Thursday, September 26, 2013

Building Unity Farm - The Ducks Arrive

Today, 10 ducks, born on Monday, arrived at Unity Farm.    Here are the details

1.  Two Fawn and White Runner Ducks

2.  Two Rouen

3.  Two Blue Swedish

4.  Two Welsh Harlequin

5.  Two Chocolate Runner Ducks

Just as with our chickens and guinea fowl, each duck has their own personality and temperament.   For prospective duck buyers, here's a behavior chart by breed.

We'll keep them in our indoor brooders for 4 weeks, then move them to the duck house.

Last weekend, we built a 10x18 pen and 4x8 enclosure to keep the ducks safe from predators and warm in stormy weather.   Ducks prefer living outdoors and do not mind wet conditions (i.e. duck weather).   Snowy, windy days with temperatures approaching zero can cause frostbite to their webbed feet, hence benefit of an enclosure.    Next weekend, I'll dig an electrical trench and wire the enclosure with a flat panel warmer that will keep the space 10 degrees warmer than the ambient temperature in the winter.

The pen includes a 50 gallon swimming trough, water and food.

We'll learn more about duck behavior as they age.   I stand ready to built ramps in and out of the pen and the enclosure to make the area more duck friendly.

Ducks are truly magnificent creatures and I look forward to seeing them run around the farm during the day.

If anyone asks me if my ducks are in a row, I can now respond that my ducks are doing very well indeed.

Wednesday, September 25, 2013

The HL7 Annual Meeting

On Monday, I had the honor of keynoting the HL7 Annual meeting in Cambridge, MA.   I used these slides.

I began with an overview of the Standards work in progress in the HIT Standards Committee and the S&I Framework.   Then, I offered personal comments (not representing the Standards Committee) as to where I believe healthcare Standards need to evolve.

My major point was this - Why did the web grow an exponential pace?  We had transport (HTTP) and content (HTML) that anyone could use without significant training to create and consume information.   Healthcare has always viewed itself as different, requiring more complex standards to address every possible edge case.   What we need is HTTP and HTML that is good enough for healthcare.  

Fast Healthcare Interoperability Resources (FHIR) using JSON is the simple HTML for healthcare that does not require knowledge of the HL7 RIM

The work of Dixie Baker and the Privacy and Security Workgroup evaluating the combination of REST/Oauth2/OpenID indicates that REST is the HTTP for healthcare.  

Although CCDA and Direct are a reasonable starting point and will exist for many years, FHIR/JSON and REST/OAuth2/OpenID is where we need to be.

Tuesday, September 24, 2013

The September HIT Standards Committee Meeting

The September HIT Standards Committee focused on image exchange, scenario-based certification,  the Food and Drug Administration Safety and Innovation Act (FDASIA) , and an important discussion about setting standards priorities for FY14.

This was Farzad Mostashari's last meeting.   He shared his worries and offered us advice:
*Do not slow  implementation of FY14 standards.  We've worked too hard to get this far
*Offering more time for Meaningful Use Stage 2 attestation may be appropriate
*New standards are coming but we can make progress today.  Do not let the perfect be the enemy of the good
*We need to create the standards and interoperability that people want, have value, and are appropriate for purpose

We began the meeting with a presentation by Jamie Ferguson about the image sharing testimony we've heard thus far.   They key points are that different standards are needed for view/download/transmit use cases, evolving DICOM standards such as Web Access to DICOM Objects  (WADO RS)  and STore Over the Web (STOW RS) may meet many of these needs, and other countries have models we should study (such as Scotland).

We next heard an update on scenario based testing from Scott Purnell-Sanders. The current approach to certification breaks up clinician workflow into discrete scripts which many not demonstrate usability in actual clinical practice.  The notion that an EHR should be certified based on a seamless clinical workflow, supporting the functions required for meaningful use, is a real improvement in certification design.

Jodi Daniel provided a policy update, focusing on the Food and Drug Administration Safety and Innovation Act (FDASIA) .  The FDASIA Working Group, chaired by David Bates, did a remarkable job outlining a framework that balances innovation and risk reduction.

The remainder of the meeting with devoted to an FY14 Standards Workplan discussion by Doug Fridsma which reviewed an activities matrix listing current HITSC priorities, S&I framework initiatives in progress/planned, and HL7 ballots in progress.   They key question for the HIT Standards Committee is how to balance scope, time, and resources over the next year to deliver those key standards needed to support national priorities- Care Coordination, Improving Quality, Engaging Patients/Family, and Population Health.    Using the matrix, we will prioritize the most important and most urgent projects over the next few weeks.

Thursday, September 19, 2013

Building Unity Farm - The Mushroom Harvest Begins

Last night was 39 degrees and we're wrapping up all the projects of summer since fall officially begins this Sunday.

We've picked our early apples (Honeycrisp and MacIntosh) and are watching our late apples (Empire) ripen quickly.

Our blueberries and raspberries are already preserved.

Squash, beans, and root vegetables are picked and sitting in our drying racks.

We're finishing the construction of our hoop house for winter vegetables (more about that next week).

All our summer babies have been born - 73 guinea fowl in 3 batches.   We've moved the 4 week olds into the coop and sold the second batch to a farm near Rhode Island.  The third batch will be going to a farm in central Massachusetts.

We'll have alpaca babies next summer.

Before the weather turns too cold, we're finishing the inoculation of the logs we cut this year and harvesting mushrooms from logs we inoculated in the spring such as the oyster mushrooms shown above.    We have three mushroom growing yards on the farm.

The first is in a grove of pine trees just outside our wetland border.   It's cool, shady and moist.    It has 48 poplar logs inoculated with two species of oyster mushrooms

PoHu - This oyster strain is the most “wide range” of Oyster strains with multiple fruitings throughout the growing season, including summer. PoHu is a heavy producer and grows many ocher to white colored mushrooms in thick clusters.

Grey Dove - This Oyster strain is prolific and reliable. Steel blue pins slowly change into silvery grey as the cap matures. The shape is classic Oyster; graceful stem with a shell-shaped cap.

The second area is in a fern grove under the largest pine trees on the farm.  It's a little drier and warmer.    It has 96 poplar logs inoculated with four species of oyster mushrooms.

Italian - A mild flavored mushroom with a thick stem that grows in gorgeous clusters. Mature mushrooms have a delicate brown colored cap with beautifully contrasting white stems.

Blue Dolphin - Also known as the “Fall Fruiting Tree Oyster,” this strain undergoes a lovely metamorphosis from the frosty blue pins through the pewter gray clusters of the mature mushrooms. Blue Dolphin is a prolific fruiter in cooler weather, especially after the first near-frost temperatures in autumn. It needs near freezing temperatures to stimulate fruiting.

Golden - A luminous citrine yellow mushroom with a tangy flavor perfect in small quantities as an edible garnish. This mushroom lightens in color when sautéed to provide a fungal feast for both palate and eye. Golden Oysters fruit naturally in late spring and again in late summer - perfect for outdoor summer cultivation.

Polar White - A lovely icy white, cool weather Oyster mushroom that fruits in the fall. This strain has dense, porcelain white caps and is incredibly flavorful.

We recently added 110 Shitake logs to the fern grove - ten logs for each species described below.

The third area is our shade house - 85% shade cloth 30 feet long, 10 feet wide and 10 feet high.   It has 11 species of Shitake in 165 logs

Bellwether -  In both spring and fall, it fruits with an abundance of large, thick, cup-shaped mushrooms with layer upon layer of white lace ornamentation.  It's a highly productive, cool season fruiter.

Chocolov -  This strain produces medium sized, round, almost glossy capped mushrooms the color of dark chocolate.  It fruits late in the fall.

Miss Happiness - A gorgeous late fall fruiting  strain with uniformly round brown caps.

Snow Cap - Produces beautiful, uniform, thick fleshed caps tufted with white lacey ornamentation. Heaviest fruiting occurs early spring and late fall.

Double Jewel - This strain produces large, dense, beautifully ornamented mushrooms, often in attractive paired clusters, inspiring the name.  Fruits naturally in the spring and fall.

Native Harvest -  Native Harvest gives a late fall flush; an added bonus for the Thanksgiving table!

West Wind - West Wind features large, thick, first flush mushrooms, and heavy yields. West Wind is also slightly more drought tolerant than other strains.  Fruits naturally in the spring and fall.

WR46 - A popular commercial strain that offers heavy first flushes and quick log recovery after fruiting.

Night Velvet - This warm weather strain produces big, plump mushrooms that are like picking apples.

WW44 - This strain produces mushrooms with thick, round, honey colored caps which are perfectly shaped and maintain high quality during periods of excessive humidity.

WW70 - This warm/cool weather strain has a late summer - late fall fruiting period. It is also one of the most beautiful, with dark caps and lots of contrasting ornamentation.

Finally, in our shade house we also inoculated 12 logs with Lion's Mane.

Last night's dinner included Italian oyster mushrooms sautéd with our farm grown onions.

Of course the woodlands at Unity Farm yield their own native mushrooms, many of which are edible - boletes, morels, chanterelles, coprinus,  and maitake (hen of the woods).   Some, like this parasol mushroom, are strikingly beautiful.

Tuesday, September 17, 2013

Our Meaningful Use Stage 2 Certification Strategy

Two weeks ago, ONC created a very helpful Certification Guide for EHR technology developers 

Many people in the industry have told me that the most challenging scripts are the demonstration of CCDA generation/display/Direct transmission (45 CFR §170.314(b)(1) and 45 CFR §170.314(b)(2)), the Clinical Quality Measures (45 CFR §170.314©(1)-(3)), and Patient View/Download/Transmit (45 CFR §170.314(e)(1)).

Although some stakeholders have suggested that these criteria are too aspirational, using standards that are still maturing, I think it is unlikely that rule making will alter their intent.   I also think it unlikely that the test scripts will be significantly revised to reduce the complexity of certification.

As I wrote recently in my post about What Keeps Me Up at Night, the only way to pass an impossible test is to change the rules.

Our approach has been to leverage the modularity of Meaningful Use Stage 2 to divide up the work among vendors, the State government, and our own developers.

Here's how we're doing it.

The State HIE, MassHIWay, fully implements the Direct protocol including certificate validation - everything required by §170.314(b)(2).   Unfortunately, modular certification does not enable the splitting of a script, so in order to use the MassHIWay for all of §170.314(b), we also need to demonstrate its ability to generate and display a CCDA.   Luckily, the MassHIWay received an innovation grant to create the Surrogate EHR Environment (SEE) application for LTAC/SNF/stakeholders without an EHR.   This application can generate and display CCDAs.   We'll leverage the MassHIWay capabilities and demonstrate its Direct functionality as part of the BIDMC self-certification efforts.   Then, we'll help all the other users in the Commonwealth by getting it certified as a §170.314(b) compliant module so that anyone in Massachusetts can include it in their attestation.

The Clinical Quality Measures require demonstration of QRDA Category I (Patient-level) and
QRDA Category III (Aggregate-level) capabilities.  They also require stratification by several demographic data elements to support disparities of care reporting.   The test script results in a QRDA that is over a megabyte because 21 test patients with 29 measures are stratified 3 ways.   Rather than apply significant resources to QRDA programming, we chose to outsource our quality reporting to the Massachusetts eHealth Collaborative Quality Data Center (QDC), as described in my earlier blog about our ACO strategy.   The QDC takes CCDAs from each of our EHRs and produces all the reports needed for ACO, Meaningful Use and PQRS reporting.    Last week, MAeHC achieved modular certification for all its CQM reporting.

The Patient View/Download/Transmit (VDT) scripts are tough because the ecosystem of products supporting patient transmit workflows is still very immature.   We are implementing VDT in two ways.   The MassHIWay will connect to a PHR and thus we'll likely include the MassHIWay VDT features in our self certification.   We'll also augment our Automated Blue Button (ABBI) functionality so that a patient can initiate an ABBI transmission instead of relying on a transition of care event, as is now the case.   Our ABBI code is open source from the Direct project.

Thus, by building our core EHR functionality and certifying it supplemented with modular certification of  the state HIE, the Quality Data Center, and Automated Blue Button, we can get to a full "shopping cart" of functionality to support hospital and professional attestation.

It took us half a day to achieve Meaningful Use Stage 1 certification.   We estimate that 3 full days of demonstrations will be required for Meaningful Use Stage 2 certification.

The division of labor described above will make it possible to us to certify all our software in time for early 2014 reporting periods and attestation.

Thursday, September 12, 2013

Building Unity Farm - Preserving the Harvest

As Fall approaches in New England we're picking apples/fermenting cider, extracting honey, canning jams, preserving vegetables, and finishing our Fall mushroom inoculation.

Here are a few scenes of the harvest - a very busy time of year.

The Unity Farm orchard contains 36 trees - Apples, Cherries, Peaches, Pears, and Plums.   We have 180 high bush blueberry bushes and 150 low bush blueberry bushes.    We have elderberry, raspberry, and pecans.    Here's an overview of the layout.

Last weekend we picked Honeycrisp, McIntosh, and Asian Pear.    We crushed the apples into cider and pasteurized it into quart containers.   Here's what the process looked like in the cider house.

In August we picked blueberries and created Unity Blue jam, a mixture of berries and other natural ingredients from the farm.    We've applied for a license to sell our farm products at farmers markets and other retail locations.   As soon as the license is granted we'll be able to sell Unity Blue - here's what the finished package looks like.

I'll write an entire post about the honey extraction process, which requires a bee suit, a smoker, a hive tool to gently remove the frames containing combs of honey, a tool to uncap the combs, and an extractor to remove the honey from the wax.    We gathered 240 ounces of honey from our 8 hives and we will leave all remaining honey for the bees to use over winter.   Below is the alternative u-pick method, that we've chosen not to use!

Finally, we've prepared 220 shitake, 72 oyster, and 6 lion's mane logs so they are ready to fruit with mushrooms in the Spring.   Here's a view of our laying yard where oyster mushrooms are growing on poplar.   Our shitake and lion's mane logs are kept in the shade house.

We're on the cusp of selling the products of Unity Farm.   By next year, we should have commercial quantities of fruit, vegetables, mushrooms, honey, and fermented cider.   The great thing about life in New England is that each season brings a new adventure and as we finish our harvest, we can dream about the new farm possibilities we'll have in the Spring.

Wednesday, September 11, 2013

EMAR Go live

On September 4, BIDMC went live with its innovative web-based, mobile, " shopping cart" inspired electronic medication administration record.

Using a combination of iPads, iPhones, bar code readers, and thin client (HTML, Javascript) cloud hosted software, we have eliminated paper-based medication records on a major medical floor.   As is typical with our user centered design methodology, we'll incorporate improvements as we incrementally implement the software across the enterprise.

Our standard user centered design process includes:
  *Clinicians define requirements in our governance committees
  *Clinicians and developers create products
  *Limited pilots are conducted and feedback gathered.
  *Revisions are made and re-piloted
  *When clinicians judge the product to be mature, pilots are expanded and phased rollout is done.
  *Governance committees meet monthly to review functionality and prioritize enhancements.

The entire process is agile, clinician focused, and continuous

Although BIDMC builds and buys software based on requirements and product maturity, EMAR is a perfect example of when clinicians writing software for clinicians makes great sense.

Nurses created the user interface following of the motif of the shopping cart - you "buy" medications with one click when giving them to a patient, then "check out" to record your "purchases" in the permanent medical record.    All of this happens in real time as bar codes are scanned.   iPhones show each nurse what has been ordered and what has been administered.  iPads at each Omnicell medication cabinet show nurses what work needs to be done.

Here are a few screen shots

Comments from nursing thus far have included "this saves me so much time", "an incredible enhancement", "a major safety gain".   Rarely have I attended a go live debrief in which all the stakeholders expressed such joy and satisfaction.

Clinicians designing software for clinicians, using mobile and thin client cloud hosted approaches, with continuous improvements during enterprise rollouts.   It's a formula that works for our culture.

Tuesday, September 10, 2013

The September HIT Council meeting

Yesterday, the Massachusetts HIT Council met to review progress on the state HIE.   Here is the presentation we used.

Important highlights include:
*41 organizations are now connected to the state HIE
*We've done nearly 1.5 million transactions
*We've decided how to create a trust fabric with other Health Information Service Providers (HISPs).   We will support authentication by exchanging trust anchors and signing HISP to HISP agreements. We will support authorization through the use of a white list that includes those organizations which have signed our Massachusetts participation agreement
*In late October/early November we will demonstrate Phase 2 of our HIE functionality - a statewide master patient index and consent registry which supports "pull" transactions such as patients arriving at Emergency Departments, enabling us to gather medical information from multiple institutions.

To me, we're near the tipping point of interoperability.   The standards, the ACO imperative to share data, and the motivation of meaningful use Stage 2 have created the perfect storm for providers, payers, and patients to share data.

Thursday, September 5, 2013

Building Unity Farm - The Cider House Tools

The orchard at Unity Farm has 36 trees, of which 24 are heritage apple varieties.   Since each tree will produce 5 bushels (a bushel is 42 pounds), we'll have 120 bushels (over 5000 pounds of apples per year) when the trees reach maturity.    Of course we'll eat, sauce, jelly and produce various apple products from them, but my favorite way to enjoy fresh apples in the Fall is to make cider.

One bushel yields about 3 gallons of cider, so we could make up to 360 gallons.

Cider can be frozen and kept for a year but even with pasteurization (which changes the flavor), unfrozen cider will not keep more than a few weeks.

The easy answer to preserving cider is to make traditional fermented hard cider.

Here's how we'll do it.

In the orchard, we have a cider house, pictured above.  All our orchard harvesting and honey processing tools are kept clean and dry in that building.  We have a 36 liter cider press and grinder which can produce about 9 gallons of juice per pressing, pictured below

We'll test our apples for flavor, acidity, tannin content, sweetness, and bitterness then choose a combination of apples that will make a balanced cider.  Our hand cranked fruit grinder sites on top of the press and we'll fill the pressing basket with approximately 2 bushels of ground apples.    We'll apply pressure via the hand cranked ratcheting screen and gather the juice a gallon at a time.  I prefer a two stage fermentation with racking of juice from the spent yeast for a clearer final product.   I have two fermenters made from food grade HDPE plastic, which is unbreakable and easy to clean.   I've had good luck in the past with Champagne yeast  and will make a starter culture the night before pressing.   Once inoculating, I'll let fermentation proceed naturally in the 60 degree outdoor temperatures that are typical in late September/early October.  When the initial fermentation is done, I'll siphon the juice from one fermenter to another and let it ferment another week.  

I prefer my ciders to be very dry, so I do not plan on adding any sweetener before bottling.   I will likely make a few bottles of sparkling cider as well, adding a bit of sugar solution then bottling in swing top containers.   After a few months the cider will mellow and carbonate, ready to ring in the new year if all goes well.

Since hard cider has been an American home brew tradition for hundreds of years, the laws regulating production and distribution are simpler than wine.   In a few years, I hope invite friends and colleagues to bring their growlers to fill with Unity Farm cider, hand made with our cider house tools.

Wednesday, September 4, 2013

The August HIT Standards Committee

On August 22nd, the HIT Standards Committee held it's 50th meeting.   We began this milestone meeting by thinking Farzad Mostashari for his national service via a formal proclamation highlighting his accomplishments.  Richly deserved.

Liz Johnson and Carol Bean then presented an Implementation Workgroup update, describing the findings from the Implementation/Usability hearing on July 23rd and presenting test scenarios which will hopefully replace/augment the existing certification scripts.  

They key idea is that scenarios would mirror real clinical workflow from registration to evaluation to transition of care, using the same data and building upon each incremental data entry step.   Such an approach not only reduces the burden of certification but also ensures the EHR is more than disconnected functions built to satisfy disconnect certification criteria.   In effect, scenarios demonstrate the usability of integrated functionality.   I'm also hoping that these scenarios remove some of the certification demonstrations are not part of attestation workflow.    In my view, certification should only include the minimum functionality clinicians need to support attestation and nothing more.   As I posted in my blog yesterday, creating too many regulatory demands can stifle innovation.

Next, Dixie Baker presented an NwHIN Power Team Update finalizing the recommendations for future transport standards.   She reviewed the work of Blue Button Plus, HL7's Fast Healthcare Interoperability Resources (FHIR), and the S&I Framework's RESTful Health Exchange (RHEx) to identify industry trends and emerging standards.   The team concluded that combination of RESTful transport supported by a specific implementation guide and supplemented with OAuth2/OpenID for authentication holds great promise as a simpler to implement approach than currently required in Meaningful Use.   The team also concluded that FHIR has many appealing simplifications as a content standard.      The Standards Committee recommended pilots and once we have real world experience with the combination of RHEx/OAuth2/OpenID/FHIR we should seriously consider their incorporating into future stages of Meaningful Use.

Finally, Lauren Thompson and Jodi Daniel provided an ONC update, highlighting work to accelerate HIE, patient/family engagement, and safety.

At our September meeting we'll present initial recommendations for image exchange and early thinking about how to represent advance directives in EHRs.

Making progress.

Tuesday, September 3, 2013

What Keeps Me Up at Night - Fall 2013

As Summer draws to a close, I have returned to my usual blogging schedule!

Now that Labor Day has come and gone,  I've thought about the months ahead and the major challenges I'll face.

1.  Mergers and Acquisitions

Healthcare in the US is not a system of care, it's a disconnected collection of hospitals, clinics, pharmacies, labs, and imaging centers.    As the Affordable Care Act rolls out, many accountable care organizations are realizing that the only way to survive is to create "systemness" through mergers, acquisitions, and affiliations.   The workflow to support systemness may require different IT approaches than we've used in the past.   We've been successful  to date by leaving existing applications in place and building bidirectional clinical sharing interfaces via  "magic button" viewing and state HIE summary exchange.   Interfacing is great for many purposes.   Integration is better for others, such as enterprise appointment scheduling and care management.   Requirements for systemness have not yet been defined, but there could be significant future work ahead to replace existing systems with a single integrated application.

2.  Regulatory uncertainty

Will ICD10 proceed on the October 1, 2014 timeline?  All indications in Washington are that deadlines will not be changed.    Yet, I'm concerned that payers, providers and government will not be ready to support the workflow changes required for successful ICD10 implementation.    Will all aspects of the new HIPAA Omnibus rule be enforced including the "self pay" provision which restricts information flow to payers?  Hospitals nationwide are not sure how to comply with the new requirements.   Will Meaningful Use Stage 2 proceed on the current aggressive timeline?  Products to support MU2 are still being certified yet hospitals are expected to begin attestation reporting periods as early as October 1.   With Farzad Mostashari's departure from ONC, the new national coordinator will have to address these challenging implementation questions against a backdrop of a Congress which wants to see the national HIT program move faster.

3.  Meaningful Use Stage 2 challenges

Although attestation criteria are very clear (and achievable), certification is quite complex, especially for a small self development shop like mine.   One of my colleagues at a healthcare institution in another state noted that 50 developers and 4 full analysts are hard at work at certification for their self built systems.   I have 25 developers and a part time analyst available for the task.   I've read every script and there are numerous areas in certification which go beyond the functionality needed for attestation.    Many EHR vendors have described their certification burden to me.    I am hopeful that ONC re-examines the certification process and does two things - removes those sections that add unnecessary complexity and makes certification clinically relevant by using scenarios that demonstrate a real world workflow supporting the functionality needed for attestation.  

4.  Maintaining agility in a resource constrained world

At the same time we have ICD10 (a multi-million dollar burden), Meaningful Use Stage 2 (a multi-million dollar burden), the Affordable Care Act (a multi-million dollar burden), the HIPAA Omnibus Rule (a multi-million dollar burden), and increasing compliance oversight (a multi-million dollar burden), reimbursement is declining, sequestration is squeezing budgets, and fee for service medicine is transitioning to risk based contracts.    The ability of provider organizations to maintain operations while implementing all the new regulatory requirements in parallel is straining healthcare operations to their limits.   Safety, quality, and efficiency innovations are no longer possible because regulatory requirements  have consumed all available resources.

5.  Leading in real time

My organizations maintain hundreds of applications and thousands of devices with 99.9% reliability.    Rather than praise us for our diligence, the average user in 2013 wants to now why we are not meeting their needs .1% of the time.  When I do not respond to a request in 5 minutes or less, I'm asked if something is wrong.   Leadership in the era of Twitter is expected to be all seeing, all knowing, and omnipresent.   Strategic thinking, planning, and consensus building is challenging in a real time world that expects instant gratification.

I do not mean to sound pessimistic in any way.   All of these challenges can be conquered.   For nearly 20 years, I've led an IT organization that has continuously delivered miracles with 1.9% of the operating budget.   I am ready for the challenges ahead but wonder if mergers/acquisitions, regulatory uncertainty, MU2 certification challenges, resource constraints, and real time demands will create a set of constraints that are impossible to optimize.    Given that my role is to understand all the constraints and find a path forward, it's the Kobayashi Maru scenario that keeps me awake at night .   As Captain Kirk figured out, if the rules of the game make it impossible to win, the only answer is to change the game.    I remain the eternal optimist and am convinced that if we all work as hard as we can, the rules of the game will be changed so that we can succeed.