A Unified Software Development Lifecycle

Recently, in response to an audit, I was asked to document our Software Development Lifecycle across all our platforms - clinical, financial, and web.    Here's what I wrote.  I hope you find it useful.

1.  Project Definition

Multi-stakeholder governance bodies of business owners and IS professionals meet on a regular basis to define the scope and requirements of new projects.    The priorities of these new projects are based on business owner strategic alignment, regulatory/compliance requirements, quality/safety imperative, impact factor (employees, clinicians, patients),  and return on investment.    Governance Committees with oversight over the software development life cycle include:

Clinical - webOMR User's group sets ambulatory development priorities.    Inpatient Clinical Applications Steering Committee sets inpatient development priorities.

Financial/Billing - IS project manager and IS fiscal manager work with Patient Financial Services stakeholders to mutually agree on the work tasks of all programmers.

Financial/Supply Chain Manaagement/Research/ERP -  Human Resources/Payroll, General Accounting, Research Finance and Supply Chain Management Steering Committees set Peoplesoft and related application priorities

Web Applications  - the Portal steering committee sets web development priorities

Once a project is approved by a governance committee, it is assigned a tracking number and assigned to programmer

In addition to project definition, these committees also oversee the portfolio of work their specific domain.    This includes monitoring progress and identifying/eliminating barriers to success.

2. User Requirements Definition, Analysis and Design

The development process for approved projects begins with user requirements definition.   This is a collaborative effort involving developers, analysts and business owners.  It is an iterative process in which a prototype is developed based on an initial set of user requirements and then modified in response to user feedback.   Multiple cycles of revising requirements and prototypes typically occur.   We employ an agile development methodology with source code control systems/versioning for every development platform.

3.   System requirements definition

Application projects may have infrastructure implications.   An infrastructure project manager is engaged if additional server capacity, novel desktop configuration, or new client hardware (mobile, specialized printers, bar code scanners) is required as part of the application

4.  Testing

BIDMC maintains dedicated development and testing environments that are separate from live/production.     Developers first unit test their changes.   Application analysts independently test changes.    End users perform acceptance testing.

Test scripts are used to perform integrated testing before go live.

No code is moved into production before end user signoff approval.

5.  Go live and continuous improvement

Go live is planned in collaboration with business owners which includes communication and post go live support planning.     Changes to infrastructure and communication plans for major go lives are presented to the IS Change Control Board to ensure awareness and coordinate timelines among all IS projects.

The push of code from a testing environment to a production environment is done via a source control system, is logged for auditing purposes, and may be rolled back quickly.   For clinical applications, this push is done by the most experienced developer, as experience has shown that this person is most able to ensure a successful deployment and rapidly identify any defects, minimizing risk.   For financial/billing  applications, this push is done by the non-IS Production Control group, since mainframe workflows are more batch oriented and more amenable to segregation of duties in go live processes.   The organization accepts this difference between the clinical and financial/billing go live process as necessary to reduce overall risk.

Once the go live push is completed, success of the process is validated by the most experienced developer, the analysts, and/or the business owner as is appropriate for the application.

Based on feedback during the go live validation process, a rollback may be done if there are unexpected consequences.  This is a very rare event, but it supported by the source code control systems which drive the go live process.

Once application  changes are live, user feedback is provided at the governance committee level and products are continuously improved to meet users needs, always following the above Software Development Lifecycle.

Thank You to the Village

From March 8 to March 17, I was focused entirely on my father - from serving as his healthcare navigator to arranging his funeral/memorial to ensuring my mother had a path forward.

For 10 days, I had to minimize my roles as a CIO/professor and maximize my roles as son/clinician.

I cancelled numerous meetings, speaking engagements, and classes.  I backed out of commitments made months ago.   My response to calls/emails/texts went from minutes to days.  

All of this was necessary and appropriate to support my father.

Now that I'm back in Boston and restarting my usual schedule, I can say that the past 10 days were only possible because of the incredible outpouring of support I received from the village of people around me.

My wife and daughter flew to Los Angeles to support my father, my mother, and me.

My parents' friends brought food to the hospital, helped with funeral arrangements, and provided emotional support.

My  staff at BIDMC covered for me in all my meetings and phone calls.   Nothing bad happened and no urgent issue was overlooked.

My colleagues in the State and Federal government ensured the cadence of all our work continued without me.

The lessons learned
*Family must come first
*There is no work related urgency that trumps a focus on major life events
*The people who surround you in life make all the difference

Thanks again to the people who supported me.   I've now completed all the tasks surrounding my father's death - from comfort care, to cremation, to memorial, to preparing  the house for my mother's needs, to working on all the financial/administrative matters surrounding the death of a father/spouse.

The healing will take time, but with the great people who came together over the past 10 days, I'm confident that all will be well.

Building Unity Farm - "Planting" the Mushroom Farm

As I mentioned last week, we're planting the orchard and developing a mushroom farm this Spring.

What is the scope and scale of the mushroom farm effort?

We've cut 200 feet of poplar trees that were too near our buildings for safety.   I chainsawed the trees into 12 four foot logs that 6-8" in diameter and 60 two foot logs that are 8-12" in diameter.  

Poplar is an ideal substrate for oyster mushrooms.    Our mushroom farm supplier, Field and Forest Products, recommends the "totem" method for inoculating poplar.

Here's what I'm planning for the last week of April.

I've cut 192 feet of pine 2x4s into 16 inch segments.  These boards will serve as the bases for 72 "totem poles".     I'll cut the 4 foot logs into three 16 inch segments.   I'll cut the 2 foot logs into 12 inch segments.   I'll lay down the 2x4 bases every 33 inches to create a 200 foot line in the moist and shaded area of our north wood.   I'll place a large trash bag on top of each base the generously add sawdust inoculated with oyster mushroom mycelium (spawn).   I'll add a log, add more spawn, add a log, and seal the totem pole in the trash bag to establish the perfect environment for growing mushrooms.

Field and Forest Products supplies 6 different subspecies of oyster, so we'll inoculate 12 totems with each type.

I've cut 25 four foot oak 3-6" oak logs from trees damaged during Hurricane Sandy for Shitake growing.   As we clear an acre for the orchard, we'll have enough oak for 220 logs arranged as 11 stacks of 20 logs.   I'll place one stack every 18 feet in the 200 foot mushroom growing area of our north wood.   I've cut 88 feet of pine 4x4s into four foot segments to serve as bases for the stacks.

Field and Forest Products supplies 11 different subspecies of Shitake, so we'll inoculate each stack with a different species.  Inoculating requires drilling 1.5 inch deep holes every 4 inches around the entire circumference and length of each log.    For 220 four foot logs, that means  220 logs * 4 feet/log * 12 inches/foot * 1 hole/4 inches for each row around the circumference * 4 rows  = 10,560 holes.

How do you use a drill to make 10,560 holes?   You don't.   You use an 8000 rpm grinder retrofitted with a drill chuck and high speed bit.   In my case, I'm using the Makita 9557pb with the Field and Forest chuck that attaches to the 5/8" inch coarse threads of the grinder.

I will fill these holes with sawdust spawn using a special inoculator then seal the holes with 25 pounds of melted food grade paraffin.

The entire process for processing the poplar and oak logs will be done in three weekends at the end of April and the beginning of May.

I've completed the survey work, the brush clearing, and layout of the mushroom farm.  I have all the tools and technologies I'll need.  The rest is the muscle power to process a few tons of wood into a production configuration.

We may see some fruiting this Fall, but likely next Spring we'll have our first mushroom harvest.   Like our Orchard, we've chosen subspecies that fruit at different times in different conditions so we'll have yields throughout the season when the temperature is over 40 degrees.   If we're lucky this batch wood of yield for many seasons, so the "heavy lifting" only needs to be done every 5 years.

The Process After Death

As a doctor, I've been asked to record the time of death for hundreds of patients.   I carefully examine the person, verify there are no signs of life, and document my findings.   I offer my prayers and condolences to the family in an attempt to comfort them.   Then I leave the room.  

As a son, I'm the one left in the room.

Next to me is the body of someone I have loved my entire life.   I'm emotionally and physically exhausted.   What are the next steps?

Hospitals typically have great social work and palliative care/hospice staff who can offer recommendations.   Churches have bereavement ministries for funeral planning.   Mortuaries have the staff to orchestrate the next steps.

My mother and I relied on the support of friends and hospital staff for recommendations.

We called church bereavement staff.   They explained the nature of the funeral mass, our options, and the guidance offered by the church.   For Catholics, cremation is fine, but scattering of ashes is not endorsed.

My mother and I had long talks about my father's preferences and her future desires.   We agreed that cremation would be better than burial.   I asked the church about facilities for internment of ashes.  I learned that they are 11 3/8 wide by 13 3/8 high by 11 5/8 deep and can store two urns.  My mother and I agreed that interment of their ashes together in the same niche was desirable.  We agreed that a mass should be a personalized memorial service and not just repetition of scripture.

We worked with the church to select a funeral time when the priest, church, and organist were available - this Saturday at 11am.   We did have to rearrange the monsignor's schedule and he was happy to accommodate us.   We are meeting with church staff on Friday to personalize the ceremony.  

We sought recommendations for a good local mortuary which would work with the church.   I called them and arranged a planning meeting for tomorrow.  We will shop for urns that will fit in the church's niche. We officially released my father's body from the hospital to the mortuary.

We asked our local realtor to help with reception planning.  We decided upon a buffet brunch so that the guests could eat the foods that they like.

We arranged a walk along the ocean on my father's favorite path.

We made a list of all local friends and family who should attend and called/emailed/texted them.

The end result is that we have mortuary plans for cremation, a mass/memorial service customized to my father to celebrate his life, and a reception to thank all those who have helped us so much.

My wife flew in at 1:30am this morning and my daughter is flying in on Friday night.   We've asked a farm hand from an adjacent property to oversee Unity Farm in our absence.

My advice is that the process after death requires just as much preparation as the healthcare proxy.     Pick a mortuary.   Pick burial or cremation.   Buy a plot or chose an internment/ash scattering site.  Decide on a church/temple service, memorial, or other event.    We completed these steps in the hours after his death when we were not at our best.

My role as healthcare navigator for my family does not end with all this planning.

My next step is to keep the survivors healthy.   I'll be flying to see my mother quarterly and help her decide if living alone is working or if she should consider a nearby over 55 community.    Last night, the kitchen drain developed a major clog and every appliance with a clock needed to be reset (we had not been home since Friday night and missed Daylight Savings Time clock adjustment rituals).   Without my father, my mother will have to manage plumbing, electrical, painting, maintenance, and landscape work herself.   It could be that she'd rather spend her time on cultural events, conversation, and intellectual pursuits with like minded people.

On New Year's Eve, I told my wife that 2013 would be less traumatic/dramatic than 2012.    Maybe the second half of 2013.

The Use of Scribes for Clinical documentation

Given the rigors of documentation required for Meaningful Use, quality measurement, and ICD10, some organizations are adding dedicated scribes to rounding and evaluation teams.

I was recently asked two questions about scribes.

Does Meaningful Use allow the use of scribes?

Meaningful Use does not specify who does the documentation, as long as the thresholds for data capture are exceeded.

What are the best practices for scribes used at BIDMC?

At BIDMC the ED scribes use their own credentials and create a "scribe note" under their own identity.

When the physician goes to chart, they have the option to import the scribe note into their own note.

This has 3 important benefits:

1) The scribe is never given access to the system with the physician's credentials (as I've heard happens with some scribe arrangements)
2) The physician has the option to import and then writes/edits the note as they wish (ie - they retain full control for the contents of the note)
3) The MD actively uses the computer and the scribe does not come between the physician and system.  (In some arrangements the scribe acts as a human UI to the system and the MD only interacts with the scribe.  This becomes a barrier to many of the benefits of online clinical decision support).

Although future improvements in clinical documentation may eliminate the need for scribes, there are best practices that minimize privacy risks and "cut/paste" documentation challenges.

Saying Goodbye to my Father

My father passed away this morning.   My mother and I were at his bedside telling him we'd be ok and care for each other.  He was 70.

My parents met when they were 17 and I was born when my mother and father were 19.

I've known him for nearly 51 years.

The community recalls him as the kindest most giving lawyer in Southern California.

To me he was a mentor, a friend, and an inspiration.

He told me a story about my early childhood.   When I was two years old, I was playing in the backyard of my grandparents home in Iowa.   I fell on grass and began crying.   It was not injured in any way.   He watched the incident and decided not to run over and console me.   Instead he let me brush myself off, realize that I could fall, and in a self reliant way recover from it myself.   Within a minute I was ok and back at play.   He taught me resilience by being a safety net but letting me find my own way.

In the entrance to my parent's home, there's a woodcut of Don Quixote.   Today, my father's unused cane leans against the wall.   I was struck by the resemblance of the lance held by the Man of La Mancha to my father's Leki walking stick.   Despite 23 years of multiple sclerosis, with the loss of walking and difficulties with activities of daily living, my father always dreamed the impossible dream.    He built a Japanese garden, he turned compost, he grew vegetables, he maintained the house, and continued to build/tinker until the end.

Some have commented that only a cruel god would afflict such a kind man with multiple sclerosis, myelodysplastic syndrome, and severe coronary artery disease.   However, my father was stubborn and met the adversity head on.   He refused pain medications for dental procedures and declined anesthesia for colonoscopies.   He made the best of every day no matter what cards life dealt him.

I will miss him but he will always be a part of me and inspire me to new levels of equanimity and endurance.

Goodbye Dad.  I love you.

Use of HIE Fully Integrated into the EHR

Note - while I was flying to Los Angeles to be with my father, I wrote the Tuesday-Thursday blog posts which will be automatically published this week.    I'm focused on his care now and will return to writing in real time once his needs have been met.

John
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I recently reviewed an article which lamented the low adoption of portal-based HIE that requires clinicians to log into a website outside of their normal EHR workflow to lookup patient information from external facilities.  Typical usage in this article was cited as 10%.

At BIDMC we've implemented several types of interoperability that is integrated into standard EHR workflows at the click of the button - no additional login or patient context specification required.

How often is it used?   As an example, we looked at the lookups from BIDMC's EHR to the Atrius' Epic applications.  As denominator, we counted all adult admissions from 1/1/12 - 9/30/12 that had an Atrius PCP or referring MD.

There were a total of 6,017 Atrius admissions.

Of these, our audit logs show that 3,455 or 57% had an Atrius Epic viewer lookup used during the admission, between the admit and discharge date.

57% for simple integrated viewing verses 10% for community wide aggregation available via a separate website.

This was not intended to be an exhaustive or controlled study.  However, it is interesting that simple viewing of external records, fully integrated into the EHR, addresses many clinician requirements for care coordination.

I'm confident that the next generation of HIE such as the work of the Commonwealth of Massachusetts to create a statewide master patient index/record locator service and the nationwide CommonWell Alliance http://www.commonwellalliance.org by a consortium of vendors will empower additional fully EHR integrated solutions.