Cool Technology of the Week

Clinicians have been adopting iPhones, iPads, and iPod Touches so fast that they have become the most popular mobile devices at Beth Israel Deaconess.   One problem - how do you use these devices in the wet and messy world of medicine?

The answer - a waterproof "case" called a Frog Skin.

How does it work?  Here's a goofy You Tube video that demonstrates the product.

Frog Skins are available for all the iDevices (iPhone 3GS/4, iPad/2).   They are not actually a case, but rather a film-like covering that is clear and wraps around. the device.  We tested it by making a phone call in a glass of water.   They are completely waterproof, but probably not under pressure.

But can you sterilize an iPhone/iPad for use in the Operating Room?

Here's Dr. Henry Feldman's description:


Last night we ran the big experiment, and placed a Frog Skin encased iPhone 3G in an ethylene oxide sterilizer (for surgical instruments that can't go in an autoclave).  We sterilized the iPhone. The cycle was  6 hours of gas time, and 12 for outgas.  I  turned the phone off, so no activity would occur causing heat or a spark, since ethylene oxide is flammable. I placed a gas detection strip inside the Frog Skin and one inside the sterile pack. The pack was placed in the sterilizer with all the other surgical instruments.

The photo above shows the iPhone inside the sterilization package (as it would be delivered to the Operating Room).  Note that both tags have turned blue. This means that gas got inside the Frog Skin.   The entire iPhone is sterile as the Frog Skin does not stop the gas. The phone booted without problems, and operates fine inside the skin.   In summary,  eth-ox doesn't affect the iPhone in any way.  The Frog Skin (polypropylene) does not stop the eth-ox form getting to the phone but will prevent Operating Room liquids from getting into the phone. And yes, you can operate the phone with gloves and the Frog Skin on.

That being said,  putting an electrical device inside of an explosive gas atmosphere is done at your own risk! (this is a oxygen depriving unit, so there should not be a fire possibility, although during outgas time there may be a risk)

We now have an iPhone/iPad solution for wet, messy health care environments, even in the Operating Room.   That's cool!

My Non-Linear Work Stream

In the era before Blackberrys, iPhones, instant messaging, social networks, and blogs,  I had a predictable day.

I could look at my week and count the meetings, lectures, phone calls, writing, and commuting I had to do.

Although my schedule was busy, I could schedule exercise time, family time, and creative time.

Today, I would not describe my work day as linear or predictable.   I do as much as I can, attending to every detail I remember, and hope that by the end of the week the trajectory is positive and the urgent issues are resolved.

Here's what I mean.

Since there are no barriers to communication, everyone can communicate with everyone.   Every issue is escalated instantly.   Processes for decision making no longer involve thoughtful steps that enabled many problems to resolve themselves.     We're working faster, but not necessary working smarter.   We're doing a greater quantity of work but not necessarily a higher quality of work.

Everyone has a mobile device and their thoughts of the moment can be translated into a message or phone call, creating a work stream of what amounts to hundreds of "mini-meetings" every day.

As issues are raised over the wire, the follow on cc's result in a volley of messages, thoughts, and more "mini-meetings".

The linear part of our work streams - face to face meetings, presentations, and travel - interrupt the non-linear work streams running through our digital lives.   Watch how many people use their mobile devices while in meetings and lectures.   Watch how many people need their Blackberry pried from their hands by flight attendants as planes are taking off.    Each day has turned into two work days - the linear one which is scheduled and the non-linear 24 hour flow through our devices and social networking applications.

I do my best to resolve every issue and declare closure on the events of each day.   However, I find myself waking up from my few hours of sleep with a full queue of tasks because our non-linear work stream is no longer is bounded by a work day.

What are the solutions to the overload we are all currently experiencing?

1.  We could eliminate the concept of 1 hour meetings, 1 hour lectures, and airline travel, realizing that much of what we need to do can be accomplished in tweets, emails, instant messages, and calls.   The non-linear work stream becomes our work and we stop trying to schedule a linear workday in the middle of it.

2.  Alternatively, we can realize that the non-linear work stream is ultimately unsustainable, tossing our mobile devices as in the Corona beer commercial.

3.  We could begin to reduce the non-linear work stream by de-enrolling from Twitter, Facebook, Google+, LinkedIn, Plaxo and Instant messaging.  We could maintain just a single email account and triage it well.

I'm not sure which answer is right, but I do believe that the conflict between our linear and non-linear work streams has reached the point where we all have "continuous partial attention"  unable to focus more than a few minutes on any one linear task.

I write my blogs in the middle of the night because that is the only moment when the non-linear work steam dips to a point that I can capture my thoughts in a single burst of uninterrupted writing.

It's clear to me that our work lives and styles are evolving.  Might there be a day when "work" is plugging into a network and managing the stream of communication, decisions, and  ideas for 9 hours a day, then unplugging and turning the stream over to the next person on shift?  Sounds very Metropolis but I'm not sure any of us can return to the linear work streams of the past.

The September HIT Standards Committee Meeting

Today was a big day - the end of Standards Summer Camp.   We presented the HIT Standards Committee work of the past 6 months and then attended a celebratory reception at the White House.

Judy Sparrow, the ONC "national coordinator" who orchestrated all our HITSC meetings, announced her retirement last month.   Jon Perlin and I presented her with a silver bowl, engraved with the words "The Standard Bearer".   Thanks for all you've done, Judy.

As we discussed our Summer Camp work during the meeting, we were guided by a few basic principles:

While it might not be perfect, does it represent the best we have at this point in history?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed going forward through the SDO community?

Doug Fridsma presented an overview of our Summer Camp activities to date:

The Metadata Analysis Power Team lea by Stan Huff completed the standards for patient identification, provenance (which organization generated the data), and security flags.   Simple XML constructs from CDA R2 and standard X.509 certificates were chosen for these requirements.

The Patient Matching Power Team led by Marc Overhage completed its analysis of best practices for patient matching, noting the types of demographics that should be captured in systems to optimize the sensitivity and specificity of patient matching applications.

The Surveillance Implementation Guide Power Team led by Chris Chute chose one implementation guide  for each of the public health transactions - surveillance, reportable lab, and immunizations.   We had a spirited discussion about the optional fields in the implementation guides and made it clear that we want the core elements to be the certification criteria.   We do not want each state public health department to mandate different "optional" fields.   Our transmittal letter will note that EHRs that send the core set should meet the certification criteria.  Public health departments should accept this core set.   Optional fields are just that - optional items for future reporting needs.

Farzad Mostashari, National Coordinator, framed the important discussion of transport standards by noting that we must move forward, boldly specifying what is good enough.   If we specify nothing, the silos of data we have today in hospitals, clinician offices, pharmacies, and labs will persist.   There's a sense of urgency to act.

The NwHIN Power Team led by Dixie Baker presented its thoughtful analysis of the 10 standards guides included in NwHIN Exchange and the 2 standards guides included in NwHIN Direct.   This analysis was not a comparison of the two, but was an objective look at the suitability of each standards guide for its intended purpose to support aspects of transport functionality at a national scale.   The team did not discuss their suitability for use at the local, state, or regional scale.   The team did not declare "push or "pull" as a superior architecture.    Their thoughtful analysis led to a very robust discussion.    I'd summarize it as:

*Direct is low risk for the purpose intended, pushing data from point A to point B using SMTP/SMIME with an optional XDR (SOAP) connector.   Additional work needs to be done on certificate discovery, but that will use DNS and LDAP, two well adopted technologies.

*Exchange needs additional work to ensure it scales at a national level for pull and push transactions.   The S&I Framework teams are working on modular specifications that should enable a subset of Exchange components to be used, simplifying implementation and support.   The Standards Committee will seek additional testimony from Exchange implementers to learn more about their experience.

*It's worthwhile to think about additional transport standards that do not yet have well specified implementation guides, such as a combination of REST, oAuth and TLS - something that Facebook, Amazon, or Google would use to create a highly scalable transport architecture.

The ePrescribing of Discharge Meds Power Team led by Jamie Ferguson presented the use of HL7 2.2-2.51 transactions to support hospital information system workflows in a manner that is compatible with Medicare Part D.   We clarified that newer versions of HL7 2.x which are backward compatible should also be allowed.

The Clinical Quality Workgroup and Vocabulary Task Force led by Jamie Ferguson presented their transition plans for vocabularies, identifying the cross maps between vocabularies that need to be created and supported as we evolve from our current use of vocabularies to a future state in which there is one structured vocabulary per domain of medicine (problems, medications, labs, allergies etc).

Doug Fridsma then presented an overview of the Standards and Interoperability Framework activities and next steps:

Transitions of Care - Doug described a brilliant approach that incorporates simple XML, such as has been used in the CCR, with the expandability of the CCD.  He calls this next evolution of clinical summaries  "Consolidated CDA templates".  It's likely that the clinical summary certification criteria will evolve to a single XML format that is easy to use, fast to implement, expandable, based on a reference model, and human readable.   Well done!

Reportable Labs -  In the past, standards harmonizers struggled to balance simple, easy to implement lab specifications such as ELINCS with the comprehensive and full featured lab specifications from HITSP.   The S&I group created a foundation based on ELINCS that is expandable to include all the features of the HITSP specifications using a single HL7 2.51 implementation guide.   Amazing work.

Provider Directories - The S&I Framework team had the courage to admit that directory standards are still evolving and need more testing/piloting before selection.   DNS/LDAP approaches are likely to work well for certificate discovery.   Other aspects of directories such as provider routing addresses and electronic service capabilities may be stored in web pages (microdata), LDAP (HPD), or X12 274 directory structures.

Doug also described new works in progress - Query Health for distributed data mining, Data Segmentation to manage disclosures of protected health information, and Electronic Submission of Medical Documentation for transmission to Medicare review contractors.

Finally and very importantly, the Implementation Workgroup led by Liz Johnson and Judy Murphy presented the Implementation Workgroup certification criteria analysis.   We had a thoughtful discussion of each open issue and suggested a path forward for each certification item.

Truly an inspiring meeting - the most work we've ever done in a single day.

The delivery of Meaningful Use Stage 2 Standards and Certification criteria was recognized at a White House celebration by Aneesh Chopra, Chief Technology Officer and numerous members of the Obama administration senior staff.   Thanks so much to Aneesh and others for celebrating our work.

As I told the Standards Committee today, I am honored to serve with this team, the hardest working Federal Advisory Committee in government.  A milestone day for the country.

Preparing for a New CEO

On October 17, 2011, Dr. Kevin Tabb MD joins Beth Israel Deaconess as the new CEO.

As part of his briefing packet, I needed to summarize all the key IS issues for the next 3 months, 6 months and 1 year.     Here's what I said:

Introduction

Information Systems at BIDMC has a 30 year tradition of industry firsts:
First web-based Healthcare Information Exchange, CareWeb - 1997
First web-based Enterprise-wide Personal Health Record, Patientsite - 1999
First web-based Enterprise-wide Provider Order Entry system - 2001
First web-based Enterprise-wide electronic medication reconciliation system - 2007
First "Magic button" for health information exchange invented at BIDMC - 2008
Pilot hospital to exchange data with Google Health, Healthvault, and CDC - 2008
Pilot hospital to exchange data with the Social Security Administration (Megahit) - 2009
First hospital to implement clinical iPads - 2010
First hospital to achieve federal certification of its EHR systems - 2011
First hospital to achieve meaningful use and receive Federal IT stimulus funding - 2011

The Information Week 500 Awards ranked BIDMC the #1 healthcare IT organization in the country for 2011.   By the end of 2011, we'll have eliminated handwritten orders and the emergency department will be paperless.

We've done this with an operating budget that is less than 2% of BIDMC's operating expenses and a capital budget that has been increasingly constrained.

Scope of responsibilities

Information Systems at BIDMC is responsible for all clinical, financial, research, education, and administrative applications.  Telecom, Media Services, Knowledge Services, and Health Information Management (medical records) are part of IS.  Our scope includes comprehensive IT support for 83 locations including the Main Campus in the Longwood Medical Area, Needham Hospital, APG (owned practices), HMFP (academic affiliates), BIDPO (physician organization that includes many private clinicians), and Community Health Centers.  Our infrastructure includes a primary and disaster recovery data center.   We support 18,626 user accounts  (of which 17,410 have email boxes), 10,600 desktops, 2000 laptops/tablets, 3000 network printers. 600 iPads, 1600 iPhones, 403 servers  (152 physical, 2501 virtual) and 1.5 petabytes of storage.

Key challenges

90 Days
Laboratory Information System - On January 21, 2012, BIDMC will replace all laboratory automation in a single day, retiring 30 years of home-built lab systems with a commercial system from Soft Computer.   Additional functionality will be added after the go live via planned additional phases.    The Laboratory Information Systems Steering Committee will prioritize ongoing future work.

 5010 go live - On January 1, 2012, all private and public payers in the US will implement a new revenue cycle transmission and content format called 5010.   All BIDMC systems and interfaces are complete.   The challenge is testing with all our payers, many of which are not yet ready.    We will be able to transmit old (4010) and new (5010) formats, so we are prepared for any payer contingency plans.  

Malware control - Harvard networks are attacked every 7 seconds, 24x7x365.  The sophistication of the attacks has increased dramatically since identity theft has become a profitable business for organized crime.  We have an expert team of security professionals and a multi-layered defense of firewalls, intrusion detection, and anti-virus tools.

Compliance - over the past three years, the number of government and plaintiff attorney requests for information has skyrocketed.    The impact on IS is that an increasing percentage of our staff time is spent on e-discovery, file sequestration, and applications that support compliance efforts.  

Hospital integration - Milton hospital will join the BIDMC family in the next few months.   The clinical system integration includes bi-directional viewing of BIDMC webOMR and Milton Meditech via the web, as well as bidirectional viewing of Atrius Epic and Milton Meditech via the web.   This is the same integration we offer all affiliated hospitals and clinician offices.  Here's an overview of the Massachusetts state-wide health information exchange effort

180 days
 Analytics-  Although the precise future of Accountable Care Organizations is unknown, their formation requires a combination of health information exchange and analytics.  Here's an overview of BIDMC's strategy.    

Community IT - As BIDMC expands its footprint to Anna Jaques, Milton, Lawrence General, more primary care offices, and potentially new affiliations, we must have a scalable community IT function that can respond to changing needs with agility.

365 days
ICD10- Despite our efforts to convince CMS and HHS to delay ICD10, reducing the burden on organizations which are trying to implement Meaningful Use, 5010, and healthcare reform simultaneously, it is clear that ICD10 will go forward with an October 1, 2013 deadline.    Here's an overview of the challenges it creates.     Although the project is burdensome, has no ROI, and will distract resources from other strategic imperatives, ICD10 will be a top hospital priority in FY12.  We have a steering committee compromised of all the right stakeholders.  ICD10 is not an IS project, but requires the unified collaboration of all operational areas.

eMAR - Medication safety has been a strength of BIDMC, with its innovative provider order entry, medication reconciliation and e-prescribing systems.  In FY12, BIDMC will leverage the work done in FY11 on idealized medication workflow redesign to implement bedside medication verification and electronic medication administration record pilots.   Hospitals which have adopted these technologies early have been limited by available technology (computers on wheels) and have low user satisfaction.  Our aim is to use mobile devices such as the iPhone/iPod/iPad to create a better workflow and user experience.

Clinical documentation - although BIDMC’s ambulatory documentation is fully automated, inpatient progress notes are still handwritten, then scanned.   A multi-disciplinary stakeholder group will devise a unified care team documentation workflow which will then automate and pilot.  Our hope is to create “wiki-like” team charting.

Learning Management System - As noted above, compliance requirements are increasing in the short term and long term.   To address the staff education aspects of compliance, BIDMC will be implementing a learning management system over the next year.  

Healthcare Reform
As discussed above, healthcare reform will require additional health information exchange and analytics.  The blog postings noted above outline the details.  Additionally, BIDMC has been been an IT pilot site for numerous state and federal efforts.  We expect to be the IT learning laboratory for healthcare reform.

Key opportunities
We’re experts in mobile, wireless, disaster recovery, security, and data standards. We lead national and statewide efforts to share data for population health, quality measurement, public health, electronic disability adjudication and payer/provider collaboration.  We're experts at interoperability and analytics.    We  host EHRs for every affiliated clinician and provide quality/outcome/process analytics.  We’ve achieved meaningful use for our hospitals and 90% of our physicians will attest by 12/31/11.    

We look forward to the opportunities ahead.

Protecting the Legacy of Bill and Dave

When I was an undergraduate at Stanford, my wife to be and I lived with Dr. Fred Terman, the Stanford Provost who first brought together William Hewlett and David Packard.   In early 1980's I had the opportunity to meet Hewlett and Packard.  Since then, I've had a special affection for the company.

HP has just hired its fifth CEO in six years, Meg Whitman, the former CEO of eBay.  Carly Fiorina, Mark Hurd and Leo Apotheker are gone, each with a checkered history and a large severance check.

Now the future of the iconic company rests with a new leader who is expected to turn it all around.

Can one person do that?  It seemed to work for Steve Jobs.

But, being a CEO is not very fun.  There's a lot of risk and CEOs can only hope that overly optimistic Board expectations are tempered by twists of fate or alignment of historic market forces at the right time in the right place.   The CEO can take credit and be a hero.

It's been a bad year for tech CEOs.   Yahoo CEO Carol Bartz was fired over the phone.  Rumors are flying about tech CEOs who may be on the way out.

I think of HP as a great printer, server, and storage company which leads the world in PC manufacturing.   Their software has always been less than perfect in my experience, since software development is not a core competency of the company.

HP may be shedding its PC business to focus on higher margin software and services.   At a time when mobile technologies such as smartphones and tablets are at the peak of consumer demand, HP has exited that business.

Every company has its lifecycle - early innovation, hypergrowth, the burden of maintaining an installed base, displacement by new early stage companies, and decline.

In the late 90's Microsoft could not be stopped.   In the late 2000's Google was invincible.   Now Apple is the most valuable company in the US and HP has lost $60 billion of shareholder value in the past year.

I truly hope that HP can be transformed by focusing the $120 billion dollar company on those businesses which are profitable and growing.    Like IBM in the 1990's, it may need to radically change its focus.

It will take more than Meg to do it.  The devoted employees of HP should be able to explain the company's core competencies to Meg and the Board.  Hopefully, they will listen.

There's a 72 year tradition at stake.

Note to Meg - Bill, Dave, and Dr. Terman are counting on you.  May you rise to the occasion.

Cool Technology of the Week

I've written that Accountable Care Organizations will require increasing amounts of health information exchange and analytics/business intelligence in order to be successful.

As we explore various tools and techniques, I've talked to people in industries outside of healthcare.

Palantir Technologies provides tools for analyzing, integrating, and visualizing data of all kinds, including structured, unstructured, relational, temporal, and geospatial.   It has traditionally has focused on government, providing such functions as

Intelligence
Defense
Regulation and Oversight
Cyber Security

and financial data exploration/visualization for analysts and traders.

Here's a cool example of its use to analyze subprime mortgages.

Here's another example of its use with the Medicare cost data sets.

Edward Tufte  has emphasized the need for creative visualizations to turn data into information, knowledge and wisdom.

Palantir's histogram and mapping tools do that nicely.

A business intelligence application that assembles disparate data sources and presents unique visualizations that empower analytic exploration.   That's cool!

My Atlantic City Memories

Today I'm in Atlantic City, New Jersey presenting at the HIMSS Mid-Atlantic Symposium.

In 1965, I lived in Wilingboro, NJ near Trenton and visited Atlantic City one weekend with my parents.

What does a 3 year old remember?

Walking the Boardwalk
Touring the attractions of the Steel Pier
Eating Saltwater Taffy
For some reason, I remember a Planter's Peanuts man.  Per Wikipedia there was a Peanut Man statue on a bench in Atlantic City, so there's some association with Planter's and the area.

My parents recall the area as a bit run down in the 1960's but I can only remember the wondrous sights, sounds, smells,  and tastes that I had never experienced before.    It was sensory overload for a 3 year old.
Above is a postcard from that era.

Today's Atlantic City has hotels, casinos, restaurants, outlet stores, and convention space, but the souvenir shops, the taffy, and the roasted peanuts are still the same.    It's amazing how much can change in a lifetime, but today I was able to relive a childhood experience on an early foggy morning in New Jersey.

The Challenges of ICD10 Implementation

On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10.   It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system.   It's a kind of Y2k for healthcare.

Most large provider and payer organizations, have a ICD10 project budget of $50-100 million, which is interesting because the ICD10 final rule estimated the cost as .03% of revenue.  For BIDMC, that would be about $450,000.   Our project budget estimates are about ten times that.

CMS and HHS have significant reasons for wanting to move forward with ICD10 including
1) easier detection of fraud and abuse given the granularity of ICD10 i.e. having 3 comminuted distal radius fractures of your right arm within 3 weeks would be unlikely
2) more detailed quality reporting
3) administrative data will contain more clinical detail enabling more refined reimbursement

Large healthcare organizations have already been working hard on ICD10, so they have sunk costs and a fixed run rate for their project management office.   At this point, any extension of the deadline would cost them more.

Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance.   They have no bandwidth or resources to execute a massive ICD10 project over the next 2 years.

Vendors have told me such things as "I have been amazed at how much we (and our third-party partners) are spending on getting prepared for ICD10 – and it's not what you would expect (extending data tables, new code lookup tools, etc.)  It's a whole host of clinician assistance tools, new documentation workflows, new kinds of provider-facing decision support to maximize coding revenue while guarding against RAC audits - all simply for billing!"

In my CIO role, not any state or federal role, I will continue to listen to concerns about ICD10, sharing them broadly on my blog and with government leaders who will listen.

The Wall Street Journal recently published an article about the granularity of ICD10.

One of my staff posted this response, which is very thoughtful:

While nice-to-have, ICD-10 comes at a time when substantial cuts await providers. The "super committee" is deliberating on these now for Medicare and Medicaid. Adding more administrative overhead to the U.S. healthcare system is untimely and will ultimately impact clinical care. Our health care system already has twice the administrative overhead of other advanced nations. We arguably have the most complex medical reimbursement system in the world. ICD-10 makes it worse.

When HHS published the requirement for ICD-10 in the January 16, 2009 Federal Register, they estimated transition costs for health care providers to be 0.03% of patient revenues. For a $1B medical center, this would be $300,000. Based on experience at our hospital and that of my colleagues at other hospitals, they missed it by a factor of 10 or more.

When a regulation of this magnitude is published, various laws and executive orders require a Regulatory Impact Analysis. Some requirements are intended to protect small businesses and non-profits from burdensome, unfunded federal mandates. The marginal cost estimate published in the Federal Register for ICD-10 was $2.966 billion over the period 2011 to 2025. Two-thirds of this was transitional cost. The benefits were estimated at $4.540 billion.

HHS has a tradition of low-balling cost estimates. Further evidence can be seen with recent estimates of HITECH privacy regulations.

If Congress was doing its job of regulatory oversight, they would sponsor hearings to learn what payers and providers are actually spending on ICD-10 conversion. Costs for consulting services alone run into the millions. This does not count the application software conversion, training and education, and other "in-house" costs. At our medical center, we would be paying $380,000 according to HHS estimates. Instead, the marginal cost of ICD-10 will be in excess of $5m. For multi-hospital systems, the costs may exceed $100m.

A Congressional review of transition costs would turn the regulatory impact assessment on its head. Costs could easily become double the estimated benefit savings.

With ICD-10, the government is perpetuating a reimbursement system that is far too complex. We spend more than any other country on healthcare administrative overhead. The Medicare Claims Processing Manual, for example, is over 4,000 pages in length. The reimbursement system needs simplification to bring the cost of this function in line with other industries.

Recently, HHS began promoting a "global payment" initiative. This had the potential for simplifying reimbursement, but they over-laid it on top of the existing system. Instead of substitution, it was additive. You bill as usual and then have a settlement process that adds one more layer of administrative overhead.

Unfortunately, there are too many activities within and outside the government whose livelihood depends on perpetuating this complex system. It is akin to the Internal Revenue Code. There are also groups who promote ICD-10 for its more granular health care research potential. This is laudable, but not affordable. There is no "free lunch". Every dollar spent on administrative overhead is one less dollar spent on clinical care.

What's needed is a fresh look at the reimbursement system. While ICD is used in other countries, it is not used for reimbursement purposes. Rather, it is used for health statistics and reporting. Using it for reimbursement adds an entirely different dimension. Because it is used for reimbursement, the U.S. version requires numerous extensions. Read this as more codes and more complexity.

Our health care system needs to change. If we are going to cut cost, let it be overhead, not clinical care.

Next Steps for Health Information Exchange in Massachusetts

Health Information Exchange (HIE) is challenging.   As I've written about previously, several state HIEs have failed or are failing.

There are Federal HIE goals,  State Medicaid goals, private sector goals, and many varied sources of funding.   Each stakeholder has their own self interest.

The Harvard Program for Health Care Negotiation and Conflict Resolution teaches about the "Walk in Woods", moving from self interest, to enlarged interests, to enlightened interests, to aligned interests.

On September 19, the HIT Council and the HIT/HIE Advisory Committee of Massachusetts stakeholders took such a walk to review a straw man plan that aligns all the interests and optimizes available budgets.

Here's the idea.

There's an ONC-approved State Health Information Exchange plan.   There's a State Medicaid plan.   There are many existing regional health information exchanges in Massachusetts.

We created a Venn diagram of all these projects and identified their points of intersection.

Then, we developed objective criteria for what could be done now, what needs minor policy/technical work and what needs substantial additional work.

The end result was a phased plan making 2012 the year of connectivity to support push transactions, 2013 the year of databases to support analytics/population health and 2014 the year of the pull transaction.

We then worked on reconciling sources of funds.

There are two state programs with substantial federal matching grants - the Medicaid Management Information System (MMIS) and HITECH funds for State Medicaid Health Plans.    Every dollar from state resources that is invested in these programs yields $10 of spending.   A very wise use of state funds would be to leverage every dollar using federal matching programs.   Since 100% of hospitals in Massachusetts receive Medicaid funds,  Federal matching programs for Medicaid improvements are ideal for building the "information highway" to connect stakeholders as well as for state public health gateways to receive syndromic surveillance, reportable lab, and immunization data required by meaningful use.

However, what if we build the highway, but no one uses it?   It's important to connect EHRs by overcoming technical and resource barriers.   Our workgroups will devise a plan to create a grant or procurement program that leverages ONC HIE funds to  accelerate EHR to HIE connectivity.

With senders, receivers, and a pipe connecting the stakeholders, we have a clear HIE plan.

With aligned federal, state and private resources, we can define the timelines and we've developed Gantt charts for all our FY12 projects.

To guide the projects, we'll have 3 "functionality" workgroups
Finance and Sustainability Workgroup,
Technology and Implementation Workgroup
Legal & Policy Workgroup

and 2 "engagement" workgroups
Provider engagement & Adoption Workgroup
Consumer and Public Engagement Workgroup

With clear goals that align the interests of all parties, a budget that optimizes every source of funds, and a multi-stakeholder Advisory Committee with community-wide participation in workgroups, we have the foundation to move forward.

As we proceed with a sense of urgency, our rallying cry to all stakeholders is "focus on making the HIE happen, not on the impediments and barriers that we'll encounter along the way."

I look forward to the work ahead and numerous go lives in FY12.

The CLIA/HIPAA NPRM - Patients’ Access to Test Reports

Can you access your lab test results directly via a non-tethered Personal Health Record like Microsoft Healthvault?

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) requires that the ordering clinician receive the lab and then release it to the patient.  HIPAA medical record access provisions excluded laboratories.

The September 14 Federal Register Notice of Proposed Rulemaking entitled CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports aims to change that:

"While individuals can obtain test results through the ordering provider, we believe that the advent of certain health reform concepts (for example, individualized medicine and an individual’s active involvement in his or her own health care) would be best served by revisiting the CLIA limitations on the disclosure of laboratory test results…

Therefore, in an effort to increase direct patient access rights, we are proposing that, upon a patient’s request, CLIA regulations would allow laboratories to provide direct patient access to completed test reports that, using the laboratory’s authentication processes, the laboratory can identify as belonging to that patient. "

Also, the HIPAA exemptions for laboratories would be removed

"In addition, this proposed rule would also amend the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule to provide individuals the right to receive their test reports directly from laboratories by removing the exceptions for CLIA-certified laboratories and CLIA-exempt laboratories from the provision that provides individuals with the right of access to their protected health information."

I believe this is a great NPRM and it's endorsed by many lab stakeholders including Quest.

On September 28, the HIT Standards Committee will discuss the content, vocabulary and transport standards that will enable HIEs to transmit labs to any stakeholder.   With standards like HL7 2.51 for lab, LOINC, and Direct, a new generation of applications will be empowered as the NPRM becomes a final rule.

Cool Technology of the Week

I've said that the paperless hospital is as likely as the paperless bathroom - an interesting goal but there are many practical barriers.

One of our approaches has been to use scanning of paper on our quest to create a single electronic location for all patient information, making the electronic record the only official record.

Putting scanners into our clinical areas is expensive and support intensive.

What if we could support scanning of documents and photographs by simply replacing the mouse on our desktops?

LG unveiled the world's first scanner mouse at CES 2011 that produces PNG, JPEG, TIFF, and PDF.

Here's a demonstration video.

It appears easy to use and saves on desk real estate.

A mouse with a built in scanner - that's cool!

Authority, Responsibility, and Risk

When I became CIO of CareGroup/BIDMC in 1998, I promised to listen to all my staff and collaboratively embrace technologies that would benefit patients while also enabling employee career growth.   The IT team worked together to implement new infrastructure and new applications.   Success led to an upward spiral of success.    Other groups such as Media Services, Knowledge Services, and Health Information Management joined  IS.  We continued to grow in scope and capability.  

My sense at the time was that additional authority, budget and span of control were great - more was better.

However, in my nearly 15 years as CIO, I've learned that while more authority may bring more opportunities to succeed, it also brings increased responsibility and with it, additional risk.

In a world of increasing regulatory pressures and compliance requirements, the likelihood of something bad happening every day in a large organization is high.    The larger your role, the larger your risk.

Today in my BIDMC role I oversee

83 locations
18000 user accounts
9000 desktops/laptops/tablets
3000 printers
600 iPads
1600 iPhones
450 servers  (200 physical, 250 virtual)
1.5 petabytes of storage

serving over a million patients.

If one employee copies data to a USB drive and loses it, a potential breach needs to be reported. If one workstation is infected with malware that could have transmitted clinical data to a third party, a potential breach needs to be reported.  If one business associate loses an unencrypted laptop, a breach needs to be reported. 30,750 such breaches have been reported since HITECH took effect   All breaches are the CIO's responsibility.

If one IT project is over time or over budget, it's the CIO's responsibility.

If one IT employee goes rogue, it's the CIO's responsibility.

If one server, network, or storage array fails, it's the CIO's responsibility

If one application causes patient harm, it's the CIO's responsibility

Life as a CIO can have its challenges!

At the same time that responsibilities are expanding, the number of auditors, regulators, lawyers, compliance specialists, and complex regulations is growing at a much faster rate than IT resources.

There are three solutions

1.  Spend increasing amounts of time on risk identification and mitigation
2.  Reduce your responsibility/accountability and thus your risk footprint
3.  Find a nice cabin in the woods and homestead as far away from regulatory burdens as possible

I'm doing #1 - about 20% of my day is spent on matters of risk, compliance, and regulation.   I'm doing #2 by transitioning my CIO role at Harvard Medical School to a successor.  #3 sounds appealing but I'm not there yet!

As healthcare CIOs face new regulations for e-prescribing of controlled substances, FDA device safety requirements, 5010 implementation,  ICD-10, new privacy rules, and Meaningful Use stages 1-2-3, the magnitude of the challenges ahead may at times seem overwhelming. I sometimes long for the days when all I had to do was write innovative software and create a nurturing environment for my staff!

There are 3 negative consequences that can result from overzealous regulation:

1.  The joy of success can turn into a fear of compliance failure
2.  Compliance can create such overhead that we lose our competitiveness
3.  We'll become less entrepreneurial because the consequences of non-compliance, such as loss of reputation, penalties, and burden of responding to agencies enforcing regulations, become a deterrent to innovation.

For now, I have accepted the risks that come with all my responsibilities, but at some point, the balance may become more challenging to maintain. As we move forward, I hope that policymakers in Washington and at the state level will be mindful of the unintended consequences of regulatory complexity.

BIDMC's Accountable Care Organization IT Strategy

No one really knows what an Accountable Care Organization is, but many provider organizations want to be one.

As a CIO, I've been asked to create the financial and clinical analytics needed to support high value care (low cost, high quality), population health, and care coordination across the community.  

I believe that Accountable Care Organizations will be based on healthcare information exchange and analytics.  BIDMC's approach is accelerate our health information exchange work and continue our existing work on financial and clinical data warehouses.

Here's how it will work.

There are over 1800 clinicians in the Beth Israel Deaconess Physicians Organization (BIDPO).    Some are owned, some are private.   The BIDPO Board of Directors mandated that a certified Electronic Health Record be in use at every BIDPO practice by December 2010 as a condition of participation in payer contracting efforts.   Those payer contracts require "clinical integration" - all clinicians must be knit together by IT.   To accomplish this goal, we implemented a cloud-based EHR which was offered to each practice that did not yet have a certified EHR.   We required all clinicians, owned and private, to send a standardized, structured summary of each visit to a central quality registry.  

As each encounter is completed and signed, eClinicalWorks, Altos Solutions, and webOMR, send a very specific Clinical Document Architecture (CDA) summary containing all the data necessary to compute quality and performance metrics to a statewide Quality Data Center, hosted at the Massachusetts Medical Society and operated by the Massachusetts eHealth Collaborative.

That warehouse is used to generate PQRI measures, the 44 meaningful use measures, and ad hoc reporting via web-based business intelligence tools.

For the financial data warehouse, all private payers claims from BIDPO patients are forwarded to a single financial data warehouse where Extract/Transform/Load tools are used to normalize the data into a single schema.

Data mining and reporting is done by Healthcare Data Services.

The interesting recent development is that all the clinical data transfers from heterogeneous EHRs pass through the New England Healthcare Exchange Network (NEHEN) gateway, such that the Quality Data Center is just a node on the HIE.   Anyone can send any data from any EHR using the standards mandated by Meaningful Use.

NEHEN also transmits summaries to the next provider of care, ensuring clinical integration.    We have live connections among Atrius, Childrens, BIDMC, and Northeast.   In a few weeks, Partners  Healthcare will go live with the ability to receive transactions.

As of last week, we have exchanged over 16,000 production clinical messages for care coordination and quality measurement.

All the Public Health transactions will soon be live on the NEHEN infrastructure.

Healthcare reform is causing hospitals, practices, payers, and government to align their healthcare IT efforts in support of the data sharing and analytics needed by new reimbursement models.

It's happening very fast in Boston/Eastern Massachusetts.

I'll continue to share all my lessons learned as BIDMC implements an entire suite of IT solutions on the road to Accountable Care nirvana.

The NwHIN Power Team

At the September meeting of the HIT Standards Committee, we'll finalize the content, vocabulary and transport standards for Stage 2 of Meaningful Use.

I've written many posts and articles about the importance of specific implementation guides for transport standards.  When every provider is connected to every provider, payer and patient, novel transactions will emerge and volume will increase per Metcalfe's law.

The NwHIN Power Team, a subcommittee of the HIT Standards Committee, has been working all Summer to analyze the NwHIN Exchange (SOAP) and Direct (SMTP/SMIME) specifications specifications using a truly brilliant methodology.    Each specification (10 Exchange, 2 Direct) was scored against the following criteria:

Need for specified capability

Maturity of the specification

Maturity of the underlying technology used in the specification

Deployment and Operational Complexity

Industry adoption

Available alternatives

Initial scores were assigned by the ONC, with inputs from the NeHIN Exchange Coordinating Committee and the National Institute for Standards and Technology (NIST).  The Power Team reviewed and refined these scores through several iterations, most recently after hearing testimony from individuals with first-hand experience implementing the Exchange specifications for the DOD and VA.  From these scores, they identified  specifications  for which the business need is low.  They also identified those specifications that are in early or moderate stages of development, and that use technologies which are in the declining phase of their life-cycle. Finally, they evaluated the specifications on deployment/operational complexity and industry adoption.

They considered alternatives using the same criteria as those used for NwHIN and Direct specifications.

Their detailed analysis will be presented on September 28, but there are two interesting conclusions in the draft report that I'd like to share now.

Industry adoption of the NwHIN and Direct specifications for health information exchange between organizations is low.   Pilots have been successful, but large scale adoption has not yet occurred.  So the scalability and workflow compatibility of these specifications have yet to be proven.

RESTful interfaces such as those used by Google, Facebook, and Amazon are appealing.  However, REST is not a standard, but a style that uses the HTTP to provide a simpler alternative to SOAP for accessing web services.  Not all RESTful implementations are implemented in the same way and thus we need a specification for secure RESTful transport of healthcare information.    Such an implementation guide would ensure that RESTful implementations for healthcare information exchange are predictable and secured.

The Power Team has one more meeting to finalize its recommendation, but I am confident that they will present a thoughtful path forward that embraces the existing NwHIN and Direct specifications for some use cases and suggests further development for other use cases if we want large scale adoption and ease of implementation.

I'm truly impressed by the work of this team and look forward to their final recommendations.

The Impact of 9/11 on Healthcare IT

On September 11, 2001, I was sitting in my Harvard Clinical Research Institute office  (I was CIO there from 2001-2007 as part of my Harvard Medical School CIO duties).  A staff member ran into my office and told me that a plane had crashed into a World Trade Center Tower.  This sounded like a horrible accident.   Then, the second tower was hit and we knew this disaster was planned.  News of the Pentagon and Pennsylvania crashes trickled in.   I gathered all the staff and told them to focus on their families and personal safety, to go home and stay in touch virtually as we learned more about the day's events.

What impact has 9/11 had on my healthcare IT world since then?

9/11 had a profound impact on our culture, making us all understand our vulnerability.

The loss of life gave us an appreciation of the preciousness of each day we have on the planet, putting the problems of our work lives in perspective.

The loss of infrastructure, including many data centers, was a wake up call that redundancy goes beyond servers, networks, and storage.   Whole buildings can disappear in an instant through natural or manmade disaster.

Since 9/11, Beth Israel Deaconess has invested over $10 million dollars to create a redundant IT infrastructure that includes geographically disparate data centers, remote hosting of our financial applications, and data replication of a petabyte with less than a minute of loss in the case of a major disaster.

We support remote, web-based access of all our applications and data so that our mission can continue even if travel into Boston is restricted.

Our healthcare information exchange efforts have created a foundational backbone for care coordination in the event of a disaster.

The events of 9/11 are felt throughout the country, but especially in Boston, the takeoff point for the planes that were flown into the World Trade Center towers.    At my daughter's recent Tufts University matriculation ceremony, the Dean reflected that  3 members of her freshman class lost parents on 9/11.  

Our homage to the events of 9/11 is a resilient IT infrastructure that can support our patients, regardless of the disasters that may strike.   Disaster recovery, security, and emergency support efforts will continue, inspired by the memories of those who perished 10 years ago.

Cool Technology of the Week

Two years ago, my daughter was walking in a Rhode Island park with a friend.  They stopped at a bench to chat and she put her purse containing an iPhone 3GS on the ground.   Across the street, two men watched them from the porch.   My daughter and her friend continued their walk but she left her purse behind.   When she returned 15 minutes later, the iPhone was gone.

She was convinced that the men watching her pilfered it, but she had no way to prove it.

If only my daughter would have lost an iPhone5, then recovery would have been easy :-)

Earlier this year, I wrote about laptop recovery via nanny cam.

I've written about BIDMC's use of our wireless network to locate 5000 devices throughout the hospital.

Now there is an entire suite of tools for mobile devices including remote camera activation, automated file replication to the cloud, and GPS reporting that help locate lost or stolen devices.

The use of mobile devices in healthcare is growing exponentially at the same time that compliance requirements to protect these devices are becoming more stringent.    It's clear that new mobile devices are going to include the geolocation tools necessary to reduce anxiety in CIOs and users.

Self recovery of your mobile device - that's cool!

Being a Good Steward of the Land

As a member of Wellesley's Community Garden, I do my best to serve the other gardeners by being a contributor to the entire property as well as a good steward of my plot.

There are basic rules and regulations covering membership in the community garden, but there has not been a advisory group of gardeners to recommend ongoing policy development or resolve disputes.   Reflecting on the work of the HIT Standards Committee and other Federal Advisory Committees which help inform regulatory decision making, I believe a group of gardening stakeholders can make a real difference by crafting policy that balances the needs of the many with the needs of the few.

Here are my early thoughts about being a good steward of the land:

1.  At the beginning of the season, gardeners should clean their spaces, removing weeds and debris that may have accumulated during the winter and early spring.   The previous year's plantings should be removed, the soil raked/turned, and fences mended.

2.  The town provides new compost that can be used to top off raised beds and planters.   Gardeners should add compost as needed to keep their spaces productive.

3.  The town provides wood chips that can be used to cover paths, controlling weed growth and covering muddy walkways.    Gardeners should weed and clear the paths around their space so that all gardeners can easily traverse the paths and so that the spread of weeds is reduced.

4.  Although the garden is primarily intended for annual fruits and vegetables, perennials can be planted, realizing that spaces are not owned, but are lent to each gardener for a finite period of time.    Brambles such as raspberries/blackberries should not occupy more than 25% of the space, since planting a bramble patch does not constitute gardening.

5.  Gardening is an ongoing labor of love, not a plant once and forget type of activity.   Plantings should be tended throughout the season with trimming, thinning, and harvesting as needed to keep the garden productive.

6.  The garden will always have a waiting list and in the interest of accommodating as many people as possible, new plots should given to 2 families.   Existing plots should be voluntarily subdivided.  Experienced gardeners who would like physical assistance with the garden should consider subdividing and serving as mentor to a gardening partner.

7.  If the Community Garden Advisory Committee (CGAC)  notes that a gardener is not being a good steward of the land, the person should be contacted and advice offered.  If no improvement occurs over 1 month, the space should be considered abandoned and given to a new tenant

8.  Gardening can be an expensive proposition and community garden improvements may benefit from grants or donations.    The Community Garden Advisory Committee should raise funds that can be used to improve fences, the water supply, and conceivably fund tools/seeds/plants that could benefit the entire community.

9.   At the end of the season, all tools and non-natural materials should be removed from each plot to ensure that the garden area is attractive during the winter to neighbors and visitors.

10.  In general, use of the garden should be viewed as a privilege, not a right.   We are being given 500-1000 square feet of valuable Wellesley land for $40/year.   We should use it as good stewards, balancing our own needs, the garden's needs, and the town of Wellesley's needs.

Our Community Garden Advisory Committee will begin meetings this Fall and then formally report out to the Wellesley Natural Resources Council.   After all my time in Washington, I look forward to playing a role in governance and policymaking at the local level.   If any of my readers have experience with community gardens, I'd welcome your input!

Vermont Information Technology Leaders

Today I'm in Vermont, meeting with the stakeholders of Vermont Information Technology Leaders (VITL), the federally designated Regional Extension Center and Health Information Exchange for Vermont.

I feel a close affinity to VITL as one of our New England collaborators (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) but more importantly because of my longstanding relationship with VITL's CEO, Dr. David Cochran, MD who was senior vice president for strategic development at Harvard Pilgrim Health Care and an influential driving force in the rollout of electronic health records in Massachusetts.

On a personal level, Vermont is one of my favorite places with remarkable countryside, a strong willed people, and a can do attitude.    Hurricane Irene has deeply affected the state but everyone is pitching in to accelerate the recovery.

My keynote will reflect on the journey from EHR implementation to true quality improvement using decision support, advanced analytics, and novel care management tools.  

For the first time in my career, I am seeing a cultural transformation such that the majority of clinicians believe an EHR is a necessary part of their practice.  Emerging accountable care organizations are stressing the need for health information exchange and financial/clinical analytics as a foundation for the healthcare reform work ahead.  

Meaningful Use Stage 1 sets the stage for quality measurement by moving clinician offices from paper to structured data entry.  Stage 2 will require more data exchanges and increasing use of controlled vocabularies that will make quality measurement easier.   Stage 3 will include new levels of decision support and data mining to prospectively and retrospectively help clinicians manage population health.

BIDMC's strategy to prepare for future stages of meaningful use and healthcare reform includes

*Embracing health information exchange by serving as a pilot site for government, academic, industry, payer, and patient engagement experiments
*Capturing the value of unstructured data by testing novel Natural Language Processing software
*Empowering users with new analytics using new business intelligence platforms
*Embracing novel sources of information including data from home care devices and patients themselves
*Exploring the implications of gathering and using genomic data for clinical care and clinical trials

I'll share examples of each of these with my colleagues in Vermont and in upcoming blog posts.

One of the most exciting developments is that we now are sending HL7 CDA document summaries from every patient visit to a community-wide registry which generates our meaningful use quality measures, submits our PQRI measures and supports ad hoc clinical queries.   By requiring every EHR vendor to send a CDA document over the New England Healthcare Exchange Network (NEHEN) to the Massachusetts eHealth Collaborative Quality Data Center, we have created the technical foundation for our emerging ACO that is in production now.   I'll post a more complete technical overview next week.

I look forward to exchanging lessons learned with Vermont.

Decision Fatigue

We're all suffering from information overload.  More projects with fewer staff on shorter timeframes mean more email, texts, blogs, online meetings, and phone calls.  

We make more decisions and have more accountability than ever before.  Regulatory complexity and the need for risk management has increased.  We're pressured to make decisions faster and there is less tolerance for mistakes.   Making all those decisions in a high stakes environment like healthcare leads to decision fatigue,  that numbness you feel at the end of an overloaded day when you decided what to spend, who to hire, and what to do, hundreds of times.

I believe decision fatigue is an escalating threat to our ability to manage the events of each day and keep balance in our lives.

When I think back on my early career as a leader, in the 1980's, there was no email, no overnight shipping, and limited numbers of fax machines.

Issues were escalated by writing and mailing a letter.    The time it took to compose, type, mail, and deliver a letter meant that many problems solved themselves.  Since the effort to escalate was significant, many problems were never escalated.

Today, everyone can escalate everything to anyone.  The barrier to communicating is nearly zero and communication is real time.   There is no mail room or team of middle management filters between you and the CEO.

This creates an interesting conundrum for leaders.  Should everything be answered in a very timely way with Solomon-like decisions about every issue?   Should everything be ignored unless truly emergent with the hope that someone else will solve the problem?  Should everything be deflected to those in middle management who would have read paper-based mail?

My goal is to never be the rate limiting step.  That means that I make hundreds of decisions every day.   Some are right and some are wrong, but they are the best answers given the information that I have.   In the IT industry,  timely action that is good enough is often more important than a delayed perfect action.

Thus at the end of every day my brain is whirring with thousands of inputs, and hundreds of decisions made.   I'm not physically tired after any workday, but I can feel mentally tired from decision fatigue.  

The problem with decision fatigue is the that quality of decisions can diminish as the quantity of issues increases.  

There are two ways to address decision fatigue

1.  Reduce the scope of your authority and hence the decisions you need to make and the risks you need to manage.  I'll post a blog next week about span of authority and risk management.

2.  Spread decisions over a wider group of people, reducing the volume of decisions that fall to any one person.

#2 depends upon having a great boss, who is supportive, responsive, and willing to share decision making risk with you.    #2 also requires great staff whom you can empower to make decisions on their own.

Thus, I make the decisions that I am uniquely qualified to make, while pushing others up and down the organizational hierarchy so that risk is mitigated (seeking approval up the org chart) and trusted staff are given the resources and authority to solve problems on their own (delegating down the org chart).

Here's an example of how I managed decision fatigue today.   Between 3pm and 4pm, I was asked to make several decisions:

1.  The regional poison control center sought my input on a mushroom ingestion case.   A 1 year old  had taken a large bite from a mushroom growing in a backyard.   Since I uniquely have mushroom toxicology knowledge, this was my decision.   The mushroom was a harmless Lactarius Fragilis  and I decided that the child would be fine.

2.  A leak in the Longwood Medical Area chilled water supply caused a 5 degree rise in our disaster recovery data center.   What should we do?   I ensured that all appropriate facilities and IT people were organized to address the problem, and asked to be informed if the temperature exceeded 90F.     The incident management decision making was delegated to others.

3.  A researcher in one of the Harvard buildings suspected that the network had been hacked because www.ups.com was unavailable.  Should I page security and networking staff to urgently investigate this on a holiday weekend?   I used my Blackberry to replicate the problem and escalated it to IT security, who found the problem was unrelated to our network/DNS servers.    The incident management decision making was delegated to others.

In the next few months, I'll be finishing the FY12 Operating Plan for BIDMC IS, so there will be plenty of decision making to spread among governance committees and executive management.

One other cure for decision fatigue that I recommend is a "time out".   On my way home in the evening, I stop at our community garden space to sit on the small bench we've placed there, eat a few cherry tomatoes wrapped in basil, and watch the birds peck at our sunflowers.   I leave my Blackberry in the car.   By the time I get home, the decision fatigue of the day has passed, so when my wife and I discuss dinner choices, I'm ready to act boldy.

Cool Technology of the Week

I recently received the press release below, which illustrates a cool trend in the healthcare IT industry.

eClinicalWorks and other EHR vendors have been piloting standard transport interfaces that are compatible with Nationwide Health Information Network Exchange transactions (pull/push) and Direct transactions (push).

Intersystems and other integration engine vendors have been building HIE appliances, cloud offerings, and software tools to connect the EHRs which support these transport standards.

The end result is a significant reduction in implementation burden and cost.

Once connectivity is enabled, novel transactions of many types can flow.

EHRs with standards-based transport interfaces and integration engines that can connect them without significant development time.   That's cool!

First Implementation of One-Click EHR Rolled Out on Brooklyn Health Information Exchange
August 31, 2011

InterSystems Corporation, a global leader in software for connected care, today announced that the Brooklyn Health Information Exchange (BHIX) is now providing breakthrough electronic health record (EHR) connectivity that is expected to dramatically speedup care delivery for BHIX clinicians. "The advanced functionality enables physicians to securely access patient records via the InterSystems HealthShare-based BHIX network directly from an eClinicalWorks EHR with just one click," said BHIX Executive Director Irene Koch. "This seamless interconnectivity makes it possible to share patient data and improve patient care coordination across the entire community served by BHIX."

The College Drop Off

I have a very hard time giving up roles and responsibilities.    Rather than change jobs, I add jobs.

In 1996, I oversaw the CareGroup Center for Quality and Value, the data warehousing and analytic operations of a Boston-based integrated delivery system comprised of Beth Israel Deaconess and 4 other hospitals.   When I became the CIO of CareGroup in 1998, it took me a year to separate myself from the operational responsibilities of the CQV.

In 2000, I oversaw the Harvard Medical School learning management system as Associate Dean of Educational Technology.   When I become the CIO of HMS in 2001, it took me a year to delegate my educational technology role.   Early in my HMS tenure, I was asked to serve as temporary CIO of Harvard Clinical Research Institute (HCRI).  That temporary job lasted a year.

Today, my wife and I spent the day at Tufts, helping our daughter move into her dorm and begin her journey as an independent adult.   In many ways, my job as parent, that began 18 years ago, fundamentally changed today.   It's very hard to let go.

I'll want to hear about my daughter's experiences each day, the decisions she's making, the challenges she's facing, and the successes she's achieving.  I'll want to offer advice, assist when I can, and give her the benefits of my 50 years of experience.

However, all of these activities are the wrong thing to do.   She needs to fly on her own, knowing that we're here when she needs us.

The Deans at Tufts emphasized 3 goals for Tufts undergraduates - develop internal curiosity for learning, be responsible for your own actions, and become an advocate for yourself.  

The only way my daughter will become a mature, experienced, and assertive young woman is to do her best, explore a college world that is much more diverse than her high school experience, and be responsible for her own decisions.

Today, my wife and I became a safety net rather than a guiding force.

Lara has fledged and we have an empty nest.

We shed tears of loss when saying goodbye, followed by tears of joy for her new possibilities.

I may have had a hard time with the CQV, HCRI, and Harvard Medical School, but for Lara, I can morph my parent job so that she that she can thrive in our increasingly complex and confusing world.   My job needs to change, so that she can change.

Lara, we only cried part of the way home.   We're ok.

Now do great things.  The world is your oyster.