Healthy Technology

A Message from a Sponsor

2009-07-20T21:25:00.000-07:00

Here are 10 things I've learned so far from sponsoring three really large infrastructure projects this year...

Infrastructure is only exciting to IT people unless it reduces cost or downtime.
A well planned change that is executed nearly flawlessly is almost like poetry OR when it goes well it goes really well.
The curve balls at the beginning of a project are nothing like the ones that you get towards the end.
If testing is running behind then you have more risk then you actually know.
Vendor's are best motivated by clear messages about what's in it (or NOT in it) for them.
Project coordination is critical when you're ripping out and reinstalling huge chunks of your business engine.
There is no adequate way to thank everyone who puts their blood sweat and tears into the projects.
There comes a point in the project where the illusion of control is no longer an illusion. This statement is intentionally ambiguous.
A decision to delay is difficult but sometimes the right thing to do.
Project accounting is best left to accounting experts.

In the wake of delays, resource constraints, financial challenges and some big wins I still enjoy this role and would do it all over again. I'll probably even feel that way after these programs are done!

Do The Right Thing

2009-05-24T23:00:00.000-07:00

The question of what "meaningful use" per the ARRA and HITEC is on the verge of driving some healthcare IT professionals nuts. I'll admit it drives me nuts. There is a lot of money on the line for this definition. Money that could put on ROI analysis for EHR projects and help get them off the ground. Money that could help hospitals and medical practices underwrite the change management associated with getting physicians and clinicians on board.

Acceptance is release and I've accepted that we'll know when we know. Our budget cycle started in March and it's too late to wait. Meaningful use and the technologies it is supposed to espouse are meant to eventually make healthcare more accessible and affordable for the people and communities that we serve. If we focus on the projects that help accomplish that then we're doing the right thing. Here's where I hope we go next year...

Shore up any antiquated ancillaries - There are a remarkable number of hospitals that don't yet have pharmacy, diagnostic imaging and laboratory automation as it is. We have all three but at differing stages of maturity and integration. We need to make sure there are no chinks in this armor.
Rational metric reporting - Manual abstracting of charts and data entry into a public reporting system is not going to be feasible over the next five years. We have an EMR, we have to find better ways to leverage it!
HIE Strategy - Once you have an EMR then there is little to no excuse to tell an outside medical practice that you can't help them see medical records, with appropriate security, through an easily repeatable, standards compliant mechanism....

Meaningful use can wait if need be. If these things aren't central to meaningful use then perhaps it's missing the mark anyways...

The Human Computer

2009-04-02T23:00:00.000-07:00

Recently I was asked to review an article about IBM and the Mayo Clinic's recent decision to release natural language processing or NLP code to the open source community and comment on how likely the open source development model and delivery mechanisms like Software as a Service (SaaS) or Service Oriented Architecture (SOA) will become the preferred models for delivering healthcare IT solutions. I've pasted my response below...

Alright, here are some observations but be prepared, it's a bit out there......

I think that it's kind of important to draw a distinction between the FSF/OSF development model and SasS/SOA etc... as delivery model. Linux was sort of special in that it really set a new visible standard for collaborative development in a community. That's not to say that it never occurred before. DARPA/ARPA and the military contractor/technical academic community were the real pioneers for this in many respects. Think of BSD UNIX vs AT&T System V for example. You basically have academia, big R and D shops in new markets (Bell Labs) and military contractors setting up collaborative environments with tons of freedom for brilliant people who want to use their creativity. Richie and Thompson invented UNIX almost in their spare time. Ritchie invented C because he couldn't write UNIX in B (true story) and C was the great grand daddy of a ton of 4th generation languages and definitely set the standard for compilers.

The point is that Linux wasn't the prototype model. It's just that over time the companies that fostered these communities got a grip on their intellectual capital and switched the focus to selling them. Once money is attached to an idea it's no longer psychologically possible to maintain an open flow of ideas and creativity around that idea. This is a system that rewards true brainstorming where no idea is a stupid idea and the person who helps his brother/sister find an answer is more valuable than the person who builds a silver bullet to feed an ego. This I think is a key concept, more on that below.

Linux and GNU revolutionized things by understanding that a large number of brilliant creative people care more about the free and open flow of creativity and ideas than making money. CPA finance best practices don't seem to mix easily with people who are wired to understand things and solve them because it's satisfying. It creates a kind of cultural dissonance and a myth that there is a choice (albeit a suckers choice) between having either the open flow of ideas/creativity OR the efficient and effective financial principles of selling in a market. There are more and more companies though who recognize this as a suckers choice and know that it's not an OR but an AND to be successful. Red Hat supports the open source community, fosters and respects it while making buck. IBM's transformation from big iron hardware vendor to services company was enabled by their willingness to embrace the FSF community, contribute generously and then fill a niche helping their business partners deploy these far cheaper and high quality solutions to a variety of business problems. I suspect their real target in considering a purchase of sun is MySQL (the fabled open source database that does 80% of what you need a database for REALLY REALLY fast) and Java. I can imagine them turning Java loose in the FSF community and watching it blossom into capabilities that make their consulting services that much more valuable.

We're moving from an industrial age and economy into a knowledge and information age. The winners are no longer going to be defined by who can protect and sell "things" or products. Instead it's going to be more effective to foster people's built in desire to be creative, productive and, well, human. I think this is an important concept and yes, more on that below.

SaaS and SOA can be thought of as architectures. What people generally call Web 2.0 are also. They're the next layer of abstraction in the evolution of computing. Just as punch cards evolved over time into 4th generation languages each evolution brings ease of use to computing and generally amplifies our ability to solve problems more naturally. I think it's easy to forget just how unnatural it is that we rely on a bunch of signals traveling through solid state logic gates to synthesize meaning on a CRT or LCD display truly is. The real work is done at the end of the day by the person who reads and interprets those images and uses the most powerful computer known (the human brain) to translate those abstractions into action. While SaaS, SOA and Web 2.0 types of technologies can ease the burden of that translation and make it easier for us to use technology to communicate they are still terribly crude compared to the richness of human interaction. There will be successors to SaaS and SOA. So I think the REAL benefit that they provide is in simplifying the common understanding and language of how we interact with computers. Music is a pure and natural human language in many respects. Emotion and meaning can be conveyed in a very real and raw state through composition and arrangement. SaaS and SOA help us get closer (even if we're still light years away) to that quality of communication by giving us standard mechanisms to arrange how we interact with each other through technology. I think this is the link between SaaS/SOA and the cost of technology. As technology evolves towards allowing us to spend more time on the message and less time on constructing it the flow of ideas becomes easier. This is a key concept.

If the keys are that creative collaboration is becoming more valuable than proprietary protection, fostering creative collaboration will be the key to being sustainable in the future and that the evolution of technology is moving towards enabling the communication required for collaboration then where in the heck is healthcare as an industry and healthcare IT going to have to go? Here are my predictions...

Healthcare's cost is driven by it's complexity and variability. The need for standardization in healthcare will be both drive and be driven by the need for easy interoperable exchange of patient information across the continuum of care.
SaaS and SOA are most effective when dealing with the standardized exchange of data (think RSS) so if standardization continues to gain traction via HITSP, IHE etc then they will become even more viable delivery options.
The need to exploit our most efficient and powerful resources, the minds of countless doctors, nurses, technologists, patients and other stakeholders, will drive us to converge on technologies that simplify the creative process.

I think that the end-point is likely to be SaaS, SOA or something that comes along later that fits this bill. Creative collaboration (aka the FSF model) is gaining momentum and will reach a tipping point once the pain of doing it the way we've always done it is greater than the pain of what will come next. I think that we're on the cusp.

So here's the deal. You can't just let me ramble like this without giving me some feedback. Help me develop this idea into something useful....

P.S. I think that NLP technology (as referenced in the article) has a ton of potential and could even break down some of the barriers and challenges associated with traditional business intelligence. In the short term though structured data and standards will serve us better since they help drive down the variability that is the root cause of our countries high cost of healthcare. The decision to open source it's development is both intelligent and responsible.

The Speed of Light is Obsolete

2009-03-22T23:57:00.000-07:00

The healthcare IT provisions of the ARRA have a lot of dollars attached to them. Elligibility for the payments starts in 2011 to the tune of 2M/hospital (acute care) and 18K/physician (ambulatory). Elligibility for the money is based on the definition of "meaningful use" of an EMR and that's interesting because "meaningful use" is yet to be defined.

From everything I hear the HIMSS Analytics group has good reason to believe that level 4 in their EMR adoption model will probably be a part of the definition. Level 4 is basically the implementation of your main ancillaries (Lab/Rad/Pharmacy etc...), a clinical data repository, bedside medication verification and CPOE (computerized physician order entry) rolled out. CPOE only has to be in one department however. Based on the low percentage of hospitals at level 4 right now there is a lot of debate if it'll be scaled back to level 3.

The speed of implementation is important because healthcare IT doesn't move at the speed of light. It moves at the speed of adoption. We're at level 3 in my organization so to get to level 4 we need to roll out CPOE. CPOE is a physician's tool. To be successful you need the buy in of the physicians and all of the folks that they work with on a daily basis from nurses to office managers.

There is a lot that can be done with technology to facilitate this. Make it easy to use, ensure that it performs well and ensure that it talks to the other systems. Not that this is easy. There's enough here to keep any IT manager a bit nutty given the complexity of these systems and the workflow that they support. We have enterprise architecgture and technology roadmaps to coordinate these pieces.

Now we just need a roadmap for physician adoption....

Is Buy to Build as David is to Goliath???

2009-03-06T21:30:00.000-08:00

In the January CIO Connection (the CHIME newsletter, no I'm not a member but a friend is) there was an interesting article on some questions asked by Insurer Executives at a Healthcare IT Summit. One of the questions was "Should our organization take a build versus buy approach to BI?". This is a good question.

When I first came to my organization it was literally in the basement as an operator changing tapes and printing UB94s. Well, before that I was a dialysis equipment tech but that was before my IT days while I was still in college. Once I got out of the basement I started working as a UNIX admin and that's how I got involved in a custom clinical portal development project. Basically two developers, a DBA and a UNIX admit had built a system that slurped up DI and Medical Records dictations in HL7 messages, dumped them to a UNIX box, loaded them into an Oracle database and presented them on the web via Cold Fusion. There were some other interesting apps that enabled physician to physician messages (almost a pre-twitter twitter really) and the ability for a MD to grab a rounding list from a Kiosk when they walked in the door. All of this before cascading style sheets and widespread use of XML. It was cool!

Until one of the key developers left and those of us who stayed behind were left the legacy of several undocumented VB4 programs running on an NT4 server that used a weird set of spaghetti like database links and PL/SQL scripts. For a long time we were afraid to touch a lot of it until we rewrote the pieces that we wanted to keep and a few years later we implemented our preferred vendor's physician portal product with great success. Now we spend some time customizing that portal so that it integrates well with some other apps that the physicians need.

So the CIO Connection article went on to point out pros and cons of both the build vs buy BI approaches. In a nutshell, build gives you depth and control while requiring more business engagement and solid processes. Buy gives you shorter time to value with less flexibility and more risk of creating information silos. Analysis like these make deciding the right path about as clear as mud. It also makes the article pretty accurate.

I've rolled the connundrum around in my head for a long while. Given the emerging maturity of the HITSP standards for integration (considered a "glimmer" on the Gartner Hype Cycle), accelerated adoption of EMRS, economic pressures and moral obligation to continue improving patient care I've fallen on the customize/build side when it comes to Business Intelligence. The need to understand, care for, manage and secure our organization's data REQUIRES that we have high levels of business engagement/sponsorship and effective process. The deep expertise required to customize/build that environment forces the issue and the facilitation in a way that "packaged" tools don't. Plus the addition of the packaged tool vendor adds a third relationship to an already complicated mix.

I feel less strongly about building other key functions, web and collaboration tools aside. The thing that might change the game over time would be widespread adoption of HITSP standards as the glimmer brightens to a beacon. Then the art of integrating systems or delivering information to the right stakeholders becomes much easier. The interfaces between systems become predictable and the data that passes in between is better defined. Organizing the components using techniques like SOA and SAAS improve flexibility and ability to respond without sacrificing supportability.

Then build would be to David and buy would be the Goliath...

Money, Medicine and Metrics

2009-02-21T22:43:00.000-08:00

A colleague of mine shared and article from the New England Journal of Medicine called "Money and the Changing Culture of Medicine" by Pamela Hartzband, M.D., and Jerome Groopman, M.D. The gist of the article is that the practice of medicine had both communal and market characteristics and that currently the balance is skewed towards the market end of things. For example, physicians are pushed by pay for performance, payors and medicare/medicaid to focus on the cost of care. There is currently no carrot for collaboration with peers or even patients. Additionally the article points out that studies have shown that the introduction of financial rewards into almost any situation tend to reduce willingness to collaborate. Scary!

Perhaps change is in the air though. Word on the street is that the National Quality Forum is considering different kinds of metrics. Metrics that measure things like patient engagement in their own care. Not that traditional quality metrics like the SCIP measures will go away but perhaps pay for performance will start to focus on actually changing the culture of healthcare. This is exciting!

We should be careful though. Just as paying physicians based on efficiency alone doesn't necessarily deliver the right outcomes, encouraging physicians who find the right ways to engage their patients to hold those techniques as strategic advantages may be less likely to share what worked. So I hope NQF successfully finds a way to reward and encourage the sharing of such best practices, among doctors and hospitals alike.

Back in the (Blogging) Saddle

2009-02-17T21:24:00.001-08:00

After a week and a half of intensity at work and intensity at home I'm about to get back in the saddle again. If you have for some reason followed my twitter posts recently they are mostly about bread and chicken coops. The work-life balance tipped away from work for a while and it's been nice. I find that once I refuel like this my mind starts looking up and around again vs the heads down daily grind that can come after intense periods of work.

Work has been intense. Strategy development, team building, infrastructure projects and new technology evaluations abound. I like to get deep into a topic, obsess about it and know as much as I can in the time I have. I then come back up for air and a reality check and figuring out how much of each is needed to keep the momentum going requires more art than science right now.

So a colleague of mine gave me a few articles to read recently and I took the opportunity in a longish large meeting to scan them and it spawned a few ideas.

An article on the effect of compensation on collaboration (negative in most cases) got cross pollinated with what I'm learning about the National Quality Forum's likely future direction on hospital metrics.
Build vs buy on the Business Intelligence front in payor organizations. What are the lesson's learned for providers and how does that relate to emerging trends on data aggregation vendors as opposed to traditional Business Intelligence vendors.
The economic recovery legislation and it's impact on adoption of EMRs and even more importantly the execution of those projects.

Today was a good reminder to stop, pay attention to everything going on around me and not just focus on the next steps and the plan. If you don't stop and smell the roses then you might just miss something important...

(Not) Lost in Translation

2009-02-03T23:42:00.000-08:00

Today I was given a fine compliment and told that I was a translator. After writing about having to "traverse the stack" and Business Intelligence as a bad word it felt good to hear evidence that bridging the gap between the technical world and the healthcare world is doable by mere humans. Like many things in our culture this talent isn't nurtured early enough and it seems that the school of hard knocks is the primary teacher. For example, how many computer science programs emphasize non-technical writing, non-academic presentation and business skills? It's been a while since I got my Bachelors Degree but I don't see the core of these programs doing a good job in this area.

There are a few ways to try and get there faster. A double major in business management, communications or an MBA. In fact many of the best and most effective translators I know got their MBAs early in their careers and I admire their grace. In a pinch though an organization can help this happen by cultivating these skills internally, not slaying people for making mistakes and committing to the development of their people. These things will evolve into part of a hard-wired culture of learning and culture definitely eats strategy for lunch!

Back to sharpening the saw...

Wordle - Check this out

2009-01-28T22:45:00.000-08:00

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

2009-01-28T21:53:00.000-08:00

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???

2009-01-17T12:39:00.000-08:00

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

2009-01-17T12:25:00.000-08:00

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

2009-01-13T17:55:00.001-08:00

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

2009-01-07T02:29:00.000-08:00

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

2009-01-03T22:09:00.000-08:00

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.

Warning - Propellerhead Update - Twitter

2008-12-19T20:14:00.001-08:00

Alright, I decided to try Twitter out. Inspired by John Halamka's blog I setup a Twitterfeed account too. The goofy part is that I'm twitterfeeding posts from this blog to my twitter account and then using a blogger widget to display my latest tweets at the bottom of my sidebar to the right. This might be fascinating. On top of that I'm also twitterfeeding my Facebook status updates to twitter too.

We'll see how well all of this bailing wire a duct tape works shant we!

P.S. I'm adding a label for propellerhead updates to my blog so that these are easy to identify as notes on tinkering with technology from an ex Oracle DBA.

Brainstorm - Top Uses For Web 2.0 at Work

2008-12-13T20:52:00.001-08:00

Support Wikis - Real time updated FAQ's for application support, problem solving and simple howtos. This shouldn't replace formal support and triage documentation but should supplement it.
Talent/Problem Markets - Offer problems or specific talents/skills online. Staff are rewarded for finding solutions to problems that get results AND for posting problems in the market that then get solved.
Management Twitter - Setup management to use a twitter like "what am I doing now" tool that keeps status in a central location. Publish to everyone so that the types of problems that managers are working on can be public. Staff know what management is working on and managers can status each other on what's up without having to setup additional meetings. Harvest comments on the "tweets" to improve employee engagement or offer help.
Newsletter Blogs - We're in the 21st century and the time has come to move away from newsletters and towards the modern equivalent. Just as many companies blog their news, updates, celebrations and upcoming work our newsletter could be a ongoing blog with multiple authors (even if we maintained a single editor to maintain quality).
Strategic Planning Wiki - Strategic planning for IT often boils down to reviewing the organizational strategic plans and brainstorming the IT internal initiatives and other projects that will support those plans. Open up the brainstorming to EVERYONE including end-users and business participants at every level.
Strategic Planning Markets - Unlike the talent/problem markets that utilize a Craig's List like structure for procuring help a strategic planning market would work more like the online election markets that are used to solicit people's projections for election outcomes online or equities markets that set price based on supply and demand. Once strategies and tactics are brainstormed the planning market would then open up voting to project which ones would best support and align with the organization's needs.
Review Board Forums - For chartered groups that review projects, proposals, designs or other instruments that benefit from a widely diverse peer review setup forums where topics or threads can be started for each item to be reviewed. Then comments can be harvested after a known deadline and submitted to the authors for consideration in the final draft.
Management Blogs - Managers can blog for two purposes. First, to share information on vision, direction, meeting outcomes or other key information that employees are hungry to know and understand. Second, to invite dialogue via blog comments on the information that can happen in a public forum.

Where are you finding success with these tools in your organization?

XML and Richness of Capability

2008-12-13T18:39:00.000-08:00

XML (extensible markup language) has been around long enough, more than ten years, to span a generation of employees so it's becoming a technology norm in a lot of respects. The explosion of blogging, RSS and other online services is empowered by this technology. It has its roots in SGML (standardized general markup language) which has it's roots in something called GML that was invented at IBM in the 60s apparently. SGML is widely used in the printing industry and HTML borrowed SGML for it's structure. I wonder if that helped XML and HTML converge over time.

What XML does is very simple. It developers the tools to organize and describe nearly any type of data with a common set of tools. For example, if I wanted to build an application that organized my fishing logs I could build an XML structure that captured every attribute and element of any given log so that they could be easily stored, displayed, shared or queried. The description of this type of XML document is captured in a document type definition or DTD. Other applications can then parse the DTD and know how to store, display share or query the log also. This makes the data self describing and self organizing.

The real power here is that using these techniques and tools creates rich sets of possibilities that can lead to rapidly deploying the data for new capabilities. This richness of capability is what gives a technology or innovation staying power in a rapidly changing world. For example, UNIX has a long and distinguished history going well back into the 60s. The ease with which a UNIX platform can be used to develop and deploy complex services is the key to it's long-term success. At it's heart is the command line interface, a set of simple core commands that can be used to accomplish huge varieties of computing tasks. I have seen healthcare applications built out of the UNIX command line interface by itself. The UNIX command line provides rich capabilities for developers and administrators alike.

Richness of capability enables agility, the ability for a technology to solve a wider set of problems that also extends its useful life and increasing its value. So a rich capability technology probably isn't easily identifiable right out of the gate. Take Java for instance. When Java first came out it promised to solve a wide array of problems including platform dependence, network portability and to further mainstream the use of object oriented programming. It was moderately successful in all of these endeavors but in the final analysis really just becomes another programing language and environment, albeit a popular one. Its capabilities are no more or less rich than other language/environment combinations like .net.

I plan on exploring this idea in future posts. The hypothesis invites a variety of questions like...

How might you define or measure a rich capability?
What role does richness of capability play in the evolution of technology?
To what extent are rich capability technologies incremental or wholesale changes to their previous versions or predecessors?
What percent of disruptive technologies tend to be rich capability technologies?

Why Business Intelligence is a Bad Word

2008-12-08T20:10:00.000-08:00

We're off and running with discovery (in depth evaluation) of an initiative that could be termed Business Intelligence or Analytics but we aren't going to call it that. Business Intelligence has become a bad word and in the never ending quest to support the needs of our hospital administrators we can't afford bad words. The challenge of communication between the clinical and IT communities is much too important. I was once told by an ex-boss that "why?" is my favorite question. Actually "how?" is my favorite. I like to understand things sooooo....

How is it that Business Intelligence became a bad word? In looking back I think there have been a variety of factors.

Business Intelligence (BI) is a technology label and technology labels are usually dreamt up by salespeople to make product offerings sound cool. Over time best practices cause the labels to refer to some sort of architecture or other anatomy that is recognizable. The label endures however and lacking the newly evolved context suffers.
Recently in reading an enterprise architecture text the difference between deploying IT solutions vs IT capabilities was highlighted. Deploying IT capabilities is a more forward looking and strategic endeavor. The difference however isn't always clear and when (as I have on occasion) heard IT folks talk about deploying a "robust business intelligence application" the wrong picture emerges. BI is an IT capability and should be treated strategically. Individual projects should focus on solving problems.
When working with business leaders on developing IT capabilities it's extremely easy to fall into the "solution looking for a problem" trap. Unless the value of the capability can be defined in terms of business value or mitigation of risk it's like telling a joke and forgetting the punchline.

So again the challenge of communication between the clinical and IT world highlights itself. So if you want to start being pro-active and develop IT capabilities you best watch your language.

Blogs In Review

2008-12-03T20:36:00.000-08:00

Being a Google blogger user I've been able to pretty easily integrate a few of my other Google tools with it and am rather fond of the result. On the right hand side of my blog you'll note a blogroll and newsreel. These are both imported automagically from my Google reader account that slurps up my favorite blog's articles. Articles that I flag with a star are automatically posted to the newsreel. I also like emailing some of the articles that are especially interesting to folks that I suspect will enjoy them. Here's a few of the characters that I follow these days...

Fred Trotter - I like to think as Fred as the Healthcare IT/FOSS curmudgeon of the group. Given the fact that my favorite comedian is Lewis Black this is definitely a compliment. He posts on lots of topics having to due with free and open source software (FOSS) as an enabler for Healthcare IT at reasonable cost.

Life as a Healthcare CIO - John Halamka's blog. He's sort of a celebrity healthcare CIO with tons of creds and experience. Some of the most interesting things that he blogs about come from his work as the Chair for HITSP (Healthcare Information Technology Standards Panel) whose work has the potential to improve integration of HIT systems across the industry. His penchant for dressing in all black reminds me of Neil Diamond for some reason.

Candid CIO - This is the blog of Will Weider who is CIO for a rather large health system. I enjoy his insights on customer service and change management the most.

Not all of my Google reader subscriptions are listed on my blogroll. There are several others as well from places like TechRepublic and even Scientific American, either science and tech research or general industry mags. It's a pretty easy mechanism to catch mostly the news that I want and post it easily to Blueberrytech. Take a gander at the others out there and see what you think...

Happy Thanksgiving

2008-11-26T18:13:00.000-08:00

Here are just a very few things that I am thankful for this year.

The continued health of my wife and children, our rich opportunities and wonderful life together.
My family and friends with whom I have had chances to grow closer this past year.
My work, colleagues and our mission.
The land that we live in, its rivers, woods, fish, birds and the peace it brings.

Have a great Thanksgiving.

Value Proposition

2008-11-16T17:14:00.001-08:00

On Friday I sat through a very cool vendor demo about a really cool new data product. The product itself is pretty innovative ad would have some really important applications in our environment right off the bat.

The topic of cost came up at the end of course. For a 500 bed hospital we'd be talking a highish 7 digit pricetag. This seems to me close to the cost of a DI instrument or two that some of our facilities are looking for. What might a better model be? One where the vendor shares the risk of delivering an roi methinks...

To centralize or decentralize, that is the question...

2008-11-13T22:33:00.000-08:00

I found the following article by Kevin Crowston and James Howiston about the Social Structure of Free and Open Source Software. It explores the implications of measurable communication patterns on the assertions of the Cathedral and the Bazaar metaphor, namely that highly decentralized and somewhat chaotic social structures are capable of creating higher quality and more generally useful products than traditional closed projects that focus on creating competitive advantage through protecting intellectual property. This is a crude definition so I highly recommend following the link above.

Crowston and Howiston examine data associated with bug tracking on a variety of open source projects and develop a methodology for measuring the degree of decentralization of a given project. Some of their conclusions are very very fascinating and made me think.

In The Wisdom of Crowds and Wikinomics the concepts around mass collaboration, ala Linux and the Cathedral/Bazaar metaphor, are explored and the potential benefits of these models are sorted and categorized. This is giving rise to some interesting conversations about organizational operating models and competitive advantage via collaboration. There is the potential here for lots of c-level executives to hop on a very popular but tricky bandwagon. Like everything else the trick is in the execution.

How many companies have adopted the tenets of process engineering or continuous improvement through six-sigma and lean techniques? Many of these companies are seeing the benefits of these tools and methods but they don't really translate to a competitive advantage because their competition deploy them as well. Like these tools mass collaboration, and it's enabling technology, is likely to become a necessary standard of operation rather than a revolutionary competitive differentiator with a few exceptions. As with all things that comprise the standard book of operating principles and tricks execution will be the real test and therein lies the trap.

The real lesson of Crowston and Howiston is that mass collaboration is not a well defined thing with clear boundaries and a cookbook for success. It's an enabler for truly inspirational and robust organizations. If the apple is rotten at the core then you're only enabling more rapid decay. If the apple is strong and fresh then you're getting ready to bake a mighty good pie. The core of any good organization is it's people.

So beware the seduction of techniques, tools and processes that claim to be the key to competitive advantage and cookbook success. Just like late night infomercials it's snake oil. Instead look to your people and the rest will come. In their minds, voices and inspiration lies the real wisdom, centralized or decentralized.

Why do we pay for software again???

2008-10-29T23:55:00.000-07:00

VistA is a HIS system developed by the government and made freely available. It's used outside of the VA as well. It's built on the same Mumps or M platform that McKesson uses for STAR and Epic uses for their EMR technology. Mirth is a freely available HL7 interface engine. There are several other open source EMR products out there. Bulletin boards, web servers, wikis, content management systems and J2EE servers can all easily be found freely available under the GPL.

Per the Wikipedia entry...

"The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA.[6]"

It also states that most organizations that implement see an approximately 6% improvement in efficiency and that the cost of the implementation can be covered by reducing a few unnecessary lab tests.

So why are we paying for software again? A full 60% of our IT budget is spent on support maintenance agreements (SMA) every year. We get the following benefits from these dollars...

The right to actually use the software, usually in the form of licensing.
The ability to call a help desk or support organization for help.
Updates and patches.

All of this even if we don't call the help desk or upgrade the software. Furthermore all of this comes with caveats that basically void any guarantee that the software will work if we don't stay up to date version wise.

VistA and Mirth both have developers that contribute to the system, user and support groups that assist when there are problems and all of this is available for FREE. There are no guarantees, unless you want to pay someone for the support.

A full 30% of our budget is labor. The lifeblood of any knowledge based industry and at our company they are the mission alive. We have been told by our biggest vendor partner that we are sometimes a challenge to support because of the quality of our technical folks. We challenge them in ways that they usually aren't on a consistent basis. Our server, application, process, data, network, development, desktop, telco and database staff regularly find bugs and fixes that our vendors struggle to tackle.

Hmmmmmm....

What if we converted to a total Open Source solution. We could dedicate half of the existing SMA budget to grow our staff. Better yet dedicate a third to labor and a sixth of it to training and deployment of (Open Source) collaboration tools. The remainder of that money gets reinvested in the hospitals and clinics. With our new staffing model and skill set we improve the products and feed the improvements back into the industry. We push the products to easier and easier to support so that smaller facilities and clinics can afford to implement an EMR. We contribute to and participate in the support forums and train other IT professionals to use the model so that all of healthcare in this country can benefit.

No more SMAs......

Barcelona, Email and Opportunity

2008-10-22T22:26:00.000-07:00

I'm back from vacation. Barcelona is a very cool city! The food, people, art and architecture are all a wonderful experience. We also stayed in Cadaques, a small coastal town in northeast Spain that still has a small working fishing fleet and also mostly caters to tourists. The quiet and peace were a stark contract to busy Barcelona! We also spent the night under Montserrat in Montistrol de Montserrat, a small village under the steep mountain atop which a monastery was built long ago. Montistrol was a taste of typical Catalan village life with people walking their dogs, a horse drawn cart still in use, pick-up games at the village football pitch and a cafe/bar in the town center that is filled to the gills after 7PM on a Thursday night. I loved Catalonia.

Now I'm back, refreshed and relaxed and cranking through several hundred emails. My task list is brimming with new assignments received while I was away. Fortunately I'm blessed with a wonderful team of folks who can tackle nearly anything that comes their way. Currently one of my team members is out of office preparing to have her second baby. There are three interim managers, one from one of her teams, our manager of systems architecture and another from an applications team, who are filling in. All of them are doing a great job and the opportunity to bring a different point of view to some of the challenges we face has been enlightening. We wish our colleague a happy and healthy birth and look forward to her return.

Many of the new assignments have related to the financial situation faced by so many people around the world. As we collaborate with our executive leadership to ensure the future of our ministry the challenges that we face occasionally feel daunting. Every challenge hides an opportunity however.

Our endeavors to improve the quality of our development application portfolio will now naturally align and be pulled along by the mandate that more scrutiny is applied to projects that do not fall into the purview of IT Governance. This will result in more opportunities to collaborate with our customers and ultimately optimize the value that our web development squad provides to the ministry. The need to report out and improve patient care quality measures will help drive a shift and transition away from old school operational reporting towards the delivery of pro-active data that allows hospital staff to step away from data-entry and spend more time on improving outcomes. The necessary slowdown of operational budget growth will reduce the overall number of discretionary projects on our plate during a period where we have at least four major infrastructure and application upgrade initiatives that are key to preventing the decay of our production environment. The need for great ideas to reduce overhead and generate revenue will provide opportunities to pilot and roll out low cost/high yield idea generation and implementation techniques that will provide scores of opportunities for long term incremental improvements in efficiency.

The list goes on and on. In times like this I reflect on the amazingly talented colleagues I work with each day and my anxiety evaporates because I know we will weather the storm and emerge stronger than ever.

Recharge

2008-10-11T07:04:00.001-07:00

Chelle, my wife, and I are sitting in Seatac airport waiting to catch the first leg of a two flight trip to Barcelona. We're both already tired after preparing the house for my parents who are babysitting the kids while we're away. I'm so grateful to them.

So we're off on our first overseas adventure. I'm so excited but not for the reasons that you may think. The real gift for me is the time I get to spend with Chelle alone.

Its easy for the daily grind to take over and wear you down. The kids come first and my work isn't, well, just a job to me. I honestly think I was meant to do this. Just as I honestly believe Chelle and I were meant to find each other.

So its always a gift to be alone together for a while without the pressures of daily life. We'll come home tired but recharged with the memory of what really counts in life fresh again.

Healthcare - Privilege, Right or Responsibility

2008-10-07T22:41:00.000-07:00

A couple of days ago I was talking to one of my colleagues who works in Quality/Risk about the project that we're working together to get launched. She had recently gone to a Mission Leadership event and when I asked where she was for the last couple of days she filled me in a bit.

This demands a bit of background. I work for nuns. I tell people this somewhat tongue in cheek but it's true. The trick is, many of the nuns that I work for have passed away but their legacy remains in the schools and hospitals that they founded. The sister who works in our office reminds us regularly that there are fewer and will continue to be fewer sisters to carry on that legacy. They are, over time, teaching the lay leaders, us, the tenets of Catholic healthcare. They do this so that the legacy will carry on. When I reflect on their faith in us it resonates as a sense of personal responsibility and humility.

My colleague told me about one of the fundamental tenets of Catholic healthcare. That healthcare is a right of every individual. I've given this a lot of thought and think I agree. It's idealistic in many respects but so are many of the beliefs that we hold to as a country, society and culture. The declaration of Independence states that we have certain inalienable rights. Life, liberty and the pursuit of happiness are tenets from our countries founding fathers that are just as idealistic. When I think about this it means to me that all individuals have a right to receive care when they are unwell. The basic problem is that not everyone can afford it right now. I'm proud to work for a system that prides itself on the amount of charity care that it provides. We're a long way away from realizing healthcare as a right.

So tonight I watch the presidential debate and what does Tom Brokaw ask? Should healthcare be a privilege, right or responsibility (Obama: a right, McCain: a responsibility)? There was talk of priorities, for Obama healthcare is number two (after climate change and energy), for John McCain it's to be worked in parallel with the other issues of the day. There was talk of tax credits, fines and small businesses. For now it's all rhetoric. I sure hope that at the end of the day whatever transpires there is real change for the better because I think the sisters have it right.

Unexpected Benefits of Blogging

2008-10-01T20:56:00.000-07:00

I've discovered a few unexpected benefits of blogging about my worklife that I thought I'd share...

It reinforces my optimism. I blog to write and as my college writing teach said, "writing is an inherently public and creative act". I can brood if left to my own thoughts alone but the creative process doesn't allow for brooding much and the public act of writing doesn't allow me to feel alone much.
It allows me to collect, synthesize and assemble thoughts that would otherwise remain unrelated. I'm rarely able to sit down and tackle a single topic when writing a new post. Several things swim around in my head at the same time. This may be because I scan my google reader account (see the newsreel box on the right) usually before blogging. The thoughts of a lot of extremely intelligent people get stirred around with thoughts about my day and memories. They sometimes stick to each other like Velcro.
Strangely enough I can use it to avenge the evil exploits of my colleagues. For example, I have my Windows Mobile cellphone setup to post directly to this blog. Today I took a picture of one of my colleagues eating an egg salad sandwich. This was in revenge for her giving me a hard time relentlessly a week ago. Now, at the touch of a button I can post that picture for anyone to see. I probably won't though, unless she gives me a hard time for blogging again.

At the Tipping Point

2008-10-01T20:34:00.000-07:00

The Tipping Point is a great book about the factors that cause an idea to "tip" over and become widely adopted. It's the difference between feeling like you're pushing a noodle uphill vs trying to keep up with the tire rolling downhill. There are several factors that create a tipping point. Some, like the "stickiness factor" can be synthesized by creating messages, communication and even marketing that "sticks" to the target audience naturally and organically. Other pieces are less easy to coordinate like the need for people to network, understand and sell the ideas (all different roles).

Today I caught myself telling someone that I really didn't expect our Business Intelligence initiative to start taking off so quickly. After working for nearly a year with my team and colleagues to research, test and market the value of the technology I'm spending a full 50% of my time now preparing charters, steering committees and presentations to secure resource commitments. It's as though a glacier doubled in size overnight or a snail traversed a county in a day. It's stark.

I'm also surprised at it's lack of isolation. As one sponsor is positioned to support and sell the initiative, dedicating her own resources to make it happen, another is beginning to emerge with a different set of requirements and a new found mandate for long awaited change from his CFO. Other parts of our organization are pursing similar paths and barriers to collaboration are evaporating. Information is beginning to flow across silos and saturate. Fear is being replaced by excitement.

So while winding down this afternoon I decided that perhaps I'm witnessing a tipping point under way. I'm not sure how much of it's due to the work of my colleagues, the current business landscape at work or the passion of our new found sponsors for the utility of this technology but it's exciting to switch from educate and sell to prepare for launch.

T minus 60 minutes and counting....

Application Porfolios and Old Data

2008-09-18T22:14:00.000-07:00

At last count we had about 480 applications in our portfolio. The 80/20 rule applies here. We spend about 80% of our time and energy on 20% of those applications. We also have run about 30% availability for our staff to support projects although following our big EMR implementations we are now probably around 15%. The portfolio keeps growing too!

There are a lot of companies out there working to write software to make the hospital experience safer, more efficient, better for physicians and better for patients and they market very aggressively to our business leaders. Fortunately we have process in place to partner with them early on to evaluate these solutions. I can still remember the old days however when a department manager would walk on over to the IS office, drop off a couple of CD's and ask if we could have their software up and running next week. We've come a long way. Now we have IT governance reviewing the major IT investments and other bodies to assist our PMO's and facility specific PM's.

So where is the portfolio growing? We support three acute care facilities and they often have different application solutions for the same problems. We can sometimes achieve standardization between them but only when the departments see value in collaboration. Even when we do achieve collaboration or the time comes to swap out an application something has to be done with the old one or more specifically the old data. We need to archive it. We have to keep it around.

This creates weird artifacts like flat file dumps of data that get shoved into Oracle database. Applications up and running without support maintenance agreements because the end-users still like the old front end. Data conversion routines that leave some minute field leftover. Requests for 130 reports against a legacy database and engagement of vendors who specialize in taking old regulatory data and making it available.

It's wacky and it keeps our portfolio from shrinking. I'm curious to hear if anyone out there has a better solution.... Seriously....

Curve Ball City

2008-09-18T21:38:00.000-07:00

All successful projects have sponsors, formal or informal, and formalizing the role is best practice. This applies to traditional IT implementation projects as well as process or organizational change projects.

We ask a lot of our sponsors. The IT Governance group is chaired by a non-IT leader and all of our key hospital leaders participate. It takes a lot of work to keep the content and focus on track. As sponsors we ask them to add to their own complex lives of caring for patients and communities in an ever changing regulatory environment. We add PMOs, processes, architecture and the costs of infrastructure, support and licensing. I can tell that it can be borderline traumatic. I have the utmost respect for them and do my best to support and serve them.

Language is of the utmost importance. In IT and healthcare we live in a sea of acronym soup. DR, ADT, ICDs, TQM, EIGRP, RAC, AD, LDAP and hordes of others. As IT leaders the burden is on us to learn the business, jargon and culture of healthcare while not burdening our business partners with the arcane (yet exciting) nuances of technology.

Technology projects are occasionally sponsored by members of the IT leadership and so I just celebrated my first anniversary as the sponsor for a huge forklift upgrade to our clinical application suite. We're scheduled to complete 3rd quarter of next year and while this challenge is not the same sponsorship required to rip out a ADT/billing system I'm starting to get a feel for what we put our business executives through.

It's been curve ball city or perhaps more like standing at the plate looking at Jamie Moyer wondering what in the heck is he gonna show you next. He winds up, the pitch comes flying down the plate breaking low and inside [scope doubles before the charter is signed], swing and a miss. He winds up again for the 0 and 1 pitch and lets fly, 89 miles of fastball, swing, get a piece of it and foul it off behind 1st base [ehr project schedule change delaying start project due to resource collisions]. Now the 0 and 2 pitch, a high arching curve ball, but it's high so hold the bat [vendor overcomes issues getting resources to the table]. I have no idea what the next one will be but I'm starting to get the hang of it.

Our hospital sponsors are mostly like a bunch of lead-off or designated hitters. I just hope I can knock a base hit in for the team.

Launching

2008-09-12T20:02:00.000-07:00

In healthcare IT I sometimes feel we see governance best practices as a way to "customer as king". Combined with tight budgets and multiple priorities this gives us a good way to align with the patients, physicians and other customers that we support. It also keeps us in a supporting actor role. We don't often have the lead role. The times are a changing though.

I've been spending a lot of time thinking about architecture lately, and not the baroque kind. I've watched our HIS applications evolve from monolithic mainframe apps (PCS on a Tandem) to open n-tier architectures that separate the data, business logic and presentation layers. It's exciting to watch. One of my favorites is an emergency room app by Picis. I remember standing up an old version and being excited to see that it was built out of Apache and Perl. It's architecture lent itself to our ability to deploy it with load balanced redundancy for the presentation layer and clustering for the data layer. This opportunity allowed us to deploy it across several emergency rooms without having to purchase totally separate infrastructure.

That is the kind of opportunity that a well considered architecture will provide for you. Yesterday I attended a meeting where an extremely complex report specification was being worked out. Part of the report requires the aggregation of data that is easy to extract at a point in time but not pull retrospectively. Fortunately our DBA team and our report writers have agreed to a set of best practices that include the development of stored procedures behind the crystal reports. Again architecture comes to the rescue because the aggregation of the snapshot data is easy to accomplish by modifying the stored procedure to save the results in a timestamped custom table.

Many of the vendors we work with still consider their architectures proprietary (even though they are built on open systems) or the separation between development and implementation is stark enough that their support can't answer questions about how the app is built.

The punchline is that good architecture can make or break new opportunities. It can launch IS out of the supporting actor role into the emmy winning lead spot. Architecture can accelerate service delivery and new architecture is being developed every day. I think there are two challenges to unlocking it. First, choosing the right elements so that they create rather than restrain opportunities. Second, capturing and selling the value of nuts and bolts that can make the delivery of service so much easier and faster. A third just occurred to me. That is making sure that we have the right organization and processes in place to deliver.

We have the right talent in place to help us with the first and most of the third. The second is vexing to me at times. Initiatives get off the ground with the help of a lot of players. Launching the right projects is the key to a better life through architecture.

Integration on my Mind

2008-09-08T23:14:00.000-07:00

Lately, like a lot of other folks in this industry, I've had integration on my mind. Specifically tying together ambulatory and acute care visit data that resides in two or more different vendor's systems. It's not trivial. It depends on a lot of technical nuts and bolts with the most important being an enterprise master person identifier (EMPI, surprisingly the wikipedia entry isn't that robust) to crosswalk patient identifiers and records across the systems. Then a collection mechanism is needed. This could be collecting the information for a patient in a single view or the development of another repository that aggregates all of the pertinent information for display. All of this has to be done quickly and efficiently for the patient and/or provider.

Then we need to factor in the dynamic nature of these environments. Healthcare evolves faster and faster. So too is the technology used to support it so whatever the solution is needs to be capable of bobbing and weaving as software, requirements, processes and regulatory needs change. The current buzzword for this is agile. If we build something cumbersome and difficult to maintain then it will not survive. This is an important trait for all healthcare technologies but they don't often deliver even though it's the promise of nearly every new development environment.

As frustrating as this is it also makes the problem fascinating. I dream about it occasionally. I wonder how Software as a Service, Service Oriented Architecture, emerging standards and market forces will eventually drive towards (hopefully) sustainable solutions. There is a lot of work being done in this domain and a lot of opportunity for innovation even as our vendors struggle to align their product lines.

My advice for all healthcare IT vendors? Be the first and fastest to integrate your product with anyone else's and provide nothing but the best customer service. I think only the best are going to survive the next few years. May the best products win.

Blueberries

2008-09-03T21:47:00.000-07:00

Not far from where my family lives there is an abandoned blueberry farm. It's not actually abandoned. It was purchased by a group that preserves farmland and now people are free to pick the blueberries. We go there nearly every year and my wife's blueberry cobbler is heaven in a bowl ala mode. There are volunteers that come in and trim back the lilacs that are trying to take over. Some years there are fewer volunteers and we trudge through boggy mud up to our calves to find unpicked berries. It's sort of a hidden community garden.

Open Source software is that way too. There are hundreds or thousands of projects developed mostly by volunteers and usually offered for free via a licensing model known as the GNU Public License (aka the GPL). Wikinomics is a great book about how open source, idea markets and the knowledge economy is being accelerated by software such as the LAMP (Linux, Apache, Mysql and PHP) stack and other technology innovations. Just as more and more farmland is preserved for future generations by passionate volunteers who see and feel the potential for a better future there are passionate volunteers who imagine, propose and participate in the development of new tools to make peoples lives better. It's inspiring.

I came to healthcare through my families love of service. I came to healthcare IT through Open Source Software so I naturally try to see our industries opportunities, challenges and possabilities through that same lens of realistic optimism. It's not always easy. The challenges are not trivial but when we get it right the blueberries are delicious and when we have a good partner to help us cook the cobbler life is good.