Life as a Healthcare CIO

Our Cancer Journey - Week 7

2012-02-02T03:00:00.000-08:00

Tomorrow we begin the third cycle of Cytoxan/Adriamycin. In the journey thus far, Kathy has had good days and bad days. High energy and low energy days. Meal days and BRAT (Bananas, Rice, Apples, Toast) days. We frequently discuss the factors that put Kathy at risk for cancer at this point in her life. We talk a lot about the future.

Kathy's typical pattern is

Friday - Chemotherapy infusion day, good energy, good appetite, some jitters from the steroids
Saturday - Good energy, good appetite, some jitters from the steroids
Sunday - Waning energy, moderate appetite, bone pain
Monday - No energy, moderate appetite, extra sleep needed, bone pain, bland diet
Tuesday - Low energy, extra sleep needed, bone pain, bland diet
Wednesday - Low energy, bland diet, extra rest needed
Thursday - Moderate energy, bland diet
Friday - Moderate energy, stomach pain, bland diet
Saturday - Moderate energy, stomach pain, bland diet
Sunday - Moderate energy, stomach pain, bland diet
Monday - Good energy, moderate appetite
Tuesday - Good energy, good appetite
Wednesday - Good energy, good appetite
Thursday - Good energy, good appetite

What environmental risks caused the cancer at this point in her life? Exposure to the cadmium and other heavy metal pigments in her traditional oil paints? Pesticides in the environment? Bisphenol in cans? Free radicals?

We've talked about psychoneuroimmunology, the impact of mood and outlook on the ability to combat disease.

The past two years have been challenging for Kathy - helping our daughter grow from high school to college, transitioning to an empty nest, creating an art gallery business in a challenging economy, sharing the stresses of my Federal/State/local work (especially Meaningful Use for several hospitals and 2000 doctors), and supporting the health needs of our parents.

Although they past few years have been stressful, all the events are consistent with our expectation for this stage of life.

One event in the past year was a bit out of the ordinary. A 19 year old with a very poor driving record (4 points on his license, 1 high speed collision, 1 hit and run etc.) drove down the wrong side of the road around a line of traffic and hit Kathy's car as she was exiting a parking lot. It was very clear from the position of the impact that it was caused by a driver violating the law.

Kathy filed an insurance claim and provided all the details of the accident.

The 19 year old driver lied about what happened.

Our insurance company decided Kathy was at fault, gave her a point on her driving record, and added a multi-year surcharge to her insurance.

When Kathy pursued the issue, noting that the 19 year old with the poor driving record was lying, the insurance company told her that without a photograph of the accident or an independent witness who was willing to verify the events, they would have to believe the 19 year old because Kathy was exiting a parking lot and that makes her at least 51% responsible. Despite Kathy's over 30 year good driving record, the insurance company representative literally ended the conversation with the statement "Life isn't fair".

That episode temporarily caused Kathy to lose her faith in humanity and gave her a sense of helplessness in a hostile world.

As with any conflict or issue, for everything there is a process.

Kathy appealed the ruling to the Massachusetts Board of Insurance and wrote an eloquent letter stating the facts.

Today the Board of Insurance ruled she was not at fault, rescinded the point on her license, and demanded that the insurance company refund/rescind the surcharge. She cried when she opened the letter. The nice guy can still finish first.

This weekend we'll continue our search for local farmland by touring Harvard, Massachusetts with locals recommended by our next door neighbor. The cancer diagnosis constrains our possibilities but has not dulled our enthusiasm for a long and fulfilling future.

Provider Directories and Public Key Infrastructure for HIE

2012-02-01T03:00:00.000-08:00

As Massachusetts prepares a Request for Response (RFR) to procure healthcare information exchange infrastructure and applications, many stakeholders have been hard at work documenting requirements.

The Provider Directory and Public Key infrastructure are some of the hardest specifications to write since they have not yet been widely deployed for healthcare information exchange anywhere in the country.

The leaders of the Massachusetts HIE effort have held 3 major vendor and user forums over the past month and have been told that no vendor has a standards-based provider directory in production at any customer site.

Here's our best thinking about Provider Directory and Public Key infrastructure services.

Provider Directory
The Directory will have a schema within a relational database that enables lookup of entities, which could include a person (John Halamka), an organization (BIDMC), a department (The BIDMC Department of Emergency Medicine), a state entity (Massachusetts Department of Public Health), a payer (Blue Cross Blue Shield of Massachusetts), a vendor (The Massachusetts eHealth Collaborative Quality Data Center), or a PHR infrastructure trusted by the HIE (Microsoft Healthvault). There will be two ways to query this database - Lightweight Directory Access Protocol (LDAP) for use within the Massachusetts state government firewall and SOAP-based web service APIs for all users external to the firewall. The response to a query will include the node name for communication to the entity i.e. John Halamka will not have a node, but the BIDMC Department of Emergency Medicine or BIDMC could. Digital certificates are not stored in the Provider Directory.

Public Key Infrastructure
Certificates will be issued by a single Certificate Authority and will be stored in one of many Domain Naming System (DNS) services capable of supporting certificate queries such as BIND or Microsoft's special implementation of DNS created for the Direct Project (http://directproject.org/). For example, BIDMC could offer a DNS service called Direct.bidmc.org which hosts the public keys for all our nodes.

Here's how it would be used. An EHR would look up an entity in the Provider Directory and then use DNS services to retrieve the certificate for the entity's node.

We're also considering an alternative approach using the open source tools available in the Direct Project's Reference Implementation. These tools include administrative tools to store and manage certificates and an adapter that links the directory store to a DNS responder. Participants could upload their certificates to this centralized data store. For example:

DNS Responder <--DNS Web Services--> Direct Reference Implementation Web Services <--BIDMC adaptor--> BIDMC datastore

The vendor community has told us that they want a single simple directory and public key infrastructure specification they can implement one time for an entire state. We'll give that to them and I'll write about their responses in future posts.

Radiology Image Exchange

2012-01-31T03:00:00.000-08:00

In my recent blog about the Standards Work Ahead in 2012, I called DICOM a non-standard standard.

This generated numerous email messages, phone calls, and blog comments.

Let me clarify what I meant.

DICOM is a great standard that has unified many processes within organizations, linking radiology modalities and PACS systems.

Why do I believe additional work is needed?

In December, my wife visited a hospital near our home for a diagnostic mammogram. It was clear she needed followup care with a cancer care team. We decided that Beth Israel Deaconess would be ideal because of its electronic health records and personal health records that would help Kathy coordinate her care. We asked for the images to be transmitted to BIDMC and we were told that we needed to visit the radiology department Monday-Friday 9am-5pm for a CD to be created so that Kathy could drive is 20 miles to BIDMC. The CD contained a proprietary viewer that required Windows and hence was not visible on our home computers (all Mac OSX).

What would have happened in an ideal world?

1. An implementation guide for DICOM would specify required vendor neutral content - a basic set of metadata (patient identifiers, name of the radiology study, imaging techniques used etc.) that would work with any viewer - Siemens, Agfa, Philips, GE, Kodak, etc. Any vendor specific/proprietary metadata would be stored separately from the required basic content, so that extensions do not impact generic viewers. CDs with proprietary viewers and media formats should become a thing of the past.

2. DICOM combines content and transport in a single standard. Although that is create for communication within an organization, it is not sufficient for a healthcare information exchange world that uses the Direct implementation guide (SMTP/SMIME, XDR) for content exchange among organizations. The fact that vendors such as LifeImage, Accelarad, and Merge Healthcare have created their own image sharing networks suggests that more standards work is needed to create an open ecosystem of image sharing among organizations.

3. We should not require organizations who want to receive images to have PACS systems. Instead, EHRs with vendor neutral DICOM viewers should be able to incorporate DICOM content sent via Direct into patient records.

Thus our work on imaging standards should build upon the DICOM foundation we have today, but eliminate optionality for a basic set of metadata, ensure that any proprietary extensions to metadata do not interfere with vendor-neutral viewing, embrace simple transport approaches for cross organizational exchange, and enable even the simplest of EHRs to be participants in image exchange.

We'll do this work in the Healthcare IT Standards Committee from April to June, engaging the industry experts who have worked so hard on DICOM to date.

I hope that makes sense!

Update on the BIDMC ICD10 Project

2012-01-30T03:00:00.000-08:00

I've written extensively about the challenge of implementing ICD10 and my belief that the billions of dollars required to implement it will not improve quality, safety, or efficiency.

I've spoken to many people at HHS, CMS and the White House about the need to rethink the ICD10 timeline, deferring it until after Meaningful Use Stage 3 which enables us to focus on improving our clinical documentation and adopt SNOMED-CT to capture structured signs and symptoms.

However, I've been told that the Affordable Care Act (ACA) includes cost savings from reduction in healthcare costs/fraud/abuse that require the implementation of ICD10. Thus, it's not likely going to be delayed.

At Beth Israel Deaconess, we're moving forward, assuming that ICD10 must be implemented by October 1, 2013. We held our kickoff meeting in June, hired external resources to create a project management office, and hired subject matter expert consultants to assist with the gap analysis, project plan and budget.

Today, I'm posting two resources for the benefit of other organizations planning their ICD-10 projects.

The first is the RFA we used to hire a consulting partner. In our case, we elected to create a single unified project for the academic medical center, community hospitals, physician organization, faculty practice, and owned community practice. We felt that creating one project for all the stakeholders would reduce costs while eliminating redundancy and aligning resources.

The second is the letter we sent to all our stakeholders, asking them to create an inventory of the software applications and processes that incorporate ICD9 and need to support ICD10.

In the next few weeks, we'll complete our detailed project plan, budgets, staffing model, and timeline. I'll share as much as I can as soon as it is available.

ICD-10 is a costly project that will have no benefits and if we're truly successful, the best we can hope for is that no one will be too upset that we implemented it.

Given a project with this many negatives (here's the AMA letter to Speaker of the House John Boehner), the least I can do is share everything we're implementing in the hopes that others will benefit from our experience.

Cool Technology of the Week

2012-01-27T03:00:00.000-08:00

As Harvard thinks about how best to enable authentication across multiple schools, organizations, affiliates and populations, it has choices to make - centralize all authentication, allow every group to pursue its own strategy, or coordinated federation that includes the best of centralized and localized approaches.

Federated authentication requires a fabric of trust. Among University collaborators, InCommon.org
has been a leader in creating tools, technologies and policies that enables multiple groups within institutions and among institutions to share data based on role-based access. It does not require organizations to issue unique credentials to every collaborator. Instead it delegates authentication to trusted institutions and then creates an ecosystem of access built on trust relationships.

The underlying technology is Shibboleth.

University collaboration via policies and technologies that support federated authentication. That's cool!

Our Cancer Journey - Week 6

2012-01-26T03:00:00.000-08:00

We're halfway through the most challenging cycles of chemotherapy, Kathy has lost her hair, and her fatigue is getting worse but her mood is still very positive.

On Friday January 20th, Kathy received Cyclophosphamide (Cytoxan) 1200 mg, Doxorubicin (Adriamycin) 120 mg and her pre-chemotherapy supportive medications Fosaprepitant 150 mg, Dexamethasone 12 mg and Ondansetron 8 mg.

She tolerated it well.

Her Complete Blood Count shows that her Granulocyte Count has dropped from 6690 to 3610 since the chemotherapy affects her fast multiplying white cells as a side effect of targeting the cancer. Her hematocrit has fallen from 42 to 32. She tires more easily but her appetite is good. Small frequent meals enable her to overcome any GI symptoms.

We've been told that the Adriamycin/Cytoxan is the most difficult chemotherapy. Only two more cycles to go.

The photograph above shows Kathy and me at age 21 in our Stanford graduation photo. She's always had long, luxuriant hair, even a waist length braid at one point.

On January 21st, her hair began falling out in clumps. It was not exactly painful, but felt very odd, as if her hair had not been washed in months and just did not lie on her scalp properly. In consultation with her cancer survivor friends, she decided to shave it off. Her hairdresser gave her a "GI Jane" cut realizing that the small hairs left will fall out soon, but in a more manageable and comfortable way. I seriously considered shaving my head in solidarity, but she asked me not to.

She's wearing wraps and hats to keep her head warm in the chill of winter. The colors and shapes of her hats give her an artistic and vibrant look.

Dropping blood counts, lack of energy, and no hair may sound depressing. How have we supported her mood?

She's avoided caffeine, alcohol and mood related medications. Instead she's remained positive because of the weekly activities we've planned and the future we're designing that goes beyond the statistics of 5 year survival rates.

In my professional life, I've written extensively about SOAP verses REST as standards for transport. In my personal life, Kathy and I have explored SOAP as Rest via a course on traditional soap making from Back Porch Soap. We've really enjoyed the art and chemistry of saponification, creating our own cold process soaps.

Although we're put our thoughts about Vermont farmland on hold, we've continued to think about how we can move to a more rural location which enables us to plan a long term life together raising vegetables and animals as part of self sufficiency, a lower carbon footprint, and sustainability. This dream of the future creates a guiding vision for fighting the cancer.

Finally, an interesting experience from our role as patients. Kathy has received her care in the middle of the X12 5010 transition which required every payer and provider to change their billing systems. Purely as a side effect of a payer eligibility error during the conversion, she received an $18,000 bill for her care to date. It was remedied quickly, but it illustrates the events that can occur while navigating healthcare in the US.

The January HIT Standards Committee Meeting

2012-01-25T10:00:00.000-08:00

The January HIT Standards Committee focused on the first quarter goals - Quality Measurement, NwHIN Exchange implementation, and Value Sets/Vocabularies.

Doug Fridsma presented the HITSC 2012 Workplan and Updates from ONC. Importantly, he outlined a comprehensive portfolio of building blocks (pictured above) that categorizes the work done to date and illustrates the work done in the future.

Jim Walker presented the work of the Clinical Quality Workgroup including the scope of effort needed to support the quality improvement efforts of Meaningful Use.

Doug and Betsy Humphreys from NLM presented an Update on Value Sets and Vocabulary Mapping including the work on "one stop shopping" for downloadable and web service addressable resources.

Finally, Rob Anthony and Jessica Kahn from CMS presented an update on Meaningful Use activities including attestation achievements.

A very important meeting that sets the agenda for FY12 and creates a foundation for our preparatory work on Meaningful Use Stage 3.

Preparing for a Wall of Shame

2012-01-24T03:00:00.000-08:00

Every day, I receive over 1000 legitimate, business-related emails. I've written about my email triage techniques and the notion of handling each email only once.

Over the past few months, the number of "business spam" emails has increased significantly. Whether its the economy, the death of paper-based advertising, or availability of bulk email newsletter creation applications in the cloud, it's getting overwhelming - about 500 unwanted, but vendor related emails per day.

Business spam is hard to filter since it represents professional communication from some of the largest technology companies on the planet. I purchase products from many of these companies. However, I do not want to receive any business spam from anyone.

I have never purchased a product based on business spam. In fact, the more business spam I receive, the less likely I will purchase products from advertisers filling my inbox.

I've spent the past two weeks unsubscribing from every newsletter, every mailing list, and every advertising campaign. It's challenging because companies send their advertising content to multiple variations of my email address - jhalamka, john.halamka, john_halamka at multiple variations of my domains, requiring me to unsubscribe more than 5 times in some cases.

Even more irritating are the unsubscribe functions that do not enable one click unsubscribe and require that type in your email address - how do I know what variation of my email address they used?

After a few weeks of unsubscribing as fast as I can, I'll post a list of those companies that are causing me to click delete so many times per day that I'm getting a repetitive stress injury.

I have never opted in to any business spam, so some of these companies have sunk to new lows with fine print such as "we're sending you this email and unless you unsubscribe, you've opted in to our future email". Even unsubscribing does not work because you are often opting out of a single marketing campaign and not all future communications.

The best I can do is create my own blacklist of these companies. Coming soon, the Geekdoctor Business Spam Wall of Shame!

Another Shade of Blue Button

2012-01-23T03:00:00.000-08:00

The Blue Button idea is simple - a large visible button on payer, provider, lab, or pharmacy websites enables patients to download their records in plain text.

The Veterans Administration has used it extensively. The Office of Personnel Management asked all health insurance carriers in the Federal Employees Health Benefit Program (FEHBP) to add Blue Button functions to personal health record systems. OPM administers health benefit programs for the civilian sector of the federal government, including all executive agencies, Members of Congress and their staffs, and the federal judiciary on their websites.

The Blue Button is one of several models of health information exchange being implemented.

I've summarized HIE models as:

View - a website or web service enables authorized patients, providers or payers to view data in plain text or HTML. A modest amount of programming is needed, but significant attention to security issues is important to protect the website and data sources.

Push - an EHR sends data to another EHR via the Direct standard. Since this is secure email, a modest infrastructure investment is needed to create directories, certificate management, and gateways.

Pull - an EHR queries a master patient index/record locator service to identify a patient and the locations of their records. The EHR then queries all the data sources to assemble a comprehensive medical history. NwHIN Exchange is an example of such an approach. Significant infrastructure must be built to support and maintain a pull architecture.

Since Push and Pull models require HIEs, which are still evolving, some organizations, including BIDMC and its affiliates have temporarily implemented View approaches inside Epic, Meditech, eClinical Works and self built applications.

Here's how it works:

1. The clinician clicks on a button inside their EHR. This click launches a query containing Name, Gender, Date of Birth, and Zip Code to a responding EHR. The physician does not need to respecify the patient or log in to a separate portal since the patient identity information and security credentials are sent from the querying EHR automatically.
2. The responding EHR checks the security, looks up the patient, and responds with a medical record number if the patient is found.
3. The querying EHR sends a new query incorporating the returned medical record number.
4. The responding EHR launches a web-page which displays clinical data for that medical record number.
5. All transactions are audited in the responding EHRs.

Since this approach works like magic, requires no HIE, and is fast/inexpensive to implement, our clinicians have described it as the "Magic button"

In effect, it serves as a web-based single sign application that retains patient context and enables clinicians to view data from any EHR that adheres to the Magic button implementation guide.

We see it as a temporary solution because it does not result in persistent exchange of semantically interoperable data. It simply enables a clinician to see data such as problem lists, medication lists, allergies, labs, radiology studies, EKRs, reports, and notes in remote systems without requiring a lot of training. It's better than having silos of data and sending faxes.

As HIEs come on line, push and pull models will enable the same kind of data exchange but will incorporate data from sending EHRs into receiving EHRs, enhancing workflow and improving the integrity of the record.

One other problem with the Magic button is that it does not scale very well - we now have buttons for Atrius, Needham, Milton, and eClinicalWorks practices. Clinicians ask the patient where they've received care, get their consent to view the data, and click on the appropriate magic button. As we add more affiliates, the number of Magic buttons will be hard to manage.

In future pull models, record locator services will keep an index of all the locations where patients have consented their data to be accessed.

But for now, having a kind of Blue Button that enables clinicians to view each other's records with patient consent is truly magic for those who use it.

Cool Technology of the Week

2012-01-20T03:00:00.000-08:00

With Kodak's bankruptcy filing and Polaroid's bankruptcy/decline, is the stand-alone camera a thing of the past?

At the Consumer Electronics Show this year, one camera product received a lot of press - a 360 degree digital imager from Tamaggo. Taking an image with Tamaggo gives shows the environment you're in and the perspective you have at the moment. I can visualize some amazing nature photography. Imagine the 360 view from Dark Shadows one of my favorite rock climbs in Red Rocks, Nevada.

Here's a YouTube overview of the product.

A portable 360 degree digital imager for consumers - that's cool!

Our Cancer Journey - Week 5

2012-01-19T03:00:00.000-08:00

This week we completed the genetic sequencing that answered two important questions:
*Should Kathy consider bilateral mastectomy?
*Should our daughter, Lara, consider early mastectomy to reduce her lifetime risk of breast cancer?

Here's how we asked the questions.

On December 20, Kathy met with Genetic Counselor Kathleen Swenson to discuss the risk of hereditary Breast Cancer. Kathleen wrote:

"Note Date: 12/20/11
BETH ISRAEL DEACONESS MEDICAL CENTER CANCER GENETICS AND PREVENTION PROGRAM
Risk of Hereditary Breast Cancer

VISIT SUMMARY: 49yo with recent dx of breast cancer. Blood was drawn today for BRCA1 and BRCA2 analysis. Results expected in 2-3 weeks.

ANCESTRY/RACE: Korean/Scottish/Irish
__ AJ _X_ non-AJ

Indication: Recent diagnosis of breast cancer; limited maternal family history.

Personal History Family History
__ None _X_ None
_X_ Breast Cancer; Age 49 __ Family Hx Breast
__ Ovarian Cancer; Age __ Family Hx Ovarian
__ Colon Cancer; Age __ Family Hx Colon
__ Other __ Family Hx Other

Risk Assessment: 49yo at age of diagnosis; premenopausal. Limited family structure on maternal side of the family limits risk assessment.

Counseling - We discussed the following issues:

_X_ Sporadic vs. hereditary cancer

_X_ Autosomal dominant inheritance

_X_ BRCA1/2 & cancer risks (breast, ovary, and other)

_X_ Risks, benefits and limitations of genetic testing

_X_ Possible Results and implications

_X_ Practicalities of testing (timing, costs)

_X_ Insurance/discrimination concerns

_X_ Testing is most informative with a known mutation in family; importance of sharing information

_X_ Testing is more informative when the first relative tested is an individual who has had cancer

_X_ Medical management options (increased surveillance, chemoprevention, and prophylactic surgery)

Implications of a Positive result (for patient and family): Management as appropriate; implications for first degree relatives.

Implications of a Negative result (for patient and family): Likely sporadic cancer. No further testing indicated at this time.

Other Notes: Kathy is a lovely woman who is an artist and owns a gallery in Boston's South End. Her husband works here at BIDMC. Kathy felt that it was important and ideal to have this information for the purpose of having a complete picture when it comes to determining her care plan moving forward. There is very little information regarding the maternal family history and limited family structure as she is an only child. We discussed testing in detail, including the issue of variants of uncertain significance. BRCA1 and BRCA2 comprehensive analysis was ordered, as was BART analysis for completeness. I will notify Kathy upon receipt of her results as well as the physicians caring for her."

This week, we received the report

"Ms. Halamka was seen previously and elected to proceed with genetic testing for BRCA1 and BRCA2. Results are NEGATIVE. No mutations were identified in either of these genes. Both comprehensive analysis and BART analysis was completed."

Thus, her cancer is environmental and not the result of specific BRCA mutations. She will not need to consider bilateral mastectomy at this time. We explained the results to our daughter and she will follow whatever best practice is recommended for standard breast cancer screening over her lifetime.

Since Kathy will lose her hair next week, we purchased a simple wig in addition to the hat and head wrap we bought last week.

Finally, Kathy has begun to have gastrointestinal symptoms . Small, frequent, bland meals work. Anything else causes abdominal discomfort and mild pain as the rapidly dividing cells in her GI tract begin to die as a result of chemotherapy.

Tomorrow, we return to BIDMC for Cycle 2 of Adriamycin/Cytoxan. Kathy was very strong and rested when she started Cycle 1. For Cycle 2, she'll be a little weaker.

Every week has its positives and negatives. Knowing that her cancer is environmental and not genetic is this week's good news for Kathy and our family.

Only Handle It Once (OHIO)

2012-01-18T03:00:00.000-08:00

In my recent post Work Induced Attention Deficit Disorder, several commenters asked how I stay focused and productive, speculating that I leverage my limited need for sleep.

Although having a 20 hour day helps, the real secret is that I end each day with an empty inbox. I have no paper in my office. I do not keep files other than those that are required for compliance purposes.

The end result is that for every document I'm asked to read, every report I'm ask to write, and every situation I'm asked to management, I only handle the materials once.

What does this mean?

In a typical week, I'm asked to review 4 or 5 articles for journals. Rather than leaving them to be read at some later time or reading them then deferring the review, I read and review them the day they are assigned. This enables me to read them once and write the review very efficiently since all the facts are fresh in my mind.

I'm asked to review budgets for various grants, state, and local projects multiple times per week. I read the budget, ask questions while the numbers are at my fingertips, and await responses.

In my 1000+ emails each day there are 10-20 that require detailed responses. I leave these to the end of the day when I know I'll have uninterrupted time. I write the responses and send them while all the details of the issues are clear to me.

Paperwork does occasionally find its way to my desk. Since all payroll and all purchasing functions are electronic at BIDMC, the paperwork I have to do is mostly for externally regulatory agencies. I read the paperwork, answer everything, and give it to my assistant to package and mail.

Each day I'm asked to find time for calls, meetings, lectures, travel, and special events. I look at my calendar in real time and respond with availability - making a decision on the spot if I can or cannot participate.

The end result of this approach is that I truly only handle each issue, document, or phone call once. It's processed and it's done without delay or a growing inbox. I work hard not to be the rate limiting step to any process.

Yes, it can be difficult to juggle the Only Handle it Once (OHIO) approach during a day packed with meetings. Given that unplanned work and the management of email has become 50% of our jobs, I try to structure my day with no more than 5 hours of planned meetings, leaving the rest of the time to bring closure to the issues discussed in the meetings and complete the other work that arrives. It's the administrative equivalent of Open Access clinical scheduling.

It's tempting, especially after a long and emotionally tiring day, to break the OHIO principle. However, doing so only removes time from the next day and makes it even more challenging to process the incoming flow of events.

One last caveat. OHIO does not mean compromising quality or thoughtfulness. Simply passing along issues to others without careful consideration does not increase efficiency. I focus on doing it once to the best of my ability. For larger projects, I use my "handle it once" approach to set aside a defined time on the weekend when I can do them in one sitting.

OHIO - give it a try and see if the free time it creates enables you to regain depth and counter the evils of work induced attention deficit disorder.

The Role of the CMIO

2012-01-17T03:00:00.000-08:00

Although my business cards and my CV list the title Chief Information Officer, I was given the title Chief Medical Information Officer (CMIO) when I was hired at BIDMC in 1998. Today, I serve three kinds of roles:

CIO - Responsible for strategy, structure, staffing, and processes for a 300 person IT organization
CTO - Responsible for the architecture of our applications and infrastructure, ensuring reliability, security, and affordability
CMIO - Responsible for the adoption of the applications by clinicians, optimizing quality, safety, and efficiency in their workflows

Although I've been able to balance these three roles because of the extraordinary IS staff at BIDMC, good governance, and a supportive CEO, it's challenging for one person to perform all these tasks. Many hospitals and health systems are expanding their management team to include a CMIO.

Here are a few thoughts about the role of the CMIO.

*Clinical applications are only as good as the processes they automate. Automating a broken process does not make it better. Clinician stakeholders working with a CMIO should re-engineer workflows, document requirements, then begin software implementation.

*Achieving consensus among clinicians is challenging. Medical education is an apprenticeship that is part art and part science. It's unlikely that one automated best practice, care plan, or guideline will be acceptable to everyone. The role of the CMIO, as a trusted practicing clinician, is to create consensus around software configuration and decision support rules.

*Selecting new applications can be a daunting experience. Integrated or interfaced? Complete or modular? Best of suite or best of breed? What may be the best solution for a department may be less than optimal for the entire institution. The CMIO can weigh the pros/cons, cost/benefits, and the overall integration into the enterprise portfolio during application selection.

*Nothing is perfect and clinical systems implementation will always be a journey, balancing compliance, security, ease of use, automation of manual processes, and safety. Clinicians have constantly evolving needs and they will frequently feel that the IT organization does not have the supply to meet their short term demands. The CMIO can run processes which engage clinicians in priority setting and resource allocation decision making. Although the projects they want will likely be done at a slower pace than they'd prefer, they will understand the balance of time, resources, and scope because they were involved in creating the plan.

*Often, there are no right answers in clinical IT. Given fixed time and resources, what is the top priority - Meaningful Use, ICD-10, healthcare reform, Joint Commission mandates, or quality improvement agendas? Some may answer, all of them. The CMIO can advise senior management how to phase an endless stream of projects so that the greatest good is done for the greatest number over the long term.

Who should the CMIO report to? Choices include the CIO, the CMO, the COO, the CEO, or some governance group i.e. the Medical Executive Committee. Every organization is different and the reporting relationship should be a function of where the CMIO can have the greatest impact, visibility, and support.

In my view, Meaningful Use, increasing demands for clinical workflow automation, and healthcare reform necessitate that every hospital larger than 50 beds have a full or part time designated CMIO. Given the daunting array of clinical IT requirements over the next 5 years, CMIOs will be increasingly important.

Cool Technology of the Week

2012-01-13T03:00:00.000-08:00

I have an iPhone 4S and to conserve power, I've turned off WiFi, location services, and Bluetooth.

Nonetheless, with my volume of email, I cannot get more than 12 hours of use from an iPhone. I charge it overnight, use it during the day, then begin recharging it as soon as I get home.

QYG has a solution - a thin iPhone 4S protective case that contains a lightweight flat battery which doubles battery life.

Several of my staff members use these and note that the mini-USB port can be used with a standard USB cable to charge the battery.

A lightweight, protective case that doubles the battery life of an iPhone - that's cool.

Our Cancer Journey - Week 4

2012-01-12T03:00:00.000-08:00

This week, we learned about the reality of chemotherapy.

On Friday, Kathy received her first cycle of Cytoxan and Adriamycin, a few days ahead of the schedule I posted on my blog last week.

I drove her to BIDMC. We checked into the ambulatory Heme/Onc clinic and she was given a warm pack to increase circulation to her hands. The lab staff drew a Complete Blood Count (CBC) via a finger stick to avoid creating punctures in her veins, given that her chemotherapy medications are vesicants that cause a chemical cellulitis if they leak into tissue.

The CBC was excellent - a white count of 10 and an hematocrit of 41. We'll follow this closely as the chemotherapeutic agents affect her white blood cells.

Her remarkable nurse, Dianne Holland-Sullivan, spent time getting to know us, then expertly inserted an IV without any issues.

I promised to reflect on the BIDMC electronic health record in describing Kathy's care.

All of her providers share data among themselves and with Kathy. Here's a view of Kathy's electronic profile, showing her problem list, medication list, allergies, appointments, labs, and social history (yes, we've been together 33 years from age 17 to age 50). She's given full consent to share this data publicly as it illustrates the importance of an electronic health record for care coordination.

She can view the same data via her personal health record. The only difference is a few delayed staging results to ensure patients and doctors speak about cancer diagnoses before the data appears on the web.

All of Kathy's chemotherapy orders were written electronically via the BIDMC Oncology Management System. Humans do not dose chemotherapy, computers calculate everything based on protocols that humans maintain based on clinical trial evidence. In Kathy's case, the oncologists designed and made the clinical decision to place her on the "Breast Oncology - CA - Dose Dense" care path.

The computer wrote these orders for her based on her height, weight, age, kidney function, and allergies.

The dedicated chemotherapy pharmacy in the heme/onc clinic prepared the medications, bar codes them, and delivers them to the chemotherapy nurse. Two chemotherapy nurses validated the medications, the dose, and the patient using bar coded patient wrist bands and verbal confirmation from Kathy. An automated medication admission record recorded when the chemotherapy agents were administered.

Kathy first received three pre-medications:

Fosaprepitant - an anti-nausea drug
Ondansetron - an anti-nausea drug
Dexamethasone - a steroid to reduce inflammation and synergistically work with Odansetron to prevent nausea

She also received 500cc's of normal saline as supportive hydration during chemotherapy.

After pre-medication, Dianne pushed 118mg of Adriamycin (doxorubicin) via two syringes over a few minutes.

She then administered 1180mg of Cytoxan (cyclophosphamide) over 45 minutes.

During the medication delivery, Dianne stayed at Kathy's side to discuss side effects, the rationale for the treatment, the likely events to follow medication administration, and the planning for the additional cycles to come over the next 8 weeks. I provided Kathy with a banana, almonds, water, and companionship.

After chemotherapy, we headed home. Kathy took .5mg of Ativan in the evening as directed to help her sleep.

On Saturday, Kathy felt fine - we walked a few miles around Lake Waban, prepared meals, and shopped together. We drove into Boston for a subcutaneous dose of Neulasta (Pegfilgrastim), a white blood cell stimulant to bolster her ability to fight infection as the chemotherapy kills her white blood cells. She took a dose of Dexamethasone in the morning and at night.

On Sunday, Kathy felt prodromal - as if she had the early symptoms of a virus. We walked in the woods near our home and selected a few logs for me to split. As romantic as it sounds, Kathy bought me a Swedish Forest Axe and Splitting Maul from Gransfors Bruks for Christmas. We carried a few hundred pounds of wood to the car together. Yes, I know that sounds odd, but we have a three decade history of doing the unusual together.

By Monday, she felt significant fatigue.

At no time did she feel any nausea.

In her words:

"Overall good reaction to the chemo materials, minimal problem with the steroids
Very light use of Ativan for first night to sleep
No use of anti-nausea meds yet.
Appetite reduced but adequate, sensation of salt tastes reduced
Digestive tract still normal, no use of any aids. Credit vegetarian diet high in fiber, legumes and leafy greens/cruciferous (eliminated all soy and added an egg to breakfast), no dairy, meat or fish consumed.
Fatigue set in hard on Sunday night from a Friday chemo session.
Early mornings and evenings are low energy, one faint period during eye exam.
Neulasta induced muscle myalgia/bone pain disturbs sleep cycle.
Evenings I feel like I am coming down with the flu (chills and aches), mornings I feel like I am recovering from the flu.
Ordered new glasses to get away from contacts during chemotherapy, warned of changes in moisture in the eyes (given Systane eye drops by opthamologist)"

Her general pattern is moderate sleep, the need for a nap after breakfast, a great afternoon, and early evening fatigue, leading to bedtime an hour earlier than normal.

I've changed my schedule to get home by 4pm, walk with her, and support her in the early evening.

I've cancelled meetings on nights and weekends.

Every other Friday is a chemotherapy day, so I've cleared Fridays.

I've cancelled my travel for the next few months.

My colleagues have been incredibly supportive of my running late afternoon and Friday meetings by phone so I can be at home.

We're on the path of treatment and the cancer cells are dying. Kathy's greatest fear has been the chemotherapy. Thus far, the anticipation has been worse than the reality. However, she started the first cycle in perfect health. As the second cycle begins on January 20, she'll be a little more vulnerable.

Today she's back at work in her Boston South End Gallery, NKG. Her spirits are good and she's fighting cancer with boundless optimism.

Servant Leadership

2012-01-11T03:00:00.000-08:00

I read every comment posted to my blog and do my best to learn from the wisdom of the community. Two comments made about my recent post Honey or Vinegar deserve special highlight.

Tony Parham posted a comment comparing Management and Leadership, quoting the work of John Kotter and Colin Powell.

"MANAGEMENT: Control mechanisms to compare system behavior with the plan and take action when a deviation is detected.
LEADERSHIP: Achieving grand visions. Motivation and inspiration to energize people, not by pushing them in the right direction as control mechanisms do, but by satisfying basic human needs for achievement, a sense of belonging, recognition, self-esteem, a feeling of control over one's life, and the ability to live up to one's ideals. Such feelings touch us deeply and elicit a powerful response."
- John P. Kotter, Professor of organizational behavior at the Harvard Business School

“LEADERSHIP is the art of accomplishing more than the science of MANAGEMENT says is possible."
- Colin Powell

My experience is that as long as a leader unites a team with a clear common goal and enables the team to do their work while supporting their self-esteem and their decisions about scope/time/resources, people thrive. Even recent medical evidence suggests that "Honey" and the positive support of a leader yields healthy, productive, and happy staff. Lack of such a leader can lead to negative health and reduced longevity. It seems intuitive that our moods are linked closely to our job satisfaction and that positive mood improves health, but now we have evidence to prove it.

Katherina Holzhauser, a fellow Stanford graduate from the Czech Republic wrote to me about Servant Leadership as part of her philosophy of favoring "Honey" over "Vinegar".

The important take home lesson about Servant Leadership is the classic organization chart really needs to be rewritten, making staff who interact with customers the most important people in the organization. The role of a leader to serve and support those staff so that they have the resources and processes they need to optimize customer experiences. I completely agree with the statement that the highest priority of a servant leader is to encourage, support and enable subordinates to unfold their full potential and abilities. This leads to an obligation to delegate responsibility and engage in participative decision-making.

The goals of a servant leader - listening, empathy, healing, awareness, persuasion (which I call informal authority), conceptualization (which I call continuous self re-examination), foresight, stewardship, commitment to people (which I call loyalty), and building community - are what guide my day to day interactions in all aspects of my life.

As we take on more work in less time at faster pace than every before, let's all strive to be servant leaders for the benefit of those who do the work and serve on the front lines healthcare and healthcare IT in our quest to alleviate human suffering caused by disease.

Work Induced Attention Deficit Disorder

2012-01-10T03:00:00.000-08:00

When you're in meetings or on phone calls, are you focused in the moment or are you distracted by emails, text messages, or social networking traffic?

When you're reading a 20 page whitepaper, RFP, or article, can you finish it?

When you're writing a presentation or article, can you keep your thoughts flowing or are they interrupted by the urge to check your email or mobile device?

Part of the problem is the expectation that we're all connected 24x7 and should respond in near real time.

Part of the problem is an addiction-like behavior caused by a need to feel connected to other people.

Part of the problem is the pace of change that makes us work two days for every workday - one with scheduled meetings and one with unscheduled electronic messaging.

Do you find that your ability to explore issues in depth has diminished over time because of the need to react to the constant flow of input?

When I write, I close my email client and put away my mobile devices. I often do this between 2a-4a when the tide of incoming messages is low.

I collect my thoughts and write in a single stream, weaving together ideas from my previous compositions when possible. I have been able to keep my 1000+ posts integrated in my mind by writing in the early morning darkness.

However, my reading has suffered. When I was younger, I could sit in my old Morris Chair underneath a Pendelton blanket and finish a book cover to cover. Today, my reading is more web like - I cover a topic and then jump to a different topic until I've rapidly covered the important messages from a book instead of reading it at a relaxed pace cover to cover.

The nature of our work has induced a kind of attention deficit disorder.

To explore this idea further, I looked at my calendar for this week. Across my jobs and volunteer efforts there are few dozen critical projects with due dates in January. Ideally my schedule should block out time to focus in depth on each of these major efforts.

Instead, my calendar demonstrates that I've delegated the "depth" to others in order to achieve a "breadth" of oversight which includes only a few minutes per critical project per day. The rest of the time is spent on urgent problem solving, unplanned work, and reducing the tension of change caused by the modern pace of activity, which is challenging for many people to process.

My blog posts taken collectively often paint themes for the year. In 2012, I'm hoping that I can restore depth, reduce breath, and begin to reform my brain into the linear path of an expert instead of the hyperlinked random walk of a dilettante.

In a world when a 5 minute You Tube video is too long for the average audience and a 140 character message has replaced a thoughtful paragraph, we all need to ask if living each day with continuous partial attention is an improvement.

I for one, am willing to say that the our modern work style is an emperor with no clothes, and we need to recapture our focus in order to solve the complex problems ahead.

Sustainability

2012-01-09T03:00:00.000-08:00

As my daughter begins her adult life (she's in Kanazawa, Japan this month doing a winter semester Japanese language intensive), I've thought a great deal about the world she will inherit from me.

I've lived in the creatively vibrant 1960's, the economic doldrums of the 1970's, the go-go 1980's, the .com era of the 1990's, the post 9/11 unrest of the 2000's, and the recovery/reform of the 2010's.

During my lifetime, my rubric for success has changed from one that is judged by salary/position/power to one that is measured by making a difference, living with a small footprint, and ensuring sustainability for the next generation.

I usually write about such topics in my Thursday personal blog post, but I think the concept of sustainability impacts the way we work every day so it's worth a Monday discussion.

Over the past 25 years the US has evolved from a manufacturing economy to a consumer economy that depends upon increasing consumption for success. Unless we grow exponentially - population, sales, and spending - our current economy falters. Since our resources and planet are finite, any strategy based on endless growth will fail.

As I begin the next stage of my life (and we successfully treat my wife's cancer), I believe my best gift to my daughter is sustainability - reducing my consumption of natural resources, reducing my carbon footprint, reducing my contribution to landfills, reducing my belongings/their turnover (what I buy and what I replace), and living closer to the land at a pace supported by nature.

As part of the cancer treatment process, it's important for my wife and me to have long term goals - what will we be doing in 5 years and what can we look forward to?

My wife and I have begun looking at land, discussed low impact/high energy efficiency building strategies, and considered how our community gardening/vegan lifestyle can be extended via additional organic farming activities in Eastern Massachusetts. We've looked at ways to reduce our travel including finding property close to rail lines that will enable us to stop driving in congested traffic and instead take the commuter rail into Boston every day.

Along the way, a few books are guiding our exploration

The Self Sufficient Life and How to Live It by John Seymour
Green from the Ground Up by David Johnston and Scott Gibson
Alternative Construction by Lynne and Cassandra Adams
Back to Basics by Abigail Gehring
Self Sufficiency by Abigail Gehring

I will strive to apply the same principles in my business life as well. Beyond reducing my commute, I will continue to closely manage the power consumption of the data centers I oversee, eliminate the use of paper in clinical workflows, and embrace recycling/reuse/reduction in procurements.

The best thing I can do to support my daughter's generation is to ensure there is healthy planet for her to live in.

You'll see many posts in the future about our sustainability efforts.

Cool Technology of the Week

2012-01-06T03:00:00.000-08:00

Hundreds of healthcare IT professionals have offered their support to Kathy as she begins cancer treatment.

Several non-profits have contacted us with educational materials and helpful tools.

One of the most useful is the Cancer Planner from Cancer101.org . Cancer 101 provides the tools and resources that patients and caregivers need to make sense of the overwhelming information and difficult emotions that accompany a cancer diagnosis.

Thanks to CEO Sarah Krug and her staff for sending it.

The Planner contains:
*How to use the Planner and Four Important Things You Need to Know
*Personalize Your Planner
*Notes
*One-year Calendar Planner
*Ten-year Follow-up Calendar Planner
*Address Book
*Medical History & Appointment Tracker
*Symptoms Tracker
*Medical Bills and Insurance Tracker
*Helpful Advice for the Diagnosed and Their Caregivers
*National Cancer Resources
*Questions to Ask Your Doctor by Cancer.Net
*Dictionary of Cancer Terms by the National Cancer Institute
*What Is a Clinical Trial? by the Coalition of Cancer Cooperative Groups
*Become a Lifesaver

Kathy describes this Planner as the perfect addition to her Personal Health Record and the hospital's Electronic Health Record since it enables her to document her thoughts and experiences in a way that complements the objective healthcare data gathered during the care process.

We plan to use the Planner document symptoms of nausea/fatigue so that we can provide feedback to the clinicians providing Kathy with supportive medication.

As I said in last week's Cancer Journey post, the initial diagnostic phase can be anxiety provoking and confusing.

The Planner brings order to the process. That's cool.

Our Cancer Journey - Week 3

2012-01-05T03:00:00.000-08:00

This weekend will be our last pre-chemotherapy time together and we're preparing our home and ourselves for the months ahead.

Last Thursday we met with the care team to assess the physical changes in Kathy's skin and left breast. The mottling of the skin was likely caused by blood settling through tissue planes after the sentinel node biopsy procedure. Over the past few days the discoloration followed the same color changes as a bruise, going from red to brown to green/yellow, then disappearing. The breast swelling was likely caused by the disruption of lymphatics during the removal of lymph nodes. Thus, the cause of all the changes was not new tumor growth but side effects of the biopsy procedure. Her physical exam is now the same as it was 2 weeks ago.

The care team briefed us on the weeks ahead. Together, we discussed the treatment options and finalized a plan - chemotherapy first, followed by mastectomy, followed by radiation oncology.

The appropriate chemotherapeutic regimen for a HER2 negative, ER/PR positive tumor is 4 cycles of cytoxan/adriamycin over the next 8 weeks, followed by Taxol for 12 weeks.

Kathy begins chemotherapy at 10am on August 11. The 3 hour infusion procedure includes anti-emetics (odansetron), steroids (dexamethasone), hydration, a 30 minute infusion of cytoxan, and a slow IV push of adriamycin.

We've been told to expect the worst symptoms to occur 48 hours after treatment and we've been given compazine and lorazepam for nausea. Kathy may also develop constipation and diarrhea, which we'll treat with over the counter medications. We'll have to watch for fever as her white blood cell counts drop to the level that she cannot fight off infections. I've cancelled all my meetings on her chemotherapy days and on the 2nd day after each treatment when her fatigue will be the most significant.

Kathy will lose all her hair about 2 weeks after the first treatment and she's arranged with her hairdresser to shave it off. We've already purchased a few warm winter hats and head wraps.

The chemotherapy medications are effective but can have profound side effects. Cytoxan causes mouth/throat sores. Adriamycin causes heart muscle damage and hand/foot syndrome. Taxol can cause numbness and pain in the hands and feet, a problematic condition for an artist.

Yesterday, she had a pre-chemotherapy echocardiogram to assess her heart function prior to receiving Adriamycin. She also visited Hester Hill, who provided her with guidance about life style, wigs, and sources of support during the treatment process.

The transition from the cancer diagnosis phase to the treatment phase occurs next week. We'll learn a great deal about being cancer patients as we ride the emotional roller coaster of the days ahead.

Honey or Vinegar?

2012-01-04T03:00:00.000-08:00

As a leader, I'm frequently asked to evaluate direct reports, provide guidance to managers, and build consensus among staff with heterogeneous opinions.

There are many ways to approach interactions with superiors, subordinates, and peers.

In my 30 years of working in complex organizations, I've observed different leadership styles with varying degrees of long term success.

I believe it is far better to establish unity, esprit de corps in the foxhole, and boost morale than to create divisiveness, uncertainty, and fear of failure.

My grandmother used to say that "You can catch more flies with honey than with vinegar" meaning that you can be more persuasive with camaraderie than confrontation.

In the short term, formal authority and fear of job loss can be very persuasive. In the long term, such behavior is likely to result in an "Occupy"-like rally of staff seeking a better organizational culture.

My own experience with "honey" includes 5 different characteristics:

Informal authority - Building trust and exploring possibilities together in a non-judgmental way creates lasting mutual respect and grants a degree of authority that is far more powerful than rule by fiat.

Loyalty - I've arranged pay increases and bonuses for staff to recognize special achievements and career growth. The increased payment creates short term joy but the impact on retention is short lived, since the novelty of the change diminishes over time. Far more important is creating a sense of long term loyalty that comes with a family-like atmosphere. All for one and one for all.

Air cover - In a crisis, you're first on the front line fighting the fight, taking the blows, and protecting those behind you. You're not watching the action from a distant hill or criticizing the troops from an armchair.

Good guy can finish first - I'm a strong believer in integrity, honesty, and fair play. I will not hurt my fellow humans to get ahead. My feeling is that those who live by the sword die by the sword.

Strong emotion never works - As a parent and as a CIO, I've raised my voice once or twice in 20 years, then felt terrible for doing it. It diminished me.

I'm sure there are those who equate intimidation with leadership, but for me, uniting people in support of a common cause against a common adversary using trust, loyalty, ethics, hard work, and support wins the day.

Thoughts on the Year Ahead

2012-01-03T03:00:00.000-08:00

While 2011 was a year of incredible change (Meaningful Use Stage 1, 5010, Pioneer ACOs, State HIE planning, security challenges, compliance/regulatory pressures), I'm hopeful that 2012 will be a year of heads down work. As I've said before, planned work that is appropriately resourced is a joy, no matter how challenging. It's the unplanned work which needs to done within the budget/resources/timeline of existing projects that's the emotional drain. Here are the significant projects I see for 2012:

ICD10

Despite the best efforts of many people to explain the burden of ICD10 and the lack of benefit, it appears that ICD10 will continue forward with a October 1, 2013 implementation date. BIDMC will spend $500,000 on application analysis, education, and project planning, then an unknown amount (could be $5 million or more) on remediation of vendor systems. I predict that 25% of the capacity of IT will be consumed by ICD10 in 2012. If we're lucky and have a perfect go live, no one will notice. Depressing.

Meaningful Use Stage 2 including inpatient clinical documentation

Meaningful Use Stage 2 will likely include replacement of paper-based inpatient progress notes with electronic (not scanned) documentation. We've been thinking about the best way to approach this leveraging templates, macros and social-networking like group documentation. This is an exciting project that will make the clinical record much easier to read, improving clinical care coordination and communication.

ACO Planning

Healthcare reform will require a completely different approach to care, focused on wellness, not just treating disease. Not only will we need new business intelligence and health information exchange capabilities, we'll also need new decision support functionality based on care plans, pathways, and event driven medicine (new data triggers interventions).

Compliance

2011 was a year of increased regulatory enforcement and compliance automation requirements. I believe 2012 will be the same with a focus on conflict of interest tracking, learning management systems for compliance education, and enhanced revenue cycle systems that provide decision support at the point of care to ensure all regulatory requirements are met.

Security

2011 saw an explosion of malware and viruses compounded by an increase of mobile personal devices accessing clinical content. It's likely that we'll need to augment our security team and infrastructure to address the escalating cold war with hackers who have turned identity theft into a business.

Let us hope 2012 is a year of innovation, creativity, and incremental progress. I remain optimistic that the chaos of 2011 built a foundation for achievement in 2012.

Cool Technology of the Week

2011-12-30T03:00:00.000-08:00

This week's post is not about a specific company's technology, but about a concept.

My wife did something very cool for me for Christmas.

Given that 2011 was filled with Hurricanes, Earthquakes, Tornados, Floods, and Fires around the world, she decided to create something that would make us more prepared for whatever the future may bring.

She created a disaster pack for the front hall closet using a Black Diamond Speed 30 mountaineering pack as a "grab and go" answer to any disaster that strikes. It contains 72 hours of food/water, basic medical supplies. a solar powered radio, tools that can be used to harvest wood/start a fire, and extra clothes.

From the point disaster strikes to the point we're in a car with our supplies driving away could be under 60 seconds.

Think about the time it would take to assemble food/water, clothing, and medical gear after disaster strikes - 15 minutes? Half an hour?

I highly recommend a "grab and go" pack as part of your family disaster preparedness plans. Thanks Kathy for building one for us - that's cool!

Our Cancer Journey - Week 2

2011-12-29T03:00:00.000-08:00

It's been two weeks since my wife said "I have cancer" to my daughter.

It's been a week since we described our workup thus far on my blog.

Reaction to our blog post was diverse, ranging from the HISTalk blog to the Boston Globe.

It's a time of anxiety and unanswered questions.   The diagnosis and staging phase has been described as one of the two major tension points in cancer.   The other is the time after remission, when the worry about recurrence is a constant burden. One of our doctors recommended we keep a "family bottle" of anti-anxiety medication ready for those times when the stress exceeds our capacity to cope.   Cancer is truly a family disease and the emotional impact extends from the patient to family caregivers.

Many friends and colleagues have offered prayers and support.   A few have lamented that care coordinated by a physician-husband at a Harvard-associated hospital in Boston lacks equity since every wife/mother/daughter may not receive the same care throughout the US. Kathy and I agree.   We posted these comments in response to those who speculated that Kathy's care consumes an asymmetric amount of healthcare resources.

John writes:
"At the same time I'm focused on Kathy's care, I'm also deeply committed to quality, safety, efficiency, and equity in healthcare across the country.   In the upcoming weeks, I'll describe how the electronic records that coordinate Kathy's treatment provide the same protocols to every BIDMC patient, regardless of insurance status, profession, or income.    My goal is the 'right care' - not too much nor too little - that follows best practices based on evidence.   Decision support driven 'right care' is the only way we can hope to improve outcomes while bending the cost curve of healthcare spending that threatens the US economy.   Universal healthcare supported by universal adoption of electronic and personal health records must be our guiding vision."

Kathy writes:
"My life with John has been entwined for 32 years, so to say "we have cancer" cannot be more completely and utterly correct. True that physically, only one of use has the obvious organic symptoms, but our close partnership has been irrevocably changed by the diagnosis. Whatever lies ahead, it is impossible to go back to that innocent moment before hearing the word "cancer".

I am luckier than most - I have health insurance, and access to a major urban medical center that is also a teaching and research hospital. But, as I encourage John to document our progress publicly in his blog, I am also keeping the memory of a friend close to my heart. She did not have health insurance (as a part time adjunct instructor of art). With this financial barrier, she unwittingly waited until the cancer had spread before seeking medical care, and although she fought bravely, she lost her battle with breast cancer.

Throughout my life, I have not needed medical resources beyond occasional primary care visits and the birth of one child. My first weeks negotiating the barrage of new terminology, new tests, and new doctors was significantly eased by my access to a personal health record. The hospital's electronic health record is important to me, since it empowers my doctors to work as a team with open access to all my clinical data, enabling the team to make the best decisions for my health. As I recall my lost friend, I also think about all patients with a breast cancer diagnosis, or other serious illnesses, and how they manage their care journey if they worry about health insurance, or have no access to a personal health record."

This week we continued the staging process in anticipation of finalizing our care plan (chemotherapy, surgery, radiation oncology) in early January.

On Friday, Kathy went to the operating room for a sentinel node biopsy. This is now the recommended standard of care for cancer staging as it uses radio-isotopes to identify those lymph nodes that directly drain the tumor. The surgeons harvested lymph nodes that were positive for radioactivity and one nearby node that was non-radioactive.

After the surgery I took Kathy home and the first thing she wanted to do was re-expand her lungs, avoiding post operative atelectasis.   We walked a few miles around Lake Waban, watched the sunset, and discovered a family of Muskrats seeking their evening meal.

Her post operative pain was helped by gentle exercise and stretching.   She took 2 Tylenol before bed. Although the anxiety of the workup has interrupted her sleep - she wakes at 3am and has a hard time failing back to sleep - her post operative course has been uneventful.

On Tuesday night, we received the pathology report from the sentinel node biopsy.   It showed one lymph node (directly draining the tumor) with micrometastasis (0.1 cm) and one lymph node (not directly draining the tumor) without malignancy.

We're guessing that the staging will indicate T3, N1, M0 - a HER2 negative ER/PR positive 5cm tumor, with positive but minimal lymph node involvement, and no distant spread.   This may imply Stage IIIA, but we will await a definitive statement from the care team, since staging is complex and multi-factorial.

The tumor is very aggressive.   Less than a month ago, there was no lump.   Today, her left breast shows skin and shape changes.   We're meeting with the oncologist this afternoon to document the physical changes.       In general, research indicates that outcomes are the same regardless of the order of treatment - chemotherapy followed by surgery verses surgery followed by chemotherapy.   However, rapid growth and skin involvement may warrant chemotherapy as the first step.    Since Kathy is continuing to heal from the sentinel node biopsy, we have to time next steps carefully.   It's likely that chemotherapy will reduce her ability to heal, so we do not want to start it too soon. However, the tumor is growing rapidly, so we want to start it as soon as possible.

Mentally, cancer can be overwhelming.   It is important to think about cancer treatment as "fitting into your life and schedule" verses letting the cancer control you.    The care journey will take time and there are many steps ahead.

Thanks so much to all who have offered their encouragement.   Kathy and I are emotional and analytic people. Our endless optimistic is only occasionally punctuated with sadness.   To paraphrase Robert Frost, the forest ahead is dark and deep, but there are promises to keep and there are miles to go before we sleep.   We're ready.

A Look Back at 2011

2011-12-28T03:00:00.000-08:00

2011 was a year of change and tumult.   For a day by day look at the top stories of 2011, check out this impressive chart from the UK Guardian.

It was a year in which the economy sputtered worldwide, the Arab Spring toppled several regimes, and unprecedented acts of nature (severe weather, earthquakes) caused billions in worldwide damage.

What about the world of healthcare IT?

Federal
In 2011, Meaningful Use and Certification accelerated healthcare IT adoption and doubled implementation of EHRs throughout the country.    Every aspect of the industry was stressed along the way
*Vendors were challenged to add the features necessary for certification resulting in some "haste makes waste" lack of usability and workflow integration.   GE admitted its faults and should be congratulated for its honesty, since many other vendors had the same problems but did not communicate them.
*IT organizations created productivity miracles to meet meaningful use timeframes with limited staff and limited budgets.   Many organizations will apply their meaningful use payments to general operations and not IT department budget increases, so the sacrifice of IT staff may remain unrecognized.
*Providers had to radically change workflows to accommodate new business processes, resulting in staff turnover and short term frustration.

However, I would argue that we achieved David Blumenthal's goal of moving the "escalator" fast enough to create rapid change but not so fast that people fell off.   The one year delay in Stage 2 gives breathing room to all stakeholders to recover from Stage 1 and for laggards to catch up.

The Standards work needed for Stage 2 was completed and although there is still substantial work ahead, I believe that "good enough" content, vocabulary, and transport implementation guides are no longer the rate limiting step to healthcare information exchange.

The Policy work needed to support privacy, quality measurement, and patient engagement made significant strides. As a country, we studied the PCAST report and incorporated its best ideas into existing federal efforts.

ONC itself matured in 2011, solidifying its operations under Farzad Mostashari, transforming from largely strategic to highly tactical, implementing the HITECH programs per the regulations written in 2010. The Standards and Interoperability Framework filled the gap created when HITSP was sunseted.

State
In 2011, States were challenged to implement Regional Extension Centers, Healthcare Information Exchanges, and in some cases Beacon Communities, Challenge grants, and SHARP research programs.

I believe there will be shining examples of success in some States, while others will provide lessons learned - political and technical - that will refine future work.

The REC program has been largely successful.   The HIE program is still an evolving work in progress, since HIE is technically and politically challenging, with limited alignment of incentives and few sustainability models.

It's too early in the lifecycle of the research grants to assess their success. Much hard work is being done to explore vocabularies, security, modular applications, and novel healthcare information exchange approaches.

In Massachusetts, all stakeholders - payers, providers, patients, employers, academia, and government aligned their efforts by forming an open, transparent state Advisory Committee (similar to a Federal Advisory Committee) to guide all state healthcare IT activities. The energy and commitment from all the volunteers is inspiring.

BIDMC
2011 at BIDMC was a year of compliance - meeting new regulatory requirements of Meaningful Use, 5010, code 44 (short stay/observation verses inpatient), ICD-10, and the Fair Labor Standards Act (FLSA).    Major IT initiatives automated workflows to support these programs.

Infrastructure continued to grow with storage, bandwidth, and virtual machine enhancements to support Big Data.

Security challenges accelerated with more malware, more sophisticated hacking, and more regulatory penalties for data breaches.   In 2011, BIDMC had two publicly reported breaches, both of which were beyond our control, as they were caused by business associates on infrastructure we did not manage.   The emotional and monetary costs of breach reporting were very significant.

As I said in my post about the Joy of Success, I believe that all my direct reports accomplished everything I asked them to do - we achieved meaningful use, addressed compliance requirements, and kept the IT staff stable/happy despite the stresses of the year.   They're heroes.

Harvard Medical School
In 2011, I continued to oversee the IT operations of Harvard Medical School during the CIO search process.   My goals have been to keep the IT staff happy, the infrastructure stable, and the budgets on track.   So far, so good.   My staff at Harvard also deserve a big thank you for a job well done. My teaching, writing, and community service as a Harvard Professor continue at a brisk pace, but I've reduced my travel to the minimum possible to better balance my work and family life.

Personal
In December 2011 my wife was diagnosed with breast cancer, so my personal life has focused on family.   I'm supporting my wife by helping her prepare her artist studio and art gallery business for the 6-8 month hiatus ahead.   I've helped my daughter balance her college life, home life, and travel (she's in Japan now for a brief winter semester abroad) in the weeks following Kathy's cancer diagnosis. I've put aside all my own pursuits including search for Vermont farmland.

On the positive side, the first semester at Tufts transformed my daughter into a self-reliant young woman.   My parents are healthy. My own physical and mental health are good.   Our home and garden are well maintained and unlikely to cause a distraction over the next year.   Kathy and I continue to simplify our lives, reducing our belongings, and focusing on a lifestyle that is sustainable, low impact, and fulfilling.

In summary, 2011 was filled with high highs and low lows.   The pace was faster than any year in my life to date. More happens every day in healthcare IT than the human brain can comprehend and I'm working harder than ever to filter the incoming data (and email) into knowledge and wisdom.

2012 will be a year of healthcare reform, new business intelligence/analytics tools, automating remaining paper processes, and creating the standards/policy/infrastructure necessary to accelerate health information exchange locally, regionally, and federally.     My only wish (beyond my wife's health) is that everyone will celebrate the problems we overcome rather than the focus on the challenges that persist.   Hard work is great if everyone around you is aligned for a successful journey rather than protecting themselves from blame when roadblocks appear along the way.

The Joy of Success

2011-12-27T03:00:00.000-08:00

As the year ends, I've spoken to many CIOs. 2011 was a hard year filled with Meaningful Use (including many upgrades to certified systems or self-certification), 5010 (the deadline for upgrading billing systems is January 1, 2012), accelerating compliance demands, new security threats, rapidly evolving technologies, and unprecedented demand for new projects driven by the consumerization of IT.

At the same time that CIOs and IT professionals are running marathons, they are being held accountable for events that are not directly under their control. They are not being congratulated for the miracles they create every day, but are being criticized for not moving faster.

What do I mean?

One CIO received a negative audit report because new generations of viruses are no longer stopped by state of the art anti-virus software. Interesting. The CIO cannot control the virus authors, nor the effectiveness of anti-virus software. No one in the industry has solved the problem, but audit firms revel in creating fear, uncertainty and doubt at the Board level as it enhances the reputation of the auditor.

Another CIO was held accountable for infrastructure demands that were not forecasted, planned, or communicated. CIOs do their best to be proactive, but in the world of Big Data, past trends may not predict future needs.

Another CIO was was given 10 goals and 5 unplanned urgent projects. She completed 8 of the planned goals and all the urgent projects, yet was told she only met 80% of expectations.

In a world that expects leaders to continuously perform miracles with constrained resources in limited time, we all need to step back and take our own steps to stop the madness.

With your own staff, celebrate the joy of success and focus on what really matters.

Did you achieve Meaningful Use?

Did you support compliance requirements on time to meet regulatory deadlines?

Did you maintain employee satisfaction and minimize turnover?

If so, you're an IT Leadership hero.

Did your Board or senior management note that a new application or website launched a few weeks late because you wanted additional testing time to minimize risk?

No one will ever remember.

Did you defer a "nice to have" project because an unplanned "must have" occurred mid year?

Good for you.

Did you have a brief infrastructure failure that led to a major improvement in security, reliability, and maintainability because the staff rallied around a tricky problem caused by a combination of rapid technology change and exponential increases in customer demand?

You'll be stronger in the future because of it.

We have to break the cycle of negativity that makes IT leadership so challenging. Create a culture that thrives on the projects you did well and does not focus on what remains undone because of circumstances beyond anyone's control.

Leaders at all levels - from Board members to team leaders need to realize that shouting louder does not make the rowing staff move the boat faster.

So celebrate the accomplishments achieved by your and your staff in 2011. It was one of the hardest years in the history of IT and we doubled EHR adoption in the US from 20% to 40%. We need to focus on that success, leveraging our energy and optimism to finish the 60% that remains.

Cool Technology of the Week

2011-12-23T03:00:00.000-08:00

In a previous post I described the capabilities of the Microsoft Kinect technology.

I've written about sterilizing iPads and iPhones for use in the operating room and that does work, but there are challenges with subjecting electronics to sterilization.

However, there's another cool option for examining medical records and digital images in the OR - a touch screen you do not touch. Check out this gestural interface to EHRs and PACS systems that uses an Xbox and Kinect.

Traverse pages, select tabs, and zoom into images using only body movements.

The system, called TedCas, was recently named one of the top applications for Kinect.

That's cool!

We Have Cancer

2011-12-22T03:00:00.000-08:00

Cancer. It's a word that creates fear and uncertainty. Many of the doctors I know use the word "hate" whenever they discuss their feelings about cancer.

Last Thursday, my wife Kathy was diagnosed with poorly differentiated breast cancer. She is not facing this alone. We're approaching this as a team, as if together we have cancer. She has been my best friend for 30 years. I will do whatever it takes to ensure we have another 30 years together.

She's has agreed that I can chronicle the process, the diagnostic tests, the therapeutic decisions, the life events, and the emotions we experience with the hope it will help other patients and families on their cancer treatment journey.

Here's how it all started.

On Monday, December 5, she felt a small lump under her left breast. She has no family history, no risk factors, and no warning. We scheduled a mammogram for December 12 and she brought me a DVD with the DICOM images a few minutes after the study. On comparison with her previous mammograms it was clear she had two lesions, one anterior and one posterior in a dumbbell shape. I hand carried the DICOM images to the Breast Center team at BIDMC.

On December 13 she had an ultrasound guided biopsy which yielded the diagnosis - invasive ductal carcinoma, grade 3.

We assembled an extraordinary team of Harvard faculty - a primary care provider (Dr. Li Zhou), a surgeon (Dr. Mary Jane Houlihan), a medical oncologist (Dr. Steve Come), a radiation oncologist (Dr. Abram Recht), a pathologist (Dr. James Connolly), and a skilled breast imaging team. I also contacted my associates from the genomics research community.

On December 16, after my daughter's last final exam at Tufts, Kathy told Lara about the diagnosis. Lara immediately offered her love and support. We also told the grandparents.

Today, Kathy completed a bone scan and chest/abdominal CT. Both are negative for metastases.

We also received the receptor studies from the tumor tissue.

HER-2/neu gene amplification - Not Amplified
Estrogen Receptor - Strong
Progesterone Receptor - Strong

Our next step is to complete the staging via an ambulatory surgical procedure on Friday - a sentinel node biopsy to determine if the lymph nodes closet to the tumor have evidence of malignant cells.

Summarizing what we know thus far - the tumor is less than 5 cm, poorly differentiated/fast growing, not yet spread to bones or organs, HER-2 negative and Estrogen/Progesterone Receptor positive. Once the staging is completed we'll be able to finalize a treatment plan and determine an estimated 5 year survival rate.

Likely, she'll begin with chemotherapy to be followed by a left mastectomy in early 2012.

We'll also explore her genome to understand the risk factors and determine if a bilateral mastectomy reduces future risk.

We'll face many decisions ahead and many emotions. We've already assembled a community of supporters.

1 in 8 women will develop breast cancer in their lifetime. We never thought we'd be the one.

My Thursday blogs for the next 6 months will document our progress on the healing journey.

Thank you for your prayers and support.

Accountable Care Organization Measures

2011-12-21T03:00:00.000-08:00

On December 19, CMS announced the selection of 32 Pioneer ACO organizations, five of which are Boston-based: Beth Israel Deaconess, Mt. Auburn, Steward, Atrius, and Partners Healthcare.

To participate in the shared savings model, we'll need to compute 33 different quality metrics and submit them via survey, claims or the group practice reporting web interface (GPRO).

What are these metrics?

7 measure the Patient/Caregiver Experience based on survey
6 measure Care Coordination/ Patient Safety 6 based on claims or submissions to the GPRO web interface
8 measure Preventative Health based on submissions to the GPRO web interface
12 measure care to At Risk Population based on submissions to the GPRO web interface

Here's a comprehensive list of what needs to be computed, how, and when.

At Beth Israel Deaconess, we'll use our all-payer claims warehouse and quality data center. My role as CIO has been to prepare the necessary analytics for panel and population health, as described in this overview

As I posted from IHI, our challenge ahead will be navigating the new business model while still maintaining the stability of the old business model during the transition.

From a CIO perspective, use this simple equation: ACO = HIE + Analytics and you'll be ready for whatever tomorrow will bring.

The Standards Work Ahead in 2012

2011-12-20T03:00:00.000-08:00

The December HIT Standards Committee included a discussion of the work ahead for the next year based on the priorities we've heard from stakeholders. We'll have 10 in person and 2 telephonic meetings in 2012. Our topics by quarter will be as follows

January-February-March
1. Assuming that the Meaningful Use Stage 2 Standards and Certification Notice of Proposed Rulemaking will be published in early 2012, the HIT STandards Committee will need to review any comments submitted. In the meantime, we'll continue work on testing criteria and will ensure any test scripts are piloted before they are finalized.

2. Quality Measurement standards
As I've mentioned in other posts, there are three key elements of work needed to improve quality measure computation and submission. First, quality measures need to be simplified so they are based on data elements that exist in EHRs and are captured during normal workflow. Second there needs to be a simple mechanism for submitting numerators and denominators (or the de-identified records that make up numerators and denominators) to CMS. Finally, there needs to be a simple query language created so that new quality measures can be designed without have to write new code.

3. NwHIN Exchange refinement
Previous analysis by the NwHIN Power Team included recommendations for improving the NwHIN Implementation Guides especially the Patient Discovery Specification and ebXML metadata.

4. Value sets/vocabulary mapping
Ideally the National Library of Medicine will host all the necessary vocabularies and crosswalks needed for Meaningful Use Stage 2 including ICD9, ICD10, SNOMED-CT, LOINC, RxNorm, and value sets (language, gender, smoking status etc)

April-May-June
1. NwHIN portfolio - the Direct and Exchange projects require supporting components such as provider directories. We need to finalize specifications for these items.

2. Query Health review - in the December HIT Standards Committee meeting we heard about Query Health and sending questions to data rather than aggregating data centrally. We'll need to finalize the standards for defining medical concepts used in queries, the query language itself, and responses.

3, Radiology Standards - DICOM is a non-standard standard. Many manufacturers of image modalities, PACS, and viewing software extend the standard in proprietary ways. If we want HIEs to support image exchange, we'll need a single, constrained implementation guide for image content. Ideally we'll separate content standards from transport standards. At present DICOM mixes the two.

4. Governance - We need to ensure alignment between the S&I Framework, HIT Standards Committee and SDOs. Setting common priorities, aligning the work, and coordinating the products of multiple SDOs will take creative governance.

July-August-September
1. Detailed Clinical Models - as we consider simplified transition of care summaries such as GreenCDA, we also need to consider simplifications to the HL7 RIM such as Stan Huff's CIMI initiative.

2. Consumer-mediated information exchange - HIE needs to include provider to provider and provider to patient models so that we have a patient centered architecture that more easily supports privacy preferences for data exchange.

3. One-stop-shop for resources - HITSP specifications were challenging for implementers because they were based on indirection - a HITSP guide pointed to an IHE guide which pointed to a password protected SDO website. We need one stop shopping with all the intellectual property necessary for implementation in one place that developers can easily access. We need to finalize the plan and resources to do this.

4. GreenCDA - Simplified XML that eliminates any need for implementers to know the HL7 RIM significantly reducing barriers to writing HIE software. We need to finalize the standard tags for Green CDA.

October-November-December
1. Maintenance strategy for standards - Once we complete the implementation guides for Meaningful Use, there will need to be ongoing maintenance and improvement by SDOs and other organizations. We need to figure out how that will be done.

2. Public Health - As new approaches for public health evolve, such as Biosense 2.0 in the Amazon Cloud, we'll need to ensure the standards are available to support them.

3. Data/Practice Portability from EHR to EHR - To date, Meaningful Use has not included the complete export of data from one EHR and the complete import of data into another EHR needed for a clinician to change vendors. Enabling "EHR portability" would be a great service to the provider community.

4. APIs/tools such as conformance testing and HIE validation - to support implementers, we'll need tools that validate the correct implementation of content, vocabulary, and transport standards.

Every year, the national standards activities expand, refine, and constrain implementation specifications. Although there will always be work to do, we're on a great trajectory in 2012.

Managing Guest Wireless

2011-12-19T03:00:00.000-08:00

BIDMC has two million square feet of wireless coverage using over a thousand 802.11n/a/g access points. We operate two separate networks - a secure network for clinical applications and a guest network for visitors.

The guest network is physically separate from the secure network and uses a commercial 14 megabit per second DSL line from Sprint for internet services, reducing BIDMC's responsibility for malware control and digital millennium copyright act violations. Like any public, unrestricted network, the guest network offers the freedom to download malware, broadcast viruses, and use insecure applications.

In a world of Netflix and YouTube, compounded by bandwidth consumptive standards such as MPEG4, the demands on the guest network are infinite. Can the hospital afford to provide free bandwidth to every visitor (inpatient, outpatient, families, students etc) when 80% of the traffic is streaming video?

If we do provide infinite free bandwidth, will employees and clinicians use the guest network instead of the Enterprise WPA secured clinical network because configuration is easier? Mixing malware infected guest traffic with secure hospital applications is something we want to avoid.

Historically, we've only used one approach to discourage our BYOD staff from using the guest wireless - keep the bandwidth limited so that the secure network offers a better user experience. This is an imperfect solution because it means that patients and visitors compete with each other from the shared megabits. Two months ago, we restricted streaming video 8a-5pm Monday-Friday so that guest network users can reliably check their email and communicate via social networks.

What are other hospitals doing with their guest networks? I asked several CIOs in Massachusetts:

Hospital A
"We limit the bandwidth of each user on the guest network to ensure a consistent experience.

We can't really block employees from accessing the guest network when they can bring in their own device It's slow though. We have about 300-400 guests using wireless per day, sharing 5Mbps.

No corporate resources are available on the guest network without a VPN"

Hospital B
"We do not limit the bandwidth of each user on the guest network. We do web content filtering and block adult content, peer-to-peer traffic, and illegal activities. We do have the guest network configured for Bronze quality of service level, which is the lowest setting we could give it."

Hospital C
"We do not limit the bandwidth of each user on our guest network. We do run web content filtering,
block inappropriate sites, and try to block torrents to limit our Digital Millennium Copyright Act exposure."

Thus, the common practice seems to be
1. Use web content filtering to block inappropriate sites
2. Block Peer to Peer traffic/Bit Torrent.
3. Consider user bandwidth limitations
4. Provide "bronze" quality of service at the network level
5. Require VPN to reach clinical applications from the guest network

We already have web content filtering and peer to peer blocks in place. What can we do to enhance the patient/visitor experience while limiting the use of clinical BYOD devices on the guest network?

Our next step is to evaluate the costs of increasing our guest bandwidth, to simplify configuration when connecting to the secure network, and to educate our providers about the evils of the guest network and joys of the secure network.

And, yes, we have to ensure those BYOD devices are protected while using the secure network.

Although wireless broadband such as 3G CDMA/UMTS and 4G LTE may provide the technical capability for smartphone users to stream video to their devices, the end of the "all you can use" data plans is likely to further motivate users to seek guest wifi networks.

I predict that any capacity increases we purchase will soon be overwhelmed and we'll have to again impose some kind of user bandwidth, quality of service, or time of day restrictions.

Feel free to share your experience with managing guest network demand. All comments are welcome.

Cool Technology of the Week

2011-12-16T03:00:00.000-08:00

Many of my posts lately have described the challenge of securing and managing consumer devices brought from home.

In the past, I've discussed the products from Good Technologies.

I recently polled the CIOs of Massachusetts hospitals and found two other products that are gaining traction - Fixmo and MobileIron

Fixmo creates a secured, encrypted container, the SafeZone, providing secure mobile messaging and data for businesses.

Companies allow mobile devices into their own SafeZone and can restrict application and data access ensuring device integrity and compliance. A safe, sandboxed environment is created in which mobile devices can run and access network resources without compromising the internal network's safety.

With SafeZone, employees can use all the features on their iPhones and Androids while a section of those devices is secure for sensitive company data. Data within SafeZone is certified FIPS 140-2 AES 256-bit encryption and encrypted within a company's infrastructure to keep data at rest and in-transi

MobileIron enables companies to manage multiple operating systems at a granular level, support corporate and personal devices, enforce controls, and create a private enterprise application storefront for employees.

I predict that many new companies will enter this marketplace over the next year, but for now, Good, Fixmo, and MobileIron are cool answers to the BYOD problem.

Distracted Doctoring

2011-12-15T03:00:00.000-08:00

I've written about some of the perils of using consumer devices on hospital networks .

Now add to that risk, the distraction of mixing personal activities with patient treatment.

Blogs are filling with debates about patient safety in a multitasking connected world.

Even the New York Times has published an article about the possible negative consequences of mobile devices.

In that context, AHRQ asked me to write a balanced commentary looking at the quality, safety, and efficiency pros and cons of using multitasking mobile devices for healthcare.

I hope you enjoy it and draw your own conclusions about how these devices are best used in your hospital of professional office setting.

The December HIT Standards Committee Meeting

2011-12-14T09:30:00.000-08:00

We began the meeting by relating our standards trajectory to today's agenda.

Our outstanding standards issues for discussion include

1. Content
Continued discussion of GreenCDA on the wire and overview of Stan Huff's CIMI initiative

Standardizing DICOM image objects for image sharing and investigating other possible approaches (e.g., cloud based JPEG2000 exchange). Consider image transfer standards, image viewing standards, and image reporting standards.

Query Health i.e. I2B2 distributed queries that send questions to data instead of requiring consolidation of data

Simplify the specification for quality measures to enhance consistency of implementation.

The December meeting included an overview of Query Health and Quality measure standards, leaving the discussion of GreenCDA/CIMI and DICOM to our 2012 meetings.

2. Vocabulary
Extend the quality measurement vocabularies to clinical summaries
Lab ordering compendium

The December meeting included a discussion of the lab ordering compendium, leaving the discussion of clinical summary vocabularies to our 2012 meetings.

3. Transport
Specify how the metadata ANPRM be integrated into the health exchange architecture

Additional NwHIN standards development (hearing re Exchange specification complexity, review/oversight of the S&I framework work on Exchange specifications simplification). Further define secure RESTful transport standards.

Accelerate provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminate lessons learned.

The December meeting included an update on the provider directory and certificate components of transport

Our first presentation was an NCVHS update on ACA Section 10109 by Walter Suarez.

The Committee emphasized the need to coordinate NCHVS work and HITSC work given that division between administrative and clinical data is becoming less distinct over time

Our second presentation was an Implementation Workgroup Update by Liz Johnson about testing procedures that support the certification process.

The committee emphasized the need to pilot these procedures, ensuring they are as simple as possible and reflect a practical evaluation of the functionality intended to support policy goals.

Next, Doug Fridsma and Rich Elmore gave an ONC update. Rich Elmore described the Query Health initiative, as referenced in my previous blog post about sending questions to data (rather than sending data to registries).

The committee endorsed the work and noted that further research will be needed to link patients across multiple databases to avoid double counting individuals in quality measure denominators. The work of Jeff Jonas, as described in my earlier blog post about linking identity.

Doug updated the committee about the S&I Framework initiatives - Transitions of Care, Lab Results, Provider Directories, Data Segmentation (for privacy protection), and electronic submission of medical documentation for Medicare review.

We then discussed a preliminary framework for HITSC 2012 Workplan to ensure the items in the standards trajectory listed above are completed in 2012 as we continue to prepare for meaningful use stage 3.

A great meeting.

Standards for Social History

2011-12-13T03:00:00.000-08:00

As we all think about the increasing needs of telemedicine and home care to support healthcare reform efforts, I was asked about integrating home monitoring devices into EHR social history data.

To my knowledge, standards for structured social history are still a work in process, but Microsoft has worked hard to standardize exercise data from home equipment as part of their Healthvault device integration effort.

Here's an overview from Sean Nolan:

"We didn't start from any existing standard for exercise data, because none really were forthcoming --- but we did work with the folks at Polar and other fitness-related companies to establish our current representation within HealthVault. The XML schema for our exercise items is documented here.

It consists of two required fields:

* time started
* activity mode (optionally coded against a custom vocabulary)

This follows our practice of trying to keep required fields to a minimum --- so "jogged on 1/1/2011" is a reasonable item

and optional fields:

* distance
* duration in minutes
* name/value attributes (e.g., "average heart rate", etc.)
* segments which each can hold their own distance/duration/attributes (represent splits - there may be one for each leg of a race)

It's amazing how detailed some of the fitness machines get, but this approach seems to be the right balance."

Thanks Sean. Monitoring diet, exercise, and other observations of daily living are going to be increasing important in a world that reimburses clinicians for wellness rather than procedures and episodic visits. I suspect observations of daily living standards will be part of the Meaningful Use Stage 3 effort, so is very useful to understand any work in progress.

Sending the Questions to the Data

2011-12-12T03:00:00.000-08:00

As hospitals and practices form accountable care organizations, they will accelerate their efforts to build healthcare information exchanges and novel analytics that support community-wide lifetime care rather than siloed episodic care, This requires "freeing the data" from the EHRs, hospital information systems, and laboratories in which it resides.

There are two basic ways to analyze data for a panel or population.

1. Send the data from multiple sources to a central repository for analysis.

BIDMC has partnered with the Massachusetts eHealth Collaborative on such an approach to build a quality data center supporting its ACO strategy.

2. Send the question to the data.

The new federal Query Health initiative is a standards-based approach that enables standardized questions to be sent to multiple federated databases without moving the data itself.

In Massachusetts, we've implemented such an architecture in two ways.

I2B2/Shrine which links together the Harvard hospitals (and many other sites nationwide) with query tools supporting clinical trials and clinical research.

MDPHNet, an ONC funded Challenge grant which sends questions to data sources, answering public health questions.

MDPHnet is being developed under contract with the Massachusetts eHealth Institute to implement a secure web-based query tool which enables predefined and ad hoc queries to be sent to participating sites, including selected practices within the Mass League of Community Health Centers and potentially, Atrius Health.

Queries are executed locally, securely returned after optional review, and then presented to the requester and displayed in a variety of ways - heat map, histogram, table etc. Results contain no patient-identifiable data. Data holders control authorization of requesters and their specific query capabilities.

The current focus for predefined reports is syndromic surveillance (Influenza-like illness) and chronic disease surveillance (diabetes). It can also support other uses, such as pharmacovigilance and quality measurement.

MDPHnet uses PopMedNet open source software developed by the Harvard Medical School Department of Population Medicine at the Harvard Pilgrim Health Care Institute, with support from AHRQ and FDA. Lincoln Peak is co-developer.

There is great synergy among i2b2, PopMedNet and MDPHnet, since they use a common architectural approach. Query Health incorporates PopMedNet in its design.

MDPHnet uses the Electronic Health Record Support of Public Health (ESP) common data model. ESP was developed by the HMS/HPHCI Department of Population Medicine with support from a CDC Center for Excellence in Public Health Informatics

The Massachusetts League of Community Health Centers transforms data from their clinical data warehouse into the ESP format. Commonwealth Informatics supports the process as needed. Additional participants will extract data from their EHR and put it into the same schema (ESP) with help from Commonwealth Informatics.

MDPHnet can be readily expanded to cover other datasources such as the I2B2 nodes which are hosted at over 60 sites nationwide.

Over the next few years I believe that for many use cases we will be sending questions to the data instead of sending the data to centralized registries. I2B2, MDPHnet, and Query Health will show us how.

Cool Technology of the Week

2011-12-09T03:00:00.000-08:00

In late November, I switched from a Blackberry to an iPhone 4S. Every day I experiment with iPhone technologies that can empower healthcare workflow, enhance security, and improve productivity.

Along the way, I've found Siri and the iPhone 4S voice recognition to be very accurate and I dictate many of my emails. Of course there are occasional embarrassing autocorrection mistakes that are beautifully illustrated on http://DamnYouAutoCorrect.com.

I've found the camera quality to be amazing and I've retired all my other still photo and video technologies. I was recently at a Japanese cultural event with my daughter and the master of ceremonies asked for iPhone 4S users to film the dance performance, knowing that the optical quality would far exceed other digital cameras. The only thing that's missing is an adjustable lens.

Now there is a cool detachable lens set for the iPhone that enables users to rotate among three different lenses - fisheye, telephoto and wide-angle. That's cool! Is it any wonder that Kodak is in trouble?

Another iPhone observation - a fall 3 feet onto concrete is not good for the glass screen (happened to me when I dropped the phone during a wind storm this morning). Thanks so much to Adam and Sydney at the Chestnut Hill Apple Store Genius Bar for their amazing replacement and reactivation of my iPhone 4S this evening!

Square Foot Gardening

2011-12-08T03:00:00.000-08:00

Over the past year, readers of my blog may have noticed my increased effort to eat locally by growing my own food in my home and community garden space. As I plan the 2012 season, I'm making a list of the fruits and vegetables I'll want to eat, choosing the seeds from my favorite catalogs like the Kitazawa Seed Company, and thinking about how best to plant them in my raised beds.

Traditionally planting is done in long thin rows. If you fertilize and water a bed with a few long thin rows, you get a great crop of weeds and less than a maximum yield of the fruits and vegetables you want per square foot of soil.

There has to be a more logical way, based on 3 dimensional thinking.

An innovative book, Square Foot Gardening by Mel Bartholomew logically examines the space and nutritional needs of various plants, enabling you to lay them out scientifically rather than randomly, per the graphic above. The end result is higher yields, fewer weeds, less watering, less environmental impact, and less work.

This year, I'll be replacing a chunk of my front lawn with a series of 4x4 foot beds, filled with vegetables and flowers laid out via a Square Foot Gardening plan.

Not only will I have more fresh foods for the table, I'll have less grass to maintain, so I'm canceling my 'mow and blow' service and buying a push mower.

As I continue to strive for better personal sustainability and self sufficiency, Square Foot Gardening is one piece of the puzzle that adds to my efficiency.

The Healthcare Leader's Dilemma

2011-12-07T03:00:00.000-08:00

At yesterday's IHI conference, I was asked to serve as a panelist for the CEO Summit. We began the day with an inspirational case study from outside the healthcare industry - the transformation of US News and World report from a paper-based subscription model to a diverse web-centric family of products.

In 2007, it was clear that offering a paper-based magazine below cost, subsidized by advertising, was unsustainable. Google's sale of targeted adds at low cost eliminated the business models of many print publications.

US News decided to become a specialized web resource offering news, college ranking, hospital ranking, and car ranking. The advertising on each of these sites is highly targeted and actionable - when a customer clicks on a car, they are redirected to a local car dealer's website. At a time when web-based advertising may be $1.00 per 1000 clicks, US News and World report can charge $30.00 per 1000 clicks for qualified car buying customers.

This transition required layoffs, sale of the paper-based subscription customers to Time magazine, and a significant temporary reduction in sales in order to transition to an entirely new business model. The future was unknown and the path to get there was risky. In retrospect, it was exactly the right thing to do.

In healthcare, we are at a similar crossroads.

In an era of healthcare reform, we have three challenging choices

*Become a pioneer Accountable Care Organization (ACO) at a time when no one knows exactly what is necessary to succeed, but risks are minimized for early adopters

*Wait to become an ACO until the tools and technologies needed to succeed are better known, but risks for failure will be higher

*Continue to rely on fee for service income and hope healthcare care reform is delayed or deferred. If healthcare reform proceeds, fee for service income will drop steadily over time leading to the slow demise of organizations which depend upon it.

Just as it was an educated guess to move US News and World Report to the internet in 2007, moving healthcare organizations to population health/wellness-focused accountable care organizations seems like the right thing to do. Yes, it may result in the downsizing of academic health centers and a reduction of some services like lab and radiology that are more expensive than community-based dedicated labs and imaging centers. However, the future of healthcare looks a lot more promising for community hospitals and outsourced ancillaries than for academic health centers with high overhead costs.

Jim Reinertsen MD, Senior fellow of IHI and former CEO of CareGroup moderated a discussion of these ideas with Derek Feeley, Chief Executive of the National Health Service (NHS) in Scotland , George Kerwin Chief Executive Officer of President Bellin Health Systems, and me.

Our panel agreed with the model shown in the graphic above. We're on a journey from episodic care to coordinated care to patient directed care. We're moving from fee for service to bundled payments/capitation. Our IT systems are evolving from segmented to integrated to community based.

Healthcare leaders must make a decision Change now and risk moving too soon, incurring high costs. Wait and risk moving too late, losing your competitive advantage.

In Boston, the healthcare marketplace is evolving so rapidly that our answer is clear - we must move to community-based coordinated care funded through bundled payments/capitation. Implementing this transformation over the next few years will be a challenge for everyone, and along the way we need to ensure that the patient experience is not compromised. We'll need leaders with a vision of the future, a guiding coalition of stakeholder supporters, a sense of urgency from the external environment, and a tolerance for risk. I'm eager to be a part of the next phase in healthcare and look forward to learning from the people who make it happen.

A great discussion - thanks to IHI for the opportunity to participate and Jim Reinertsen for facilitating it.

The 2011 IHI Conference

2011-12-06T12:00:00.000-08:00

Today I'm at the Institute for Healthcare Improvement Annual Forum in Orlando.

Every year, the keynote frames the state of healthcare in the US and the work ahead to make it better.

Maureen Bisognano delivered an energetic keynote that I would summarize as "join a community of motivated people and change the world"

She started with a refection on the book Connections by James Burke. Innovation happens when people come together as teams and seize the right opportunities at the right time, often by accident. Change can be surprising when different ideas combine, leading to a sum greater than the parts. 1+1 will equal 3.

Every year at the Annual Forum, IHI brings together the healthcare community to share stories of improvement efforts with the hope that these lessons learned will spark innovation around the globe. By listening to others stories, healthcare leaders will be inspired to envision a different, better future.

Maureen described IHI's goals as

*Realize Patient Centered Care and Outcomes

*Strengthen Healthcare Delivery Systems

*Drive the Triple Aim - improving the experience of care, improving the health of populations, and reducing per capita costs of health care

*Build Improvement Capability

She shared examples of people and organizations that have embraced these goals.

Christian Farman, an engineer and athlete from Jonkoping, Sweden developed glomerunephrtitis and the dialysis treatments were making him sick. He worked with his nurse to design a program of self dialysis, putting him in control of his own health. Today at the same Jonkoping dialysis center, 60% of patients self dialyze. Christian returned to health, quit his engineering job, and became an RN.

Derek Feeley leads the National Health Service efforts in Scotland, where he has worked tirelessly to reduce central line infections and ventilator associated pneumonia. Today, the central line infection rate in Scotland is zero - that's quality improvement for an entire country, not just a single healthcare system.

Intermountain Healthcare has reduced recovery times for ventilator dependent patients by encouraging early mobility - walking and exercising even before the ventilator is removed.

Kaiser has supported 6 million e-visits, using the web in creative ways for diagnosis, treatment, and followup.

At the Centers for Disease Control, Tom Frieden has championed the health impact pyramid - categorizing the interventions that have the greatest impact. The base of the pyramid is socioeconomic factors followed by changing the context of decision making, long lasting protective interventions, clinical interventions, education and counseling. The most effective way to treat chronic disease may not be a mediation or education, but eliminating homelessness and improving diet.

Maureen described the remarkable effort of a community group working to eliminate homelessness and improve health - www.100khomes.org

Socioeconomic factors are critically important when the economy is fragile. Current 20% of the US has less than $1000 in savings. 50% has less than $5000. At the same time
5% of population accounts for 50% of the cost of healthcare.

We live in an era of information and have an ability to share experiences ad collaborate on innovation more than ever before.

It's up to us to spread our stories and make a difference, working together as a community.

The Promise of Electronic Healthcare Records

2011-12-05T03:00:00.000-08:00

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid. The nation should be grateful that such a visionary was at the helm. The nation should frustrated that he was never confirmed.

In his parting interview with the press, he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care. When I make decisions today, I reflect back on that intense training. However, thousands of journal articles have been written since then, there's new evidence suggesting more effective treatment plans, and new therapies are available. How do I ensure the just the right amount of care is delivered - neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders - just in time advice as to what my patients need. Educational materials and literature can be embedded in the workflow for easy reference. Population/panel health tools can identify those patients who need followup or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system - it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers. Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport, vocabulary, and content standards needed to support it. Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume. Some are so arcane that experts cannot agree on the interpretation. If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests - building new functional or purchasing new products to meet every increasing numbers of rules. We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.

Fraud

Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse. Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense - Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance. Don Berwick is a great supporter of the EHR's potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform - the federal 5 year plan to increase the use of electronic health records and healthcare information exchange - has broad bipartisan support.

As Don Berwick returns to the private section, I'm hopeful that he'll turn his energy back to fixing the US healthcare system and that he'll be a tireless champion for electronic health records.

Tonight, I'm flying to the Institute for Healthcare Improvement Conference in Orlando to serve as faculty for the CEO summit. I'll report on Maureen Bisognano's keynote tomorrow morning.

Cool Technology of the Week

2011-12-02T03:00:00.000-08:00

Now that I'm a Macbook Air and iPhone 4S user, I find myself consuming multiple electrical outlets when I travel. There's a solution - the Plugbug from Twelve South.

The Plugbug is a simple addition to your existing Macbook adapter that enables you to charge the Macbook and your iPad or iPhone simultaneously.

Twelve South has many other interesting Mac accessories to declutter your desktop and enhance your use of Apple devices.

Simple charging with one adapter for all your devices - that's cool!

Family Friday

2011-12-01T03:00:00.000-08:00

I rarely take vacations and only celebrate major events (like birthdays) when schedules permit my family to assemble, since celebrations are more about the people present than the day of the event.

Thanksgiving weekend is one of those dates when everyone's celebration schedules coincide. It's common to travel on Wednesday, to spend Thursday preparing a meal together, and to take Friday as a vacation day.

This year, I received fewer than 50 email on Friday, November 25, down from my usual daily count of 1000-1500 messages.

I believe that shopping during the holidays is a contact sport. Traffic slows to crawl , tempers boil, and now there's even pepper spray to worry about.

Unless some twisted souls think of Black Friday as entertainment, I believe the concept should be replaced by Family Friday.

Talk a walk, go to the zoo, play Apples to Apples, talk about the future, have a Kazoo concert.

My experience with discounts, sales, and bargains is that they will be offered again or tempt you to buy something unnecessary. A designer tie that's discounted 50% is no bargain if you have enough ties already.

I do not reserve my shopping for any particular day of the year or align it with any retailer's event.

Instead, I use Consumer Reports to identify high value products - good quality at reasonable prices. I buy few things, but always buy them to last, given that the real expense is churn - buying a poor quality item 10 times is generally more expensive than buying a good quality item once and keeping it for years.

My Prius has 120,000 miles on it and likely will be fine through 200,000 miles. I'll replace it when its total cost of ownership exceeds the value of a replacement, regardless of the date on which that occurs.

I realize there are implications to discouraging a retail frenzy on Black Friday. Sales imply profits which create jobs.

However, if we consider the big picture - that the US needs to move away from a consumer economy back to one in which we create innovative products and services that the world wants to buy, we'll not need Black Friday.

So let's spend time with our families next Black Friday and focus on innovation at work next Cyber Monday.

Our country and our sense of well being will be better for it.

Creating the Office Space of the Future

2011-11-30T03:00:00.000-08:00

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.

Green CDA Over The Wire

2011-11-29T03:00:00.000-08:00

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!

Ambulatory IT Priorities

2011-11-28T03:00:00.000-08:00

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.

There is Hope

2011-11-24T03:00:00.000-08:00

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!

More BYOD Worries

2011-11-23T03:00:00.000-08:00

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.

The Job of a CIO - Content verses Context

2011-11-22T03:00:00.000-08:00

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.

From Blackberry to iPhone

2011-11-21T03:00:00.000-08:00

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.

Cool Technology of the Week

2011-11-18T03:00:00.000-08:00

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!

Exploring Vermont

2011-11-17T03:00:00.000-08:00

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.

The November HIT Standards Committee

2011-11-16T15:00:00.000-08:00

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:

Content
*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

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

Transport
*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.

Massachusetts State HIE Update

2011-11-15T03:00:00.000-08:00

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.

Nutrition Planning Resources on the Web

2011-11-14T03:00:00.000-08:00

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:
http://www.calorieking.com/ (One can download a free CalorieKing-Joslin Food Awareness Toolbar to count carbs)
http://caloriecount.about.com/ (Nutrition information with a recipe analysis feature)
http://calorielab.com/ (Information on calorie content of foods and caloric expenditure of activities)
http://www.dietfacts.com/ (Nutrition information website that includes many restaurants)
http://www.eatright.org/ (Website for the American Dietetic Assn)
http://nal.usda.gov/fnic/foodcomp/search/ (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.

Cool Technology of the Week

2011-11-11T03:00:00.000-08:00

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.

Where Have All Our Heroes Gone?

2011-11-10T03:00:00.000-08:00

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.

The Growing Malware Problem

2011-11-09T03:00:00.000-08:00

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.

The EHR/HIE Interoperability Workgroup

2011-11-08T03:00:00.000-08:00

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.

The Accountable Care Organization Final Rule

2011-11-07T03:00:00.000-08:00

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!

Cool Technology of the Week

2011-11-04T03:00:00.000-07:00

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)

The Benefits of RxNorm

2011-11-02T03:00:00.000-07:00

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.

The New Metrics for CIO Success

2011-11-01T03:00:00.000-07:00

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.

What Keeps Me Up at Night, FY12 Edition

2011-10-31T03:00:00.000-07:00

Every year I write about the projects and trends which keep me up at night. Here's my list for FY12:

1. Workforce recruitment/retention - $27 billion in stimulus funds from HITECH have increased demand for experienced IT staff to implement and support electronic health records. In many ways, it's a mini "dot com" boom for healthcare IT experts. This makes recruiting and retaining qualified staff even harder. Tomorrow, I'm meeting with a consulting team to formulate an FY12 workforce strategy.

2. 5010/ICD10 - 5010 describes a set of X12 standards used for administrative transactions (benefits/authorization. referral authorization, claims). Payers and providers must support 5010 by January 1, 2012 or risk disruption of the revenue cycle. BIDMC completed all its 5010 work and is now in final testing with every payer. Most payer and provider stakeholders will meet the deadline, but significant resources have been pulled from other projects. ICD-10 implementation is required by October 1, 2013 and I've written about those challenges. Billions will be spent, many healthcare IT projects will be deferred for the next 2 years, and the end result will be no cost savings (coding costs are likely to increase 50%), no quality improvement, no increased safety, and no efficiency gains. If we complete the ICD-10 project on time, no one will notice, but customers will all be angry at the IT department (and the CIO) for the work on other projects that was deferred.

3. Vendor Product Quality - over the past year, I've had several bad experiences with infrastructure and application vendors which delivered products that did not have the reliability, security, or performance promised. Why?
* the pace of innovation is so fast, that time for quality assurance is diminished.
* the economy has stressed companies and they are focused on making as many sales as fast as they can while controlling development and support costs
* the end result is less satisfied customers.

4. Storage growth - BIDMC is approaching 2 petabytes of clinical data and Harvard Medical School has exceeded 3 petabytes of research data. Balancing transactional performance, reliability, and the cost of storage at petabyte scale is very challenging. In FY12, I'll continue to introduce new storage technologies and management tools (including chargebacks to sustain the cost of storage growth), with the hope that I'll be able to keep up with demand.

5. Analytics/Business Intelligence - We have petabytes of data but users want information, knowledge and wisdom. In FY12, I have a five part strategy to support analytics:

a. For comprehensive ad hoc analytics with quality assurance, BIDMC has an expert data mining team which can explore any clinical or financial data while reviewing the accuracy of the underlying data.

b. For less rigorous ad hoc analytics, we have a self service query tool which enables users to explore data themselves. However, such self service queries are unlikely to filter out data of questionable quality (men having babies, women having prostate procedures etc)

c. For reports that are run frequently, we're developing a new set of business intelligence tools that use Microsoft SQL Analysis and Reporting services.

d. For our Blue Cross Alternative Quality Contract and our Accountable Care organization activities we have a Quality Data Center that aggregates clinical data. We also have an all payer claims data warehouse.

e. For unstructured data we plan to experiment with a new generation of natural language processing tools

6. Healthcare Reform and Mergers - Accountable care organizations require substantial IT investments and new processes to coordinate/manage care across the community. Smaller organizations may be unable to implement all that is needed so they may seek mergers with a larger organization. Today I oversee the IT requirements for 2 hospitals and multiple clinician groups. Over the next year, I believe the number of affiliated organizations requiring IT support will increase, requiring new investments in healthcare information exchange and analytics.

7. Mobile devices/consumer IT - We have 1000+ iPads accessing our web-based applications today. Clinicians are mobile people and need to view results, enter orders, and communicate with team members at the bedside. Increasingly they'll want to use their own devices, which creates support and security challenges.

8. Governance - Governance is essential to maintain satisfaction in budget constrained times. In all IT organizations, the supply of resources is fixed, but demand is infinite. There’s an direct relationship among project scope, project timing, and project resources. Governance and communication are the best tools to reduce scope, limit demand, and keep satisfaction at reasonable levels. Here’s how BIDMC does it.

9. Compliance/Regulatory Pressures - At the same time that Meaningful Use empowers care coordination, population health, and public health with health information exchange, the penalties for privacy breaches have increased. Thousands of new regulations have been enacted in the US during my 15 years as CIO. With nearly 25% of my IT organization working on some aspect of compliance, the amount of time left for innovation is diminishing.

10. Security - The internet has become a swamp with nearly 50% of internet devices infected with some type of malware. The most basic freedoms we've enjoyed on the internet - the ability to visit any site, experiment with new applications, and share media with friends, is now a threat to the privacy of business data. The next year will require us to rethink how consumer computing and business computing can co-exist.

That's an intimidating list. However, there is always hope and we'll make progress in all these areas over the next year. By FY15, we will not even remember the events of FY12. Accelerating challenges come with the territory of being an IT leader. Keep smiling.

Cool Technology of the Week

2011-10-28T03:00:00.000-07:00

On November 18, I'm giving a lecture about technologies that educators can use to mentor their students.

My experience running Harvard's Mycourses taught me that social networking for student/faculty interaction works very well. Blogs, wikis, chat rooms, and interactive simulations are useful, but structured community question/answer requires a more powerful tool.

I recently heard about Piazza, a Silicon Valley startup that supports over 900 school campuses and ten thousands of students with a free online collaboration platform.

It has received investment from several venture capitalists, no doubt because it has attracted a large number of devoted users who spend hours per day using the site.

It provides a faculty platform for managing queues of questions, triaging crowd sourced answers to questions, and entering answers.

Also, there's a student platform for reading answers and sharing ideas with other students.

A social networking platform for students and faculty that empowers students to master difficult concepts together. That's cool!

A Personal Experience with 4G LTE

2011-10-27T03:00:00.000-07:00

Steve Berry, BIDMC's Director of Academic and Research Computing, wrote this guest blog entry, about his experience with 4G LTE:

"I've had the Verizon MiFi 4G LTE card for 6 months.

In a 4G network area, the access and speed is incredible. It is so good that you can exceed the 5GB monthly service cap in 4-5 hours!

Once you limit your new found flexibility, it is like having your Ethernet access everywhere. It even worked well while driving long distances.

In a limited 4G network (like the commuter rail line between Boston and Worcester), it is very problematic. When the 4G signal is low and a 3G is available, the device switches modes. This drops the existing connection and 3G takes 20-30 seconds to activate. If you happen to come back into a 4G area (signal level above the 3G value), it switches modes again taking another 30 seconds to establish an active link. In the 1 hour Worcester to Boston route, I used to lose 3G connectivity twice and lose about 2 minutes while the SSLVPN and MiFi resynchronized. Since moving to the 4G, I lose 30 minutes of the 1 hour commute due to continuous mode changes.

There is no ability to force the unit into 3G or 4G only mode. There is no standard for setting up a new connection before dropping an existing connection. Recent firmware updates have not improved performance.

If you have not yet upgraded to 4G LTE, it's important to first study your usage patterns and the 3G/4G coverage in your area. Moving through a mixed area is actually the worst of both worlds.

On my recent vacation, my daughter found that the iPad easily linked to the MiFi (all LTE in Tampa). She happily watched her Netflix videos for several days and I was none the wiser until a month later when the monthly bill came and I was being charged for 25GB of data activity. I had no idea what caused the overage until I reviewed the dates!"

Thanks for your insights Steve.

My iPhone 4S arrives soon and should not have this problem because it does not yet support LTE. By the time Apple releases an LTE phone, 4G wireless should be more ubiquitous in Massachusetts.

It Takes a Village

2011-10-26T03:00:00.000-07:00

In 2008, four people stopped by my BIDMC office to chat about the future. They were Farzad Mostashari, Todd Park, Aneesh Chopra, and Peter Basch. They had a vision to change the world through technology, EHR adoption, and data liquidity.

Little did I know that at the meeting, I was chatting with the future National Coordinator for HIT, the future CTO of HHS, the future CTO of the US, and an influential policy thinker at the Center for American Progress.

Since that meeting, I've stayed in touch with them to exchange ideas, seek their advice, and share lessons learned.

In 2009, I became co-chair of the HIT Standards Committee. Little did I know that the HIT Standards Committee would become the most functional, most productive, and hardest working federal advisory committee in the Obama administration. Its experts have helped me enhance IT capabilities in all my technology roles.

In 2010, I worked with Brian Biles and Steven Morrison of the Center for Strategic and International Studies on Japanese healthcare IT policy. Little did I know that the work would become a foundation for earthquake/tsunami recovery IT planning. Brian and Steve inspired several trips to Japan and meetings with numerous government, academic, and industry leaders.

In 2011, I began working with Rick Shoup, Manu Tandon, and Micky Tripathi on Healthcare Information Exchange planning for Massachusetts. Little did I know that together they would create a unified Healthcare Information Exchange strategy for the Commonwealth that integrates public sector and private sector priorities with multiple funding streams into a single, extraordinary work plan. It has become one of my favorite projects.

On Friday, I'm co-leading a design session for public key infrastructure (PKI) in Massachusetts. I called my friend Dixie Baker at SAIC, my friend Arien Malec at RelayHealth, and my colleagues in government to share their experiences creating a trust fabric for large groups. Massachusetts will succeed by seeking the wisdom of others.

When I was young, I thought I had to be smart enough to solve every problem myself. In today's world, I'm convinced the best way to make a difference is surrounding yourself with people who are smarter than you. The best solutions take a village.

I've said that my tombstone will hopefully read "he made a difference". After the past few years of working with smart people, I'm convinced it would be better as "he was part of a village that changed the world."

The Healthpad Panel at AMIA

2011-10-25T03:00:00.000-07:00

Yesterday I was in Washington DC at the American Medical Informatics Association annual meeting in Washington to join a panel with Dr. Henry Feldman, Dr. Larry Nathanson, and Janet Meyers RN discussing the use of tablet computers in medicine - Session S36 "Tablets in Healthcare: No Just for Pills Anymore"

Dr. Feldman began the presentation with great showmanship, pulling his iPad from a bucket of water, illustrating how the FrogSkin protects even a submerged iPad. He discussed his iPhone sterilization experiments. As a busy hospitalist, he explained the value of the iPad in providing "everywhere" computing - access to healthcare records, provider order entry, and clinical documentation applications at the bedside. He illustrated patient education materials that he uses to consent patients and explain care plans. He noted that the iPad's touch screen keyboard is good enough and that he has never used his physical keyboard dock.

Dr. Nathanson described his early adoption of the iPad to manage workflow in the Emergency Department. Over the past year we've worked on a streamlined web-based provider order entry application from the Emergency Department which brings one click ordering on the iPad to all our ED docs. Clinical documentation is fully functional on the iPad. Dr. Nathanson cleans his iPad with alcohol wipes and notes that he drops it at least once shift, with no discernible damage to date.

Janet Meyers RN presented an overview of Airstrip technologies, noting that they make perinatal telemetry available anywhere anytime to clinicians.

I presented an enterprise view of mobile technologies, highlighting they importance of infrastructure, mobile-enabled applications, an organizational culture which fosters adoption of new technology, and a willingness to invest in enhanced security protections to address the security risks of supporting consumer technologies on hospital network.

I'm a great champion of mobile devices and I truly believe the future of all clinician workflow is mobile, but that enthusiasm has to be tempered by the risks of commingling "Angry Birds" with clinical lookup on the same device. I highlighted the need for applications such as Good Technologies which separate the memory space/storage of work related applications from consumer applications. Only through the use of advanced intrusion detection/prevention, restrictive firewalls, web content filtering, web application firewalls, and security education can we keep mobile devices safe enough for use with clinical applications.

A great discussion with the important take home lesson - tablet/pad-based computing in healthcare is the future, but it must be implemented and managed prudently.

The October HIT Standards Committee Meeting

2011-10-24T03:00:00.000-07:00

The October HIT Standards Committee meeting included recommendations for privacy/security certification criteria, a discussion of next steps for the Standards and Interoperability framework priorities, and a review of the comments received from the Metadata Advanced Notice of Proposed Rulemaking.

We began with a discussion of the challenge of writing certification criteria for privacy and security, since the security of EHRs should depend primarily upon infrastructure assurances (networks, servers, storage, client devices, operating systems) and specialized security services. The EHR itself should provide only those security services which are specific to protecting the confidentiality, integrity, and availability of the electronic health information it manages.

The certification criteria that the Privacy and Security Workgroup developed are all “addressable”. To meet the criteria, each Complete EHR or EHR Module submitted for certification needs to either:
– Implement the required security functionality within the Complete EHR or EHR Module(s) submitted for certification or
– Assign the function to a third-party security component or service, and demonstrate how the certified EHR product, integrated with its third-party components and services, meets the criterion

We discussed the important topic of securing data at rest and recommended encryption for data on end-user devices controlled by EHR. However, we recognized that encryption of data in data centers is a risk management decision and out of scope for certification criteria.

We discussed audit trails and recognized that applications collect audit data in different formats using different architectures. The real value of an audit trail is the events it captures, not the format it stores them in. We selected the ASTM E2147-01 standard which specifies auditable events, leaving implementation details to each vendor. At some future time, it may be useful to standardize audit trail formats, but for now, there is limited value in imposing a standard audit trail format and architecture on existing products.

The HITSC approved the privacy and security certification criteria recommendations by consensus, with one small clarification of SHA-1/SHA-2 encryption requirements.

Next, we discussed the Standards and Interoperability Framework efforts on the NwHIN Exchange transport standards and transitions of care as well as a brief discussion of future work on radiology image exchange standards.

We agreed that additional testimony is needed from implementers of NwHIN exchange to understand their experiences with each component of the Exchange specification:
NHIN Messaging Platform Specification
NHIN Web Services Registry Specification
NHIN Authorization Framework Specification
NHIN Patient Discovery Specification
NHIN Query for Documents Specification
NHIN Retrieve Documents Specification
NHIN Access Consent Policies Specification
NHIN Health Information Event Messaging (HIEM) Specification
NHIN Document Submission Specification
NHIN Administrative Distribution Specification

We're developing a set of questions for implementers and will seek broad input from those in trenches who have coded or operated NwHIN Exchange environments.

We had a rich discussion about the consolidated CDA project. Consolidated CDA enhances and further constrains CCD/C32. Wes Rishel made the following comments:

Many standards experts who have been actively working on the Consolidated CDA project feel that it is a major accomplishment by HL7 to consolidate the specifications into a single document, organize them so that consistent XML structures are used for common data items in multiple document types, and to include well-specified data element names.

Many feel that the consolidated CDA alone will prevent as much as 50% of the programming errors found in C32 testing and that disagreements on the interpretations of the specifications will be far more easily resolved.

Programming, testing and resolution will all be enhanced again when the data element names are used in less highly nested XML and when Green CDA becomes accepted as the "over the wire" format.

HITSC will continue work on Consolidated CDA as it represents an important step forward for Transition of Care summaries.

Finally, we discussed the comments received about the Advanced Notice of Proposed Rulemaking. This input will be incorporated into the Notice of Proposed Rulemaking.

September and October were landmark meetings for the HITSC, with completion of the standards and certification criteria needed for Meaningful Use Stage 2. What's next? Based on my discussion with HITSC experts, I believe our work ahead includes:

Content
*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.
*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.
*Simplifying the specification for quality measures to enhance consistency of implementation.
*Query Health - distributed queries that send questions to data instead of requiring consolidation of the data

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

Transport
*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.

I look forward to our November meeting.

Cool Technology of the Week

2011-10-21T03:00:00.000-07:00

In the aftermath of the Blackberry outage last week, many people have asked me about iPhone 4S and Droid devices. As I wrote about yesterday, I chose the iPhone 4S to achieve a consistent user experience between my phone and my Macbook Air laptop.

Many of my staff use Android-based devices and are very happy with application availability and phone performance.

I polled my staff and asked them to identify the best Droids available today. Here's what they said:

1. Droid Charge by Samsung

2. Droid Bionic by Motorola

3. Droid Incredible 2 by HTC

Also worth mentioning is the Galaxy S II by Samsung

I welcome your comments about these 4 devices. My 500 staff have spoken and believe these are the best Android phones on the market - that's cool!

Reflections on My Daughter's College Experience

2011-10-20T03:00:00.000-07:00

My daughter made the transition from high school to college about 2 months ago. Already, she's matured emotionally, intellectually, and physically, becoming an independent adult.

When I reflect on my own college experience, it was not the math, science and engineering coursework that was transformative, but instead was the people I met and the independency I had to master.

In my case, I developed mentoring relationships with several professors and researchers. I learned to shop for meals and cook for myself. I learned how to become an advocate for my own projects and priorities. I evolved from introverted geek to a convener of peers.

My daughter is going through the same transformation. After two months, she's developed mentoring relationships with the Tufts faculty who are experts in Japanese language and culture. She's advocating for a special educational experience during winter break in Japan. She's been elected to the boards of the Tufts Japanese Culture Club and the Anime Club, making numerous friends and building relationships along the way. She's cut her hair, replaced her glasses, and replaced her high school clothes with a look that gives her adult credibility.

Importantly, she's done this by herself - accepting all triumphs and setbacks as the consequence of her own actions. She sets her own goals, a pace for meeting them, and the criteria for success. Her internal motivation is responsible for getting up in the morning, triaging her activities, and defining the future.

To me, only a small portion of college is about grades and coursework. After all, Steve Jobs and Bill Gates both dropped out. Peter Thiel (founder of PayPal) will even pay the best and brightest to leave college and found companies to accelerate their life experience.

College is about building a desire for lifelong learning, becoming an advocate for yourself, and understanding the possibilities that life offers (both careers and relationships).

I'm extremely proud of her progress thus far.

The Technology I Own, 2011 edition

2011-10-19T03:00:00.000-07:00

In 2009, I wrote about the technology I own.

In 2011, I own less. My devices have converged and everything I need is available in two products:

1. A Macbook Air 11" with 4G of RAM and 128 G of SSD running Mac OSX 10.7.2. The only software I've added is Keynote, Pages, and Numbers. Nothing more.

2. An iPhone 4S on the Verizon network. For 2012, I've concluded that CDMA is the best network in the US, while GSM/GPRS/EDGE/3G is the best network in the rest of the world. The iPhone 4S is the first Apple product that enables me to leverage both technologies. I've retired all my still and video cameras, my dictation devices, and most importantly, my Blackberry.

Starting in 2003, I was one of the first adopters of Blackberry technology, carrying the trusty 850 which was basically a push email device that looked like a pager.

From 2003-2011, I've sent over 3 million emails from these devices. Unfortunately, my current needs are more than text messaging. I need to read complex documents, access numerous web resources, and run a rich array of local applications.

The simplicity of owning two devices is that I carry only two small power supplies, a VGA dongle, and less than 3 pounds in my briefcase.

The iPhone weighs 4.9 ounces

The Macbook Air weighs 2.38 pounds.

The user interfaces, software applications, and engineering on the two devices is very similar, which means a fast learning curve and great synergy.

It's amazing that in 2012 I will not own any music equipment, any video equipment, any camera equipment, a desktop, or a land line phone. All I will own is an Air and a 4S.

As with many things in life, less is more.

Two years from now, my parsimony of devices (2) may converge further to a single device. My prediction is that it will not be a Blackberry, which by 2013 is more likely to be associated with fruit sellers than IT organizations.

An Update on Massachusetts Health Information Exchange

2011-10-18T03:00:00.000-07:00

As I've described previously, Meaningful Use Stage 1 was focused on the electronic capture of data into EHRs. The standards we specified included content and vocabulary but not transport.

Stage 2 will be more focused on Health Information Exchange. Transport standards will likely be included in the Notice of Proposed Rulemaking.

In order for Health Information Exchange to work, I believe we need
a. A transport standard which can be implemented consistently for multiple senders and receivers (such as Direct)
b. A certificate distribution infrastructure to secure the endpoints (such as via DNS)
c. A directory for routing information between organizations (such as a RESTful API to a SQL database)
d. Connections to the last mile - sending/receiving directly into EHRs (such as via XDR/SOAP) or into a standalone web-portal as a short term solution while vendors build transport features into EHRs.
e. Governance to guide the technology and policies that support the above

On October 17, the Massachusetts HIT/HIE Advisory Committee (think of it as the state equivalent of a Federal Advisory Committee) presented its recommendations to the HIT Council (the governance for Massachusetts HIT activities). The Advisory Committee asked for the input of 88 stakeholders divided into 5 groups - legal and policy, technology and implementation, finance ad sustainability, consumer and public engagement, provider engagement and adoption.

The state HIE implementation plan we presented:

*Aligns with national interoperability standards and emerging MU stage 2 requirements
*Maximizes State Medicaid Health Plan/Medicaid Management Information System Federal Financial Participation funding, a 9 to 1 match
*Focuses Medicaid funding on building infrastructure for statewide services, and the ONC Cooperative Agreement HIE funding for last mile implementation

What is last mile implementation?

1. Our regional extension center (REC) will do a pareto analysis of EHR adoption in Massachusetts to identify the most commonly used EHRs. I believe that 20 EHRs are common but 5 EHRs (eClinicalWorks, AthenaHealth, NextGen, Allscripts, GE Centricity) cover 90% of the providers. We'll negotiate with those vendors to create the software which is necessary to connect their EHRs to the statewide Direct backbone in 2012. Yes, we could wait until 2013 when Meaningful Use Stage 2 requires them to implement transport standards, but coordinated procurement now will accelerate HIE integration.

2. We'll provide System Integrator services to support on boarding of small practices and subnetworks of clinicians to the state HIE backbone.

3. We'll provide education and training to foster adoption and use of HIE services.

4. We'll devise grants and subsidies that serve as incentives for HIE adoption

5. We'll facilitate the addition of value added services to the backbone such as public health reporting, clinical registries, and quality measurement services

As I've spoken with vendors, many have noted that State HIEs tend to build central infrastructure but assume endpoints will connect to it on their own. My experience is that a centralized project management office and a single coordinated plan is needed to connect the endpoints. Once every provider, payer and patient is connected, the value proposition of the HIE will increase significantly per Metcalfe's law.

We agreed that by November the Advisory Committee will complete:

*Initial State Medicaid Health Plan Implementation Advanced Planning Documents (IAPD) for review by Advisory Committee workgroups and the Secretary of EOHHS before submission to CMS
*An outline of Statewide HIE Policy Guidance that complements the technology to be built via IAPDs
*A high-level plan for entire project, so that all stakeholders understand what we're creating

I'm extremely optimistic - we have a plan with alignment of support, appropriate funding, and mature technologies that are low risk for failure. The HIT Council, MeHI, and Federal government stakeholders are reviewing our recommendations over the next few weeks and we'll seek their approval to move forward in November.

The momentum for Health Information Exchange in Massachusetts is building among payers, providers, patients, government, and industry. 2012 will mark the tipping point that enables us to stop talking about barriers to Health Information Exchange and instead focus on the accelerators.

Exploiting Privacy Breaches

2011-10-17T03:00:00.000-07:00

I've described information security as a Cold War, requiring constant investment and vigilance to innovate faster than the hackers and criminals who are stealing data to commit identity theft.

I'm spending an increasing percent of my resources on regulatory compliance and data protection.

Over the past year, Federal and State governments have

1. Specified standards to protect healthcare data during transport
2. Required encryption of data at rest.

3. Required breach notification to patients and prominent media

4. Created policy to define meaningful consent and other important patient privacy rights
5. Launched a new initiative on data segmentation in an effort to support more granular healthcare privacy preferences

CIOs and Chief Information Security Officers are working as hard as they can, hackers are intensifying their attacks, and the world is accelerating its adoption of mobile technologies that make perfect control of data more challenging. Despite all our efforts, breaches will occur. Even the most sophisticated security companies have been breached by increasingly sophisticated malware.

There's a dark side to all of this that is the subject of today's blog post - using the new privacy breach reporting laws for personal gain.

There are many good attorneys. My parents are attorneys (patent and business law). Some of my favorite colleagues are attorneys working hard in the public interest (Deven McGraw at CDT, Jodi Daniel at ONC).

As with any profession there are those attorneys who use the law for personal gain. Here's a list of privacy breach class action suits, comparing payments to attorneys versus their clients.

There are many good investors. Accelerating new technology by providing funding to those who can build high value businesses is a good thing. As with any profession, there are investors who put profits ahead of societal benefits.

I've heard discussion about an alarming new business model. Investors paying attorneys to file class action suits related to privacy breaches in return for a portion of the profits.

Prviacy Breach reporting is now public. Identifying a class is easy.

However, if the risk of harm from the privacy breach is low, attorneys may not want to bear the expense and burden of filing a suit, given that recoveries might be minimal. If investors underwrite the risk, realizing that most healthcare organizations will want to settle rather than spend time and resources on litigation, we'll likely see a lawsuit following every reported privacy breach.

To me, there are different kinds of privacy breaches - those which are caused by true carelessness and those which occur because of sophisticated attacks that the Pentagon could not even repel. We should hold organizations accountable for implementing best security practices to protect privacy. We should report breaches to patients and prominent media, since breach reporting regulations provide a great incentive to invest in appropriate security. However, we should do this in an effort to enhance the society we live in, not generate profits.

As we all work together on electronic health records and healthcare information exchange, let's try to create regulations that do that right thing

1. Protect the data
2. Respect patient privacy preferences
3. Recognize the difference between hard to prevent breaches and those that occur because basic protections were not in place

Investing in class action suits that asymmetrically benefit the finance and legal professions is not something that benefits society.

As the eternal optimist, I'm convinced we can all work together for the common good and make every day better than the last. If you hear about someone using privacy breach reporting for their own personal gain, shout out that it's the wrong thing to do.

Cool Technology of the Week

2011-10-14T03:00:00.000-07:00

Big data has arrived. At BIDMC, I oversee 1.5 petabytes of clinical and administrative data. At HMS, I oversee nearly 3 petabytes of research data.

As Blackberry's recent outage illustrates depending on single monolithic infrastructure has its risks and impact of failure can be enormous.

How can we leverage commodity hardware infrastructure, reduce risk, and meet user demands for mining big data? Apache Hadoop is a cool technology worth knowing about.

Hadoop is an open source framework that allows for the distributed processing of large data sets across clusters of computers, designed to scale from a single server to thousands of machines. Rather than rely on hardware to deliver high-availability, Hadoop detects failures and automatically finds redundant copies of data. The Hadoop library includes

*The Hadoop Distributed File System (HDFS), which splits user data across servers in a cluster.

*MapReduce, a parallel distributed processing system that takes advantage of the distribution and replication of data in HDFS to spread execution of any job across many nodes in a cluster.

Microsoft has just introduced support for Hadoop into SQL Server 12 as part of their end-to-end Big Data roadmap.

A fault tolerant distributed file system using commodity hardware for big data that is even integrated into mainstream data mining tools like SQL Server. That's cool!

Columbus Day in New England

2011-10-13T03:00:00.000-07:00

Every Columbus Day, my family visits New Hampshire for hiking, apple picking, and autumn color at peak.

Here's my ideal Columbus Day Weekend:

1. Climb Mount Monadnock via the Marlboro trail - it's the road less traveled that includes easy rock scrambling, great views, and beautiful foliage. I've climbed Mt. Monadnock over 100 times.

2. Pick Apples and buy fresh chestnuts at Old Cider Press Farm in Westmoreland, NH. My favorites are Gala, Empire, and Black Gilliflower.

3. Spend the night at the Inn at East Hill Farm in Troy, NH - we've rented the upper floor of Sugarhouse on Columbus Day weekend for the past 15 years.

4. Have a vegetarian lunch at the Zeppelin and Kaliedoscope in Marlborogh, NH. My favorite is the Falafel platter.

5. Meet artists throughout Southern New Hampshire as part of the Friends of Dublin Art Colony Columbus Day weekend open studios.

It's quintessential New England. Robert Frost would be proud.

The Impact of Consumer IT on the CIO

2011-10-12T03:00:00.000-07:00

I've written about the implications of staff bringing their own devices to the office instead of using corporate desktops and the challenges of keeping mobile devices secure.

I own a Blackberry Bold 9700, first released on December 18, 2009. Since I do not read email when I drive, I hand it to my wife who instinctively tries to navigate my email by gesturing on the screen (it does not work). I receive one email every 30 seconds (over 1000 per day), many of which contain web sites and attachments. Reading them on a Blackberry Bold is not a satisfying experience. It's a messaging device, not a comprehensive mobile platform.

In 2007, owning a Blackberry was cool and RIM interviewed me about the my mobile lifestyle.

The iPhone 3GS was released on June 19, 2009 and since then Blackberry has become less cool and RIM has lost $30 billion in market value.

Market changing consumer products are introduced every 6 months. In the same timeframe, I've been working on hundreds of important enterprise initiatives. The average hospital IT project, given limited resources and large scope, takes 18 months.

The consumer IT marketplace moves at such a fast pace, applying thousands of people to create a single device, that the average employee now expects every hospital IT project to proceed in the same manner, even though only one person may be working on a niche project that serves a small number of users.

I sometimes describe the job of the CIO as a quest to minimize negative reinforcement - "I only received 100 challenging emails, it's been a great day". The accelerated pace of consumer IT multiplies impatience, intolerance, and emotion.

It would be great if mobile devices and the Cloud solved all our problems, but unfortunately, the enterprise world has compliance requirements, security constraints, complex business processes, controls, and workflows that are not addressed by consumer technologies.

What's a CIO to do?

1. Embrace mobile devices and the cloud when they make sense. We do support iPhones and Android devices for email. We do support the cloud for image exchange and a private cloud for hosting community physician electronic health records. BIDMC Information Systems is considered "consumer device friendly", which helps my reputation.

2. The expectation of new infrastructure and applications every 6 months tempered by the reality of 18 month hospital project plans requires intense communication. This week, I sent my staff a plan to create "IT concierges" for our key stakeholders, ensuring that monthly project updates keep users informed and better align expectations with reality.

3. Meetings with disgruntled stakeholders are really important to maintain credibility. "Presence" of the CIO can really make a difference when customers perceive the pace of enterprise IT innovation to be slower than the consumer marketplace.

4. Maintaining agility and flexibility without being dogmatic ensures the CIO is not the rate limiting step to innovation. I've always said that if emerging companies can provide superior service at lower cost to any product we have currently, we should openly evaluate it. Customers will appreciate that IT has a culture of innovation even if product life cycles are longer than the consumer marketplace.

5. CIOs need to accept that 10% of users will dislike you on a given day because enterprise technologies are unlikely to keep pace with consumer technologies. Rather than get frustrated, realize that by focusing on continuous measured progress, you'll create a trajectory that prudently moves forward, balancing security, innovation, and functionality. As my daughter would say, Ganbatte!

Complexity, unrealistic customer expectations, and resource limitations make the job of CIO increasingly difficult. By focusing on the possible, communicating your plans broadly, and accepting consumer technologies for the use cases that make sense, the CIO can continue to thrive.

The BIDMC FY12 Operating Plan

2011-10-11T03:00:00.000-07:00

This is my 1000th blog post. Readers have visited the geekdoctor blog over a million times. The discipline of writing every day has helped me become a better communicator in my work and personal lives. Thanks for being a part of it.

Today, I'm publishing the BIDMC FY12 Information Systems Operating plan which includes all the high priority projects I identified in my earlier post about preparing for a new CEO.

In the Clinical Information Systems area there are numerous important goals, but five that deserve a more focused discussion:

ICD-10 - A challenging and expensive compliance project that must be done because 70% of the revenue cycle is at risk. The scope of the project includes BIDMC, it's community hospital affiliate BIDH-Needham, the owned physician group APG, the academic affiliated group HMFP and the private physicians in BIDPO. The likely budget - $5-10 million. The likely safety, quality, efficiency improvements - none at all. Many in the industry recognize ICD-10 as a colossal waste of time and effort. I've tried very hard to communicate this broadly and will continue that effort in articles, lectures and personal meetings in Washington.

Clinical Documentation - although all the ambulatory areas and ICU areas of BIDMC have online documentation, progress notes in the wards are still written on paper. In order to improve care coordination, decision support, and provide the granularity necessary for ICD-10 coding, we will work hard to create multi-disciplinary documentation in our ward areas.

Electronic Medication Administration Records - We're redesigning medication management from the supply chain to the bedside. We'll adopt innovative tools to automate the new idealized processes.

Healthcare Information Exchange - Accountable Care Organizations will require increased health information exchange analytics. All the stakeholders in Massachusetts have worked together on an HIE plan that connects every provider, payer and patient. Now we need to build it.

Analytics - Turning data into information, knowledge and wisdom will require a new generation of analytics. We're building those now.

The Fiscal Systems area includes several important compliance goals such as 5010 and enhancements to our human resources management systems.

Knowledge services will continue curation of our electronic library resources.

Media Services will enhance our streaming and conference room infrastructure.

In the Infrastructure area, there are important 15 important themes:

Data Protection - Develop and implement a strategy for protecting BIDMC authentication credentials and sensitive data accessed from personally owned computers including mobile devices.

Patch Management - Improve patch management sufficiently to reduce vulnerabilities by 50 percent or more on I.S. managed systems.

Voice Mail System - Replace the current voice mail system that supports over 6,000 accounts with a more up-to-date, IP-based system without incurring extended disruption of service or loss of old content.

Clinical Systems Service Level - Implement high availability features using Cache ECP and Red Hat Enterprise Linux clustering technologies. Increase service levels from 99.9 percent to 99.99 percent due to Cache or Linux related problems.

DR Data Network - Virtualize the distribution layer of the data network in the disaster recovery center to permit more flexible repositioning of assets without regard to VLAN assignment.

Life Cycle Management - Replace one-third of the approximately 120 data network access switches in the east and west campuses with more up-to-date and efficient devices.

Security Dashboard – Develop metrics that in combination provide a way to quantify the risk, by subnet, of devices attached to our data network. Using this information, apply security measures that are tailored to the relative risk each subnet presents.

Vulnerability Assessments – Deploy a commercial Vulnerability scanner along with updated processes and procedures to enhance our ability to identify and remediate vulnerable systems network wide.

Windows 7 – Upgrade all kiosk/public managed workstations to Windows 7 to enhance the user experience, improve security, and take advantage of better management features. Upgrade at least 50 percent of business builds to Windows 7 with the balance targeted for FY13.

SQLServer Enterprise Edition – Migrate two-thirds or more of the 32 data bases still using Standard Edition to Enterprise Edition. EE provides higher availability, larger hardware, improved auditing, and other features.

Rights Management – Improve the utility of the Varonis rights management system to include surveillance of unusual access patterns that may indicate a security issue.

Exchange 2010 – Plan the upgrade and deployment from Exchange 2007 to Exchange 2010.

Internet Access – Develop and implement a strategy that reduces the exposure of BIDMC IT technical resources and sensitive data to Internet-based malware that strikes a workable balance between the security threat and business need for Internet access.

Service Level Monitoring – Extend the use of Nagios software monitoring to 75 percent or more of the data center assets to improve the reliability, granularity, and accuracy of system alerts.

Storage – Migrate all new image acquisition PACs to Atmos and begin conversion of all Centera assets to Atmos.

We'll do all of this within the FTE, operating budget (less than 2% of the BIDMC Operating budget) and capital budget assigned.

I look forward to a great year ahead and share with all of you the lessons learned along the way.

Cool Technology of the Week

2011-10-07T03:00:00.000-07:00

As the discussion of the functionality to be included in a Nationwide Health Information Network (NwHIN) continues, there are 3 different secure transports being evaluated:

Exchange: “NHIN Messaging Platform Specification”, which uses SOAP for transport and WS-I Basic Security Profile for security (TLS + XML signature + WSDL + AES + X.509 + SAML)

Direct: “Applicability Statement for Secure Health Transport”, which uses SMTP for transport and S/MIME for security (AES + X.509)

Secured REST: specification to be done, but will use HTTP for transport; candidates for security include TLS, X.509, and OAuth.

Each has different characteristics and different strengths. The barrier to RESTful implementation is lack of a consistent implementation guide.

The folks at MITRE have implemented project hData noting that "Current electronic health data standards are complex, hard to implement, and difficult to manage”.

hData separates transport and packaging from content – something the HIT Standards Committee has supported. This FAQ provides more details. Clearly hData is still in development and not yet adopted, but I do think they are pursing an appropriately simple approach to transport.

The hData content format has been balloted by HL7 and a Draft Standard for Trial Use (DTSU) is expected this month. The hData transport format (RESTBinding) is in the Open Management Group comment resolution phase.

A RESTful implementation guide for healthcare that separates content and transport, providing easy to implement, secure transport. That's cool.

The Vortexes of Sedona

2011-10-06T03:00:00.000-07:00

Last weekend, I gave a keynote address at the eClinical Works National User Conference in Phoenix, Arizona. As is usual when I travel, I look for interesting places to explore in the natural world within driving distance of conferences. I flew in at 2am on Saturday morning, giving me the entire day on Saturday to explore before my Sunday morning lecture and redeye back to Boston.

Sedona is 120 miles north of Phoenix and is well known for its red rock vistas, its spirituality, and great hiking trails.

Most intriguing to me was the concept of the Sedona "vortexes", which have been described as swirling centers of energy emanating from the surface of the earth.

Whether or not you believe in the physical manifestation of such energy centers, there are 4 great hikes to visit the vortex locations.

As you enter the Sedona area on Highway 179, you'll pass Bell Rock and Courthouse Butte. There's a trailhead on the right side of the highway with access to numerous loop trails from 1 mile to 4 miles in length. I highly recommend the Courthouse Butte loop, which passes the Bell Rock Vortex.

The photo above is the Cathedral Rock Vortex which is accessed via a .7 mile walk/climb accessed from Back-O-Beyond Road off Highway 179. It's easy slab climbing and a 700 foot elevation gain from the parking lot to a beautiful vista. I'm not sure if it recharged my spiritual batteries, but the breeze cascading through the pillars at the peak was refreshing on a 100 degree day and the shade of the Cathedral Rock walls boosted my hiking endurance.

The Airport Vortex is located on Airport Road off Highway 89A. The view of Sedona from Airport Mesa is spectacular.

The Boynton Canyon Vortex is located at Dry Creek Road off Highway 89A. I'm a fan of old Juniper trees (said to be an indicator of strong vortex energy) and you'll find plenty in Boynton Canyon.

After climbing/hiking 4 vortexes, I enjoyed a vegan lunch in a shaded outdoor garden at the Chocolatree Cafe , a very hip spot on Highway 89A. Highly recommended.

Sedona proved to be a very invigorating place, well worth the day trip from Phoenix and preparing me for the double redeye flights of the weekend.

A Moment for Steve Jobs

2011-10-05T19:13:00.000-07:00

Earlier this evening, I emailed my staff about the passing of Steve Jobs. Many responded that they were genuinely sad.

It's not about being Apple "fanboys" or disliking the competition. It's about recognizing the possibilities for what might have been if Steve had lived longer.

In some ways, his death seems like Faustian bargain - revolutionize the world with products beyond our imagination, then die too young.

In my life, I crossed paths twice with Steve Jobs.

As an undergraduate at Stanford from 1980-1984, I met Steve Wozniak and Steve Jobs at the Stanford Computer Club and saw early demonstrations of Apple II, III, and Lisa products. I taught the first undergraduate personal computer course at Stanford in1981, using Apple products in an era when the Stanford Computer Science department told me that personal computers were a fad that soon would end.

In 1983, Steve Wozniak's mom called me and asked me to design an electronic greeting card for the Woz's 33rd birthday. To this day, I hold the patent on all e-cards, both the paper type that play music and those you send over the internet.

Steve Jobs was at the party where my card was demonstrated for the first time.

I bought a Mac SE30 in 1990.

I was an early adopter of the NeXT cube and used it to develop all my early web applications at BIDMC when I first arrived in 1996.

My Windows years were limited to 1995-2006. Since then I've used MacBooks, iPads and iPods as my hardware devices. This year, I'll retire my Blackberry and replace it with an iPhone 4S.

Thanks Steve, you really made a difference.

The Responsibility of Formal Authority

2011-10-05T03:00:00.000-07:00

You probably expected me to write about the new iPhone 4S today, but the press has analyzed it well, especially Computerworld. Next week I will write about the impact of accelerated consumer IT product releases on CIOs, including managing customer expectations for business IT innovation.

In the meantime, a few thoughts on the wise use of formal authority i.e. that job description we were handed when we first became CIOs.

In previous blog posts I've reflected on the fact that none us of really have authority. Instead, we have responsibility and risk.

The work that I do in all my lives - Federal, State, BIDMC, Harvard Medical School, and my home life as father/husband/son - do not rely on formal authority. They rely on my informal authority to inspire, align, and communicate.

I have never "ordered" a change. The best I can do is to facilitate consensus and follow Harvard Business School Professor John Kotter's principles for change management:

1. Establish urgency.
2. Form a powerful guiding coalition.
3. Create a vision.
4. Communicate the vision.
5. Empower others to act on the vision.
6. Plan for and create short-term wins.
7. Consolidate improvements, creating more change.
8. Institutionalize new approaches.

Relationship building and fostering trust bring me the informal authority I need to lead people through change.

Although the formal authority I have is never used, there are behavioral responsibilities that come with the title CIO. I have to be careful what I say, who I speak with, and what I do, because the hierarchy of the organization assigns power relationships to the role I serve. There are five guidelines I've assigned myself:

1. Respect hierarchical boundaries - if I bypass my direct reports and communicate directly with their direct reports, I always ensure the communication includes everyone in the chain of command. If I did not do this, I would disempower my managers and directors.

2. Communicate consistently with everyone - it's bad behavior is to tell different versions of the truth to people based on what you believe various audiences want to hear. By communicating consistently, I create a culture of collaboration. The last thing I want to do is create discord in the organization by encouraging people to work against each other or foster dissension among teams.

3. Work via standard processes - it may seem expedient to invent your own processes, bypass hierarchies, or work around established lines of communication in an effort to accelerate projects. My experience is that such an approach causes confusion, misalignment of priorities, and wasted effort. Just as I respect hierarchical boundaries, I follow standard processes when problems need to be resolved.

4. Communicate broadly and honestly - if there is problem in the organization, I communicate it to all stakeholders. It is far better to over communicate, even if the news is challenging/difficult, than to work in silos and try to hide failures for fear of embarrassment.

5. Work openly and transparently - we've all worked in organizations with office politics that happen behind the scenes. Back channel conversations, blind cc's on email, escalation around hierarchical boundaries, different conversations in the open verses behind closed doors, and undermining the authority of others can occur in any organization. If someone suggests solving a problem by working on it clandestinely, I refuse. Problems should be solved openly and transparently with all the stakeholders in the room.

These are the responsibilities of formal authority. Although you may never use the power you've been given in your job description, your actions every day can impact your peers and your staff in subtle ways. Once you understand that your every word and behavior can inspire, influence, or irritate, you'll have mastered the responsibility of formal authority.

Simvastatin Safety and Information Systems

2011-10-04T03:00:00.000-07:00

The following is a broadcast email written by Dr. David Feinbloom, Medical Director, Medication Safety and Information Management at BIDMC. It nicely illustrates the collaboration among clinicians, pharmacists, and Information Systems:

To all –

I am writing to update you on the simvastatin patient alert process that was initiated in July. As you will remember, this initiative was prompted by the recent Food and Drug Administration (FDA) warning for patients taking simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.

In response to this alert, the Medication Safety Subcommittee, in concert with Healthcare Quality, decided that an institutional response was warranted and we proceeded with the plan described in the original email below. In brief, we reached out to all stakeholders, developed a data query to help providers identify these patients, allowed sufficient time for providers to reach out to these patients, and then sent letters to all the remaining patients who were still taking simvastatin, at a high dose and/or in combination with several other medications. Last Monday we sent 2800 letters to the remaining patients.

This size of this initiative was unprecedented for BIDMC, and although it was largely successful, there were many important observations and lessons learned which will inform our process going forward; these include:

1. The volume of alerts, and the number of patients affected, continues to grow (see the recent FDA warning on Celexa and abnormal heart rhythms).
2. Sorting through the level of evidence and clinical relevance of these alerts is difficult and time consuming.
3. Running queries on our patient’s medication lists with sufficient sensitivity and specificity to meet our provider’s needs is not always possible.
4. Provider preference on how, or whether, to address each alert with their patients is variable.
5. Resources, at both the institutional and provider level, are insufficient to support this work.

We have assembled a group to evaluate how to meet this challenge, and anyone who would like to join is welcome. I will provide you with updates as they become available.

Thanks for your help and support.

David Feinbloom

----------
Email to Providers

As you know, the Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.

(FDA Drug Safety Communication: Simvastatin). Although it is not uncommon for the FDA to issue safety warnings when surveillance data identifies unanticipated adverse drug effects, this case is somewhat unique because simvastatin is such a common medication among our patients at BIDMC. In addition, we know from previous medication safety initiatives in that past that most of providers do not have the time or resources necessary to identify and contact all of their patients who may require notifications. For these reasons, we are proposing the following strategy:

Healthcare Quality will work with IT to generate of list of patients that have an active simvastatin prescription, either at a dose, or in a combination identified by the FDA to be associated with an increased risk for adverse events (see Search Query below). We will then send a list to each provider by email to give them an opportunity to reach out to their patients and update their medication list.

In several weeks time we will run the same query on all patient medications again. Patient that still have a prescriptions for simvastatin in a dose or combination of concern will then be sent a standard letter asking that they contact the prescribing provider to discuss whether any medication changes should be made (see Patient Letter below).

If you have already contacted your patient and made changes to their medication list such that they no longer have a dose or combination of concern, they will not be receiving a letter. Unfortunately, if you have made the clinical decision to continue your patient on a dose, or in a combination of concern, we will not be able to suppress the letter. We expect this will happen infrequently, and if it does, the language of the patient letter is clear that if they have already discussed this you they need not re-contact you.

Your list may include some patients for whom you are not the primary provider, or may omit some patients who you consider to be part of your panel. Similarly, problems may occur for patients whose medication list is not up to date, contains errors, or includes prescriptions for split doses.

Please let me know if this plan is acceptable to your practices. The queries we are running include

1. All patients in who have an active prescription for simvastatin 80 mg prescribed < 1 year ago.

2. All patients in who have an active prescription for simvastatin > 10 mg and any of the following medications:

· Amiodarone
· Verapamil
· Diltiazem

3. All patients in who have an active prescription for simvastatin > 20 mg and any of the following medications:

· Amlodipine
· Ranolazine

4. All patients in who have an active prescription for simvastatin (any dose) and any of the following medications:

· Itraconazole
· Ketoconazole
· Posaconazole
· Clarithromycin
· Erythromycin
· Telithromycin
· Amprenavir
· Atazanavir
· Darunavir
· Fosamprenavir
· Indinavir
· Lopinavir/ritonavir
· Nelfinavir
· Ritonavir
· Saquinavir
· Tipranavir
· Cyclosporine
· Danazol
· Gemfibrozil
· Nefazodone

----------
Letter to Patients

Dear Patient –

You are receiving this letter because according to our records you are currently taking the cholesterol-lowering medication simvastatin. Simvastatin is also sold under the brand name Zocor, and is found in the combination medications Vytorin and Simcor.

The Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.

The risk of muscle damage is low and we do NOT recommend that you stop any of your medications without first talking to your healthcare provider. Simvastatin is an excellent cholesterol-lowering medication and in many instances continuation of the medication is appropriate. However, we are recommending that you contact the provider who prescribed the simvastatin to discuss whether any medication changes should be made. You may have already had a discussion with your healthcare provider about this issue; if so, it is not necessary for you to re-contact him or her. You should immediately contact your healthcare provider if you experience muscle pain, tenderness or weakness, or dark or red colored urine.

Bring Your Own Device

2011-10-03T03:00:00.000-07:00

At BIDMC, I oversee 10,600 desktops and 2000 laptops. They are all locked down with System Center Configuration Manager 2007 and McAfee ePolicy Orchestrator.

Given that most of our applications are thin client and web-based, we can stretch the lifetimes of our desktops to 5-6 years and our laptops to 3-4 years. Capital funding puts limits on how much hardware we can buy and how long we keep it.

Like many IT departments, we have to balance many priorities - security, cost, software compatibility, performance and the user experience.

This balance means that the locked down, image managed, economical device provided by the IT department will almost always be older, lower powered, and less capable than the device in your home.

The same is true of mobile devices like Blackberries which are a one time purchase and are only replaced when they stop functioning.

Consumer devices are more than just technology, they've become lifestyle accessories. Are you an iPad2 or a Macbook Air 11 person? Does Android tickle your fancy or are you holding out for the Samsung tablet with Windows 8?

The cost of these devices is low enough that consumers can buy them on their own and may upgrade yearly as new models are released.

All of this has led to the BYOD movement - Bring Your Own Device to work.

One of my passions as a CIO has been to create web-based applications that run anywhere on anything. That approach has enabled our applications to run on every version of the iPad, iPhone and iPod touch as well as Android and Blackberry devices like the Playbook.

However, I'm also accountable for the privacy and security of each byte of person identified data and we have over 1.5 petabytes to protect.

The internet is an increasingly hostile place. Clicking on a picture of Heidi Klum results in a 1 in 10 chance that your device will become infected.

Online apps distributed via social networks are filled will malware.

Hacked websites can bring malware onto our device. A CIO at the recent Information Week 500 conference described that hackers inserted malware, which was only one pixel by one pixel, into a public-facing website his lab supported. All internal users who browsed to the website and did not have the latest version of Adobe Flash were infected. Once infected, their workstations scanned for other vulnerabilities on the network.

Breach reporting regulations in HITECH are strict. If a keystroke logger embedded in malware results in username/password compromise and a hacker downloads files or views data for more than 500 people, the prominent media needs to be notified. It is unlikely that the media will see much difference between an infected personal device and something under the CIO's control - the CIO will be held accountable!

BIDMC has over 1000 iPads and over 1600 iPhones accessing its network for email and web applications. I absolutely see the value of the Bring Your Own Device movement.

However, the compliance and regulatory requirements that grow more complex every day make the BYOD movement very problematic.

It may be that we'll find some compromise, such as encouraging BYOD, noting that little support will be available, and requiring mobile device security solutions such as Good Technologies before a personal device is allowed on the network.

BYOD can be empowering to users. Let's hope we can mitigate the risk and afford the applications needed to comply with federal and state laws.

Cool Technology of the Week

2011-09-30T03:00:00.000-07:00

Clinicians have been adopting iPhones, iPads, and iPod Touches so fast that they have become the most popular mobile devices at Beth Israel Deaconess. One problem - how do you use these devices in the wet and messy world of medicine?

The answer - a waterproof "case" called a Frog Skin.

How does it work? Here's a goofy You Tube video that demonstrates the product.

Frog Skins are available for all the iDevices (iPhone 3GS/4, iPad/2). They are not actually a case, but rather a film-like covering that is clear and wraps around. the device. We tested it by making a phone call in a glass of water. They are completely waterproof, but probably not under pressure.

But can you sterilize an iPhone/iPad for use in the Operating Room?

Here's Dr. Henry Feldman's description:

Last night we ran the big experiment, and placed a Frog Skin encased iPhone 3G in an ethylene oxide sterilizer (for surgical instruments that can't go in an autoclave). We sterilized the iPhone. The cycle was 6 hours of gas time, and 12 for outgas. I turned the phone off, so no activity would occur causing heat or a spark, since ethylene oxide is flammable. I placed a gas detection strip inside the Frog Skin and one inside the sterile pack. The pack was placed in the sterilizer with all the other surgical instruments.

The photo above shows the iPhone inside the sterilization package (as it would be delivered to the Operating Room). Note that both tags have turned blue. This means that gas got inside the Frog Skin. The entire iPhone is sterile as the Frog Skin does not stop the gas. The phone booted without problems, and operates fine inside the skin. In summary, eth-ox doesn't affect the iPhone in any way. The Frog Skin (polypropylene) does not stop the eth-ox form getting to the phone but will prevent Operating Room liquids from getting into the phone. And yes, you can operate the phone with gloves and the Frog Skin on.

That being said, putting an electrical device inside of an explosive gas atmosphere is done at your own risk! (this is a oxygen depriving unit, so there should not be a fire possibility, although during outgas time there may be a risk)

We now have an iPhone/iPad solution for wet, messy health care environments, even in the Operating Room. That's cool!

My Non-Linear Work Stream

2011-09-29T03:00:00.000-07:00

In the era before Blackberrys, iPhones, instant messaging, social networks, and blogs, I had a predictable day.

I could look at my week and count the meetings, lectures, phone calls, writing, and commuting I had to do.

Although my schedule was busy, I could schedule exercise time, family time, and creative time.

Today, I would not describe my work day as linear or predictable. I do as much as I can, attending to every detail I remember, and hope that by the end of the week the trajectory is positive and the urgent issues are resolved.

Here's what I mean.

Since there are no barriers to communication, everyone can communicate with everyone. Every issue is escalated instantly. Processes for decision making no longer involve thoughtful steps that enabled many problems to resolve themselves. We're working faster, but not necessary working smarter. We're doing a greater quantity of work but not necessarily a higher quality of work.

Everyone has a mobile device and their thoughts of the moment can be translated into a message or phone call, creating a work stream of what amounts to hundreds of "mini-meetings" every day.

As issues are raised over the wire, the follow on cc's result in a volley of messages, thoughts, and more "mini-meetings".

The linear part of our work streams - face to face meetings, presentations, and travel - interrupt the non-linear work streams running through our digital lives. Watch how many people use their mobile devices while in meetings and lectures. Watch how many people need their Blackberry pried from their hands by flight attendants as planes are taking off. Each day has turned into two work days - the linear one which is scheduled and the non-linear 24 hour flow through our devices and social networking applications.

I do my best to resolve every issue and declare closure on the events of each day. However, I find myself waking up from my few hours of sleep with a full queue of tasks because our non-linear work stream is no longer is bounded by a work day.

What are the solutions to the overload we are all currently experiencing?

1. We could eliminate the concept of 1 hour meetings, 1 hour lectures, and airline travel, realizing that much of what we need to do can be accomplished in tweets, emails, instant messages, and calls. The non-linear work stream becomes our work and we stop trying to schedule a linear workday in the middle of it.

2. Alternatively, we can realize that the non-linear work stream is ultimately unsustainable, tossing our mobile devices as in the Corona beer commercial.

3. We could begin to reduce the non-linear work stream by de-enrolling from Twitter, Facebook, Google+, LinkedIn, Plaxo and Instant messaging. We could maintain just a single email account and triage it well.

I'm not sure which answer is right, but I do believe that the conflict between our linear and non-linear work streams has reached the point where we all have "continuous partial attention" unable to focus more than a few minutes on any one linear task.

I write my blogs in the middle of the night because that is the only moment when the non-linear work steam dips to a point that I can capture my thoughts in a single burst of uninterrupted writing.

It's clear to me that our work lives and styles are evolving. Might there be a day when "work" is plugging into a network and managing the stream of communication, decisions, and ideas for 9 hours a day, then unplugging and turning the stream over to the next person on shift? Sounds very Metropolis but I'm not sure any of us can return to the linear work streams of the past.

The September HIT Standards Committee Meeting

2011-09-28T18:52:00.000-07:00

Today was a big day - the end of Standards Summer Camp. We presented the HIT Standards Committee work of the past 6 months and then attended a celebratory reception at the White House.

Judy Sparrow, the ONC "national coordinator" who orchestrated all our HITSC meetings, announced her retirement last month. Jon Perlin and I presented her with a silver bowl, engraved with the words "The Standard Bearer". Thanks for all you've done, Judy.

As we discussed our Summer Camp work during the meeting, we were guided by a few basic principles:

While it might not be perfect, does it represent the best we have at this point in history?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed going forward through the SDO community?

Doug Fridsma presented an overview of our Summer Camp activities to date:

The Metadata Analysis Power Team lea by Stan Huff completed the standards for patient identification, provenance (which organization generated the data), and security flags. Simple XML constructs from CDA R2 and standard X.509 certificates were chosen for these requirements.

The Patient Matching Power Team led by Marc Overhage completed its analysis of best practices for patient matching, noting the types of demographics that should be captured in systems to optimize the sensitivity and specificity of patient matching applications.

The Surveillance Implementation Guide Power Team led by Chris Chute chose one implementation guide for each of the public health transactions - surveillance, reportable lab, and immunizations. We had a spirited discussion about the optional fields in the implementation guides and made it clear that we want the core elements to be the certification criteria. We do not want each state public health department to mandate different "optional" fields. Our transmittal letter will note that EHRs that send the core set should meet the certification criteria. Public health departments should accept this core set. Optional fields are just that - optional items for future reporting needs.

Farzad Mostashari, National Coordinator, framed the important discussion of transport standards by noting that we must move forward, boldly specifying what is good enough. If we specify nothing, the silos of data we have today in hospitals, clinician offices, pharmacies, and labs will persist. There's a sense of urgency to act.

The NwHIN Power Team led by Dixie Baker presented its thoughtful analysis of the 10 standards guides included in NwHIN Exchange and the 2 standards guides included in NwHIN Direct. This analysis was not a comparison of the two, but was an objective look at the suitability of each standards guide for its intended purpose to support aspects of transport functionality at a national scale. The team did not discuss their suitability for use at the local, state, or regional scale. The team did not declare "push or "pull" as a superior architecture. Their thoughtful analysis led to a very robust discussion. I'd summarize it as:

*Direct is low risk for the purpose intended, pushing data from point A to point B using SMTP/SMIME with an optional XDR (SOAP) connector. Additional work needs to be done on certificate discovery, but that will use DNS and LDAP, two well adopted technologies.

*Exchange needs additional work to ensure it scales at a national level for pull and push transactions. The S&I Framework teams are working on modular specifications that should enable a subset of Exchange components to be used, simplifying implementation and support. The Standards Committee will seek additional testimony from Exchange implementers to learn more about their experience.

*It's worthwhile to think about additional transport standards that do not yet have well specified implementation guides, such as a combination of REST, oAuth and TLS - something that Facebook, Amazon, or Google would use to create a highly scalable transport architecture.

The ePrescribing of Discharge Meds Power Team led by Jamie Ferguson presented the use of HL7 2.2-2.51 transactions to support hospital information system workflows in a manner that is compatible with Medicare Part D. We clarified that newer versions of HL7 2.x which are backward compatible should also be allowed.

The Clinical Quality Workgroup and Vocabulary Task Force led by Jamie Ferguson presented their transition plans for vocabularies, identifying the cross maps between vocabularies that need to be created and supported as we evolve from our current use of vocabularies to a future state in which there is one structured vocabulary per domain of medicine (problems, medications, labs, allergies etc).

Doug Fridsma then presented an overview of the Standards and Interoperability Framework activities and next steps:

Transitions of Care - Doug described a brilliant approach that incorporates simple XML, such as has been used in the CCR, with the expandability of the CCD. He calls this next evolution of clinical summaries "Consolidated CDA templates". It's likely that the clinical summary certification criteria will evolve to a single XML format that is easy to use, fast to implement, expandable, based on a reference model, and human readable. Well done!

Reportable Labs - In the past, standards harmonizers struggled to balance simple, easy to implement lab specifications such as ELINCS with the comprehensive and full featured lab specifications from HITSP. The S&I group created a foundation based on ELINCS that is expandable to include all the features of the HITSP specifications using a single HL7 2.51 implementation guide. Amazing work.

Provider Directories - The S&I Framework team had the courage to admit that directory standards are still evolving and need more testing/piloting before selection. DNS/LDAP approaches are likely to work well for certificate discovery. Other aspects of directories such as provider routing addresses and electronic service capabilities may be stored in web pages (microdata), LDAP (HPD), or X12 274 directory structures.

Doug also described new works in progress - Query Health for distributed data mining, Data Segmentation to manage disclosures of protected health information, and Electronic Submission of Medical Documentation for transmission to Medicare review contractors.

Finally and very importantly, the Implementation Workgroup led by Liz Johnson and Judy Murphy presented the Implementation Workgroup certification criteria analysis. We had a thoughtful discussion of each open issue and suggested a path forward for each certification item.

Truly an inspiring meeting - the most work we've ever done in a single day.

The delivery of Meaningful Use Stage 2 Standards and Certification criteria was recognized at a White House celebration by Aneesh Chopra, Chief Technology Officer and numerous members of the Obama administration senior staff. Thanks so much to Aneesh and others for celebrating our work.

As I told the Standards Committee today, I am honored to serve with this team, the hardest working Federal Advisory Committee in government. A milestone day for the country.

Preparing for a New CEO

2011-09-27T03:00:00.000-07:00

On October 17, 2011, Dr. Kevin Tabb MD joins Beth Israel Deaconess as the new CEO.

As part of his briefing packet, I needed to summarize all the key IS issues for the next 3 months, 6 months and 1 year. Here's what I said:

Introduction

Information Systems at BIDMC has a 30 year tradition of industry firsts:
First web-based Healthcare Information Exchange, CareWeb - 1997
First web-based Enterprise-wide Personal Health Record, Patientsite - 1999
First web-based Enterprise-wide Provider Order Entry system - 2001
First web-based Enterprise-wide electronic medication reconciliation system - 2007
First "Magic button" for health information exchange invented at BIDMC - 2008
Pilot hospital to exchange data with Google Health, Healthvault, and CDC - 2008
Pilot hospital to exchange data with the Social Security Administration (Megahit) - 2009
First hospital to implement clinical iPads - 2010
First hospital to achieve federal certification of its EHR systems - 2011
First hospital to achieve meaningful use and receive Federal IT stimulus funding - 2011

The Information Week 500 Awards ranked BIDMC the #1 healthcare IT organization in the country for 2011. By the end of 2011, we'll have eliminated handwritten orders and the emergency department will be paperless.

We've done this with an operating budget that is less than 2% of BIDMC's operating expenses and a capital budget that has been increasingly constrained.

Scope of responsibilities

Information Systems at BIDMC is responsible for all clinical, financial, research, education, and administrative applications. Telecom, Media Services, Knowledge Services, and Health Information Management (medical records) are part of IS. Our scope includes comprehensive IT support for 83 locations including the Main Campus in the Longwood Medical Area, Needham Hospital, APG (owned practices), HMFP (academic affiliates), BIDPO (physician organization that includes many private clinicians), and Community Health Centers. Our infrastructure includes a primary and disaster recovery data center. We support 18,626 user accounts (of which 17,410 have email boxes), 10,600 desktops, 2000 laptops/tablets, 3000 network printers. 600 iPads, 1600 iPhones, 403 servers (152 physical, 2501 virtual) and 1.5 petabytes of storage.

Key challenges

90 Days
Laboratory Information System - On January 21, 2012, BIDMC will replace all laboratory automation in a single day, retiring 30 years of home-built lab systems with a commercial system from Soft Computer. Additional functionality will be added after the go live via planned additional phases. The Laboratory Information Systems Steering Committee will prioritize ongoing future work.

5010 go live - On January 1, 2012, all private and public payers in the US will implement a new revenue cycle transmission and content format called 5010. All BIDMC systems and interfaces are complete. The challenge is testing with all our payers, many of which are not yet ready. We will be able to transmit old (4010) and new (5010) formats, so we are prepared for any payer contingency plans.

Malware control - Harvard networks are attacked every 7 seconds, 24x7x365. The sophistication of the attacks has increased dramatically since identity theft has become a profitable business for organized crime. We have an expert team of security professionals and a multi-layered defense of firewalls, intrusion detection, and anti-virus tools.

Compliance - over the past three years, the number of government and plaintiff attorney requests for information has skyrocketed. The impact on IS is that an increasing percentage of our staff time is spent on e-discovery, file sequestration, and applications that support compliance efforts.

Hospital integration - Milton hospital will join the BIDMC family in the next few months. The clinical system integration includes bi-directional viewing of BIDMC webOMR and Milton Meditech via the web, as well as bidirectional viewing of Atrius Epic and Milton Meditech via the web. This is the same integration we offer all affiliated hospitals and clinician offices. Here's an overview of the Massachusetts state-wide health information exchange effort

180 days
Analytics- Although the precise future of Accountable Care Organizations is unknown, their formation requires a combination of health information exchange and analytics. Here's an overview of BIDMC's strategy.

Community IT - As BIDMC expands its footprint to Anna Jaques, Milton, Lawrence General, more primary care offices, and potentially new affiliations, we must have a scalable community IT function that can respond to changing needs with agility.

365 days
ICD10- Despite our efforts to convince CMS and HHS to delay ICD10, reducing the burden on organizations which are trying to implement Meaningful Use, 5010, and healthcare reform simultaneously, it is clear that ICD10 will go forward with an October 1, 2013 deadline. Here's an overview of the challenges it creates. Although the project is burdensome, has no ROI, and will distract resources from other strategic imperatives, ICD10 will be a top hospital priority in FY12. We have a steering committee compromised of all the right stakeholders. ICD10 is not an IS project, but requires the unified collaboration of all operational areas.

eMAR - Medication safety has been a strength of BIDMC, with its innovative provider order entry, medication reconciliation and e-prescribing systems. In FY12, BIDMC will leverage the work done in FY11 on idealized medication workflow redesign to implement bedside medication verification and electronic medication administration record pilots. Hospitals which have adopted these technologies early have been limited by available technology (computers on wheels) and have low user satisfaction. Our aim is to use mobile devices such as the iPhone/iPod/iPad to create a better workflow and user experience.

Clinical documentation - although BIDMC’s ambulatory documentation is fully automated, inpatient progress notes are still handwritten, then scanned. A multi-disciplinary stakeholder group will devise a unified care team documentation workflow which will then automate and pilot. Our hope is to create “wiki-like” team charting.

Learning Management System - As noted above, compliance requirements are increasing in the short term and long term. To address the staff education aspects of compliance, BIDMC will be implementing a learning management system over the next year.

Healthcare Reform
As discussed above, healthcare reform will require additional health information exchange and analytics. The blog postings noted above outline the details. Additionally, BIDMC has been been an IT pilot site for numerous state and federal efforts. We expect to be the IT learning laboratory for healthcare reform.

Key opportunities
We’re experts in mobile, wireless, disaster recovery, security, and data standards. We lead national and statewide efforts to share data for population health, quality measurement, public health, electronic disability adjudication and payer/provider collaboration. We're experts at interoperability and analytics. We host EHRs for every affiliated clinician and provide quality/outcome/process analytics. We’ve achieved meaningful use for our hospitals and 90% of our physicians will attest by 12/31/11.

We look forward to the opportunities ahead.

Protecting the Legacy of Bill and Dave

2011-09-26T03:00:00.000-07:00

When I was an undergraduate at Stanford, my wife to be and I lived with Dr. Fred Terman, the Stanford Provost who first brought together William Hewlett and David Packard. In early 1980's I had the opportunity to meet Hewlett and Packard. Since then, I've had a special affection for the company.

HP has just hired its fifth CEO in six years, Meg Whitman, the former CEO of eBay. Carly Fiorina, Mark Hurd and Leo Apotheker are gone, each with a checkered history and a large severance check.

Now the future of the iconic company rests with a new leader who is expected to turn it all around.

Can one person do that? It seemed to work for Steve Jobs.

But, being a CEO is not very fun. There's a lot of risk and CEOs can only hope that overly optimistic Board expectations are tempered by twists of fate or alignment of historic market forces at the right time in the right place. The CEO can take credit and be a hero.

It's been a bad year for tech CEOs. Yahoo CEO Carol Bartz was fired over the phone. Rumors are flying about tech CEOs who may be on the way out.

I think of HP as a great printer, server, and storage company which leads the world in PC manufacturing. Their software has always been less than perfect in my experience, since software development is not a core competency of the company.

HP may be shedding its PC business to focus on higher margin software and services. At a time when mobile technologies such as smartphones and tablets are at the peak of consumer demand, HP has exited that business.

Every company has its lifecycle - early innovation, hypergrowth, the burden of maintaining an installed base, displacement by new early stage companies, and decline.

In the late 90's Microsoft could not be stopped. In the late 2000's Google was invincible. Now Apple is the most valuable company in the US and HP has lost $60 billion of shareholder value in the past year.

I truly hope that HP can be transformed by focusing the $120 billion dollar company on those businesses which are profitable and growing. Like IBM in the 1990's, it may need to radically change its focus.

It will take more than Meg to do it. The devoted employees of HP should be able to explain the company's core competencies to Meg and the Board. Hopefully, they will listen.

There's a 72 year tradition at stake.

Note to Meg - Bill, Dave, and Dr. Terman are counting on you. May you rise to the occasion.

Cool Technology of the Week

2011-09-23T03:00:00.000-07:00

I've written that Accountable Care Organizations will require increasing amounts of health information exchange and analytics/business intelligence in order to be successful.

As we explore various tools and techniques, I've talked to people in industries outside of healthcare.

Palantir Technologies provides tools for analyzing, integrating, and visualizing data of all kinds, including structured, unstructured, relational, temporal, and geospatial. It has traditionally has focused on government, providing such functions as

Intelligence
Defense
Regulation and Oversight
Cyber Security

and financial data exploration/visualization for analysts and traders.

Here's a cool example of its use to analyze subprime mortgages.

Here's another example of its use with the Medicare cost data sets.

Edward Tufte has emphasized the need for creative visualizations to turn data into information, knowledge and wisdom.

Palantir's histogram and mapping tools do that nicely.

A business intelligence application that assembles disparate data sources and presents unique visualizations that empower analytic exploration. That's cool!

My Atlantic City Memories

2011-09-22T03:00:00.001-07:00

Today I'm in Atlantic City, New Jersey presenting at the HIMSS Mid-Atlantic Symposium.

In 1965, I lived in Wilingboro, NJ near Trenton and visited Atlantic City one weekend with my parents.

What does a 3 year old remember?

Walking the Boardwalk
Touring the attractions of the Steel Pier
Eating Saltwater Taffy
For some reason, I remember a Planter's Peanuts man. Per Wikipedia there was a Peanut Man statue on a bench in Atlantic City, so there's some association with Planter's and the area.

My parents recall the area as a bit run down in the 1960's but I can only remember the wondrous sights, sounds, smells, and tastes that I had never experienced before. It was sensory overload for a 3 year old.
Above is a postcard from that era.

Today's Atlantic City has hotels, casinos, restaurants, outlet stores, and convention space, but the souvenir shops, the taffy, and the roasted peanuts are still the same. It's amazing how much can change in a lifetime, but today I was able to relive a childhood experience on an early foggy morning in New Jersey.

The Challenges of ICD10 Implementation

2011-09-21T03:00:00.000-07:00

On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10. It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system. It's a kind of Y2k for healthcare.

Most large provider and payer organizations, have a ICD10 project budget of $50-100 million, which is interesting because the ICD10 final rule estimated the cost as .03% of revenue. For BIDMC, that would be about $450,000. Our project budget estimates are about ten times that.

CMS and HHS have significant reasons for wanting to move forward with ICD10 including
1) easier detection of fraud and abuse given the granularity of ICD10 i.e. having 3 comminuted distal radius fractures of your right arm within 3 weeks would be unlikely
2) more detailed quality reporting
3) administrative data will contain more clinical detail enabling more refined reimbursement

Large healthcare organizations have already been working hard on ICD10, so they have sunk costs and a fixed run rate for their project management office. At this point, any extension of the deadline would cost them more.

Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance. They have no bandwidth or resources to execute a massive ICD10 project over the next 2 years.

Vendors have told me such things as "I have been amazed at how much we (and our third-party partners) are spending on getting prepared for ICD10 – and it's not what you would expect (extending data tables, new code lookup tools, etc.) It's a whole host of clinician assistance tools, new documentation workflows, new kinds of provider-facing decision support to maximize coding revenue while guarding against RAC audits - all simply for billing!"

In my CIO role, not any state or federal role, I will continue to listen to concerns about ICD10, sharing them broadly on my blog and with government leaders who will listen.

The Wall Street Journal recently published an article about the granularity of ICD10.

One of my staff posted this response, which is very thoughtful:

While nice-to-have, ICD-10 comes at a time when substantial cuts await providers. The "super committee" is deliberating on these now for Medicare and Medicaid. Adding more administrative overhead to the U.S. healthcare system is untimely and will ultimately impact clinical care. Our health care system already has twice the administrative overhead of other advanced nations. We arguably have the most complex medical reimbursement system in the world. ICD-10 makes it worse.

When HHS published the requirement for ICD-10 in the January 16, 2009 Federal Register, they estimated transition costs for health care providers to be 0.03% of patient revenues. For a $1B medical center, this would be $300,000. Based on experience at our hospital and that of my colleagues at other hospitals, they missed it by a factor of 10 or more.

When a regulation of this magnitude is published, various laws and executive orders require a Regulatory Impact Analysis. Some requirements are intended to protect small businesses and non-profits from burdensome, unfunded federal mandates. The marginal cost estimate published in the Federal Register for ICD-10 was $2.966 billion over the period 2011 to 2025. Two-thirds of this was transitional cost. The benefits were estimated at $4.540 billion.

HHS has a tradition of low-balling cost estimates. Further evidence can be seen with recent estimates of HITECH privacy regulations.

If Congress was doing its job of regulatory oversight, they would sponsor hearings to learn what payers and providers are actually spending on ICD-10 conversion. Costs for consulting services alone run into the millions. This does not count the application software conversion, training and education, and other "in-house" costs. At our medical center, we would be paying $380,000 according to HHS estimates. Instead, the marginal cost of ICD-10 will be in excess of $5m. For multi-hospital systems, the costs may exceed $100m.

A Congressional review of transition costs would turn the regulatory impact assessment on its head. Costs could easily become double the estimated benefit savings.

With ICD-10, the government is perpetuating a reimbursement system that is far too complex. We spend more than any other country on healthcare administrative overhead. The Medicare Claims Processing Manual, for example, is over 4,000 pages in length. The reimbursement system needs simplification to bring the cost of this function in line with other industries.

Recently, HHS began promoting a "global payment" initiative. This had the potential for simplifying reimbursement, but they over-laid it on top of the existing system. Instead of substitution, it was additive. You bill as usual and then have a settlement process that adds one more layer of administrative overhead.

Unfortunately, there are too many activities within and outside the government whose livelihood depends on perpetuating this complex system. It is akin to the Internal Revenue Code. There are also groups who promote ICD-10 for its more granular health care research potential. This is laudable, but not affordable. There is no "free lunch". Every dollar spent on administrative overhead is one less dollar spent on clinical care.

What's needed is a fresh look at the reimbursement system. While ICD is used in other countries, it is not used for reimbursement purposes. Rather, it is used for health statistics and reporting. Using it for reimbursement adds an entirely different dimension. Because it is used for reimbursement, the U.S. version requires numerous extensions. Read this as more codes and more complexity.

Our health care system needs to change. If we are going to cut cost, let it be overhead, not clinical care.

Next Steps for Health Information Exchange in Massachusetts

2011-09-20T03:00:00.000-07:00

Health Information Exchange (HIE) is challenging. As I've written about previously, several state HIEs have failed or are failing.

There are Federal HIE goals, State Medicaid goals, private sector goals, and many varied sources of funding. Each stakeholder has their own self interest.

The Harvard Program for Health Care Negotiation and Conflict Resolution teaches about the "Walk in Woods", moving from self interest, to enlarged interests, to enlightened interests, to aligned interests.

On September 19, the HIT Council and the HIT/HIE Advisory Committee of Massachusetts stakeholders took such a walk to review a straw man plan that aligns all the interests and optimizes available budgets.

Here's the idea.

There's an ONC-approved State Health Information Exchange plan. There's a State Medicaid plan. There are many existing regional health information exchanges in Massachusetts.

We created a Venn diagram of all these projects and identified their points of intersection.

Then, we developed objective criteria for what could be done now, what needs minor policy/technical work and what needs substantial additional work.

The end result was a phased plan making 2012 the year of connectivity to support push transactions, 2013 the year of databases to support analytics/population health and 2014 the year of the pull transaction.

We then worked on reconciling sources of funds.

There are two state programs with substantial federal matching grants - the Medicaid Management Information System (MMIS) and HITECH funds for State Medicaid Health Plans. Every dollar from state resources that is invested in these programs yields $10 of spending. A very wise use of state funds would be to leverage every dollar using federal matching programs. Since 100% of hospitals in Massachusetts receive Medicaid funds, Federal matching programs for Medicaid improvements are ideal for building the "information highway" to connect stakeholders as well as for state public health gateways to receive syndromic surveillance, reportable lab, and immunization data required by meaningful use.

However, what if we build the highway, but no one uses it? It's important to connect EHRs by overcoming technical and resource barriers. Our workgroups will devise a plan to create a grant or procurement program that leverages ONC HIE funds to accelerate EHR to HIE connectivity.

With senders, receivers, and a pipe connecting the stakeholders, we have a clear HIE plan.

With aligned federal, state and private resources, we can define the timelines and we've developed Gantt charts for all our FY12 projects.

To guide the projects, we'll have 3 "functionality" workgroups
Finance and Sustainability Workgroup,
Technology and Implementation Workgroup
Legal & Policy Workgroup

and 2 "engagement" workgroups
Provider engagement & Adoption Workgroup
Consumer and Public Engagement Workgroup

With clear goals that align the interests of all parties, a budget that optimizes every source of funds, and a multi-stakeholder Advisory Committee with community-wide participation in workgroups, we have the foundation to move forward.

As we proceed with a sense of urgency, our rallying cry to all stakeholders is "focus on making the HIE happen, not on the impediments and barriers that we'll encounter along the way."

I look forward to the work ahead and numerous go lives in FY12.

The CLIA/HIPAA NPRM - Patients’ Access to Test Reports

2011-09-19T03:00:00.000-07:00

Can you access your lab test results directly via a non-tethered Personal Health Record like Microsoft Healthvault?

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) requires that the ordering clinician receive the lab and then release it to the patient. HIPAA medical record access provisions excluded laboratories.

The September 14 Federal Register Notice of Proposed Rulemaking entitled CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports aims to change that:

"While individuals can obtain test results through the ordering provider, we believe that the advent of certain health reform concepts (for example, individualized medicine and an individual’s active involvement in his or her own health care) would be best served by revisiting the CLIA limitations on the disclosure of laboratory test results…

Therefore, in an effort to increase direct patient access rights, we are proposing that, upon a patient’s request, CLIA regulations would allow laboratories to provide direct patient access to completed test reports that, using the laboratory’s authentication processes, the laboratory can identify as belonging to that patient. "

Also, the HIPAA exemptions for laboratories would be removed

"In addition, this proposed rule would also amend the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to provide individuals the right to receive their test reports directly from laboratories by removing the exceptions for CLIA-certified laboratories and CLIA-exempt laboratories from the provision that provides individuals with the right of access to their protected health information."

I believe this is a great NPRM and it's endorsed by many lab stakeholders including Quest.

On September 28, the HIT Standards Committee will discuss the content, vocabulary and transport standards that will enable HIEs to transmit labs to any stakeholder. With standards like HL7 2.51 for lab, LOINC, and Direct, a new generation of applications will be empowered as the NPRM becomes a final rule.

Cool Technology of the Week

2011-09-16T03:00:00.000-07:00

I've said that the paperless hospital is as likely as the paperless bathroom - an interesting goal but there are many practical barriers.

One of our approaches has been to use scanning of paper on our quest to create a single electronic location for all patient information, making the electronic record the only official record.

Putting scanners into our clinical areas is expensive and support intensive.

What if we could support scanning of documents and photographs by simply replacing the mouse on our desktops?

LG unveiled the world's first scanner mouse at CES 2011 that produces PNG, JPEG, TIFF, and PDF.

Here's a demonstration video.

It appears easy to use and saves on desk real estate.

A mouse with a built in scanner - that's cool!