Over the past few weeks, the number of new infrastructure project requests has peaked to unprecedented levels. The usual triage mechanisms described in my previous blog entry work well for applications, but infrastructure is different. Adding a new network port, a new telephone, or a new desktop is viewed a service business that can be ordered on demand, making it very challenging to say 'no'.
The sudden surge in requests re-emphasized to me the basic law of all IT projects - timeline, scope and resources are inter-related. If scope increases, timeline or resources must increase. If timeline is shortened, scope must be decreased or resources increased. Increasing scope, shortening timeline while leaving resources constant is not possible.
Of course, we can all work harder. There are 168 hours in a week, vacations can be postponed and nights/weekends filled. This works in the short term, but is not sustainable. "Lean" and "mean" organizations pushed too hard become "bony" and "angry" organizations.
New FTEs are not typically the short term answer. Getting new positions raises expectations of delivery capacity but hiring and training new staff take resources from existing capacity, so paradoxically getting new positions actually reduces capacity for a few months.
This means there is only one short term answer for unplanned, unbudgeted, unscheduled infrastructure requests - the scope of these requests needs to be reduced/phased or the time to do them increased.
For my requests this week, I've done the following
a. Assigned my staff to develop a standard worksheet which outlines the major time limiting steps (i.e. network connections take 90 days to provision) and thus specifies the minimum lead time for building IS support for a new location
b. Negotiated a change in scope with phasing - the initial request for a high bandwidth connection and new telephone system was morphed into a low bandwidth connection and use of the existing telephone system for now.
c. Reordered priorities - previous request were placed on hold in order to service the new 'once in a lifetime' opportunities
d. Asked for new staff - with the caveat that they will not add to capacity/throughput for 6 months
e. Requested governance changes - to ensure a central committee triages and communicates infrastructure requests for new offsite locations
There is one other strategy that I could employ if this surge in requests becomes chronic. In the past, I've staffed to average work load, not peak workload. This means that staff can put in extra hours for short term urgent increases in demand. However, I may have to staff to peak so that excess capacity is always available for the continuous infrastructure tyranny of the urgent I'm a frugal guy, doing a great deal on a limited budget , so I've never built in excess capacity.
As I work through these issues, I'll keep you updated on my progress.
Tuesday, December 4, 2007
Monday, December 3, 2007
It's time to take back the internet
Today, I've received over 250 unsolicited email advertisements for IT related products, services and seminars. This is not the usual egregious SPAM (Viagra ads, Nigerian businessmen, or phoney eBay phishing emails) which are already filtered out (see my previous post). These are legitimate emails that I do not want to receive from real companies. At the bottom of these emails are the words "This is not SPAM because you have opted in to receive these emails from us or our partners". I have never opted in to receive any such emails from anyone.
My email address appears in the masthead of many of the columns I write for print and web-based media. This has led to my inclusion in just about every IT mailing list on the internet.
I've tried opting out. Removing myself from 250 mailing lists each day can take an hour, so that's clearly not a sustainable part of my schedule. Also, some unsubscribe links just do not work. What are our options?
Short term, I advocate that CIOs start blacklisting the email domains that pummel us with unsolicited IT advertising. I'm a kind and gentle soul, so I'm willing to give companies a chance to redeem themselves. This month, I'm responding to these companies with a polite request to never send me emails again. If they continue to fill my inbox, I will blacklist their domain on my local email servers, preventing delivery of their advertising throughout my enterprise.
Thus far, I have received courteous responses from my first few companies i.e.
"Thank you for your response. Receiving 250 business solicitations each day is too much of a burden. I will happily remove your name. Your feedback is appreciated"
Long term, I'd recommend a national "do not call list" for email just as we use to discourage telemarketers from making unsolicited calls to households which have opted out on the national list. I would happily submit my name to a national email opt out list.
Other long term alternatives - we could create local whitelists of companies we do business with, but maintaining such a whitelist is challenging for companies and individuals. Other possibilities include expansion of Spam legislation and enforcement which provides sanctions for violators of unsolicited email rules.
I'm ok with "pull" advertising on websites that is customized to me, but is easy to ignore. However, I consider "push" unsolicited email contact an invasion of a personal communication vehicle.
Thus, for companies that send out endless unsolicited emails, watch for my responses begging you to stop sending me email advertising! The only recourse I have left is to block your domain if you continue.
My email address appears in the masthead of many of the columns I write for print and web-based media. This has led to my inclusion in just about every IT mailing list on the internet.
I've tried opting out. Removing myself from 250 mailing lists each day can take an hour, so that's clearly not a sustainable part of my schedule. Also, some unsubscribe links just do not work. What are our options?
Short term, I advocate that CIOs start blacklisting the email domains that pummel us with unsolicited IT advertising. I'm a kind and gentle soul, so I'm willing to give companies a chance to redeem themselves. This month, I'm responding to these companies with a polite request to never send me emails again. If they continue to fill my inbox, I will blacklist their domain on my local email servers, preventing delivery of their advertising throughout my enterprise.
Thus far, I have received courteous responses from my first few companies i.e.
"Thank you for your response. Receiving 250 business solicitations each day is too much of a burden. I will happily remove your name. Your feedback is appreciated"
Long term, I'd recommend a national "do not call list" for email just as we use to discourage telemarketers from making unsolicited calls to households which have opted out on the national list. I would happily submit my name to a national email opt out list.
Other long term alternatives - we could create local whitelists of companies we do business with, but maintaining such a whitelist is challenging for companies and individuals. Other possibilities include expansion of Spam legislation and enforcement which provides sanctions for violators of unsolicited email rules.
I'm ok with "pull" advertising on websites that is customized to me, but is easy to ignore. However, I consider "push" unsolicited email contact an invasion of a personal communication vehicle.
Thus, for companies that send out endless unsolicited emails, watch for my responses begging you to stop sending me email advertising! The only recourse I have left is to block your domain if you continue.
Sunday, December 2, 2007
Safe Driver Discounts for Technology
Automobile insurers have long seen the sense of giving drivers an incentive, in the form of safe-driver discounts, to avoid taking risks when they’re behind the wheel. In health care, more and more payers are rewarding doctors for the quality of care they deliver and not the quantity. Aligning incentives with outcomes makes good sense.
Vendors of technology should follow those examples and revise their pricing models for yearly hardware and software maintenance contracts. If they rewarded customers who adhere to best practices, they would essentially pay customers for their performance.
As a CIO of multiple companies, I have to sign off on a lot of maintenance contracts every year. These contracts have a list price, and there’s usually a discount that the manufacturer passes along to the value-added reseller (VAR). The VAR decides how much of the discount to pass along to customers. No extra consideration is given to customers who abide by the vendor's best practices for the implementation and management of its products.
But why not? Why not give technology buyers the equivalent of a safe-driver discount? If customers were given incentives to hire highly competent internal staff, follow all the vendor-recommended configurations and install all the latest upgrades, life would be better for both the vendor and the customer. The vendor would receive fewer support calls and requests for emergency priority service. The customer would get higher reliability, better performance and lower maintenance costs.
Five years ago this month, we experienced a devastating network outage that led me to change a lot of our practices. Before the outage, my only incentive to adopt best practices was fear of downtime. The cost of support was certainly not a factor. We could make hundreds of support calls and send out an SOS during numerous high-priority emergencies, and the cost would be the same as it would be with a spotless performance record. The outage led me to replace much of our infrastructure, enhance my support team and ensure that our engineering practices are world class. We now place an extremely low burden on our vendors, but our maintenance discounts for all the technology we operate today don’t reflect that.
Here’s my idea. Vendors would give each customer a yearly technology safety rating, starting at, say, 100 points. If you miss an upgrade, 10 points would be deducted. Deviate significantly from a recommended configuration and you lose another 10 points. Make a support call that’s due to your lack of appropriate IT staffing and more points are taken away.
Discounts would no longer be arbitrary. Instead, they would be a direct function of the yearly safety rating. The harder a customer worked to avoid calls for help, the less the maintenance would cost. The best customer of the year could even be rewarded with completely free maintenance.
Of course, there are potential problems. Vendors could abuse the system by defining best practices as the elimination of all competing products, or they could take away points if customers didn’t buy all the optional add-on software they recommend. But such tactics would defeat the spirit of this proposal. Any vendor that adopted them could expect a good deal of pushback from customers; hopefully, they would see that such transparently cynical ploys have no real value.
So let me publicly ask my good friends at Cisco, EMC, Dell, HP and IBM, What do you think? You'll find that my driving record is exemplary.
Vendors of technology should follow those examples and revise their pricing models for yearly hardware and software maintenance contracts. If they rewarded customers who adhere to best practices, they would essentially pay customers for their performance.
As a CIO of multiple companies, I have to sign off on a lot of maintenance contracts every year. These contracts have a list price, and there’s usually a discount that the manufacturer passes along to the value-added reseller (VAR). The VAR decides how much of the discount to pass along to customers. No extra consideration is given to customers who abide by the vendor's best practices for the implementation and management of its products.
But why not? Why not give technology buyers the equivalent of a safe-driver discount? If customers were given incentives to hire highly competent internal staff, follow all the vendor-recommended configurations and install all the latest upgrades, life would be better for both the vendor and the customer. The vendor would receive fewer support calls and requests for emergency priority service. The customer would get higher reliability, better performance and lower maintenance costs.
Five years ago this month, we experienced a devastating network outage that led me to change a lot of our practices. Before the outage, my only incentive to adopt best practices was fear of downtime. The cost of support was certainly not a factor. We could make hundreds of support calls and send out an SOS during numerous high-priority emergencies, and the cost would be the same as it would be with a spotless performance record. The outage led me to replace much of our infrastructure, enhance my support team and ensure that our engineering practices are world class. We now place an extremely low burden on our vendors, but our maintenance discounts for all the technology we operate today don’t reflect that.
Here’s my idea. Vendors would give each customer a yearly technology safety rating, starting at, say, 100 points. If you miss an upgrade, 10 points would be deducted. Deviate significantly from a recommended configuration and you lose another 10 points. Make a support call that’s due to your lack of appropriate IT staffing and more points are taken away.
Discounts would no longer be arbitrary. Instead, they would be a direct function of the yearly safety rating. The harder a customer worked to avoid calls for help, the less the maintenance would cost. The best customer of the year could even be rewarded with completely free maintenance.
Of course, there are potential problems. Vendors could abuse the system by defining best practices as the elimination of all competing products, or they could take away points if customers didn’t buy all the optional add-on software they recommend. But such tactics would defeat the spirit of this proposal. Any vendor that adopted them could expect a good deal of pushback from customers; hopefully, they would see that such transparently cynical ploys have no real value.
So let me publicly ask my good friends at Cisco, EMC, Dell, HP and IBM, What do you think? You'll find that my driving record is exemplary.
Thursday, November 29, 2007
Cool Technology of the Week
Have you ever wanted to record MP3's of voice or a musical instrument? Since the iPod does not do this, the easy way to record sound is to buy a portable MP3 recorder such as the Edirol R-09, M-Audio MicroTrack or Zoom H2.
However, then you're stuck with yet another gadget that does only one thing. Why not use your existing laptop for this purpose?
I tried it and the sound quality was so bad, that I was ready to give up. My audiophile friends explained that typical microphones really need a pre-amp before plugging them into a laptop. However, I did not want to spend the money on a high quality microphone plus pre-amp.
I discovered an entirely different technology that worked perfectly - USB Microphones. These devices include a high quality analog microphone, a pre-amp and an analog to digital converter. They plug directly into a USB port and do not use the audio components of your computer at all! Here's an overview of the technology and the leading products
I purchased a Blue Snowball Microphone for $100 and was amazed by its quality. I used the Snowball with my Mac using Garage Band, my Ubuntu Linux laptop using Audacity and a Windows XP laptop using Sound Recorder. Here's a sample of my Shakuhachi Japanese Flute recorded with the Snowball.
The Blue Snowball USB Microphone - truly a Cool Technology
In my Cool Technology of the Week entry two weeks ago, I discussed the Orb. This week, our Orbs went live. Per this picture, we've placed an Orb on the CEO's desk and linked it to our Emergency Department waiting room volume metrics.
The Orb supports 35 different colors and glows Blue if no patients are waiting, Greens for 1 to 5, Yellows for 6 to 10, Reds for 11 to 20 and Flashing Red for over 20. We were able to create this fully automated "glance-able" interface in one day by simply repurposing existing Service Orientated Architecture (SOA) tools already deployed in our clinical systems. If it is successful in the CEOs office, we'll add additional Orbs and a menu of performance metrics to track.
Tuesday, November 27, 2007
The Cost of Information Technology
I'm often asked how about my budgets for hospital information systems. In the interest of transparency here it is, in narrative and spreadsheet form.
Typically, Academic Health Centers spend about 2.5% of their operating budget on Information Technology. Our budget is between 1.8-3.1% depending on what you include. Overall, we receive $37.1 million out of BIDMC's $1,195 milllion dollar budget (3.1%) but we provide services for many non-BIDMC entities which are charged back. We also provide Media Services/Telemedicine, Library Services, Telecommunications and Health Information management services (medical records). If you remove these items to create an apples to apples comparison with other academic health centers, the percentage drops to 1.8%. These percentages are mixed blessing. Although it's laudable we can do so much with under 2% of the operating budget, there are clearly opportunities to enhance operations via additional IT expenditures.
The narrative is a breakdown of direct and indirect IS costs. Important to note - it includes fringe benefits, leased space costs and utilities, and capital depreciation on IS related items. It also includes the cost of services provided to non-BIDMC sites who we charge for our service. The grand total is $59m; much higher than our net operating budget. To properly represent the cost of an application such as Peoplesoft or Email, you really need to include these expenses. At the bottom of the table, I show the revenue recovered from other entities and address some of the typical questions often asked about operating and capital comparisons.
The spreadsheet shows the IS expense for FY08 for each of our cost centers. This includes a breakdown of fringe, space/utilities, and depreciation. We depreciate everything on a 5 year basis for purposes of the allocation.
This year's $169.4m BIDMC capital includes $57.8m for our new Center for Life Sciences Research building and $23m for backfilling vacated space as researchers move into the new building. The $15.4m IS capital budget also includes $3.4m for the Center for Life Sciences build out of telecom and network services. If you remove these for both BIDMC and IS, we are 13.5% of the total. The remainder is $8.5m for infrastructure, $.5m for Peoplesoft, and $3m for Disaster Recovery.
The most difficult variable to express when comparing institutions is the quality of information systems. Quality for IS comes through reliability, fast transaction speeds, application breadth and depth, and customer satisfaction. At present, I believe that the capital and operating budgets I've provided here will result in more than 99.9% reliability, under 2 second transactions speeds in all applications, reasonable progress on our effort to be 85% electronic in all our care areas, and high customer satisfaction. As I often say, providing Information Systems is a continuous journey, so we will continue to seek additional budgets to support ever evolving user requirements.
Typically, Academic Health Centers spend about 2.5% of their operating budget on Information Technology. Our budget is between 1.8-3.1% depending on what you include. Overall, we receive $37.1 million out of BIDMC's $1,195 milllion dollar budget (3.1%) but we provide services for many non-BIDMC entities which are charged back. We also provide Media Services/Telemedicine, Library Services, Telecommunications and Health Information management services (medical records). If you remove these items to create an apples to apples comparison with other academic health centers, the percentage drops to 1.8%. These percentages are mixed blessing. Although it's laudable we can do so much with under 2% of the operating budget, there are clearly opportunities to enhance operations via additional IT expenditures.
The narrative is a breakdown of direct and indirect IS costs. Important to note - it includes fringe benefits, leased space costs and utilities, and capital depreciation on IS related items. It also includes the cost of services provided to non-BIDMC sites who we charge for our service. The grand total is $59m; much higher than our net operating budget. To properly represent the cost of an application such as Peoplesoft or Email, you really need to include these expenses. At the bottom of the table, I show the revenue recovered from other entities and address some of the typical questions often asked about operating and capital comparisons.
The spreadsheet shows the IS expense for FY08 for each of our cost centers. This includes a breakdown of fringe, space/utilities, and depreciation. We depreciate everything on a 5 year basis for purposes of the allocation.
This year's $169.4m BIDMC capital includes $57.8m for our new Center for Life Sciences Research building and $23m for backfilling vacated space as researchers move into the new building. The $15.4m IS capital budget also includes $3.4m for the Center for Life Sciences build out of telecom and network services. If you remove these for both BIDMC and IS, we are 13.5% of the total. The remainder is $8.5m for infrastructure, $.5m for Peoplesoft, and $3m for Disaster Recovery.
The most difficult variable to express when comparing institutions is the quality of information systems. Quality for IS comes through reliability, fast transaction speeds, application breadth and depth, and customer satisfaction. At present, I believe that the capital and operating budgets I've provided here will result in more than 99.9% reliability, under 2 second transactions speeds in all applications, reasonable progress on our effort to be 85% electronic in all our care areas, and high customer satisfaction. As I often say, providing Information Systems is a continuous journey, so we will continue to seek additional budgets to support ever evolving user requirements.
Monday, November 26, 2007
Devices for Bedside Computing
We're currently evaluating several devices for mobile bedside computing including subnotebooks (Dell D420, Lenovo X61), tablets (Motion Computing LE1600), and small form factor devices (the Apple iPhone/iPod Touch, Emano-Tec MedTab ). I will write another blog entry on stationary bedside computing devices such as wall mounted thin client devices.
Our early results are that nothing on the market yet meets our ideal requirements:
8 hour battery life
Can be easily disinfected to prevent the transmission of disease
Can be dropped 5 feet without significant damage
Under 2 pounds
Here's a list of those machines which attempt to fill the niche for mobile bedside computers
DellD420
Battery Life - 3 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 11.6 x 1/ 3.0 pounds
Lenovo X61
Battery Life - 6 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 10.5 x 1.4 / 3.6 pounds
Motion Computing C5 (Also known as the Intel Mobile Clinical Assistant)
Battery Life - 3 hours
Ability to disinfect - excellent
Drop resistance - good
Size/Weight - 10.0" x 10.0" x .95” / 3.3 pounds
Motion Computing LS800
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 8.94” x 6.69” x 0.87”/ 2.2 pounds
Motion Computing LE1700
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 11.65" x 9.64" x 0.74” / 3.3 pounds
Apple iPhone/iPod Touch
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - fair
Size/Weight - 2.4 x 4.5 x .46/ 4.8 ounces
Emano-Tec MedTab(a startup which is just entering the market)
Battery Life - 24 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 5.5" X 7.5" X 0.5"/12 ounces
I'm personally carrying around the Dell D420 and Lenovo X61 to assess their reliability and durability.
We're piloting 5 LE1700's in our Emergency Department. The LE1700 has a 12.1" screen size compared to a 10.4" in the C5 and 8.4" i the LS800. We're testing it with a medication reconciliation application and will soon know more about its support of clinician workflow. In general, all the Motion Computing devices seem rugged, relatively easy to disinfect, and well engineered. However, battery life is limited to 3 hours, so we'll need to keep charging stations handy throughout the department.
The Emano-tec MedTab form factor and battery life are ideal. It uses an eInk display just like the recently announced Amazon Kindle. The lack of color may be a major limitation for some applications. At present, the device is not available in large quantities, so we're testing a prototype, also in our Emergency Department.
The iPod Touch is promising. A slightly larger form factor and better power management (longer life and/or hot swappable batteries) could make this an ideal medical device. Apple's attention to human interface features really shows here, but it's clearly intended to be a device for personal, not business use. We're testing it with our Emergency Department dashboard application.
Size and battery life for laptops is not as relevant if used as a Computer on Wheels on carts. We use two kinds of carts - The unpowered Ergoton StyleView and the powered Infologix SL Ultra Cart
The hardware and software development efforts of the past few years are getting us closer to the ideal mobile clinical device. At BIDMC one challenge is the difficulty involved in secure authentication. We use secure passwords (requiring capital letters, numbers, symbols, etc) which are difficult to rapidly enter via a tablet. Solutions include biometrics (we are testing Omnipass) and novel login mechanisms such as graphical authentication.
More to come as we complete our evaluation by the end of the year. I welcome any comments on other's experiences with mobile bedside computing devices.
Our early results are that nothing on the market yet meets our ideal requirements:
8 hour battery life
Can be easily disinfected to prevent the transmission of disease
Can be dropped 5 feet without significant damage
Under 2 pounds
Here's a list of those machines which attempt to fill the niche for mobile bedside computers
DellD420
Battery Life - 3 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 11.6 x 1/ 3.0 pounds
Lenovo X61
Battery Life - 6 hours
Ability to disinfect - poor
Drop resistance - fair
Size/Weight - 8.3 x 10.5 x 1.4 / 3.6 pounds
Motion Computing C5 (Also known as the Intel Mobile Clinical Assistant)
Battery Life - 3 hours
Ability to disinfect - excellent
Drop resistance - good
Size/Weight - 10.0" x 10.0" x .95” / 3.3 pounds
Motion Computing LS800
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 8.94” x 6.69” x 0.87”/ 2.2 pounds
Motion Computing LE1700
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 11.65" x 9.64" x 0.74” / 3.3 pounds
Apple iPhone/iPod Touch
Battery Life - 3 hours
Ability to disinfect - good
Drop resistance - fair
Size/Weight - 2.4 x 4.5 x .46/ 4.8 ounces
Emano-Tec MedTab(a startup which is just entering the market)
Battery Life - 24 hours
Ability to disinfect - good
Drop resistance - good
Size/Weight - 5.5" X 7.5" X 0.5"/12 ounces
I'm personally carrying around the Dell D420 and Lenovo X61 to assess their reliability and durability.
We're piloting 5 LE1700's in our Emergency Department. The LE1700 has a 12.1" screen size compared to a 10.4" in the C5 and 8.4" i the LS800. We're testing it with a medication reconciliation application and will soon know more about its support of clinician workflow. In general, all the Motion Computing devices seem rugged, relatively easy to disinfect, and well engineered. However, battery life is limited to 3 hours, so we'll need to keep charging stations handy throughout the department.
The Emano-tec MedTab form factor and battery life are ideal. It uses an eInk display just like the recently announced Amazon Kindle. The lack of color may be a major limitation for some applications. At present, the device is not available in large quantities, so we're testing a prototype, also in our Emergency Department.
The iPod Touch is promising. A slightly larger form factor and better power management (longer life and/or hot swappable batteries) could make this an ideal medical device. Apple's attention to human interface features really shows here, but it's clearly intended to be a device for personal, not business use. We're testing it with our Emergency Department dashboard application.
Size and battery life for laptops is not as relevant if used as a Computer on Wheels on carts. We use two kinds of carts - The unpowered Ergoton StyleView and the powered Infologix SL Ultra Cart
The hardware and software development efforts of the past few years are getting us closer to the ideal mobile clinical device. At BIDMC one challenge is the difficulty involved in secure authentication. We use secure passwords (requiring capital letters, numbers, symbols, etc) which are difficult to rapidly enter via a tablet. Solutions include biometrics (we are testing Omnipass) and novel login mechanisms such as graphical authentication.
More to come as we complete our evaluation by the end of the year. I welcome any comments on other's experiences with mobile bedside computing devices.
Are Regional Health Information Organizations (RHIOs) Sustainable?
As CEO of the Massachusetts Regional Health Information Organization (RHIO) called MA-SHARE, I have spent 4 years working with stakeholders in Massachusetts to create a sustainable business model for health information exchange.
MA-SHARE’s first effort in 2004 was the MedsInfo project, a state-wide medication history exchange pilot based on payer claims data. We learned a great deal about privacy, workflow, data expectations, and health information exchange operations. The project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations given the lack of integration of the data into clinician workflow and the inherent incompleteness of the data (only 66% of patients had medication data in our regional payer databases as of 2004). As of 2007, the two largest national e-Prescribing exchanges, RxHub and SureScripts, have much more complete networks and we've integrated the former MedsInfo functionality into our e-Prescribing utility, described below.
In 2005 and 2006, working with the Markle Foundation and the Office of the National Coordinator, we developed a Nationwide Health Information Network implementation pilot based on a state-wide master patient index called the Record Locator Service. The pilot demonstrated the value of the emerging clinical data exchange architecture to support provider-to-provider data exchange, personal health records, and biosurveillance. The architecture worked well, but the project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations required to maintain the Record Locator Service.
In 2006 and 2007, we implemented a state-wide e-Prescribing gateway. We've transmitted over 100,000 electronic prescription transactions through our exchange and we are live with formulary enforcement, eligibility checking, dispensed medication history including drug/drug interaction checking and routing to retail/mail order pharmacies. The stakeholders have found value in paying for the cost of ongoing operations of this infrastructure since it reduces costs to the payers by enhancing the use of generics/formulary medications, it reduces costs to pharmacies by eliminating paper workflows and it improves workflow for providers by streamlining renewal workflow. We've implemented our e-Prescribing gateway at CareGroup, Partners and soon Children's Hospital. We will work in 2008 to expand the use of the gateway to connect to vendor systems such as Cerner and Meditech, as well as to encourage its use in more institutions.
In 2007, we implemented our "push pilot" using national standards to share discharge summaries and emergency department summaries among caregivers. We use the same software application that routes prescriptions between providers and pharmacies to securely route documents provider to provider. This clinical data exchange approach is truly low cost and simple. All that is required is a sender which can summarize tabular and narrative data in the format specified by HITSP and an organization which can receive this data via direct integration into an electronic health record, secure email or fax. Cerner, MEDITECH, eClinicalWorks and GE Centricity are among the EMR vendors supporting the design and implementation of this project. We are optimistic that the value to the stakeholders of exchanging clinical summaries will be sustainable based on cost avoidance. By eliminating the expense of chart copying, mailing, and paper-based record storage, hospitals seem willing to fund health information exchange of summaries out of projected cost savings. It's also a great political win for the hospital, since pushing clinical summaries keeps the primary caregivers and referring physicians well informed, enhancing their satisfaction. It provides care continuity by ensuring all caregivers (inpatient, outpatient, Emergency Department, rehabilitation, and long term care facilities) are given a consistent medication list, problem list, laboratory summary, and discharge narrative. As personal health record services such as Microsoft HealthVault, Google's Health efforts and Dossia through Indivo Health are more widely deployed, we may also push data directly into personal health repositories at patient request.
MA-SHARE’s budget in 2008 is approaching the same kind of sustainablity we've achieved with our financial data exchange, NEHEN. All 'lights on' operations are funded by the stakeholders plus $250,000 is available each year for new projects and enhancements. No grant funding or soft money source will be used in 2008. Our hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for our community. The big lesson learned in our statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. To achieve sustainability, the initial efforts must be expanded to meet the needs of the common marketplace. We believe our push model addresses this issue.
Health Information Exchanges in the US are in tenuous financial shape. We've been exploring sustainable business models in Massachusetts for 4 years. Many RHIOs still depend on grants, which eventually end and thus are not a good business model. I believe that Health Information Exchanges will evolve to meet the local business needs of many communities but that a nationwide health information network linking together these local exchanges will not be widely deployed until more consistent funding is available. In many ways, data exchange is a public good, which is hard to support entirely from local stakeholders. Additional funding from federal and state sources would help. The level of investment in healthcare information exchange in Canada and the UK far exceeds that in the US. I hope that Bush's 2004 commitment to have every clinician in the country wired by 2014 will be met with increases in funding to support it.
MA-SHARE’s first effort in 2004 was the MedsInfo project, a state-wide medication history exchange pilot based on payer claims data. We learned a great deal about privacy, workflow, data expectations, and health information exchange operations. The project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations given the lack of integration of the data into clinician workflow and the inherent incompleteness of the data (only 66% of patients had medication data in our regional payer databases as of 2004). As of 2007, the two largest national e-Prescribing exchanges, RxHub and SureScripts, have much more complete networks and we've integrated the former MedsInfo functionality into our e-Prescribing utility, described below.
In 2005 and 2006, working with the Markle Foundation and the Office of the National Coordinator, we developed a Nationwide Health Information Network implementation pilot based on a state-wide master patient index called the Record Locator Service. The pilot demonstrated the value of the emerging clinical data exchange architecture to support provider-to-provider data exchange, personal health records, and biosurveillance. The architecture worked well, but the project was terminated after the pilot because participants were not ready to fund the true cost of ongoing operations required to maintain the Record Locator Service.
In 2006 and 2007, we implemented a state-wide e-Prescribing gateway. We've transmitted over 100,000 electronic prescription transactions through our exchange and we are live with formulary enforcement, eligibility checking, dispensed medication history including drug/drug interaction checking and routing to retail/mail order pharmacies. The stakeholders have found value in paying for the cost of ongoing operations of this infrastructure since it reduces costs to the payers by enhancing the use of generics/formulary medications, it reduces costs to pharmacies by eliminating paper workflows and it improves workflow for providers by streamlining renewal workflow. We've implemented our e-Prescribing gateway at CareGroup, Partners and soon Children's Hospital. We will work in 2008 to expand the use of the gateway to connect to vendor systems such as Cerner and Meditech, as well as to encourage its use in more institutions.
In 2007, we implemented our "push pilot" using national standards to share discharge summaries and emergency department summaries among caregivers. We use the same software application that routes prescriptions between providers and pharmacies to securely route documents provider to provider. This clinical data exchange approach is truly low cost and simple. All that is required is a sender which can summarize tabular and narrative data in the format specified by HITSP and an organization which can receive this data via direct integration into an electronic health record, secure email or fax. Cerner, MEDITECH, eClinicalWorks and GE Centricity are among the EMR vendors supporting the design and implementation of this project. We are optimistic that the value to the stakeholders of exchanging clinical summaries will be sustainable based on cost avoidance. By eliminating the expense of chart copying, mailing, and paper-based record storage, hospitals seem willing to fund health information exchange of summaries out of projected cost savings. It's also a great political win for the hospital, since pushing clinical summaries keeps the primary caregivers and referring physicians well informed, enhancing their satisfaction. It provides care continuity by ensuring all caregivers (inpatient, outpatient, Emergency Department, rehabilitation, and long term care facilities) are given a consistent medication list, problem list, laboratory summary, and discharge narrative. As personal health record services such as Microsoft HealthVault, Google's Health efforts and Dossia through Indivo Health are more widely deployed, we may also push data directly into personal health repositories at patient request.
MA-SHARE’s budget in 2008 is approaching the same kind of sustainablity we've achieved with our financial data exchange, NEHEN. All 'lights on' operations are funded by the stakeholders plus $250,000 is available each year for new projects and enhancements. No grant funding or soft money source will be used in 2008. Our hope is that more stakeholders will sign up to participate in MA-SHARE over time, further funding research and development of high value health information exchange products for our community. The big lesson learned in our statewide initiatives, MA-Share and NEHEN, is that grant funding and large stakeholder (academic medical centers/payers) contributions precede sustainability. To achieve sustainability, the initial efforts must be expanded to meet the needs of the common marketplace. We believe our push model addresses this issue.
Health Information Exchanges in the US are in tenuous financial shape. We've been exploring sustainable business models in Massachusetts for 4 years. Many RHIOs still depend on grants, which eventually end and thus are not a good business model. I believe that Health Information Exchanges will evolve to meet the local business needs of many communities but that a nationwide health information network linking together these local exchanges will not be widely deployed until more consistent funding is available. In many ways, data exchange is a public good, which is hard to support entirely from local stakeholders. Additional funding from federal and state sources would help. The level of investment in healthcare information exchange in Canada and the UK far exceeds that in the US. I hope that Bush's 2004 commitment to have every clinician in the country wired by 2014 will be met with increases in funding to support it.
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