Unity Farm Journal - Fifth Week of April 2016

Unpredictable New England weather continues - we’ve had temps in the 70’s and temps below freezing.   Hard frosts are tough on new leaves and buds, so we’re assuming the fruit tree crops will be diminished this year.    We’ll hold off on hoop house planting of our tomatoes, peppers, and eggplants until the first week of May.  Although we may have cold weather in May, the soil temperatures of the hoop house are likely to be sufficient to support cold sensitive plants.

We’re continuing our Sunday morning lettuce harvest ritual.   This year, we’ll be able to sell about 500 heads of Boston, Bibb, and Romaine from our hoop house.

This week we submitted our Organic Certification application that includes all the data we need to seek approval for the “USDA Organic” symbol to appear on our mushrooms, fruits, and vegetables.   In the upcoming weeks, we’ll have an unannounced inspection of our orchard, hoop house, and mushroom growing yard.   Organic growing requires use of materials that appear on the  Organic Materials Review Institute lists as well as use of organic seeds/seedlings.    We believe we’ve done everything right to achieve certification, but the inspector will let us know soon.

The alpacas and llama get sheared on May 4, and aftewards they’ll be itchy.   Think of giving your wool sweater a haircut.   A nearby sweeping company donated a 6 foot sweeping wheel and we mounted it as a scratching post in the female paddock.   Here’s the new alpaca back scratcher ready for action.

It’s Spring and our outdoor activities mean more exercise and better fitness.    At Unity Farm, we do a variety of strength building exercises.

Here’s an example of farm Yoga - we call it “The Downfacing Pig”

Some pursue Pilates but on the farm, we prefer Piglates  - stretching while rubbing two pig bellies simultaneously.   Very challenging.

This weekend, we’ll bottle 30 gallons of Honey Lager and plant all our tomatoes, peppers, and eggplant in the beds we’ll empty of winter letttuce.    Next week I have to be in Chicago, Las Vegas, and Houston for various speaking engagements, so Kathy will be running the farm alone.    I’ll be back on Friday to help finalize all the final preparations leading up to my daughter’s wedding on the farm at the end of May.

The MACRA Notice of Proposed Rulemaking

This afternoon, the MACRA Notice of Proposed Rulemaking was released.  I'll publish a comprehensive analysis of the 900+ pages next week, but in the meantime, a few thoughts.

The major ideas are:

*The ONC 2015 Certification Rule applies to all technology used to satisfy MACRA requirements

*Meaningful Use is being replaced by a more flexible construct that is tailorable to specific workflows and specialty practices

*Quality Measures can be selected by each practice to be relevant and aligned with their goals.

This NPRM applies to physician practices only, not hospitals, so we do not yet have clarity on the future of Meaningful Use for hospitals.

Many of the concepts are good - reducing documentation burden, enabling flexbility, focusing on outcomes/quality, engaging patients in novel ways, and emphasizing connectivity/interoperability.

However, the use of  the ONC 2015 Certification Rule is probably not a good idea.      The 2015 Rule is a kitchen sink of standards, many of which are not ready for production deployment.   The Rule is an example of regulatory overambition - instead of narrowing the scope to specific goals or workflows, it includes a cornucopia of use cases unrelated to Meaningful Use.    I highly recommend that we use the Standards Advisory concept to provide a constrained list of standards  but then let vendors innovate as needed to support the workflows desired by patients, clinicians, and hospitals.   Using the 2015 Certification Rule as written will have 3 bad consequences:

*The burden of certification will consume  developer resources that could be used for innovation
*The standards listed in the certification rule have varying degrees of maturity and we'll be setting in concrete some technologies that should not be used
*The certification rule did not envision the kinds of products or services the private sector would develop 2016-2018

I applaud a focus on outcomes and quality.  Meaningful Use has run its course and achieved its goals.   It needs to be replaced.     Along with replacing Meaningful Use, let's rethink the certification concept too.     More to come next week!

Being a Cancer Treatment Partner

Recently my wife was asked to advise one of our friends about the process of cancer treatment.    As I wrote in my 2011 post about our family's experience with cancer, the treatment involves everyone close to the patient.   Here are Kathy's notes for families of cancer patients, which I post in the hope that they will help others.

"I promised  to pencil out tips for how you can best serve as a cancer treatment partner.

Here is a great resource to read on the general way to help.

At the treatment planning visit, you should take notes so the patient can remember things later more clearly. Also, if you have a list of questions the patient specifically wants answered, you can remind her of them if she forgets to ask her doctor.

You will want the details of the final staging results, but  have found that it is not useful to focus too hard on longevity curves and results because your individual case will follow its own course. You already take the diagnosis seriously.

Confirm the details of the radiation plan.
Ask what the side effects are.   Long term risks.
Confirm the details of the chemotherapy plan.
Do you need a port?
Ask what the side effects are of your chemotherapy. Long term risks.
Do you need to look at clinical trials?
Ask about the specific drugs used for the supportive/palliative part. Palliative is the word to define the pain relief team and elements that relieve any discomfort you have from the tumor or the therapies.
Is there anything you should not take while on their treatment (like ibuprofen or any other prescriptions, or food/vitamin)
One of my own chemo therapies involved intravenous Benadryl so I could not drive myself home during that one. So ask if there are any guidelines for your specific treatment.
Ask about any risks of neuropathy (numbness in hands and feet) from chemotherapy, and what dialog or change in treatment plan they expect if you should experience neuropathy. Ask about any plan or need to boost white blood counts with therapies such as Neulasta. Connected to that is any discussion of increased risk of catching viruses or infections due to a suppressed immune system.
If you have questions about surgery and why they do not recommend it - simply ask why they find it to be not recommended in your specific case.
Ask about alternative and supportive therapies (nutrition/massage/etc)

After this initial treatment, what tests will be performed to evaluate the degree of remission?
What are the current tumor and post treatment impacts on function?
Are there ongoing post treatment medications you will have to take. Six month, one year followup plan, and beyond.

 Only use a second opinion if the treatment plan does not align with your own comfort zone or desires."

Unity Farm Journal Fourth Week of April 2016

It’s Spring harvest time and we’ve been up at dawn gathering lettuce for delivery to Tilly and Salvy’s in Natick, our local farmstand.    Tilly and Salvy’s is a fourth generation farm/farm stand and they have agreed to sell Unity Farm products including vegetables, mushrooms and our cider/mead.    Our organic lettuces (bibb, boston, butter, romaine, winter density) are grown without pesticides, herbicides or chemicals of any kind on a bed of alpaca manure compost, peet and vermiculite.  We picked them at 6am when the hoop house was 36F, hydrocooled them in 36F water, and delivered them to the farmstand where they went on the shelves at 8am.     Here’s what the p[rocess looked like.

We’re harvesting Shiitake again this week and delivering our mushrooms to local farmstands.   Here’s what happens to a Shiitake over 24 hours on an oak log

This week we had a rabid skunk visit the farm.   There are two kinds of behavior in rabid animals - “dumb” rabies  and “aggressive” rabies.    Dumb means that infected animals walk in circles, lose their fear of humans and wander into the mouths of waiting Great Pyreenees Mountain dogs.     Aggressive means they bite and attack whatever walks by them.   This skunk had dumb rabies and wandered into Shiro’s mouth.   He was covered in skunk spray but the skunk wandered off and we presume it died in the forest.     We trap all aggressive infected animals, but dumb infected animals seem to disappear on their own.   Everyone on the farm is immunized.

We installed farm cam so that we can watch the barnyard 24x7 from our iPhones.   We chose the DLINK DCS-5029L.   I highly recommend this high definition wireless camera which has a crisp, cloud hosted video feed day and night.

This week, Hazel, our 200 pound female pig, developed a little sunburn on her ears.   I covered them with a lidocaine containing ointment and she’s doing fine .    This weekend, we’ll move the pigs to their summer house which now has a 30x10 foot shaded area - we repurposed our mushrooom shade house to keep the pigs cool.

This weekend we’ll innoculate mushrooms,  give the alpaca their monthly Ivermectin (anti-parasite) injections, and harvest more vegetables.   I’ll finish our farm business plan (as part of my University of Massachusetts coursework), and submit our organic certification application.   Life on the farm is never dull!

Protecting Patient Information

In my 20 years as a CIO, my expertise has evolved to include infrastructure provisioning, software architecture, strategic planning, mobile application advocacy and cloud procurement.   However, in recent years, my focus has been guided by privacy and security risk mitigation.

I’ve learned a great deal responding to incidents, educating stakeholders, and working with government.

You’ll find all those lessons summarized in  “Protecting Patient Information, 1st Edition, A Decision-Maker's Guide to Risk, Prevention, and Damage Control”

It’s available online.

I think you’ll find it to be a great resource for clinicians and executives who need practical advice.

Although I provided guidance and experience for each chapter, the book is the hard work of veteran medical writer Paul Cerrato.   I contributed the Preface.   I do not receive any royalties, so I’m not using my blog for self-interested advertising!

With matters of security,  the best strategy is to prepare for incidents before they occur rather than respond to them once they occur.   This book should help.

Paul and I have already begun work on our next writing adventure, a practical guide to the reality of precision medicine and population health.

Also, the novel about privacy and security I co-wrote with Italian CIO Giuliano Pozza has now been open sourced.  You'll find it here.   Enjoy!

Unity Farm Journal - Third Week of April 2016

The Spring of 2016 continues to be highly volatile with hot, cold, snow/ice, and wind alternating, sometimes on the same day.    The wet/heavy snow combined with 40mph winds caused one of our large poplars to fall.  Although I do most of the forestry work at Unity Farm, I draw the line at activities that are likely to kill me.   Freeing a fallen 5 ton popular that is caught on a nearby tree qualifies as a true “widow maker”.   Next week a local tree company will use a crane to fix the problem.  At the same time they will cut down two old dead cedars that are about to fall on power lines.   I also draw the line on electrocution.

Last weekend I finished building 15 “biological test beds”.    I divided the forest into a grid of 15 sectors and placed a raised bed surrounded by a deer fence in each sector.   I added compost/peat/perlite/greensand/kelp meal/rock phosphate to each bed and planted 100 ginseng seeds per bed.   The intent is to discover what microclimates of sun/shade, heat/cold, wetness/dryness create the best growth.   Once we figure it out, we’ll expand our woodland cultivation efforts.

Our Spring mushroom flushes are in full swing and we’re delivering Shiitake to local markets.  There is a real demand for gourmet mushrooms - they are an essential part of our business plan.

Speaking of business planning, I’m finishing up the final paper for my University of Massachusetts Farm Marketing course.     My paper will begin with a summary of my meetings with potential customers - local wholesalers and restaurants.   I’ve completed those meetings and have insight into what products are in demand and how much I can charge for them.

That knowledge has enabled me to refine my business plan and understand potential income/expenses.

The end result is that there are a few structural reasons our farm will need a creative approach to sustainability.    We are vegans and have 150 animals, all rescued from suboptimal situations.    We will not eat/sell any of our animals so we’ll have a $10,000 annual animal expense with little income from them.  As I’ll present in my paper, our accountant recommends creating a 501 c(3) non-profit farm sanctuary so that all animal related expenses will be charitable contributions taken from pre-tax income.

The combination of an educational mission/ecotourishm/charity plus sales of mushrooms, hard cider, and apples/berries is likely to be sustainable.

Just as we completed the process for becomming a federal/state licensed farmer winery, I’ll begin work on a non-profit farm sanctuary application.

Also, I’m working on our organic certification, starting with the mushrooms.  We use organic spawn on fresh oak logs harvested from a forest that has never been exposed to herbicides/pesticides.     Hopefully we’ll pass!

This weekend I’ll finish up the shade house in the summer pig paddock.   As some have told me, “when I die, I hope I’m reincarnated as one of the Unity Farm creatures”.   The irrigation goes back on line this weekend and I have a feeling there will be many broken heads to replace and pipes to repair after a challenging Winter with too much temperature variation.

Assessing Interoperability for MACRA

Dr. Larry Garber, Medical Director for Informatics at Reliant Medical Group penned this response to the HHS request for an assessment of interoperability needed to support MACRA.

It’s so good that I wanted to share it with you as a guest post

"To:  Department of Health and Human Services
Office of the National Coordinator for Health Information Technology
330 C Street SW., Room 7025A
Washington, DC 20201

Re: ONC RFI Regarding Assessing Interoperability for MACRA

I am writing as a practicing physician, an implementer of electronic health records (EHRs), a designer/developer/director of EHRs and health information exchanges (HIEs), and a participant in standards development processes. It is my firm belief that our goal is “Hassle-Free HIE.”  In order to achieve that goal, it is not only important to measure progress towards that goal, but also to ensure that all of the tools necessary to achieve that goal are readily available.

Interoperability is a continuum measured on 3 major axes with 9 sub-axes scored regarding their level of automation:

1. What the holder/releaser of data had to do (including the patient in the case of Personal Health Records (PHRs) and personal devices):
a. Authorization
i.    Can’t be done
ii.  Manual determination of patient authorization
iii.  Automated (either authorization was covered by federal and state laws/regulations and that patient had provided any other required authorization/acknowledgement prior to transaction; or EHR was able to automatically convey consent requirements and interpret the nature of the release (e.g. requestor, purpose and data types) and assertions of collected authorization in order to automatically release the data)

b. Addressing/authentication
i.   Can’t be done
ii.  Manual identification of where/how to send the data and authenticating the requestor
iii. Automated identification/authentication of where/how to send the data

c. Gathering data
i.   Can’t be done
ii.  Collection of the data for sending required some manual intervention or entry
iii. Automated collection of the data to send (including device data)

d. Sending data
i.   Can’t be done
ii.  Manually triggering the data to be sent
iii. Automated sending of the data

2. What the receiver of data had to do:
a. Identifying data source(s)
i.   Can’t be done
ii.  Manual identification of holder(s) of data
iii. Automated identification of data source(s)

b. Requesting data
i.   Can’t be done
ii.  Manual request for data
iii. Automated request for data (including subscription or data pushed to receiver)

c. Authorization
i.   Can’t be done
ii.  Manual determination of requirements and assertion of patient authorization
iii. Automated (either authorization was covered by federal and state laws/regulations and that patient had provided any other required authorization/acknowledgement prior to transaction; or EHR was able to automatically determine consent requirements and assert the nature of the release (e.g. requestor, purpose and data types) and assert the collection of the authorization)

d. Importing data
i.   Can’t be done
ii.  Display/view of data only
iii.  Manual reconciliation
iv.  Automated reconciliation/incorporation

3. What the patient also had to do:
a. Authorization
i.   Can’t be done
ii.  Manually provide authorization for the transaction
iii. Nothing (i.e. authorization was covered by federal and state laws/regulations and that patient had provided any other required authorization/acknowledgement prior to transaction so transaction can be automated)


These measures can be applied to specific types of data (e.g. Medications, Problems, Allergies, Immunizations, Test Results, etc…) or document-level data (e.g. Patient Summaries, Care Plans, etc…)

I’m not sure how to automatically measure these, so they probably require attestations based on certain types of data as noted above (e.g. Test Results and Discharge Summaries).

HOWEVER, it is important to note that the scores on these measures do not reflect on the capabilities of an individual provider, their EHR vendor, their EHR’s implementation/training, the community/state/national infrastructure, the available standards, or the local/state/federal laws/regulations.  Instead, it is a collective measure of all these combined.  So while I think it’s important to measure these as a nation (because you can’t improve what you can’t measure), I do not believe that you can force Hassle-Free HIE by measuring and penalizing providers for things that are out of the control of the providers.  You first need to create the national infrastructure to give the providers the opportunity to be successful (see below).  Only then can you use positive incentives to encourage interoperability; but it’s still not fair to impose punitive payment withholds.  While I recognize those are essentially the same, the difference is the message that you send when you market this…

In order to accomplish Hassle-Free HIE, we need these catalysts that are missing today:
1. National federated Master Patient Index (MPI) network
a.Standards for patient demographic recording
b. Standards for patient matching algorithms
c. Shows how to communicate with patients, including Personal Health Records
d. Shows proxy relationships and how to communicate with them
e. Show authenticated devices and how to communicate with them

2. Relationship Listing Services (RLS) affiliated with the MPIs
a. Show providers affiliated with patients and their roles (e.g. PCP)
b. Show patient authorizations for communication with specific providers
c. Show provider subscriptions for specific types of information, including events

3. National federated Provider Directory network
a. Show provider services offered
b. Show provider capabilities to communicate electronically, including necessary certificates/addresses
c. Provider Directory is automatically updated/maintained by EHR that each provider uses

4. Standard consents/authorizations
a. Types of data, uses of data, restrictions on redisclosure, timeframes, etc…
b. How to convey requirements and assert that they have been received from patient
Hc. ow to convey authorization for proxy access (e.g. to parents of minors, or children of elderly parents) on behalf of patient

5. Standard vocabulary for orderable tests and procedures

6. Standard APIs
a. Querying data from EHRs
b. Submitting device data to EHRs

7. Support and encourage free text summaries of problems and encounters
a. C-CDA updated to allow free-text descriptions/explanations of Problems in the coded data part of the Problem Concern Act and Problem Observation templates
b. EHRs capable of generating C-CDA R2.1 documents that include free-text descriptions/explanations of Problems and Medical Decision Making in the Assessment or Assessment and Plan Sections
c. Other document and API support for free-text problems and encounter summaries

Thank you for this opportunity to provide input into the future of our healthcare system."

Unity Farm Journal - Second Week of April 2016

I’ve returned to Unity Farm after another round of international travel - this week was 48 hours in the UK.   It seems that every time I travel, the weather turns cold and Kathy is left to keep the animals safe and warm.    A few hours before I boarded the plane, 4 inches of wet heavy snow covered the farm in a thick paste.   Tree branches fell and the blueberry netting collapsed under the weight of the ice that collected unexpectedly on the nylon fibers.

I did my best to shake the ice free and stack the netting in a protected corner of the orchard but I ran out of time.    I left the farm in the most stable state possible and readied the animals for cold days ahead.

While I was in London, the pigs, birds, and alpaca had to bear with 16F,  a record 100 year low for mid April.    This winter we had temperatures as low as -17F, but the variation was from a baseline near 0F.   In April, we had 78F temps, so 16F was a shock to the system.    The animals had their heaters, fresh hay/water, and blankets, but the apple trees/blueberries had their buds exposed to the unseasonable cold.    We may have reduced fruit crops this Summer.    The pigs never came out of their warm winter palace during the storm.

This weekend we're brewing Honey Lager, cutting up the tree branches that fell in the recent storm, and hopefully planting our hops.    It's time for the snow to be over!

Dispatch from London

I’m in London today with Bob Wachter, Dave deBronkart , Julia Adler Milstein, David Brailer and others working on healthcare IT planning for the National Health Service England.

The actual report will be crafted from now to June, but in general my impression is that the UK is exploring exactly the issues the US has tackled over the past 5 years.

Applicable US lessons learned include

1. Investment in people is even more important than technology

2. Interoperability needs to use case based with requirements crisply defined

3. Digitizing existing workflows is not very helpful - future state planning needs to envision the possibilities created by automation instead of “electronic paper”

4. Policies must be created and culture must be changed before disruptive technology is implemented

5. Scope, time, and resources are inexorably linked.    You cannot have infinite scope in zero time with few resources.  Haste makes waste.

My sense is that European economies  including the UK are struggling economically and government is looking for quick wins based on technology return on investment.   Unfortunately I’ve never experienced an IT project with a  measurable return on investment.

The UK is wonderful country with a rich history and amazing people.    Our group will do everything in its power to share the HITECH/Meaningful Use experience so that the UK benefits from our successes and avoids our failures.

Introducing Snapchart

Check out this game changer - Snapchart deletes patient information as soon as it’s viewed.

What could be more secure than an empty EHR?

Be sure to watch the video!