Kathy heads to surgery tomorrow at 7am. She’ll be NPO (nothing by mouth) after midnight. She’ll wake at 5am, shower with Hibiclens (a antibacterial prep), and I’ll drive her to surgical check in. Prior to surgery, the radiology department will insert a wire adjacent to the titanium markers that were placed in her tumor at first diagnosis. Her surgeon will use this wire to guide the lumpectomy.
Her left breast will become smaller than her right. She jokes that her career in exotic dancing will come to an end.
The operating room will call me at the end of her procedure and I’ll pick her up. Since she’ll not have had general anesthesia, we’re presuming she’ll feel good enough for a bit of an extended ride home. The last of our chickens arrives on Friday (Buff Orpington’s) and we’ll pick them up as we drive back to our new farm.
We’ll anxiously await the results of pathology. If the margins on the lumpectomy tissue are clear, Kathy will start Radiation Therapy 1-2 months after surgery, likely late June or early July.
By Labor Day, if all goes well, this phase of our cancer journey will end, although our continued vigilance for reoccurrence will be lifelong.
Today, my team presented a list of risks to the Compliance, Audit and Risk Committee at BIDMC. Here’s my list of top risks for 2012:
1. Old Internet browsers – many vended clinical applications require specific versions of older browsers such as Internet Explorer 6, which are known to have security flaws. We’ve worked diligently to eliminate, upgrade or replace applications with browser specificity. At this point we are 96% Internet Explorer 8/Firefox 7/Safari 5 minimizing our risks to the extent possible.
2. Local Administrative rights – Of our 18,000 devices on the network, a few thousand are devices that require the user to have local administrative rights to run their niche applications (often the research community doing cutting edge research with open source or self developed software). We have done everything possible to eliminate Local Administrative rights on our managed devices.
3. Outbound transmissions – Security has historically focused on blocking evil actors from the internet. Given the current challenges of malware and infections brought in from the outside, it’s equally critical to block unexpected outbound activity.
4. Public facing websites – any machine that touches the internet has the potential to be targeted for attack. We’ve implemented proxy servers/web application firewalls on most public websites.
5. Identity and Access management – Managing the ever changing roles and rights of individuals in a large complex organization with many partners/affiliates is challenging. If an affiliate asks for access to an application, how do you automatically deactivate accounts when users leave an affiliate, given the lack of direct employment relationships?
It highlights the problem and a series of solutions.
Nearly half of employees report the overwhelming stress and burden of their current jobs, not based on the hours they work, but the volume of multitasking – too many simultaneous inputs in too little time. They’ve lost the sense of a beginning, middle, and an end to their day, their tasks and their projects. There is no work/life boundary.
As a case in point, I’m writing now while doing email and listening to a Harvard School of Public Health eHealth symposium. Am I being more productive or just doing a greater quantity of work with less quality?
The author of the post points to evidence that multi-tasking increases the time to finish a task by 25%. He also notes that our energy reserves are depleted by a constant state of post traumatic stress induced by our continuous connectivity.
He suggests three strategies:
1. Rather than multi-task, reduce meeting times to 45 minutes, leaving 15 minutes for email catchup and transition.
We’re halfway through the most challenging cycles of chemotherapy, Kathy has lost her hair, and her fatigue is getting worse but her mood is still very positive.
On Friday January 20th, Kathy received Cyclophosphamide (Cytoxan) 1200 mg, Doxorubicin (Adriamycin) 120 mg and her pre-chemotherapy supportive medications Fosaprepitant 150 mg, Dexamethasone 12 mg and Ondansetron 8 mg.
She tolerated it well.
Her Complete Blood Count shows that her Granulocyte Count has dropped from 6690 to 3610 since the chemotherapy affects her fast multiplying white cells as a side effect of targeting the cancer. Her hematocrit has fallen from 42 to 32. She tires more easily but her appetite is good. Small frequent meals enable her to overcome any GI symptoms.
We’ve been told that the Adriamycin/Cytoxan is the most difficult chemotherapy. Only two more cycles to go.
The photograph above shows Kathy and me at age 21 in our Stanford graduation photo. She’s always had long, luxuriant hair, even a waist length braid at one point.
On January 21st, her hair began falling out in clumps. It was not exactly painful, but felt very odd, as if her hair had not been washed in months and just did not lie on her scalp properly. In consultation with her cancer survivor friends, she decided to shave it off. Her hairdresser gave her a “GI Jane” cut realizing that the small hairs left will fall out soon, but in a more manageable and comfortable way. I seriously considered shaving my head in solidarity, but she asked me not to.
Last week, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid. The nation should be grateful that such a visionary was at the helm. The nation should frustrated that he was never confirmed.
Berwick listed five reasons for the enormous waste in health spending:
*Patients are overtreated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.
In the era before Blackberrys, iPhones, instant messaging, social networks, and blogs, I had a predictable day.
I could look at my week and count the meetings, lectures, phone calls, writing, and commuting I had to do.
Although my schedule was busy, I could schedule exercise time, family time, and creative time.
Today, I would not describe my work day as linear or predictable. I do as much as I can, attending to every detail I remember, and hope that by the end of the week the trajectory is positive and the urgent issues are resolved.
Here’s what I mean.
Since there are no barriers to communication, everyone can communicate with everyone. Every issue is escalated instantly. Processes for decision making no longer involve thoughtful stepsthat enabled many problems to resolve themselves. We’re working faster, but not necessary working smarter. We’re doing a greater quantity of work but not necessarily a higher quality of work.
Everyone has a mobile device and their thoughts of the moment can be translated into a message or phone call, creating a work stream of what amounts to hundreds of “mini-meetings” every day.
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.