Friday, September 28, 2012

The BIDMC Technology Ventures Office Conference

Today, I joined Kevin Tabb (CEO at BIDMC), Alexandra Drane (Eliza Corp), Nina Nashif (Healthbox), Graham Gardner (Kyruus), and Mark Chalek (Chief of Business Ventures at BIDMC) to explore Digital Health and Patients' Needs via a very energetic panel discussion.

Key themes we discussed - in order to create value for patients and families, an entirely new generation of products and services will be needed.   Ideas ranged from "Zagat" type guides to help patients select providers based on personal preferences, easy ways for patients to find appropriate clinical trials, and 'Facebook for Health' as a means for patients to seek and exchange data with a community of caregivers, family members, and supporting services.

In a world of healthcare reform, there is a need for better capture of data including patient generated data.   There is a need for more exchange of information for care coordination and population management.    There is a need for more analytics and decision support.   All of this must done while protecting patient privacy.

Although the conversation started with buzzwords like "cloud", "mobile", and "BYOD", it rapidly changed focus to patients and their families.

One thing is clear.   In order for an ecosystem of products to develop which enhance the experience of healthcare, there must be more data liquidity.   Silos of information and silos of care must be eliminated.

Massachusetts goes live with its statewide HIE on October 15, 2012.   Several institutions in the Commonwealth have already implemented distributed/federated queries for clinical trials and clinical research.   State government is working on infrastructure to record and exchange consent preferences.   The ingredients for innovation are well aligned - funding, political will, and infrastructure.   Our rate limiting factors to improving the status quo are fear of the unknown and the challenges of managing the change itself.

A great discussion.

Thursday, September 27, 2012

Building Unity Farm - the Dogs and Cats

No farm can be complete without dogs and cats.

In the 1980 and 1990's, my wife Kathy raised Chow-Chows professionally.   We have fond memories of Syrah, Callie, and Thor, our champion dogs who all passed away from old age.

My daughter, Lara, loves Alaskan/Siberian Huskies and she learned to mush two Summers ago during a trip to Alaska.

When we planned Unity Farm, we knew we needed livestock guardian dogs.   Chow Chows guard their families but are not known for guarding other animals.   Huskies eat other animals.  We considered  Komondors, Anatolian Shepherd Dogs, and Great Pyrenees.  After significant research and visiting local farms, we selected Great Pyrenees.

We chose a pair so they could effectively work together against predators and keep each other company.   Bundle (short for Bundle of Joy) is our 10 month old female.  Shiro (Japanese for white) is our 12 week old male.   We do not intend to breed them and by agreement with her breeder, Bundle was spayed two weeks ago.    Shiro will be neutered at the appropriate time.

They are the best of friends and sleep together during the day, play together all afternoon and guard together at night.    Bundle is 60 pounds (the runt of her litter).  Shiro is already 30 pounds and per canine growth charts he will be over 90 pounds at maturity.

They guard the male alpacas - Stanley, Domino, and Midas.   Bundle has already chased away one coyote.    Shiro has lived with our Alpacas for over a month and he's bonded with them.   The only challenge he's had occurred when he squeezed into the female pen and was stepped on (accidentally) by our 300 pound llama.   Other than a small corneal abrasion (which we treated with tobramcyin opthalmic drops), he suffered no ill affects.

The only downside to Great Pyrenees is that they are very protective of their food and the two dogs have to eat separately to avoid squabbling.

Every night I take them for a long walk outside of the paddocks, exploring our forest filled with deer, wild turkeys, foxes,  owls, and really great wilderness smells for dogs.

Bundle and Shiro are true farm dogs, rolling in hay, playing in mud, and frolicking with chickens/guineas.   They have not shown aggressive behavior toward any prey animal, but they are quite aggressive with predators.

Although a traditional barn should have barn cat to control the rodent population, our two cats live inside.   Tigger and Lily are feral strays that we adopted 12 years ago.   At this point they enjoy lying in the sun, chasing dustballs, and munching kibble (to the extent their remaining teeth allow).    Tigger is a 16 pound male, and Lily is 10 pound female.    He enjoys as much petting as his humans can sustain.  She enjoys hunting, licking her humans, and giving gentle love nips.

Both are healthy and happy in their "retirement" as geriatric cats.

At the moment, the barn remains rodent free because we've stored all our grain in sealed aluminum containers.   I'll write about our hay, grain, and other food management next week.

As is generally the case at Unity Farm, our dogs and cats live in harmony with their surroundings and the other animals.   They all have jobs to keep them busy, and our dogs partner with us to manage the livestock, keeping them safe.

Wednesday, September 26, 2012

Mobile Devices for Medical Education

Today I'm doing a video teleconference keynote to a group in Thailand to discuss the use of mobile devices in medical education at Harvard.

Here are the slides I'll use.  Thanks to Jason Alvarez at HMS for preparing the data.

Key findings from the 2012 HMS Mobile Survey

89% of teaching faculty are mobile users
97% of students in their clinical years own a smart mobile device
49% of Preclinical Students own an iPad
37% of teaching Faculty have iPads
70% of HMS teaching faculty that have a mobile device use an iPhone

Creating mobile apps using mobile-friendly style sheets worked well for us in the past,   Native apps provide a better user experience so HMS has created an iPhone native app for use by clinical students who need a more responsive user experience in areas with slow internet connections.

Android devices are used by 23% of students.   HMS tries to support both Apple and Android platforms but Apple devices are always the first implemented and are easier to support due to their consistent configuration and predictability, especially around security management.

To help students and faculty find the best apps, HMS has created a "Zagat Guide" for apps that enables the community to share evaluations and ratings.   For example, the top 5 apps per the crowdsourcing input are

John Hopkins Antibiotics Guide
ePocrates Essentials
5 Minute Clinical Consult

Bottom line - the educational platform for 2012 is no longer the web, it's mobile.

Tuesday, September 25, 2012

Can We Stop Throwing Stones?

I'm a glass half full kind of guy and an eternal optimist.   I glorify progress and quickly forget defeat.

Often I feel that I'm in the minority.  Bad news sells.  Criticism has a Schadenfreude attraction - the apparent failure of others makes some feel more successful.

 Monday Morning Quarterback commentary frustrates me.

1.  Steve Jobs would have never allowed Apple maps to launch on the iPhone 5 and thus Apple is past its prime. 

In the business world, every company has its peaks and troughs.  I think of the greatness some Massachusetts companies like Polaroid, Digital Equipment Corp, and Wang Computer had in their day.   Today, there are empty buildings or construction sites where those once great companies used to be.

For those in operational roles, we all know how hard it is to keep the trains running on time while managing change and trying to innovate.   It's like changing the wings on a 747 while its flying.

At the moment, Apple is the most valuable company on the planet and the iPhone 5 sold five million units in 3 days.  

Yet, instead of stories (which I would personally find interesting) about how you manage a supply chain to deliver five million high tech products to customers in a weekend, the stories are about analysts expecting six million or more weekend sales and the earth shattering question about first generation Apple mapping software signifying the downfall of the company.  My comment - engineer an innovative product with minimal defects at multi-million scale.  After you've done that, write an article that incorporates your operational experience in the evaluation of vendors.

2.  Last week I bought a Prius C, trading in my 2005 original Prius with 150,000 miles.   The Prius C a joy to drive, with nimble steering, a very comfortable cabin, and 60+ miles per gallon  (mixed city/highway commuting).   I'm not sure what car Consumer Reports was driving when the put the Prius C on the "do not recommend list".    Increased visibility, a smaller size that makes it very maneuverable in traffic, and intuitive controls make the Prius C a winner.   My only guess is that the Consumer Reports writer owns a Ferrari or a Hummer and was evaluating the Prius C based on an inappropriate set of requirements.    I would like to see an automotive engineer describe the tradeoffs of weight, power, and gas mileage, then objectively evaluate all the hybrids on the market.

Bottom line - I welcome operational people  in the trenches sharing the good and the bad of their own experiences.    In a world of naysayers looking to take potshots at success, I have little tolerance for those who throw stones at those who are trying their best to make the world a better place.

Monday, September 24, 2012

The Countdown to the Golden Spike

On October 15, the Massachusetts Statewide Health Information Exchange goes live.   The "Golden Spike" for HIE in the Commonwealth is just 3 weeks away and we're all busy doing three things:

1. Modifying our clinical systems to read the statewide provider directory and public key infrastructure certificate repository

2.  Planning our workflows so that we generate continuity of care document/consolidated CDA XML clinical summaries for transitions of care

3.  Installing appliances in our data centers that will transmit our clinical summaries to among providers in the state

Many HIEs have struggled.  Many have closed.   Why is Massachusetts so excited about what we're doing?

We have a sustainability model based on the distribution of stakeholders we have in each category - large provider organization, medium provider organization, small provider organization, solo provider organization, payer, third party service provider, sub network etc. and their willingness to pay a subscription fee.

We have policies that support a trust fabric among all our trading partners.

We have technology that is inexpensive, easy to implement, and standards-based.

In my previous blogs about our State HIE efforts, I promised to provide updates.

Last week Partners Health care sent the first test transaction ("the Golden thumbtack")  by exporting a CCD from their LMR clinical system and placing the XML file with appropriate metadata in a directory on the HIE appliance installed inside their data center.   The file was sent via the state HIE gateway to a test recipient appliance.      We also validated that a receiving hospital could display the CCD within their EHR in human readable form (all certified EHRs can already do this since it's a stage 1 certification criteria).

BIDMC is installing its HIE appliance today.   Our plan is to export CCDs and Consolidated CDAs from our clinical system in response to specific triggers i.e. a discharge event, a consult event, an encounter note signing event etc.   and place these files with metadata in a directory so that the HIE appliance can send it via the Direct protocol to the designated recipient organization.

Thus far, most of the Golden Spike group of early adopters has elected to install an appliance in there data center to support standards-based transmission via Direct.   Since Meaningful Use Stage 2 requires Direct standards (SMTP/SMIME is required, XDR is optional), EHRs in the next year will be able to connect to the HIE without appliances.

The project is proceeding well, on time and on budget.   The technology works.   The participants trust each other and the anticipation for breaking down data silos is high.

And now off to a planning call to make sure we're "laying track" in perfect alignment with other participants.   We're getting the spikes ready for successful participants.

Friday, September 21, 2012

Cool Technology of the Week

Now that we have 50 animals at Unity Farm, we're responsible for their medical care.   Veterinary medications and equipment are very similar to those I use in human health care.

How do you tell if your llama is pregnant? Search for two heart rhythms.

How do you tell if your guinea fowl has ingested foxglove (digitalis) leaves? Look for bradycardia .

How can you get an EKG device that works in the barnyard?

There's an app for that!

The AliveCor Veterinary Heart Monitor  iPhone case and application provides a comprehensive EKG device that can be used on any animal.   It's not FDA approved for humans, but certainly could work on them.

An EKG in your iPhone - that's cool!

Thursday, September 20, 2012

Building Unity Farm - Manure and Fly Management

We have 50 animals at Unity Farm - alpacas, llamas, chickens, guinea fowl, rabbits, cats, and livestock guardian dogs.

Our "inputs" are second cut orchard grass hay, multi-grain chicken feed, a high protein game bird feed for the guineas, and various forms of kibble for the dogs and cats.

Our output is compostable manure.

Here's what we've done.

For the chickens and guinea fowl:

We created a 3 stage composting area and a mulch storage area, using compost bins made from lobster trap wire.

Every Tuesday we clean the coop and add the mixture of manure and wood shavings to the first compost bin.   We add water to the bin so that mixture is moist but not soaked.

Every morning I turn the compost and after a few days, steam begins to rise from as the bacteria break down the mixture of carbon (wood) and nitrogen (manure).   After a week, we move the compost from bin 1 to bin 2, and add fresh manure and wood to bin 1.  After another week, we move bin 2 to bin 3.   After another week, we move bin 3 to the mulch storage area.   From start to finish we get complete hot composted mulch in about 30 days.    That mulch is providing the foundation for our apple orchard, which we'll plant this fall (Empire, Macintosh, Russet, Honeycrisp)

For the alpaca/llama:

We created a 16x16 foot manure management containment area 4 feet tall.  Every morning we clean the stalls and paddocks using a Durafork and Muck bucket

"Llama beans" provide the nitrogen and hay/straw from the stalls provides the carbon.   We moisten this mixture and turn it frequently.   The management management area generates a fair amount of heat and with each new addition we mix the old and new, encouraging and active break down process.  

One side effect of all this manure management is flies.   They congregate around manure piles and lay their eggs in the cooler edges of the compost.   What have we done to manage flies?

1.  Prevent them from laying eggs in the first place - keep the compost hot!

2.  Once laid, prevent them from developing - we use parasitic wasps that are too small to bother humans.      Their offspring eat fly larvae

3.  For mature flies that escape our first two strategies, we use two types of fly traps - fly tapes and a handmade cedar fly trap that uses yeast to attract flies

With these three approaches, no flies bother our animals at all.

Although Unity Farm is intended to be a sanctuary for animals and an orchard/blueberry patch, it's also a compost factory, which will ensure all our hay growing and fruit/vegetable growing is very productive.

Wednesday, September 19, 2012

The September HIT Standards Committee Meeting

We began the meeting by noting this was the 40th meeting of the HIT Standards Committee and the bulk of the meeting was spent thoroughly reviewing the Stage 2 ONC and CMS rules so that all members can evangelize about the accomplishments of the past 3 years, ensuring every stakeholder understands the amount of work done to specify content, vocabulary and transport standards for healthcare.   Given the hundreds of pages of detailed regulations outlining very specific standards developed by hundreds of people working thousands of hours, we were confused by yesterday's Wall Street Journal article which noted:

"The industry could not agree on data standards - for instance on how to record blood pressure or list patients' problems"

Those standards were finished and included in the Stage 2 Standards and Certification Final Rule

"Instead of demanding unified standards, the government has largely left it to vendors who declined to cooperate, thereby ensuring years of non communication and non coordination"

For Stage 2, interoperability testing will be done by government authorized bodies using standards mandating by government.

Armed with the details of the Stage 2 rules, the members will ensure such mis-information is not promulgated.

Travis Broome from CMS began the meeting with an overview of the Stage 2 CMS rule.   He noted that the schedule is highly customizable such that a clinician begins and proceeds at a pace that works for his/her practice.  He noted the 2014 reporting period was changed to 90 days instead of a year to enable more flexibility in implementation of Stage 2 technologies.

He outlined the 17 eligible professional core measures

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

E-Rx for more than 50% - controlled substances are optional

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 years

Provide online access to health information for more than 50% with more than 5% actually accessing

Provide office visit summaries for more than 50% of office visits

Use EHR to identify and provide education resources more than 10%

More than 5% of patients send secure messages to their EP

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Conduct or review security analysis and incorporate in risk management process

The eligible professional menu set measures (pick 3 of 6) are:

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Successful ongoing transmission of syndromic surveillance data

Successful ongoing transmission of cancer case information

Successful ongoing transmission of data to a specialized registry

Enter an electronic progress note for more than 30% of unique patients

The Hospital Core objectives are:

Use CPOE for more than 60% of medication, 30% of laboratory, and 30% of radiology

Record demographics for more than 80%

Record vital signs for more than 80%

Record smoking status for more than 80%

Implement 5 clinical decision support interventions + drug/drug and drug/allergy

Incorporate lab results for more than 55%

Generate patient list by specific condition

eMAR is implemented and used for more than 10% of medication orders

Provide online access to health information for more than 50% with more than 5% actually accessing

Use EHR to identify and provide education resources more than 10%

Medication reconciliation at more than 50% of transitions of care

Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR

Successful ongoing transmission of immunization data

Successful ongoing submission of reportable laboratory results

Successful ongoing submission of electronic syndromic surveillance data

Conduct or review security analysis and incorporate in risk management process

The hospital menu set measures (pick 3 of 6) are:

Enter an electronic progress note for more than 30% of unique patients

More than 10% electronic prescribing (eRx) of discharge medication orders

More than 10% of imaging results are accessible through Certified EHR Technology

Record family health history for more than 20%

Record advanced directives for more than 50% of patients 65 years or older

Provide structured electronic lab results to EPs for more than 20%

He highlighted the patient engagement and electronic exchange requirements that ensure EHRs must actively share data among payers, providers, and patients before stimulus payments are made to hospitals or professionals.

We discussed the fact that lab results transmission only includes those ordered electronically and this could be challenging because many hospitals receive orders manually and return results electronically.   We also discussed the hardship exceptions for Pathologists, Radiologists,  and Anesthesiologists.

Steve Posnack then reviewed the standards rule, noting that it includes 5 major themes - enhancing standards-based exchange, promoting EHR technolog/safety, enabling greater patient engagement, introducing greater transparency, and reducing regulatory burden.

There are 50 certification criteria - 17 clinical, 7 care coordination, 3 clinical quality measures, 9 privacy/security, 3 patient engagement, 6 public health, and 4 utilization

Standards include a common MU Data set - including standards for Problems and Vital signs, which were two items called "without standard" in the Wall Street Journal article referenced above.

slides 16-18 in his presentation nicely summarize these standards

Certification can be "right sized" to align vendor capabilities with customer needs.  For example, BIDMC could elect not to do advance directives, progress notes, or lab transmissions (since it requires receiving incoming electronic orders to qualify and EHRs in the community may not be able to send them), BIDMC would not have to create or certify technologies for menu set items it does not plan to use in attestation

Farzad noted that based on very valuable feedback on the Governance RFI, there will be more focused work on certificate management, provider directories, and helpful convening instead of writing regulation for the NwHIN.   All concurred that this was a good approach.

Liz Johnson and Cris Ross presented an Implementation Workgroup Update on Testing Methods.
They highlighted the notion of scenario based testing - a workflow that requires the execution of multiple related actions.  Chris Brancato presented a medication management example  illustrating how building blocks of unit testing can be assembled into a single logical progression that aligns with workflow.  Carol Bean noted that the next wave of testing procedures, test data , and test tools will be released this Friday.

Finally, Doug Fridsma, provided an update on ONC Standards Activities, highlighting the new Health eDecisions and Automate Blue Button Initiative.

A great meeting demonstrating very important progress.   It's clear to me that Meaningful Use Stage 2 and its associated testing criteria accelerate interoperability more than any previous initiative.

Tuesday, September 18, 2012

An Update for the Medical Executive Committee

Of all the governance and oversight bodies I serve at BIDMC, the Medical Executive Committee (MEC) is one of the most important.   Here is a communication I wrote today for the MEC Newsletter which summarizes our major FY13 efforts.

"Every year, Information Systems at BIDMC completes dozens of projects prioritized by steering committees and advisory groups of clinicians, staff, and administrators.    Although those involved in these activities track our progress day to day, it's important to widely share our goals and activities so that everyone knows what to expect over the coming year.

BIDMC has a build and buy strategy.   We buy those clinical products that are mature, are regulated by the FDA, or are required by departments with very specialized functionality.   We build those products that need seamless integration, more functionality than commercial products, or are uniquely innovative.    For example, there is no commercial web-based, iPad compatible provider order entry or inpatient medication reconciliation application available on the market today.   BIDMC created them.

Many of our clinical applications are world class, enabling BIDMC to be the first hospital in the country to achieve Meaningful Use as part of the federal stimulus program for healthcare information technology.  However, there are gaps.      We do not perform bedside medication verification with bar codes at the point of medication administration.   We currently do not chart progress notes or nursing flowsheets from inpatient ward areas electronically.  We do not have an entirely electronic hospital record or billing workflow, instead using a hybrid of paper and electronic approaches.

In the next two years we'll develop and pilot systems to fill many of these gaps.

1.  We have a multidisciplinary committee, led by clinicians, pharmacy, and IS, to optimize the entire medication management process, ensuring that we support the '5 rights' of medication administration:

the right patient
the right drug
the right dose
the right route
the right time

As first steps, we're designing screens for electronic medication administration records, and selecting the right bar coding hardware (a combination of mobile and fixed devices) to support bedside medication verification.

2.  We have another multidisciplinary committee, which includes clinicians, administrators, and expert staff to design inpatient clinical documentation.  We're considering the best approaches including the use of templates (such as disease specific structured data), macros (easy to use standard text), computer assisted coding which can prompt clinicians for the precise details needed to improve documentation, social networking approaches that enable team authorship of notes, and single click incorporation of med lists/labs/other parts of the record.

We've already deployed electronic documentation in the Emergency Department and we hope to pilot inpatient ward documentation/nursing notes in FY13.

3.  ICD10, which expands coding from 14,000 to 170,000 codes, will have a profound impact on the way we document and bill.   This critical project will require the intense participation of stakeholders throughout the medical center.    A side benefit of the project will be automating many of our remaining paper billing processes.

In addition to filling these gaps, the years ahead will include many challenges to support compliance requirements and security mandates.   We have 50 projects that IS and compliance have prioritized together that will reduce our risks over the next two years.   Many of these projects are driven by Federal and State regulations which mandate they be done.  However, some of the projects will introduce restrictions, limitations, and responsibilities that some will find inconvenient.   We'll work closely with all stakeholders to balance confidentiality and ease of use.

Finally, FY13 will be a time of preparation for the next phase of meaningful use.  There will be 16 core objectives for hospitals and 17 core objectives for professionals.   BIDMC was the first hospital in the country to attest to meaningful use and we'll work hard to be an early adopter of the next stage.

These are a few of the many projects we'll work on together in FY13.   As we evolve into a mature accountable care organization coordinating wellness across the community, I'm sure more projects and the need for innovation will keep us all busy."

Monday, September 17, 2012

An Update on Controlled Substance e-Prescribing

I recently had a dialog with Surescripts about the current  state of policy and technology enabling controlled substance e-prescribing.   Here's a summary:

1.       Surescripts is “open for business” nation-wide for e-prescribing of controlled substances (“EPCS”), subject of course to restrictions in state laws that do not permit EPCS.
2.       There are 4 physician vendors who are certified on the Surescripts network to transaction EPCS, and are in fact doing so.
3.       There are 6 pharmacies / pharmacy vendors who are certified on the Surescripts network to transaction EPCS, and are in fact doing so.
4.       There are many other prescriber vendors and pharmacies in our certification pipe-line, including some of the larger vendors.
5.       Admittedly, the actual volume of EPCS is still very modest, but it is beginning to increase.
6.       The primary barriers in my view have been:  the development time and effort the vendors and pharmacies needed to come into compliance with the Interim Final Rule (IFR); the third party-audit (this is a reference to the section required IFR Section 1311 audit, not the Surescripts certification), which is both costly and time-consuming; an incorrect perception that no pharmacies can accept EPCS; vendors’ competing development priorities (Meaningful Use Stage 2, ICD-10, etc.); and having all the docs ID proofed and authenticated in conformance with the Drug Enforcement Agency IFR.
7.       Surescripts has been actively working with vendors to communicate and drive adoption.
8      Surescripts will run a report for me that will illustrate the volume in Massachusetts, which does permit EPCS of all scheduled drugs.  I'll publish that report on my blog.
9   There are about 12 states that either prohibit or limit EPCS.
10.    New York has mandated that all drugs, including controlled substance, be prescribed electronically by 12/31/14.

I hope this is helpful to illustrate the work in progress.    The country is on the right trajectory to e-Prescribe all medications, including controlled/scheduled substances.

Friday, September 14, 2012

More Meaningful Use Stage 2 Resources

Two important resources you can use as you plan for MU Stage 2 certification and attestation.

1.  The Advisory Board has prepared a poster, available to the public, comparing meaningful use Stage 1 with the Stage 2 final rule, including objectives, measures, numerators, denominators, exclusions, as well as certification criteria and standards.

2.  ONC has released the first wave of certification test procedures .

All Test Procedures will undergo public review and comment before being finalized and approved by ONC for use in testing and certification.

Comments and suggestions should be submitted to All submissions should include "Test Procedure" in the subject line.

The HIT Standards Committee's Implementation Workgroup is reviewing these in detail and I'm hopeful that they'll be rigorously tested in real world settings before the procedures are finalized.

Thursday, September 13, 2012

Building Unity Farm - the Chickens and Guinea Fowl

Last week I discussed the Alpaca and Llamas, which were examined by our traveling veterinarian, Cindy Fuhs, this week and given a clean bill of health.

On September 16, our chickens, now about 6 months old, began laying their first eggs.   Our Ameraucanas are the first layers, with green, blue, and sage colored eggs.   Our other breeds - Jersey Giants, Brahmas, and Buff Orpingtons should begin laying net month.

Our guinea fowl, also 6 months old, are likely to start laying next Spring, but since they free range our property, their egg laying habits will be harder to track.

How did we prepare for our birds?

The western boundary of our property is a 50 acre apple orchard filled with coyotes.  We have foxes and fisher cats roaming our meadow.    Weasels and birds of prey are frequent visitors.   To prepare for our birds, we had to build Fortress Gallus - a 10x14 coop on a stone foundation, sealed to ensure no predators can enter, attached to a 10x14 run that includes buried barriers and a thick wired roof.   It was build by Ponderosa Pines Wood Products.

Our coop is divided into two sections, a chicken section with access to the run and a guinea fowl section with access to alpaca paddocks and a path that circles our entire property.

The coop has hanging feeders and water supplies to ensure we do not attract rodents and keep everything clean.    Every morning at dawn we open a small door and let the chickens into the run.   Our rooster crows throughout the day - it's not just a dawn phenomenon.   He protects his hens with great vigilance.   Several of our chickens are very personable and will roost on our arms.   They enjoy having their necks rubbed.   Each has a name and is generally inquisitive.   We feed them a grain mix, supplemented by fresh vegetables (trimmings from our garden) and insects mixed into the forest duff we give them to explore.

Our guinea fowl are amazing.   They were raised in our basement, then moved into the coop at 6 weeks.   At 12 weeks we introduced them to the great outdoors, but they believe the coop is home.   They spent 12+ hours a day eating ticks and exploring our forest and wetlands but at dusk all return to the coop.  One of our guineas has a birth defect and cannot walk, but the other guineas care for him/her by ground flocking nearby.

Every Tuesday, we clean the coop and add new wood chips.  We scrub the food/water containers and the laying boxes.    We clean off the roosts.

On hot days we turn on ceiling mounted fans to keep the birds cool.

There is something very relaxing about watching our birds explore the world around them, scratching the soil, interacting with their fellow creatures, and enjoying the day until it is time to roost at sunset.

Thus far all our birds are happy and healthy as they move from "teenagers" to adults.   I highly recommend chickens and guinea fowl if you have a large property, appropriate zoning, and tolerant neighbors.

Next week, I'll discuss how we manage all the llama/alpaca and chicken manure.   That's its own engineering challenge.

Wednesday, September 12, 2012

The Information Week 500

Today, Beth Israel Deaconess issued this press release, noting that BIDMC Information Systems has been named the No. 1 technology innovator in the United States for 2012.    The incredible people of BIDMC IT earned this recognition.   They are an amazing, hard working, and dedicated group.

BOSTON – Beth Israel Deaconess Medical Center has been named the No. 1 technology innovator in the United States in this year’s InformationWeek 500 – a list of the top technology innovators in the US.

The annual list was released Tuesday at an awards ceremony at the exclusive InformationWeek 500 Conference at the St. Regis Monarch Beach Resort, Dana Point, CA.

“Beth Israel Deaconess has gotten into the habit of being No. 1,” says Rob Preston, VP and editor in chief of InformationWeek. “It was the first medical center to go live with iPads for clinical use, the first with a Web-based medical record system, the first to attest to ‘Meaningful Use’ via the national HIT stimulus program.

“Now it’s leading the way with Clinical Query, its clinical research business intelligence system. All of that innovative thinking and doing – and the outcomes those efforts are producing – has earned the hospital one more top slot: No. 1 on our annual InformationWeek 500 ranking of business technology innovators.”

Clinical Query enables investigators to ask questions, preliminary to research, that will help them understand the potential statistical power of a clinical trial or the availability of data for clinical research.
It was built by loading 2.2 million patients (1997 to the present) and 200 million data elements into a repository, then creating a web-based query tool capable of navigating 20,000 medical concepts to ask questions such as “how many people have a certain disease and what treatments did they receive?”
“The remarkable IT professionals, caregivers and administrators of BIDMC have worked together for more than 30 years to create a culture of technology innovation,” says John Halamka, MD, BIDMC’s chief information officer. “Boston is a kind of medical mecca and I can think of no better place than BIDMC to serve as a healthcare IT learning lab for the country. All of us are honored to be named No. 1 for 2012 on the Information Week 500.”

Now in its 24th year, the InformationWeek 500 recognizes business technology teams that have made a notable improvement to how their companies operate. To be considered, companies complete a rigorous application on their business technology strategies. The ranking process is quantitative and qualitative, with applicants earning points based a questionnaire and based on the achievements they outline in an essay submission. Applications are evaluated by a panel of InformationWeek editors. The survey data is aggregated across all InformationWeek 500 companies and by industry; individual responses are kept confidential and individual company data is never disclosed without permission.
Past overall winners include PACCAR Inc., The Vanguard Group, CME Group, National Semiconductor, Con-Way, and Principal Financial Group. The InformationWeek 500 rankings are unique among corporate rankings as it spotlights the power of innovation in information technology, rather than simply identifying the biggest IT spenders.

Additional details on the InformationWeek 500 can be found at 

About InformationWeek Business Technology Network (
The InformationWeek Business Technology Network provides IT executives with unique analysis and tools that parallel their work flow—from defining and framing objectives through to the evaluation and recommendation of solutions. Anchored by InformationWeek, the multimedia powerhouse that looks across the enterprise, the network scales across the most critical technology categories with online properties such as (security), (networking and communications) and BYTE (consumer technology). The network also provides focused content for key IT targets, such as CIOs, developers and SMBs, via InformationWeek Global CIO, Dr. Dobb's and InformationWeek SMB, as well as vital vertical industries with InformationWeek Financial Services, Government and Healthcare sites. Content is at the nucleus of our information distribution strategy – IT professionals turn to our experts and communities to stay informed, get advice and research technologies to make strategic business decisions.

About Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit

Tuesday, September 11, 2012

The ITDotHealth Conference

Today, I participated in the ITDotHealth Conference in Boston, discussing one simple question with a selection of the nation's EHR and PHR experts :

How we can best innovate/change our EHRs while also operating them to transact daily patient care?

Here's what I suggested:

1.  Federal

Meaningful Use Stage 3 is likely to include bidirectional exchange between patients and providers to ensure patient generated data is incorporated into EHRs.  It's also likely to include federated query capability (see Query Health for details) supporting quality measures, population management, and public health.    Meaningful Use Stage 2 requires many core interoperability features including 1) specific implementation guides for content, vocabulary, and transmission standards supporting transition of care exchanges among different vendor products 2) patient view/access/download/transmit and 3) ability to export summary records to aid in migration from one EHR to another.    Combine,  these requirements will create a new level of data liquidity which will inspire new modular "apps" that supplement core EHR functionality and will even be used in the certification process to fill gaps in EHR capabilities.

2.  State

Next month, Massachusetts goes live with a Statewide HIE that includes a comprehensive provider directory, Public Key Infrastructure trust fabric, and gateways supporting the Direct protocol.   Payers, Providers, and innovative third parties companies (including those which connect to patients) can all participate in data exchange as long they are trusted members of the community which sign the participation agreement and follow HIE security/privacy policies.   This ecosystem will result in many new innovative applications that leverage the frictionless data exchange to create value added services for all stakeholders.

3.  Local

BIDMC and its affiliated practices are preparing for the globally capitated future of medicine by embracing healthcare information exchange, analytics, and patient/family engagement.  We serve as the pilot site for many Federal, State, and Accountable Care Organization initiatives .   To us, innovation is a requirement for success.  Without a foundation of data liquidity, we cannot survive in a healthcare reform world.

My colleagues on the panel offered their own insights into the future of iPhone-like application platforms that extend the capabilities of EHRs by offering bidirectional interfaces and APIs to the thousands of agile start ups eager to change healthcare.   A great conference.

Thursday, September 6, 2012

Building Unity Farm - the Alpacas and Llamas

Many folks have asked about the reality of running a farm.

As the owner of a winery on the Marin/Sonoma border from 1986-1993, I can tell you that there is little romance in agriculture - it's hard work.

In my ongoing Thursday personal posts about Building Unity Farm, I'll tackle a variety of lessons learned as I've transitioned from suburban gardener to rural farmer.

Today's post is about preparing for alpacas and llamas - camelids

First the basics.  Alpacas and llamas are native to the Andes of southern Peru, northern Bolivia, Ecuador, and northern Chile.  They enjoy cold, dry weather and do not do well in New England Summer heat.

A barn or loafing shed with cooling fans, fresh water, and access to hay is essential.

We improved our barn to create male and female indoor living areas (Camelids ovulate on demand, so you do not want them living together unless you want an every increasing herd).   We cut (with Japanese hand saws) thick rubber floors to provide a clean, durable surface in the barn.

We installed heated buckets (to keep water from freezing in the winter) hung on wall brackets  32 inches off the floor.

We hung indoor hay saving feeders.

We added mineral feeders since alpacas and llamas need access to selenium salts to stay healthy.

We mounted circulating barn fans to keep the living areas cool.

Finally, as part of our overall fly management program we hung flytapes.

We clean the indoor areas every morning at dawn using rakes and manure scoops.   I built a 16x16 foot manure management area (picture shows the compost, manure and woodlot management areas) to compost the 5 tons of "llama beans" we'll move every year.

Outdoors, we fenced (5 foot woven wire with electric top wire) 1/2 acre for each gender and created gates that enable us easy access to the paddocks for feeding, cleaning, and herd health (monthly medications, toenail trimming and weighing).

We added covered 6 foot feeders and hanging water buckets.

We planted a mixture of orchard grass, timothy hay and alfalfa in our paddocks and in an adjacent pasture where the alpacas (one gender at a time) can graze during the day.

We have coyotes roaming our property and the adjacent 50 acre apple orchard, so we needed to plan for livestock guardians.   We placed two Great Pyrenees Mountain dogs in the male paddock and a large llama in the female side.

Camelids eat 2% of their body weight per day, which means that we need about 10,000 pounds of hay per year.   We built a hay loft capable of storing 7 tons, adding seven foot loft doors for easy loading from delivery trucks and ventilation to keep the hay cool and dry.

We did all over this before the camelids arrived.

Our daily routine includes cleaning the inside and outside living areas, refreshing water/food/minerals, and spending time with each animal to ensure they are healthy.   There's nothing like hot llama breath or a nose to nose alpaca nuzzle to start your day.

At night we repeat our morning chores, feed the guardian dogs, and turn on the electric fence.

When we're woken by alert barking (or llama yodeling) in the middle of the night, we chase away predators.  Although we do not own a firearm, we have taken classes in firearm safety should we ever need to provide another layer of defense.

On weekends, you'll find me sitting in the paddocks with my laptop, a dog at my side, and alpacas eating fresh second cut hay (the September harvest is higher in protein and sweeter than the July first cut hay) and guinea fowl running around the barnyard eating insects.   It's hard work, but the sights and sounds of a camelid filled barnyard are priceless.

Wednesday, September 5, 2012

A Meaningful Use Stage 2 FAQ

Today I had the privilege of speaking with CMS colleagues about Meaningful Use Stage 2.

As I've written in previous posts, MU 2 is truly a work of art and the stakeholder response to it has been very positive.

There are a few persistent questions about the MU program that are worth sharing with the community

1. What is the timing of each stage for early adopters - those who wish to attest as early as possible?

2012 - use stage 1 criteria
Eligible Professional (EP) reporting period is  January 1, 2012-December 31, 2012  with attestation in Jan/Feb 2013
Hospital reporting period is October 1,2011-Sept 30, 2012 with attestation in Oct/Nov 2012

2013 - use stage 1 criteria with optional refinements
EP reporting period is January 1, 2013-December 31, 2013  with attestation in Jan/Feb 2014
Hospital reporting period is October 1,2012-Sept 30, 2013 with attestation in Oct/Nov 2013

2014 - use stage 2 criteria (NOTE the 90 day reporting period to enable adoption of new MU Stage 2 certified products)
EP reporting period is January 1, 2014-March 31, 2014 with attestation in April/May 2014
Hospital reporting period is October 1, 2013-December 31, 2013 with attestation in Jan/Feb 2014

I'm guessing that stage 3 will return to the year long reporting period pattern
2015 - use stage 3 criteria
EP reporting period is January 1, 2015-December 31, 2015  with attestation in Jan/Feb 2016
Hospital reporting period October 1,2014-Sept 30, 2015 with attestation in Oct/Nov 2015

The program ends in 2016 and then penalties for non-attestation begin.

I've also been asked by pathologists, , anesthesiologists and especially radiologists about penalties for non-attestation.   These hospital-based specialists may file for the hardship exemption.  See the MU Stage 2 final rule page 446 for more detail

Finally, the stage 2 tip sheets provide valuable educational material for EPs and hospitals.  In the past, I've created educational materials on my blog, but these are so good, you can use materials directly from CMS!

Tuesday, September 4, 2012

A Milestone for Interoperability

Today, HL7 announced its decision to make much of its intellectual property, including standards, freely available under licensing terms. . The new policy is expected to take effect in the first quarter of 2013.

Why is this so important?

Over the past few years the HIT Standards Panel  (HITSP) and the HIT Standards Committee (HITSC) have developed standards readiness/standards maturity and adaptability evaluation metrics.    Each has included implementation guide accessibility, licensing permissiveness, and affordability.

When federal advisory committees have chosen HL7 standards as the most appropriate for the clinical need, some have commented that the intellectual property is only available with HL7 membership and thus it is not easily accessible.

Today's announcement eliminates that concern.

HL7 intellectual property will become free, but not open source i.e. HL7 will still retain copyright and the usual consensus processes will still be used to maintain and improve standards.  However, anyone will be able to license the intellectual property without charge.

HL7 and the teams that worked on this radical transformation of HL7's policies should be congratulated.

Meaningful Use Stage 2 depends upon many HL7 standards -HL77 2.51 for transactions and Consolidated CDA for summaries.   Today's announcement is very timely and we can expect that the Meaningful Use Stage 2 HL7 intellectual property will be available without charge to all stakeholders in the first quarter 2013, months before the first reporting period for October 1, 2014 attestation begins.

For more details, here's the press release about HL7's achievement.

Today is a milestone for interoperability and the entire HIT industry should offer their thanks.