Building Unity Farm - Adopting Alpaca

Memorial Day weekend was a busy time at Unity Farm - spending time with our newly adopted alpaca, doing woodland/forestry management, and inoculating mushroom logs.

How did we adopt new alpaca?

In an unusual chain of events,  a leading alpaca breeder in Maine was the former editor of a healthcare IT magazine and knows me well.   When she heard about a family in Massachusetts trying to place their three alpaca, she recommended Kathy and me as caring adoptive parents.

We gently loaded the alpaca into a transport vehicle and drove them 20 miles from their current home to their new home at Unity Farm.

Since we're introducing new animals to an existing herd, we decided to quarantine them for 4 weeks in our pasture, away from the other alpaca.    

We drove the vehicle into our pasture, closed the gate, and let the alpaca step out on their own.   The picture above shows our newly adopted alpaca - Juniper (dark brown), an 8 year old female; Mint (white), her 2 year old daughter;  and Tahoe (light brown), an 8 year old gelded male.

They have their own loafing shed, hay supply, minerals, grain bowls, and half an acre of orchard grass to munch.  

Our traveling large animal vet will visit them on June 5.  We'll update all their inoculations, do fecal samples for parasites, and begin injections of ivermectin as a preventive treatment for meningeal worm.

Since we had a 3 day weekend, we also aggressively worked on woodland management.   Now that the orchard has opened up the lower 5 acres of the property, I began hauling fallen trees to the woodcutting area and wood chip grinding area.

Saturday was devoted to clearing an old hickory tree that blew down in hurricane Sandy.  Hickory is the finest firewood available - easy to split, yields high heat, and burns cleanly.     I added half a cord of split hickory to our 5 cords of firewood storage.

Sunday was devoted to ash.  Over the past few years a virus killed many old ash trees and the emerald ash borer caused dieback of ash trees in New England.   Some of those trees have fallen and some are still standing, likely to fall in the next big storm.  I began the process of clearing ash and moving it to the woodcutting area for splitting.  Ash does not require aging and can be burned immediately.   We lit a roaring fire of freshly cut ash wood on Sunday night since the temperatures on the farm dropped into the 30's.

Monday was devoted to poplar.   Many of the poplars on the farm are 65 feet tall and are approaching an age when they are likely to fall in a storm.   Poplar is poor firewood and we generally chip it for use on our trails.    On Monday, I was spreading mulch on the Orchard trail, a winding path between the orchard and our stream.   I stopped for a moment to check email and received an important budget to review.   I walked to the house to view the spreadsheet on a larger screen.   While sitting at my computer, I heard a loud explosion from the lower portion of the property.   Everyone on the farm ran to discover the source of the disturbance.  What we saw made us turn pale.   A 5 ton poplar had fallen on the exact spot I was standing while spreading mulch.   It crushed a portion of the orchard fence and ripped down the gate, 50 feet away.    Can an email save your life?  On Memorial Day, an email saved mine.    It's hard to imagine an obituary that reads "John was standing in the forest when a 10,000 pound poplar spontaneously fell on top of him."    

My wife gave me a large chainsaw for our 28th anniversary last year (the traditional gift), so we had the tools necessary to carefully cut up the 18 inch diameter trunk into 200 pound chunks which we carried to our grinding area.   We temporarily stabilized the fence (two posts were broken and one crossbeam was smashed.    At the moment, the orchard is still deer proof while we await permanent repair.

Finally,  Kathy and I finished our first 110 Shitake mushroom logs - 5000 holes, 30 pounds of mushroom spawn, and 10 pounds of cheese wax to seal the holes.     We can process about 300 pounds of oak per hour, which we did in the late afternoon on Saturday, Sunday, and Monday.     Now that the first 11 oak stacks are completed, each with a different sub-species of Shitake, we'll work on expanding the size of the stacks so that by the end  of June we'll have completed 220 logs - a total of 15,000 pounds of wood.

Luckily, next weekend we'll be moving our daughter into her own apartment at Tufts University.   After our farm workouts, hauling furniture should be easy!

Clinical IT Governance Update

Yesterday I led the Clinical IT Governance meeting at BIDMC and I thought it would be interesting for my readers to get an inside look of the kind of topics we're discussing and how we're implementing our most challenging projects.

1.  Joint Commission debrief
Last week the Joint Commission visited BIDMC and the experience was very positive.  When there are process variations and potential shortcomings identified by the Joint Commission, IT solutions are often suggested.   In this particular visit, there were a few small software changes made during the visit to better support National Patient Safety goals such  as ensuring all care team members know the preferred oral and written language preferences of each patient.   We made modifications to ensure all our sites of care - ED, inpatient, outpatient, OR, and ICU gather this information consistently and display it routinely.   That was the only issue involving IT in this Joint Commission visit.

One of the great challenges of IT governance is maintaining focus on the annual operating plan and avoiding the distraction of the day.   Audits, visiting committees, and even Joint Commission visits have the potential of creating attention deficits which derail IT staff from long term must do's.    I'm grateful that Joint Commission preparation has become such an integrated part of our standard work that no projects were derailed.

2.  Enterprise and Community interoperability
I'm often asked when interoperability will become a standard practice in communities.   In many Massachusetts institutions, data exchange is already happening and the state HIE is processing over a million transactions a month.   However, there are still gaps in offering hospital-based clinicians access to the EHRs of private practice referring physicians.   I outlined the work we're doing this Summer to ensure that opt-in consent to disclose is captured at referring clinician practices as this will enable us to complete the electronic linkage which provides 24x7x365 on demand data sharing.

3.  Annual Operating Plan update
IT has 5 goals in 2013 and I reviewed our progress on all of them
Meaningful Use Stage 2 - we have achieved all MU2 hospital requirements except Electronic Medication Administration Records/Bedside Medication Verification.   Our new EMAR/BMV application goes live in July and we are on track to have 10% of all medication orders processed through it for the October-December Meaningful Use reporting period.

ICD10 - our greatest challenges are clinical documentation improvement such that enough information is available to justify highly detailed ICD10 codes and outpatient coding strategies so that we do not need paper-based superbills hundreds of pages long for every clinic.   We're working with 2 established companies and one start up to create novel computer assisted coding workflows and real time documentation improvement, linking the act of documenting to the requirements for accurate billing in a single workflow.

Laboratory Information System - we go live with the pathology module in our new Laboratory Information System on August 2.  Integrated testing is going well.

ACO support - we've worked hard to generate all the data necessary for our ACO to produce the quality and financial performance reports required by CMS.   We finished our first year as an ACO with a positive margin.  

Compliance/Security - I presented the project plans for 14 work streams of security enhancements suggested by our recent security audit.   Improvements include network access control, security information and event management applications, and a comprehensive NIST 800 ongoing risk management program.

4.  Conversation Ready Project - As part of  the Joint Commission visit, we showed the reviewers screenshots for a new end of life preference documentation application we're building.   Our feeling is that structured data and metadata around end of life planning is not sufficient.   We need documents which reflect a deep conversation about preferences, so that it what we are creating.   Documents may be handwritten, faxed, typed, or natively electronic, so we need to support multiple document capture workflows.

5.  Patient and Family Engagement in ICUs Grant - We collaborating with a major private foundation to think about patient and family engagement in ICUs.   The Clinical IT Governance committee needed to understand the level of work and its alignment with our strategic plan, meaningful use, and compliance requirements.    I always discuss grant opportunities  with governance committees, because sometimes grants are not well aligned with existing work and become a costly distraction.    The committee asked many good questions about this grant opportunity and we're now poised to refine the workplan with the foundation leaders.

A very productive meeting.

HISP to HISP communications

As Massachusetts works through the details of building a trust fabric for health information exchange, we have been working through another set of challenges in HISP to HISP communication.

Meaningful use Stage 2 requires EHRs to support the Direct Project implementation guide, which uses SMTP/SMIME as a transport protocol.   Optionally, Stage 2 also supports XDR/SOAP.

In the world of standards, "OR" always means  "AND" for implementers.   Massachusetts needs to support HISPs that allow XDR as well as those which only allow with SMTP/SMIME.   This gets confusing when there is a mismatch between the sender's protocol and the receiver's protocol, requiring a HISP to convert XDR to SMTP/SMIME or SMTP/SMIME to XDR.

There are 4 basic scenarios to think through
1. An SMTP/SMIME sender to an SMTP/SMIME receiver
2. An SMTP/SMIME sender to an XDR receiver
3. An XDR sender to an SMTP/SMIME receiver
4. An XDR sender to an XDR receiver

Scenarios 1 and 4 could be done without a HISP at all if the EHR fully implements the Direct Standard including certificate discovery.

Cases 2 and 3 require thoughtful security planning to support end to end encryption between two HISPs.

These slides provide the detail of what must be done for Cases 2 and 3.  

The challenge of supporting XDR is that the HISP must act as the agent of senders and receivers, holding their private key for use in the conversion from/to SMTP/SMIME.

As Massachusetts continues to enhance its state HIE capabilities and connect many other HISPs (eClinicalWorks, Cerner, Surescripts, AthenaHealth etc) to state government users and those using the Massachusetts HISP as part of their EHR (Partners, BIDMC, Atrius, Tufts Medical Center, Meditech users, NextGen users etc.) we now know what must be done to provide end to end encryption among different HISPs and users connected via 2 protocol choices.

We're learning once again that optionality in standards seems like a good idea, but ultimately adds expense and complexity.
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Everyone on the HIT Standards Committee knows my bias - offer no optionality and replace the existing SMTP/SMIME and XDR approaches with RESTful APIs such as the Mitre hdata initiative.

Maybe for Stage 3!

Building Unity Farm - The Bees Arrive

On Saturday night 96,000 Italian bees arrived at Unity Farm in 8 hives.   What are Italian bees?   Here is an overview of bee types.
There are many subspecies of the honeybee, Apis mellifera.  Each has different characteristics in temperament, honey production, winter hardiness, swarming behavior, and disease resistance.    We chose Italians that had overwintered in Massachusetts for their lack of aggressiveness, consistent ability to produce honey, and their likelihood of reproducing sufficiently to sustain a stable population in our orchard and meadow.

Our Guinea fowl enjoy eating bees, so we created an elevated platform using oak pallets that ensures the hive entrances are higher than guinea mouth height.

To begin our bee journey, we placed 4 "nucs" or nucleus hives in the orchard and 4 nucs in the meadow near the stream.   A nuc is a fully functional starter hive consisting of a laying queen and bees on frames of brood, honey and pollen.  Soon these frames will be transferred to standard Langstroth hives which consist of combs hung in vertical sheets for easy honey harvesting and bee care.

At the moment, the bees are staying close the their hives, circling to get oriented to their new home.   They're very gentle and will land on me as I approach the hive.   I've not been stung and expect that we'll have a great long term symbiotic relationship.   The apple trees are in full bloom and pollen/nectar is plentiful in the orchard.   Similarly, wildflowers are abundant in the meadow, so all 8 hives are buzzing with food gathering activity.

During our first year as beekeepers, we'll be guided by Noah Wilson-Rich, Ph.D, a behavioral ecologist, a beekeeper, and the founder of Boston’s Best Bees.

In 2014, we'll evaluate our progress and think about adding bee care to our weekly farm tasks.

Some will debate if beekeeping is vegan.   Since no bees are harmed and the quality of life of the bee is not changed in any way by beekeeping, I believe it is consistent with vegan ideals.   The same cannot be said about the dairy industry or factory farmed chickens producing eggs.   Honey is not secreted by bees, it's the product of nectar mixed with bee digestive enzymes.

I look forward to our first honey harvest and comparing the characteristics of orchard honey to meadow honey.

Documenting End of Life Care Preferences

Following up on yesterday's post about ICU dashboards, I think it is equally important to document end of life care preferences in the electronic health record.   The HIT Standards Committee has been charged in 2013 with developing the standards for structured data capture of end of life care preferences.

At BIDMC, we've already designed an approach in conjunction with the Institute for Healthcare Improvement's Conversation Ready project.

Conversation Ready is a collaborative effort between the Institute for Healthcare Improvement (IHI) and a handful of "pioneer" institutions, of which BIDMC is one, to ensure that we're ready to 1. receive/elicit patients' goals of care or preferences, 2. record them in our systems, 3. retrieve them when needed, and thereby 4. do a better job respecting them.

As a healthcare system, the US is not currently very good at doing these things, and there is a strong push to get better. To that end, it is one of BIDMC's Annual Operating Goals to become Conversation Ready, and we have a large team working to do this, which includes: the Senior VP for Quality Improvement, the Director of Ethics and Palliative Care Programs the Medical Director of Inpatient Quality, the Director of Performance Assessment & Regulatory Compliance, the Director of Social Work and Patient/Family Engagement, Patient Advisors, Associate Chief Nursing Officer of Ambulatory & Emergency Services, a Palliative Care and HCA Primary Care Physician, and several IT professionals.

A BIDMC hospitalist is the project director, and a BIDMC communications manager serves as the project manager.  We've been meeting for about 5 months now, and in addition to the IT solutions presented in these slides, we're collecting stories and data to motivate conversations, as well as developing training modules, scripts and other materials to improve our ability have these conversations.

The slides reflect the team's preliminary vision of how to improve the way we record patients' wishes around end-of-life care and retrieve them when needed.  We believe that becoming "conversation ready" requires a centralized place to store this information which is accessible from all our clinical applications.  The slides also outline a system for managing PDFs of paper Advance Care Planning documents (e.g. Proxy forms, Advance Care Directives, letters to family members, DNR/MOLST forms) that would enable us to effectively store, update and retrieve them as needed, thus capturing all the work and time that were put into creating those documents and enhancing our ability to best respect our patients wishes.  Ultimately we hope that this Advance Care Planning data could become part of health information exchanges to ensure a shared mental model across care settings.

Reflecting on my father's recent experience with end of life care, such an approach would have ensured his wishes were widely understood and respected.

I look forward to the project.

Patient and Family Engagement in ICUs

My father died 2 months ago and now with a bit of distance from that emotional event, it's time to further reflect on technology to support patients and families in ICUs.

BIDMC has been speaking with a major foundation about creating a cross-disciplinary, multi-institutional, open source application to turn critical care data into wisdom for patients and families.

How might it work?  Let me use my father as an example.

My father had multiple sclerosis for 23 years, myelodysplastic syndrome for 2 years, and 3 myocardial infarctions since 2009.

When I arrived at his ICU bedside in early March, I spoke with all his clinicians to create a mental dashboard of his progress.   It looked something like this

Cardiac - history of 2 previous myocardial infarctions treated with 5 stents.   New myocardial infarction resulting in apical hypokinesis and an ejection fraction of 25%.   No further stent placement possible, maximal medical therapy already given.  

Pulmonary - New congestive heart failure post recent myocardial infarction treated with diuretics, nitroglycerine drip, afterload reduction, upright position, and maximal oxygenation via bilevel positive airway pressure.  O2 saturation in the 90s and falling despite maximal therapy (other than intubation)

Hematologic - failing bone marrow resulting in a white count of 1, a platelet count of 30, and a hematocrit of 20

Neurologic - significant increase in muscle spasticity, resulting in constant agitation.   Pain medication requirements escalating.  Consciousness fading.

Renal - Creatinine rising

Although I did not have realtime access to his records, I gathered enough data from my conversations to turn this dashboard into a scorecard green, yellow and red indicators.

Cardiac - Red due to irreversible low ejection fraction

Pulmonary - Red due to the combination of falling O2 saturation despite aggressive therapy

Hematologic - Red due to lack of treatment options available for myelodysplastic syndrome and an inability to transfuse given the low ejection fraction and congestive heart failure

Neurologic - Yellow due to the potential for successful symptom control with pain medications

Renal - Yellow due to treatment options available for renal failure

My father had expressed his wishes in a durable power of attorney for healthcare - do not intubate, do not resuscitate, no pressors,  no feeding tubes, and no heroic measures.

From the combination of the dashboard, scorecard, and his end of life wishes, it was clear that hospice was the best course of action.

I'm a physician with 20 years of practice experience.   I'm a CIO with 30 years of data analysis experience.   I'm a decision maker with 35 years leading teams.

Making the hospice decision required all of my skills.

Ideally, patients and families should have the tools  needed to make such decisions regardless of their medical sophistication.

Our proposed project is an automated ICU dashboard/scorecard for patients and families updated in realtime based on data aggegrated from the medical record and patient connected telemetry.    The architecture will be a decision support web service , Hospitals send data in and the web service returns the wisdom of a graphical display.

The project is ambitious and will bring together patients, providers, and IT experts.    We look forward to the challenge of creating a patient and family friendly dashboard for ICUs.    My healthcare navigator service to my father would have been empowered with such a resource.

Building Unity Farm - The Mushroom Farm Begins

Last weekend, my wife Kathy, Bill Gillis (CIO of the Beth Israel Deaconess Care Organization), and I completed 72 Oyster mushroom totems and 60 Shitake logs - about 10,000 pounds of wood requiring 3000 individual inoculations.

Here's how we did it.

I cut 72 two foot segments of poplar, 8 to 16 inches in diameter, from the trees we felled behind the house in the early spring when sap was flowing but leaves had not yet emerged.   This wood has the maximum amount of moisture possible.   Over the weekend, we cut each log into 2 one foot pieces plus a thin third piece.   I purchased 6 sub-species of oyster mushroom spawn.   First, we poured about a cup of spawn into the bottom of a thick black trash bag.  We placed the first log segment on top of the spawn.   We then added another cupful on top of that log and placed another log on top of it.  Finally we added another cupful and placed the thin third piece on top.   We closed the bag with a rubber band and stored each completed "totem" in the shade of a pine grove.    We inoculated 12 totems for each species.  The end result of 72 totems stacked in the forest is pictured below.

 After Labor Day we'll remove the bags and enable the inoculated logs to fruit.   We'll get some Oyster mushrooms this Fall, but the bulk of our first harvest will arrive next Spring.

For Shitake, I cut 220 four foot oak logs between 4 and 12 inches in diameter when clearing land for the orchard.   They were also harvested for maximum moisture.   I purchased 11 sub-species of shitake mushroom spawn.  Over the weekend we placed a log in the wheels of the assembly line we designed, drilled 12mm holes 1.5 inches deep every 6 inches along the log, and repeated the pattern every 2 inches around the circumference.

We used inoculator tubes to place spawn in each hole, then sealed it with cheese wax heated to 400 degrees F.   We carried the finished logs to the shade house (85% shade cloth) and stacked them lincoln log style.

We have room for 11 stacks of 20 logs.   We did 60 last weekend and will do another 60 this weekend.     By the time we're done, we'll have drilled and filled 10,550 holes.

Next Spring we'll move the logs from stacks to leaning upright in the forest.  Like the Oyster mushrooms we may get some fruiting this Fall but the bulk will be next Spring.

These logs will produce for years to come and our hope is to start a mushroom community supported agriculture program (CSA) once we've proven our ability to produce large quantities of high quality mushrooms.

Making progress.

Personal Health Record Use by Adolescents

In response to many questions about PHR use by adolescents, I asked Fabienne Bourgeois, the expert at Children's Hospital Boston, to write this guest blog post -

As more and more practices and hospitals are making patient portals available to their patients, providers of adolescent patients are encountering a major hurdle: how to handle confidential adolescent information.

While adult patients generally maintain full personal control of their personal health record (PHR), adolescent PHRs are anything but personal.  Adolescents rarely have full control of their record, but instead rely on parents and guardians to share control.  The details around this shared access changes over time, depending on developmental and age-appropriate considerations, as well as guardianship arrangements.  

The biggest challenge then, becomes how to protect the adolescent’s legal right to privacy and confidentiality within this hyprid/proxy-control model.  Many medical encounters with adolescents come with the verbal assurance that what they tell us will (under most circumstances) remain entirely confidential, meaning we will not discuss personal health information pertaining to reproductive health, sexually transmitted diseases, substance abuse and mental health with their parents or anyone else without their consent.   As it turns out, this type of confidential information is pervasive through most EHRs.

We've spent a lot of time thinking about this issue and adolescent access to our patient portal, and ultimately developed a custom built solution to meet our and our patients’ needs.

Our approach is built around differential access to the patient portal with the goal of mirroring current clinical practice and works as follows:

Access to the patient portal: Separate accounts are created for the patient and parent(s) that are linked. The parent has sole access to the patient's portal until the patient turns 13, at which point both the parent and the patient can have access.  We chose 13 years as our cut off based on a number of factors, including developmental maturity and other precedents at our institution based on their policies.  At 18 years, the patient becomes the sole owner of the portal account, and we deactivate the parent's link (unless we receive court documents stating that the parent remains the medical guardian).

Health information contained in the patient portal: We have identified and tagged certain information from our EHR that we consider sensitive, such as labs related to pregnancy, sexually transmitted illnesses, genetic results, select confidential appointments, and potentially sensitive problems and medications. This information is currently filtered from both parent and adolescent accounts, but in the near future the sensitive information will flow to the adolescent account, but not to the parent account. So, even if a patient is less than 13 years, the parent would not have access to this information.
This solution does take a lot of time and effort, but best replicates the current clinical practice. Many other current PHR structures do not allow for this type of differential access and only enable full proxy access.

Alternative solutions include the following:
1.    Shared access for patient and parent, but filtering of sensitive information. One could then choose the age at which patients would gain access without worrying about the parent seeing sensitive information at any age. This makes the age at which the patient obtains access, whether it is 10 or 13 years, less important. Unfortunately, this option restricts adolescent access to confidential information and creates a fragmented and incomplete record.

2.       Adolescent access only. This is trickier, because choosing the appropriate age when parental access is discontinued is difficult and may vary depending on patient characteristics.  Many practices choose 12 or 13 years. However, if sensitive information is not being filtered, you may very well have the occasional 11 year old with an STI. Also, some parents object to being cut off from their child's medical information and many play an important role in supporting their adolescent children and guiding them through healthcare decisions.

The issues and solutions involved with adolescent PHRs are certainly complex and will continue to evolve over time. However, I am hopeful that PHRs will start incorporating the unique needs of the adolescent population in the near future, allowing both parents and adolescents to share responsibility and engage in their healthcare.

For additional information, see this publication

Bourgeois FC,  Taylor PL, Emans  SJ, Nigrin DJ, Mandl KD. Whose personal control? Creating Private, Personally Controlled Health Records for Pediatric and Adolescent Patients  J. Am. Med. Inform. Assoc. 2008;15(6):737-743

Building a Trust Fabric in Massachusetts

Yesterday, several Massachusetts HIE stakeholders discussed how best to create a trust fabric among the array of vendors, organizations, and regional subnetworks that will exchange transfer of care summaries using the Meaningful Use Stage 2 standards.    Here's the presentation we used to facilitate our discussion.

Initially our state HIE, the MassHIWay, presumed it would be the certificate authority/registration authority for all state stakeholders, creating a trust fabric through a single set of processes and agreements.    As often occurs in life, theory and the practice differ.  

eClinicalWorks users are likely to use the eCW HISP to send and receive transactions from/to their EHRs, using SMTP/SMIME to connect to users of the MassHIWay.

Cerner users are likely to use Cerner's HISP are in the same way.

Epic users may use Surescripts' HISP similarly.

Meditech users will connect directly to the state's HISP via SOAP (XDR).

How do we knit together all of the HISPs into a trust fabric that authenticates our users, authorizes access for appropriate clinicians, and minimizes privacy risks?

It's clear that we must embrace technology and policies which enable HISP to HISP communications, not just a single HISP and certificate authority.

From a technology perspective there are a few options:
 - Use DirectTrust.org certificate bundles backed by processes that enable organizations to trust a common entity and thus transitively trust each other.
 - Create a Massachusetts specific process to trust the root certificates of each HISP that connects to the MassHIWay
 - Ask each provider in the state to sign a MassHIWay participant agreement regardless of the HISP they use, ensuring common policy and legal protections are in place.

We did not answer all these questions yesterday and we've assigned workgroups to finalize the policy and technology details.  We did accept the fact that there will be several HISPs connecting providers, payers, and patients in Massachusetts.  We'll need to trust other HISPs that have registration and certificate authority processes in place to identity proof/authenticate their senders and receivers.   The reality of Meaningful Use Stage 2 certified software is that sometimes the connections will be with the EHR directly, sometimes through the EHR vendor's cloud, and sometimes through third parties.  

Just as the internet itself is ultimately a network of networks, so will be healthcare information exchange in Massachusetts, the US, and the world.

2013 is the year we'll address the policy and technology barriers that have historically slowed adoption of large scale HIE.

Building Unity Farm - Shearing the Alpaca

Last weekend we sheared the alpacas and llama.  As Unity Farm works to become a self sustaining agricultural entity,   we plan to sell natural colored alpaca yarn and hand made raw fiber cat toys this Summer.

Above, you'll find the before and after photos.    Our enormous and fluffy animals now look like creatures from a Dr. Seuss book.

Here's how the day went.

We sheared from 12:30pm-9:30pm, with a few small breaks.  We spent about an hour per animal to gently cut each animal's fiber into a single large "blanket".  We also trimmed nails and did a thorough job cleaning and trimming the teeth.

We used a commercial blow dryer to clean their fiber before trimming, once for each side of the animal.

The animals were handled respectfully and were very cooperative (they look completely content in the paddocks this morning)

This was our first shearing experience, so there were many lessons learned that will make next year faster and easier.   My blog will never be a commercial site, but later this year I will post links to the Unity Farm products that we'll be offering - berries, apples/cider, shitake mushrooms, oyster mushrooms, alpaca yarn, eggs, and honey.

The May Massachusetts HIT Council Meeting

Just as the national HIT Standards Committee meets every month and I record its deliberations on my blog, the Massachusetts HIT Council, a governance body for healthcare IT activities in the Commonwealth, meets monthly.   The Council is a multi-stakeholder body including public and private sector participants from every aspects of the healthcare system.

We met on Monday to review progress on State HIE implementation.   Here are the presentation materials.

In May, Tufts Medical Center will go live with transfer of care summaries sent to payers in support of disease management programs.

BIDMC will go live with immunization and reportable lab submissions to the Department of Public Health.   Also in May, BIDMC will go live with sending 4000 care summaries each day to our quality registry provider, the Massachusetts eHealth collaborative.

Holyoke Medical Center will go live with transfer of care summary transmission to its community providers in May.

27 implementation grants to stakeholders through the commonwealth have been awarded to accelerate connectivity to the state HIE backbone.

Meaningful Use Stage 2 and ACO formation have created a business case for data sharing and we'll see accelerating adoption over the next few months.

Lastly, Medicaid approved the funding for the second phase of the HIE - the community wide master patient index, record locator service and consent registry.   We'll have these built by the end of 2013.

It's an exciting time in Massachusetts - HIE has finally achieved the level of policy and technology maturity we've been anticipating for the past decade.

A Bold New Vision for Meditech

I have no financial relationships with any EHR vendor, but feel a great affinity for the vendors in Massachusetts - eClinicalWorks, AthenaHealth and Meditech.

For the past few years, I've suggested to Meditech that cloud hosted, standards-based, web-centric and mobile enabled hospital information systems would be very welcome by the marketplace.

The industry has had a mixed reaction to Meditech version 6, a proprietary, non-standard, non-web, non-cloud, non-mobile, client/server application that requires complete hardware and software replacement when upgrading from version 5.

I spent last Monday afternoon at Meditech and can tell you that they have listened to industry feedback (and my obsessive focus on web-based applications).

The  Meditech senior team demonstrated version 6.1, a cloud hosted, standards-based, web-centric, mobile enabled, ambulatory and inpatient, analytics backed, personal health record enabled, and care managed focused application that will be shipping in 2014.

What did I see?

A new ambulatory EHR written from scratch to work on iPads supporting a voice-based or typed workflow.   Some vendors have created two applications often with different copies of the data- one for the desktop and one for mobile devices.  Meditech has wisely optimized the 6.1 EHR application for multiple devices using the same architecture from the same database.   LSS, the previous ambulatory application, will be replaced by the new application that includes very friendly medication management, clinical documentation, and order entry tools.

A new Meaningful Use Stage 2 compliant Hospital Information System that is available anywhere without Meditech specific client software.   The Direct protocol for interoperability is fully enabled.

A new PHR written from scratch designed for mobile devices and including many advanced wellness/preventative care features.

A new analytics platform that includes self service data mining tools

A new "post EHR" application that synthesizes the lifetime experience of the patient and enables non-physician care managers to ensure patients are receiving  optimized care per protocols.

Everything was demonstrated via an iPad.

They are also working on applications to support anesthesia, ICUs, and infection surveillance.  My only advice to them was to create  a few full featured, highly usable products rather than try to launch an entire suite of products simultaneously that lack comprehensive functionality.   The 6.0 product was a complete re-platforming for Meditech which resulted in some upgraded products not having all the features of their 5.x predecessors.

In the past two years, Epic has gained a very large share of the hospital IT marketplace.    Since competition is a good thing for the industry, I'm hopeful that Meditech 6.1 will be very attractive to hospitals which want to implement a modern platform at an attractive price.

Meditech's new vision is bold and in my opinion, right on track.

I'm eagerly awaiting the production delivery of 6.1.

Building Unity Farm - The Orchard is Born

When Kathy and I began looking at farmland, we developed a set of requirements (and a project plan) for selection of a property that would nurture us into retirement and beyond.

After reading many books about sustainability and farming, we decided that 15 acres was more in line with our goals than 150 or 1500.   Our plan was to work the land on our own, not involve a staff of farm hands.  

We wanted a diverse ecosystem and not just a flat empty fields.   The ideal property would include pasture for animals, woodland for fuel, marsh/stream/vernal ponds for wildlife habitat, wildflowers/grasses for pollinators, and space for an orchard/hoop house/berry patch.

As of today, Unity Farm has come very close to that goal.

We now have 15 acres divided into
 5 acres of dry woodland (oak, maple, ash, hickory, cedar, poplar, elm, pine)
 2 acres of orchard/hoop house/berry patch
 2 acres of marsh/stream/vernal ponds
 1 acre for house, shed, roads, and lawn
 1 acre of pasture (orchard grass/timothy hay)
 1 acre of meadow (wildflowers/grasses)
 2 acres of barnyard (barn, paddocks, poultry coop)
 1 acre of work areas for wood processing, composting, and mushroom farming

The orchard, pictured above, now contains 30 fruit/nut trees, 180 blueberry bushes, 30 raspberry bushes, and a foundation for the 21' x 50' foot hoop house we'll build later this Summer, all surrounded by an 8 foot deer fence.

In the past, I was a rock climber, an ice climber, and an alpinist.   Creating the orchard involved many weekends with a chainsaw, a pushcart for wood hauling, and a wheelbarrow.   I've burned more calories and gained more upper body strength as a farmer than I ever had as a mountaineer.

Thanks to my wife Kathy for her vision, Stumpy's for tree clearing, Tree Specialists/Barbara Keene-Briggs for tree species selection and design, Paul Rossi for excavating/grading artistry, and River Valley Fencing for protecting all the produce from being eaten.

In three years we'll harvest our first fruit crops.  Now that the orchard is done, our next task is to shear the alpaca and complete the mushroom inoculation so that we'll have our first crops of Shitake and Oyster mushrooms by next Spring.

The Toad and the Snake

Over the weekend while working in the orchard, I found a small garter snake trying to eat an enormous toad, pictured above.

Did the toad not realize that by wriggling its feet, it could easily escape?   Was the toad unaware of the impending threat?  Might the toad have given up and thought that the end was inevitable?

Did the snake not realize that the toad was much larger than it could possibly digest?  Garter snakes have special jaw hinges that allow them to swallow things wider than their bodies.  Was the snake so optimistic about the benefits of an enormous meal that it was willing to discount the risks it faced in the swallowing process?  Might the garter snake have seized the opportunity because the conditions were right for eating the toad slowly over time?

As if often the case, I tried to find deeper meaning in this encounter with survival of the fittest.   On a daily basis, I examine my life, asking who I am, where I've been, and where I'm going.

In my early years as CIO, I did not know the risks I faced, what I had to lose, and who I might upset along the way.    I was the garter snake.   Out of this period came new advances in interoperability, patient portals, and clinical applications.    Everything was developed in a disruptive rapid cycle improvement fashion.

Today, might I have become the toad?

Have I become too risk adverse in a world of enhanced regulatory enforcement?  Have I evolved from the innovative rogue to the keeper of the status quo?  Have I become too attached to the customer relationships I've formed, the incumbent vendors I've chosen, and the strategy I have shepherded for 15 years?

In analyzing my behavior, I do not believe I've become the toad quite yet, but am I very sensitive to the warning signs.

In 1996, when I was faced with impossible tasks for which there was no technology, no standards, and no policy, the answer was simple - create them and if they failed, try again.

In 2013, with auditors reviewing my every project, government agencies scrutinizing my process maturity, and boards wanting to minimize risk, how can we reduce the barriers to innovation?

I do not have a complete answer, but I have an idea.

I would like to begin raising funds from inspired philanthropists, grateful BIDMC patients, and partner companies to create what I'll metaphorically call the New Organization for Transformative Outside-the-box Application Development  (NO TOAD)

Of course we'll continue innovating in all my operational BIDMC IT groups, but somehow NO TOAD has to be constructed and chartered to do work unconstrained by convention, risk adversity, or anxiety about the things that create overhead in 2013 and did not exist in 1996 such as

Project management offices
Application development methodology
Communication and milestone reporting
Operational oversight during workflow design and development
Business readiness
Policies, procedures and guidelines documentation
Training and education plans
Cutover planning
Functional/performance testing approach
End-to-end and user acceptance testing
System support plans
Infrastructure and controls
General and organizational controls
Physical and logical controls
Program change controls
Disaster recovery and business continuity plans

Is this possible?   I think so.

We'd create a large de-identified data set that could be openly used by developers without fear of violating HIPAA.

We'd isolate devices from the hospital network to enable freedom and experimentation with technology not allowed in a high security production environment.

Prototyped code would be reimplemented into production software using formal approaches only after it had proven its value.

By design (a separate LLC?) NO TOAD would be considered outside the scope of healthcare audit and regulatory burdens.

Projects would be audacious, aggressive, and agile.   Many would be expected to fail.   The culture would be high risk, high reward without concern for the limitations of current healthcare policies or technologies.

Lessons from Bell Labs, Steve Jobs' reality distortion field, and Google's 20% freethinking policy would guide the selection of ideas to pursue.

Over the past few months I've joined a number of BIDMC philanthropy activities, building awareness of the unique culture that is BIDMC and the amazing talented people that work there.

My challenge is now to incubate a true learning laboratory for BIDMC that can enable garter snakes who are not intimidated by the impossible tasks ahead.  Think of it as healthcare IT unchained.

If it works, I'll happily tell people that the entire idea was inspired by a concern that we've become prisoners of risk avoidance and a toad that decided the status quo was unchangeable.

NO TOAD.  An idea whose time has come.

And so the fundraising begins.