Virtually Priceless Thoughts

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).

This is a follow up to my earlier post on the challenge of writing my dissertation.

For 25 days this summer, I counted my days by the word. I set myself the task of writing 1,000 words per day on my dissertation.

That was the minimum I could write. I could write more, but not less — and no banking of words. And contrary to my earlier post on pictures being worth 1,000 words, they didn’t count.

I had to write at least 1,000 words a day.

Every. Day.

My idea was to set up a chain of accomplishments so that even when I was waning, I would not want to break the chain by missing a day. I had to reach 1,000, then I could stop and rest. Or edit. Or revise a picture. Or re-review my findings. Or do something else. Anything, as long as I wrote my 1,000 words.

25 days later and I was at the end of my 1,000 word days. The body of my dissertation was drafted. 228 pages, over 66,000 words.(1)

This proved to be a successful approach for me to get through my draft and one I will likely use again in future projects.

I think the trick to find the right metric that is an accomplishment that is significant for a day without being overwhelming that cannot be achieved. For me, last month, 1,000 words a day worked.

Since then I have started the editing process. I have shifted metrics to a set of tasks, determined based on a review cycle and laid out over a week. Not as clean as the 1,000 word metric, but that’s the nature of editing.

____________

1. Yes, 66,000 / 25 is more than 1,000 words a day. I was working on my draft prior to July 30th, so I had several chunks completed before I started (that I didn’t count in my 1,000).

Right now I’m in the deep, dark part of the PhD – the dissertation writing. Having cleared away everything else, but the blank papers in front of me, I have no excuses but to write.

Well I have actually discovered plenty of excuses… that is the nature of writing, isn’t it?

I am moving steadily along and feel like I have a handle on where I need to go. I have done enough of the analysis work before now that this is mostly about writing, instead of doing the conceptualizing / analysis in parallel with the writing. That definitely seems to help.

I have my daily and weekly goals and that’s good.

One of my touch points is volume of words. The target is at least 1,000 words a day. I feel like I have accomplished something if, among the other pieces (e.g. editing, etc) that I have generated 1,000 words. It’s not the only measure, but it is one metric to work against (to quote Monty Python:

Sir Edwin: Ah, well, I don’t want you to get the impression it’s just a question of the number of words… um… I mean, getting them in the right order is just as important. Old Peter Hall used to say to me, “They’re all there already– now we’ve got to get them in the right order.”

But number of words is a good metric. It’s clear and measurable. And I start to create a chain of activity that I don’t want to break — every day, 1000 words. What if I miss a day? Can’t do that, I’ve had 9 1000 word days in a row. Gotta make it ten. That works well.

In a break today I started thinking about ways to keep the chain and slack off (the human mind never ceases to amaze me). “Never fear, I can count my pictures… that’s right. A pictures worth a thousand words, isn’t it? If I miss a day, I’ll count one of those…” My dissertation is full of pictures. Excellent! My brain has found a way around my own self imposed productivity standards… but maybe pictures are really worth a 1,000 words.

So I surfed and – even better – I came across this image:

It appears there was an error in translation – 10,000 words! I can take off the whole week and still make quota! Ah, I love August by the lake… but alas, no matter how I count my actions, I still have to reach “done” as defined by my supervisor and my committee in fairly short order and cannot bask in the warm shade much.

Also, it turns out that there were a couple of errors in the translation of the chinese proverb, actually. As Paul Lester explains:

In fact, the literal translation is: A Picture’s Meaning Can Express Ten Thousand Words.

He goes on to explain that:

With the correct interpretation of the proverb, words and pictures live in harmony as they are both used equally in order to understand the meaning of any work that uses them both.

This is a wonderful interpretation that works well with my dissertation. I’m sure to find a use for it somewhere as much of the work in the study relies on visual communication of findings through pictures and (visual) models.

Until then, however, I am either going to have to change my metrics (1000 words, and 1 picture) or I am going to have to up my daily quota for words, otherwise I am sure I am going to find myself slacking off, counting pictures as 10,000 words each.

“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.

______________________

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.