Gifts and Giving

Now that Black Friday and Cyber Sunday are behind us, it's time to reflect on gift giving. There are been several great articles which provide guiding principles.

George F. Will wrote an excellent column about how not to give gifts. When recipients say "You shouldn't have", they're right!

Joel Waldfogel, the author of ”Scroogenomics: Why You Shouldn’t Buy Presents for the Holidays,” provides a detailed economic analysis of the economic consequences of random gift giving, concluding the best bet is to focus on children and give adults gift cards or named charitable contributions in their honor.

Here's the approach I've used with my close family members.

My daughter has not asked for any specific gifts (she's not a shopper or someone who seeks the season's "must have" items). She has asked that any gifts focus on her three loves - the outdoors, Japan, and archery. We hike, bike, and cross country ski together. This year, I'm helping her choose a few Arcteryx pieces - base layers and shell layers to keep her safe during all the outdoor activities she does with and without me. She's been an archer for several years and this is the year she'll get her own bow - her preference is for something simple in wood, not high-tech carbon or fiberglass.

My wife is starting a gallery in Boston's South End and is reorganizing her studio. My gift to her is all the time, heavy lifting, and construction work she needs to be successful. In addition to being a CIO, I do plumbing, electrical, carpentry, and painting.

My parents are transitioning from cell phones to PDAs, so I'll help them choose and integrate those devices into their lives. I'll also upgrade their computers to Snow Leopard.

The common theme among all these gifts, is the Gift of Time. More than things, I'm giving my experience, my effort, and my expertise in things outdoors, home improvement, and technological.

Hopefully, my family will not conclude that "I shouldn't have"!

A Vegan Thanksgiving 2009

Last year I wrote about my vegan Thanksgiving and the reason I became vegan in the first place.

Here's the 2009 menu - healthy, light, and traditional. Since there is no grease, cleanup is easy. Since there is no tryptophan (no turkey), you do not fall into a stupor afterwards.

Tofurky - a tofu and grain-based roast available from Turtle Island Foods . I do not typically eat meat substitutes since I enjoy the inherent food qualities of tofu, tempeh and seitan, but a Tofurky is great for family holiday entertaining.

Harvest vegetable medley - carrots, parsnips, onions and fresh herbs from our garden roasted at 425F

Steamed Brussels sprouts from our local Community Supported Agriculture (CSA) farm

Boiled fresh rutabegas from our garden

Mashed Kennebec potatoes (no butter or cream added, just a bit of soy milk) from our CSA

Mashed buttnernut squash from our CSA

Roasted Sweet Potatoes from our CSA

Pecan stuffing

Homemade cranberry sauce

Homemade sweet pickles

Wine: Louis Roederer Cristal 1999 (a gift)

Dessert: Vegan pumpkin pie, Sencha from Uji

I really look forward to those fresh Tofurky sandwiches after Thanksgiving!

A Plea for Civility

It's Thanksgiving Day and we should all take time for our families, our mental health, and a pause from the pressures of the modern world. As I've told my staff, it's been a typical Fall - we go from the doldrums of Summer to a sprint post Labor Day with numerous urgent (and sometimes unplanned) projects.

This takes a personal toll. Tempers can flare, and patience can run thin. Civility disappears.

What do I mean by civility?

Webster's calls it "civilized conduct; especially courtesy, politeness"

How was your drive to work yesterday? Put another way - what is the shortest unit of measurable time? Answer - the time between the light turning green in front of you and the person honking behind you.

Did people stop for pedestrians in crosswalks? Did they let you into merging traffic? Did they stop at yellow lights to keep intersections clear and prevent gridlock?

If you boarded a flight yesterday, did passengers wait until their seats or zones were called before standing in line? Did they check their steamer trunk sized bags so that there was plenty of room in the overhead bins for others with smaller carry ons? Did the person in front of you avoid reclining their seat so that you could have a more enjoyable flight?

I realize that more people are competing for fewer resources and the economy is less than robust. That does not mean we have to turn each day into our own personal Lord of the Flies.

It is my hope that as we enter the holiday season, the pace will slow and we'll be able to do our work in a predictable way, with the scope, resources and timelines we need to get them done.

Today, raise a toast to the good things we have in life - family, wellness, and the boundless opportunity to make the world a better place. Let's use the Thanksgiving weekend to renew our spirits, prepare for the challenges ahead, and regain our civility.

I'm off to roast the squash and carve the Tofu.

Status emailicus

My day is spent running meetings - staff meetings, steering committee meetings, and various kinds of national/regional/local governance bodies.

Over the past year I have noticed a trend in all these meetings. The number of emails that people receive each day exceeds their ability to respond to them, so they develop "status emailicus" - a bit like status epilepticus (persistent seizures) but it involves retrieving a blackberry, iPhone, or other mobile device from its holster every 15 seconds throughout the meeting.

The end result is continuous partial attention. You'd like to believe that everyone is participating in the discussion, especially if complex issues are being debated. Ideally, when consensus is achieved, everyone leaves the meeting marching to the same tune. However, by multi-tasking in meetings, we see every other frame of the movie. We miss the subtleties of conversation and critical details that may later turn into deal breakers.

How do we solve this problem?

We could throw away our mobile devices, but that ignores their positive aspects. My travel to Washington is possible because I can use my mobile device for command and control of all the projects I'm running, even while in planes, trains, and automobiles.

One option is to reset expectations. Email is not the same as Instant Messaging. A 5 minute response time throughout the day only works if there are no meetings to attend.

Another option is to realize that we all work 8 hours a day in meetings/calls and 8 hours in email. We could limit meetings to 30 minutes in duration - enough time for efficient discussion, but not too long to result in overwhelming email backlog. Following each 30 minute meeting, we could get a 30 minute recess to act on decisions made and catch up on emails.

As I've mentioned in my Open Access Scheduling for Administrators blog, I'm trying to reserve 50% of my time to address the issues that arise each day. Maybe that will reduce my need to check email during meetings.

The bottom-line is that email overload exists and we can

a. Ignore it and hope it goes away

b. Continue to let email run our lives and distract our every waking moment

c. Take control and organize our email responses by reserving a part of each day, outside of meetings, for timely email responses.

I already sense that people are beginning to rethink the way they manage connectedness. Twitter's popularity is decreasing, Instant Messaging is on the wane, and social networks seem less of an obsession.

I welcome your thoughts - just don't email me :-).

A Visicalc moment

If you were an early Apple II or IBM PC user, you may remember the first time you saw Visicalc (1979), SuperCalc (1980), MultiPlan (1982), or Lotus 1-2-3 (1983).

The spreadsheet solves a real problem - it saves time, it empowers its users, and people are more productive using it.. No more paper, pencil and calculators. No more days wasted manually computing "what if" scenarios.

I call this joy from the early days of personal computing a "Visicalc moment".

One challenge we face as we roll out electronic health records to every clinician is that the first time they see an EHR (of any type, from any vendor), they rarely have a "Visicalc moment".

Because we have not marketed the benefits of EHRs to clinicians, they are not sure an EHR saves time, streamlines their workflow, or brings them a better quality of worklife.

There are 3 ways to motivate most clinicians

1. Pay them more

2. Offer them more free time

3. Apply Peer Pressure

How can we leverage these principles clinicians so they will have Visicalc moments?

A few thoughts

1. Electronic medication workflow in an EHR saves time, reduces the number of calls/pages due to unreadable prescription and streamlines the refile process.

2. Templates, Macros and voice recognition can speed up clinical documentation. Of course, they must be used wisely to avoid creating inaccuracies that are persisted forever in the record. Electronic clinical documentation can be electronically exchanged between referring clinicians and specialists, leading to a peer preference for those who document electronically.

3. Patient Education can be automated by linking problem lists and prescriptions to resources such as UptoDate, Healthwise, and Preop.com

4. Decision Support such as automated ordering ensures the safest, most effective therapies are given based on evidence and patient specific data. It can also be used to generate alerts and reminders in support of pay for performance programs.

5. Administrative simplification streamlines the revenue cycle, reducing denials and AR days.

Thus, EHRs, especially those offered via the web in software as a service models can generate income, save time, and keep peers happy.

Let's hope the regional healthcare IT Extension Centers and hospitals which rollout EHRs for their community physicians can achieve a few "Visicalc moments".

Marketing Interoperability

In the past, it's been challenging to market interoperability because incentives to share data between organizations are often not aligned.

You can imagine the following conversation

"Hi - I'm from your local health information exchange. You may know that over 20% of lab and radiology tests ordered in our state are redundant and unnecessary. We're solving that problem through interoperability and we need you to invest $300,000 in capital plus $100,000 per year to connect to our state wide exchange. When it's all working, we'll eliminate all the redundancy, reducing your lab and radiology income by 20%. "

Interoperability is great for patients, a benefit to society, but can create a loss of income for some stakeholders. How do we sell it?

1. Health Reform - if healthcare reform aligns incentives for wellness and care coordination, stakeholders will be incentivized to share data. For example, if medical error is no longer reimbursed and hospital readmissions become a cost rather than a profit center, care summaries are likely to be shared among providers and data sharing between patients and providers will be used for home monitoring and keeping patients out of the hospital.

2. Meaningful Use Metrics/Pay for Performance

The HIT Policy Committee has proposed 29 metrics for 2011 - 17 measures of quality and 12 measures of meaningful use. Although the definition of meaningful use will not be published until next month, It is likely that clinical summary data exchange between organizations, e-prescribing, electronic laboratory workflow, quality measurement, and public health will be included. Thus, for organizations to claim their stimulus funds, they must be interoperable. Exchanging data between facilities within an organization does not count, per Dr. Blumenthal's recent newsletter. Many private insurers also ofter pay for performance incentives for reduced readmission rates, appropriate testing, and medication management. The combination of stimulus funds, Medicare Part D funds, and private insurer pay for performance should provide a reasonable incentives.

3. Peer pressure

I've seen several types of interoperability "peer pressure" in our communities. Primary Care physicians would rather work with specialists who can exchange clinical data, ensuring a closed loop referral workflow. Specialists who are not interoperable are likely to experience a decline in business. Among hospitals, our local CEOs have decided that healthcare IT should not be be considered a competitive asset for any one organization, it should raise the bar for all organizations to improve the health of the population. Thus, each CEO had decided to eliminate silos and share clinical summaries at transitions of care, even if this means exchanging data between competitive organizations.

4. Cost avoidance

The NEHEN network has eliminated paper for 90% of the administration transactions in Massachusetts, taking the cost of claims submission from $2.50 to .25 . We've been able to make the ROI/business case for funding interoperability operations based on cost avoidance. Clinical data exchange also has cost avoidance. ePrescribing eliminates the need for staff to process refills and reduces calls/pages to clarify prescriptions. Malpractice assertions are less likely when care is coordinated among patients and provides. Disease management programs administered by payers and case management activities are more efficient when data is shared electronically.

5. Increased business

Providing interoperable connections in and out of an organization should make that organization a more attractive business partner for clinical collaboration, clinical research, and diagnostic services. I recently was asked to enable data sharing between BIDMC and a business partner. I was told that interoperability was a significant value add to the relationship.

Thus, although there may be a short term misalignment of incentives caused by reducing redundancy and waste, the are many reasons to implementation interoperability for the long term. With new regulations and healthcare reform on the horizon, I'm hoping it becomes a business imperative!

Cool Technology of the Week

We've all used Google products - Search, Gmail, Blogger, You Tube, Docs, and Analytics. Along the way, we've provided information about ourselves - our preferences, our searches, and our customizations.

Google has created a dashboard that serves as a "disclosure log" of everything they know about each user.

To access it, go to Google Dashboard

It's fascinating to see the accumulated data. Google does have strong policies to provide the Google Personal Health Record (Google Health). Any information related to that product is not mined, resold, distributed or used for advertising in any way.

With the Dashboard, I can better understand the data Google gathers about me and be a better informed user.

A dashboard that consolidates all information about my use of Google products - that's cool.