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Tag: John Halamka

Meaningful Consent

One major issue facing private and public Health Information Exchanges (HIE) is how to ensure patients privacy preferences are respected by obtaining their consent before data is shared.

Today I met with a multi-disciplinary team of attorneys, vendor experts, and IT leaders to discuss BIDMC’s approach to private HIE consent.

After two hours of discussion, here’s what we agreed upon:

Patients and families should be able to control the flow of their data among institutions.  The ability for the patient to chose what flows where for what purpose is “meaningful consent.”

To achieve “meaningful consent” we will ask all the patients of our 1800 BIDMC associated ambulatory clinicians to opt in for data sharing among the clinicians coordinating their care.

Patients may revoke this consent at any time.

Consent for patients under 18 years old and not emancipated will be sought from their parents.   Upon turning 18, the patients themselves will select their consent preferences.

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Crafting a Social Media Policy

Today’s Computerworld has a great article about the issues of mixing social media and healthcare.

As hospitals and clinics formulate social networking policies, there are three broad considerations.

1.  Given HIPAA and HITECH privacy and breach rules, how can you best prevent the disclosure of protected healthcare information on insecure social media sites?

2.  Given the distraction factor and productivity loss that can occur with social media, how can you best align the benefits of groupware communication while minimizing the negatives?

3.  How can you reduce the security risks of malware embedded in games and other applications that are downloaded from social networking sites?

To date, Beth Israel Deaconess has focused on #1, ensuring that our employees do not post data to social networking sites in violation of state and federal laws.

We’ve not yet completed a  policy covering #2, although several hospital sites and departments are discussing the issue.

We’re developing a pilot for #3, including blocks on selected websites, Facebook add-on applications, and personal email.

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Our Cancer Journey

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.

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What Keeps Me Up at Night 2012

I’ve written several posts about the issues that keep me up at night.  Here’s what I wrote in 2011.

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?

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The Magic of Doing One Thing at a Time 

I’ve previously written about multitasking and work induced attention deficit disorder.

I’ve also written about the burden of having two workdays every 24 hours – one for meetings and one for email

Yesterday, I was sent a post from the Harvard Business Review that summarizes these issues very well.

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.

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Our Cancer Journey – Week 6

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.

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The Promise of Electronic Healthcare Records

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.

In his parting interview with the press,  he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

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
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

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My Non-Linear Work Stream

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.

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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 eConnectresigned, and Minnesota Health Information Exchange ceased operations.

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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.

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