Tag Archives: innovation

Adaptation, on the origin of the integrated health registry.

For more than two years I’ve witnessed firsthand the evolution of healthcare via skunk works in Southern Colorado. The concept seemed simple enough. The need to coordinate care for clients between multiple agencies.  With enough familiarity with the local resources that are available to guide, to “navigate”, to council medicaid members through their care decisions they’ll justify the extra effort in reducing waste from a few key areas. It seemed simple.

“I felt a bit like Noah suggesting that we build an ark.”

“The missing link in this evolution was the tool. EHR [Electronic Health Record] software is designed to document treatment from a limited and pretty specific list of specialties. Care coordination is an entirely different thing. Purposely broad and general in nature. I felt a bit like Noah suggesting that we build an ark. When the state seems to be suggesting that they are going to flood your organization with 100,000 new responsibilities a sense of urgency is an understatement. We panicked a bit in a very good way. Two years ago we panicked. Now it’s raining and we’re enjoying the rain. We didn’t misinterpret the signs. We’ve hit 60,000 members in January and that population is growing weekly. So far our ark is holding up.”

That “ark” is an application that Spanish Peaks refers to as an integrated health registry (IHR).


“We originally just called it ‘the care coordination application’ internally, and then we called it ‘CareTracker’ until we discovered there was already an EHR of the same name and we were even using that EHR at one of our centers!”

Now they call it an integrated health registry. Whatever they call it the functions are crucial to the management of a large influx of members and needs.

“Just like Noah, we haven’t gotten to this point without our share of detractors. Now some of them are standing in the rain and still shaking their fists, pleading ignorance, and rationalizing their strategies. When the state gives us two years’ notice that our entire medicaid population is going to transition into a new model of accountable and integrated care, it’s imperative that we adapt.”

Adapt they did, and only now is the necessity of their new tool becoming evident. Spanish Peaks has now dedicated a large portion of a building and more than a handful of FTEs to this effort. Their jobs are somewhere between RN, social worker, and telemarketer. The contact management data they require and collect is just such a different schema from care-oriented electronic health record software.

“You can try to store your eggs in the cookie jar with the cookies, but it won’t be very efficient.”

“We realized early on that trying to use an EHR to do integrated care would be like trying to jam a square peg into a round hole. There are names and addresses, basic demographics like any system, but beyond that one needs to get far too creative to justify creating bogus treatment plans, placeholder services, and then tripping through the clumsy process all that would necessitate. You can try to store your eggs in the cookie jar with the cookies, but it won’t be very efficient.”

Spanish Peaks Behavioral Health Centers of Southern Colorado have leveraged technology effectively to perfect integrated care coordination through their integrated health registry program. When asked about the technology:

“We’re mostly a Microsoft shop, and we’ve combined a few key products in an unconventional way. Not the expensive products either. This effort cost the organization nothing in new licensing.”

When pressed further, one of the developers admitted with a smirk:

“I didn’t say it was entirely Microsoft. I said mostly. So 51% or so, make of that what you want. We’ve had to roll with a lot of punches, so this thing had to be fantastically flexible, but also functionally concise. We’re back to not even knowing what to call it, but in my 20 years of software development I’ve never seen a system architecture quite like this. It is quite literally infinitly flexible, without being cumbersome. That’s a tough balance to maintain on top of the rigorous security requirements.”

I got a peek at their system and it is quite unique. The user interface looked more like a colorful PDF report than an average windows application. Yet tap elements in the report and the magic begins. On the Windows Surface tablet I was using – rumor has it it works on iPads too – the gestures and format were very intuitive. A drill-down report that was literally a robust interface to a full featured IHR (Integrated Health Registry), or whatever they decide to call it next month. Leadership in Integrated Care coming from a rural area of Southern Colorado. Newsworthy.


Scapegoating The Telecommuters

Recently Yahoo CEO Marissa Mayer admitted the potential incompetence of corporate middle-management but – as is usually the case in corporate America – she held the wrong people responsible.

She claimed that telecommuters are “unproductive”. To which I’d ask a question, are they the only ones that are “unproductive”? Did she actually compare telecommuters to cubicle bound bench warmers? What about the social butterflies? I would bet she hasn’t, in fact I would bet this is not even her idea. This will be the consensus of her own middle-management. There’s a certain irony about a technology company that cannot tolerate technologists that prefer less social interaction – technologists that use technology to allow them to focus their efforts on the task at hand. The irony being that the good ones will be the ones that leave.

How many of the people that report directly to her do you think are telecommuters? Not many, so when the rubber meets the road, do you think middle-management will be taking responsibility for having no clue what their direct reports are working on? I can assure you they will not. They will pass the buck.

The recent news comes with some predictable backlash, however there is also a subtext to be analysed. It was mentioned that not only were many “unproductive” but Yahoo didn’t even know some of them were still on the payroll. Talk about supervisor incompetence!

So we get to the point of this post. One thing some in middle-management fear, is exceptionalism. In the type of corporate environment where supervisors “kiss-up” and “blame-down” the only threat to their existence is for their staff to be too productive. How can they “blame” down when the exceptionalism of their staff is well known? The answer is, they cannot. The clock begins ticking on middle-management’s illusion as soon as they cannot blame someone else. Politicians tend to work precisely the same way. In fact exceptionalism at the management level is demonstrated by not behaving this way but rather taking responsibility. Sadly it is the road less traveled.

Those of us who are truly exceptional will experience this consistently. Even in management, there will be a lot of pressure to find someone to blame when things go wrong. Only small organizations, hardly comparable to the average “Corporate America” are capable of tolerating exceptionalism and that only lasts for as long as the organization remains small. For instance, a CEO/Owner (like mine) will perceive little threat from great staff. They will only perceive value. However, once the CEO is not the owner. Instead, they answer to a board of directors, and ownership has been relinquished to stock holders. When there is no clear “owner” the scale tips, and even the CEO will be tempted to “blame down” and “kiss up”.

It takes a very unique individual to fire a “kiss up” but a diva/rock star wizard that is productive and knows it. They are easy to dislike. They don’t tend to be very good at “kissing” they are much better at “kicking” … kicking arse at what they do.

I had a corporate gig once upon a time. I left over my manager’s obsession with me sitting in my absurdly uncomfortable desk chair. The reality, I recovered more revenue for that company in a single day than they paid me the whole time I worked there. Of course my manager didn’t mention that to my CEO. What if she had? Then she would be forced to accept responsibility for her poor communication and often complete ignorance of current projects. When she wasn’t in meetings “kissing up” to corporate leadership, she sat at her desk wasting time in ways that would make a soap opera addict seem productive. To this day the CEO believes that I was just “insubordinate”. That CEO has just as much responsibility. Marissa Mayer has just as much responsibility. She needs to stop looking for yes men, and find the rock star managers who aren’t afraid of rock star staff.

Today, as I type this article and prepare to dive into a wrestling match with some ugly ASP, I have sat on the floor, in two different recliners, and had zero water-cooler conversations about my new tie. Yes, Ms. Mayer, there are unproductive telecommuters. Productivity can be directly related to accountability. There are always people who will take advantage of poor leadership. If it’s your supervisors’ jobs to supervise, then no matter how much “kissing up” they do, it’s your job to hold them accountable for that and not allow them to create scapegoats. You’d have to let them stop kissing up and get back to their jobs. If all of that kissing up is too important to you Ms. Mayer, then you’re part of the problem. Being CEO, if you are ever any “part” of the problem then you are likely the whole problem.

OSX Lion Preview Review

Here’s a quick summary of about 30 minutes with OSX Lion (© Apple):

1. Little “lights” under icons in dock were by default turned off in Lion (© Apple).
2. Smaller control buttons on the windows.
3. There is a new link in the dock called “launchpad” that makes your desktop look just like an iPhone/iPad (© Apple).
4. Address book looks like a book.
5. Strange sliding effect on finder view selector.
6. The finder’s (apple copyright lion Apple) left pane is now nearly identical to windows 7 explorer’s left pane.
7. The mail application looks quite different and again not in a good way.
8. Safari (© Apple) finally supports full screen.

In short, I may suggest some reservation when your desktop OS is modeling its “innovations” after a 4 year old mobile device. There are rumors of pending “multi-touch” capability but our touch-pad did not indicate any sign of it. If this is for touch screens they must be planning to tabletize their iMacs (© Apple) or something since it is obvious that touchscreens in a desktop formfactor are impractical. You think your carple tunnel is acting up now? Try holding your hand up in the air for long periods of “touch time”.

The beta is buggy and does not appear to behave correctly. It really looks like they may be attempting to create a 1 size fits all OS for all devices. Safari (© Apple) finally supports full screen. Something most other browsers have done for longer than we can remember. I used to use Netscape’s full screen mode, which means it’s definitely been around a while.

Those little lights in the doc that tells you the app is running are by default turned off. This could be a further hint at their plans to clamp down on mult-tasking the same way they have on their small devices. Windows 7’s “glass” box around the icon is synonymous with this. Exposé (© Apple) has a strange habit of overlapping the windows which seems to be a bug & dashboard (© Apple? If not, I’m sure they’ve tried to) looks different. The window comes from the side and is no longer transparent. Perhaps something not finalized.

Scrolling by default is backwards! Thankfully this can be fixed in mouse settings.
Apple (© Apple) is really in love with their own mobile OS, so much so that they are willing to deprecate their desktop OS features in favor of the mobile OS. Very counter-intuitive strategy. IMO.

However, last but not least, the most exciting change in OSX Lion (© Apple) so far! Drum roll please… Resizing windows from any side and as a special bonus, window animations! Welcome to the last decade Steve Jobs (© Apple).

So Apple (© Apple) manages to simultaneously salute the other OSes with some of their copycat enhancements while oddly moving toward what appears to be constraining a full computer to the input and formfactor limitations of a PDA. We can certainly cheer the prior.

As far as I’m concerned there is nothing better than Ubuntu’s “jiggly” windows. Or as I like to refer to them, the Jiggy Windows… or as the song goes “na na na na na na, getting jiggy windows.” But, Apple (© Apple) has done well to take a clue from them. Once again we will certainly be astounded to see how Steve (© Apple) spins these imitations as innovations.

Credits: thanks to Apple (© Apple) for sending the Lion (© Apple) Preview DVD and thanks for making it the easiest yet to install on my 5 year old Dell.
And thank you Dell for making the M1710. An amazing machine.

Disclaimer: We are not sure that Apple (© Apple) has ©ed the word Lion (© Apple) however since we are aware (© Apple) of their (© Apple) propensity for lawsuits (© Apple) we figure it can’t hurt (© Apple) to © the heck out of this.