Skin Rash-Pityriasis rosea

My 17 year old son showed me the strange rash that was developing on his chest and back.  It was itchy and each day seemed to be getting worse and worse.  The rash spread around his back and under the arms but spared his face and arms and legs.  After examining the pattern, I was sure of the diagnosis...Pityriasis rosea.

This strange rash occurs in the spring and the fall and mainly strikes

The BIDMC Technology Ventures Office Conference

Today, I joined Kevin Tabb (CEO at BIDMC), Alexandra Drane (Eliza Corp), Nina Nashif (Healthbox), Graham Gardner (Kyruus), and Mark Chalek (Chief of Business Ventures at BIDMC) to explore Digital Health and Patients' Needs via a very energetic panel discussion.

Key themes we discussed - in order to create value for patients and families, an entirely new generation of products and services will be needed.   Ideas ranged from "Zagat" type guides to help patients select providers based on personal preferences, easy ways for patients to find appropriate clinical trials, and 'Facebook for Health' as a means for patients to seek and exchange data with a community of caregivers, family members, and supporting services.

In a world of healthcare reform, there is a need for better capture of data including patient generated data.   There is a need for more exchange of information for care coordination and population management.    There is a need for more analytics and decision support.   All of this must done while protecting patient privacy.

Although the conversation started with buzzwords like "cloud", "mobile", and "BYOD", it rapidly changed focus to patients and their families.

One thing is clear.   In order for an ecosystem of products to develop which enhance the experience of healthcare, there must be more data liquidity.   Silos of information and silos of care must be eliminated.

Massachusetts goes live with its statewide HIE on October 15, 2012.   Several institutions in the Commonwealth have already implemented distributed/federated queries for clinical trials and clinical research.   State government is working on infrastructure to record and exchange consent preferences.   The ingredients for innovation are well aligned - funding, political will, and infrastructure.   Our rate limiting factors to improving the status quo are fear of the unknown and the challenges of managing the change itself.

A great discussion.

Building Unity Farm - the Dogs and Cats

No farm can be complete without dogs and cats.

In the 1980 and 1990's, my wife Kathy raised Chow-Chows professionally.   We have fond memories of Syrah, Callie, and Thor, our champion dogs who all passed away from old age.

My daughter, Lara, loves Alaskan/Siberian Huskies and she learned to mush two Summers ago during a trip to Alaska.

When we planned Unity Farm, we knew we needed livestock guardian dogs.   Chow Chows guard their families but are not known for guarding other animals.   Huskies eat other animals.  We considered  Komondors, Anatolian Shepherd Dogs, and Great Pyrenees.  After significant research and visiting local farms, we selected Great Pyrenees.

We chose a pair so they could effectively work together against predators and keep each other company.   Bundle (short for Bundle of Joy) is our 10 month old female.  Shiro (Japanese for white) is our 12 week old male.   We do not intend to breed them and by agreement with her breeder, Bundle was spayed two weeks ago.    Shiro will be neutered at the appropriate time.

They are the best of friends and sleep together during the day, play together all afternoon and guard together at night.    Bundle is 60 pounds (the runt of her litter).  Shiro is already 30 pounds and per canine growth charts he will be over 90 pounds at maturity.

They guard the male alpacas - Stanley, Domino, and Midas.   Bundle has already chased away one coyote.    Shiro has lived with our Alpacas for over a month and he's bonded with them.   The only challenge he's had occurred when he squeezed into the female pen and was stepped on (accidentally) by our 300 pound llama.   Other than a small corneal abrasion (which we treated with tobramcyin opthalmic drops), he suffered no ill affects.

The only downside to Great Pyrenees is that they are very protective of their food and the two dogs have to eat separately to avoid squabbling.

Every night I take them for a long walk outside of the paddocks, exploring our forest filled with deer, wild turkeys, foxes,  owls, and really great wilderness smells for dogs.

Bundle and Shiro are true farm dogs, rolling in hay, playing in mud, and frolicking with chickens/guineas.   They have not shown aggressive behavior toward any prey animal, but they are quite aggressive with predators.

Although a traditional barn should have barn cat to control the rodent population, our two cats live inside.   Tigger and Lily are feral strays that we adopted 12 years ago.   At this point they enjoy lying in the sun, chasing dustballs, and munching kibble (to the extent their remaining teeth allow).    Tigger is a 16 pound male, and Lily is 10 pound female.    He enjoys as much petting as his humans can sustain.  She enjoys hunting, licking her humans, and giving gentle love nips.

Both are healthy and happy in their "retirement" as geriatric cats.

At the moment, the barn remains rodent free because we've stored all our grain in sealed aluminum containers.   I'll write about our hay, grain, and other food management next week.

As is generally the case at Unity Farm, our dogs and cats live in harmony with their surroundings and the other animals.   They all have jobs to keep them busy, and our dogs partner with us to manage the livestock, keeping them safe.

Mobile Devices for Medical Education

Today I'm doing a video teleconference keynote to a group in Thailand to discuss the use of mobile devices in medical education at Harvard.

Here are the slides I'll use.  Thanks to Jason Alvarez at HMS for preparing the data.

Key findings from the 2012 HMS Mobile Survey

89% of teaching faculty are mobile users
97% of students in their clinical years own a smart mobile device
49% of Preclinical Students own an iPad
37% of teaching Faculty have iPads
70% of HMS teaching faculty that have a mobile device use an iPhone

Creating mobile apps using mobile-friendly style sheets worked well for us in the past,   Native apps provide a better user experience so HMS has created an iPhone native app for use by clinical students who need a more responsive user experience in areas with slow internet connections.

Android devices are used by 23% of students.   HMS tries to support both Apple and Android platforms but Apple devices are always the first implemented and are easier to support due to their consistent configuration and predictability, especially around security management.

To help students and faculty find the best apps, HMS has created a "Zagat Guide" for apps that enables the community to share evaluations and ratings.   For example, the top 5 apps per the crowdsourcing input are


John Hopkins Antibiotics Guide
VisualDx
ePocrates Essentials
5 Minute Clinical Consult
iRadiology


Bottom line - the educational platform for 2012 is no longer the web, it's mobile.

Can We Stop Throwing Stones?

I'm a glass half full kind of guy and an eternal optimist.   I glorify progress and quickly forget defeat.

Often I feel that I'm in the minority.  Bad news sells.  Criticism has a Schadenfreude attraction - the apparent failure of others makes some feel more successful.

 Monday Morning Quarterback commentary frustrates me.

1.  Steve Jobs would have never allowed Apple maps to launch on the iPhone 5 and thus Apple is past its prime. 

In the business world, every company has its peaks and troughs.  I think of the greatness some Massachusetts companies like Polaroid, Digital Equipment Corp, and Wang Computer had in their day.   Today, there are empty buildings or construction sites where those once great companies used to be.

For those in operational roles, we all know how hard it is to keep the trains running on time while managing change and trying to innovate.   It's like changing the wings on a 747 while its flying.

At the moment, Apple is the most valuable company on the planet and the iPhone 5 sold five million units in 3 days.  

Yet, instead of stories (which I would personally find interesting) about how you manage a supply chain to deliver five million high tech products to customers in a weekend, the stories are about analysts expecting six million or more weekend sales and the earth shattering question about first generation Apple mapping software signifying the downfall of the company.  My comment - engineer an innovative product with minimal defects at multi-million scale.  After you've done that, write an article that incorporates your operational experience in the evaluation of vendors.

2.  Last week I bought a Prius C, trading in my 2005 original Prius with 150,000 miles.   The Prius C a joy to drive, with nimble steering, a very comfortable cabin, and 60+ miles per gallon  (mixed city/highway commuting).   I'm not sure what car Consumer Reports was driving when the put the Prius C on the "do not recommend list".    Increased visibility, a smaller size that makes it very maneuverable in traffic, and intuitive controls make the Prius C a winner.   My only guess is that the Consumer Reports writer owns a Ferrari or a Hummer and was evaluating the Prius C based on an inappropriate set of requirements.    I would like to see an automotive engineer describe the tradeoffs of weight, power, and gas mileage, then objectively evaluate all the hybrids on the market.

Bottom line - I welcome operational people  in the trenches sharing the good and the bad of their own experiences.    In a world of naysayers looking to take potshots at success, I have little tolerance for those who throw stones at those who are trying their best to make the world a better place.

Obama vs. Ryan at AARP

President Obama and Vice-pres nominee Paul Ryan went head to head at the recent AARP convention in New Orleans and addressed the group on Medicare and the Accountable Care Act (aka: Obamacare).  Their appearances were back to back.

Ryan told the audience,"The first step toward a stronger Medicare is to repeal "ObamaCare" because it represents the worst of both worlds".  He argued that the

The Countdown to the Golden Spike

On October 15, the Massachusetts Statewide Health Information Exchange goes live.   The "Golden Spike" for HIE in the Commonwealth is just 3 weeks away and we're all busy doing three things:

1. Modifying our clinical systems to read the statewide provider directory and public key infrastructure certificate repository

2.  Planning our workflows so that we generate continuity of care document/consolidated CDA XML clinical summaries for transitions of care

3.  Installing appliances in our data centers that will transmit our clinical summaries to among providers in the state

Many HIEs have struggled.  Many have closed.   Why is Massachusetts so excited about what we're doing?

We have a sustainability model based on the distribution of stakeholders we have in each category - large provider organization, medium provider organization, small provider organization, solo provider organization, payer, third party service provider, sub network etc. and their willingness to pay a subscription fee.

We have policies that support a trust fabric among all our trading partners.

We have technology that is inexpensive, easy to implement, and standards-based.

In my previous blogs about our State HIE efforts, I promised to provide updates.

Last week Partners Health care sent the first test transaction ("the Golden thumbtack")  by exporting a CCD from their LMR clinical system and placing the XML file with appropriate metadata in a directory on the HIE appliance installed inside their data center.   The file was sent via the state HIE gateway to a test recipient appliance.      We also validated that a receiving hospital could display the CCD within their EHR in human readable form (all certified EHRs can already do this since it's a stage 1 certification criteria).

BIDMC is installing its HIE appliance today.   Our plan is to export CCDs and Consolidated CDAs from our clinical system in response to specific triggers i.e. a discharge event, a consult event, an encounter note signing event etc.   and place these files with metadata in a directory so that the HIE appliance can send it via the Direct protocol to the designated recipient organization.

Thus far, most of the Golden Spike group of early adopters has elected to install an appliance in there data center to support standards-based transmission via Direct.   Since Meaningful Use Stage 2 requires Direct standards (SMTP/SMIME is required, XDR is optional), EHRs in the next year will be able to connect to the HIE without appliances.

The project is proceeding well, on time and on budget.   The technology works.   The participants trust each other and the anticipation for breaking down data silos is high.

And now off to a planning call to make sure we're "laying track" in perfect alignment with other participants.   We're getting the spikes ready for successful participants.

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