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    Clear To The Cloud and Collaboration - Don’t Forget To BYOD

    June 24, 2013
    It's 2013. Healthcare information technology is far more prevalent and standardized then it has ever been in the past. Some concepts that have been evolving from other industries, as well as in healthcare IT, have important applications and implications. From cloud computing to active collaboration and mobile computing this post analyzes what we should consider and provides simple suggestions to get started.
    It's 2013. Healthcare information technology is far more prevalent and standardized then it has ever been in the past. Some concepts that have been evolving from other industries, as well as in healthcare IT, have important applications and implications.Cloud ComputingThe notion of doing things “in the cloud” has become a buzzword and an almost faddish term in recent years. Initially, it was used to put a new shine on old things. Simply storing information on remote servers as standard files was called cloud computing. Many of us are currently using services like Dropbox, Google Docs, SugarSync, etc. Similarly, connecting to a remote server as opposed to doing something locally on one's desktop or laptop computer is also dubbed cloud computing. An example here is simply web-based email.In both philosophy and in practice, cloud computing has become something distinctly more and in some ways different. I'll highlight just two aspects of this, surpassing file storage (and even traditional database record storage), and transcending the tyranny of an implied single concurrent user.

    Files and the closely related notion of document storage has become a terrific and convenient way to store and exchange information. Cloud computing has brought the availability and the expectation of concurrent versioning with undo and redo of multiple steps, and transcending the distinction from each end-user’s device.    For example, today I can open an existing file on my smartphone and add three sentences to it. Moments later, I can access that same file in its current and recently updated states on a tablet or laptop computer without explicitly opening it to undo one or two of the new sentences.  The applications are not behaving like old-school word processors, requiring me to open, save, and close the file. Instead, they are maintaining the transactions against that document, apart from and in addition to any static snapshots of that file. The result is the need to back up, send, print, continually rename, and other operational requirements of the old file/document/word processing metaphor are now gone. So are some of the tasks required to collaborate with others.

    I referenced the issue of the tyranny of the single concurrent-user model. A common manifestation of this tyranny was that if one user opened a file, changed it and saved it back to a shared space on the network, they have the potential to overwrite changes made by another user during the same period of time. Someone's work would be deleted, invisibly, and unceremoniously, without any notification to any party involved in the process.    In the world of cloud computing, with applications designed and engineered to achieve the behaviors I’ve described, this lethal overwrite tyranny is replaced. Instead of having to resort to old-school techniques, such as “checking out a single copy of the document,” the cloud computing world surpasses that. When changes are made concurrently, either by multiple users, or by the same user on multiple devices, they are reconciled in real time.  Where there is a concurrency going on (actions happening at the exact same time, potentially in different places, and on different, often mobile devices by the same person or by different people, in cloud computing the  divergence or “forking” of the document is automatically captured and maintained. There is no additional work, duty, or responsibility by the person editing the document.This capability is adequately mature, in productive use, and available for no additional cost to hundreds of millions of current users of platforms by major providers including Google and Apple. In many cases, tens of millions of people are already using these cloud capabilities and not realizing they are there and how strong they are!The availability, application, and integration to healthcare information technology, especially specific to documentation are less advanced, but likely to rapidly catch up. Of course, the definition of "rapidly" in HIT for providers is a lot slower than "rapidly" in the world of consumer applications and products.Active CollaborationIn November 2012, at the AMIA annual meeting, there was a celebrated debate on the relative merits of health information exchange models.   This debate included those primarily constructed to serve enterprise-to-enterprise HIE between healthcare providers and an alternative model that is more patient centered. The distinctions and challenges of ensuring patient information is available and important considerations like privacy were recognized and contrasted between the two models. There was a huge contrast among the presenters including John Halamka, Mark Frisse, Bill Yasnoff and Latanya Sweeney. John Halamka provides details here.  What was largely implicit in this discussion were the roles and responsibilities of the participants in terms of communication, task tracking, and decisions closely associated with the patient information being exchanged, shared, downloaded, or otherwise directed. That is true where the participants are patients, as well as when the participants are providers. This is part of the weakness, and in some cases failure, of care coordination today, which leads to such visible things as unnecessary readmissions and other gaps in care.For example, it was noted if a physician prescribes a medication that is changed in the pharmacy, there does need to be a mechanism to ensure the appropriate subsequent providers are aware the medication listed was changed, why, and perhaps additional information on the intentions of those involved. Otherwise, subsequent providers are sure to act on obsolete information.Therefore, if the patient reported to the pharmacist that they were intolerant of the medication because it gave them profound muscle weakness, severe rash, or other issues, more than the medication list probably needs to be updated, i.e. the allergy list, and the problem list. This notion overlaps with the notion of clinical reconciliation that came to life in ARRA Stage Two.Clarity on care related responsibilities and results is currently not part of the explicit expectations on the capabilities and use of HIEs or their patient directed alternatives. The same can be said for care related responsibilities and results (more frequently referred to as outcomes) in electronic health records of all sizes.  Today, when a provider leaves a practice or an institution, for example, there is not a standard process in the majority of institutions that can be trusted to ensure there is follow-up for tests that were ordered by the outgoing provider. There is a brilliant elaboration of this problem described by Dr. James Walker and collaborators in HealthAffairs here. One example in the article is of a double-digit prevalence of mammogram results not being followed up in a timely fashion, leading to clearly avoidable tragic deaths.Mobile Computing and the Age of BYODIn wrapping up this short list of what's becoming clear in the evolution of HIT, my final point is that mobile computing is more than just mobile devices (smartphones, tablets, notebooks, and intelligent connected everything else) and the ubiquity of wireless connections.Let's skip the vanity battles over which devices are better and the privacy and security issues of hardening these devices. They are important topics, but addressed well elsewhere.

    In the same way that “cloud” and “collaboration” are transcending their previous definitions, so is mobility. The implicit in mobility stems from the integration of global positioning services and related ubiquitous connectivity. A simple example of this is spouses routinely checking on the whereabouts of each other and their children using free services such as “Find My iPhone.”    Similarly, the unification of communication modalities (defined in detail here), including email, instant messaging, voice, etc., are making old processes obsolete and new ones compelling. Mobility and adjunct tools like mobile hotspots are making it practical for our pens, shoes, and other devices like Fitbit to facilitate, through the cloud and collaboration, new ways to track and encourage compliance, exploit social and gaming motivations, and otherwise redefine how we get things done. Many tasks can now be done better, faster, and cheaper.The implications for improving health and healthcare, reducing costs, and increasing safety are enormous.I'll end this post with a call for action. The only way to achieve the benefits described here is to connect these dots for oneself. This is a bit of a "Gandhi" thought in that unless one experiences it personally, technology is all a somewhat of a joke, a threat, or a potential time-consuming source of embarrassment.So right now, in the real world, try the following:1. Use videoconferencing instead of voice-only cell phone with your friends, peer collaborators, and direct reports.2. Maintain your grocery list on your smartphone using a cloud-based note taker. Everyone in the family can then readily add to the list and you'll always have it up to date when you're in the grocery store or ordering through an online delivery service.3. Encourage and support experimentation with diverse devices, including mobile, to establish workflows that are efficient, safe, effective, and productive for yourself and those you serve. This can't be figured out in a board room or living room environment and be expected to have a successful rollout. They often become laughably wrong in the first hour of rollouts, despite careful planning by otherwise smart people with otherwise good experience-based planning.  Establish a proof case for yourself!  The ONC's Judy Murphy offered a splendid discussion of the common shortcomings healthcare IT plans. A Healthcare Informatics story is here, and Judy discusses her plenary presentation here on YouTube.4.  Possibly the most important to thing consider is to support and encourage this experimentation by direct reports, our families and friends. For example, how many of us are helping our parents using the technologies discussed here? One notable physician, over Thanksgiving, established a personal health record for his parents including the use of a Medicare Cloud Service and an app called iBlueButton. All free. The explicit benefits became apparent the next day!What do you think?Joseph I. Bormel, MD, MPHHealthcare IT Consultant[email protected]

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