Although my business cards and my CV list the title Chief Information Officer, I was given the title Chief Medical Information Officer (CMIO) when I was hired at BIDMC in 1998. Today, I serve three kinds of roles:
CIO - Responsible for strategy, structure, staffing, and processes for a 300 person IT organization
CTO - Responsible for the architecture of our applications and infrastructure, ensuring reliability, security, and affordability
CMIO - Responsible for the adoption of the applications by clinicians, optimizing quality, safety, and efficiency in their workflows
Although I've been able to balance these three roles because of the extraordinary IS staff at BIDMC, good governance, and a supportive CEO, it's challenging for one person to perform all these tasks. Many hospitals and health systems are expanding their management team to include a CMIO.
Here are a few thoughts about the role of the CMIO.
*Clinical applications are only as good as the processes they automate. Automating a broken process does not make it better. Clinician stakeholders working with a CMIO should re-engineer workflows, document requirements, then begin software implementation.
*Achieving consensus among clinicians is challenging. Medical education is an apprenticeship that is part art and part science. It's unlikely that one automated best practice, care plan, or guideline will be acceptable to everyone. The role of the CMIO, as a trusted practicing clinician, is to create consensus around software configuration and decision support rules.
*Selecting new applications can be a daunting experience. Integrated or interfaced? Complete or modular? Best of suite or best of breed? What may be the best solution for a department may be less than optimal for the entire institution. The CMIO can weigh the pros/cons, cost/benefits, and the overall integration into the enterprise portfolio during application selection.
*Nothing is perfect and clinical systems implementation will always be a journey, balancing compliance, security, ease of use, automation of manual processes, and safety. Clinicians have constantly evolving needs and they will frequently feel that the IT organization does not have the supply to meet their short term demands. The CMIO can run processes which engage clinicians in priority setting and resource allocation decision making. Although the projects they want will likely be done at a slower pace than they'd prefer, they will understand the balance of time, resources, and scope because they were involved in creating the plan.
*Often, there are no right answers in clinical IT. Given fixed time and resources, what is the top priority - Meaningful Use, ICD-10, healthcare reform, Joint Commission mandates, or quality improvement agendas? Some may answer, all of them. The CMIO can advise senior management how to phase an endless stream of projects so that the greatest good is done for the greatest number over the long term.
Who should the CMIO report to? Choices include the CIO, the CMO, the COO, the CEO, or some governance group i.e. the Medical Executive Committee. Every organization is different and the reporting relationship should be a function of where the CMIO can have the greatest impact, visibility, and support.
In my view, Meaningful Use, increasing demands for clinical workflow automation, and healthcare reform necessitate that every hospital larger than 50 beds have a full or part time designated CMIO. Given the daunting array of clinical IT requirements over the next 5 years, CMIOs will be increasingly important.
Tuesday, January 17, 2012
Saturday, January 14, 2012
Skin Conditions With Aging
Patients often have growths or skin changes that they wonder about. After examining them, in many cases I say "happy birthday"...it's a manifestation of getting older. Aging leads to a number of skin and hair changes and when you add the effects of sun, smoking and the environment, the changes can be profound.
Over time the epidermis thins and by age 60 the dermis is 20% thinner than before.
Friday, January 13, 2012
Cool Technology of the Week
I have an iPhone 4S and to conserve power, I've turned off WiFi, location services, and Bluetooth.
Nonetheless, with my volume of email, I cannot get more than 12 hours of use from an iPhone. I charge it overnight, use it during the day, then begin recharging it as soon as I get home.
QYG has a solution - a thin iPhone 4S protective case that contains a lightweight flat battery which doubles battery life.
Several of my staff members use these and note that the mini-USB port can be used with a standard USB cable to charge the battery.
A lightweight, protective case that doubles the battery life of an iPhone - that's cool.
Nonetheless, with my volume of email, I cannot get more than 12 hours of use from an iPhone. I charge it overnight, use it during the day, then begin recharging it as soon as I get home.
QYG has a solution - a thin iPhone 4S protective case that contains a lightweight flat battery which doubles battery life.
Several of my staff members use these and note that the mini-USB port can be used with a standard USB cable to charge the battery.
A lightweight, protective case that doubles the battery life of an iPhone - that's cool.
Thursday, January 12, 2012
Haiti Remembered
This is the 2nd anniversary of the terrible Haiti Earthquake that measured 7.0 on the scale. The disaster killed 316,000 people and displaced 1.5 million more. Even now more than 500,000 people are still in makeshift shelters and only half of the aid pledged for reconstruction has been spent.
My organization sent medical teams and supplies to the disaster zone and our doctors and nurses
Our Cancer Journey - Week 4
This week, we learned about the reality of chemotherapy.
On Friday, Kathy received her first cycle of Cytoxan and Adriamycin, a few days ahead of the schedule I posted on my blog last week.
I drove her to BIDMC. We checked into the ambulatory Heme/Onc clinic and she was given a warm pack to increase circulation to her hands. The lab staff drew a Complete Blood Count (CBC) via a finger stick to avoid creating punctures in her veins, given that her chemotherapy medications are vesicants that cause a chemical cellulitis if they leak into tissue.
The CBC was excellent - a white count of 10 and an hematocrit of 41. We'll follow this closely as the chemotherapeutic agents affect her white blood cells.
Her remarkable nurse, Dianne Holland-Sullivan, spent time getting to know us, then expertly inserted an IV without any issues.
I promised to reflect on the BIDMC electronic health record in describing Kathy's care.
All of her providers share data among themselves and with Kathy. Here's a view of Kathy's electronic profile, showing her problem list, medication list, allergies, appointments, labs, and social history (yes, we've been together 33 years from age 17 to age 50). She's given full consent to share this data publicly as it illustrates the importance of an electronic health record for care coordination.
She can view the same data via her personal health record. The only difference is a few delayed staging results to ensure patients and doctors speak about cancer diagnoses before the data appears on the web.
All of Kathy's chemotherapy orders were written electronically via the BIDMC Oncology Management System. Humans do not dose chemotherapy, computers calculate everything based on protocols that humans maintain based on clinical trial evidence. In Kathy's case, the oncologists designed and made the clinical decision to place her on the "Breast Oncology - CA - Dose Dense" care path.
The computer wrote these orders for her based on her height, weight, age, kidney function, and allergies.
The dedicated chemotherapy pharmacy in the heme/onc clinic prepared the medications, bar codes them, and delivers them to the chemotherapy nurse. Two chemotherapy nurses validated the medications, the dose, and the patient using bar coded patient wrist bands and verbal confirmation from Kathy. An automated medication admission record recorded when the chemotherapy agents were administered.
Kathy first received three pre-medications:
Fosaprepitant - an anti-nausea drug
Ondansetron - an anti-nausea drug
Dexamethasone - a steroid to reduce inflammation and synergistically work with Odansetron to prevent nausea
She also received 500cc's of normal saline as supportive hydration during chemotherapy.
After pre-medication, Dianne pushed 118mg of Adriamycin (doxorubicin) via two syringes over a few minutes.
She then administered 1180mg of Cytoxan (cyclophosphamide) over 45 minutes.
During the medication delivery, Dianne stayed at Kathy's side to discuss side effects, the rationale for the treatment, the likely events to follow medication administration, and the planning for the additional cycles to come over the next 8 weeks. I provided Kathy with a banana, almonds, water, and companionship.
After chemotherapy, we headed home. Kathy took .5mg of Ativan in the evening as directed to help her sleep.
On Saturday, Kathy felt fine - we walked a few miles around Lake Waban, prepared meals, and shopped together. We drove into Boston for a subcutaneous dose of Neulasta (Pegfilgrastim), a white blood cell stimulant to bolster her ability to fight infection as the chemotherapy kills her white blood cells. She took a dose of Dexamethasone in the morning and at night.
On Sunday, Kathy felt prodromal - as if she had the early symptoms of a virus. We walked in the woods near our home and selected a few logs for me to split. As romantic as it sounds, Kathy bought me a Swedish Forest Axe and Splitting Maul from Gransfors Bruks for Christmas. We carried a few hundred pounds of wood to the car together. Yes, I know that sounds odd, but we have a three decade history of doing the unusual together.
By Monday, she felt significant fatigue.
At no time did she feel any nausea.
In her words:
"Overall good reaction to the chemo materials, minimal problem with the steroids
Very light use of Ativan for first night to sleep
No use of anti-nausea meds yet.
Appetite reduced but adequate, sensation of salt tastes reduced
Digestive tract still normal, no use of any aids. Credit vegetarian diet high in fiber, legumes and leafy greens/cruciferous (eliminated all soy and added an egg to breakfast), no dairy, meat or fish consumed.
Fatigue set in hard on Sunday night from a Friday chemo session.
Early mornings and evenings are low energy, one faint period during eye exam.
Neulasta induced muscle myalgia/bone pain disturbs sleep cycle.
Evenings I feel like I am coming down with the flu (chills and aches), mornings I feel like I am recovering from the flu.
Ordered new glasses to get away from contacts during chemotherapy, warned of changes in moisture in the eyes (given Systane eye drops by opthamologist)"
Her general pattern is moderate sleep, the need for a nap after breakfast, a great afternoon, and early evening fatigue, leading to bedtime an hour earlier than normal.
I've changed my schedule to get home by 4pm, walk with her, and support her in the early evening.
I've cancelled meetings on nights and weekends.
Every other Friday is a chemotherapy day, so I've cleared Fridays.
I've cancelled my travel for the next few months.
My colleagues have been incredibly supportive of my running late afternoon and Friday meetings by phone so I can be at home.
We're on the path of treatment and the cancer cells are dying. Kathy's greatest fear has been the chemotherapy. Thus far, the anticipation has been worse than the reality. However, she started the first cycle in perfect health. As the second cycle begins on January 20, she'll be a little more vulnerable.
Today she's back at work in her Boston South End Gallery, NKG. Her spirits are good and she's fighting cancer with boundless optimism.
On Friday, Kathy received her first cycle of Cytoxan and Adriamycin, a few days ahead of the schedule I posted on my blog last week.
I drove her to BIDMC. We checked into the ambulatory Heme/Onc clinic and she was given a warm pack to increase circulation to her hands. The lab staff drew a Complete Blood Count (CBC) via a finger stick to avoid creating punctures in her veins, given that her chemotherapy medications are vesicants that cause a chemical cellulitis if they leak into tissue.
The CBC was excellent - a white count of 10 and an hematocrit of 41. We'll follow this closely as the chemotherapeutic agents affect her white blood cells.
Her remarkable nurse, Dianne Holland-Sullivan, spent time getting to know us, then expertly inserted an IV without any issues.
I promised to reflect on the BIDMC electronic health record in describing Kathy's care.
All of her providers share data among themselves and with Kathy. Here's a view of Kathy's electronic profile, showing her problem list, medication list, allergies, appointments, labs, and social history (yes, we've been together 33 years from age 17 to age 50). She's given full consent to share this data publicly as it illustrates the importance of an electronic health record for care coordination.
She can view the same data via her personal health record. The only difference is a few delayed staging results to ensure patients and doctors speak about cancer diagnoses before the data appears on the web.
All of Kathy's chemotherapy orders were written electronically via the BIDMC Oncology Management System. Humans do not dose chemotherapy, computers calculate everything based on protocols that humans maintain based on clinical trial evidence. In Kathy's case, the oncologists designed and made the clinical decision to place her on the "Breast Oncology - CA - Dose Dense" care path.
The computer wrote these orders for her based on her height, weight, age, kidney function, and allergies.
The dedicated chemotherapy pharmacy in the heme/onc clinic prepared the medications, bar codes them, and delivers them to the chemotherapy nurse. Two chemotherapy nurses validated the medications, the dose, and the patient using bar coded patient wrist bands and verbal confirmation from Kathy. An automated medication admission record recorded when the chemotherapy agents were administered.
Kathy first received three pre-medications:
Fosaprepitant - an anti-nausea drug
Ondansetron - an anti-nausea drug
Dexamethasone - a steroid to reduce inflammation and synergistically work with Odansetron to prevent nausea
She also received 500cc's of normal saline as supportive hydration during chemotherapy.
After pre-medication, Dianne pushed 118mg of Adriamycin (doxorubicin) via two syringes over a few minutes.
She then administered 1180mg of Cytoxan (cyclophosphamide) over 45 minutes.
During the medication delivery, Dianne stayed at Kathy's side to discuss side effects, the rationale for the treatment, the likely events to follow medication administration, and the planning for the additional cycles to come over the next 8 weeks. I provided Kathy with a banana, almonds, water, and companionship.
After chemotherapy, we headed home. Kathy took .5mg of Ativan in the evening as directed to help her sleep.
On Saturday, Kathy felt fine - we walked a few miles around Lake Waban, prepared meals, and shopped together. We drove into Boston for a subcutaneous dose of Neulasta (Pegfilgrastim), a white blood cell stimulant to bolster her ability to fight infection as the chemotherapy kills her white blood cells. She took a dose of Dexamethasone in the morning and at night.
On Sunday, Kathy felt prodromal - as if she had the early symptoms of a virus. We walked in the woods near our home and selected a few logs for me to split. As romantic as it sounds, Kathy bought me a Swedish Forest Axe and Splitting Maul from Gransfors Bruks for Christmas. We carried a few hundred pounds of wood to the car together. Yes, I know that sounds odd, but we have a three decade history of doing the unusual together.
By Monday, she felt significant fatigue.
At no time did she feel any nausea.
In her words:
"Overall good reaction to the chemo materials, minimal problem with the steroids
Very light use of Ativan for first night to sleep
No use of anti-nausea meds yet.
Appetite reduced but adequate, sensation of salt tastes reduced
Digestive tract still normal, no use of any aids. Credit vegetarian diet high in fiber, legumes and leafy greens/cruciferous (eliminated all soy and added an egg to breakfast), no dairy, meat or fish consumed.
Fatigue set in hard on Sunday night from a Friday chemo session.
Early mornings and evenings are low energy, one faint period during eye exam.
Neulasta induced muscle myalgia/bone pain disturbs sleep cycle.
Evenings I feel like I am coming down with the flu (chills and aches), mornings I feel like I am recovering from the flu.
Ordered new glasses to get away from contacts during chemotherapy, warned of changes in moisture in the eyes (given Systane eye drops by opthamologist)"
Her general pattern is moderate sleep, the need for a nap after breakfast, a great afternoon, and early evening fatigue, leading to bedtime an hour earlier than normal.
I've changed my schedule to get home by 4pm, walk with her, and support her in the early evening.
I've cancelled meetings on nights and weekends.
Every other Friday is a chemotherapy day, so I've cleared Fridays.
I've cancelled my travel for the next few months.
My colleagues have been incredibly supportive of my running late afternoon and Friday meetings by phone so I can be at home.
We're on the path of treatment and the cancer cells are dying. Kathy's greatest fear has been the chemotherapy. Thus far, the anticipation has been worse than the reality. However, she started the first cycle in perfect health. As the second cycle begins on January 20, she'll be a little more vulnerable.
Today she's back at work in her Boston South End Gallery, NKG. Her spirits are good and she's fighting cancer with boundless optimism.
Wednesday, January 11, 2012
Servant Leadership
I read every comment posted to my blog and do my best to learn from the wisdom of the community. Two comments made about my recent post Honey or Vinegar deserve special highlight.
Tony Parham posted a comment comparing Management and Leadership, quoting the work of John Kotter and Colin Powell.
"MANAGEMENT: Control mechanisms to compare system behavior with the plan and take action when a deviation is detected.
LEADERSHIP: Achieving grand visions. Motivation and inspiration to energize people, not by pushing them in the right direction as control mechanisms do, but by satisfying basic human needs for achievement, a sense of belonging, recognition, self-esteem, a feeling of control over one's life, and the ability to live up to one's ideals. Such feelings touch us deeply and elicit a powerful response."
- John P. Kotter, Professor of organizational behavior at the Harvard Business School
“LEADERSHIP is the art of accomplishing more than the science of MANAGEMENT says is possible."
- Colin Powell
My experience is that as long as a leader unites a team with a clear common goal and enables the team to do their work while supporting their self-esteem and their decisions about scope/time/resources, people thrive. Even recent medical evidence suggests that "Honey" and the positive support of a leader yields healthy, productive, and happy staff. Lack of such a leader can lead to negative health and reduced longevity. It seems intuitive that our moods are linked closely to our job satisfaction and that positive mood improves health, but now we have evidence to prove it.
Katherina Holzhauser, a fellow Stanford graduate from the Czech Republic wrote to me about Servant Leadership as part of her philosophy of favoring "Honey" over "Vinegar".
The important take home lesson about Servant Leadership is the classic organization chart really needs to be rewritten, making staff who interact with customers the most important people in the organization. The role of a leader to serve and support those staff so that they have the resources and processes they need to optimize customer experiences. I completely agree with the statement that the highest priority of a servant leader is to encourage, support and enable subordinates to unfold their full potential and abilities. This leads to an obligation to delegate responsibility and engage in participative decision-making.
The goals of a servant leader - listening, empathy, healing, awareness, persuasion (which I call informal authority), conceptualization (which I call continuous self re-examination), foresight, stewardship, commitment to people (which I call loyalty), and building community - are what guide my day to day interactions in all aspects of my life.
As we take on more work in less time at faster pace than every before, let's all strive to be servant leaders for the benefit of those who do the work and serve on the front lines healthcare and healthcare IT in our quest to alleviate human suffering caused by disease.
Tony Parham posted a comment comparing Management and Leadership, quoting the work of John Kotter and Colin Powell.
"MANAGEMENT: Control mechanisms to compare system behavior with the plan and take action when a deviation is detected.
LEADERSHIP: Achieving grand visions. Motivation and inspiration to energize people, not by pushing them in the right direction as control mechanisms do, but by satisfying basic human needs for achievement, a sense of belonging, recognition, self-esteem, a feeling of control over one's life, and the ability to live up to one's ideals. Such feelings touch us deeply and elicit a powerful response."
- John P. Kotter, Professor of organizational behavior at the Harvard Business School
“LEADERSHIP is the art of accomplishing more than the science of MANAGEMENT says is possible."
- Colin Powell
My experience is that as long as a leader unites a team with a clear common goal and enables the team to do their work while supporting their self-esteem and their decisions about scope/time/resources, people thrive. Even recent medical evidence suggests that "Honey" and the positive support of a leader yields healthy, productive, and happy staff. Lack of such a leader can lead to negative health and reduced longevity. It seems intuitive that our moods are linked closely to our job satisfaction and that positive mood improves health, but now we have evidence to prove it.
Katherina Holzhauser, a fellow Stanford graduate from the Czech Republic wrote to me about Servant Leadership as part of her philosophy of favoring "Honey" over "Vinegar".
The important take home lesson about Servant Leadership is the classic organization chart really needs to be rewritten, making staff who interact with customers the most important people in the organization. The role of a leader to serve and support those staff so that they have the resources and processes they need to optimize customer experiences. I completely agree with the statement that the highest priority of a servant leader is to encourage, support and enable subordinates to unfold their full potential and abilities. This leads to an obligation to delegate responsibility and engage in participative decision-making.
The goals of a servant leader - listening, empathy, healing, awareness, persuasion (which I call informal authority), conceptualization (which I call continuous self re-examination), foresight, stewardship, commitment to people (which I call loyalty), and building community - are what guide my day to day interactions in all aspects of my life.
As we take on more work in less time at faster pace than every before, let's all strive to be servant leaders for the benefit of those who do the work and serve on the front lines healthcare and healthcare IT in our quest to alleviate human suffering caused by disease.
Tuesday, January 10, 2012
Patients Owning Their Medical Records
Traditionally, the patient chart stayed in the doctors office and rarely did a patient get a glimpse of anything in the record. Photocopying the chart is expensive and no physician would let a chart leave her office because the record must be held safely for a minimum of 7 years. Now more and more offices are doing away with clunky paper charts and electronic medical records are becoming
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