Most Popular Educational Technologies

In 2001, Harvard Medical School went live with the Mycourses educational portal (check it out by clicking on take a tour) , which includes content management, collaboration, and online evaluation for faculty and students.

Here's an overview of the most popular technologies in Mycourses and the reasons they've been popular.

Virtual Microscopy
Remember using a light microscope and the trying to get a clear, focused image while dripping oil on the 1200x lens? Using a microscope is a different skill than learning pathology/histology, so we teach them separately. Students have a few hours of hands on experience with lenses and oil followed by a 100 hours of learning the pathology/histology via Virtual microscopy - streaming, high definition, zoom-able, movable images onto the web using technologies from Aperio and MicroBrightField.

With Virtual Microscopy, faculty navigate tissue sections via the web and project them on an HDTV display or LCD projector, pointing out salient areas on a slide in real-time without the use of a 12 headed microscope or other expensive optical technology previously needed for group work. Faculty digitize rare slides and make them accessible to all students and faculty in a very convenient way for both education and research purposes. From the student’s point of view, slides can be reviewed 24x7 from their dorm room.

Visual Encyclopedias
The web is an ideal vehicle for delivering "new media" that beyond the text based content of traditional textbooks. We've created our own specialized visuals for radiology instruction and visual diagnosis, but we've also licensed two commercial products.

VisualDx, an online visual decision support tool, was developed to assist students and physicians in pattern recognition, diagnosis, and treatment. Unlike traditional atlases or textbooks, VisualDx allows one to enter the patient’s key signs and symptoms (eg, dyspnea, abdominal pain, widespread papules), and in seconds the system generates a patient-relevant differential diagnosis.

Primal Pictures is a 3-D Online Anatomical resource with extremely detailed models of the human body that we've used in the anatomy lab by placing flat screens on mobile mounts above cadavers. The students can navigate three dimensional images, remove virtual tissue layers, and explore the relationships of structures to one another in real time while doing dissection.

Online Procedures and Simulations
Does the bevel go up or down when doing a blood gas? What are the anatomical landmarks when doing a lumber puncture? By making flash and streaming video procedure instruction available via the web and mobile devices, we provide our students with just in time instruction before they do a procedure.

We also use Flash for highly interactive simulation/exploration of difficult to learn concepts. For example, to teach the relationship between heart sounds, PA catheter tracings, EKG, and Pressure-Volume loop, we've used flash. We have 200 of these simulations for all aspects of human physiology.

Collaboration tools
We've implemented centralized shared storage for individuals and ad hoc collaborations which enable any groups to exchange files and set file read/write/delete attributes for every participant.

For real time group collaboration, we've deployed Webex and Elluminate. Although we do have video teleconferencing facilities available, we've found that audio conference calls combined with real time presentation tools are the most effective way to deliver real time educational materials to collaborative groups.

Streaming videos and podcasting
Our most popular application is streaming video of recorded lectures with over 60,000 views each year. We also podcast all our lectures so that students can replay lectures on their ipods. We use Apreso for combining lecture slides and videos, Streamsage for full text indexing of spoken words, and Real Server/Player for routine video delivery. One of the most popular features is Enounce Time Scale Modification of Audio , which enables videos to be watched at twice normal speed with frequency correction so that voices sound normal. Students can watch 8 hours of lectures in 4 hours! It is true that attendance of lectures has diminished since we made streaming video available, but attendance at interactive sessions such as tutorials has stayed the same.

Our next generation of portal will include more social networking features, more opportunities for collaboration among the medical school and hospital affiliates, and support for classrooms of the future which incorporate more real time video collaboration and resource sharing.

It's very clear that the web is empowering entirely new ways to deliver educational material and the way we teach must evolve.

Cool Technology of the Week

I travel about 400,000 miles a year.

I can tolerate the late departures and arrivals, the surly airline staff, and the sardine-like seating arrangements, but the unpredictability of the security screening process is a nightmare. Sometimes I arrive at an airport and jog through the security line in minutes. Many times I arrive to find a security line longer than a football field with an hour long wait, causing me to miss my flight.

Given that I'm a trustworthy traveler who only carries a toothbrush and an extra pair of socks, should I wait in the same line as the once a year traveler with a bag full of liquids/gels, a giant carry on suitcase, and a stroller?

The notion of a "Registered traveler", who is trustworthy and carries non-repudiatable identity credentials makes a great deal of sense.

Clear has implemented a fast pass for airport security with a process and a smart card. It's the Cool Technology of the Week. Clear members are pre-screened via a government approval process and carry an identity card which allows them to access designated airport security "fast lanes" nationwide. In my experience at Orlando, Dulles, Reagan, and San Francisco, Clear members pass through airport security faster, with more predictability.

The smart card contains basic demographic data - name and address, but also contains biometric data including a photograph, height, fingerprints and iris scans.

Enrollment is a two step process - an online application and in person identity verification.

The identity verification is completed at a Clear enrollment station (airports supporting the technology), where a Clear staffer verifies two government issued IDs, takes your picture, captures your iris and fingerprint scan, then submits everything to the government for clearance.

Clear's identity theft policy is well thought out and minimizes the risk to the Clear members if their database or card technology is compromised.

The price is $100 per year plus the TSA vetting fee of $28.

I plan on completing my Clear enrollment on my next flight to Washington DC in May. Once I have the card, I can bypass security lines and go directly to baggage screening.

The number of airports supported Clear is growing, but just the support for the Washington DC and San Francisco airports make it worthwhile for me, since I pass through these dozens of times per year. Making the airport experience a little more predictable is about the best way I can improve my mental health in 2008, so Clear is a definitely cool technology.

The Cosmopolitan Dating Test

Today's blog is about that fine academic journal of all things health and relationships, Cosmopolitan. I do not read Cosmo, but I know several people who have.

I was recently told about groundbreaking Cosmopolitan research that identified the "4 Types of Men You Never Want to Date". I have to publicly admit that I have failed the "Cosmopolitan Dating Test".

Let's take a look at the 4 personality types that Cosmo has declared to be losers:

1. The Adrenaline Junkie - You definitely want to stay away from rock climbers, alpinists, and ice climbers because they will spend so much time on their outdoor adventures that there will never be quiet time for a bowl of popcorn and "Sleepless in Seattle". They'll be planning their next adventure, coiling their ropes, and checking their gear lists. Next thing you'll know they'll want to climb every mountain in New Hampshire.

2. Nice Guy with a Chip on His Shoulder - I am a nice guy, but alas, I have a Chip in my shoulder containing all my medical records. In addition, the Cosmo researchers warn against the guy with stylized dressing habits, definitely ruling out my black Nehru jacket, black shirt, and vegan shoes. Stylish dressers spend so much time thinking about ways to accessorize that they'll never have time for moonlit walks on the beach.

3. Smooth Operator - The guy with the polished anecdotes about life as a CIO, leadership lessons learned, and spellbinding tales of project management will never have time to whisper sweet nothings in your ear.

4. Workaholic Hotshot - Definitely be wary of the guy with an 80 hour work week who has multiple jobs and doesn't sleep much. He'll be so attached to his Blackberry that there will never be a romantic moment away from a keyboard.

My wife and I have been together for 28 years, through sickness and health, Windows and Mac OS, residency and network outages, so I think it will last. When I explained what a loser I am according to Cosmopolitan, her response is that she would never want to date me, just marry me. Aw shucks...

The Challenges of a Software Legacy

Ever year as I prioritize new application development, I remind my governance committees that 80% of my staff resources are devoted to keeping existing systems stable, secure, and error free. These staff maintain infrastructure and add incremental improvements to support compliance with new rules, new standards, and new workflow requirements.

As I reflect on Microsoft's current challenges with Vista, I sympathize with their dilemma. On the one hand, the user community expects each upgrade to offer bold new features and innovation. On the other, users expect all their Windows 98, NT, 2000, and XP software to work flawlessly.

The amount of engineering required to ensure this backward compatibility is enormous and in large part explains the difficulty the Microsoft Operating System Development group has in releasing something that is boldly new.

Industry analysts point to the speed of innovation of Google or the fact that Canonical's Ubuntu is rapidly converging on the Windows feature set. Both Google and Canonical have the advantage of little legacy compatibility support.

I've experienced this same burden of a software legacy several times.

At Harvard Medical School, we introduced Mycourses.med.harvard.edu as the educational portal in 2001. Each year through Mycourses, we deliver 60,000 streaming videos, thousands of documents, and hundreds of simulations. Per my recent post about Educational Technology priorities, there is a desire to enhance usability and add many new features. The challenge is that we need to maintain existing features while innovating. This is like changing the wings on a 747 while it's flying. A perfect example is our Surveybuilder and Testbuilder. These web-based applications in Mycourses evolved over years based on hundreds of user feature requests. At this point, adding new features will likely break old features. Our best approach is to rewrite them from scratch, based on a streamlined set of user requirements. Thus, we'll evolve the existing Mycourses into a new portal framework, then rewrite the applications over time. This will be evolution rather than revolution. Some people will comment that our pace of innovation is slower in 2008 than it was in 2001. This is the reality of an existing legacy of highly functional software.

At BIDMC, we launched our intranet in 1998. At that point in web history an intranet was just a list of links and not a highly interactive Web 2.0 infrastructure supporting blogs, wikis, forums, and new media. In 2007 we introduced a new intranet based on many modern features such as single sign on, user customization, support for RSS feeds, and Sharepoint features. Today, of our 5000 users, 4000 use the old portal and 1000 use the new portal. Our user survey indicated that the average user just does not want to change. Learning a new portal is more effort than is justified by the new features. In 2008, we're relaunching the portal again, making the look and feel more similar to the old portal but supporting many new collaboration and content management features. In 1998, launching the intranet was simple because there was nothing to compare it with. In 2008, it's very hard because we have to support the legacy of highly functional old portal features while moving forward.

In both cases, we're leveraging our governance processes to build top down and bottom up support for change. We hope that by creating an urgency to change, a vision for the future and a guiding coalition, we'll be able to overcome the burden of our software legacies.

Thus, Vista may have its warts, but I understand the struggle Microsoft faces.

Electronic Health Records for Non-owned doctors - Support

This is my tenth entry about providing electronic health records for non-owned doctors. The previous entries have described the efforts to go from vision to live implementation. The subject of this post is support after go live and ongoing operational funding. As with my post about implementation funding, I've asked all the implementers of EHR projects in Massachusetts to comment on their plans.

BIDMC
At BIDMC, we'll provide a central help desk (Concordant), outsourced desktop/network support (Concordant), and ongoing application support (internal staff, Mass eHealth Collaborative staff and eClinicalWorks). Clinicians will pay a fixed monthly rate for this service. We'll centrally contract for all these services, so the cost will be as low as possible. BIDMC may pay for the ongoing operation of the centrally hosted eClinicalWorks system (i.e. rent in the co-location data center, server support staff) and this is still under discussion.

Caritas
Cartias is evaluating their strategy for ongoing support. They are considering the possibly of reassigning members of the implementation team to support as implementation is completed. The have not yet identified a specific funding model for support, but are considering an approach similar to BIDMC.

Childrens
Children's will provide a similar model to BIDMC. The help desk function and first tier application support will be outsourced to a third party vendor (The Ergonomic Group). They will escalate to eClinicalWorks as necessary. Ergonomic will also manage and support network operations at each of the practice sites. Children's will support the central hosting site hardware and infrastructure. Children's will also support all network operations inside the core data center. Clinicians will pay a fixed monthly rate for this service.

Mt. Auburn Hospital/MACIPA
Mt. Auburn/MACIPA will provide a central help desk and ongoing hardware/application support. They are currently retraining clinicians to help them increase the utilization of the product, given that during the initial training there is only so much a physician can absorb. They also intend to also hold classes at the IPA periodically. Post live financial support is still being discussed.

New England Baptist Hospital
NEBH will provide an outsourced help desk, ongoing hosting, and application support. Clinicians will pay for non-Meditech interfaces, software maintenance, and connectivity/support to billing companies.

Partners
Partners will follow the same model as BIDMC, with clinicians funding ongoing support services.

Winchester
Community physicians will fund ongoing software and hardware support. The team in Highland Management (joint venture between the hospital and IPA) will provide guidance in the development of templates and the use of the system for reporting to meet P4P goals and clinical integration. Winchester IT will also be involved in the development of interfaces and the transfer of patient data for care delivery.

This post marks the conclusion of my first series about electronic health records for non-owned physicians.

Today, the BIDMC Finance Committee approved our pilots, so we'll be moving forward with all the plans I've outlined. This is a major milestone for our project that enables all our contracts, service level agreements and spending to progress.

My next series about this topic will start in July as our pilots go live. I'm sure there will be many more lessons learned to share including comments on budgets, practice workflow transformation and loss of productivity. I hope these first 10 posts about planning the project have been useful to you!

Tamperproof prescriptions

On May 27, 2007, Congress enacted regulations requiring the use of tamper-resistant prescription pads. This primarily affects patients covered by state Medicaid programs.

Following several meetings internally, with state agencies and with professional organizations, BIDMC elected to use tamper proof paper stock in printers which produce electronic prescriptions (not e-prescribing, which is exempt from the regulation). The new stock will be used to write all prescriptions, regardless of payer/insurer and contains the features proposed by MassHealth as "standards" for Tamper-Resistant Prescription Pads:

It has a greenish hue.

It is perforated (twice) so that up to three prescriptions can be printed on one sheet.

When photocopied, the word "VOID" will appear in multiple locations.

The backside has Rx icons printed in thermochromic ink. This means the icon will disappear when rubbed with your finger and then reappear when you stop.

We're implementing this in two phases. From April 1, 2008 to October 1, 2008, we can still use plain paper, but we've modified prescription printing as permitted by the new regulation :

“Quantity Border and Fill (for computer generated prescriptions on paper only), i.e. Quantities are surrounded by special characters such as an asterisk to prevent alteration; e.g. QTY **50** and Value may also be expressed as text, e.g. (Fifty), (optional).”

“Refill Border and Fill (for computer generated prescriptions on paper only), i.e. Refill quantities are surrounded by special characters such as an asterisk to prevent alteration; e.g. QTY **5** and Value may also be expressed as text, e.g. (FIVE), (optional).”

Here is a link to an example of our new printed prescriptions. This is live now.

We're also providing a Notice to Dispensing Pharmacies which we're attaching to prescriptions.

By October 1, 2008, we'll replace all plain paper with the tamperproof paper as required by the regulation.

This has been an effort requiring coordination among IT, providers, administration, pharmacies, and government. It's been quite complex and we're hopeful that our planning, communication, and phased implementation effort will be successful.

Cool Technology of the Week

One of the challenges of being a CIO is the "application is slow, can you fix it" phone call. Generally, the network is blamed first, but there are many layers that all need to be examined - desktop, network, server, storage, database, active directory, internet service provider etc. For example, a complaint about email slowness can be caused by a multitude of factors.

We recently worked with our electronic health record infrastructure partner, Concordant, to do an end to end application performance analysis.

The tools they employed were:

WhatsUp Gold for Network and Server Monitoring
Windows Performance Monitor for Server and Client Monitoring
OPNET Ace for End to End Network traffic analysis
Computer Associates eHealth for Network Monitoring

The general approach they used covered three domains. They began by identifying and defining the problems from a user perspective. This helped to identify issues related to system performance versus non-technical issues that amplified the technical issues and affected user perception of performance, e.g. training, improper usage of the application. They used multiple subject matter experts to focus on the different domains to ensure they had the in-depth knowledge to evaluate each of them.

The three investigation domains and key focus areas within each domain were:

Client
End User Observation & Interviews
Client device performance analysis
Device configuration & Log review
Device specification analysis per application vendor recommendations

Network
WAN link utilization
Device performance analysis
Device configuration & Log review
Packet Loss & Latency analysis
Traffic Analysis

Infrastructure
Server and Storage performance analysis
Device configuration & Log review
Service and Process performance analysis
Device specification analysis per application vendor recommendations

The findings from the assessment did not identify a "magic bullet" issue that caused performance issues, but instead identified multiple smaller issues that combined to impact system performance.

In my experience of troubleshooting complex IT systems, I've found that the comprehensive approach outlined above works very well.

If I had to choose one simple approach to determine the cause of application performance issues, I would:

1. Check to see that the desktop, the server, and the database all have their network cards set to Auto, since performance problems are often network card duplex mismatches

2. Install OPNET agents on the client and server. More often than not, OPNET rapidly identifies root causes of application performance issues.

Based on my positive experience with OPNET, including in this particular project, I'm naming OPNET as the cool technology of the week. Now I can respond to the "application is slow" question with an OPNET answer.