Avert your eyes if you can't stand this weeks Medical Challenge from the New England Journal of Medicine. Click on the image for a better view.
This Patient is being treated for an endocrine disease. What is it?
1. Acromegaly ("giantism")
2. Cushing's disease (excess cortisol)
3. Graves' Disease (hyperthyroidism)
4. Hashimoto's thyroiditis (a thyroid disorder)
5. Type 1 diabetes
The
Wednesday, October 5, 2011
A Moment for Steve Jobs
Earlier this evening, I emailed my staff about the passing of Steve Jobs. Many responded that they were genuinely sad.
It's not about being Apple "fanboys" or disliking the competition. It's about recognizing the possibilities for what might have been if Steve had lived longer.
In some ways, his death seems like Faustian bargain - revolutionize the world with products beyond our imagination, then die too young.
In my life, I crossed paths twice with Steve Jobs.
As an undergraduate at Stanford from 1980-1984, I met Steve Wozniak and Steve Jobs at the Stanford Computer Club and saw early demonstrations of Apple II, III, and Lisa products. I taught the first undergraduate personal computer course at Stanford in1981, using Apple products in an era when the Stanford Computer Science department told me that personal computers were a fad that soon would end.
In 1983, Steve Wozniak's mom called me and asked me to design an electronic greeting card for the Woz's 33rd birthday. To this day, I hold the patent on all e-cards, both the paper type that play music and those you send over the internet.
Steve Jobs was at the party where my card was demonstrated for the first time.
I bought a Mac SE30 in 1990.
I was an early adopter of the NeXT cube and used it to develop all my early web applications at BIDMC when I first arrived in 1996.
My Windows years were limited to 1995-2006. Since then I've used MacBooks, iPads and iPods as my hardware devices. This year, I'll retire my Blackberry and replace it with an iPhone 4S.
Thanks Steve, you really made a difference.
It's not about being Apple "fanboys" or disliking the competition. It's about recognizing the possibilities for what might have been if Steve had lived longer.
In some ways, his death seems like Faustian bargain - revolutionize the world with products beyond our imagination, then die too young.
In my life, I crossed paths twice with Steve Jobs.
As an undergraduate at Stanford from 1980-1984, I met Steve Wozniak and Steve Jobs at the Stanford Computer Club and saw early demonstrations of Apple II, III, and Lisa products. I taught the first undergraduate personal computer course at Stanford in1981, using Apple products in an era when the Stanford Computer Science department told me that personal computers were a fad that soon would end.
In 1983, Steve Wozniak's mom called me and asked me to design an electronic greeting card for the Woz's 33rd birthday. To this day, I hold the patent on all e-cards, both the paper type that play music and those you send over the internet.
Steve Jobs was at the party where my card was demonstrated for the first time.
I bought a Mac SE30 in 1990.
I was an early adopter of the NeXT cube and used it to develop all my early web applications at BIDMC when I first arrived in 1996.
My Windows years were limited to 1995-2006. Since then I've used MacBooks, iPads and iPods as my hardware devices. This year, I'll retire my Blackberry and replace it with an iPhone 4S.
Thanks Steve, you really made a difference.
The Responsibility of Formal Authority
You probably expected me to write about the new iPhone 4S today, but the press has analyzed it well, especially Computerworld. Next week I will write about the impact of accelerated consumer IT product releases on CIOs, including managing customer expectations for business IT innovation.
In the meantime, a few thoughts on the wise use of formal authority i.e. that job description we were handed when we first became CIOs.
In previous blog posts I've reflected on the fact that none us of really have authority. Instead, we have responsibility and risk.
The work that I do in all my lives - Federal, State, BIDMC, Harvard Medical School, and my home life as father/husband/son - do not rely on formal authority. They rely on my informal authority to inspire, align, and communicate.
I have never "ordered" a change. The best I can do is to facilitate consensus and follow Harvard Business School Professor John Kotter's principles for change management:
1. Establish urgency.
2. Form a powerful guiding coalition.
3. Create a vision.
4. Communicate the vision.
5. Empower others to act on the vision.
6. Plan for and create short-term wins.
7. Consolidate improvements, creating more change.
8. Institutionalize new approaches.
Relationship building and fostering trust bring me the informal authority I need to lead people through change.
Although the formal authority I have is never used, there are behavioral responsibilities that come with the title CIO. I have to be careful what I say, who I speak with, and what I do, because the hierarchy of the organization assigns power relationships to the role I serve. There are five guidelines I've assigned myself:
1. Respect hierarchical boundaries - if I bypass my direct reports and communicate directly with their direct reports, I always ensure the communication includes everyone in the chain of command. If I did not do this, I would disempower my managers and directors.
2. Communicate consistently with everyone - it's bad behavior is to tell different versions of the truth to people based on what you believe various audiences want to hear. By communicating consistently, I create a culture of collaboration. The last thing I want to do is create discord in the organization by encouraging people to work against each other or foster dissension among teams.
3. Work via standard processes - it may seem expedient to invent your own processes, bypass hierarchies, or work around established lines of communication in an effort to accelerate projects. My experience is that such an approach causes confusion, misalignment of priorities, and wasted effort. Just as I respect hierarchical boundaries, I follow standard processes when problems need to be resolved.
4. Communicate broadly and honestly - if there is problem in the organization, I communicate it to all stakeholders. It is far better to over communicate, even if the news is challenging/difficult, than to work in silos and try to hide failures for fear of embarrassment.
5. Work openly and transparently - we've all worked in organizations with office politics that happen behind the scenes. Back channel conversations, blind cc's on email, escalation around hierarchical boundaries, different conversations in the open verses behind closed doors, and undermining the authority of others can occur in any organization. If someone suggests solving a problem by working on it clandestinely, I refuse. Problems should be solved openly and transparently with all the stakeholders in the room.
These are the responsibilities of formal authority. Although you may never use the power you've been given in your job description, your actions every day can impact your peers and your staff in subtle ways. Once you understand that your every word and behavior can inspire, influence, or irritate, you'll have mastered the responsibility of formal authority.
In the meantime, a few thoughts on the wise use of formal authority i.e. that job description we were handed when we first became CIOs.
In previous blog posts I've reflected on the fact that none us of really have authority. Instead, we have responsibility and risk.
The work that I do in all my lives - Federal, State, BIDMC, Harvard Medical School, and my home life as father/husband/son - do not rely on formal authority. They rely on my informal authority to inspire, align, and communicate.
I have never "ordered" a change. The best I can do is to facilitate consensus and follow Harvard Business School Professor John Kotter's principles for change management:
1. Establish urgency.
2. Form a powerful guiding coalition.
3. Create a vision.
4. Communicate the vision.
5. Empower others to act on the vision.
6. Plan for and create short-term wins.
7. Consolidate improvements, creating more change.
8. Institutionalize new approaches.
Relationship building and fostering trust bring me the informal authority I need to lead people through change.
Although the formal authority I have is never used, there are behavioral responsibilities that come with the title CIO. I have to be careful what I say, who I speak with, and what I do, because the hierarchy of the organization assigns power relationships to the role I serve. There are five guidelines I've assigned myself:
1. Respect hierarchical boundaries - if I bypass my direct reports and communicate directly with their direct reports, I always ensure the communication includes everyone in the chain of command. If I did not do this, I would disempower my managers and directors.
2. Communicate consistently with everyone - it's bad behavior is to tell different versions of the truth to people based on what you believe various audiences want to hear. By communicating consistently, I create a culture of collaboration. The last thing I want to do is create discord in the organization by encouraging people to work against each other or foster dissension among teams.
3. Work via standard processes - it may seem expedient to invent your own processes, bypass hierarchies, or work around established lines of communication in an effort to accelerate projects. My experience is that such an approach causes confusion, misalignment of priorities, and wasted effort. Just as I respect hierarchical boundaries, I follow standard processes when problems need to be resolved.
4. Communicate broadly and honestly - if there is problem in the organization, I communicate it to all stakeholders. It is far better to over communicate, even if the news is challenging/difficult, than to work in silos and try to hide failures for fear of embarrassment.
5. Work openly and transparently - we've all worked in organizations with office politics that happen behind the scenes. Back channel conversations, blind cc's on email, escalation around hierarchical boundaries, different conversations in the open verses behind closed doors, and undermining the authority of others can occur in any organization. If someone suggests solving a problem by working on it clandestinely, I refuse. Problems should be solved openly and transparently with all the stakeholders in the room.
These are the responsibilities of formal authority. Although you may never use the power you've been given in your job description, your actions every day can impact your peers and your staff in subtle ways. Once you understand that your every word and behavior can inspire, influence, or irritate, you'll have mastered the responsibility of formal authority.
Tuesday, October 4, 2011
Simvastatin Safety and Information Systems
The following is a broadcast email written by Dr. David Feinbloom, Medical Director, Medication Safety and Information Management at BIDMC. It nicely illustrates the collaboration among clinicians, pharmacists, and Information Systems:
To all –
I am writing to update you on the simvastatin patient alert process that was initiated in July. As you will remember, this initiative was prompted by the recent Food and Drug Administration (FDA) warning for patients taking simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
In response to this alert, the Medication Safety Subcommittee, in concert with Healthcare Quality, decided that an institutional response was warranted and we proceeded with the plan described in the original email below. In brief, we reached out to all stakeholders, developed a data query to help providers identify these patients, allowed sufficient time for providers to reach out to these patients, and then sent letters to all the remaining patients who were still taking simvastatin, at a high dose and/or in combination with several other medications. Last Monday we sent 2800 letters to the remaining patients.
This size of this initiative was unprecedented for BIDMC, and although it was largely successful, there were many important observations and lessons learned which will inform our process going forward; these include:
1. The volume of alerts, and the number of patients affected, continues to grow (see the recent FDA warning on Celexa and abnormal heart rhythms).
2. Sorting through the level of evidence and clinical relevance of these alerts is difficult and time consuming.
3. Running queries on our patient’s medication lists with sufficient sensitivity and specificity to meet our provider’s needs is not always possible.
4. Provider preference on how, or whether, to address each alert with their patients is variable.
5. Resources, at both the institutional and provider level, are insufficient to support this work.
We have assembled a group to evaluate how to meet this challenge, and anyone who would like to join is welcome. I will provide you with updates as they become available.
Thanks for your help and support.
David Feinbloom
----------
Email to Providers
As you know, the Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
(FDA Drug Safety Communication: Simvastatin). Although it is not uncommon for the FDA to issue safety warnings when surveillance data identifies unanticipated adverse drug effects, this case is somewhat unique because simvastatin is such a common medication among our patients at BIDMC. In addition, we know from previous medication safety initiatives in that past that most of providers do not have the time or resources necessary to identify and contact all of their patients who may require notifications. For these reasons, we are proposing the following strategy:
Healthcare Quality will work with IT to generate of list of patients that have an active simvastatin prescription, either at a dose, or in a combination identified by the FDA to be associated with an increased risk for adverse events (see Search Query below). We will then send a list to each provider by email to give them an opportunity to reach out to their patients and update their medication list.
In several weeks time we will run the same query on all patient medications again. Patient that still have a prescriptions for simvastatin in a dose or combination of concern will then be sent a standard letter asking that they contact the prescribing provider to discuss whether any medication changes should be made (see Patient Letter below).
If you have already contacted your patient and made changes to their medication list such that they no longer have a dose or combination of concern, they will not be receiving a letter. Unfortunately, if you have made the clinical decision to continue your patient on a dose, or in a combination of concern, we will not be able to suppress the letter. We expect this will happen infrequently, and if it does, the language of the patient letter is clear that if they have already discussed this you they need not re-contact you.
Your list may include some patients for whom you are not the primary provider, or may omit some patients who you consider to be part of your panel. Similarly, problems may occur for patients whose medication list is not up to date, contains errors, or includes prescriptions for split doses.
Please let me know if this plan is acceptable to your practices. The queries we are running include
1. All patients in who have an active prescription for simvastatin 80 mg prescribed < 1 year ago.
2. All patients in who have an active prescription for simvastatin > 10 mg and any of the following medications:
· Amiodarone
· Verapamil
· Diltiazem
3. All patients in who have an active prescription for simvastatin > 20 mg and any of the following medications:
· Amlodipine
· Ranolazine
4. All patients in who have an active prescription for simvastatin (any dose) and any of the following medications:
· Itraconazole
· Ketoconazole
· Posaconazole
· Clarithromycin
· Erythromycin
· Telithromycin
· Amprenavir
· Atazanavir
· Darunavir
· Fosamprenavir
· Indinavir
· Lopinavir/ritonavir
· Nelfinavir
· Ritonavir
· Saquinavir
· Tipranavir
· Cyclosporine
· Danazol
· Gemfibrozil
· Nefazodone
----------
Letter to Patients
Dear Patient –
You are receiving this letter because according to our records you are currently taking the cholesterol-lowering medication simvastatin. Simvastatin is also sold under the brand name Zocor, and is found in the combination medications Vytorin and Simcor.
The Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
The risk of muscle damage is low and we do NOT recommend that you stop any of your medications without first talking to your healthcare provider. Simvastatin is an excellent cholesterol-lowering medication and in many instances continuation of the medication is appropriate. However, we are recommending that you contact the provider who prescribed the simvastatin to discuss whether any medication changes should be made. You may have already had a discussion with your healthcare provider about this issue; if so, it is not necessary for you to re-contact him or her. You should immediately contact your healthcare provider if you experience muscle pain, tenderness or weakness, or dark or red colored urine.
To all –
I am writing to update you on the simvastatin patient alert process that was initiated in July. As you will remember, this initiative was prompted by the recent Food and Drug Administration (FDA) warning for patients taking simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
In response to this alert, the Medication Safety Subcommittee, in concert with Healthcare Quality, decided that an institutional response was warranted and we proceeded with the plan described in the original email below. In brief, we reached out to all stakeholders, developed a data query to help providers identify these patients, allowed sufficient time for providers to reach out to these patients, and then sent letters to all the remaining patients who were still taking simvastatin, at a high dose and/or in combination with several other medications. Last Monday we sent 2800 letters to the remaining patients.
This size of this initiative was unprecedented for BIDMC, and although it was largely successful, there were many important observations and lessons learned which will inform our process going forward; these include:
1. The volume of alerts, and the number of patients affected, continues to grow (see the recent FDA warning on Celexa and abnormal heart rhythms).
2. Sorting through the level of evidence and clinical relevance of these alerts is difficult and time consuming.
3. Running queries on our patient’s medication lists with sufficient sensitivity and specificity to meet our provider’s needs is not always possible.
4. Provider preference on how, or whether, to address each alert with their patients is variable.
5. Resources, at both the institutional and provider level, are insufficient to support this work.
We have assembled a group to evaluate how to meet this challenge, and anyone who would like to join is welcome. I will provide you with updates as they become available.
Thanks for your help and support.
David Feinbloom
----------
Email to Providers
As you know, the Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
(FDA Drug Safety Communication: Simvastatin). Although it is not uncommon for the FDA to issue safety warnings when surveillance data identifies unanticipated adverse drug effects, this case is somewhat unique because simvastatin is such a common medication among our patients at BIDMC. In addition, we know from previous medication safety initiatives in that past that most of providers do not have the time or resources necessary to identify and contact all of their patients who may require notifications. For these reasons, we are proposing the following strategy:
Healthcare Quality will work with IT to generate of list of patients that have an active simvastatin prescription, either at a dose, or in a combination identified by the FDA to be associated with an increased risk for adverse events (see Search Query below). We will then send a list to each provider by email to give them an opportunity to reach out to their patients and update their medication list.
In several weeks time we will run the same query on all patient medications again. Patient that still have a prescriptions for simvastatin in a dose or combination of concern will then be sent a standard letter asking that they contact the prescribing provider to discuss whether any medication changes should be made (see Patient Letter below).
If you have already contacted your patient and made changes to their medication list such that they no longer have a dose or combination of concern, they will not be receiving a letter. Unfortunately, if you have made the clinical decision to continue your patient on a dose, or in a combination of concern, we will not be able to suppress the letter. We expect this will happen infrequently, and if it does, the language of the patient letter is clear that if they have already discussed this you they need not re-contact you.
Your list may include some patients for whom you are not the primary provider, or may omit some patients who you consider to be part of your panel. Similarly, problems may occur for patients whose medication list is not up to date, contains errors, or includes prescriptions for split doses.
Please let me know if this plan is acceptable to your practices. The queries we are running include
1. All patients in who have an active prescription for simvastatin 80 mg prescribed < 1 year ago.
2. All patients in who have an active prescription for simvastatin > 10 mg and any of the following medications:
· Amiodarone
· Verapamil
· Diltiazem
3. All patients in who have an active prescription for simvastatin > 20 mg and any of the following medications:
· Amlodipine
· Ranolazine
4. All patients in who have an active prescription for simvastatin (any dose) and any of the following medications:
· Itraconazole
· Ketoconazole
· Posaconazole
· Clarithromycin
· Erythromycin
· Telithromycin
· Amprenavir
· Atazanavir
· Darunavir
· Fosamprenavir
· Indinavir
· Lopinavir/ritonavir
· Nelfinavir
· Ritonavir
· Saquinavir
· Tipranavir
· Cyclosporine
· Danazol
· Gemfibrozil
· Nefazodone
----------
Letter to Patients
Dear Patient –
You are receiving this letter because according to our records you are currently taking the cholesterol-lowering medication simvastatin. Simvastatin is also sold under the brand name Zocor, and is found in the combination medications Vytorin and Simcor.
The Food and Drug Administration (FDA) recently issued a new warning for patients and healthcare professionals regarding simvastatin because of an increased risk of muscle damage when taken at high doses or in combination with several other medications.
The risk of muscle damage is low and we do NOT recommend that you stop any of your medications without first talking to your healthcare provider. Simvastatin is an excellent cholesterol-lowering medication and in many instances continuation of the medication is appropriate. However, we are recommending that you contact the provider who prescribed the simvastatin to discuss whether any medication changes should be made. You may have already had a discussion with your healthcare provider about this issue; if so, it is not necessary for you to re-contact him or her. You should immediately contact your healthcare provider if you experience muscle pain, tenderness or weakness, or dark or red colored urine.
Monday, October 3, 2011
scintillating scotoma
image from myaspiebrain
Nothing like experiencing a medical condition first-hand to really help a doctor understand it from the patient's point of view. After all these years, I had my first (and hopefully last) scintillating scotoma while sitting on the couch playing "words with friends" on my ipad and watching TV. A scotoma is a partial loss of vision in a normal visual field. Scintillate
Bring Your Own Device
At BIDMC, I oversee 10,600 desktops and 2000 laptops. They are all locked down with System Center Configuration Manager 2007 and McAfee ePolicy Orchestrator.
Given that most of our applications are thin client and web-based, we can stretch the lifetimes of our desktops to 5-6 years and our laptops to 3-4 years. Capital funding puts limits on how much hardware we can buy and how long we keep it.
Like many IT departments, we have to balance many priorities - security, cost, software compatibility, performance and the user experience.
This balance means that the locked down, image managed, economical device provided by the IT department will almost always be older, lower powered, and less capable than the device in your home.
The same is true of mobile devices like Blackberries which are a one time purchase and are only replaced when they stop functioning.
Consumer devices are more than just technology, they've become lifestyle accessories. Are you an iPad2 or a Macbook Air 11 person? Does Android tickle your fancy or are you holding out for the Samsung tablet with Windows 8?
The cost of these devices is low enough that consumers can buy them on their own and may upgrade yearly as new models are released.
All of this has led to the BYOD movement - Bring Your Own Device to work.
One of my passions as a CIO has been to create web-based applications that run anywhere on anything. That approach has enabled our applications to run on every version of the iPad, iPhone and iPod touch as well as Android and Blackberry devices like the Playbook.
However, I'm also accountable for the privacy and security of each byte of person identified data and we have over 1.5 petabytes to protect.
The internet is an increasingly hostile place. Clicking on a picture of Heidi Klum results in a 1 in 10 chance that your device will become infected.
Online apps distributed via social networks are filled will malware.
Hacked websites can bring malware onto our device. A CIO at the recent Information Week 500 conference described that hackers inserted malware, which was only one pixel by one pixel, into a public-facing website his lab supported. All internal users who browsed to the website and did not have the latest version of Adobe Flash were infected. Once infected, their workstations scanned for other vulnerabilities on the network.
Breach reporting regulations in HITECH are strict. If a keystroke logger embedded in malware results in username/password compromise and a hacker downloads files or views data for more than 500 people, the prominent media needs to be notified. It is unlikely that the media will see much difference between an infected personal device and something under the CIO's control - the CIO will be held accountable!
BIDMC has over 1000 iPads and over 1600 iPhones accessing its network for email and web applications. I absolutely see the value of the Bring Your Own Device movement.
However, the compliance and regulatory requirements that grow more complex every day make the BYOD movement very problematic.
It may be that we'll find some compromise, such as encouraging BYOD, noting that little support will be available, and requiring mobile device security solutions such as Good Technologies before a personal device is allowed on the network.
BYOD can be empowering to users. Let's hope we can mitigate the risk and afford the applications needed to comply with federal and state laws.
Given that most of our applications are thin client and web-based, we can stretch the lifetimes of our desktops to 5-6 years and our laptops to 3-4 years. Capital funding puts limits on how much hardware we can buy and how long we keep it.
Like many IT departments, we have to balance many priorities - security, cost, software compatibility, performance and the user experience.
This balance means that the locked down, image managed, economical device provided by the IT department will almost always be older, lower powered, and less capable than the device in your home.
The same is true of mobile devices like Blackberries which are a one time purchase and are only replaced when they stop functioning.
Consumer devices are more than just technology, they've become lifestyle accessories. Are you an iPad2 or a Macbook Air 11 person? Does Android tickle your fancy or are you holding out for the Samsung tablet with Windows 8?
The cost of these devices is low enough that consumers can buy them on their own and may upgrade yearly as new models are released.
All of this has led to the BYOD movement - Bring Your Own Device to work.
One of my passions as a CIO has been to create web-based applications that run anywhere on anything. That approach has enabled our applications to run on every version of the iPad, iPhone and iPod touch as well as Android and Blackberry devices like the Playbook.
However, I'm also accountable for the privacy and security of each byte of person identified data and we have over 1.5 petabytes to protect.
The internet is an increasingly hostile place. Clicking on a picture of Heidi Klum results in a 1 in 10 chance that your device will become infected.
Online apps distributed via social networks are filled will malware.
Hacked websites can bring malware onto our device. A CIO at the recent Information Week 500 conference described that hackers inserted malware, which was only one pixel by one pixel, into a public-facing website his lab supported. All internal users who browsed to the website and did not have the latest version of Adobe Flash were infected. Once infected, their workstations scanned for other vulnerabilities on the network.
Breach reporting regulations in HITECH are strict. If a keystroke logger embedded in malware results in username/password compromise and a hacker downloads files or views data for more than 500 people, the prominent media needs to be notified. It is unlikely that the media will see much difference between an infected personal device and something under the CIO's control - the CIO will be held accountable!
BIDMC has over 1000 iPads and over 1600 iPhones accessing its network for email and web applications. I absolutely see the value of the Bring Your Own Device movement.
However, the compliance and regulatory requirements that grow more complex every day make the BYOD movement very problematic.
It may be that we'll find some compromise, such as encouraging BYOD, noting that little support will be available, and requiring mobile device security solutions such as Good Technologies before a personal device is allowed on the network.
BYOD can be empowering to users. Let's hope we can mitigate the risk and afford the applications needed to comply with federal and state laws.
Saturday, October 1, 2011
Bedside Manners Worth $42 Million
A Chicago couple believes doctors should have good bedside manners and they have ponied up $42 million dollars to teach it. Matthew and Carolyn Bucksbaum have donated to the Bucksbaum Institute for Clinical Excellence at the University of Chicago. They made the donation for their own personal physician to lead it and say he's the kind of doctor students should emulate. They were motivated to
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