Article – Registries playing catch up with Stage 3

As Meaningful Use criteria advances to require sharing of population information with registries, this article explores some opinions on the readiness of public health agencies to accept and manage this data.

Is Radiology ready now? Check out all the ACR registries.

100th Blog Post: What I know about Software Development and Crisis Management

I started writing this blog post about this…

Opinions on policy and politics aside, this article on the struggles of tells a classic tale of large software development project failures, and how not to react when trying to solve the issues.

But as I continued to write my thoughts, this became more about my views on software development and crisis management. So, enjoy (or ignore, or comment).

Hopefully, it is worthy of my 100th blog post (which this is).

On software development

  • Software development, no matter how much research is done on development methodology effectiveness, is as much art as it is science. Treat the artists like factory workers, and you get what you deserve.
  • Not all software developers are great at developing all applications in all languages, using all tools. Web development, especially when connecting to legacy systems, is a specific discipline. The best Web developers don’t work at large contract system development houses, in my experience. That’s usually because there are more interesting projects in the world for them to work on.
  • In software, one of the most common reasons for failure is complexity. For large projects like the one cited in the article, you have to work very hard to come up with an architecture that makes concepts and aspects of the application simple to extend and use. This is not cheap—it takes time and significant energy from artists to achieve. But, when it is achieved, it is a beautiful thing. You owe it to yourself to experience this at least once in your career.
  • Never ignore or otherwise skimp on quality User Experience Design (UXD). Never.
  • Designs change. New needs and unidentified technical risks are discovered. Requirements evolve. But if you want to get something done on time, quit changing the (in scope) requirements. If a good design forces you to re-write significant parts of your requirements, that is a good sign that you didn’t write effective requirements. In fact, they may not be true requirements at all. And, BTW, a list of features from a competitor’s brochure are not requirements. If you don’t how to write effective, (mostly) design-neutral requirements, learn. Start here. Then read this.
  • Well-written use cases—that everyone on the team has read and understands—solve a lot of problems. So does identifying the operating environment and performance goals sooner rather than later. Tip: Print this stuff out and hang on the walls were the developers and testers sit. Or (if you want to save some trees) make a JPEG of it and ask everyone to set it as their desktop wallpaper for the duration of the project.
  • Make developers create unit and integration tests for their code. Have them do code reviews with peers. Make them use code comments and consistently format their code. Make them fix their own bugs. Hold them accountable to the quality of software build they provide to the test team. Make them perform design checkpoints with their peers (or even customers) for any significant component. Anything less and they are not a serious professional developer.
  • Developing for security and performance are specific skill sets, but these are most often “want to” issues. As in, if a talented developer truly wants their product to be secure and fast, they will figure out how to make it happen.
  • Do daily stand ups. Make the product manager show up.
  • A good tester is as valuable as a good software developer. So is a good technical documentation person. They are artists too.
  • Give them all good, fast computers with at least two monitors and reliable Internet access. You want something done faster, remove inexpensive barriers.
  • Don’t make them pay for coffee. And don’t buy the cheap stuff.

On crisis management (in IT)…

  • The comment in the article about the “war room” is spot-on. I call it “the body cannon”. When **it hits the fan, there is usually some executive wanting to pull anyone and everyone off their current work and throw them at the problem, with no real plan. They are simply hoping that through volume, that the problem will be solved faster, when in fact it usually has the opposite affect. The better approach: select a small team of talented, trusted artists (that know the code!) and simply ask them: “What do you need?”, and then get it for them ASAP. Then, be prepared to pay the price of pulling these people off their current project (usually in the form of a schedule slip), once the crisis is over. These things are always about choices, not decisions.
  • Yelling at software developers doesn’t work. People that choose a career creating art by typing all day with headphones on are not the type that react well to yelling. If you don’t know how to convey a sense of urgency without yelling, the problem is you. If you don’t understand the problem or software really well, get out of the way.
  • If you have hired talented people, they can become heroes. Let them.

And, finally, if you are making an application for use in healthcare, take it seriously. Lives are at stake. It can still be fun and rewarding, but the problems within healthcare are large and demand our best efforts all the time. Now, go be great.

Article – Privacy guru knocks patient ID as ploy

I posted some thoughts recently about an article on impact of privacy on patient record sharing.

Now, here is an article that discusses the merits of giving the patient control over how they are identified and how their records should be shared.

Fundamental to this are the two approaches:

  • A formal managed infrastructure that provides (cross-)identification and record transport services (like eHealth Exchange, formerly NwHIN), or;
  • An ad hoc one that allows participants to send record information from point-to-point (ala the DIRECT or Blue Button Plus projects).

Some thoughts…

  • As I discussed with a respected colleague of mine at the recent ACR Informatics Summit, I believe that new standards like the emerging DICOMweb (aka QIDO-RS, WADO-RS, STOW-RS) and HL7 FHIR will more easily enable ad hoc exchange of records, but the role of more formal application infrastructures, like those defined by IHE XDS (and its domain specific variants, like XDS-I) will still be used where a mandate for managed patient records across a consortium exists (such as in Canada with the Canada Health Infoway).
  • As I mentioned in my prior post, society may have different motivations than those paying for the infrastructure and tools. This article attempts to express some of the concerns consumers may have about how their data is handled, which contrasts with the prior article’s statements about how “nobody under 30 cares about privacy”.

Article – New HIPAA rule could change BAA talks

As this article explains, the rules of accountability need to apply to all parts of the delivery chain, from the healthcare provider to the infrastructure vendor.

It is my experience that the readiness of the vendor to provide the necessary security controls (technical, policy, etc.) is usually not the issue. It is often the healthcare provider staff that lacks the knowledge of appropriate and effective controls that prevents proper security from being in place.

For example, even when proper single sign-on (SSO) methods are available in systems, rather than taking the time to implement this between systems (which often requires some learning), staff will often default back to wanting to simply pass a user ID and password (often a generic one) from one system to the next, because that was all they could do 10 years ago to avoid having the user log into multiple systems.

Imaging 3.0 at ACR Annual Imaging Informatics Summit

Quote: “If you don’t like change, you are going to like irrelevance even less.”

Dr. Bibb Allen talking about the importance of accepting change to the practice of Radiology, explained the rationale behind the American College of Radiology’s Imaging 3.0 framework.

Imaging 3.0 - Dr. Bibb Allen

FDA and New Cybersecurity Regulations

A friend forwarded this post to me.

Links worth checking out…

Here are my thoughts…

  • Frankly, security in healthcare devices ranges from embarrassing to terrifying—especially at the interface point between devices/systems. As more devices become network enabled, the level of risk is exponentially increased. Too often, software in medical devices are built by clinically focused developers, or hardware engineers tasked also with the software layer. Developing for security (and performance) is a specific skill set within software development, and it is not commonly found in the average developer. I have found that developers with experience in Web-based consumer applications (that manage personal data) and those with banking application experience generally “get it” more than others, but that’s just my experience. Also, product managers need to get a lot smarter about security and make it a priority in the product scope.
  • Regulations are brought in when industry fails to protect the public interest, and that is what is happening here. If the medical device industry was better at doing proper risk-based design and validation—which security and protection of data would certainly be an area of focus—and including risk mitigation controls in their designs, the FDA would not need to issue regulations. But, here we are. Now we get to see if government regulators can produce effective regulations, and keep pace with the ever-evolving security model best practices and methods.
  • Where the HIPAA Security and Privacy rule applies to the healthcare provider organization (that is, it is their responsibility), FDA regulations apply to the registered device manufacturer. Regulatory Affairs staff working for the vendor community are going to have to learn a lot more about cybersecurity. Most of the professionals in this field that I know, know very little about this topic. If you are a cybersecurity consultant that knows even a little about healthcare IT application design patterns and existing medical device regulations, this is a goldmine. Hmmm, maybe I will study this FDA stuff in more detail. 🙂

Quebec EHR …the difference 2 years makes

The news from today (May 2013) “Quebec to expand $1.6 billion EHR“. And, from 24 months ago (May 2011), “Quebec’s EHR late and over budget, AG says“.

One thing is for sure: implementing an EHR of that size and scale (with public funds), is not for the faint of heart.