Wednesday, November 24, 2010

What Keeps Me Up at Night - FY11 edition

Every year, I reflect on those projects that are risky or so fraught with change management peril that they keep me up at night  (it's a metaphor, since I sleep soundly for 4 hours a night). Here's the FY11 edition of my concerns in each of my 5 lives:

*Transport Standards - the Standards and Certification Final Rule provided detailed implementation guides for Content, Vocabulary, and Security standards but nothing for Transport standards.   NHIN Direct and numerous private sector approaches are piloting REST, SOAP, and SMTP approaches to send data from point A to point B.   We need to converge on a single approach for Transport by 2011 to accelerate interoperability and avoid the chaos of 50 different state HIE implementations.

*Mobile and Homecare Devices - As Ray Ozzie described in his farewell memo to Microsoft staff,  mobile devices such as phones, iPads, smart appliances, and wearable sensors are likely to serve as the human-application interface in the future.  We need content, vocabulary, security, and transmission standards to support interoperability of all the devices we'll use.

*Vocabulary Resources - We need a one stop shop for all the vocabularies and code sets required to support Meaningful Use Stages 1, 2, and 3.  This resource needs to be easy to use and free (see Intellectual Property issues below)

*Intellectual property issues - Today, most standards implementation guides are incomplete because they cannot include the intellectual property from Standards Development Organizations (SDOs) without disrupting the business models of those organizations.   We need a new model - government funding, a simple annual assessment paid to a government agency/administrative organization to enable download of complete implementation specifications, or some combination of public/private funding.  Otherwise we'll suffer the problem of indirection - incomplete implementation guides which refer to proprietary information which refer to proprietary information etc.  Here's an example of a perfect implementation guide from the Social Security Administration - everything you need to create seamless interoperability without indirection.

*Adoption and Implementation - Standards are not imposed, they are adopted.   The measure of success for all Federal standards efforts will be the number of transactions flowing in 2011, 2013 and 2015 using the harmonized standards selected to support meaningful use.

*Governance - The Commonwealth of Massachusetts is exploring several HIE Governance models and needs to implement open, transparent, public/private governance to ensure trust and investment from the private sector.

*Procurement - The Commonwealth needs to procure directory services, certificate management services, and routing services to support all unconnected stakeholders.

*Sustainability - The Commonwealth needs to consider subscription, transaction, assessment, government subsidy, and bond offerings to provide a sustainability model for the HIE which connects all stakeholders

*Connecting the little guy - A public good HISP (healthcare information services provider) needs to provide healthcare information exchange at low cost to small practices that may not be served by the private sector because of the expense of implementing connectivity to a small, isolated site.

*Moving at meaningful use speed - The Commonwealth needs to have these solutions in place by 2011.  Hospital meaningful use attestation needs to be done by November 2011, so we need to act now on Governance, Procurement, and Sustainability.

Harvard Medical School
*Research liaison - The research community at Harvard needs a scientist and a team of experts who can translate challenging scientific problems into creative IT solutions.    Our traditional method of providing storage services, high performance computing, and software licensing is no longer sufficient.   We need to merge science and IT in novel ways.

*Extranet migration to a content management system -  Like many organizations, Harvard's web presence is a collection of sites created by departments, labs, and administrators.    It needs to be completely transformed into a content management system with a common look and feel, Google search, and federated authoring/editing.

*Sustainability model for staff and infrastructure -  In challenging economic times, getting additional FTEs/operating budget is problematic.   However, ARRA funds have brought new demands, new infrastructure, and new services to Harvard, all of which require additional staff.   There needs to be an NIH compliant direct and indirect cost chargeback model which enables IT to grow organically as new grants are received.

*Compliance and Security - In all my organizations, 2011 is going to be a year of increased compliance.  Harvard has new data security rules.  Internal audit is focusing on applications which manipulate person identified data.  Conflict of Interest tracking requires new reporting capabilities.   The reaccreditation of Harvard Medical School  in 2011 will bring increased scrutiny to business processes.   Labs require new training and certifications for safety,  administered electronically.

*Matching IT supply and demand through Governance - In all my organizations, 2011 is the year of Governance.   As we emerge from the economic doldrums of 2009-2010 we have the potential to increase FTEs.    Governance committees for research, administration, and education can balance supply and demand as well as advocate for new resources.


*Certification/Behavioral Change for Meaningful Use - During the week of December 6, I'll work with CCHIT to certify all the hospital and ambulatory systems of BIDMC, both built and bought, as part of their Site Certification program.   I'll document the experience so that other hospitals with heterogeneous systems will be successful in achieving certification.   The real risk is that private clinicians in the community will not find incentives compelling and will not use EHRs in a meaningful way over the next several years, making quality measurement, global payments, and accountable care organization implementation difficult.

*Preparing for healthcare reform and accountable care organizations - Is it better to create a strategic plan to become an Accountable Care Organization or be an opportunist, creating affiliations and IT integration on the path of healthcare reform over the next few years, given the continuously changing policy landscape?   We're creating the foundation by ensuring BIDMC can send and receive healthcare data with patient consent to any provider organization, public health entity, or registry which measures outcomes on our behalf.

*Clinical Documentation (including ICD-10 and Medication Management) - 2013 is right around the corner and we need full compliance with 5010 and ICD-10 standards in our clinical and financial systems.   More importantly, we need robust clinical documentation in all areas of care to be able to justify the ICD-10 codes that our HIM professionals select.  We also need robust medication management including bedside medication verification and electronic medication administration records to support Stage 2 and Stage 3 of meaningful use in 2013 and 2015.   This will require a substantial effort by business owners to define new workflows and automation requirements.

*Ever Increasing Demands for Compliance and Security - Just as with HMS, there will be numerous compliance efforts in the next year  - FLSA compliance with advanced time keeping systems, followup to our Joint Commission and CMS visits to ensure we meet all their criteria, and increasingly sophisticated monitors/audits to address new Massachusetts Data Protection requirements.

*Matching IT supply and demand through Governance - The BIDMC IS Governance Committees help match supply and demand, set priorities/timing, and support the need for additional resources.   Increased resources for project management, allocation of appropriate resources for ongoing support/maintenance of technology, and reduction of mid-year unplanned projects are essential to our success.

*Parents -  After their recent hospitalizations, I need to support them in any way I can to keep them healthy and happy.

*Daughter - As my daughter approaches adulthood (she'll be 18 in 2011), I need to provide a balance of guidance and independence.   We'll hear about her college application (early decision to Tufts) in 3 weeks.

*Wife  - My wife and I have been together for 30 years.   In 2011, we'll transition to empty nesters, entering a new stage of our lives.   We'll continue our morning walks, our moonlight conversations, and our enjoyment of the world around us.

*Self - In 2011, I'll continue allocating time for mental and physical health.   My outdoor activities - hiking, biking, kayaking, climbing, and skiing ensure I keep a clear mind and fit body.

*The world around me - In the interesting of leaving my daughter with a world she can thrive in, I'm  reducing my carbon footprint by eliminating travel whenever possible, focusing on Green energy, and maximizing sustainability in my lifestyle choices.

That's what keeping me up at night this year.   The great joy about life is that I never know what next year will bring!


TWM said...

Where does Disaster Preparedness fit into your nightly musings?

John Halamka said...

Disaster Recovery with specific Recovery Time and Recovery Point objectives has been one of my significant focus over the past 5 years. BIDMC spent $12 million to ensure all data and applications are replicated in geographically separated data centers. HMS has two data centers, a two geographically separated network cores, and offsite backup. In 2005, I would have listed this as my #1 keep me awake at night issue, but it has been mitigated.

Miguel Vilaplana said...

a) Cool answer about Disaster Preparedness... hope many other institutions could say the same (thumb rule but I guess hardly 20- 25% of other institutions in the US could say the same... it means that 75 -80% of the CIOs elsewhere will have it as #1 problem... hopefully!, because it means that at least they realized about it!)

b) I bet that one of the major challenges will be not in a federal or state level, but at Harvard level while just insinuating your approach. I have found very difficult to understand the balance between distributed management in other big institutions (like Hopkins). Ironically, today I called to BU to know if we had BioIT class tonight, their answer was negative, but they connected me with MET College to confirm it. In other institutions, you have to call yourself again instead of being connected.

c) Another great point: ICD 10... it is a major movement that many institutions have not approached yet and are opening new settings/ practices, launching IT systems etc... without even have checked their compatibility between current ICD9 and near future ICD10 (let alone the economic consequences it will have at the reimbursement level)

d) I wish you could work out “one stop shop” and moreover if it is actually affordable (it is if you make big numbers, but then, you have politics and other considerations)

Good Thanksgiving to you and everybody else reading the blog.