Thursday Unity Farm Journal - Second Week of October 2015

We had 4 inches of rain this week, bringing a welcome end to the drought of the past 30 days.   Over the past few years we’ve worked hard to regrade the landscape around the farm and ensure water drains away from buildings.    Not a drop entered any structure.

The nights are turning cold and we’ve restarted the fireplaces at night.   I welcome the opportunity to spend evenings around a cheery fire.

We’re splitting the last of the 2015 harvested wood - ash and cedar can be burned without aging, but all other woods will be cured for a year.

We’ve cleaned the barn loft in anticipation of our 2015 hay delivery - 4 tons of second cut arrives this week.

This week we replaced the barn doors that were over 20 years and starting to decay.  Our first clue was the one foot hole the geese poked in the rotting wood.

I put the finishing touches on the zip line this week, adding a backup stop block, just in case the brake fails.   I also built a landing platform that allows the rider to stand, step, and unclip before climbing back to ground.

We picked apples - everything in the orchard that was over 15 Brix.   My favorite eating apples are Empire and Macoun, which we’ve set aside.  We’re making craft cider from the Ben Davis, McIntosh, Cortland, Pink Lady, and other varieties.    Some have have asked if we have help with the harvest.   Here’s a photo of our 4 picking staff, who really enjoy eating apples and pears during the process.

Cool Fall nights are great for growing lettuce.   Here’s a photo of the lettuce harvesting crew

Our smallest rooster, Tyrion (Bantam Cochin), has paired with our largest female, Midnight
(Jersey Giant).    We look forward to seeing the offspring of that pair!

Our last major project of Spring is replacing our aging driveway before the snow falls.   We’re digging down 9 inches, adding course rock drainage and using pavers instead of asphalt.    Kathy designed a compass rose to sit at the center drive and the serve as a directional guide for all our farm locations.

I do not sleep much, which works out well on farm that requires me to check on the animals in the middle of the night.   At 2am last night, the geese were particularly upset.   In the morning, I found out why - a raccoon had been pestering them but could not enter their secure pen.    As soon as we let the geese out in the morning they chased the raccoon back to its home in the hollow of a tree - here’s what a raccoon looks like after it’s been chased by angry geese.

The weekend ahead (Columbus Day) is packed with cider making, mushroom log inoculation (Japanese Reishi mushroom), garlic planting, and preparing the farm for my absence next week in China.

The farm will miss me as much as I’ll miss it!

The CMS and ONC Final Rules Arrive

Steve Posnack from ONC declared today IT Bonanza Day.   The Interoperability Roadmap, CMS Meaningful Use Final Rules with a Comment Period (Stage 2 and 3) as well as the ONC 2015 Certification Rule were published today.

Here are a few resources to help you navigate these rules

A press release for today’s announcement 

For more detailed information about today’s announcement

For more information on the CMS final rule with comment period

For more information on the ONC final 2015 Edition Certification Rule

The EHR Incentive Programs final rule itself

The 2015 Edition Certification final rule itself 

Here’s my first impression:

It remains to be seen how the comment period on the EHR Incentive Programs final rule will be used to align the Meaningful Use program  with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) effort.    It would not surprise me that the CMS final rules are not really final.

There will be one Meaningful Use rule that will cover 2016 to 2018 both modifications (to Stage 2) and Stage 3.

The final rules are not substantially different than the proposed rules, but the thresholds have been reduced.   Given that existing certified EHRs were created to support the previous  Stage 2 thresholds, I'm guessing vendors will have to modify code to support the changes.  

2017 will still be an optional Stage 3 reporting year.   2015 will be a 90 day reporting period for everyone.

Quality measures have not changed, but the industry will have to support other initiatives in merit-based performance that have requirements.

In the upcoming days, I will review the certification criteria in detail.   Immature standards such as HPD for provider directory query have been removed.  Others such as DS4P for data segmentation are included but are not required.

CMS and ONC have incorporated many of the changes requested by professional organizations and expert commentators, which is a good thing.

I'll post details and briefs on these rules in the next week.

The Joint HIT Standards and Policy Committee meeting

All the members of the ONC Federal Advisory Committees met in Washington to review delivery system reform and the Interoperability Roadmap.

We began the meeting with a thank you to Jodi Daniel, who will be leaving ONC after 10 years of service.

Elizabeth Holland presented a data update on the Meaningful Use program.   She noted that 2015 attestation will open Jan 4, 2016-Feb 29, 2016.  The Meaningful Use Stage 2 final rule has not yet been released (but rumor suggests it may be released later today).

Next, Karen DeSalvo presented a Delivery System Reform Update  setting the context for the kinds of interoperability needed in the future as fee for service is replaced by population-based payment.

Kate Goodrich presented the Medicare Access and CHIP Reauthorization Act (MACRA) request for information which was mandated by the sustainable growth rate fix.

The afternoon was filled with a review of the Interoperability Roadmap by Erica Galvez and Steve Posnack.  The roadmap is divided into three themes - drivers, policy & technical components, and outcomes.

A very good discussion and our last in person meeting for 2015.

Not only ONC is working on these issues, but also the private sector is stepping up its efforts.     Last week the CEOs of every major EHR company in the country met in Salt Lake City, convened by KLAS to have a two day discussion with leading provider organizations and informatics experts.   The end result - a consensus on the objective measures we can use to quantify interoperability.   The message to Congress and to all stakeholders outside of government is that an independent entity will be publishing transparent quantified measures of health information exchange that can serve as the basis for understanding our current position and trajectory.    We’ll understand gaps, barriers, and next steps.    Every vendor CEO agreed that interoperability is a public good  that should be embraced by all.  You’ll hear more about this meeting soon.

The Early Experience of ICD10

Many in the press have asked me about the first few days of ICD10.   The answer for my institutions, like many, is that other than a few small refinements, the impact has been unnoticeable.

We trained 850 ambulatory clinicians in comprehensive ICD10 code entry and all are entering electronic billing tickets using the new vocabulary.

All our provider order entry systems have Medicare Advanced Beneficiary Notification logic using ICD10 and our clinicians are using it.

Every financial system is able to process both ICD9 and ICD10 to support patients who were admitted on 9/30 and discharged on 10/1

We added some subtle post go live modifications to decision support logic, ensuring all ICD10 codes are supported and we modified some very esoteric charge entry items directly related to the transition day.

Our ICD10 go live scorecard listed only 5 minor issues across all sites which our local teams were able to review and quickly close.

Congratulations and thanks to all involved in this extremely smooth go live.   Our next steps will be monitoring the coding of the initial inpatient cases and payer submissions along with watching reimbursements over the next 60 days.   We’ve done all we can to prepare.  Let’s hope the ecosystem around us can process our transactions with the same resilience.

Unity Farm Journal - First Week of October 2015

When we first moved to Unity Farm, I became a timber expert - managing 15 acres of oak, maple, cedar, birch, poplar, and hickory.   I learned about the character of each of the trees, their wood, and their ecosystems.

By building the Unity Farm tree house, I became an expert in tree house support systems, ensuring structural stability while avoiding harm to the tree.

Last weekend, building a 300 foot zip line, I’ve learned how to create transportation systems between trees.   There were many lessons learned.

First, everything you’ve seen in movies about zip lines is false.  Batman just shoots a cable into a wall and then glides down the 45 degree slope.    Not possible.

Zip lines are typically constructed with a 6% slope.  An 8% slope would be very exhilarating.   A 10% slope would be terrifying.   Anything greater would be deadly.

First, I used a sight level to assess the change in elevation of the topography of the Unity farm upland forest.

I chose two trees, 300 feet apart, that were 2.5 feet in diameter with an appropriate elevation difference.  

I then applied a protective 12 inch collar of 2x4s around the trees such that the zip line would be 7 feet high at the termination.   I created a 6% rise over 300 feet to the launching tree.   Can you find the straight cable going through the forest in the picture below?

Using a cable grip and come along tool, I pulled 5/16’s aircraft cable between the two trees and attached it to the trees by using a separate piece of cable around the 2x4 collar and turnbuckles.     Here's a photo of the tree at the end of the run

I ensured the cable was not piano wire tight, but had about a 2% sag.  

I created a 30 foot bungee brake set at 60 feet from the termination.  

Donning a climbing helmet, harness, carabiners, and climbing sling, I attached myself to a trolley pulley on the line.    Just in case my planning failed and I needed medical attention, I put my cell phone on my harness and launched.

I survived the experience, going from tree to tree at about 30 mph.   The brake worked perfectly and I stopped about 15 feet from the end point.

There is a bit more work to do, creating a landing platform that makes it easy to unclip the harness from the trolley, but I’m impressed by the ease of creating and managing zip lines as long as you have the right equipment and tools.

Last weekend I did another refractometer check of the apples and the Macoun, Gala, McIntosh and Northern Spy are all at 15% sugar.    We’ll harvest them this weekend.

For our first cider batch of 2015 we chose a two parts Honey Crisp, one part Gala, and one part McIntosh.   The apples are in our walk in refrigerator, ready for crushing this weekend.

A local resident was recently asked to give up his rooster because neighbors complained about crowing at all times of day and night.    At Unity Farm, we have crowing, barking, honking, quacking, and buckwheating (Guineas) 24 hours a day, so extra crowing would not even be noticeable.

The rooster is a bantam cochin - small chicken with a very ornamental look.    His size may be small but his personality looms large over the barnyard.   In homage to Game of Thrones, we named him Tyrion.   Here’s a photo

I travel to China on October 15 for a week, so the first part of the month will be finishing all the harvesting and cider making before I leave.    This will be my last year of traveling in October.   Planting can be done at many times during the year, but harvest is always in October.   As my wife says, living things must take precedence

Confidence versus Competence

Sometimes an article inspires and resonates with me.    Such was the case two weeks ago when I read about an alternative to the Peter Principle, that suggests you are promoted  to your level of misery, not your level of incompetence.

However, incompetence still exists.   We’re reminded in the press on a daily basis that we have presidential candidates who are absurdly unqualified.  

This week, I read an article in the Harvard Business Review that asks us to separate confidence and competence when evaluating people.  

Donald Trump is confident (a legend in his own mind) but is he competent?   Carly Fiorina is certainly confident, but did her track record at Lucent and HP illustrate leadership competence?

I’ve hired hundreds of people in my life and my track record has been generally good.

The few mistakes I’ve made, which resulted in voluntary or involuntary separation from the company, have occurred because I was blinded by self-confidence.

In a one hour interview, a person who uses all the correct jargon, is assertive, and is forceful about their opinions can appear competent.   Of course, confidence does not imply an ability to lead a consensus discussion, build bridges among stakeholders, or adapt to changing technology.

When I promote from within, it’s easy to evaluate competence because there is a known, objectively observed track record.

When I hire new leaders from outside of healthcare  - and it is important to hire innovators with a different perspective - there needs to be an objective screen for competence.  

You’d think that references could be such a screen, but all of my  “bad hires” have had glowing references.  Of course, these references were not from people I know.  It makes me wonder if the applicants pre-arranged “reference” calls from their relatives/friends or if the previous employers could not give a compete reference because of legal/separation agreements.

Epic does something novel - it gives prospective employees a written exam that assesses logical thinking and problem solving, not healthcare domain knowledge.

BIDMC has used personality classification instruments to predict cultural fit but has not used any other specific competence tests.

In academic medicine, we sometimes hire leaders for the wrong reason - success with grant applications, a stellar publication record, or amazing teaching skills.  These may not imply anything about management competence.

The Harvard Business Review article and personal experience opened my eyes to the need for objective criteria for competence.   Epic has the right idea with their competence test.  About the only substitute for such a test would be a reference from someone you know and trust.   My fellow CIOs are always candid about strengths and weaknesses of our colleagues.

I described the competence/confidence dilemma to a fellow leader earlier this week.  They’ve told their children to rely on confidence to get them through a situation for which they lack competence.    Good advice for prospective employees, but probably not for prospective employers!   Food for thought.

Unity Farm Journal - Fourth Week of September 2015

The temperatures are in the 40’s at night, the pastures are covered with dew, and the pumpkins are ready for harvesting.    Fall arrived this week at the Farm.   Here's the front door of the farmhouse today.

The forest creatures know that winter is coming - our raptor activity is at an all time high with red tail hawks, cooper’s hawks, and owls circulating the barnyard.   The poultry spends their day in the forest, under their Caravan canopy, or tucked under shrubs.   One pheasant was eaten (we found her remains) but the ducks, geese, guineas, and chickens are all healthy.

At night, the barred owls are calling.   Our Great Pyrenees hear them in the woods and bark to keep them away from the barnyard.    The call of the barred owl is very distinctive , it sounds something like “WHO barks for you”

The Shitake mushroom logs are fruiting with the onset of cold, moist nights,   Here’s what 50 pounds of fresh gathered Shitakes looks like.

All the pumpkins, squash, eggplant, tomatoes, and peppers have been harvested.   The lettuces and root vegetables are timed for weekly winter harvests.

The tree house has been working out well, but it’s challenging to carry honey lager up the ladder, so I built a hoist on a nearby tree.  I’m working on a plan to add walls, a roof and a small cast iron wood burning stove to the tree house.   It will require an insulated stovepipe and protections against fire.   Burning wood in a tree house does sound a bit odd, but watching the snow fall while warm inside the tree house will be magical.    For the moment I'm using my tree house desk for writing.

This weekend I’m engineering a 300 foot zip line from the tree house to the farm house, aiming for an 8% grade and taking into account 2% sag of the 5/16 aircraft cable due to the weight of the rider.   There are many unknowns (i.e. I do not know what I’m doing).   I’ll safety test it with a simulated human (logs) before I climb aboard wearing full protective climbing gear and a helmet.   Wish me luck.

Cider pressing begins this weekend and we'll be fermenting McIntosh, Macoun, Gala, and Northern Spy.    The work of summer is waning and now the joys of the harvest are upon us.