The Innovator's Challenge

I've written many blog posts about our efforts along the path to ICD-10 that will enhance our inpatient clinical documentation.  We're hard at work planning the improvements we think are foundational to support care coordination, compliance, and quality measurement goals.

It's very challenging to create tools which simultaneously enable rapid, accurate, and complete clinical documentation.   We've deferred radical redesign of inpatient documentation for several years awaiting the alignment of technology, policy, and urgency to create the perfect storm for innovation.

BIDMC has had many firsts - early personal health record adoption, first in the country attestation for meaningful use, innovation in the use of web-based provider order entry, rapid adoption of iPads, and one of the first vendor neutral image archives.

Sometimes we're a leader and sometimes we're a follower.  Deciding which to be is the innovator's challenge.

BIDMC decided to ignore the entire client/server era in the mid 1990's.   As others were creating Visual Basic, Filemaker Pro, Delphi, and Access front ends to applications, we continued the use of roll and scroll terminal emulators.  When the web appeared, we jumped in with both feet and moved all our clinician facing applications to thin client, cloud hosted, web-service architectures in 1998.  That approach has served us well.   It still feels modern in 2013.

Recently we completed the implementation of a next generation electronic medical administration record (EMAR) using iPhones, iPads, and an Amazon-like shopping cart motif for choosing medications.   In the past, other organizations were first with EMAR designs, but they had to use computers on wheels and cumbersome user interfaces because the technology was not quite ready for a more streamlined approach.

We feel the same way about clinical documentation.   Offering clinicians an enhanced word processor does not result in orderly, complete, and readable documentation.   On the other hand, forcing structured input of every clinical observation may yield high quality data but usability will be poor.   We're working with 4 different companies to create next generation documentation tools that we think will benefit inpatient documentation the same way that waiting for the iPhone/iPad benefited EMAR.

Characteristics of this new approach include

*Natural Language Processing - the ability to prospectively or retrospectively identify key concepts in unstructured text
*Clinical documentation improvement - the ability to pop up templates just in time that offer structured input in the middle of unstructured text i.e. laterally and specific bone names for fractures
*Vocabulary crosswalks - linkage between problem lists, documentation, and billing diagnoses based on mapping SNOMED-CT to ICD-9,ICD-10, and CPT.
*Metadata markup - near real time SNOMED-CT markup of unstructured data so that structured clinical concepts are embedded within typed or dictated documents
*Computer assisted coding - suggesting ICD-10 codes to clinicians or coders based on the markup in current notes combined with structured data extracted from past notes

Also, we've considered social documentation  (group authoring) and patient generated data.

As with many IT innovations our stakeholders will feel that we lag existing commercial products while we're in the midst of developing these new ideas.   However, once we go live with the finished product, incorporating cutting edge built and bought technologies, no one will remember the days of the hybrid medical record that today includes many electronic features but paper-based progress notes.

Although the paperless hospital is about as realistic as the paperless bathroom, we will substantially reduce paper on our inpatient units in the next 18 months.  As a CIO, I look forward to the day when we've closed the last gap in our self built systems compared to commercial EHRs so that our users can revel in the innovation rather than describing the greener grass available elsewhere.   Luckily, we're as good as our latest go live and we're confident now is the time to implement advanced approaches to clinical documentation.  Tolerating impatience until technology, policy, and urgency align is what makes an innovator successful.

What Matters

I've been at Beth Israel Deaconess Medical Center for 17 years this week.   I'm sometimes asked why BIDMC has been and will continue to be my long term career home.

 The answer is simple - it's a foundation for what matters.

1.  Colleagues matter
Loyalty to my staff is the number one reason I stay at BIDMC.  Together we've shared the network outage of 2002, security challenges, first in the country meaningful use attestation, hundreds of innovative application go lives, and the creation of a world class cloud computing infrastructure.    The average tenure of IS people at BIDMC is 17 years.   Many have been here over 30 years.   Turnover is never more than 10% per year across all IS divisions.

2.  Mentoring matters
The real world experience of operating large scale applications and infrastructure at BIDMC enables me to share lessons learned with students and professionals all over the world.  Whether I'm doing a Harvard Business School case study, helping a government in Asia, or empowering young investigators by connecting them to collaborators, it is my experience at BIDMC building and buying technology that gives me a broad base of successes and failures to share.

3.  Patients and Providers matter
Creating technology for technology's sake is not as impactful as using technologies to achieve policy goals.  BIDMC is a learning laboratory with 250,000 active patients, 3000 doctors, and 2 million patient records.   Every day we can iteratively improve quality, safety, and efficiency by listening to our stakeholders and testing new technologies in production environments.

4.  Innovation matters
BIDMC has a unique blend of built and bought technologies that enable us to control our own destiny.   If a new meaningful use idea needs to be piloted, a new technology investigated, or a new workflow trialed, we can move with agility, often without dependency on vendors.   When a vendor wants to accelerate innovation by testing new technologies we can be a development partner.  Many commercial infrastructure and application products had their start at BIDMC.

5.  Culture matters
For 30 years, BIDMC has had an impatience with the status quo.   The complaints we hear from our stakeholders often relate to problems that other organizations have not yet thought about.   There is never time to rest on our laurels.  At times it seems that memories of our successes fade fast, but the culture of impatience ensures we get rapid adoption of whatever new features we introduce.

While on the plane back from Osaka on Friday, I spoke with a gentleman who has worked in many companies throughout  his career.   At this point he's decided that he needs a company of the right size, right leadership, and right structure to empower problem solving - he has no tolerance for people and organizations that impede progress.    For me, BIDMC has all the characteristics which are foundational to a satisfying career.

As I reflect on my time in Japan, my most influential moments were those I spent teaching, talking with colleagues, listening to others' experiences, connecting people for collaboration, and sharing meals.    BIDMC provides me a base of operations that enables these international experiences, national committee membership, and regional cross institutional cooperation.

Life is complex, budgets are limited, and people are diverse.   Our careers will have their frustrations when there is competition for resources, ever-increasing regulatory pressure, and accelerating change.   However, if you have  great colleagues, remarkable students, a learning lab, a capacity to innovate, and a supportive culture, you have all the ingredients you need for a career home where you can make a difference.  That's what matters.  

Building Unity Farm - Water management

I was recently asked how we manage irrigation at Unity Farm during the peak of Summer heat.

Although we have a stream running through the farm, it's part of a protected wetland, so we do not use it for irrigation.

Our water source is a 300 foot deep well that consistently produces 7 gallons per minute all year long.   Sherborn was founded in 1652 and was initially called Bogostow ("Bog's town") because of the many streams, ponds, and wetlands.   Our well has the benefit of being at near a drainage swale an nature keeps the aquifer seasonally recharged.

However, irrigating acres of orchards, paddocks, and produce as well as meeting the water needs of the 3 generations living at Unity Farm via a 7 gallons per minute well takes careful planning.

Here's what we do:

In 2012, we replaced the 18 year old well pump, wiring, and control system to give us the best infrastructure possible.   We also replaced the pressure tank.   The water is so chemically pure that it does not need a filter, a settling tank, or treatment of any kind. We were able to retire all the water treatment equipment that was initially installed after the well was drilled.   We placed digital flow gauges on the internal and external water mains so we can measure our water use and rapidly identify any unexpected variations such a broken pipe or leaking valve.

As we designed our animal and crop areas, we incorporated over 50 zones of irrigation controlled by two Hunter irrigation controllers, that enable us to selectively apply drip irrigation or low volume rotors to each area based on rainfall, plant maturity, and seasonal conditions.

For example, 7 gallons per minute can supply 420 one gallon per hour drip heads.   For each blueberry zone, we ran 400 feet of drip hose containing built-in one gallon per hour heads spaced every foot.   With two heads per plant and twice weekly 30 minute waterings, each plant receives 2 gallons per week precisely targeted to the roots.  We have 7 of these zones, running on Wednesday and Sunday nights between midnight and 3:30am.

Our pastures and paddocks have 23 zones of 4 low flow 1 gallon per minute rotors.   We run these for 10 minutes between midnight and 4am on Tuesday, Thursday, Saturday.

We tend to be generous with water to new plantings and parsimonious with water to well established plants.

We also have two rain sensors that automatically shutdown all our watering systems whenever more than half an inch of precipitation falls within a 24 hour period.

In summary we have

Crop zones
23 low volume rotor zones for pasture
7 drip lines for berries

House and Barn zones
8 low volume rotor zones for paddocks
4 drip lines for foundation plants around the house
11 low volume rotors zones for landscaping

We've also placed seven 75 foot hoses around the property for selective hand watering, cleaning, and animal care

From 1986-1993 we ran a vineyard on an arid mountaintop in Northern California and developed all the skills needed to carefully manage an agricultural operation from a well with limited capacity.

We've had record heat this season.  With targeted use of drip, rotators, and hand watering, everything is thriving on Unity farm.

Dispatch from Osaka

This week I'm in Osaka keynoting the IEEE Engineering in Medicine and Biology Society annual meeting.

Dr. Hiroyuki Yoshihara, my colleague from Kyoto University, hosted a pre-conference workshop on the state of EHRs throughout the world.   For years I've said that the challenges of EHR adoption and healthcare information exchange are the same in every country.    This workshop confirmed my impressions.   Speakers from Japan, New Zealand, and Brazil each spoke about issues such as:

Do we centralize data from multiple EHRs into a single repository for care coordination, patient engagement, and research?  Or do we create federated options with just in time data sharing from distributed EHRs?   The answer is that every locality approaches the problem based on requirements and policy concerns.   There is no one right answer.   Care coordination works well with distributed approaches (pushing summaries, pulling summaries, viewing external records) but analytics for population health and quality measurement benefit from data aggregation and normalization.

Do we accelerate change via top down government programs or bottom up industry driven initiatives?   The consensus was that top down, standardized, regulated approaches may temporarily slow innovation but they are effective in promulgating widespread adoption.   In the US, we've tripled adoption of EHRs since HITECH.  

Do we issue a national patient identifier (required or voluntary) to improve the accuracy of healthcare data aggregation?  Every country has different policy concerns and varying cultural tolerance of government mandated programs.   However, there was widespread agreement that an identifier for healthcare, required or voluntary, would make healthcare information exchange and analytics easier.   A curated national provider directory is also desirable.

How do we ensure data is comparable across multiple EHR systems?   Should we adopt detailed clinical models such as the work of the CIMI effort?  There was widespread agreement that vocabularies and clinical models are foundational to semantic interoperability and data aggregation.

Finally, how do we protect privacy?  Issues of consent, metadata, and de-identification are important throughout the world and approaches are highly variable based on culture, privacy laws, and regulations.   There is no single right answer but all agree that patient mediated exchange in which the patient is steward of their own information addresses many of the concerns.

My keynote today will focus on the grand challenges facing all engineers, informaticians, and policymaking professionals.  The five topics above - ubiquitous healthcare information exchange, universal adoption of standardized EHRs, accurately identifying patients/providers, creating foundational semantic interoperability tools, and protecting privacy are important worldwide and I look forward to solving them in our generation.

The FY14 BIDMC Information Technology Budget

Beth Israel Deaconess Medical Center runs on an October 1 to September 30 fiscal year, so Summer is
always a time of capital and operating budget decision making.

We've finished our FY14 capital budget submission and requested $10.7 million to fund all the needed infrastructure/applications supporting 3000 doctors, 22000 users, and a growing 1.2 billion dollar clinical enterprise.     This breaks down into $7.5 million for general operations, $3 million for security/regulatory initiatives and $210,000 (plus a $1.3 million FY13 carryover) for ICD10.

We've finished our FY14 operating budget submission and requested a base budget which is flat compared to FY13.   However, we have added two special operating budget requests - $2.6 million for security/regulatory initiatives ($1.3 million in new FTEs, $1.3 million in purchased services),  and $4 million in ICD-10 related costs.     Our total IS expense will be about 2 percent of the operating budget of the entire organization.

It is interesting to note that like many CIOs, more and more of my budget is directed to government mandated initiatives.  I've published the graphic above previously which shows what a healthcare CIO must do 2010-2015 -  Meaningful Use, ICD-10, HIPAA 5010, Physicians Quality Reporting Initiative, Value Based Purchasing, and Affordable Care Act/ACO formation all while ensuring appropriate protections are put in place to comply with the new HIPAA Omnibus Rule and increased Office of Civil Rights enforcement.   Also, there is an uptick of audits of all kinds motivated by federal, state, and internal risk reduction mandates.

My modest budgets are not a sign of unwillingness of the organization to allocate resources to IT - they are a function of the budget realities facing all healthcare organizations.

The work that we do is a function of time, scope, and resources.    As I reflect on the external pressures all CIOs face in 2014, change is accelerating, reducing time to complete projects.   Scope is increasing as healthcare moves from fee for service to global captitated risk.    Resources are shrinking with increasing pressure to reduce reimbursement, merge/acquire/affiliate, and overall reduce total medical expense associated with the care we give.

We all need to be very careful that CIOs and their staff do not approach the breaking point as the requirements for time, scope, and resources (FTEs, capital, operating) no longer align supply and demand. As I discussed in a previous blog post, we're moving forward diligently to inform the Board and senior management about the cost of every new project and deal.