Tuesday, January 31, 2012

Radiology Image Exchange

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!

Monday, January 30, 2012

Update on the BIDMC ICD10 Project

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.

Friday, January 27, 2012

Cool Technology of the Week

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!

Thursday, January 26, 2012

Our Cancer Journey - Week 6

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.

Wednesday, January 25, 2012

The January HIT Standards Committee Meeting

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.

Tuesday, January 24, 2012

Preparing for a Wall of Shame

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!

Monday, January 23, 2012

Another Shade of Blue Button

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.

Friday, January 20, 2012

Cool Technology of the Week

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!

Thursday, January 19, 2012

Our Cancer Journey - Week 5

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
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.

Wednesday, January 18, 2012

Only Handle It Once (OHIO)

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.

Tuesday, January 17, 2012

The Role of the CMIO

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 four kinds of roles:

CIO - Responsible for strategy, structure, staffing, and processes for a 300 person IT organization with 83  hospital, ambulatory, and emergency/urgent care locations
CTO - Responsible for the architecture and operations of our applications and infrastructure, ensuring reliability, scalability, and affordability
CMIO - Responsible for the adoption of the applications by clinicians, optimizing quality, safety, and efficiency in their workflows
CISO - Responsible for the security and data integrity of all applications and infrastructure, supporting regulatory compliance and maintaining privacy

Although I've been able to balance these 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.

Friday, January 13, 2012

Cool Technology of the Week

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.

Thursday, January 12, 2012

Our Cancer Journey - Week 4

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.

Wednesday, January 11, 2012

Servant Leadership

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.

Tuesday, January 10, 2012

Work Induced Attention Deficit Disorder

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.

Monday, January 9, 2012


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.

Friday, January 6, 2012

Cool Technology of the Week

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
*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.

Thursday, January 5, 2012

Our Cancer Journey - Week 3

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.

Wednesday, January 4, 2012

Honey or Vinegar?

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.

Tuesday, January 3, 2012

Thoughts on the Year Ahead

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:


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).


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.


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.