Unity Farm Journal - Third Week of November 2015

The leaves have fallen, the nights are below freezing, and the water systems have been drained for the season.    Salt marsh hay covers all the outdoor vegetable beds, all cider has been moved indoors, and every bucket has been taken down from outdoor paddocks (heated buckets keep liquid water available inside the barn.).   We’re on the countdown to snow.

Thanksgiving is next week, so all the turkeys in the neighborhood are congregating at Unity Farm, which they seem to know is vegetarian ground.    As I’ve said before we have turkeys for every Thanksgiving dinner - the challenge is finding enough chairs for them to sit in.

We had two unexpected bird deaths this week.  One of our older chickens, Snow, who had a chronic respiratory ailment, and an older guinea fowl both died.   We’ve refrigerated their bodies in case a necropsy is warranted but for the moment no other birds are sick and this does not appear to be an infectious disease.   With the spread of Avian Flu throughout the US, causing mass culling of birds, we’re very vigilant.

Last year, we planted American ginseng in a 1000 square foot woodland patch.  Ginseng likes sandy loam soil that is moist, but not too moist.   It takes 2 years to get significant growth of a new planting.     Our challenge is that we are really not sure what habitat in our 15 acres is ideal.    This weekend, we’re creating 10 raised beds in different environments around the farm.   We’ll plant ginseng roots and ginseng seeds, then surround the bed with a 5 foot deer fence.   Hopefully, this “controlled trial” will teach us where best to plant understory permaculture crops like ginseng.

Over the Thanksgiving break, I will be writing a paper for my Umass Organic Farming program entitled “The Organic Treatment of Pests and Diseases at Unity Farm”.   The outline is below:

Pest and Disease treatment/risk mitigation plan by species:
Legumes (Bush Beans, Runner Beans, Peas)
Brassicas (Cabbage, Broccoli, Cauliflower)
Curcurbits (Cucumber, Pumpkin, Squash)
Lettuce
Carrots
Chenopodiaceae (Swiss chard, beets, spinach)
Garlic
Solanaceae Family (Potatoes, Eggplant, Peppers and Tomatoes)
Asparagus

When finished, this paper will be a primer for the processes and procedures needed to keep our produce healthy throughout the seasons.    In the Winter, I take a Homesteading course and in the Spring, I take a Farm Marketing and Finances course, which will result in a formal business plan for the future of Unity Farm.

With every passing year, we grow more sophisticated about farming.    Our trajectory is looking good.

A Followup on the MU Path Forward

After last week’s post about my suggested path forward for Meaningful Use,  I received a large number of comments.   I thought it would be useful to summarize them and clarify some of my opinions.

In general, 95% of commenters agreed that CMS should pivot the concept of Meaningful Use functional requirements into pay for performance rewards for achieving outcomes via MACRA.

Several commenters pointed out that the MU program has different approaches for Medicaid providers and Medicare providers.       Medicaid funding is available to help providers purchase technology.  Medicare providers received stimulus in the past and now are entering the penalty phase for not attesting to Meaningful Use.  I did not mean to suggest that Medicaid funding should cease before EHRs are fully deployed in Medicaid provider locations.    My suggestions referred to the Medicare programs and penalties for not implementing prescriptive functional requirements.

I was asked to clarify my thoughts about certification.    Today’s certification program includes onerous requirements that consume vast amounts of resources for items not related to interoperability.   If we focus on three goals (provider to provider push,  provider to provider pull, and patient pull), then a streamlined certification program validating those three functions would make sense.   Just as a DVD player includes a sticker guaranteeing “Blu-Ray” compliance, I can imagine a streamlined certification program that issues “stickers” for each of the three interoperability goals, reassuring clinicians that the health information exchange claimed is fully functional in the products they buy.

I was asked if I was criticizing CMS or ONC work.    I’m really not criticizing anyone.   I’m suggesting that the work done in the past was foundational, but the future requires a different approach - outcomes based incentives.    I’m confident that CMS and ONC staff can evolve existing programs into this new approach.

Finally, some have advocated for a transitional approach along the road to FHIR, since existing standards such as IHE XDS/XUA are already in the marketplace.     I realize that we cannot go from cars to jet planes without a few intermediate steps.  However, we have to proceed very carefully because for vendors, every OR becomes an AND.   If we say that you could use IHE XDS or FHIR, we will run into impedance mismatches. Not only will vendors have to implement every option, they will have to implement step up/step down conversions between organizations that use different options.   In general, optionality is the greatest impediment to interoperability.      If the entertainment industry decided that laser disc and Blu-Ray should be used simultaneously, our home systems would become very complex and hard to maintain.   While I understand that some optionality could be offered during a transition period, I am advocating for a move to FHIR/OAuth as the ONLY approach, with minimal optionality, as quickly as is practical.

I look forward to the continued comments - let’s keep the dialog going!

Unity Farm Journal - The Second Week of November 2015

There are still a few weekend opportunities to work outside before the snow falls.   We’ve shut off the irrigation, blown out all external pipes, put away the hoses, taken down all the temporary fences we used to keep the poultry out of fresh plantings, and covered all the firewood with tarps.     We’re hoping to finish the driveway project before Thanksgiving because the polymeric sand to hold the pavers in place requires a night above freezing to set.

   Kathy and I inoculated 30 oak logs last weekend (that’s 1500 holes drilled, filled and waxed over).   We’re using a strain of Shitake called WR46 that fruits early and has a high yield.    Our hope is to finish 100 logs before the weather turns too cold.

   All the leaves have fallen, creating a foot deep blanket over our 15 acres.   I’ve used the Stihl Magnum blower to clear the barnyard and pond areas.     The zip line is an entirely different experience traversing 300 feet of forest through leafless trees.

We have diesel powered (no volkswagens) and gas powered equipment on the farm.   I’ve added winter fuel stabilizers to every fuel source and filled every tank to avoid evaporation/consensation/water accumulation and to prevent gas line freeze up.

It feels like the grasshopper and the ant.   By working tirelessly on nights and weekends during Fall, Spring and Summer, the winter will be a time to rest/recharge and enjoy the foods/fermentations/fuel we’ve stored up when the living was easy.

 As the weather draws cold and animals begin to spend more time underground, the coyotes are visiting the barnyard more often.   Every night for the past week, I’ve heard their howling (and the dogs barking), so I’ve run around the forest at 2am, 4am and 6am to keep all the animals safe.

One last construction project for the Fall- building raised beds for American ginseng.   We planted 5000 ginseng plants in the woodland last year but had spotty results - deer and rabbits ate them, moisture was not ideal, and we’re not sure what microclimates they really prefer.    My idea is to create ten 2x2 foot raised beds, each protected by a 5 foot high welded wire fence.    We’ll look for areas with jack-in-the pulpit, bloodroot, Solomon's seal, jewel weed, galax, trillium, wild yam, hepatica, black cohosh, wild ginger and ferns, since those plants have similar environmental requirements.   With ten different “test stations” we’ll have a much more controlled experiment as to where ginseng grows best.    Ginseng, paw paw and chestnut are all part of our permaculture program, creating crops in native woodland.

This weekend I’m in Los Angeles helping my mother with home maintenance tasks, receiving the “Don Detmer award” from AMIA in San Francisco as a policy influencer, and giving an AMIA tutorial about the next generation of interoperability standards.   Back to Boston on the Sunday night red eye!

 
 

The Path Forward for Meaningful Use

Below is my assessment of the current Meaningful Use program and a proposal to better serve the needs of stakeholders.  I’m likely going to violate many rules with this post.   First, it’s over 1500 words, which is not ideal for social media.     Second, there are many who will find my conclusions politically unpopular.   I’m not criticizing people, I’m just commenting on ideas.   Finally, many of these topics do not have black and white answers. I hope my suggestions improve upon our current trajectory.

Where We Are

1.   I believe that the Meaningful Use programs have served their purpose.

Stage 1 created a foundation of functionality for everyone.   That was good.   Stage 2 tried to change too much too fast and required an ecosystem of applications and infrastructure that did not exist.   Clinicians struggled to engage patients and exchange data because they could send payloads but there were few who could receive them.    Stage 3 makes many of the same mistakes as Stage 2, trying to do too much too soon. It requires patient accessible Application Programming Interfaces (APIs) without specifying any standards.   It requires sending discharge e-prescriptions although pharmacies cannot widely support the cancel transaction that is essential to discharge medication management workflow.   It requires public health transactions but CMS has no authority to require public health authorities to standardize the way they receive data.  

Clinicians cannot get through a 12 minute visit, enter the necessary Stage 3 data elements, reconcile problems/allergies/medications from multiple institutions, meet the demands of the  Stage 3 clinical quality measures, make eye contact with patients, and deliver safe medical care.  There needs to be a new approach.     The same thing is true about certification.    I believe that early stage certification set a floor on EHR capability that was appropriate.   Certification is NOT good for the next stage of maturity, which will be driven by heterogeneous use cases and dynamic technology evolution.  Certification is now at the point where it threatens usability, interoperability, and EHR quality, while at the same time diverting research and development resources of health IT developers and providers.

2. I believe that volitional Information Blocking does not really exist.

There may be incompetence that feels like blocking but I’ve never encountered a competent organization with a business need blocking the secure exchange of information. I realize that there are folks in Congress who believe that a new crime called Information Blocking necessitates civil/monetary penalties and enforcement.    I have never encountered a Chief Information Blocking Officer at a health IT developer or provider organization.   The barriers are lack of enabling infrastructure, data governance, uniform policies, appropriately constrained standards, and economic incentives.  Focusing on information blocking is a distraction.

3.  I believe we cannot solve every societal problem through regulation.

The layers of requirements in Meaningful Use, the HIPAA Omnibus Rule, the Affordable Care Act, ICD-10 and the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)  are so complex and confusing that even government experts struggle to understand the implementation details.    Each of the regulations leads to various audits.  My experience is that even the auditors do not understand the regulatory intent and ask for documentation that far exceeds the capabilities of existing technology.   I was recently asked to support a Meaningful Use audit because the auditor wanted proof that a clinician performed a certain task during the reporting period (a report with a time and date stamp was not enough).   Maybe a video of a clinician at a keyboard with a calendar/clock on the wall in the background?

4.  I do not believe that adding numerous structured data elements and new quality measures to existing software creates disruptive innovation.  We need a business imperative for change and innovation based on the needs of customers.

I’ve already seen the rise of the Care Management Medical Record at our ACO, enabling care managers to examine data from all the EHRs in the community and identify gaps in care/variance from expected protocols.   Patient Relationship Management applications are in development, making healthcare more like other service industries.   None of this is driven by prescriptive regulation.

5.   I believe that health IT developers have already committed to piloting and developing Application Program Interfaces (APIs).

Creating regulation before there is any industry experience as to what works makes little sense.   Government can help with issues such as data governance principles, rationalizing  privacy policy,  and coordinating federal agencies but should not specify workflow or business process.  

What We Should Do

1.  Replace the Meaningful Use program with Alternative Payment Models and Merit-based Incentive Payments as part of MACRA.

Stage 2 and Stage 3 will not improve outcomes.   If alternative payment models offer compelling reimbursement for health and wellness, then clinicians and hospitals will adopt products and change behavior to achieve that goal.

2.  Replace certification with enabling infrastructure.

To accelerate interoperability we need a national provider directory, a master patient index/relationship locator service, a consent service, a certificate management service, and test beds for developers to exercise these services.   Today in Massachusetts we exchange over 3,000,000 patient records per month among 500 organizations because we created such enabling infrastructure backed by data governance (common policies and agreements).   Certification will not accelerate interoperability.

3.  Consider evolving the role of ONC to become a focused policy shop (supported by advisory committees) with a narrowed scope such as identifying ways to reduce errors, improve safety, enhance quality, accelerate interoperability, and meet the needs of diverse populations.

It could also provide transparency and true coordination for actions of government, communicating the IT efforts of agencies including DOD/VA.   ONC has become distracted by grant making, political agendas (see “information blocking” above), and expansive certification ambition.  It's time to narrow the scope and enhance the effectiveness of this important agency.

4.  Stop considering health IT developers and providers as the enemy.

Some believe health IT developers are responsible for creating information silos or resisting interoperability.   Some believe clinicians are lazy or greedy, requiring  government mandates to become patient-centric.   I’m sure there are exceptions, but in general, both are myths.   I’ve said that there are a few effective ways to influence clinician behavior - align incentives, give them a better work/life balance and help them avoid public humiliation (malpractice assertions, poor quality scores, negative Yelp reviews).   A partnership of government, payers, providers, patients, and health IT developers working together to achieve common goals is possible if there are mutually aligned incentives, such as the ideas embodied in value-based purchasing/MACRA.

5.  Focus our efforts on a few things that really matter.

The Federal Interoperability Roadmap has 117 goals.    The certification program has so many objectives that it takes a few hours just to read them all (summary slide below).

How about a laser-like focus on interoperability that includes just 3 objectives?

-ability to use FHIR to read a provider directory (could be hosted by government such as CMS as part of the national provider identifier or the private sector such as Surescripts, DirectTrust, or an HIE) and send a Direct message to that provider.

-ability to use FHIR/OAuth to read a relationship locator service (could be hosted by government or the private sector such as Surescripts, Commonwell, Sequoia, or HIE) and perform a query/response of the MU Common Data Set using a FHIR API.

-ability for a patient to download the MU Common Data Set using an app (that is curated/reviewed to ensure security and data integrity) using FHIR/OAuth or appropriate variants of OAuth such as HEART.   Several folks have contacted me to discuss the real purpose behind the consumer API requirement in the ONC and CMS rules.  Some suggest it was motivated by special interests who want to monetize patient submitted data.   Some suggest that it is an enabler for future provider to provider transactions.   Some say it is the best government lever to motivate the industry to move from messaging to APIs.    I’m not sure which interpretation is correct, but it is certainly true that providing data to the patient should be one of the focuses of interoperability.

Since MACRA will base payment on wellness which requires care coordination, providers will demand appropriate interoperability features when buying an EHR product.     Additionally, an independent third party such as KLAS could publish unbiased statistics about the actual experience of interoperability by speaking with hundreds of clinicians and staff.    Recently all the major health IT developers agreed to have their interoperability measured by KLAS via customer interviews using this questionnaire. 

I’m really trying to be helpful here and incorporate the overwhelming feedback I’ve heard from stakeholders.    More Meaningful Use and Certification criteria are not the answer.    Paying for outcomes that encourage government, payers, providers, patients and health IT developers to work together, instead of being adversaries, is the path forward.

The First Week of November 2015

We’ve had a sudden burst of warmth that enables us to do additional outdoor work.   Among our 15 acres are several very old and large trees.   The old oak on the hill now hosts the 12x12 tree house.   The old maple in the marsh now hosts a 4x4 foot platform.     A 42” old pine overlooking the railroad tracks now hosts a 5x5 foot platform that I built over the weekend.   It has a 16 foot staircase, sloped at a comfortable 65 degrees, with stairs every foot.  

A freight train passes Unity Farm every morning at 7am, every afternoon at 2pm and every evening at 11pm.    Now, sitting in the old pine tree, you’re suspended above the train as it goes by.    Here’s what it looks like

Our second cut hay was delivered this week.   How do you move 7 tons of hay from truck to barn loft?    One bale at time (300 bales)

We finished the last of the cider making using a 50/50 mixture of Baldwin and Winesap apples.    The end result tastes a bit like Sauvignon Blanc.   It will undergo a 2 stage fermentation then I’ll bottle it in the Spring.

All our produce is ready for winter - the hoop house lettuce will continue to grow for a few months, the fruit trees are ready for a long winter’s nap. and the garlic roots will grow over the winter (below)

The bees hives are stocked with enough honey to last the 100 days of winter.   The aplaca have regrown their fiber, and the dogs are fully fluffed for the cold winter ahead.


The days are getting shorter which means that all the barn chores are done in the dark.    The fireplace is filled with flaming oak, ash, and maple.    Dinner has returned to the soups, roasted vegetables, and pickled foods from summer harvests.

Soon, the outdoor work will fade and plowing snow will be the main task.   Our 52” snowblower attachment for the tractor arrives next week.

The November HIT Standards Committee

The November HIT Standards Committee included a comprehensive review of the CMS Meaningful Use Stage 3/Modification Rule and the ONC 2015 Certification Rule.

We begin the meeting with a presentation from Robert Anthony of the Meaningful Use Stage 3 and Modification Rule 

A robust discussion followed.   Issued raised as those similar to the ones I identified in previous blog posts.

The main concern was the alignment of the CMS Meaningful Use rule with future pay for performance criteria that will be part of MACRA/Merit-based Payment Incentive programs.

Additionally there was significant discussion about the API requirement and the notion that “an API that can be used by applications chosen by the patient” implies that there cannot be curation or security review of patient selected applications.    All agreed that CMS and OCR need to clarify how patient access can be balanced with security imperatives.

The 6 public health requirements apply to providers but CMS has no authority to standardize communications on the public health side.  This could lead to significant regional variation in public health transaction flow.

The next presentation from Elise Sweeney Anthony and Mike Lipinski covered the 2015 Certification Rule  

Issues discussed included privacy and security criteria, safety enhanced design, field audits,  and the API requirements.

As I’ve stated in previous posts and articles, I believe the CMS Stage 2 modifications are good but the Stage 3 requirements could be moved into merit-based incentive programs and the Meaningful Use program eliminated.

Regarding the ONC Certification rule, the API requirement should include additional specificity for FHIR/OAuth.   I realize that it is too late, since the rule is final,  but the ONC rule includes so many criteria for so many purposes that I believe the market will find it very confusing.  It has the potential to create enormous burden beyond the intent and original goals of HITECH.    Private sector innovation in support of MACRA/MIPS is likely more powerful than certification to accelerate the functionality and interoperability we need.