Strategic Informatics

A blog about the strategic application of technology

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Lessons Learned from Implementing a Service Oriented Architecture in Healthcare

I thought I would take the time to post some lessons learned over the past three years leading a ground-up initiative at WellMed Medical Management creating a service oriented enterprise application for physicians and medical management staff to treat and transition care for patients.  Service Oriented Architecture (SOA) is an often misunderstood concept even among the ranks of IT professionals.  While many SOA initiatives have manifested and exposed internal business logic in the form of web services the approach for SOA is actually very non-technical and is rooted in a deep understanding of the business and strategic goals and involves an ever evolving process of continuous improvement and refinement.  This makes the approach both strategic and operationally focused.  In this post I will outline what I feel are some critical components necessary for a successful SOA-based project.

 

Understand the Business Domain Model

While many companies evolve over time it is important to ensure your view of the business domain evolves with it.  Healthcare organizations are no different.  Communication is key especially in rapidly changing and evolving environments such as healthcare and defining a clear functional domain model will help pave the way for future development or shifts in business.  Find natural lines of separation within the business and look for natural service boundaries which allow you to build services that make sense.  By creating separation of services boundaries you help define sources for data and information and avoid duplication within your architecture.

Lines of separation can be found between:

  • Different lines of business (e.g.. Medical Management, Clinical, Research, Transportation, MSO, HMO, etc…)
  • Product & Service Lines (e.g., Transportation, Disease Management, Chronic and Complex programs)
  • Product Variations

Understanding the business is critical to ensuring that IT is aligned adequately to support business functions.  IT is often a common service that crosses multiple business functions.  Common services that cross boundaries include infrastructure, data warehouse, applications, development, etc…  Through this modeling effort many IT organizations can quickly identify gaps in existing service and support for the business community.

 

Maintain a Common Definition of Terms

In complicated environments like healthcare where efficiently managing risk for medically managed patients and members is critical to the success of your business you must take a solid look at the data flowing into and out of your organization.  Having a solid definition of what a bed-day is from a hospital visit, as an example, is important from both a financial perspective and a medical management perspective.  Stratifying patients based on acute events such as historic hospitalizations, lab results, HRA’s, or audits are equally important for the management of that patents care.   Both finance and medical management aspects of the business are critical to the patients care yet the consumption of information can be viewed and assessed slightly diffent unless a common method for defining data and terms associated with managing your business are clearly defined.

 

To effectively define these terms you must:

  • Build from business domain knowledge
  • Evangelize the terms and their correct usage
  • Introduce new terms slowly
  • Seeking definitions that are both
    • Unambiguous
    • Context insensitive

 

Maintain a Consistent View of the Ideal System

 

I’ve always been an advocate of having a strategic and long-term vision for a product.  Knowing where you are going will help you make day-to-day decisions that will ultimately help you get to where you need to be.  The ideal system will often seem unrealistic to many but setting the bar higher than others will help make your organization more agile and ready to change as market or other external factors shape your business.   Our approach to building a strategic enterprise application included components for mobile devices (pre-iPad) and both patient and provider portals.  They will not always manifest themselves as a product immediately but setting the groundwork and service breakdown will allow you to readily transition to other products or services.

 

The following items will help you build a consistent view of your ideal system:

  • High level design or model of the:
    • Goal system and
    • Intermediate steps
  • Consider all relevant aspects
    • Hardware/Networking
    • Services/Communication Protocols
    • Data/Access
  • Keep it in a maintainable form
  • Evangelize the roadmap

 

I’ve found that keeping a current copy of the ideal system will help you in many other aspects as well such as quickly describing the business to potential employees, vendors, partners, and even internal staff.

 

Seek Opportunities to Advance the System

 

Service Oriented Architecture is a concept and proposition you must be dedicated to and not a passing trend you can close as part of a project.  As such you must change your mindset and approach to all your projects.  Often SOA initiatives are grounded in major strategic initiatives.  Like any major IT initiative it should fundamentally support the businesses core objectives and strategic goals.  Your choices from a day-to-day perspective should seek to advance this strategic effort and build upon the shoulders of what has already been created.  A core tenant of SOA initiatives is the concept of re-usability.  When building new services or implementing new features you should always seek opportunities to advance the system as a whole.  Ways to do this include:

  • Avoiding Big Bang Architectural Changes
  • Implement the final system in small steps
  • Places to look for strategic opportunities include
    • New lines of business
    • New clients or partners
    • 3rd party software updates
    • New vendor software that complements your core products (i.e. Med Management & EMR)
  • Incorporate changes with the highest potential return
    • Looking for small changes with the highest amount of return
  • Seek to learn from each opportunity

 

Evangelize the Vision

The architect is a business leader and will often be your biggest advocate for driving business change using technology.  This is a very collaborative role and this person must work closely with executives and have a firm understanding of business trends, strategic initiatives and goals so changes or shifts are adequately made within the application and technology architectures supporting the business.  Ways to evangelize the vision include:

  • Continually show the company
    • Where the IT end of the business is headed
    • How it’s going to get there
    • Why it should go there
  • Create opportunities in
    • Design Meetings
    • Architecture, Development & Governance meetings
    • Hallway conversations within IT and with senior leadership

 

 

Continuously Improve Everything

 

Lastly, I would say continuous improvement is an overarching requirement and mindset you must install in all of your initiatives.  This can’t be drove from the architect or developers alone but must involve changes in processes of the business departments.  In our case it involved the close interaction of  infrastructure, executive management, line workers (nurses, case managers, health coaches, etc…).  Like the agile methodologies we put in place to develop our enterprise product you must have continuous interaction and have the mindset of continually improving your product and services.  To do this you and your entire team must:

  • Seek a to maintain a better understanding of the business even as it evolves and changes
  • Add and refine terms in the domain dictionary
  • Evangelize, Evangelize, Evangelize…. (E Cubed)
  • Seek alignment between the business and IT and use changes in business as opportunities

 

This is by no means an easy process but evoking change within an organization, especially a large one, is not a simple undertaking.  I’m sure I will have more to add as time goes on but take these little tokens of knowledge, go-forth and build your own agile enterprise applications.

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Recovering a hard driving using SpinRite on a Mac using VMWare Fusion

I recently found myself faced with a 2.5″ NTFS formatted laptop hard drive from a 5 year old laptop that wouldn’t cooperate and would constantly fail so I decided to try and recover what I could from the drive by running SpinRite, a great application from Steve Gibson of Gibson Research that I have used successfully many times in the past to recover damaged or unreadable magnetic based media.  The last time I actually used it was about 12 years ago over the course of several days to recover a failing HD.  Computing and hard drive technology has changed a lot since then but they are still very much part of our day-to-day IT lives.  When I encounter a problem that needs extensive evaluation I would just run SpinRite on the x86 based PC from which the hard drive came.  However, after creating a bootable CD and USB key with SpinRite for use on the 5 yo laptop neither one would work so I decided to take a different route.  Without another PC handy I decided to assess my options…  My daily laptop is a MacBook Pro, doesn’t (thankfully) have an internal 2.5″ SATA bay and is sealed tighter than the sub in the Hunt for Red October…  So what’s a Mac user to do with an NTFS formatted magnetic HD that can’t be read, an old Laptop that won’t boot SpinRite, and no other PC’s within easy reach?  Try to run SpinRite from a Virtual Machine on a Mac of course….

Now for those of you who don’t know SpinRite was written in assembly and does very low level reads and writes against a computers magnetic mass storage drives.  FreeDOS has been incorporated into SpinRite distribution to allow it to boot to a bare-metal PC and mount any connected drives so you can exercise the individual bits of 1’s and 0’s stored on the drive, exercising it enough to get a magnetic drive in as good a working condition as the physical hardware will allow.  With any luck it will operate just well enough to get your information to a readable state and backed up before you have complete hardware failure…   Running SpinRite from a VM was a bit more involved to configure via VMWare Fusion on a Mac and I wasn’t completely sure it would work… so I thought I would share my experiences.

 

I created a spinrite.iso file from another Windows VM I use.  I then created a new MS-DOS based VM mounting the SpinRite.iso created from the SpinRite.exe file.  It booted to a familiar screen without any issues.

SpinRite_and_Blank_website__Blank_site__Nothing_to_see_here_

SpinRite_and_Blank_website__Blank_site__Nothing_to_see_here_

Now the challenge was to get the physical hard drive mounted to the VM…  Looking through the settings there was no way to get RAW access to a physical HD.  I used a SATA to USB adapter and had to connect the drive to my Macbook Pro ensuring it was mounted to the Mac not the VM.

I needed to create a Raw Disk vmdk to make the RawDisk accessible to the VM so I did the following:

From a Mac terminal (I prefer iTerm) type:

diskutil list

In my case the 160GB HD came up as /dev/disk2 but your particular configuration may be different.

1__bash

 

Next from the terminal run the following command to list the partitions that rawdiskCreator can see:

/Applications/VMware Fusion.app/Contents/Library/vmware-rawdiskCreator print /dev/disk#

Note: Ensure that the last entry /dev/disk# is changed to the drive you are targeting for raw access.  In my case it was /dev/disk2

1__bash

What you should see next is your drive partitions…  My particular drive was split into two partitions (#1 was very small and #2 made up the bulk of my 160G HD)

With your partitions known and visible by the rawdiskCreator tool you can create the vmdk file that refers to the physical hard disk you are trying to mount and make it available to the existing SpinRite VM you created earlier.  You will need to know the location of the Disk and the partitions you want to mount from the previous command, which in my case is /dev/disk2 1,2 which says it’s disk2 and both partitions 1 & 2.  You will also need the path to the actual SpinRite .vmwarevm Virtual Machine that you created earlier (in my case ~/Documents/Virtual Machines/SpinRite.vmwarevm/rawDiskFile).  Now I used rawDiskfile but this is the name of your vmdk file and can be called whatever you like.  Make sure to include the ide designator at the end so the VM knows how to mount the drive.

/Applications/VMware Fusion.app/Contents/Library/vmware-rawdiskCreator create /dev/disk2 1,2 ~/Documents/Virtual Machines/SpinRite.vmwarevm/rawDiskFile ide

After you execute this command successfully you can option click the SpinRite.vmwarevm file and choose Show Contents.  Here you should see the files that makeup the .vmwarevm file including the new .vmdk file (if that’s what you named it) for each partition you listed above (1,2).  In my case it was rawDiskFile.vmdk & rawDiskFile-pt.vmdk

If you boot the VM now you won’t see the additional drive so you have to manually edit the configuration file for the VM to recognize the drive.  With the VMWare file contents still being displayed in finder you need to edit the .vmx virtual machine configuration file.  In my case it was called SpinRite.vmx because SpinRite is what I named my VM…  You should probably back up this file incase there is a problem and you need to start over.  Use your favorite editor (BBEdit, TextWranger, TextEdit, etc…) to edit the .vmx configuration file.  You want to insert the following lines to your configuration file being careful not to duplicate an existing ide#:# entry:

ide0:1.present = “TRUE”
ide0:1.fileName = “rawDiskFile.vmdk”
ide0:1.deviceType = “rawDisk”
suspend.disabled = “TRUE”

If the VM already has in its .vmx configuration ide0:1, use another port such as ide1:1.  It is also possible to use scsi#:# or sata#:# if the VM is somehow configured to use a SATA or SCSI controller.   The suspend.disabled=”TRUE” entry prevents the VM from suspending and being out of sync with the attached HD.  Important since most of SpinRite’s scans can take a long time to run.

The last step is to power on the VM and select your HD…  You may be prompted to enter your administrators password to get RAW access to the HD as the VM powers up.

Screenshot_4_30_15__4_12_PM

If you run into trouble it may be necessary to unmount the HD from your Mac by ejecting or un-mounting from Disk Utility prior to turning the VM on.

I won’t go into detail on how to use SpinRite as the tool is pretty self explanatory but the 160GB HD partition did appear in the interface ready to begin SpinRite’s operations.

SpinRite

SpinRite_and_Blank_website__Blank_site__Nothing_to_see_here_

SpinRite

 

Again this certainly isn’t an ideal setup as SMART access to the HD wasn’t available from within SpinRite menu options because, and I’m guessing here, of the SATA to USB setup but it might work in a pinch.  Hopefully it proves useful to your IT Toolkit and helps you extend the life of your SpinRite license which is worth every penny…

Update:  I tried a couple of drives and while it worked for one drive there was an error that completely stopped SpinRite and the VM in it’s tracks…   It only occurred on a specific section of the hard drive where there was clearly an issue…

SpinRite

SpinRite

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2014 InfoWorld Enterprise Architecture Award

The InfoWorld/Forrester Enterprise Architecture Award, presented by InfoWorld, Forrester Research, and Penn State University Center for Enterprise Architecture recognize organizations whose practice of enterprise architecture has delivered substantial business benefit.   I’m pleased to announce that my team at Molina Healthcare was recognized this year for our re-organization efforts to make our department more business outcomes focused.

enterprise-arch-image-2014-100449595-primary.idge

 

The announcement can be found on the InfoWorld Website:
http://www.infoworld.com/article/2686202/enterprise-architecture/2014-enterprise-architecture-awards.html?page=6

Forrester Research VP and Practice Director, Alex Cullen stated:
http://blogs.forrester.com/alex_cullen/14-09-22-2014_enterprise_architecture_award_winners_wow

Molina’s EA team, headed by Cary Brown, Director of EA, responded with a strategy that simplified its own service offering, narrowed its focus, and fundamentally redefined how it needed to fit within the organization. As part of its re-chartering efforts, EA also reorganized services around two primary groupings of Enterprise Architecture offerings: strategic services (focused on future state planning, roadmapping, governance and standard setting) and tactical services (focused on new technology evaluation, solution design and facilitation).

Collectively these re-chartering efforts have resulted in a streamlined, partner approach. By partnering with stakeholders in each business area EA is now ensuring:

– Decisions made in one initiative benefit for the first time from an enterprise-wide perspective;
– The company no longer invests in “one-off” parochial technology solutions that favor a particular business unit or project;
– All initiatives, including ad-hoc IT efforts, have clearly stated objectives and end with a positive outcome or transparent decision be it a new capability or some new business function that improves quality or removal of barriers to healthcare services.

Of this submission, Eric Meredith, VP Architecture Governance at PNC Financial, said: “What was most intriguing was that they began by applying EA principles to the EA practice, i.e. applied EA principles to themselves to identify challenges in their own EA strategy. Brilliant and Gutsy. “

Source: http://blogs.forrester.com/alex_cullen/14-09-22-2014_enterprise_architecture_award_winners_wow

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Speaking Engagement at the Troux Worldwide Conference 2014

I’m honored to have been asked to speak at the Troux Worldwide Conference 2014 in Austin, TX.   I will be discussing the re-chartering and re-organization efforts  for our Enterprise Architecture division at Molina Healthcare.  Below is an overview from the Troux Website…

Molina Healthcare – Re-Chartering EA to Focus on Business Outcomes

Managing the demands of government funded healthcare is a certainly a big challenge.  Re-Chartering EA to deliver positive business outcomes in the midst of massive healthcare reform is an even bigger challenge.  This session will offer key insights and the approach Molina Healthcare has taken in reshaping Enterprise Architecture to tackle hurdles, such as defining how EA aligns with and supports the business, demonstrating the business benefits of an EA program, and how Molina uses Troux to improve the quality of information for decision making through the development of capability maps, standards, and customized roadmaps.
Cary Brown, Director, Enterprise Architecture, Molina Healthcare

The agenda can be found here:  http://www.troux.com/resources/events/conference2014/agenda.asp#

We have taken some very unique and innovative approaches to leveraging the Troux EPM tool at Molina.  I hope you can join us for what has historically been a very informative and educational conference.

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Certified ScrumMaster

I wrapped up training two weeks ago to be come a Certified ScrumMaster.  The course was a solid foundation on the fundamentals of Scrum and the process of product management and development in an agile environment.  While I’ve participated in Scrum sessions many times in the past this formal indoctrination into the process was very insightful and will prove very useful in future meetings with teams.  Most sessions you see in practice are variations of the real process which, to the Scrum Alliance’s credit, has evolved and been refined over the years is actually very good.  With some effort, practice, and discipline of your teams the breakdown of product backlogs, into deliverable sprints could prove fruitful for any product focused company.

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Social Network Data Visualization

Linked-In Labs has a new data visualization feature that shows the links between your different contacts and relationships within LinkedIn.  Simply log-in to inmaps.linkedinlabs.com and you can see the relationships unfold.

Above is a copy of my map of contacts and their corresponding relationships primarily in the healthcare and IT fields grouped by relationship types, affiliations, and general experience domains.  You can find other inventive concepts at www.linkedinlabs.com.

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Designing an Electronic Medical Record

Some big ideas come from asking pretty simple questions…

As it turns out the inspiration and vision for the development of an innovative Care Delivery Platform at WellMed was born out of necessity.  A necessity to accurately and efficiently deliver timely information about patients health status to caregivers at the point of care and document in a way that did not inhibit the caregivers ability to deliver quality care to seniors.

Many physicians are burdened with a mass of paperwork detailing patient activity.  The simple idea of putting relevant and timely information in the hands of a physician when it is most important to help manage risk and provide adequate decision support at the point of care is a goal many EMR vendors have tried to achieve by simply aggregating and archiving data.  There are several decision support tools available for physicians that manifest themselves in different ways such as ePrescribing applications, Reference Material, Patient Education Handouts, Risk Adjusted Payment Attestations, Document Management Repositories, Clinical Protocol sheets, etc… some within a single application, many others completely disconnected and disjointed requiring the user to log into multiple applications to perform seemingly simple functions.

When you think about it clinicians and many tertiary healthcare providers live and work in an environment where the vast majority of documents sent and received are in paper form and it is still growing.  When you add electronic information in the form of e-mail, document management systems, and patient data to the mix it becomes inefficient and cumbersome for providers to effectively manage.

We’re two decades into the internet revolution, and despite many efforts to create an all electronic clinic, paper is still the predominant method of healthcare communication in this country.  It’s 2010 and many providers get their documents more or less the same way we did 200 years ago!!!

That’s absurd…

While we can’t change an entire industry we can start by looking at ourselves and how we deliver healthcare to seniors.  When I started with WellMed 2 years ago I was inspired by our CEO’s vision and approach to wanting to leverage technology to gain efficiencies and better manage risk for our patients to keep them healthy and out of the hospital.  At the same time I saw his frustration with current solutions that did not allow us to progress to the next level of patient care.  The truth is we will never completely get rid of paper, this is a common misnomer, but we can manage it more effectively and make it more accessible to clinicians.  What the our clinics needed was a new, complementary approach for managing patient information.

So here is the simple questions that led to the creation of the Care Coordination Platform:

What would it take to deliver quality information to physicians at the point of care?

What would empower physicians to help deliver quality care for seniors and help improve outcomes?

After much thought and effort we think we’ve got an approach that nails these things.  It brings efficiency, new benefits for both business and physicians and more importantly our seniors.  So far the feedback and the demand for a solution have been terrific.

As we get ready to bring the solution we started developing a year ago to physicians we will continue to evolve the platform to include many other data elements in the patients continuum of care.  We have not been sitting idle and have solicited feedback from many providers and will continue to be engaged with all users of this new system.  Initial feedback has been great and we’ve got lots more work ahead, but we are off to a great start.

When we introduce the EMR Preview in 1Q 2011, it will have exceeded our current EMR functionality in many ways and plan on quickly following with quarterly releases of additional functionality including ePrescribing, and document management integration in subsequent iterations.  I’m very proud of what our team has created in such a short amount of time and will continue to develop as we forge new ground and develop new integrations with other custom and vendor solutions.  I would love to show you more than just a teaser image as the user interface takes full advantage of rich internet application (RIA) functionality.   I truly believe what we have designed will empower our providers to delivery quality care to seniors.  Until such time we make our internal development efforts widely available to contracted providers I will instead focus future posts on our approach to architecture, user interface, SOA, and agile development.

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San Antonio HIMSS August Meeting

Join us on August 19th Educational Session at Dave & Busters at 11:30 a.m.
To register online visit our website at www.sahimss.org or click Register Securely Online here

Our speaker this month is Bill Oldham, President & CEO, Evolvent Technologies, a rapidly growing provider of health IT services and solutions for the Military Healthcare Systems as well as online security services for government and commercial sectors. Since taking the helm in 2005, he has led Evolvent’s growth from a $5m company in 2004 to more than $60m in 2010 and expansion from its original location in Falls Church, VA to two additional Washington, DC area offices in the Dulles corridor and also San Antonio, TX. Mr. Oldham has an extensive background in technology and finance. His experience includes serving as Vice President of Technology Applications at Danya International; Project Director at MeduNet, a $100m international health information network project, as well as Chief Operating Officer of a Wall Street startup, IDEAglobal, providing online, real-time forecasting and analysis to the financial world. Mr. Oldham received his MBA from Manchester Business School in Manchester, England and has served as a management consultant to organizations as varied as Roche, Littlewoods plc, and Johns Hopkins University. Mr Oldham is the lead author of Better Data for Better Care, 2010, a book on leveraging technology to transform the management and delivery of care and he is also the co-author of Securing Business Intelligence – Knowledge and Cybersecurity in the Post 9/11 World, Evolvent, 2004.

We anticipate a large showing for Mr. Oldham’s presentation so please register today as we will close registration once all spaces are filled.

Don’t forget to follow our Twitter feed @sahimss or visit our website www.sahimss.org for future educational sessions and networking events.

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Panelist on Healthcare Security & Privacy at the The Texas Lyceum

I’ve been asked to participate in the Texas Lyceum in San Antonio, February 6th, 2010.  The title of the event is “Our Growing Lives Online:  Safe or Not?” and will attempt to tackle the risks associated with our connected society.   The weekend event which I will participate includes interactive and team activities to help Lyceum Directors better understand how these privacy and security risks affect their day-to-day lives.  The goal is to raise awareness regarding public policy involving security and privacy.  San Antonio is a great backdrop for this event as it is quickly becoming a central hub of computer security with the Air Forces locating its 24th Air Force Cyber Command at the city’s Lackland air force base.  There is an invisible war going on that we don’t even see involving cyber security and the public needs to understand how companies are protecting their information as it moves online.

Events kick off on Thursday and continue through Sunday afternoon.  I will be joining is the “Healthcare Security & Privacy” panel from 1:30 p.m. – 2:30 p.m. at the International Center, 203 S. St Mary’s, Third Floor (Two blocks away from the Hotel Contessa).  Joining me in this panel are David Finn, Health Information Technology Officer, Symantec and William Phillips, Chief Information Officer, University Health System.  Moderating the event is Dr. Adolfo Valadez.

I look forward to the event and engaging the Lyceum Directors on the virtues and risks associated with exchanging healthcare information online.  Coming from both the payer and provider sides the importance of efficiently exchanging information online not only helps manage rising cost but more importantly can drive better healthcare for our members and patients.  Our primary member demographic at WellMed Medical Management includes Medicare eligible seniors.  Over the past 5 years I’ve seen an increasing number of seniors flock to the Internet to educate themselves on health related issues.  The Internet has ushered in a new age of convenience in sending digital information.  These electronic tools and applications are an extension of your organization and your ability to deliver quality care to patients.  The same level of trust your patients have with you to manage their health in a clinic should carry through to your ability to maintain the security and delivery of their personal health information to those specialists and care providers .   I believe that technology can play a huge part in the delivery of care.  As both healthcare payers and providers we are trusted sources for our seniors and are constantly evaluating new ways to empower our seniors with the tools necessary to manage their care.

Please join our discussion…  You can find the site online at www.texaslyceum.com

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San Antonio HIMSS Chapter Approved by HIMSS Board of Directors

HIMSS (Healthcare Information and Management Systems Society)-1

A few weeks ago the HIMSS National Board of Directors convened and reviewed our application for forming a local chapter in San Antonio.  Texas is the only state to have more than two chapters.  Given the large health care presence in San Antonio I think this chapter is long overdue and a welcome addition to the solid foundation already established in the Alamo city.  This process has been several months in the making with weekly calls occurring among the board of directors.  If interest via our LinkedIn group is any indication we should have a very solid showing.  Stay tuned for more information as we get our first official meeting and speakers lined up.  A revised website is in the works.  In the mean time you can join our LinkedIn group “SA HIMSS” or follow us on Twitter at @sahimms.