IT (R)Evolutions

Apple, iDevices and HealthCare IT

2010-04-23T10:41:00.000-04:00

Apple’s recent announcement on the new iPhone Developer agreement is making waves in the technical community; HealthCare IT should be paying attention as well.

Essentially, Apple has mandated that any applications for their iDevices be written, from scratch, not ported over, in one of 4 languages – Objective-C, C++, C or JavaScript. No third party API calls of any sort are allowed – no Flash, SilverLight, ActiveX. While web applications should be exempt, those apps can’t leverage any plug-in’s themselves on the iDevice – unless those plug-in’s are written from scratch.

Quite simply, unless your iApp complies, it doesn’t get deployed to an iDevice.

This has effectively increased the barrier of entry. While on the one hand this could ostensibly be seen as a quality gate, in reality the same could be achieved with less restriction – mature software development shops do so every day.

But what does this mean for HealthCare?

If you don’t already have docs beating on your door for iPad and iPod support you’re in a deep bunker somewhere. Not only do they want these devices supported, but they want to access their EMR, their Imaging, etc system via those devices. Quite reasonable, right?

Most hospitals IT staffs are now faced with not only supporting these devices, but also working with HIT vendors, some of whom are also notoriously behind the technology adoption curve, in getting their application, be it an EMR or a PACS Web Viewer, to comply. Support at the desktop is challenging enough with a lot of these apps requiring an older Operating System, browser, version of Java, etc. Now add the challenge of supporting, or creating from scratch, these same clinical applications on what is essentially a closed platform.

Apple isn’t going to change its mind – it doesn’t need to. While physician’s can certainly be educated as to the challenges involved with their iDevices, at the end of the day this support will end up happening. So, yes, I’m taking a shrug and deal with it approach here. The HIT vendors and HIT staffs writing software are going to have to make a conscious decision to support and resource custom versions of their apps for iDevices. Or not. If the same can be accomplished with web apps, so much the better.

One approach might also be to wait and see what the next generation of HP, Dell, HTC and Android smart phones and devices bring to the table. How effectively will they compete with Apple and how open will those platforms be?

Regardless, this raises two glaring prospects. First, HIT vendors probably have their hands full between CONNECT, HITECH, Meaningful Use and whatever else is screaming down the pipe. I shudder to think of the quality that could be sacrificed to meet those time-boxed needs alone, much less clamor from the consumer space for mobile device support.

Second, and more pertinent to Healthcare in general, is that this will only serve to expose just how fragment HIT and the back office is. There is no silver bullet or fairy dust that will solve this and there really isn’t a turnkey vendor offering that will make up for decades of trying to run integration via HL7. This is going to be a lot of heavy lifting – it’s not technically complex, but it’s still a lot of grunting, heaving, sweat equity required to bring about real world data or even application interoperability to HealthCare.

Fundamentally it comes down to HealthCare recognizing that mature, real world enterprises a) own their data b) have access to that data anytime, anywhere. The first can be resolved with some system of record data source – whether this is federated, consolidated, backed with an EMPI or not. The second can be resolved with a technology architecture that allows access to that data – preferably some sort of Web or Service Oriented Architecture (WOA or SOA)

Towards that effect the Enterprise SOA and Operational Data Store (ODS) that I’ve evangelized and campaigned, begged, pushed, pulled and sometimes just bullied through where I work lays the foundations of solutions for not only the challenges of data ownership but also those of data integration.

If Apple is one of the catalysts that brings about the realization of the importance of such foundational works, so much the better.

Had we started on that work effort three years ago, we would have two of the keystones necessary to rapidly launch whatever the heck you can dream off on whatever platform you want. That client interface is typically the easiest to do once you square away your User eXperience (UX). I can right iPhone, Web, desktop clients all day long once I a) have the data somewhere b) have a consistent interface.

But for now I’m doing a lot of grunting, heaving, sweating and more than a little cursing (sorry mom!)

Mind you, I’m not stating this is THE solution, I’m stating this is A solution. There’s at least one marketplace solution I could think of. But, still, there will be time, money and resources that are required.

The piper, ladies and gentlemen, will be paid, one way or another, before he plays.

Reference Reading:

iPhone Developer Agreement Reaction Posting:

http://daringfireball.net/2010/04/iphone_agreement_bans_flash_compiler

Key Point:

3.3.1 — Applications may only use Documented APIs in the manner prescribed by Apple and must not use or call any private APIs. Applications must be originally written in Objective-C, C, C++, or JavaScript as executed by the iPhone OS WebKit engine, and only code written in C, C++, and Objective-C may compile and directly link against the Documented APIs (e.g., Applications that link to Documented APIs through an intermediary translation or compatibility layer or tool are prohibited).

Follow-up Posts:

http://www.taoeffect.com/blog/2010/04/steve-jobs-response-on-section-3-3-1/

The “insightful” response mentioned by Steve Jobs: http://daringfireball.net/2010/04/why_apple_changed_section_331

Run Healthcare IT as a business -- why that's a train wreck waiting to happen

2010-01-20T09:21:00.002-05:00

This InfoWorld article on why running IT as a business is a train wreck waiting to happen couldn’t have come at a more appropriate time.

If it’s one thing I’ve grown despondent about changing is this pervasive attitude in most enterprise IT shops, but especially HealthCare IT, about how it’s all about making the customer happy – not the patient, but just about everyone else from clinicians to backoffice.

If there’s a more antiquated and downright utterly wrong attitude in IT I have as yet to find it. It is not all about the customer, I am not a customer service organization, I do not serve the customer. I serve the business, and I partner with the business.

Not for nothing has my first question consistently been: What business problem are we trying to tackle – not – what do you want?

Yet we still persist in playing the masochistic role of Sisyphus, in between Scylla and Charybdis.

This is Heresy some will want to burn me at the stake for, but HealthCare IT and business leaders, as far behind the curve as it is, should especially read this, grok it and work it into their cultural change plans. I have oft been told HealthCare is not an IT business. That’s one of the attitudes that needs to be adjusted as you cannot run a business, any business much less Healthcare, without being plugged in or otherwise have a peer relationship with a trusted technology resource.

Everyone talks about how important HealthCare IT is to cost savings; what they neglect is that one of the root cause issues with HealthCare IT is that it’s culture and approach to problem solving is something that no amount of tangential legislation, or funding will solve – it is an attitude that needs to infect the organization. To be sure there are a handful of healthcare entities that are moving in the right direction with their IT. The vast majority, well over 80%, are either only gradually adjusting or remain stuck in amber.

Here’s some pertinent quotes that should encourage you to read the article:

“Your ticket to the promised land begins with this: No one inside your company is your customer.”

"IT should relinquish its increasing stance as an order taker, and earn and advance its intended role as the qualified engineer of what makes a business hum."

“To achieve a quality architecture, the internal customer of one project pays more so that a different internal customer, some time in the future, receives the benefit.” -- This, by the way, is something that is sacrosanct to me and has been very successfully evangelized where I’m at – even if it’s not generally or widely understood, I have enough buy-in, and real world results, to backup the approach we’ve taken to architectural quality.

“Chargebacks are an attempt to use market forces to regulate the supply and demand for IT services. If that's the best a business can do, it means the business has no strategy, no plans, and no intentional way to turn ideas into action.”

Instead, they should say, "My job is to help you and the company succeed," followed by "Show me how you do things now," and "Let's figure out a better way of getting this done." -- This is one thing that my team has done since day one. It’s a HUGE culture shock, but we’ve stuck with it. The good news is that it works and with the business units we’ve dealt with the most they’ve embraced it – especially since the results have borne fruit. The disappointing news is that in a $2B/yr multifacility hospital system, it has become a non-cost-effective task to repeat the evangelize\adopt\show cycle with EACH business unit.

“That's what proper governance requires: effective leadership. It's the hard work of turning the company's top executives into a team that agrees on strategy and turns it into a plan for coherent action. IT's priorities are built into that plan. They aren't bought and sold by whomever plays the budget game best.”

“IT's job is to recommend better ways to operate, using technical capabilities business managers might not even know are possible.” – This again is something my team is well known for. The reception varies as does the reputation earned. Invariably some segment will see you as barriers to their success. Reference the points made here-in and through the linked article as to why this doesn’t bother me in the least.

So, you’re choices are this – or build a car with the accelerator and steering wheel in the back, brake in the front, 2 and a half gears in reverse, 3 forward –in other words, a typical healthcare IT solution.

Ripples from the HealthCare Reform D.C. Silo – Why Transparency Matters

2009-10-29T12:01:00.000-04:00

Ripples from the HealthCare Reform D.C. Silo – Why Transparency Matters

A lot has been said about the impact of technology on HealthCare and how 50,000 HealthCare IT jobs will be created as part of the healthcare reform debate.

Let me share an example of the reality of what is occurring due to the utter lack of transparency coming from D.C. around HealthCare reform.

Healthcare organizations are planning to run lean in 2010. While the quality and quantity of care will continue to be emphasized and of paramount importance, the much touted impact on HealthCare IT is a different story.

Capital expenditures are being scaled back to the absolute critical projects – and even there hard choices are being made. Maybe you can wait another year for new hardware or the next version of software.

New HIT jobs are being scaled back or eliminated directly; the money, rightfully so, goes towards clinical service and quality first. Maybe you can just buy a third party product, if you can get a pricebreak.

Healthcare Organizations just don’t know and simply cannot divine from the offal of entrails they are being thrown from D.C. as to what the impact to their bottom lines are going to be – and keep in mind, most of them struggle to stay in the black, and what profit is made is typically reinvested, not sent to line any pockets. Further many of these organizations genuinely emphasize quality care of their customers (aka patients!).

Gone is the talk of decoupling insurance, patient choice, portability standards and tort reform, replaced instead with an obfuscated miasma from the swamp that is already having a negative impact on that which can bring about efficiencies – information technology.

If healthcare organizations, even healthy ones, are scaling back on IT now, what, one wonders will occur when it finally becomes a reality?

HL7 & the ODS

2009-10-29T11:33:00.001-04:00

In the process of designing and prototyping our Operational Data Store (ODS) for our Enterprise Products, we’ve noticed a couple of things that we expected but (vainly) hoped weren’t there.

First, a good number of our HL7 messages don’t follow documented standards closely. Most importantly, there are Z-segments (custom messages) in all sorts of places in a message instead of where they should be. This means our integration implementation has to be smarter and more defensive in handling these messages, such that the message transactions continue to flow when an unexpected or unanticipated message is consumed.

Second, we are replicating a lot of data with our HL7 messages. Say you change a zip code on a registration screen. You get the entire screen of data, not just the change, replete with whatever customized Z-segments. This means we’ll have some extra heavy lifting to do when consuming messages.

The key points here are two fold.

First, this is no one person’s fault – no one did a bad job – people work to their level of awareness. What it does indicate is that HIT hasn’t evolved. We’re still making the same mistakes we’ve been making for the last few decades, and that is inexcusable.

Second, this only reinforces why HL7 and standard don’t ever belong in the same sentence. It doesn’t matter than one vendor’s HL7 specifications may adhere to the standard, such as it is, the problem is that the HL7 message is too easily hijacked. Z segments should be the exception, not the rule and they certainly shouldn’t cause a problem when it comes to consuming the message nor require defensive coding to accommodate it.

The only way this is going to be solved is if an alliance of HIT-centric entities, not vendors, not the government, work together to force industry adoption of standards and practices that are common place across most enterprises else. In short, HIT needs to evolve out of its current calcification by having the people that feel the pain the most do something about it

For our project needs, we knew these would be problems, we planned and allocated for them. For anyone else embarking on similar ODS or Data Warehousing projects in HIT – caveat emptor, a standard isn’t always a standard in HIT.

On the Advent of Inadvertent Mediocrity

2009-10-20T23:14:00.001-04:00

Fair warning, this is more of an internalized discussion written down, appropriate caveats on misinterpretations apply.

While I feel that American Exceptionalism is being apathetically eroded into guilt-ridden mediocrity, this post is going to focus on the beginnings of a sort of depressing epiphany that I’ve stubbornly fought against for the better part of my nearly 2 decade career in computing, far preferring a bloody head over what I, personally, deem an ethical compromise of commitment.

Until now.

Based on personal observation and comparison of peer experiences, exceptionalism is neither encouraged nor rewarded in corporate computing. I’m sure the odd corporate computing environment exists out there where this may not be the case, but a very odd duck it will be.

HealthCare IT, regardless of talks of reform and funding, sadly suffers from the same issue that cancerously gnaws at the heart of ingenuity and innovation in corporate computing, but writ larger.

Unfortunately, HealthCare IT seems to have further devolved into purchasing disparate solutions and cramming them into weak integration platforms, repeated ad infinitum with insufficient focus on first, defining the problem, then designing the solution, before creating or purchasing or integrating anything. The tumor has spread to the extent that few things seem possible without the intervention or resources of a third party vendor, from defining the need to delivering the solution to supporting and training.

We’ve achieved 100% de facto outsourcing! The counterpoint of course is that you have a body of knowledge workers who have been robbed of the opportunity to gain the knowledge they need to replace that vendor mentality.

Healthcare organizations: the consultants you want are the ones who will not sell you a single license or product until they have helped you define the problem and design the solution; expect to pay for their time.

Fundamentally, this is no one person’s fault, per se, nor should this be seen as an assignment of blame, but rather a general reflection that, for all the books, talks, discussions, groups, whitepapers and consultants, corporate computing will remain mired in a necrotic momentum that seeks to continue to survive instead of thrive and grow, learning the same wrong lessons from each ancestral generation and imparting it on to each successive descendant generations in situ. What mold-breaking successes that do come, stagnate and seem to not develop into behavior that can be consistently repeated.

In considering root causes, there is one key, very lacking, cornerstone. Accountability - the accountability that speaks to a pride in ownership and a desire to excel, to step up instead of cleave to the accepted status quo, in particular by those very same computing professionals. This isn’t just a management problem, this isn’t just a business problem.

There are many understandable, wholly justifiable reasons, mostly rooted in fear and lack of support, as to why this doesn’t occur. While the parable of the tortoise and the hare teaches that slow and steady get’s you there, I have to wonder if what’s missed is that the hare likely only lost the race once, then learned a valuable lesson and modified its behavior. That tortoise is welcome to that singular gold medal, hanging lonesome on its mantle, it’s only true testament that it lead to another’s success, another who wears shades from the overpowering brilliance of its accolades.

Now replace speed with accountability in the above story. Dig deeper and realize the other lesson here is that a lesson was learned and applied.

The lesson learned for me has been that it’s not for me to expect nor to demand, except in myself and those I lead, mentor or raise, a level of accountability that I hold myself to.

For me the this leads to my epiphany. I have defined myself by my work for the better part of two decades, the cornerstone of which is accountability – from which I am convinced all other things such as delivery, flows. I can no longer afford to do so, largely for my own sanity but also because of the perception this sets. While I take at least half of the responsibility in setting that perception, it appears that the balance of the half remains looking for a home. Sound familiar? Yes, there’s accountability (or lack thereof) again.

So, where the balance of my career in corporate computing is involved, it would appear that a reset of expectations is called for and the balance to be sought is contentment, not satisfaction nor happiness.

The sub-conclusion here is that as risky as entrepreneurial endeavors’ are it would appear that my happy professional place is there, which leads me to considered thought on my future professional growing exercises. I’m still ruminating on that; been there, got the t-shirt(s), if I’m unwilling to return to that fertile ground …

Certainly, I will not allow qualities to neither suffer nor erode, instead, they will enjoy a tighter scope!

There is comfort in this, in a way; it’s the self-inflicted globe off Atlas’ shoulders. There’s certain liberation in looking forward to not being defined by work and expelling those same energies into other avenues too long neglected.

While this still has legs to run around and finish baking, I can honestly say that I am breathing easier now than I have in years.

I will, however, shed a tear, but not for myself, but rather for the endurance of mediocrity where it already existed rather than the desperately needed elevation of excellence.

The loss here, is not mine.

Conversation with a Liberal ...

2009-08-13T13:24:00.004-04:00

I'll link here to a page which contains an email conversation, cleaned up and colored, of an email discussion between me and (apparently) a liberal around, well, many a topic.

We'll call her Miss Informed Liberal and I've colored her emails orange.
Call me Concerned American and I've colored my emails green.
Aside from some spelling corrections, I've left the content alone.

Read it from the bottom up.

The most telling part for me was the largely defensive, partisan tone she took and the lack of factual references or refutation of my references with facts of her own. Strikes me as a typical response from a liberal. To be fair, the conservatives also have their fringe, but I at least try to stay factual.

In as much a healthy shouting match is, in moderation, a necessary part of a healthy debate, it's also critical that what you are shouting is at least factual.

Ad Hominem attacks are never acceptable.
Enjoy ...

Pity the underinsured ... ?

2009-07-23T00:55:00.003-04:00

I watched with a mix of pity but also no little amount of indignation at the parade of stories today of folks who relayed stories about their struggle with cancer and health insurance. It seemed like the very real issue of under-insurance and other healthcare reformation needed was being buried under saccharine sap driven by lawyers who were our elected officials, that sought to play the heart strings instead of address the real issues head on.

Let me relay a different kind of story. I know of a sole proprietorship on the east coast of Florida who's owner, let's call him Tom, ran his own pool maintenance business for many years. He always made sure to carry health insurance and disability insurance.

He got cancer after about fifteen years in his profession. Although his prognosis was poor, his initial good health and fighting attitude (alongside with a heaping of prayers which never hurt), he survived and has been cancer free for about 3 years now.

He still drives his own car, lives in his own house, he had to shut down his business as he couldn't work, but he has income in the form of long term disability.

What makes Tom so different?

Personal accountability to research and procure health and disability insurance that would protect him in the event of a catastrophe, such as what he experienced.

This healthcare reform, for me, comes down to exactly that - personal accountability.

First, the disclaimer, there will always be citizens who can't work, can't cover themselves adequately. Personal choices aside, there should certainly be some sort of adequate and appropriate safety net, not crutches, for them. For those who cannot provide for themselves, our Republic owes it to help them provide for themselves and in as much as possible get them on a path to personal prosperity so they can provide for themselves.

For everyone else ... what the hell is your excuse? I, and Tom, would like to hear why you can't, or couldn't, take enough responsibility for yourself when you could provide, to cover yourself for when you couldn't provide.

In such a vast, rich, blessed land such as America, you have no one to blame but yourself.

But for this I am now to believe that I have to make up for poor choices made by others.

Here's a very real problem: the working poor or those who work for small businesses that cannot afford health insurance. Instead of levying taxes and penalties in a manner akin to spitballs at a gradeschool classroom, why not provide some multiple of dollars in tax breaks, on some revenue-based sliding scale so that businesses will be incentivized to provide better healthcare insurance. Hand in hand with that is breaking the imaginary borders that prevent organizations in getting better rates by shopping for insurance; and much as I would be loathe to suggest this next part, additionally, yes, some sort of public supplemental assistance should be made available, where government and small business work hand in hand. This is just one idea.

But there are no powerful lobbyists for small businesses. There are no lobbyists for you, the American people. You only have your own voices that you sit mutely on.

When you're tired of being mute, start here:

Senators of the 111th Congress and Representatives of the 111th Congress

Doc Searls: patient as platform and “point of integration”

2009-07-21T02:20:00.002-04:00

If you want some very good reading, read Doc Searls article on e-patients.net AND read all the associated comments. Agree or disagree on the direction that your elected officials are taking your healthcare reform in, there's a lot of very good information.

As an aside, if you're anywhere near business and technology, you owe it to yourself to read The ClueTrain Manifesto. Keep in mind, there is no such thing as bad data (back in your corner ETL chuckleheads, you know what I mean)

Innovator? Entrepreneur?

2009-07-08T09:45:00.002-04:00

In a recent interview, I was asked a good question - do I consider my self an Innovator or an Entrepreneur?

An innovator is a dreamer, an entrepreneur finds ways to make the innovator and himself wildly successful.

Whereas most innovators might be focused in a subset of activities, an entrepeneur can reach across many of them, but in that way he too is an innovator.

For that reason I would say I am an innovator who has grown into an entrepeneur. I find ways to make current tech do new tricks, come up with new tech for new problems, and I'm always thinking about ways to convert that into dollars, then forwarding a strategic plan with tactical milestones to build or extend, and market, sell and support. So much so that I'm evangelizing the idea that more often than not, it may be a good idea to view some projects as products from the get go.

No matter the type or size of your org, there's always opportunity to take your good ideas and make money from them OR to somehow better the lot of those around you. The latter is especially important as the world shrinks in size and the old Donne saw about no man being an island is writ large in the virtual Pangaea of the current age.

HIT "Primer"

2009-07-06T13:59:00.000-04:00

A twitter friend (and high content value tweeter) @daphneleigh recently asked if she could get a HealthCare IT (HIT) primer. Sure I said, shoot me some questions - and what good questions they were. I've answered these below.

Note that I consider this post a bit of a work in progress and will stamp it final at some later date.

Comments welcome.

1. What, exactly, does HIT include? Are we talking EHR/EMR/PHR, or are we talking beyond these technologies (which I assume we are, but don't know what the "beyond" is...medical devices and equipment? hospital tech infrastructure? etc., etc.).
HealthCare Information Technology – is a catchall category for information technology and systems used within HealthCare. Although some folks use it and healthcare informatics interchangeably, I believe there is a differentiation. HIT is more technical\technology in nature and informatics is more about the acquisition, accumulation and assessment of information, data, having to do with healthcare, for example, quality on episodic care. I think it’s critical this distinction exists because all too often HIT is not approached with the sensible, strategic approach as it should be (more on that below) in healthcare.

a) By extension, HIT covers EMR, EHR and PHR, Medical Devices, Mobile Medical Devices, server systems and other infrastructure used in the conveyance of healthcare – that’s all HIT (not informatics). Note that in many instances the technology is the same for healthcare as it is in any other vertical. For example, server, network and telecom systems are the same. Business Intelligence, Data Warehousing tools remains the same. The key different systems are EMRs, PHRs, EHRs, medical devices and other clinical (lab, radiology) systems – those are unique to Healthcare.

b) I think that sometimes EMR, EHR and PHR also get muddied, I think the differentiation is as follows:

i. EMR’s are used by healthcare organizations to assist in the practice of healthcare, being an electronic medical record of all pertinent demographic, clinical and billing data, surrounded by a (clinical) process automation system and, in better systems, having strong clinical heuristics and analytics around clinical data. Hospital Information Systems (HIS) and Physician Office Management Systems (POMIS) are types of EMR’s

ii. EHR is a more generic term mean to refer directly to the clinical data for a patient that resides in some system, be it an EMR or PHR

iii. PHR is a system that allows users, or users and certain slices of the healthcare vertical, to share, collaborate and otherwise act on electronic health data

2. Alot of back and forth about whether HIT can reduce healthcare cost? Does it? How? And for whom? Patients? Docs? Hospitals? All? Others?
HIT, correctly implemented with a plan and a strategy, using best practices standards and systems, CAN reduce the cost of doing HealthCare business. MOST of these systems are fairly significant in cost and time to implement. We’re talking, for example, seven years and $250M, or more for larger multisystem orgs or around $50k and about three of months for a smaller practice – and that’s just the licensing cost. Extra interfaces to other systems carry a cost as does annual maintenance and support. I’ll reference additional points about HIT in point 4. HIT is one component but not the leading component to bring about change in HealthCare. As with any properly run business it means the difference between surviving and thriving, but herein is the rub: properly run business. A LOT of hospitals aren’t run as a business, in terms of process and fiscal discipline, in terms of strategic planning not just for growth and services but also for infrastructure and IT. Although I can’t comment as to why this would be the case, it’s likely one that has to do with a complex culture that’s inherited the good (process focus) with the bad (emotion, not facts based decision making). When you DO have a properly run hospital – and there are many – where compassion and enterprise thinking work well together – a properly implemented HIT strategy\system can cut costs for all parties concerned. Data is more readily available, transportable and consumed by all parties that need it while respecting the appropriate security needs – this is why something like HealthVault succeeds but most EMR’s fail (more in point 4). This is the reason most enterprises survive or thrive – they know where and how to get to the data they need to run their business effectively. The magic of Amazon is not in their pricing (although that helps) – it’s in how data driven their business is. Hospitals, in particular, need to evolve to the point where they are more data driven as well.

3. Who should care about HIT and why?
Everyone who is or will one day be a patients, should care about HIT. Hospitals likely have their hands full with quality initiatives, patient safety, physicians satisfaction and fighting government contractors on Medicare\Medicaid denials – contractors who get paid a percentage of the takebacks! Smaller orgs and practices also have the added concern of defensive medicine, liability issues and staffing and the cash-flow challenges of being a small business, dealing with third parties (insurers) for their cash flow. Who’s left minding the (data) bank? It should be patients, empowering patients. A patient should care that HL7 is a standard in name only and that almost every single EMR or HIT system out there does not play well with each other. Getting data from system A to system B requires either paying one, or both, vendors a custom interface fee or having an in-house interface team. Two issues crop up here

a) On a simpler basis, the in-house team is typically using HL7 specific tools and technologies that have not evolved in 20 years, or more

b) On a more complex basis, the concept of charging a custom interface fee is a little disingenuous, after all, isn’t HL7 supposed to be a healthcare data exchange standard? The vendors might defensively, and correctly, state that the nature of the beast compels such custom interfaces because the business of providing healthcare is so diffracted and disjoint. My counterpoint to that is that Healthcare is series of repeatable processes and steps – yes every sick patient is unique but a lot of the processes around the sick patient – labs, radiology, treatments fall within established guidelines meant to enforce standard, repeatable processes.

i. This is where running like a business comes in and the needs for an umbrella industry standards (think ISO) comes in not just for the business of running a hospital but also for the systems that supports them to come into play. While I’m not espousing assembly-line medicine, what I am suggesting is that healthcare take a long hard look at itself as industry. It is in that way, an industry like no other where it is responsible for saving lives. As such it lacks the maturity to hold itself accountable to a standard greater than itself, on a local basis. Remember, standards don’t restrict thought or creativity, they govern the known and give freedom to explore the unknown, identify it and codify it. I have little illusions that this is easier said and done – there are a LOT of different opinions on standards of care and they’re likely all right to some extent. The industry owes it to itself to at least try.

ii. As an example, I know of a multisystem organization that had several thousand order sets. They recently started an initiative to reduce those to hundreds. The wailing and gnashing and lamentation of teeth was smoothed over and the effort proceeded regardless. They are on their way to meeting that goal.

iii. It can be done.

4. Is HIT on par with other industry technology? How? Or how not?
Which brings us to HIT – first, a caveat, I’ve been in Healthcare\HIT for 7 of my 17 years and, others from the “outside” who’ve come to work within HIT can attest to what I attest to here. Succinctly, HIT is at least 20 years behind where other IT verticals are. You will be hard pressed to see a more disjoint, backwards, insular, silo’d mindset, which, being an IT professional at heart, is morally and ethically repugnant to me at least. IT exists to codify, encapsulate, secure and transport data for the betterment of some entity, be it a person or a business. HIT exists to force the client into an expensive silo and paint them into a corner. A LOT of the systems are poorly written with a horrible user experience and neither themselves nor their interfaces scale well. In part this is due to the fact that HIT traditionally hasn’t been able to attract a lot of talent (pay being a prime cause, IT strategy akin to aimless wandering being another) so they’ve not had the talent on staff to call bullshit on these vendors – and so, the traditional vendors have gotten away with highway robbery. The other aspect of the problem is that most orgs don’t have time to pay attention to IT or deprecate it (reference running your business as a business) and so buy something off the shelf from a vendor, pay a lot of money to implement it, pay more money for interfaces, then either by more of that vendor’s product or some other vendor’s product for another segment of their business, pay more money for more interfaces, ad naseum. Seeing that most healthcare orgs spend 2%-4$% of their revenue on IT where most other verticals spend closer to 8% and up, it’s not a surprise. In those scenarios it is easier to justify and expend on a capital basis than it is on an operational basis. A nurse takes care of patients and helps doctors who bring in revenue. What’s an IT guy do?

a) This is starting to shift and the smarter, traditional vendors have picked up on it and started to become a lot more part of the solution than the problem. We’ll see. As more attention has focused on healthcare and HIT over the last decade, more folks from other industries have come into the HIT space, motivated by the profits to be made, justifiably. But along the ways we’ve inherited more disciplined folks and folks who work FOR the org or for a vendor who knows that the money to be made isn’t in the traditional Big Blue silo’ing of their customers.

b) Add in some of the newer technologies and platforms, such as Google Health and Microsoft HealthVault, and you’ll see that most vendors want to get on board with the rest of modern IT principles.

5. What are biggest challenges facing HIT right now, and how/why is it important to the whole healthcare reform debate?
The biggest challenge to HIT now is that it get’s incorrectly labeled as the #1 way to save on costs. It simply isn’t. No IT system in the world will help if you can’t run a business properly and, most importantly, don’t have good interoperability between systems. Throwing money at docs to implement HIT systems, or worse throwing money at vendors, isn’t going to help the situation. There are fundamental, process-based & cultural changes that need to occur before IT even enters into the picture. A good example, I know of an in-house development shop at a large org that has demonstrably shown that it can deliver value and products far faster than the org can absorb them. In a recent project 40% of the time was spend on product development and 60% on making up for the failure of clinical leadership on integrating that product, which they asked for\demanded, into their clinical workflows. The product was very well received and is now in active use, yet talk about a lot (60%) of effort expended outside of development and deployment. You could have the best EMR system in the world with every feature under the sun – clinical transformation is still required, and cultural adjustment, before it will be meaningful enough to make change.

a) For what it’s worth, clinical transformation and cultural adjustment are change. Change is scary. I understand that. IT changes every day, sometimes twice a day. So while I don’t expect change overnight I do expect that change does at least start to occur and that folks compartmentalize their fear. Folks should be allowed to fail and be encouraged to learn from those failures. Finally, at some point, after the healthy debate is over, someone needs to make a decision and folks be held accountable to follow in that decision.

b) There is an aside here that begs to be talked about which is process. The development and deployment process is all too often also mired in decades old processes or heavyweight processes that do not work. There are newer, more up to date HIT processes that should be leveraged.

6. What are biggest myths/misperceptions about HIT among general public?

This is a good question. I think most folks, especially these days, would be aghast to find out how backwards HIT is and how non-transportable and paper based their health information is. When’s the last time you wrote a paper check? Or got a paper utility statement? Or got a letter in the mail or sent a roll of film in to get developed? Sure you can still do those things but you can just as easily do without them. ebanking, paperless statements (save the tree’s and my filing cabinet please!), email (grandma sends emails to her grandkids!), Flickr to Walmart. Yet more clinicians than you would guess are stubbornly married to their paper. And you can’t, not if you are a large hospital beat them over the head (they are revenue streams remember!) nor can you easily incentivize them (Stark law). If there’s an ugly secret anywhere, it’s how distinctly Cro-Magnon HIT is when it’s surrounded by Homo Sap Sap examples of cogent IT around it.

So, what’s the bottom-line then, right?

The bottom line is that HIT is sclerotic and backwards and everyone owns and is accountable to it being so. Patient’s for not demanding more and that it keep pace. Clinician’s for some of the same but also for being resistors to change instead of change agents. Organizations for not making IT strategy part of their life blood. But especially vendors, vendors who should be living, eating and breathing technology, who know better, but who have like a drunk driver who knows he’s drunk, gotten behind the wheel and wrapped the industry around a tree.

But there is a silver lining. The driver didn’t cry, turns out they only side-swiped a sapling and the car, the industry, is repairable. Folks from outside Healthcare are coming into HIT. There are CEO’s, CIO’s and CFO’s cropping up internally and from other verticals that understand that Healthcare fundamentally only succeeds when it’s run like an enterprise business. Docs, usually younger, are demanding more electronic mediums for healthcare and the older docs are glomming on as they get fed up with the fragmented continuity of care. Vendor’s, perhaps driven by crowdsourcing, open source and the twin titans of Google and Microsoft are realizing they need to bring about a change in how they structure their solutions. Finally, the consumer, the Alpha and the Omega, the Patients, are waking up, connecting, getting educated and, lead by Mom’s everywhere, are asking tough questions and demanding more.

The pity of it is we didn’t have to get to this point, but at least we can recover from it and are starting too. Now, if only the government will listen to what works instead of throwing money around and focus on universal process guidelines, liability reform and enforce real interop standards, well, we might see a change for the better sooner rather than later.

The Machine is (Changing) Us: YouTube Culture and the Politics of Authenticity

2009-07-02T10:56:00.001-04:00

Check out this SlideShare Presentation, very pertinent to our times

The Machine is (Changing) Us: YouTube Culture and the Politics of Authenticity

View more documents from mwesch.

Cross-Posting - Good or Bad? TBD.

2009-04-08T22:56:00.002-04:00

Until I can figure out if it's beneficial or detrimental to cross-blog, I'm

blogging exclusively at http://hit-revolutions.blogspot.com
twittering at http://twitter.com/1samadams
facebooked at http://profile.to/1samadams

Once I figure out if cross-blogging is a good thing or a bad thing, I'll either re-enable cross-posting or keep blogging here.

I might also just decide to shift my primary blogging to Wordpress or LiveJournal, dunno, we'll see.

SOA Wins. HIT Vendor looses. HIMSS Dithers?

2009-04-08T06:02:00.006-04:00

I'm shocked, I tell you, shocked, looking back at my 02/18/08 post about Interop and hearing how it's suddenly become a buzzword at this year's HIMSS. About time. Now to see if that organization will evolve into a driver of those better standards.

But now a mini-case study.

We recently wrapped up a fifteen month effort to create a new Physicians' Portal and, to quote some folks, we hit the covers off the ball and nailed it well out of the ballpark? Is it perfect? HECK no, but it's eons ahead from the prior user experience and vendor solution that was put into place and best of all, the health system owns this solution and can extend it. No vendor lock-in. Sure, there's technology vendors, that's a different story.

A brief note on the timeline: 3 months on architecture design, foundation and framework development, 5 months on solution development, then the balance of 7 months on feature releases and post-production support. It would have been 4 months except for one significant mis-step, referenced below.

When we started there was nothing, zip, nada in terms of anything resembling a SOA layer or enterprise interop. We created it from scratch. Is it perfect? Again, no. It was focused on delivering what was needed for this portal, but it's extensible and it's based on open, transparent systems.

Here's where the one mis-step came and yes, it had to do with a piece of interop the HIT vendor provided. First, it wasn't the technology as was advertised - it was a couple of generations behind. A servlet is not a Web Service. Second, it was non-performant. Third, we got it implemented anyway. In retrospect we had a level of trust without verify and the vendor was already in place across the board. They do what they do very well and I would recommend them for their space as day is long. Interop, shame on me for thinking otherwise, we should have been more diligent on a deeper test before implementing. But we made it with some arm-twisting, teeth-pulling, carrot and stick. It was deemed a Catholic Wedding and we made it work. Along the way, the vendor learned some things and even implemented a better load-balancing mechanism. Word to the wise: ping's are insufficient in a SOA world for load-balancing. Unfortunately it's not as violently fast as we would like it to be.

So what's the long-term "fix" for the performance issue? Unfortunately the answer to that is to plan for refactoring that vendor's interop point out of the picture. It was never meant for the transactional load an enterprise SOA layer is going to place on it. We had a plan B all along, we should have gone with our gut and made it a plan A even though it would have added 3 months to our foundation & framework development. But it's okay, we architected this thing like an M1-Abrams, we can refactor it in piece-meal with minor updates along the way that don't require significant rewrites. Isn't n-tier just grand? Isn't it great when you follow proper software engineering disciplines?

The long-term "fix" has several added bonuses. Coming out of that effort, which will be neccesasry for our forthcoming patient portal, will be several enterprise benefits. First, you'll have an OLTP database that you can transform into an OLAP database - and keep the two synched. Out of the OLAP database you can glom on other data to boost CRM efforts and KPI monitoring. Finally, it will be violently fast and once it's setup, it'll stay in synch. I'm sure we'll realize other benefits as we go along.

So what other benefits did we deliver? We built on top of a popular collaboration portal from a major technology vendor. Bonuses there were less time spent on content management and authenticaiton and authorization. With AD integration (could easily have done LDAP instead or too) provisioning and password resets went from a nightmare 3-month process on the old process to a 2-day process - and that includes provisioning into multiple different clinical systems. As AD matures at this organization, content management and audiencing are going to be relatively easy to implement, at least from a techology perspective. The platform already has numerous different widgets and plug-ins and can easily be extended with custom development - and again, it's all SOA and n-tier so it's technology agnostic.

We have a SOA layer that can be refactored over time for performance or extended with additional integration points. This connects two of our major clinical systems that span 80% of a clinical encounter from registration, to care to discharge and billing. I think that speaks volumes for a system that had nothing of the sort before.

We built in a secure, encrypted SSO solution for the users enterprise applications, no plug-in's or installs requried. The user can mantain their own account information in some cases. Support for maintaining all instances is on the Product Backlog.

So where do we go from here? Start designing and implementing extensions to the SOA framework for Patient Portal, refactor where possible. That's our next 3 month effort starting in May. We've got some smaller projects to roll-out in April including one which will soon be HealthVault integrated.

It says something when the IBM strategy and MS assessments indicated that we've gone from non-existent to highest ranked within the enterprise for SOA, Interop and Integration. I think we've got a ways to go yet, being just into this first layer of the onion.

Mind you, incredible amounts of credit go to our peer technology and business teams and especially our CEO, CIO, CMIO and senior leadership. It's their vision and drive that started this and I hope, and believe, that the trust they placed in us has been well placed. This was not a one-team effort. There was signficant effort, dedication and sweat equity from a lot of different teams and yes even from our HIT vendor. Their square peg will have a place, just not at the enterprise table.

The silo's are crumbling. The customer is winning.

HIT (R)Evolutions: The Importance of Fresh Perspectives

2009-04-08T05:58:00.000-04:00

HIT (R)Evolutions: The Importance of Fresh Perspectives

Blag .. Blog Lag :)

2009-04-08T05:29:00.002-04:00

Yes I know it's been a while since I posted ... I need to link my twitter account in, I find I have more capacity to microblog and blog every once in a while

The Importance of Fresh Perspectives

2008-02-18T08:49:00.001-05:00

HIT&S need fresh perspectives.

This is not a dig against the valiant crews manning the HIT&S guns these days - quite the contrary. However, for multiple reasons, HIT&S has hit the doldrums. In part this is due to vendor FUD. Again, not all of them are guilty, but enough of them are ... and the rest are the silent majority. In part this is because the other verticals, shame on them, haven't done a better job of infecting HIT&S with the same evolutions they've gone through in the last five, ten, fifteen years.

Software engineering has evolved quite a bit in the last five, ten and - even more so - fifteen years.

Sure, some of the processes seem the same. Agile might recall JAD/RAD.
Sure, some of the technologies seem the same. OOP might recall modular development.

But in a very real sense software engineering has evolved continually. Engineering management hasn't, but more on that later.

Much as doctors were likely told, anyone getting into computing should have been told they were in for a lifelong learning experience - at warp speed. Although it is not necessary for a vendor to be a first adopter, it is necessary for a vendor to evolve. There are sound engineering principles for doing so and equally sound business reasons for doing so - not the least of which is lower cost of development, without having to resort to off-shore development work.

Imagine urban planners putting out an RFP and getting a bid back from a contractor using technology, materials and processes 5 or 10 years out of date.

So given all these evolutions, what's up with HIT&S? Why hasn't it kept pace?

Honestly, I'm still ruminating on it. I've been so focused on busting myths and thinking about solutions recently that I haven't spent enough time thinking about how this situation came about and why in some instances it seems fossilized.

Part of it I'm sure comes down to vendor FUD. When you've heard the same classical tunes, rock'n'roll can be a little disturbing, sometimes unbelievable. When you combine that with the fact that most of those same vendors are well behind the technology curve and are themselves unaware of what can be done with today's technology, even the simpler tasks - by today's' standards - can seem complex and daunting.

I will resist, for the moment, the temptation to go into the motivations of greed.

Part of it comes from the very nature of the business which focuses on patient health & safety first, physician satisfaction & revenue generation 2nd and 3rd (or 3rd and 2nd ... or 2nd and 2nd ...). There aren't obvious ways for how technology might improve some parts of the process, such as patient-physician interaction. On the flip side, imagine an RFID identifier that triggers a microphone to record what a physician says during his rounds. This can be reviewed by both the physician, the patient or the patient's guardians in the case of minors. Yet the first reaction is typically a legal implication.

So does another part now reside with a litigious beast eating away at the heart of our system? Let's not be quick to give it too much blame, but blame it has, I'm sure. There's a point past which consumer protection goes overboard.

So how do you fix these parts that make a barrier sum?

I'm going to pointedly not address the litigation issue - suffice it to say it does need to be addressed through a combination of process, security & audit best practices and injecting some sense into the legal precedents that have been set.

With that being said, technologists and vendors need to step up.

Interoperability Standards: HL7 is a farce, not a standard - and either it's going to become a real standard real quick or the federal government will step in and will solve this problem for us, much to everyone's detriment. I give this between five and ten years, depending on how the next election cycle and global events go. You cannot run an effective enterprise with silos and HL7 is an excuse for interoperability. There's another cautionary note here. Unless a real standard is developed the whole question will become moot if Service Oriented approaches & architectures gain faster adoption. This is starting to happen and if it reaches critical mass, it will be the vendors that will be on the loosing end and the customers that win. Wouldn't it be better for all of us to win?

Let me put it bluntly with SOA, I can and I will get to your data bank and there's nothing you can do to stop me. If you try, I will find another more compliant vendor. If you try, I will flood you with customer requests for interop. Interoperability is your borg. The system I paid you to implement holds my data, not yours, it is not acceptable for your system to dictate how or when or where that data can be used in my enterprise.

It is in my best interest to run my enterprise connected, not disconnected. This is one of the key drivers behind fragmented patient healthcare and physician dissatisfaction. Once I have the patient and the physician on the side of sanity there is nothing, nothing, that a vendor can do to stop the interoperability tsunami. Best hop on that surfboard now.

And while we're at it. please don't call it a web service if it's not a web service, don't call it SOA when you don't know what the 'S' and the 'O' stand for. It's embarrassing when a technology vendor doesn't understand or label what they're selling correctly.

Technology Standards: I don't care if you're using Java or .NET or some other technology. Is it widely supported or is it a niche technology? Are you on the latest stable release or something several versions behind? The excuses about adoption of newer technologies can be traced back to poor fundamental engineering principles in the first place. Anyone can mash-up code. Not everyone applies the engineering principles they should to ensure their code base is extensible and flexible - it's not that hard, but it requires expertise, forethought, planning and sweat equity.

Communications: This is not a call to the bleeding edge, that's only for those with deep pockets or with the funding for research projects. For the every-day rank and file hospitals, technologists need to do a better job of listening to their customers - clinicians and office staff. By the same token, those same clinicians and office staff need to speak up about what their needs are. This is no different than encouraging the patient to speak up.

Cooperation: we're going to get there together, or we're going to get there with someone else, together.

Complex Problems

2008-02-15T11:54:00.002-05:00

I've recently had the opportunity to speak with several peers, most without significant HIS experience, about the entire thorny EMPI problem.

We've all come to the conclusion that we must be incredibly stupid for missing some incredibly evasive component for what should otherwise be a simple problem - yet is portrayed by those with years of HIS experience as being a deep, complex problem with many vectors and possible matches.

Look, I'm not looking to denigrate those who do think it's complex. If it was easy, far smarter minds than mine would have fixed this problem by now. And I'm also sure it's not 100% accurate and that a lot of the ROI comes from whether a tool will leave you with 1% intervention on mediation, or 10%. I'm also quite willing to admit that I must be missing something, I just can't quite seem to put my finger on it.

I'll, for the moment, shy away from painting this problem with a broad brush as being tied to vendors making it more complex than it is, to a, hereforeto, unsophisticated audience.

First, it's all data. Fundamentally, zeroes and ones yes, but simple, textual data with no more meaning comported to it that what it represents. A name is a name, an address is an address, a social security number is - you get the drift.

Second, you are not, contrary to apparently popular opinion, carrying out deep, complex mathematical, or sacrificially driven inarticulate arcane divinations. You want complex, arcane & mathematical, try pattern recognition, AI systems and understanding the "gentler" gender. You are comparing one string, to another string. Levenshtein is one, of many, ways this comparison can be undertaken.

You have a whole matrix of data? Oh, big fracking deal, comparing (and I'm simplifying here) one array of strings to another array of strings is trivial, unless, apparently, you're one of these aforementioned vendors, in which, enter stage left the complex, queue the arcane.

Third, there is no third, there's either a big, steaming pile of Bantha PooDoo or I'm really missing something that makes this far, far more complex than it really is.

I'm not guaranteeing 100% matching, ain't going to happen. But I'm telling you, from what I know, it's not complicated, it's being done in other industries and it shouldn't cost you the GDP of a Banana Republic.

Prescient Commentary

2008-02-13T21:35:00.000-05:00

Many moons from now when someone reads this post and my post yesterday about Microsoft's HIS strategy, there will be allegations made about foreknowledge, Secret Santas and Fairy Godmothers about today's Amalga announcement from Microsoft.

Did I know about Azyxxi, heck yeah (hello EMPI!)!

Did I wonder why the heck there wasn't more from Microsfoft such as an HIS sysem or an RIS\PACS system. Most definitely.

I understand the dynamics here, don't get me wrong. Partner relationships, motivation perceptions and a slew of other sensitive landscape issues. Those still aren't good reasons why Microsoft, or any other technology company, wasn't invading this vertical and putting things on a more even keel. To say the typical HIT&S vendor has the typical Life Sciences\Health Care customer rather rudely over a barrel is an understatment and not an inaccurate generalization. There are exceptions, but they are exceptions.

I should have been pining for a million bucks.

Times have just become even more interesting and promise to get even more interesting. Stay tuned, I have a feeling there's going to be a few more MOAB's dropped on our little landscape in the coming months.

As for you vendors ... There's a reason slashdotters derisively refer to Microsoft as the Borg.

'Nuff said me boyos.

Yahoo Mis-Steps

2008-02-13T21:25:00.002-05:00

I think Yahoo's run by a bunch of Yahoo's. One the one hand, if you're going to merge with a traditional media company, at least it's Murdoch's News Corp - besides which other media companies pale green with envy.

On the other hand, just what convoluted thought process makes this an attractive proposition. Never mind the shareholders, it's a heck of an interesting (as in what the heck are they thinking interesting) approach to counter Microsoft's offer. And a cash infusion from News Corp isn't going to help a company adrift, rudderless and lacking innovation. It's asking for more of the same pain. At least Murdoch's News Corp has a chance in heck of making such a marriage work - one in which MySpace and "other Internet properties" would be merged in with Yahoo.

Were I to have a voice, I would let Yahoo run down this path. In a few more months, when shareholders in turn reject this deal, Yahoo will be even cheaper to acquire.

Delusions of Net Worth

2008-02-12T09:41:00.000-05:00

It's interesting times when one of the grand-daddies of the information age rejects a reasonable buy-out offer from one of the antediluvian elders of the computing world. It's especially interesting given their recent poor-performance, market loss to an upstart and pending layoffs - 1000 people all told.

It's certainly understood this is part of some unnatural, virtual mating-dance - with rules as old as the oldest profession. It appears however that Yahoo is going to experience how the game is played when you're playing with a brazen rules-maker\rules-breaker. I say that with a certain awe mind you, not disparagingly. Where bashing the gorilla might be du jour, Microsoft remains an example of how to do business successfully as a software & services company. Any stones cast their way is high-brow posturing and makes for little more than amusement. Don't get me wrong, they're not perfect, but they are a successful enterprise. That says a lot and, in fact, may be the only metric that matters.

So, Yahoo in their arrogant folly, is going to be allowed to sit and stew, enjoying, if you will their position in a company that is valued, they feel, at $40/share. Nevermind a fairer (indeed, in my opinion overly fair) valuation is closer to $26/share. If Yahoo thinks they're going to be allowed to merge or JV with Google, they must have carved the part of their brain out that processes anti-trust. I would hope that Microsoft would stick by their guns - Yahoo is not critical to their success, but it sure would be nice. On the flip side, Yahoo needs a wake-up call, being in a multi-year slide like they are. Last I checked, they're the only one's laying folks off.

And of course, populist reaction is as spread across the spectrum as you would expect. Microsoft should fret, no they're not going to dither. Granted Microsoft has had a few years of stagnant growth, largely in stock price, but anyone who doesn't see a giant gathering itself up for the next 10, 20 year hurl forward is in for a rude surprise.

Let me ask this of the naysayers. Where is Google's Healthcare strategy? Yahoo? Oracle? I'm sure they have solutions they can market to Life Sciences, what about a strategy? Microsoft is starting to get it.

I will admit that for such a large enterprise they do seem to suffer in one significant way - they're doing an absolutely horrible job of selling their success stories, while their competitors are doing a most excellent job, even if some of it is built on smoke and mirrors.

Interesting times.

HIT vs HIT&S

2008-02-09T21:22:00.000-05:00

Why do I differentiate between HIT & HIT&S? It's the anal-retentive OCD communicator in me.

Information Technology typically pertains to the hardware infrastructure. Telecom, Telephony, Internet, Routers, Switches, Mainframes, Midranges, Servers, Desktops, Tablets, Cell Phones, Desk Phones, IP Phones, Smart Devices, PDAs - you get the drift?

Information Systems typically pertains to the software infrastructure. Databases, Desktop O/S, Server O/S, Desktop software, Server applications, clinical applications, financial applications, HR applications.

Vendor and internally created technology and systems are subsets of both horizontal layers - this is one distinctions to be mindful of.

Technology is what Systems runs on. This is a key distinction.

Typically, one skill-set translates easily in a particular horizontal, but not across into another horizontal. The interface layer between the two, strangely enough, is where a lot of miscommunication typically occurs. It is an exceedingly rare individual this day that groks both and can interoperate between the two - those individuals should be opportunity hires.

It is a further rarer individual that can strategically plan and tactically operate. This is a dying breed.

While a significant amount of the blame, yes blame, can be placed on an educational system that pushes specification over generalization, the balance can be placed on the shoulders of enterprises across all verticals that have failed to really capitalize on what a catalyst good IT&S can be on business. Don't get me wrong, there are some enterprises that do get it - and there's more everyday that are waking up to better IT&S.

I would go so far as to posit that there are fewer innovative minds being produced today in colleges - supposed hotbeds of intellectual activity. Most of the innovation comes from industry as it seems college has become an exercise to drive funding grants for research. There is a sublime but critical differentiation between research and innovation. On the one hand, research amounts to mental masturbation. Sure, it feels good, but what have you got at the end except for a sticky mess that few mortal minds can make heads or tails of. Innovation's stated intent from the beginning of the exercise is the delivery of consumable fruit. Some might point to the Internet as a child of research, think carefully on the origins of the Internet (thank you DARPA) and you might consider a shift of thought that the Internet was an innovation. Granted, what we do with that fruit can be great (enterprise connectivity and knowledge sharing) or embarrassing (YouTube).

In the final analysis, this is neither good nor bad, it's simply an interesting observation on the composition of IT&S teams in general and the elan of HIT&S teams specifically.

Old geeks never die, they just fade away.

The Lost Art of Customer Services

2008-02-09T21:06:00.000-05:00

I do quite a bit of Internet Banking - to be more precise, I have an Internet only bank I transact business with - no storefronts. That's supposed to translate into lower costs and more money in terms of interest back into the pockets of account holders. Well, and it's pretty cool the power of the Internet, most of these banks have front ends far smarter than some humans.

The one downside is you don't get paper checks.

That's a pretty big downside when you realize most Metrourbs aren't quite there when it comes to all electronic banking. So what are you to do when you need to work with a local small businessperson who doesn't take credit cards and you need a check yesterday ... ?

There's cash right? Well, silly me, apparently some businesses prefer to not be paid in cash. Given some neighborhoods, I can understand that.

No problem right? Just go to an ATM on the network, yank out some cash and get a money order ... from a bank ... that you don't have an account with.

Oh-oh. Problem.

Did you realize that most banks will charge you, if you are a member, for a money order or cashiers check?

Did you also realize you can't get either if you're not a member ... even if you have the cash right there in your hands?

Did you further realize that most banks close their lobbies at 4pm and their drive-through tellers, open until 5pm, can't get you a cashiers check even if you were a member?

Trust me, I did a lot of driving away, too shocked and amazed to argue about the insanity.

Amscot to the rescue. Oh, and they don't care if you have an account, you're a member, a communist or a leftist gorilla with banana on your breath. You have the cash? They have the money order. Or the cashiers check. At no charge.

Now tell me the logic there, that a bank which has your money (or even one that doesn't) gives you less customer service than Amscot? Granted, Amscot can't help me with an annuity, a home loan, a commercial account - but one would think that an institution that provides those advanced services could do something as trivial as a no-fee money order.

Especially when one has cash on hand.

Amscot 1, Banks Zilch.

So what's this got to do with HIT&S? Plenty.

First, it's a rare HIT vendor that actually emphasizes customer services. There's a certain disservice done when you loose track of what's most important to your customer - it's a good idea to align your value structure with theirs. No one begrudges any corporation profitability - at least, not in the Capitalist Domains - I mean, just look at Exxon-Mobil. However, a close second to the bottom line, the value structure apparently diverges rather significantly.

I don't get it.

Second, internally, HIT&S departments are largely undervalued and underbudgeted for the same-size organization in other verticals. Yet it is stunning the consistency and productivity which some (certainly not all) of those departments create. They have all the typical challenges, from lack of appreciation to lack of understanding, but yet, they still produce. There's a certain elan those departments have that most IT&S departments lack. It's an interesting study in passing value judgements.

Finally, regardless of what actor you are, in interacting with Life Sciences there should be an almost Hippocratic Value: the benefit, the service, the epic ROI\CBA should always underscore the needs of the patient, typically under-educated about their own healthcare, sickly and in fear.

At the end of the day, it's about the patient experience. Capture that, improve it. It's not as elusive as it seems.

Health 2.0 - A Great Idea, but ...

2008-02-07T12:18:00.000-05:00

If you're anywhere near Life Sciences and HIT&S, you should take a good long read at the content at Health 2.0 Con

An excerpt from their site:

Our definition is currently focusing on user-generated aspects of Web2.0 within health care but not directly interacting with the mainstream health care system. That means, a) search, b) communities, c) tools for individual and group consumer use. But clearly there are blurring boundaries between all these, and the question of connecting Health2.0 user-generated content to the wider health care system--which hasn't exactly adopted Web1.0 with a flourish yet--is still open.

There is huge room for debate about whether we're talking about limited use of tools and technologies or a wider movement to change the whole healthcare system--or perhaps if it's just all buzzwords with no substance.

I'm glad to see a bit of honesty here - and they raise a very good point - several actually.

Honestly, it’s a fantastic idea, but it’s beyond bleeding edge for most health care organizations to even fathom – this is where’s there’s a HUGE opportunity to drop in a product stack\services (against the typical HIT vendor grain I might add) to enable 2.0 for Health Care. Most institutions would find their brains running out of their ears if an initiative like this was tacked on top of their already slender IT&S budgets – it’s simply not a focus for them. Should it be? Good question, I’m gnawing on it.

From the Agenda, it appears interesting and mostly out-loud thinking, which is good exposure. I also notice that they are emphasizing Consumers and Providers, yet they seem to be missing out on EMR repositories (the docs offices aren’t going to be an HRB) and on the consumer relationship management vector. They need more time in the oven, IMO. EMR repositories aside, who's going to provide and syndicate the content and create relationships. 3rd party aggregator sites such as HealthCentral ... ? Ok, sure, but where's the value proposition?

In a lot of ways this strikes me as the best of Web 2.0 and the worst. Connecting content from multiple sources syndicated to a consumer. It’s overload and the snapback is going to be a Web 3.0 world that focuses on:

Single-source/Trusted-Source identity: I am who I say I am and I don’t need to be infinitely replicated – here’s my ‘fingerprint’
- I am an observer (user)
- I am an consumer (registered)
- I am an interactor\contributor (trusted)
Content interaction: ok, great I got this content, now what?
- I don’t want to register again to comment
- I don’t want to register again to digg\deli.cio.us\twitter\whatever it
Evolved Syndication Engines: think FeedBurner on HGH, evolved

Regardless, before they get to 2.0, they’ve got to get to 1.0 (in some cases to 0.1 …).

Vendor, know thy market.

HIT from the Trenches

2008-02-06T22:17:00.000-05:00

I'm debating the wisdom of relaying the good, the bad and the Medusa's you see in the trenches of HIT. You know, the lack of product strategy, wonky business processes and vendors who must be living in the days of Robber Barons. On the one hand I certainly don't pretend to be a know-it-all, albeit I may come across sounding like one. On the other hand, I can't stand sloppiness and doing something just to get it done, instead of trying to do it as right as you can the first time.

I also realize the risk I run in exposing myself to fallout from puncturing some ruinously overbearing egos. Then again, I'm too ingrained with brutal honesty, try as I might, I can't go against that grain.

So, here's an example. You have good companies, you have bad companies and you have companies on their way to either category from the other. Take the old 80-20 rule - and this is being generous, 80% of the companies out there are bad companies. What sets them apart can be described as part necrotic momentum, part willful stupidity and a huge dose of incompetent leadership. Speaking optimistically, tempered energy, honest intelligence and brazen, modern leadership. This isn't the whole list but it's a handful of the Big Factors.

Necrotic Momentum - due to size, market forces in a particular vertical, complacency (from either success or delirium) the company ceases to innovate. Cure: Fend off your desire to bring in a horde of consultants - no one knows better than the folks working for a company how best to start the process of honest introspection.

Willful Stupidity - doing the same thing over and over in the hopes of a different result. What makes it worse is when you know better, or you suspect something is off, but you don't cease action long enough to give thought time to catch-up, like some massive dinosaur that's just been bitten on the tail by a nimble predator, you can't quite process the "Danger Will Robinson" messages. Cure: stop, drop and roll. At the very least, you'll crush that nimble predator or make it jump.

We'll get to leadership shortly.

Tempered Energy - Look, I'm all for high-intensity, AAA personalities and the aggressive wolf pack mentality. But, if it's not directed, if it's not leashed, it's wasted. Like a good friend of mine said, it's like having a Ferrari in the garage and no gas. Looks real pretty... Pretty useless.

Honest intelligence - a close cousin to honest introspection. There's a lot of smart folks out there. Smart enough to know that sometimes it's best to just play along and get along. You're wasting potential, shamefully, by not engaging in honest bi-directional communication with your teams. Put the egos away, put the flamethrowers down and talk honestly and openly about issues. You may not hang separately, but you shall certainly hang together.

So now we get to leadership. There's nothing mythical or mystical about it - maybe something in our caveman days wired us to recognize a leader when we see it. The body language, the verbal cues, the mannerisms and behavior all say - follow me, I will lead us in stalking and staking the Great Wooly Mammoth. Leaders can be born or made - but it's no easy task to make one. A leader engenders trust, encourages open communications, looses his temper when he has too, takes accountability, apologizes when he needs to, is brazen enough to try new directions and sublime enough to change course in increments that can be withstood with minimal disruption.

I guess, it all comes down to leadership, at every level. The folks in the trenches have their own flavor of leadership running on up the scale to the chief executives.

So why do I mention this with respect to HIT? Certainly, HIT can approve. Understanding the primary focus remains on patient care, physician satisfaction and revenue generation, HIT must partner with the business it supports to educate and learn from and to evolve and, perhaps most importantly, not accept the status quo either internally or from vendors and business partners. Why are we using abacuses and Dixie cups in the 21st century? Certainly we shouldn't expect a jump to light speed, but we should have a plan and a roadmap to get us there. It can be done, I've seen it being done.

On a personal note, I'm ever thankful and blessed to be with an organization that gets it - get's the pain, understands the need for change, shows respect to the individual and the organization and works - and hard work it is - hand in hand with the business on bringing about that change. It's a lot of hard work by a lot of folks - and its exhilarating.

Change happens.

You can make it happen.

Or it can happen to you.