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Over the last couple of weeks I have been running across various success and failure stories of EMR implementation in various settings, ranging from small practices to large hospital wide implementations. 

The number one factor in a successful EMR implementation from all the read reports have been due to physician/surgeon buy in.  Makes sense, after all these are end users of the applications and if you don't have anyone on the provider side vying for a successful workflow adaptation, there is no reason to implement an EMR.  Also, if you have an M.D. as your champion, won't the rest of the staff have to buy in for fear of replacement of someone who will?  I know in other occupations, what the boss says, goes.  The true is same in healthcare, no?

The next seemingly most important factor is the ability to customize the application in a way that will best benefit the providers.  This is absolutely a main component in the success factor of an EMR in my opinion.  Vendors have to do what they can to include everything in their system that a practice, clinic or hospital may use.

In a hospital system, this problem is very clear.  A hospital system has to be a nightmare to the specialists who use it.  Why would a provider want to sift through literally thousands of medications when they typically only prescribe certain ones for their patients.  This is where careful planning and delegating comes in.  The customer needs to understand that the hospital system is meant to meet the needs of all providers in the entire system.  It is recommended that each specialty department within the community appoint select staff to create a list of "Favorites" within the medications, procedures, diagnosis, orders etc. tabs.  This way, time will be saved when completing a patient visit.

In a smaller setting, I have to recommend going with a specialty specific vendor.  In doing this, the provider will have a more robust system specifically catered to their needs and will not include any additional data fields that they will never have a need for.  The specialty specific vendors are also more likely to already have certain reporting tools already preloaded in the system to generate specialty specific and relative reports, such as those required for Centers of Excellence.  Exemplo Medical (  is one such company that develops specialty specific software.  For example, Exemplo's application for Breast Cancer, eMD for Breast Centers, is an application designed in conjunction with Breast Surgeons and staff that only shows pertinent workflows that a typical Breast Center or Practice may use.  The workflow includes specific data fields for patient visits, orders, medications, procedures and so on.  They even have a specific report that automatically generates a NQMBC report that is easily submitted to the National Consortium of Breast Centers for their COE compliance.

Of all the success stories these two themes: provider buy in and customization seem to be at the top of the list and perhaps the easiest to attain.  Some may disagree with that statement of being "easy to attain" however if a provider has been given a clearly painted picture of the benefits of EMR implementation, then it should be a no brainer on their end.  As for the customization...providers do your homework, there are wonderful systems out there that you will be amazed to find how easily adaptable they are to any practice.


Two studies were published in the Archives of Internal Medicine this past Monday showing "The risk of cancer associated with popular CT scans appears to be greater than previously believed".

I originally read this article in the WSJ and they included a nifty graph showing the increase in CT scans over the years (1993-2006, and included projected 2007 numbers). I can't say I was shocked. Obviously there will be an increase, population increases year over year.

As expected, the American College of Radiology (ACR), released their own statement in response to the recent studies. The ACR statement was wonderfully put together and basically stated that if an imaging center abides by the standards put forth, then there should be no increased risk as the benefit of the scan outweighs the risk. Seems like common sense to me.

This is where I believe that patients need to take more responsibility for their own health by asking questions instead of just going along with whatever their physician says. After all, when you break it down, its a business that strives to make a profit. I am not putting down all clinicians who perform CTs, I am putting down the clinicians who abuse the system to make the money to pay for their fancy state-of-the-art equipment. Those machines come with a hefty price tag and the ROI must be met somehow. Some clinicians go about it the right way, others don't unfortunately. They are human after all.

Now for the other issue with this...clinicians have to protect themselves. If a patient comes in complaining of a mild condition that a CT may show, its up to the doc to determine the severity of the situation. This is a very fine line due to the liability involved. Unfortunately we live in a world of money hungry individuals who are willing to sue if their coffee if too hot. This is where the relationship of the physician and patient comes into play. There has to be a level of understanding and trust for the situation at hand.

Personally, I have a wonderful relationship with my GP and others specialists that I see because I feel comfortable with them. If you don't feel comfortable asking the hard questions with your provider, maybe its time to look into a different one. Good ones are out there, more good than bad fortunately for us. But it is up to us to sift through the population to find one that fits best. Unfortunately for doctors now a days, it is getting harder and harder to make money and that is unfortunate because I believe that some of the "good" docs may be susceptible to becoming more focused on business side rather than patient care, which I can't say I don't necessarily blame them, they have bills to pay too, big ones like student loans, salaries, mandatory EMR adoption etc.

Now for my cynical comment....I wonder which diagnostic test or treatment or whatever will be next to take some heat in order to cut healthcare costs? Keep in mind this is at the expense of the public who desperately wants change, but I have to ask, at what price? So far it has been more about money than human lives.


The National Consortium of Breast Centers (NCBC) has just released their position statement regarding the recent mammography guideline changes:

“The National Consortium of Breast Center's Board of Trustees has given their consent to the following position statement reflecting their stand on the issue of mammographic screening, in response to the recommendations made by the US Preventive Services Task Force.

National Consortium of Breast Centers, Inc.

Position Statement regarding the Mammography Screening Recommendations of the United States Preventive Services Task Force (USPSTF)

The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening.

The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefits and harms to women screened for breast cancer with mammography.1 They provided an updated USPSTF recommendation statement on screening for breast cancer for the general population that alters currently accepted guidelines for women over 40 years old.2

The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammography leads to early detection which leads to improved survival.3 In every country starting population screening, mortality declines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data, namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent data from randomized controlled trials reveal significant mortality reductions evident approximately five years after screening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990 define screening program benefits not seen in the prior six decades. In the United States, these mortality declines continue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public health achievement.

In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breast imaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patient outcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists, reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.

The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the cited literature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, which supports currently accepted breast cancer screening guidelines.

We would also like to note that quality of life has a significant value, not just survival. It is well established that if we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likely need more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.

The NCBC requests input into future guideline development and vows to work with government, scientists and industry to keep the process transparent and keep the focus on the patient. We recommend further efforts target screening, risk assessment, education and awareness regarding the implications of positive and negative screening findings. Funding for further research is imperative and supported by the controversy these articles have generated.

Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment and finds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed at risk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on this specific women’s healthcare screening policy.

# # # #

About NCBC: The National Consortium of Breast Centers (NCBC) is the largest national organization devoted to the inter-disciplinary care of breast disease. In keeping with our mission, to promote excellence in breast care through a network of diverse professionals dedicated to the active exchange of ideas and resources including: 1) To serve as an informational resource and to provide support services to those rendering care to people with breast disease through educational programs, newsletters, a national directory, and patient forums; 2) To encourage professionals to concentrate and specialize in activities related to breast disease; 3) To encourage the development of programs and centers that address breast disease and promote breast health; 4) To facilitate collaborative research opportunities on issues of breast health; and 5) To develop a set of core measures to define, improve and sustain quality standards in comprehensive breast programs and centers.


1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747.

2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726.

3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731.

4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.

All content and design © 2009 by the National Consortium of Breast Centers, Inc.”

As mentioned in the recent post, "Scrapping the Barrel to Support Health Reform", it seems like the current Health care reform plan is costing the nation a trillion dollars yet is taking away money from preventative care of deadly diseases, mainly its been cancer that has been hit the hardest.

The optimist in me at first said that with these changes, maybe techniques and other medical procedures will be forced to improve based on this change. I still believe this will be the case, but does one outweigh the other? The best approach would be to do both of course. Maintain the guidelines that have been proven effective through various published trials, and allocate ARRA funds to increase R&D of new treatments or improved quality of current techniques. Who knows, there may be money left over from the HITECH stimulus funds by ARRA if physicians are unable to collect the 44k in order adopt EMR.

Once improved procedures allow for a change in the guidelines, then the change is warranted. If not, guidelines should not be altered.

The National Consortium of Breast Centers (NCBC) is currently the largest national organization devoted to the care of Breast Disease. Through their quality measures program, the National Quality Measures for Breast Centers (NQMBC), breast care centers have the opportunity to collect and standardized data to the NCBC in hopes to improve clinical care of Breast Cancer Patients.


As usual, its been a busy few weeks in the Health IT world and things continue to get shaken up with many recent announcements.

In a press release on 10/22/2009 the Certification Committee for Health Information Technology (CCHIT) announced that they are seeking candidates to serve as Trustees and Commissioners.

Another press release on 11/13/2009, announced that CCHIT's well known Chair, Mark Leavitt will be retiring in March of next year after 5 years of service.

Once the first press release came through on my feed, I thought it was only a matter of time before this happened. Changes need to be made by the CCHIT to gain acceptance by many skeptics. Then I received the second feed, an interesting decision made by Dr. Leavitt to announce his retirement, especially since the CCHIT has been under major scrutiny lately for being the sole certifier of EMR systems and carrying a rather large price tag, so large in fact that most of the smaller vendors are unable to afford the certification. I'm just not sure if leaving his organization now, especially announcing it, was the greatest business decision for the CCHIT.

The CCHIT has also been accused by it's critics for catering to the larger EMR vendors that also conveniently sit on their Board of Trustees and Commissioners.

I find it quite coincidental that after undergoing such a large amount of scrutiny for favoritism that the CCHIT is now holding interviews to replace some of it's Board Members. I know that you are probably thinking, damned if you do damned if you don't. Thats not where I'm headed. I want to give kudos to the CCHIT and Dr. Leavitt for their accomplishments in the past years as well as the realization, or wake up call, that changes need to be made their board, specifically the board member ratio, which I'm sure will be affected. The positions are open to members of physician practices and hospitals, payers, health care consumers, vendors, safety net providers, public health agencies, quality improvement organizations, clinical researchers, standards development and informatics experts and government agencies. I would imagine that the vendor to healthcare provider ratio will be severely affected.

As for Dr. Leavitt leaving, personally I don't think this is the greatest time the CCHIT during this critical time, especially when the certification business is open for business according to Health and Human Services. Who know's, maybe its a career move...he would be a perfect candidate to head up a start-up certifying company.

That brings me to my next topic, the Drummond Group may prove to be a worthy alternative. They had their own press release on 11/02/2009 that they will submit to become a certifying body. I haven't heard of any progress, but if anyone out there has heard anything, please let me know. For those of us who are new to the Drummond Group, they are a company specializing in interoperability testing. Rik Drummond, CEO of Drummond Group was quoted in the press release saying, "Drummond Group has been supporting Fortune 500 industries and government by certifying the transfer, identity and cybersecurity of their internet information flow over the last ten years. We have also done testing for the CDC, DEA and GSA. Certification of EHR is a natural extension of our testing program, and we believe we can provide great value for the medical community. We look forward to the publishing of the ONC requirements in the days ahead so we can get started."

There seems to be a lot of progress within the Certification realm. My only other questions and worries are targeted towards getting everything in place in time for physicians to get their reimbursements.


What a past couple of days in the Healthcare realm. First of all, the Health Reform bill passed in the House with a price tag of $1 trillion. The money has to come from somewhere and it seems like it is coming down to the preventative care of women as for now. In other releases, separated by one day each, new guidelines came out for mammograms and pap smears. Another release just came out regarding a 5% tax on non-elective plastic surgery procedures.

I have to wonder who is influencing these recently altered guidelines and their research findings. I have my opinions on can be manipulated to prove a desired point. I have to assume this is what is going on in these recent releases regarding the preventative care for serious cancers that specifically target women. For the past year I have heard more news to promote preventative care than ever before. Why? Because it saves lives and yes money too. So now, why are they changing these guidelines that promote a higher level preventative cancer? Has anyone thought that the numbers may be down because of the preventative measures that have been in place?

With a $1 trillion price tag, one has to wonder is its to free up funds to pass this bill. Unfortunately, these changes are going to be just the beginning I believe.

As for the elective plastic surgery procedures, in 2008 it was reported that $10.3 billion was spent on these procedures. People choose to get certain procedures to benefit their quality of life in some way, which can ultimately change certain mental conditions such as depression and anxiety which both play an enormous factor in the progression of other serious health factors. Not everyone who elects to get plastic surgery are the typical "trophy wife" getting a different nose every 5 years, its also those people that have little money to pay for a procedure to correct something that may have been caused by an accident for example. Now, these people who have to spend thousands of dollars, that may have had to scrape it together, are expected to spend 5% more. Is that fair to the little girl who was in a car accident and suffered injuries to her face that left her scarred for life without plastic surgery? This is just an example, but it is also a reality of how people are going to be affected by this health care reform push.

I believe something has to change in Healthcare, but at what cost? Certainly not time, after all the current administration is rushing this thing out without the proper time to think of how it will actually pan out in the future.

Its going to be an interesting couple of years to say the least.


Since the inception of ARRA, there has been mixed emotions of whether or not throwing money at a situation will benefit the struggling incumbent health care system. Having only worked in Healthcare IT for a limited amount of time I believe I can shed some light on the subject from an outsider's perspective rather than a biased, perhaps jaded, insider's view.

First lets talk some basics. Approx $19.2 bill in incentives available to physicians who adopt a certified, meaningful use EMR system. This breaks down to around $44k/provider on up to $64k/provider depending on Medicaid/Medicare patient ratio (the more CMS customers, the higher stimulus awarded). Incentives start this 2010 and penalties start 2015.

The main debates have been lying in the "certified" and "meaningful use" or simply "MU" realms. Let's first talk about certification. The only certifying body to date is the CCHIT which was spawned off of HIMSS and even has a former HIMSS member as its leader. For those of you that are new to this area, the Certifying Commission on Health Information Technology (CCHIT) is a non-profit group based out of Chicago, near HIMSS HQ, that is comprised of different executives who have vested interest in the large EMR vendors...because they run and/or work for them. That is all I will rant about for this post on the CCHIT.

The next big issue, which needs to be radically simplified is MU. Every practice and specialty are different. Meaningful use may vary from specialty to specialty. This needs to be a simplistic model, not a complicated matrix that was originally released, for everyone to understand. There also has to be a lot of gray area as well in this definition to allow for proper payment if a practice is able to show that they use MU.

These 2 criteria, certification and MU, have yet to be decided on. Deadlines are set, but as we all know and have experienced, they may be moved again.

So back to the original question in the title, has the stimulus money caused a boom for HIT or has it been a bust thus far?

Certain areas of the HIT market has seen an increase due to the stimulus funds for HIT for sure, but on the same note, many HIT vendors have seen a lull in sales. Why, when there is at least 44k on the table and adoption needs to happen quickly in order to qualify for the 1st and biggest stimulus handout.

The stimulus money has put providers on a bit of a "wait and see" mentality. There are far too many providers who do not see the value of EMR. Should this stimulus money have been allocated differently? Should more money have went to education and research rather than purchase and implementation?

EMR is not a thing of the future. It is a technology that has been around and in use for over a decade. They have time over time proven effective, efficient and reliable. I am not going to go into detail because the case studies are out there. The only problems that I have seen are due to bad matches between vendor and customer, not the idea or technology itself.

Look at our world now, smartphones that allow us to answer emails while out of the office, telecommuting from home to save on overhead costs etc. Technology will continue to improve upon quality. Be it quality of care or quality of life.

EMR is a way to do both. The incentive from ARRA is there yes, but treat it as a bonus for adopting a new way of patient care and reporting to improve the overall quality of care and patient health for futures to come by adopting and embracing a sound technology that you may, or may not, get some extra cash from.

News and Views
MedTech and Devices

Laura O'Grady; PhD



Recently I found some written instructions I had prepared several years ago to help my parents program their VCR. It took me three pages to write out the steps to record a program.  Where applicable each step included a hand drawn representation of the button the VCR (and/or the remote) to ensure clarity and understanding.

The first page explained how to bring up the menu to record a program in the future. The second provided further details and discussed potential troubleshooting strategies. The third included the final steps and introduced the steps for recording a program currently being viewed.  Even with these detailed instructions mistakes were made and recordings were missed. We will never know if the error was occurred in the programming stage or if show never actually aired.

I believe I also wrote out similar instructions for my grandmother. As she was even less inclined to adapt she opted to use her own technique. My grandmother would start recording a program hours in advance of its airing before leaving her home by putting the television on the desired channel and pressing the record button on the VCR. It may have required hours of rewinding but it worked for her. Since this time technology has evolved and we now “one touch” programming through the use of on-screen guides that list program dates and times. However, I’m pretty sure if my grandmother were alive today she would use her old system – start recording on the PVR when she went out rather than using the on-screen guide.

In 1988 Donald Norman wrote about this issue in “The Psychology of Everyday Design“. He made reference to digital watches and microwave ovens as well as VCRs as examples of devices that were difficult to operate. Yet they were supposed to be for an average person to use on a daily basis. Why were they so difficult to use? One theory suggests that the skill set required to design such devices doesn’t necessarily translate in a way that is evident to someone who does not have a similar background or training. What is apparent to one is not necessarily so to others. A lack of applying design principles (human-computer interaction) or examining how the device works in real use (e.g. usability testing) were provided as possible reasons. One resolution was to utilize technical writers, those skilled in interpreting complex electronic interfaces using plain language written material  Some things are made to be obvious or intuitive – you use the sharp edge of the knife to cut. Others have developed over time with common usage – it is universally understood that turning the knob is a necessary step in opening a door.

Human behaviour is like running water. It always finds the path of least resistance. But can we ‘afford’ this type of affordance in health care?




In a previous post I presented an analysis of the tweets from the Health Care Social Media Canada (#hcsmca) Twitter community.  By using a network analysis tool (NodeXL) I was able to determine that two Twitter identities (@infoway and @jasonboies) were participating but perhaps not in a connected way. When community members are “off to the side” it may be an indication of lurking behaviour (reading messages but not posting). However, since tweets were present from these Twitter accounts this label may not be applicable. A similar concept, labeled “legitimate peripheral participation” (described more thoroughly here) in which novices engage in a community of learners in limited fashion may be a more accurate descriptor of the phenomenon captured in the data set. In order to understand the findings from this network analysis a more thoroughly examination of the tweets containing referenced to the two outliers was required. To facilitate this process I used a tool called ITCA (Internet Community Text Analyzer) developed by Dr.Anatoliy Gruzd at Dalhousie University.

Using the Excel spreadsheet created by NodeXL from the network analysis I exported it into .cvs format, which was then imported into the ITCA tool. The dates of the tweets included Thursday November 24th, Friday November 25th and Saturday November 26th. There were 953 unique messages and 243 posters in this sample. The top ten posters (Image 1) is essentially in alignment with the network analysis, which was ordered by eigenvector centrality. In other words importance is, in part, reflected by the number of tweets.

top ten posters













Image 1: Top Ten Posters in #hcsmca Twitter community

The ‘local concepts’ (characters, words, terms and concepts) were extracted by looking for patterns frequently used in the data set. The ITCA tool revealed that there were 9812 unique terms. Image 2 shows the thirty most frequent terms and the number of times the term appear in the data set. The tag cloud formation shown in Image 2 also provides a visual representation of frequency (the larger the word the more times it appears). An individual term can be removed by clicking on the red X or explored further by clicking on its hypertext link, which reveals all instances by which has been tweeted.

top thirty terms extractor





Image 2: Top 30 Results of Local Concept Extractor (click to enlarge)

Using this tool I was able to search for the tweets associated with @Infoway. The results indicated that the two tweets were related to an upcoming HL7 (health level seven, a concept related to standardization in health information technology) certification. A hand search of the .cvs file indicated that one tweet on Friday November 25th, 2011 was directly from @infoway. The other was a re-tweet of this tweet by @alexanderberler on the same day. The second tweet was also recorded because @mentions were included in the data set obtained using NodeXL. Image 3 shows the @alexanderberler RT.

contents of infoway tweet





Image 3: @alexanderberler Re-tweet of @infoway tweet (click to enlarge)

A search of jasonboies revealed twelve tweets. Image 4 shows the total number of times in which tweets contained this Twitter identity in this data set.

search of jasonboies









Image 4: Incidents of jasonboies

Tweets with jasonboies appear to have taken place from Friday November 25th (four in early evening UTC) to Saturday November 26th (eight in late evening UTC). This time frame is outside the weekly hcsmca tweet chat, which took place in the evening on Thursday November 24th (the weekly tweet chat is held every Wednesday at 1:00 pm EST except for the last week of the month in which it is held on Thursday evenings).

Based on this preliminary analysis it would appear as though connecting with other members of the hcsmca community is a phenomenon beyond just using the hashtag in your tweet. These findings may indicate that being engaged means participating with others in the real time chat.

Perhaps more importantly this analysis demonstrates the need to examine not only the pattern of tweets as yielded using network analysis tools but also to examine the content. In addition, these findings should be interpreted with the aid of survey data and interview findings obtained directly from members of hcsmca community. For example, a survey could determine which participants are tweeting as part of their work, which may affect which time of the day they use Twitter. Interviews would provide even richer detail allowing us to understand what exactly prompts someone to both tweet and re-tweet material in the hcsmca community.

Recommended reading

Daniel, B. K. (2010). Handbook of research on methods and techniques for studying virtual communities: paradigms and phenomena. Hershey, PA: Information Science Reference.

Feldman, R., & Sanger, J. (2007). The text mining handbook: advanced approaches in analyzing unstructured data. Cambridge ; New York: Cambridge University Press.



In the ethnography, “Situated Learning” (Lave & Wenger, 1991) it was observed that learning a trade or profession such as a tailor or midwifery was best supported by engaging in this activity within the actual community in which it was taking place. In this context the learner, as an apprentice, can be exposed to others with varied skill levels within that particular job or trade from which they can learn. Initially they may engage in some limited tasks such as maintaining inventories of equipment or tools and ordering supplies. Over time and with more exposure to the task their role will evolve and increase in responsibility. For this to take place they must learn from others with more experience. Some members of this particular community may have expert status whereas others may be at more of an intermediary level. At the beginning those new to the community participate only on a peripheral level. As novices they have yet to learn the terms, concepts and practices that would allow them to engage in the profession in a meaningful way. For example, someone new to programming may subscribe to a mailing list or follow a newsgroup that discusses the computer language they want to learn. These groups are often composed of individuals with varying levels (novices, intermediaries, experts) of skill level forming what has been termed “communities of practice”. This legitimate peripheral participation or “lurking” is an acceptable and supported behaviour amongst many well established online communities. After reading the messages for a period of time novices may feel more comfortable and post questions of their own. This may lead to some form of debate amongst other participants in which new knowledge is co-created. Novices may contribute in other ways by sharing information related to issues they have already encountered. For example, the novice programmer may have been advised before participating in the message forum that using an integrated development environment (IDE) will aid their learning of how to program. Over time the community shares their experiences and members of all levels engage and learn from and with each other. This phenomena has been documented amongst mailing lists and newsgroups.

But what about the newer forms of social media such as Twitter?

Founded by social media expert and plain language writer Colleen Young (@colleen_young) the Health Care Social Media in Canada (hcsmca) Twitter-based community was designed as a means by which Canadians with an interest in social media within a health care context could exchange information. By posting tweets using the acronym, “hcsmca” those wanting to share and learn more about this topic area can follow the posts. Each week the community meets for a live tweet-up in which messages are exchanged in real time providing for a more conversational tone to the exchange. I have participated in this community almost since its inception. Over this time I have wondered about the types of connections that were being formed, what information is being shared and learned and how effective Twitter is as forms of information dissemination in this context.

To explore this further I examined the network relationships in the hcsmca community with NodeXL ( Using the import tool I limited the results to 100 people for this initial exploration. I requested edges (or connections) for each of these Twitter scenarios: “follows” relationship (an individual and their followers), “replies-to relationship in tweet” (a reply to an individual tweet), “mentions relationship in tweet” (a tweet that mentions a user) and a “tweet that is not a reply-to or mention” (a posted message or tweet). NodeXL calculates a variety of statistics related to network analysis. By using filters you can refine the resulting graph in form that provides meaning.

Image I provides one static representation of a many possible layouts of the results. The NodeXL tool allows for more dynamic views (e.g. colour coded relationships between users such as “follows”, “replies-to relationship in tweet” and depictions of the other metrics mentioned above). It also provides for the ability to re-position the location of each user. Image I (below) demonstrates one instance of these options.

Network relationships of hcsmca Twitter communityImage I: Network analysis of #hcsmca community – November 26th, 2011

To better view the relationships I limited the out degree (people with the most connections) to seven. I then arranged the display from left to right by eigenvector centrality (a measure of importance in the network). Community leader Colleen Young, who often moderates the weekly tweet chats is positioned at the far left as she has the highest eigenvector centrality in this group. @DoctorFullerton is next, @nursefriendly and @ehealthmusings follow and so on. What may be of most interest are the two outliers positioned on the far right: @infoway and @jasonboies. They were represented in the graph because they had an out degree value greater than seven. However, I am curious as to why they had no connections to the remaining members in this particular snapshot of the #hcsmca community tweets. Does this indicate some form of lurking? How can this behaviour be explained?

In order to understand this further a content analysis of the tweets will be conducted. In the next installment I will explore the contents of these tweets using Netlytic (, an Internet Community Text Analyzer.


Lave, J., & Wenger, E. (1991). Situated learning: legitimate peripheral participation. Cambridge [England] ; New York: Cambridge University Press.

Recommended Reading

Hansen, D. L., Schneiderman, B., & Smith, M. A. (2010).  Analyzing social media networks with NodeXL: insights from a connected world. Burlington, MA: Morgan Kaufmann.

Valente, T. W. (2010).  Social networks and health: models, methods, and applications. Oxford ; New York: Oxford University Press.

Thanks to @marc_smith for his assistance.



Accidents happen. Often when we are tired, overwhelmed with too much information and too much to do we make mistakes. Many of us work long hours, interacting with complex machinery and in noisy environments. Few of us, however, are required to work 36 or more hours in a row, with little or no sleep. Physicians do this on a regular basis and patient safety is at risk as a result.

Why does this happen? Many years ago I asked a senior staff physician who worked in a large metropolitan hospital this question. He told me there were three reasons: (1). A physician needs to learn how to make decisions no matter how they feel physically (2). We are short-staffed and (3). It was done to us before therefore it will also be done to those who come after us.  I’ve since heard another reason: the more hours you work the more opportunity you have to learn new things. I don’t know how effective this latter strategy is for physicians-in-training. Or whether it is used as a fear tactic. For example, someone might be told: “if you don’t treat enough cases of X you will not have enough knowledge to pass the board exam in your specialty”.

This clip (1:23 minutes) from the television show “ER” in which Dr. Elizabeth Corday explains at a weekly M&M (Morbidity and Mortality) meeting reasons why and ways in which the system could be changed.

Her concluding marks are quite poignant.  I don’t think the situation is much different now then it was when this show aired in 1998. Or when I asked a physician ten years previous to that. But I do think her point is valid. Who would want to fly in a plane in which an air traffic controller co-coordinating its take-off and landing had worked 36 hours in a row without sleep?

But I think the real question is whether you would want to fly in plane with a pilot who had worked 36 hours without sleep. However that would never happen. Pilots (and the airline industry) know that if they had people flying jets for many hours in a row they would likely make a mistake. The plane could crash and many lives would be lost. Including the pilot. Not quite the same scenario for a physician. Maybe the rules regarding work hours would change if their lives and not just those of the patient were also in danger. For this to be achieved we need more collaboration between everyone involved in providing care.



A couple of great posts from other bloggers on the peer review process, journal publishing and the open access movement:

I’m excited that others are sharing their thoughts on this issue. I’ve written about this before (see “Access to peer reviewed journals“ ). Petermr’s piece specifically advocates for patients (among other groups) to have access to this information and uses the Human Rights code as a foundation to make the argument. Brilliant work!

It should be noted that JMIR has adopted two unique methods for open access publishing. The fast track fee provides the option of paying a fee for a three week turnaround. I believe the money is used to compensate the reviewers for their time. There is also an Open Peer Review Articles process, which allows JMIR users to review articles who have yet to undergo peer review. Abstracts for these articles are posted at the site so please take a look if you are interested in engaging in this process.

Update: Monday October 3rd, 2011

I recently found out about a repository, arXiv that has been used for pre-publication papers in the sciences since 1991. It was started in physics and later expanded to include other fields such as computer science, mathematics and astronomy. Although the papers posted are not peer reviewed moderators do review the submissions to ensure they are relevant topic-wise. We should consider this unique model to disseminate information when considering changes to the current system.



Deb Matthews, Minister of Health and Long–Term Care Webchat Transcript: Ontario Liberal Party plan for health care

Tuesday September 20, 2011 8:00 pm

Note: This transcript is also available on Facebook. Each comment or question is followed by a time stamp indicating when it was posted. Inclusion of this transcript is for informational purposes only. No endorsement intended.

Ontario Liberal Party: Hello everyone and thank you for joining us tonight on Facebook. Tonight we’re joined by Deb Matthews, Minister of Health and Long–Term Care, to talk about the Ontario Liberal plan to keep building the healthiest province to grow up in and grow old in. 8:01

Deb Matthews: Welcome to tonight’s webchat! So glad you could all join us. Please start submitting your questions – we’ll try to get to as many as possible tonight but it probably won’t be possible to get them all. Looking forward to the conversation! 8:02

Comment From Guest:  Good evening Ms. Matthews, thank you for providing a forum to ask questions and open discussions for all Ontarians. 8:02

Comment From Philip: Can you confirm that, if re-elected, the Liberals will continue to support the First Link program and roll it out across the province? 8:03

Deb Matthews: Thanks for the First Link question. I can tell you that we enthusiastically support First Link! It’s making a real difference for people with Alzheimer’s and their families — and will continue to do so! 8:04

Comment From Jacquie Micallef:   Good Evening – The 8-week unpaid caregiver leave is a step in the right direction, however we (Alzheimer  Societies in Ontario) hear from caregivers that flexible respite is critical to their health and wellbeing. If re-elected, how will Liberals give caregivers the break from caregiving that they need? 8:05

Deb Matthews: The 8-week job guarantee for caregivers is an important part of our strategy to keep people home, where they want to be, as long as possible. i’m glad you support it, and i look forward to working with you to find other ways to support caregivers.8:06

Deb Matthews: As you know, tomorrow is World Alzheimer’s Day. I want to take this opportunity to say “thank you” to everyone committed to improving the lives of people with Alzheimer’s Disease. 8:07

Comment From Natrice Rese: Thank you for this chance to ask questions, can you elaborate more on the coming PSW Registry and how it will protect our elderly and vulnerable please, as their protection is paramount. 8:07

Comment From OntarioPSWAssoc: We would like to know what you plan on doing about the PSW issue in this province? 8:07

Comment From OntarioPSWAssoc: Minister Matthews; Societies most vulnerable are dependent upon PSWs everyday. How do you plan to standardize the PSW profession? 8:08

Deb Matthews: I’m very excited about the PSW registry, and I know PSWs are too! I’m also excited that we’re committed to 3 Million more hours of PSW homecare – three times the number of hours the NDP is committed to! 8:10

Comment From Paula Schuck: How will the McGuinty government meet the needs of the coming demographic shift. The sheer number of seniors that will be diagnosed with dementia and alzheimers as well as other health issues in the coming decades is staggering. What are we doing to meet this co 8:10

Comment From Paula Schuck: Families like ours have been sitting on a waitlist for special services at home for three years. What will be dine to clear up the wait-list?. No respite money right now for far too many struggling families. 8:11

Deb Matthews: Thanks for joining us, Paula! Embracing the demographic shift is exactly what we’re doing. There are many parts to our strategy, outlined to some degree in our Party platform, but the foundation is building community supports to allow people to stay home as long as possible, instead of moving to LTC before they need to. 8:13

Comment From Jacquie Micallef: Thank you so much for the recognition of World Alzheimer Day. This chat is very timely! 8:13

Deb Matthews: Another piece is that we’ll refocus a portion of our province’s research investments to support the prevention, treatment and possible cure of conditions such as Alzheimer’s and related dementias. 8:14

Comment From Patricia: I keep hearing about what the Conservatives will cut — and I am growing tired of this talk. Instead, I want to hear what you and the Liberals will build. 8:15

Deb Matthews: Our plan is to strengthen local decision making through the LHINs. We have seen great examples of how communities are working together to get better results for patients and better value for health care dollars. 8:16

Deb Matthews: No matter how good the bureaucrats in Toronto are, they’ll just never be able to pull communities together the way local decision-makers are. People in Thunder Bay will make better decisions about health care in  Thunder Bay than people in Toronto can! 8:17

Comment From Guest: What is the Liberal plan for Local Health Integration Networks, as compared to the Conservative plan to eliminate them, to reduce administrative health care costs and increase funds for direct care? 8:17

Comment From Patricia: LHINs? I’m not familiar with that. 8:18

Ontario Liberal Party:  “Local Health Integration Networks”: 8:19

Deb Matthews: Patricia, I urge you to take a look at our platform. We set out a challenge to make Ontario the healthiest  place in North America to grow up and grow old. Part of that is a goal to reduce child obesity by 20% in 5 years, and to develop an Active Aging Strategy. It’s time to focus on wellness!! 8:20

Ontario Liberal Party: The Ontario Liberal plan: 8:20

Comment From Ritika Goel: Hello Ms. Matthews. I’m representing an organization of young health providers concerned with the state of publicly-funded healthcare in Canada called Students for Medicare. We are interested in hearing how the Liberal party would put a stop to and prevent the further emergence of for-profit facilities in Ontario. 8:21

Comment From StudentsforMedicare: Hello Ms. Mathews, Our organization is interested in knowing how the Liberal party will do to prevent and curb the proliferation of private, for-profit clinics in Ontario to uphold the Canada Health Act. 8:21

Comment From Dan Raza: A few months ago, the government passed a law prohibiting extra, out-of-pocket billing as a measure to prevent creeping privatization. On behalf of physicians that want to continue to practice in a pro-medicare system, thank you! What plans to do you have to enforce it? 8:23

Deb Matthews: Protecting universal health care in Ontario is a sacred trust, as far as I’m concerned. We’ve passed The Commitment to the Future of Medicare Act, and we’re enforcing it. Last year, we collected over $600,000 for patients who had paid illegal fees. Sad to say, both the NDP and PCs voted against the CFMA 8:24

Deb Matthews: Thanks Dan, Ritika and The Students for Medicare, for standing up for universal health care! 8:25

Ontario Liberal Party:  Thank you everyone for your questions. We are trying to get to as many of them as possible before 9:00. 8:27

Comment From Guest: Tim Hudak has promised to shut down eHealth Ontario. What are your plans for eHealth Ontario? 8:28

Deb Matthews: Anyone who works in health care knows that we need to continue to transform it unless we want to move to two-tier health care, which Ontario Libs certainly don’t!! A vital part of that transformation is moving forward with eHealth. We’ve now got about half of Ontarians with EHRs – shutting down eHealth would be just dumb! 8:29

Ontario Liberal Party: “EHRs”: electronic health records 8:31

Comment From Laura O’Grady: Then why do we rely on population-based research for decision making? (i.e. one study in Windsor, for example, informs the policy around screening for the whole province because it is considered “evidence-based”) 8:32

Deb Matthews:  Sustainability of universal health care requires reliance on evidence. The Excellent Care for All Act reinforces that principle. Of course, there will always be debates about how strong that evidence is, so we need to keep investing in better research. 8:33

Deb Matthews: I urge you all to participate in the Ontario Health Study! It will give us extraordinary data!!8:33

Ontario Liberal Party: 8:34

Comment From Don Seymour:  Deb, can you talk about how your will improve services for persons with mental illness? 8:35

Deb Matthews:  Thanks for joining us, Don! Our Mental Health and Addictions Strategy is already being implemented. It’s a 10 year strategy, starts with kids, and backed up by a $257M commitment in our last budget. 8:36

Deb Matthews: I was very disappointed that neither the PCs nor the NDP even mention mental health in their platforms. For us, it’s a high priority. 8:37

Comment From Natrice Rese: Can you tell us more about in home dr. visits? Many elderly and infirm, special needs in our population do not get seen by professionals when they have crisis 8:39

Deb Matthews: Bringing back House Calls is part of our strategy to help people stay home longer. It’s proving to be very popular with seniors and the families that support them. It’s more than just doctors, it will include nurses, OTs and other health care professionals. Also telemedicine and on-line support! 8:41

Deb Matthews: The Libs are the only party that is facing the demographic challenge seriously. Our health care system wasn’t designed for the demographic reality of tomorrow — we need to fix that! 8:43

Comment From Nicole: What about support for Community Health Centres? They service vulnerable and marginalized populations and provide great interdisciplinary service for the community….and are often undersupported in funding. 8:44

Deb Matthews: We are thrilled to have supported the greatest expansion of CHCs ever! We’re in the middle of doubling sites from 53 to 101. Delighted with the announcement of new CHCs just a few weeks ago! Also,  increased funding for CHCs by 108% — that’s $152M! 8:45

Comment From Nicole: That’s fantastic news! 8:48

Comment From J: Will you support OHIP to fund IVF procedures?8:49

Comment From Josee L: 1 in six couples suffer with infertility. My husband and I being included in that statistic. If elected, will you support IVF funding for Ontario families struggling with infertility?8:50

Comment From J: We also suffer from infertility. 8:50

Deb Matthews:  I know how important it is that we support Ontarians as they build their families. That’s why we established the Expert Panel on Adoption and Infertility. We’re moving on their recommendation re: educating both public and providers. And we’re watching the Quebec experience very carefully and doing the research in Ontario to be better able to make the decision here. At this time, we’re not moving with OHIP funding of IVF, but we’re not closing the door, either. 8:53

Comment From Zach: What role does preventative care play in the Liberal health care plan? 8:55

Deb Matthews:  Now that we’ve come such a long way in rebuilding our health care system – cut wait times in half, got 94%  of Ontarians with primary care, and rebuilding infrastructure – it’s possible to focus on prevention. We know that 1/4 of our health care spending is spent on preventable illness. So making Ontario the healthiest place in North America is our next goal!!8:59

Comment From Laura O’Grady: The system was designed for acute care. Now we have chronic complex disease. This should be part of  focus for change. 9:00

Deb Matthews:  You are so right! People with chronic, complex needs deserve special care.That’s why we’ll provide a Health Care Coordinator to facilitate care between specialists and family doctors, hospitals, and the community to assist seniors who’ve been hospitalized within the previous 12 months. 9:02

Deb Matthews: Thank you so much for all your questions and comments! I wish we had more time to get through everything. Please make health care an issue in this election and ask your local candidates to support  better health care for all! Hope you’ll all vote Liberal so we can do this again!! 9:03

Ontario Liberal Party: Thank you for joining us Deb.

If you don’t yet, make sure you follow her on twitter: @Deb_Matthews

We hope we’ll see you on Facebook again for our next webchat. Stay tuned for details in the next coming days.

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Appropriate IT



A colleague of mine came up with this brilliant distillation of wisdom:

It is possible to force a project plan to match reality but impossible to force reality to match a project plan. So why is it the latter is attempted more then the former?

S. Yetter


My DSL has been flakey for a couple of weeks. Today, it finally went out for good. The administrative web app on our 2Wire router said the DSL signal was kaput. So began my experience with AT&T High-Speed Home Network support.

The first person to answer my call is Macy. I’m using her real name because everyone should know it. Especially her supervisor. Macy hung up on me because I couldn’t understand her accent. To her credit, before hanging up on me, she tried to communicate by talking REAL LOUD.

I called again hoping to get Macy as I had a few things to say but Joy answered the call instead. Joy asked me some questions and made me unplug the entire deal and move it to another phone jack. She put me on hold a lot while she multi-tasked with other support calls. Joy didn’t seem terribly enthusiastic about the whole affair. Most of the time I thought we had lost contact but after while she’d come back on the call. Eventually, Joy escalated the call to Ron after she was unable to figure out the problem. Even after I had to move the whole deal to another phone jack. Did I mention that I have (had) all of my cables neatly tied and tucked away?

Ron was from California and asked me all of the same questions Joy had. He was unable to find the ticket in the system. He announced that he had some diagnostic tools and could see that the signal in our house was intermittent (tools and progress!). Then he announced that our 3mb downstream should have never worked because we were too far away from the hub (sigh. so much for progress). I was about ready to write off the entire organization but Ron was very personable and seemed very interested in helping me out. I told him we’ve had this setup for three years with no problems except in the last couple of weeks. Somewhere, something has changed. Ron asked me about every phone we had in the house and if they were all attached to filters and expressed surprise that Joy hadn’t asked this earlier. I couldn’t remember so I did reconnaissance. Basement, first level and upstairs. And there it was: Jaime’s new cordless phone. Unfiltered. Got that about two weeks ago. I unplugged it and Ron announced that the signal to the house turned strong and steady.

This two-hour ordeal really reinforced in my mind what it takes for successful support:

  1. People
    We need more Rons and no Macys.

  2. Systems
    Accurate, accessible ticket information saves time for everyone. Additionally, Ron had access to diagnostic tools that Joy apparently did not. Finally, while high productivity is a key goal, multi-tasking to the point of ineptidude is not an effective component of a solid productivity system.

  3. Process
    Ron fell back to a first level diagnostic process that started at square one. Having and using such processes is the only way to efficiently diagnose and solve issues.


The Premise of Covey's, The Speed of Trust, is that when there is trust in any business or human transaction, the transaction takes less time and thus, costs less.

Think of any transaction, whether it be buying something or talking with your boss. If there is trust, things move along quickly. If there is no trust, we get bogged down in analysis and take extra time checking things out. Trust is the lubricant for effective human transactions. Increased friction is the result of lack of trust.

Typical of Covey materials is the framing of principles around values and specific behaviors, an approach adapted by Ministry Health Care for our Patient Promise.

Trust is a key element of effective leadership. I highly recommend this one. It's an easy listen, only 75 minutes (executive summary version from


In the aftermath of a virus or malware outbreak, we typically beat up on our Client Technology and Data Center folks or even our security software vendor and demand answers, “How could you let this through? Why didn’t our technology block this threat? Where was your vigilance?” Frankly, the question we really want to ask is:

“Who’s the nincompoop that clicked on the malware that kicked this catastrophe off?”

Virus and malware outbreaks typically cause us to revisit our usage of Windows local administrative rights. In a nutshell, local admin rights serve double duty as a requirement for certain, critical applications as well as the scourge of IT Support.

One approach to keep malware from attacking a device is to “lock it down”, that is, to remove local admin rights so that the user can’t install anything on it. This approach has its advantages because it protects users from the negative consequences of their own actions. This is similar to web filtering where we keep users away from harmful sites. Standard tools in the IT Security arsenal, right?

The problem I have with employing blocking technologies as the sole deterent is that we do two things:
1) We imply a lack of trust whereby we further are viewed as “big brother”.
2) We create a nanny security environment where users assume no responsibility for their actions (for what they click on).

While blocking technologies are important and necessary, I strongly believe we need to cultivate another, farther-reaching approach: personal responsibility and consequences. Before you call me naïve, consider this: Is it better to instruct our teenagers about the dangers of alcohol consumption or should we prominently lock the liquor cabinet and call it a day? Clearly the healthier and more sustainable answer is the former. (Having said that, there are certainly times when we may have to resort to the latter!)

I propose educating users on what they can and cannot install. We don’t want them installing games and we don’t need them to help us update their virus scanners. In fact, we don’t want them to install anything without the consent of the Service Desk. If, after this simple education, a user decides to install something, we will impose simple consequences. If it takes 30 minutes for a technician to remove Google Earth, then the user will forfeit 30 minutes from their paid-time-off (PTO) account. If they click on something that requires a 2-hour reimaging and reconfiguration of their device, they forfeit 2 hours from their PTO account.

In essence, we need to employ a two-prong approach: blocking technologies AND user responsibility and consquences.

In Jurassic Park, John Hammond tells Dennis Nedry that he doesn’t blame people for their mistakes, but he does ask that they pay for them. I agree and believe that this stance would vastly cut down on the number of illicit software installations, with blocking technologies providing the final cover.


Our Lady of Victory Hospital (OLVH) routinely posts the best employee culture scores in the Ministry Health Care system. I'm often asked how it is that OLVH consistently rates so high. We're certainly not perfect nor perfectly consistent across all departments but I see OLVH's cultural strengths as follows:

Leadership by Example

OLVH leaders are "working managers". I think that makes the layer between managers and staff less pronounced. Whether it's our DON working ED shifts or the Rehabiliation Director going to the prison to provide therapy, the leaders at OLVH have their sleeves rolled up just like the staff does. I believe that fosters more of a "we're all in this together" environment.


Values and culture activities are treated seriously and sincerely by our leadership. These initiatives are always followed by serious and sincere action. Employees can smell disingenuous lip service a mile away.

Connection with Staff: Honesty and Openness

From a senior leadership level, the hospital President does a great job of keeping everyone appraised of what is happening, even if the news is negative. There are few, if any, secrets. Discordance is hard to hide in a small environment so it's typically dealt with quickly resulting in less time to fester (certainly there is variability in performance here but overall this is a strength at OLVH). Conversely, good works and good staff are more visible to all. The President's weekly email is a great example of how she openly connects with staff to relay good news, bad news and give sincere kudos and encouragement to specific individuals.

Focus, Accountability and Follow-through

There is a strong current of accountability here complete with follow-through and closure of initiatives. Thus, things get done. This leads to the sense of accomplishment as well as confidence that what we focus on will be accomplished.


All of the above lead to a higher sense of trust among leaders and staff and trust is probably the main ingredient of commitment.


This is the time of year when I field a lot of questions about point-and-shoot digital cameras for gifts or for capturing pictures of kids and grandkids during the holidays. Luckily, a very highly respected digital camera review site,, is coming out with a series of reviews of cameras within various classes. Each class review will select the best cameras in their respective classes.

Their first review is of the budget camera class and includes cameras under $150. According to the review, the two best cameras in the group are (with Amazon links) the Sony DSCW120 at approx. $130 and the Panasonic LZ8 at approx $117.

Remember, this first review is of budget cameras so the winners will provide good quality photos yet may or may not have all of the features you desire. Read the reviews carefully as DPReview does a good job of specifying the pros and cons of each class of camera as well as for the individual cameras themselves. I'm actually quite amazed that both the Sony and the Panasonic above have Image Stabilization and large viewing screens. Clearly, high-end camera technology is working it's way down to the budget models!

If you're interested in digital camera buying this Christmas, check back at the DPReview site for more information and more reviews as they become available.


(BTW- Don't judge a camera based on the number of megapixels it has. All new cameras have enough megapixels to produce large prints.)
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