of a CIO - Content verses Context

I recently spoke with the CIO of Boston Medical Center, Meg Aranow, who I respect a great deal.   We talked about the nature of our jobs, the state of the industry, and the change ahead that is needed to support healthcare reform.

She offered a profound observation - the content of our jobs is great, the context is really challenging.

What does that mean?

Who could ask for better content - cool applications that support live saving medical care and cutting edge research.   Innovative healthcare information exchange, patient engagement, and workflow applications.    Multi-million dollar infrastructure, great staff, and interesting problems to solve.   During my years as an undergraduate, graduate, medical student, and post doc, I dreamt about such content.

However, the context of being a CIO is a struggle.   Don't worry, I'm not depressed or pessimistic, just sharing the observations I'm hearing from other healthcare CIOs in 2011.

*You'll create miracles every day (99.99% reliability and great security with a low budget), but you'll not receive credit for everything that works.   Instead you'll be held accountable for the .01% that doesn't.

*No matter what your budget, demand will always exceed supply.  Success will be finishing half the projects you've been asked to do.   You're unlikely to keep a significant percentage of your customers happy.

*You'll be asked to share more data with more trading partners for more purposes, but be held accountable for all privacy breaches, even though you cannot control many of the data flows.  Users will demand controls over their devices, bring devices from home, and expect broad freedoms, but you'll be responsible for any security problems they create.

*The pace of consumer IT change - new products and new services arriving every few months - will create expectations for IT service delivery that far exceed  the abilities of a thinly staffed IT organization.

*Regulatory burdens will increase exponentially.   Compliance is a must do but customers will not appreciate that work.  20% of your budget will be spent on compliance, 20% on security, and 60% on operations.    That leaves nothing for innovation (unless its required for compliance or security).   Meaningful Use, 5010, ICD-10, new Privacy rules, and healthcare reform will occur simultaneously.

*Every year the amount of infrastructure and applications you support will increase dramatically.   However, budgets will increase 2-3% or stay flat.   You'll be asked to do more with less.   Before long, you'll be asked to do everything for nothing in no time.

*Healthcare organizations in the US are structurally flawed.   Hospitals are essentially hotels with operating rooms and patient rooms that are rented by the doctors.   Hospitals (other than Kaiser) do not employ the doctors so it's a bit like Toyota owning the factory but allowing the workers to build whatever they want.   How about a car with 7 doors and 2 trunks?   No problem - do what you want inside the factory.   IT will be caught in the middle because hospitals and doctors will want technology solutions that may not be aligned.

*You'll need to constantly change systems while keeping them stable and secure.  It will be like changing the wings on a 747 while it's flying.

*Many IT services will not be charged back and the demand for a free service will be infinite.   Users will consume whatever computing, storage, and network bandwidth they wish, but you'll be held accountable for provisioning enough to support demand you cannot control.

*Unplanned work will consume 20% of your agenda.  Compliance/regulatory change, auditors, and reaccreditation will require urgent redeployment of staff, but you will be held accountable for all the projects that were delayed.   You should plan for unplanned work.

Demand management, even with good governance, will be an increasing challenge for CIOs in the future.    Here's a bold thought - might the context of being a CIO be nearly impossible in 2012 and beyond,  requiring us to rethink the way that IT services are planned and delivered in the future?

As I hear more from my fellow CIOs about compliance burdens, overwhelming demands, and impossible expectations, I will compose another post, speculating about IT organizational models for the future that enable CIOs to improve the context of our work.

Monday, November 21, 2011

From Blackberry to iPhone

Last week I retired my Blackberry Bold, removed myself from the Blackberry Enterprise Server, and began using an iPhone 4S as my mobile email, web, and telecommunications platform.

This was not a casual decision.   I've used Blackberry products since 1998.  The original Blackberry 850 was named one of the top 50 technologies of the past 50 years.

I receive a wireless communication approximately every 30 seconds from 7am-7pm every day.  On Tuesdays and Thursdays I receive over 1500 emails per 24 hour period.   These communications are filled with media - documents to read, presentations to review, websites to access, and streaming video.    Yes, I still use the email triage approach I outlined in 2007 but it's a losing battle.   The volume of communication exceeds my ability to process and respond to the information.   I could cancel all my meetings, phone calls, and presentations but still fill the entire day with email communication.

I'm not suggesting this is healthy or sane, but it is the reality of communications today.

The iPhone 4S gives me a touch screen user interface to scroll, zoom, and manage my incoming messages.   I can view every document, website, and video over 3G networks.   Siri and voice recognition features enable me to manage my email by voice.   I find myself dictating responses to about a quarter of my email with amazing accuracy.

I'm still in the learning stage, so my ability to type on a touch screen is still not quite as nimble as on the Blackberry keyboard.   It's also harder to type while walking between meetings.    However, the learning curve is fast, and the toolset provided by the 4S includes much better web browsing and Exchange integration than Blackberry.  My Macbook Air running Mac OS X Lion with Apple Mail/iCal/Address book is essentially the same software as on the iPhone 4S, so I can switch seamlessly from my mobile device to my laptop with perfect data synchronization.

RIM has been an innovator.   The Blackberry is secure.  The Blackberry has been easy to manage at the enterprise level.    However,  Blackberry is architected to route messages via RIM's centralized infrastructure.  If that fails, every Blackberry in the world fails.   Blackberry's user experience has not kept pace with the competition.   Blackberry's application development tools and app store have not kept pace with iPhone or Android.   Devices such as the Playbook have been introduced before they were ready.

All companies regress to the mean  and for RIM it appears to be the beginning of the end.   In the past year, its stock has declined from 70 to 20, a loss of 70%.

The pace of technology change is accelerating so fast, that even those of us in the industry can hardly keep up.   The consumer device world is a shark tank.    Competition is fierce and devices come and go as fast as hemline heights and tie widths change.

My switch to an iPhone 4S was predicated on a need to communicate with more flexibility, power, and speed than a Blackberry could support.

 I'm not the only one.  Per our email administrator:

"I'm seeing a slow death of Blackberry.  We have about 400 people still on the Blackberry Enterprise Server. I imagine as contracts expire more will jump to iPhones and Androids.  We lose 5-10 Blackberry accounts per month. iPhones currently outnumber Blackberry 3 to 1"

Thus, you'll likely be receiving iPhone 4S emails from me, generated via voice recognition.    Apologies for the typos, I'm still learning.

Friday, November 18, 2011

Cool Technology of the Week

This week, I was asked to evaluate a longstanding slow website problem.

One of the most challenging questions that CIOs receive is the "application is slow, can you fix it?" problem.

Root causes range from underpowered laptops, virus infected desktops, slow wireless connections, firewall congestion, web server memory leaks, storage I/O bottlenecks, database indexing, and poorly written HTML.

For this particular issue, I suspected application issues in the use of Javascript, style sheets, graphics, and flash objects, not infrastructure.

A quick search on Google yielded this great website optimization tool , which is a companion to an O'Reilly book Website Optimization: Speed, Search Engine & Conversion Rate Secrets by Andrew B. King.

It diagnosed the problem immediately as an inefficient web page design.   We implemented compression of stylesheets, Javascript, and images, which increased performance ten-fold.  The entire site is being rewritten and we'll be sure to use this tool before go live to verify that we've followed best practices.

A great tool and an O'Reilly Book for optimizing website performance - that's cool!

Thursday, November 17, 2011

Exploring Vermont

Last Friday, I lectured at Dartmouth about the increasing challenges of information security in a world filled with malware.

After spending a few hours with the Dartmouth TISH group, my wife and I drove to Burlington, Vermont for a weekend of exploration.   It's always been our retirement plan to run a small family farm, raising organic vegetables and a few animals that contribute to the ecosystem ie. chickens for insect control/fertilizer, pigs for consumption of food scraps, and goats for trimming grass/plant overgrowth.    Vermont has the rolling hills, fertile farmland, and agricultural zoning we desire but also has close proximity to arts, culture, and great small businesses.

On our first night, we ate at our favorite Vermont vegan friendly restaurant, A Single Pebble  in Burlington and stayed at the Willard Street Inn, in a cozy 3rd floor nook.

On Saturday morning, we explored Burlington, South Burlington, Williston, and Shelburne.  We walked the grounds of Shelburne Farm (pictured above), then enjoyed a loaf of fresh broad, local mustard, apple cider, and fruit while sitting on the shore of Lake Champlain.    We spent the afternoon exploring Charlotte and Hinesburg, cities south of Burlington with extensive farming.    For dinner, we enjoyed a vegan spicy corn and black bean pudding at the Bearded Frog and stayed the night at The Elliot House.

On Sunday we drove the covered bridges and back roads of Charlotte and Hinesburg, then explored central and southern Vermont, driving to Bristol (near Middlebury), Lincoln, and Warren/Sugarbush.      Road closures due to Hurricane Irene rerouted us through Killington and Woodstock, then to White River Junction and the drive home to Boston.

My conclusion - Vermont is a remarkable place with warm people, strong locavore/small business support , and the perfect combination of wide open spaces with access to high tech services.

Our quest for farmland begins.

Wednesday, November 16, 2011

The November HIT Standards Committee

Today, the HIT Standards Committee shifted gears from the Summer Camp work on Meaningful Use Stage 2 and began new interoperability efforts.

We began the meeting with a presentation by Liz Johnson and Judy Murphy about the Implementation Workgroup's recommendations to improve the certification and testing process.   These 15 items incorporate the Stage 1 experience gathered from numerous hospitals and eligible professionals.   If ONC and NIST can implement this plan, many stakeholders will benefit.  The Committee approved these recommendations without revision.

Next, we focused on content, vocabulary and transport standards.

In my October HIT Standards Committee blog post, I noted that HITSC should work on the following projects:

*Continued refinement of the Consolidated CDA implementation guides and tools to enhance semantic interoperability including consistent use of business names in "Green" over-the-wire standards.
*Simplifying the specification for quality measures to enhance consistency of implementation.
*Standardizing DICOM image objects for image sharing and investigating other possible approaches.   We'll review image transfer standards, image viewing standards, and image reporting standards.
*Query Health - distributed queries that send questions to data instead of requiring consolidation of the data

*Extending the quality measurement vocabularies to clinical summaries
*Finalizing a standardized lab ordering compendium

*Specifying how the metadata ANPRM be integrated into health exchange architectures
*Supporting additional NwHIN standards development (hearings about Exchange specification complexity, review/oversight of the S&I Framework projects on simplification of Exchange specifications).   Further defining secure RESTful transport standards.
*Accelerating provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminating lessons learned.

The November Committee agenda included a discussion of  Consolidated CDA, Quality Measures, and NwHIN Implementation Guides.

Doug Fridsma began with a discussion of the Consolidated CDA work and the tools which support it.

The Committee had a remarkable dialog with more passion and unanimity than at any recent discussion.   We concluded:
*Simple XML that is easily implemented will accelerate adoption
*That simple XML should be backed by a robust information model.   However, implementers should not need expert knowledge of that model.  The information model can serve as a reference for SDOs to guide their work
*Detailed Clinical Models, as exemplified by Stan Huff's Clinical Information Modeling Initiative (CIMI) hold great promise.   Stan has assembled an international consensus group including those who work on
 -Archetype Object Model/ADL 1.5 openEHR
 -CEN/ISO 13606 AOM ADL 1.4
 -UML 2.x + OCL + healthcare extensions
 -OWL 2.0 + healthcare profiles and extensions
 -MIF 2 + tools HL7 RIM – static model designer

Their work may be much more intuitive than today's HL7 RIM as the basis for future clinical exchange standards.

*Rather than debate whether Consolidated CDA OR GreenCDA(simplified XML tagging) should be the over the wire format, the Committee noted that "OR" really implies "AND" for vendors and increases implementation burden.   The Committee endorsed moving forward with GreenCDA as the single over the wire format.  
*We should move forward now with this work, realizing that it will take 9-12 months and likely will not be included in Meaningful Use Stage 2, but it is the right thing to do.

Thus, the future Transfer of Care Summary will be assembled  from a simple set of clinically relevant GreenCDA templates, based on CIMI models, as needed to support various use cases.  There will be no optionality  - just a single way to express medical concepts in specific templates.

To support this approach, we'll need great modeling tools.    David Carlson and John Timm presented the applications developed to support the VA's Model Driven Health Tools initiative.  This software turns clinical models into XML and conformance testing tools.   The committee was very impressed.

Next, Avinash Shanbhag presented the ONC work on Quality Measures  that seeks to ensure quality  numerators and denominators are expressed in terms of existing EHR data elements captured as part of standard patient care workflows.

Avinash also presented an update on transport efforts, which include easy to use, well documented implementation guides for SMTP/SMIME and SOAP.   The work is highly modular and does not require that the full suite of NwHIN Exchange specifications be implemented for SOAP exchanges.

As part of the ongoing efforts to improve NwHIN Exchange, the HIT Standards Committee is seeking input from NwHIN implementers per this blog post.

Finally, Wil Yu updated the committee on the SHARP and other innovation programs.

There will be a great body of challenging work to do in 2012.   What's needed after that?  The next 5 years will include many new regulations as healthcare reform is rolled out.   It's clear that the Standards Committee will have many topics to discuss.

Tuesday, November 15, 2011

Massachusetts State HIE Update

Yesterday, Rick Shoup, Manu Tandon and I presented the updated Massachusetts Stategic/Operating Plan, State Medicaid Health Plan/Medicaid Management Information System plan, and the Implementation Advance Planning Documents for Health Information Exchange to the HIT Council and the HIT/HIE Advisory Committee.   The budgets and strategy were approved by the Council.

Here's the overview of the strategy.

It's based on 3 principles

*Leveraging the components needed by the State Medicaid Health Plan/Medicaid Management Information System for use by all public/private Health Information Exchange Stakeholders
*Building upon existing private sector investment
*Connecting the "last mile" of every payer, provider and patient to the state HIE backbone.

What do we mean by "last mile"?

There are roughly 20,000 licensed practicing physicians in Massachusetts and of those approximately 10,000 are currently or will be active users of EHRs and a Health Information Exchange (HIE). Some hospital and ambulatory applications are already connected to local or regional health information exchanges (HIEs) such as the New England Healthcare Exchange Network (NEHEN), SafeHealth, the North Berkshire eHealth Collaborative HIE, the Community Hospital and Physicians Practice System’s (CHAPS) HIE, the UMass HIE and Wellport HIE. However, many small providers have no HIE connectivity or use a web portal approach which is not integrated into their EHR workflows.

In order to optimize the transport capabilities of the state HIE, all hospital information systems and EHRs need to be connected to the transport backbone. The end result will be an integrated network of networks that enables any payer, provider, patient or consumer to exchange data. We refer to this as the “last mile.”  

The “last mile” will be implemented as follows:

First, a better understanding of the scope must be gained.   MeHI, the State Designated Entity and Regional Extension Center for Massachusetts, will do an analysis of Hospital Information System and EHR adoption in Massachusetts to identify those providers, institutions and applications which are not yet connected to an HIE.

 Second, further analysis will identify the additional software or services required to enable HIE connectivity such as  sending and receiving clinical summaries and HL7 lab/public health messages from Hospital Information Systems and EHRs to the HIE backbone.  Massachusetts wants to move quickly to implement this connectivity before it is required by future stages of  Meaningful Use.

Third, is the delivery of system integration services to connect to the HIE based on the prior analysis. These services will include the resources necessary to install and configure software, provide training and education or other support activities to practices throughout the Commonwealth.

Some types of providers were not included in the original scope of meaningful use incentives or have been slow to adopt for other financial reasons.  These include the Behavioral Health and Long Term Care communities and some solo and two clinician practices.   Last mile connectivity for these late adopters may include web-based applications that are easy to use and support.  These applications will generate and receive electronic data that is being developed as part of the Commonwealth's IMPACT Challenge Grant. Thus the Massachusetts HIE approach includes those without EHRs and those with EHRs but lacking the capabilities to send and receive data directly.

Fourth, a single project management office will manage support of the project.  MeHI, as that project management office and in collaboration with EOHHS, will centralize last mile integration expertise and achieve economies of scale by creating an efficient approach to last mile integration.

Fifth, MeHI will provide educational materials and training so that clinicians are aware how to optimize their new HIE connectivity, achieving meaningful use stage 2 and maximizing the amount of data flowing to other clinicians, public health, and quality registries.

Hospital information system and electronic health record vendors report that State HIEs tend to build central infrastructure while assuming the endpoints will be able to connect to the HIE on their own.  However, most practices lack the technical capability and incentives to do this work, so the value of the HIE is not realized and sustainability is never achieved.  Massachusetts intends to avoid this failed scenario by actively ensuring the connection of the last mile.

With stakeholders aligned and the strategy approved, Massachsetts is ready to accelerate its HIE efforts.

Monday, November 14, 2011

Nutrition Planning Resources on the Web

I was recently asked the question:

"BIDMC does not have any sample menus to give to patients – either for weight loss or for healthy eating in general. Our nutritional counseling still consists of meeting with a nutritionist and being advised regarding “good” vs. “bad” foods, getting some instruction on calculating calorie content and some advice how to turn a list of foods into a meal.

I’ve checked around on the internet and there are some commercially available programs that will generate menus, based on the kind of diet that one wants but they seem to have substantial constraints in terms of items that are included and how easy it is to exclude things.
What I’m a interested in finding out is the possibility of creating an EHR interface that would allow either a patient or a physician to generate not a diet, but a two week menu  which would be customized to dietary preferences and a set of calories.

So for example if I have a patient that needs to lose 30 pounds, doesn’t eat breakfast, is a pescatarian and would like to consume 1/3 of their calories at lunch and the rest at dinner, is there a way of doing that?"

Margo Coletti, our Director of Knowledge Services (formerly the Medical Libraries) researched the question and wrote the following answer

"There is no database currently that produces menus with that much specificity.  However, Nutrihand Pro comes very close.

BIDMC subscribes to the Nutrition Care Manual which is available through our Intranet Portal.  The Client Education tab at the top lists several menus for weight loss and for various health conditions and dietary restrictions (MI, tyramine-restricted, diabetic, etc)

The Joslin Clinic has excellent nutritionists for you to refer your diabetic or prediabetic patients to. These nutritionists will work with the patient to tailor menus to their needs.

Joslin also has an excellent weight loss program for diabetics.  The nutritionists, again, will work with patients to tailor their menus.

There are also several databases that produce nutrition facts for a given food or food product. Here are some that the Joslin Clinic uses in their nutrition education: (One can download a free CalorieKing-Joslin Food Awareness Toolbar to count carbs) (Nutrition information with a recipe analysis feature) (Information on calorie content of foods and caloric expenditure of activities) (Nutrition information website that includes many restaurants) (Website for the American Dietetic Assn) (Nutrient Data Laboratory; provides extensive nutrition information and values for potassium, sodium, protein)

I hope this is helpful."

Per their website, Nutrihand is free when you join with your nutritionist or dietitian.  If you're getting professional help offline, it enables you and your counselor to work together online on meal plans, shopping lists, and fitness goals. You can print out reports to bring to your sessions. Diabetics who use insulin pumps can upload data from their glucometer on a private and secure network and chart or graph glucose levels, blood pressure , and other personal data to adjust pump settings and track health status.

We'll study these resources and incorporate the most useful ones into our patient and provider portals.

Friday, November 11, 2011

Cool Technology of the Week

In a HIPAA and HITECH compliant environment, I have to carefully watch where and how data is stored.

Unfortunately, there are many stakeholders and collaborators who want to use Dropbox, which lacks the necessary privacy protections.

What we really need is Dropbox for the private cloud that enables similar functionality on our HIPAA compliant enterprise storage.

We're evaluating 4 alternatives

1) Dropbox Teams - Encrypted enterprise Dropbox
2) Oxygen Cloud  -  Supports EMC Atmos Cloud Oriented Storage (used at BIDMC for image archiving)
3) Blackboard Learn - Formerly Xythos
4) ShareFile - Recently acquired by Citrix

HIPAA compliant Dropbox-like functionality.   That's cool!  I'll let you know what we decide.

Thursday, November 10, 2011

Where Have All Our Heroes Gone?

Does it seem to you that we've lost our sense of wonder and our respect for heroes?

The press is filled with stories of flawed or fallen heroes but little praise for the tireless work done every day to make the world a better place.

In the Northeast, 2 million people lost power due to an act of God - an early winter storm.   One week later, a few thousand were still without power.   Local politicians demanded answers from power companies to explain why it took so long and why their planning for the unexpected storm was so poor.   As an infrastructure provider myself, I can tell you that utility workers have done a heroic job - deciding what work would restore power most quickly based on a Pareto analysis, doing the main/trunk/substation work rapidly and leaving the most remote parts of the grid for last.   It's been 24x7, cold, wet, and physically demanding work.    They've done their best and I respect the people that did the work.

Steve Jobs, a remarkable person,  was brilliant and charismatic but could be overly demanding, emotional, and less than perfect with his family and personal relationships.   His death was met with initial shock and an outpouring of respect.   After a week, the press turned to the dark side of Steve's personality, as nicely summarized in this New York Times article  about the short sainthood of Steve Jobs.

I'm an eternal optimist and believe that mankind is basically good.  However, I cannot help but believe that society has lost its perspective when we spend time tearing down our heroes, highlighting their mistakes, and reveling in Schadenfreude when someone falls from grace.  

Everything regresses to the mean, but wouldn't it be best to capture people at their peak of creativity and remember them for what they did right?  Of course we can learn from their mistakes and failures, but we do not need to perseverate on their nadirs when their zeniths are where they had the most impact.

As someone who lives in operational roles 24x7x365, I can say that it is very hard to achieve and maintain perfection. I've written that I do not have power or authority - what I really have is risk of failure.

I would rather celebrate success, learn from failure and acknowledge those human beings who have made a difference.  

The héroes in my life are my wife, my daughter, my parents, economist Milton Friedman, Steve Jobs, former HIT National Coordinator David Blumenthal, former Harvard Medical School Dean Joseph Martin, my second in command at BIDMC John Powers, CEO of the Massachusetts eHealth Collaborative Micky Tripathi, and the current head of CMS Don Berwick.    I'm sure each has had moments of incredible success and events they would rather forget.    They have all been inspirational to me.

So for one day, let's celebrate our heroes, flaws and all.   Let's ban all news about Lindsey Lohan and Kim Kardashian.

If we try hard enough, maybe our sense of wonder and magic will return.

Wednesday, November 9, 2011

The Growing Malware Problem

On Friday. I'm lecturing at Dartmouth College to the TISH workgroup (Trustworthy Information Systems for Healthcare) about the growing malware problem we're all facing.

Have you ever seen a Zombie film?   If so, you know that to stop Zombies you must shoot them in the head - the only problem is that the steady stream of Zombies never seems to end and they keep infecting others.   Just when you've eradicated every Zombie but one, the infection gets transmitted and the problem returns.   You spend your day shooting them but you never seem to make any progress.

A Zombie in computer science is a computer connected to the Internet that has been compromised by a cracker, computer virus or trojan horse and can be used to perform malicious tasks of one sort or another under remote direction.

Staring in March of 2011, the rise in malware on the internet has created millions of zombie computers.   Experts estimate that 48% of all computers on the internet are infected.   Malware is transmitted from infected photos (Heidi Klum is the most dangerous celebrity on the internet this year),  infected PDFs, infected Java files,  ActiveX controls that take advantage of Windows/Internet Explorer vulnerabilities and numerous other means.

Here's the problem - the nature of this new malware is that it is hard to detect (often hiding on hard disk boot tracks), it's hard to remove (often requiring complete reinstallation of the operating system), and anti-virus software no longer works against it.

A new virus is released on the internet every 30 seconds.   Modern viruses contain self modifying code.  The "signature" approaches used in anti-virus software to rapidly identify known viruses, does not work with this new generation of malware.

Android attacks have increased 400% in the past year.   Even the Apple App Store is not safe.

Apple OS X is not immune.  Experts estimate that some recent viruses infections are 15% Mac.

If attacks are escalating and our existing tools to prevent them do not work, what must we do?

Alas, we must limit inbound and outbound traffic to corporate networks.

BIDMC will pilot increased restrictions in a few departments to determine if it reduces the amount of malware we detect and eradicate.    I'll report on the details over the next few months.

One of these restrictions will be increased web content filtering.    I predict in a few years, that corporate networks will advance from content filtering to more restrictive "white listing".   Instead of blocking selective content categories, they will allow only those websites reputed to be safe (at that moment anyway).  I think it is likely corporate networks will block personal email, auction sites, and those social networking sites which are vectors for malware.

It's truly tragic that the internet has become such a swamp, especially at a time that we want to encourage the purchase of consumer devices such as tablets and smartphones.

I've said before that security is a cold war.   Unfortunately, starting in March, the malware authors launched an assault on us all.    We'll need to take urgent action to defend ourselves and I'll update you on our pilots to share our successful tactics.

Tuesday, November 8, 2011

The EHR/HIE Interoperability Workgroup

Today,  the EHR/HIE Interoperability Workgroup, originally formed by the New York eHealth Collaborative (NYeC), will announce the collaborative work of seven states (California, Colorado, Maryland, Massachusetts, New Jersey, New York, and Oregon), eight EHR vendors (Allscripts, eClinicalWorks, e-MDs, Greenway, McKesson Physician Practice Solutions, NextGen Healthcare, Sage, and Siemens Healthcare), and three HIE vendors (Axolotl, InterSystems, and Medicity.)

The objective of the EHR/HIE Interoperability Workgroup has been to define a single set of standardized, easy-to-implement interoperability specifications that will increase the adoption of EHRs and Health Information Exchange services. The effort leverages existing published standards for interoperability from the Office of the National Coordinator (ONC).

The work includes refinements to mature, well tested standards including:

*A summary of care implementation guide that further constrains the CCD/C32

*An enhanced Direct specification including SMTP/SMINE, XDR for connection to HISPs, and PKI/Certificate distribution.

The work also includes enhanced guides for those standards that the HIT Standards Committee felt required additional testing and refinement including:

*A detailed guide for implementing HPD/LDAP provider directories

*An updated guide to the components of the NwHIN Exchange specifications for "pulling" data from multiple data sources.

I offered the following quote to describe their work:

"I applaud the work that the EHR/HIE Interoperability Workgroup is doing to move states from implementation guides to production.   Their selection of Consolidated CDA and Direct is well aligned with HIT Standards Committee discussions.  The EHR/HIE Interoperability Workgroup is  also doing important work with NwHIN Exchange and Provider Directories that will provide the country with lessons learned, so that the HIT Standards Committee can recommend refinements to these emerging technologies.   I expect that the flexibility and agility of the EHR/HIE Interoperability Workgroup will serve as an ideal laboratory for standards that are rapidly evolving."

Massachusetts is rapidly implementing Direct for exchange of clinical summaries.   It's very likely that our implementation will be able to leverage the work of EHR/HIE Interoperability Workgroup for multi-state compatibility and reusability.

It's going to be a great year for HIE.

Monday, November 7, 2011

The Accountable Care Organization Final Rule

Robin Raiford has been hard at work annotating the Final ACO Rule.    Here's a version that is fully bookmarked.

She's also recommended important new resources on the CMS website:

Eligible Professionals
*Updated CMS Specification Sheets 

Eligible Hospitals
*Updated CMS Specification Sheets 

Thanks Robin!

Friday, November 4, 2011

Cool Technology of the Week

The recent power outages through the Northeast have caused everyone to think about the reliability of the electrical grid.   Throughout Massachusetts, New Hampshire, Vermont, and Maine our power lines pass from pole to pole through brilliant fall foliage.  Last week's pre-winter snow was trapped on those leaves, broke branches, and tore power lines.

Thus, the water cooler chatter is all about generators.

Although a Bloom box would be nice, the $700,000 price tag is a barrier.   Alternatives such as solar do not really work in New England winters with limited sunlight.

The next best thing is a natural gas powered generator that automatically starts and provides backup power when street power fails.  Generac is a popular model.  It's highly unlikely that natural gas will stop flowing when electricity fails.   In New England, our issue is that electricity is needed to circulate heated water, steam, or hot air, so a power failure results in a heating failure.   A generator is a necessity in places like rural New Hampshire which can be without power for weeks every year.

Here's a handy calculator to help you size your generator.

Natural gas generators that keep you powered and warm when power lines fail.  That cool! (or hot as the case may be)

Wednesday, November 2, 2011

The Benefits of RxNorm

I was recently asked about the benefits of RxNorm and asked my friends at the National Library of Medicine for the answers:

1.       What are the benefits of RxNorm over NDC, or SNOMED?

RxNorm represents drugs in a way that corresponds directly to a prescriber's view of a drug, as an ingredient + strength + dose form. The dose form is the form as it is actually administered (e.g. 'Injectable suspension"), not necessarily the form as it is manufactured and delivered to a pharmacy (e.g. 'Powder for suspension). The NLM has taken government and commercial sources of data, creating normalized names to produce a complete list of the drugs used in the United States. We have a very slim policy-making process, allowing us to respond quickly and effectively to tweak our model if necessary, which we have done a number of times.

The benefit of this approach is that the drugs are named consistently, the names and codes are centrally published and maintained, improvements can be incorporated quickly, and the set of drugs is complete (for the U.S.).

NDC codes represent drugs from what might be called an 'inventory' perspective. NDCs characterize and differentiate drugs on the basis of manufacturer and package size, for example. Two different NDCs could correspond to a singe RxNorm identifier; a generic drug could be made by different manufacturers or provided in different package sizes. NDCs require the use of a 'representative NDC' in order to provide a single identifier for a single clinical drug. Schemes of representative NDCs has proven to be very clumsy to use here in the US. In addition, NDCs are not centrally assigned or maintained. Each manufacturer/packager issues its own NDCs and there is no 'official list' of all NDCs in the US.

SNOMED CT is an international terminology that has a relatively complex editorial process, and requires license fees and participation in its governing organization, the International Health Terminology Standards Development Organization (IHTSDO). The SNOMED CT International Release is meant to contain the 'common denominator' of drugs across the world; each country using SNOMED CT for drugs needs to develop a National Extension separate from the International Release.

2.       What evidence is there for its use, that it has worked successfully and in which hospitals?

RxNorm has been tested by the US Centers for Medicare and Medicaid (CMS) in both a live and a 'lab' environment and found to be complete and usable. Some minor challenges noted in some details of implementation, but overall it was found extremely useful and work-able.

For a variety of reasons having to do with legacy workflows in the US, RxNorm is not currently used in e-prescribing (sending prescriptions from a prescriber to a pharmacy). However it is used in both research and in after-the-fact analysis of drug data in institutions like Stanford Hospital and  University of Florida.

3.       What is the current percentage of hospitals using RxNorm, and what has been the uptake over the last few years in the US, forecast for the next few years?

The standards environment in the US is quickly converging upon RxNorm as the designated drug vocabulary for sending electronic messages containing drug content, and I anticipate that RxNorm will be mandated for many of these uses within the US very shortly.

Thanks to the NLM for this and I look forward to continued implementation of RxNorm in my own institution.

Tuesday, November 1, 2011

The New Metrics for CIO Success

When I begin my career as a CIO in 1997, success was function of the basics - email delivery, network connectivity, and application functionality.    I personally wrote code, experimented with new operating systems, and created analytics using web servers, SQL, and ASP pages.

In 2011, CIO success is much more complex to measure.  

Infrastructure success can be defined as 99.99% uptime of all systems and no loss/corruption/breach of data.   The magical belief in the cloud sets expectations that IT infrastructure should be like heat, power, and light - just there as a utility whenever it is is needed in whatever amount is needed.

Application success could be defined as on time, on budget delivery of go lives according to project plans.  Two important forces make this more complex
*Consumer software stores set expectations that enterprise software should be easy - we need to fix revenue cycle workflow, isn't there an app for that?
*As the economy forces downsizing and efficiency gains, there's an expectation that workflow automation is a pre-requisite to organizational change so there is more pressure on the IT department to deliver application solutions quickly.

This all sounds impossible - deliver massive infrastructure with constant change but keep it entirely reliable and secure.   Deliver applications that support business processes in increasingly short timeframes with limited IT and business owner resources.

Thus, the modern CIO is no longer a technologist or evangelist for innovation.   The modern CIO is a customer relationship manager, a strategic communicator, and a project manager, delicately balancing project portfolios, available resources, and governance.  

Modern CIOs have little time to get infrastructure and applications right, so they must "skate where the puck will be", thinking more like CEOs about business needs and future strategies, so that critical information technology is deployed by the time it is needed.

What am I doing in FY12 to become a more effective modern CIO?

1.  I've defined key business customers (BIDMC senior management and chiefs).   I'm meeting with each one to ensure their priorities for the next year and beyond are reflected in the FY12 IT operating plan and the 5 year IT strategic plan.  Planning much more than 5 years in IT is problematic given the pace of technology change.   Working with the governance committees, I will trim this list into those projects that have the greatest impact on business strategy, quality/safety, and efficiency.

2.  I'm standardizing communication so that key customers receive monthly updates about their priority projects.

3.  I'm defining a process for managing IT projects across the enterprise that includes standardizing the IT Project Intake Process, the IT Project Life-cycle, and Project Management tools ( project documentation, project plans, and status reports).

It's my hope that by focusing on customer relationship management, communication and project management that I will create a positive working environment for the IT staff with a more limited set of well-defined projects and more engaged customers.     Doing fewer projects with greater speed and depth which meet the most critical needs of the business is much harder than agreeing to do many niche projects and moving forward slowly on all.   Given that the supply of IT resources is likely to be  fixed since healthcare budgets are under increasing pressure from healthcare reform, the modern CIO should be judged on demand management and achieving reasonable levels of customer satisfaction despite having to focus on a narrower project portfolio delivered at a faster pace.