Today I met with a multi-disciplinary group at BIDMC that is rethinking traditional academic medical center office space and is planning the office space of the future with innovations such as shared open floor plan workspaces, "huddle rooms" for ad hoc meetings, shared IT infrastructure, easy to use wall mounted displays, electronic conference room availability indicators, and ubiquitous use of scanners to eliminate paper.
Like many academic medical centers, BIDMC has a high demand for closed door offices but has a limited supply of real estate. Most clinicians are in the their office less than 10% of the time, so conventional approaches to academic departmental space are very inefficient.
Today's meeting focused on work flow. How is clinical and administrative paperwork eliminated in a shared office space environment? Who does scanning/metadata tagging/quality control of scanned documents? What regulatory/compliance issues need to be addressed as paper filing cabinets are turned into electronic folder systems?
Clinical scanning is easy - we already have a comprehensive approach that uses high speed scanners, Captiva software, and an automated upload directly into our medical record.
Administrative scanning is harder - we have not implemented a document management system such as Documentum. I welcome advice from my readers - how you eliminated administrative paper storage with scanning? What are your retention and security policies? How do you query and retrieve selected documents?
Since there are no closed door offices in the new design, several small "huddle areas" enable ad hoc private meetings with automated electronic display of room availability and appropriate wall mounted LCDs supporting presentations from laptops and iPads.
Finally, since new data will be entered electronically and not on paper, we've deployed eScription voice recognition software in our data center. Clinicians can use a phone or an iPad/iPhone app to upload voice files for immediate voice recognition and insertion into our electronic record.
There will be many lessons learned from this office space of the future. Hopefully we'll offer a very attractive space with high productivity in a smaller real estate footprint that is used efficiently More to come as we go live.
Wednesday, November 30, 2011
Tuesday, November 29, 2011
Green CDA Over The Wire
Over the past decade, I've been closely involved in the evolution of clinical summary/transition of care content standards. We started with CDA, then merged the CDA and CCR to create the CCD, which we further constrained with the C32 implementation guide. This year, the Consolidated CDA initiative refined/constrained/optimized the CCD/C32 specifications from IHE, HITSP and HL7 into one easy to use implementation guide.
The only problem with CDA-based standards is that implementation requires expert knowledge of the HL7 Reference Information Model (RIM), a steep learning curve for new developers. Ideally, HL7 and informatics experts would use the RIM or Detailed Clinical Models to develop templates containing easy to read and parse XML that does not require knowledge of the underlying information model.
Green CDA aims to do that - the simplicity of CCR XML tagging with the expandability and modeling of CDA. However, there is a controversy. What do we send on the wire - full CDA or Green CDA?
At the November HIT Standards Committee meeting we endorsed moving forward with GreenCDA as the single over the wire format.
It's likely that existing users of full CDA over the wire will be concerned about the costs and effort required to move to Green CDA on the wire.
Robert Worden, an expert on HL7 mapping tools, wrote a great summary that explains the path forward through the use of transforms:
"There is now tooling which can define a Green CDA and generate 100% reliable transforms to full CDA, all in the same step. That tooling is being used in the UK for the NHS Interoperability Toolkit; and it has been linked to MDHT, so it could be used to Green consolidated CDA and generate the transforms.
Once you have reliable, maintainable transforms, the question “Green CDA or full CDA on the wire?” becomes much less crucial. Any organization, such as ONC, which wishes to endorse Green CDA over the wire (to make life much easier for implementers), can do so, provided they make the transforms readily available. Then, people can use Green CDA over the wire – but anyone who prefers to receive full CDA can always do so, by applying the transform to the Green CDA he receives. RIM experts and non-experts can both be happy.
It is like using banknotes instead of gold for currency, as has been done for several hundred years. Using gold bars for every transaction would be very clumsy, so people used notes which were backed by gold. The bank “promises to pay the bearer on demand” the equivalent in gold. Similarly the Green=>full transform “promises to pay the bearer on demand” a full CDA, if he wants it.
HL7 has now realized that its CDA gold bars are rather clunky, and should encourage the use of banknotes, backed by its RIM-based gold semantics. CDA is the reserve currency, and Green CDAs are the banknotes that people want to use (but counterfeit notes, not backed by the gold transforms, would be worthless!)."
Green CDA over the wire is the right future state. Transforms will help us get there without requiring stakeholders to rip and replace what they have already built.
We have a plan!
The only problem with CDA-based standards is that implementation requires expert knowledge of the HL7 Reference Information Model (RIM), a steep learning curve for new developers. Ideally, HL7 and informatics experts would use the RIM or Detailed Clinical Models to develop templates containing easy to read and parse XML that does not require knowledge of the underlying information model.
Green CDA aims to do that - the simplicity of CCR XML tagging with the expandability and modeling of CDA. However, there is a controversy. What do we send on the wire - full CDA or Green CDA?
At the November HIT Standards Committee meeting we endorsed moving forward with GreenCDA as the single over the wire format.
It's likely that existing users of full CDA over the wire will be concerned about the costs and effort required to move to Green CDA on the wire.
Robert Worden, an expert on HL7 mapping tools, wrote a great summary that explains the path forward through the use of transforms:
"There is now tooling which can define a Green CDA and generate 100% reliable transforms to full CDA, all in the same step. That tooling is being used in the UK for the NHS Interoperability Toolkit; and it has been linked to MDHT, so it could be used to Green consolidated CDA and generate the transforms.
Once you have reliable, maintainable transforms, the question “Green CDA or full CDA on the wire?” becomes much less crucial. Any organization, such as ONC, which wishes to endorse Green CDA over the wire (to make life much easier for implementers), can do so, provided they make the transforms readily available. Then, people can use Green CDA over the wire – but anyone who prefers to receive full CDA can always do so, by applying the transform to the Green CDA he receives. RIM experts and non-experts can both be happy.
It is like using banknotes instead of gold for currency, as has been done for several hundred years. Using gold bars for every transaction would be very clumsy, so people used notes which were backed by gold. The bank “promises to pay the bearer on demand” the equivalent in gold. Similarly the Green=>full transform “promises to pay the bearer on demand” a full CDA, if he wants it.
HL7 has now realized that its CDA gold bars are rather clunky, and should encourage the use of banknotes, backed by its RIM-based gold semantics. CDA is the reserve currency, and Green CDAs are the banknotes that people want to use (but counterfeit notes, not backed by the gold transforms, would be worthless!)."
Green CDA over the wire is the right future state. Transforms will help us get there without requiring stakeholders to rip and replace what they have already built.
We have a plan!
Monday, November 28, 2011
Ambulatory IT Priorities
The BIDMC Clinical IT Governance Committee was chartered to prioritize project requests and ensure our clinical applications work together as a managed portfolio.
Today we met to discuss ambulatory/outpatient priorities for FY12.
Here's the presentation and the list of ambulatory priorities.
Our top priorities include those workflow enhancements that are necessary to support all the stages of Meaningful Use and emerging healthcare reform requirements.
Key items include many "close the loop initiatives" such as enhancing electronic bidirectional referral communications between primary care givers and specialists.
Also we want to ensure that every diagnostic result - radiology, lab, and pathology/cytology is "signed off" by the ordering clinicians and followup is arranged for any abnormal findings.
Health Information Exchange is always a priority for BIDMC and we continue to be the pilot site for many community efforts which support care coordination, population health and public health.
We're been a leader in e-prescribing and medication management workflow. Electronic pharmacy initiated renewals (rather than calling your physician) for all our patients will be complete in FY12.
We'll continue to implement novel decision support tools so that clinicians are given the right actionable information at the point of care.
We know that population/panel management tools are important to support accountable care organizations and we'll use tools outside of ambulatory systems to produce the necessary reports but make them available inside our ambulatory systems.
Governance is key to demand management and per my recent Thanksgiving post, our governance committees try to complete 80% of the requests we receive. This is not triage, it is stratification. Per the presentation at today's Clinical IT Governance meeting, we'll definitely do our high priorities this year, but lower priorities may or may not be completed based on the unplanned work that arrives, especially "must do" compliance requirements.
Today we met to discuss ambulatory/outpatient priorities for FY12.
Here's the presentation and the list of ambulatory priorities.
Our top priorities include those workflow enhancements that are necessary to support all the stages of Meaningful Use and emerging healthcare reform requirements.
Key items include many "close the loop initiatives" such as enhancing electronic bidirectional referral communications between primary care givers and specialists.
Also we want to ensure that every diagnostic result - radiology, lab, and pathology/cytology is "signed off" by the ordering clinicians and followup is arranged for any abnormal findings.
Health Information Exchange is always a priority for BIDMC and we continue to be the pilot site for many community efforts which support care coordination, population health and public health.
We're been a leader in e-prescribing and medication management workflow. Electronic pharmacy initiated renewals (rather than calling your physician) for all our patients will be complete in FY12.
We'll continue to implement novel decision support tools so that clinicians are given the right actionable information at the point of care.
We know that population/panel management tools are important to support accountable care organizations and we'll use tools outside of ambulatory systems to produce the necessary reports but make them available inside our ambulatory systems.
Governance is key to demand management and per my recent Thanksgiving post, our governance committees try to complete 80% of the requests we receive. This is not triage, it is stratification. Per the presentation at today's Clinical IT Governance meeting, we'll definitely do our high priorities this year, but lower priorities may or may not be completed based on the unplanned work that arrives, especially "must do" compliance requirements.
Sunday, November 27, 2011
Scientists and Tattoos
Prof Datta's Love Tattoo
A surprising number of scientists have tattoos hidden under their lab coats and these tattoos are examples of their cool geekiness. Prof Sandeep Robert Datta has a tattoo of a twisting ladder of DNA. The DNA message spells out the initials of his wife, Eliza Emond Edelsberg. True love manifested through amino acids that are the building blocks of protein!!!
Thursday, November 24, 2011
Thanksgiving Idea
Happy Thanksgiving to EverythingHealth readers.
Thanks to KM for this way to appreciate Thanksgiving. I did it and it only took about 7 minutes. Here's the concept:
Get a piece of paper or a word doc on your computer. Write one thing you are grateful for for each year of your age. If you are older, you have lots of reasons to give thanks. Don't over think it or try to put it in order of "
Thanks to KM for this way to appreciate Thanksgiving. I did it and it only took about 7 minutes. Here's the concept:
Get a piece of paper or a word doc on your computer. Write one thing you are grateful for for each year of your age. If you are older, you have lots of reasons to give thanks. Don't over think it or try to put it in order of "
There is Hope
Every Thanksgiving I reflect on the state of the world, the state of Healthcare IT, the state of my various roles, my family, and my life.
My message this year - there is hope.
Some may think that the tone of my blog has changed in 2011 - from a focus on cutting edge technology that will revolutionize healthcare to themes of compliance, limited resources, unbridled demand, urgent unplanned projects, and security challenges.
That's a valid observation.
In my 15 years as CIO, I've evolved from creating innovative applications to maintaining customer relationships. I've gone from strategic visionary to resource planner.
This transformation is not about me or my jobs, it's about the world we live in. According to the Center for Health System Change, households with Broadband in the US increased from 47% to 66% from 2007-2010. Smartphones are ubiquitous and the majority of households in the US are IT savvy. That creates a very different expectation for Healthcare IT service delivery.
When I first started as a CIO, mobile devices had not yet been invented, computers were the domain of geeky early adopters, and solutions to problems involved workflow change, not automation.
Today, most of my work is managing demand. I aim to complete 80% of the requests I'm given. I've been told that 50% is typical. Few other industries move so fast and yet have so little tolerance for mistakes.
So, why do I have hope?
I recently met with a Clinical Fellow who is very likely going to be chair of an academic department or a senior hospital administrator some day.
We spoke about the need to understand workflow, the need change behavior, and the critical role of piloting new processes before automating them.
We talked about the need to balance functionality, security, and maintainability. We talked about defining requirements before selecting a solution.
In my blog about Content verses Context, I described the job of the CIO as becoming increasingly impossible because many people expect flying cars when we live in an era of IT bicycles.
However, it is clear that the next generation of leaders, who were born in the 1980's personal computing era, understand that technology is the easy part - policy and process are the hard part.
Also, I have hope because I believe the BIDMC FY12 IT Operating Plan is well aligned with the needs of the business. Today I did a "Venn analysis" of 5 resources
*The BIDMC FY12 IT Operating Plan
*BIDMC FY12 requirements from key customers
*The BIDMC FY12 Annual Operating Plan
*The Meaningful Use Stage 1 and recommended Stage 2 Standards and Certification criteria
*Emerging Compliance projects
I found that the existing BIDMC FY12 IT Operating Plan addresses the needs of all these stakeholders. There are only a few items to defer or reconsider.
Today, the CEO of BIDMC, Kevin Tabb, sent out his Thanksgiving message and highlighted BIDMC Information Systems: "We were named the #1 health care IT organization in the United States for 2011 by Information Week 500, and BIDMC was the first hospital in the country to achieve Meaningful Use of electronic health records, meeting a key set of new federal government standards."
I'll transition my Harvard Medical School CIO role by February 2012. I serve on the search committee, which is following a multi-stakeholder process to find a visionary CIO to lead a great organization.
In my International, National, and State lives, I've worked with incredible people and the trajectory is very good. In 2011, we completed a healthcare IT plan for Japan and for New Zealand. The content, vocabulary, and transport standards for the US are submitted to ONC, completing the foundational work for Meaningful Use Stage 2. The State of Massachusetts has submitted a new State Medicaid Health Plan and completed a new HIT Strategic and Operational plan.
But most importantly, my family life is earning an A.
My daughter has blossomed into a resilient college woman with clear goals, deep friendships, and a very positive self-worth. She's excelling in her coursework, immersing herself in the culture of Tufts University, and traveling to Japan as part of study abroad program this winter. I'm so proud that she has left the nest and is building a life on her own.
My wife and I are planning the next stage of our lives and we'll be in Vermont this weekend visiting farm properties. I'll be 50 this year and although I have many years to go before retirement, it seems the right time to find a property to grow organic vegetables, raise chickens/goats/llamas, and revel in a self sufficient lifestyle, learning to live nearly off grid.
My parents are doing well in a new house and enjoying time with friends, cultural events, and gardening time.
So, there is hope. The world is experiencing a challenging time marked by economic fragility and social unrest. The Occupy movement is raising our consciousness about the disparities in the US. However, it is possible for a strong team of people working hard to excel in healthcare IT. It is possible for your family to thrive based on love, trust, and lifelong learning.
Revel in the next few days of Thanksgiving (we're roasting root vegetables, Brussel spouts and tofu). When you receive your next challenging email or are asked to define a timeline before you understand requirements, scope, or resources, take a breath. There is hope!
My message this year - there is hope.
Some may think that the tone of my blog has changed in 2011 - from a focus on cutting edge technology that will revolutionize healthcare to themes of compliance, limited resources, unbridled demand, urgent unplanned projects, and security challenges.
That's a valid observation.
In my 15 years as CIO, I've evolved from creating innovative applications to maintaining customer relationships. I've gone from strategic visionary to resource planner.
This transformation is not about me or my jobs, it's about the world we live in. According to the Center for Health System Change, households with Broadband in the US increased from 47% to 66% from 2007-2010. Smartphones are ubiquitous and the majority of households in the US are IT savvy. That creates a very different expectation for Healthcare IT service delivery.
When I first started as a CIO, mobile devices had not yet been invented, computers were the domain of geeky early adopters, and solutions to problems involved workflow change, not automation.
Today, most of my work is managing demand. I aim to complete 80% of the requests I'm given. I've been told that 50% is typical. Few other industries move so fast and yet have so little tolerance for mistakes.
So, why do I have hope?
I recently met with a Clinical Fellow who is very likely going to be chair of an academic department or a senior hospital administrator some day.
We spoke about the need to understand workflow, the need change behavior, and the critical role of piloting new processes before automating them.
We talked about the need to balance functionality, security, and maintainability. We talked about defining requirements before selecting a solution.
In my blog about Content verses Context, I described the job of the CIO as becoming increasingly impossible because many people expect flying cars when we live in an era of IT bicycles.
However, it is clear that the next generation of leaders, who were born in the 1980's personal computing era, understand that technology is the easy part - policy and process are the hard part.
Also, I have hope because I believe the BIDMC FY12 IT Operating Plan is well aligned with the needs of the business. Today I did a "Venn analysis" of 5 resources
*The BIDMC FY12 IT Operating Plan
*BIDMC FY12 requirements from key customers
*The BIDMC FY12 Annual Operating Plan
*The Meaningful Use Stage 1 and recommended Stage 2 Standards and Certification criteria
*Emerging Compliance projects
I found that the existing BIDMC FY12 IT Operating Plan addresses the needs of all these stakeholders. There are only a few items to defer or reconsider.
Today, the CEO of BIDMC, Kevin Tabb, sent out his Thanksgiving message and highlighted BIDMC Information Systems: "We were named the #1 health care IT organization in the United States for 2011 by Information Week 500, and BIDMC was the first hospital in the country to achieve Meaningful Use of electronic health records, meeting a key set of new federal government standards."
I'll transition my Harvard Medical School CIO role by February 2012. I serve on the search committee, which is following a multi-stakeholder process to find a visionary CIO to lead a great organization.
In my International, National, and State lives, I've worked with incredible people and the trajectory is very good. In 2011, we completed a healthcare IT plan for Japan and for New Zealand. The content, vocabulary, and transport standards for the US are submitted to ONC, completing the foundational work for Meaningful Use Stage 2. The State of Massachusetts has submitted a new State Medicaid Health Plan and completed a new HIT Strategic and Operational plan.
But most importantly, my family life is earning an A.
My daughter has blossomed into a resilient college woman with clear goals, deep friendships, and a very positive self-worth. She's excelling in her coursework, immersing herself in the culture of Tufts University, and traveling to Japan as part of study abroad program this winter. I'm so proud that she has left the nest and is building a life on her own.
My wife and I are planning the next stage of our lives and we'll be in Vermont this weekend visiting farm properties. I'll be 50 this year and although I have many years to go before retirement, it seems the right time to find a property to grow organic vegetables, raise chickens/goats/llamas, and revel in a self sufficient lifestyle, learning to live nearly off grid.
My parents are doing well in a new house and enjoying time with friends, cultural events, and gardening time.
So, there is hope. The world is experiencing a challenging time marked by economic fragility and social unrest. The Occupy movement is raising our consciousness about the disparities in the US. However, it is possible for a strong team of people working hard to excel in healthcare IT. It is possible for your family to thrive based on love, trust, and lifelong learning.
Revel in the next few days of Thanksgiving (we're roasting root vegetables, Brussel spouts and tofu). When you receive your next challenging email or are asked to define a timeline before you understand requirements, scope, or resources, take a breath. There is hope!
Wednesday, November 23, 2011
More BYOD Worries
I've written about the increasing trend to Bring Your Own Devices (BYOD) to work and the accountability it brings to the CIO.
Every day I receive articles highlighting the increasing risk of mobile devices on the network
The explosion of Android malware
The hacking of Siri
The vulnerabilities of the iPad
It's very clear that in 2012 and beyond we will have to move beyond policy-based controls and we'll have to implement technology based controls that may cost up to $10 per device per month. Given our 1000+ mobile devices, that could be a $150,000/year increased operating expense to protect consumer devices brought from home.
In many ways, 2012 at BIDMC will be the year of increased compliance and we've just named an interim Senior VP of Compliance to build an enterprise-wide compliance team.
CIOs - it's time to tell your CFO to expect an unplanned 6 figure expense to protect your institutional data while at the same time embracing the mobile devices that will enhance productivity and user satisfaction.
Every day I receive articles highlighting the increasing risk of mobile devices on the network
The explosion of Android malware
The hacking of Siri
The vulnerabilities of the iPad
It's very clear that in 2012 and beyond we will have to move beyond policy-based controls and we'll have to implement technology based controls that may cost up to $10 per device per month. Given our 1000+ mobile devices, that could be a $150,000/year increased operating expense to protect consumer devices brought from home.
In many ways, 2012 at BIDMC will be the year of increased compliance and we've just named an interim Senior VP of Compliance to build an enterprise-wide compliance team.
CIOs - it's time to tell your CFO to expect an unplanned 6 figure expense to protect your institutional data while at the same time embracing the mobile devices that will enhance productivity and user satisfaction.
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