One of the issues that any medium- to large-organization can encounter is how to deal with requests that place a requirement of work from one department to another. Specifically, requests for something shiny and new (especially technology).

In the first educational session of the day, Strategic Portfolio Management: “Governing the Ungoverned” I heard Effie Econompolous discuss UI Health’s transformation from an organization that had very little control over their IT projects to one that has transformed into a highly regulated Project Management Organization.

My key takeaways from this talk were:

• segregation of Projects (with a capital P) from Incidents and Problems
• The IT Roadmap was posted on the intranet for all to see
• Projects that are ‘IT’ related don’t just include the time of resources from IT, but also time and resources from impacted departments throughout the organization

These are some amazing points. My only real question was, If you segregate Projects from Incidents and Problems, how do you ‘train’ users for Project submission. How are they do know the difference between the two (sometimes users aren’t even sure which system is broken when reporting problems in the first place). I’m not sure of the answer, but I’m sure it’s just thought more education and tighter controls over submission of requests.

There was a real time poll during the session which asked, ‘What is the most significant challenge in your organization?’. Fifty percent of attendees that responded indicated inconsistent priorities as the (which is what I answered as well). Turns out, we’re not alone.

A lot of the talk focused on the process that UI Health uses which had gone through 3 iterations in 2 years. It seemed like it would work for a large(ish) hospital or hospital system, but seemed too bureaucratic for my organization.

Overall, a very good talk and I’m glad I went. I believe I have some real actionable ideas that I can take away.

My second educational session of the day Improving Patient Health Through Real-Time ADT Integration I heard about a Managed Medical Group from Minnesota and their journey to get ADT feeds into the Care Management system.

I was hoping to hear something a little more helpful, but while their situation was similar to the one we have at my organization, it was different enough that all I really heard was that, although my organization doesn’t have ADT feeds (yet) we seem to be a bit ahead of them in many other areas of managed care.

The tips that they offered up (getting user buy-in, working through issues with all of the various vendors) were things I had already known would need to be done.

One thing I did hear, that I hope I don’t have to go through, is a ‘Live’ testing process where we get all of the vendors, hospital IT and group IT on the phone to test the system in a ‘Live’ environment to identify deficiencies.

I also hope that any user manual we have to create isn’t 70 pages like the one they have (eeek!!!).

I think it will also be important to have metrics regarding efficiencies before and after any ADT implementations to make sure that we have actually done something helpful for the organization and the member.

My third talk Closed Loop Referral Communications was a bit of a disappointment. A group from North Carolina reviewed how they closed the loop on referral management.

I was hoping for some key insights, but it ended up being mostly about stuff that we had already done (identifying workflow issues, automating where possible) but they still have a fundamental issue with external provider referrals (just like us). I guess I was just hoping that someone would have solved that problem, but if they have, they aren’t sharing the information.

My forth session Breaking Down Barriers with Master Data Management and Data Governance was really interesting and in the same vein as the first talk of the day.

Several good points mentioned during the talk:

• Limited access to data leads to duplication of efforts and numerous sources of the ‘truth’
• If you have Tech and People then you get ‘automated chaos’ ... this is why we NEED process
• Difficult to turn data into actionable information
• Significant barriers to accessing information
• use reference data regarding report creation ... instead of asking the report requester questions, you need domain experts to define various categories (Diabetes, sepsis).
• Best Version of the Truth and Golden Record ... need to review this and see how it applies to DOHC/AZPC

The most astounding thing I heard was that each report costs between \$1k and \$5k to create ... 40% are used 5 times or less! What a source of potential waste that could perhaps be ‘solved’ by self service. We need to have metrics that show not many reports have we created, but instead how many are bing used!

The lessons learned by speaker :

• Governance: keep information at forefront for all front line areas
• Governance: not a one time effort, it’s on-going
• KPI Standardization: requires resilience
• KPI Standardization: processes that work around the system need to be identified and brought into the fold

The fifth talk of the day From Implementation to Optimization: Moving Beyond Operations. Much of what was presented resonated with me and was stuff that we have dealt with. It was nice to know that we’re not alone! The most interesting part of the talk were the 2 polls.

The first one asked, “Do you use an objective tool for prioritization of incoming work?” Most responses were for No, but would be interested (47%); next response was yes but we bypass (32%). Only about 20% have one, use it and it’s effective

The second poll asked, “Do you collaborate with Clinical Stakeholders?” Most responses were yes and split 2-1 between Yes and there’s tension to Yes and we’re equal partners (which is where I think we’re at).

My Last talk of the day, How Analytics Can Create a Culture of Continuous Improvement. It was an interesting talk that focused on using Analytics to drive continuous improvement. Some of the things that really caught my attention were the ideas of implementing continuous improvement is part of the job description. Part of that was something that is stated in the New Employee Orientation, “Do the job you were hired for and make it better.”

Another interesting point was that there is no one Big Bang solution for Emergency Department throughput (though the idea can be applied to any problem you’re facing). You need to look at improving each step a little bit along the way.

But, in order to do this effectively, you need data, team and a process. This reminded me of the Breaking Down Barriers with Master Data Management and Data Governance talk I was at earlier in the day!

It was a great final day at HIMSS.

I’ve learned a ton at this conference and writing about it (like this) has really helped to solidify some thoughts, and make me start asking questions.

I’ll need to remember to do this at my next conference.

Posted by ryan on Thu 08 March 2018

Day 2 was a bit more draining than day 1, but that was mostly because I made my way into the exhibition hall for the first time. That many people and that much cacophony always leave me a bit ... drained.

On the flip side I went to several good presentations (a couple on Block Chain).

Today’s sessions were:

• Empowering Data Driven Health
• Blockchain 4 Healthcare: Fit for Purpose
• The Use of Blockchain to Improve Quality Outcomes

One of the more interesting things I heard today was that in Health Care, tech spending has gone up (over the last 20 years) but so has overall health spending. Usually we see Tech spending go up and other spending levels off (or goes down!).

Something else to consider (that I never had) was that “we need to think about doing what’s most cost effective for a person in their lifetime not just episodically!

The Blockchain sessions I went to were enlightening, but I’m still not sure I understand what it is and how it works (perhaps I’m just trying to make it more complicated than it is).

That being said, the consensus was that Blockchain is not a panacea for all the ails us. It is a tool that should be used in conjunction with current systems, not a replacement of those systems.

Something else of note, there isn’t a single implementation of Block Chain, there are almost 20 variations of it (although the IEEE is working on standardizing it). This leads me to believe that it is simply too new and too ‘wild’ to be implemented just yet.

That being said, I think that if/when Microsoft bundles or includes BlockChain (in some way) into SQL Server, then it might be the time to look at implementing it in my organization.

In my last session (another on eon BlockChain) the idea of using BlockChain to effect quality measures was discussed. The main point of the speaker was that Blockchain may allow us to give agency to patients over their health data.

Another interesting point was that Blockchain may be able to allow us to dynamically observe quality measurement instead of just at point of care. This could lead to higher quality and lower costs.

Overall, the BlockChain talks were good, and kind of helped point me in the right direction on what questions to start asking about it.

Well, day 2 is in the books. One more day of educational sessions and exhibits!

Posted by ryan on Thu 08 March 2018

I was able to make it to 5 educational sessions today. And the good thing is that I learned something at each one. I think the highlight of the day for me was actually my first session titled, Stacking Predictive Models to Reduce Readmissions.

A couple of key things from that presentation was the idea of focusing on a patient that readmits, not just from a clinical perspective, but from a human perspective. There were lots of technology that they used to help the care coordinators identify who was going to readmit, but the why of the readmission was always done via human interaction. I think that may be the single most important thing to remember.

Something else that was mentioned was that the grou got their tool out quickly instead of trying to be perfect. It went through a couple of iterations in order to get a tool that was usable by all their various clinics.

Some other key takeaways from today:

• We need to focus on Augmented Human Intelligence instead of Artificial Intelligence (from How Machine Learning and AI Are Disrupting the Current Healthcare System)
• Don’t treat Cloud Service Providers as Plug and Play vendors (from HIPAA and a Cloud Computing Shared Security Model)
• Creation of a committee of ‘No’ to help flesh out ideas before they are implemented (from Intrapreneurship and the Approach to Innovation From Within)
• Think about how to operationalize insights from data, and not just explore the data (from Beyond BI: Building Rapid-Response Advanced Analytics Unit)

That’s a wrap on day 1 at HIMSS. Day 2 looks to be just as exciting (meet with some vendors, attend some more educational sessions, go to a sponsored luncheon).

Posted by ryan on Wed 07 March 2018

The thing about HIMSS is that there are a lot of people. I mean ... a lot of people. More than 43k people will attend as speakers, exhibitors or attendees.

Let that sink in for a second.

No. Really. Let. That. Sink. In.

That’s more than the average attendance of a MLB game of 29 teams. It’s ridiculous.

As an introvert you know what will drain you and what will invigorate you. For me I need to be cautious of conferencing too hard. That is, I need to be aware of myself, my surroundings and my energy levels.

My tips are:

1. Have a great playlist on your smart phone. I use an iPhone and get a subscription to Apple Music just for the conference. This allows me to have a killer set of music that helps to drown out the cacophony of people.
2. Know when you’ve reached your limit. Even with some sweet tunes it’s easy to get drained. When you’re done you’re done. Don’t be a hero.
3. Try to make at least one meaningful connection. I know, it’s hard. But it’s totally worth it. Other introverts are easy to spot because they’re the people on their smart phones pretending to write a blog post while listening to their sweet playlist. But if you can start a conversation, not small talk, it will be worth it. Attend a networking function that’s applicable to you and you’ll be able to find at least one or two people to connect with.

The other tips for surviving HIMSS are the same for any other conference:

1. Don’t worry about how you’re dressed ... you will always be underdressed when compared to Hospital Administrators ... you’re in ‘IT’ and you dress like it
2. Wear good walking shoes (see number 2 about being under dressed)
3. Drink plenty of water
4. Wash your hands and/or have hand sanitizer
5. Accept free food when it’s offered

Ok. One day down. 3+ more to go!

Posted by ryan on Tue 06 March 2018

This last weekend was the divisional round of the NFL playoffs. There were 3 really good games and the game that the Patriot played in. This is unfortunate because I only had the Patriots game on the calendar for the weekend so that meant other things could get scheduled whenever and I would end up missing many, if not all, of the other games.

Sunday had 2 amazing games. The Steelers lost to the Jaguars in an upset and I got to see the last drive that put the Steelers down by a Field Goal as time expired. It was simply amazing to see how hard they played even though they must have known that they weren’t going to win.

When I got home from being out the New Orleans at Minnesota game was at half time with Minnesota up 17-0. It looked like it was going to be a route and I was glad that I wasn’t really watching it.

I started to do the chores that needed to be done (laundry, straightening up, getting ready for the week) and had the game on in the background.

And then the improbable started to happen. Drew Brees played an amazing half of football and all of a sudden it’s 21-20 New Orleans. After a couple of field goals are exchanged it’s 24-23 New Orleans with Minnesota in possession of the ball.

Case Keenum had made a couple of errors earlier in the game (one interception lead to a touch down and really helped the Saints get back in the game). It looked like he was on track to do something similarly ill-advised.

Then, with 10 seconds left the bar is snapped and he passes the ball to Stefon Diggs who catches the ball. And just as he catches the ball Marcus Williams, a defensive back for New Orleans is cued up to make an ordinary tackle in an extraordinary situation.

I was only on my high school football team for 2 years, but one thing the coaches were always on us about was wrapping up the ball carrier when we were going to tackle. “Wrap him up” they’d scream at us. Over and over again.

It became something we did just so they’d stop yelling at us (for that anyway).

So Marcus Williams is getting ready to tackle Stefon Diggs and all he has to do is “Wrap him up!” But something inside of Willliams’ head is saying, “Sports Center highlight” and instead of going for the boring, but effective arm wrapping tackle, he tried to hit Diggs with his shoulder to hopefully get the ball to be knocked loose.

Instead, he whiffs by Diggs who spins, plants his hand on the ground to stay up and proceeds to run 60 yards for the game winning, walk-off, touchdown.

I truly believe that Williams was thinking about how cool it would be to get on Sport Center when he was deciding how to tackle Diggs, and that cost the Saints the game.

Dear Sports center, stop making our sports be bad and our athletes make dumb decisions. Can you just go away now. Ok, thanks, bye

Posted by ryan on Sun 04 February 2018

I started writing my last post on my iMac but because Apple Photos is a bit ... finicky with the iCloud syncing a screenshot I had taken on my iPad wasn’t there.

No fear, just keep writing in Ulysses, then move from the iMac to the iPad and drop the image in. It worked, no problems no fuss. It just works.

Now, if only iCloud would just work ...

Posted by ryan on Fri 15 December 2017

This weekend I migrated my site from Square Space to WordPress. I had been planning to do this for a while (ever since a Hover ad read on ATP earlier this summer). This weekend was the last weekend before my Square Spacesubscription was set to expire so I finally made the switch.

Why I did it

Square Space offers a beautiful interface and great templates to get you started. They make everything about setting up a blog, portfolio or online store as easy as it can get. But ... that’s kind of where it ends for me. While the set up is amazingly easy, the actually content posting (for me this means my writing) was more difficult than I would have liked.

In order to get something posted to my Square Space site I would write something in anyone of a number of Plain Text Editors (BBEdit, Drafts, Editorial, Ulysses). Then I would preview the generated HTML to verify it looked the way I wanted it to. Finally, I would post my MarkDown to the Square Space Blog App on iOS and do it All. Over. Again.

To say that it was frustrating is a bit of an understatement. I looked really hard to see what APIs existed and found that there used to be an API but that Square Space removed them for some reason. So no direct posting to my blog by my favorite text editors.

So, with Hover having a discount on domains, and me getting an AWSaccount where I could host WordPress and a rich set of WordPress APIs to post directly from some of my favorite text editors, it seemed like a no brainer to make the switch.

How I set up my Wordpress Install

The AWS ecosystem has some amazing documentation on how to do just about anything that you want. So, instead of laboriously taking screenshots and writing up what I did, I’ll just link to Amazon’s Launch a WordPress Website tutorial

Exporting from Square Space to Wordpress

For all the pain it was to get content into SquareSpace, it was a breeze to get it out. Again, no need to get screenshots or write it up if I can just link to it instead!

What I hope to gain from it

As I wrote earlier my main reason for leaving Square Space was the difficulty I had getting content in. So, now that I’m on a WordPress site, what am I hoping to gain from it?

1. Easier to post my writing
2. See Item 1

Writing is already really hard for me. I struggle with it and making it difficult to get my stuff out into the world makes it that much harder. My hope is that not only will I write more, but that my writing will get better because I’m writing more.

Ulysses integration

With all of that, what has my experience been with writing my first post to my WordPress site?

This entire post was written and edited in Ulysses. I was able to preview my post in Ulysses. I was able topost my content to the site with Ulysses. Basically, Ulysses is a kick ass app and on day one of the conversion, I’m about as happy with a decision that I can be given the short amount of time since I’ve made it.

Posted by ryan on Sun 01 October 2017

Podcasts I like:

• Accidental Tech Podcast
• Cortex
• Free Agents
• Connected
• Talk Python to Me
• Canvas
• Robosim
• Ben, Ben and Blue
• Mac Power Users
• Upgrade
• Back to Work

Posted by ryan on Sun 24 September 2017

As a a manager no one will ever agree with every decision you make. Not the people you manage, and not the people that manage you. But if you always know why you made a decision and you can articulate that decision, then you’ll be on a good footing when someone asks you, “How did you know to do that?” or “How did you know to make that decision?”

One of the best lessons I learned from my boss LB is that the decision is less important than the why of the decision. Make no mistake, bad decisions are bad decisions, but they are much less likely to be made if you know why you made it.

Once I was able to internalize that lesson, it freed me to actually make decisions.

When faced with a decision, I tend to ask these questions:

1. What do I know?
2. How do I know it (i.e. how confident am I in the information I know)?
3. What do I gain by waiting for more information?
4. What’s the worst that happens if I make the wrong decision?
5. What’s the worst that happens if I make no decision now?
6. Who can I talk to about this decision?

Having answers to these questions doesn’t guarantee that my decision will be right, but it does help me to understand why I’m making the decision that I’m making. It will also help me to explain the decision later on if needed.

One of the things I try to tell the people I work with is this:

The decision itself is less important than why you made the decision. If you don’t know why you made a decision, then you shouldn’t be making the decision yet.”

Know why you made a decision and you’ll be better equipped to make the decision.

Posted by ryan on Thu 24 August 2017

The Technical Debt of Others

Technical Debt as defined on technopendia is:

a concept in programming that reflects the extra development work that arises when code that is easy to implement in the short run is used instead of applying the best overall solution.

In the management of software development we have to make these types of easy-to-implement-and-we-need-to-ship versus need-to-do-it-right-but-it-will-take-longer decisions all of the time.

These decisions can lead to the dreaded working as designed answer to a bug report.

This is infuriating.

It’s even more infuriating when you are on the receiving end of this.

A recent feature enhancement in the EHR we use touted an

Alert to let proscribing providers know that a medication is a duplicate.

For anyone in the medical field you can know what a nightmare it can be to prescribe a duplicate medication from a patient safety perspective, so we’d obviously want to have this feature on.

During our testing we noticed that if a medication was prescribed in a dose, say 75mg, and stopped and then started again at a new dose, say 50mg, the Duplicate Medication Alert would be presented.

We dutifully submitted a bug report to the vendor and the responded

The Medication is considered a true duplicate as when a medication is stopped it is stopped for that day it is still considered active till (sic) the end of the day due to the current application logic, which cannot be altered or changed. What your providers/users may do is enter a DUR Reason and Acknowledge with something along the lines of "New Prescription". These DUR reasons can be added via Tools > Preferences > Medications > DUR > Override Reason tab - type in the desired DUR Override Reason > Select Add > OK to save.

If functionality and logic outside of this is desired this will need to be submitted as an Idea as well since this is currently functioning off of development's intended design.”

Then the design is broken.

From a technical perspective I know exactly what is going on. This particular vendor stores date values as varchar(8) but stores datetime values as datetime. There may be some really good reasons for making this design decision.

However, when the medication tables were designed, the developers asked the question, "Will we EVER care about the time a medication is started or stopped?"

They answered no and decided to set up a start date (and by extension an end date) for medications to not respect the time that a prescription started or stopped and therefore set them as varchar(8) and not as DATETIME.

But now they’ve rolled out this awesome feature. A feature that would actually allow providers to recognize duplicate medications potentially saving lives. But because they don’t store the time of the stopped medication, their logic can only look at the date. When it sees the same medication (but in different doses) active on the same date a warning appears letting the provider know that they have a duplicate medication (even though they don’t).

Additionally, this warning serves no purpose other than to be one more damned click from a provider’s perspective because the vendor is not storing (ie ignoring) the time.

When clinicians complain about the impact of EHRs on their ability to deliver effective care ... when they complain about EHRs not fulfilling their promise of increased patient safety, these are the types of things that they are complaining about.

I think this response from one of the clinicians sums up this issue

I don't see the logic with the current "intended design" in considering a medication that has just been inactivated STILL ACTIVE until the end of the day. A prescriber would stop current and start new meds all in one sitting (which includes changing doses of the same med), not wait until the next day to do the second step. It decreases workflow efficiency to have to enter a reason when no real reason exists (since there IS no active entry on med list). The whole point is to alert a prescriber to an existing entry of a medication and resolve it by inactivating the duplicate, if appropriate (otherwise, enter reason for having a duplicate), before sending out a new Rx.

While it's relatively easy to follow and resolve the duplication alert if the inactivation and new prescribing is done by the same prescriber, I can see a scenario where prescriber A stops an old ibuprofen 600mg Rx[\^2] (say PCP) and patient then goes to see prescriber B (say IC[\^3]) who then tries to Rx ibuprofen 800mg…. and end up getting this duplication alert. The second prescriber would almost be lost as to why that message is showing up.

The application logic should augment the processes the application was designed to facilitate, but right now it is a hindrance. (emphasis added)

I know that sometimes we need to build it fast so that we can ship, but developers need to remember, forever is a long freaking time.

When you make a forever decision, be prepared to have push back from users of your software when those decision are markedly ridiculous. And be prepared to be scoffed at when you answer their bug report with a Working-as–Designed response.

[\^2]: Rx = prescription

[\^3]: IC = Immediate Care

Posted by ryan on Fri 28 July 2017