Unity Farm Journal - Fourth Week of May 2016

What is the definition of the perfect wedding?   Joy, love, happiness, inspriration and energy are felt by everyone?    Families come together without conflict, embarrasment, or awkwardness?   The guinea fowl avoid flying over the guests?

If that’s the definition, my daugther’s wedding at Unity Farm this weekend was a 10 out of 10.

Here are two photos

My daughter Lara and my son in law David designed the ceremony, wrote the vows, and created an afternoon at the farm in which all the guests told stories about their lives with the bride and groom.   We had 18 guests total - just family and close friends.

We drank Unity Farm beverages, ate Unity Farm foods, and gave farm tours - the tree houses, the pigs, the vegetables, the trails, and the revolutionary war era graves.    We even picked "marriage carrots".

I’ll post a digital album of the festivities soon.

Although the wedding prep, events, and cleanup consumed our weekend, we still were able to deliver vegetables to the Tilly and Salvy’s farm stand.   Here’s my notebook entry

1 case Farmhouse cider
2 dozen eggs
1.5 pounds of Shiitake mushrooms
6 heads of Romaine
24 Atomic purple carrots
1 pound kale
1 pound mache
6 heads of Bibb lettuce

We’re truly a small family farm delivering items picked by hand and grown with care.   This weekend, we’re running a mushroom mini-course.  We may offer educational seminars on weekends in the future.   We’ll continue our summer planting - marketmore cucumbers, purple bell peppers, and bellstar tomatoes.   The berries are all in flower and the farm is burst of green everywhere - we’re at the peak of Spring growth, which provided the perfect setting for a relaxed wedding.

A Zero Tolerance Policy for Business Spam

In 2011 and 2012 I wrote about the increasing problem of Business Spam - unsolicited, unconsented advertising that has grown in volume to the point that it constitutes more than half of my email .    In 2016, I’ve done an experiment - I’ve not opted in to any newsletter, any website offering notifications or any vendor offering information.   I’ve monitored my mailbox for violators of good email practices.

This month, we put a stop to it - cold turkey.   Anyone sending business spam is now blocked from the 22,000 users of Beth Israel Deaconess and its affiliates.

Here’s how we did it - using a commercially available appliance we have black listed organizations which send bulk email and companies which violate unsolicitied email policies.

I realize there are many categories of activity going on here

1. Those who have my contact information for a legitimate business reason but sell that information without my consent.  Maybe there is something buried in a conference registration that suggests my information will be sold, but I’ve never found such a disclosure.

2.  Those who create mailing lists by guessing at email addresses.   John.halamka,  halamkaj, john_halamka, halamka.john are all guesses since I’ve never used such addresses on any materials.

3.  Those who facilitate bulk mailing.   I’ve had conversations with the management of companies that provide bulk mailing services such as newsletters/product updates/special deals.   Many of these bulk mailing companies have sound anti-spam policies.   However, they have to trust that organizations which use their services adhere to the policies, accepting attestation that consent/subscription has been obtained from receipients on mailing lists.   Many customers of bulk mailing outfits submit false attestations.    Remember, I’ve not opted into a single thing in 2016 and I’m receiving hundreds of bulk emails every day.

May of 2016 marks “email liberation” month at BIDMC, since  we put a stop to the electronic equivalent of garbage passing through our email gateways.   This Zero tolerance for bulk email approach may very well transform email into a once again useful medium for communication.   Sure, we’ll implement secure texting and groupware over the next year as alternatives to email, but there is a chance email could be salvaged.

My email box has gone from 1500 emails a day to 150.    If everyone does this, maybe the business spammers will stop their flood of unwanted communications.

Viva the email liberation!

A Multi-Stakeholder Discussion in Washington

On Thursday, I spent the day in Washington with a group of government, provider, and developer sttakeholders convened by the Institute of Healthcare Improvement.      We operated under Chatham House Rules, so I can summarize the discussion but not identify any of the participants or their specific statements.       Below are three questions we discussed and the observations we made:

1.  What worked in CMS and ONC rules (HIT related regulations)?
*Meaningful Use  provided a foundation of basic electronic record functionality
*We enhanced systemness thinking and created learning groups to address vulnerabilities in discconnected systems
*We made safety improvements and enabled analytics
*We enhanced patient engagement and dispelled several myths
*We automated quality measurement processes and recorded social determinants of healthcare
*We encouraged EHR optimization
*We enhanced  Interoperability for public health transactions, eprescribing and entry of vocabulary controlled data (problems/meds/allergies/labs)
*We incentivized new entrants into the marketplace
*We enabled standardization of workflows
*We found that CMS was a good listener
*We began to engage post acute providers
*We caused infrastructure to be upgraded (to support EHR implementation)
*We enabled remote access to records
*We created an ecosystem for home care devices  and wearables to become relevant
*We taught stakeholders that clinical automation is not an  IT project
*We began to focus on the user experience

2. What didn’t work or could have been done better?
*Products were rushed to market and they were not as usable or as intuitive as we’d like
*We did not achieve a consensus on national priorities - where we want electronic records to be in 5 years
*We did not include behaviorial health providers
*We did not enable team communication
*We did not enable substitutable apps that can be shared across vendors
*We required too much non-valued data entry
*We often digitized the  paper world
*We ended up with regulatory complexity
*We required too many clicks, causing a loss of patient focus
*Once the foundation was laid we did not have time to digest the changes, interatively improve and innovate
*Certification consumed too many development resources
*We hired scribes as a workaround to overwhelming  data entry requirements
*We required documentation to satisfy legal and regulatory concerns rather than patient care needs
*We demanded Interoperability without first building enabling  infrastructure
*IT service levels did not always align with clinical requirements
*We underestimated the burden of the impact of HITECH on providers and developers
*We made patient engagement too hard
*We did not turn data into information, knowledge and wisdom
*We focused on compliance instead of joy in the workplace (or joy for the patients)
*We did not enable the marketplace to meet customer demands
*We focused on billing rather than clinical workflow
*We tried to do too much, too soon

3.  How do we shape the future based on lessons learned?
*IHI  Leadership Alliance/EHR workgroup should submit a comment letter about  MACRA/MIPS to CMS
*Reconciling the tension among Developers, Government , Providers, Patients   will required  argreement about who is the user/customer, what is success, what is considered a good outcome
*Instead of just Interoperability we need to think about the functionality needed for a collaborative work and a more uniform  user experience
*We need to build Infrastructure enablers - a catalog of constrained standards, a national patient identifer (or private sector solution i.e. CHIMEchallenge/Commonwell/Surescripts/CareEverywhere), a national provider directory, a trust fabric, uniform consent policies among states
*We need to align economic incentives among stakeholders
*We need to consider the impact of the emerging consumer driven digital ecosystem
*We need to recognize that the EHR is not the center of the universe and enable other tools such as EHR agnostic warehouse solutions
*We need liquidity of claims data
*Documentation/coding rules need  to enable team-based care by all clinicians
*We need education to dispel fear of HIPAA and enable a culture of sharing

Unity Farm Journal - Third Week of May 2016

Wedding plans have occupied much of this week at Unity Farm, ensuring that my daughter’s marriage weekend has perfect logistics.    A wedding on a farm is more challenging than you think - how do you prevent flying guinea fowl from leaving “gifts” on the guests?   Should the pigs be moved to minimimze squealing during the ceremony?   How do you prevent chickens from eating the flowers?   We’ll be serving Unity Farm foods and beverages, accompanied by vegan/vegetarian catering.   The family begins arriving tonight.

This week, another goose,  Hermes, was born.    Our weather has been very unusual and we’ve had a series of nights with temperatures in the 30’s.    Hermes was wet and chilled while hatching and became hypothermic.   We warmed and dried him in the incubator then placed him in the brooder.     He was so weak that he could not stand/walk and had splayed legs 

We’ve treated splayed legs in guinea fowl before so we knew how to make a brace, keeping the femurs aligned so that the hip joints would not develop laxity.  It’s critical to intervene on the first day of life, otherwise the bird will never walk.  With the brace in place, fresh food/water, and physical therapy every few hours, Hermes gathered strength and today he is walking.   We’ll return him to the goose house today or tomorrow.    We named him Hermes because we knew he’d heal and become a swift runner through the barnyard.

The transition from winter crops to summer crops continues with tomatoes, peppers, eggplant now filling beds that held lettuce, spinach, kale, chard, and carrots.    We built a 16x16 foot raised squash bed outside the hoop house, which gives our kabocha (Japanese pumpkins) plenty of room to spread.    

Now that we have so much produce production, we’ve had to improve the efficiency of our harvest and packing operation.   We built a wash stand so that vegetables go from raised bed, to washing, to packaging, to farm stands in minutes.      On Sunday morning, before anyone in the wedding party is even awake, we’ll be delivering lettuce to Tilly and Salvy’s.

In between wedding planning and project work, Kathy has been hard at work on bee hives this week.    It’s the time of year when bees tend to expand their territory and she’s been called all over the Metrowest area to capture swarms.    Unity Farm is the temporary home to many new colonies this week since Kathy has been climbing ladders, cutting swarm covered branches and placing them in “nuc” boxes.     She’ll be creating more hives and spreading the bees among the many hive hosting locations she’s now managing.     We’ll likely end up with 25 hives by the end of the season.

I’m in Washington today, attempting to constrain healthcare IT regulatory zeal.    Tomorrow is a day off to finish all the wedding details.    Pictures to follow next week

Unity Farm Journal - Second Week of May 2016

It’s Spring so it’s time for new farm babies.   Welcome Athena and Apollo, two baby geese born this week.    They have the benefit of 3 mothers and 1 father watching over them.   The adults took them to the pond and taught them how to swim within a few hours after hatching.   We’re keeping the goose pen closed during the day when we’re not around because of all the hawk activity.   A week old goose is an easy target.

Temperatures are edging up to the mid 70’s so the pigs are getting hot.   Yesterday, we moved them to their summer paddock with its shade and cool mud.   The pigs are very smart and aren’t sure why they are on “vacation” from their usual home, but I’m sure they will adapt soon.

Now that the weather is warmer we’ve been able to drain, clean and maintain all the ponds around the barnyard.   A winter of accumulated goose poop can create quite a cleaning challenge, including a rotten egg or two in the muck.    All our water features are running perfectly now and we’re ready to be the local watering hole for dozens of species over the summer.

This week we sold lettuce, mushrooms, and spinach to Tilly and Salvy’s, our local farmstand.   We’re learning an immense amount about consumer behavior  - what we should grow and how we should package it for maximum sellability.   Although we’re nearly done with our Umass organic farming courework, it’s the day to day activity of selling at retail that really teaches you farming.  

Our organic certification application was accepted as complete this week, so now we await our unscheduled inspection (a kind of Joint Commission visit for organic farms) and then hopefully we’ll join the ranks of USDA certified organic producers.  

In today’s complex world, certifications and compliance require perseverance.   We’re one of 7 bonded cideries and one of 72 bonded wineries in the state of Massachusetts. Add the organic certification to that and Unity Farm will be unique in its accrediitions.

Kathy is very busy with the bees now that we’re approaching honey making season.   We’ll be running about 25 hives this year in 4 locations.   I suspect this will be the year that we’ll upgrade our hand cranked honey extractor to something more automated.

This weekend we’ll be doing the final preparations for my daughter’s wedding next weekend at the farm - trimming, planning, and cleaning.   By next weekend, we’ll be ready for the cover of Farm Beautiful magazine!

Rethinking MACRA, a follow up

In my blog posts, I speak from the heart without a specific political or economic motivation.   Although I’ve not written about highly controversial subjects such as religion, gun control, or reproductive policy, some of the topics in my posts can be polarizing.   Such as was the case with MACRA.   Some agreed with my initial analysis that clinicians will have a hard time translating complex MACRA payment processes into altered clinical behavior.   Others felt I was overharsh, negative and inappropriate.    It’s never my intent to criticize people, instead I want encourage dialog about ideas.    In that spirit, here’s my opinion on how we should evolve from fee for service to pay for value/outcomes.

1.  Humans can never really focus on more than 3 things at a time.  Although we sometimes believe multi-tasking is efficient, in reality we do work faster with less quality.    Instead of 6 or 8 dimensions of Meaningful Use performance combined with a large number of quality indicators, why not delegate each medical specialty the task of choosing 3 highly desirable outcomes to focus on each year, then reward those outcomes?  For example, I have glaucoma.   Asking my opthalmologist to record my smoking status or engage in secure messaging with me is probably less important than ensuring my intraocular pressures are measured, appropriate medications are given, and my visual field does not significantly worsen.    The cost to society of my blindness would be significant.    Keeping my sight intact represents value.   Care Management software could ensure I’m scheduled for pressure check appointments, given medications, and have my visual field checked once per year.   Some percentage of reimbursement could be withheld until those outcomes are achieved. How  software does that is not important and innovative workflow would be left to the marketplace where clinicians will choose applications based on usability, cost, and time savings instead of regulatory oversight.

2.  Care coordination is important and there is a role for government to drive consensus around standards selection.   Certification could be limited to an application’s ability to perform a few key interoperability functions such as

a.  Look up a recipient address from a national provider directory and send a clinical summary of care (transition, referral request, consult note) to that address securely

b.  Query a record locator service/master patient index and retrieve a list of electronic addresses where patient data is stored, then be able to retrieve a small common data set from those locations (problems, meds, allergies, labs, notes)

c.  Be able to send a clinical summary of care to a patient provided electronic address.

d.  Be able to send a small number of data elements to a relevant registry

e.  Be able to participate in a prescription drug monitoring program

Each of these functions would use a single standards implementation guide without significant optionality,  tested in the marketplace and deemed mature enough for use.  How these transactions are implemented in workflow would be up to each vendor.    Certification would test nothing more than successful transactions against a publicly available test bed.

3.  All other Meaningful Use criteria and quality measures would be eliminated so that clinicians can focus on just the three goals per year relevant to their specialty while  working in an environment that thrives on the simple information exchanges listed above.

We need to avoid unnecessary burden for clinicians, hospitals and software developers.   Think about all the effort (and dollars) spent during the Meaningful Use Stage 1 and 2 processes to report quality measurements, which were never used for anything.   Think about all the certification done that was not related to health policy goals or outcomes.  Think of all the data entry required which resulted in clinicians  spending time practicing below the top of their licenses.  

Focusing on 3 outcomes per specialty which are easily measurable, while radically focusing certfication on a few key interoperability transactions is likely to be acceptable to provider and developer stakeholders.   The big question - would it satisfy CMS goals for MACRA based on Congressional mandates?  I hope to have that dialog in several forums over the next few weeks.

A Deep Dive on the MACRA NPRM

As promised last week, I’ve read and taken detailed notes on the entire 962 page MACRA NPRM so that you will not have to.

Although this post is long, it is better than the 20 hours of reading I had to do!

Here is everything you need to know from an IT perspective about the MACRA NPRM.

1.  What is the MACRA NPRM trying to achieve with regard to healthcare IT?

The MACRA NPRM proposes to consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs), creating a single set of reporting requirements.  The rule would sunset payment adjustments under the current PQRS, VM, and the Medicare EHR Incentive Program for eligible professionals.

2.  Who is affected?

In the MACRA NPRM, the word Eligible Professional is replaced with the term Eligible Clinician, expanding the population of individuals covered by Merit-based Incentive Payment Programs (MIPS).  MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.   Hospitals are not affected by this rule and  hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.

3.  When does the rule take effect?

The rule proposes that the first performance period would start in 2017 for payments adjusted in 2019.   It’s not exactly a stimulus program - some clinicians will see reduced payments for non-performance and some will see enhanced payments for exemplary performance - a zero sum redistribution of payments.

4.  Does Meaningful Use and electronic clinical quality measure reporting go away?

MACRA’s enactment altered the EHR Incentive Programs such that the existing Medicare payment adjustment for a eligible professionals ends after calendar year 2018.  Generally,  MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for professionals in the Medicaid EHR Incentive Program.

Meaningful use of certified EHR technology is renamed to  “advancing care information” and the criteria are streamlined - removing the CPOE and Clinical Decision Support requirements.   In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures.   By 2018, clinicians need to use 2015 edition certified technology and report on six Stage 3 measures, described below.

Quality measures will be selected annually through a call for quality measures process.

5.  What is the role of ONC and Certification?

On March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight, requiring that clinicians give access to their EHR for “field inspection” of functionality by ONC.

The MACRA NPRM proposes that clinicians must attest they have cooperated with ONC surveillance and oversight activities.  Further, they must attest they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

6.   What are the MACRA advancing care information objectives and measures that have replaced Meaningful Use?

The six criteria which are required as of calendar year 2018 are

1. Protect Patient Health Information - Security Risk Analysis
2. Electronic Prescribing
3. Patient Electronic Access - Patient Access, Patient-specific education
4. Coordination of Care through Patient Engagement - View/Download/Transmit, Secure Messaging, Patient Generated Health Data
5. Health Information Exchange - Patient Care Record Exchange, Request/Accept Patient Care Record, Clinical Information Reconciliation
6. Public Health and Clinical Data Registry Reporting - Immunization Registry Reporting

Here are examples of the actual measurements:

Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

View, Download, Transmit (VDT) Measure: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either—(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology; or (3) a combination of (1) and (2).

7.  So what must a clinician do and when?

For the period January 1, 2017 to December 31, 2017 (yes, it’s a full year, not 90 days), clinicians must
a.  Use a 2014 or 2015 Edition Certified EHR
b.  Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:
c.  Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHR
d.  Attest to their support for health information exchange and the prevention of information blocking.
e.  Continue to practice medicine

Sorry, e. was an attempt at humor.    Listening to each patient’s story, being empathic, and healing are optional.     After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.    Sometimes when you remodel a house, there is a point when addtional improvements are impossible and you need to start again with a new structure.    The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them.    Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.    This may sound cynical, but there are probably only two rational choices for clinicians going forward - become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.

The folks at CMS are very smart and  well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.   I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.    I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow.    Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.

Unity Farm Journal - First Week of May 2016

I’ll be 54 this month and this week we delivered 54 heads of organic lettuce to Tilly and Salvy’s, the local farm stand selling Unity Farm products.  Who would have thought that my “portrait” would look like this at 54

Here’s what the fresh organic vegetabes growing at Unity Farm look like this week.

I dropped by Tilly and Salvy’s on Sunday afternoon and spoke with a customer buying our produce.    I introduced myself as the farmer and she thanked me for growing such wonderful fresh vegetables.

It’s been a wild week - I had to be in Chicago, Las Vegas and Houston from Monday-Thursday.     That left Kathy at the farm in charge of the maturing vegetables, animals at the peak of mating season (chickens, ducks, geese, and guineas are all broody), and our annual alpaca shearing.  When I agree to travel a year ahead of time, this always happens.   As a farmer, living things always come first, so travel becomes increasingly problematic (or stressful for your spouse!)

Shearing went well although it has been raining, so keeping the alpaca dry was an adventure.     Kathy called in a few friends to help.   No animals or humans were harmed in the process.

Also in my absence, a tree company removed  the “widowmakers” - trees that partially fell or branches that partially broke during the winter.    Now that the ground is drying out and mud season is over, the trucks can navigate the forest roads.    Although I do all the forest management myself, I draw the line at activities that could result in a 10 ton tree or 1 ton branch falling on me.

I’m flying back from Houston tonight after giving a commencement address at the University of Texas.

I’ve heard that the pigs miss our nightly tuck in rituals and the dogs are desparate to explore the territory that the coyotes have been visiting outside the paddocks.    It’s clear that there is a litter in the den since the female coyote is visiting the farm every day looking for food.  Thus far, her hunting activities have been unsuccessful.

I’ll spend the weekend doing all the farm work that I should have done on early mornings and evenings during the week.  The next few weeks will be a bit chaotic with my daughter’s upcoming farm wedding and move.    All is well.