Case Study #1 - Health Information Exchange (H.I.E.):
A community Health Information Exchange effort applied for and received grant funding to enable local Emergency Departments to refer appropriate patients to receive primary care services from safety net providers who are established in the community. This program was likely to generate a major increase in case load for the Certified Application Assisters who help new patients understand and apply for appropriate benefit or grant programs. The case intake interview typically would run to an hour or more.
We identified an electronic service that offers the Certified Application Assister an automated tool that includes a customized interview and data gathering process. At the end of this new screening interview, which typically takes less than 15 minutes, the on-line service can usually print or electronically file a benefit or grant application. The new approach costs less than $15/case and typically saves $400 or more in write-offs of Emergency Department charges.
The program grew to include the local 2-1-1 agency and is variously referred to as "Medical Home Finder" and "E.R. Transition To Community Care."
Case Study #2 - Health Information Exchange (H.I.E.):
Interns spent much of their time gathering key information from the charts and EMR's in several different hospitals. This work provided familiarity with a variety of very different solutions to collecting and archiving information. The chief of medical informatics had a vision of equipping the interns with simple computer based access to a standard view of patient data. It turned out that each hospital did have an interface engine with Health Level 7 (HL7) capabilities. And the PDA's issued to the interns as part of another training program had a secure wireless communication feature. Within a few months, interns, residents, professors and even senior students were using the new mobile patient browser. The chief of medical informatics declared that the initial idea of making rounds more effective was fulfilled - even surpassed.
Case Study #3 - Health Information Exchange (H.I.E.):
The expanding requirement for Elder Care as that segment of our population grows has consequences that may be major indirect drivers of Health Information Exchange (H.I.E.). See this webinar for some background on how H.I.E. relates to elder care at home - http://www.transtimemed.com/mn-WS-Oct2006.html. The Robert Wood Johnson Foundation is supporting specific innovation programs in how patients can have better ways to engage with their Personal Health Records - http://www.projecthealthdesign.org/. And even the US Government is working on a rapid shift to how the Money Following the Person might allow us to fulfill the national mission of care delivery without needing to build colossal senior care centers that we cannot afford - and may not even have time to construct, were there no other constraints to consider - http://www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp. The $888 Million dedicated to this effort over five years is indicative of the challenge. It may well be that the reality of engaging and delivering care to our senior population where they prefer to live with comfort, convenience and dignity may do more to force H.I.E. adoption than many other drivers of this valuable health information technology.
Case Study #4 - Critical Information Technology (I.T.):
The applications development team was a blend of World-Class Industry Experts, early leaders in the Customer Relationship Management sector, Hardware Vendor practice leaders, Software Vendor practice leaders and senior executive champions. The solution was designed to break new ground in responsiveness and rapid response to customer issues. Tens of millions of dollars were approved and spent. The new customer service centers were built, equipped and furnished. Training materials were ready and the trainers were eager to lead their first classes of new call center agents. But the solution could not be taken forward to production - the scalability test could not be passed. And the fail-over test would not run at all.
We convened all the expert resources from every corner of the project and the organization at large. This team built a run book for testing that covered every item that could be observed, measured or extracted.. Full scale testing cycles ran on third shift, out of concern that the test suite might saturate the enterprise network or overwhelm the regional data centers. The answer to the fail-over puzzle emerged when an operating system developer reading a memory dump observed that fail-over was proceeding, but at very slow pace. A new system load had the hot standby racks boot up with all the required system, data base and business logic processes live and ready to work, but with all the queues empty. Fail-over was less than two minutes after an extensive performance tuning exercise.
Scalability just would not happen. The test generator would start to crank up and, sooner or later, everything would go silent. The server racks would simply go quiet. No disk activity. No processor activity. No error codes. No logs. No dumps. Nothing. Finally, the developer who originally wrote the core process management utilities for the operating system (brought in on a special subcontract because his team had been replaced by an off-shore group), observed that the system lock pool was "running on empty." He pointed out that the system was tuned to give higher priority to any database task than to the lock manager. We asked the data base vendor development lead how they responded to "dirty locks" - lock blocks that never had a chance to make it to the "clean lock queue." The response was that Dirty Lock was not on the Approved Error List. And what happens when the data base sees any error not on the Approved Error List? Somehow, the database vendor had the credentials needed to Force Kill all their processes - gone without a trace.
The solution? The business owner weighed all their options and decided to go into production with a specially patched version of the operating system that Cleans the Locks before dispatching any applications work.
Case Study #5 - Critical Information Technology (I.T.):
Work flow efficiency and fraud reduction were driving objectives of this point of service project. The solution under evaluation required that a separate "appliance" be installed at every transaction location. These appliances were not cheap and needed commercial power to run. A cleaning crew "borrowing" the power outlet to run a vacuum had caused several painful outages. And there was a requirement for a physically separate WAN connection in order to update and manage each appliance. A transition from a session-oriented application architecture to a connectionless approach made it possible to run the enhanced application from the existing desktop workstations already installed at every transaction location.
Case Study #6 - Critical Infrastructure:
An elite biotechnology Research & Development team is pursuing a potential treatment for bird flu. This promising new drug is working well in the animal models. Word came back of the unqualified success of this compound against the authentic virus. The very next U.S. Government proposal specification suddenly required a Site Security Plan. This was much more than calling a locksmith to put in Medeco locks. While no template could be offered and no approved plans could be made available for review, it was clear that the new Plan needed to address the steps needed to established a fully secured remote security perimeter, as well as provisions to activate upon request "7 by 24 comprehensive facility protection".
The Draft Plan was created in a matter days, and included close coordination with local first responders, who were just starting to implement new protocols and systems that came on-line after special training with the Department of Homeland Security. The R&D team now pursues their work in full confidence, knowing that any 911 call for their facility will receive the appropriate priority and attention. And they've been introduced to both the local government first response leaders and appropriately certified private specialists who address requirements ranging from site monitoring to critical shipment protection.
Case Study #7 - Critical Infrastructure:
The corporate data center had gone 100% dark, except for the emergency lights, which activated promptly when all commercial power vanished. This center was "fully protected" - ample diesel generator set and fuel stores, over sized battery plant - itself fully redundant with automated fail-ever. But the power was gone. All the servers and mainframes weren't just off line - everything was dark and silent. During the incident review, staff described an unusual alarm sound. This was eventually identified as the gas alarm in the battery room. Power to the battery ventilation had failed - just a fauly cable.
The active battery plant warmed up and begin emitting gas, triggering that alarm. After the auto-change to the redundant battery plant, that unit went over temp and triggered the gas alarms again. With both battery plants over temp, the auto-change become a rapid cycle. How rapid? The inside of the power distribution unit was empty. The metal casing had caught and held the ionized contents of that protection device. Had the gas alarm been recognized, flipping a manual bypass switch on the battery plant might have avoided catastrophe. But the capital projects manager achieved a cost reduction bonus by deleting the manual bypass switch from the order when the facility was constructed. Event remediation included addition of the manual bypass switches - and gas alarm rehearsals.