Cool Technology of the Week

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

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

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

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

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

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

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.