In my role at CIO at Harvard Medical School and CareGroup, I'm often asked if we build or buy our enterprise applications. The answer is that we build AND buy, a strategy that has worked very well for over 20 years and I anticipate will serve us well for the next 20.
The trend in IT today is outsourcing, offshoring, buying software as a service (SAAS), and retiring home built legacy systems. Since I've just declared that we build software and will continue to do so, have I lost touch with the latest Gartner and Forrester reports?
Several healthcare application vendors are my close partners (I'm writing this at the Elephant Walk in Waltham just before dinner with 3 vendor partners). Vendors can produce full featured software on a regular release schedule and can be very innovative. Buying software means that I do not have manage developers and can leverage product development costs that are spread over many customers. Buying software means that the internal politics of development prioritization can be bypassed by relying on the vendor to adjudicate which features are included in upgrade releases. With reduced management responsibility, shared development costs and relief from institutional politics, what's not to love?
In complex organizations like Harvard and Caregroup, we have hundreds of applications. If we purchased all these applications, it's likely they would have dozens of different user interfaces, many navigation paradigms, several passwords, incomplete data integration and a high training burden. In 1998, my team and our stakeholders made the decision to implement a service oriented architecture (SOA) throughout the enterprise and own the "front end" of our applications. This means that our clinical systems have a single sign on, a single means of navigating the application and appear to have all our clinical data integrated completely, even though there are dozens of applications involved behind the scenes. We've built just about every system that our clinicians touch directly but buy the underlying departmental systems such as laboratory/blood bank, PACS imaging, critical care systems that interface with patient monitors and drug dispensing systems that require FDA approval. When we purchase a system from a vendor we require "Web 2.0" XML exchanges that enable us to link together the data housed in each application with our front end user interfaces. In a sense we've become experts at the plumbing that connects web applications.
This build and buy approach benefits the users with "virtual integration", ease of use and significant reduction in training requirements, but the real power in the strategy is that we can control the pace of innovation. Here's a case in point.
BIDMC was visited by the Joint Commission on July 23, 2007. A major focus of their visit was medication reconciliation, ensuring an accurate medication list at every transition of care. Very few vendor applications provide the tools necessary to do this. In a matter of weeks we built a community wide medication history health information exchange empowering physicians and patients to add, edit, delete and correct medications in every site of care. We brought this application live on July 24, 2007 and passed an audit for 100% utilitization of the software by October 1, 2007. It's highly unlikely this pace of innovation could have been accomplished with vendor software.
When folks ask about my build and buy strategy, I refer to them to the book "Built to Last" by Jim Collins and Jerry Porras, which highlights a concept called the "Tyranny of the OR verses the Genius of the AND". The authors suggest that highly successful companies are not dogmatic in their choices. It's ok to embrace Open Source AND Microsoft technologies. It's ok to embrace Linux, Mac OSX AND Windows. This does not mean that we're indecisive, it means that we use the right tools for the right task.
Hopefully, our broadly communicated strategy that we buy those applications which are mature, highly functional and widely deployed while we build the front end, the data integration and those applications which are cutting edge for which no vendor products are available will be viewed as the "genius of the AND" when the next generation of IT professionals looks back on our work.
Rabu, 19 Desember 2007
Selasa, 18 Desember 2007
A Chip in My Shoulder
I'm often asked about the RFID chip containing my medical records which is implanted in my right arm.As a physician and chief information officer, I felt qualified to evaluate the medical, legal, moral, and privacy aspects of the device. After using the device for three years, I am not an evangelist for implanted RFID, but I believe it can be valuable for some patients who understand the risks and benefits. My implantation process in December 2004 was simple—a five minute office procedure, which included disinfection of the implant site on my upper right arm, a few cubic centimeters of lidocaine, and insertion of the injector into my subcutaneous fascia. I did not experience pain, bleeding, or any post-procedure infection. The implant is not palpable, does not migrate, and has no physical side effects such as itching, irritation, or changes in skin appearance. The RFID device does not impede my activities; even while rock or ice climbing I have hit the implant site many times without any problems. The device is undetectable by airport security metal detectors and hand scanners.
One possible side effect is that my RFID device can be scanned by retail security systems using 134.2 kHz RFID technology, the frequency of my implant. I have had experiences at Home Depot and Best Buy where my device seemed to set off the anti-theft systems. My personal data are not readable by such systems, but they may be able to detect the presence of an implanted RFID tag.
Given my experience, what are the risks and benefits? The medical risks of any implant are infection, pain, keloid formation at the puncture site, and reaction to the local anesthetic. There are quite a range of nonmedical risks. After my implant, I received many e-mails saying that I had become a “Borg” and had lost some of my humanity because I was now a hybrid human/machine. Some e-mails even referred to the Book of Revelation, noting that I now carried the number of the Beast. Thus, chip carriers have a risk of being social outcasts.
The chip holds a static and unencrypted 16 digit number, which is used to point to a Web site containing personal health record data. The Web site requires a username and password, ensuring appropriate security. It is conceivablethat a person on a subway could scan a patient’s number without their knowledge and steal their medical identity by creating an identical chip and implanting it. This is a very theoretical risk because hospitals are not widely using implanted RFID chips as a means of identification. If the implanted chip were used for security purposes, such as opening a door to a secure area, the person who scanned the patient on the subway could replay the RFID signal and gain access to the secure area. Again, this is purely theoretical since implanted RFID devices are not often used as security authenticators.
If these are the potential risks, what are the benefits? Since we have no universal health identifier in the US, there is no simple way to uniquely identify a patient at all sites of care. The result is a fractured medical record scattered in inpatient, outpatient, laboratory, pharmacy, and emergency department sites. The implanted RFID devices enable patients to establish health care identities and become the stewards of their own data. The patient can assemble a reconciled medication list, a complete problem list, and a list of diagnostic study results, and then apply personal privacy preferences—for example,deleting information about mental health, HIV, or substance abuse. This patient-controlled record is available to treating clinicians in the case of emergency via the implanted device.
It is a personal choice whether or not to be fitted with an RFID device, but for some patients such a record has value. For example, such devices may be particularly helpful for a patient with Alzheimer disease who cannot give a history, a patient prone to syncope who may not be initially conscious during an emergency department visit, or a very active person who engages in extreme sports activities and could be noncommunicative due to injury.
I believe that in the near future, patients will own their medical records and be the stewards of their own health care data. Implantation of RFID devices is one tool, appropriate for some patients based on their personal analysis of risks and benefits, that can empower patients by serving as a source of identity and a link to a personal health record when the patient cannot otherwise communicate.
Senin, 17 Desember 2007
New Healthcare Data Standards for the Country
Over the past 2 years, I've had the priviledge of working with 350 organizations as part of the US national effort to standardize healthcare data, supporting the secure exchange of healthcare records among patients, providers and payers with patient consent. On Thursday, December 13, the Healthcare Information Technology Standards Panel (HITSP), completed its 2007 work and approved 4 new "interoperability specifications"
Quality - all the initial standards needed to support the process and outcome measures for the Institute of Medicine's highest priority diseases.
Consumer Empowerment - all the initial standards needed to support personal health records exchanged via networks or via removable media (such as thumb drives). These standards make products like Microsoft Health Vault, the upcoming Google Health, Dossia, Medem, and Relay Health much more useful for patients, as they make the patient the stewards of their own data.
Lab - all the initial standards to order and result laboratories including a consistent description of lab types, reasons for ordering and units of measure. Today, the thousands of labs throughout the US use a heterogeneous collection of standards which require custom programming/configuration to connect them with electronic health records and public health reporting systems.
Emergency Responder - all the initial standards needed to support transfer of information among hospitals and emergency first responders such as paramedics when delivering care in the field, such as might occur in a Katrina-like event.
Also on December 13, the panel approved a Privacy Framework which provides a mechanism to categorize all the various privacy policies that exist in this country. This is important, since security technology to protect confidentiality can only be implemented by first understanding the policies which need to be enforced.
What are the next steps? All of the work done by HITSP on consumer empowerment, labs and biosurveillance will be "recognized" by HHS Secretary Michael Leavitt this month, except for the HL7 2.5.1 message (used to communicate lab results) and the OASIS HAVE standards (used to report hospital resources) which will be recognized in June 2008. Recognition means that federal procurement will require these standards to be included in systems deployed for federal government use. Also, these standards will be included in the Certification Commission for Healthcare Information Technology in 2008 and 2009, encouraging vendors to incorporate them into electronic health records, personal health records and hospital information systems.
As more and more clinicians use electronic health records and interoperability standards become more common, care will become more coordinated, improving quality and reducing costs. Standardization also lays the foundation for patients to be move involved with their care by getting access to all their healthcare data.
Creating a secure, interconnected healthcare system is a journey, but the completion of these healthcare standards for the country is a major first step down that path.
Quality - all the initial standards needed to support the process and outcome measures for the Institute of Medicine's highest priority diseases.
Consumer Empowerment - all the initial standards needed to support personal health records exchanged via networks or via removable media (such as thumb drives). These standards make products like Microsoft Health Vault, the upcoming Google Health, Dossia, Medem, and Relay Health much more useful for patients, as they make the patient the stewards of their own data.
Lab - all the initial standards to order and result laboratories including a consistent description of lab types, reasons for ordering and units of measure. Today, the thousands of labs throughout the US use a heterogeneous collection of standards which require custom programming/configuration to connect them with electronic health records and public health reporting systems.
Emergency Responder - all the initial standards needed to support transfer of information among hospitals and emergency first responders such as paramedics when delivering care in the field, such as might occur in a Katrina-like event.
Also on December 13, the panel approved a Privacy Framework which provides a mechanism to categorize all the various privacy policies that exist in this country. This is important, since security technology to protect confidentiality can only be implemented by first understanding the policies which need to be enforced.
What are the next steps? All of the work done by HITSP on consumer empowerment, labs and biosurveillance will be "recognized" by HHS Secretary Michael Leavitt this month, except for the HL7 2.5.1 message (used to communicate lab results) and the OASIS HAVE standards (used to report hospital resources) which will be recognized in June 2008. Recognition means that federal procurement will require these standards to be included in systems deployed for federal government use. Also, these standards will be included in the Certification Commission for Healthcare Information Technology in 2008 and 2009, encouraging vendors to incorporate them into electronic health records, personal health records and hospital information systems.
As more and more clinicians use electronic health records and interoperability standards become more common, care will become more coordinated, improving quality and reducing costs. Standardization also lays the foundation for patients to be move involved with their care by getting access to all their healthcare data.
Creating a secure, interconnected healthcare system is a journey, but the completion of these healthcare standards for the country is a major first step down that path.
Embracing Innovation
I'm almost 46 years old and am in the prime of my capacity to adapt to mental and physical change. I crave innovation just as I crave my weekend time climbing ice and scaling mountains. However, I know that my mental and physical capacity to embrace change are likely to diminish over time.
My Grandmother (passed away in the 1990's) spent her youth learning the Palmer method of perfect handwriting. When I learned to type in 6th grade and began typing all my correspondence, she could not embrace the notion that cursive handwriting was an anachronism.
As a college student, I had the privilege of living with Dr. Frederick Terman, former Provost of Stanford University and the person who brought Bill Hewlett/David Packard together in the 1930's. Dr. Terman was known for his foundational work in radio engineering, especially the creation of novel amplifier circuits. One night in the early 1980's, I brought Dr. Terman an integrated circuit that cost under $1 dollar and did the work of his most complex radio engineering designs in a single device smaller than a dime. I proudly explained that his foundational work made this integrated circuit possible. His response was that he could not understand the technology inside the device and thus he had no interest in it.
Recently, in her Nobel acceptance speech, Doris Lessing explained that the Internet is destroying creativity and intelligence because it enables anyone to be a publisher and it removes rigorous training in the history of literature as a barrier entry to authorship. Although I have the greatest respect for anyone who earns a Nobel prize, these statements reminded me of my conversation with Dr. Terman. Just because the new forms of social networking, blogging, wikis, and instant messaging are different than previous forms of scholarship does not mean they are inherently flawed. In the past, I would have not shared my experiences as CIO with everyone because the barriers to writing a book about it were too great. Now, anyone can benefit from my decade of successes and failures as a CIO for free, anytime, anywhere. In a sense, the internet has democratized access to knowledge.
My committment to my staff is that if I ever become the rate limiting step in adoption of new technologies, then it will be time for me to go. In the meantime, bring on the AJAX, the Continuous Data Replication, Host-based Intrusion Protection and all the new acronyms that cross my desk every day. I may not immediately understand every new technology, but I look forward to being a student, learning about the latest innovations, for life.
My Grandmother (passed away in the 1990's) spent her youth learning the Palmer method of perfect handwriting. When I learned to type in 6th grade and began typing all my correspondence, she could not embrace the notion that cursive handwriting was an anachronism.
As a college student, I had the privilege of living with Dr. Frederick Terman, former Provost of Stanford University and the person who brought Bill Hewlett/David Packard together in the 1930's. Dr. Terman was known for his foundational work in radio engineering, especially the creation of novel amplifier circuits. One night in the early 1980's, I brought Dr. Terman an integrated circuit that cost under $1 dollar and did the work of his most complex radio engineering designs in a single device smaller than a dime. I proudly explained that his foundational work made this integrated circuit possible. His response was that he could not understand the technology inside the device and thus he had no interest in it.
Recently, in her Nobel acceptance speech, Doris Lessing explained that the Internet is destroying creativity and intelligence because it enables anyone to be a publisher and it removes rigorous training in the history of literature as a barrier entry to authorship. Although I have the greatest respect for anyone who earns a Nobel prize, these statements reminded me of my conversation with Dr. Terman. Just because the new forms of social networking, blogging, wikis, and instant messaging are different than previous forms of scholarship does not mean they are inherently flawed. In the past, I would have not shared my experiences as CIO with everyone because the barriers to writing a book about it were too great. Now, anyone can benefit from my decade of successes and failures as a CIO for free, anytime, anywhere. In a sense, the internet has democratized access to knowledge.
My committment to my staff is that if I ever become the rate limiting step in adoption of new technologies, then it will be time for me to go. In the meantime, bring on the AJAX, the Continuous Data Replication, Host-based Intrusion Protection and all the new acronyms that cross my desk every day. I may not immediately understand every new technology, but I look forward to being a student, learning about the latest innovations, for life.
Selasa, 11 Desember 2007
Cool Technology of the Week
This week's cool technology is truly for the nerdy - it's about bandwidth and fiberoptics now available in our homes, made possible by new products from Corning. Infrastructure in the walls is often ignored because it's not sexy. To me it's necessary and deserving of a cool technology highlight.
The kinds of technologies that are enabling fiber to be run to houses, apartments and dorm rooms is illustrated here. The streaming video is worth watching. Gone are the days of fragile glass fibers that were instantly destroyed when bent or stepped on. These new fiber products empower HDTV, support high fidelity voice over IP and turn our homes into data centers. The future of nearly limitless, low cost bandwidth is arriving.
When I first began software development at the age of 12, I used a dial up acoustic coupler at 110 baud. In college, I was first in my dorm with a CP/M computer that included a 300 baud modem. When I did research at Lawrence Livermore Labs as a Sophomore, I was given a state of the art 9600 baud connection to the Arpanet, the Internet predecessor. In medical school, I had my own 1200 baud dial up, then 14.4K as a post doctoral fellow. In my early days as CIO I had 28.8K then 56K. I was Media One's (predecessor to Comcast) third customer for Broadband in the home at 1 Megabit speeds.
Today, I use Verizon FIOS, which includes a complete fiberoptic infrastructure in my basement. I average 20 Megabit download speeds and 5 megabit upload speeds. My home has 802.11g in every room. My sofa has nearly the same bandwidth as my office as work.
All this connectivity has enabled me to work wherever my laptop is located. Home video teleconferencing is no problem. Skype works well for world wide voice over IP calling. My family is completely connected with me via our home infrastructure regardless of where I am in the world.
Of course, there is a dark side to all this bandwidth - the digital divide. I live in Wellesley - one of the 'W' towns in Massachusetts (including Weston and Wayland ) that havehigh median household incomes. Verizon FIOS is not yet available to all towns, especially less populated rural locations. I hope that the future brings high bandwidth wireless technologies such as free community Wifi and WiMax that enable anyone with a computing device, including the $188 One Laptop per Child device, to experience all the benefits of connectivity to knowledge resources, personal healthcare applications, and social networks that are available today to those living in higher income locations.
The kinds of technologies that are enabling fiber to be run to houses, apartments and dorm rooms is illustrated here. The streaming video is worth watching. Gone are the days of fragile glass fibers that were instantly destroyed when bent or stepped on. These new fiber products empower HDTV, support high fidelity voice over IP and turn our homes into data centers. The future of nearly limitless, low cost bandwidth is arriving.
When I first began software development at the age of 12, I used a dial up acoustic coupler at 110 baud. In college, I was first in my dorm with a CP/M computer that included a 300 baud modem. When I did research at Lawrence Livermore Labs as a Sophomore, I was given a state of the art 9600 baud connection to the Arpanet, the Internet predecessor. In medical school, I had my own 1200 baud dial up, then 14.4K as a post doctoral fellow. In my early days as CIO I had 28.8K then 56K. I was Media One's (predecessor to Comcast) third customer for Broadband in the home at 1 Megabit speeds.
Today, I use Verizon FIOS, which includes a complete fiberoptic infrastructure in my basement. I average 20 Megabit download speeds and 5 megabit upload speeds. My home has 802.11g in every room. My sofa has nearly the same bandwidth as my office as work.
All this connectivity has enabled me to work wherever my laptop is located. Home video teleconferencing is no problem. Skype works well for world wide voice over IP calling. My family is completely connected with me via our home infrastructure regardless of where I am in the world.
Of course, there is a dark side to all this bandwidth - the digital divide. I live in Wellesley - one of the 'W' towns in Massachusetts (including Weston and Wayland ) that havehigh median household incomes. Verizon FIOS is not yet available to all towns, especially less populated rural locations. I hope that the future brings high bandwidth wireless technologies such as free community Wifi and WiMax that enable anyone with a computing device, including the $188 One Laptop per Child device, to experience all the benefits of connectivity to knowledge resources, personal healthcare applications, and social networks that are available today to those living in higher income locations.
Standards for Personal Health Records
In my post about Personal Health records , I identified the 4 major types of Personal Health records - provider-hosted, payer-based, employer-sponsored and commercial. As more products are offered, it's key that all the stakeholders involved embrace national healthcare data standards to ensure interoperability of the data placed in personal health records.
To illustrate the point, I am posting my entire lifelong medical record on my blog (this is with my consent, so there are no HIPAA issues) in two ways.
The first is a PDF which was exported from a leading electronic health record system. It's 77 pages long and contains a mixture of clinical data, administrative data, normal and abnormal results, numeric observations, and notes. It's a great deal of data, but is very challenging to understand, since it does not provide an organized view of the key elements a clinician needs to provide me ongoing care. It is not semantically interoperable, which means that it cannot be read by computers to offer me or my doctors the decision support that will improve my care.
The second is a Continuity of Care Document , using the national Health Information Technology Standards Panel (HITSP) interoperability specifications. It uses "Web 2.0" approaches, is XML based, machine and human readable, and uses controlled vocabularies enabling computer-based decision support.
It's critical that Vendors, Payers, Providers and Employers embrace these standards. A standards-based personal health record can be used to prevent medication errors, ensure best practice disease prevention, and serve as the basis for decision support systems which recommend optimal care. Using CCD, data can be turned into wisdom , can be incorporated into EHRs, transmitted between PHRs, and can be easily expanded by the patient throughout life.
Today (December 13), HITSP will deliver the harmonized standards for Personal Health Records, Labs, Emergency Records, and Quality measurement to HHS Secretary Leavitt. These "interoperability specifications" will become part of Federal contacting language and be incorporated into vendor system certification criteria (CCHIT) over the next two years.
To illustrate the point, I am posting my entire lifelong medical record on my blog (this is with my consent, so there are no HIPAA issues) in two ways.
The first is a PDF which was exported from a leading electronic health record system. It's 77 pages long and contains a mixture of clinical data, administrative data, normal and abnormal results, numeric observations, and notes. It's a great deal of data, but is very challenging to understand, since it does not provide an organized view of the key elements a clinician needs to provide me ongoing care. It is not semantically interoperable, which means that it cannot be read by computers to offer me or my doctors the decision support that will improve my care.
The second is a Continuity of Care Document , using the national Health Information Technology Standards Panel (HITSP) interoperability specifications. It uses "Web 2.0" approaches, is XML based, machine and human readable, and uses controlled vocabularies enabling computer-based decision support.
It's critical that Vendors, Payers, Providers and Employers embrace these standards. A standards-based personal health record can be used to prevent medication errors, ensure best practice disease prevention, and serve as the basis for decision support systems which recommend optimal care. Using CCD, data can be turned into wisdom , can be incorporated into EHRs, transmitted between PHRs, and can be easily expanded by the patient throughout life.
Today (December 13), HITSP will deliver the harmonized standards for Personal Health Records, Labs, Emergency Records, and Quality measurement to HHS Secretary Leavitt. These "interoperability specifications" will become part of Federal contacting language and be incorporated into vendor system certification criteria (CCHIT) over the next two years.
Resolving Conflict
I've written about leading change, managing personnel transitions and the next in this series is resolving conflict. Most people do not enjoy conflict and want highly contentious situations to resolve themselves. Sometimes this works and some times it ends in chaos. I am convinced that to be a successful CIO, you must embrace conflict.
Here's the approach I use to resolving conflict.
1. Listen before talking. I find that many conflicts are the result of poor communication. Just understanding the issue deeply can resolve many conflicts. Being proactive by learning more about controversial situations early in the conflict is much easier than getting involved after the situation escalates.
2. Never use email to resolve complex issues. Anytime I receive more than 3 successive email exchanges about an issue, I call a "time out" and schedule a meeting or conference call.
3. Pick up the phone to diffuse emotion. Anytime I receive an emotional email, I do not respond via email. I pick up the phone, even if I know the conversation will be painful. Most people react differently in a person to person conversation than in email.
4. Never send an emotional email or make an emotional statement. If I ever feel a negative emotion while writing an email, I save as draft. Although an emotional email may feel like an effective weapon, it only wins the battle not the war. Emails last forever, can be circulated widely and make conflict resolution much harder in the long run. My experience with emotion, written or spoken, is that no one who responds to any issue with anger looks good while doing it. Those with polished executive presence are always emotionally neutral when dealing with conflict.
5. Talk a walk in the woods, a technique named after a famous story in which international negotiators at loggerheads over a nuclear arms treaty went for a walk in the woods near Geneva and discovered common interests that led to new solutions. The four negotiation steps developed by the Harvard Program for Health Care Negotiation and Conflict Resolution are:
Step one: self interests. Each participant articulates his or her view of key problems, issues, and options. Stakeholders are encouraged to actively listen, question, and interact with one another.
Step two: enlarged interests. The participants reframe their understanding of current problems and possible options with a wider perspective, based on the integrative listening and confidence-building that occurred in step one.
Step three: enlightened interests. The group is ready to engage in innovative thinking and problem-solving, generating ideas and perspectives that had not previously been considered.
Step four: aligned interests. Participants build common ground perspectives, priorities, action items, agreement, or plans for moving forward. Depending on the scope of the intended objectives, at this point they recognize the tangible contributions and opportunities accomplished through the meeting.
My "walks in the woods" usually take place at the Elephant Walk Restaurant on Beacon Street in Boston, so if you ever see someone dressed in all black eating a vegan meal at the Elephant Walk, it's a good guess that I'm resolving conflict!
Here's the approach I use to resolving conflict.
1. Listen before talking. I find that many conflicts are the result of poor communication. Just understanding the issue deeply can resolve many conflicts. Being proactive by learning more about controversial situations early in the conflict is much easier than getting involved after the situation escalates.
2. Never use email to resolve complex issues. Anytime I receive more than 3 successive email exchanges about an issue, I call a "time out" and schedule a meeting or conference call.
3. Pick up the phone to diffuse emotion. Anytime I receive an emotional email, I do not respond via email. I pick up the phone, even if I know the conversation will be painful. Most people react differently in a person to person conversation than in email.
4. Never send an emotional email or make an emotional statement. If I ever feel a negative emotion while writing an email, I save as draft. Although an emotional email may feel like an effective weapon, it only wins the battle not the war. Emails last forever, can be circulated widely and make conflict resolution much harder in the long run. My experience with emotion, written or spoken, is that no one who responds to any issue with anger looks good while doing it. Those with polished executive presence are always emotionally neutral when dealing with conflict.
5. Talk a walk in the woods, a technique named after a famous story in which international negotiators at loggerheads over a nuclear arms treaty went for a walk in the woods near Geneva and discovered common interests that led to new solutions. The four negotiation steps developed by the Harvard Program for Health Care Negotiation and Conflict Resolution are:
Step one: self interests. Each participant articulates his or her view of key problems, issues, and options. Stakeholders are encouraged to actively listen, question, and interact with one another.
Step two: enlarged interests. The participants reframe their understanding of current problems and possible options with a wider perspective, based on the integrative listening and confidence-building that occurred in step one.
Step three: enlightened interests. The group is ready to engage in innovative thinking and problem-solving, generating ideas and perspectives that had not previously been considered.
Step four: aligned interests. Participants build common ground perspectives, priorities, action items, agreement, or plans for moving forward. Depending on the scope of the intended objectives, at this point they recognize the tangible contributions and opportunities accomplished through the meeting.
My "walks in the woods" usually take place at the Elephant Walk Restaurant on Beacon Street in Boston, so if you ever see someone dressed in all black eating a vegan meal at the Elephant Walk, it's a good guess that I'm resolving conflict!
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