Happy Holidays to All

Just as Thanksgiving is an introspective time for me, the Holiday season is a time I look back on the year and reflect on all the good things that have happened.

In 2007:

At BIDMC, IS and clinicians came together in the midst of the Joint Commission visit to create some of the most innovative medication reconciliation and e-prescribing functionality in the country. We've had 99.9% uptime of our infrastructure. All our application and infrastructure vendor relationships are strong. We're working well with all our customers and among all our IS teams.

At Harvard, a new Dean has arrived and the Dean's strategic planning process is proceeding successfully. We've opened a new data center, created a new vision for collaboration tools among all the stakeholders in the Harvard community, and we've had 99.9% uptime of our infrastructure.

At NEHEN, we're made administrative data sharing among payers and providers available to every clinician in the state.

At MA-Share, we've created an e-prescribing and continuity of care document health information exchange for the state.

At HITSP, we've harmonized standards for electronic health records, personal health records, labs, medications, quality and public health.

Personally, I've flown 166 times without losing my sanity or optimism. My wife and daughter are happy and healthy. My Japanese flute playing is progressing and I've climbed many of the classic rock and ice climbs in New England.

All of this would not have been possible without the thousands of people who gave so much of their time, support and enthusiasm to make 2007 a remarkable success.

Thank you to my family, friends, and colleagues at CareGroup, Harvard, NEHEN, MA-Share, HITSP and the IT industry. You're making the world of healthcare better for everyone.

The holidays are about celebrating the good, highlighting the spiritual, and forgetting the stress of the rest of the year whenever possible. So, revel in best characteristics of your personal and work life, turn off the email/pager/cellphone for a few hours, and recharge your batteries. 2007 may have had its ups and downs, but we've moved forward in so many positive ways that you can be completely satisfied with a job well done.

The Weather Outside is Frightful

Since many people outside of New England read this blog, you may want to know what I do for fun at this time of year. It's around zero degrees with 25mph winds on Mt. Washington in the White Mountains, so it's time for a stroll.

There are 48 mountains over 4000 feet in New Hampshire, so for fun, I climb each of them in the winter. Hikes range from 7 miles up Mt. Tecumseh to 26 miles up Mt. Bond. The rules of winter hiking require that it must take place between the winter solstice (Dec 21/22) and the Spring equinox (March 20/21) in order to count as a winter ascent. Snow drifts can be 6 feet deep, ice covers every rock up to a foot thick and waterfalls become solid and climbable. Temperatures vary from +20 to -20F. Wind speeds can gust to 70mph. Windchills of -40F are not unusual. At -40F, the battery life of a Blackberry is 2 minutes (I thought you'd want to know), exposed skin lasts about 3 minutes and eyeballs freeze solid. But, there is no such thing as bad weather, just bad planning.

Here's a few photos to put you in the New England Holiday spirit

Ice Climbing the Frankenstein Cliffs in Crawford Notch



Feeding a hungry Grey Jay on Mt. Wiley



Lonesome Lake on Mt. Kinsman



Life at -40F


Happy Holidays from the land of ice and snow!

Cool Technology of the Week

Over the past year, High Definition Television (HDTV) has gained market momentum and many households are eliminating the last generation of video technologies. The combination of LCD HDTV, digital camcorders, and computer-based video editing software is truly a cool technology.

Figuring out what to buy is challenging. My household has a Sharp Aquos 46" LCD television (2006), a Sony DCR-HC40 MiniDV Camcorder (2005), and an iMac 20" running iMovie (2007)

If you are buying a suite of tools today, here are my recommendations:

HDTV - you want well-defined blacks, a wide viewing angle, and 1080p resolution. I recommend the Sharp Aquos or Sony Bravia that fits your wall and your budget.

Camcorder - you want one that can work easily with computer-based editing tools such as Apple's iMovie or Final Cut Pro. Camcorder options include standard definition (SD) verses high definition (HD) video, recording to tape using MiniDV, recording to hard disk, and recording to DVD. In the under $1000 category, I recommend:

Standard definition
Panasonic PV-GS500 3-CCD Mini DV Camcorder - $699.
This camera is the smallest form-factor 3-CCD camera that I've seen. With 3 CCDs, you will get a comparable image to that of a pro-sumer camera at the cost, size, and ease-of-use of a consumer model. Just like photography, you can have the highest megapixel camera available, but if the optics are sub-standard you're just getting a hi-res capture of a poor image.

High definition
Canon HV20 HDV Camcorder - $749.
This looks like the best tape-based HD camcorder on the market. I personally prefer digital tape for the reliability of the footage. The HV20 can shoot in 4:3 or 16:9 mode (4:3 is a slightly higher resolution) and captures in full 1080p (1920 x 1080). iMovie can import and edit high definition video and still output to standard video DVD, making the technology future and backward compatible. There is no additional overhead to high definition other than slightly larger files during the editing stage.

Both of these cameras use the IEEE1394 cable standard so iMovie can control them without issue. The baseline requirements for utilizing iMovie for video capture is that video compression needs to be DV for standard definition format and HDV for high definition format, and use IEEE1394/iLink (Firewire Protocols) for capture.

Computer - the latest iMac's with OS X Leopard are amazing multimedia machines, equipped with all the tools you need to create professionally edited movies. My 14 year old daughter just completed a movie for school using our Sony camcorder, an IEEE1394 cable, and iMovie. The results were stunning. Here is a great page from Apple with the details about using Camcorders with Macs.

Thanks to David Bozzi at Harvard Medical School for help with this research.

Build AND Buy

In my role at CIO at Harvard Medical School and CareGroup, I'm often asked if we build or buy our enterprise applications. The answer is that we build AND buy, a strategy that has worked very well for over 20 years and I anticipate will serve us well for the next 20.

The trend in IT today is outsourcing, offshoring, buying software as a service (SAAS), and retiring home built legacy systems. Since I've just declared that we build software and will continue to do so, have I lost touch with the latest Gartner and Forrester reports?

Several healthcare application vendors are my close partners (I'm writing this at the Elephant Walk in Waltham just before dinner with 3 vendor partners). Vendors can produce full featured software on a regular release schedule and can be very innovative. Buying software means that I do not have manage developers and can leverage product development costs that are spread over many customers. Buying software means that the internal politics of development prioritization can be bypassed by relying on the vendor to adjudicate which features are included in upgrade releases. With reduced management responsibility, shared development costs and relief from institutional politics, what's not to love?

In complex organizations like Harvard and Caregroup, we have hundreds of applications. If we purchased all these applications, it's likely they would have dozens of different user interfaces, many navigation paradigms, several passwords, incomplete data integration and a high training burden. In 1998, my team and our stakeholders made the decision to implement a service oriented architecture (SOA) throughout the enterprise and own the "front end" of our applications. This means that our clinical systems have a single sign on, a single means of navigating the application and appear to have all our clinical data integrated completely, even though there are dozens of applications involved behind the scenes. We've built just about every system that our clinicians touch directly but buy the underlying departmental systems such as laboratory/blood bank, PACS imaging, critical care systems that interface with patient monitors and drug dispensing systems that require FDA approval. When we purchase a system from a vendor we require "Web 2.0" XML exchanges that enable us to link together the data housed in each application with our front end user interfaces. In a sense we've become experts at the plumbing that connects web applications.

This build and buy approach benefits the users with "virtual integration", ease of use and significant reduction in training requirements, but the real power in the strategy is that we can control the pace of innovation. Here's a case in point.

BIDMC was visited by the Joint Commission on July 23, 2007. A major focus of their visit was medication reconciliation, ensuring an accurate medication list at every transition of care. Very few vendor applications provide the tools necessary to do this. In a matter of weeks we built a community wide medication history health information exchange empowering physicians and patients to add, edit, delete and correct medications in every site of care. We brought this application live on July 24, 2007 and passed an audit for 100% utilitization of the software by October 1, 2007. It's highly unlikely this pace of innovation could have been accomplished with vendor software.

When folks ask about my build and buy strategy, I refer to them to the book "Built to Last" by Jim Collins and Jerry Porras, which highlights a concept called the "Tyranny of the OR verses the Genius of the AND". The authors suggest that highly successful companies are not dogmatic in their choices. It's ok to embrace Open Source AND Microsoft technologies. It's ok to embrace Linux, Mac OSX AND Windows. This does not mean that we're indecisive, it means that we use the right tools for the right task.

Hopefully, our broadly communicated strategy that we buy those applications which are mature, highly functional and widely deployed while we build the front end, the data integration and those applications which are cutting edge for which no vendor products are available will be viewed as the "genius of the AND" when the next generation of IT professionals looks back on our work.

A Chip in My Shoulder

I'm often asked about the RFID chip containing my medical records which is implanted in my right arm.

As a physician and chief information officer, I felt qualified to evaluate the medical, legal, moral, and privacy aspects of the device. After using the device for three years, I am not an evangelist for implanted RFID, but I believe it can be valuable for some patients who understand the risks and benefits. My implantation process in December 2004 was simple—a five minute office procedure, which included disinfection of the implant site on my upper right arm, a few cubic centimeters of lidocaine, and insertion of the injector into my subcutaneous fascia. I did not experience pain, bleeding, or any post-procedure infection. The implant is not palpable, does not migrate, and has no physical side effects such as itching, irritation, or changes in skin appearance. The RFID device does not impede my activities; even while rock or ice climbing I have hit the implant site many times without any problems. The device is undetectable by airport security metal detectors and hand scanners.

One possible side effect is that my RFID device can be scanned by retail security systems using 134.2 kHz RFID technology, the frequency of my implant. I have had experiences at Home Depot and Best Buy where my device seemed to set off the anti-theft systems. My personal data are not readable by such systems, but they may be able to detect the presence of an implanted RFID tag.

Given my experience, what are the risks and benefits? The medical risks of any implant are infection, pain, keloid formation at the puncture site, and reaction to the local anesthetic. There are quite a range of nonmedical risks. After my implant, I received many e-mails saying that I had become a “Borg” and had lost some of my humanity because I was now a hybrid human/machine. Some e-mails even referred to the Book of Revelation, noting that I now carried the number of the Beast. Thus, chip carriers have a risk of being social outcasts.

The chip holds a static and unencrypted 16 digit number, which is used to point to a Web site containing personal health record data. The Web site requires a username and password, ensuring appropriate security. It is conceivablethat a person on a subway could scan a patient’s number without their knowledge and steal their medical identity by creating an identical chip and implanting it. This is a very theoretical risk because hospitals are not widely using implanted RFID chips as a means of identification. If the implanted chip were used for security purposes, such as opening a door to a secure area, the person who scanned the patient on the subway could replay the RFID signal and gain access to the secure area. Again, this is purely theoretical since implanted RFID devices are not often used as security authenticators.

If these are the potential risks, what are the benefits? Since we have no universal health identifier in the US, there is no simple way to uniquely identify a patient at all sites of care. The result is a fractured medical record scattered in inpatient, outpatient, laboratory, pharmacy, and emergency department sites. The implanted RFID devices enable patients to establish health care identities and become the stewards of their own data. The patient can assemble a reconciled medication list, a complete problem list, and a list of diagnostic study results, and then apply personal privacy preferences—for example,deleting information about mental health, HIV, or substance abuse. This patient-controlled record is available to treating clinicians in the case of emergency via the implanted device.

It is a personal choice whether or not to be fitted with an RFID device, but for some patients such a record has value. For example, such devices may be particularly helpful for a patient with Alzheimer disease who cannot give a history, a patient prone to syncope who may not be initially conscious during an emergency department visit, or a very active person who engages in extreme sports activities and could be noncommunicative due to injury.

I believe that in the near future, patients will own their medical records and be the stewards of their own health care data. Implantation of RFID devices is one tool, appropriate for some patients based on their personal analysis of risks and benefits, that can empower patients by serving as a source of identity and a link to a personal health record when the patient cannot otherwise communicate.

New Healthcare Data Standards for the Country

Over the past 2 years, I've had the priviledge of working with 350 organizations as part of the US national effort to standardize healthcare data, supporting the secure exchange of healthcare records among patients, providers and payers with patient consent. On Thursday, December 13, the Healthcare Information Technology Standards Panel (HITSP), completed its 2007 work and approved 4 new "interoperability specifications"

Quality - all the initial standards needed to support the process and outcome measures for the Institute of Medicine's highest priority diseases.

Consumer Empowerment - all the initial standards needed to support personal health records exchanged via networks or via removable media (such as thumb drives). These standards make products like Microsoft Health Vault, the upcoming Google Health, Dossia, Medem, and Relay Health much more useful for patients, as they make the patient the stewards of their own data.

Lab - all the initial standards to order and result laboratories including a consistent description of lab types, reasons for ordering and units of measure. Today, the thousands of labs throughout the US use a heterogeneous collection of standards which require custom programming/configuration to connect them with electronic health records and public health reporting systems.

Emergency Responder - all the initial standards needed to support transfer of information among hospitals and emergency first responders such as paramedics when delivering care in the field, such as might occur in a Katrina-like event.

Also on December 13, the panel approved a Privacy Framework which provides a mechanism to categorize all the various privacy policies that exist in this country. This is important, since security technology to protect confidentiality can only be implemented by first understanding the policies which need to be enforced.

What are the next steps? All of the work done by HITSP on consumer empowerment, labs and biosurveillance will be "recognized" by HHS Secretary Michael Leavitt this month, except for the HL7 2.5.1 message (used to communicate lab results) and the OASIS HAVE standards (used to report hospital resources) which will be recognized in June 2008. Recognition means that federal procurement will require these standards to be included in systems deployed for federal government use. Also, these standards will be included in the Certification Commission for Healthcare Information Technology in 2008 and 2009, encouraging vendors to incorporate them into electronic health records, personal health records and hospital information systems.

As more and more clinicians use electronic health records and interoperability standards become more common, care will become more coordinated, improving quality and reducing costs. Standardization also lays the foundation for patients to be move involved with their care by getting access to all their healthcare data.

Creating a secure, interconnected healthcare system is a journey, but the completion of these healthcare standards for the country is a major first step down that path.

Embracing Innovation

I'm almost 46 years old and am in the prime of my capacity to adapt to mental and physical change. I crave innovation just as I crave my weekend time climbing ice and scaling mountains. However, I know that my mental and physical capacity to embrace change are likely to diminish over time.

My Grandmother (passed away in the 1990's) spent her youth learning the Palmer method of perfect handwriting. When I learned to type in 6th grade and began typing all my correspondence, she could not embrace the notion that cursive handwriting was an anachronism.

As a college student, I had the privilege of living with Dr. Frederick Terman, former Provost of Stanford University and the person who brought Bill Hewlett/David Packard together in the 1930's. Dr. Terman was known for his foundational work in radio engineering, especially the creation of novel amplifier circuits. One night in the early 1980's, I brought Dr. Terman an integrated circuit that cost under $1 dollar and did the work of his most complex radio engineering designs in a single device smaller than a dime. I proudly explained that his foundational work made this integrated circuit possible. His response was that he could not understand the technology inside the device and thus he had no interest in it.

Recently, in her Nobel acceptance speech, Doris Lessing explained that the Internet is destroying creativity and intelligence because it enables anyone to be a publisher and it removes rigorous training in the history of literature as a barrier entry to authorship. Although I have the greatest respect for anyone who earns a Nobel prize, these statements reminded me of my conversation with Dr. Terman. Just because the new forms of social networking, blogging, wikis, and instant messaging are different than previous forms of scholarship does not mean they are inherently flawed. In the past, I would have not shared my experiences as CIO with everyone because the barriers to writing a book about it were too great. Now, anyone can benefit from my decade of successes and failures as a CIO for free, anytime, anywhere. In a sense, the internet has democratized access to knowledge.

My committment to my staff is that if I ever become the rate limiting step in adoption of new technologies, then it will be time for me to go. In the meantime, bring on the AJAX, the Continuous Data Replication, Host-based Intrusion Protection and all the new acronyms that cross my desk every day. I may not immediately understand every new technology, but I look forward to being a student, learning about the latest innovations, for life.