Cool Technology of the Week

This week's post is not about a specific company's technology, but about a concept.

My wife did something very cool for me for Christmas.

Given that 2011 was filled with Hurricanes, Earthquakes, Tornados, Floods, and Fires around the world, she decided to create something that would make us more prepared for whatever the future may bring.

She created a disaster pack for the front hall closet using a Black Diamond Speed 30 mountaineering pack as a "grab and go" answer to any disaster that strikes.   It contains 72 hours of food/water, basic medical supplies. a solar powered radio, tools that can be used to harvest wood/start a fire, and extra clothes.

From the point disaster strikes to the point we're in a car with our supplies driving away could be under 60 seconds.

Think about the time it would take to assemble food/water, clothing, and medical gear after disaster strikes - 15 minutes?  Half an hour?

I highly recommend a "grab and go" pack as part of your family disaster preparedness plans.   Thanks Kathy for building one for us - that's cool!

Our Cancer Journey - Week 2

It's been two weeks since my wife said "I have cancer" to my daughter.

It's been a week since we described our workup thus far on my blog.

Reaction to our blog post was diverse, ranging from the HISTalk blog to the Boston Globe.

It's a time of anxiety and unanswered questions.   The diagnosis and staging phase has been described as one of the two major tension points in  cancer.   The other is the time after remission, when the worry about recurrence is a constant burden.  One of our doctors recommended we keep a "family bottle" of anti-anxiety medication ready for those times when the stress exceeds our capacity to cope.   Cancer is truly a family disease and the emotional impact extends from the patient to family caregivers.

Many friends and colleagues have offered prayers and support.   A few have lamented that care coordinated by a physician-husband at a Harvard-associated hospital in Boston lacks equity since every wife/mother/daughter may not receive the same care throughout the US.  Kathy and I agree.   We posted these comments in response to those who speculated that Kathy's care consumes an asymmetric amount of healthcare resources.

John writes:
"At the same time I'm focused on Kathy's care, I'm also deeply committed to quality, safety, efficiency, and equity in healthcare across the country.   In the upcoming weeks, I'll describe how the electronic records that coordinate Kathy's treatment provide the same protocols to every BIDMC patient, regardless of insurance status, profession, or income.    My goal is the 'right care' - not too much nor too little - that follows best practices based on evidence.   Decision support driven 'right care' is the only way we can hope to improve outcomes while bending the cost curve of healthcare spending that threatens the US economy.   Universal healthcare supported by universal adoption of electronic and personal health records must be our guiding vision."

Kathy writes:
"My life with John has been entwined for 32 years, so to say "we have cancer" cannot be more completely and utterly correct. True that physically, only one of use has the obvious organic symptoms, but our close partnership has been irrevocably changed by the diagnosis. Whatever lies ahead, it is impossible to go back to that innocent moment before hearing the word "cancer".

I am luckier than most - I have health insurance, and access to a major urban medical center that is also a teaching and research hospital. But, as I encourage John to document our progress publicly in his blog, I am also keeping the memory of a friend close to my heart. She did not have health insurance (as a part time adjunct instructor of art). With this financial barrier, she unwittingly waited until the cancer had spread before seeking medical care, and although she fought bravely, she lost her battle with breast cancer.

Throughout my life, I have not needed medical resources beyond occasional primary care visits and the birth of one child.  My first weeks negotiating the barrage of new terminology, new tests, and new doctors was significantly eased by my access to a personal health record. The hospital's electronic health record is important to me, since it empowers my doctors to work as a team with open access to all my clinical data, enabling the team to make the best decisions for my health. As I recall my lost friend, I also think about all patients with a breast cancer diagnosis, or other serious illnesses, and  how they manage their care journey if they worry about health insurance, or have no access to a personal health record."

This week we continued the staging process in anticipation of finalizing our care plan (chemotherapy, surgery, radiation oncology) in early January.

On Friday, Kathy went to the operating room for a sentinel node biopsy.  This is now the recommended standard of care for cancer staging as it uses radio-isotopes to identify those lymph nodes that directly drain the tumor.  The surgeons harvested lymph nodes that were positive for radioactivity and one nearby node that was non-radioactive.

After the surgery I took Kathy home and the first thing she wanted to do was re-expand her lungs, avoiding post operative atelectasis.   We walked a few miles around Lake Waban, watched the sunset, and discovered a family of Muskrats seeking their evening meal.

Her post operative pain was helped by gentle exercise and stretching.   She took 2 Tylenol before bed.  Although the anxiety of the workup has interrupted her sleep - she wakes at 3am and has a hard time failing back to sleep - her post operative course has been uneventful.

On Tuesday night, we received the pathology report from the sentinel node biopsy.   It showed one lymph node (directly draining the tumor) with micrometastasis (0.1 cm) and one lymph node (not directly draining the tumor) without malignancy.

We're guessing that the staging will indicate T3, N1, M0 - a HER2 negative ER/PR positive 5cm tumor, with positive but minimal lymph node involvement, and no distant spread.   This may imply Stage IIIA, but we will await a definitive statement from the care team, since staging is complex and multi-factorial.

The tumor is very aggressive.   Less than a month ago, there was no lump.   Today, her left breast shows skin and shape changes.   We're meeting with the oncologist this afternoon to document the physical changes.       In general, research indicates that outcomes are the same regardless of the order of treatment - chemotherapy followed by surgery verses surgery followed by chemotherapy.   However, rapid growth and skin involvement may warrant chemotherapy as the first step.    Since Kathy is continuing to heal from the sentinel node biopsy, we have to time next steps carefully.   It's likely that chemotherapy will reduce her ability to heal, so we do not want to start it too soon.  However, the tumor is growing rapidly, so we want to start it as soon as possible.

Mentally, cancer can be overwhelming.   It is important to think about cancer treatment as "fitting into your life and schedule" verses letting the cancer control you.    The care journey will take time and there are many steps ahead.  

Thanks so much to all who have offered their encouragement.   Kathy and I are emotional and analytic people.  Our endless optimistic is only occasionally punctuated with sadness.   To paraphrase Robert Frost, the forest ahead is dark and deep, but there are promises to keep and there are miles to go before we sleep.   We're ready.

A Look Back at 2011

2011 was a year of change and tumult.   For a day by day look at the top stories of 2011, check out this impressive chart from the UK Guardian.

It was a year in which the economy sputtered worldwide, the Arab Spring toppled several regimes, and unprecedented acts of nature (severe weather, earthquakes) caused billions in worldwide damage.

What about the world of healthcare IT?

Federal
In 2011, Meaningful Use and Certification accelerated healthcare IT adoption and doubled implementation of EHRs throughout the country.    Every aspect of the industry was stressed along the way
*Vendors were challenged to add the features necessary for certification resulting in some "haste makes waste" lack of usability and workflow integration.   GE admitted its faults and should be congratulated for its honesty, since many other vendors had the same problems but did not communicate them.
*IT organizations created productivity miracles to meet meaningful use timeframes with limited staff and limited budgets.   Many organizations will apply their meaningful use payments to general operations and not IT department budget increases, so the sacrifice of IT staff may remain unrecognized.
*Providers had to radically change workflows to accommodate new business processes, resulting in staff turnover and short term frustration.

However, I would argue that we achieved David Blumenthal's goal of moving the "escalator" fast enough to create rapid change but not so fast that people fell off.   The one year delay in Stage 2 gives breathing room to all stakeholders to recover from Stage 1 and for laggards to catch up.

The Standards work needed for Stage 2 was completed and although there is still substantial work ahead, I believe that "good enough" content, vocabulary, and transport implementation guides are no longer the rate limiting step to healthcare information exchange.

The Policy work needed to support privacy, quality measurement, and patient engagement made significant strides.  As a country, we studied the PCAST report and incorporated its best ideas into existing federal efforts.

ONC itself matured in 2011, solidifying its operations under Farzad Mostashari, transforming from largely strategic to highly tactical, implementing the HITECH programs per the regulations written in 2010.  The Standards and Interoperability Framework filled the gap created when HITSP was sunseted.

State
In 2011, States were challenged to implement Regional Extension Centers, Healthcare Information Exchanges, and in some cases Beacon Communities, Challenge grants, and SHARP research programs. 

I believe there will be shining examples of success in some States, while others will provide lessons learned - political and technical - that will refine future work.

The REC program has been largely successful.   The HIE program is still an evolving work in progress, since HIE is technically and politically challenging, with limited alignment of incentives and few sustainability models.  

It's too early in the lifecycle of the research grants to assess their success.  Much hard work is being done to explore vocabularies, security, modular applications, and novel healthcare information exchange approaches.

In Massachusetts, all stakeholders - payers, providers, patients, employers, academia, and government aligned their efforts by forming an open, transparent state Advisory Committee (similar to a Federal Advisory Committee) to guide all state healthcare IT activities.  The energy and commitment from all the volunteers is inspiring.

BIDMC
2011 at BIDMC was a year of compliance - meeting new regulatory requirements of Meaningful Use, 5010, code 44 (short stay/observation verses inpatient), ICD-10, and the Fair Labor Standards Act (FLSA).    Major IT initiatives automated workflows to support these programs.

Infrastructure continued to grow with storage, bandwidth, and virtual machine enhancements to support Big Data.

Security challenges accelerated with more malware, more sophisticated hacking, and more regulatory penalties for data breaches.   In 2011, BIDMC had two publicly reported breaches, both of which were beyond our control, as they were caused by business associates on infrastructure we did not manage.   The emotional and monetary costs of breach reporting were very significant.

As I said in my post about the Joy of Success,  I believe that all my direct reports accomplished everything I asked them to do - we achieved meaningful use, addressed compliance requirements, and kept the IT staff stable/happy despite the stresses of the year.   They're heroes.

Harvard Medical School
In 2011, I continued to oversee the IT operations of Harvard Medical School during the CIO search process.   My goals have been to keep the IT staff happy, the infrastructure stable, and the budgets on track.   So far, so good.   My staff at Harvard also deserve a big thank you for a job well done.  My teaching, writing, and community service as a Harvard Professor continue at a brisk pace, but I've reduced my travel to the minimum possible to better balance my work and family life.

Personal
In December 2011 my wife was diagnosed with breast cancer, so my personal life has focused on family.   I'm supporting my wife by helping her prepare her artist studio and art gallery business for the 6-8 month hiatus ahead.   I've helped my daughter balance her college life, home life, and travel (she's in Japan now for a brief winter semester abroad) in the weeks following Kathy's cancer diagnosis.  I've put aside all my own pursuits including search for Vermont farmland.

On the positive side, the first semester at Tufts transformed my daughter into a self-reliant young woman.   My parents are healthy.  My own physical and mental health are good.   Our home and garden are well maintained and unlikely to cause a distraction over the next year.   Kathy and I continue to simplify our lives, reducing our belongings, and focusing on a lifestyle that is sustainable, low impact, and fulfilling.

In summary, 2011 was filled with high highs and low lows.   The pace was faster than any year in my life to date.  More happens every day in healthcare IT than the human brain can comprehend and I'm working harder than ever to filter the incoming data (and email) into knowledge and wisdom.

2012 will be a year of healthcare reform, new business intelligence/analytics tools, automating remaining paper processes, and creating the standards/policy/infrastructure necessary to accelerate health information exchange locally, regionally, and federally.     My only wish (beyond my wife's health) is that everyone will celebrate the problems we overcome rather than the focus on the challenges that persist.   Hard work is great if everyone around you is aligned for a successful journey rather than protecting themselves from blame when roadblocks appear along the way.

The Joy of Success

As the year ends, I've spoken to many CIOs.   2011 was a hard year filled with Meaningful Use (including many upgrades to certified systems or self-certification),  5010 (the deadline for upgrading billing systems is January 1, 2012), accelerating compliance demands,  new security threats, rapidly evolving technologies, and unprecedented demand for new projects driven by the consumerization of IT.

At the same time that CIOs and IT professionals are running marathons, they are being held accountable for events that are not directly under their control.   They are not being congratulated for the miracles they create every day, but are being criticized for not moving faster.

What do I mean?

One CIO received a negative audit report because new generations of viruses are no longer stopped by state of the art anti-virus software.   Interesting.  The CIO cannot control the virus authors, nor the effectiveness of anti-virus software.    No one in the industry has solved the problem, but audit firms revel in creating fear, uncertainty and doubt at the Board level as it enhances the reputation of the auditor.

Another CIO was held accountable for infrastructure demands that were not forecasted, planned, or communicated.   CIOs do their best to be proactive, but in the world of Big Data, past trends may not predict future needs.

Another CIO was was given 10 goals and 5 unplanned urgent projects.   She completed 8 of the planned goals and all the urgent projects, yet was told she only met 80% of expectations.

In a world that expects leaders to continuously perform miracles with constrained resources in limited time,  we all need to step back and take our own steps to stop the madness.

With your own staff, celebrate the joy of success and focus on what really matters.

Did you achieve Meaningful Use?

Did you support compliance requirements on time to meet regulatory deadlines?

Did you maintain employee satisfaction and minimize turnover?

If so, you're an IT Leadership hero.

Did your Board or senior management note that a new application or website launched a few weeks late because you wanted additional testing time to minimize risk?

No one will ever remember.

Did you defer a "nice to have" project because an unplanned "must have" occurred mid year?

Good for you.

Did you have a brief infrastructure failure that led to a major improvement in security, reliability, and maintainability because the staff rallied around a tricky problem caused by a combination of rapid technology change and exponential increases in customer demand?

You'll be stronger in the future because of it.

We have to break the cycle of negativity that makes IT leadership so challenging.  Create a culture that thrives on the projects you did well and does not focus on what remains undone because of circumstances beyond anyone's control.

Leaders at all levels - from Board members to team leaders need to realize that shouting louder does not make the rowing staff move the boat faster.

So celebrate the accomplishments achieved by your and your staff in 2011.   It was one of the hardest years in the history of IT and we doubled EHR adoption in the US from 20% to 40%. We need to focus on that success, leveraging our energy and optimism to finish the 60% that remains.

Cool Technology of the Week

In a previous post I described the capabilities of the Microsoft Kinect technology.

I've written about sterilizing iPads and iPhones for use in the operating room and that does work, but there are challenges with subjecting electronics to sterilization.

However, there's another cool option for examining medical records and digital images in the OR - a touch screen you do not touch.  Check out this gestural interface to EHRs and PACS systems that uses an Xbox and Kinect.

Traverse pages, select tabs, and zoom into images using only body movements.

The system, called TedCas, was recently named one of the top applications for Kinect.

That's cool!

We Have Cancer

Cancer.  It's a word that creates fear and uncertainty.   Many of the doctors I know use the word "hate" whenever they discuss their feelings about cancer.

Last Thursday, my wife Kathy was diagnosed with poorly differentiated breast cancer.    She is not facing this alone. We're approaching this as a team, as if together we have cancer.  She has been my best friend for 30 years.  I will do whatever it takes to ensure we have another 30 years together.

She's has agreed that I can chronicle the process, the diagnostic tests, the therapeutic decisions, the life events, and the emotions we experience with the hope it will help other patients and families on their cancer treatment journey.

Here's how it all started.

On Monday, December 5, she felt a small lump under her left breast.   She has no family history, no risk factors, and no warning.   We scheduled a mammogram for December 12 and she brought me a DVD with the DICOM images a few minutes after the study.   On comparison with her previous mammograms it was clear she had two lesions, one anterior and one posterior in a dumbbell shape.    I hand carried the DICOM images to the Breast Center team at BIDMC.

On December 13 she had an ultrasound guided biopsy which yielded the diagnosis - invasive ductal carcinoma, grade 3.

We assembled an extraordinary team of Harvard faculty - a primary care provider (Dr. Li Zhou), a surgeon (Dr. Mary Jane Houlihan), a medical oncologist (Dr. Steve Come), a radiation oncologist (Dr. Abram Recht),  a pathologist (Dr. James Connolly), and a skilled breast imaging team.   I also contacted my associates from the genomics research community.

On December 16, after my daughter's last final exam at Tufts, Kathy told Lara about the diagnosis.   Lara immediately offered her love and support.   We also told the grandparents.

Today, Kathy completed a bone scan and chest/abdominal CT.   Both are negative for metastases.

We also received the receptor studies from the tumor tissue.

HER-2/neu gene amplification - Not Amplified
Estrogen Receptor - Strong
Progesterone Receptor - Strong

Our next step is to complete the staging via an ambulatory surgical procedure on Friday - a sentinel node biopsy to determine if the lymph nodes closet to the tumor have evidence of malignant cells.

Summarizing what we know thus far - the tumor is less than 5 cm, poorly differentiated/fast growing, not yet spread to bones or organs, HER-2 negative and Estrogen/Progesterone Receptor positive.   Once the staging is completed we'll be able to finalize a treatment plan and determine an estimated 5 year survival rate.

Likely, she'll begin with chemotherapy to be followed by a left mastectomy in early 2012.

We'll also explore her genome to understand the risk factors and determine if a bilateral mastectomy reduces future risk.

We'll face many decisions ahead and many emotions.   We've already assembled a community of supporters.

1 in 8 women will develop breast cancer in their lifetime.   We never thought we'd be the one.

My Thursday blogs for the next 6 months will document our progress on the healing journey.

Thank you for your prayers and support.

Accountable Care Organization Measures

On December 19, CMS announced the selection of 32 Pioneer ACO organizations, five of which are Boston-based:  Beth Israel Deaconess, Mt. Auburn, Steward, Atrius, and Partners Healthcare.

To participate in the shared savings model, we'll need to compute 33 different quality metrics and submit them via survey, claims or the group practice reporting web interface (GPRO).

What are these metrics?

7 measure the Patient/Caregiver Experience based on survey
6 measure Care Coordination/ Patient Safety 6 based on claims or submissions to the GPRO web interface
8 measure Preventative Health based on submissions to the GPRO web interface
12 measure care to At Risk Population based on submissions to the GPRO web interface

Here's a comprehensive list of what needs to be computed, how, and when.

At Beth Israel Deaconess, we'll use our all-payer claims warehouse and quality data center.   My role as CIO has been to prepare the necessary analytics for panel and population health, as described in this overview

As I posted from IHI, our challenge ahead will be navigating the new business model while still maintaining the stability of the old business model during the transition.

From a CIO perspective, use this simple equation: ACO = HIE + Analytics  and you'll be ready for whatever tomorrow will bring.

The Standards Work Ahead in 2012

The December HIT Standards Committee included a discussion of the work ahead for the next year based on the priorities we've heard from stakeholders.    We'll have 10 in person and 2 telephonic meetings in 2012.   Our topics by quarter will be as follows

January-February-March
1.  Assuming that the Meaningful Use Stage 2 Standards and Certification Notice of Proposed Rulemaking will be published in early 2012, the HIT STandards Committee will need to review any comments submitted.   In the meantime, we'll continue work on testing criteria and will ensure any test scripts are piloted before they are finalized.

2. Quality Measurement standards
As I've mentioned in other posts, there are three key elements of work needed to improve quality measure computation and submission.   First, quality measures need to be simplified so they are based on data elements that exist in EHRs and are captured during normal workflow.   Second there needs to be a simple mechanism for submitting numerators and denominators (or the de-identified records that make up numerators and denominators) to CMS.   Finally, there needs to be a simple query language created so that new quality measures can be designed without have to write new code.

3.  NwHIN Exchange refinement
Previous analysis by the NwHIN Power Team included recommendations for improving the NwHIN Implementation Guides especially the Patient Discovery Specification and ebXML metadata.

4. Value sets/vocabulary mapping
Ideally the National Library of Medicine will host all the necessary vocabularies and crosswalks needed for Meaningful Use Stage 2 including ICD9, ICD10, SNOMED-CT, LOINC, RxNorm, and value sets (language, gender, smoking status etc)

April-May-June
1.  NwHIN portfolio  - the Direct and Exchange projects require supporting components such as provider directories.   We need to finalize specifications for these items.

2.  Query Health review - in the December HIT Standards Committee meeting we heard about Query Health and sending questions to data rather than aggregating data centrally.   We'll need to finalize the standards for defining medical concepts used in queries, the query language itself, and responses.

3,  Radiology Standards - DICOM is a non-standard standard.  Many manufacturers of image modalities, PACS, and viewing software extend the standard in proprietary ways.   If we want HIEs to support image exchange, we'll need a single, constrained implementation guide for image content.   Ideally we'll separate content standards from transport standards.  At present DICOM mixes the two.

4.  Governance - We need to ensure alignment between the S&I Framework, HIT Standards Committee and SDOs.   Setting common priorities, aligning the work, and coordinating the products of multiple SDOs will take creative governance.

July-August-September
1. Detailed Clinical Models -  as we consider simplified transition of care summaries such as GreenCDA, we also need to consider simplifications to the HL7 RIM such as Stan Huff's CIMI initiative.

2. Consumer-mediated information exchange - HIE needs to include provider to provider and provider to patient models so that we have a patient centered architecture that more easily supports privacy preferences for data exchange.

3. One-stop-shop for resources - HITSP specifications were challenging for implementers because they were based on indirection - a HITSP guide pointed to an IHE guide which pointed to a password protected SDO website.   We need one stop shopping with all the intellectual property necessary for implementation in one place that developers can easily access.   We need to finalize the plan and resources to do this.

4. GreenCDA - Simplified XML that eliminates any need for implementers to know the HL7 RIM  significantly reducing barriers to writing HIE software.   We need to finalize the standard tags for  Green CDA.

October-November-December
1. Maintenance strategy for standards - Once we complete the implementation guides for Meaningful Use, there will need to be ongoing maintenance and improvement by SDOs and other organizations.  We need to figure out how that will be done.

2. Public Health - As new approaches for public health evolve, such as Biosense 2.0 in the Amazon Cloud, we'll need to ensure the standards are available to support them.

3. Data/Practice Portability from EHR to EHR - To date, Meaningful Use has not included the complete export of data from one EHR and the complete import of data into another EHR needed for a clinician to change vendors.   Enabling "EHR portability" would be a great service to the provider community.

4.  APIs/tools such as conformance testing and HIE validation - to support implementers, we'll need  tools that validate the correct implementation of content, vocabulary, and transport standards.

Every year, the national standards activities expand, refine, and constrain implementation specifications.   Although there will always be work to do, we're on a great trajectory in 2012.

Managing Guest Wireless

BIDMC has two million square feet of wireless coverage using over a thousand 802.11n/a/g access points.   We operate two separate networks - a secure network for clinical applications and a guest network for visitors.

The guest network is physically separate from the secure network and uses a commercial 14 megabit per second DSL line from Sprint for internet services, reducing BIDMC's responsibility for malware control and digital millennium copyright act violations.    Like any public, unrestricted network, the guest network offers the freedom to download malware, broadcast viruses, and use insecure applications.

In a world of Netflix and YouTube,  compounded by bandwidth consumptive standards such as MPEG4, the demands on the guest network are infinite.    Can the hospital afford to provide free bandwidth to every visitor (inpatient, outpatient, families, students etc) when 80% of the traffic is streaming video?

If we do provide infinite free bandwidth, will employees and clinicians use the guest network instead of the Enterprise WPA secured clinical network because configuration is easier?    Mixing malware infected guest traffic with secure hospital applications is something we want to avoid.

Historically, we've only used one approach to discourage our BYOD staff from using the guest wireless - keep the bandwidth limited so that the secure network offers a better user experience.    This is an imperfect solution because it means that patients and visitors compete with each other from the shared megabits.   Two months ago, we restricted streaming video 8a-5pm Monday-Friday so that guest network users can reliably check their email and communicate via social networks.

What are other hospitals doing with their guest networks?    I asked several CIOs in Massachusetts:

Hospital A
"We limit the bandwidth of each user on the guest network to ensure a consistent experience.

We can't really block employees from accessing the guest network when they can bring in their own device  It's slow though. We have about 300-400 guests using wireless per day, sharing 5Mbps.

No corporate resources are available on the guest network without a VPN"

Hospital B
"We do not limit the bandwidth of each user on the guest network.  We do web content filtering and block adult content, peer-to-peer traffic, and illegal activities.  We do have the guest network configured for Bronze quality of service level, which is the lowest setting we could give it."

Hospital C
"We do not limit the bandwidth of each user on our guest network.  We do run web content filtering,
block inappropriate sites, and try to block torrents to limit our Digital Millennium Copyright Act exposure."

Thus, the common practice seems to be
1.  Use web content filtering to block inappropriate sites
2.  Block Peer to Peer traffic/Bit Torrent.
3.  Consider user bandwidth limitations
4.  Provide "bronze" quality of service at the network level
5.  Require VPN to reach clinical applications from the guest network

We already have web content filtering and peer to peer blocks in place.  What can we do to enhance the patient/visitor experience while limiting the use of clinical BYOD devices on the guest network?

Our next step is to evaluate the costs of increasing our guest bandwidth,  to simplify configuration when connecting to the secure network, and to educate our providers about the evils of the guest network and joys of the secure network.

And, yes, we have to ensure those BYOD devices are protected while using the secure network.

Although wireless broadband such as 3G CDMA/UMTS and 4G LTE may provide the technical capability for smartphone users to stream video to their devices, the end of the "all you can use" data plans is likely to further motivate users to seek guest wifi networks.

I predict that any capacity increases we purchase will soon be overwhelmed and we'll have to again impose some kind of user bandwidth, quality of service, or time of  day restrictions.

Feel free to share your experience with managing guest network demand.  All comments are welcome.

Cool Technology of the Week

Many of my posts lately have described the challenge of securing and managing consumer devices brought from home.

In the past, I've discussed the products from Good Technologies.

I recently polled the CIOs of Massachusetts hospitals and found two other products that are gaining traction - Fixmo and MobileIron

Fixmo creates a secured, encrypted container, the SafeZone, providing secure mobile messaging and data for businesses.

Companies allow mobile devices into their own SafeZone and can restrict application and data access ensuring device integrity and compliance. A safe, sandboxed environment is created in which mobile devices can run and access network resources without compromising the internal network's safety.

With SafeZone, employees can use all the features on their iPhones and Androids while a section of those devices is secure for sensitive company data. Data within SafeZone is certified FIPS 140-2 AES 256-bit encryption and encrypted within a company's infrastructure to keep data at rest and in-transi

MobileIron enables companies to manage multiple operating systems at a granular level, support corporate and personal devices, enforce controls, and create a private enterprise application storefront for employees.

I predict that many new companies will enter this marketplace over the next year, but for now, Good, Fixmo, and MobileIron are cool answers to the BYOD problem.

Distracted Doctoring

I've written about some of the perils of using consumer devices on hospital networks .

Now add to that risk, the distraction of mixing personal activities with patient treatment.

Blogs are filling with debates about patient safety in a multitasking connected world.

Even the New York Times has published an article about the possible negative consequences of mobile devices.

In that context, AHRQ asked me to write a balanced commentary looking at the quality, safety, and efficiency pros and cons of using multitasking mobile devices for healthcare.

I hope you enjoy it and draw your own conclusions about how these devices are best used in your hospital of professional office setting.

The December HIT Standards Committee Meeting

We began the meeting by relating our standards trajectory to today's agenda.

Our outstanding standards issues for discussion include

1. Content
Continued discussion of GreenCDA on the wire and overview of Stan Huff's CIMI initiative

Standardizing DICOM image objects for image sharing and investigating other possible approaches (e.g., cloud based JPEG2000 exchange).   Consider image transfer standards, image viewing standards, and image reporting standards.

Query Health i.e. I2B2 distributed queries that send questions to data instead of requiring consolidation of data

Simplify the specification for quality measures to enhance consistency of implementation.

The December meeting included an overview of Query Health and Quality measure standards, leaving the discussion of GreenCDA/CIMI and DICOM to our 2012 meetings.

2. Vocabulary
Extend the quality measurement vocabularies to clinical summaries
Lab ordering compendium

The December meeting included a discussion of the lab ordering compendium, leaving the discussion of clinical summary vocabularies to our 2012 meetings.

3. Transport
Specify how the metadata ANPRM be integrated into the health exchange architecture

Additional NwHIN standards development (hearing re Exchange specification complexity, review/oversight of the S&I framework work on Exchange specifications simplification).   Further define secure RESTful transport standards.

Accelerate provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminate lessons learned.

The December meeting included an update on the provider directory and certificate components of transport

Our first presentation was an NCVHS update on ACA Section 10109 by Walter Suarez.

The Committee emphasized the need to coordinate NCHVS work and HITSC work given that division between administrative and clinical data is becoming less distinct over time

Our second presentation was an Implementation Workgroup Update by Liz Johnson about testing procedures that support the certification process.

The committee emphasized the need to pilot these procedures, ensuring they are as simple as possible and reflect a practical evaluation of the functionality intended to support policy goals.

Next, Doug Fridsma and Rich Elmore gave an ONC update.   Rich Elmore described the Query Health initiative, as referenced in my previous blog post about sending questions to data (rather than sending data to registries).

The committee endorsed the work and noted that further research will be needed to link patients across multiple databases to avoid double counting individuals in quality measure denominators.  The work of Jeff Jonas, as described in my earlier blog post about linking identity.

Doug updated the committee about the S&I Framework initiatives - Transitions of Care, Lab Results, Provider Directories, Data Segmentation (for privacy protection), and electronic submission of medical documentation for Medicare review.

We then discussed a preliminary framework for HITSC 2012 Workplan to ensure the items in the standards trajectory listed above are completed in 2012 as we continue to prepare for meaningful use stage 3.

A great meeting.

Standards for Social History

As we all think about the increasing needs of telemedicine and home care to support healthcare reform efforts, I was asked about integrating home monitoring devices into EHR social history data.

To my knowledge, standards for structured social history are still a work in process, but Microsoft has worked hard to standardize exercise data from home equipment as part of their Healthvault device integration effort.

Here's an overview from Sean Nolan:

"We didn't start from any existing standard for exercise data, because none really were forthcoming --- but we did work with the folks at Polar and other fitness-related companies to establish our current representation within HealthVault. The XML schema for our exercise items is documented here.

It consists of two required fields:

* time started
* activity mode (optionally coded against a custom vocabulary)

This follows our practice of trying to keep required fields to a minimum --- so "jogged on 1/1/2011" is a reasonable item

and optional fields:

* distance
* duration in minutes
* name/value attributes (e.g., "average heart rate", etc.)
* segments which each can hold their own distance/duration/attributes (represent splits - there may be one for each leg of a race)

It's amazing how detailed some of the fitness machines get, but this approach seems to be the right balance."

Thanks Sean.    Monitoring diet, exercise, and other observations of daily living are going to be increasing important in a world that reimburses clinicians for wellness rather than procedures and episodic visits.    I suspect observations of daily living standards will be part of the Meaningful Use Stage 3 effort, so is very useful to understand any work in progress.

Sending the Questions to the Data

As hospitals and practices form accountable care organizations, they will accelerate their efforts to build healthcare information exchanges and novel analytics that support community-wide lifetime care rather than siloed episodic care,   This requires "freeing the data" from the EHRs, hospital information systems, and laboratories in which it resides.

There are two basic ways to analyze data for a panel or population.

1.  Send the data from multiple sources to a central repository for analysis.

BIDMC has partnered with the Massachusetts eHealth Collaborative on such an approach to build a quality data center supporting its ACO strategy.

2.  Send the question to the data.

The new federal Query Health initiative is a standards-based approach that enables standardized questions to be sent to multiple federated databases without moving the data itself.

In Massachusetts, we've implemented such an architecture in two ways.

I2B2/Shrine which links together the Harvard hospitals (and many other sites nationwide) with query tools supporting clinical trials and clinical research.

MDPHNet, an ONC funded Challenge grant which sends questions to data sources,  answering public health questions.

MDPHnet is being developed under contract with the Massachusetts eHealth Institute to implement a secure web-based query tool which enables predefined and ad hoc queries to be sent to participating sites, including selected practices within the Mass League of Community Health Centers and potentially, Atrius Health.

Queries are executed locally, securely returned after optional review, and then presented to the requester and displayed in a variety of ways - heat map, histogram, table etc.  Results contain no patient-identifiable data.  Data holders control authorization of requesters and their specific query capabilities.

The current focus for predefined reports is syndromic surveillance (Influenza-like illness) and chronic disease surveillance (diabetes).  It can also support other uses, such as pharmacovigilance and quality measurement.

MDPHnet uses PopMedNet open source software developed by the Harvard Medical School Department of Population Medicine at the Harvard Pilgrim Health Care Institute, with support from AHRQ and FDA. Lincoln Peak is co-developer.

There is great synergy among i2b2, PopMedNet and MDPHnet, since they use a common architectural approach.  Query Health incorporates PopMedNet in its design.

MDPHnet uses the Electronic Health Record Support of Public Health (ESP) common data model.  ESP  was developed by the HMS/HPHCI Department of Population Medicine with support from a CDC Center for Excellence in Public Health Informatics 

The Massachusetts League of Community Health Centers transforms data from their clinical data warehouse into the ESP format. Commonwealth Informatics supports the process as needed.  Additional participants will extract data from their EHR and put it into the same schema (ESP) with help from Commonwealth Informatics.

MDPHnet can be readily expanded to cover other datasources such as the I2B2 nodes which are hosted at over 60 sites nationwide.

Over the next few years I believe that for many use cases we will be sending questions to the data instead of sending the data to centralized registries.    I2B2,  MDPHnet, and Query Health will show us how.

Cool Technology of the Week

In late November, I switched from a Blackberry to an iPhone 4S.  Every day I experiment with  iPhone technologies that can empower healthcare workflow, enhance security, and improve productivity.  

Along the way, I've found Siri and the iPhone 4S voice recognition to be very accurate and I dictate many of my emails.   Of course there are occasional embarrassing autocorrection mistakes that are beautifully illustrated on http://DamnYouAutoCorrect.com.

I've found the camera quality to be amazing and I've retired all my other still photo and video technologies.  I was recently at a Japanese cultural event with my daughter and the master of ceremonies asked for iPhone 4S users to film the dance performance, knowing that the optical quality would far exceed other digital cameras.    The only thing that's missing is an adjustable lens.

Now there is a cool detachable lens set for the iPhone that enables users  to rotate among three different lenses - fisheye, telephoto and wide-angle.   That's cool!  Is it any wonder that Kodak is in trouble?

Another iPhone observation - a fall 3 feet onto concrete is not good for the glass screen (happened to me  when I dropped the phone during a wind storm this morning).   Thanks so much to Adam and Sydney at the Chestnut Hill Apple Store Genius Bar for their amazing replacement and reactivation of my iPhone 4S this evening!

Square Foot Gardening

Over the past year, readers of my blog may have noticed my increased effort to eat locally by growing my own food in my home and community garden space.    As I plan the 2012 season, I'm making a list of the fruits and vegetables I'll want to eat, choosing the seeds from my favorite catalogs like the Kitazawa Seed Company, and thinking about how best to plant them in my raised beds.

Traditionally planting is done in long thin rows.   If you fertilize and water a bed with a few long thin rows, you get a great crop of weeds and less than a maximum yield of the fruits and vegetables you want per square foot of soil.

There has to be a more logical way, based on 3 dimensional thinking.

An innovative book, Square Foot Gardening by Mel Bartholomew logically examines the space and nutritional needs of various plants, enabling you to lay them out scientifically rather than randomly, per the graphic above.   The end result is higher yields, fewer weeds, less watering, less environmental impact, and less work.

This year, I'll be replacing a chunk of my front lawn with a series of 4x4 foot beds, filled with vegetables and flowers laid out via a Square Foot Gardening plan.

Not only will I have more fresh foods for the table, I'll have less grass to maintain, so I'm canceling my 'mow and blow' service and buying a push mower.

As I continue to strive for better personal sustainability and self sufficiency, Square Foot Gardening is one piece of the puzzle that adds to my efficiency.

The Healthcare Leader's Dilemma

At yesterday's IHI conference, I was asked to serve as a panelist for the CEO Summit.   We began the day with an inspirational case study from outside the healthcare industry - the transformation of US News and World report from a paper-based subscription model to a diverse web-centric family of products.

In 2007, it was clear that offering a paper-based magazine below cost, subsidized by advertising, was unsustainable.    Google's sale of targeted adds at low cost eliminated the business models of many print publications.

US News decided to become a specialized web resource offering news, college ranking, hospital ranking, and car ranking.   The advertising on each of these sites is highly targeted and actionable - when a customer clicks on a car, they are redirected  to a local car dealer's website.   At a time when web-based advertising may be $1.00 per 1000 clicks, US News and World report can charge $30.00 per 1000 clicks for qualified car buying customers.

This transition required layoffs, sale of the paper-based subscription customers to Time magazine, and a significant temporary reduction in sales in order to transition to an entirely new business model.  The future was unknown and the path to get there was risky.   In retrospect, it was exactly the right thing to do.

In healthcare, we are at a similar crossroads.

In an era of healthcare reform, we have three challenging choices

*Become a pioneer Accountable Care Organization (ACO) at a time when no one knows exactly what is necessary to succeed, but risks are minimized for early adopters

*Wait to become an ACO until the tools and technologies needed to succeed are better known, but risks for failure will be higher

*Continue to rely on fee for service income and hope healthcare care reform is delayed or deferred.   If healthcare reform proceeds, fee for service income will drop steadily over time leading to the slow demise of organizations which depend upon it.

Just as it was an educated guess to move US News and World Report to the internet in 2007, moving healthcare organizations to population health/wellness-focused accountable care organizations seems like  the right thing to do.  Yes, it may result in the downsizing of academic health centers and a reduction of some services like lab and radiology that are more expensive than community-based dedicated labs and imaging centers.   However, the future of healthcare looks a lot more promising for community hospitals and outsourced ancillaries than for academic health centers with high overhead costs.

Jim Reinertsen MD, Senior fellow of IHI and former CEO of CareGroup moderated a discussion of these ideas with Derek Feeley, Chief Executive of the National Health Service (NHS) in Scotland , George Kerwin Chief Executive Officer of President Bellin Health Systems, and me.

Our panel agreed with the model shown in the graphic above.   We're on a journey from episodic care to coordinated care to patient directed care.   We're moving from fee for service to bundled payments/capitation.   Our IT systems are evolving from segmented to integrated to community based.

Healthcare leaders must make a decision  Change now and risk moving too soon, incurring high costs.  Wait and risk moving too late, losing your competitive advantage.

In Boston, the healthcare marketplace is evolving so rapidly that our answer is clear - we must move to community-based coordinated care funded through bundled payments/capitation.  Implementing this transformation over the next few years will be a challenge for everyone, and along the way we need to ensure that the patient experience is not compromised.   We'll need leaders with a vision of the future, a guiding coalition of stakeholder supporters, a sense of urgency from the external environment, and a tolerance for risk.   I'm eager to be a part of the next phase in healthcare and look forward to learning from the people who make it happen.

A great discussion - thanks to IHI for the opportunity to participate and Jim Reinertsen for facilitating it.

The 2011 IHI Conference

Today I'm at the Institute for Healthcare Improvement Annual Forum in Orlando.

Every year, the keynote frames the state of healthcare in the US and the work ahead to make it better.

Maureen Bisognano delivered an energetic keynote that I would summarize as "join a community of motivated people and change the world"

She started with a refection on the book Connections by James Burke.   Innovation happens when people come together as teams and seize the right opportunities at the right time, often by accident.   Change can be surprising when different ideas combine, leading to a sum greater than the parts.  1+1 will equal 3.

Every year at the Annual Forum,  IHI brings together the healthcare community to share stories of improvement efforts with the hope that these lessons learned will spark innovation around the globe.  By listening to others stories, healthcare leaders will be inspired to envision a different, better future.

Maureen described IHI's goals as

*Realize Patient Centered Care and Outcomes

*Strengthen Healthcare Delivery Systems

*Drive the Triple Aim - improving the experience of care, improving the health of populations, and reducing per capita costs of health care

*Build Improvement Capability

She shared examples of people and organizations that have embraced these goals.

Christian Farman, an engineer and athlete from Jonkoping, Sweden developed glomerunephrtitis and the dialysis treatments were making him sick.  He worked with his nurse to design a program of self dialysis, putting him in control of his own health.  Today at the same Jonkoping dialysis center, 60% of patients self dialyze.  Christian returned to health, quit his engineering job, and became an RN.

Derek Feeley leads the National Health Service efforts in Scotland, where he has worked tirelessly to reduce central line infections and ventilator associated pneumonia.  Today, the central line infection rate in Scotland is zero - that's quality improvement for an entire country, not just a single healthcare system.

Intermountain Healthcare has reduced recovery times for ventilator dependent patients by encouraging early mobility - walking and exercising even before the ventilator is removed.

Kaiser has supported 6 million e-visits, using the web in creative ways for diagnosis, treatment, and followup.

At the Centers for Disease Control, Tom Frieden has championed the health impact pyramid - categorizing the interventions that have the greatest impact.   The base of the pyramid is socioeconomic factors followed by changing the context of decision making, long lasting protective interventions, clinical interventions, education and counseling.   The most effective way to treat chronic disease may not be a mediation or education, but eliminating homelessness and improving diet.

Maureen described the remarkable effort of a community group working to eliminate homelessness and improve health - www.100khomes.org

Socioeconomic factors are critically important when the economy is fragile.  Current 20% of the US has less than $1000 in savings.  50% has less than $5000.   At the same time
5% of population accounts for 50% of the cost of healthcare.

We live in an era of information and have an ability to share experiences ad collaborate on innovation more than ever before.

It's up to us to spread our stories and make a difference, working together as a community.

The Promise of Electronic Healthcare Records

Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should frustrated that he was never confirmed.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care.   When I make decisions today, I reflect back on that intense training.  However, thousands of journal articles have been written since then, there's new evidence suggesting more effective treatment plans, and new therapies are available.   How do I ensure the just the right amount of care is delivered - neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders - just in time advice as to what my patients need.  Educational materials and literature can be embedded in the workflow for easy reference.  Population/panel health tools can identify those patients who need followup or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system - it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers.   Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport,  vocabulary, and content standards needed to support it.  Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume.   Some are so arcane that experts cannot agree on the interpretation.    If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests - building new functional or purchasing new products to meet every increasing numbers of rules.    We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.

Fraud

Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse.    Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense - Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance.   Don Berwick is a great supporter of the EHR's potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform - the federal 5 year plan to increase the use of electronic health records and healthcare information exchange - has broad bipartisan support.  

As Don Berwick returns to the private section, I'm hopeful that he'll turn his energy back to fixing the US healthcare system and that he'll be a tireless champion for electronic health records.

Tonight, I'm flying to the Institute for Healthcare Improvement Conference in Orlando to serve as faculty for the CEO summit.  I'll report on Maureen Bisognano's keynote tomorrow morning.

Cool Technology of the Week

Now that I'm a Macbook Air and iPhone 4S user, I find myself consuming multiple electrical outlets when I travel.    There's a solution - the Plugbug from Twelve South.

The Plugbug is a simple addition to your existing Macbook adapter that enables you to charge the Macbook and your iPad or iPhone simultaneously.

Twelve South has many other interesting Mac accessories to declutter your desktop and enhance your use of Apple devices.

Simple charging with one adapter for all your devices - that's cool!

Family Friday

I rarely take vacations and only celebrate major events (like birthdays) when schedules permit my family to assemble, since celebrations are more about the people present than the day of the event.

Thanksgiving weekend is one of those dates when everyone's celebration schedules coincide.  It's common to travel on Wednesday, to spend Thursday preparing a meal together, and to take Friday as a vacation day.

This year, I received fewer than 50 email on Friday, November 25, down from my usual daily count of 1000-1500 messages.

I believe that shopping during the holidays is a contact sport.   Traffic slows to crawl , tempers boil, and now there's even pepper spray to worry about.

Unless some twisted souls think of Black Friday as entertainment, I believe the concept should be replaced by Family Friday.

Talk a walk, go to the zoo, play Apples to Apples, talk about the future, have a Kazoo concert.

My experience with discounts, sales, and bargains is that they will be offered again or tempt you to buy something unnecessary.   A designer tie that's discounted 50% is no bargain if you have enough ties already.

I do not reserve my shopping for any particular day of the year or align it with any retailer's event.

Instead, I use Consumer Reports  to identify high value products - good quality at reasonable prices.   I buy few things, but always buy them to last, given that the real expense is churn - buying a poor quality item 10 times is generally more expensive than buying a good quality item once and keeping it for years.

My Prius has 120,000 miles on it and likely will be fine through 200,000 miles.   I'll replace it when its total cost of ownership exceeds the value of a replacement, regardless of the date on which that occurs.

I realize there are implications to discouraging a retail frenzy on Black Friday.  Sales imply profits which create jobs.

However, if we consider the big picture - that the US needs to move away from a consumer economy back to one in which we create innovative products and services that the world wants to buy, we'll not need Black Friday.

So let's spend time with our families next Black Friday and focus on innovation at work next Cyber Monday.

Our country and our sense of well being will be better for it.

Creating the Office Space of the Future

Today I met with a multi-disciplinary group at BIDMC that is rethinking traditional academic medical center office space and is planning the office space of the future with innovations such as shared open floor plan workspaces, "huddle rooms" for ad hoc meetings, shared IT infrastructure, easy to use wall mounted displays,  electronic conference room availability indicators, and ubiquitous use of scanners to eliminate paper.

Like many academic medical centers, BIDMC has a high demand for closed door offices but has a limited supply of real estate.   Most clinicians are in the their office less than 10% of the time, so conventional approaches to academic departmental space are very inefficient.

Today's meeting focused on work flow. How is clinical and administrative paperwork eliminated in a shared office space environment?  Who does scanning/metadata tagging/quality control of scanned documents?  What regulatory/compliance issues need to be addressed as paper filing cabinets are turned into electronic folder systems?

Clinical scanning is easy - we already have a comprehensive approach that uses high speed scanners, Captiva software, and an automated upload directly into our medical record.

Administrative scanning is harder - we have not implemented a document management system such as Documentum.    I welcome advice from my readers - how you eliminated administrative paper storage with scanning?  What are your retention and security policies?   How do you query and retrieve selected documents?

Since there are no closed door offices in the new design, several small "huddle areas" enable ad hoc private meetings with automated electronic display of room availability and appropriate wall mounted LCDs supporting presentations from laptops and iPads.

Finally, since new data will be entered electronically and not on paper, we've deployed eScription voice recognition software in our data center.   Clinicians can use a phone or an iPad/iPhone app to upload voice files for immediate voice recognition and insertion into our electronic record.

There will be many lessons learned from this office space of the future.  Hopefully we'll offer a very attractive space with high productivity in a smaller real estate footprint that is used efficiently    More to come as we go live.

Green CDA Over The Wire

Over the past decade, I've been closely involved in the evolution of clinical summary/transition of care content standards.    We started with CDA, then merged the CDA and CCR to create the CCD, which we further constrained with the C32 implementation guide.  This year, the Consolidated CDA initiative refined/constrained/optimized the CCD/C32 specifications from IHE, HITSP and HL7 into one easy to use implementation guide.

The only problem with CDA-based standards is that implementation requires expert knowledge of the HL7 Reference Information Model (RIM), a steep learning curve for new developers.    Ideally, HL7 and informatics experts would use the RIM or Detailed Clinical Models to develop templates containing easy to read and parse XML that does not require knowledge of the underlying information model.

Green CDA aims to do that - the simplicity of CCR XML tagging with the expandability and modeling of CDA.    However, there is a controversy.  What do we send on the wire - full CDA or Green CDA?

At the November HIT Standards Committee meeting we endorsed moving forward with GreenCDA as the single over the wire format.

It's likely that existing users of full CDA over the wire will be concerned about the costs and effort required to move to Green CDA on the wire.

Robert Worden, an expert on HL7 mapping tools, wrote a great summary that explains the path forward through the use of transforms:

"There is now tooling which can define a Green CDA and generate 100% reliable transforms to full CDA, all in the same step.  That tooling is being used in the UK for the NHS Interoperability Toolkit; and it has been linked to MDHT, so it could be used to Green consolidated CDA and generate the transforms.

Once you have reliable, maintainable transforms, the question “Green CDA or full CDA on the wire?” becomes much less crucial. Any organization, such as ONC, which wishes to endorse Green CDA over the wire (to make life much easier for implementers), can do so, provided they make the transforms readily available. Then, people can use Green CDA over the wire – but anyone who prefers to receive full CDA can always do so, by applying the transform to the Green CDA he receives. RIM experts and non-experts can both be happy.

It is like using banknotes instead of gold for currency, as has been done for several hundred years. Using gold bars for every transaction would be very clumsy, so people used notes which were backed by gold. The bank “promises to pay the bearer on demand” the equivalent in gold. Similarly the Green=>full transform “promises to pay the bearer on demand” a full CDA, if he wants it.

HL7 has now realized that its CDA gold bars are rather clunky, and should encourage the use of banknotes, backed by its RIM-based gold semantics. CDA is the reserve currency, and Green CDAs are the banknotes that people want to use (but counterfeit notes, not backed by the gold transforms, would be worthless!)."

Green CDA over the wire is the right future state.  Transforms will help us get there without requiring stakeholders to rip and replace what they have already built.

We have a plan!

Ambulatory IT Priorities

The BIDMC Clinical IT Governance Committee was chartered to prioritize project requests and ensure our clinical applications work together as a managed portfolio.

Today we met to discuss ambulatory/outpatient priorities for FY12.

Here's the presentation and the list of ambulatory priorities.

Our top priorities include those workflow enhancements that are necessary to support all the stages of Meaningful Use and emerging healthcare reform requirements.

Key items include many "close the loop initiatives" such as enhancing electronic bidirectional referral communications between primary care givers and specialists.

Also we want to ensure that every diagnostic result - radiology, lab, and pathology/cytology is "signed off" by the ordering clinicians and followup is arranged for any abnormal findings.

Health Information Exchange is always a priority for BIDMC and we continue to be the pilot site for many community efforts which support care coordination, population health and public health.

We're been a leader in e-prescribing and medication management workflow.   Electronic pharmacy initiated renewals (rather than calling your physician) for all our patients will be complete in FY12.

We'll continue to implement novel decision support tools so that clinicians are given the right actionable information at the point of care.

We know that population/panel management tools are important to support accountable care organizations and we'll use tools outside of ambulatory systems to produce the necessary reports but make them available inside our ambulatory systems.

Governance is key to demand management and per my recent Thanksgiving post, our governance committees try to complete 80% of the requests we receive.   This is not triage, it is stratification.   Per the presentation at today's Clinical IT Governance meeting, we'll definitely do our high priorities this year, but lower priorities may or may not be completed based on the unplanned work that arrives, especially "must do" compliance requirements.

There is Hope

Every Thanksgiving I reflect on the state of the world, the state of Healthcare IT, the state of my various roles, my family, and my life.

My message this year - there is hope.

Some may think that the tone of my blog has changed in 2011 - from a focus on cutting edge technology that will revolutionize healthcare to themes of compliance, limited resources, unbridled demand, urgent unplanned projects, and security challenges.

That's a valid observation.

In my 15 years as CIO, I've evolved from creating innovative applications to maintaining customer relationships.     I've gone from strategic visionary to resource planner.

This transformation is not about me or my jobs, it's about the world we live in.   According to the Center for Health System Change, households with Broadband in the US increased from 47% to 66% from 2007-2010.  Smartphones are ubiquitous and the majority of households in the US are IT savvy.  That creates a very different expectation for Healthcare IT service delivery.

When I first started as a CIO, mobile devices had not yet been invented, computers were the domain of geeky early adopters, and solutions to problems involved workflow change, not automation.

Today, most of my work is managing demand.   I aim to complete 80% of the requests I'm given.   I've been told that 50% is typical.  Few other industries move so fast and yet have so little tolerance for mistakes.

So, why do I have hope?

I recently met with a Clinical Fellow who is very likely going to be chair of an academic department or a senior hospital administrator some day.

We spoke about the need to understand workflow, the need change behavior, and the critical role of piloting new processes before automating them.

We talked about the need to balance functionality, security, and maintainability.   We talked about defining requirements before selecting a solution.

In my blog about Content verses Context, I described the job of the CIO as becoming increasingly impossible because many people expect flying cars when we live in an era of IT bicycles.

However, it is clear that the next generation of leaders, who were born in the 1980's personal computing era, understand that technology is the easy part - policy and process are the hard part.

Also, I have hope because I believe the BIDMC FY12 IT Operating Plan is well aligned with the needs of the business.  Today I did a "Venn analysis" of 5 resources

*The BIDMC FY12 IT Operating Plan
*BIDMC FY12 requirements from key customers
*The BIDMC FY12 Annual Operating Plan
*The Meaningful Use Stage 1 and recommended Stage 2 Standards and Certification criteria
*Emerging Compliance projects

I found that the existing BIDMC FY12 IT Operating Plan addresses the needs of all these stakeholders.  There are only a few items to defer or reconsider.

Today, the CEO of BIDMC, Kevin Tabb, sent out his Thanksgiving message and highlighted BIDMC Information Systems: "We were named the #1 health care IT organization in the United States for 2011 by Information Week 500, and BIDMC was the first hospital in the country to achieve Meaningful Use of electronic health records, meeting a key set of new federal government standards."

I'll transition my Harvard Medical School CIO role by February 2012.  I serve on the search committee, which is following a multi-stakeholder process to find a visionary CIO to lead a great organization.

In my International, National, and State lives, I've worked with incredible people and the trajectory is very good.   In 2011, we completed a  healthcare IT plan for Japan and for New Zealand.    The content, vocabulary, and transport standards for the US are submitted to ONC, completing the foundational work for Meaningful Use Stage 2.   The State of Massachusetts has submitted a new State Medicaid Health Plan and completed a new HIT Strategic and Operational plan.

But most importantly, my family life is earning an A.

My daughter has blossomed into a resilient college woman with clear goals, deep friendships, and a very positive self-worth.   She's excelling in her coursework, immersing herself in the culture of Tufts University, and traveling to Japan as part of study abroad program this winter.    I'm so proud that she has left the nest and is building a life on her own.

My wife and I are planning the next stage of our lives and we'll be in Vermont this weekend visiting farm properties.   I'll be 50 this year and  although I have many years to go before retirement,  it seems the right time to find a property to grow organic vegetables, raise chickens/goats/llamas, and revel in a self sufficient lifestyle, learning to live nearly off grid.

My parents are doing well in a new house and enjoying time with friends, cultural events, and gardening time.

So, there is hope.   The world is experiencing a challenging time marked by economic fragility and social unrest.   The Occupy movement is raising our consciousness about the disparities in the US.    However, it is possible for a strong team of people working hard to excel in healthcare IT.   It is possible for your family to thrive based on love, trust, and lifelong learning.

Revel in the next few days of Thanksgiving (we're roasting root vegetables, Brussel spouts and tofu).   When you receive your next challenging email or are asked to define a timeline before you understand requirements, scope, or resources, take a breath.  There is hope!

More BYOD Worries

I've written about the increasing trend to Bring Your Own Devices (BYOD)  to work and the accountability it brings to the CIO.

Every day I receive articles highlighting the increasing risk of mobile devices on the network

The explosion of Android malware 

The hacking of Siri 

The vulnerabilities of the iPad 

It's very clear that in 2012 and beyond we will have to move beyond policy-based controls  and we'll have to implement technology based controls that may cost up to $10 per device per month.   Given our 1000+ mobile devices, that could be a $150,000/year increased operating expense to protect consumer devices brought from home.

In many ways, 2012 at BIDMC will be the year of increased compliance and we've just named an interim Senior VP of Compliance to build an enterprise-wide compliance team.

CIOs - it's time to tell your CFO to expect an unplanned 6 figure expense to protect your institutional data while at the same time embracing the mobile devices that will enhance productivity and user satisfaction.

The Job of a CIO - Content verses Context

I recently spoke with the CIO of Boston Medical Center, Meg Aranow, who I respect a great deal.   We talked about the nature of our jobs, the state of the industry, and the change ahead that is needed to support healthcare reform.

She offered a profound observation - the content of our jobs is great, the context is really challenging.

What does that mean?

Who could ask for better content - cool applications that support live saving medical care and cutting edge research.   Innovative healthcare information exchange, patient engagement, and workflow applications.    Multi-million dollar infrastructure, great staff, and interesting problems to solve.   During my years as an undergraduate, graduate, medical student, and post doc, I dreamt about such content.

However, the context of being a CIO is a struggle.   Don't worry, I'm not depressed or pessimistic, just sharing the observations I'm hearing from other healthcare CIOs in 2011.

*You'll create miracles every day (99.99% reliability and great security with a low budget), but you'll not receive credit for everything that works.   Instead you'll be held accountable for the .01% that doesn't.

*No matter what your budget, demand will always exceed supply.  Success will be finishing half the projects you've been asked to do.   You're unlikely to keep a significant percentage of your customers happy.

*You'll be asked to share more data with more trading partners for more purposes, but be held accountable for all privacy breaches, even though you cannot control many of the data flows.  Users will demand controls over their devices, bring devices from home, and expect broad freedoms, but you'll be responsible for any security problems they create.

*The pace of consumer IT change - new products and new services arriving every few months - will create expectations for IT service delivery that far exceed  the abilities of a thinly staffed IT organization.

*Regulatory burdens will increase exponentially.   Compliance is a must do but customers will not appreciate that work.  20% of your budget will be spent on compliance, 20% on security, and 60% on operations.    That leaves nothing for innovation (unless its required for compliance or security).   Meaningful Use, 5010, ICD-10, new Privacy rules, and healthcare reform will occur simultaneously.

*Every year the amount of infrastructure and applications you support will increase dramatically.   However, budgets will increase 2-3% or stay flat.   You'll be asked to do more with less.   Before long, you'll be asked to do everything for nothing in no time.

*Healthcare organizations in the US are structurally flawed.   Hospitals are essentially hotels with operating rooms and patient rooms that are rented by the doctors.   Hospitals (other than Kaiser) do not employ the doctors so it's a bit like Toyota owning the factory but allowing the workers to build whatever they want.   How about a car with 7 doors and 2 trunks?   No problem - do what you want inside the factory.   IT will be caught in the middle because hospitals and doctors will want technology solutions that may not be aligned.

*You'll need to constantly change systems while keeping them stable and secure.  It will be like changing the wings on a 747 while it's flying.

*Many IT services will not be charged back and the demand for a free service will be infinite.   Users will consume whatever computing, storage, and network bandwidth they wish, but you'll be held accountable for provisioning enough to support demand you cannot control.

*Unplanned work will consume 20% of your agenda.  Compliance/regulatory change, auditors, and reaccreditation will require urgent redeployment of staff, but you will be held accountable for all the projects that were delayed.   You should plan for unplanned work.

Demand management, even with good governance, will be an increasing challenge for CIOs in the future.    Here's a bold thought - might the context of being a CIO be nearly impossible in 2012 and beyond,  requiring us to rethink the way that IT services are planned and delivered in the future?

As I hear more from my fellow CIOs about compliance burdens, overwhelming demands, and impossible expectations, I will compose another post, speculating about IT organizational models for the future that enable CIOs to improve the context of our work.

From Blackberry to iPhone

Last week I retired my Blackberry Bold, removed myself from the Blackberry Enterprise Server, and began using an iPhone 4S as my mobile email, web, and telecommunications platform.

This was not a casual decision.   I've used Blackberry products since 1998.  The original Blackberry 850 was named one of the top 50 technologies of the past 50 years.

I receive a wireless communication approximately every 30 seconds from 7am-7pm every day.  On Tuesdays and Thursdays I receive over 1500 emails per 24 hour period.   These communications are filled with media - documents to read, presentations to review, websites to access, and streaming video.    Yes, I still use the email triage approach I outlined in 2007 but it's a losing battle.   The volume of communication exceeds my ability to process and respond to the information.   I could cancel all my meetings, phone calls, and presentations but still fill the entire day with email communication.

I'm not suggesting this is healthy or sane, but it is the reality of communications today.

The iPhone 4S gives me a touch screen user interface to scroll, zoom, and manage my incoming messages.   I can view every document, website, and video over 3G networks.   Siri and voice recognition features enable me to manage my email by voice.   I find myself dictating responses to about a quarter of my email with amazing accuracy.

I'm still in the learning stage, so my ability to type on a touch screen is still not quite as nimble as on the Blackberry keyboard.   It's also harder to type while walking between meetings.    However, the learning curve is fast, and the toolset provided by the 4S includes much better web browsing and Exchange integration than Blackberry.  My Macbook Air running Mac OS X Lion with Apple Mail/iCal/Address book is essentially the same software as on the iPhone 4S, so I can switch seamlessly from my mobile device to my laptop with perfect data synchronization.

RIM has been an innovator.   The Blackberry is secure.  The Blackberry has been easy to manage at the enterprise level.    However,  Blackberry is architected to route messages via RIM's centralized infrastructure.  If that fails, every Blackberry in the world fails.   Blackberry's user experience has not kept pace with the competition.   Blackberry's application development tools and app store have not kept pace with iPhone or Android.   Devices such as the Playbook have been introduced before they were ready.

All companies regress to the mean  and for RIM it appears to be the beginning of the end.   In the past year, its stock has declined from 70 to 20, a loss of 70%.

The pace of technology change is accelerating so fast, that even those of us in the industry can hardly keep up.   The consumer device world is a shark tank.    Competition is fierce and devices come and go as fast as hemline heights and tie widths change.

My switch to an iPhone 4S was predicated on a need to communicate with more flexibility, power, and speed than a Blackberry could support.

 I'm not the only one.  Per our email administrator:

"I'm seeing a slow death of Blackberry.  We have about 400 people still on the Blackberry Enterprise Server. I imagine as contracts expire more will jump to iPhones and Androids.  We lose 5-10 Blackberry accounts per month. iPhones currently outnumber Blackberry 3 to 1"

Thus, you'll likely be receiving iPhone 4S emails from me, generated via voice recognition.    Apologies for the typos, I'm still learning.

Cool Technology of the Week

This week, I was asked to evaluate a longstanding slow website problem.

One of the most challenging questions that CIOs receive is the "application is slow, can you fix it?" problem.

Root causes range from underpowered laptops, virus infected desktops, slow wireless connections, firewall congestion, web server memory leaks, storage I/O bottlenecks, database indexing, and poorly written HTML.

For this particular issue, I suspected application issues in the use of Javascript, style sheets, graphics, and flash objects, not infrastructure.

A quick search on Google yielded this great website optimization tool , which is a companion to an O'Reilly book Website Optimization: Speed, Search Engine & Conversion Rate Secrets by Andrew B. King.

It diagnosed the problem immediately as an inefficient web page design.   We implemented compression of stylesheets, Javascript, and images, which increased performance ten-fold.  The entire site is being rewritten and we'll be sure to use this tool before go live to verify that we've followed best practices.

A great tool and an O'Reilly Book for optimizing website performance - that's cool!