Choosing the Right Nordic Skis

From December to April I do "OTBD" skiing.  What's that?  "Out the back door" through nature preserves, forested hills, and old railroad beds.  I ski the 1500 acres of Noanet in Dover, the Audubon Broadmoor Reserve in South Natick, and the Wellesley Golf Course.

Choosing the right skis can be challenging and the marketing materials from the manufacturers doesn't help much.

Here's the way I think about it.

First choose the places you want to ski and the style of skiing that you plan to do.

Are you skiing for fitness, doing mile after mile of groomed tracks as fast as you can go?

Are you skiing for the experience of nature, venturing off track to snow filled hiking trails and rolling terrain with hills a few hundred feet high?

Are you into steep powder, seeking the thrill of downhill turns at high speeds?

Once you know where and how you'll ski, you can pick the skis, boots, bindings, and poles you'll need.

There are many types of nordic skis but for the purposes of my analysis, I'll refer to them by their typical width and edge configuration.

1. The endorphin junkie in groomed tracks - Skis less than 60mm wide without a metal edge are perfect for groomed tracks.  You'll go fast on the flats.  As long as the track is not too steep or too filled with turns, you'll be fine.

2.  The OTBD skier (me) - Skis between 65mm and less than 80mm with metal edges are a compromise - slower on the flats but with more stability and control for ungroomed trails, turning around trees/rocks, and traversing more varied terrain in forests, streams, and hilltops.

3.  The adrenaline junkie on steep slopes - Skls above 85mm with metal edges have great control for turning - telemarking, parallel turns, and stemming (letting one ski slide on the uphill side of the turn).   They are slow on the flats and are too wide to be used in tracks.

You may need more than one pair of skis if you do more than one type of skiing.   One size does not fit all since each ski is optimized for some types of skiing and a compromise for others.

One you've chosen your ski, you can chose your bindings.

1.  For groomed track skiing, chose the New Nordic Norm T3 or Salomon Profile

2.  For OTBD choose the New Nordic Norm BC Auto binding

3.  For steep slopes chose the New Nordic Norm BC Magnum binding or 75mm Telemark bindings

Choose a boot that fits the binding you've selected, noting that all these binding systems are not interchangeable - the boot must be designed to accompany a specific binding type.

Poles are generally as tall as your armpits.   For OTBD and steep slops, choose an adjustable length pole so you can set it longer for climbing and shorter for descending.

What do I use?

For long distances in groomed tracks - Fischer Nordic Cruiser skis, 50mm wide with NNN T3 bindings, Fischer XC Tour boots, and Fischer XC Sport poles - generally about $250 for the package.

For OTBD skiing - Fischer Outbound Crown, 70mm wide with a metal edge and NNN BC Auto bindings, Fischer BCX 6 boots, and Fischer BCX poles - generally about $500 for the package.

Of all the websites with educational materials about Nordic skis, the most useful I've found are the videos at Onion River Sports and an older collection of pages called Dave's Backcountry Skiing page.

I hope this overview is helpful.   Let it snow!

Healthcare IT implications of Healthcare Reform

I'm often asked how Healthcare Reform will impact IT planning and implementation over the next few years.

First, some background.  The Patient Protection and Affordable Care Act (HR 3590) and Health Care and Education Reconciliation Act (HR 4872)  were passed to to address several problems with healthcare in the US.    We're spending 17% of our Gross Domestic Product on healthcare, yet we have worse population health outcomes than many other industrialized societies spending half as much.  Healthcare costs are rising faster than inflation.   We have significant variation in practice patterns that is not explained by patient co-morbidities nor justified by comparative effectiveness evidence.    We want to expand access to health insurance to 95% of the population, lower our spending growth rate, and incentivize delivery system change.

How will we do this?

Health insurance reform expands coverage, makes features and costs of plans transparent, and removes the barriers to enrollment created by pre-existing condition considerations.  

Payment reform transforms the Medicare payment systems from fee-for-service to Value Based Payment - paying for good outcomes rather than quantity of care.    Pilot projects will test new payment methods and delivery models.  Successful innovations will be widely implemented.

Let's look at the payment reform details that will lead to delivery system reform.

Medicare Initiatives include
*Medicare shared savings program including Accountable Care Organizations (ACOs)
*National pilot program on payment bundling
*Independence at home demonstration program
*Hospital readmissions reduction program
*Community-Based Care Transitions Program
*Extension of Gainsharing Demonstration

Medicaid Initiatives include
*Health Homes for the Chronically Ill
*Medicaid Community First Choice Option
*Home and Community Based Services State Plan Option
*Hospital Care Integration
*Global Capitation Payment for Safety Net Hospitals
*Pediatric ACOs

I believe that Accountable Care Organizations will be the ideal place to host several of these innovations including bundled payments, the medical home, and an increased focus on wellness.

All of this requires innovative IT support.  

Here are my top 10 IT implications of healthcare reform

1.  Certified EHR technology needs to be implemented in all practices and hospitals which come together to form Accountable Care Organizations.   EHRs are foundational to the capture of clinical and administrative data electronically so that data can be transformed into information, knowledge and wisdom.
2.  Health Information Exchange among the PCPs, Specialists, and Hospitals is necessary to coordinate care.   Data sharing will start with the "pushed" exchange of patient summaries in 2011 and evolve to just in time "pulls" of data from multiple sources by 2015.
3.  Health Information Exchange to Public Health registries is necessary to  measure population health across the community.
4.  Quality data warehousing of key clinical indicators across the ACO is necessary to measure outcomes.   2011 will be about measuring practice and hospital level quality, 2013 will be about measuring quality throughout the accountable care organization, and 2015 will be about measuring patient-centric quality regardless of the site of care.
5.  Decision support that occurs in real time is needed to ensure the right evidence-based care is delivered to the right patient at the right time - not too little or too much care, but just the right amount of care to maintain wellness.
6.  Alerts and Reminders are critical to elevate the overwhelming amount of data about a patient to action that a caregiver (or the patient) can take to maintain wellness.
7.  Home care is needed to prevent hospital readmissions, provide care that is consistent with patient preferences, and to enlist families as part of the care team.  Novel IT solutions range from connected consumer health devices (blood pressure cuffs, glucometers, scales) to wireless telemetry informing clinicians about compliance with treatment.
8.  Online access to medical records, secure communication with caregivers and customized patient educational materials are needed to enhance workflow, improve coordination, and engage patients.
9.  Outcomes are challenging to measures and we'll need new innovative sources of data such as a patient reports of wellness, exercise, and symptoms.
10. Revenue Cycle systems will need to be significantly modified as we move from fee for service models to value-based payment and gainsharing when ACOs deliver higher quality care for less cost.

So there you have it - find the PCPs, Specialists and Hospitals you want to form an ACO then fully implement EHRs, PHRs, Quality Data Warehouses, Health Information Exchange, Decision Support Systems with alerts and reminders, homecare support including consumer healthcare device interfaces, and new revenue cycle systems.  Luckily this is well aligned with Meaningful Use Stages 1,2, and 3, so you'll be doing it anyway.

For IT professionals, we truly live in interesting times.

A Glass Half Full

My 17 year old daughter recently wrote an essay that began "we cannot see our own eyes.  The perception of ourselves comes from the reflections of others - how we're perceived and treated by the world around us".

Later in the essay she laments that the modern world seems to embrace bad news, negativity, and criticism rather than joy, optimism and gratitude.

I agree with her.

2010 has been a particularly strange year filled with audits, new compliance requirements, and regulatory review.    Negative commentators have been granted more airtime than those trying to make the world a better place. We have become a nation that thrives on sensational news,  usually to someone's discredit.

There may come a time when we spend more time defending our work to consultants, regulators, and naysayers than doing it.

I wonder if it is possible to reverse this trend.

Imagine the following - instead of a statement with an accusatory overtone such as

"40% of clinicians in Massachusetts do not have an electronic health record.   Clearly the state has challenges."

How about

"60% of clinicians in the state have an electronic health record, making Massachusetts one of the most wired regions in the country.   For the remaining 40%, there is a step by step plan to achieve 100% adoption by 2015.   Massachusetts is the only state to mandate EHR adoption as a condition of licensure by 2015."

Instead of highlighting a small number of flaws in a person, a team, or an organization, I would rather celebrate their strengths.  Then in the context of a positive trajectory, discuss that ways they could be even better.

I rarely see this approach.   Instead there is a focus on what is not done, not planned, and not budgeted, sometimes declaring risk without providing a benchmark as to the real current state of the industry.

For example, what if an audit or consulting report declared

"IT has not implemented flying cars"

Senior management or Board members might think they should worry about IT management, IT planning, or Governance processes.

Of course, no one in the country has implementing flying cars and the first production vehicle is not expected until 2011.

Business owners facing their own operational challenges might say - we cannot move forward with our workflow redesign because IT has not deployed the flying cars needed to support our automation needs.

Thus, IT becomes the bottleneck, the area of scrutiny, and point of failure.

Consultants might even be hired to analyze why IT has not implemented flying cars and make recommendations for accelerating the flying car program.

Of course, there are numerous other projects that deserve time, attention and resources before flying cars are even considered.

So what's needed to make this better?

First, we need to eliminate our default tone of negativity.   The quality, safety and efficiency risks we have today were there last year. Somehow we still delivered appropriate care.   They is focusing on the trajectory, making each day better than the last.

I've recently rewritten several reports to take this more positive, optimistic approach.  Instead of a gap or failure mode analysis, I created a trajectory analysis and mitigation analysis.

If we persist with a negative approach in the way we interact with others and manage our organizations, our work lives will continue to change for the worse.   How so?

A recent NY Times column relates the modern world to life in a Zombie film in which we spend each day shooting Zombie after Zombie in a war of attrition until the Zombies are all gone or we become one of them.   Think of your email, your cell phone, and your meeting schedule as a daily battle against Zombies and you'll see the author's point.

As my daughter said, we define ourselves based on the reflections we see from others.   If others are negative, we become negative.  If others highlight the positive, the good, and the trajectory to become even better, we will do the same.

Thus, each one of us can make a difference.   Start tomorrow with a glass half full and soon, those around you will see the world for what it can be instead of of what it is not.

A Lookback at 2010

Every Summer I work with my governance committees and IS staff to develop operating plans for the year ahead.  Every Winter, I think about the new issues and challenges that keep me awake at night and review the progress on the previous year.

In FY10, the following were my keep awake at night issues.   How did would do?

BIDMC
Intranet - Our new intranet went live with all expected features and technologies.   As part of the project, we introduced a web application firewall and reverse proxy capability.   Mastering any new technology and ensuring it is configured for disaster recovery and high reliability takes training and resources.  We are not shutting off our old portal, which at this point is just a fallback and is not used much, until early 2011 to allow time for hardening all our newly introduced technologies.

Enterprise Image Management -  We migrated all cardiology images to our new GE Enterprise Archive 4.0/EMC Atmos Enterprise Image Archive.   Vendor neutral archives are definitely becoming more mainstream, but they are still a challenge for RIS/PACS vendors.   I expect support for these archives to be built into imaging products in 2011.

EHR rollouts - By January all 1700 clinicians in our physician's organization will have a certified EHR in place.  The major challenges have been workflow redesign, change management, and communication.

Business Intelligence - After years of experimentation and investigation, we settled on a suite of new functionality using Microsoft SQL Server 2011 Reporting and Analysis services to meet our business intelligence needs.

Interoperability - Our Meaningful Use related interoperability efforts (provider to provider summary exchange, public health exchange, and quality data warehousing) will all be live by the end of 2010.   The standards for content and vocabulary were taken from the Standards Final Rule.   The standards  used for transport were SOAP 1.2 using XDR.  We are seeing convergence of vendor approaches to healthcare information exchange, which is making our integration task easier.

HMS
High Performance Computing - In November we expanded our High Performance Computing facility from 1000 cores to 2000 cores.  By January it will be at 5000 cores.   By March it will be at 6000 cores, incorporating graphics processing unit support and InfiniBand connections to storage.  The major challenge was more power and cooling support.

Storage - Our enterprise storage now includes over 1 petabyte of replicated storage at 2 different service levels - high performance and standard performance.   The challenge has been developing an NIH compliant chargeback model to sustain the growth of our storage infrastructure and staff.

Content Management - we experimented with content management but the project to migrate all externally facing content to a single infrastructure with a common navigation experience and search was not funded in the past year.   Hopefully it will be in 2011.

Social Networking for Research - We completed several releases of our social networking platform for research, open sourced it,  and implemented it at 60 Universities throughout the world.   Profiles has been a great success story.

Governance - We completed the design for our new governance committees - Research Computing Governance Committee, Educational Technologies, Administrative IT, and overall IT Governance.

NEHEN/State Healthcare Information Exchange
At NEHEN, we added more transactions and more trading partners, obtained additional funding to accelerate our work, and went live with all the capabilities needed to support meaningful use.   At the State level, our trajectory to complete a governance design, prepare for procurement, and plan for business operations has been positive.

Federal
Over the past year, the Standards and Certification Final rule was published, work on transport standards moved forward, and multiple efforts to accelerate implementation and adoption are in process.

Personal
My daughter applied to college (early decision results are available in 10 days).

My parents are back home after their healthcare experiences in November.

My wife and I are spending even more time together walking, talking, and enjoying nature.

My commitment to the outdoors has included more kayaking, skiing, hiking, biking, and mountaineering experiences

Thus, despite the tyranny of the urgent, substantial new work, a continually changing healthcare environment and new compliance/regulations, 2010 was a good year.   In many ways, I'm surprised that the 2010 things that kept me up at night are all on track.   Along the way, 2010 was a roller coaster.  But due to the hard work of hundreds of people, all will be well.

Cool Technology of the Week

I'm not a gamer, but I have a great appreciation for the technologies incorporated into gaming systems.   Sometimes, technologies using in gaming can have an impact on healthcare education, such as in physical simulators and virtual patient tools.

The Microsoft Kinect controller, introduced in November, is likely to be one of those technologies.

The device features an RGB camera, depth sensor and multi-array microphone  which provides full-body 3D motion capture, facial recognition and voice recognition capabilities. The depth sensor consists of an infrared laser projector combined with a monochrome sensor, and allows the Kinect sensor to see in 3D under any ambient light conditions.

What are the possibilities?   This New York Times article highlights some of the creative ways Kinect has already been used to control robotics, create immersive 3D renderings, and control movement of virtual objects.

Microsoft would be wise to offer a Software Development Kit and embrace a community of innovative developers, just as iRobot has done with its iRobot Create variant of the Roomba consumer cleaning robot.

3D motion capture, facial recognition, voice recognition and depth sensing for $150.00.   That's cool!

Publicity is Cheap, Privacy is Expensive

When I was 18 years old, publicity was hard to come by.   Media outlets were limited to newspapers with very high editorial standards, television with few channels and very limited news time, and a few high profile news magazines.

My first 15 minutes of fame came in 1981 when I was interviewed by Dan Rather for a CBS Evening News spot on entrepreneurialism in the Silicon Valley.  In 1982, I appeared in Newsweek, as a student correspondent at Stanford, writing about religion, politics and the culturally important trends of the day.  In 1983, I appeared in US News and World Report in an article about the emerging importance of software.

Today, blogs, wikis, forums, YouTube, Facebook, Twitter, and Google enable fame and publicity without editorial control.   Use your phone to take a video of a squirrel doing something amusing and a few minutes later you've got publicity and thousands of people watching your work.

The democratization of information is a good thing.   It enables freedom of expression and instant access to news and information.   Of course, it's hard to tell fact from fiction, opinion from news, and accomplishment from self promotion, but it's left up to the consumer to turn data into information, knowledge and wisdom.

The downside of a completely connected world is that publicity is cheap, but privacy is expensive.

How much effort does it take to not appear on the internet, not be tracked by vendors maximizing sales by analyzing your browsing behavior, and not be findable from the innumerable legal/property/licensure records available on the internet?

In 1981, publicity was expensive, and privacy was cheap.

30 years later, publicity is cheap, and privacy is expensive.

In another 30 years, it will be interesting to see how the concept of privacy evolves.

My daughter's generation shares everything about their day on Facebook.   Maybe the concept of privacy will disappear for most aspects of life, except for those items, like medical records, which are protected via regulation and policy.  

My advice to my daughter about privacy is simple - content on the web lasts forever, on the internet nobody knows you're a dog http://en.wikipedia.org/wiki/On_the_Internet,_nobody_knows_you're_a_dog, and share what you will such that no one gets hurt including you.

To discover just how "expensive" it is to preserve your privacy, here's a great WikiHow about deleting yourself from the internet.

30 years ago I had to wait for a call from Dan Rather.   Today, I just press Post.  How we balance the expense of publicity and privacy is a question that society will need to continuously evaluate as we become more and more connected.

Good Consultants, Bad Consultants

In 1998 when I became CIO of CareGroup, there were numerous consultants serving in operational roles at BIDMC and CareGroup.   My first task as CIO was build a strong internal management team, eliminate our dependency on consultants, and balance our use of built and bought applications.   Twelve years later, I have gained significant perspective on consulting organizations - large and small, strategic and tactical, mainstream and niche.

There are many good reasons to hire consultants. One of my favorite industry commentators, Robert X. Cringley wrote an excellent column about hiring consultants.   A gold star idea from his analysis is that most IT projects fail at the requirements stage.  If business owners cannot define their future state workflows, hiring consultants to implement automation will fail.

I've been a consultant to some organizations, so I've felt the awkwardness of parachuting into an organization, making recommendations, then leaving before those recommendations have an operational impact.   Many of my friends and colleagues work in consulting companies.    Some consultants are so good that I think of them as partners and value-added extensions of the organization instead of vendors.  From my experience, both hiring and being a consultant, here's an analysis of what makes a consultant good or a consultant bad.

1. Project Scope
Good - They provide work products that are actionable without creating dependency on the consultant for follow-on work.     There are no change orders to the original consulting assignment.

Bad - Consultants become self-replicating.  Deliverables are missing the backup data needed to justify their recommendations.  Consultants build relationships throughout the organization outside their constrained scope of work, identifying potential weaknesses and convincing senior management that more consultants are needed to mitigate risk.   Two consultants become four, then more.   They create overhead that requires more support staff from the consulting company.

2.  Knowledge Transfer
Good - They train the organization to thrive once the consultants leave. They empower the client with specialized knowledge of technology or techniques that will benefit the client in operational or strategic activities.

Bad  - Their deliverable is a PowerPoint of existing organizational knowledge without insight or unique synthesis.   This is sometimes referred to as "borrowing your watch to tell you the time".

3.  Organizational Dynamics
Good - They build bridges among internal teams, enhancing communication through formal techniques that add processes to complement existing organizational project management approaches.   Adding modest amounts of work to the organization is expected because extra project management rigor can enhance communication and eliminate tensions or misunderstandings among stakeholders.

Bad  - They identify organizational schisms they can exploit, become responsible for discord and cause teams to work against each other as a way to foster organizational dependency on the consultants.

4.  Practical Recommendations
Good - Recommendations are data-backed, prioritized by relative value (cost multiplied by benefit), reflect current community standards, and take into account competing uses of the organization's resources and time.

Bad - Recommendations lack depth.  They are products of uncorroborated interviews.  They lack factual details and are a scattershot intended to create fear, uncertainty and doubt.   They focus on parts rather than systems.   Implementing these recommendations causes energy to be drained away from more strategic and beneficial initiatives.

5.  Fees
Good - Consultants use markup factors (amount they charge verses the amount they pay their staff) such as the following:
Staff augmentation / placement only, with no management oversight = 1.5
Commodity consultants, largely staff augmentation, but with "account management" = 1.5-2
Consulting / systems integration, project-based  = 2-3.5
Management consulting / very senior and high-demand specialists = 3.5-4

Bad  - The engagement partner becomes more concerned about billing you than serving you.    Meetings appear on your calendar weeks before the end of a consulting engagement to discuss your statement of work renewal.   You begin to spend more time managing the consultants than managing the project.   Consultants justify a markup factor of 5 or 6 by saying "We're so good that we have high overhead".

6.  Balancing Priorities
Good  - Complex organizations execute numerous projects every year in the context of their annual operating plans.  Although consultants are hired to complete very specific tasks, good consultants take into account the environment in which they are working and balance their project against the other organizational priorities.   In this way, the organization can adapt to the changes caused by the presence of the consultant while not significantly disrupting their other work.

Bad - Meetings are consistently scheduled with little advance notice that conflict with other organizational imperatives.   Any attention paid to organizational demands outside the consulting engagement are escalated to senior management as being "uncooperative".

7.  Quality of deliverables
Good  - The deliverables are innovative, customized to the organization, and represent original work based on significant effort, due diligence, and expertise.

Bad - Material is reused from other organizations.   The volume of deliverables is increased with boilerplate.   The content seems unhelpful, general, or unrelated to the details of your organization.

8.  Managing project risk
Good - Risk is defined as the likelihood of bad things happening multiplied by the impact on the organization.   Real risks to the project are identified and solutions are recommended/developed collaboratively with project sponsors.

Bad - There is greater concern about risk to the reputation of the consultants than the risks to project success.

9.  Respect for the org chart
Good -  Work is done at the request of the project sponsors.   The chain of command and the hierarchy of the organization are respected, so that consultants do not interact directly with the Board or senior management unless directed to do so by the project sponsors.

Bad  -  Governance processes are disrupted and consultants seek to establish the trust of the organizational tier above the project sponsors.  Sometimes they will even work against the project sponsors to ensure organizational dependency on the consultants.

10.  Consistency
Good - Transparency, openness, and honesty characterize all communications from the consultants to all stakeholders in the organization.

Bad - Every person is told a different story in the interest of creating the appearance of being supportive and helpful.   This appearance of trustworthiness is exploited to identify weaknesses and increase dependency on consultants.
  
I'm the greatest ally of good consultants.   Per Robert Cringely's article, we'll bring in a few "Consulting Type A" experts each year for specific well-defined tactical projects requiring deep expertise.  

If survival of the fittest applies to consultants, then the good ones should thrive and the bad ones should see fewer engagements over time.   However, I'm not sure Darwinian selection pressures apply to consultants, since organizations may have short institutional memories about consulting experiences due to their own staff turnover.  

The best you can do for your organization is think about the good and bad comparisons above, then use them to evaluate your own consulting experiences, rewarding those who bring value added expertise and penalizing those who bring only "powerpoint and suits".