We're ALL on the same team

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Have you ever noticed that when baseball players hit a single and land on 1st base, they can be seen chatting with their "enemy" on the bases?

I enjoy watching them - and wonder what they're talking about.  It reminds me that despite the animosity often expressed by fans, baseball is just a game.    The players are all players.  They may switch sides sometimes, but they are really all the same - working toward the same goals, with the same methods.

Players in every industry change teams.  It's normal, common and in fact it's a good thing.   When we leave one "team," we bring the culture, values, passion and insight that we built into another organization.  Such diversity of thought, values, vision and culture is what keeps us all growing as people and as teams - working toward shared success.

This isn't always apparent to those off the field. A few years ago - a good friend of mine was diagnosed with a serious illness.  Some of the greatest support for her (and her family) was provided by her counterparts at competing companies.  It was touching - but not surprising - to see others rally around her and support her as she fought back to complete recovery.  

And what a privilege it has been for me to work within a community of government leaders, industry leaders, community leaders, consumer advocates, informaticists, and researchers as we strive toward better health for all.  

I started this blog fifteen years ago on November 15th.  Here's the first post.  Stay tuned for (much) more from me in the next few weeks - toward a 15 year anniversary post on 11/15/14, and a re-launch of Docnotes for its 15th year.  


It's not about the technology

I got a call from a friend last night.    He's the CMIO for a large hospital.  He's smart, works 80 hour weeks, and he's passionate about getting his EHRs to work right, the providers trained right, the order sets configured right, and (most importantly) the patients treated right.

He's been in the role for a number of years - and he's good at his job.  Very good at his job.  He knows the systems (from two EHR vendors - an inpatient system from company A and an ambulatory system from company B) better than many employees of the companies.    He's memorized the criteria for Meaningful Use down to the section and subsection numbers.  It's amazing.  I had a similar role once - about ten years ago - and I vividly recall mentoring him into his new position back then - thinking that his hospital would do so much better than mine - as he'd see the puddles we had already stepped in.  .. 

He's an incredibly gifted physician too - and continues to see patients at least 20 hrs a week - with a full call schedule.  

But tonight he called me because he wants to quit his IT job and go back to being "just a doctor."

Because the politics of the IT world have been too much for him.

"The analysts didn't finish the order sets and blamed the doctors for not reviewing them."

"And the doctors insist that they WANT to review them, but the analysts tell them that they're not ready to be reviewed!"

"We're behind schedule and all they do is blame someone else."

"Why are they lying?  Why do they get mad at me when I point out what's going on?" 

I listened.  And listened.  It sounds dreadfully challenging.  He's implementing TWO EHRs, and getting CPOE up and running in an outlying hospital, and migrating a community of physicians to new workflows, new processes and new habits.  This is no simple task - and he's got the technical details down cold.  

And he's done a great job with all of it ...

Except his relationship with the IT team.    

This is not uncommon.  But there is a solution.  An easy one, in fact.  

"Your should pretend you're a doctor."  I said.

    "I am a doctor!"

"You're a doctor when you are with your patients. But it doesn't sound like you're a doctor when you're with the IT team.  It sounds like you are an angry parent!"

We talked about this for a while.  He wasn't sure where I was going - but he was intrigued.  He knew that somehow I have found it less difficult to navigate the political mine fields of hospitals, academia, industry and government.  Indeed - his minefield is my Fenway Park!  Am I serious that I want him to treat the IT team like they are his patients?


"If your patient tells you that they have been dieting and exercising but they are still gaining weight - what do you say?" 

    "I would say that I believe them 100% - that they are dieting and exercising and that I want to find ways to help them."

"Do you really think they have been dieting and exercising as much as they say?"

    "No.  Of course not."

"So why do you not challenge them?  Why don't you point out how wrong they are - and that they are fibbing?"

    "Because it's not important if I am right.  That won't help them."

"So why is it important that you are right that the analyst streched reality a bit about doing the order sets for Dr PooBah?"

    "Because they didn't do what they are supposed to do.  I need to point that out."


    "OK - I can see what you are saying but it still doesn't make sense.  How will my NOT judging them make them get their work done?"


So this is the key leap of faith for him.  It seems like these are different settings, different goals, and he should use different skills.

But it's not necessary.  The same skills that make a great empathic physician will also make a great empathic results-oriented CMIO.

He's built a (medical) career of great habits that we can leverage.  The habits he'd built are the ones he uses every day to care for his patients in a collaborative, meaningful, non-judgemental way.

The key to his success in the IT world is to say (to himself) just what he says to his patients:

  "Because it's not important if I am right.  That won't help them."

The focus shifts from blaming them for being lazy, lying IT enemies - to "folks who need my support."

Dr CMIO - you already know how to do this!

I could tell he was interested - but still wasn't quite at the point where he could make the leap.  We talked about the dysfunctional team of IT analysts, how they gossip and argue and sidestep work.

"It sounds like they are very unhappy"  I say.

He got quiet.

"Yes - they are - and they make everyone else unhappy."

"So what do you think would happen if they felt like you were an ally?  Like you wanted them to be successful?"

We went on like this for an hour or so.  It's a hard shift - but quite powerful.  He remarked that I was soundling like a buddhist - and I pled guilty - but pointed out that this is not just a buddhist principle to avoid judgment - it's a core component of many of the "success in management" books too - most of which avoid invoking religeon or spirituality.    A few good ones to consider - probably required reading for any CMIO:

Energy Leadership

Five Dysfunctions of a Team

7 Habits of Highly Successful People

I'm giving a talk to a bunch of CMIOs in a few weeks.  Maybe I'll leverage this vignette into a little sermon powerpoint.


Seven e-mail patterns for more efficient work

Like you - I get (and send) more e-mail at work than I would like.  E-mail is a great communication tool, but it's hard to manage.  Many add-on tools and processes exist to help people manage their own e-mail, but I've adopted some processes that (I hope) are helpful to the people who are RECEIVING the e-mails that I send.  

A core principle of great communication is that we must meet the recipient of our message where they are.

  • In education - this means we focus on the needs of the STUDENT rather than the needs/skills/ knowledge of the teacher.  
  • In health care - this means we focus on the needs/readiness/goals of the PATIENT rather than the skills/knowledge/bias of the provider(s).
  • In journalism, fiction, poetry, art - the creator is most sucessful when they focus on expressing things in a way that will be MEANINGFUL the audience.
  • In software and technology design - the best products understand and ANTICIPATE the needs of the intended user.

So in e-mail - how can we help the recipient(s) who already have 329 unread messages in their inbox.  We need to help them understand what we expect them to do with this message - so they can "done" it right away and get on with their day.

Seven Rules for Sending E-Mail

  1. Always clearly define an "owner" for a requested action.   If you are asking for something to be done - only one person should be in the "To:" line - and you should be clear that this person is the one you're asking to be responsible for getting it done.    
  2. Prepend "FYI" messages with "FYI-" in the subject line.  This lets the recipient know that they an review it later - or that reading it will be quick and won't necessarily cause new work.  If you are not asking anyone to do anything - then there is no task for anyone.  An "FYI" e-mail just informs others of something that they may need to know - so that they can (if they so choose) incorporate it into their future decision-making, or so that they are not surprised.  You may find that you often send "FYI" notes to your boss.  A wonderful mentor once taught me never let your boss be surprised.  An "FYI" note should be short and clear.  If someone has to scroll an FYI note when it shows up on their screen - it's probably too long.
  3. Private messages should be clearly identified with "DNF" (Do Not Forward) in the Subject Line.  This is clear request to your recipient(s) that you want the information in the message to remain private. Use this sparingly and with people you trust - since of course there is nothing that technically prevents them from sharing your message.  Nonetheless - "DNF" makes it very clear to the recipient that you trust them with this confidential information, and that you want them to keep it to themselves.  Use this sparingly.
  4. Use Whitespace.  The "return" key is your friend.  It's much easier for your recipient to read a message (especially on a smartphone) when you use short paragraphs of no more than three sentences.
  5. Use spaces or hyphens for numbers greater than four digits. English readers have a hard time keeping more than a handful of digits in working memory.  Conference lines often have a dial-in number and then a four to eight digit access code.  While you may have memorized the access code - your recipient has not - and will struggle as they finger it into their phone if you don't break it up into three or four digit chunks.   Extra credit here for adding the number in a form that smartphones can parse with one "press" on the screen.

    Blackberry, iPhone and Android can all parse a sequence where the conference line follows (with no spaces) the dial-in number and a lower-case "x" like this:  800-123-4567x123-456-7890.   Note that you can/should still use hyphens here so the humans reading this number can do so easily too.
  6. Use "out of office autoreply" sparingly.  Offer clear feedback for when you will be able to return messages (not just when you will be online again), who is your delegate while you are offline, and how you can be reached in an emergency.  People don't need to know if you are "away on business" or the name/location of the conference/meeting you are attending or where you will be on vacation.  Keep such details out of the "autoreply" message. 
  7. Keep it short.  "I would have written a shorter letter, but I did not have the time." - Blaise Pascal.  Take the time to make it short.  This shows respect for your reader and their time.



12 years of blogging .. about medicine, technology and their intersection ...

This post from November 26th, 1999 - was the first on this blog.  There were a few months of previous posts, but due to several platform changes back then - these seem to be lost.  

No matter.  12 years is a long time.  My blog is now officially an adolescent.  I wonder what it will be when it grows up!  Long-time readers are of course observant that I've been remarkably quiet for the past few years.  This is due to my evolving work for an HIT vendor and now the Federal Government.  

So I've been operating with this in the background for the past six years:

The opinions expressed on this blog are my own and do not represent the veiws of my employer.

And there is a rough "social media policy" (google docs - you have edit rights .. feel free to steal or enhance ... ) that I have in my head as well .. so in general I have done my best to observe and occasionally point to important publicly available information, but take care not to comment too deeply - for fear that others would interpret my commentary as a telegraph of my employer's next steps.  This wouldn't be appropriate for me to share - and increasingly - I am concerned that most of my public thoughts could be interpreted in this way - so I've been holding back from any public commentary.

So for now - here we are. 

I'll push the envelope a teensy bit and comment on some events of the past few months:

Tim HISTalk covered my arrival at ONC in a post about a month ago.    He asked the right questions about the topic at hand - but he didn't get to the one that I am hearing often these days - which is .. "Why did you leave your leadership role at one of the top health IT companies, choose to spend weekdays away from your family, AND (with two kids in college) take a giant pay cut?"  

The answer is easy:   It's the right thing to do.  

Health Care in the United States  is at a turning point.  It is well known that despite great advances - we don't provide the quality of care that we would.   It is also self-evident (to me) that technology - carefully applied - will improve both the quality of care - and the efficiency, sensitivity, and ease with which it is delivered.  Yes - some of those words may not be familiar to you - but why WOULDN'T we want it to be EASY to deliver great care?  Why shouldn't we deliver SENSITIVE care (sensitive to your hopes, religion, fears, preferences) - in addition to efficient, evidence-based and (of course) cost effective) care?

 So I have always tried to focus my work on helping others meet their true potential.   In my first career - as a 16 year old sailing teacher, I helped kids find the freedom and autonomy that a good breeze and a sunfish will provide.   As a teacher of junior high school kids - I witnessed breathtaking intellectual growth in a herd of 12 year olds who were otherwise distracted by adolescence and its daily challenges.  Working with (some say "caring for") patients as a family physician - I found that my most important work was not to take control and "fix" my patients (as some of my mentors had advised in medical school) but to partner with my patients - serving as a resource - without any judgment or critique.  As Bill Miller and James Prochaska have demonstrated (motivational interviewing, transtheoretical model) - people change when they choose to - and no sooner.  Can we facilitate growth in others?  Of course we can.  But "facilitate" and "cause" are inherently different.

As a leader in a large health IT software company - my role was often to help our teams align the software products we were producing with the needs of our customers.  This is not unlike the role of a good physician:  we need to listen carefully and critically so that we understand the needs (which will sometimes differ from the "wants") so that we can facilitate success.

And isn't that the role of government too?   Perhaps that's a political question.  Some would argue that government should get out of the way, while others would argue that there is an important role for government to provide an infrastructure with which success can be facilitated.  Is a healthy happy nation something that is important?  Are there ways that government can facilitate a migration toward these goals? 

I think so.  Keep an eye on my occasional tweets , g+ posts (rss), and posts here on this blog.  It will continue to be sparse here on the blog. 

PREVENT SPAM! - Marathon Fundraising

I'm sending out the following e-mail to my friends and family on Monday.  

You can prevent this spam .. (I'm learning from Public Radio!) .. but only if you make a generous donation TODAY!

Don't put it off! .. 



Keeping this short for ya:

a) I'm running in a marathon in January. 

b) To raise cash for a good cause (LLS).

c) You have some cash you can spare.  I know you do - even just a little.  That's why I am sending you this email.

d) Click here to see my "make a donation" page .. or skip it and click here to skip the "info" page and make a donation of $4 for every mile I run.  Just $4.  Not much at all - right?     Thanks!

- Jacob   

P.S. Feel free to forward this email (or URL) to as many people as you like to encourage them to donate as well!

Oesh Running Shoe Review

Oesh (shoe spelled sideways and backwards) had gotten some good press lately.  I've read a handful of Casey Kerrigan's papers on gait and movement - so my interest was piqued when I learned that she and her husband had created a company to manufacture and sell shoes with a scientific basis - rather than a marketing/sales basis.

They started selling shoes about six months ago - but only in womens' sizes.  So I e-mailed them to ask when they would carry men's sizes, and Bob (Oesh CEO/husband) suggested that I could wear a women's size 11 since I am a dainty men's 9.5.  Yes - I am no sasquatch.

So I ordered them up and have done four runs with them in the past week.  Two short ~ 2 mile runs on pavement just to get the feel for them - then a long 15 miler - mostly on a dirt bike path over the weekend - and then about 6 miles on pavement and concrete sidewalk yesterday.

I did one 3 mile run in my Saucony Kinvara 2's two days ago.

First impressions:

  • BIG

These are not racing flats - or super light - or "minimalist" in any way. The upper is 60% leather and about 40% regular-shoe-upper-stuff (whatever that is .. nylon/dacron etc.) over padding.   The women's 11 weighs in at abuout 16 ounces dry - and much more when wet (one day was raining).  Leather loves water - as does padding - so this is not the shoe you want to wear in the rain (so I learned).  These shoes will last a very long time - and I don't doubt the company's claim that they could last 2000 miles.  There is no foam to wear out - so the only life-limiting factor will be the upper and the sole - both of which seem quite durable.

If we compare them to the Saucony Kinvara 2's - you can see that the Oesh is a more substantive shoe:


  • image from picasaweb.google.com
  • image from picasaweb.google.com
image from picasaweb.google.com
  • Comfortable. 

They feel good on the foot.  Soft inside - and - yes - the carbon fiber cantilever supports a very natural running or walking gait. I won't repeat all the theory behind the shoes here.  Go take a look at the website and get a quick overview of the rationale for these shoes.  Basic concepts:

  1. Impact is good.  Don't cushion the impact that happens when the foot hits the ground.
  2. Injuries happen at the point/time of maximal force - when the foot is bearing the most weight. Traditional running shoes try to reduce the force of impact with foam - so as the foor hits the ground - there is a softer landing, but a few fractions of a second later - when all of the body's weight is on this foot - the foam is now compressed - allowing rather little force to be absorbed by the shoe.

The goal is therefore to have a shoe that preserves impact forces (which theoretically build bone and muscle strength) and reduces maximal force - when the foot is bearing the most weight.    Minimalist runners will of course ask why we need to reduce ANY of this force - and I think there may be merit to such a question.  Casey Kerrigan has done a lot of research on where/when these forces occur, and what will maximize them - but I haven't seen research that demonstrates that it's better to absorb some of this force in a shoe.  Just as we need to critically questions some of the theories behind traditional shoes - it's appropriate for us to critically question some of the assumptions here as well - yes?

The method OESH uses is to put a cantilever made of carbon fiber into the sole of each shoe.  The cantilever is basically a v-shaped wedge - laid on its side - so the closed end is on the lateral (outside) edge of the shoe and the wider open end is on the medial (inner) side of the shoe.  This makes the medial edge of the sole entirely open - and I could see/feel (especially when walking) as the wedge compresses under my foot and then releases.  I didn't percieve a "spring" release - so I don't know that there is a claim that these return energy as newton does.

Here's a view of the open medial edge of the shoe.  I can put my fingers all the way in!


image from picasaweb.google.comimage from picasaweb.google.com image from picasaweb.google.com 

Rnning experience:

My first run - a slow ~ 2 mile test drive - was quite comfortable.  I've been wrestling with some left foot pain for the past 15 months on and off - and I was pleased to find that the run in these shoes didn't hurt at all.   Forefoot strike is easy - as they have no "drop" from heel to toe - and I found the impact noise to be a bit of a surprise.  I wonder if the neighbors thought that the Clydesdales were coming!  Clap/clap/clap/clap.  These are not the shoes to wear when you don't want anyone to know you're coming!

 As my foot makes impact with the ground - I found that the lateral inch or two of my foot was where most of the impact was felt.  Especially at the end of my 6 mile run (all on pavement and concrete) - the soles of both feet were a bit numb.  Not in a bad way - but imagine you've beel clapping your hands at a Red Sox game for a few hours - hard.  It's that sort of sensation - which isn't bad or even painful - but it's new - and likely due to the fact that the impact of footfall is preserved with these shoes.  It takes some getting used to and I found myself occasionally trying to "tiptoe" on occasion as one would do walking in the woods - trying not to make any noise - as if that would reduce the clap/clap/clap of impact with every stride.   But I kept reminding myself that impact is good - and to go with the flow - and as I stopped thinking about it - my stride got back to normal.

On my long (wet) run - the weight of these things was certainly noticeable - and when I put on my Kinvaras for a short run two days after the long run with Oesh - it was like I was running on air.  Bob (Oesh CEO/husband) suggested to me that I need to think of these things as trainers - certainly not to be worn to achieve my PR in some race - and he's spot on there.  

Like the heavier bat that little Dustin Pedroia  image from boston.sportsthenandnow.com swings in the "on deck" circle - these shoes will get you ready for walking up to the plate - and after four runs - I can say without hesitation that my nagging left foot injury is no worse - and perhaps a bit better - than it would have been had I been wearing the Kinvara 2's every day for the past week.  Last summer - I had a metatarsal fracture in my left foot - and in the context of these conversations - I think that it's entirely possible that my rotten running form had as much to do with the injury as anything else.  It's hard to get the hang of Forefoot running - especially if you've been running with a heel-strike for so long.  I went to a "chi running clinic" last Fall - and recall that even after the clinc - the teacher watched me run and said told be to stop running "on my toes."  This is a common mistake that new forefoot runners make - and it takes some practice to LIFT the foot - rather than PUSH OFF with the toes.  Since my left leg is about 3/8" shorter than my right leg (1974 injury) - I think that I am pushing off MORE with my left than my right in a subconscious effort to keep my pelvis even.  This puts too much force on the left metatarsals - and could have resulted in the fracture.  It hasn't felt quite right ever since.

The injury kept me sidelined for the 2010 marathon - but I am (so far) on track for this year's event - and I think that including the Oesh in my shoe rotation - especially on my long runs - will help me avoid injury.

Health IT Workforce Curriculum - initial impression

I've spent a number of hours today reviewing the ONC HIT Workforce Curriculum materials, and since I've seen many tweets referencing them .. I've seen little substantive narrative on their value - so I'll offer a bit here - with the caveat that this is the product of ~ 4 hours of review of only one component.  There is a mountain of material here - and while I had previously flipped through a handful of PowerPoints - today was the first time I sat down and listened to the presenters talk through each module from start to finish.  

It's an impressive set of work.  I was assigned component #12 (Quality Improvement) to review.  I can say with certainty that this isn't how I would have approached educating a group of HIT students on this topic.  Why not?

  • There is way too much detail.  Far too many trees - with only occasional views of the forest.  If I was a community college student - I wouldn't be able to digest or retain all of this detail - nor would I be able to distinguish between what's really important and what isn't.
  • Too acute-care focused.  There is far more emphasis on the challenges / opportunities / processes of acute care - with only occasional reference to outpatient care.   This is the opposite of what I would do.  Implementing HIT in mature settings (acute care facilities) is very different from outpatient settings - and small practices in particular.  Does an educated HIT worker really need to understand the Donabedian model or the SEIPS model?  No.  Never.  Call me anti-academic if you like (recall that I was an Associate Dean of Biomedical Informatics) but this material is just too deep for this audience.  
  • Disconnected from the roles that the learners are training for.  In many cases - speakers make reference to the "leadership roles" that the learners will play in health care organizations.  In the vast majority of cases - I can't imagine that the graduates of these training programs will become change agents or leaders in the organizations that hire them initially. This isn't to say that these folks aren't important (they are very important) or that they won't evolve into leaders in the years to come.  But this program isn't about training leaders - it's about training a group of  students to become familiar with this important field in order to fill a resource gap that exists in the "engine room" of the industry.  

    Again - I want to be very clear:  this is IMPORTANT work - but we shouldn't suggest that these folks will be "leading" HIT initiatives in the near term.  That's just not realistic.   The educational needs of this group are therefore quite different from the needs of undergraduate computer science students (HIT developers-to-be?) , MPH students (strategic guides to-be?), AMIA 10x10 students (CMIOs-to-be?), or Medical/Nursing informatics students (CMIO/CNIO/etc to-be?).  Alas, in many instances - I got the sense that I was listening to the re-purposed lectures of educators who had been teaching to these other groups, but failed to separate the most salient nuggets for this new type of trainee.

Way back in the "dark ages" (10 years ago) when I was a full-time educator, I worked hard to make sure that I deeply understood the needs of my learners before I launched into "covering" material for them.    I think that's a core problem here:  the faculty who developed these materials were developing them for an audience with whom they have had little interaction - and the reviewers of the materials (generally informatics experts) are looking at this from a perspective of completeness with respect to informatics education curricula that exist today.  At one point - one of the faculty mentions a book that he has written on the topic of patient safety: "as you may have read in my book on this topic .. "  Oh please.  Really?  Do you expect that these folks have read your book?  Unlikely.  Have I?  Well .. yes I have - and it's a good book.  But this isn't a forum for pitching a book.  I would suggest that this sort of narrative offers little value - and may actually detract from the curriculum.  It's easy to remove - and probably should be.

While I am certainly  looking for gaps (as I've been asked to do) - my overall sense so far is that the flaws are the opposite:  too much detail - and too much expertise - with too much of a focus on what the educator KNOWS - and too little focus in the foundational material that the learner must UNDERSTAND.  

Having said all of this - I need to be clear that I think these materials are a great resources - and a great foundation for a strong training program. 



This post on the-blog-that-used-to-be-kevin's-blog (alas, Kevin Pho writes rather few posts these days) ... is accurate, but I wish that the medical community was saying the same thing.  In general - we are not.  Patients who have guts will say this - but on the other side of the stethoscope - we continue to use such terms as "noncompliant" and "adherence" on a daily basis - and nobody recognizes how offensive it is.   I blogged about this in 2002.  Same story today.    This is a nomenclature is symptom of a problem - not the problem itself.  Care providers who have been taught to expect patients to "comply" are not learning the skills they will need to really help patients meet their treatment goals.