Here are some great articles I found this week.

Australian Students ditching Outlook for gMail

This is something I was really excited about, being a big fan of gMail and Google Apps for Your Domain in particular, and not a big fan of Outlook/Exchange. Basically one and a half Australian students just started using gMail. This is particularly interesting, as these students will enter the workforce familiar with a whole new set of tools.

http://www.techcrunch.com/2008/06/23/15-million-australian-students-dump-outlookexchange-for-gmail/

Patient Records Safeguarding

More on topic with health care, the article below from Ars Technica talks about safeguarding patient medical records, and extending it to cover things like Google Health and Microsoft's HealthVault.

http://arstechnica.com/news.ars/post/20080625-privacy-security-and-health-it.html

FriendFeed and Brands

In the realm of branding and social networking, I found an interesting article on FriendFeed. Now, if I can only figure out what email address I used when I signed up, I'll be happy.

http://bhc3.wordpress.com/2008/06/10/will-brands-figure-out-friendfeed/

Finally, some cool new web tools worth looking at:

Snapcasa - SnapCasa is a quick and free screen shot gatherer.

http://mashable.com/2008/06/03/snapcasa-quick-free-website-screenshots/

Embedding RSS with Google's Ajax API

Google has apparently made embedding RSS super easy, and since I am working on a bunch of feed related projects, I will be all over this. At first glance it is cool, but I'd like to be able to jut add feeds directly. I'll need to spend more time with it.

http://lifehacker.com/395354/google-makes-rss-embedding-easy

Thats it for today!

We have been working on adding additional features of Community Health Network's Personal Health Record (PHR) and a question occurred to me.

What is the expectation of privacy a patient has about the data they enter into a PHR on a health care provider’s web site?

If we used the information to help with providing patient care, do we need to ask the patient's permission before viewing the information?  Or is there an assumption that we can use the data because they have entered it into a health care organization's PHR as long as we follow the requirements detail in HIPAA?

Google, Microsoft, Revolution Health and the other non-health care organizations offering PHRs do not need to follow HIPAA guidelines as far as I understand because the law was only written for health care entities.

I think I'm leaning to that we should ask for permission but it is not required for us to view it.  Or we should detail in the PHR terms of use that we can use the information to help provide patient care and that we will not sell the information.

What do you think?

Mark Dixon, president and CEO of Community Hospitals of Indianapolis, recently became a Fellow of the American College of Healthcare Executives (ACHE), the nation's leading professional society for health care leaders. Dixon is privileged to use the FACHE credential, which signifies board certification in health care management and ACHE Fellow status.

"Because health care management ultimately affects the people in our communities, it is critically important to have a standard of excellence promoted by a professional organization," says Thomas C. Dolan, Ph.D., president and CEO of ACHE. "By becoming an ACHE Fellow and simultaneously earning board certification from ACHE, health care leaders can show that they are committed to providing high-quality service to their patients and community."

Fellow status represents achievement of the highest standard of professional development. In fact, only 7,500 health care executives hold this distinction.

To obtain Fellow status, candidates must fulfill multiple requirements, including passing a comprehensive examination, meeting academic and experiential criteria, earning continuing education credits and demonstrating professional/community involvement. Fellows are also committed to ongoing professional development and undergo recertification every three years.

"I'm thrilled to be recognized as Fellow of the American College of Healthcare Executives," Dixon says. "This is such an amazing honor and I am so pleased to be able to serve our patients and our organization at Community Health Network."

ACHE is an international professional society of more than 30,000 health care executives who are leaders in a variety of health care settings.

From PEDIATRICS Vol. 120 No. 3 September 2007, pp. 649 (doi:10.1542/peds.2007-1911)

The American Academy of Pediatrics endorsed the publication: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;

Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.  Those are prosthetic cardiac valve, previous IE, unrepaired cyanotic congenital heart disease (CHD) including palliative shunts and conduits, completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device which inhibit endothelialization, cardiac transplantation recipients who develop cardiac valvulopathy.  For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.  Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

Refer to the publication below for more background and details:

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1.pdf

You may comment on this topic below.

I bought my wife a 1 gigabyte iPod Shuffle a year and a half ago.  I have a fourth generation 20 gigabyte iPod that I constantly add and remove music on and take time to select what music/artist/album I want to hear.  I also have created a vast network of playlists that coordinate to load the iPod with music.

Recently, I used the iPod Shuffle when mowing.  I loaded it up with a playlist and listened to it with the songs playing randomly.  It felt so nice to just listen to whatever came up.  I was like freedom, freedom from deciding what music I was in the mood for.

This experience made me think of a book I’d read about, 'The Paradox of Choice: Why More Is Less" by Barry Schwartz.  The choice of deciding what to listen to can sometimes be paralyzing because I have so many choices.  Using the iPod Shuffle takes away the overwhelming choices that Schwartz discusses in his book.

I think this applies to health care also.  There are overwhelming treatment options for conditions and making the best decision can be difficult especially because it is a critical choice.  In the health care world, many (most?) patient rely on their family practice physician to guide them.  I know I do.  That physician helps the patients by narrowing their choices in selecting treatments by recommending the best options.  Just like the iPod Shuffle does about music selection.

Google Health is live and looking good. I'll be playing around with it for a bit.

I recently read this article, The 411 on mobile snap technology, about a mobile phone technology and it made me think about how we could apply this to health care.

I couldn't think of anything that would fit in with what patients would naturally use.

But we are working on a mobile site that will have scaled down/phone optimized applications that make sense to use on a phone.  We will not be putting the entire eCommunity.com site on this mobile site because it won't all work effectively on a small screen with a slower bandwidth.

Which is how our team operates.  Instead of rushing to do something cool, we make the technology fit a need to process.  We make the new application fit in our existing structure and make sure it is user friendly.

A good example is our News section on eCommunity.com.  We have news stories that have an RSS feed linked to them all and the monthly news stories also have a podcast feed.  In addition to offering the podcast, we allow the user to listen to an individual story without subscribing to the podcast.

All made as user friendly as possible with explanations of what a RSS feed is.

We also use Feedburner to make the RSS feeds as easy as possible to use for users on any browser.

We added a Google Maps mash-up to our Find a Doctor application because it made sense to do so.

These are all intelligent uses of new technology that are used to benefit the application they are added to.  They were no implemented just because it’s cool and want to build something with it.  Those types of applications will disappear in a few years leaving only the truly useful ones.  Just like what happened with the tech bubble in the 90's.  The good stuff remained and the bad ideas failed.

Congratulations to Community Hospital Anderson and The Indiana Heart Hospital for being selected to receive 2008 Leadership Awards for Clinical Excellence from VHA Inc., a national health care alliance based in Irving, Texas.

Community Anderson and The Indiana Heart Hospital were recognized at the VHA Leadership Awards Recognition Banquet on Sunday, May 4, at the 2008 VHA Leadership Conference in Philadelphia.

• Community Anderson received an award for Clinical Excellence for Acute Myocardial Infarction Care
• TIHH received awards for Clinical Excellence for Congestive Heart Failure Care and Surgical Care

The 2008 VHA Leadership Award for Clinical Excellence honors VHA member organizations that have distinguished themselves by meeting or exceeding national performance standards in specific clinical activities. To be selected for a Clinical Excellence award an organization’s composite score must be in the top 10 percent for at least the core measure category beginning third quarter 2006 through fourth quarter 2007. All information was based on data from the Joint Commission. VHA serves more than 1,400 not-for-profit hospitals nationwide.

Community Anderson: Acute Myocardial Infarction Care

See how Community Health Network compares for heart attack care >>

Community Anderson is one of 16 VHA member hospitals nationwide to receive a 2008 Leadership Award for excellence in treating heart attack patients.

For heart attacks, best practice standards include:

• Aspirin prescribed at time of patient’s arrival
• Aspirin prescribed at time of patient’s discharge
• ACE inhibitors or beta blocker administration for left ventricular systolic dysfunction
• Adult smoking cessation advice/counseling provided to patient prior to discharge
• Beta blocker prescribed at time of patient’s arrival
• Beta blocker prescribed at time of patient’s discharge
• Amount of time until thrombolysis administered
• Amount of time until PCI administered

"At Community Hospital Anderson and throughout Community Health Network, we treat common health care problems uncommonly well, always focusing on quality and safety, which leads to better outcomes for our patients." says Bill VanNess, M.D., president and CEO of Community Hospital Anderson. "We are proud to be recognized for these high standards and to provide exceptional health care in Madison County and across Central Indiana."

TIHH: Congestive Heart Failure Care

See how Community Health Network compares for congestive heart failure care >>

TIHH is one of 20 VHA member hospitals nationwide to receive a 2008 Leadership Award for excellence in treating congestive heart failure. The best practice standards for treating congestive heart failure include:

• ACE inhibitors or beta blocker administration for left ventricular systolic dysfunction Detailed discharge instructions provided to patient
• Left ventricular function assessment performed on patient
• Adult smoking cessation advice/counseling provided to patient prior to discharge

"Our participation in VHA helps us achieve a higher level of performance both operationally and clinically, and we are pleased to receive recognition from VHA for our work in cardiac care," says Tom Malasto, president of TIHH.

Surgical care

TIHH is one of 13 hospitals nationwide to receive a 2008 Leadership Award for surgical care. These steps toward quality include:

• Administering antibiotic within one hour prior to surgical incision
• Selecting appropriate antibiotic for surgery patients
• Discontinuing antibiotic administration within 24-hours after surgery (within 48 hours for cardiovascular procedures)

"The award validates the dedicated focus of our clinical staff and physicians to pursuing excellence in the care provided to our surgical patients," Malasto says. "Preventing infections following surgery is a key objective of our surgical team. To ensure the proper outcome, our staff focuses on national indicators of quality."

I was at the annual meeting for my homeowners' association last night and I begin to think about open communication and transparency.

There a lot of complaints and questions about what's been going on with the leadership of the community.  There is only one meeting a year, the monthly board meetings have been either closed to the public or unadvertised.  The main source of communication has been phone or email from a web site that many homeowners didn't know about.

There have been issues with the former property manager and people in the community didn't know about that or the resignations from the board.  Consequently, many felt disenfranchised, and were distrustful of the board members and how the dues have been spent.

Watching all of this I realized that if communication had been kept in the open and homeowners informed of changes in the board and property management, their distrust would have been minimized.  And giving people a chance to speak during the previous year would have lessened the complaints in the meeting.  I believe that most people respond to open honest communication.  Explanations of community issues before this meeting would have lowered the level of hostility in the room.

How does this apply to health care?

Imagine if health care providers were open and honest all the time about what a patient is experiencing.  

You arrive on time for your doctor appointment but wait forty-five minutes to see the doctor.  Why did that happen?  The doctor may have had a complicated patient case come in and needed to spend more time with someone.  Or other patients’ lateness has caused the doctor to be running behind.  I read an article somewhere I can’t remember that stated that the main reason patients need to wait for their doctor is that other patients before have been late.  I don’t think most people know that.

Would knowing one of those situations help you be less frustrated with your doctor when you have to wait?

There are many other examples that can be imagined.  Ones that apply to hospital visits or even organization decisions.  The tools and technology for open communication are different depending on the situation.  In a hospital, talking to the patients individually would be more effective then later blogging about the event; for an organization blogging about a decision or event is more effective than individually talking to everyone interested.

I believe that open, honest communication in health care would reduce complaints and malpractice suits and allow the health care industry to spend more time treating patients.

Some reading for Friday, sent to me courtesy of Pete Turner, V.P. of Business Development at The Indiana Heart Hospital.

Reading this article on NPR, Internet Health Records: Convenience at a Cost?,  prompted me to think more about Personal Health Records (PHRs) and Electronic Medical Records (EMRs).  In re-reading my previous post The Ideal Personal Health Record, I'm not sure that it was clear about my thoughts.

The other day in a meeting I described the relationship between the EMR and PHR this way:

Think of the PHR and the EMR as two separate entities sitting side by side.

The patient’s PHR can look at the patient’s EMR but is not allowed to change it.  The patient can add items from their EMR to their PHR.  Then they are able to modify that item only in their PHR to add additional details, etc.

The physician’s EMR about a patient can look at the patient’s PHR but can’t change it.  The physician can pull pieces of the patient’s PHR into the EMR as they feel it is appropriate because they are ultimately responsible for the accuracy of the EMR.  The physician is able to modify a patient’s EMR.

The two systems exist separately but are able to communicate with each other.

This system will only be able to work if the PHR is linked to a health care provider’s EMR.  The larger PHR systems like HealthVault and Google Health may be used to transmit data between PHRs so if a patient moves they can take their data with them.

A crucial piece of our health care technology arsenal is a homegrown content management system (CMS) we (read: I) use for publishing our Web content. After a year of design (and redesign) sessions, the brand spanking new "CMS2008" is in production! We are still working out some kinks as is to be expected. However, there are many upgrades: The information architecture is more logical, the WYSIWYG-ness is more user-friendly and the editor functionality is more robust.

In addition to the Web content publishing piece, CMS2008 also contains administrative tools that we can use to mange user-generated content, such as that found in our eCommunity blogs, discussion boards, and SharingSites.

The big idea here is that if we can make our CMS tool easier to use, this will help the content owners distributed across the organization feel empowered to also be active content publishers.

I had the pleasure of listening to a lecture/conference call with Seth Godin yesterday talking about his book "Meatball Sundae."  I began to wonder how the health care industry fits into his model.  At first glance it seems like health care provides a meatball service, but there are unique aspects to it that work well as the whip cream, cherry and other toppings.  Health care and health care technology doesn’t seem to fit into his model.

The e-Business team has seen a lot of new media/new marketing trends that work really well in health care.  Patient blogs are one example that we have built.  Our SharingSite application allows patients to blog about their condition and treatment in or out of the hospital.  We are also using it to post our baby/nursery pictures.  This eliminates the phone calls to family and repeatedly telling relatives the same information by a patient or family member who is already stressed and busy.

Our discussion boards that we have really not promoted are gaining more and more usage because people want to talk about their health condition, ask questions and compare their experience to other patients.  This is a common patient behavior that used to (and still does to some extent) happen in person, but now you can go online and talk to many more people.

Patients also want to find out more about their health conditions so they are using online health information libraries along with just reading blogs, discussions boards, etc to find out as much as they can about their health issues.

I believe that health care is different, that it doesn't fit the Meatball Sundae model.  Maybe it has to do with all the regulations, etc. on our industry, or that we aren’t selling a product that users generally have a choice about purchasing or not.  But they do have a choice about where to purchase it.

I met with a vendor earlier this week and one of the services they are selling was Business Process Management (BPM).  I realized that the e-Business team has been doing this for several years now, before it was the new thing.  We have been building applications that are designed with the process in mind.  We build applications that improve process and workflow.  Our applications work within the process workflow already created.

On the other hand, IT in many organizations builds or buys an application and fits the process to it, or tries to.  One reason for project failure with applications and vendor product purchases is that they don't match the process previously developed in the organization.  The project fails because there is an attempt that doesn't succeed to change the process or the process isn't understood.

In our requirements gathering we review the current process and sometimes make suggestions to improve the process.  But then take the process requirements and build an application that meets the requirements and matches the predefined process.  I think that is a major factor in our success in this organization and outside it.

I believe this is especially true in the health care field.  The medical staff is very busy and there checks in place that need to be met to insure quality health care.  Processes have been created and in place for some time and it can be difficult to change them.  Health care technology systems generally don’t work together well and there are difficulties with interoperability.  Forcing a system into this environment without considering the work flows and processes already in place will ultimately fail.  Failure can mean a lack of usage of the system, a break down in work flow or issues with patient care.

Community's bariatric services has partnered with Medical Animatics, LLC, to provide weight loss surgery patients with access to an online, interactive, media-rich educational program. The program's tools help patients and families learn about upcoming procedures, manage their post-surgical lives and "make healthier lifestyle choices." A highlight of the online tools is a self-paced informed consent agreement that guides patients through the details; this replaces the traditional paper-based consent form. Bariatric patients simply log in to My Informed Choice to interact with the product.

I used to work in the e-learning industry, so I find this company and program interesting, particularly the niche approach the company takes by focusing on scientific and medical content. It will be interesting to see the measurable outcomes of this program in terms of patient understanding and knowledge application as well as any process improvement in bariatric surgery services.

I just read an extremely interesting article in last month's Wired magazine, "Free! Why $0.00 Is the Future of Business."  (Yes, I am behind on my reading.) I started to think about how I could apply it to my work and projects.  We offer a free consumer health library and a free medication library for anyone to use.  I would be against any attempt to charge a subscription fee to get to those services.  When I was in graduate school I remember discussing the subscription model on the Internet as a business model that doesn't work.  I've seen that most organizations (especially newspapers) have tried this model and have moved to free online access to archives.

We offer these applications (and many others as part of the free myCommunity membership) as a service to our patients and hope that users who are not currently patients will consider these services when selecting a health care provider.  But these services are available to people outside of the Indianapolis area who may never be able to use our hospitals.  They are still allowed and encouraged to use our site. 

In addition some applications like health information are becoming the standard for health care providers like ATMs are now a standard for banks to offer.  By paying attention to these services the health care organization can increase their reputation and trustworthiness, and secure a patient's attention.  Just like Chris Anderson writes:

"The word is externalities, a concept that holds that money is not the only scarcity in the world. Chief among the others are your time and respect, two factors that we've always known about but have only recently been able to measure properly. The "attention economy" and "reputation economy" are too fuzzy to merit an academic department, but there's something real at the heart of both."

We provide free services but also use free services.  We use Google Analytics as another source for web statistics, we use Feedburner to help manage our RSS feeds and we use Google Maps in our Find a Doctor application.  There is tons of free services available we could use but have chosen not to because they can be overwhelming to manage and get value from.

It makes me wonder what else we could offer for free that would return value through other avenues.

I love reading Wired for articles like this.  I read about The Long Tail some time before it became popular in this magazine.  Who knows, maybe this will be the next big idea?

There is a spectrum of physician readiness regarding Internet technology acceptance. Some influencing factors include; physician's work and home access, perceived quality of usability, the amount of the individual physician's browser and email experience. Physician engagement in the use of technology has been a very staged and gradual process. It has taken some 8+ years (in our organization) to accomplish the current primary care adoption rate of the EMR (> 70% of total), portal and email usage (don't have definitive measures on these yet). We see ourselves as progressive, but relatively early in our physician e-culture journey. Within this spectrum there are physicians of all ages who embrace technology and are willing to expend the energy to learn "how to" get stuff done. Others, do not have the tolerance, or are at a point in their professional working lives that they do not desire to expend such time on transitioning their respective work flow and clinical practice. That is by the way a key phrase to focus upon "work flow!"

Key learnings regarding physician web based technology engagement:

• Influential peers make a difference
• Measurable, improved clinical outcomes speak volumes
• Financial incentives can play a part
• Reproducible time effectiveness drives change
• Motivated, enthusiastic office staff essential
• Temporary, focused, additional support resources a must
• Effective governance structure must be in place to achieve large numbers

I can't find where I read it but I remember reading a discussion, I think it was in Wired Magazine, about how the presidential candidates were using the Web and Web 2.0 technologies.  I remember a chart of the candidates and what they were using.  And one of them, Edwards I think, said something like blogs, wikis, rss, Twitter..too..much...Web 2.0 (I always imagine this with the voice of the best Captain Kirk impression).

I like Web 2.0 technologies and they can be useful in health care if applied intelligently to problems, but they can be abused.  Just like Flash was abused in the 90's, a site can have an overload of these applications and overwhelm the user.  We try to use them where appropriate to solve business problems.  One of the best examples is the Google Maps mash-up we incorporated into our find a doctor application.  It displays a map of the office locations in a physician profile.

Why are we trying to hammer Internet nails with screwdrivers?

I have become enamored with the line from my post and wondered if I should have titled my last post with that line.  I decided not to and then I decided to make another post with that title and link it to the post, because the phrase will look good as a title.  Just like Ralphie in "A Christmas Story" writing his theme about what he wants for Christmas and proclaiming, Yeah, that's good.

The original post is text messaging and health care.

Five years from now...text messaging will replace web sites.  I don't believe that.  I had a meeting with a vendor today and we were discussing text messaging and uses in health care.  It was a good discussion and one thing that was stressed is that text messaging is for very small discreet messages or interactions with a user.  It won't replace a web site but it can support a web site strategy.  One of the advantages is that it is easier to, in some cases, use your phone to interact with a site than to log on to the Internet and then a web site and then interact with it.  Convenience is an advantage but there is a lack of user interface and it's difficult to supply user feedback or correction.  So if the task is small, like recording a single piece of numeric data or being sent a reminder, text messaging works great.  If the interaction is complex and involves several pieces of data text messaging is not a good medium for the interaction.

Like Marshall McLuhan says, “The medium is the message.”  To create a text messaging application, you need to consider the medium, its benefits and its constraints.  Then select a project that benefits from the medium and could not be done as effectively in some other medium.  Work with the process and not try to impose a technology on situation and force a new process.

In another meeting there was a discussion about using Internet technology to accomplish a goal but the methodology was from another medium.  The idea was to use the internet but in a way that would be better accomplished in another older technology.  The medium is the message and the medium should be part of the determination of the tools used to accomplish a goal.  You can use a screwdriver to hammer a nail but a hammer would be more effective for that task.  Why are we trying to hammer Internet nails with screwdrivers?