A blether ’bout Scotland

As you know, I’ve been enjoying Twittering lately, and I’ve added folks from both my professional and personal interests in one little microblogging stream.  This dichotomy to my personality has been interesting to more than one person.

@ePatientDave asked that I blog about my experiences in Scotland, why I went there, what happened, and I felt that it was more appropriate that I blog about it here, rather than EHR and EMR (since I have to write an entry about HL7 for that anyway – I’ve been far too busy for anything other than 140 characters lately).

So, here it is, in relative brief (yet longer than Twitter) detail. 

When I was first introduced to the idea of working in Scotland, I was working at a very prominent medical center on the east coast.  If I even got specific enough to name a city, most savvy people would recognize where it was and who I worked for, and I’d really rather just leave that to someone digging than to me naming names.  I do try to protect the privacy of my clients.  Anyway, I was working at a large, multi-site cancer facility.  I had essentially reverse engineered a database that was at the core of what was called a ‘record and verify’ system, which is a radiation oncology system that actually controls the linear accelerators during cancer treatment.  Additionally, it had a medical record and billing component, and a companion piece of software on which treatment planning was performed.  So, the treatment planning system would be used by folks to determine where and how much (and sometimes when) to dose someone with radiation, and it all hooked into a system on the linear accelerator (where the cancer patient is placed) that would control how the treatment was performed.

And my, oh my was I good at my job — but I am a very opionated woman, and this job was no different.  When I disagreed, I would make no secret of it, and at the point at which I met the Scottish, I had managed to piss off some big wigs.  They couldn’t bully me (that’s the power of being a person who DOES the work), but they were making my job (and therefore my life) a living hell by this point.

I even remember the day I met the Scottish — I had four interviews for an employee position, about 7 hours of meetings scheduled through the day, and a new employee that I was still training.  It was a crazy day.  Mid way through it, during my only break in my 12 hour day, I received a call from our most influential software vendor.   She had been trying to work through our technical folks (you know, my server friends), and the problem with software like this, is that it is so heavily process / clinical / workflow based (it matters HOW people use it), that the technical folks couldn’t help.  No one had suggested I be there (even though my machine was named “RadOncDbGuru”) due to an oversight – and she asked that I come and talk with them for an hour.

I was reluctant, but I agreed, and I found myself being asked very good questions by the representatives of the clinic.  It was an enjoyable, and frank conversation in a time when such conversations were becoming less and less frequent.  I joined them for dinner at a posh restaurant, and found myself engaged in lively conversation with their chief physicist, who asked me if I was interested AT ALL in coming to Scotland, and I gave him my contact information, and told him to let me know.

Immediately, I got a response — it ends up he sat on a radiotherapy group at Parliament, certainly did have hiring power, and they were more than willing to have me come in for any kind of time that I could spare.  I had six weeks of vacation coming to me, and I presented some choices to my employer — that I take a six week vacation but work for them for the five hours I gained due to time difference, that I take the vacation outright, that I be given a sabbatical — all were rejected.  During this time, the physicist emailed me an early story about this woman, and asked if I knew how to make the two systems talk (I managed to figure it out just by watching how they should talk, and reading up on our policies on ensuring that the two were in sync).  Essentially, just that piece of this implementation, would prevent the tragedy he forwarded to me from ever happening.  

By the numbers, I made about the same as my US salary, but I would give up all my benefits (including, ironically, healthcare), and my home — I couldn’t afford to save my apartment, my car — all that once.  I was told I wouldn’t have to pay Scottish tax, but I would have to account for my American tax unless I stayed.  It was all this complicated mess that meant I was taking a hit and having to give up all my possessions except two suitcases in the end of it (though it didn’t present itself that way at first.  Again, more complicated than one blog). 

So, I quit the secure job for the job I knew was doing the right thing.  I know it was a shock to a lot of people I worked with, but to those who were really close, they knew that was the decision I was going to make.  I packed my things, sold what I thought I needed to.  It all seemed to be falling into place.

Until the date of my flight neared, and I had no paperwork in sight.  Originally I gave myself two nights between when stopped working one job and flew to the other — and my paperwork for my work permit in the UK was delayed.  There was nothing anyone could do — and I booked my flights out two more weeks to wait for the paperwork to arrive.  Remember that, ok?

Take two had me arriving at the airport on april 6, 2006, to arrive on the next day in Amsterdam and then Glasgow.   I arrived at the airport early, and hunted down a bar that would let me smoke.  I found TGI Friday’s, and smoked as I drank rum and cokes to prep me for the longest stretch of flights I had ever endured.  While at the bar, a very handsome man next to me engaged me in conversation — it ended up I knew him from college — we had gone through writing classes together.  As in, all of them.  As a bonus, I loved his work and had always found him super cute, but I had been married then, and divorced since.  We traded emails, and I scurried off, only to find I was too late for my flight.  The next flight cut down my time in layover, so ultimately I ended up cutting it really, really close.

I was fascinated by Scotland from the beginning, and we had lengthened the time I would stay from six weeks to three months, and by the time I arrived there, there was already talk of me staying six months, to expand the project to include not only full implementation of the Record and Verify, integration with Treatment Planning, and Practice Management / EHR records to include a national data standard and guide for other centers to be able to nationally share data between clinics.  I was really excited over the prospect, and put in ridiculous hours over the next few weeks.

There are extraordinary differences between the ways that a clinic runs in the UK to the way they run in the US.  Each seems suited to its environment, but has its own little infuriating stumbles along the way.  In the US, you normally would have some capital for expansion each year, while in the UK normally you saw ‘lump upgrades’ and then no activity for a few years.  In both cases, I always tried to eliminate duplicate work, support automation(yet above all accuracy), account for all stkeholder’s needs,   make the system easy to use for clinicians, and make cohesive reports to management that report back on information that was key to their operations and research. 

But, the Scottish had some of their own problems.  I found myself getting into arguments about EVERYTHING.  And, my boss encouraged it — he had hired me to tell the hard truths no one wanted to hear — a job I’m rather good at, but it can sometimes lead to lonely nights filled with alcohol.

My nights were filled with data analysis, crocheting, and talking with Darren, that wonderful man I met at the airport.  Between him and the support network of my friends, I was able to get through this very trying time.  It seemed sometimes it was even more of an uphill battle.  I would have to argue “No, you can’t schedule downtime for the cancer treatment device so you can have tea,” to “Yes, you have to take the patient’s picture, how many times have you treated the wrong person because you didn’t, because right now, one is too many.”  

As I went, I started interviewing physicians, physicists, dosimetrists, and ‘consultants’ (that’s what they call doctors) to get a feel for what they wanted in their data, and I began to construct a cohesive cancer data set by using my knowledge of the cancer registry here in the states combined with the knowledge of what Scotland was finding their needs would be.  I came up with a completely different animal.

It was fascinating and hard work — I found myself doing many different tasks — from giving lectures on good system use (40 of them in two weeks, one hour each, in addition to everything else), to recording videos, meeting with power users, writing to Darren . . .

During all of this, I fell completely in love with Darren, and the more we talked, the more that we planned instead of me staying in Europe, that I would go to Los Angeles to be with him when it was all over.  Considering the isolated life I was leading (I would venture out on hikes along the West Highland Way, or to a pub or ‘stitch and bitch,’ and would dine with my boss and his family, but truly little else social), he was a great comfort.  Every call home that I could afford, I made. 

We went live with the system three months later.   During this time, I had earned weeks of overtime (lieu time), and had two paid weeks coming to me.  Because of the phenomenal work effort of the vendor, all of the employees and champions, and the technical staff, we actually got it up and running with very few glitches less than three months after I had stepped into the clinic.  I am still intensely proud of all those folks for doing that.  It was an effort (and sometimes a begrudged one) on behalf of all of those employees — and we are talking hundreds.  They should be proud.  And I always will be.

About a week after all seemed well, until there was a dispute about the authorship some of the national data work.  It got a bit nastier, and by the end of it, I decided I had done everything I had contractually said I would, and even more, and that it was time for me to move on to my life in the US, with Darren.

It was a happy ending — everyone was satisfied, and I did what I set out to do in absolutely record time.  I came back to the US, came to LA, fell completely in love, and have been honored to work at some fine institutions here in the Western US.   Scotland taught me so much more than I can probably express in any overall fashion — it comes more in short spurts of enlightenment or moments of recollection as I pour over policies, procedures, and system usage elsewhere.  I learned more about myself, the world, and my profession in that short space of time than in few others — I was taught a lot in this enormous personal and professional challenge.  I learned about goal setting, limitation, and communication on more than one level, and I can never express my gratitude for being given that “crisitunity.”

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One thought on “A blether ’bout Scotland

  1. Wellllll, that is SOME story.

    The opening “as you know” suggests that you’re writing to your usual audience, and candidly I’d like to spread your story a bit more widely. Another post here, or a guest post elsewhere? Like, this post doesn’t say a THING about why you were brought to Scotland, the process errors you discovered, what remedies you put in place, etc.

    I want this because I want to hold it up as an example. See, on Tuesday when I was in DC testifying at a committee hearing about EMR stuff for the Dept of Health & Human Services, one phrase that came out of my mouth is that “The IT grownups haven’t shown up yet in health IT,” and there were many nodding heads and some laughter. But policy people in general don’t yet know what to do about it. So it would be great to have a concrete case to point to.

    You pretty much said it with “it is so heavily process / clinical / workflow based (it matters HOW people use it)” but I want to take it down to concretes. Like, “at decision time, the system presumes that Datum X is accurate, so in order for the system to work, we need to have good controls on the accuracy of the data. In this case, there weren’t, so Datum X was wrong, and nobody realized is. To fix it, we instituted a Framisvanger Duplex Twistum.”

    The thing is, a whole lot of IT decisions are going to be made in the next 1-3 years, and all the kerfuffle about my Google Health adventure has shined a spotlight on the issue, and people are wondering. We have a chance to teach. Let’s.

    Or, said differently: wanna play with our brains?? (And I ain’t talkin about it in the sense of zombies playing with their food.)

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