I recently read another person’s account of their sabbatical where it said, “If I had it do do again, I would have taken more time off.” I am incorporating that philosophy into my experience by taking scheduled Internet holidays during this time. The first starts tomorrow, and then another one later on in the winter. Best to do it now before things switch into high gear. I’ll be back in a week. Comments on this blog will be closed, but will reopen when I return. In this week’s quote of the week on the DailyKaizen blog, I posted a story that I recently ran across that’s useful here. Enjoy!

Continuing on a theme started a few weeks ago, this week’s photo is of one of the most important libraries in the world, Library of Congress. Employing 4,000 individuals and housing 134 million items makes long cavernous tunnels like the one pictured necessary. It really is larger than life. In case you were wondering (I was), you cannot check out items from this library, and you can take your computer into the reading rooms to work, you just can’t take the computer bag in with you. Which is fine, it was worth the trip.

October 7th through October 10th:

• Pew Internet: E-patients With a Disability or Chronic Disease - Latest from Pew Internet - lots of mention of online health informaiton increasing confidence. This is a good thing.
• Jack and Suzy Welch: Generation Y’s Bad Rap - Driven, self-aware, motivated, and able to make choices.
• The Welch Way: Breaking Through the Bias - Really nice discussion of diversity in the workplace. We support it not for ourselves, but for those who come after us, as Jack and Suzy thoughtfully wrote.
• Encouraging Dissent in Decision-Making ? HBS Working Knowledge - Article about encouraging different views in a business environment. There’s a reference to LEAN in the end - if we treat ideas as inventory and don’t waste them, then I think we can see balanced conversations in organizations.
• The Fakebook Generation - New York Times - “My generation has long been bizarrely comfortable with being looked at, and as performers on the Facebook stage, we upload pictures of ourselves cooking dinner for our parents or doing keg stands at last night?s party; we are reckless with our personal

Besides working with different organizations, I am going to experiment with working with different technologies to do my work. Because I am essentially detached from a big enterprise for the time being, I am my own Chief Information Officer. It’s fun! This gives me lots of room to pick and choose what I want to use to run things. I will basically try anything (and in life, why not try anything) for organizing and communicating tools. The ground rules I have settled on:

• Open source or public source (avoid proprietary standards)
• Affordable
• Web 2.0 friendly (maybe I’ll create Web 3.0) - incorporating social networking, tagging, interaction
• Easy to maintain (and maybe to tinker with)
• Compatible with Apple, Inc., produced products (which typically means open standards)

A short list of what this means in practical terms

• Goodbye Outlook, goodbye Entourage, hello Apple Mail, iCal, Address Book
• Goodbye Word, Excel, Powerpoint, hello Pages, Numbers, Keynote
• Goodbye project management software, hello ActiveCollab, except they just raised their prices, so maybe dotProject now (things change quickly in this world!)
• Goodbye firewalled opaque Intranet, hello transparent blog
• Goodbye content management system (wait, there was no personal content management system in the enterprise), hello personal wiki, hello del.icio.us.
• Goodbye image management system (wait, there was no image management system in the enterprise), hello iPhoto
• Goodbye weekly/monthly/yearly business memos, hello blog
• Goodbye Blackberry, hello iPhone

So far so good. These technologies are lightweight and easy to work with, and for many of them, there are no parallels in enterprise IT, because it hasn’t caught up yet. There have been a few little hacks that I have had to do to make things work, but they are working. E-mail is the best example so far, switching from a proprietary protocol (MAPI, the Microsoft Protocol) to an open source one (IMAP), makes things work much more seamlessly across a computer, the Web, and a phone.

If there’s a Web 2 or other technology that I haven’t mentioned that I should try, or you want me to try because you haven’t been able to, let me know in the comments and I’ll give it a whirl. When I’m done, I should be able to assemble a nice toolkit for the modern Internet-enabled professional, and probably the consumer, too.

I spent my last day in New York shadowing in one of Institute for Family Health’s smallest practices - two physicians and a nurse practitioner. Like the other practices in the system, this one is busy, taking scheduled patients and walk-ins. And like the others, it is fully enabled using an electronic health record. Pictures are below. Click on any to see full size.

I saw the art of family medicine here, which is that regardless of the time pressures always faced in medicine, physicians are able to focus and be there for their patients. The physician I saw practice on this day had a really nice rapport with her patients and I noticed was able to connect with them on topics important to them outside of health care - trips they might be taking, or significant family issues. This is always great to see in the context of an electronically enabled practice - doctors can still be doctors. The other significant thing for me was the kindness of the patients in their willingness to let me learn about their relationship with their doctor by watching the interaction. The several that I observed were welcoming after an informed consent was obtained by their physician.

Also, a new best practice for me (I think) - sitting while shadowing. I have traditionally stood in a corner to be as unobtrusive as possible, but it was brought to my attention that my height may be a little imposing in the exam room. I liked it - more at the level of the patient, and more blended in. With great thanks to the 13th street practice.

What about the PHR? I was informed that this practice is diligent about sending patients results and other important health information, which made me think about the value of a personal health record here. What if patients could retrieve their own information, accompanied by information about each test automatically (Information Therapy)? It was important for me to come visit and see that reality for this practice. I think there could be win here in physicians empowering patients to become informed about their own care on their own time. One issue this system will face is in their use of external ancillaries, such as lab and radiology. The PHR may force the issue of establishing a solid interface to both, and this is a good thing - the patients will expect their data to be available to them and to their provider. Everyone wins.

Later in the day, I met with Karen Nelson, MD, MPH, the CEO of Unite HERE Health Center. The facility is beautiful and modern (see pictures below), and also fully electronic, using the General Electric Centricity Product.

We talked about the history of UNITE HERE! and the patients seen here. They are doing a lot of work in Ambulatory ICU and serve a distinct group of special patients in the city. I would very much like to come visit on my return, and had the idea that I would not only like to shadow a provider, but shadow a patient living with chronic disease, if this is possible.

October 4th through October 5th:

• CHCF Announces Fellows for Health Care Leadership Program - Press Releases - CHCF.org - Congratulations to these medical leaders!
• Microsoft HealthVault Developer Center - The SDK for linking to HealthVault. It looks like an EHR vendor or two is in line?
• HealthVault : Home - Microsoft jumps into the PHR arena
• Primary Care Information Project : NYC DOHMH - PCIP project, which will bring EHRs to small practices in New York
• Public Health Detailing Program : Clinical System Improvement : NYC DOHMH - New York City’s work promoting adoption of EHR’s

On this day, I visited the Institute’s Walton Family Health Center in Bronx, New York. Due to a time constraint on my part, I did not get to shadow providers caring for patients, but I did attend a CME in the morning and then walked around the facility with it’s Medical Director. Pictures are below, click on any to see it in gallery format.

The facility is about 10 years old, and to my eyes, it seems very well designed, as well designed as any outpatient medical center I have seen. This is a medical center that has transitioned to the EHR that the rest of the Institute uses, so they have experienced the return of space back to the practice now that paper charts are gone. You can see a scanning station in one of the images - this is where the medical records room used to be.

This medical center is interesting in that it also houses a dental practice, which coexists well according to the Medical Director. It was pointed out to me that the dental exam rooms have no doors, to promote team efficiency. The dental practice also uses a dental-specific EHR, that in this case does not communicate with the medical EHR. I have long been fascinated with dental practices, because I believe that they have done a lot of work to maximize workflow in the era of electronic records that allopathic medicine could learn from. I have seen that dentists do a great job of involving care team members in the use of the EHR and in producing documentation, and this was the case here, when I asked how documentation was supported.

You’ll note the picture of the flourescent viewbox - physicians are forgetting how to use this in the area of digital radiology, and that’s the case here. There are challenges in this medical center in not having on site radiology, though. Radiology services can be challenging to arrange, and retrieval of exam data that goes with it can be equally challenging. This has implications for a personal health record and patients’ desire to have complete results available to them.

I was also able to talk with Paloma Hernandez, CEO of Urban Health Plan of Bronx, NY, and her Medical Director, Samuel De Leon, MD, about visiting this organization as one of our future sites. I got the sense of their innovation by the fact that they are now piloting iris scanners for patient identification, linked to their EHR system. It looks like they are doing outstanding work, as is the Institute.

As has been rumored for some time, Microsoft Corporation has jumped into the PHR arena, with HealthVault, which seeks to consolodate needed health information for patients. It looks to have a facebook-like integration quality, with developers able to add applications that users can subscribe to.

Microsoft Introduces No-Cost, Online Personal Health Record - iHealthBeat

More diversity in the field is welcome. The PCHIT project is really about understanding things at the health system level, to allow projects like this to flourish - whatever it takes to empower patients in their care.

I happened to run across this display in Grand Central Station this week. The photo is a perfect complement to the quote of the week, which I posted on our LEAN blog, DailyKaizen (I am filling in for the other host while he is in Europe).

Today marked a bit of a milestone for me in that my company issued pedometer died. I’ve been walking with it non-stop since 2004 - it was my permanent company brand. The thing about pedometers is that you can’t really buy them easily, but you can get them because so many organizations give them away. So today, courtesy of the Clinical Systems Improvement Group in the New York Department of Health and Mental Hygeine, I got rebranded. I’m still trying to evangelize the walking meeting here, but I admit it’s a little hard if the humidity is at a level that makes you want to duck into the nearest air conditioned space.

I spent the morning in the South Bronx, visiting one of the Institute’s facilities and meeting with leaders of Urban Health Plan, and then in the afternoon with folks from Clinical Systems Improvement. I will detail that information on the PCHIT blog when it’s up.

One thing I notice about New York is that people walk as fast as I do here (well, some of them do). It’s good that I can count my steps again.