Recently, I've met with several internet startups, web thought leaders, and venture capitalists.
There's one word that's come up in every conversation and it's not Plastics . It's Gamification
Gamification, described by Wikipedia is applying gaming principles to non-gaming applications and processes,
"in order to encourage people to adopt them, or to influence how they are used. Gamification works by making technology more engaging, by encouraging users to engage in desired behaviors, by showing a path to mastery and autonomy, by helping to solve problems and not being a distraction, and by taking advantage of humans' psychological predisposition to engage in gaming."
Whenever technologists create a cool new application, they often focus on the innovation necessary to solve a hard engineering problem rather than the user experience or how to ensure the ongoing use of the software.
Many internet companies have tried and failed (such as Google Health) to create highly usable healthcare sites, but failed to engage customers over the long term.
Although the biology behind gamification is controversial, the claim is that the human brain inherently enjoys problem solving and the dopamine-mediated emotional rewards that come with it. Sticky platforms like Facebook implement many gamification features to keep users coming back. Group competitions, customer loyalty programs, and goal achievement are all examples of gamification strategies.
We're in the midst of a redesign of the BIDMC Personal Health Record, Patientsite. Not only do we want to make it easier to use and more visually appealing, we want to ensure it adds value and becomes a destination that patients want to revisit. We'll certainly keep Gamification principles in mind.
So next time you're faced with a software redesign, think about its use more than its engineering. Replace Plastics with Gamification in your lexicon. There's a great future in it.
Monday, 14 May 2012
Friday, 11 May 2012
Cool Technology of the Week
I've written many times about the Bring Your Own Device movement (BYOD) and the need for increasing security controls.
For years, we've controlled device settings on Blackberry devices with the Blackberry Enterprise Server (BES). We force passwords, encryption, and device memory wipes for ten failed passwords so that every user has enterprise enforced security
With iPhones and Android devices it's harder to control settings and behavior on personal equipment.
We think the best we can do within the limitations of present server-side technology is to enforce the use of passwords on all devices using Active Sync, require a timeout of 10 minutes, and eliminate the use of the most simple passwords (1234, 1111 etc). Microsoft Exchange/Active Sync can query the device for the settings currently in place and only synchronize email if the device adheres to enterprise security policies.
We'll eliminate support for POP and IMAP protocols because these cannot be used to inspect and enforce desirable device settings.
We've debated the use of settings that automatically wipe the device for 10 failed password attempts, as we do with Blackberry. However, given that we cannot selectively purge corporate verses personal data, we'll likely avoid that setting for now.
BYOD management is a journey. Server side tools that inspect personal devices and only allow synchronization of corporate data such as email when settings are consistent with policies seem like a cool solution.
In the future, we may add client software (Mobile Device Management) to each device to provide more control over encryption on Android devices and permit selective memory wiping of corporate data.
I welcome comments on what others have done. BYOD is here to stay. Compliance and IT departments need to collaborate on a set of policies and technologies that will meet the needs of regulatory requirements while maintaining service capabilities and user productivity.
For years, we've controlled device settings on Blackberry devices with the Blackberry Enterprise Server (BES). We force passwords, encryption, and device memory wipes for ten failed passwords so that every user has enterprise enforced security
With iPhones and Android devices it's harder to control settings and behavior on personal equipment.
We think the best we can do within the limitations of present server-side technology is to enforce the use of passwords on all devices using Active Sync, require a timeout of 10 minutes, and eliminate the use of the most simple passwords (1234, 1111 etc). Microsoft Exchange/Active Sync can query the device for the settings currently in place and only synchronize email if the device adheres to enterprise security policies.
We'll eliminate support for POP and IMAP protocols because these cannot be used to inspect and enforce desirable device settings.
We've debated the use of settings that automatically wipe the device for 10 failed password attempts, as we do with Blackberry. However, given that we cannot selectively purge corporate verses personal data, we'll likely avoid that setting for now.
BYOD management is a journey. Server side tools that inspect personal devices and only allow synchronization of corporate data such as email when settings are consistent with policies seem like a cool solution.
In the future, we may add client software (Mobile Device Management) to each device to provide more control over encryption on Android devices and permit selective memory wiping of corporate data.
I welcome comments on what others have done. BYOD is here to stay. Compliance and IT departments need to collaborate on a set of policies and technologies that will meet the needs of regulatory requirements while maintaining service capabilities and user productivity.
Thursday, 10 May 2012
Our Cancer Journey Week 21
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.
Her hair is beginning to regrow and she's progressed from peach fuzz to GI Jane. Her nails are becoming less brittle and losing their black pallor. Her body is beginning to recover.
2012 has been a year of learning. We've learned how to deal with the unknowns of cancer care. We've learned the value of personal health records. We've learned how to buy and sell a house in the middle of chemotherapy. We've learned how to keep our sanity and patience in the face of adversity. Although we would have preferred not to learn some of these lessons, we're stronger for it.
Onward to the next step in the morning.
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.
Her hair is beginning to regrow and she's progressed from peach fuzz to GI Jane. Her nails are becoming less brittle and losing their black pallor. Her body is beginning to recover.
2012 has been a year of learning. We've learned how to deal with the unknowns of cancer care. We've learned the value of personal health records. We've learned how to buy and sell a house in the middle of chemotherapy. We've learned how to keep our sanity and patience in the face of adversity. Although we would have preferred not to learn some of these lessons, we're stronger for it.
Onward to the next step in the morning.
Wednesday, 9 May 2012
The American Hospital Association Letter
On April 30, the American Hospital Association issued a 68 page letter to CMS outlining their response to the Meaningful Use NPRM.
There are elements of the letter I can appreciate - implementing electronic medication administration records and bedside medication verification can be expensive for a hospital that has not yet begun the process, especially the 1300 critical access hospitals in the US.
Implementing some aspects of interoperability require using technologies that are very new. Vendor products will need to be enhanced to support efficient health information exchange workflows.
However, as David Blumenthal said with stage 1 of Meaningful Use, we have to set the pace of the policy "escalator" so that it gets us to our destination with reasonable speed but not so fast that passengers fall off. In my view, the AHA sets the speed too slowwith its patient and family engagement language:
"Patient Portal. CMS proposes as a new objective: provide patients the ability to view online, download, and transmit information about a hospital admission. The AHA recommends that this objective be removed for two reasons: (1) CMS does not have regulatory authority over patients’ access to their health records; and (2) the objective is not feasible as specified."
Also
"Remove the measure on patient use of the portal to both minimize measurement burden and eliminate a provision that makes provider performance contingent on actions of others."
Patient and Family engagement is an area that needs to be pushed aggressively if progress is to be made. The fears and myths about the burden and expense of implementing it are unfounded in my experience. Unless we ramp up the policy "escalator" in the patient/family engagement area, vendors will not innovate and providers will not overcome their inertia.
What do I mean?
When the telephone was introduced, there was fear in the medical community that it would disrupt doctor patient relationships. History has shown that It did not.
When secure email and patient portals were introduced, clinicians believed the burden of communications would escalate. It did not.
When BIDMC began sharing notes with patients there was fear of litigation, misunderstanding, and level of effort to support patient questions. Nothing bad happened.
BIDMC has had a patient portal in place since 1999 that does everything required in the Meaningful Use 2014 edition NPRM language. 60,000 patients per month have used it for over a decade. They can view their records in real time, send secure email, make appointments, refill prescriptions, request referrals, and access numerous patient specific educational materials. 20% of our patients send secure email and look up their records - double the threshold recommended by the NPRM.
The technology is simple and the impact on the hospital (cost, workflow, burden) has been insignificant.
As the spouse of a cancer patient, I can describe firsthand the critical importance of PHRs. Kathy has navigated her entire cancer care experience by using the BIDMC patient portal to track her care plan, her treatment progress, and her diagnostic test results. She's securely communicated with her clinicians and accessed patient educational materials. True, we built this system ourselves in 1999 with a budget of less than $50,000, but today's commercial products such as Epic's MyChart, and eClinicalWorks Patient Portal offer similar functionality.
I'm passionate about patient and family engagement.
I hope that the public response to their letter will encourage the AHA to reconsider their patient engagement recommendations and ensure they carefully consider the patient record access provisions in upcoming recommendations coming from the Office of Civil Rights. I welcome the opportunity to share the experiences of early PHR adopters with AHA membership.
Working together as an industry, we can manage the concerns voiced by AHA membership. I encourage us to push the limits of the "escalator" on patient and family engagement policies/technologies. My wife's treatment and patients everywhere depend on it.
There are elements of the letter I can appreciate - implementing electronic medication administration records and bedside medication verification can be expensive for a hospital that has not yet begun the process, especially the 1300 critical access hospitals in the US.
Implementing some aspects of interoperability require using technologies that are very new. Vendor products will need to be enhanced to support efficient health information exchange workflows.
However, as David Blumenthal said with stage 1 of Meaningful Use, we have to set the pace of the policy "escalator" so that it gets us to our destination with reasonable speed but not so fast that passengers fall off. In my view, the AHA sets the speed too slowwith its patient and family engagement language:
"Patient Portal. CMS proposes as a new objective: provide patients the ability to view online, download, and transmit information about a hospital admission. The AHA recommends that this objective be removed for two reasons: (1) CMS does not have regulatory authority over patients’ access to their health records; and (2) the objective is not feasible as specified."
Also
"Remove the measure on patient use of the portal to both minimize measurement burden and eliminate a provision that makes provider performance contingent on actions of others."
Patient and Family engagement is an area that needs to be pushed aggressively if progress is to be made. The fears and myths about the burden and expense of implementing it are unfounded in my experience. Unless we ramp up the policy "escalator" in the patient/family engagement area, vendors will not innovate and providers will not overcome their inertia.
What do I mean?
When the telephone was introduced, there was fear in the medical community that it would disrupt doctor patient relationships. History has shown that It did not.
When secure email and patient portals were introduced, clinicians believed the burden of communications would escalate. It did not.
When BIDMC began sharing notes with patients there was fear of litigation, misunderstanding, and level of effort to support patient questions. Nothing bad happened.
BIDMC has had a patient portal in place since 1999 that does everything required in the Meaningful Use 2014 edition NPRM language. 60,000 patients per month have used it for over a decade. They can view their records in real time, send secure email, make appointments, refill prescriptions, request referrals, and access numerous patient specific educational materials. 20% of our patients send secure email and look up their records - double the threshold recommended by the NPRM.
The technology is simple and the impact on the hospital (cost, workflow, burden) has been insignificant.
As the spouse of a cancer patient, I can describe firsthand the critical importance of PHRs. Kathy has navigated her entire cancer care experience by using the BIDMC patient portal to track her care plan, her treatment progress, and her diagnostic test results. She's securely communicated with her clinicians and accessed patient educational materials. True, we built this system ourselves in 1999 with a budget of less than $50,000, but today's commercial products such as Epic's MyChart, and eClinicalWorks Patient Portal offer similar functionality.
I'm passionate about patient and family engagement.
I hope that the public response to their letter will encourage the AHA to reconsider their patient engagement recommendations and ensure they carefully consider the patient record access provisions in upcoming recommendations coming from the Office of Civil Rights. I welcome the opportunity to share the experiences of early PHR adopters with AHA membership.
Working together as an industry, we can manage the concerns voiced by AHA membership. I encourage us to push the limits of the "escalator" on patient and family engagement policies/technologies. My wife's treatment and patients everywhere depend on it.
Tuesday, 8 May 2012
Metadata in an HIE
Last week, the Technology Workgroup of the Massachusetts State HIE Advisory Committee was asked to address an interesting policy and technology question.
When a payload of data (a clinical summary, a public health transaction, a lab result) is sent from provider to provider, what data should be included in the electronic envelope used in the sending process?
Massachusetts uses the Direct protocol so the payload is encrypted during transport. The Healthcare Information Services Provider (HISP) cannot read the contents of the message. All routing information i.e. who is the sender, who is the receiver, when was it sent, are there special privacy restrictions etc. must be placed as metadata in an electronic envelope around the payload.
Most metadata is not very controversial. Beth Israel Deaconess sent a payload to Dr. Smith on May 9th at 8:00am with patient consent.
However, for auditing purposes, it could be important to send patient identifiers in the envelope. If the HIE is asked a question like "we sent 10 payloads about John Halamka, can you tell us the time/date and location of delivery?" For medical/legal, data integrity, and service level guarantees, patient identifiers in the audit trail make HIE operations easier.
However, there are downsides. The audit trail becomes protected healthcare information. Operators of the HIE now have access to person identified information.
How could this be a problematic?
What if the audit trail is itself is breached? The HIE must follow HITECH reporting requirements. The Direct Protocol was designed so that transport intermediaries minimize risk of breach by sending unidentified payloads.
What if someone asks the HIE to provide the date/delivery times of a patient's payloads sent from a substance abuse or psychiatric treatment facility? The public is likely to have concerns that HIE staff (especially state government operators) have access to audit trails which contains such sensitive details.
Furthermore, applications that will perform novel routing and linking may need more than just limited amounts of person identified metadata in the envelope to add functionality. Clinicians on the Tech Workgroup noted that data elements such as visit type (inpatient or outpatient), message purpose (discharge summary, medication summary, admission notification), author of the message etc. are needed to automate advanced routing functions. Thus, the recipient organization will likely open the payload after it is securely received to access additional information for processing.
What did we decide?
We elected to remove all human readable patient identifiers from the audit trail, instead using hashes of such data elements as name and date of birth for auditing purposes.
How will that work?
Suppose my PCP wants to send a clinical summary to a specialist as part of a referral.
We agreed to use a secure hashing algorithm (such as salted SHA-2) to anonymize identifiers.
The hash of John becomes AY#!
The hash of Halamka becomes *iUOP
The hash of my birthday becomes G5^*
If the audit trail is breached or mined by HIE staff, there is no way to know that AY#! *iUOP refers to me
However, I can ask the HIE to run an audit on AY#! *iUOP G5^* messages to ensure the payloads were delivered. We get a perfect audit trail that's non-disclosing.
Such hashing approaches for anonymous linkage of patient records are very powerful and I recommend you study the work of Jeff Jonas, described in this post and this powerpoint. Linking identity among heterogenous databases will be required for healthcare reform and emerging ACO business intelligence applications. Doing it without having to disclose identity of the patient gives us the functionality we need without the risk.
Thus, Massachusetts has decided to use Direct without human readable personally identified metadata, instead adopting hashes of personal identifiers in the envelope and audit trail. The HIE cannot be asked to mine audit trails by anyone but the sender of the messages, and the audits themselves are non-disclosing.
We have broad support for this approach and we'll let you know how it works in production.
When a payload of data (a clinical summary, a public health transaction, a lab result) is sent from provider to provider, what data should be included in the electronic envelope used in the sending process?
Massachusetts uses the Direct protocol so the payload is encrypted during transport. The Healthcare Information Services Provider (HISP) cannot read the contents of the message. All routing information i.e. who is the sender, who is the receiver, when was it sent, are there special privacy restrictions etc. must be placed as metadata in an electronic envelope around the payload.
Most metadata is not very controversial. Beth Israel Deaconess sent a payload to Dr. Smith on May 9th at 8:00am with patient consent.
However, for auditing purposes, it could be important to send patient identifiers in the envelope. If the HIE is asked a question like "we sent 10 payloads about John Halamka, can you tell us the time/date and location of delivery?" For medical/legal, data integrity, and service level guarantees, patient identifiers in the audit trail make HIE operations easier.
However, there are downsides. The audit trail becomes protected healthcare information. Operators of the HIE now have access to person identified information.
How could this be a problematic?
What if the audit trail is itself is breached? The HIE must follow HITECH reporting requirements. The Direct Protocol was designed so that transport intermediaries minimize risk of breach by sending unidentified payloads.
What if someone asks the HIE to provide the date/delivery times of a patient's payloads sent from a substance abuse or psychiatric treatment facility? The public is likely to have concerns that HIE staff (especially state government operators) have access to audit trails which contains such sensitive details.
Furthermore, applications that will perform novel routing and linking may need more than just limited amounts of person identified metadata in the envelope to add functionality. Clinicians on the Tech Workgroup noted that data elements such as visit type (inpatient or outpatient), message purpose (discharge summary, medication summary, admission notification), author of the message etc. are needed to automate advanced routing functions. Thus, the recipient organization will likely open the payload after it is securely received to access additional information for processing.
What did we decide?
We elected to remove all human readable patient identifiers from the audit trail, instead using hashes of such data elements as name and date of birth for auditing purposes.
How will that work?
Suppose my PCP wants to send a clinical summary to a specialist as part of a referral.
We agreed to use a secure hashing algorithm (such as salted SHA-2) to anonymize identifiers.
The hash of John becomes AY#!
The hash of Halamka becomes *iUOP
The hash of my birthday becomes G5^*
If the audit trail is breached or mined by HIE staff, there is no way to know that AY#! *iUOP refers to me
However, I can ask the HIE to run an audit on AY#! *iUOP G5^* messages to ensure the payloads were delivered. We get a perfect audit trail that's non-disclosing.
Such hashing approaches for anonymous linkage of patient records are very powerful and I recommend you study the work of Jeff Jonas, described in this post and this powerpoint. Linking identity among heterogenous databases will be required for healthcare reform and emerging ACO business intelligence applications. Doing it without having to disclose identity of the patient gives us the functionality we need without the risk.
Thus, Massachusetts has decided to use Direct without human readable personally identified metadata, instead adopting hashes of personal identifiers in the envelope and audit trail. The HIE cannot be asked to mine audit trails by anyone but the sender of the messages, and the audits themselves are non-disclosing.
We have broad support for this approach and we'll let you know how it works in production.
Monday, 7 May 2012
A Moving Experience
On weekends and nights, we packed, moved, and unpacked.
The rules we followed during the process were
1. Living things first - ensure the health of each other, Kathy's father (who is moving in with us), and our animals
2. Empty the old house - although it's appealing to focus on creating a new life, the old one must be swept clean first
3. Focus on basic function in the new house - bedrooms, the kitchen, and bathrooms are more important than the living room, family room, or garage
4. Repairs to the new house - no matter how attentive a seller might be, there will always be dozens of small repairs to do whenever a house changes hands
5. Aesthetics in the new house - it will be weeks before all the boxes are emptied and everything is restored to order. That's ok.
When we packed, we triaged items into three piles - save, donate, or recycle.
During the unpacking process, I reflected on the things we kept. Why did we save the things we did?
Because they are meaningful parts of our lives.
The photo above illustrates a few items from the top drawer of my dresser:
C. Everett Koop's Coin that he gave me in 2008 after I presented the Koop lecture at Dartmouth
The neckerchief holder for my cub scout uniform from 1969. My father made it for me by hand tooling leather using supplies he purchased from the Tandy Company in the pre-Radioshack days
An integrated circuit tie tack given to me by Professor Frederick Termon, commemorating the first microprocessor used in Hewlett Packard products. The chip has an embedded photo-micrograph signed by David Packard and Bill Hewlett
A tiny birdhouse that my daughter and I found while geocaching at one of the most remarkable geocaches - the Depot in Needham.
A sleigh bell that my daughter received when our family spent a winter's night on the Polar Express. I can still hear it's sweet sound
A coin, a piece of leather, a plastic tie tack, a little birdhouse, and a bell may seem like trinkets, but to me they represent milestones, emotional moments, and treasured memories. They may have little monetary value, but to me they're priceless.
During our move we wanted to consciously think about what we own and why we own it. Now that we've moved, we're reducing our belongings to those things that really matter as we chart a new course to the future.
Thursday, 3 May 2012
Our Cancer Journey Week 20
This has been a busy week moving Kathy, 2 cats, 2 rabbits, and 6 chickens to our farm in Sherborn, Massachusetts. I've spent my nights unpacking boxes instead of posting blogs. I'll return to a normal writing schedule next week.
Here's the MRI results from Kathy's imaging last week:
HISTORY: 49-year-old female with locally advanced left sided breast cancer who is undergoing neoadjuvant chemotherapy. Please assess response to treatment.
COMPARISON: No prior breast MRIs are available. Correlation is made with mammograms dated April 25, 2012 and December 13, 2011.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the uneventful IV administration of 0.1 mmol/kg of gadolinium-DTPA.
Multiplanar 2D and 3D reformations and subtraction images were generated on an independent workstation. The dynamic contrast enhanced 3D series was sent to an independent workstation for computerized assessment of contrast dynamics. CAD analysis facilitated DCE interpretation.
BILATERAL BREAST MRI WITH AND WITHOUT CONTRAST: There is minimal background
parenchymal enhancement. There is no suspicious focal enhancement or mass in either breast. The left breast skin appears thicker compared to right. Post-surgical changes are present in the left axilla consistent with history of sentinel node biopsy. There is no evidence of pathologically enlarged axillary lymphadenopathy.
IMPRESSION:
No suspicious focal enhancement or mass seen on MRI to correspond with known malignancy. The left breast skin appears thicker compared to right; clinical correlation is recommended.
In summary, there is no longer any evidence of tumor. Based on this positive finding, her breast surgeon scheduled an urgent appointment with Kathy to formulate next steps. Together, Kathy and Dr. Houlihan agreed on the following:
"I just saw Kathy Halamka who has had a complete remission by MRI after Cytoxan/Adriamycin times 4 dose dense and 5 rounds of Taxol, which was discontinued due to Taxol toxicity. I plan to do a wire location with two wires of the two clips on 5/11. I plan an en bloc resection. If margins are ok, plan Radiation Therapy. If residual disease, probable mastectomy. Single micro met in sentinel node--plan no axillary dissection based upon current guidelines."
So far so good The numbness in Kathy's hands and feet is better than it was - pins and needles rather than complete lack of sensation.
This week our lives are returning to normal post chemotherapy and post move. Six more chickens arrive tomorrow. Our next milestone will be lumpectomy with local anesthesia on May 11. We're all hoping for negative margins (no sign of active disease).
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