Friday, August 29, 2014

New CMS rule allows flexibility in certified EHR technology for 2014

Today is my one day of Summer vacation, enabled by the large number of people taking a long labor day weekend.

Some things are worth interrupting your vacation.

This afternoon, CMS published he long awaited final rule on Meaningful Use flexibility.

Here’s my interpretation.

Many CIOs tell me that they will be ready for transition of care and patient view/download/transmit for the full year October 1, 2014-September 30, 2015.   However, the ecosystem (trading partners, patient awareness, policy) is not ready for the period July 1, 2014-September 30, 2014.   Thus, the ONC final rule is a welcome relief.

I do have one concern - the rule notes that Stage 1 criteria can be used by those on Stage 2 timelines for

"Only providers who could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.”

Although certified products may have been introduced into the marketplace, the time to implement, train, and ensure safe use exceeded the Stage 2 time limits.

I hope ONC/CMS/HHS interpretation of delays includes the time needed for successful adoption.

Thursday, August 21, 2014

Unity Farm Journal - 4th week of August 2014

Over the past week, the combination of rain and cool Fall-like temperatures caused our 165 shitake logs to fruit, resulting in over 50 pounds of fresh mushrooms.   We inoculated 5 tons of oak logs last August and throughout the year have had a few pounds to deliver to local farm stands.   We really did not know if our work would be successful, since this is our first effort at growing mushrooms to commercial scale.   We’re guided by this excellent research paper which illustrates how a family can create a 500 log Shitake operation yielding $5000-$10000 in farm income per year.




Now that we know that the combination of our Unity Farm oak, local environment, weather, spawn, and techniques resulted in successful production, we’ll turn our attention to the marketing details - how to package/label them, how to deliver them to local customers, and how to price them.   This year, we’ll dry some and sell some fresh.   We’ve also contacted two local tree maintenance companies, agreeing to take delivery of any fallen/trimmed oak trees and branches to expand our operation.  

I moved the logs from the shade house where they had their spawn run to the laying yard in the forest where they’re leaned upright on wooden stands and are easier to pick.   Our mushroom farm is off and running!    The 100+ Oyster logs will start to fruit in late September and October, so Unity Farm might even become the site of a first in the country “Mushroom” Community Supported Agriculture (CSA) site.

Our apples and other fruit trees are nearly ready to pick.   Our heirloom cider apples will yield commercial quantities in a few years, but  this year we’ll have enough for early cider experiments.   The hard cider we made last year is now fully mature and I’m confident in my cider making skills and the process I’ve chosen which is very similar to making a full bodied Chardonnay.

The hoop house fall plantings have sprouted and we’re expecting to harvest greens, root vegetables, and broccoli through December.

Still no cria - Mint, our pregnant alpaca is enormous and clearly ready to deliver.  Maybe labor day weekend will finally bring labor and delivery.

This weekend includes herd health and all the usual medical care of our herds/flocks, preparing the bees for Fall (it’s nearly time to harvest honey), and some of the final trail maintenance before the leaves begin to drop.

I’m going to try to take off a long Labor Day weekend to enjoy the fruits of our labor - harvest time on the farm makes all the work of Summer worthwhile.

Wednesday, August 20, 2014

The August HIT Standards Committee

The August HIT Standards Committee focused on the work ahead to accelerate interoperability.   It’s no longer about Meaningful Use, it’s about Meaningful healthcare information exchange.  

I offered my opinion about the work ahead.  ONC is in the middle of regulation writing for Meaningful Use Stage 3, so the standards work of the next 10 weeks is not going to be incorporated into the NPRM.

Regulation is not the only way that health IT standards are defined, selected, or adopted by industry.
Learning from Stage 2, it’s critical that we decouple regulation writing from creating test procedures and scripts for certification.  I’m confident that our upcoming standards work will result in implementation guides and certification criteria outside the initial NPRM process.   Also, it’s important to remember that the NPRM is a proposal.   If the final rule needs to incorporate the standards work of the next few months, HITSC can recommend specific standards in its formal review of the NPRM.

All of the presentations at the August meeting explored different aspects of interoperability.

Jacob Reider offered opening remarks, reflecting on the timeline and staging of the work ahead, including the transition of workgroups to a new structure that will make us more agile

Steve Posnack presented an update specifically focusing on the new Standards Implementation and Testing Environment that enables robust testing of interoperability including CCDA, QRDA, Provider Directory and Transport (Direct) standards.

Erica Galvez, ONC Interoperability Portfolio Manager, described the interoperability portfolio and timeline for ONC work including the building blocks of the ONC 10 year vision:
1. Core technical standards and functions
2. Certification to support adoption and optimization of health IT products and
services
3. Privacy and security protections for health information
4. Supportive business, clinical, cultural, and regulatory environments
5. Rules of engagement and governance

Vaishali Patel presented a data update on interoperability, highlighting growth in exchange capability and activity.  Interoperability measurement will be a key focus going forward.

Finally, Liz Johnson presented the Implementation Workgroup review of the CCDA, identifying issues such as heterogeneity of CCDAs from different vendors, excessive optionality, mixture of structure/unstructured data, challenges with usability, and a need to evolve to something simpler such as FHIR.    The Standards Committee approved a resolution for the Steering Committee to assemble experts and recommend CCDA improvements or its replacement.

With every Standards Committee meeting we're getting closer to creating a national "Automated Teller Machine" for healthcare.    CCDA and Direct with a few supporting standards such as provenance, provider directory, and query/response will get us started.    FHIR, REST and OAuth2 will take us to the finish line.


Friday, August 15, 2014

Thursday, August 14, 2014

Unity Farm Journal - Third Week of August 2014

As a doctor for over 20 years, I’ve learned how to treat critical healthcare issues.   As a father, son, and husband I’ve learned how to support my own family through injury, sickness, and death.

As a farmer responsible for over 100 animals, life and death are part of the daily experience.

Sunny, our baby alpaca, is now doing extremely well.   She did not successfully receive the immunoglobulin transfer that happens between mother and baby with consumption of colostrum, the first mother’s milk.   Her tests revealed she had an incomplete immune system and was unlikely to survive an infection.   She was not gaining weight and was at high risk for infant mortality.   A peritoneal infusion of alpaca plasma and daily bottle feedings have brought her back on track.   Her immune system is now fully complete and her weight is normal.   Today’s she’s running around the paddock and warming up in the sun on a cool Fall-like morning.   We’re still awaiting the arrival of our newest alpaca baby - should be any day now.


It’s natural to expect a fair amount of mortality in bird populations.   Chickens, ducks, and guineas lay so many eggs because few are expected to make it to adulthood.   A few of our guineas have died in the past few weeks.   The four guineas raised by ducks had a hard time socializing with the rest of the guinea flock - they tended to prefer the quiet of the forest (with the coyotes, fisher cats, foxes, raccoons, and hawks) to the bustle of the barnyard.   One of the “teens” (they are 10 weeks old) ran away from all other creatures deep into what we call “the forest of death”, the densest predator load on our property.  The guinea refused to come back to the safety of the coop.   It lasted 4 days and this week we found a large collection of feathers - an ex guinea.    Another teen would not flock with the group for protection and wandered around the barnyard in solitude.   On Sunday afternoon, a large hawk spotted the unprotected guinea and grabbed it, carrying it to the orchard behind our property, proudly announcing its new meal with a shrill scream tseeeeeeaarr.   The two remaining teens (below) have socialized with the group and spend part of their day in the coop for protection.   The still have a preference for the ducks however (below).   With all the eggs from nests in the forest hatching, we're up to 75 guineas today.



It’s time for Fall planting in the hoop house.  Every night I harvest a bushel or two of vegetables and as the beds empty from our Spring planting, Fall planting follows.   Below is a map of the 15 raised beds in the hoop house and the crop rotation schedule from Spring to Fall.  I have a large selection of seeds from the Kitazawa Seed Company that will give us a continuous supply of Japanese vegetables through the Fall and early Winter.

Left
1 Tomatoes -> Winter density lettuce  (Agaricus mushrooms in compost)
2 Parsley -> Green spray mibuna/Garland chrysanthemum greens
3 Long Beans/Peppers ->  Green towers lettuce
4 Kale -> Tokinashi daikon/Hakurei turnip
5 Cucumbers -> Brussels sprouts/Beets
6 Cucumbers -> Broccoli
7 Tomatoes -> Vit mache

Right
1  Chard-> Solar yellow/New kuroda carrot
2  Carrots -> Kintsai celery/Upland cress/Mitsuba parsley
3  Chard-> Kyoto red/Cosmic purple carrot
4  Zucchini -> Dwarf pak choi/Purple choi  (Agaricus mushrooms in compost)
5  Kabocha ->  Bloomsdale spinach
6  Peppers ->  Rainbow chard
7  Eggplant/Tomatillo/Poha ->  Rouge D’Hiver lettuce
8  Cauliflower/Leeks -> Wasabini mustard/Early mibuna




We’ve prepped the bees for Fall by treating for Varroa mites with formic acid strips.   We'll treat for Nosema in September with Fumagillin B.    Reducing the mite count, preventing nosema infection and ensuring ample honey stores are our best protection for the winter when the bees have to cluster inside the hive for 4-6 months.

Finally, we continue to prepare the trails and forest for the upcoming stormy weather of Fall and Winter.   Recently two trees fell (an oak and a maple) during a thunderstorm and I immediately bucked them up into 4 foot logs perfectly for mushroom cultivation.   This weekend we'll be inoculating the oak with Shitake spawn and chipping the maple for Wine Cap cultivation.    The weekend ahead is filled with Fall planting, mulch hauling, and animal care.    And we'll hope the new alpaca is born!


Wednesday, August 13, 2014

The Meaningful Use Stage 2 Finish Line

Hospitals across the country have until September 30 to complete their 2014 reporting period for Meaningful Use Stage 2.

Recently Ashish Jha and Julia Adler-Milstein published important articles in Health Affairs about the current state of EHRs  and Health Information Exchange .  What can we learn about the status of Meaningful Use Stage 2 across the country?

The trajectory is very positive but the position is less than perfect.    Hospitals are struggling with patient view/download/transmit and provider/provider transition of care summaries.   Eligible professionals, often with limited resources, are implementing Stage 2 certified software less rapidly than hoped.  

As Beth Israel Deaconess completes it’s 2014 reporting period, we’re very close, approaching the finish line.

We’ve certified all our self built systems for both inpatient and ambulatory 2014 criteria.

We’ve outsourced the Meaningful Use quality measure computations to the Massachusetts eHealth Collaborative.

Last week we completed a milestone, using our self built iPhone/iPad-based electronic medication record (EMAR) to administer the one millionth medication dose since go live.  Our 10th inpatient unit is now live with 100% of doses bar coded.   The Emergency Department goes live in early September.

The patient View/Download/Transmit function is undergoing broad rollout and we’re on target to surpass the 5% Meaningful Use transaction volume requirement.   Although many hospitals have been challenged to get patients signed up for a personal health record, resorting to registering them during the discharge process, BIDMC has been using a patient/doctor shared medical record since 1999, so we already have the patients enrolled.

Transitions of care, with a 10% transaction volume requirement, is our final hurdle.  Although BIDMC has been sending clinical transactions for years, the number of trading partners capable of receiving Meaningful Use Stage 2 is limited, especially smaller clinician offices.

Below is a timeline for integration of various vendors and health information service providers (HISPs) into the Massachusetts HIE.


Luckily, one of our major referral partners, Atrius Healthcare, represents over 10% of our discharges.   Their Epic system is already connected to the HIE and is in the final stages of testing.   Later this month, we should be able to pass the 10% threshold.   However, it’s not entirely under our control since the transitions of care requirement depends upon an ecosystem of connectedness that is still evolving.   On some days it feels that we have the only fax machine in town and thus it’s hard to fax.

Over the next few weeks, we’ll complete an external  review of our readiness as well as an updated security audit.    And just in case, we’re all awaiting word on the NPRM offering possible flexibility for Stage 2 attestation requirements for 2014.

Thursday, August 7, 2014

Unity Farm Journal - First Week of August 2014

We continue to be on cria watch, as our last pregnant alpaca, Mint, waddles around the paddock.   The alpaca gestation period is 11.5 months and Mint is just about there.

Just as 17 keets (baby guineas) appeared from the forest last week, 10 appeared this week.   One of the teenage keets that was raised by ducks disappeared into the forest and likely was eaten by a coyote.    That means our current guinea inventory is

27 adults
3 keets born June 9 - will be released to the barnyard on August 17
9 keets born on July 4 - will be released to the barnyard on September 12
17 keets born on July 27 will be released to the barnyard at October 5
10 keets born on August 4 will be released to the barnyard on October 12

giving us a total of 66 at the farm.   We can overwinter about 40, so we’ll be placing 26 to other farms before the snow falls.

If you are in the New England area and are interested in Guinea Fowl (great tick hunters), let me know.

We continue to harvest cucumbers, tomatoes, squash, eggplant, and peppers from the hoop house.   Our homemade cider vinegar is the base for our fermented dill pickles, our refrigerator sweet pickles, and our even our homemade ketchup.

The mushrooms are fruiting the warmth and moisture of summer rains.   Here’s a typical day’s picking of Shitake from the shade house.   We delivered these to 3 local farm stands.


The Terex front loader is back from repair and the hydraulic fluid leak is fixed.  I was able to move 120 cubic feet of chips to trails, and 60 cubic feet of manure to our windrows.    It’s great to have the right tools available again.

The bees continue to build out their honey stores and each of the 12 hives has a healthy queen, a high population of workers, and plenty of local pollen sources.  Here’s a view of the bee yard after a recent hive inspection.



This weekend may include the birth of a new alpaca and we’ll continue all our forest/trail maintenance while the weather is good in preparation for the winter weather that is just around the corner.