Wednesday, September 30, 2015

Confidence versus Competence

Sometimes an article inspires and resonates with me.    Such was the case two weeks ago when I read about an alternative to the Peter Principle, that suggests you are promoted  to your level of misery, not your level of incompetence.

However, incompetence still exists.   We’re reminded in the press on a daily basis that we have presidential candidates who are absurdly unqualified.  

This week, I read an article in the Harvard Business Review that asks us to separate confidence and competence when evaluating people.  

Donald Trump is confident (a legend in his own mind) but is he competent?   Carly Fiorina is certainly confident, but did her track record at Lucent and HP illustrate leadership competence?

I’ve hired hundreds of people in my life and my track record has been generally good.

The few mistakes I’ve made, which resulted in voluntary or involuntary separation from the company, have occurred because I was blinded by self-confidence.

In a one hour interview, a person who uses all the correct jargon, is assertive, and is forceful about their opinions can appear competent.   Of course, confidence does not imply an ability to lead a consensus discussion, build bridges among stakeholders, or adapt to changing technology.

When I promote from within, it’s easy to evaluate competence because there is a known, objectively observed track record.

When I hire new leaders from outside of healthcare  - and it is important to hire innovators with a different perspective - there needs to be an objective screen for competence.  

You’d think that references could be such a screen, but all of my  “bad hires” have had glowing references.  Of course, these references were not from people I know.  It makes me wonder if the applicants pre-arranged “reference” calls from their relatives/friends or if the previous employers could not give a compete reference because of legal/separation agreements.

Epic does something novel - it gives prospective employees a written exam that assesses logical thinking and problem solving, not healthcare domain knowledge.

BIDMC has used personality classification instruments to predict cultural fit but has not used any other specific competence tests.

In academic medicine, we sometimes hire leaders for the wrong reason - success with grant applications, a stellar publication record, or amazing teaching skills.  These may not imply anything about management competence.

The Harvard Business Review article and personal experience opened my eyes to the need for objective criteria for competence.   Epic has the right idea with their competence test.  About the only substitute for such a test would be a reference from someone you know and trust.   My fellow CIOs are always candid about strengths and weaknesses of our colleagues.

I described the competence/confidence dilemma to a fellow leader earlier this week.  They’ve told their children to rely on confidence to get them through a situation for which they lack competence.    Good advice for prospective employees, but probably not for prospective employers!   Food for thought.

Thursday, September 24, 2015

Unity Farm Journal - Fourth Week of September 2015

The temperatures are in the 40’s at night, the pastures are covered with dew, and the pumpkins are ready for harvesting.    Fall arrived this week at the Farm.   Here's the front door of the farmhouse today.

The forest creatures know that winter is coming - our raptor activity is at an all time high with red tail hawks, cooper’s hawks, and owls circulating the barnyard.   The poultry spends their day in the forest, under their Caravan canopy, or tucked under shrubs.   One pheasant was eaten (we found her remains) but the ducks, geese, guineas, and chickens are all healthy.

At night, the barred owls are calling.   Our Great Pyrenees hear them in the woods and bark to keep them away from the barnyard.    The call of the barred owl is very distinctive , it sounds something like “WHO barks for you”

The Shitake mushroom logs are fruiting with the onset of cold, moist nights,   Here’s what 50 pounds of fresh gathered Shitakes looks like.

All the pumpkins, squash, eggplant, tomatoes, and peppers have been harvested.   The lettuces and root vegetables are timed for weekly winter harvests.

The tree house has been working out well, but it’s challenging to carry honey lager up the ladder, so I built a hoist on a nearby tree.  I’m working on a plan to add walls, a roof and a small cast iron wood burning stove to the tree house.   It will require an insulated stovepipe and protections against fire.   Burning wood in a tree house does sound a bit odd, but watching the snow fall while warm inside the tree house will be magical.    For the moment I'm using my tree house desk for writing.

This weekend I’m engineering a 300 foot zip line from the tree house to the farm house, aiming for an 8% grade and taking into account 2% sag of the 5/16 aircraft cable due to the weight of the rider.   There are many unknowns (i.e. I do not know what I’m doing).   I’ll safety test it with a simulated human (logs) before I climb aboard wearing full protective climbing gear and a helmet.   Wish me luck.

Cider pressing begins this weekend and we'll be fermenting McIntosh, Macoun, Gala, and Northern Spy.    The work of summer is waning and now the joys of the harvest are upon us.

Tuesday, September 22, 2015

The September 2015 HIT Standards Committee

The September 2015 HIT Standards Committee was notable for the naming of new members and for the incorporation of the NwHIN Power Team (Dixie Baker) Standards Maturity model in all of ONC’s planning.

Ten members of the committee reached their term limit in June.   New confirmed members announced today are

Jitin Asnaani, Technical Expertise – Information Exchange
Josh Mandel, Provider Representative
Rich Elmore , Technical Vendor Representative
Angela Kennedy, Consumer/Patient Representative
Patty Sengstack, Provider Representative

Three more will be announced this Fall and the final two will be named in early 2016.

Jon White and Leslie Kelly Hall presented the Precision Medicine Task Force Recommendations

As you can see in the presentation, they divided up the required standards into green, yellow, red - ready for use, promising for use, and more work to be done.    The committee offered a few recommendations i.e. move genomics standards from green to yellow, move consent standards from red to yellow, and clarify the interoperability standards advisory examples.  The committee adopted the recommendations as revised.    As mentioned above, the entire classification effort was guided by the Standards Maturity Model published in JAMIA 

Next we heard from Steve Posnack , who presented the rubric/framework for sub regulatory standards guidance i.e. what standards are appropriate for what use case and what is their level of maturity?   Specific scores (bubbles) are given to the adoption of every standard, making it very easy for developers to identify the right standard (or promising standard) to incorporate into their products.

Our October 6 meeting will be a joint meeting of the HIT Policy Committee and Standards Committee.   I imagine we’ll discuss the recently released Federal Health IT Strategic Plan 2015-2020  .  Still no word on the timing of Meaningful Use Stage 2 revisions and Meaningful Use Stage 3.

Friday, September 18, 2015

Unity Farm Journal - Third Week of September 2015

The tree house is done and is engineered to hold 20 visitors plus a good supply of cider.  I’ve suggested to my daughter that she gets married in the treehouse, but she thinks I’m out of my mind.

Many folks have asked - why a treehouse?

First answer - it can serve an outdoor workspace  on those wonderful days in the Spring and Fall when the air is dry and the temperature is in the high 60’s.   I made a desk and chair from the scrap wood left over from the tree house joists.    Below I'm sitting in my desk and chair looking out at the forest canopy - about a 50 foot drop down the hillside to the farm below.  

Second - every summer thousands of fireflies begin their nightly flights from the grasses in the swale below the treehouse.    We’ll be able to sit above them and watch them rise.  Deer, foxes, coyotes, raccoons and turkeys frequent the area and we’ll have a unique perspective on them from the forest canopy.

Third - the treehouse becomes the focal point of our upper forest.  It’s at the highest point in our land, at the center of the western half of the property.    It’s brought new visibility and utility to the dense forest.   I can imagine constructing other elements in the canopy - bridges/walkways, observation platforms and a zip line transportation system.    Now that I understand treehouse engineering the possibilities are limitless.

Our apples are nearing harvest and to check on their readiness, we use a refractometer on each type.    Ideally we’ll harvest at about 15 brix (percent sugar), but we also taste each variety because the perfect apple is a combination of the right acidity and the right sweetness.   Here are the current measurements

Empire - tart, 12 brix
Braestar - very tart, 10 brix
Northern Spy - well balanced, 14 brix
Ben Davis - very tart, 10 brix
Pink Early - very tart, 11 brix
Macoun - well balanced, 13.5 brix
Red Delicious - very tart, 10 brix
MacIntosh - tart, 12 brix
Roxbury Russet - tart, 12 brix
Rome Beauty - tart, 11 brix
Cortland - slightly tart, 13 brix

Next weekend, we’ll harvest Northern Spy and Macoun.    The following weekend, we’ll crush our first batch of 2015 cider.

The pheasants, although wild, continue to visit us every day.   They’ve learned to recognize our voices and come when called for their afternoon mealworms.

We’ve had very few Summer loses of poultry due to fox/coyote/hawk/fisher cat/raccoon predation and heading into Fall our poultry count is

Guinea 55
Chickens -  29 total with 4 roosters
Pheasants 6
Ducks 6
Geese 4

We’ve kept the guinea population stable by emptying their nests every weekend.   This year, we’ve lost 4 ducks through predation and disease.    Luckily we’ve not lost a single chicken or goose.

Our winter preparations continue. We’ve walked the property looking for trees with dead branches and preemptively cut them down.   We’ve chipped the branches into mulch and spread the chips on our 1.5 miles of trails.  

Our Umass Organic Vegetable Production course is going well.    Every Sunday is filled with reading and homework.   By the end of the semester I hope to have solved our issues with cucumber and squash beetles using an organic approach.

The weather is finally cooling and nights are dipping into the 40’s.   This weekend, I'll clear out the last of tomatoes, peppers, and eggplant from the hoophouse and plant Fall lettuce.    We’ve enjoyed the bounty of Summer and look forward to the leafy greens and root vegetables of Fall, followed by a winter that will give us a chance to catch up on all the indoor maintenance tasks.

Thursday, September 17, 2015

The Changing Role of the CIO

Over my 8 years of blogging (since 10/21/07) I've written many posts about IT leadership, career development and re-inventing yourself (something to do every 5-10) years.    As a CIO for nearly 20 years, I've seen the nature of the role undergo remarkable evolution.

In the early days of my CIO career, it was really important to be a technologist.  Networks were unstable, servers were unreliable, desktops were difficult to manage, most vendors did not have enterprise-grade products, and it was often challenging to make infrastructure buying decisions.

As products became more reliable, attention turned to functionality.   It was really important to be an informatics expert to translate business owner workflow into application automation.

As data became more digital and larger attack surfaces appeared, hackers found healthcare more attractive and it became really important to understand security technology/policy.

Once security was improved, interoperability because the major focus (and that is where we are today), since care coordination and reducing total medical expense requires population health, community-wide data sharing, and alerts/reminders between organizations.

As I¹ve written about, interoperability is improving and with the new standards, enabling infrastructure, and refinements in policy, we¹re headed toward a good place.

What will be the next great challenge for CIOs?   Governance, priority setting, and managing a portfolio of services, many of which will be procured, not provisioned.

What do I mean?

Let me start with a story.   I live at Unity Farm in Sherborn, MA. Nearby is a 'feed and seed' supply store.   Over the weekend I bought grain for the poultry and behind the counter, the saleswoman showed me the new retail management system she built for the store in one afternoon using off the shelf components from Apple, Square, and Amazon.    She has comprehensive inventory control, full credit card processing, management information reports, supply chain controls, and security protections, all created for under $1000.    Upgrades and new features are just a click away on the app store.

This is the new expectation in a world of IT consumerization.    Long gone are proprietary systems from NCR and IBM.  Long gone is the expensive maintenance contract, the need to call for service, and weeks long implementation.

Such experiences in our every day lives with  products that leverage mobile, cloud, and social networking technologies suggest to us that healthcare IT organizations should deliver with the same agility, efficiency, and low cost.

How long does it take to build 30 servers, install all security controls, implement disaster recovery, add applications, and go live with licensed software - 6 months?  a year?

How long does it take spin up 30 servers fully configured with an application on Amazon Web Services?   About an hour with zero capital investment.

The new expectations of customers will require CIOs to procure services such as hosting, storage, and application services rather than provision them locally.   Upgrades will be continuous and instantly available for all customers of such services.    Budgets will shift from capital projects to subscription operating expenses.

CIOs need to convene multi-stakeholder steering groups, agree on a finite list of important projects, and get buy in for the time/resources/scope necessary to deliver those projects.    New regulatory/compliance requirements need to be 'owned' by the steering groups so that any external factor causing project delays is not considered an IT failure.

I've said before that in 5 years, the IT department will be replaced with the 'Cloud Services' department and the CIO will be the air traffic controller to identify and coordinate the services procured.

Today in my IT Town meeting, I outlined a vision for the future that includes new IT governance/steering/workgroups, new strategic planning and communication tools, and enhanced air traffic control.   I promoted my second in command, Manu Tandon, to be the full time CIO at BIDMC Medical Center, enabling me to serve as the CIO of the BIDMC System, which I've been doing part time.

The work ahead will be exciting and different.   In just one organization, I've experienced a journey as engineer, informatician, security officer, interoperability expert, and now air traffic controller/cloud broker, ensuring that we have all the planning processes in place to be successful in every part of the BIDMC empire.

Manu will bring new focus to BIDMC¹s governance, priority setting and portfolio management. There will be many blog posts to come about his efforts at the academic medical center and my efforts in the heterogenous system of care that includes community hospitals, primary care practices and urgent care clinics.   The adventure awaits.

Thursday, September 10, 2015

Unity Farm Journal Second Week of September 2015

The work on the tree house continues.  The Labor Day weekend provided plenty of time for me to labor (in 90+ degree heat)

First, I built a small model  of the tree house platform using lightweight 2x2 pine and placed it on the tree 10 feet up to serve as a template for drilling the permanent supports.

I rented a 2000W generator and a high torque right angle drill.    Using a self feeding 3 inch bit at the east and west edges of the tree 10 feet high, I drilled 2 inches into the cambium (past the bark).   I then used a 1 1/8 bit to drill a 6.25 inch hole past the 3 inch hole.    I used a rather large 1 7/8 socket wrench three feet long (pictured below) to screw in the 9 inch long treehouse attachment bolts, ensuring they were perfectly level and square to the template.

Then, with the help of two friends, we lag bolted four 2x8x12 pressure treated timbers to the treehouse attachment bolts.

We bought 1000 pounds of lumber at Home Depot and built the treehouse in the driveway of the farm.    We numbered each piece and then took it apart can carried the 52 individual 12 foot boards half a mile into the forest.

Here’s a view of the truck at Home Depot, the platform in the driveway, and the joists mounted in the tree.

This weekend we’ll add the knee braces (four 10 foot 4x6’s), supporting the edges of the platform, add the decking, and install a 12 foot staircase to the treehouse.   Hopefully by the end of the weekend, I’ll be able to work on IT strategic plans from the forest canopy.

Last weekend we released our 7 pheasants and they have adapted well to the forest.   The male and 6 females seem to constitute a loosely knit harem that spends the days in the shade of ferns then arrives back to the barnyard at 5pm for a few mealworm snacks.   They are so timely about their 5pm farm visits that we assume they must have Apple watches underneath all those feathers.

We’ve had an immense amount of hawk activity in the barnyard (red tail and cooper’s hawks), so we’ve put a Caravan canopy in the chicken dust bath area to protect them from predation.  The dogs and guineas have done a good job warning the chickens, ducks, and geese of the incoming raptor flights, so thus far all is well.

We’ll continue with apple picking this weekend - the Northern Spies, Galas, Macs, and Red Delicious are ready.   The Empires will wait until October.     Soon we’ll be crushing cider and our fermenters will be bubbling with the 2015 vintage!

Wednesday, September 9, 2015

The New Peter Principle

I grew up in the Southern California town of Palos Verdes Estates, where a nearby neighbor, Laurence J. Peter became famous  by stating "In a hierarchy every employee tends to rise to his level of incompetence ... in time every post tends to be occupied by an employee who is incompetent to carry out its duties ... Work is accomplished by those employees who have not yet reached their level of incompetence."

Dr. Peter served on the faculty of the Marshall School of Business at the University of Southern California, where my mother also served as faculty.

You could say I had one degree of separation from Dr. Peter.

Over the weekend, a brilliant article in the New York Times suggested that there is a new Peter Principle - you are promoted to your level of misery.

For example,

Folks who are brilliant teachers become department chairpeople.

Accomplished researchers become Deans

Intensively creative engineers become management executives.

And many start drinking heavily to overcome the angst of their new roles.

My wife has watched my progression from software developer to entrepreneur to doctor to administrator and knows that I must always keep an outlet for my engineering creativity.   Generally innovation is always possible in the hospital setting, but during periods of intense regulatory burden that co-opts the innovation agenda, my creativity is expressed during my night and weekend work at Unity Farm.

Thinking about the New York Times article, I’ve put together a top 10 guide for IT leaders to avoid the decline into misery at work while keeping their livers intact.

1.   Review every meeting on your calendar and assess its value - can meetings be eliminated, consolidated, or reduced in frequency?   No one ever died and had a tombstone that reads “my only regret is missing meetings”.   Fewer meetings means more time for creativity.

2.   Build thinking time into your calendar.   One executive recently told me - “I’m giving up my laptop, because as a leader I never create anything, I just review other people’s work.”   A day of reviewing endless email with no time for personal authorship stifles creativity.

3.  Wait out the naysayers/evil people.   You can choose to engage in political battles or just ignore them.   Most naysayers will eventually implode or leave.   Put your energy into creative doing rather than being consumed by arguments you cannot win.

4.  Change management often depends on external events.  As Rahm Emmanuel said, “You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before.”   Propose creative solutions when the urgency for change is clear.

5.   Delegate conflict management among many people, reducing the creative drain  for all.   However, you should be willing to invest 10% of your time to  confrontation, reducing the future burden created by bad planning, so that 90% can be freed up for innovation.

6.   If there is a vacuum of leadership in the hierarchy of your organization, do not be overwhelmed by it, work around it to implement your creative ideas.

7.   You cannot solve every problem simultaneously and sometimes you need to let sleeping dogs lie.    It is far better to have a few creative wins in the short term and accept that some longstanding problems will be solved incrementally over time.

8.   Accept that there are some things you cannot change and if there is misalignment of authority and accountability, focus instead on things you can creatively improve.

9.   Know when you are the rating limiting step to creativity.    Many years ago, I showed an early microprocessor to a “tube era” technology leader.   The person told me “I do not understand the technology and I never want to discuss it again.”    I’m a web developer but not an app developer.    I keep myself useful by enabling creative app developers to do work that is beyond my expertise.

10.  Re-invent yourself.    Even though I have been a CIO since 1997, my job has morphed every 3 years - I have been an infrastructure expert, a security expert, a cloud expert, a mobile expert, and an interoperability expert.    As the goals change, the work changes, ensuring that I’m never complacent, always solving new problems creatively.

As the summer ends and the post Labor Day chaos returns, I encourage everyone to reduce misery whenever possible.   And the drinking will get better, I promise.

Thursday, September 3, 2015

Unity Farm Journal - First Week of September 2015

It’s hard to believe that September is already here.  Apple picking has started and cider pressing begins soon.    Our Asian pears are sweet, our Bosc pears are beginning to soften and the last of the berries have been picked.

I was recently asked for the percentage breakdown of apple types in our Unity Farm hard ciders.  Here are the proportions of apples by weight

Sweet cider (refreshing but slightly sweet)
21% Honey Crisp
56% McIntosh
15% Macoun
8% Crab

Dry cider (crisp, well balanced)
23% Golden Delicious
40% Baldwin
13% McIntosh
13% Macoun
10% Crab

“Apple wine” cider (tastes like Sauvignon Blanc)
49% Winesap
32% Baldwin
19% crab

As I mentioned last week, I’m continuing to explore the possibilities for Unity Farm’s unique ecosystem which spans from upland dry oak forest to low land marsh.    Near the marsh there are stands of young willow trees that are quite flexible.    Last weekend, I wove together willow trees creating a building 12 feet long and 6 feet wide, then added a floor and a stone entry way.    I’ve designated this the “Hobbit House”.   On Sunday afternoon, I retreated to the Hobbit House to work on FY16 IT strategic plans.   Hobbits do not have wifi, social media, or instant messaging, so my hours surrounded  only by the wind in the willows were very productive.

Over the long Labor Day weekend, we’ll release the pheasants into the wild and watch their transition to the Unity Farm forests, eager to see if they will return to the barnyard for their favorite meal worm treats.

You never know what will happen on the farm.    Kathy was driving by a local farmstead and found an abandoned Toulouse goose.   The farmstand owner explained the people sometimes abandon unwanted poultry at the farmstand during the night.    Since we have geese, Kathy asked if we could bring the goose to Unity Farm, adding to our gaggle.   Based on the goose’s high pitched call, we believe he’s a male.   Since our other Toulouse goose is named Hercules, we named this new goose, Iolaus, since he’ll be Hercules’ sidekick.   Our farm Transit Connect van is ready to transport any animal anytime and here’s what a goose transport looks like.    Iolaus and Hercules are now watching over the farm along with their traveling companions, two Buff Geese named Xena and Gabrielle.

As labor day weekend approaches, the shadows are beginning to grow longer, the mist is gathering the meadow and night is falling earlier.   We look forward to the changing of the seasons, with crisp mornings and cool afternoons.  

This weekend will including gathering all the lumber needed for the treehouse platform I’m building, which includes

 14 2x8x12,
 2 2x8x8,
 27 5/4x6x12,
 4 4x6x10

All the hardware arrives on Thursday, so if I’m industrious, I’ll have the tree house to work in by Labor Day.   Then again, if I discover while building it that my carpentry skills need a little mentoring, I’ll finish it with the help of a  contractor friend by the end of the month.

Winter is coming...

Wednesday, September 2, 2015

Solving the Provider Directory Problem for the Country

In many previous posts, I’ve written about the importance of enabling infrastructure to accelerate interoperability.   The standards are not the rate limiting step, but the lack of a provider directory, patient identifier, and consent registry are.

David McCallie of Cerner has solved the provider directory problem of the country.

He downloaded the NPPES national provider database.

He created a FHIR-based Application Program Interface to the database by writing 300 lines of Python code and put it live on Amazon Web Services (for $15/month)

You can try it yourself here:

Just look up last name Halamka (or any other physician know)

Some important caveats:

It’s based on loading the imperfect and often out-of-date CMS national provider database. database.

The national provider database does not contain Direct addresses, so to run it as a real national service, Health Information Services Providers (HISPs) would need to submit a comma separated value (CSV) file of Direct Addresses and National Provider Identifiers at reasonable intervals.

Each night, the database could be re-loaded  using the then-current CSV files.  That would easily allow a HISP to remove or correct names, or even drop out (submit an empty CSV.)

As I wrote about in my recent post, Trajectory not Position, we all need to be doers.

The Provider Directory for the country issue has been solved, we just need to get HISPs involved in updating it.

I look forward to including the David McCallie Provider Directory FHIR implementation in upcoming national standards recommendations.