Service Oriented Architecture for Healthcare

As chair of HITSP, I am a non-voting facilitator who supports all stakeholders equally - large/small, open source/commercial, payers/providers. It's rare for me to personally champion an idea, but today's HITSP Board meeting has given me a cause to celebrate.

We reviewed a proposal, to be widely circulated among all stakeholders, which envisions a future for HITSP as the champion of "service oriented architecture (SOA)" for healthcare.

Before you declare that SOA is just another fad at the peak of the Gartner hype curve, realize that SOA is not about a specific technique such as web services, but about a way of connecting organizations using a set of principles that adapts easily to changes in technology.

The joy of a service oriented architecture is that it is loosely coupled - each participant does not need to understand the internal applications of trading partners. SOA exchanges typically do not require complex technical rules for interactions between senders and receivers.

Highlights of SOA include:

* Service "contract" - Services adhere to a communications agreement, as defined collectively by one or more service description documents
* Service abstraction - Beyond what is described in the service contract, services hide logic from the outside world
* Service reusability - Logic is divided into services with the intention of promoting reuse
* Service composability - Collections of services can be coordinated and assembled to form composite services
* Service autonomy – Services have control over the logic they encapsulate
* Service discoverability – Services are designed to be outwardly descriptive so that they can be found and assessed via available discovery mechanisms

To date, HITSP interoperability specifications have focused on the contents of the medical record and vocabularies, not the transaction rules among participating systems needing to exchange data. Although HITSP has developed specifications for transmission of data, it has not specified a common "envelope" for routing and delivery of healthcare information, leaving that to individual implementers.

The HITSP Board voted to establish a working group which will deliver a plan within 90 days to wrap all HITSP work so that it will plug and play with a service oriented architecture. The advantages of doing this
is that it provides strategic position for HITSP within national initiatives as the coordinator and harmonizer of SOA for healthcare. It also helps all the other national healthcare IT stakeholders by:

* Incorporating the lessons learned from the recent Nationwide Health Information Network demonstration
* Providing CCHIT with the necessary standards and framework for certifying Health Information Exchange
* Aligning HITSP work with industry trends including the Federal Health Architecture and IHE efforts
* Rationalizing the reuse and repurposing of HITSP interoperability specifications and their components

You'll hear much more about this effort over the next several months.

When a healthcare stakeholder asks questions such as "I need to exchange medication lists, discharge summaries, personal health records, glucometer data and quality data" the answer will be - HITSP has a well defined service component for that!

The Wall Street Crisis

During the decade I've been CIO, IT operating budgets have been 2% of my organization's total budget, which is typical for the healthcare industry.

During the same period, IT budgets for the financial services industry have averaged 10% or higher.

Since 1998, I've often been told that Healthcare IT needs to take a lesson from the financial folks about doing IT right.

Today's Boston Globe nicely summarizes the financial issues at the core of the crisis

1. Mortgage backed securities
2. "Stop loss" insurance on mortgage backed securities
3. The credit crunch
4. The Banking system
5. The Bailout
6. Recession v. Depression

Given the recent challenges of Lehman, Merrill, AIG, Washington Mutual, and others, you wonder just how effective the IT systems of these companies have been.

Of course they had great transactional systems, disaster recovery, infrastructure, and data warehouses.

However, did they have the business intelligence tools and dashboards that could alerted decision makers about the looming collapse of the industry?

Did the financial services industry have controls, risk analysis, or a memory of previous crisis - the Depression, the Japanese banking crisis, Enron/Worldcom? Was it greed, irrational expectations or too much data and not enough information that brought down these great institutions?


I'm sure many books will be written about the causes and those who are to blame.

One thing is for certain, In 2008, no one is going to tell me that healthcare IT should run as well as Lehman Brothers. I've even talked to folks in the industry who are rewriting their websites and resumes to remove historical references to their overwhelming historical successes in financial services IT.

I certainly feel for everyone in the financial services industry - the anxiety and stress must feel overwhelming. Given that every person in the US will be paying $3000 in tax dollars to rescue the industry if the bailout bill passes today, we're all going to accept responsibility for the IT systems and the management using them that led the unsinkable ship of the financial services industry into an iceberg at full speed.

Cool Technology of the Week

You may have seen the recent American Express Commercial featuring Jim Henson, Ellen DeGeneres and others which highlights "The Members Project", a $2.5 million grant program for innovative, out of the box ideas.

The funds to be awarded are
* $1,500,000 for the winning project
* $500,000 for the 2nd place project
* $300,000 for the 3rd place project
* $100,000 each for the two remaining finalist projects

One Project, New Affordable Cancer treatments, was submitted by a group from the Boston healthcare community. It's a cool idea.

Cancer incidence is rising at an alarming rate all over the world. As many with cancer know, treatments are often toxic, marginally effective, and expensive. For patients without health insurance, here and in the developing world, many newer treatments are simply too expensive.

And yet, there may exist today new, affordable and effective treatments for cancer using combinations of generic drugs and substances that were never patented. To be truly useful to patients, one needs to conduct clinical trials with these substances to determine the proper combinations and doses for effective therapy. Pharmaceutical companies will not invest money in such trials, since the profit potential with non-patentable or patent expired drugs is small.

GlobalCures was established last year as a non-profit medical research organization to address this problem. GlobalCures’ outstanding scientific team has identified many promising treatments available immediately to test in clinical trials.

The GlobalCures idea was posted under the title: New, Affordable Treatments with Existing Drugs . After the first round, thanks to the overwhelming support of voters and the review panel, the project is in the top 25 (out of 1190 projects posted).

If you're interested, you can help in two ways
1. If you have an Amex card, you can VOTE for the project by clicking New, Affordable Treatments with Existing Drugs (you will need to log in on the top right corner of the page)
2. Help us spread the word about the idea by posting to your blog, facebook, website etc.

The Idea:
The idea is to rapidly develop affordable, new therapies for major diseases by conducting clinical trials with combinations of generic or unpatented substances. Pharmaceutical companies will not conduct such trials, since they will not be able to recover their investments. Without evidence from such trials, doctors will be reluctant to prescribe such medicines and health insurance will not cover their cost. We estimate this idea will reduce suffering and save millions of lives within a few years.

The Problem:
Most laboratory research that generates ideas for promising therapies is funded by the government. Pharmaceutical companies then conduct clinical trials to get FDA approval. Since clinical trials are expensive, only lab work with patent protection is singled out by commercial enterprises for further investment. This scenario has left behind untapped opportunities: potential therapies based on substances that were never patented or generic drugs that could be used for new indications.

A cool idea that could save lives by better using technology we already have!

Cycling in the Suburbs of Boston

Outdoor activities in New England are a function of the seasons. It's challenging to cycle in ice and snow. Kayaking in 40 degree water can be deadly. Climbing frozen rock that is not yet quite thick enough for ice climbing is dicey.

Thus, my outdoor activities are timed to maximize the best of each season and safety:

Cycling - April 1 to December 1 (dry roads)
Kayaking - May 1 to October 1 (water temperature above 50F)
Rock Climbing - June 1 to October 1 (warm, dry rock)
Ice Climbing - January 1 to March 1 (cold, solid ice)
Winter Mountaineering - December 21 to March 21 (solid snow pack)
Nordic skiing - December 1 to April 1 (reasonable snow cover)

I've blogged about many of these activities, but I've not written about cycling in the Boston area.

For folks from bike friendly cities like Portland, Oregon, you should know that cycling in Boston is a death sport - bad drivers on poorly maintained narrow roads. In the past decade, none of my friends have been injured while rock climbing. Several of my friends have been injured and one has been killed while cycling in Boston.

On the scale of Morts, cycling is probably about the most dangerous activity I do.

How do I mitigate risk? I cycle in Dover, Massachusetts where the roads are great, traffic is light, and the navigation is easy.

Here's a list of my favorite rides.

I pass great places like Cochrane Falls (picture above), the Charles River along South Street, Noanet Woodlands, Lookout Farm, Broadmoor Audubon Reserve, and some of the most scenic farmland inside the 495 loop.

I ride a Trek Hybrid FX 7.5 which is a road bike with 32mm hardened tires. This means I can cycle 20 miles to a great wilderness area and then cycle a few miles on single track trails to truly spiritual places.

For example, today after the work day, I cycled trails through Noanet Woodlands past a series of old Mill ponds and played my Japanese flute in harmony with the call of the Northern Saw-Whet owl at sunset.

Cycling in Dover, South Natick, Needham, and Wellesley can be safe and provide solace for the soul. I highly recommend cycling in the more rural suburbs of Boston before the ice and snow make riding a high risk adventure.

I've Got the Cold Calling Blues

Readers: An important update! I just exchanged email with Elizabeth Cutler, Group Vice President, US Conferences at IDC. IDC is not having a 2009 conference IT Expo/CIO Summit, so the calls I've been receiving are a scam. That explains the reason they would not email me any materials about the conference. I have not experienced cold calling scams as a CIO before. My apologies to IDC. When I receive my next cold call from the company pretending to be IDC, I'll play along and forward the info to Elizabeth. Life as a CIO is never boring!

Today in the middle of a meeting, I received my 5th cold call from IDC trying to sell me a registration to the 2009 IDC IT Expo and CIO Summit

I'm always kind to cold callers, and I explained that I know it's their job to sell me products and services I have not specifically solicited and do not want to buy.

In this case, I explained that I travel 200,000-400,000 miles per year and keynote all over the world. My goal in 2009 is to travel less, so I will not be attending any IDC conferences which require travel.

I also said that I would be happy to read about their conference and circulate it to my peers. However, this particular IDC marketing campaign seems to prohibit email communications. I've told the callers 5 times to email me an overview and they've explained that they cannot. Must be part of the sales pitch.

As a society, we have declared unwanted email to be Spam and various states and localities have tried to restrict the flow of spam with legislation.

At what point will cold calling a business to the sell the CIO an unsolicited product or service constitute telephone Spam or even harassment?

In the case of IDC, they have somehow obtained my private, unpublished office number that only my assistant and direct reports are supposed to know.

My phone rings about once a month, so I always answer it, assuming its an urgent call from someone close to me.

Today, I replaced my standard desk phone with a caller ID enabled phone so that I can screen unwanted sales calls. This strategy has been very effective at home, where my unlisted number is called several times a day by

The Boston Museum of Fine Arts
The Boston Ballet
The Massachusetts Fraternal Order of Police
The Boston Symphony Orchestra
Marketing and Survey organizations
The Unknown Caller (whoever that is, 8am on a Sunday morning is popular)

They never leave a message.

I have politely asked that my name be removed from all future fund raising lists and I am on the do not call list. Unfortunately, I made small contributions years ago to some of these organizations, which technically gives them the right to call because of a pre-existing business relationship.

Here is my action plan:

1. Sign up for every do not call list, do not mail list, do not send catalog list etc.
2. Put an embargo on donations to any unsolicited caller or visitor to my home.
3. Create an department wide ban on sales to any company making unsolicited calls to any IT staff member at BIDMC or Harvard

And of course, my blog can serve as a public wall of shame for these cold calling companies. I'll ask my staff to send me lists of company names for publication. I see that WallofShame.org is available from GoDaddy.com

CIOs are very busy people. They are providing complex services to demanding organizations and are given limited resources. They last thing they want is

"Hi, I'm Bob and I need to tell you about the best widget ever from xyz.com..."

when they are in the middle of a meeting, negotiating a contract, or writing a strategic plan.

As I tell all my vendors - I'm a voracious reader and when a new product is announced or a new need arises, I'll call you. Until then, tell your cold calling salesman to chill!

Maintaining an Agile IT Organization

I tell my managers that their professional lives will be like a rotating lighthouse. The beam will pass each part of the landscape and sometimes you'll find yourself and your group in the beam.

As strategic plans change, compliance demands arise, and board level priorities create highly visible projects, each team will feel the spotlight and may struggle with timelines and resources. The beam may focus for days or even months on a particular group.

Since all IT projects are a function of Time, Scope and Resources , when the lighthouse focuses on a group, I'm often asked about increasing FTEs. Getting new positions approved, especially in this economy, is very challenging. I go through an internal due diligence process following the Strategy, Structure, Staffing, and Processes approach I use for all IT management.

Here's what I do:

1. Strategy - When IT groups are created and position descriptions written, it's generally in response to a strategic need of the organization or mission critical projects. Strategies change and projects end, so it is important to revisit each part of the organization episodically to ensure it is still aligned with the strategic needs of the organization. Imagine an application group created at the peak of client/server technology. When the spotlight shines on such a group to deliver web-based applications, it may be that the group was never designed to be an agile web delivery department. Thus, I look at the strategy of the organization, the current state of technology in the marketplace/in the community and, the level of customer demand. We can then re-examine the assumptions that were used to charter the group and its positions. For example, 2 years ago, the Peoplesoft team faced growing demands for application functionality and high levels of customer service. As chartered, our Peoplesoft team was a technology group without staff devoted to workflow analysis, subject matter expertise, and proactive alignment of new Peoplesoft functionality with customer needs. We re-chartered the group as a customer facing, business analyst driven, service organization backed by a world class technology team. Given the visibility of our financial projects at that time, the organization was willing to fund expansion of the team.

2. Structure - it may be that the team is not structured properly to deliver the level of service needed by the customers. Recently, I worked with my Harvard Media Services team to align job descriptions and hours worked with customer demand. This restructuring was entirely data driven and demonstrated that in order to meet evolving customer expectations we needed one person to work 4 ten hour days, four people to work 5 eight hour days, and one person to serve as a line supervisor, scheduling everyone and communicating to customers. The end result was a minimal increase in expense but a complete realignment of our organizational structure with the current needs of the enterprise.

3. Staffing - it may be that staff skill sets are perfect for their job descriptions as originally written, but they are no longer appropriate for the current state of technology. Training is critically important to maintain an agile IT organization so that staff can grow as technology grows. Based on expertise, levels of training, and capacity to evolve, staff in a group may be promoted or reassigned to best align them with the current strategy and structure.

4. Processes - it may be that customer service issues are related to less than optimal communication or lack of a consistent service process. In my blog about Verizon, a few cents spent on a sticker telling customers to call for router activation would markedly improve the customer experience. When the spotlight focuses on a group, I make sure we have optimized and documented our processes to serve the needs of customers.

CIOs should not assume their organization will be static. Technology changes rapidly and customer demands continue to grow. A healthy re-examination of each part of the organization to ensure strategy, structure, staffing and process are optimized will ensure an agile IT organization that grows and thrives over time. When the lighthouse beam shines on your group, welcome it as an opportunity to renew!

When Technology Gets Too Complex

At home, my family relies on me for tech support. When a home requires an MIT trained CIO to keep it running, you know that technology has gotten too complex for the consumer. Here's the story.

I have Verizon FIOS at home. Despite a rocky start up it's been a fantastic service, offering me consistent 20 megabit/second download speeds.

Verizon has partnered with ActionTec to provide a wireless router called the MI424-WR to home users.

As one of the first FIOS subscribers, I received Hardware Revision A of this device.

Verizon automatically pushes firmware upgrades to their FIOS customers and on January 3, 2008, my ActionTec router received the 4.0.16.1.56.0.10.7 upgrade.

Since that point my home wireless connections have become unstable, DHCP leases cannot be renewed, and my family has made a ritual of rebooting the router several times a day.

Our household echoed with commentary that was like a scene from the Waltons. Goodnight, John Boy. Mary Ellen, can you reboot the router?

I searched the web and found hundreds of similar stories. Each one contained a "fix" that sounded more like voodoo than technology.

Hardcode the wireless channel to 11 and it will solve the problem.

Begin DHCP IP assignment at 192.168.1.150 and it will solve the problem.

Limit wireless to 802.11g only and it will solve the problem.

I reset the router to factory defaults and tried each one of these solutions. Since each required a router reboot, it appeared to solve the problem temporarily but in the end the router was still unstable.

My comprehensive review of all the blogs, forums, and user sob stories all over the web suggested one final solution. At this point, ActionTec has redesigned the MI424-WR four times and the new circuit board, hardware Revision D, contains completely different wireless networking chips

Interesting that ActionTec has redesigned the device to address some technical issues, but Verizon does not have a customer notification or router replacement program. It also seems strange that one set of firmware revisions could work well on 4 different hardware revisions.

I called Verizon and spoke to a very competent and helpful person. I explained the history of my problem and the various attempts I'd made to solve it. I requested an exchange of my Model A router for a Model D router. She checked with management and agreed to the exchange. She did note that Verizon provides a wireless router but does not support wireless - it's a use at your own risk service.

Two days later the Model D router arrived and it was clearly a major technology change. The form factor of the device was half the size of the Model A.

I connected the Model D router and could not connect to the internet - wired or wirelessly.

As a CIO, I predicted that the Verizon uses MAC address filtering to prevent rogue connections to FIOS. Thus, Verizon would have to activate the MAC address of my new router in order for it to work.

There was no documentation in the router package or user manual that suggested this step, it was just my CIO intuition.

I called the automated Verizon FIOS service number and it identified me as a customer who recently received a new router. The system then offered me the option of activating my new router, which I did. Internet connectivity was restored in 90 seconds.

Dumb question - if this is required and expected of all consumers, then why not put a big label on the router - please call to activate?

I then began setting up wireless connections. The manual that accompanied the router had a MAC address and WEP key printed on it for my router, so I used that information in my laptop setup. No luck.

I then logged into the router via a wired connection and checked the MAC address and WEP key assigned to the device - they were completely different than those provided in the printed documentation.

I reconfigured my Macbook Air, my wife's Macbook Pro, my daughter's iMac, and suddenly everything was working.

A week has passed without a router reboot. After 9 months of struggle, the problem is resolved.

The bottomline of all of this is that Verizon did a great job getting me the router I needed, but it took a CIO with 25 years of technology troubleshooting experience to diagnose and repair the problem. Clearly, the combination of Verizon's policy to not provide full support for wireless, the bleeding edge technology provided by ActionTec, and the lack of change management caused by numerous hardware and firmware upgrades is too much complexity for the average consumer to deal with.

Between the HP printer woes of early September and this Verizon/Actiontec issue, my family is convinced that every modern household needs its own CIO. Now you know why Geek Squad and similar home technology consulting services are likely to be a growing business.