Virtually Priceless Thoughts

I usually take time each holiday season to think about what to learn over the next year.

This year, I have decided to ask, publicly, for advice on what to learn.

I have always had personal learning activities related to work that keep stretching me. My learning program is meant to be fun and – at the same time – useful. It provides some additional direction into areas that I would want to extend myself to know about or apply. It complements my “required reading” for the various projects, papers, and books I am working on as part of my normal work.

When I was an animator, my personal projects would stretch me in areas I had not animated before, for example. Since medical school, my personal learning program has included: learning about leadership and leaders, adult learning techniques, public speaking and presentation skills, user interface patterns, management techniques, and even how comic books work(1).

There are many areas that I could pursue that I am interested in. Some include (in no order):

• Visual Thinking / Visual Modelling Research in Healthcare
• Prototyping and GUI Design Methods / Best Practices / Tools
• Learn a modern programming language
• Do a deep dive into to some Health Information Standards / Models
• Focus more on various management and leadership methods

I thought it might be interesting to pose the question to those that know me and see where you think I should spend my learning time. You can recommend topics, specific books, resources, courses, or conferences.

I’d love suggestions that start with something like “It would be amazing if you…” or “Imagine having more…” or “You are good at X, and Y would really will take you to the next level”. You could even add a few extra bits like “It would be fun because…” and “You’d find it useful because…” You can make suggestions based on past experience (“If only Morgan was better at X”) or future trends (“Personalized Health 3.0 is the next big thing”).

Please feel free to post a comment. I am really looking for ideas from you.

I will, in return, record my learnings here on the blog as I go.

Thanks,

– Morgan

PS – And YES! Before you say it, I will most definitely be spending time with my family this year and learning what I need about being a good father. This question is just focused on my own, quiet, learning time when everyone is sleeping.

PPS – Feel free to register under a fake name / email if you are not comfortable using a name I would recognize.

1. I highly recommend “Understanding Comics” by Scott McCLOUD as a place to start. I read it only last year.

A great colleague and friend is moving on to bigger and better things next week.

I was lucky enough to meet Glen when he was still an undergraduate student — he was experimenting with building prototype clinical decision support tools around the time I was receiving a grant to build a standards-based CDSS tool. He was keen, but was I noticed was his desire to make a difference with what he spent his time on. It was not long after that that I managed to get Glen to join our little EGADSS research team as a Masters student. He was instrumental throughout that work and developed some excellent skills, which only added to his fantastic approach to healthcare IT.

After our research project ended and Glen moved on to other work, we stayed in touch.

Two years ago I had the opportunity to recruit Glen back to work with me on some clinical architecture projects for Vancouver Island Health Authority. He has become a true colleague. Together, we have worked with VIHA to establish a greater understanding for the importance of clinical design, data design / standards, and process improvement. He helped to shape – and increase people’s understanding – of the clinical information architecture principles among other things.

It has been wonderful for me to work with Glen, not once, but twice. I have learned much from him over the years and hope that I will find ways to continue to collaborate with him.

Glen,

I want to wish you all the best in this next opportunity, one that I think is an important step for you and one I fully support. Make sure we stay in touch so our kids can play at the playground by the lake.

– Morgan

PS – For people reading this, who might be interested in applying for Glen’s position at VIHA, one piece of advice comes to mind. When applying for a job, it helps to be better than the person before you. This might be hard to do, filling Glen’s shoes. I suggest you think about ways of getting creative (like below).

Here is an interesting conference on line from Mayo. I’ve just watched Clay Christensen’s keynote on disruptive technologies and healthcare.

He spends time comparing business and healthcare and does it quite well.

An interesting piece at about 21 minutes, where he talks about non-disruptive competition leading to increased prices. He gives examples in the Boston-area and others where head on competition results in increased prices. Competing groups tend compete on features, driving up costs.

He argues that disruptive technologies come in that are simpler and cheaper. They enter the marker in a related, but more decentralized market that could not afford the incumbent’s full product but could use some features (his big example was the mainframe computer being disrupted by the minicomputer being disrupted by the personal computer). Each one was increasingly cheaper, less powerful, and more widely available – they were increasingly decentralized and thus were able to provide value in markets that where the others could not / would not compete and then provided more over time.

In healthcare this means enabling outpatient services and primary care to do many of the things that hospitals do. IV antibiotics, for example, could be given at my clinic much cheaper than they could in the Emergency Department, with all of its overhead, skills and equipment that are there, designed to manage acute traumas and heart attacks.

Today, our nurse practitioners and nurses in my clinic do many of the things I might have done in my private office (or might still be done in a typical family physician office without nursing support).

This decentralization ultimately would extend out far beyond the walls of hospitals directly to patients, providing them with the technology for self management.

Three Enablers for disruption to be successful:

• Simplifying Technology – that can maintain quality
• Business Model allows for innovation
• New Value Ecosystem that can consume the disruptive technology

At around 39 minutes, he makes a statement that general hospitals are not a viable business model and spends some time talking about types of business models and how general hospitals are really a mush of all three major types of models. No wonder that hospitals and the flows of patients through hospitals are so complex.

He ends with an interesting piece on where chronic disease management is best situated, in terms of motivation. While I have concerns about heavily engaging employers in patient care, I found his mapping of motivation and requirements for behavioural change something that resonating both my clinical experience and my work on PHRs at the National Research Council.

Here’s a version of his chart from my notes:

(click for larger version)

I found this an hour well spent – thanks KL for the link to this excellent talk.

I’ve been lucky over the years to have worked with some very good and well intentioned groups.

This post, from Eight to Late relates Elinor Ostrom’s work to project management and I found it an enjoyable read.

Elinor Ostrom is the 2009 recipient of the Nobel Prize in Economics for her work on how groups can effectively self manage shared resources. This goes against the prevailing theory that groups with access to limited resources must be governed otherwise self-interest will lead to dwindling of that resource (i.e. short-term individual gains would win out over collective, long-term gains).

This work definitely resonates with my experiences with my favourite teams. Whether on project teams or on standing groups or working with patients, whether being a leader or a member, I have found “light hand on the rudder” approach works well. Having everyone in a collaborative mode, managing scare resources for the common — and collectively agreed to — good, is very important. Add to that having fun and what you have is just about ideal. For me, that usually means coupling a clear ability for everyone to have a sense “safe autonomy” and a good chance of reaching success both individually and as a group.

It is an approach that, at least anecdotally from patients and team members, appears to work.

Thank you to all the various teams I’ve been involved in like these – and you know who you are, those conspirators for the common good, the skunkwyrrks, the rebel alliances. Thank you all.

I enjoyed this Joel on Software post about scalability of consultants and dangers of creating the Method (with a capital M). Using McDonalds vs the Naked Chef is a nice story.

Improvisational fit to the context of one’s work is important to making the best use of what you have.

I find that this was a nice supporting reason to stay small.

Here’s a wonderful You Tube video that relates too well to my life and work – both tongue and cheek and spot on.

I came across this little slide show that I quite liked this morning on visual thinking. I like the 4 Ms and 6 steps of visual thinking (starting on slide 21).

“Across VIHA Regional Clinical Information Systems, clinical information must have a defined Source of Truth, be up to date, and consistently available.”

In order to achieve consistent and comprehensive information across VIHA’s regional CISs, clear delineation of the sources of truth is required, both for individual data elements (author) and for types of information (system).

Information will be available to users (in accordance with access policies) consistently in each regional CIS. Information accessed in each system should be consistent in terms of content, currency, and presentation. This is important for safe practice and to ensure continuity. There are several approaches to ensuring consistency:

1. One integrated system – no sharing needed. Display, functionality and content are consistent. This is the preferred approach in VIHA.
2. Information will be shared between such that each piece of clinical information is stored only once. The other system accesses and displays that information through background messaging. Functionality (e.g. CDSS rules) will need to be duplicated and display standards will be required to ensure consistency and safety. This is the second preferred option.
3. The less desirable approach would be to duplicate information and have copies of data stored in each system. Full multi-directional synchronization will be required for clinical information documented in more than one system (e.g. if allergies were to be documented in three systems).
4. The final option is that some information is not available through one of the CISs. In this case, providers may view or use the other regional system as needed (links may be provided). This is not interoperability.

It is not acceptable to have similar information captured in multiple systems without any form of syncing. The risk of not clearly defining sources of truth is that some systems may have partial information; the information is not up to date, or conflicting. Providers will not know what information is missing. Gaps in continuity of information will occur. The risk is that clinical decision-making will suffer due to incomplete / inaccurate information. This is a safety issue.

Commentary:

There are some strong words in this last principle. They speak to the dangers and safety issues when having information in silos that are inappropriately inaccessible. I realize that “option 5″ (not shown, but is basically disconnected systems that are not accessible) is very common practice today, at least in Canada. Still, the intent of the principle is to put a stake in the ground, or some writing on a page, that can be pointed to when another isolated system is requested or when IM/IT project teams are looking for guidance on how to prioritize how systems are selected / configured. Thus some strong words seemed important.

The ranking of options was debated. Specifically 2 and 3 were heavily discussed. The very real issue that many disparate systems cannot realistically support option 2 was debated over, what I have begun to call the “Syncing Calendar Issue”(1) that would plague option 3. In the end, from a principle perspective, we agreed that 2 outranked 3. We also agreed would likely see more HL7 messages floating around copying and syncing content than shared tables, from a practical perspective. Shooting for option 3 is never my favorite target (nor is it Seth Godin’s) and I would like to push for option 1.

This principle is focused on information continuity. It does not really speak to the workflow issues of having multiple systems and the challenges providers face in trying to manage multiple systems with overlapping content. We were leaving that for part 2 – a set of clinical business process principles.

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1. Syncing Calendar Issue: Every once in a while, my calendar syncing goes awry. Somewhere between the cloud, my desktop, my phone, my laptop, and some (I think) edit to a recurring series from exchange, my syncing gets a bit broken. I have to decide which calendar is the “best”, manually make changes to make sure “best” is accurate and then push that calendar back to my other devices. I’m sure many of us have this problem – and patient records are much more complex than our schedules.