Wordle - Check this out

Wordle automatically draws a picture of all of the words on a site, biggest word being the most common. Here's this blog's wordle for this moment in time.



Apparently I still lean towards being a technology guy. Hmmm...

IT - It's Not About The Bits Anymore

Two things happened recently that made me feel a little closer to the ambulatory care world. First, my sister got a job at a clinic as a business analyst. I'm very proud of her and am excited that she's joining the healthcare IT world! She's going to be great at it.

Second, I was recently at a clinic, wearing my operational excellence hat, doing some value stream mapping. They are going to be implementing an EMR soon and are looking closely at their current state processes to see where they might be able to streamline them. The hope is that doing so will help free up the time and energy that it'll undoubtedly take to get it up and running. I was reminded of a physician's email to a another clinic's project team. The best quote was "if you're not used to working with computers and technology get ready for the pain train!".

The culture and human change represent the real work. The process design and management piece is engaging and challenging. The technology can be equally complex but the truly hard part is helping people unwire the parts of them that rely on the muscle memory of paper, pen and pencil. To rewire those pieces with the habits and skills that make their transition to keyboard, stylus and tablet possible and as painless as possible.

For that and other reasons Gartner and other pundits forsee IT being less about the nuts and bolts. Less about buses, bits, boards and 4th generation languages and more about the relationships, conversations and art of change. I used to long for the good old days when I was a shepherd for a bunch of Digital UNIX, HPUX and Linux boxes. When it was just me, the hardware and a command line. Now that part of my brain has found more joy at home designing chicken coups, garden walls and the occasional bookshelf.

Instead I find myself doing value stream maps, investigating ROIs, understanding changes in CMS core measures and gathering high level requirements. It took me 13 years to get here. My sister was able to step into her first HIT job without ever seeing a UNIX command line or configuring a IP network. She's never hacked a registry or plugged an ethernet cable into a frigid datacenter patch panel. Instead what she has is far more valuable. Ten years of everyday experience working with doctors and nurses while they care for and treat patients. Ten years of immersion in the process of caring for patients. I hope I can keep up!

Richness of Capability - Um, why do I care???

In my post on "Richness of Capability" I realized that I perhaps went a bit out there without explaining why I'm curious about it. Well imagine...

• If we had a way to measure when a foundational technology will deliver way more than it promises?
• If we had a way to communicate and measure when an investment in capability will multiply compound on existing processes?

That's why I'm curious. I also don't think the topic hasn't been looked at, I probably just don't know where the research is or how it's already measured. Topics to consider looking for these answers include innovation, enterprise architecture and information theory. More to come...

The Process and the Technology

Evidence based care (EBC) is coming and I'm pretty darn sure it's a good thing. The thought that my diagnosis and treatment will be based on research that statistically shows the best outcomes gives me some confidence in a world where I get two answers from two doctors on the same question. Last Thanksgiving I was at the table with a friend of my Mom's who is a case manager who focuses on EBC. There are basically three key things you "do" when implementing it.

• Scan the research on a regular basis to find out what it's telling you.
• Assess your processes to find out where you can bake compliance with the correct order sets/protocols into patient care.
• Continuously measure and update based on the results.

Obviously BI tools play a part in the measure piece. Without those you don't have a way to find out if you're getting the results you expected. I'm also very curious about how you turn a culture around to address the process piece. Physicians like to do things the way they like to do them. I suspect that standard order sets aren't terribly popular.

Last but not least how do you efficiently and effectively scan and look up all of that literature and research. What opportunities are there to use technology to search unstructured federated data quickly and effectively. Google of course comes to mind but how do you hone the edge of the search to get exactly what you want.

As a six sigma green belt I look at all of this and think about how beneficial it might be to reduce variability in outcomes and results. As I'm currently learning LEAN concepts I think about how much waste there might be in these systems and how can it be squeezed out, to benefit patients, consumers and the rising cost of healthcare. As an IT professional I can imagine the day when the lines between the process and technology blur....

Traversing the Stack

Today I was in a meeting where project prioritization for 2009 was being discussed. There were four projects that are looking for funding in an environment where capital is not as abundant as it was prior to the economic meltdown. There are already a lot of projects approved. Several of them have to do with infrastructure as varied as data center requests to integration engines to desktop virutalization. They wanted to better understand these requests to see if they could be re prioritized as well.

Infrastructure is tricky because it's the foundation on top of which everything else runs. It's "lower in the stack". That's geek code for "close to the machine" and "close to the machine" as explained in Tracy Kidders The Soul of a New Machine. I had a computer science teacher once point out that the communications and hardware ancestor for all computers was the telegraph. It was an electrical device that communicated information by changing between two states, off and on, so it was binary. All you needed to know about the state of a telegraph at any point in time is if the wire was "hot" or "cold". A computer is like this too and at the lowest level, close to the machine, the state of a computer can be described in terms of the state of it's circuits signals and the contents of it's memory, registers and cache.... The next layer "up" in the stack is machine language, the binary codes stored in memory that are decoded by a CPU to trigger the different circuit signal states. The next layer up from that is assembly language, pseudo human readable codes that correspond nearly one to one to machine language. The next layer up is a compiler that takes a conceptual language like C or Fortran and compiles it into assembly language to be assembled into machine language to be decoded into circuit signals. Every layer up takes a set of hot or cold signals on a set of wires and translates them into something more and more understandable to people. These are the layers of abstraction that turn what are fundamentally electronic abacuses into clinical applications that might make sure I don't get a transfusion of the wrong blood type.

Infrastructure is lower in the stack than applications so describing it's value in business terms is more challenging because it isn't the technology touch point that a nurse uses to make patient care happen. It's out of sight/out of mind (unless it fails!) so requested investments seem a little bit suspect to the lay person. It's also EXPENSIVE and once you buy it it needs to be upgraded, updated, maintained and replaced.

That's where the foundation analogy fails. Usually a house's foundation is poured, cures and doesn't ever have to be touched again. Imagine that you constantly improve and update your foundation or else parts of your house might come undone. If you got behind you'd have to run around putting braces and temporary fixes in place to make sure you had a place to live! Then imagine that every time you mentioned the work that needed done your spouse suggested buying say, a new kitchen appliance. Depending on your relationship that might be a tricky conversation!

So over the course of the next week I'll be preparing for exactly that same conversation with our hospital leaders to help them traverse the stack and understand what will happen to that kitchen remodel we worked so hard on if the foundation doesn't get re poured.

My Ideal Healthcare Experience

Recently someone very dear to me had a disappointing experience. She saw a physician's assistant at group health who did several disparaging things...

• He criticized diagnosis made by her regular physician in front of her.
• He didn't listen to her concerns about shoulder pain and her previous history.
• His critical manner and disparaging comments made her feel as though she was crying wolf.

Needless to say she won't be seeing this physicians assistant again however hearing about the episode got me thinking to what an ideal health care would be so here it is...

My family would have a long-term relationship with a highly competent family practitioner. That family practitioner would see them selves as physician, trusted advisor and most importantly partner in helping manage all aspects of healthcare for my family. They would be comfortable with the level of knowledge and more complex questions that they receive from us as we learn about our own health online, willing to discuss what we have found and open to hearing us explore different options. Their guidance would be spring from evidence based best practices that are consistently communicated and applied across the discipline with tweaks as necessary that account for the individual characteristics of my family members. As a partner there would be other avenues of communication than having to schedule a visit, reducing the amount of visits necessary.

Implication

• A model of compensation that allows family physicians the flexibility to care for their patients in this fashion.

In the case of an emergency for one of my family members we would arrive to an ED that rarely had long lines/wait times and where the physicians on duty had easy access to their medical histories. Our family practitioner would automatically know about the episode and when necessary collaborate with hospital and ED physicians on the right plan of care. Again, the ED and hospital physicians would make heavy use of evidence based best practices with an understanding of the individual patient. This would all apply in the case of hospitalization sans emergency admit, i.e. giving birth...

Implications

• A model where healthcare coverage and/or urgent care clinics replace the overwhelming use of EDs as a surrogate for family medicine.
• A mechanism that allows easy ad-hoc collaboration between hospital and primary care physicians.
• An acute care setting reimbursement model that rewards hospitals and physicians that utilize evidence based care.

In the case where a member of my family has to grapple with a chronic illness or condition the family practitioner would recommend and collaborate with the right specialists to develop a plan that focused on the well being of the patient. Updates to the patent's history would be available to both physicians as needed and the family practitioner would have easy access to the treatment record as well. Again the baseline for the care plan would be evidence based best practices with changes that are necessary for the individual situation of the patient. Communication with the specialist would also not always need to occur via an encounter/visit and it would be easy for patient, family practitioner and specialist to have dialogue outside of the office setting.

Implication

• A reimbursement model for specialists that rewards the use of evidence based care.

Global Implications

• Medical schools would need to begin training physicians towards newer highly collaborative models of care where they collaborate both with other physicians and their patients.
• A industry mechanism for identifying, deploying and educating physicians about evidence based best practices.
• Medical history and updates need to flow seamlessly to and from all settings on demand. THERE IS ONLY ONE PATIENT RECORD PER PATIENT.
• Mechanisms for physician and patient collaboration need to be made available and easy to use outside of the office visit setting.
• Healthcare insurance is available to all Americans.

What does your ideal healthcare experience look like???

Ideas, Ipods and Smartphones

Today I drove to Portland to pick up my kids. They had spent two nights with their grandparents. I've made the two hour run many times (even on the same day) so the trip is uneventful, the landmarks tick off in my subconscious except for the rivers where I pay attention checking color and level. Chelle got me an Ipod nano for Christmas. I previously had an Ipod Shuffle, the memory stick variety, but I grew weary of forwarding over and over again to get to the song I'm after. Now the shuffle will be relegated to when I exercise.

I've decided that my favorite part of an Ipod is not listening to downloaded Old Crow Medicine Show tracks while driving home but passing the time of a long commute with podcasts. Podcasts are basically audio content that is published via RSS to which you can subscribe using Itunes, the Ipod pc-side software. National Public Radio has recorded and published many of their shows via podcast and I downloaded a whopping amount of This American Life, The Best of Car Talk and NPR Technology. NPR Technology is a collection of segments from all of the NPR news shows that have to do with Technology and how it affects our lives.

My cellphone, or more properly I guess, smartphone is a Windows Mobile 6 device. A Motorola Q9c that I selected because I like non-stylus interfaces, it had a very handy querty keyboard and a built in GPS. Among my favorite apps are Google Maps and the Google Search Mobile widgets. Google Maps has saved my bacon when it comes to making meetings on time and at least once when it came to a fishing rendezvous. The google search widget puts a google search box right on the front/main screen of my phone. A tool that I haven't often used is the voice note recorder. You fire it up and can record voice notes (ala the old school mini-tape recorder)for later playback.

The long drive to Portland and back goes a lot easier when my conscious mind has something to engage it and I actually can accomplish a lot of thinking while on the road but today I did something a little bit different. While I was thinking, as I found an idea that was particularly engaging I fired up my voice note recorder and recorded it. I was listening to the NPR technology podcast, all episodes back to June 2006. After I got home I looked at my voice note recorder and transcribed the thoughts into my Moleskine notebook. There were twelve in all. Considering that on the way back I had to attend to the kids that means I had about three hours to generate these ideas or about four/hour. Among the 12 there were five that may have implications at work and at least three that applied to problems that I'm actively trying to solve. There were five primarily personal ones of which two applied to my daughters (generated before I picked them up incidentally). Two of them could be considered musings for my friends and I.

My main office is about two miles from my house but at least a couple times a week I have to commute north to the regional office which is an hour away. About half of this time is spent (safely on my bluetooth) on conference calls but that leaves at least two hours a week where I could be listening to something that spurs questions and generates ideas. If I surmise that three ideas/hour will come along during that time I should have at least captured six ideas a week that otherwise would have been forgotten after a long drive to or from home.

So Ipod + podcasts + smartphone + voicenotes + Moleskine = ideas remembered, almost like keeping a dream journal. The kicker is it's fun both to listen to the news about technology AND think about this stuff. It may not go anywhere or materialize but I think I'll keep writing them in my Moleskine just to find out.