Tuesday, February 25, 2020

What is the Architecture of a Modern Platform?

Platform businesses require technology that promotes interoperability and scalability.  For those who live in platform companies day-to-day, my thinking below may sound obvious, but for those who are thinking about a cloud journey, the list of technologies below may be helpful.

Storage and compute functionality in the cloud enables agility via "infrastructure as code" products such as Terraform.    Terraform enables virtual server spin up on demand within applications to provision and manage any cloud, infrastructure, or service.   Each cloud provider has strengths.    Customers like Google Cloud Platform because of BigQuery, which scales infinitely.  Customers like Amazon because of the tools like Comprehend Medical and Sagemaker.   Customers like Azure because of its integration with existing Microsoft components. 

Similarly, database functionality such as MySQL or PostgreSQL can be rapidly deployed using a front end service such as Google's SQL Cloud that makes it easy to set up, maintain, manage, and administer relational databases on Google Cloud Platform.

Kubernetes is an open-source container-orchestration system for automating application deployment, scaling, and management. It was originally designed by Google, and is now maintained by the Cloud Native Computing Foundation. 

For healthcare applications, it's clear that Fast Healthcare Interoperability Resources (FHIR) interfaces for inbound and outbound data exchange are the right approach to application/EHR integration.    Highly scalable FHIR services are available via HAPI FHIR on Smile CDR . Google Health's FHIR endpoint is also a good choice.

FHIR is best for exchanging summary data, as well as making EHR data available to an application more broadly.   For HL7 version 2, the Google Healthcare API supports a Minimal Lower Layer Protocol  (MLLP) entry point and a message repository (along with cloud publication/subscription notifications).

And of course, modern network security requires data be stored in encrypted form as well as in transit in encrypted form.  This simple idea will mitigate numerous security risks.

I recently met with well respected industry leaders and asked how Mayo Clinic can future proof its Platform  efforts.    I was told

"Ensure that infrastructure as code is used to deploy storage and compute.   Ensure relational databases can be deployed and managed on the cloud hosting platform.   Use Kubernetes to automate application deployment.  Embrace hosted FHIR and API management services."

As we evaluate new partnerships and collaborations, we do a technical deep dive to avoid locally hosted, siloed, and proprietary approaches, instead favoring a cloud native architecture using Terraform, Kubernetes, and FHIR.

As Wayne Gretzky taught us, you need to skate where the puck will be.    These cloud native architectures are clearly where the puck is going.

Friday, February 14, 2020

The Future of Elder Care

Last weekend I moderated an amazing group of presenters for Harvard Business School's 17th Annual Healthcare Conference, debating the future of elder care throughout the world.

Discussants were

Geoff Price - Oak Street Health, Chief Operating Officer

Susan Diamond - Humana, President of Home Solutions

Neil Wagle - Devoted Health, Chief Medical Officer

 We started with a statement of the problem - in many countries such as Japan, the Nordics, Germany, Italy, and the United States, societies are rapidly aging.   Birth rates are declining.    Costs are rising and access to clinicians is becoming more challenging

 We delved into several major themes - the role of home care, the rise of digital health, and the evolution of financial models that incentivize wellness over sickness.

Mayo Clinic is building home hospital capabilities and, later this year, will evaluate these efforts in two sites.    Through this early work, we'll learn about the supply chain, telemetry, command center capabilities, staffing, and the characteristics of patients best suited to home hospital care. 

 All of the panel members agreed that the future belongs to delivering high quality care in the right setting at the right cost.   Medicare Advantage reimbursement models, accountable care organizations, and alternative quality contracts all focus on reducing total medical expense while sustaining quality/safety/patient satisfaction.     If home hospital care reduces cost while improving outcomes, I believe that refined reimbursement models for home care will emerge.

Delivering digital capabilities - telemetry, communication, and care orchestration to elders requires a comprehensive technology strategy.   Many homes do not have fast, reliable wifi.    LTE and 5G cellular networks will be increasingly strategic for home care.     It's likely that a technology services partner will be needed to keep home-based devices configured, secure and stable. 

Just gathering the telemetry as part of elder home care is not enough.   Algorithms and analytics are needed to turn raw data into action, filtering signal from noise.   It's not yet entirely clear how to understand the precision/accuracy of remote monitoring, how to interpret individual variation, and when to ignore false positive signals.

Mayo Clinic is also launching a remote diagnostics and monitoring capability over the next year, via a platform approach that connects telemetry to novel machine learning algorithms, supporting patient wellness.

We also discussed the digital divide.    As we create more digital interventions to the home, we must meet patients at their level of technology comfort, literacy, and affordability.    We'll need organizations that can help patients access care, optimize the use of devices in their home, and encourage follow through with care plans.   

The future of platform components to enhance elder care is bright and an ecosystem of supportive businesses will be needed.  I look forward to being part of that journey.

Tuesday, February 4, 2020

Innovation at Work

Over the past 40 years I've worked in a variety of workplace settings, each appropriately serving its intended purpose. I did not appreciate how much a workspace influences my productivity and mood until I starting working at Mayo. My new role focuses on convening stakeholders and facilitating discussion.     A supportive workspace is transformational.

In my mid-teens, I worked in shared office space at TRW (a predecessor company to Raytheon) with large metal desks, filing cabinets and fluorescent tube lighting

In my late teens, I founded a company in a basement and worked at a drafting table next to a bed

In my 20's, while running the growing company and completing my medical education, I worked in a glass walled private office so I could watch the flow of daily activity.

 In my 30's, 40's, and 50's as a CIO, clinician and professor,  I worked in a cube but spent much of my time with customers in other people's offices.

For the past 2 years, I've worked in an open space ad hoc desk/meeting room arrangement that was efficient, attractive, and highly functional. 

Now, as I approach 60 at Mayo Clinic, I work in the most innovative and collaborative space of my career, the recently remodeled Mayo 11 administrative floor. No one on the Mayo senior team has an office - not the CEO, COO, CFO nor Presidents. Everyone uses open plan hoteling desks. The desks are surrounded by huddle rooms and meeting spaces that can be reserved via touch screen or calendar invite. Everyone sees each other every day for hallway conversations. I can ask the CEO any question, any time, by just walking through the space. There's a common kitchen area with meeting tables and healthy food offerings

The furnishings are simple - a kind of Zen functional elegance. Reminders about Mayo's vision, mission and values adorn the walls. The lighting is all 5000K LED daylight.  See photos below.

While rigorous days are common,  the time never feels long because of the richness of human interaction that takes place in the Mayo 11 space.

Per my previous post, my apartment is a 6 minute walk from my bedroom to the Mayo 11 office. I've shaped my new life routine around these living and work spaces for maximal focus and impact. I leave the apartment at 6am, walk 2 minutes to the skyway, which is a heated walking corridor connecting buildings in downtown Rochester. I arrive in the office by 6:10am, have breakfast, write goals for the day in my journal then review the day's presentation materials and agendas. Every 30 minutes from 7am to noon, it's easy to move among meeting rooms, some on Mayo 11 and some in surrounding buildings. A shuttle that runs every 5 minutes takes me to nearby St. Mary's Hospital where I spend time with my clinical and laboratory colleagues. By noon I return to Mayo 11 for lunch and a catchup with my colleagues. Meetings and presentations continue from 12:30pm until evening. The walk back to my apartment passes by a great market, an all vegan restaurant, craft breweries, and a boutique wine store. Dinner is usually a simple bowl of rice, beans and vegetables.  I spend the late evening writing plans and reading the briefing materials prepared by the Mayo Platform team, partners, and collaborators. 

From 7pm on Sunday night until 7pm Thursday night, I'm in Minnesota, living this very productive and satisfying pattern. I return to Unity Farm Sanctuary in Massachusetts by midnight on Thursday. Friday is a mixture of calls, video chats, and writing in my farm office.

On Saturday, I work with the animals and do complicated/time consuming farm tasks from 6am until late evening, completing a task list that my wife writes in a notebook awaiting my return. On Sunday, the morning is filled with less complicated work, leaving me relaxed for my afternoon flight back to Minnesota.

Well engineered, highly ergonomic workspaces make this level of commitment possible in Minnesota and Massachusetts. In 2019 I flew 400,000 miles to 40 countries, while also spending 3 hours a day driving around Boston in traffic. Comparatively, my 5 hour commute to Mayo on Sunday and Thursday is a respite.   

I'm a fan of a life that is constantly self-examined. At this point, I could not ask for a better workplace ecosystem that encourages accomplishment and engagement by design. 

Innovation at Home

This is the first of a two part series that describes where I live and where I work at Mayo Clinic.   

To me, life and work are inseparably intertwined.    You cannot have a productive work life if your home life is unstable.    You cannot have a balanced home life if your work life is unstable.    When I decided to work at Mayo, my wife and I agreed that we would live in Massachusetts running Unity Farm Sanctuary but I would work in Rochester/Jacksonville/Scottsdale Sunday night through Thursday night. 

Over the past month, I've organized a life in Minnesota, maximizing my well-being and efficiency.     I rented a 600 square foot apartment that is a 2 minute walk from Mayo Clinic.   I've moved those things from the farm that make the space uniquely mine - my morris chair, my desk, woodblock prints, green tea supplies, and a simple antique bed. 

Outside the window I can see the Mayo building and the Plummer building.   I'm near a great vegan restaurant and the local food coop.   I have a small stacked washer/dryer in the apartment.    Home Depot is 8 minutes away.   I purchased a used Subaru for airport commuting.

All of this means that I can arrive each Sunday night and drive myself from Minneapolis to Rochester.   Once in my apartment, I can create a simple dinner, write in my journal and prepare for the week ahead.   My bedroom is 10x10 - a perfect place to retreat and rest. 

Monday-Thursday I walk to work (and my workspace is the subject of the next blog) in the morning, spend the day with remarkable colleagues, then walk back to my apartment at night, stopping at the food coop to pick up fresh vegetables for dinner.

Thursday night I drive back to Minneapolis and fly to Boston, getting home about midnight. 

Just as with Unity Farm Sanctuary, I've turned my Minnesota apartment into an internet of things demonstration site.   I have a 100 megabit fiber connection to a Google mesh network.   I replaced the apartment thermostat with a Nest device that I can control remotely, keeping the apartment at 60F when I'm gone but adjusting it to 65F when I'm in town.  I've added smart plugs so that my morning routine turns on lights/music automatically while my evening routine prepares the space for sleep.   The locks are RFID controlled. 

The end result is that I have a stress free, highly functional environment around me when I'm not at the office.    I can cook, clean my clothes, write at my desk, review strategic plans in my chair, and sleep comfortably, all within the 600 square foot layout.    Pictures are attached below.   My many years collaborating with Japan have taught me well and my home space at Mayo is simple, spiritual, and supportive.