Thursday, July 23, 2015

Unity Farm Journal - Third Week of July 2015

In yesterday’s blog post, I wrote about mobile devices and my own blood pressure variability.  

The one time that my blood pressure is normal is during a day of farm work.   After hauling wood, planting/harvesting, caring for animals, maintaining trails, and repairing infrastructure, I’ll walk down our farm road through the orchard on the way back to the house.   All the tension of the week fades away with walk along the road.

Last week we moved 10,000 pounds of manure from the barnyard compost area to wind rows near the orchard.   We use “llama beans” to amend the soil in our hoop house and supplement our trees/squash beds.    A heavy rain made the manure very heavy and on the way to the wind rows, a buried underground stump collapsed, causing the Terex front loader to tip over with a 1000 pound load.    Luckily I was standing nearby and the opened the emergency exit for the driver who exited unharmed.   We used a truck and heavy duty nylon webbing to pull the Terex back into the upright position.   No harm done!

With the manure cleared, we’re redesigning the barnyard so that we can install a 17’x24’ hoop house for equipment storage - moving the Terex out of the barn and the mowers out of our pasture lean-to’s.    We’re also creating an area that might be used for pigs in the future.  We’ve scaling back our wood storage to just 4 cords (from 8 cords).   We’re re-grading/leveling the barnyard and applying gravel to the working surfaces to minimize the low spots that become mud wallows.   With every passing season we’re learning more about how to run a farm and optimize the physical arrangement/equipment to minimize maintenance tasks.

We did our annual vet visit for a full physical exam of all the animals this week.   The 14 camelids (alpaca/llama) are entirely healthy.   We gave the rabies and clostridial vaccines, checked their nutritional status, and carefully examined eyes/ears/teeth.    The only issues were that the llama is slightly overweight (but no change from last year) and one of our older alpaca has irritated eyes that we’re treating with ophthalmic ointment.   Our young alpaca continue to grow like weeds.   Danny (4 weeks old) is now 35 pounds and Sunny (1 year old) is 85 pounds.

The geese continue to follow us around the farm.  It’s as if we have 5 dogs - two Great Pyrenees plus 2 buff geese and 1 tuft goose.

The young chickens are learning the ropes of farm life, roosting in the coop night, staying safe from hawks during the day, and avoiding conflict with the other birds.

At midsummer, the hoop house is filled with peppers, tomatoes, cucumbers, eggplant, and beans.  I fill a basket with fresh food every night.   Kathy is busy pickling and preserving the foods we’re not eating now.

The weekend ahead includes harvesting our garlic, potatoes and squash.   I’ll plant a few beds of lettuce and chard for early Fall picking.     We’ll spin frames of honey and bottle in anticipation of mead making and honey lager brewing this Fall.

I’m working remotely on Mondays and Fridays in August.   Although it seems early, the planning for harvest and the winter ahead is already in progress.

Wednesday, July 22, 2015

Patient Generated Healthcare Data

I’ve often written about the IT strategies of Accountable Care Organizations and the need for a Care Management Medical Record which incorporates EHR data, patient generated data, customer relationship management features, protocols/guidelines and a workflow engine.

Although I have yet to see mature products in the marketplace, components are evolving that will fundamentally change the way we deliver care.

People know that I have been very transparent about my own medical history, as described in this Politico editorial.

Here’s how I’m using Patient Generated Healthcare Data in my own care management activities.

For the past 15 years, I’ve had a supraventricular tachycardia (SVT) - an AV nodal reentry issue.    My resting heart rate is 45-50 beats per minute.   On hot days, after I’ve eaten, my heart rate leaps to 170 beats per minute if I exercise vigorously then suddenly stop.     I perform a Valsalva Maneuver  and within a few minutes, my heart rate returns to normal.

I’ve never had any lasting consequences from this SVT.    I could take beta blockers, have an ablation of the ectopic pacemaker in my heart, or just accept that a few times per year I’ll have an arrhythmia.    I’ve chosen the later.

We’ve attempted to capture an ECG of my arrhythmia, but have never been successful.  We’ve tried a stress test, a holter monitor, and other wearable approaches.   It occurs too infrequently to capture.

We now have a solution.   I have attached an AliveCor ECG monitor to my iPhone 6.   The next time I have symptoms, I’ll just hold my phone and capture a perfect Lead I ECG.    From my phone, I can send it after capture to my PCP and the BIDMC electrophysiology expert for review.    It will be reassuring to know that I do not have episodic atrial fibrillation or an unstable ventricular tachycardia.

The cost of this technology is $70 dollars.

Although my body mass index has been constant at 22 for the past 15 years and my caffeine free, low sodium, vegan diet has kept me healthy, my genome is finally catching up to me and I’m starting to experience the essential hypertension (systolic of 140-150) that has been present in generations of both sides of my family.    Diet, exercise, blood pressure monitoring, vitamin D (may be helpful), and salt restriction are reasonable first approaches.   If they fail, then thiazide diuretics, calcium channel blockers or ace inhibitors are the next step, presuming there is no underlying root cause to treat.

As part of my initial assessment, I’m using a Withings Wireless blood pressure monitor with my iPhone 6.

I’m taking readings when I first wake up, before/after the Massachusetts Turnpike commute, at the end of the business day, and before bed.

Thus far, I’m seeing normal blood pressures on weekends after a day of farm work.  I’m seeing 140-150’s after the commute.   In case you’re not familiar with driving in Boston, it looks like this 

After a 12 hour day of meetings, I’ve seen a few spikes to 160, then a return to 130’s by bed time.

All of my measurements are uploaded automatically to the BIDMC electronic health record from my phone within 1 second.

The cost of this level of monitoring is $120.00

I also use a Withings Pulse to monitor my steps/elevation/distance/calories burned/pulse/pulse ox and a Withings Smart Body Analyzer to track my weight/body mass index.

All of this data is displayed with a variance analysis on my phone.

I’m not endorsing these products and have no financial relationship with either AliveCor or Withings.   I’m simply describing my experience that an iPhone 6 can become a middleware hub for healthcare information, enabling me to be the steward of my own data and share it with a healthcare system/provider at minimal cost.

The devices are easy to use and there is end to end data integrity from point of origin (the measurement) to point of use (the doctor).  

It’s clear to me that patient wellness (rather than treating sickness) will require more objective and subjective (pain score, mobility, mood) data than we gather today.   EHRs are not yet optimized for incorporating these novel data sources, but the Care Management Medical Record used for team-based coordination of life time care, must leverage the power of new healthcare enabled mobile devices.

Thursday, July 16, 2015

Unity Farm Journal - Second Week of July 2015

Living on the farm means that every day is an adventure.   As Forrest Gump said, “you never know what you’re going to get”.

Last Thursday evening, at midnight, the Great Pyrenees began to bark with a cadence and volume that indicated a serious problem.   The llama began to trumpet.   The guinea fowl began to "buckwheat" inside their coop.    The ducks and geese quacked and honked.

I grabbed a flashlight and ran out to the barnyard.   A pack of 12 coyotes was circling the alpaca paddock, howling at the top of their lungs.  There were old, adolescent and young coyotes all making menacing movements toward the alpaca.

The coyotes and I have a tenuous relationship.    Like other predators, I know they are the top of food chain and play a valuable role in the ecosystem.   I’m a vegan and do not want to kill/injure any living thing.

When a single coyote appears in the barnyard I chase it away (or the guineas gang up on it).    With a pack of 12, I was a little less sure of myself.    I immediately began yelling at the top of my lungs I broke a few thick branches across a tree trunk, making a very loud noise.     I do not own a firearm (although Kathy and I are licensed to do so), and recognized my options to defend the animals were limited.

I threw rocks at the trees/bushes in their general direction, further creating noise.  They backed off.

Did I know what I was doing?  No?  Was it the right thing?  Per WikiHow, I did everything right when encountering a coyote pack.

The coyotes have not returned and all the animals are safe.

Keeping predators away was important this week since we released our eight week old chickens into the barn yard to free range.   We released

3 Buff orpingtons
6 Barred rocks
2 Andalusian blues
2 Ameraucana
2 Cuckoo marans
2 Golden laced wyandottes

that we had been raising in our mini-coops from 1 day old chicks.

They are running all over the property (including a rest on the air conditioners) and each night have come safely home to the coop.

With the mini-coops empty, we moved the last of our baby chicks (Ameraucanas) to the mini-coops and we moved 7 pheasants to the chicken pen, where they will mature until they are 16 weeks old and we can release them to the forest.

The geese continue to patrol the property and act like watchdogs.  This week they learned to swim but they still aren’t sure what to do with running water (streams are scary)

The bees continue to make honey, capturing the last of the summer nectar from the wildflowers around the farm, including this grove of mint.

We’ve completed the picking of our strawberries raspberries, gooseberries, and early blueberries for the season.   The mid-blueberries should be picking next week and the late blueberries in August.

Our coursework at Umass is going well.  I’m learning a great deal about the role of temperature, humidity, ethylene, O2/CO2, and physical handling of vegetables post harvard.

As Kathy and I think about our strategic plan for the year, we’ve both agreed that we must be careful not to produce too much of any one commodity and find that farm life has become a burden instead of a joy.   We’re working on refining our daily routines, automating processes, reorganizing workflows, and thinking about the right tools that will simplify our tasks.    At the moment, I’m adding a 16 cubic foot trailer to the barnyard so that we can more easily haul manure to windrows in the orchard instead of composting thousands of pounds of manure for months then moving it in mass.   I’m considering another hoop house just to keep the farm equipment organized and out of the elements.  I’m refining the layout of the barnyard.  

Just as a hospital would re-engineer its business using toyota production techniques (LEAN, six sigma etc), we’re doing the same.   Who would have thought that engineering ideas would be so useful in an agricultural setting!

Wednesday, July 15, 2015

Trajectory not Position

In my various state, federal, and international roles I interact with a large number of policy makers from the executive and legislative branches of government.  I testify to them, write policy papers, and call their support staff frequently.

At the moment in our society,  there tends to be a general proclivity to be a criticizer rather than a doer, to tear down rather than build up, and to have hearings instead of taking individual action.

Everyone talks about what has not been done instead of examining the progress made.

A great deal of leadership time is spent defending the actions of the past, making promises for the future and filling the present with powerpoint instead of programming.

How do we break this cycle of negativity?

My view is that we must believe in incremental progress, communicate broadly, and focus on our trajectory not our position.

What do I mean?

Ten years ago when I chaired the Health Information Technology Standards Panel (HITSP), the debate focused on such topics as

Is your XML better than my XML? (CCD versus CCR)
Is your HL7 2.x implementation guide better than mine?
Should LOINC coding of labs be required?
Can clinicians code problem lists using SNOMED-CT?
Are electronic public health submissions even possible?

In 2015, none of these items are debated.  The dialog has shifted beyond controlled vocabularies to such topics as building trust fabrics across organizations, refining transition of care standards and embracing new architectures based on FHIR/OAuth/REST.

John Kotter taught us that all change requires a sense of urgency.   I agree that there is an urgency to improve healthcare IT usability, workflow, and functionality.    

However, there is no need to panic.     We are in the biplane era of healthcare IT.    Flying cars are better than biplanes but that does not imply we can widely deploy flying cars without inventing jet aircraft first.    There are logical steps from our current state to our future state.

When I testify, I listen intently to questions and commentary.    Often there is limited domain understanding of the nature of healthcare data, existing regulatory requirements, and clinical workflow.    Rarely is technology the rate limiting step to innovation - the challenges are policy, psychology, and culture.

At age 53,  my personal medical data is electronic.   That was not true when I was 43.

At age 22, my daughter has never encountered a paper based record as an adult.   She has always had access to 100% of her healthcare data on her iPhone.  That was certainly not the case for me.

Since 1996, our ability to respect patient privacy preferences has improved immensely.   See this twenty year review of HIPAA that illustrates how far we’ve come.

Some people call me overly optimistic.   I tell people I am even tempered and predictable.   I will neither over promise future progress nor use hyperbole to over simplify the complexity of the process issues involved in IT transformation.

I  look at the experience of three generations of my family.  The trajectory of IT over the past 10 years has been overwhelmingly positive.    The next 10 years will continue to improve data liquidity, patient access, and usability.

Let’s all be doers.    Our position will be imperfect because there will always be room for improvement.   However, looking back after years of effort I can say that our trajectory vanquished many IT dragons along the way.

Thursday, July 9, 2015

Unity Farm Journal - First Week of July 2015

It’s a week for strategic planning.   Just as I wrote a basic draft framework for  FY16 BIDMC information systems, I’ve written a draft plan for the next year at Unity Farm.

Here’s our best thinking as of July 2015:

Unity Farm was founded on a few basic principles

1.  A complete environment that challenges us mentally and physically
2.  A nurturing place for animals and plants
3.  A place that enables us to pursue a life focused on sustainability
4.  A place to reduce and optimize belongings
5.  A place for generations to gather

It is meant to be a labor of love, not a profit center or large supplier of any one commodity.   It will be diverse, experimental, and manageable without requiring a permanent staff.

The Living Things

Alpaca/Llama - we have the barn facilities for housing no more than 14 camelids i.e. 5 male alpaca, 8 female alpaca, and 1 llama.   Our breeding program will be limited to keeping the herd vital.  We will not breed camelids for sale.

Dogs - the Great Pyrenees dogs are our companions and have successfully kept predator losses to a minimum.    Recognizing that their lifespan may not exceed 10 years, we’ll have to plan for replacement/possible overlap of young/old but will only keep two dogs at steady state.   We will not breed dogs for sale.

Cats - the cats keep our indoor rodent population under control and provide a vibrant presence inside the house.

Ducks - we have the facilities for housing no more than 12 water birds.   They provide eggs, fertilizer, and insect/slug control.   We will not breed ducks for sale.

Geese - we have the facilities for housing no more than 12 water birds.   They eat weeds and guard the barnyard against predators.    We will not breed geese for sale.

Chickens - we have the facilities for housing no more than 100 land birds.   They provide eggs, fertilizer, and insect control.   We will not breed chickens for sale

Guinea Fowl -  we have the facilities for housing no more than 100 land birds.  They provide tick control and guard the barnyard against predators.    We will only sell guinea fowl when the population exceeds 60 birds.

Pheasants - we have a property size that can accommodate 6 pheasants.   They will be released at maturity and propagate in the forest as nature allows.

Bees - we have the nectar sources that can accommodate 12 hives.   We will maintain 22 hives by keeping bees at multiple local properties.

Pigs -  We have space for 2 pigs.  Pigs can efficiently process our fruit waste/pomace, vegetable waste, and edibles that would otherwise be composted.   We will not breed pigs for sale.   They would be companion animals.

Others - we will not add sheep, goats, horses, donkeys, or cows to Unity Farm.

The Products

Vegetables - We’ll grow four seasons of vegetables in the hoop house for Unity farm friends/family and creatures.  We will not sell fresh vegetables.

Orchard - We’ll grow apples, stone fruits and berries for Unity farm friends/family.  We will sell not run a U-pick.

Mushrooms - We’ll grow Shitake, Agaricus, Winecap, Nameko, Oyster, Lion’s Mane, and Ganoderma for Unity farm friends/family.  We will sell Shitake.

Cider and beer - We’ll make hard cider and beer for Unity farm friends/family.  We will sell cider.

Honey - We’ll make honey and wax products for Unity farm friends/family.  We will sell honey and wax.

Mead - We’ll make mead for Unity farm friends/family.  We will sell mead.

Eggs - We’ll have eggs for Unity farm friends/family and sell eggs.

Fiber - We’ll harvest fiber yearly and sell yarn.

Permaculture - We’ll experiment with paw-paw, ginseng, and other produce to determine what works in our environment.

Goals for next year

1.  Coursework in the UMass Sustainable Food and Farming Certificate Program
2.  Raise 21 young chickens, 3 geese and 6 pheasants
3.  Try permaculture experiments  (paw paw, ginseng, rice, sun choke)
4.  Refine cider, mead and beer recipes
5.  Raise our young alpaca
6.  Build up our 22 hives for winter
7.  Evaluate the best use of our remaining barnyard space - build a pig enclosure or an equipment barn
8.  Grow vegetables, fruits, and mushrooms
9.  Process our alpaca fiber
10.  Maintain woodland and trails

Wednesday, July 8, 2015

Creating the FY16 BIDMC IS Strategic Plan

I recently wrote about the process of setting FY16 Clinical Information System Priorities for the next year.   That project is proceeding well and in parallel I’ve created my own contribution.   I do not want to  influence the stakeholder consensus at all, but members of the IS Governance committee asked for my opinion.

Here’s my thinking:


Each year, BIDMC Information Systems works with business owners to support BIDMC annual goals with information technology tactics.  This ensures that the mission of BIDMC is supported by suitable operational tools.   From 2012-2015, all hospitals in the US were compelled to focus their attention on Meaningful Use, ICD-10, the HIPAA Omnibus Rule, and the Affordable Care Act.  Since those projects are nearly completed, it is important for BIDMC stakeholders to enumerate the new technology priorities which will best support their activities in the coming year.

In the past, input of all stakeholders was gathered and assembled into a plan.   Given the increasing complexity of quality, safety, and regulatory demands shaping the behavior of hospitals and professionals, it is important that a standard framework with benchmarking and gap analysis be used in strategic planning, adding maturity and formality to the process.

The Framework

Specific industry frameworks exist today that apply to the different divisions of information systems.   For security, BIDMC has chosen the NIST 800 framework to support yearly security audits, gap analyses and strategic planning.   For clinical functionality, the Health Information Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM) provides industry standard, frequently updated benchmarks.   For infrastructure, the Information Technology Infrastructure Library, is a set of practices for IT service management.   For financial systems (enterprise resource planning and revenue cycle), best practices are documented by industry analyst firms such as Gartner as well as software vendors.

The Process

For FY16, we convened stakeholders in June and July to examine the current state of BIDMC applications and infrastructure using the appropriate framework tool for each domain.    In August, we will document the gaps and clustered projects into 15 specific areas for action.

My input

1.  Continue to self build the core inpatient, outpatient and ED systems of BIDMC for at least 5 years until the market for cloud hosted, mobile friendly, population health focused commercial EHRs matures.  Today at BIDMC, inpatient clinical documentation is a hybrid model of paper and electronic documentation.   This includes nursing. notes,  vital signs/flowsheets, and care plans.   It also includes physician daily progress notes, operative notes, history & physicals, consult notes and discharge summaries.   In FY16 we will implement structured and unstructured clinical documentation for these functions  to 50% of the ward beds.   We will complete the rollout in FY17.

2.  Today, the owned BIDMC community hospitals use 3 different installations of Meditech with different configurations.   We will migrate all owned BIDMC community hospitals to a cloud hosted version of Meditech with a single record per patient, implementing in FY16 for a go live in FY17.

3.  Today,  BIDMC community ambulatory practices use multiple different medical record systems.   We will migrate BIDMC community ambulatory practices to the smallest reasonable number of ambulatory solutions in FY16 and FY17.

4.  Today, BIDMC uses an older PACS system that no longer meets business needs.  We will replace our PACS FY16 and FY17.

5.  Today, the laboratory instruments at BIDMC are approaching end of life.   We will focus on lab analyzer replacement in FY16

6.  Today, there are gaps in interoperability among the owned and non-owned affiliates.   We will continue our phased implementation of interoperability, ensuring every affiliate has the appropriate data sharing (push, pull, view) necessary for the level of clinical integration required in FY16 and FY17.   We will also share email directories in FY16.

7.  Today, patient generated healthcare data is manually entered in applications and websites.  We will better engage patients and families using mobile technologies and automated data capture including the BIDMC@Home app in FY16 and FY17.

8.  Today, interaction among staff is limited to email, windows file sharing, and the web portal.  We will enhance staff communication using internally hosted social media technologies including secure texting, groupware collaboration, and cloud-based file sharing in FY16 and FY17.

9.  Today, we have largely remediated our applications for ICD-10 in anticipation of an October 1, 2015 go live.  In FY16 we will support the ICD-10 go live and ongoing optimization

10. Today we have attested to Meaningful Use Stage 2, but will have to attest again in FY16 and FY17.  We will not focus on Meaningful Use Stage 3 until its requirements are clarified in a final rule.

11. Today, we have a robust security program with 14 work streams.   We will continue to follow the NIST 800 framework and respond to emerging new security threats in FY16 and FY17.

12. Today, we submit our ambulatory and hospital data to the Massachusetts eHealth Collaborative Quality Data Center for computation of pay for performance, accountable care, and benchmarking measures.   We will continue to support this process for emerging new measures.

13. Today, we run an older version of Peoplesoft.   We will upgrade to the most current version and attempt to retire as many third party add ins/customizations as possible in FY16 and FY17.

14. Today, our owned community hospitals support their own networks, active directory and email.   We will consolidate networks, active directory, and email with BIDMC in a phased, incremental manner that takes into account budgets, competing priorities, and business cases.

15. We will continue to refine our disaster recovery capabilities using a combination of public cloud, private cloud, and multi-data center redundancy.

Thursday, July 2, 2015

Unity Farm Journal - Fifth Week of June 2015

I sometimes joke with my daughter that I finished 25th grade, doing 2 bachelor’s degrees, 2 masters degrees, an MD, and a fellowship.   As a Harvard Professor, you’d think I would be done with sitting on the student side of the room.

Last year Kathy and I completed Bee-school (not Harvard, Wharton or Sloan B-school) at the Norfolk Agricultural School

For the next year, we’re enrolled in the 15 credit UMass Sustainable Food and Farming Certificate Program, an online/evening curriculum.    The core course is  Organic Vegetable Production (3 units).   We’ll also be taking Backyard Homesteading (3 units), Introduction to Permaculture  (3 units), Farm planning, marketing, and management (3 units) and Post Harvest Handling  (3 units).

Life is about continuous learning and with each passing year we are polishing our  life skills.

We can now make near perfect hard cider, mead, and honey lager.

We can raise numerous mushroom species from spore to farmer’s market.

We can keep 100 animals happy and healthy, protected from predators while free ranging over 15 acres.

However, we still have much to learn about packaging, preserving, and marketing farm goods.  I look forward to the year of classwork ahead.   We'll fill the time previously allocated to House of Cards and Game of Thrones.

The Summer continues to be a busy time on the farm with planting, harvesting, and maintenance activities still continuing at full tilt.

We’ve planted more peppers, eggplant and tomatoes.   We’re harvesting peas, carrots, strawberries, raspberries, and blueberries this week.   We’ll plant daikon radish, standard radish, chard, lettuce, and spinach this weekend for early Fall harvesting.

We kegged our honey lager this week and racked our mead.    Honey production is ramping up and we extracted 25 pounds of honey over the weekend.   If we’re lucky, we could bottle 500 pounds of honey this year.  Each 10 gallon batch of mead takes 35 pounds.   We age our mead for a year, so watch for it on the Unity Farm Store website next year.   Next week we’ll brew a summer wheat beer.

We dried 100 pounds of  fresh Shitakes (which became 20 pounds of dried mushrooms).  Not only does drying preserve the mushrooms for several years, it concentrates the flavor.  A rehydrated dried mushroom makes better mushroom soup than a fresh one.

Our new baby alpaca continues to thrive.    Mom is very protective and hums whenever he leaves the barn to play with the other alpaca.

This week, we’ll set the geese free to  range in the forest.   They are now fully feathered, nearly full grown, and have acclimated to the idea that the duck pen is home.

We’ve decided, based on the advice of experts, to free range the pheasants in the Fall, once they are older and stronger.

We continue to harvest guinea eggs from all over the property, hopefully reducing the fecundity of our growing guinea population.

I’ve trimmed and re-cut all our trails.  The burst of summer growth, especially vines, has narrowed all our paths.   They’re now back to their original 6 foot wide design.

And yes, on July 4 we’ve committed to sitting under the pergola, sipping a honey lager, and watching the clouds roll by.   As Kathy says, if there is a time when we sit down, we’ll be sure to memorialize it with a picture!

Wednesday, July 1, 2015

Managing Up

I took my first job at age 13, building model planes and skateboards at Palos Verdes Hobby Shop. Over the past 40 years, I’ve reported to over a dozen people.   Some were inspirational and charismatic.   Others were more task delegation oriented.   Some were problem solvers.  Others shunned detail.    Some were great listeners.   Others were talkers.

Every leader is different and working for them requires an understanding of their preferences.   Although I’ve never “managed up”, I have adapted to the needs of the various people I’ve worked for.

Here’s my advice on thriving in complex hierarchical organizations.

1.   Assess your peers and your superiors frequently.   Imagine yourself on a balcony watching the people in your organization as if you were watching a play.   Understand the self interest of each character.   Just as personalities would be described in a work of fiction, you’ll see the self-interested careerist, the  servant leader, the manipulator, the fair weather friend, and the person you’d want in your foxhole during battle.  

2.  When you run a meeting, play to the characteristics of each person you have assessed.   If someone does not like details, do not ask them to be on a task force to write the plan, ask them to serve on the steering committee to approve the plan.  If someone wants to avoid blame at all cost, shield them from any direct responsibility for the project.   If someone needs credit to reinforce their ego, give credit liberally.   Keep in mind - “Success has many fathers, failure is an orphan” and “It is amazing what you can accomplish if you do not care who gets the credit.”

3.  Determine the information flow needs of your superior.   Does the person want a detailed progress report with an honest assessment of delays and goals not met?  Does the person want a single high level powerpoint slide with green, yellow, red?   Do they want any communication at all?   Will they offer to remove barriers/accelerate enablers, solving problems?   Will they shoot the messenger?   Based on the style of your superior you may produce an elegant project summary documenting progress or adopt a ‘don’t ask, don’t tell’ approach.

4.  CEOs last about 4 years.    This Harvard Business Review article describes the typical  pattern of a CEO transition.  If you find the leader of an organization hard to work for, you can leave, ignore the problem, or just wait them out.    Be careful of believing the grass is greener elsewhere.  As one wise person recently told me - “If you study the leadership of large, complex organizations you’ll find it’s the same clowns, different circus”

5.  Recognize that 10-20% of your work life will be spent on non-value added activities.   Your organization will likely have standing meetings that may not be relevant to your area, but your presence/visibility reinforces your place on the team.   Such meetings may feel like an interruption in your ability to do creative work, but maintaining a supportive environment for real achievement requires the buy in of your peers and superiors.   Convince yourself that investing 10-20% of your work time in the meetings required by your superiors will pay dividends over time.  And if you find a particular standing meeting to lack value, remember that with senior leadership turnover every 4-5 years, the meetings will change soon enough.

Life is short and none of us will have a gravestone that says “I managed up and lost 10-20% of my productivity”.   However, part of maturing as a leader is realizing that to accomplish the things you like, you have to actively manage the things you don’t like.    Managing up, adapting to your superiors and peers of the moment, is an advanced leadership skill.

Friday, June 26, 2015

Cool Technology of the Week Special Edition

BIDMC has 4 Apple Watches (the inexpensive Sport model) for development and evaluation.    Our programmers have 3 of them and I’m passing the 4th around to various folks including a 65 year old techie and a 22 year old digital native (my daughter Lara).    Here’s Lara’s review:

“As the Apple Watch arrives at retail stores, a lot of people will be asking 'How is it? Is it worth buying?' I think a question that needs to be asked first, however, is ‘What is it?’ The Apple Watch is not a new, independent Apple product. It is a watch that pairs with your iPhone and acts as a mirror of sorts, enabling you to access select apps and features from your phone.  It is not an independent product. I was certainly surprised by that!

Just as the iPhone functions very well as a phone, the watch also functions very well as a watch. The Sport Band is incredibly comfortable, and easily adjustable. It has a very clear, readable face with both digital and analog options, as well as a small selection of customizable watch faces. (Honestly, I hope they add more selection over time- its currently quite limited.) You can display a few other bits of information on the screen, such as the date, weather, and other time zones. The customizability here is definitely a highlight, and a feature that goes beyond a standard wristwatch.

But let’s be honest here- nobody cares much about the iPhone’s phone capabilities. They care about the apps. I imagine the Apple Watch will be viewed in the same way. ‘What nifty non-watch things can I do on my Apple Watch?’  Well, this is where the product falls slightly short at the moment. The Apple Watch is an interface for some select apps, but with less features than that of the iPhone. You can read your texts and emails, but you cannot write them (Unless you do so through dictation, but talking to your wrist in public does not look as cool as it does in the movies, trust me.) You can activate the camera on your phone with it, but it doesn’t have a camera of its own. (Funny story- I thought the camera was on the watch itself, and took plenty of lovely pictures of the wall while trying to figure out what was going on.)

On the flip side, some apps are designed very well for the watch. The health app in particular does a great job of utilizing what the watch has to offer. I was especially fond of the little notification it gives you when you’ve been sitting down for over 50 minutes. It’s a perfect reminder for when I lose track of time on my computer. I’ve also found some nifty vocabulary and kanji flashcards that have helped me with my Japanese studies. I’m sure that over time, more apps will be released that are compatible with and suited to the Apple Watch, and I’m looking forward to trying them out.

On a final note, for anyone worried about the battery life- the first time you use it, while setting up the watch itself, the battery drains quickly. Every time after that, it will last you the entire day. Have the charger set up on your bedside and you’re good to go.

So, is the Apple Watch worth the price tag? Well, that depends on what you’re looking for. If you’re looking to replace your iPhone, then no. But if you’re looking for a very high quality watch with limited iPhone features and app use, then yes. I love my watch for what it is- a watch with some perks. "

Thursday, June 25, 2015

Unity Farm Journal - Fourth Week of June 2015

We brought our alpaca mom and new baby, Daisy and Danny, home after a brief thunderstorm cleared.   Nature concluded what we’ve always known - Unity Farm is the end of the rainbow.

Mom and baby are healthy, happy and content.   Daisy has become an overprotective mom and Danny eats vigorously every hour.   We’ve kept them in a shaded pen to give them quiet recovery time from the trauma of being driven to a hospital and kept away from the farm for 4 days.    Danny’s IgG is nearly 1700, which means he has a fully intact immune system.  He’s gained a few pounds and is a non-stop bundle of energy.

What a great outcome.

We moved the geese outdoors into the duck pen.   The geese are happy but the ducks are not sure.    They tend to hide inside the duck house.   We’ll keep the geese in the pen for a few days so that they recognize it as home before letting them free range.   We’ve had a female coyote visiting a few times a day this week, so we want to be conservative on releasing new animals to free range.

We moved 17 chicks into our mini-coops inside the main coop.   We added buff orpingtons, barred rocks, cuckoo marans, americaunas, and andalusians    In another 6 weeks, they’ll also free range.

The mead is nearly fully fermented.   It started with a specific gravity of 1.100 and now is at 1.010.   We expect about 14% alcohol.   I’ll age it for one year before bottling.

The bees continue to gather nectar from the acres of summer wildflowers growing in the orchard.    The hives are so large and healthy that Kathy needs a ladder to maintain them.  So far, no swarms from the Unity Farm hives!

We are harvesting strawberries, peas, cucumbers, broccoli, and chard this week.   The garlic harvest is approaching and many of our tomatoes are large and plump.

Inspired by our bounty of tomatoes, mushrooms, fresh basil, and more garlic than we can consume, I’m convinced my next project should be building a wood-fired pizza oven.   I have to do something with the extra cords of wood we store for winter every year - why not whole wheat thin crust!

This weekend will be filled with trimming and trail maintenance tasks now that the burst of Summer growth has turned our orchard and trails into a wilderness.    Some weekends are animal focused and some are plant focused.    Not a single weekend goes by without a new adventure.

Wednesday, June 24, 2015

The June 2015 HIT Standards Committee

The June 2015 HIT Standards Committee focused on celebrating the accomplishments of those individuals who have reached their federal advisory committee term limits.  Most served 6 years:

Dixie Baker
Anne Castro
Marty Harris
David McCallie
Stan Huff
Liz Johnson
John Derr
Sharon Terry
Jon Perlin
Jeremy Delinsky

Karen DeSalvo thanked each one and I offered comments about their unique contributions, changing the fundamental trajectory of standards in the US from a 1990’s “EDI” payload model to a 2015 “Facebook” Application Program Interface model.   Their leadership has brought modern, open web standards to the healthcare domain, specified controlled vocabularies, and established appropriate security. They will be missed.

Next, John Feikema and Dragon Bashyam presented a summary of the Data Access Framework project.   We thanked them for the foundational work that has been incorporated into the private sector Argonaut project.

Chris Muir provided an Interoperability Standards Advisory Update and described the process by which a task force will refine the FY16 sub regulatory guidance.   While regulation generally includes only mature standards, sub regulatory guidance can enumerate emerging standards that are likely to become mature.

The next portion of the meeting focused on the  final recommendations of the committee for the standards to include in regulation and those to specifically exclude from regulation.

We highlighted the measures of maturity that Dixie Baker outlined in her paper about standards readiness.

We emphasized that standards require a business case, policy enablers, and supporting infrastructure.  As David McCallie wrote, Standards Alone are not the Answer for Interoperability.

In that spirit, Rich Elmore presented the recommendations from the Content Standards Workgroup

Mitra Rocca presented the recommendations of the Semantic Standards Workgroup
David McCallie and Arien Malec presented the recommendations of the Architecture, Services, and APIs Workgroup

Liz Johnson and Cris Ross presented the recommendations of the Implementation, Certification, and Testing Workgroup 

The themes included:

*CCDA is mature but needs to significantly constrained
*FHIR is nearly ready for widespread use and should be highlighted as directional
*Quality standards such as HQMF and QRDA will be refined in their next version
*Many standards are just not ready for regulatory or sub regulatory recommendation including HPD+ (provider directory), eSMD (electronic submission of medical documentation), DS4P (data segmentation for privacy), and HeD (Healthy Decisions)
*Providing a laundry list of immature standards is not going to accelerate interoperability

After the meeting I spoke with several members about writing a journal article that will summarize the lessons we’ve learned providing standards advice for the Obama administration.  The most significant point is that interoperability doesn’t happen when standards are named.   Interoperability happens when there is a business case, trust between two parties, and governance over the process.    It generally takes a few years to achieve all the enablers  and there is no magic standard that will make the cultural and policy changes needed to accelerate information flow.

Monday, June 22, 2015

Driving Miss Daisy

It’s been a long weekend.   Here’s the story of the birth of our new Alpaca, Dandelion Wine (Danny)

On Thursday at 12:03pm, Kathy texted me the picture below and the message “HELP!”   Mom had delivered the long legs of a new baby.   I rushed back to the farm and by the time I arrived, baby and placenta had been successfully delivered by Daisy Mae, with Kathy’s help.     The newborn weighed 18 pounds.    Typical for an alpaca is 10-17 pounds.   Since Daisy Mae is a small alpaca (140 pounds), the birth was very difficult.    You can see how big he is - my daughter is 5 foot 5 inches and she is holding him shortly after birth.

I examined Daisy and she had no tears or bleeding.  However, she was very tired and rejected the baby’s attempts to nurse.   Alpaca babies generally start nursing within 90 minutes and have about 24 hours to consume colostrum - the early mother’s milk that provides them with an immune system.  If they do not eat, they have no immune system and can easily die of infection.  

We gently haltered Daisy Mae and held her while encouraging Danny to eat.   Mom and baby just could not collaborate.   We tried restraining Daisy.   No luck.   We had to initiate bottle feeding to keep Danny hydrated.   We put him in a cria coat (a down jacket for baby alpaca) for the night since mom was not keeping him warm.      However, the rest of the herd protected him.

All day Friday we tried keeping them together and encouraging bonding.   It did not work.  As the window closed for colostrum transfer, we had to proceed to plan B - transfusion with alpaca plasma to provide the IgG he needed to fight off infection.    We drove him to Tufts large animal hospital in Grafton, MA.   They infused plasma and his IgG counts rose slowly.   He did not develop a fever and his white count was normal.

While Danny was being treated, we also had to treat Daisy - she was not nursing and she was at risk for mastitis.   We had to massage her teets every two hours to express milk and reduce the risk of infection.    She became more agitated with every treatment.   Clearly she was not dealing with motherhood very well, which is typical for first time alpaca moms.

Transfusions continued for Danny on Saturday and counts were rising but slower than expected, although he looked clinically well.  Thus, we had two patients, a young patient with IgG counts rising slowly and a mom increasingly agitated.   Saturday was frustrating.

We made a decision that we had to bring them together so that as his counts became normal, he could be re-introduced to her and she could be sedated if necessary so that nursing could proceed.   It’s typical for horses that a few hours of sedation can lead to a successful mother-baby feeding/bonding experience.    We lifted all 140 pounds of Daisy into the Ford Transit truck and drove her to the Tufts facility.   We checked her in, and spent an hour with Danny.  Clearly he missed his herd.

Mother and baby were re-united on Sunday night.    Danny was joyful, Daisy was skeptical.   She was mildly sedated and he began to feed.  By late Sunday night, Daisy was mothering him without sedation.

If all goes well, Danny’s transfusions will be done today and Daisy will be a fully functional mother.     If we’re lucky, tonight we’ll put them both in the van and bring them back to Unity Farm.

Such is the life of a farmer - you never know what the future will bring.

Thursday, June 18, 2015

It's a Boy!

Born at 12:25pm at Unity Farm today

Unity Farm Journal - Third Week of June 2015

Last week’s 3 inches of rain yielded this week’s 50 pounds of Shitake.   Here’s a few photos of the massive mushroom harvest.

The winecaps, agaricus, and wild mushrooms in our forest are also fruiting abundantly.   Our permaculture efforts, including the recently planted paw-paw trees, are fully leafed out      We’ve not yet seen much activity in our ginseng beds.   I have a feeling that the deer and wild turkeys are eating them.

Now that all our ciders are fully mature, Kathy and I did a tasting of 7 different five gallon batches.   All were technically perfect and had no off flavors.   We are now able to focus our future efforts based on the aroma, complexity, and mouth feel we can achieve using different combinations of sweet, tart, aromatic, and astringent apples.

   Sweet - Golden, Gala
   Tart - McIntosh, Rhode Island Greening, Gravenstein
   Aromatic -
   Astringent  -
   lightly carbonated, clean/dry, primarily tart character

   Sweet -  Honey Crisp
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, complex/complete/balanced, aromatic

   Sweet -  Baldwin
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, less complex

  10/25 *****The Winner
   Sweet -  Baldwin, Golden Delicious
   Tart - McIntosh
   Aromatic - Macoun
   Astringent - Crab
   moderately carbonated, clean/dry, complex/complete/balanced, aromatic

   Sweet -  Baldwin
   Tart -  Winesap
   Aromatic -
   Astringent - Crab
   moderately carbonated, clean/dry, more tart, less complex

   Sweet -  Baldwin
   Tart - Red Spy
   Aromatic - Macoun
   Astringent -  Russet
   moderatedly carbonated, clean/dry, rounded, buttery, very wine like

   Sweet -  Baldwin, Golden Delicious
   Tart -  Winesap, Cortland
   Aromatic -
   Astringent -
   moderatedly carbonated, clean/dry, lacks complexity

We also ordered another 4 kegs so that we can keep 8 different kinds of beverages on our tap system as part of our product development.   I’m adding a keg of honey lager next week and a keg of sparkling mead this Summer.

We’re still on cria  (baby alpaca) watch - Daisy Mae has not yet given birth, although it is clear she is near.  He’s a photo of Sunny, who is 1 year old this month.

We continue to raise our young Spring birds - chickens, geese, and pheasants.   At the moment, our bird count is

Ducks - 8
Chickens - 26
Geese - 3
Guinea Fowl - 65

Our goal is to keep the guinea fowl population from expanding.    We try to discover their hidden forest nests and gather their eggs on a daily basis.

The hives continue to grow and Kathy now has to use a step ladder to take off the honey supers.    We have 22 hives, 12 at Unity Farm and 10 at five distributed locations within a few miles.   Below is a photo of one of our queens - look at the center of the picture for the bee with the black thorax.

Our vegetables continue to be prolific and we’re harvesting 20 pounds per day for family, friends, and creatures.     The strawberries are ripe and I’m eating them for breakfast, lunch and dinner.    The monarch butterfly caterpillars are feasting on milkweed and the wild flowers are in bloom all over the pastures.   It's almost Summer.

Wednesday, June 17, 2015

Setting Clinical IT Priorities

In my previous writing, I’ve suggested that the federal government co-opted our Clinical IT agenda over the past three years with Meaningful Use Stage 2, ICD-10, the HIPAA Omnibus Rule, and the Affordable Care Act (ACA).

Now that Stage 2 attestation is done, ICD-10 is on a trajectory for October go live, OCR/OIG/internal security audit activities are done for the moment, and the care management medical record we need to support the Affordable Care Act is live, we can once again ask our customers to help set priorities.

Here’s the process we’re following:

In June, we’re convening a group of senior VPs, clinicians, and IT professionals to jointly review the current HIMSS Electronic Medical Record Adoption Model (EMRAM) Stage 7 criteria and benchmark ourselves.   It’s likely that we’ll amend the HIMSS criteria in a few areas where BIDMC considers itself a market leader - patient family engagement, mobile technologies, big data analytics, and cloud adoption.     We’ll then identify gaps in functionality/workflow to focus our strategic goals for FY16.

Once we have identified the goals, we’ll ensure we have the right organizational structure and staffing to accomplish those goals.    We’ll verify the operating and capital budgets required.    We’ll create Gantt charts and resource leveling artifacts to illustrate the relationship among the scope of projects, timing, and resources.

These artifacts will be used in FY16 by all our clinical governance bodies.    As new projects are mandated by government, mergers/acquisitions, or changes in local requirements, additions will be weighed against the scope, timelines, and resources already allocated.

I expect FY16 to be  focused on the clinical documentation needed to support ICD-10, quality measurement, and care coordination.

It will be interesting to see what  projects bubble up to the top and  to identify the gaps between the ideal state of an academic medical center and our current state.

I’m hopeful that the process will have such transparency and inclusiveness that it will be an effective means to align supply and demand in FY16, increasing customer satisfaction by documenting the prioritized goals and communicating the progress we’re making.

Thursday, June 11, 2015

Unity Farm Journal - Second Week of June 2015

It’s mid-June so the farm is filled with Summer greenery, rapidly growing fruits, new animal babies, a flurry of harvesting/planting activity, and beekeeping.

Here’s a view of chives near the hoop house, ready for harvest.  The orchard grass is growing so fast, we mow it weekly.

Our baby geese continue to feather out and in a few weeks we’ll add them to the barnyard.   We’re also raising baby pheasants per the picture below.   They are the size of ping pong balls and constantly bouncing around the brooder.   Our intent is to release them into the wild of our forests once they are mature enough to defend themselves.

We check on Daisy, our pregnant alpaca, multiple times per day.   She’s nearly at term and spends her time lying comfortably in the hay.   The baby is so large that I’m sure she’s anticipating the birth.

On Tuesday, all of the alpaca began alarming and Peter, who helps us when I’m out of town,  explored the cause of their concern.    On the lawn outside the paddock, a newborn fawn lay resting, temporarily abandoned by its mother.    Peter examined the fawn to ensure it was not sick/injured and then carefully placed it in the nearby forest.   Within the hour, mom returned and the unsteady fawn rambled along behind its mother.    Mother and baby are doing well, feeding on grass at the edge of the paddock.

All our 22 hives in 4 locations are doing well.   Kathy believes we’ll have significant honey production this year.   What to do with all that honey?

Our mead recipe calls for 22 pounds of honey in each 6 gallon batch.  Last Sunday’s batch is fermenting vigorously.

Our honey lager recipe calls for 10 pounds of honey in each 15 gallon batch.  This could become our Unity Farm signature beer.   I’ll keg it in 3 weeks and know for sure.

This weekend we’ll harvest snap peas,  shitake mushrooms, lettuce, and chard.   The tomatoes are doing well and a few cucumbers are nearly ready.    Kathy is attending a queen bee rearing class and I’ll do the usual weekend farm chores.   Maybe for the first time this year, I’ll sit down on Saturday afternoon and enjoy a glass of cider while overlooking the fruits of our labor.  Then again, there will always be something to do at Unity Farm.

Wednesday, June 10, 2015

Standards Alone are not the Answer for Interoperability

Today I have the honor of presenting a guest blog by David McCallie MD, SVP Medical Informatics, Cerner.   He summarizes the collective feeling of the industry about the trajectory of interoperability.

"I have been honored to have served on the HIT Standards Committee from its beginning in 2009. As I reach my term limits, I have reflected on what we have all learned over the past six years of helping to define the standards for the certified EHR technology that lies behind the Meaningful Use program.

But before diving into those reflections, we should acknowledge what we have accomplished.  It's fashionable to complain that we haven't 'solved interoperability.'  This is certainly true, but we have come a long way, and have achieved significant and lasting advances.

In particular, we have mostly settled the vocabulary questions for encoding the record.  We have widely deployed a good ePrescribing standard. We have established a standard for secure email that will eventually replace the fax machine, and we have widely (but not yet universally) deployed a good standard for document-centric query exchange.  We are close to broad support for a stable standard for encoding complex clinical data into summary documents.  And perhaps most interestingly, we have opened the door to the promising world of API-based interoperability.

Nonetheless, the refrain we hear from Capitol Hill is that we have failed to achieve the seamless interoperability that many had expected. This has lead to numerous legislative attempts to 'fix' the problem by re-thinking government approaches to the standard setting processes authorized by HITECH.

We should be careful not to overreact in light of any disappointments and perceived failures around interoperability.  There are many things we must improve, but we should not inadvertently take steps backwards.

I think the biggest mistake Congress appears to be legislating is to assume that standards alone are what creates interoperability.

Standards are necessary, but are not sufficient, for interoperability to occur.

Standards organizations (SDOs) can create standards, but they do not create the additional entities that are necessary for standards to deliver useful interoperability.

I believe that the sufficient conditions for interoperability include the following:

*A business process must exist for which standardization is needed. As Arien Malec put it recently, 'SDOs don't create standards de novo. They standardize working practices.'

*A proven standard then needs to be developed, via an iterative process that involves repeated real-world testing and validation.

*A group of healthcare entities must choose to deploy and use the standard, in service of some business purpose. The business purpose may include satisfying regulatory requirements, or meeting market pressures, or both.

*A 'network architecture' must be defined that provides for the identity, trust, and security frameworks necessary for data sharing in the complex world of healthcare.

*A 'business architecture' must exist that manages the contractual and legal arrangements necessary for healthcare data sharing to occur.

*A governance mechanism with sufficient authority over the participants must ensure that the network and business frameworks are followed.

*And almost no healthcare standard can be deployed in isolation, so all of the ancillary infrastructure (such as directory services, certificate authorities, and certification tests) must be organized and deployed in support of the standard.

The Jason Task Force (which I was privileged to co-chair with Micky Tripathi) summed up these requirements into what they called a 'Data Sharing Arrangement (DSA).' DSAs do not emerge from SDOs. DSAs cannot be simply created by legislative fiat.  They require the active engagement and collaboration of the many entities who are willing to do the hard work to create the necessary infrastructure for an interoperability standard to find real-world, widespread use.

We've learned that forcing providers to simply deploy standards and then to expect interoperability to happen is ineffective policy. The most rapid progress has happened when DSAs have emerged because provider organizations, Health IT developers and SDOs agree to work together to achieve a clear mission, focused on meaningful outcomes. Congress should accordingly define the 'what' and let the U.S. health care stakeholders define and achieve the 'how.'"

Thursday, June 4, 2015

Unity Farm Journal - First Week of June 2015

As I’ve written previously, running a farm is about life and death.   When you’re supporting over 100 creatures, every day is filled with unpredictable events.   This week, one of our chickens, Terra, developed “sour crop”.

We treated her by inducing vomiting, feeding her olive oil, offering apple cider vinegar in water, and isolating her from the other chickens.   Despite 2 days of treatment, she passed away.   She’s buried in our forest garden, near the Shinto shrine.

With the death of our rooster, Lucky, by coyote and Terra by infection, we’re down two Ameraucana chickens.

Kathy and I discussed our last three years of chicken raising and decided that we should supplement our flock.   This week we added 6 Barred Rock hens (1 week old) and 3 Buff Orpingtons (2 weeks old).    Although our Guinea Fowl have multiplied on their own (they lay 40 fertile eggs per day), we’ve not hatched our chicken eggs.    With 9 adult chickens and 9 new chicks, the population should be stable despite occasional losses.

We also had another thought.   Our guineas, Great Pyrenees and llamas sound an alarm when predators threaten.    However, one of the best watch dogs for the barnyard is a goose.   Here’s a photo of the 3 geese babies that recently joined the farm ecosystem.   In another 6-8 weeks, they’ll be added to our existing poultry flocks and begin defending them all.

Last week, the IEEE Spectrum published Kathy’s cancer story in the context of big data.   Here’s the article.   IEEE took a family portrait to illustrate Kathy and I in our natural state.

Daisy Mae, one of our alpaca, is nearing the 11th month of her pregnancy.   As alpaca approach delivery, they develop a condition that some call “alien butt” - the features of the soon to be born young alpaca appear on the rear of the mom.   I consider this a clinical photograph, educating the public about the appearance of a gravid alpaca.

Shiro, our 150 pound male Great Pyrenees,  is always looking for toys.   He figured out a way to bury his bowl in a hay bale.  Very artistic

This weekend will include mead making with 21 pounds of honey and harvesting mushrooms after the 3 inches of rain this week.    I’ve also signed up with a local brewer to create a honey lager next week - my honey, his hops.   Now that we’re a bonded winery from a federal and state perspective, the test batches of interesting beverages are beginning to multiply.

Wednesday, June 3, 2015

So What is Interoperability Anyway?

One of my most memorable experiences as an IT leader was working with with a dissatisfied customer.   I asked what requirements were unmet, what features were priorities, and what future state was desired.   The answer was “I’m not sure, but I know I’m not getting what I need”.

The use of the term interoperability is being tossed around in ways that makes it seem like the test for obscenity used by Supreme Court Justice Potter Stewart in 1964 when he wrote “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"], and perhaps I could never succeed in intelligibly doing so. But I know it when I see it…”

Congress is angry about the lack of interoperability.   What does that mean?

House and Senate stakeholders believe that vendors enjoyed a government funded windfall yet are building proprietary networks.   They have heard that vendors are blocking information sharing by charging significant interface fees and that HITECH distributed $30 billion with minimal requirements for information sharing. Many in the House feel after all this investment, the country is not prepared for new payment models.

Some in the House have stated that Americans can communicate because "we speak English" so interoperability is about picking a common language.

Senate HELP Committee Chairman Lamar Alexander plans to take up this issue, working closely with Ranking Member Senator Patty Murray through a bipartisan effort over the coming months. 

So what is the real issue causing providers anxiety and resulting in Congress wanting to take action?

Providers are fed up with interface fees and at how hard it is to accomplish the workflow required by Accountable Care business models including care management and population health. They are unsatisfied with the kind of summaries we’re exchanging today which are often lengthy, missing clinical narrative and hard to incorporate/reconcile with existing records.

All these things are true.

So what is our next step to help providers do their job and improve satisfaction to the point that Congress no longer wants to legislate the solution to the problem?

I think we all have to step back, carefully define the requirements for care coordination and care management in an ACO world and admit that the Meaningful Use regulations did not address those requirements.   We should allow the private sector initiatives already in progress (Argonaut, Commonwell, eHealthExchange) to address these market needs in collaboration with vendors, entrepreneurs, and innovators.   The economic incentives of the Affordable Care Act and the Sustainable Growth Rate fix will result in hospitals and professionals demanding different kinds of technology than was prescribed in regulation.

The role for Congress should be to hold us accountable for the outcomes we want to achieve.

At a recent AMIA presentation in Boston, Zak Kohane, Ken Mandl and I were asked to be provocative - to go rogue.

I suggested that the Meaningful Use program should be eliminated.    Yes, there should be Merit-based incentives for achieving stretch goals, but those can be created in another CMS program. Meaningful Use is no longer necessary.

ONC should focus on the 5 enablers I’ve written about

1.  Facilitating the creation of a national provider directory for message routing

2.   Encouraging the adoption of a voluntary national identifier for healthcare

3.  Providing guidance to streamline the heterogeneous patchwork of state privacy laws that are impeding information exchange

4.  Serve as the coordinating body for aligning federal government health IT priorities.

5.  Supporting private sector initiatives such as Argonaut that are simplifying the tools for health information exchange.

It's not a problem of "language".  We have the terminologies we need, already included in certified EHRs. We have standards for content and transport, again written into certification requirements. So what's the gap? We need to make the standards better, and build interoperability into EHR workflow. That doesn't require top down regulation, it takes the kind of  goal-oriented interaction between providers, developers, and standards bodies that characterizes efforts like the Argonaut Project.

No more regulation, no more legislation.   Those will only crush innovation.

Instead of saying we need interoperability, the conversation needs to include a crisp set of requirements for care management and care coordination with defined metrics of success, supported by government enablers, and accelerated with the economic incentives provided by new reimbursement models.

To paraphrase Justice Potter, if patients and providers are happier, I’ll know it when I see it.

Thursday, May 28, 2015

Unity Farm Journal- Fifth week of May 2015

Spring and Fall are very busy days on the farm.   With each passing day in May, you never know what new task will appear.

On Saturday, Kathy and I drove to Western Massachusetts near the border of Vermont and New York to pick up our Russian “nucs”, the mini-hives used to start a new hive.   Russian bees are challenging (I’m not making this up) since they tend to swarm and take over territory.  They are unpredictable and hard to control.    Thus, we created a site for them to take over, called a swarm trap.   We mounted a 10 frame deep hive with wax and lemon grass extract (a bee attractant) on one of our 8 foot fence posts.   If the bees swarm, they are likely to find this new home, making it easy to put the bees in a new hive.      Here's what a Russian nuc looks like.

The bees are busy gathering nectar from our 15 acres of wildflowers.    Here's a glimpse of the bees on wild honeysuckle.

This week one of our roosters, Lucky, disappeared.   He was a fierce defender of our hens.   I found a collection of his feathers in the deep forest, near coyote droppings.   He gave his life to protect his women.  Thanks Lucky.

Just as the West Coast has had water issues, the Spring in New England has been dry, windy, and problematic for growing crops.  We’ve had to use our stored water - the snow melt from this winter now in our local aquifer, to keep our orchard healthy.

The hoop house continues to burst with vegetables.   I harvest 25 pounds a day for humans and animals on the farm.

Our state Farmer-Winery license arrived this week, so now we’re a Federal bonded winery and licensed by the state to produce wines of all kinds including hard cider and mead.   Next weekend we’ll be making Spiced Orange Mead.   I sterilized all the equipment in the cider house in preparation for the fermentation to come.   You’ll see our beverages available for sale soon!

The dogs have been groomed and the alpaca sheared, so everyone looks picture perfect.   Here’s a random family portrait of the creatures gathered in the barn.

We're very close to all our creatures.    There's nothing like a roll in the hay with a Great Pyrenees.  I'm 6 foot 2.  Shiro is 6 foot 5 end to end.   Our weights are identical.

The weekend ahead includes mushroom inoculation, mead making, planting, harvesting, and mowing meadows.     It's joyful work!

Wednesday, May 27, 2015

Interoperability and the Trough of Disillusionment

Every technology has an adoption journey.     The classic Gartner hype curve travels from a Technology Trigger  to the Peak of Inflated Expectations followed by the Trough of Disillusionment. It often takes years before organizations reach the Slope of Enlightenment and finally achieve a Plateau of Productivity.

Have you noticed that Congress and the popular press have entered the Trough of Disillusionment for EHRs and interoperability over the past month?

Congressional staffers writing the 21st Century Cures bill (which is not yet law) seem to have concluded

1) we don¹t have interoperability (although no one is sure what exactly we have and do not have)
2) therefore we need more standards and that will solve all the business, political, and policy barriers to health information exchange
3) The Health IT Standards Committee must not be doing a good job because there are not enough standards
4) Therefore we should disband it and create a new politically appointed body
5) That new body will invent all the standards we need and then force vendors to stop their information blocking behavior (whatever that is), enabling precision medicine

USA Today, in one of the most one sided articles I’ve read, confuses ACA and HITECH, ignores the data about EHR adoption/health information exchange and concludes that EHRs “don’t talk to each other”, whatever that means.

It’s time to take a step back, define our requirements, examine our current state, and then focus on closing any gaps we find.

I oversee 5,000 patient data exchanges at BIDMC every day.   50,000 patients view/download/transmit their data every month.   We’re in beta testing with apps using Apple HealthKit, connecting home devices, iPhones and our EHR.     We have numerous affiliates with bidirectional data exchange.    There are few technology limitations.  The real challenges are political and policy barriers.

The Direct protocol, although more complex than the RESTful methods used by Facebook, Amazon and Google that we should embrace, has provided a foundation for health information exchange across the country.    Below is a snapshot of the current Massachusetts State HIE (the Mass HiWay) connections to Health Information Services Providers (HISPs), creating thousands of connections among hospitals and eligible professionals nationwide.   Every week, some new practice or hospital comes knocking at the BIDMC door and within hours we can create a connection.

Interoperability is real.  Interoperability has a very positive trajectory.   Saying otherwise is oversimplifying the reality of ongoing good work in progress.

When confronted by naysayers, we have only three choices

1.  Give up and declare defeat
2.  Get angry, frustrated, and flustered by the negativity
3.  Move forward with gusto, identifying gap after gap, then solving them.   We eat the elephant of interoperability one bite at a time.

Over the past week, I’ve found myself setting aside my emotions.   I’ve redoubled my commitment to doing the right thing, hiring great people and broadly communicating the change processes needed to ensure more data is exchanged with more people for more reasons, while still respecting patient privacy preferences.

I’ve thought long and hard about the day to day criticism we hear from government, special interests, and various press resources.  We have to avoid being distracted by the politics of any given moment.  In  a year and half the federal government will change completely .  Every major political leader in healthcare IT has changed since 2013.

If we stay above the fray, work on interoperability one practice and one institution at a time, and toil diligently to enable new infrastructure such as record locator services/provider directories/quality registries, we will create a learning healthcare system that is better with each passing year.

So next time you encounter the Trough of Disillusionment about interoperability, do your best to educate stakeholders about the trajectory we’re on and the challenges we can overcome by focusing and working together.

Maybe we can all stand on a hilltop and sing "I'd Like to Teach the World to Interoperate (In Perfect Harmony)" celebrating our progress to date and highlighting the work yet to be done?

Thursday, May 21, 2015

Unity Farm Journal - Fourth Week of May 2015

I’ve always thought that shearing transforms a fluffy overstuffed alpaca into a creature from a Dr. Suess book (the Lorax?).   Below are before and after shearing pictures of the alpaca herd.

In May the temperatures at Unity Farm have varied from a high of 90F to a low of 32F.   At 90F, a fully insulated alpaca will be heat stressed.   At 32F, a sheared alpaca will shiver.   It’s always challenging to pick the right date to shear.     Our timing this year has been positive - the sheared alpaca were cool on the hot days.   The low since shearing was 38F, but the alpaca warm up quickly after sunrise.

Kathy and I inoculated 500 pounds of oak logs with Ganoderma Lucidum mushrooms (Reishi, Lingzhi).   After 2 years in the forest, the logs should yield harvestable quantities which we’ll make available fresh and dried.

The apples, plums, cherries, peaches, pecans, and paw paw trees are now fully leaved out and covered with flowers.   The bees are rapidly filling their hives with pollen and nectar.

In May, the work of the farm is largely planting and bee maintenance   I’ve harvested our winter crops and have busily planted potatoes, squash, pumpkins, tomatoes, beans, and cucumbers.   The hoop house raised beds have all been refilled with fresh compost and we’ll have a new round of crops ready to harvest in 60 days.

Kathy continues to work with the bees every day, expanding their hives, inspecting them for disease, and ensuring they have everything they need for successful honey production.   We’re expecting to gather 100 pounds of honey this year, leaving 80% for the bees to overwinter.

One of our chickens, Terra, is moving sluggishly.   She’s three years old and had an orthopedic injury last year (chased into a fence by a predator).    At the moment, there are no signs of infection, so we’re keeping her warm, fed, and hydrated.   We’ll watch her closely.

One of our wood racks was knocked over, likely by a coyote chasing a guinea fowl.   I’ll restock the quarter cord this weekend.

Speaking of guinea fowl, although we are a vegan/vegetarian household and do not eat guineas, they are popular in other cultures.   Here’s a menu from my recent trip to Eastern Europe.  Check out the second main course.

This weekend I’ll continue planting, helping Kathy build bee equipment, and spend time with all the creatures of Unity Farm, basking in the perfect weather of Spring.