"What's Your Weapon?": Billie Jean King, Arthritis Foundation, Ad Council, and USTA Launch Arthritis Campaign

Before Twitter and the U.S. Open was a flutter this afternoon with the news of Venus Williams withdrawing due to the diagnosis of the autoimmune disease- Sjogren's Syndrome, the U.S. Tennis Association was focused on another health related issue. Today the press release went out that tennis legend Billie Jean King was joining the Arthritis Foundation, the Ad Council, and the US Tennis Association (USTA) to launch a public service campaign against arthritis (the leading cause of disability in America).



The ads, launched at the U.S. Open today, feature King (who has osteoarthritis- OA) and highlight the power of movement and exercise as "weapons" in the fight against arthritis. King tells viewers "tennis is my weapon" against arthritis. The ad then asks viewers, "what is your weapon against arthritis?" and directs them to the campaign's website in order to find out: Fight Arthritis Pain. On first view, I was not terribly impressed. The brief ad (33 seconds) does not tell you very much (e.g., King says tennis is her "weapon" but nothing is said about the benefits of movement). The goal of the ad simply appears to be motivating viewers to visit the website for additional information.



The other thing that is not clear in the ad (but clarified in the press release and website) is that this campaign is targeting OA specifically. While OA is the most common type of arthritis, it is not the only type. For example, in contrast to OA which breaks down cartilage, rheumatoid arthritis (RA) (a chronic autoimmune disease) causes inflammation of the lining of the joints. Would the exercise recommendations be the same no matter what type of arthritis? I would say that distinction is unclear for viewers.



However, I did feel better when I read the press release and saw that these ads were tested in focus groups by the Ad Council. Testing your images and messages with your target population is incredibly important. It is reported that participants felt that the concept of "having a weapon" against arthritis was powerful and motivating. That is good news considering formative research by the Ad Council found that only 16% of OA sufferers surveyed felt "very confident" that they could manage their pain. Therefore, if an ad can make viewers feel empowered and confident- that is a good thing.



The press release did not describe the demographics of the focus group participants, but I am assuming they were similar to those originally surveyed (adults age 55+ with OA). If so, it would mean that Billie Jean King was an appropriate "Champion" for the cause and someone that audience admired, having watched her in the 1960s-1970s, her prime competitive years. However, I wonder if she would be the best choice for ads targeting arthritis sufferers in a younger demographic? After all, different types of arthritis can affect people of all ages. Again, this is another reason that I would have wanted to see a clearer definition of the audience for these ads. If we are focused on older adults with OA, then it is a great choice. If we are focused on people of all ages with all types of arthritis, then maybe not.



Overall, I give this campaign a "B". The impetus of the campaign is good in that it is based on research...research that shows that arthritis suffers are too sedentary and do not feel like they have control over their pain management. The campaign aims to address these barriers by empowering viewers with a "champion" who they admire and can model. The campaign also links them to a website with all the information they need about the benefits of exercise for arthritis. However, the execution of this campaign is not as strong as its foundation. It would have benefited from a more clearly defined audience and message.

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The Standards Summer Camp Deliverables

On September 28 2011, the HIT Standards Committee (HITSC) will officially deliver to ONC its 6 months of hard work from Standards Summer Camp.  HITSC subcommittees and workgroups have met every other day since April to prepare the standards recommendations needed to support Meaningful Use Stage 2 rule making.

The S&I Framework teams have been working in parallel on important issues - Certificates, Provider Directories, Lab Result Reporting, and Transfer of Care Summaries.

Here's how it all fits together.

Certificate Recommendations - HITSC recommended specific implementation guidance for X.509 certificates.  The S&I Framework teams developed a strategy  for certificate authorities to issue trusted credentials that will eventually be cross-certified with the Federal Bridge Certificate Authority (FBCA), enabling exchange with Federal agencies.

Metadata recommendations -  HITSC recommended CDA R2 headers for patient, provenance, and security metadata.  These were included in the Advanced Notice of Proposed Rulemaking.   HIEs should use these standards as metadata envelopes for content payloads that are sent between different organizations.

Provider Directory recommendations - HITSC considered LDAP but noted that federated LDAP directories and internet-based LDAP queries between organizations have not yet been widely deployed.   HITSC also considered microdata and web search engine retrieval of structured directory data.   The S&I Framework teams concluded that pilots of federated LDAP queries and microdata are a reasonable next step, because no provider directory standard is mature.  Additionally the S&I Framework teams recommended DNS for certificate distribution with the addition of LDAP if an organization's implementation of DNS does not support certificate discovery.

Vocabulary recommendations - HITSC recommended a parsimonious set of standards for vocabularies supporting quality measures including SNOMED-CT for problems, LOINC for labs, and RxNorm for medications.   The September HITSC meeting will include a transition plan for those vocabulary standards required for Stage 1 that are being retired/replaced in Stage 2.

Patient Matching recommendations - HITSC recommended a set of best practices that will guide implementors who want to match patients using demographic data elements with appropriate specificity and sensitivity.

ePrescribing of Discharged Medications recommendations - HITSC recommended NCPDP and HL7 standards that are widely implemented and compliant with Medicare Part D requirements.

Public Health recommendations - HITSC recommended HL7 2.51 implementation guides for syndromic surveillance, reportable lab, and immunizations - one highly constrained implementation guide for each transaction.

NwHIN recommendations - At September's meeting, HITSC will recommend one set of building blocks to support Nationwide Health Information Network Exchange transactions (pull/push) and Direct transactions (push).

Lab Results recommendations - The S&I Framework teams recommended an HL7 2.51 transaction that is very similar to the public health implementation guides already approved by HITSC.  It also includes vocabularies and code sets that constrain the optionality of the transaction.  The Implementation Guide  is broadly supported by ELINCS developers, commercial labs, and numerous informatics experts.   It will be balloted by HL7 in the next few weeks and then piloted before any regulations are written.

Transitions of Care recommendations - The S&I Framework teams recommended a transfer of care summary that is a natural stepwise evolution of the work we've done for the past 10 years  - CDA --> CCD --> C32 --> transfer of care CDA templates.   These CDA templates are easier to implement than C32 and more flexible,   Given that CCR is a declining standard (little new work is being done on it), CDA templates are a reasonable next step.   The HITSC will be asked to comment on the trajectory of this work and will evaluate the results of pilot testing.

At the September meeting of the HITSC, we'll review all the work we've done as well as the S&I Framework efforts on Certificates, Provider Directories, Reportable Lab and Transfers of Care.

What evaluation criteria should we use?   In the words of Doug Fridsma, who oversees the ONC Office of Standards and Interoperability

"While it might not be perfect, does it represent the best we have so far?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed through the SDO community?

All standards, even those that have wide-spread uptake, require constant updating and refinement. Vocabularies, terminologies, and other existing standards will require piloting to make sure that we maintain relevance.

We can't let the perfect be the enemy of good. Standards will require continued support and community refinement. If we can generally answer 'yes' to the questions above, then we need to continue to push forward toward the goals of interoperable health exchange."

I look forward to the September meeting and the delivery of all the great work done by the HITSC and S&I framework teams, bringing closure to this phase of Stage 2 preparation activities.

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Lessons Learned from Steve Jobs

I recently spoke with several reporters about Steve Jobs' impact on healthcare , thanking him for the past 15 years of innovation.   In preparing for those interviews, I reviewed Steve's career milestones,

In 1997, Apple Computer was in trouble.  Its sales had declined from 11 billion in 1995 to 7 billion in 1997.  Its energies were focused on battling Microsoft.   It had lost its way.

Steve Jobs made these remarks at MacWorld 1997, a few months before becoming Apple's CEO.  He outlined a simple go forward plan:

1.  Board of Directors
2.  Focus on Relevance
3.  Invest in Core Assets
4.  Meaningful Partnerships
5.  New Product Paradigm

How can we apply these 5 ideas to the work we're doing in HIT?

It's clear that Health Information Exchanges across the country are in trouble - CareSpark closed its doors,  the CEO of Cal eConnect resigned, and Minnesota Health Information Exchange ceased operations.

Let's consider the application of Steve's principles to Healthcare Information Exchange in Massachusetts.

1.  Board of Directors - Governance in general is very important to healthcare information exchange.   HIEs need a multi-stakeholder governance body to set priorities, monitor progress, and ensure all stakeholders are engaged.   In the past few months, state government and the private sector experts have worked together to define roles and responsibilities.   The State's HIE coordinator, Rick Shoup, and I presented this consensus plan to the state's HIT Council, the decision making body established by state regulation Chapter 305.   Governance will be done by the HIT Council plus an HIT HIE Advisory Group consisting of payers, providers, employers, patients, academics, and government.    This "Board of Directors" of the Massachusetts HIE activities is top notch.

2.  Focus on Relevance -  HIEs can do many things.  They can push data among payers, providers, patients, and public health.   They can create master patient indexes, record locator services, and registries.    However, what will the market pay for today?   At the moment, simple secure transport that connects every stakeholder with easy to use web applications and native EHR interfaces seems to be the answer.   Rather than do everything simultaneously, we need to tightly focus on just secure routing, making 2012  the year of the state "information highway".

3.  Invest in Core Assets -  Massachusetts already has production HIEs that serve the business needs of several customers.   We have NEHEN, CHAPS, SafeHealth, North Adams HIE, and the MAeHC Quality Data Center.   Rather than reinvent these, we need to focus on the gaps, creating a state backbone that will connect every stakeholder, establishing a network of networks that leverages existing investments.

4.  Meaningful Partnerships - The State Medicaid Health Plan includes 14 projects that cover over 90% of the providers in Massachustets.   Since Medicaid is eligible for 90/10 matching funds (90% Federal/10% State), it makes great sense to do as much as we can via Medicaid.   Multiplying our purchasing power by 10 is a meaningful partnership!

5.  New Products - Once connectivity from every stakeholder to every stakeholder is in place, we can create novel functionality such as clinical registries and the ability to query data to support the "unconscious in the emergency department" use case.  

Thus, if 2011 was the year of governance, 2012 will be the year of connectivity, 2013 the year of registries, and 2014 the year of queries.

Thanks Steve, for an approach that gives us focus and momentum.    I'm completely confident our Massachustets HIE activities will succeed by embracing your 5 principles.

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At Home with Hurricane Irene

For the past 2 years, I've operated a weather station which provides realtime data for Wellesley, Massachusetts to the National Weather Service, the Citizens Weather Observation Program, and Weather Underground.

If you search Google for Weather Wellesley, you'll get my data.

For graphs of the temperature, barometric pressure, wind speed, wind direction, and rainfall rate during Irene, here's a summary from Weather Underground.

To prepare for the storm, I took down flags, removed hanging bird houses, and stored every object that could become a projectile in the wind.

Interestingly, we never had sustained winds more than 10 mph.  Our peak gust was 17 mph.    Likely, the impact of the storm on my location was much less than the surrounding neighborhood because of the grove of old hemlocks nearby that serves as a windbreak.

However, we did have a substantial amount of rain - 2.24 inches on Sunday and 4.66 inches in 24 hours related to Irene.

I retrofitted all our gutters with extenders to push water away from the house and sandbagged the bulkhead to our basement, just in case standing water accumulated in the backyard.

The key technology that saved our house was not anything wind related, but was the disaster recovery sump pump I created last year.

At the height of rain intensity, a tree down the street collapsed. due to the weight of water on its leaf canopy, and fell through power lines.   The Department of Water and Power cut power to the neighborhood to do the repair.

Water began rising in my basement drains and as designed, the battery backup sump pump worked perfectly, pumping the basement dry despite the loss of power.

Installing a battery backup sump pump makes great sense - the likelihood is that in the worst storms, you'll also lose power, so having an AC powered sump pump will not help you (unless you engineer a complete alternative power solution for your home)

If my neighborhood was typical, the storm did have a profound impact.   Down the street, a tree fell into two cars.   My father in law lost a portion of his entry roof.   Downed limbs have impacted traffic flows throughout the area.

However, our engineered systems for power backup and water control plus our preparation for the storm made our experience of Irene, our first hurricane, uneventful.

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Anti-wrinkle care for oily, acne prone skin??

For every woman, anti-wrinkle care is essential. Yes, even for those that have acne prone skin. Those that still have moderate to moderate severe acne should not buy any anti-wrinkle products until most of your active acne has been taken care of. However, those with oily or acne prone skin that have their conditions more or less under control should get some anti-wrinkle care products.

So, what is most essential? Anti wrinkle eye cream is the most essential. If you don't know already, the skin around your eyes are the most fragile and sensitive. You should take care of this area well because wrinkles around your eyes are going to show your age or make you look older. This area is usually not affected by acne. From what I have seen, even for people with the most severe acne, the area around the eyes remains clear. You should use an anti wrinkle eye cream as soon as you turn 25 if not sooner.

What about the rest of your face?? Fortunately, those that suffer from acne problem do not have the same problems as other women when it comes to wrinkles. Even though oily skin over lubricates the skin, it tends to keep it young as well. Most people with oily skin tend to look younger. So, do we still need any anti wrinkle anti aging products? Yes and no. For those that are moderately oily, you can use a very light (water based) moisturizer to keep the wrinkles away. No need for those expensive anti wrinkle cream that most brands sell. Those really expensive creams that target wrinkles are for those with dry skin.

Your neck is an important part that you should not neglect. Your neck can show your age as well. You should apply moisturizer daily to your neck to take care of it well. This area is more prone to aging because this area is not as oily. You should use a generous amount of moisturizer on this area to keep it moist. Keeping your skin hydrated is the best way to avoid wrinkles.

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Acne scar before and after retin-A (Tretinoin) treatment

I have some acne scars from years of suffering with acne. No surprise, most people have a lot more scars than me. I am lucky because my skin healed pretty well. However, I still have scars on my face that I am aware of. I had a very bad acne episode almost one year ago and you should take a look at those pictures because they are horrible (but I recovered, so there is hope for everyone). Since I had that episode, my family doctor prescribed Tretinoin for my skin.

Not only does it help with acne, it also helped a lot for my scars. It is amazing that most of my rolling scars have disappeared. I have a before and after photo to showing you the difference. My prescription is Tretinoin 0.025% gel. I am sure there are different concentrations of this stuff on the market. This drug works by making your skin peel.

I suspect that this drug will only help with the rolling scars because my little ice pick scar did not look any different. I guess I will just have to deal with that small scar on my face. Anyways, I have already used this drug continuously for about 3 to 4 months. My rolling scar in the picture on the side of my face were there from 7 to 8 years ago. I am very pleased with the results because I haven't seen anything that worked so well with minimal cost and side affects. You should give this treatment a try if you haven't already.

Last thing, when using retin-A products (Tretinoin), protect your skin well from the sun because it makes the skin more sensitive to UV-rays. Use a SPF 30 sunscreen for your face at all times even indoors because even short exposures have bad effects on your skin. I hope everyone can get rid of all their acne scars because acne scars are even worse than acne itself. It constantly reminds us of how much we suffered in the past.

Will keep you posted on other information I know about acne and acne treatments, check back often!!

Before (not a very good picture of the scars because I didn't believe anything can get rid of them, didn't want to take photo of these bad acne scars, however you can see a little bit of rolling scars beneath the acne itself).

After (note the better texture, looks like it's from different side, but it's the way the photo is taken).

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My current situation with acne

My acne is more or less under control. It is not possible to get rid of it for good but it is largely under control. I stopped the birth control pill because having light to moderate upset stomach at night is very bothersome. I will only get on it if it's absolutely necessary again.

My cheeks are clear. My jawline is clear. My nose is clear. I have occasional small pimples on my forehead. However, my forehead is always a problem area for me in the past. So, I am pretty satisfied with just a few zits here and there.

My current products, tretinoin gel 0.025% on acne, erythromycin tropical gel USP, 2%, Bare minerals moisturizer and makeup and Neutrogena deep clean cream cleanser. No oral medicine is taken at this point. I must say that this routine works pretty well for me. For the first time in years, my skin is actually very soft to the touch. Almost unbelievable to me!! This is especially thanks for daily applications of the Bare minerals moisturizer.

Here are a few pictures of my face from different angles. Note the redness is due to spider veins.

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Cool Technology of the Week

I've written about strong identity management and the use of biometrics for secure applications such as prescribing controlled substances.

Bio-key, a web-based biometric provider we have used at BIDMC, has now developed an iPhone and iPad finger print reader that does identity verification in the cloud.

Although I've argued with the FDA that SMS messages sent to clinician cell phones should be enough for 2 factor authentication, their response has been that doctors cannot use Blackberry's, they must use Barackberry's - fully encrypted highly secure devices when writing e-prescriptions.

Bio-key's approach to two factor authentication on iPhones and iPads will enable a new level of functionality and productivity for clinicians who want to use these consumer platforms for healthcare applications.   Today, over 1000 physicians at BIDMC use iPads and they are becoming the mobile device of choice for clinicians.

A cloud-based biometric authentication system for iPhones and iPads.  That's cool!

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Preparing for the College Transition

In one week, we drop off our daughter to Tufts University so she can began the next era of her life as a college woman.

All of us have been preparing.

High School is a time of many emotions - high highs and low lows.   It's about discovering independence, making choices, accepting responsibility, developing relationships, and balancing parental authority with the desire for autonomy.

More is expected of today's teens than in my generation.  It's very stressful on a young person.

In one week, she'll make decisions on her own.  She'll decide what to eat (and drink), when to study, and who to spend her time with.

Over the past few weeks, she's thought about her transition in a very spiritual way.

I did not approach my college transition formally.   I packed my clothes and typewriter the night before and we drove from Los Angeles to Stanford for the drop off.     That was 31 years ago this week.

She realizes that she has to prepare for this new era while bringing closure to her childhood growing up in Wellesley, Massachusetts.

She has thought about all her Wellesley relationships.   She's scheduled events with every one of her friends to create positive memories and energy before they go their separate ways.    She's arranged hikes, picnics, movies, meals, and sleepovers.

She's taken private walks to her favorite places in Wellesley.    She's also made a conscious decision not to visit many of the places she treasured when very young so that she can remember them as they were from a child's point of view.

Yes, she'll stay in touch with friends on Facebook, but that will fade as she develops new relationships, new interests, and new goals.   The closure she's bringing now will leave lasting memories among all her friends, creating a sense of optimism and energy for the future ahead.

My wife and I know that next Wednesday will be hard.   We'll bring our daughter's carefully packed belongings (4 small bins that will fit perfectly in a cozy dorm room) to her new living space, set up her IT infrastructure (the home CIO at your service), and attend a formal matriculation ceremony.   My wife and I will give her the space she needs to bond with her new colleagues and we'll retreat to a quiet vegan cafe to reflect on the next era in our lives.

We've already planned a few short trips together.  My wife will join me for keynote addresses in Burlington Vermont, Phoenix Arizona, and London England.    We've already planned a family get together on Mt. Monadnock over Columbus Day weekend.    We've thought about the next few months and years as we've considered the implications of staying close to our daughter, our parents, and our jobs.

The end result is a solid plan that will launch all of us into the next stage of life.   For my daughter, it's adulthood.   For my wife and I, it's a refocus on each other, the world around us, and our careers.   The past 18 years with our daughter have been a gift, but the next era will be positive for all of us too.   Our evolution begins next Wednesday.

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Storage Dreams

As I continue to support the infrastructure requirements of the research faculty of Harvard Medical School (in parallel with the process to find my own successor at HMS),  I have a storage dream.

The scene opens to a researcher logging into "Storage Central", a browser neutral, operating system neutral website that even runs perfectly on an iPad.

After thoughtful analysis of faculty needs, Harvard Medical School will have concluded that there are 3 different directory types in 3 different storage workflows

Directory types
a.  Massive numbers of small files (i.e. next generation sequencing) that needs solid state metadata management (i.e Isilon 32000X SSD)
b.  Small numbers of really large files (i.e. image processing) that needs high I/O throughput (i.e. Isilon 72000X)
c.  Average numbers of average sized files that can use lower performance technologies (i.e. Isilon 72NL)

Workflows
a.  Files with a high turnover rate (scratch space) that are created and destroyed daily.  No snapshot or archival tier is needed
b.  Files with a low turnover rate that do not need replication because the data is easy to regenerate. Snapshots are needed to protect the data against drive failure.
c.  Files with a low turnover rate that need to be retained for years due to compliance requirements and the difficulty of regenerating the data.  An archival tier is needed. (i.e. arrays of inexpensive 2 Terabyte drives)

The researcher sees a visual representation of her storage use in each directory and workflow, both currently and monthly over the past year.   Data on primary storage, snapshots used to protect the data, and archival copies of the data are shown separately.

The researcher oversees several post docs.   By clicking on a link, the researcher can see the storage use of all those she supervises.

Each directory type has a fixed three year cost per terabyte.   Workflows with snapshots or archives have an incremental cost.   These costs are well known and accepted by all the users.

The researcher can set their own quotas for directory types and workflows.   A calculation of cost for current storage and total quota is shown.   The researcher can type in a grant number or departmental account number to reserve the directory types and workflows they need.

The departmental administrator oversees many researchers.    She can view the storage use of all her faculty with historical, current, and projected costs shown on screen.

She can discover who is likely to exceed their budget and who is responsible for the largest amount of storage growth over time.

An IT storage concierge is assigned to each department to help researchers and administrators move data among directory types and workflows to balance performance and cost.    There is complete transparency between the demand created by the users and the supply provided by the IT department.  

The Dean knows the total costs charged to departments, the IT department, and the school (as overhead components in indirect costs).

The CIO and the infrastructure team receive daily summary reports which forecast growth so that additional storage can be added as necessary, ensuring that each directory type and workflow always has 20% unused capacity.   Storage vendors can ship nodes to expand each directory type and workflow within 1 week of receiving a PO, so storage can be expanded just in time without risking over or under provisioning.

The chargeback model is NIH compliant and motivates researchers to maintain files via the easy to use move/deletion tools in the web interface.

The research community, school administration, and  IT are deliriously happy.  Storage challenges are a solved problem.    The governance committees have turned their attention to cool applications that advance science instead of infrastructure limitations that impede it.

We're assembling industry experts to work on this dream.   My hope that is that I can report back in 2012 that the dream is now the Harvard Medical School reality.

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The East Coast Earthquake, Real Time Twitter Chat, and Facebook Applications for Disasters

Well! Today was an interesting day at the office. Up and down the east coast, many of us felt the tremors resulting from an earthquake in Virginia. While I would like to report that we all stayed calm and participated in orderly, safe, and well rehearsed evacuations...that was not the case. It appeared that the shock of experiencing an earthquake (such a rare event on the east coast) caused a little chaos. On my way into my office to grab my bag before hitting the stairs, I experienced a "George Costanza" type moment as a fellow staff person almost knocked me down in her rush to get out. I heard similar stories from my husband who works 4 blocks away. Upon recognition of the earthquake, his co-workers made a beeline for the safest escape route...the elevator?!



After the shaking took us down 13 flights of stairs, I quickly turned to the only reliable source for real time information- Twitter. Since I was the only one in the area who either grabbed my phone or had twitter, I quickly read off what I knew: "It is a 5.9 earthquake in Virginia"; "My colleagues felt it in- Baltimore, DC, Boston, NYC, North Carolina"; "No damage except one broken window is reported in Philadelphia". After being given the go ahead to return to the building and settling back into our work, we received an official text/email from the University reiterating the information Twitter delivered an hour before. According to Twitter's official profile tonight, within one minute of the #earthquake, there were more than 40,000 earthquake-related tweets. They reached 5,500 tweets per second (TPS).



As I discussed in a related post back in March 2011, the question for public health professionals continues to be- "What is the role of social media in emergency preparedness and recovery?"



I believe we are making some strides in answering that question. Just yesterday, the Office of the Assistant Secretary for Preparedness and Response (ASPR)- located within the US Dept of Health and Human Services (HHS)- launched a contest: The ASPR Lifeline Facebook Application Challenge. The goal of the contest is to create applications that prepare individuals for disasters and build resilient communities. Those who opt into the application will be able to identify "lifelines" or Facebook friends that agree to be an individual's emergency contact and act on their behalf in case of an emergency. They will also be able to create a personal preparedness plan and share that plan and the application with others.



Even without the formal application, we have seen social network sites be used for checking in with friends/family and for getting information out quickly. For example, I follow the Philadelphia Office of Emergency Management on Twitter, so I got the message quickly that our 9-1-1 system was being inundated with calls since the earthquake and we should only use it with a real emergency...for infrastructure damage, call 3-1-1 instead.



While the Facebook application sounds like a great addition to emergency preparedness, it is important to also consider implementation issues which will impact its reach and effectiveness:

• Is the application only available to Facebook members who download it ahead of time? Or will it be available to anyone via the mobile web?
• Do these Facebook members typically update their profile via mobile devices in addition to stationary computers (which may not be available during an emergency)?
• During the emergency, are there cell networks/wifi to support the communication? (e.g., many reported that cell networks were jammed immediately following the earthquake)
• Do these "electronic" preparedness plans need to be rehearsed the same way as "in person" plans in order to increase effectiveness?

The HHS-ASPR contest runs August 22-November 4, 2011. I look forward to seeing the winning applications and hearing about how the dissemination will be conducted and evaluated.



What were your experiences today during the east coast earthquake? What did you hear/see from your colleagues? How did you get/send information to others? Please share in the comments section below.

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Experience with Lion Part II

I recently wrote about my first experiences with Mac OSX Lion.

Now that I've been running Lion exclusively for a few weeks, I've learned a lot about my Macbook Air and the lifecycle of Apple products.

There are 4 variations of the Macbook air in use today:

Generation 1 - the 2008 Air with a sluggish 1.8" hard drive or an equally slow but expensive Toshiba SSD drive with 50 MB/s reads and 14MB/s writes.  It had a real world battery life of 2.5 hours.

Generation 1.5 - the 2009 Air that replaced the Intel GMA X3100 integrated Graphics Processing Unit with a Nvidia GeForce 9400M to support a 1280x800 pixel display.   The Toshiba SSD drive was replaced with a slightly faster Samsung 128 SSD.

Generation 2 - the 2010 Air that was SSD-only (Samsung 128C).  SSD performance improved beyond that of magnetic spinning hard disk drives. A new Nvidia GeForce 320M GPU enhanced graphics performance and the Air's screen resolution was increased to 1440x900 pixels.  The CPU was slower than in the previous models, but in practice it often performed better, because, unlike the old Airs, the newer ones didn't have to throttle down the CPU speed to keep the system from overheating.  Generation 2 included two USB ports, but peripherals were still limited by the maximum performance of the 480Mbps USB connections. In addition, Apple introduced an 11.6" model.

Generation 3 - the 2011 Air is based on the latest Intel Sandy Bridge Core i5 and i7 CPUs, which include hardware support for AES encryption and a Graphics Processing Unit on the CPU silicon.  The Mini DisplayPort connector which supported external displays in previous generations  was transformed into a Thunderbolt port, which drives external displays and provides I/O at 10 Gig/s.

I purchased my Macbook Air at the end of 2009, so I have a Generation 1.5 - a 2.13 Ghz Core 2 duo with 2G of RAM and a Samsung 128 SSD.

I installed Lion and fully encrypted the filesystem with Filevault2.

In practice Generation 1.5 does not have the CPU power and I/O necessary to sustain Filevault2 and application performance for I/O intensive operations such as Mail 5.0.

Here's a study of the I/O degradation caused by Filevault2 on the Generation 2 Air - a 44% decrease.   Generation 2 lacks the hardware AES encryption support (used by Filevault2) of Generation 3.

Generation 1.5 is even worse.  

The end result is that Mail 5.0  on my Macbook Air could not process the typical 1500+ emails I receive each day and encrypt/decrypt the filesystem simultaneously.   Deleted emails reappeared.   Emails that I moved between folders unmoved.    Only a reboot brought my Inbox up to date.

The solution - I reinstalled Lion without encryption and now Mail 5.0 works well, but running I/O intensive applications simultaneously like Skype 5.3 and Mail 5.0  is still problematic.

I do not store protected health information (or even personally identified information) on my laptop, so encryption is optional.

The Generation 3 Macbook Air with its I5 or I7, hardware AES support, and faster SSD drive is absolutely good enough for Lion, encryption, and I/O intensive applications.    However, the Generation 1.5 is not.    Running Lion and one application at a time is about all it can support.

Moore's law is alive and well at Apple,  with doubling of CPU capabilities every 18 months.   You should upgrade to Lion warily if you are running anything but the latest Air.

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Healthcare is Different Part II

I recently posted a blog entry,  Healthcare is Different, examining the ways that healthcare differs from  other businesses.

Numerous folks sent me email agreeing and disagreeing with my points.

Here's a compilation of some additional ways that my readers suggested healthcare is different.

*Domain Expertise - the vocabulary, science, and physical skills necessary to practice medicine are very complex compared to most other professions.   For example to become a neurosurgeon requires kindergarten-high school, 4 years of college, 4 years of medical school, 7 years of residency, and generally a 2 year fellowship.   That's 30 years of education.

*No second chance -  In retail, if a good is defective it can be exchanged.  In service businesses, there is the concept of a redo, a repair, or renovation.  The concept of "returned goods" does not existing healthcare.

*Trainees.   There's probably no industry that is so inundated with "trainees" as health care; especially in an academic medical center.  They add a level of inefficiency during the learning process that is required to produce the next generation of health care workers.   In other industries, trainees come in small streams as you bring in co-ops, interns etc.    They don't come by the hundreds in July of each year.

*Highly regulated and compartmentalized workforce.   Healthcare has dozens of professionals whose practice is limited to certain privileges.   This inhibits mobility and cross-coverage that could improve the efficiency of the workforce.   If demand gets light in Cardiology, you can't easily move the clinicians to the Gastrointestinal suite.

*Reimbursement and payment process.   There is a well defined commercial code for how payment occurs in most industries.   In health care, each payer creates their own rules.   In aggregate, these rules represent thousands of pages of policies and procedures that a health care provider must follow to be paid.   For example, Medicare's claims processing manual is over 4,000 pages long and this doesn't include national and local coverage determinations, advisories, and other manuals devoted to specific types of Medicare sponsored activities.   Add to this the claims processing rules for Medicaid and private health plans and you have an overwhelming regulatory and compliance challenge.  A cynical person might suggest that payers and government agencies purposely create rules that no provider can possibly follow, then seek compliance penalties for the arcane rules they created.    Providers are in a losing battle to keep up with rules that are in a constant state of flux.

These are all great observations.  

My personal goal is to build software and workflow processes that make the complex seem easy, reducing the burden on providers so that they can focus on what's really important, the patient.   That's why the work for a healthcare CIO will never be done.

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Cool Technology of the Week

I've been riding between meetings in the Boston area for 2 years using my Strida folding bike.

It's been great for me but not everyone has a  bike they can carry with them into the office.  

Now, there's a new way to get around Boston - Hubway , funded in part by Beth Israel Deaconess Medical Center.

Using solar powered, cellular connected, high tech bicycle racks with well engineered nearly maintenance free bicycles, it's now possible to commute between 61 stations in the Boston area for a low annual membership or daily fee.

The technology was perfected in Montreal and has solved the problem of bicycle theft, availability, and parking.

It's a truly amazing system and one that is a model for cities around the globe.

A secure, internet connected, solar powered way to rent a bike when you need to ride between points in the Boston area.  That's cool!

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What Causes Clogged Pores on The Face?

When pores on your face become clogged there can be more than one reason why. As a result of which, there will almost always be an outbreak of acne. Firstly though, the mechanics behind your acne will have resulted from a particular substance known as sebum.

It is waxy and oily by nature and is made up of the body's lipids (fats). Sebum is created in the sebaceous gland, which in turn is an integral part of the pilosebaceous unit. This unit is home to not only the sebaceous gland but also it contains the hair and hair follicle. Your whole body (sparing the palms of your hands and soles of your feet) is covered in tiny hairs, the most dense area of course would be your scalp. The reason we have these tiny hair follicle factories all over our body is because sebum is crucial to the moisturizing of not only your hair but your skin also.

However, when too much sebum is created, it can for one reason or another, get stuck in your pores, this creates the right (or wrong, depending on how you look at it) environment for infection and inflammation, resulting in acne.

Teenagers are most at prey from acne, since their bodies produce far more sebum from enlarged sebaceous glands. This is why spots are more associated with the youth.

Most of the time, spots and acne will be a come and go affair, only a few pimples or whiteheads will make a short lived ugly appearance but unlucky individuals will suffer far more virulent forms of acne, ance conglobata or acne vulgaris to name two.

Causes of clogged pores on your face?

The places on your face that usually suffer the most will be the chin, the cheekbones and the forehead.

A typical reason an individual could be suffering from clogged pores on their face is from irregular or improper cleansing. You should be washing your face once in the morning and once before bed. Throughout the day, oily skin is a magnet for dust, dirt and grime. The stuff literally sticks to it from out of the atmosphere. By washing your face twice a day, you could be helping towards staving off spots.

A word of warning though, don't over wash, your skin will fight back if all the oil has been removed, it will create even more to compensate.

Cheap brand make up is another culprit, full of chemicals that can stick to your skin and sink into the pores, clogging them up and causing the right conditions for spots. Switch to water based make up where ever possible. Never ever go to bed at night without having first removed your make up.

Using a good quality skin exfoliate every few days and a good face mask once a week can help remove any build up of dead unmoved skin cells.

Lastly, before you start using any moisturizer, make sure you have picked one that is suited to your type of skin. There is a reason the manufacturers have a range of them. Everyone's skin is different and if you take the time to find out which one suits you, you could be saving yourself trouble in the long run.

Learn more about clogged face pores and what can be done about them. Visit acneandcure.com to discover the best types of acne cure

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Neutrogena Transparent Bar Acne Prone skin Formula Review

Used the Neutrogena Transparent Bar for Acne prone skin for many years in the past. I am not currently using this (replaced with Neutrogena Deep Clean Cream Cleanser, better for my more mature skin). When I first started using this almost 5 years ago, it was recommended to me by a dermatologist.

Benefits: good for teenage or very oily skin. Tends to get rid of oil and keep it at bay. Did not cause any irritation.

Side-affects: Leaves skin very dry and sometimes flaky.

Best for: teenager with very oily skin or adult with very oily skin.

Overall recommendation (out of five stars): 3 1/2 stars. I will only recommend this product to you if your skin is so oily it is almost unmanageable. This product will definitely help you get rid of some of those unwanted oil on the face.

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Neutrogena Deep Clean Cream Cleanser Review

Currently using this product for my daily routine. This is not targeted for acne prone skin but I used it because of a recommendation from a friend. This product is available at most drug stores, Target, Walmart and online stores. Two dermatologists have recommended Neutrogena brand for my skin and it tends to be one of the lesser expensive brands that works for me. Here is the review.

Benefits: Very good for acne prone or currently active acne skin. Very gentle. Good for all kinds of acne skin. I have a friend that have moderate to severe acne and this product actively cleared up most of his acne. It is amazing and that had made me started using it.

Side-affects: None for me.

Best for: all kinds of acne skin to use.

Overall recommendation (out of five stars): a solid 5 stars. Please give this a try if you haven't. This product will not irritate the most sensitive skin (ie. me).

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Neutrogena Acne Oil Free Acne Wash Daily Scrub Review

I am still using this product every night because it is so effective against my blackheads on the nose. You can get this product in most drug stores, Target, Walmart or online sources. This is one of my favorite products from Neutrogena. My skin is ultra sensitive and oily at the same time, but most Neutrogena products tend to be good for my skin. Okay, here is the complete review.

Benefits: So effective against blackheads. The little bead gets rid of all the most stubborn blackheads you have in a very gentle way. You just have to gently message the beads around the area that you have lots of blackheads for less than a minute. You will notice afterwards that all the blackheads are gone. This product is better than Biore's blackhead strip in two ways. First, it gets rid of the most stubborn blackheads. Second, it won't cause irritation to the nose because Biore's strip needs to be removed after it sticks to the nose (for me, this caused slight irritation). This is also very good for exfoliating your skin because the beads are just so gentle and effective.

Side-affects: Slight irritation to cystic acne. The little beads that help with blackhead removal tend to irritate the cystic acne.

Best for: Blackheads, slight to moderate acne. I wouldn't recommend this product for someone with moderate severe or severe acne because it can cause injury to a deep cystic acne.
Overall recommendation (out of five stars): 5 stars. This is the best treatment for blackheads and slight acne. Gentle yet effective.

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Neutrogena On-the-Spot Acne Treatment Review

I have used this product extensively in the past where my acne was moderate to moderate severe. Since I am doing a series of reviews on Neutrogena products that I have used in the past or still currently using, I will be using the same format so that people can easily follow. So this entry is dedicated to the Neutrogena On-the-Spot Acne treatment gel.

Benefits: Helps acne heal faster and also prevent scars. The active ingredient is benzoyl peroxide which works really well to help the healing process of an active acne. It can also prevent new acne from forming. However, it is 2.5% benzoyl peroxide which will irritate those that are sensitive to this chemical. This caused only slight irritation for my skin.

Side-affects: Can cause redness / itchy for those that are sensitive to this chemical. You can also get little red bumps all over the area that you applied this gel to. However, it is gentler than other benzoyl peroxide medicine or gel that I have used in the past.
Best for: Moderate acne. This will not help those deep cystic acne. It is only good for slight to moderate acne time.

Overall recommendation (out of five stars): 4 stars, because it is overall an effective product for slight to moderate acne. Does help the healing process significantly. However, it is brand name so it is on the more expensive side. For a little container, it cost around six dollars.

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Unfriendly Skies Part II

In 2007, I wrote about the experience of flying in my post Unfriendly Skies.   In the past 4 years, the domestic flying experience has gotten worse.

Two weeks ago today, I was in Japan at Narita airport for my flight back to Boston.  The check in and security lines were extremely long.   Although I had 1.5 hours before my departure, it was clear that getting to the plane on time would be challenging.

I asked the customer service staff at All Nippon Airways (ANA) for their advice.   Immediately, they assessed the situation and escorted me to a check in window for a  boarding pass.   (Note that I was flying the lowest cost economy possible, not business or first class).  The check in person then left her post to escort me to the crew line in security and walked with me through the screening process.   During X-ray scanning,  the Japanese security staff noted I was carrying a handcrafted broom that violated their security guidelines because it could be used as a "nightstick" weapon.   They paged an ANA baggage carrier who wrapped my broom and checked it on the spot.   I arrived to my gate on time, but unfortunately my departure was delayed 45 minutes because ANA wanted to accommodate a late arriving plane with numerous connecting passengers.

During the flight to Los Angeles, ANA called ahead to my connecting flight on American Airlines to give me the best chance to make my tight connection.

When I arrived at LAX, ANA staff escorted me to Customs/Immigration and gave me a special "expedited" sticker to ensure I could bypass lines and delays.   It worked flawlessly.

I walked out of the Tom Bradley International terminal and then walked to the American Airlines gates at Terminal 4.   I might as well have walked into the 9th circle of Dante's Inferno.

Immediately, the American Airlines staff were hostile and uncaring.   They told me I'd never make my flight and sent me to the back of a long customer service line.  Shortly thereafter a single mother with 4 young children was sent to the same line and began crying in despair because she was going to miss her flight.    A truly unpleasant American Airlines staffer told her  "I know what you're going through and I cannot help you, just stand in line", as if a 25 year old male understood the challenge of being a single mother with 4 children.   I escorted her to the front of the line explaining to everyone else that she and her children needed their help.   We got her onto her flight to Shanghai.   I missed my flight and was told by American Airlines that all Boston flights were so overbooked that I had no hope of getting a flight until the next day.   They would offer me a $5.00 discount on a hotel room…

Let's see - in Japan, caring people walked me through the process to ensure success.  In the US, I was hassled, ignored, impeded, and overbooked.    My flight to Boston took 30 hours including an overnight stay at a motel near LAX.

There is truly something wrong with an industry that sets policies and hires people who are customer hostile.   I will amend what I said in 2007.   I will try as hard as possible to limit my travel to international carriers that want my business, while using teleconferencing instead of domestic travel.   When I'm asked if my domestic travel experience met my expectation, my only response can be - it landed and I guess I'm thankful for that!

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The August HIT Standards Committee meeting

The August meeting of the HIT Standards Committee (the 28th meeting of this FACA) was a milestone in parsimony.   As you'll see, we approved a set of vocabulary recommendations and public health standards that represent harmony as well the fewest number of standards possible for the intended purpose.  

Since April, we've been working hard on Summer Camp.   At our September meeting, we'll wrap up all that work and hand off the finished standards recommendations to ONC for regulation writing.

Per our Summer Camp plan, the August meeting included final recommendations on vocabulary standards for quality measures, final recommendations on all public health transactions, preliminary recommendations on patient matching, and preliminary recommendations on transport/security standards.   We also heard from the Standards and Interoperability Framework team about their work and the Implementation Workgroup on their review of Certification Criteria.

This was a powerful meeting, discussing the standards that so many people have been working on for the past decade - one vocabulary standard for each class of data used in quality measures, one approach to public health transactions, one approach to transfer of care summaries, one approach to laboratory results, and a building block approach to data transmission that supports the portfolio of health information exchange options.

We began with the final recommendations from the Clinical Quality Workgroup and Vocabulary Task force on vocabulary standards.   Per the marching orders we gave them, they selected one vocabulary standard for each domain - problems, medications, allergies, labs etc.    SNOMED-CT and LOINC are the default vocabularies used whenever possible.   The committee approved these recommendations by consensus with 2 caveats

-the Implementation Workgroup will be charged with ongoing review of the implementation burden of using these standards in a variety of settings
-the September meeting of the HIT Standards Committee will include discussion of a transition plan for those vocabulary standards required for Stage 1 that are being retired/replaced in Stage 2.

Marc Overhage presented best practices for patient matching, identifying the metadata that should be standardized in patient records and health information exchange.   These recommendations are complementary to the metadata standard recommendations in the Advanced Notice of Proposed Rulemaking, enabling stakeholders to optimize a patient matching strategy as needed for their applications using best practices and evidence from industry experience.

Chris Chute presented the recommendations for public health standards  - one HL7 2.51 implementation guide for surveillance, one HL7 2.51 implementation guide for immunizations and one HL7 2.51 implementation guide for reportable labs.   The optionality specified in meaningful use stage 1 was eliminated and the end result is simple un-ambiguous implementation guides for public health.

Dixie Baker presented the preliminary recommendations for building blocks that support data exchange in both "push" and "pull" models.   The key innovation in Dixie's work is the process for reviewing existing standards for appropriateness, adoption, maturity, and currency.

Jitin Asnaani from ONC presented the S&I Framework update including Certificates, Lab Results, Transitions of Care, and Provider Directories. These will be reviewed and hopefully turned into guidance for ONC in the next few months.

Finally, Judy Murphy and Liz Johnson presented their work on certification criteria.

A remarkable meeting from a world class team.  I'm proud to be a part of it!

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The Role and Future of HIT in an Era of Health Care Transformation

Today I'm at George Washington University's "The Role and Future of HIT in an Era of Health Care Transformation Symposium" serving as moderator of a panel discussing the barriers and enablers to health information exchange, including the impact of PCAST Work.

We began the day with an introduction from Dr. Alfred Hamilton, assistant professor, The George Washington University School of Public Health, and Dr. Ward S. Casscells, professor of medicine and public health, The University of Texas Health Science Center at Houston.   Drs. Hamilton and Casscells organized the conference so that stakeholders and policymakers could discuss barriers and enablers to creating a connected, learning healthcare system.

Paul Egerman, retired CEO/software entrepreneur, educated the group about the PCAST report's main ideas - accelerating interoperability through the use of a universal exchange language (UEL) and a data element access service (DEAS).  Reviews of the report thus far have raised policy and operational feasibility concerns, suggesting  pilots and an incremental approach to implementing its ideas.  The Office of the National Coordinator has released an Advanced Notice of Proposed Rulemaking containing the PCAST-related metadata recommendations from the HIT Standards Committee.   As a next step, PCAST ideas will be tested using CDA R2 headers to identify the patient, the provenance of the data, and privacy flags, ideally in the PHR to EHR data exchanges described below.

Dr. Stephen Ondra, White House Office of Science and Technology Policy, presented an overview of the impact that interoperability and data sharing will have on healthcare systems, providers, healthcare purchasers and patient advocacy groups.   He noted that HIT is not a goal in itself but is a critical foundation for health reform efforts.  The Obama administration has recommended a portfolio of approaches rather than one size fits all health information exchange.   Choices include query/response "pull" (Exchange type), directed "push" (Direct type) and consumer based viewing (Blue Button type).  

Dr. Farzad Mostashari, national coordinator for health information technology, discussed how interoperability and data sharing support the stages of meaningful use.   He identified the issues we've all been diligently working on - standards, governance, architecture, creating trust, and sustainability.   He thanked the HIT Policy and HIT Standards Committee for their hard work- an average of a meeting every other day for the past 2 years.    He noted that our policy drivers are quality, safety, efficiency, public health, and patient centeredness while protecting privacy and security.    He emphasized the use cases with early wins - laboratory report exchange, e-prescribing, and patient summary sharing.   He suggested the need for bold incrementalism - balancing innovation with the reality of implementation cost and timing.    The recent debt ceiling negotiation illustrates that we cannot afford to pay for more healthcare quatity, instead we need to pay for quality and value.  Healthcare IT is foundational to new reimbursement models and needs to be available for every stakeholder, large and small.

I had the opportunity moderate a panel discussion of policy and technology enablers and barriers to healthcare information exchange.   Participants included

*Dr. Farzad Mostashari
*Dr. Stephen Ondra
*Ms. Christine Bechtel, vice president, National Partnership for Women and Children
*General Douglas Robb, joint staff surgeon, Office of the Chairman, Joint Chiefs of Staff, the
Pentagon

Major themes of the dialog included

*Consumers can be effective stewards for their own summary data and care plans, but there needs to be standards-based, easy to use, automated interfaces between EHRs and PHRs before there will be significant adoption of PHRs.  One easy way to do this is a certification criterion for every EHR and PHR to support the Direct specifications, enabling providers to send patient summaries to any PHR without requiring custom interfaces.   PHRs need to be more than just passive containers for data.   Ideally there will be an ecosystem of applications which enable patients to seek second opinions, obtain personalized educational materials, and enroll in clinical trials using their PHR data.

*Although HITECH incentives are great in the short term, the best way to foster healthcare IT adoption in the long term is to ensure it supports workflow, saving time and bringing value-added services to providers, payers, and patients.   John Rother from AARP noted that online appointment making, referrals, and medication renewals have high value to patients.  Such transactions are not typically offered by standalone commercial PHRs.

*The culture of healthcare needs to be changed so that providers and patients expect healthcare information exchange at every patient encounter.   A culture change will create market demand for healthcare information exchange.   Patient and provider trust in the data integrity and privacy of healthcare information exchange is a pre-requisite to culture change.

*Healthcare reform will create incentives for health information exchange, since payments for wellness will require community-wide care coordination and decision. support.  The Patient Centered Medical Home is likely to become an electronic medical home that receives all data about patients from labs, pharmacies, hospitals, specialty practices, and home care devices.

*There needs to be innovation in care models, services, and technologies.   Although the government can catalyze innovation, the private sector will need to fund ongoing efforts, since grants are only short term and are not a sustainable business model.

The audience was very engaged in the discussion and there will be a whitepaper summarizing the conference.  A great meeting.   Thanks to Drs. Hamilton and Casscells for organizing it!

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The Importance of Corporate Culture

Can one person make a difference in a large organization?

Absolutely.

Although many modern executives operate under such regulatory constraints that they have infinite responsibility but limited authority,  a single person can create a corporate culture that impacts everyone's work experience.

What do I mean by creating the corporate culture?

While flying back from Japan, the in flight magazine on All Nippon Airways featured an article about Zappos' corporate culture noting that the CEO has created an environment which emphasizes fun, creativity and happiness in the workplace.  Happy employees deliver great customer service without needing micromanagement or clandestine monitoring of every conversation.

When evaluating leaders we often think of characteristics such as vision, interpersonal skills, commitment to quality, staff engagement, financial acumen, ability to raise money, and domain expertise.

However, we rarely consider their impact on corporate culture.  It can make a huge difference.

In my professional life, I've had two dozen bosses, each with a different style, approach, and culture.

Here's a few questions to ask about your culture

1. Do you arrive at the office every day thinking about the joy of success or the fear of failure?  Are you supported such that a negative outcome is a learning experience that results in policy or process change to improve the organization rather than blaming the person who caused it?

2. Is communication open and transparent, or guarded and reserved?

3. Do managers share accountability and see their role as enabling your success, or are they pugilists who punish unmet goals by screaming louder?

4. Do you have clear expectations for the work you do and clear metrics for success?

5. Is loyalty and trust valued?  Is hierarchy respected or is your authority undermined by senior executives who work around you?  Would you trust your boss to hold your rope?

6. Do staff feel respect and admiration for their colleagues such that there is a family-like atmosphere in which people will go the extra mile for each other?

7. If someone impedes the work of others through passive aggressive behavior or scheming for their own self interest, is it tolerated?

8. Is everyone empowered to make a difference?  Are policies and procedures clear so that they know how to make a difference?

9.  Are all emails/communications asking for guidance answered promptly?

10.  Do you feel positive energy about the possibilities ahead when you wake up each day or does each day end in a tailspin of emotional exhaustion?

Throughout my career I've worked in positive cultures and negative cultures.   I do whatever I can to create a positive culture in the organizations I oversee.  It's not always possible to create a positive culture within a larger organization that has a negative culture, but we should all try.

May you always work in a positive culture and if you do not, have the wisdom to seek a better place!

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Cool Technology of the Week

While in Japan last week, one of my lectures focused on emerging privacy and security issues.  I highlighted the fact that increasingly sophisticated malware can breach every defense we put in place and that our best strategy is early detection when prevention fails.

Such an approach works well when the risk for damage is minimal.  But what happens when the malware infects a medical device such as a smart pump or pacemaker?   The risk of harm is far more dire than data integrity and includes physical harm up to an including death.

Sound far fetched?

This article illustrates that many of the command and control systems  used in medical devices have inadequate security protections.

Hacks and malware aren't cool, so my cool technology of the week is a plea to the medical device industry - you need to engineer new devices with hardware level safeguards that impose sanity checks on the commands being given.   Use encryption to protect all data transmissions and data at rest.   Set limits on the minimum and maximum amounts of insulin that should ever be injected into the patient.   Assume that hackers will penetrate and take control of the device.

We need your innovation now and that will be very cool.

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Our Lives Together

Monday, August 8 was my 27th wedding anniversary.   My wife Kathy and I met at Stanford on September 1, 1980, so we've been together for 31 years.  That means that we've spent two-thirds of our lives on this planet together.   We've been collaborators, soul mates,  homeowners, parents, and friends together.   For three decades, our relationship has just worked.   Here's why.

My entire life has been math/science/engineering - digital, white and black, linear, orderly, and left-brained.

Kathy's entire life has been the visual arts/humanities/creativity - analog, splashes of color, wabi sabi, Victorian clutter, and right-brained.

Our talents are entirely different, our approaches complementary, and we never compete on any level.

In our 20's we were vigorous hiking partners and built a home together.

In our 30's we focused on raising a young child.

In our 40's we created stability by planning for the future, caring for our parents, and preparing our child to leave the nest.

In our 50's we're likely to travel, create, and tend our garden together.

In our 60's and beyond we're likely to create a Japanese inspired wilderness retreat to serve as a home base between experiences around the world that are part of our work lives, volunteer lives, and personal lives.

We've evolved together and continue to expand and refine our relationship every day.

When I read literature from the scientific and lay press about the "seven year itch", it makes me realize that needs change, people change, and relationships need to change over time if they are going to last.

In your 20's you're likely at the peak of your physical life with more endurance, strength, and biological resilience than any other era.   You can climb mountains and if you fall you bounce.

In your 40's, you're likely to be at the peak of your mental life with more experience, intellectual agility, and intuition than any other era.   You can climb mountains, but if you fall you break.   You're more likely focused on your 401k than your surfboard.

In your 60's you're likely to be at the peak of your financial life with more savings, more earning, and stability than any other area.   If you've kept up your workouts and managed your diet, you can climb mountains, but if you fall, you shatter.   You're more likely to be focused on supporting your children and aging parents, than thinking about a bleached blonde in a red convertible (unless you're a Congressman…)

If you and your partner are perfect for each other in your 20's, you may not be perfect in your 60's unless you adapt to your changing bodies, changing needs, and changing abilities together.

Kathy and I have been able to do that.

We've always treated each other as equals - there has never been a superior/subordinate aspects to our home lives, work lives, or family lives.   Our division of labor is not cast in stone, it remains fluid based on the schedule and needs of each day.  We share housework, we share parenting responsibilities, and we support each other's career.

Of course, we've had stress, anxiety, joy, sadness, and conflict along the way, that's life.  But we've been able to weather the challenges, relish the successes, and treat each other fairly along the way.

This month we become empty nesters as our daughter begins her college life at Tufts on August 31.   The house will seem quieter, the schedules will change, and our roles will need to evolve again as we focus more time on each other and our careers while our daughter becomes increasingly independent.   It's another risky time for relationships.

But we'll navigate the transition, overcome the sense of loss, and plan our future together.

Given human life expectancy, we're likely to live another 31 years (I'm using Japan rather than US because our diet and lifestyle are distinctly Japanese).   That means that Kathy and I are only halfway through our life together.

Happy Anniversary, Kathy.  The second half of our time together will be even better than the first.   I love you and always will.

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Should Public Health Professionals "Give A Shit" About MTV's New Campaign?

Has anyone else seen #giveashit on Twitter in the past few days? MTV has launched the "Give a Shit" campaign to increase civic engagement and encourage people to voice their concerns for any issue about which they are passionate. Many are voicing concerns about important public health issues like access to clean water. Great way to engage young people, right? Using a play on words. Using foul language. But the question remains- what are the goals of the campaign? Will the campaign actually improve public health?



The primary strategy for messaging about the campaign is a YouTube video featuring Nikki Reed (of Twilight fame). The tone of the two-minute video is hard to classify. In some ways it appears to be a parody of a real PSA (e.g., it simulates Nikki on the toilet so she can use that time to "give a shit"). But then it seems to have genuine moments when it motivates people to join a movement- any movement. Nikki tells viewers that all they have to do is "give a shit". It doesn't matter if they don't actually DO anything...if they CARE, then the world's problems will cease to exist.



As you can imagine, I take issue with this premise. So much of what we know in public health is based on evaluation data that has shown us that "knowledge" does not equal behavior change. "Increasing awareness" about pregnancy does not eliminate unprotected sex. Having the "intention" to stop smoking does not help when someone is addicted to nicotine. Therefore, it is unclear to me how just caring about an issue like access to clean water will result in positive change.



Next, the video goes on to say that once you care about the issue, you should alert your social networks. It shows images of posts to Twitter like, "I just gave a shit about global warming". So I went into Twitter to see if it is actually happening, and it is. The #giveashit hash tag is alive and well and users are reporting that they care about children with special needs, animal cruelty, etc. But again, I'm still at a loss as to how this "caring" and "twitter posting" actually leads to an increase in positive civic engagement. I tried to look for additional information on their website: www.give-a-shit.org but the site is not currently functioning. That is a problem as well. If the goals of the campaign are already unclear, it does not help that users cannot access information beyond the YouTube video. Several advocacy websites offer a brief overview of the campaign that may be helpful in the absence of a functioning website.



So while the play on words is "cute" and I appreciate a campaign that aims to combat the apathy that can be rampant regarding serious public health issues...I don't understand how this campaign will actually change behavior. And no- I don't agree that just caring about an issue will make all problems go away. If it did, we in public health would be out of a job.

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Media Must Cover Suicides Cautiously- In Today's Philadelphia Inquirer

An editorial that I co-authored ran in today's Philadelphia Inquirer. The piece is in response to media coverage of the suicide of a Philadelphia Firefighter. In a previous blog post following a celebrity suicide, I discussed the public health implications of the media coverage that follows. It can either encourage negative behavior in the audience by including unsafe and unnecessary details like detailing suicide methods...or it can encourage positive help-seeking behavior by including resources like the National Suicide Prevention Lifeline. I encourage all bloggers, communication professionals, and journalists to review the expert recommendations on how to safely report on suicides.

I look forward to hearing your comments!

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Healthcare is Different

I'm often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I'm going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here's an inventory of the issues

1.  Flow of funds - Hospitals and professionals are seldom paid by their customer.   Payment usually comes from an intermediary such as the government or insurance payer.  Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

2. Hiring and training the workforce - Important members of the workforce, the physicians delivering care, are seldom employed by the hospital.   This is rare if not non-existent in any other industry.  It's as if Toyota built a factory that anyone can use but does not hire or train the workers who build cars.   If someone wanted to create a Toyota with wings and an outboard motor, they would have the freedom to do it.

3. Negotiating Price - Reimbursement no longer is based on a price schedule hospitals and professionals can control.   It is based on a prospective payment model such as DRGs that someone else designs and dictates.   Where else in the US do prices get dictated to a firm?

4. Establishing referral relationships - We cannot market services to those who control our patient flow due to Stark anti-kickback regulations.   In other industries, you can build relationships, offer special incentives, and arrange mutually beneficial deals to develop your referral business.   In health care, it's illegal even when unilaterally funding an action would make things easier for both parties and the patient.

5. Standardizing the product - In most industries, the product or service can be standardized to improve efficiency and quality.   In health care, every person is chemically, structurally, and emotionally unique.   What works for one person may or may not work for another.   In this environment, it is difficult to standardize and personalize care in parallel.

6. Choosing the customer - In most other industries, you can chose with whom you do business.    Not so in health care.   If you have an emergency department, you must provide treatment even if the customer has no means to pay.

7. Compliance - Data flows in healthcare in increasingly regulated.    What other business, including the IRS, is required to produce, on-demand, a three year look back of everyone who accessed your information within their firm.

As I noted in my recent post about the Burden of Compliance  "the more complex a health system becomes, the more difficult it becomes to find any system design that has a higher fitness."

We are successfully automating healthcare workflows, motivated by HITECH incentives and the requirements of healthcare reform.   The 7 characteristics above have required vendors to create full featured software applications and organizations to create complex rollout/funding models that take time.  By 2015 we will be there and I will be proud of all we've accomplished, given that the constraints on the healthcare industry are truly different than industries which have been earlier adopters of technology.

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A Tale of Telecom Woe

My wife and her business partner have tried for weeks to get a large telecom provider to reactivate an existing DSL connection to their art gallery.   However, they will not do it per an official letter which states that my wife has an outstanding balance of ZERO and until that balance is paid, no further work can be done.

As Joseph Heller would have written - you do not have an account and you owe nothing.   Until you pay us nothing on an account you do not have, we cannot give you an account.

Numerous phone calls to the telecom's service centers have been answered by people who will not give their full names or contact information.

No one seems empowered to solve the problem, there is no accountability, and no possible escalation.

How can a company with such great technology have such onerous customer service?   I'm a CIO so I understand the challenges of running a large organization.   I accept variability in individual employee behavior.   What I cannot tolerate is weeks of effort across many employees that demonstrates this telecom provider has lost control of its own business processes.

Here's my wife's account of the struggle thus far.

"We would simply like to contract for internet and phone in a commercial building. We are a registered LLC with a 4 year lease, in the second year of operations with this landlord.

Business partner Natacha Sochat is so frustrated that we will need to start reviewing our alternative options. We have been operating our business without phone and internet since May 3 and need to start service as soon as possible.

NK Gallery LLC (Massachusetts) was established January 2010 by business partners Natacha Sochat and Kathy Halamka.  Our initial location beginning February 2010 was 460 Harrison Ave #17, Boston, MA 02118.

On May 1, 2011, we relocated to a larger space at 450 Harrison Ave #61, Boston MA 02118 (current lease runs to November 2014).  The landlord/property manager is the same in both locations - GTI Properties.

The 450 Harrison building space #61 has preexisting writing, so we wish to purchase your phone and internet service.

On May 3, 2011, Natacha initiated contact.  Your business services informed Natacha they would not proceed with our application until we updated the lease to prove we were a real business in the 450 Harrison #61 location.

On May 20, we obtained a finalized signed lease from the landlord. The lease includes our personal names, Kathy Halamka and Natacha Sochat, as this is the standard policy of the landlord, consistent with our prior lease in the 460 Harrison building.

On May 23, Natacha devoted the entire day to resolving this issue.  Natacha visited your website and spoke with Laura.  She was helpful and pleasant, but could not navigate your internal business operations.

Natacha called the your Credit Center twice while Laura was on the phone with her.

Four hours later, Natacha received a "denial of lease" fax.

Natacha again called your Credit Center and spoke with a heavily accented woman.   The representative said she had no idea why the application was denied but told Natacha it may be because the lease refers to people rather than a corporation as the tenant.

Laura had no insight as why NK Gallery had been tormented, as no one else that day had been required to call your Credit Center, and when Laura  called her fellow employees at the Credit Center they would not explain it to her either!

Laura advised Natacha to speak with a supervisor at your Credit Center.  Natacha spoke with a supervisor and he would only tell Natacha his first name, Travis.  He refused to provide any further contact information.  He was very challenging to understand and requested many additional documents. (IRS, Fed ID documents etc).  Natacha asked him to send her an email with a list of the documents he needed.  She asked him if she could respond via e-mail instead of fax.  He said no - the  Credit Center cannot print anything, so fax is required.

You then sent a letter refusing to offer services until we paid a ZERO balance on the account that had not yet been created."

So there you have it.   We tried desperately to give this telecom the business, but they refused.

As a test, I used my role as CIO and a major purchaser of services to escalate this Catch 22 situation and instantly received numerous offers of help from the telecom's Director and VP level.   I chose not to pursue those offers and the gallery purchased services from  a competitor.   A CIO with a multi-million dollar budget should not be required to get simple DSL service!

There's a point at which companies get too big and lose touch with their customers.   This particular telecom is a case study in broken business processes.

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