Thursday, March 26, 2015

Unity Farm Journal - Fourth Week of March 2015

The temperatures are finally above freezing and we can get back to the usual workflow of the farm.   There is only a foot of snow left on the ground and we can actually walk to all our buildings and paddocks.

We opened the bee hives and did a thorough inspection.   We lost 4 of our 12 hives over the winter, which is not bad considering the snow/ice/cold over the past 6 months.   There is no evidence of infection or stress in the remaining hives.    We’re learning how to support our bees.

The guineas, chickens and ducks can finally wander as they please because their hiding places (from hawks) are no longer covered with snow.    Here’s our “partridge in a pear tree”

The wild turkeys are once again able to roam the property, eating early spring greens and cleaning up the fallen birdseed

As the snow melts we’re discovering the damage one by tons of snow - broken gates, damaged fences, and cracked irrigation pipes.     Over the next few weeks, we’ll repair everything I have the tools, equipment and know how to maintain all of our farm infrastructure at this point.

We’ve spent hours in the hoop house doing additional spring planting.   All our lettuces are forming heads and the vegetables that grew slowly over winter are now bursting with life.

With each cycle of the seasons, we are getting more certain about the maintenance tasks to perform in the house and barn.   Here’s the current list

Daylight savings time changes  (March/November)
Change furnace filters
Change humidifier panels
Change house water filter
Change osmotic filter
Change clock batteries

Prep for Summer
Startup fountains and pond
Start irrigation/place garden hoses
Sharpen mower blades
Pressure wash mower/Terex

Prep for Winter
Change oil in mower, pressure washer, splitter
Fill gas tanks/fuel treatment
Service Terex
Place driveway snow stakes
Change thermostat batteries
Shutdown fountains
Shutdown irrigation/remove garden hoses

Planting calendar
  Spring planting in hoop house
  Plant seedlings indoors
  Transplant seedlings
  Inoculate mushrooms
   Plant outdoor beds
   Harvest blueberries
   Harvest apples
   Make cider
   Harvest mushrooms
   Fall planting in hoop house
   Order hay and chaff hay

The work of a farmer is never done, but it’s joyful work.   Seeing the tangible result of a year working the land is very satisfying.    As the days lengthen and the seasonal affective disorder wanes, the farm is reborn.    It’s time to move from indoor tasks to outdoor tasks.   May the growing season begin!

Tuesday, March 24, 2015


This analysis was written by Micky Tripathi and John Halamka.

On Friday March 20, CMS released the Electronic Health Record Incentive Program-Stage 3 and ONC released the 2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications.

Perhaps the most important statement in the entire 700+ pages is the following from the CMS rule:  "Stage 3 of meaningful use is expected to be the final stage and would incorporate portions of the prior stages into its requirements."

Providers and vendors alike were all hoping for something lean and clean.  The CMS Stage 3 rule weighs in at 301 pages, but the ONC Certification rule takes the cake at 431 pages.  The JASON Task Force, whose recommendations were unanimously approved by the HIT Standards and Policy Committees, recommended that ONC and CMS make an explicit trade-off:  Decrease the breadth and complexity of the MU program, and in return, increase the expectations in a few key areas, such as interoperability.  The CMS MU Stage 3 rule, for the most part, has adopted this philosophy.  Unfortunately, the same can't be said for the ONC Certification rule.

We provide a brief synopsis of the MU and Certification Rules below, followed by our analysis of these proposals.

CMS Stage 3 MU Rule Synposis

The CMS Meaningful Use Rule is focused and narrowed to 8 objectives.

There is some fine-print though.  Contained within many of the objectives are multiple measures.  Depending on which options one chooses, and whether you are a provider or a hospital, the total number of MU measures could range from 15 to 20, and that's NOT INCLUDING the Clinical Quality Measures, which have always been like a MU menu all of their own, and which are now going to be determined through a different process and won't be defined until later in 2015.

Here is a synopsis of the MU Stage 3 requirements:

Provider-facing EHR functions:

*ePrescribing:  The thresholds have increased to 80% for EPs and 25% for EHs, but overall this is just asking for more of the same.  Of note is that controlled substance prescriptions can now be optionally included in states where it is allowed electronically.

*Clinical decision support:  There are 2 measures:  1) implement 5 CDS interventions tied to 4 quality measures; and 2) turn on drug-drug and drug-allergy interaction alerts for the entire EHR reporting period.  This is aligned with the past trajectory from earlier stages.

*CPOE:  There are 3 measures:  use CPOE on at least 80% of medication orders, 60% of lab orders, and 60% of diagnostic imaging orders.  CMS has given a little flexibility here by now counting entry by "scribes" (personnel with at least a medical assistant credential), excluding standing orders, and including a broader array of imaging such as ultrasound, MRIs, and computed tomography.

Patient-facing EHR functions:

*Patient access to information:  There are 2 measures:   1)  80% of patients must be able to access their records either through the View/Download/Transmit function or through an ONC-certified API; and 2) give 35% of patients access to patient-specific educational resources.  Note, this objective just requires that access is provided to patients.  No patient action is required in order to meet these objectives

*Active patient engagement:  There are 3 measures:  1)  25% of patients must access their records either through View/Download/Transmit or through an ONC-certified API; 2)  35% of patients must receive a clinically-relevant secure message; and 3) provider must incorporate information from patients or "non-clinical" settings for 15% of patients.  These measures do require patient action, though there is some flexibility because provider-initiated messages now count toward the secure messaging measure, for example.  The most challenging measure will be the last one, which requires patient-generated data or data from non-clinical settings such as home health, physical therapy, etc.


*Health information exchange:  There are 3 measures:  1)  send electronic summary for 50% of TOCs and referrals; 2)  get electronic summary for 40% of TOCs and referrals; and 3)  perform med/allergy/problem reconciliation for 80% of TOCs and referrals.

*Public health and clinical data registry reporting:  There are 6 measures.  "Active engagement" is required for:  1)  immunizations; 2)  syndromic surveillance; 3)  reportable conditions case reporting; 4)  public health registries; 5)  non-public health registries; 6)  electronic lab reporting.  EPs need to choose 3 out of 1-5, and EHs need to choose 4 out of 1-6.  Having witnessed that that there is wide variability in public health capacity across the country, CMS has provided some flexibility here by defining "active engagement" broadly to include either registering, testing, or transacting.  In short, you'll get credit even if you're not actively transacting as long as you are on the path and making a good faith effort.

The CMS rule is laid out logically and pretty easy to follow.  (That is, for a 300+ page federal regulation.)

ONC 2015 Edition Certification Rule Synopsis

We wish we could say the same about the ONC Certification Rule.  Whereas the CMS rule seems to be using MU Stage 3 to stabilize expectations, the ONC rule does the opposite and crams too much into the 2015 Edition Certification.  To make matters worse, the rule isn’t laid out clearly or logically, so it's hard to ascertain how all of the pieces fit together.

There are 68 individual certification requirements described in the ONC rule.  It would be impossible to lay out all of the details here.  The list of all of the requirements is here.

There are 36 of the 68 requirements that are required for Meaningful Use.  ONC introduces the concept of the "Base EHR", which has the following 16 requirements.  New requirements are marked with a *.

 • Demographics
 • Problem List
 • Medication List
 • Medication Allergy List
 • Smoking Status
 • Implantable Device List*
 • Clinical Decision Support
 • CPOE – medications
 • CPOE – laboratory
 • CPOE – diagnostic imaging
 • Transitions of Care
 • Application Access to Common Clinical Data Set*
 • Direct Project, Edge Protocol, and XDR/XDM
 • Direct Project
 • Clinical Quality Measures – record and export
 • Data Portability

But for meaningful use, CMS says that you need the Base EHR, plus 20 more requirements:

 • Automated Measure Calculation
 • Automated Numerator Recording
 • Patient Health Information Capture*
 • Family Health History – pedigree
 • Family Health History
 • Transmission to Public Health Agencies – health surveys*
 • Transmission to Public Health Agencies – antimicrobial use and resistance reporting*
 • Transmission to Public Health Agencies – reportable condition reporting*
 • Drug-drug, Drug-allergy Interaction Checks for CPOE
 • Transmission to Cancer Registries
 • Transmission to Public Health Agencies – reportable laboratory tests and values/results
 • Transmission to Public Health Agencies – syndromic surveillance
 • Transmission to Immunization Registries
 • Secure Messaging
 • View, Download, and Transmit to 3rd Party
 • Drug-formulary and Preferred Drug List Checks
 • Electronic Prescribing
 • Clinical Information Reconciliation and Incorporation
 • Patient-specific Education Resources
 • Clinical Quality Measures -- Report

So what are the additional 32 requirements if they're not required for Meaningful Use?  It's the list below, arrayed in order of decreasing complexity as estimated by ONC.

 • Electronic Submission of Medical Documentation*
 • Accessibility Technology Compatibility*
 • Consolidated CDA Creation Performance*
 • Vital Signs, BMI, and Growth Charts
 • Data Segmentation for Privacy (Federal substance abuse privacy law) – send*
 • Data Segmentation for Privacy (Federal substance abuse privacy law) – receive*
 • Quality Management System
 • Decision Support – knowledge artifact (send CDS interventions)*
 • Transmission of Laboratory Test Reports
 • Clinical Quality Measures – filter*
 • Incorporate Laboratory Tests and Values/Results
 • Safety-Enhanced Design
 • Care Plan  (consolidated from multiple care plans)*
 • Social, Psychological, and Behavioral Data*
 • Decision Support – service (receive CDS interventions)*
 • Healthcare Provider Directory – query response*
 • Healthcare Provider Directory – query request*
 • Clinical Quality Measures – import and calculate
 • Accessibility-Centered Design*
 • Integrity
 • End-User Device Encryption
 • Emergency Access
 • Automatic Access Time-out
 • Amendments
 • Audit Report(s)
 • Auditable Events and Tamper-resistance
 • Authentication, Access Control, Authorization
 • SOAP Transport and Security Specification and XDR/XDR for Direct Messaging
 • Accounting of Disclosures
 • Image Results
 • Patient List Creation
 • Electronic Medication Administration Record

Buried within these 700+ pages of proposed federal regulations are many objectives, measures, and requirements, as well as a lot of hopes, dreams, and aspirations -- what we would characterize as The Good, The Bad, and The Ugly.

The Good

The CMS rule level sets everyone at Stage 3 by 2018.  That makes life easier for providers, vendors, and the government.

Some of the objectives and thresholds need adjustment to align with workflow, change management and market realities, but overall the CMS MU Stage 3 proposal is a good first draft.  CMS deserves a lot of credit for streamlining and consolidating a lot of the stray threads from MU Stages 1 and 2, and making the Stage 3 rule coherent and relatively easy to understand.

Both the MU and Certification rules emphasize application program interfaces (APIs), and do so in a judicious and thoughtful way.  They give credit to those early adopters who may implement APIs ahead of the market, signal toward RESTful FHIR APIs and OAuth as future certification candidates, but don't lock in those standards before they are mature and market-tested.  This glide path is directly in line with recommendations from the JASON Task Force, HITSC and HITPC, as well as the Argonaut Project, and thus has a lot of community momentum behind it.  They seem to have learned the lessons of the Direct standard, which should be commended.

The MU rule makes a practical leap into query-based exchange by requiring receipt of records from other entities.  Few will be able to generate queries electronically at the outset, but it gives credit to those who can, and motivates others to enable workflows and technologies to do so as quickly as possible.

The “Base EHR Definition" was introduced in the ONC 2014 Certification Edition and included all of the security certification criteria and standards.  However, no individual module submitted for certification was required to meet the "Base EHR Definition," nor was any module required to meet any security criteria at all.   Instead, it was up to each purchaser to determine whether the set of modules purchased collectively met the "Base EHR Definition" and therefore would be capable of meeting the requirements of HIPAA. The  ONC 2015 Certification Edition removes security from the "Base EHR Definition" and instead assigns each security requirement to the types of modules where that functionality is most applicable.

Finally, patients are given a high priority, as they should be.  The big problems of health care can't be solved without making patients better custodians of their own care, and the MU and Certification rules give a large boost to those efforts.

The Bad

In the Meaningful Use rule, CMS undermines a bit of the simplicity by allowing a reporting period exception for year 1 Medicaid participants. They should have Medicaid year 1 follow the same requirements as everyone else which will level set everyone.

While it is good to align the CQMs with other CMS quality programs, the detail on CQMs now won't be provided until later this year.  We’re asked to weigh in now on quality measurement policy issues (such as whether all products should be required to support all measures) absent important information such as how many measures CMS is considering, whether they are all well suited to EHRs, and if they would be generally applicable to all EHR products.

There are 3 main issues with the ONC rules.  First is the concept of "decoupling".  CMS and ONC have “decoupled” their rules, so that CMS can specify a smaller number of objectives/certification criteria, while ONC can provide a list of everything health IT could/should/might be, including a broad scope beyond EHRs.  CMS now owns the "CEHRT definition.” CMS sets the program policy requirements for MU and defines what minimally needs to be certified.  This is a change in the directionality of the ONC/CMS regulatory relationship.  In the past two regulatory cycles ONC’s rules have included MU program policy and pointed to CMS for details.  Now, ONC’s rule is agnostic to any program and the CMS MU program points to ONC for certification specifications.  Thus, the ONC rule includes a variety of certification specifications for which there are no corresponding MU requirements from CMS.   This has the potential to create market confusion, an overwhelming scope for vendors/developers, and a laundry list of requirements that serve narrow interests.

Second, if we care about patient health, it's not intuitively obvious why some requirements are where they are.  For example, why is "Vital Signs, BMI, and Growth Charts" excluded on the MU list, but "Transmission to Public Health Reporting -- health surveys" is included on the MU list?

Third, it feels as if every wish of every stakeholder was included in the rule without setting priorities, rather than being specifically focused on functions the directly serve patient care and patient engagement.  There is not a really bad idea among the 68 proposed requirements, but do all of the problems of public health and Medicare FFS post-payment medical documentation review and safety-enhanced design and a host of other needs have to be solved at the same time as MU-related certification?  ONC estimates that all the development they propose would take 23,000 hrs to 47,000 hrs to develop. They have improved at estimating but that is still low (for example, for safety-enhanced design, they estimate 300-600 hrs, but it's taken most vendors >1000hrs in the past and they just doubled the number of things you're expected to summative usability test).  And by ONC's own estimates, vendors will have to spend 44% more development hours to meet all of the non-MU related certification requirements.  It would be much more simple if ONC created a 2015 Edition Rule for only MU-required functions, and then separate rules for the many other non-MU certifications that it would like to propose.

Fourth, while the API part of the Certification Rule seems to reflect the lessons learned from our experience with Direct, other areas seem to be making some of the same mistakes.  By casting the net so widely on the types of functions it wants to certify, the Rule inevitably proposes some standards that are not sufficiently market-tested to be de facto requirements for the entire industry.  The Health IT Standards Committee developed a very thoughtful framework for identifying which standards will have high chances of market acceptance.  Standards for such functions as provider directories, multi-entity care plans, exchange of CDS interventions, submission of FFS post-payment documentation, data segmentation to meet cumbersome federal substance abuse law requirements, etc don’t yet meet that test.  Standards for public health transactions (such as requiring bidirectional interfaces for immunization registries and reportable conditions reporting) are not only novel, they are not even deployed by most public health agencies.  We should have a high bar for anointing a standard to be worthy of federal-level certification, even if such requirements are “voluntary”.  The Rule does much to promote the move to RESTful APIs, and in most cases, we may very well find that following the path of facebook, and google, and twitter will be much faster and valuable than burdening the industry with even more older generation, health-care specific approaches.

The Ugly

If a clinician has 12 minutes to see a patient, be empathetic, document the entire visit with sufficient granularity to justify an ICD-10 code, achieve 140 quality measures, never commit malpractice, and broadly communicate among the care team, it’s not clear how the provider has time to perform a "clinical information reconciliation" that includes not only medications and allergies, but also problem lists 80% of the time.

Maybe we need to reduce patient volumes to 10 per day?  Maybe we need more scribes or team-based care?  And who is going to pay for all that increased effort in an era with declining reimbursements/payment reform?

As one of us wrote about in the Information Week article, Boiling the Frog, each incremental proposal is tolerable, but the collective burden is making practice impossible.

The sheer number of requirements may create a very high, expensive and complex set of barriers to product entry.  It may stifle innovation in our country and reduce the global competitiveness for the entire US Health IT industry by over-regulating features and functions with complicated requirements that only apply to CMS and US special interests.    The certification criteria are often not aligned with what EHR users ask for. In some cases, the criteria are completely designed to accrue benefits to people who aren't feeling the opportunity cost. So if certification is loaded by non-EHR users, EHR users are going to find that even if the MU objectives are fewer in number and more focused, that their EHRs are focused on a lot of things they haven't asked for.

There needs to be a very public discussion with providers as to who should prioritize EHR development -- ONC and the stakeholders they've included, or EHR users.  The work of the country over the next few months needs to be achieving a consensus about what should be in the Certification rule and what should be removed.   If industry, academia, clinicians, payers, and patients can align on a minimal set of requirements, we're confident ONC will listen.

Friday, March 20, 2015

Thursday, March 19, 2015

Unity Farm Journal - Third Week of March 2015

The effort to keep the chickens/ducks/guinea fowl safe from the hawks has had its own complications.    We originally built the coop (10x16) and pen (10x20)  to hold less than 50 birds.    Although it’s easy to limit population growth of chickens and ducks (collect the eggs), the guineas lay eggs in hidden forest nests.  Our 25 guineas became 70 guineas over the Summer.    The coop today has 64 guineas and 11 chickens - 75 birds in close proximity.  Normally they roost from dusk to dawn and are running around the farm during daylight hours.   By limiting them to the coop during hawk hunting hours, they have less free outdoor time.    The consequences are that they have increased proximity and less fresh air movement.  

Chocobo, one of our Buff Orpington chickens, is low on the pecking order.   This week, while confined, she was pecked by other birds and had mild bleeding of her comb.   We cleaned her up, applied Vetericyn (a spray on antibiotic), and  isolated her into the mini-coops we use for raising young birds.    She’s healed nicely.  

Snow, one of our Brahma chickens, developed an upper respiratory infection and began sneezing violently.    We’ve done our best to keep the coop open on cloudy days.   We’ve dug out all the bushes (buried under 7 feet of ice) that the poultry uses to hide from hawks.   Given that Boston just broke all historic winter records, that’s been an ongoing battle.     Snow the chicken is doing well now that she has more outside time.

I’ve tried very hard to minimize travel this year, but I was asked to join an important strategic planning session at a foundation in California, support one of our industry partners by giving a keynote in Dubai, and chair the Standards Committee in Washington. Kathy has had to keep the farm running during my time away.   The dogs miss me and we tend to defer maintenance tasks and the more physical projects until my return.    Balancing my various work tasks, my farm tasks and travel makes me want to use Skype as much as possible, minimizing travel time so that I can serve all the organizations, people, and creatures in my life instead of sit in airports.

As a farmer, my role is maximize the life quality of every creature on the farm.   As a CIO, my role is to make a difference with my staff, my country, and the world.    In 2014, we acquired all the technologies necessary to maximize farming efficiency, enabling me to use my nights and weekends most wisely.   As we ramp up production and scale, we may need to bring on some part time help to support Kathy when my job responsibilities fill the 24 hour day.

Our Spring planting is now done, both hoop house seed planting and indoor seedling germination.   The BIDMC COO asked why my fingertips are cracked.   My upper extremities are now farmer’s hands and not surgeon’s hands.

I look forward to the thaw of the next few weeks and exciting projects we have planned for late spring including new mushroom production, tree planting, fence mending, wiring the cider house to support the move from hand cranked tools to powered tools, and replacing the 30 year old farm driveway.

In our modern era, each of us will have 5 or more jobs.   My heart leads me to farming but my brain drives me to make a difference on as large a scale as possible.  For many years to come, I will shovel manure on nights and weekends while “fertilizing” ideas in my technology day jobs.

Wednesday, March 18, 2015

The March HIT Standards Committee

The March 2015 HIT Standards Committee was one of the most impactful meetings we have ever had.    No, it was not the release of Meaningful Use Stage 3 or the certification rule.   It was the creation of a framework that will guide all of our work for the next several years - everything we need for a re-charted standards harmonization convening body as well as a detailed interoperability roadmap, complementing the 10 year general plan developed by ONC.   Thanks to Arien Malec for yeoman’s work in both areas.

We started the day with an overview of current security risk presented by Ron Ross, National Institute of Standards and Technology (NIST).    Admittedly I missed that presentation.   Although my flight from Dubai to Washington was early, Metro was shutdown due to an equipment failure at the Rosslyn station.     I’m told it was a sobering overview of the increased threats we all are facing.

Next, Dawn Heisey-Grove provided an overview of progress on the most difficult aspects of Meaningful Use Stage 2 - transitions of care, patient/family engagement, electronic medication administration records, and public health data submission.   Progress is being made in all areas.

Evelyn Gallego-Haag presented a progress update on the Electronic Long Term Support Services (eLTSS).    Committee members offered two kinds of advice.  Care plan development and exchange maybe an “app” and not a standard.   If a standard is needed, existing standards should be leveraged instead of creating a new approach.

Stan Huff and Arien Malec presented a work of art - the Standards and Interoperability (S&I) Initiative Task Force Recommendations .   Their guiding principles were welcomed by all - ONC does need a convening function for aligning SDO work and national priorities, but standards making should be left to SDOs.   Prioritization must be multi-stakeholder and not dominated by any one entity.   We must align demand with the reality of the supply of mature standards.     The S&I Framework can be re-chartered with these new guidelines and will represent the third generation of standards harmonization efforts, building on the lessons learned from HITSP and the existing S&I efforts.

Next we heard a series of reports from workgroups reviewing the ONC Interoperability roadmap.

Liz Johnson and Cris Ross provided the perspective of the Implementation, Certification, and Testing workgroup.  The most important aspect of the presentation was the cleanup of CCDA, reducing optionality.    CCDA R2 will be much easier to parse than CCDA R1.

Andy Wiesenthal and Rich Elmore summarized the work of the Content Standards workgroup.

Jamie Ferguson presented the work of the Semantic Standards workgroup.

Dixie Baker and Lisa Gallager presented the recommendations of the Transport and Security Standards workgroup.

Next we heard the most important presentation thus far in 2015, Arien Malec and David McCallie presenting the work of the Architecture, Services, and APIs workgroup.   The key recommendation was aligning healthcare standards with the approach that has been used by the groups creating internet standards - bring running code and embrace phased improvement in real world implementations.    They elegantly categorized the work to be done on existing standards while transitioning to a broad implementation of future standards - FHIR, OAuth2, and REST.   The entire Standards Committee applauded the effort which contains enough detail to implement now.   It provides all the interoperability planning detail that Congress has been asking for.    We declared the effort, a yellow brick road leading to standards nirvana, with courage, wisdom and heart (ending with finished FHIR specifications from the land of Oz)

The day ended with a roadmap for Quality Measurement standards presented by Julia Skapik.

After the Standards Committee meeting, many joined the Argonauts steering committee meeting to hear and updated on the accelerated effort to bring FHIR/OAuth2/RESTful application program interfaces to most mainstream EHRs.   It’s on track through the diligent efforts of many dedicated participants.

Today was a banner day for healthcare interoperability.    In the next days to weeks as Meaningful Use Stage 3 NPRMs are released, we all hope that the frameworks presented today can be applied to the policy goals of emerging regulations.

Thursday, March 12, 2015

Unity Farm Journal - Second Week of March 2015

The thaw has begun.   This week, for the first time in 2015, we’ll have daytime temperatures above freezing.    The 8 foot snowbanks are starting to recede, although the Great Pyrenees can still look down on the 6 foot fences.

As the snow melts, creatures are becoming more active.  Birds are gathering hay for nesting (I cleaned out all the birdhouses in February), skunks have wakened from the dormant state and are wandering around the farm (I can smell them), and the fisher cats are prowling around the barn at night looking for prey.     The dogs have been barking for hours every night, keeping the barnyard animals safe from predators.    This morning, I noticed fisher cat tracks around the entire poultry area.   Everyone is safe and healthy.

It’s Spring planting time, and last weekend was spent creating our transplant stock in anticipation of hoop house planing over the next 2 months.   Although I directly seed many of the vegetables into raised beds, the heat loving plants are germinated indoors.   This year that includes

  Cucumbers - 12 large pots
  Peppers - 24 small pots
  Broccoli - 12 small pots
  Eggplant - 12 small pots
  Zucchini - 4 large pots
  Kabocha Pumpkin/Squash- 5 large pots

This weekend, I’ll finish planting the spring greens - 3 different kinds of spinach and 5 different kinds of lettuce.

The Federal Alcohol and Tobacco Tax and Trade Bureau is nearly ready to approve our cider making application as a bonded cider winery.    I’ve made 8 different kinds of hard ciders as test batches for personal consumption and once licensed, we can ramp up production.   We’ll have 6000 pounds of apples each season in the next few years.     I’ve been designing a premium beverage -  Halamka’s India Pale Ale with Apple - HIPAA.    It builds strong bodies twelve ways and protects your privacy!

I’m off to Dubai on Saturday night to give a keynote and Kathy will be running the farm until Tuesday.  I really hope the fast melting snow does not become a fast melting flood in my absence.

Wednesday, March 11, 2015

Outcomes as a Service

On Monday, I wrote a brief op-ed for the Wall Street Journal about the reality of cloud computing.   You can read the full article here.

I classified cloud computing in three different concepts

Infrastructure as a Service (IaaS) - your applications outsourced to someone else’s servers.

Platform as a service (PaaS) - a set of foundational software tools for building your applications on someone else’s servers and software.

Software as a service (SaaS) - a set of applications, created and operated by a third party which does not require installation of local hardware or software. You subscribe to comprehensive remotely hosted functionality.

I concluded that outsourcing your mess to someone else to host is not cloud computing.

Instead IT leaders should focus on a variation on SaaS, which I called “Outcomes as a Service”. Software and hardware are one component, but the combination of business processes, people, and technology work in concert to achieve a desired result. Payment is made when that result is delivered.  Examples are the athenahealth EHR/practice management/billing service, the Cornerstone Learning Management System service, and the Workday financial applications.

CIOs throughout the country are struggling with IT scalability - the capacity to meet the automation needs of the business given regulatory demands (ICD10, Meaningful Use, HIPAA Omnibus Rule, Affordable Care Act), limited time, and relatively fixed resources.

Often IT is asked to delivered unplanned work,  within current budgets, and without disrupting current projects in process.   It’s like asking 9 women to gestate a baby in 1 month.

One of the few ways that a CIO can stay sane (other than resource leveling and governance, which I discussed last week ) is to have the flex capacity to deliver outcomes for a price.

The business can be told that an Outcomes as a Service provider exists and the business can have as much of that service as they can pay for.  The CIO enables the service but does not provision it or operate it.

As I’ve written about before, the CIO’s role is increasingly diverse.  I’ve watched CIOs crumble under the strain the job, which often seems overwhelming - demand exceeding supply, constant change with complete reliability, and perfect security with ubiquitous access.

Relying increasingly on Outcomes as a Service vendors, freeing up the CIO to spend more time with business owners and governance activities, is likely one of the most successful tactics to enhance CIO job retention and satisfaction.

Thursday, March 5, 2015

Unity Farm Journal - First Week of March 2015

The snow, ice and sleet continues.  February was the snowiest month we have ever had in Boston had with 64.8 inches.  It was also the second-coldest February on record.

I’ve attacked the endless frozen tundra of Unity Farm with the Terex front loader,an ice chipper, and a stainless steel SnowEx salt/sand spreader.   I try to use Calcium Chloride or a Magnesium Chloride mix which is safer for the plants and animals.    We’ve gone through 250 pounds of salt and 250 pounds of sand every weekend in 2015.   The March weather thus far has varied between a high of 43 and a low of zero F.    The snow melts a bit, then refreezes.  It’s like chunky concrete at this point.   The industrial sized snowblower attachment for the Terex arrives this weekend, but I’m not sure a snowblower can help with the glaciers that now surround the farm.   Next year, I’ll move the powder before it becomes a solid.

The bees continue to struggle with the record low temperatures and precipitation.   We started the winter with 11 living hives and now we have 7.   In the Spring, we’ll refill a few of the hives by moving a portion of the bees and queens from existing hives to empty hives - a kind of forced swarming.   The queen-less hives will make new queens.   We’ve also ordered some “mini-hives” of overwintered Russian bees from Western Massachusetts.  These small hives are called a “nucleus” or “nuc”.   I’m sure that folks overhearing our conversation were worried when my wife announced that she purchased two Russian Nukes.

Last week, I wrote about my conversation with the hawk that visited the chicken coop and killed a guinea.    The hawk did not return, but unfortunately, it told two even larger friends about the coop.   Kathy noticed an enormous hawk sitting on the coop roof one morning.  Last weekend, I found the dismembered body of Belle, the duck who we nursed back to health after a serious eye infection.   The hawks broke her next and ate about half of her upper body.   I buried her under 6 feet of snow, since I cannot dig the frozen ground.

We’ve changed the daily schedule for all the poultry at Unity Farm.  During the lean times for the predators, when all natural food sources are covered with snow, we’ll keep all the coops and pens locked until 4pm each day, since the peak of the hunting seems to occur between 9am-3pm.   Once the snow melts and the trees begin to leaf out, we’ll restore the usual daylight freedom that the poultry have always enjoyed.  Our task as farmers is to maximize the quality of life of the creatures at Unity farm, while also keeping them alive!

We’ve ordered all our seeds for 2015, so hopefully I can plant peas next week and begin to prepare the overwintered raised beds for the Spring growing season ahead.

Wednesday, March 4, 2015

Resource Leveling

In an era when demand for IT services always exceeds supply, it’s important to triage incoming requests and allocate existing resources to completing the highest priority projects in the shortest time.

Time, scope, and resources are the only three levers available to a CIO.   Scope can be set by governance and steering committees, but time and resources often fall to the CIO to allocate.

I have long used the concept of resource leveling, which sets project start and end dates based on available resources.

This year, I’m bringing resource leveling dashboards to all my governance committees so that as new projects are requested, it is clear which projects will be delayed (or not started) by the insertion of new scope.

Expectations of service delivery in 2015 are compounded by the instant gratification of “there’s an app for that, how hard can it be”.    Cycle times of 18 months are no longer acceptable.   I can reduce the scope of projects by moving as many applications to Software as a Service subscriptions, relying on the scalability of vendors rather than the relatively fixed pool of IT staff, but for the many tasks still only available through internal building, I need to expand the resource leveling accountability beyond the office of the CIO to the business owners, so that the start/end times for projects are not “my” plan but “our” plan.

When the stakeholders have visibility into the allocation of resources, understanding the trade offs that must be made as new regulatory requests, urgent incident response, and unplanned strategic projects are added to the plate, hopefully there will better alignment between expectations and service delivery.

As the entire healthcare industry experiences accelerating change, and pressure to perform in a resource constrained environment increases, it is easy to single out IT as the rate limiting step to success.     Over the next 6 months, I hope to turn that conversation around as stakeholders have a role in resource leveling and can broadly communicate the decisions made collectively, providing the greatest IT good for the greatest number of stakeholders in the shortest time.