Today marks a blogging milestone for me, my 100th daily post. Thanks for your support and comments along the way.
My 14 year old daughter and I recently talked about my jobs. I gave her the long explanation about what I do - strategy, structure, staffing, and process optimization. She asked for the elevator speech version and I said, "Basically, I run a lot of meetings."
Running an effective meeting takes a lot of energy. The meeting organizer is responsible for the logistics, bringing together the right people, ensuring all stakeholders are heard, managing the interactions, and documenting the results. Many meetings are not a good use of time. Here's columnist Dave Barry's analysis:
"Compare the modern corporate meeting to a funeral, in the sense that you have a gathering of people who are wearing uncomfortable clothing and would rather be somewhere else. The major differences are 1. Usually only one or two people get to talk at a funeral 2. Most funerals have a definite purpose (to say nice things about a dead person) and reach a definite conclusion (this person is put in the ground); whereas meetings generally drone on until the legs of the highest ranking person fall asleep."
Here's my guidance to running an effective meeting:
1. Organize the meeting in the most painless way possible
Outlook invitations work well for folks who have a lot of flexibility in the calendars or who are always working in a single location. For executives who attend meetings 12 hours a day and who travel between several corporate locations, automated invitations just do not work. I cannot be in Los Angeles for breakfast and Boston for lunch. Outlook invitations do not take into account travel time, location, and the general pace of the day. In my view, there are three effective ways to organize a meeting
a. Propose 4 or 5 possible dates/times and circulate them via email among the attendees/administrative assistants. Determine the "must have" attendees at the meeting. Based on the best fit of the "must haves", select a date/time. Just about all meetings can be organized this way.
b. If urgency is required, get all the admins on a conference call and do a real time reconciliation of calendars for the best fit. A use case for this is a meeting to discuss a strategic opportunity with time sensitivity.
c. If real urgency is required, just set a date and time and ask everyone to cancel their other commitments. A use case for this is a Joint Commission visit. Just drop everything you're doing.
Using endless "reply to all" emails among a large group of attendees to schedule a meeting generally does not work. For a senior leader, trying to organize a meeting yourself, without administrative coordination is very problematic, since there is a lot of communication required to find the best fit among many schedules.
2. Food and drink are real motivators to attend a very early, lunch time or very late meeting
Be kind to your attendees. They are giving their time to you and have very busy schedules. We are all under such time pressure that the only near term free times in our calendars are breakfast, lunch and dinner. If you use those times, bring refreshments.
3. Arrive early and begin the meeting promptly
Meetings take a lot of energy to organize. Time is the one commodity that people cannot make more of. If the meeting organizer arrives late, it's a sign of disrespect. Begin and end the meeting on time. The attendees will appreciate it.
4. Circulate meeting materials including a formal agenda, ahead of time
I've attended several meetings without a clear understanding of who's attending, the purpose of the meeting, the desired outcome, and any preparation I should do ahead of time. Circulate an agenda a few days before the meeting containing
a. The attendees, location, and call in number (for remote attendees)
b. The overall purpose of the meeting
c. The items to be discussed, identifying the main presenters
d. The background briefing materials to help with decisionmaking
The meeting is likely to be much more productive.
5. Ensure everyone has a chance to speak and interacts professionally
As the master of ceremonies of the meeting, the convener must prevent hegemony of any one speaker and should rapidly quash any emotional outbursts. It's fine to criticize ideas in a meeting but not to criticize or attack a person. I often use humor, real time compromise, and personal stories of similar past controversies to bring out the best behavior in everyone. If I know that a meeting has potental landmines, I'll openly state them at the beginning of the meeting and give permission to everyone to openly discuss them in a non-judgemental forum.
6. Put your Blackberry away
During long meetings that I run, I will very occassionally (once an hour) scan the inbox on my Blackberry for downtime messages, urgent notices, email from the CEO etc., but I will never use the Blackberry to respond to an issue while I am running a meeting.
7. Adhere to the agenda
Running a meeting requires focus. If there are tangential discussions, bring the focus back to the agenda. If there are private sidebar conversations, bring them into the whole meeting. The only way for the meeting to move forward is with everyone listening and progressing through the agenda.
8. Do a mid meeting summary
Halfway through the meeting, I take a checkpoint. Are we on track, what have we decided thus far? I summarize the main points of agreement and the remaining items on the agenda, so we can bring closure to the work we've done thus far and move forward.
9. Own the last two minutes
The last two minutes of the meeting are the most important. The convener should review all the decisions made, the next steps decided upon, the resources committed, the timelines, the deliverables, and most critically, the paths not chosen i.e. we will not do this project, spend this money, pursue that opportunity. By ending the meeting with an overall summary, all will leave the meeting with a common understanding of the consensus, even if some do not agree with it. The last two minutes can make or break the meeting by ensuring there is no ambiguity about the meeting's results. With a clear summary, all participants will understand the value of the meeting and their role in the meeting events.
10. Send a followup email summary with minutes
Even with a great last two minute summary, some stakeholders will have selective memory. It's best to memorialize the last two minutes of the meeting in meeting minutes, circulated to all meeting attendees and stakeholders. Also, take the time to thank those who attended the meeting and praise them for their work.
By following these steps, you maximize your meeting time, optimize communication, and maybe even reduce the number of meetings needed because of your remarkable efficiency running the process!
Sabtu, 01 Maret 2008
Kamis, 28 Februari 2008
Cool Technology of the Week
As I've mentioned in my entries about personal health records and my recent Dispatch from HIMSS , 2008 is an important year for personal health records that are linked to clinical EHRs, employer sponsored, payer based, and commercially offered. Yesterday, Google publicly announced their Google Health application which is the Cool Technology of the Week. A disclosure - I did serve on the Google Health Advisory Council over the past year.
The concept behind Google Health is that patients login to the Google application using credentials that are secure but not trusted. This means that anyone can set up a Google Health profile, but there is no specific assertion of identity. I can claim I'm Bill Clinton if I want to.
Once in Google Health, I can manually add information about my problem lists, medication lists, allergies etc. and get decision support about my conditions. However, it's unlikely that many people will enter their data manually. A much more powerful approach is self populate the personal health record based on standards-based connections to hospitals, laboratories, clinics and pharmacies. Cleveland Clinic was the first partner to support this connection. Beth Israel Deaconess will be a part of the next group of connections.
To self populate the Google Health record, a patient who has a relationship to one of the Google interfaced providers, just clicks on the icon of their hospital. That icon offers up to 3 links. In the case of BIDMC, we'll offer
Upload your records
Make an Appointment
Securely Email your Clinicians
If a patient clicks on Upload your records, they will be asked to login to BIDMC's Personal Health Record, Patientsite, using the secure credentials that have been issued by their doctor, validating the patient's identity. Once they sign a consent, they will be given the option to initiate an upload of problems, medications, allergies and laboratories into Google Health. The patient initiates this transfer, with their consent, after understanding the risks and benefits of doing so. Once the data is in Google Health, the value to the consumer is expert decision support, disease information, and medication information based on the patient's data.
There have been several articles about the Google/Cleveland Clinic pilot and Microsoft Health Vault/Mayo pilot noting that none of the organizations have signed HIPAA business associate agreements with each other. The reason for this is that Google and Microsoft are not HIPAA covered entities or business associates. Their products are just secure storage containers used by the patient, like a flash drive. The patient can delete the data at any time, apply privacy flags, print the data, and add to the data. Since the patient is in total control, there are no covered entity or business associate issues.
As part of the Google Advisory Council, I can tell you that many thoughtful people worked on the legal, technical, and policy issues around data use. Google will not advertise based on this data, resell it, data mine it , or repurpose it in an way. These consumer centric policies are similiar to the best practices adopted by Microsoft Health Vault.
It's important to me that in my role as chair of the national standards effort, HITSP, that I support all the major personal health record initiatives with interoperability. I've committed to Microsoft that BIDMC will work with Health Vault. I've committed to Dossia that we'll link with their Indivo Health platform. It's my hope that all of these efforts will converge to use one plug and play standard for clinical content and transport. Once they do, patients will be able to select the personal health record of their choice based on features, not just data.
Selasa, 26 Februari 2008
How to be a Bad CIO
In my decade as a CIO, I've seen a lot of turnover in the IT industry. Each time a CIO is fired, I've asked around to learn about the root cause. Here's my list of the top 10 ways to be a bad CIO.
1. Start each meeting with a chip on your shoulder
Human nature is such that every organization has politics and conflicts. Sometimes these differences of opinion lead to emotional email or confrontational meetings. If the CIO develops an attitude the presupposes every request will be unreasonable and every interaction unpleasant, then every meeting will become unproductive. I find that listening to naysayers, understanding common ground, and developing a path forward works with even the most difficult customers. Instead of believing that meetings with challenging customers will be negative, I think of them as opportunities for a "walk in the woods"
2. Bypass governance processes and set priorities yourself
Although it's true that some budget decisions must be made by the CIO, such as maintaining infrastructure, the priorities for application development should be based on customer driven Governance Committees . Even the best of intentions can lead to a mismatch between customer expectations and IT resource allocation. I recently participated in a meeting to discuss technology problems, when in fact the problem was governance - a lack of communication among the stakeholders, resulting in unclear priorities and unmet expectations. Once the governance is clarified and communication channels established, IT can deliver on customer priorities and meet expectations.
3. Protect your staff at the expense of customer and institutional needs
As a CIO, I work hard to prevent my 'lean and mean' staff from becoming 'bony and angry'. However, I also work with the customers to balance resources, scope and timing, rather than just saying 'no'. Sometimes organizational priorities will be overwhelming due to sudden compliance issues or "must do" strategic opportunities. I do my best to redirect resources to these new priorities, explaining that existing projects will slow down. My attitude is that I do not know the end of play in the middle of Act I, so I cannot really understand the impact of new priority initiatives until I accept their positive possibilities and start working on the details. Tolerate some ambiguity, accept change, support the institution and if a resource problem evolves, then ask for help.
4. Put yourself first
I've written that life as a CIO is a lifestyle, not a job. Weekends and nights are filled with system upgrades. Pagers and cell phones go off at inopportune moments. Vacations and downtime are a balance with operational responsibilities. When I go on vacation, I get up an hour before my family, catch up on email, then spend the day with my family. At night, I go to bed an hour after they do, catching up on the day's events. It's far worse to ignore email and phone calls for a week then come back to a desk filled with loose ends. Being a CIO requires a constant balance of personal and professional time.
5. Use mutually assured destruction negotiating tactics
Walking into the CEO's office and saying that you will quit unless your budget is increased does not win the war. It may result in temporary victory but it demeans the CIO. Similarly, telling customers that the CEO, COO and CFO are to be blamed for lack of resources does not make the organization look good. The CIO should be a member of senior management and all resource decisions should be made together by consensus, even if the outcome is not always positive for IT.
6. Hide your mistakes/undercommunicate
My network outage in 2002 resulted in what was called "the worst IT disaster in healthcare history". By sharing all my lessons learned with the press and internal customers, everyone understood the combination of issues and events that caused the problem. I received email from CIOs all over the world explaining their similar problems that had been hidden due to PR concerns. I have found that transparency and overcommunication may be challenging in the short term, but always improves the situation in the long term.
7. Burn Bridges
It's a small world and the best policy is to be as cordial and professional as possible with every stakeholder, even your worst naysayers. A dozen years ago before I was CIO, I presented to the IT steering committee about the need to embrace the web. I was told by a senior IT leader that they did not care what I had to say since I was not an important stakeholder. A year later, I became CIO and that IT senior leader left the organization within a week.
8. Don't give your stakeholders a voice
Sitting in your office and not meeting with customers is doom for the CIO. Every day, I fill my schedule with meetings in the trenches with all the stakeholders to understand what is working and what is not. I never shoot the messenger when I'm told that our products or services need improvement. A CIO can earn a lot of respect just by listening to the honest feedback from every part of the organization.
9. Embrace obsolete technologies
The CIO should never be the rate limiting step for adoption of new technologies and ideas. If Open Source, Apple products, and Web 2.0 are the way is world going, the CIO should be the first in line to test them.
10. Think inside the box
Facebook as a Rapid Application Development platform? Empowering users to do self service data mining? Piloting thin client devices and flexible work arrangements? Although exploring new ideas will not always result in a breakthrough, it's much more likely to create innovation than maintain the status quo.
Each time you approach a senior manager, a customer or an employee, remind yourself of the top 10 ways to be a bad CIO. By avoiding these behaviors, you may find yourself embraced by the organization for many years to come.
1. Start each meeting with a chip on your shoulder
Human nature is such that every organization has politics and conflicts. Sometimes these differences of opinion lead to emotional email or confrontational meetings. If the CIO develops an attitude the presupposes every request will be unreasonable and every interaction unpleasant, then every meeting will become unproductive. I find that listening to naysayers, understanding common ground, and developing a path forward works with even the most difficult customers. Instead of believing that meetings with challenging customers will be negative, I think of them as opportunities for a "walk in the woods"
2. Bypass governance processes and set priorities yourself
Although it's true that some budget decisions must be made by the CIO, such as maintaining infrastructure, the priorities for application development should be based on customer driven Governance Committees . Even the best of intentions can lead to a mismatch between customer expectations and IT resource allocation. I recently participated in a meeting to discuss technology problems, when in fact the problem was governance - a lack of communication among the stakeholders, resulting in unclear priorities and unmet expectations. Once the governance is clarified and communication channels established, IT can deliver on customer priorities and meet expectations.
3. Protect your staff at the expense of customer and institutional needs
As a CIO, I work hard to prevent my 'lean and mean' staff from becoming 'bony and angry'. However, I also work with the customers to balance resources, scope and timing, rather than just saying 'no'. Sometimes organizational priorities will be overwhelming due to sudden compliance issues or "must do" strategic opportunities. I do my best to redirect resources to these new priorities, explaining that existing projects will slow down. My attitude is that I do not know the end of play in the middle of Act I, so I cannot really understand the impact of new priority initiatives until I accept their positive possibilities and start working on the details. Tolerate some ambiguity, accept change, support the institution and if a resource problem evolves, then ask for help.
4. Put yourself first
I've written that life as a CIO is a lifestyle, not a job. Weekends and nights are filled with system upgrades. Pagers and cell phones go off at inopportune moments. Vacations and downtime are a balance with operational responsibilities. When I go on vacation, I get up an hour before my family, catch up on email, then spend the day with my family. At night, I go to bed an hour after they do, catching up on the day's events. It's far worse to ignore email and phone calls for a week then come back to a desk filled with loose ends. Being a CIO requires a constant balance of personal and professional time.
5. Use mutually assured destruction negotiating tactics
Walking into the CEO's office and saying that you will quit unless your budget is increased does not win the war. It may result in temporary victory but it demeans the CIO. Similarly, telling customers that the CEO, COO and CFO are to be blamed for lack of resources does not make the organization look good. The CIO should be a member of senior management and all resource decisions should be made together by consensus, even if the outcome is not always positive for IT.
6. Hide your mistakes/undercommunicate
My network outage in 2002 resulted in what was called "the worst IT disaster in healthcare history". By sharing all my lessons learned with the press and internal customers, everyone understood the combination of issues and events that caused the problem. I received email from CIOs all over the world explaining their similar problems that had been hidden due to PR concerns. I have found that transparency and overcommunication may be challenging in the short term, but always improves the situation in the long term.
7. Burn Bridges
It's a small world and the best policy is to be as cordial and professional as possible with every stakeholder, even your worst naysayers. A dozen years ago before I was CIO, I presented to the IT steering committee about the need to embrace the web. I was told by a senior IT leader that they did not care what I had to say since I was not an important stakeholder. A year later, I became CIO and that IT senior leader left the organization within a week.
8. Don't give your stakeholders a voice
Sitting in your office and not meeting with customers is doom for the CIO. Every day, I fill my schedule with meetings in the trenches with all the stakeholders to understand what is working and what is not. I never shoot the messenger when I'm told that our products or services need improvement. A CIO can earn a lot of respect just by listening to the honest feedback from every part of the organization.
9. Embrace obsolete technologies
The CIO should never be the rate limiting step for adoption of new technologies and ideas. If Open Source, Apple products, and Web 2.0 are the way is world going, the CIO should be the first in line to test them.
10. Think inside the box
Facebook as a Rapid Application Development platform? Empowering users to do self service data mining? Piloting thin client devices and flexible work arrangements? Although exploring new ideas will not always result in a breakthrough, it's much more likely to create innovation than maintain the status quo.
Each time you approach a senior manager, a customer or an employee, remind yourself of the top 10 ways to be a bad CIO. By avoiding these behaviors, you may find yourself embraced by the organization for many years to come.
Dispatch from HIMSS
I'm at HIMSS for 24 hours. For those who want say hello, I'm keynoting the Electronic Health Record Vendor's Association Breakfast from 7am to 8am in Convention Center Room 240D, keynoting the HITSP Town Hall from 8:30am-9:30am in Convention Center Room 204C, then meeting with several groups on the Exhibition floor until my plane departs back to Boston in the afternoon.
Here are a few observations from my hallway discussions at HIMSS thus far
1. Personal Health Records have gone mainstream . With Microsoft's Healthvault, Revolution Health, Dossia, and anticipated announcements from Google, it's clear that patients will have many options to become stewards of their own healthcare data. The next step will be for labs, pharmacies, payers, clinics and hospitals to provide standards-based connections to these personal health records. Now that Secretary Leavitt has recognized the national standards for personal health records, there should be convergence on the use of the continuity of care document for personal health record interoperability.
2. Personal Health Records will accelerate Health Information Exchange efforts. Health Information Exchanges and RHIOs have faced many challenges, including funding for central infrastructure and privacy concerns. Personal Health Records which enable the patient to move records from place to place are peer to peer, and use the free infrastructures provided by Microsoft, Google et al. Since the patient does the transfer, there are no HIPAA business associate agreements or covered entity issues. The patient is in full control of who sees what and when.
3. Electronic Health Records and Computerized Provider Order Entry are now seen as essential. Hospitals realize that Joint Commission accreditation, pay for performance programs, care coordination efforts, and quality measurement require these technologies. They are committed to making the investments. Of course there are still issues with rural hospitals and solo practioners, but the larger organizations have passed the tipping point.
4. Interoperability is being taken seriously. At the Interoperability Showcase, the IHE Theater, the EHRVA meetings, and throughout the Exhibition floors, I'm hearing about the possibilities of using the standardized patient summaries for EHR, PHR, Quality, Public Health, and clinical research. The next year should see significant adoption of these new standards. Here's an overview of all the interoperability events at HIMSS.
5. Security is increasingly a focus of many CIOs. Several states, such as Massachusetts and California have new data protection compliance and reporting requirements. Intrusion detection and prevention technologies are hot.
6. Storage and archiving technologies are become more sophisticated and lower cost. Healthcare CIOs are faced with storing more images and other data, so having easy to manage enterprise class storage and archiving is key.
7. Software as a service/ASP models are increasingly popular as a means to reduce total cost of ownership and ease deployment.
8. New mobile devices for clinicians have longer battery life, larger screens and lighter weight. PDAs are vanishing. Small form factor tablets/laptops are growing.
9. Collaboration tools for virtual teams are growing in popularity as local healthcare IT expertise becomes hard to find and retain.
10. Open Source is finding its way into the healthcare data center, with Linux providing the server side operating system support for Oracle databases, MySQL, and numerous vendor supported appliances.
A great gathering with 25,000 of my closest friends!
Here are a few observations from my hallway discussions at HIMSS thus far
1. Personal Health Records have gone mainstream . With Microsoft's Healthvault, Revolution Health, Dossia, and anticipated announcements from Google, it's clear that patients will have many options to become stewards of their own healthcare data. The next step will be for labs, pharmacies, payers, clinics and hospitals to provide standards-based connections to these personal health records. Now that Secretary Leavitt has recognized the national standards for personal health records, there should be convergence on the use of the continuity of care document for personal health record interoperability.
2. Personal Health Records will accelerate Health Information Exchange efforts. Health Information Exchanges and RHIOs have faced many challenges, including funding for central infrastructure and privacy concerns. Personal Health Records which enable the patient to move records from place to place are peer to peer, and use the free infrastructures provided by Microsoft, Google et al. Since the patient does the transfer, there are no HIPAA business associate agreements or covered entity issues. The patient is in full control of who sees what and when.
3. Electronic Health Records and Computerized Provider Order Entry are now seen as essential. Hospitals realize that Joint Commission accreditation, pay for performance programs, care coordination efforts, and quality measurement require these technologies. They are committed to making the investments. Of course there are still issues with rural hospitals and solo practioners, but the larger organizations have passed the tipping point.
4. Interoperability is being taken seriously. At the Interoperability Showcase, the IHE Theater, the EHRVA meetings, and throughout the Exhibition floors, I'm hearing about the possibilities of using the standardized patient summaries for EHR, PHR, Quality, Public Health, and clinical research. The next year should see significant adoption of these new standards. Here's an overview of all the interoperability events at HIMSS.
5. Security is increasingly a focus of many CIOs. Several states, such as Massachusetts and California have new data protection compliance and reporting requirements. Intrusion detection and prevention technologies are hot.
6. Storage and archiving technologies are become more sophisticated and lower cost. Healthcare CIOs are faced with storing more images and other data, so having easy to manage enterprise class storage and archiving is key.
7. Software as a service/ASP models are increasingly popular as a means to reduce total cost of ownership and ease deployment.
8. New mobile devices for clinicians have longer battery life, larger screens and lighter weight. PDAs are vanishing. Small form factor tablets/laptops are growing.
9. Collaboration tools for virtual teams are growing in popularity as local healthcare IT expertise becomes hard to find and retain.
10. Open Source is finding its way into the healthcare data center, with Linux providing the server side operating system support for Oracle databases, MySQL, and numerous vendor supported appliances.
A great gathering with 25,000 of my closest friends!
Sabtu, 23 Februari 2008
Electronic Health Records for Non-owned doctors - Managing the project
As I've indicated in my blog about managing IT projects and managing consulting engagements projects do not manage themselves. Although we've put together a remarkable partnership of vendors and service providers for our Electronic Health Record for non-owned doctors project, it's all wrapped in $1 million dollars of project management, coordination and "air traffic control". The geographically dispersed set of independent physician practices makes the project that much harder to manage. Our partners for this project are
eClinicalWorks - a leading provider of practice management and CCHIT certified electronic health records, accessible over the internet using a smart web client, from anywhere in the world. They will provide the software, training, and review of all our infrastructure designs.
Concordant - a leading provider of desktop, network, and server hosting services for clinician offices throughout our region. They will provide the hosting center for our Software as a Service (SaaS) EHR applications, operate our help desk, and deploy all our hardware to clinician offices.
Massachusetts eHealth Collaborative - our regional implementer of electronic health records with expertise in practice transformation. They will provide the practice consulting expertise to move clinicians from paper-based workflows to electronic systems.
Third Brigade - a leading provider of security, ethical hacking and host-based intrusion protection services. They will ensure we protect the privacy of patient records, since confidentiality is foundational to the entire project.
My internal staff, consisting of a Project Director, Project Manager, Project Coordinator, and design engineer will coordinate all the work done by our partners, design the model office/ideal configurations for the entire rollout, and manage the budget. Our first 4 pilot sites will go live this Summer and by Fall we will have gained enough experience that we'll refine our project plans and management oversight to be the equivalent of a "Starbucks franchising model." We expect that this model will enable us to choose a practice and then 6 weeks later have them fully up and running with hardware, software supplied from our central hosting facility, training, data conversions and interfaces. Being able to rollout practices in this timeframe, leveraging economies of scale, and using our partners most efficiently will result (we hope) in low cost and high customer satisfaction, since we'll do all the work with a minimum amount of wasted effort.
My experience with a project of this complexity is that a few additional months spent planning, project managing, and piloting will improve the quality of the project immensely and ultimately reduce our costs. The expense of doing the project twice to get it right far exceeds an investment in project management to get it right the first time. As we develop our "Starbucks franchise" Gantt charts, I'll post them, so all can see the critical path items that are being managed for each practice site.
eClinicalWorks - a leading provider of practice management and CCHIT certified electronic health records, accessible over the internet using a smart web client, from anywhere in the world. They will provide the software, training, and review of all our infrastructure designs.
Concordant - a leading provider of desktop, network, and server hosting services for clinician offices throughout our region. They will provide the hosting center for our Software as a Service (SaaS) EHR applications, operate our help desk, and deploy all our hardware to clinician offices.
Massachusetts eHealth Collaborative - our regional implementer of electronic health records with expertise in practice transformation. They will provide the practice consulting expertise to move clinicians from paper-based workflows to electronic systems.
Third Brigade - a leading provider of security, ethical hacking and host-based intrusion protection services. They will ensure we protect the privacy of patient records, since confidentiality is foundational to the entire project.
My internal staff, consisting of a Project Director, Project Manager, Project Coordinator, and design engineer will coordinate all the work done by our partners, design the model office/ideal configurations for the entire rollout, and manage the budget. Our first 4 pilot sites will go live this Summer and by Fall we will have gained enough experience that we'll refine our project plans and management oversight to be the equivalent of a "Starbucks franchising model." We expect that this model will enable us to choose a practice and then 6 weeks later have them fully up and running with hardware, software supplied from our central hosting facility, training, data conversions and interfaces. Being able to rollout practices in this timeframe, leveraging economies of scale, and using our partners most efficiently will result (we hope) in low cost and high customer satisfaction, since we'll do all the work with a minimum amount of wasted effort.
My experience with a project of this complexity is that a few additional months spent planning, project managing, and piloting will improve the quality of the project immensely and ultimately reduce our costs. The expense of doing the project twice to get it right far exceeds an investment in project management to get it right the first time. As we develop our "Starbucks franchise" Gantt charts, I'll post them, so all can see the critical path items that are being managed for each practice site.
Scanning Technologies
One of the great things about writing a blog is that I can share my experiences so that other CIOs can avoid mistakes I've made. Over the past 5 years, I'm made several mistakes - not understanding network technology enough to prevent our 2002 network outage, underestimating the popularity of voice recognition dictation systems, and believing that users would migrate to our new intranet site purely based on the advanced technology we implemented. One area where I need to formally state I was wrong is scanning technologies. I have never liked scanned images of medical records. They are not interoperable, they are challenging to store, and they are difficult to navigate because they are not searchable. However, I have recently found a few use cases for scanning technology that have proven me wrong.1. Inpatient records
Although BIDMC's outpatient records are entirely electronic, our inpatient progress notes, nursing notes,and Input/Output records are still paper-based. In 2008, we're creating electronic History and Physicals that will serve as the foundation for future work on inpatient clinical documentation, but in the meantime we need to make our paper records available electronically for several reasons. Hiring and retaining medical record coders is challenging in the Boston area. If we can make scans of our inpatient records available electronically via a secure web-application, we can hire medical record coders anywhere in the country. Additionally, real estate in the Longwood Medical Area of Boston is very expensive. Storing paper records nearby is just too expensive, so we built a storage facility in Dedham 15 miles away. Retrieving a chart from the storage facility can take a few hours. Having an electronic version of paper records saves time, storage space and energy.
2. Doctor's doodles, outside labs and lab requisitions
In some clinics, doctors make drawings of skin lesions and physical exam findings. Our ambulatory medical record does not include real time graphical input via Wacom tablets or other electronic drawing devices. Hence we need some way to include these doodles as part of the electronic record. Creating a drawing, then bar coding it, makes automated scanning into the right patient's record possible. Also, every day we receive 15 inches of paper from referring clinicians and outside providers. Today, that's all filed in a paper chart. Scanning paper received from outside providers and making it available within our ambulatory record ensures continuity of care. Finally, we receive paper-based lab requisitions from clinicians who want to order BIDMC labs but are not using our electronic health records or provider order entry system. Although we do not consider these requisitions part of the medical record, the lab needs to retain them as proof that the specified tests were performed on the basis of a signed order. Scanning them eliminates the need to store paper and makes retrieving them for audits much easier.
3. Consent workflow
Although we've experimented with automating the consent process, we've found that most consents are done in private clinician offices where we have no control of the technology or workflow. By scanning these paper consents into the record and making them available as part of peri-anesthesia testing, we ensure that all documentation necessary for a successful surgery is available before the patient arrives at the Operating Room.
We're now live with scanning our lab requisitions and inpatient records. We will soon go live with scanning doctor's drawings and outside labs. Consent scanning is planned for next year. The technology we use includes Fujitsu high speed scanners and Captiva image capture software. Our Health Information Management professionals scan any written documentation in the paper record and generate a PDF for each tab in the record, making the electronic version easy to navigate. We've created an automated link to a web-based viewer (screen shot above) that associates the scanned records with the right patient based on a bar code included on the first page of each scan that is optically recognized by Captiva. We've made these scans available to our medical record coders working at home. Homesourcing saves time, reduces real estate costs, and enhances productivity. It's a win/win.
Thus, scanning technology with automated creation of PDFs and web-based viewing organized by document type does work very well during the transition from paper to natively electronic workflows. I stand corrected.
Selasa, 19 Februari 2008
Cool Technology of the Week
Storage backup and data recovery is at the top of my list of things that will keep me awake in 2008. In healthcare IT, we need short recovery times with minimal or no data loss. Accomplishing this with once-a-day tape backups is not possible. The Cool Technology of the Week, Data Domain de-duplication storage, solves this problem.At BIDMC, we generate 28 terabytes of new file and email storage each year. Basic file stores have grown so large that we struggle to copy them within our 24 hour backup window. Additionally, our disaster recovery efforts now require us to replicate our data across two geographic locations.
Tape backup, which has been in use at BIDMC for decades, suffers from a variety of problems. Tape backups are time-consuming. Tapes are fragile and require physical security when transported. The time required to retrieve and recover from tape stresses our service availability objectives. In years past, we considered backup to disk, but the economics did not work. Data Domain de-duplication now makes disk an economical backup media. Here's how.
Instead of making full tape backups, we can backup changes on a sub-block level to disk then compress the result. There is an important distinction between a tape-based, incremental backup and de-duplication. With incremental backups, files that changed since the last backup are copied. A major problem with this approach is that each incremental backup must be recalled in sequence to recover files. This is a slow and complex process that does not detect if the same file was stored in several locations.
De-duplication, on the other hand, has sophisticated methods for identifying changes at the sub-block level. For example, if a spreadsheet has '&date' in the heading, each time you save it, the date in the title will change. An incremental backup will copy the whole document again. De-duplication at the sub-block level will only copy the date change. If multiple copies of the file are sent in email, it will only save one copy.
Over a two year period we examined many products from many companies. Most of them required proprietary hardware, specialized software, new management tools, training, and multiple staff to support the technology 24x7x365. We believe in information life cycle management/hierarchical storage management, but want one set of tools and compliance with the technology standards already in use in our data center. We chose Data Domain because:
- The product de-duplicates at the sub-block level yielding better reduction ratios
- The product looks like regular storage supporting NFS and CIFS file mounts
- The product requires little training since it's completely managed by Data Domain
- The product is an in-line appliance and does not require installation of server agents
- The product works with all our existing backup software
- The product is highly reliable, using RAID 6 SATA drives and built in hardware redundancy
We're so impressed with Data Domain's performance as a backup infrastructure that we're also planning to use it as an archival tool for less frequently accessed files. To do so, we'll first implement file virtualization technology such as Acopia or Rainfinity. This will enable us to move content from one storage medium to another without impacting file shares, our web-based file access tools, or our SSLVPN remote file access applications. The combination of file virtualization and Data Domain will enable us to support three tiers of storage.
Tier 1 - SAN storage with lower density, high performance drives.
Tier 2 - SAN or NAS storage with high density, low performance drives.
Tier 3 – NAS-based, archival storage with high density drives coupled with Data Domain de-duplication and compression.
With these 3 tiers of storage, we'll reduce our cost of information life cycle management while reducing complexity.
After a 2 year journey exploring backup, recovery, and archiving solutions, I feel we've finally found the answer that will let me sleep at night in 2008.
Langganan:
Postingan (Atom)