I'm sure you've heard the consulting stereotypes.
"For a large sum, they will ask for your watch and tell you what time it is."
"They gather an immense amount of knowledge from the organization, create a splashy presentation summarizing what you already know, then leave the organization taking that knowledge with them to apply to other consulting engagements."
However, there are 3 specific circumstances in which I hire consultants.
1. As part of change management by having an external group validate the path chosen
Change is hard and sometimes politics in an organization are such that no internal stakeholder can champion the new idea. Bringing in consultants to publicly validate the idea can build transparency and break down barriers. It may sound strange to pay an external party to explain to an organization what it already knows, but sometimes it is necessary. Also, I've seen stakeholders in politically charged situations be more honest and open with external consultants than with their peers. Many staff seem to be happy to tell all to an external party, which can accelerate information gathering.
2. To extend the capacity of the organization for short term urgent work
I've recently been asked to significantly expand the services offered by IT. All of my existing staff are working at 120% on existing projects. Bringing in consultants for a very focused, short term engagement will enable my staff to focus on their deadlines while getting extra work done by consultants in parallel. A few caveats about doing this. Consultants need to be managed carefully to ensure travel expenses are minimized and the time spent is tightly scoped toward a specific deliverable. This means that consultants will take management time and staff time, so adding 1 consultant FTE comes at a cost of .5 FTE to manage and provide support for the consultant. Also, the organization must buy into the consulting engagement. I've seen passive/aggressive behavior toward consultants, so stakeholders should ask for the consulting engagement rather than have one forced upon them.
3. As contractors that add new knowledge to the organization
In 2002, I had a serious network outage because there aspects of network management "that I did not know that I did not know". We brought in experts in network infrastructure and applications (DNS/DHCP) design. These folks were more educators and contractors than consultants. We now have one of the most resilient networks in healthcare due to their education about best practices.
There are also reasons not to hire consultants
1. Do not outsource your strategy to consultants
Although many talented consulting firms offer strategic planning, I've not seen business changing strategic plans come out of outsourcing strategy. Consultants can be helpful facilitators of strategic planning, organizing all the ideas of employees, customers and senior management, but the strategy should belong to the organization, not external consultants.
2. Do not hire consultants as operational line managers
Sometimes positions are hard to fill and consultants are brought in as temporary staff. This can work. However, hiring a consultant to manage permanent employees does not work. It generates a great deal of resentment from the existing employees and it's hard to sustain because everyone knows their manager is temporary. It's a bit like having a substitute teacher in school.
3. Do not allow consultants to hire consultants
Sometimes consultants are self-propagating. A tightly scope engagement grows as consultants discover new work for other consultants to do. Keep the consulting engagement focused and move the work to the permanently employed staff in the organization as soon as possible.
On rare occasions, I make myself available for one day consulting engagements doing comprehensive IT audits of healthcare organizations. When I do this, I donate all fees to BIDMC or Harvard, not accepting any payment for my time. I create an overview analysis of the strategy, structure and staffing of the IT organization as a guide for the existing management and staff. I hope these efforts follow my guidelines above - bringing external validation, extending capacity, and offering new perspective.
Rabu, 09 Januari 2008
Selasa, 08 Januari 2008
National Healthcare Identifiers
I was recently asked to comment on the likelihood that a national healthcare identifier will be created for the United States, such as those that are already used in Canada, Norway, and the UK. Many people do not know that Congress has imposed a hold since 1998 on any funding to plan or implement a national health identifier, so the US Department of Health and Human Services cannot even discuss the issue. Here's the background
August 1996
HIPAA enacted, "Sec. 1173(b) ... The Secretary [of HHS] shall adopt standards providing for a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system." Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. 1320d-2(b)).
February 1998
Due to controversy and a lack of consensus, National Committee on Vital and Health Statistics (NCVHS) issues recommendation that the Secretary delay selection and implementation of the unique health identifier. Recommends publication of a Notice of Intent (NOI) in the Federal Register with a 60-day comment period to solicit input from the public.
July 2, 1998
NCVHS publishes background paper, “Unique Health Identifier for Individuals, A White Paper” discussing options for identifying individuals and associated implications.
July 20-21,1998
NCVHS Subcommittee on Standards and Security holds in Chicago what was to be the first in a series of regional public hearings on the Unique Health Identifier for Individuals. Due to public reaction further hearings, as well as the planned publication of an NOI by HHS, are canceled.
July 31, 1998
Vice President Gore announces that the Clinton administration will block implementation of unique health identifiers until comprehensive privacy protections are in place.
October 1998
Congressional hold on provision in FY1999 HHS budget: "Sec. 514. None of the funds made available in this Act [the HHS appropriation act for the next fiscal year] may be used to promulgate or adopt any final standard under section 1173(b) of the Social Security Act (42 U.S.C 1320d-2(b)) providing for, or providing for the assignment of, a unique health identifier for an individual (except in an individual’s capacity as an employer or a health care provider), until legislation is enacted specifically approving the standard." - Public Law 106-554, 105th Congress (114 STAT. 2763).
2000 – 2007
Annual Congressional hold on provision in HHS budget such as H.R.3010.ENR - 109th Congress (2006) Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2006 - Making appropriations for the Departments of Labor, Health and Human Services, and Education, and Related Agencies for the fiscal year ending September 30, 2006, and for other purposes. Sec. 511
My opinion is that a compulsory national health identifier is unlikely but that personal health records may catalyze the development of a voluntary health identifier used to facilitate continuity of care.
Currently, each healthcare provider uses a different medical record numbering scheme, making unification of records from inpatient, ambulatory, lab, pharmacy, and payers a true informatics challenge. At CareGroup we use a statistical, probabilitistic algorithm from Initiate.com that incorporates name, gender, date of birth, zip code and other demographics to link multiple medical records together into a virtual patient record. This works great for John D. Halamka, male, 05/23/1962, 02481 but not perfectly for John Smith, Boston. The Markle Foundation's Connecting for Health Record Linking report is a great backgrounder on this approach.
A voluntary patient identifier, assigned purely with patient consent, would add another element to the matching algorithm and would significantly increase the confidence of linking together demographics of patients with common names.
The benefit to the patient is clear. With new personal health record products like Microsoft Health Vault, and the rumored Google Health offerings, patients would be able to link more accurately to their data at all sites of care, then be able to be stewards of their lifetime records. Since the voluntary identifier would be completely patient consented and controlled, only those patients wanting one would opt in, ensuring personal privacy preferences are respected.
How long will this take? In 2008 , many doctors will start using electronic health records which will provide enough clinical data to make personal health records more value added. In 2009 personal health records will become much more popular but will require manual linking of patient identifiers by requiring patients to establish accounts to access their data with each healthcare provider. I predict that by 2010 a voluntary health identifier will be considered and implemented by some vendors and institutions. Over the next decade, if patients gain confidence in the security of a healthcare information exchange system they control, it is conceivable that Congress would revisit their ban on a secure national identifier for healthcare. Until then, a national identifier is not a prerequisite to getting started with personal health records and I will fully enable any patient to retrieve their health records from BIDMC with their consent via the new generation of standards-based vendor, employer-sponsored, and payer-based personal health records using manual linking methods.
August 1996
HIPAA enacted, "Sec. 1173(b) ... The Secretary [of HHS] shall adopt standards providing for a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system." Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. 1320d-2(b)).
February 1998
Due to controversy and a lack of consensus, National Committee on Vital and Health Statistics (NCVHS) issues recommendation that the Secretary delay selection and implementation of the unique health identifier. Recommends publication of a Notice of Intent (NOI) in the Federal Register with a 60-day comment period to solicit input from the public.
July 2, 1998
NCVHS publishes background paper, “Unique Health Identifier for Individuals, A White Paper” discussing options for identifying individuals and associated implications.
July 20-21,1998
NCVHS Subcommittee on Standards and Security holds in Chicago what was to be the first in a series of regional public hearings on the Unique Health Identifier for Individuals. Due to public reaction further hearings, as well as the planned publication of an NOI by HHS, are canceled.
July 31, 1998
Vice President Gore announces that the Clinton administration will block implementation of unique health identifiers until comprehensive privacy protections are in place.
October 1998
Congressional hold on provision in FY1999 HHS budget: "Sec. 514. None of the funds made available in this Act [the HHS appropriation act for the next fiscal year] may be used to promulgate or adopt any final standard under section 1173(b) of the Social Security Act (42 U.S.C 1320d-2(b)) providing for, or providing for the assignment of, a unique health identifier for an individual (except in an individual’s capacity as an employer or a health care provider), until legislation is enacted specifically approving the standard." - Public Law 106-554, 105th Congress (114 STAT. 2763).
2000 – 2007
Annual Congressional hold on provision in HHS budget such as H.R.3010.ENR - 109th Congress (2006) Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2006 - Making appropriations for the Departments of Labor, Health and Human Services, and Education, and Related Agencies for the fiscal year ending September 30, 2006, and for other purposes. Sec. 511
My opinion is that a compulsory national health identifier is unlikely but that personal health records may catalyze the development of a voluntary health identifier used to facilitate continuity of care.
Currently, each healthcare provider uses a different medical record numbering scheme, making unification of records from inpatient, ambulatory, lab, pharmacy, and payers a true informatics challenge. At CareGroup we use a statistical, probabilitistic algorithm from Initiate.com that incorporates name, gender, date of birth, zip code and other demographics to link multiple medical records together into a virtual patient record. This works great for John D. Halamka, male, 05/23/1962, 02481 but not perfectly for John Smith, Boston. The Markle Foundation's Connecting for Health Record Linking report is a great backgrounder on this approach.
A voluntary patient identifier, assigned purely with patient consent, would add another element to the matching algorithm and would significantly increase the confidence of linking together demographics of patients with common names.
The benefit to the patient is clear. With new personal health record products like Microsoft Health Vault, and the rumored Google Health offerings, patients would be able to link more accurately to their data at all sites of care, then be able to be stewards of their lifetime records. Since the voluntary identifier would be completely patient consented and controlled, only those patients wanting one would opt in, ensuring personal privacy preferences are respected.
How long will this take? In 2008 , many doctors will start using electronic health records which will provide enough clinical data to make personal health records more value added. In 2009 personal health records will become much more popular but will require manual linking of patient identifiers by requiring patients to establish accounts to access their data with each healthcare provider. I predict that by 2010 a voluntary health identifier will be considered and implemented by some vendors and institutions. Over the next decade, if patients gain confidence in the security of a healthcare information exchange system they control, it is conceivable that Congress would revisit their ban on a secure national identifier for healthcare. Until then, a national identifier is not a prerequisite to getting started with personal health records and I will fully enable any patient to retrieve their health records from BIDMC with their consent via the new generation of standards-based vendor, employer-sponsored, and payer-based personal health records using manual linking methods.
Senin, 07 Januari 2008
Knowledge Navigators Combat Information Overload
One of my greatest challenges in 2008 is information overload. 700 emails a day on my Blackberry, RSS feeds, Facebook, Instant Messaging, LinkedIn, MySpace and Second Life all create a pummeling amounts of data.
With email and other information sources escalating year to year, we all need a knowledge navigator to help us sort through all this data and ensure that we triage our incoming information flows into that which is important and that which is just FYI. I've started to build a team of navigators beginning with my medical librarians.
In my CIO role at Beth Israel Deaconess, I oversee the medical libraries. In the past, Libraries were "clean, well lighted places for books". With the advent of Web 2.0 collaboration tools, blogging, content management portals, lulu.com on demand publishing, and digital journals, it is clear that libraries of paper books are becoming less relevant. By the time a book is printed, the knowledge inside may be outdated. Instead, libraries need to become an information commons, a clean, well lighted lounge for digital media staffed by expert knowledge navigators. In my institution, the librarians have thinned the book collection, migrated paper journals to digital media, and spent their time indexing digital knowledge resources to support our search engine optimiziation efforts.
The end result is that the Medical Library has been renamed the Information Commons and the Department of Medical Libraries has been retitled the Department of Knowledge Services. Librarians are now called Information Specialists.
Here's a few examples of how they turn data into knowledge:
Every day Harvard faculty generate numerous new presentations for students, residents and the medical community. Since all Harvard courseware is web enabled, all these presentations are placed online. It's not enough to free text index these materials because search engines, even Google, are only helpful for exact matches of text, not searching concepts. Our Knowledge Services staff apply metadata tags using the National Library of Medicine Medical Subject Heading (MeSH) concept hierarchy to these presentations. For example, a presentation may be about neurons which are part of the brain, but the word brain may not appear anywhere in the text. As user searches from articles about the brain, any presentation containing a part of the brain is automatically included.
Our web portals contain hundreds of links to journals, books, databases and collections of medical references. The challenge with using any search engine is that they page rank based on popularity, not necessarily authorativeness or value to the patient. Just because a certain diet is popular does not mean it is medically sound. Our librarians ensure our links and resources are dynamically updated and refer to the most credible resources, not the most popular.
Every day I receive advertisements about new web-based and mobile knowledge resources. Our Department of Knowledge Services is laboratory for testing these products and we deploy those which are most relevant to our stakeholders. One of their recent projects was acronym resolving tools and developing quantifiable standards for abbreviations.
Although we keep 5000 journals online, we also have access to many pre-digital resources. Our Knowledge Services folks respond to requests for complex historical literature searches with desktop PDF delivery of scanned articles.
Finally, our information commons, formerly the medical library is now an array of desktop computers, printers, wireless access points, scanners and staff to assist users with the technology.
Ideally, we'll all have software agents in the future that turn data into information into knowledge into wisdom, but the first step has been building a department of Knowledge Services within my institution staffed with Knowledge Navigators. Because of them, I'm optimstic that in 2008, I'll receive more wisdom and not just more data.
With email and other information sources escalating year to year, we all need a knowledge navigator to help us sort through all this data and ensure that we triage our incoming information flows into that which is important and that which is just FYI. I've started to build a team of navigators beginning with my medical librarians.
In my CIO role at Beth Israel Deaconess, I oversee the medical libraries. In the past, Libraries were "clean, well lighted places for books". With the advent of Web 2.0 collaboration tools, blogging, content management portals, lulu.com on demand publishing, and digital journals, it is clear that libraries of paper books are becoming less relevant. By the time a book is printed, the knowledge inside may be outdated. Instead, libraries need to become an information commons, a clean, well lighted lounge for digital media staffed by expert knowledge navigators. In my institution, the librarians have thinned the book collection, migrated paper journals to digital media, and spent their time indexing digital knowledge resources to support our search engine optimiziation efforts.
The end result is that the Medical Library has been renamed the Information Commons and the Department of Medical Libraries has been retitled the Department of Knowledge Services. Librarians are now called Information Specialists.
Here's a few examples of how they turn data into knowledge:
Every day Harvard faculty generate numerous new presentations for students, residents and the medical community. Since all Harvard courseware is web enabled, all these presentations are placed online. It's not enough to free text index these materials because search engines, even Google, are only helpful for exact matches of text, not searching concepts. Our Knowledge Services staff apply metadata tags using the National Library of Medicine Medical Subject Heading (MeSH) concept hierarchy to these presentations. For example, a presentation may be about neurons which are part of the brain, but the word brain may not appear anywhere in the text. As user searches from articles about the brain, any presentation containing a part of the brain is automatically included.
Our web portals contain hundreds of links to journals, books, databases and collections of medical references. The challenge with using any search engine is that they page rank based on popularity, not necessarily authorativeness or value to the patient. Just because a certain diet is popular does not mean it is medically sound. Our librarians ensure our links and resources are dynamically updated and refer to the most credible resources, not the most popular.
Every day I receive advertisements about new web-based and mobile knowledge resources. Our Department of Knowledge Services is laboratory for testing these products and we deploy those which are most relevant to our stakeholders. One of their recent projects was acronym resolving tools and developing quantifiable standards for abbreviations.
Although we keep 5000 journals online, we also have access to many pre-digital resources. Our Knowledge Services folks respond to requests for complex historical literature searches with desktop PDF delivery of scanned articles.
Finally, our information commons, formerly the medical library is now an array of desktop computers, printers, wireless access points, scanners and staff to assist users with the technology.
Ideally, we'll all have software agents in the future that turn data into information into knowledge into wisdom, but the first step has been building a department of Knowledge Services within my institution staffed with Knowledge Navigators. Because of them, I'm optimstic that in 2008, I'll receive more wisdom and not just more data.
Jumat, 04 Januari 2008
Clinical Systems Midyear Update
Every year, I work with my governance committees to create the Information Systems Operating Plan. Each January, I given an update on our progress. I thought my blog readers would enjoy the insight into the details of our clinical systems work.
Inpatient
Outpatient
Radiology Information System
Work in progress to create Pre-Anesthesia Testing documentation (medication reconciliation, nursing assessment form) and web-based versions of the CCC PACU log that are integrated with OR Scheduling. On track for late winter/early spring go live.
Decision Support
A subgroup of the Decision Support Steering Committee has been formed to oversee development of ambulatory quality reporting, with the SVP of Healthcare Quality as chair. First priority is to develop diabetes management reports based on the diabetes registry.
Electronic Health Records for non-owned physicians
Work continues on implementation of a hosted ASP model for BIDPO eClinical Works. Final design completed. Beginning work on Model Office setup.
Positive Patient ID
Rollout of bar-coded wristbands to the remaining (23) inpatient is scheduled for completion by February 2008. Once done, all inpatient units will have the ability to print new or replacement bands on demand at the time the patient presents.
Critical Care Documentation System
Testing complete; planning in progress for a late January / early February Pilot in one adult ICU and the NICU; expected roll-out to all ICUs to follow.
OB-TV Fetal Monitoring Surveillance System
Emergency Department – Rev E. All testing completed in December 07; go-live planned in February 08 (the ED pushed go-live out due to other commitments).
OB - Upgrade to Rev E. Funding approved in November 07; contract discussions beginning.
Anesthesia Information System (AIMS)
Major upgrade to Rev E is in early planning stages; timeline TBD. This will allow the AIMS to begin receiving lab data.
NTRACS Trauma Database
Successful December go-live of NTRACS Performance Manager Upload. ’08 work will include, version upgrade, implementation of a report module and modified National Trauma Data Standard (NTDS) dictionary.
New Laboratory Information System Implementation
Participating in discussions to explore the potential to leverage Radiology PACS to meet growing imaging and storage needs in other departments (e.g. Cardiology, GI).
Rad Onc Infrastructure Improvements
Upgrades to Oracle databases completed; move of RadOnc and Cyberknife databases to a more secure environment recently completed. Rollout of Portal Vision workstations nearing completion.
Cardiology
Participating in planning for upcoming consulting engagements to assess and develop a strategy for Cardiovascular Institution (CVI) related needs at both BIDMC and CVI’s growing number of remote locations. Clinical Systems staff participating in assessment of EMR and imaging requirements at CVI remote locations.
Continue to support various Apollo efforts including:
Participating in planning discussions for MacLab 6.5.3 upgrade
Other
Billing system interface for ED visits enhanced to improve accuracy and reduce the need for manual billing interventions.
Inpatient
- We will go live with statewide clinical summary exchange through the Massachusetts Regional Heath Information Organization called MA-Share in early February 2008. Inpatient discharge documents and the ED discharge documents will be electronically sent to providers using the HITSP Continuity of Care Document format.
- New influenza vaccine prompting and tracking features went live in Provider Order Entry
- Chemotherapy ordering for inpatient setting will integrate with inpatient Provider Order Entry and our outpatient Oncology Management system. It will go live in late March 2008, completing our effort to eliminate handwriting in chemotherapy treatment at every site of care.
- Provider Order Entry for the NICU – Planning meetings held with NICU to discuss resources needed for work. Formal project kick off planned for early March 2008, after the iMDSoft Metavision ICU documentation pilot is completed. Once completed we will eliminate the last handwritten orders in any site of care in the institution.
- Inpatient History and Physical with medication reconciliation – Initial meeting of Clinician Advisory Group held in December, with much interest expressed for this project. Formal kick off planned for late January/early February 2008. This project will eliminate paper history and physicals while also supporting medication reconciliation at the point of patient arrival.
- Scanning of inpatient paper records with a web viewer on track for go live in early 2008. This will enable our medical record coders to work anywhere in the world, expanding the pool of talented people we can hire. It also gives clinicians easy access to any historical paper records.
- Completed all requested order sets for clinical pathways in Provider Order Entry.
- Completed dashboard to support inpatient physician rounding.
Outpatient
- Completed numerous medication list enhancements to make outpatient medication reconciliation more efficient, and to foster better communication/workflow among the multiple providers who often care for patients.
- Completed a onetime “autoretire” of old medications to help remove inactive drugs from medications lists.
- Numerous ePrescribing enhancements have gone live: eligibility, formulary, alternate drug recommendations, mail order, and community medication history. Further piloting and roll out in coming months.
- Automated Results notifications and sign off – Additional specialty divisions have begun using the system (Pulmonary, Orthopedics, GI, Dermatology, Rheumatology). New physician coverage features have been developed and are being piloted. The pathology orders interface was enhanced to improve the accuracy of results routing.
- Ordering for BID Needham (our community hospital) studies is now live in webOMR. Areas that are included are lab, radiology, cardiology, EEG, pulmonary and sleep.
- Work on outpatient scanning with viewing in webOMR will begin after inpatient scanning goes live in early 2008. Projects will be prioritized by the webOMR Users Group with a goal of facilitating standardization of webOMR documentation at BIDMC. First project will be Dermatology outpatient progress notes.
Radiology Information System
- RIS enhancements – An initial set of requirements for a web-based portal that focuses on integration with other clinical systems is currently being defined.
- Preliminary reports and wet reads – Medical Executive Committee mandated changes to remove preliminary ( unsigned) reports from clinical viewers and provide a workflow to request wet reads. Work in progress and will be completed in Feb 2008.
Work in progress to create Pre-Anesthesia Testing documentation (medication reconciliation, nursing assessment form) and web-based versions of the CCC PACU log that are integrated with OR Scheduling. On track for late winter/early spring go live.
Decision Support
A subgroup of the Decision Support Steering Committee has been formed to oversee development of ambulatory quality reporting, with the SVP of Healthcare Quality as chair. First priority is to develop diabetes management reports based on the diabetes registry.
Electronic Health Records for non-owned physicians
Work continues on implementation of a hosted ASP model for BIDPO eClinical Works. Final design completed. Beginning work on Model Office setup.
Positive Patient ID
Rollout of bar-coded wristbands to the remaining (23) inpatient is scheduled for completion by February 2008. Once done, all inpatient units will have the ability to print new or replacement bands on demand at the time the patient presents.
Critical Care Documentation System
Testing complete; planning in progress for a late January / early February Pilot in one adult ICU and the NICU; expected roll-out to all ICUs to follow.
OB-TV Fetal Monitoring Surveillance System
Emergency Department – Rev E. All testing completed in December 07; go-live planned in February 08 (the ED pushed go-live out due to other commitments).
OB - Upgrade to Rev E. Funding approved in November 07; contract discussions beginning.
Anesthesia Information System (AIMS)
Major upgrade to Rev E is in early planning stages; timeline TBD. This will allow the AIMS to begin receiving lab data.
NTRACS Trauma Database
Successful December go-live of NTRACS Performance Manager Upload. ’08 work will include, version upgrade, implementation of a report module and modified National Trauma Data Standard (NTDS) dictionary.
New Laboratory Information System Implementation
- Soft Computer module build nearing completion
- Work with the lab managers in progress to develop approach for managing security, patient & management reporting, specimen tracking, etc.
- Solution for handling organizational and workflow issues around creation of fiscal number in the ambulatory, outreach and community sites is in discussion
- Key lab vacancy (LIS Manager) filled; two additional lab FTEs for the project just approved
- A software upgrade (Lab/Path) which includes contracted customizations is scheduled for installation in early January
- Work is progressing on the clinical viewer with the expectation that all requested changes will be completed by spring 08
- Integration work with POE and ADT is moving forward
- Validation test scripts in development;
- Validation testing is targeted to begin in late spring/early summer 08
Participating in discussions to explore the potential to leverage Radiology PACS to meet growing imaging and storage needs in other departments (e.g. Cardiology, GI).
Rad Onc Infrastructure Improvements
Upgrades to Oracle databases completed; move of RadOnc and Cyberknife databases to a more secure environment recently completed. Rollout of Portal Vision workstations nearing completion.
Cardiology
Participating in planning for upcoming consulting engagements to assess and develop a strategy for Cardiovascular Institution (CVI) related needs at both BIDMC and CVI’s growing number of remote locations. Clinical Systems staff participating in assessment of EMR and imaging requirements at CVI remote locations.
Continue to support various Apollo efforts including:
- Implementation of new Vascular Surgery module
- Development and testing of new Cardiac Cath Registry export
- Planning and implementation of a Physical Inventory module
- Assisting with development of STS reports
Participating in planning discussions for MacLab 6.5.3 upgrade
Other
- Adverse Events Tracking – Numerous enhancements based on user feedback were included in a major version release.
- Transfer Log – New features to allow MD comments and to allow log data to be viewed even after patients have been admitted.
- New ADT feed to support rollout of new lab and coding systems went live
Kamis, 03 Januari 2008
Cool Technology of the Week
As readers of my blog know, I drive a Toyota Prius Hybrid which includes built in GPS navigation and Bluetooth links to my Blackberry. I drive about 30,000 miles a year to customer sites and to various speeches throughout New England. The challenge in the Boston metro area (and in most metro areas) is that a GPS navigation system is only one small part of the puzzle. Traffic congestion can be so bad that a 5 mile commute can take over an hour. On December 21, traffic in the Boston area was so bad that many folks took 5-7 hours to go 10 miles from downtown to the suburbs. That night I commuted from Washington DC to Wellesley in 6 hours simply because the airport is directly connected to the Mass TurnPike via the Big Dig, avoiding all congested side roads.
Every morning I need to decide which route to take to the office, guessing about traffic congestion points based on radio news reports that are often wrong or not current.
My cool technology of the week is Google Maps with Traffic for Blackberry
This morning, I downloaded the application from Google to my Blackberry 8707G while driving and instantly got a map of all traffic congestion points in the Boston area. I made it into the office in record time. I took a photo (above) of my Blackberry running the application. You'll see traffic patterns in green, yellow and red. Congestion points are Route 93 and the intersection of Route 128/Mass Pike.
The application is a relatively thin client - it took about 1 minute to download and includes live traffic updates for 30 major US metropolitan areas, movable maps with satellite imagery, directions, and business locations. Interactive maps let you zoom and move in all directions so you can orient yourself visually.
I look forward to the day when the Prius includes this functionality, but for now, Google Maps with Traffic for Blackberry will save me up to an hour a day, making me more productive.
Rabu, 02 Januari 2008
Trapped in the 9th Circle of Verizon
For those who are not familiar with the reference to Dante's Inferno, let me summarize without being profane. The opposite of "Heaven" is the Verizon Customer Service infrastructure.
On Thursday, December 20, my FiOS internet/TV service was shut off by Verizon without any notice or warning. Verizon has the best wireless and wired technology in New England, but not the best customer service. Since I receive 4 separate paper bills every month (we've tried to get them electronic for a year, more on that later) for my home Verizon phone, internet, TV, and wireless services, I was fairly confident that Verizon could not figure out where to credit my payments, so my wife called their customer service number. What follows is a tale involving an army of customer service representatives, 4 hours on the phone, and 24 hours to restore my service.
December 20, 2007
3:00pm My wife turned on the television and it displayed "no channels available". Verizon did not call, send us a dunning letter or attempt to contact us in any way before terminating our service. My wife went to the Verizon website and found the customer service number 1-888-553-1555.
4:00pm After she held for some time, the friendly gentleman that finally came on the line said that because we lived in Massachusetts, he (inexplicably) could not actually help. He transferred her to another number 1-888-338-9333 .
4:30pm Another courteous gentleman came online, and because my wife did not have our FiOS account number available, he eventually indicated he could not locate our account number with only name, address and phone number, so he would have to transfer her to someone within the FiOS Repair Order area that had access to a different kind of customer relationship management system.
4:45pm Another kind gentleman came on line from the repair area and indicated that he could find our account, and that FiOS service had been switched off due to the mailed funds not being applied, but he could not help her with the problem since he was a repair area service facilitator. He gave my wife the number of Verizon Financial Services 1-888-250-4909.
5:30pm She waited on hold for a representative for 35 minutes. When Tiffany answered, she was clearly not pleased with my wife's lack of knowledge of our FiOS account number. She told her that the only way to pay the bill was to dial the automated payment system (no humans) at 1-800-345-6563 using the FiOS account number. She gave my wife a 9 digit alphanumeric account number but unfortunately the automated payment system needs an 18 digit account number. The automated payment system recommended another number 1-866-326-7937.
6:00pm A pleasant woman came on the phone and found our FiOS account number with no difficulty using our phone #, and reiterated that we must call the automatic payment number at 1-800-345-6563, be sure to get the receipt number, and then call 886-438-3467 to reinstate service, but they had of course already closed shortly before at 6pm Eastern Time.
6:30pm My wife called 1-800-345-6563 for automated payment and obtained a receipt number for the payment, but then had to wait until 8 am the following day to call for reinstating.
December 21, 2007
8:00amMy wife called 1-886-438-3467 and through good karma, the phone was answered by Renee, who trains others for Verizon and has a broader working knowledge of Verizon workflow. She found our account, noted that all past due balances were paid and that we did not need the receipt from the automated payment system. She also noted that our Verizon accounts have non-matching social security numbers in the phone number and the FiOS accounts. Somehow, Verizon does not believe that Dr. and Mrs. Halamka at the same address are related.
Renee initiated a three way conference call with me on my Verizon cell phone and my wife on our home phone to verify our identities and social security numbers. She then began the long and complex, multi-division process to create one bill. She also got the FiOS division on the phone and confirmed our service was reinstated.
Renee planned to call back after the holidays, and after all the various work orders went through their system, planned to create an integrated billing package for us. Unfortunately, she told us that she could not give out her full name, email address, or phone number to call her back.
January 2, 2008
5:00pm Renee deserves an immense amount of praise - she called me back today, the first Verizon employee to ever followup with us. She noted that she put in the order to consolidate all our accounts but noted that one of our cell phone accounts had the zip code 02482 instead of 02481. She agreed to place a conference call to Verizon Wireless because she is not empowered to change zip codes. She even tried to save us money by putting us into one of the national service rollup plans. All sounded perfect, until she checked her computer and noted that none of the consolidation orders she entered seemed to have processed. I have complete faith in Renee, and her tenacity may end up resolving these issues over the next few weeks.
Meanwhile, today I received the following mysterious billing notice from Verizon:
"Regarding your Telephone, we recently received a request to change the billing address on your account".
Who knows what that means? Maybe they'll move my phone service next door?
There's another great Catch 22 with Verizon. We've tried for a year to enable electronic payments so that bills are automatically paid without having to worry about paper, the US Mail or figuring out what account to credit. Each month, we fill out the paperwork but still receive a paper bill the next month. According to the electronic billing policy, if you pay the paper bill, your election to pay electronically is instantly voided. If you don't pay, your service is shut off. Rock or Hard Place, Frying Pan or Fire? Your choice.
All I ask of Verizon is a single, obvious phone number to call, hiding the complexity of the company from the customer. Maybe, they could call this idea One-Bill (R). When I call that service number, a human should be empowered to take action. As CIO of Harvard Medical School and CareGroup, I spend millions every year with Verizon and I cannot navigate Verizon Customer Service. If anyone at Verizon reads this and cares about customer service, please feel free to make this blog entry a case study. I'm sure dozens of broken processes could be identified just by highlighting my experience.
I'm off to write 4 checks for my 4 paper Verizon bills now, but I feel better and at least the TV works.
On Thursday, December 20, my FiOS internet/TV service was shut off by Verizon without any notice or warning. Verizon has the best wireless and wired technology in New England, but not the best customer service. Since I receive 4 separate paper bills every month (we've tried to get them electronic for a year, more on that later) for my home Verizon phone, internet, TV, and wireless services, I was fairly confident that Verizon could not figure out where to credit my payments, so my wife called their customer service number. What follows is a tale involving an army of customer service representatives, 4 hours on the phone, and 24 hours to restore my service.
December 20, 2007
3:00pm My wife turned on the television and it displayed "no channels available". Verizon did not call, send us a dunning letter or attempt to contact us in any way before terminating our service. My wife went to the Verizon website and found the customer service number 1-888-553-1555.
4:00pm After she held for some time, the friendly gentleman that finally came on the line said that because we lived in Massachusetts, he (inexplicably) could not actually help. He transferred her to another number 1-888-338-9333 .
4:30pm Another courteous gentleman came online, and because my wife did not have our FiOS account number available, he eventually indicated he could not locate our account number with only name, address and phone number, so he would have to transfer her to someone within the FiOS Repair Order area that had access to a different kind of customer relationship management system.
4:45pm Another kind gentleman came on line from the repair area and indicated that he could find our account, and that FiOS service had been switched off due to the mailed funds not being applied, but he could not help her with the problem since he was a repair area service facilitator. He gave my wife the number of Verizon Financial Services 1-888-250-4909.
5:30pm She waited on hold for a representative for 35 minutes. When Tiffany answered, she was clearly not pleased with my wife's lack of knowledge of our FiOS account number. She told her that the only way to pay the bill was to dial the automated payment system (no humans) at 1-800-345-6563 using the FiOS account number. She gave my wife a 9 digit alphanumeric account number but unfortunately the automated payment system needs an 18 digit account number. The automated payment system recommended another number 1-866-326-7937.
6:00pm A pleasant woman came on the phone and found our FiOS account number with no difficulty using our phone #, and reiterated that we must call the automatic payment number at 1-800-345-6563, be sure to get the receipt number, and then call 886-438-3467 to reinstate service, but they had of course already closed shortly before at 6pm Eastern Time.
6:30pm My wife called 1-800-345-6563 for automated payment and obtained a receipt number for the payment, but then had to wait until 8 am the following day to call for reinstating.
December 21, 2007
8:00amMy wife called 1-886-438-3467 and through good karma, the phone was answered by Renee, who trains others for Verizon and has a broader working knowledge of Verizon workflow. She found our account, noted that all past due balances were paid and that we did not need the receipt from the automated payment system. She also noted that our Verizon accounts have non-matching social security numbers in the phone number and the FiOS accounts. Somehow, Verizon does not believe that Dr. and Mrs. Halamka at the same address are related.
Renee initiated a three way conference call with me on my Verizon cell phone and my wife on our home phone to verify our identities and social security numbers. She then began the long and complex, multi-division process to create one bill. She also got the FiOS division on the phone and confirmed our service was reinstated.
Renee planned to call back after the holidays, and after all the various work orders went through their system, planned to create an integrated billing package for us. Unfortunately, she told us that she could not give out her full name, email address, or phone number to call her back.
January 2, 2008
5:00pm Renee deserves an immense amount of praise - she called me back today, the first Verizon employee to ever followup with us. She noted that she put in the order to consolidate all our accounts but noted that one of our cell phone accounts had the zip code 02482 instead of 02481. She agreed to place a conference call to Verizon Wireless because she is not empowered to change zip codes. She even tried to save us money by putting us into one of the national service rollup plans. All sounded perfect, until she checked her computer and noted that none of the consolidation orders she entered seemed to have processed. I have complete faith in Renee, and her tenacity may end up resolving these issues over the next few weeks.
Meanwhile, today I received the following mysterious billing notice from Verizon:
"Regarding your Telephone, we recently received a request to change the billing address on your account".
Who knows what that means? Maybe they'll move my phone service next door?
There's another great Catch 22 with Verizon. We've tried for a year to enable electronic payments so that bills are automatically paid without having to worry about paper, the US Mail or figuring out what account to credit. Each month, we fill out the paperwork but still receive a paper bill the next month. According to the electronic billing policy, if you pay the paper bill, your election to pay electronically is instantly voided. If you don't pay, your service is shut off. Rock or Hard Place, Frying Pan or Fire? Your choice.
All I ask of Verizon is a single, obvious phone number to call, hiding the complexity of the company from the customer. Maybe, they could call this idea One-Bill (R). When I call that service number, a human should be empowered to take action. As CIO of Harvard Medical School and CareGroup, I spend millions every year with Verizon and I cannot navigate Verizon Customer Service. If anyone at Verizon reads this and cares about customer service, please feel free to make this blog entry a case study. I'm sure dozens of broken processes could be identified just by highlighting my experience.
I'm off to write 4 checks for my 4 paper Verizon bills now, but I feel better and at least the TV works.
Selasa, 01 Januari 2008
Disaster Recovery Planning
In response to my posting about IT Governance, I received a very good question about prioritizing infrastructure spending: "Without an IT infrastructure steering committee, how do you resolve investment prioritization around these unseen but critical investments?"
Every year, I receive approximately $10 million dollars at BIDMC and $3 million at HMS for infrastructure spending on networks, servers, desktops, storage and wiring. This budget is an annuity based on the value of our IT infrastructure and the lifecycle of the components. However, it does not include funding for disaster recovery.
Five years ago, an audit at BIDMC pointed out our vulnerability to a disaster affecting the CareGroup data center, since the building itself is a single point of failure. I worked with the Board and senior management to raise awareness of disaster recovery planning and the need to make a multi-year capital investment. I've mentioned our disaster recovery work in previous blog entries, but not provided the details.
Cost of Information Technology
What will keep me up at night in 2008
Some Like it Hot
Here are all the details of how we're doing it including our budgets.
BIDMC
Step 1 We inventoried all our applications and determined the service levels required based on the business impact of downtime. We did not hire a team of expensive consultants for a formal business impact analysis. Instead, we used our existing governance committees to brainstorm how long applications could be interrupted before clinical workflow would be disrupted to the point of causing harm. Here are some examples of our informal business impact analysis:
Code Paging system - If a patient suffered a cardiac arrest and the code team did not respond, the patient could die. Hence, downtime of the code paging system must be a few minutes per year at most. No downtime at all is the goal.
Provider Order Entry - If medications, diagnostic testing and diets cannot be ordered, patients could have delays in therapy resulting in pain, extended illness or harm. Hence downtime of POE must be hours per year at most.
Revenue Cycle systems - If bills cannot be sent out for a day, no real harm is done since billing in hospitals is not a real time activity. However, if several days pass without billing, cash flow could be interrupted. Hence, downtime of revenue cycle systems must be a few days per year at most.
Library catalog - If the library catalog is disrupted, users will have to seek other sources of information on the web. A slight inconvenience will occur. Downtimes could be extensive without causing harm.
Step 2 We mapped out single points of failure in power, cooling, networks, servers, storage and infrastructure applications (i.e. DNS/DHCP) We developed an incremental plan to address these vulnerabilities and hired a new employee to coordinate risk mitigation efforts, beginning with enhancements to our existing data center.
Step 3 Since the data center itself was a single point of failure, we constructed a geographically distant data center to mitigate loss of the primary data center and have begun replicating data and applications in this secondary location.
BIDMC is in year 3 of a 5 year disaster recovery center implementation plan. The year by year budget totaling $13 million dollars which will support the recovery time and point objectives specified by our business impact analysis is here.
Harvard Medical School
HMS is in year 2 of a 5 year plan to provide similar protections. Since HMS is not a healthcare delivery organization but provides education, research and administrative services, the uptime requirements are less rigorous. HMS had a slightly different set of business requirements to meet when we began this project. Its primary data center was located in a 100 year old building with limited electrical and cooling support. Hence we wanted to establish a secondary data center which was an extension of the existing primary data center, then move all mission critical systems to the new data center, reserving the original data center for less critical applications and disaster recovery. The HMS five year milestones can be summarized as
Year 1 Create a new Data Center and run both the old and new physical locations as a single "virtual data center". This allowed us to keep existing applications running, add new applications to the new data center, and migrate servers from old to new in phases.
Year 2 Create a redundant network core and begin to operate the two physical locations as a primary and backup data center. Hire a disaster recovery coordinator.
Year 3 Create redundant storage, high performance computing and active/passive email hosting divided between the two data centers.
Year 4 Create redundant installations of critical applications between the two data centers
Year 5 Create redundant installations of critical applications between the two data centers
Each year of these plans enables us to progressively reduce risk. Of course, this disaster recovery planning must be complemented by a disaster response plan including calling/paging trees, communication strategies, and a playbook for responding to critical incidents. I'll post these plans in a later blog entry.
Just like security, disaster recovery planning is a journey. It requires a dedicated team, a project plan and a budget. We'll never be done, but by 2011 we'll have mitigated the risk of single points of data center failure for the majority of our applications.
Every year, I receive approximately $10 million dollars at BIDMC and $3 million at HMS for infrastructure spending on networks, servers, desktops, storage and wiring. This budget is an annuity based on the value of our IT infrastructure and the lifecycle of the components. However, it does not include funding for disaster recovery.
Five years ago, an audit at BIDMC pointed out our vulnerability to a disaster affecting the CareGroup data center, since the building itself is a single point of failure. I worked with the Board and senior management to raise awareness of disaster recovery planning and the need to make a multi-year capital investment. I've mentioned our disaster recovery work in previous blog entries, but not provided the details.
Cost of Information Technology
What will keep me up at night in 2008
Some Like it Hot
Here are all the details of how we're doing it including our budgets.
BIDMC
Step 1 We inventoried all our applications and determined the service levels required based on the business impact of downtime. We did not hire a team of expensive consultants for a formal business impact analysis. Instead, we used our existing governance committees to brainstorm how long applications could be interrupted before clinical workflow would be disrupted to the point of causing harm. Here are some examples of our informal business impact analysis:
Code Paging system - If a patient suffered a cardiac arrest and the code team did not respond, the patient could die. Hence, downtime of the code paging system must be a few minutes per year at most. No downtime at all is the goal.
Provider Order Entry - If medications, diagnostic testing and diets cannot be ordered, patients could have delays in therapy resulting in pain, extended illness or harm. Hence downtime of POE must be hours per year at most.
Revenue Cycle systems - If bills cannot be sent out for a day, no real harm is done since billing in hospitals is not a real time activity. However, if several days pass without billing, cash flow could be interrupted. Hence, downtime of revenue cycle systems must be a few days per year at most.
Library catalog - If the library catalog is disrupted, users will have to seek other sources of information on the web. A slight inconvenience will occur. Downtimes could be extensive without causing harm.
Step 2 We mapped out single points of failure in power, cooling, networks, servers, storage and infrastructure applications (i.e. DNS/DHCP) We developed an incremental plan to address these vulnerabilities and hired a new employee to coordinate risk mitigation efforts, beginning with enhancements to our existing data center.
Step 3 Since the data center itself was a single point of failure, we constructed a geographically distant data center to mitigate loss of the primary data center and have begun replicating data and applications in this secondary location.
BIDMC is in year 3 of a 5 year disaster recovery center implementation plan. The year by year budget totaling $13 million dollars which will support the recovery time and point objectives specified by our business impact analysis is here.
Harvard Medical School
HMS is in year 2 of a 5 year plan to provide similar protections. Since HMS is not a healthcare delivery organization but provides education, research and administrative services, the uptime requirements are less rigorous. HMS had a slightly different set of business requirements to meet when we began this project. Its primary data center was located in a 100 year old building with limited electrical and cooling support. Hence we wanted to establish a secondary data center which was an extension of the existing primary data center, then move all mission critical systems to the new data center, reserving the original data center for less critical applications and disaster recovery. The HMS five year milestones can be summarized as
Year 1 Create a new Data Center and run both the old and new physical locations as a single "virtual data center". This allowed us to keep existing applications running, add new applications to the new data center, and migrate servers from old to new in phases.
Year 2 Create a redundant network core and begin to operate the two physical locations as a primary and backup data center. Hire a disaster recovery coordinator.
Year 3 Create redundant storage, high performance computing and active/passive email hosting divided between the two data centers.
Year 4 Create redundant installations of critical applications between the two data centers
Year 5 Create redundant installations of critical applications between the two data centers
Each year of these plans enables us to progressively reduce risk. Of course, this disaster recovery planning must be complemented by a disaster response plan including calling/paging trees, communication strategies, and a playbook for responding to critical incidents. I'll post these plans in a later blog entry.
Just like security, disaster recovery planning is a journey. It requires a dedicated team, a project plan and a budget. We'll never be done, but by 2011 we'll have mitigated the risk of single points of data center failure for the majority of our applications.
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